Foot and Ankle Somatosensory Deficits Affect Balance and Motor Function in Children With Cerebral Palsy

Are tactile function and body awareness of the foot related to motor outcomes in children with upper motor neuron lesions?

Introduction

Somatosensory function can be reduced in children with Upper Motor Neuron (UMN) lesions. Therefore, we investigated relationships between somatosensory functions of the foot and motor outcomes in children with UMN lesions.

Method

In this cross-sectional study, we assessed the Tactile Threshold (TT) with monofilaments and body awareness with Tactile Localisation Tasks for spatial-related action (TLTaction) and structural-related perception (TLTperception) body representation at the foot sole. Furthermore, we assessed four motor outcomes: the Selective Control Assessment of the Lower Extremity (SCALE), the modified Timed Up and Go test (mTUG), the Gillette Functional Assessment Questionnaire (FAQ), and the Functional Mobility Scale (FMS). Spearman's correlations (ρ) were applied to assess relationships between the somatosensory function of the foot sole and the applied motor outcomes.

Results

Thirty-five children with UMN lesions, on average 11.7 ± 3.4 years old, participated. TLTperception correlated significantly with all lower limb motor outcomes (|ρ|=0.36-0.57; p < 0.05), but TLTaction (|ρ|=0.00-0.27; p = 0.15-0.97, and TT did not (|ρ|=0.01-0.83; p = 0.73-0.94). TLTperception correlated strongly with the Gross Motor Function Classification System (|ρ|=0.62; p = 0.001) in children with cerebral palsy (n = 24).

Discussion

Assessing structural body representation of the foot sole should be considered when addressing lower limb motor impairments, including gait, in children with upper motor neuron lesions. Our results suggest that the assessment of tactile function and spatial body representation may be less related to lower limb motor function.

Ankle proprioception in children with cerebral palsy

PURPOSE

There is no established clinical standard to evaluate ankle proprioception in children with cerebral palsy (CP). This study compared ankle position sense of children with CP to age-matched children who are typically developing (TD).

METHODS

Children aged 6-17 years participated (15 CP, 58 TD). Using a custom-built device, the ankle was passively rotated to two positions for 25 trials. Using a psychophysical forced-choice paradigm, participants indicated which position was more plantarflexed. A psychometric function was fitted to the response data to determine the just noticeable difference (JND) threshold and the associated uncertainty (random error) for ankle position sense.

RESULTS

Median JND thresholds for the CP group were elevated (CP: 4.3°, TD: 3.0°). Three children with CP exceeded the 95th percentile of TD. No differences in random error were found.

CONCLUSION

This method assessed ankle proprioception relative to norm data and identified position sense impairments in children with CP. Using this method can provide data on proprioceptive status in CP, augmenting the assessment of motor impairment.

Subthreshold electrical noise alters walking balance control in individuals with cerebral palsy

BACKGROUND

Sensory deficits in individuals with cerebral palsy (CP) play a critical role in balance control. However, there is a lack of effective interventions that address sensory facilitation to improve walking balance. Stochastic Resonance (SR) stimulation involves delivering sub threshold noise to improve balance in patients with sensory deficits by enhancing the detection of sensory input.

RESEARCH QUESTION

To investigate the immediate effects of SR on walking balance in individuals with and without CP.

METHODS

Thirty-four participants (17 CP, 17 age-and sex-matched typically developing controls or TD) between 8 and 24 years of age were recruited. SR stimulation was applied to the muscles and ligaments of ankle and hip joint. An optimal SR intensity during walking was determined for each subject. Participants walked on a self-paced treadmill for three trials of two minutes each using a random order of SR stimulation (SR) and no stimulation (noSR) control conditions. Our primary outcome measure was minimum lateral margin of stability (MOS). Secondary outcome measures include anterior MOS before heelstrike and spatiotemporal gait parameters. We performed two-way mixed ANOVAs with group (CP, TD) as between-subject and condition (noSR, SR) as within subject factors.

RESULTS

Compared to walking without SR, there was a small but significant increase in the lateral and anterior MOS with SR stimulation, implying that a larger impulse was needed to become unstable, in turn implying higher stability. Step width and step ength decreased with SR for the CP group with SR stimulation. There were no significant effects for other spatiotemporal variables.

SIGNIFICANCE

Sub threshold electrical noise can slightly improve walking balance control in individuals with CP. SR stimulation, through enhanced proprioception, may have improved the CP group's awareness of body motion during walking, thus leading them to adopt a more conservative stability strategy to prevent a potential fall.

Feasibility, Validity, and Reliability of Lower Limb Tactile and Body Awareness Assessments in Children With Upper Motor Neuron Lesions

OBJECTIVE

To investigate the feasibility, discriminative and convergent validity, and inter-rater reliability of a lower limb tactile function and 2 body awareness assessments in children with upper motor neuron (UMN) lesions.

DESIGN

Cross-sectional psychometric study.

SETTING

Pediatric rehabilitation center.

