Systematic review of physiotherapy interventions to improve gross motor capacity and performance in children and adolescents with an acquired brain injury

Clinicians' perspectives on motor learning strategy selection and application in occupational therapy and speech-language pathology interventions for children with acquired brain injury

PURPOSE

Explore occupational therapists' (OTs) and speech language pathologists' (SLPs) process of selecting and applying motor learning strategies (MLS) in their interventions for children with acquired brain injury (ABI), and identify similarities and differences between OTs and SLPs in MLS selection and application.

METHODS

This qualitative descriptive study involved individual semi-structured interviews with OTs and SLPs from the ABI program at Holland Bloorview Kids Rehabilitation Hospital (Toronto, Canada). Interviews were analyzed using thematic analysis. A modified constant comparison method permitted comparison within and between professions.

RESULTS

Four OTs and three SLPs were interviewed. Four themes were developed: aligning MLS application with the child's cognitive ability, using MLS to promote success within a single session, adjusting MLS across treatment sessions, and promoting generalization and transfer of motor skills beyond the therapy session. MLS application was predominately based on child-specific factors with task-specific considerations. OTs and SLPs used similar clinical reasoning processes for selecting and applying MLS.

CONCLUSIONS

This study provides a greater understanding of OTs' and SLPs' clinical reasoning process when applying MLS in pediatric ABI interventions. The similarities in MLS selection and application between disciplines suggest that an interprofessional approach to MLS is suitable for pediatric ABI rehabilitation.

Emerging methods for measuring physical activity using accelerometry in children and adolescents with neuromotor disorders: a narrative review

BACKGROUND

Children and adolescents with neuromotor disorders need regular physical activity to maintain optimal health and functional independence throughout their development. To this end, reliable measures of physical activity are integral to both assessing habitual physical activity and testing the efficacy of the many interventions designed to increase physical activity in these children. Wearable accelerometers have been used for children with neuromotor disorders for decades; however, studies most often use disorder-specific cut points to categorize physical activity intensity, which lack generalizability to a free-living environment. No reviews of accelerometer data processing methods have discussed the novel use of machine learning techniques for monitoring physical activity in children with neuromotor disorders.

METHODS

In this narrative review, we discuss traditional measures of physical activity (including questionnaires and objective accelerometry measures), the limitations of standard analysis for accelerometry in this unique population, and the potential benefits of applying machine learning approaches. We also provide recommendations for using machine learning approaches to monitor physical activity.

CONCLUSIONS

While wearable accelerometers provided a much-needed method to quantify physical activity, standard cut point analyses have limitations in children with neuromotor disorders. Machine learning models are a more robust method of analyzing accelerometer data in pediatric neuromotor disorders and using these methods over disorder-specific cut points is likely to improve accuracy of classifying both type and intensity of physical activity. Notably, there remains a critical need for further development of classifiers for children with more severe motor impairments, preschool aged children, and children in hospital settings.

Gross motor proficiency deficits among children and adolescents post posterior fossa brain tumor removal vs. traumatic brain injury in the chronic phase of recovery: a cross-sectional study

Introduction

Acquired brain injury (ABI) is a prevalent diagnosis in pediatric rehabilitation. Gross motor skills are often affected by ABI and limit the ability to participate in various physical activities. However, as ABI injury location is diverse, children and adolescents (youth) with localized ABI, such as ABI in the posterior fossa (ABI-PF) may present unique and different motor disabilities than youth with ABI on account of traumatic brain injury (TBI).

Aims

The aims of the study were: (1) to compare gross motor deficits in youth with TBI vs. ABI-PF; and (2) to compare two methods on scoring BOT2 to determine which is better for identifying motor deficits.

Methods

Participated in this study youth with TBI (N = 50) and ABI-PF (N = 30). Participants were tested on Bruininks-Oseretsky Test of Motor Proficiency-2nd Edition (BOT2) Upper-Limb Coordination, Balance, Strength, Running Speed and Agility, and Bilateral-Coordination subtests. Motor performance deficits were established using two-standard deviations (2SD) and age-equivalent methods. Between-group differences were assessed via independent t-tests and receiver operating characteristic curves (ROC).

Results

According to the 2SD method, motor deficits in the ABI-PF group ranged from 20% to 66.66%, whereas in the TBI group 8%-16%. According to the age-equivalent method, in the TBI and ABI-PF groups 40%-66.0% and 46.66%-76.66% of the youth presented motor deficits, respectively. Moreover, ROC analysis showed that motor performance deficits of both groups in all sub-scales except for Bilateral Coordination differed enough to result in medium area under the curve.