PARTICIPANTS

Forty individuals with UMN lesions (mean age 11.7 years, SD 3.4 years; 27 girls) and 40 neurotypically developing children of the same age participated (N=80).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

We assessed the tactile threshold (TT) with monofilaments and body awareness with tactile localization tasks (TLTs) for structural (TLTaction) and spatial (TLTperception) body representation at the foot sole. We compared the test outcomes between children with UMN lesions and neurotypically developing children with the Wilcoxon signed-rank test. Furthermore, we quantified the relations between the 3 tests with Spearman correlations (rs) and the interrater reliability with quadratic weighted kappa (κQW).

RESULTS

About 80% of the children with UMN lesions perceived the tests easy to perform. The children with UMN lesions had significantly reduced somatosensory function compared with the neurotypically developing children. For the more affected leg, we found good relations between the TT and the TLTaction (rs=0.71; P<.001) and between the 2 TLTs (rs=0.66; P<.001), and a fair relation between the TT and the TLTperception (rs=0.31; P=.06). The inter-rater reliability analyses for the sum scores showed almost perfect agreement for the TT (κQW more affected leg 0.86; less affected leg 0.81), substantial agreement for TLTaction (κQW more affected leg 0.76; less affected leg 0.63), and almost perfect agreement for TLTperception (κQW more affected leg 0.88; less affected leg 0.74).

CONCLUSION

The 3 tests are feasible to assess lower limb somatosensory function in children with UMN lesions. Discriminative and convergent validity and reliability of the 3 tests were confirmed. Further studies should investigate responsiveness and association with motor function of these outcome measures.

Lower extremity proprioception and its association with activity and participation in children with unilateral spastic cerebral palsy

OBJECTIVE

This cross-sectional study aimed to assess lower extremity proprioception and investigate its relationship to activity and participation levels in children with unilateral spastic cerebral palsy (USCP).

METHODS

A total of 22 children with USCP between the ages of 5 and 16 years participated in this study. Lower extremity proprioception was evaluated with a protocol that consisted of verbal and location identification, unilateral and contralateral limb matching, and static and dynamic balance tests performed with the impaired and less impaired lower extremities under eyes-open and eyes-closed conditions. Furthermore, the Functional Independence Measure (WeeFIM) and Pediatric Outcomes Data Collection Instrument (PODCI) were used to evaluate the independence levels in daily living activities and participation levels.

RESULTS

Children demonstrated proprioceptive loss, as evidenced by an increase in matching errors under the eyes-closed condition compared to the eyes-open condition (p<0.05). Also, the impaired extremity had greater proprioceptive loss than the less impaired extremity (p<0.05). The 5-6-year age group experienced greater proprioceptive deficits than did the 7-11 and 12-16 age groups (p<0.05). Children's lower extremity proprioceptive deficit was moderately associated with their activity and participation levels (p<0.05).

CONCLUSIONS

Our findings suggest that treatment programs based on comprehensive assessments, including proprioception, may be more effective in these children.

Youth with Cerebral Palsy Display Abnormal Somatosensory Cortical Activity During a Haptic Exploration Task

There are numerous clinical reports that youth with cerebral palsy (CP) have proprioceptive, stereognosis and tactile discrimination deficits. The growing consensus is that the altered perceptions in this population are attributable to aberrant somatosensory cortical activity seen during stimulus processing. It has been inferred from these results that youth with CP likely do not adequately process ongoing sensory feedback during motor performance. However, this conjecture has not been tested. Herein, we address this knowledge gap using magnetoencephalographic (MEG) brain imaging by applying electrical stimulation to the median nerve of youth with CP (N = 15, Age = 15.8 ± 0.83 yrs, Males = 12, MACS levels I-III) and neurotypical (NT) controls (N = 18, Age = 14.1 ± 2.4 yrs, Males = 9) while at rest (i.e., passive) and during a haptic exploration task. The results illustrated that the somatosensory cortical activity was reduced in the group with CP compared to controls during the passive and haptic conditions. Furthermore, the strength of the somatosensory cortical responses during the passive condition were positively associated with the strength of somatosensory cortical responses during the haptic condition (r = 0.75, P = 0.004). This indicates that the aberrant somatosensory cortical responses seen in youth with CP during rest are a good predictor of the extent of somatosensory cortical dysfunction during the performance of motor actions. These data provide novel evidence that aberrations in somatosensory cortical function in youth with CP likely contribute to the difficulties in sensorimotor integration and the ability to effectively plan and execute motor actions.

Effects of stochastic resonance stimulation on manual function in children with hemiplegic cerebral palsy: A pilot clinical trial

OBJECTIVE

To investigate the effect of stochastic resonance stimulation (SRS) on manual abilities in children with hemiplegic cerebral palsy.

DESIGN

This pilot study is a randomized, sham-controlled, one-period, crossover trial.

SETTING

A neuroscience clinic with specialty therapy programs at an urban, university-based children's hospital.

PARTICIPANTS

Sixteen children ages 3 to 16 years who were diagnosed with hemiplegic cerebral palsy and had hand Manual Abilities Classification scale score of I to III with sufficient cognitive abilities to follow instructions.

INTERVENTIONS

Children donned wrist and arm bands that delivered SRS via embedded piezoelectric actuators in two randomly assigned conditions: sham (devices powered off) and subthreshold stimulation (SBT-SRS). Following the randomized protocol, a subset of participants also completed an open-label, above-threshold stimulation (AT-SRS) condition. Children carried out the same uni-manual and bimanual tasks during the randomized and open-label protocols; all data were collected in a single session.

MAIN OUTCOME MEASURE(S)

Box and Blocks (B&B) test, a uni-manual function test, and the Shriners Hospital Upper Extremity Evaluation (SHUEE). The SHUEE was video recorded and scored by two raters who were blinded to the experimental condition.

RESULTS

Thirteen children completed the B&B task and 14 children completed the SHUEE. Children in the SBT-SRS condition relative to sham condition moved an average of 1.8 more blocks in 1 minute (p = .08); scored an average of 3 points higher on SHUEE spontaneous functional analysis (p < .002); and scored an average of 2.7 points higher on SHUEE dynamic positional analysis (p = .20). In the open-label protocol, children in the AT-SRS condition relative to sham moved 3.9 more blocks than in the sham condition (n = 8, p < .001); scored an average of 4.5 points higher on SHUEE spontaneous functional analysis (n = 6, p = .08); and scored an average of 10.5 points higher on SHUEE dynamic positional analysis (n = 6, p = .01).

CONCLUSION(S)

In this pilot study, we found preliminary evidence that children with hemiplegic cerebral palsy demonstrated improved uni-manual abilities and increased function of the impaired hand on bimanual tasks when receiving a single session of SBT-SRS. Preliminary evidence also suggests that some children with hemiplegic cerebral palsy may improve more when receiving a single session of AT-SRS. Future research using larger, controlled studies should evaluate the optimal intensity, duration, and long-term effect of SRS for improving impaired manual abilities.

Robotic Ankle Training Improves Sensorimotor Functions in Children with Cerebral Palsy-A Pilot Study

Children with cerebral palsy (CP) have sensorimotor impairments including weakness, spasticity, reduced motor control and sensory deficits. Proprioceptive dysfunction compounds the decreased motor control and mobility. The aims of this paper were to (1) examine proprioceptive deficit of lower extremities of children with CP; (2) study improvement in proprioception and clinical impairments through robotic ankle training (RAT). Eight children with CP participated in a 6-week RAT with pre and post ankle proprioception, clinical, biomechanical assessment compared to the assessment of eight typically developing children (TDC). The children with CP participated in passive stretching (20 min/session) and active movement training (20 to 30 min/session) using an ankle rehabilitation robot (3 sessions/week over 6 weeks, total of 18 sessions). Proprioceptive acuity measured as the plantar and dorsi-flexion motion at which the children recognized the movement was 3.60 ± 2.28° in dorsiflexion and -3.72 ± 2.38° in plantar flexion for the CP group, inferior to that of the TDC group's 0.94 ± 0.43° in dorsiflexion (p = 0.027) and -0.86 ± 0.48° in plantar flexion (p = 0.012). After training, ankle motor and sensory functions were improved in children with CP, with the dorsiflexion strength increased from 3.61 ± 3.75 Nm to 7.48 ± 2.75 Nm (p = 0.018) and plantar flexion strength increased from -11.89 ± 7.04 Nm to -17.61 ± 6.81 Nm after training (p = 0.043). The dorsiflexion AROM increased from 5.58 ± 13.18° to 15.97 ± 11.21° (p = 0.028). The proprioceptive acuity showed a trend of decline to 3.08 ± 2.07° in dorsiflexion and to -2.59 ± 1.94° in plantar flexion (p > 0.05). The RAT is a promising intervention for children with CP to improve sensorimotor functions of the lower extremities. It provided an interactive and motivating training to engage children with CP in rehabilitation to improve clinical and sensorimotor performance.

The Experience of Dancing Among Individuals with Cerebral Palsy at an Inclusive Dance Group: A Qualitative Study

BACKGROUND

Art practices such as dance have the potential to support people with disabilities. It is possible that through dancing, bodies that may be regarded as "deficient" can be strengthened while enhancing their personal and cultural identities. It is also possible that inclusive group dance classes can enable the integration of people with disabilities in their social context. However, there is limited research on how these potential benefits are experienced by participants.

AIM

The purpose of this research is to describe the experience of people with cerebral palsy participating in regular dance classes.

METHODS

Semi-structured interviews were conducted with six participants with cerebral palsy who participated in an inclusive dance group that was informed by the creative approach of Laban. The interviews were transcribed, coded, and analyzed according to the thematic analysis of Braun and Clarke. The qualitative analysis software program ATLAS.TI version 8 was used for organizing and data analysis.

FINDINGS

The six interviews were analyzed and codified in four main categories: (1) the experience of cerebral palsy (the body does not help); (2) dance as a form of relationship with myself and the other; (3) the value of dancing and; (4) the dancer. These categories led to the creation of two subthemes: (a) the "unlocking" concerning the therapeutic effect of dance and (b) the "acquisition of a dancer's identity" by engaging with dance as an artform. An overall theme also emerged, "the passage from darkness to light."

CONCLUSIONS

Individuals with cerebral palsy, while taking the risk of being physically "exposed" in dance classes and dance group performances, managed to unlock their bodies, develop connections with others, acquire the identity of a dancer, and move from "darkness" to "light."