Conclusions

Motor deficits post-pediatric ABI are prevalent. In comparison to the TBI group, deficits are greater in the ABI-PF group. Moreover, compared to the 2SD method, the extent of motor deficiency is greater in the age-equivalent method. Therefore, using the later might provide a more valid classification of deficits in gross motor proficiency for youth post-ABI.

Secure windows for child safety: a retrospective study of window falls in children, aiming to raise prevention awareness

PURPOSE

The aim of the study is to enhance understanding, raise awareness and inform prevention programmes regarding potential factors that lead to severe paediatric injuries caused by unintentional falls from windows.

METHODS

This is a retrospective review from a major Trauma Centre, covering the majority of North West England and North Wales and included children under the age of 16 that had sustained falls from windows and were hospitalised between April 2015 and June 2020.

RESULTS

Overall, 825 patients' records have been reviewed, 39% of which exhibited neurosurgical injuries (322 admissions). The most common cause of injury was falls (42%), out of which 19% was identified as falls from windows which was eventually the core focus of this review (25 patients). The records showed that 72% of the falls were not witnessed by another individual, suggesting that children were being left unattended. Average GCS recorded at presentation was 11.2 and 56% of cases were identified as severe major traumas. With a mean stay of 2.2 days in ICU, 1.6 days in HDU and 6 days in the neurosurgical clinic, average treatment costs per patient were £4,493, £651 and £4,156 respectively. Finally, 52% of patients were identified to require long-term physiotherapy/occupational therapy due to permanent disabilities, 20% long-term antiepileptic treatment for seizures and 44% long-term psychological services input.

CONCLUSION

This study presents our experience at a major tertiary trauma centre in the UK over a 5-year period, from a paediatric neurosurgical injuries perspective due to fall from windows. We aim to raise awareness and highlight the importance of establishing prevention programmes which would hopefully decrease the incidence of paediatric window falls.

Gross motor change after inpatient rehabilitation for children with acquired brain injury: A 10-year retrospective review

AIM

To estimate gross motor change in inpatient school-aged children with subacute acquired brain injury (ABI), identify factors associated with gross motor change, and describe inpatient physiotherapy focus.

METHOD

This retrospective chart review involved inpatient children (5-18 years) with subacute ABI who had either two Gross Motor Function Measure (GMFM-88) assessments or one GMFM-88 with another pre/post gross motor outcome measure. Outcome change scores and Goal Attainment Scaling (GAS) T scores were calculated. Regression analyses examined factors predicting gross motor change. GAS goal areas were analysed to determine physiotherapy focus.

RESULTS

Of the 546 charts screened, 266 (118 female) met study criteria. The GMFM-88 was generally administered first, followed by other measures. GMFM-88 (n = 202), Community Balance and Mobility Scale (n = 89), and Six-Minute Walk Test (6MWT) (n = 98) mean change scores were 18.03% (SD 19.34), 17.85% (SD 10.77), and 142.3 m (SD 101.8) respectively. The mean GAS T score was 55.06 (SD 11.50). Lower baseline scores and increased time between assessments were most predictive of greater GMFM-88 change (r ≥ 0.40). Twenty-five percent of GAS goals were ambulation-based.

INTERPRETATION

Appropriate outcome measure selection is integral to detecting gross motor change in pediatric inpatient ABI rehabilitation. Mean change score estimates can be used to compare standard inpatient rehabilitation with new treatment approaches.

Telerehabilitation during COVID-19 lockdown and gross motor function in cerebral palsy: an observational study

BACKGROUND

COVID-19 (Coronavirus disease 2019) refers to a mainly respiratory disease, caused by a new SARS-CoV-2 virus predominantly transmitted through direct or indirect contact with mucous membranes of eyes, mouth, or nose. The main control measures are physical distancing, use of specific protective devices, hand hygiene and disinfection of environments and tools. During this health emergency, telemedicine and telerehabilitation guaranteed patients to receive continuity of care through a virtual support while maintaining physical distance.

AIM

The aim of this study was to evaluate the effects of telerehabilitation on gross motor skills in children with cerebral palsy (CP) during COVID-19 lockdown.

DESIGN

This is an observational study.

SETTING

Pediatric Outpatient Neurorehabilitation Service.

POPULATION

Fifty-three children with cerebral palsy aged between 6 months and 12 years classified according to the Gross Motor Function Classification System (GMFCS).

METHODS

Variation on the Gross Motor Function Measure-66 (GMFM-66) Score calculated before and after the telerehabilitation period was analyzed.