Enhanced nociceptive behavior and expansion of associated primary afferents in a rabbit model of cerebral palsy

Spastic cerebral palsy (CP) is a movement disorder marked by hypertonia and hyperreflexia; the most prevalent comorbidity is pain. Since spinal nociceptive afferents contribute to both the sensation of painful stimuli as well as reflex circuits involved in movement, we investigated the relationship between prenatal hypoxia-ischemia (HI) injury which can cause CP, and possible changes in spinal nociceptive circuitry. To do this, we examined nociceptive afferents and mechanical and thermal sensitivity of New Zealand White rabbit kits after prenatal HI or a sham surgical procedure. As described previously, a range of motor deficits similar to spastic CP was observed in kits born naturally after HI (40 min at ~70%-80% gestation). We found that HI caused an expansion of peptidergic afferents (marked by expression of calcitonin gene-related peptide) in both the superficial and deep dorsal horn at postnatal day (P)5. Non-peptidergic nociceptive afferent arborization (labeled by isolectin B4) was unaltered in HI kits, but overlap of the two populations (peptidergic and non-peptidergic nociceptors) was increased by HI. Density of glial fibrillary acidic protein was unchanged within spinal cord white matter regions important in nociceptive transmission at P5. We found that mechanical and thermal nociception was enhanced in HI kits even in the absence of motor deficits. These findings suggest that prenatal HI injury impacts spinal sensory pathways in addition to the more well-established disruptions to descending motor circuits. In conclusion, changes to spinal nociceptive circuitry could disrupt spinal reflexes and contribute to pain experienced by individuals with CP.

Individuals with cerebral palsy show altered responses to visual perturbations during walking

Individuals with cerebral palsy (CP) have deficits in processing of somatosensory and proprioceptive information. To compensate for these deficits, they tend to rely on vision over proprioception in single plane upper and lower limb movements and in standing. It is not known whether this also applies to walking, an activity where the threat to balance is higher. Through this study, we used visual perturbations to understand how individuals with and without CP integrate visual input for walking balance control. Additionally, we probed the balance mechanisms driving the responses to the visual perturbations. More specifically, we investigated differences in the use of ankle roll response i.e., the use of ankle inversion, and the foot placement response, i.e., stepping in the direction of perceived fall. Thirty-four participants (17 CP, 17 age-and sex-matched typically developing controls or TD) were recruited. Participants walked on a self-paced treadmill in a virtual reality environment. Intermittently, the virtual scene was rotated in the frontal plane to induce the sensation of a sideways fall. Our results showed that compared to their TD peers, the overall body sway in response to the visual perturbations was magnified and delayed in CP group, implying that they were more affected by changes in visual cues and relied more so on visual information for walking balance control. Also, the CP group showed a lack of ankle response, through a significantly reduced ankle inversion on the affected side compared to the TD group. The CP group showed a higher foot placement response compared to the TD group immediately following the visual perturbations. Thus, individuals with CP showed a dominant proximal foot placement strategy and diminished ankle roll response, suggestive of a reliance on proximal over distal control of walking balance in individuals with CP.

What are the relevant categories, modalities, and outcome measures for assessing lower limb somatosensory function in children with upper motor neuron lesions? A Delphi study

PURPOSE

Somatosensory function of the lower limbs is rarely assessed in children with upper motor neuron lesions despite its potential relevance for motor function. We explored consensus regarding somatosensory categories (exteroception, proprioception, interoception, and body awareness), modalities, and outcome measures relevant to lower limb motor function.

METHODS

Fifteen international experts with experience of somatosensory function assessment participated in this Delphi study. Surveys of four rounds, conducted online, included questions on the relevance of somatosensory categories and modalities for motor function and on the use of potential outcome measures in clinical practice.

RESULTS

The experts reached consensus on the relevance of six modalities of the categories exteroception, proprioception, and body awareness. Based on their feedback, we formulated three core criteria for somatosensory outcome measures, namely suitability for clinical practice, child-friendliness, and relevance for motor function. None of the nine available outcome measures fulfilled each criterion. The experts also highlighted the importance of using and interpreting the tests in relation to the child's activity and participation.

CONCLUSION

There was expert consensus on three categories and six modalities of somatosensory function relevant for lower limb motor function. However, existing outcome measures will need to be adapted for use in paediatric clinical practice. IMPLICATION FOR REHABILITATIONConsensus was established for the categories and modalities of somatosensory function relevant for lower limb motor function of children with UMN lesion.Outcome measures should cover tactile function, joint movement and joint position and dynamic position sense, and spatial and structural body representation.None of the nine existing outcome measures fulfilled the core criteria: feasibility for clinical practice, child-friendliness, and relevance to motor function.

Use of accelerometry to investigate standing and dynamic body balance in people with cerebral palsy: A systematic review

BACKGROUND

People with cerebral palsy (CP) often have difficulties related to maintaining body balance in their daily living activities. Accelerometers are low-cost wearable devices with potential use to objectively assess balance.

RESEARCH QUESTION

What are the main characteristics and findings from protocols used in research aiming to investigate standing or dynamic body balance stability through trunk accelerometry in people with CP?

METHOD

We searched in December 2021 seven databases, Pubmed, Embase, Cochrane, Science Direct, Scopus, PEDro, and Lilacs, with descriptors related to cerebral palsy, accelerometer, and balance.