RESULTS

After telerehabilitation there was a statistically significant increase in the median value of GMFM scores both on the total sample (from 54.82% to 63.18%, P=0.000005) and in the subgroups. Specifically, in children classified as level I and II at the GMFCS, this value increased more after the telerehabilitation period. Only the GMFCS level V group did not show statistically significant changes and only in two cases a decrease in the GMFM Score after the telerehabilitation phase occurred.

CONCLUSIONS

Telerehabilitation can be considered an efficient tool that can temporarily replace the in-person therapy. It can allow the patient or caregiver to acquire skills in performing home exercises and to integrate and implement activity carried out at the Rehabilitation Center.

CLINICAL REHABILITATION IMPACT

This study shows a positive effect of telerehabilitation on gross motor function in children with cerebral palsy.

Physical rehabilitation interventions in children with acquired brain injury: a scoping review

AIM

To synthesize the evidence about the characteristics (frequency, intensity, time, type) and effects of physical rehabilitation interventions on functional recovery and performance in daily functioning in children and young people with acquired brain injury (ABI), including traumatic brain injuries (TBI) and non-TBI, during the subacute rehabilitation phase.

METHOD

Using scoping review methodology, a systematic literature search was performed using four databases. Articles were screened by title and abstract and data from eligible studies were extracted for synthesis.

RESULTS

Nine of 3009 studies were included. The results demonstrated a variety of intervention characteristics: frequency varied between 1 and 7 days per week; time of intervention varied between 25 minutes and 6 hours a day; intervention types were specified in seven studies; and none of the included studies reported details of intensity of intervention. All studies reported positive results on the International Classification of Functioning, Disability and Health: Children and Youth (ICF-CY) levels of body function and activities after the intervention period, with study designs of included studies being cohort studies without concurrent controls (n=7) or case reports (n=2).

INTERPRETATION

Inconsistency in results hampers generalizability to guide clinical practice. Physical interventions during subacute rehabilitation have potential to improve functional recovery with intervention characteristics as an important factor influencing its effectiveness. Future well-designed studies are indicated to gain knowledge and optimize rehabilitation practice in paediatric ABI and high-quality research including outcomes across all ICF-CY domains is needed.

Determining the utility of a smartphone-based gait evaluation for possible use in concussion management

Objectives: Our was objectives were to (1) assess the validity of a smartphone-based application to obtain spatiotemporal gait variables relative to an established movement monitoring system used previously to evaluate post-concussion gait, and (2) determine the test-retest reliability of gait variables obtained with a smartphone.Methods: Twenty healthy participants (n = 14 females, mean age = 22.2, SD = 2.1 years) were assessed at two time points, approximately two weeks apart. Two measurement systems (inertial sensor system, smartphone application) acquired and analyzed single-task and dual-task spatio-temporal gait variables simultaneously. Our primary outcome measures were average walking speed (m/s), cadence (steps/min), and stride length (m) measured by the inertial sensor system and smartphone application.Results: Correlations between the systems were high to very high (Pearson r = 0.77-0.98) at both time points, with the exception of dual-task stride length at time 2 (Pearson r = 0.55). Bland-Altman analysis for average gait speed and cadence indicated the average disagreement between systems was close to zero, suggesting little evidence for systematic bias between acquisition systems. Test-retest consistency measures using the smartphone revealed high to very high reliability for all measurements (ICC = 0.81-0.95).Conclusions: Our results indicate that sensors within a smartphone are capable of measuring spatio-temporal gait variables similar to a validated three-sensor inertial sensor system in single-task and dual-task conditions, and that data are reliable across a two-week time interval. A smartphone-based application might allow clinicians to objectively evaluate gait in the management of concussion with high ease-of-use and a relatively low financial burden.

The presence of high level physical difficulties in children and young people with severe acquired brain injuries who regain independent mobility

Background/Aims

Children and young people with acquired brain injuries take part in less physical activity than age-matched peers. A possible cause of this is reduced high level motor proficiency. This study aimed to determine whether children and young people who regain independent mobility following a severe acquired brain injury continue to experience high-level physical difficulties.

Methods

A retrospective review of routinely collected Bruininks-Oseretsky Test of Motor Proficiency 2 assessments was performed. Descriptive data analysis of motor proficiency results, both overall and within the different subsections, was conducted.

Results

Out of 26 participants (5–17 years) with severe traumatic and non-traumatic acquired brain injury, 22 scored below or well below average in overall motor composite score. The mean standard scores across all participants in three of the subsections were below average: manual coordination 35.9; body coordination 37.1; and strength and agility 37.9. The only subsection that produced scores within the average for participants' ages was fine motor control (mean 41.8).