RESULTS

Ten studies were included, with a total of 197 evaluated people with CP. These studies were classified as moderate or high methodological quality. We found convergence on the use of the sensor at the lumbar region (L3), with sampling frequency at 100 Hz. For balance assessment, 60 % of the reviewed studies used the 10-m walk test, while the other studies used different walking distances, or the quiet standing test. For data processing, the low-pass filter at 20 Hz has been used predominantly, and the most commonly used variable to evaluate balance stability has been root mean square of trunk acceleration. Children and adolescents with CP had higher acceleration values and greater gait complexity than typically developing children. Individuals with bilateral impairment had greater anteroposterior and mediolateral trunk accelerations than those with unilateral impairment. Trunk acceleration was shown to be sensitive to improvement in gait stability from interventions, and acceleration-based measures have been found to correlate with qualitative balance assessment tools.

SIGNIFICANCE

Trunk accelerometry in quiet posture and dynamic tasks was shown to be a valid and sensitive measurement to evaluate balance stability in children and adolescents with CP. It is a small, light, low-cost and easy-to-handle tool that is effective for measuring body balance on different tasks in this population.

Psychometric Properties of Lower Limb Somatosensory Function and Body Awareness Outcome Measures in Children with Upper Motor Neuron Lesions: A Systematic Review

PURPOSE

A systematic review of the psychometric properties and feasibility of outcome measures assessing lower limb somatosensory function and body awareness in children with upper motor neuron lesion.

METHODS

We followed the COnsensus-based Standards for the selection of health Measurement INstruments guidelines. Two raters independently judged the quality and risk of bias of each study. Data synthesis was performed, and aspects of feasibility were extracted.

RESULTS

Twelve studies investigated eleven somatosensory function measures quantifying four modalities and eight body awareness measures quantifying two modalities. The best evidence synthesis was very low to low for somatosensory function modalities and low for body awareness modalities. Few feasibility aspects were reported (e.g., the percentage or minimum age of participants able to perform the tests).

CONCLUSION

Current evidence on the psychometric characteristics of somatosensory function and body awareness outcome measures are relatively sparse. Further research on psychometric properties and practical application is needed.

Aberrant movement-related somatosensory cortical activity mediates the extent of the mobility impairments in persons with cerebral palsy

KEY POINTS

Persons with cerebral palsy (CP) have reduced somatosensory cortical responses at rest and during movement. The somatosensory cortical responses during movement mediate the relationship between the somatosensory cortical responses at rest and mobility. Persons with CP may have altered sensorimotor feedback that ultimately contributes to impaired mobility.

ABSTRACT

There are numerous clinical reports that persons with cerebral palsy (CP) have proprioceptive, stereognosis and tactile discrimination deficits. The current consensus is that these altered perceptions are attributable to aberrant somatosensory cortical activity. It has been inferred from these data that persons with CP do not adequately process ongoing sensory feedback during motor actions, which accentuates the extent of their mobility impairments. However, this hypothesis has yet to be directly tested. We used magnetoencephalographic (MEG) brain imaging to address this knowledge gap by quantifying the somatosensory dynamics evoked by applying electrical stimulation to the tibial nerve in 22 persons with CP and 25 neurotypical (NT) controls while at rest and during an ankle plantarflexion isometric force motor task. We also quantified the spatiotemporal gait biomechanics of participants outside the scanner. Consistent with the literature, our results confirmed that the strength of somatosensory cortical activity was weaker in the persons with CP compared to the NT controls. Our results also showed that the strength of the somatosensory cortical responses were significantly weaker during the isometric ankle force task than at rest. Most importantly, our results showed that the strength of somatosensory cortical activity during the ankle plantarflexion force production task mediated the relationship between somatosensory cortical activity at rest and both walking velocity and step length. These results suggest that youth with CP have aberrant somatosensory cortical activity during isometric force generation, which ultimately contributes to the extent of mobility impairments seen in this patient population. Abstract figure legend Magnetoencephalographic brain imaging was used to determine the effect of sensory feedback during movement on mobility in persons with cerebral palsy. Persons with cerebral palsy had reduced somatosensory cortical activity at rest and during movement compared with their neurotypical peers. Further, the somatosensory cortical activity during movement mediated the relationship between somatosensory cortical activity at rest and mobility. These results indicate that difficulties in sensorimotor integration may contribute to the mobility impairments seen in this patient population. This article is protected by copyright. All rights reserved.

GMFCS Level-Specific Differences in Kinematics and Joint Moments of the Involved Side in Unilateral Cerebral Palsy

A variety of gait pathologies is seen in cerebral palsy. Movement patterns between different levels of functional impairment may differ. The objective of this work was the evaluation of Gross Motor Function Classification System (GMFCS) level-specific movement disorders. A total of 89 individuals with unilateral cerebral palsy and no history of prior treatment were included and classified according to their functional impairment. GMFCS level-specific differences, kinematics and joint moments, exclusively of the involved side, were analyzed for all planes for all lower limb joints, including pelvic and trunk movements. GMFCS level I and level II individuals most relevantly showed equinus/reduced dorsiflexion moments, knee flexion/reduced knee extension moments, reduced hip extension moments with pronounced flexion, internal hip rotation and reduced hip abduction. Anterior pelvic tilt, obliquity and retraction were found. Individuals with GMFCS level II were characterized by an additional pronounced reduction in all extensor moments, pronounced rotational malalignment and reduced hip abduction. The most striking characteristics of GMFCS level II were excessive anterior pelvic/trunk tilt and excessive trunk obliquity. Pronounced reduction in extensor moments and excessive trunk lean are distinguishing features of GMFCS level II. These patients would benefit particularly from surgical treatment restoring pelvic symmetry and improving hip abductor leverage. Future studies exploring GMFCS level-specific compensation of the sound limb and GMFCS level-specific malalignment are of interest.