Conclusions

Children and young people demonstrate reduced motor proficiency following acquired brain injury despite regaining functionally independent mobility. Those not participating in physical activities should be screened for high level motor difficulties that may impact on their participation.

Effect of Robot-Assisted Gait Training in a Large Population of Children With Motor Impairment Due to Cerebral Palsy or Acquired Brain Injury

OBJECTIVE

To evaluate retrospectively the effect of robotic rehabilitation in a large group of children with motor impairment; an additional goal was to identify the effects in children with cerebral palsy (CP) and acquired brain injury (ABI) and with different levels of motor impairment according to the Gross Motor Function Classification System. Finally, we examined the effect of time elapsed from injury on children's functions.

DESIGN

A cohort, pretest-posttest retrospective study was conducted.

SETTING

Hospitalized care.

PARTICIPANTS

A total of 182 children, 110 with ABI and 72 with CP and with Gross Motor Function Classification System (GMFCS) levels I-IV, were evaluated retrospectively.

INTERVENTIONS

Patients underwent a combined treatment of robot-assisted gait training and physical therapy.

MAIN OUTCOME MEASURES

All the patients were evaluated before and after the training using the 6-minute walk test and the Gross Motor Function Measure. A linear mixed model with 3 fixed factors and 1 random factor was used to evaluate improvements.

RESULTS

The 6-minute walk test showed improvement in the whole group and in both ABI and CP. The Gross Motor Function Measure showed improvement in the whole group and in the patients with ABI but not in children with CP. The GMFCS analysis showed that all outcomes improved significantly in all classes within the ABI subgroup, whereas improvements were significant only for GMFCS III in children with CP.

CONCLUSIONS

Children with motor impairment can benefit from a combination of robotic rehabilitation and physical therapy. Our data suggest positive results for the whole group and substantial differences between ABI and CP subgroups, with better results for children with ABI, that seem to be consistently related to time elapsed from injury.

Action, observation or imitation of virtual hand movement affect differently regions of the mirror neuron system and the default mode network

Virtual reality (VR)-based paradigms use visual stimuli that can modulate visuo-motor networks leading to the stimulation of brain circuits. The aims of this study were to compare the changes in blood-oxygenation level dependent (BOLD) signal when watching and imitating moving real (RH) and virtual hands (VH) in 11 healthy participants (HP). No differences were found between the observation of RH or VH making this VR-based experiment a promising tool for rehabilitation protocols. VH-imitation involved more the ventral premotor cortex (vPMC) as part of the mirror neuron system (MNS) compared to execution and VH-observation conditions. The dorsal-anterior Precuneus (da-Pcu) as part of the Precuneus/posterior Cingulate Cortex (Pcu/pCC) complex, a key node of the Default Mode Network (DMN), was also less deactivated and therefore more involved. These results may reflect the dual visuo-motor roles for the vPMC and the implication of the da-Pcu in the reallocation of attentional and neural resources for bimodal task management. The ventral Pcu/pCC was deactivated regardless of the condition confirming its role in self-reference processes. Imitation of VH stimuli can then modulate the activation of specific areas including those belonging to the MNS and the DMN.

Variations in physiotherapy practice in neurological rehabilitation trajectories -an explorative interview and observational study

Rehabilitation following acquired brain injury requires multidisciplinary efforts, including physiotherapy, across health care levels. Recent changes in the organization of health care services in western societies have led to earlier hospital discharge and increased responsibility for rehabilitation in primary care. The aim of this study was to describe and increase knowledge on the variations in physiotherapy practice for people with acquired brain injury across health care levels in Norway. We performed qualitative interviews with physiotherapists and field observations of physiotherapy treatments for 10 rehabilitation trajectories. We also performed systematic analyses using data from field observations, interviews, and hospital discharge records related to perspectives on social practices. The institutionalized rehabilitation context in hospitals promoted a more uniform approach by physiotherapists, emphasizing quality of movement and reacquisition of function. Physiotherapists in primary health care had to balance between interventions aiming to improve quality of movement versus interventions enabling patients to identify coping strategies. The informants highlighted the relevance of contextual surroundings when patients were discharged earlier from the hospital, as these patients' level of function was perceived to be lower. Moreover, the preconditions for providing rehabilitation in primary care challenged physiotherapists to practice and use their knowledge base in novel ways.