Power training alters somatosensory cortical activity of youth with cerebral palsy

OBJECTIVE

Our prior magnetoencephalographic (MEG) investigations demonstrate that persons with cerebral palsy (CP) have weaker somatosensory cortical activity than neurotypical (NT) controls, which is associated with reduced muscular strength and mobility. Power training can improve lower extremity isokinetic strength, muscular power, and walking performance of youth with CP. Potentially, these clinically relevant improvements are partially driven by changes in somatosensory processing. The objective of this investigation was to determine if power training has complementary changes in muscular function and somatosensory cortical activity in youth with CP.

METHODS

A cohort of youth with CP (N = 11; age = 15.90 ± 1.1 years) and NT controls (N = 10; Age = 15.93 ± 2.48 years) participated in this investigation. Youth with CP underwent 24 power training sessions. Pre-post bilateral leg press 1-repetition maximum (1RM), peak power production, 10-m walking speed, and distance walked 1-min were used as outcome measures. MEG neuroimaging assessed the changes in somatosensory cortical activity while at rest. NT controls only underwent a baseline MEG assessment.

RESULTS

Youth with CP had a 56% increase in 1RM (p < 0.001), a 33% increase in peak power production (p = 0.019), and a 4% improvement in 1-min walk (p = 0.029). Notably, there was a 46% increase in somatosensory cortical activity (p = 0.02).

INTERPRETATION

These results are the first to show that power training is associated with improvements in muscular function, walking performance, and the resting somatosensory cortical activity in individuals with CP. This treatment approach might be advantageous due to the potential to promote cortical and muscular plasticity, which appear to have carryover effects for improved walking performance.

Interrelationships of Touch and Proprioception with Motor Impairments in Individuals with Cerebral Palsy: A Systematic Review

Considering that somatosensory impairments may impact motor performance in individuals with cerebral palsy (CP), a better understanding of these relations is relevant to planning interventions. To synthesize research evidence to date on the interrelationships between the somatosensory functions of touch and proprioception with motor functions in persons with CP, we systematically searched Embase, CINAHL, PsycINFO, and Medline databases for studies relating these variables that were published in English from the inception of these databases to November 2020. We targeted the following content categories in our literature search: (a) cerebral palsy; (b) sensory functions; (c) tactile functions; (d) proprioception functions; and (e) motor functions. The selection, data extraction, and methodological quality assessment of these studies were performed in duplicate. We retrieved and analyzed information regarding the studies' methodological approaches and synthesized results. The 11 studies that met our inclusion criteria showed that, in individuals with CP, impairments in tactile discrimination, proprioception, and stereognosis are related to motor functions in terms of overall manual ability, grip strength, postural control and locomotion. Thus, clinical practitioners should attend to somatosensory aspects of motor impairment in individuals with CP. More research is needed to clarify the direction of these associations.

Somatosensory deficits and neural correlates in cerebral palsy: a scoping review

AIM

To synthetize studies assessing somatosensory deficits and alterations in cerebral responses evoked by somatosensory stimulation in individuals with cerebral palsy (CP) compared to typically developing individuals.

METHOD

A scoping review of the literature was performed in the MEDLINE, Embase, PsycInfo, CINAHL, Evidence-Based Medicine Reviews, and Web of Science databases (last search carried out on 6th and 7th August 2020) with a combination of keywords related to CP and somatosensory functions. Somatosensory deficits were measured with clinical tests and alterations in cerebral responses were measured with functional magnetic resonance imaging, electroencephalography, and magnetoencephalography.

RESULTS

Forty-eight articles were included. Overall, 1463 participants with CP (mean [SD] age 13y 1mo [4y 11mo], range 1-55y; 416 males, 319 females, sex not identified for the remaining participants) and 1478 controls (mean [SD] age 13y 1mo [5y 8mo], range 1-42y; 362 males, 334 females, sex not identified for the remaining participants) were included in the scoping review. For tactile function, most studies reported registration (8 out of 13) or perception (21 out of 21) deficits in participants with CP. For proprioception, most studies also reported registration (6 out of 8) or perception (10 out of 15) deficits. Pain function has not been studied as much, but most studies reported registration (2 out of 3) or perception (3 out of 3) alterations. Neuroimaging findings (18 studies) showed alterations in the somatotopy, morphology, latency, or amplitude of cortical responses evoked by somatosensory stimuli.

INTERPRETATION

Despite the heterogeneity in the methods employed, most studies reported somatosensory deficits. The focus has been mainly on tactile and proprioceptive function, whereas pain has received little attention. Future research should rigorously define the methods employed and include a sample that is more representative of the population with CP. What this paper adds Most of the papers reviewed found tactile registration and perception deficits in the upper limbs. Proprioceptive deficits were generally observed in cerebral palsy but results were heterogeneous. Pain has received little attention compared to tactile and proprioceptive functions. Neuroimaging studies supported behavioral observations. Alterations were observed for both the most and least affected limb.

Active Joint Position Sense in Children With Unilateral Cerebral Palsy

Objective

The aim of the study was to examine the differences in joint position sense at the elbow joint between 15 children with unilateral cerebral palsy (CP) and 15 typically developing (TD) controls without neurological or other health deficits.

Methodology

Joint position sense, a major proprioceptive component, was evaluated actively using a Kin Com 125 AP isokinetic dynamometer (Chattanooga Group, Chattanooga, TN).

Results

A significant interaction was found (p<0.05) between disability and side, with respect to the active reproduction movement scores. Post-hoc independent t-tests, with Bonferroni adjustments, revealed significant differences for the dominant (t=-3.63, p=0.001) and non-dominant sides respectively (t=-6.19, p=0.000). Repeated measures t-test revealed wider errors with the non-dominant (affected side) in the active reproduction test, compared to the dominant (nonaffected) side for the CP group of children (t=-4.73, p=0.000). A positive correlation was evident between the level of spasticity and joint position sense (Rho=0.71, p=0.003).

Conclusions

Based on our findings, joint position sense is impaired at the elbow joint in children with spastic hemiplegia. The proprioceptive deficit is present at both the affected and unaffected sides and is related to the level of spasticity.

Effect of Dance on Balance, Mobility, and Activities of Daily Living in Adults With Cerebral Palsy: A Pilot Study

The age-related decline in motor function with respect to balance and mobility may hamper the activities of daily living, quality of life, and social participation. Despite the importance of managing secondary conditions leading to premature aging, the literature regarding appropriate physical activity for adults with cerebral palsy (CP) is still scarce. Dance forms have emerged as an effective physical activity that improves balance and mobility in individuals with neurological conditions and boosts social engagement. However, its effect on adults with CP has yet to be examined. This pilot study aimed to examine the long-term effect of dance on improving balance and mobility in adults with CP. This single-cohort study included 10 adults with CP. They attended two 90-min-long creative dance sessions per week for 12 weeks. The outcomes measured effects on balance, mobility, balance confidence, and level of functional independence. These measurements were obtained at pre-intervention, post-intervention, and the 3-month follow-up. Outcome data of pre- to post-intervention and pre-intervention to 3-month follow-up were analyzed and compared. Statistically significant differences were found in the pre- and post-intervention displacement of the center of pressure (CoP) in the eyes-opened (EO) condition, timed up and go test (TUG), and Berg Balance Scale (BBS), Dynamic Gait Index (DGI), and Korean-Activity of Balance Confidence (K-ABC) scores. Significant improvements were also observed for the CoP-EO, BBS, TUG, DGI, and K-ABC between the pre-intervention and 3-month follow-up assessments. However, there were no significant differences in the CoP in the eyes-closed condition and Korean modified Barthel Index score. Participants expressed enjoyment without any pain or fatigue. Our findings suggest that dance may have a positive impact in improving balance and mobility and may consequently contribute to healthy aging in adults with CP.

Lower Limb Sensorimotor Training (LoSenseT) for Children and Adolescents with Cerebral Palsy: A Brief Report of a Feasibility Randomized Protocol

Motor disorders in cerebral palsy (CP) are often accompanied by disturbances of sensation and impaired somatosensory functions have been reported in individuals with CP. To test the feasibility of a sensorimotor training protocol for lower limbs in children and adolescents with unilateral and bilateral CP, and to analyze the preliminary effects of this training on sensory and motor variables. This is a single-blind, prospective phase I feasibility randomized protocol. A total of twenty participants with uni or bilateral cerebral palsy, GMFCS level I-III, ages 5 to 20 years will be recruited. The LoSenseT protocol is composed of tactile and proprioceptive activities in a child-friendly format. An original qualitative feedback questionnaire was developed to assess the protocol feasibility. Additionally, proprioception, tactile discrimination, postural stability, and gait parameters will be assessed. The LoSenseT protocol can support the implementation of interventions targeting lower limbs somatosensory impairments in individuals with CP.

An investigation of the effect of the lower extremity sensation on gait in children with cerebral palsy

BACKGROUND

Sensory disorders frequently accompany the motor disorders in children with cerebral palsy (CP).

RESEARCH QUESTION

Do children with CP have sensory disturbances in their lower extremities? If there are sensory impairments, do these impairments affect gait?

METHODS

In total, 45 children (18 females, 27 males) in an age range between 5 and 18 years were included in the study: 15 typically developing children, 15 unilaterally affected children with cerebral palsy, and 15 bilaterally affected children with cerebral palsy. They could walk independently at the levels of I or II according to the gross motor function classification. After the demographic data of the children were recorded, their tactile sense, vibration sense, two-point discrimination, and proprioception were evaluated, and the Edinburgh Visual Gait Score (EVGS) was used for gait assessment.

RESULTS

Failures were discovered in lower extremity tactile (p = 0.001), two-point discrimination (p = 0.001), and proprioceptive senses of the children with CP (p = 0.001), and the loss of tactile sense was found to be related to gait disorders (p = 0.02, r = 0.41).