Epigenome-wide analysis in newborn blood spots from monozygotic twins discordant for cerebral palsy reveals consistent regional differences in DNA methylation

Background

Cerebral palsy (CP) is a clinical description for a group of motor disorders that are heterogeneous with respect to causes, symptoms and severity. A diagnosis of CP cannot usually be made at birth and in some cases may be delayed until 2–3 years of age. This limits opportunities for early intervention that could otherwise improve long-term outcomes. CP has been recorded in monozygotic twins discordant for the disorder, indicating a potential role of non-genetic factors such as intrauterine infection, hypoxia-ischaemia, haemorrhage and thrombosis. The aim of this exploratory study was to utilise the discordant monozygotic twin model to understand and measure epigenetic changes associated with the development of CP.

Methods

We performed a genome-wide analysis of DNA methylation using the Illumina Infinium Human Methylation 450 BeadChip array with DNA from newborn blood spots of 15 monozygotic twin pairs who later became discordant for CP. Quality control and data preprocessing were undertaken using the minfi R package. Differential methylation analysis was performed using the remove unwanted variation (RUVm) method, taking twin pairing into account in order to identify CP-specific differentially methylated probes (DMPs), and bumphunter was performed to identify differentially methylated regions (DMRs).

Results

We identified 33 top-ranked DMPs based on a nominal p value cut-off of p < 1 × 10⁻⁴ and two DMRs (p < 1 × 10⁻³) associated with CP. The top-ranked probes related to 25 genes including HNRNPL, RASSF5, CD3D and KALRN involved in immune signalling pathways, in addition to TBC1D24, FBXO9 and VIPR2 previously linked to epileptic encephalopathy. Gene ontology and pathway analysis of top-ranked DMP-associated genes revealed enrichment of inflammatory signalling pathways, regulation of cytokine secretion and regulation of leukocyte-mediated immunity. We also identified two top-ranked DMRs including one on chromosome 6 within the promoter region of LTA gene encoding tumour necrosis factor-beta (TNF-β), an important regulator of inflammation and brain development. The second was within the transcription start site of the LIME1 gene, which plays a key role in inflammatory pathways such as MAPK signalling. CP-specific differential DNA methylation within one of our two top DMRs was validated using an independent platform, MassArray EpiTyper.

Conclusions

Ours is the first epigenome-wide association study of CP in disease-discordant monozygotic twin pairs and suggests a potential role for immune dysfunction in this condition.

Electronic supplementary material

The online version of this article (10.1186/s13148-018-0457-4) contains supplementary material, which is available to authorized users.

An Immersive Virtual Reality Platform to Enhance Walking Ability of Children with Acquired Brain Injuries

Background: Acquired brain injury (ABI) may result in lifelong impairment of physical, cognitive, and psychosocial functions. Several rehabilitative treatments are often needed to support walking recovery, thus participants’ engagement becomes a crucial aspect, especially when patients are children. In the last few years, traditional physiotherapy (PT) has been flanked by innovative technologies for rehabilitation in the fields of robotics and Virtual Reality (VR). Preliminary results have shown interesting perspectives in the use of a VR system, the GRAIL (Gait Real-time Analysis Interactive Lab), in improving walking abilities in a small group of children with ABI, although further insights are needed about its use as rehabilitative tool in the pediatric population.

Objectives: To evaluate the efficacy of a rehabilitation treatment on a GRAIL system for the improvement of walking abilities, in a group of children suffering from ABI.

Methods: 12 children with ABI (study group – SG; mean age = 12.1 ± 3.8 years old) underwent a 10-session treatment with the GRAIL, an instrumented multi-sensor platform based on immersive VR for gait training and rehabilitation in engaging VR environments. Before (T0) and at the end of the treatment (T1), the participants were assessed by means of functional scales (Gross Motor Function Measure (GMFM), Functional Assessment Questionnaire (FAQ), 6-Minute Walk Test (6minWT) and the 3D-Gait Analysis, over ground (OGA) and on GRAIL (GGA).

Results: All the participants completed the rehabilitative treatment. The functional evaluations showed an improvement in Gross Motor abilities (GMFM-88, p = 0.008), especially in standing (GMFM-D, p = 0.007) and walking (GMFM-E, p = 0.005), an increase of the endurance (6minWT, p = 0.002), and enhanced autonomy in daily life activities (FAQ, p = 0.025). OGA identified a significant decrease of the Gillette Gait Index for the impaired side and a general increase of symmetry. GGA showed improvements in spatiotemporal parameters and joints range of motion that moved towards normality and symmetry recovery.

Conclusions: A 10-session treatment with GRAIL on children with ABI led to improvements in their walking abilities and enhanced their engagement during the training. This is desirable when long life impairments are faced and children’s motor functions have to be regained and it supports the leading role that VR might have in the rehabilitation field.