SIGNIFICANCE

There were deficiencies in the lower extremity senses, and deficiencies in the tactile sense negatively affected gait. Performing sensory assessments, which are considered to be fundamental for gait training in the rehabilitation of children with CP, and providing support for the lacking parameters in the intervention programs may create positive effects on gait.

Dynamic and static stability in para-athletes with cerebral palsy considering their impairment profile

BACKGROUND

Balance impairment is a common feature in people with cerebral palsy (CP), affecting the performance of daily-life and physical activities.

OBJECTIVES

To (1) explore the absolute and relative intrasession reliability of two balance tests to assess dynamic and static balance in ambulant para-athletes with CP; (2) explore the relationships between the two balance tests to determine potential application in sport classification; (3) assess the differences between CP profiles (ie, spastic diplegia, athetosis/ataxia, and spastic hemiplegia) in comparison to those with a minimum impairment; and (4) compare the outcomes of the static and dynamic balance of ambulant para-athletes with CP regarding controls.

METHODS

A group of 129 male well-trained para-footballers with CP, classified as Level I according to the Gross Motor Function Classification System, participated in the present study. Static balance was assessed using the One-Leg Stance test, performed bilaterally on a force platform, and the dynamic balance was assessed in two conditions of the Tandem Walk test (TW): walking heel-toe contact over a 5 -m straight line and performing 10 steps.

RESULTS

Moderate-to-excellent intrasession reliability (intraclass correlation coefficient = 0.60-0.98) was obtained for all the measurements and groups. However, only small to moderate correlations were found between the dynamic and the static measurements of balance for the CP group when performing the One-Leg Stance test with the unimpaired or dominant leg (0.23 < r < 0.30; P < .01). The TW performed over 10 steps revealed more sensitivity to discriminate between CP profiles. Those para-athletes with ataxia/athetosis performed worse in all the tests whereas all CP profiles performed worse than the control group (P < .01).

CONCLUSIONS

Balance performance and postural control are constrained to a higher extent in those with impaired voluntary control due to ataxia or with involuntary contractions of the muscles due to athetosis.

Foot and ankle somatosensory deficits in children with cerebral palsy: A pilot study

PURPOSE

To investigate foot and ankle somatosensory function in children with cerebral palsy (CP).

METHODS

Ten children with spastic diplegia (age 15 ± 5 y; GMFCS I-III) and 11 typically developing (TD) peers (age 15 ± 10 y) participated in the study. Light touch pressure and two-point discrimination were assessed on the plantar side of the foot by using a monofilament kit and an aesthesiometer, respectively. The duration of vibration sensation at the first metatarsal head and medial malleolus was tested by a 128 Hz tuning fork. Joint position sense and kinesthesia in the ankle joint were also assessed.

RESULTS

Children with CP demonstrated significantly higher light touch pressure and two-point discrimination thresholds compared to their TD peers. Individuals with CP perceived the vibration stimulus for a longer period compared to the TD participants. Finally, the CP group demonstrated significant impairments in joint position sense but not in kinesthesia of the ankle joints.

CONCLUSIONS

These findings suggest that children with CP have foot and ankle tactile and proprioceptive deficits. Assessment of lower extremity somatosensory function should be included in clinical practice as it can guide clinicians in designing more effective treatment protocols to improve functional performance in CP.

Toe walking in children with cerebral palsy: a possible functional role for the plantar flexors

Equinus and toe walking are common locomotor disorders in children with cerebral palsy (CP) walking barefoot or with normal shoes. We hypothesized that, regardless of the type of footwear, the plantar flexors do not cause early equinus upon initial foot contact but decelerate ankle dorsiflexion during weight acceptance (WA). This latter action promoted by early flat-foot contact is hypothesized to be functional. Hence, we performed an instrumented gait analysis of 12 children with CP (Gross Motor Function Classification System class: I or II; mean age: 7.2 yr) and 11 age-matched typically developing children. The participants walked either barefoot, with unmodified footwear (4° positive-heel shoes), or with 10° negative-heel shoes (NHSs). In both groups, wearing NHSs was associated with greater ankle dorsiflexion upon initial foot contact, and greater tibialis anterior activity (but no difference in soleus activity) during the swing phase. However, the footwear condition did not influence the direction and amplitude of the first ankle movement during WA and the associated peak negative ankle power. Regardless of the footwear condition, the CP group displayed 1) early flattening of the foot and ample dorsiflexion (decelerated by the plantar flexors) during WA and 2) low tibialis anterior and soleus activities during the second half of the swing phase (contributing to passive equinus upon foot strike). In children with CP, the early action of plantar flexors (which typically decelerate the forward progression of the center of mass) may be a compensatory mechanism that contributes to the WA's role in controlling balance during gait.NEW & NOTEWORTHY Adaptation to walking in negative-heel shoes was similar in typically developing children and children with cerebral palsy: it featured ankle dorsiflexion upon initial contact, even though (in the latter group) the soleus was always spastic in a clinical examination. Hence, in children with cerebral palsy, the early deceleration of ankle dorsiflexion by the plantar flexors (promoted by early flattening of the foot, and regardless of the type of footwear) may have a functional role.