Deficits in upper limb position sense of children with Spastic Hemiparetic Cerebral Palsy are distance-dependent

This study examined the arm position sense in children with Spastic Hemiparetic Cerebral Palsy (SHCP) and typically developing children (TD) by means of a contralateral matching task. This task required participants to match the position of one arm with the position of the other arm for different target distances and from different starting positions. Results showed that children with SHCP exhibited with both arms larger matching errors than the TD group, but only when the distance between the arms at the start of the movement was large. In addition, the difference in errors between the less-impaired and the impaired limb changed as a function of the distance in the SHCP group whereas no interlimb differences were found in the TD group. Finally, spasticity and restricted range of motion in children with SHCP were not related to the proportion of undershoot and size of absolute error. This suggests that SHCP could be associated with sensory problems in conjunction with their motor problems. In conclusion, the current study showed that accurate matching of the arms is greatly impaired in SHCP when compared to TD children, irrespective of which arm is used. Moreover, this deficit is particularly present for large movement amplitudes.     

The effect of intensive bimanual training on coordination of the hands in children with congenital hemiplegia

Recent studies have suggested efficacy of intensive bimanual training in improving the quality and quantity of affected hand use in children with hemiplegia. However, it is not known whether such training affects the coordination of the two hands. In the present study, 20 children with congenital hemiplegia (age 4-10 years; MACS levels I-II) were randomly assigned to either an intensive bimanual training (Hand-Arm Bimanual Intensive Therapy: HABIT) group, or a control group consisting of equally intensive unimanual treatment (Constraint-Induced Movement Therapy, CIMT) for 6 h per day for 15 days (90 h). To assess their bimanual coordination, children were asked to open a drawer with one hand and manipulate its contents with the other hand. 3-D movement kinematics were recorded and subsequently analyzed by a blind evaluator. The role of the two hands was varied. Following treatment, superior improvement in bimanual coordination was found for the bimanual training group as indicated by greater movement overlap (the percentage of time with both hands engaged in the task p = 0.047) and better goal synchronization (reduced time differences between the two hands completing the task goals, p = 0.005). The results suggest that bimanual training improves the spatial-temporal control of the two hands, and are in agreement with the principle of practice specificity.     

Capturing neuroplastic changes after bimanual intensive rehabilitation in children with unilateral spastic cerebral palsy: A combined DTI,TMS and fMRI pilot study

Intensive rehabilitation interventions have been shown to be efficacious in improving upper extremity function in children with unilateral spastic cerebral palsy (USCP). These interventions are based on motor learning principles and engage children in skillful movements. Improvements in upper extremity function are believed to be associated with neuroplastic changes. However, these neuroplastic changes have not been well-described in children with cerebral palsy, likely due to challenges in defining and implementing the optimal tools and tests in children. Here we documented the implementation of three different neurological assessments (diffusion tensor imaging-DTI, transcranial magnetic stimulation-TMS and functional magnetic resonance imaging-fMRI) before and after a bimanual intensive treatment (HABIT-ILE) in two children with USCP presenting differential corticospinal developmental reorganization (ipsilateral and contralateral). The aim of the study was to capture neurophysiological changes and to document the complementary relationship between these measures, the potential measurable changes and the feasibility of applying these techniques in children with USCP.Independent of cortical reorganization, both children showed increases in activation and size of the motor areas controlling the affected hand, quantified with different techniques. In addition, fMRI provided additional unexpected changes in the reward circuit while using the affected hand.     

Motor learning of a bimanual task in children with unilateral cerebral palsy

Children with unilateral cerebral palsy (CP) have been shown to improve their motor performance with sufficient practice. However, little is known about how they learn goal-oriented tasks. In the current study, 21 children with unilateral CP (age 4–10 years old) and 21 age-matched typically developed children (TDC) practiced a simple bimanual speed stack task over 15 days of practice. Both groups demonstrated their ability to learn the current bimanual task, but their rate of improvement and learning pattern differed. Children with unilateral CP overall were slower and improved ~10% less than TDC. Most of the improvement occurred during the first 3 days for the TDC, whereas performance did not plateau until 6–8 days for the children with unilateral CP. This initial slower learning rate for children with unilateral CP was also confirmed by better fitting of the curve to an exponential function than the power law function (p < 0.05). Therefore, when working with children with unilateral CP, sufficient practice is important (two to three times more than for TDC), and delayed improvement is expected.     

Travail bimanuel versus travail unimanuel chez les enfants (0–18 ans) atteints de paralysie cérébrale spastique unilatérale

ObjectiveThe objective of this work is to research, from the literature, whether there is an interest of bimanual training compared unimanual training in improving the upper limb function in children with unilateral spastic cerebral palsy.MethodPubMed and Science Direct databases have been consulted to find articles since 2000 discussing the intensive bimanual therapy and the constraint induced movement therapy in these patients.ResultsFive articles were selected between 2011 and 2017, including two systematic reviews, a multisite clinical trial, a secondary analysis of a randomized controlled trial and a literature review.ConclusionThe literature shows a strong but nonspecific recommendation for one or the other approach in improving the hemiparetic upper limb function. However, constraint induced movement therapy appears to be more effective in improving grip in the injured hand and there is a weak recommendation for intensive bimanual therapy in improving coordination between limbs and for bimanual activities. The conclusion would be to approach these two therapies by making them complementary and to link unimanual training and bimanual training in the rehabilitation of children with unilateral spastic cerebral palsy.     

Bimanual force coordination in children with spastic unilateral cerebral palsy

In this study bimanual grip-force coordination was quantified using a novel “Gripper” system that records grip forces produced while holding a lower and upper unit, in combination with the lift force necessary to separate these units. Children with unilateral cerebral palsy (CP) (aged 5-14 years, n = 12) were compared to age matched typically developing (TD) children (n = 23). Compared to TD, the CP-group is much slower and takes 50% more time to generate grip and lift forces with more fixating force before lifting the upper unit. In addition the coordination between forces in both hands is reduced. The CP-group increases the lift force in the upper hand 2.5 times more than the holding force when pulling the two units apart, while this is only 1.5 times in TD. Moreover, the correlation between forces generated in both hands in the CP-group is lower. The lack of fine tuning of the forces, measured by the linearity error is increased, especially when the magnet load keeping the unit together is low. The results indicate an impaired pull-hold synergy between upper and lower hand and the lift force. Bimanual tasks evaluating bimanual grip and lift forces in children with CP and can give us new insights in the underlying force control mechanisms of the spastic hand.     

Visual feedback of the non-moving limb improves active joint-position sense of the impaired limb in Spastic Hemiparetic Cerebral Palsy

This study examined the active joint-position sense in children with Spastic Hemiparetic Cerebral Palsy (SHCP) and the effect of static visual feedback and static mirror visual feedback, of the non-moving limb, on the joint-position sense. Participants were asked to match the position of one upper limb with that of the contralateral limb. The task was performed in three visual conditions: without visual feedback (no vision); with visual feedback of the non-moving limb (screen); and with visual feedback of the non-moving limb and its mirror reflection (mirror). In addition to the proprioceptive measure, a functional test [Quality of Upper Extremity Skills Test (QUEST)] was performed and the amount of spasticity was determined in order to examine their relation with proprioceptive ability. The accuracy of matching was significantly influenced by the distance that had to be covered by the matching limb; a larger distance resulted in a lower matching accuracy. Moreover it was demonstrated that static (mirror) visual feedback improved the matching accuracy. A clear relation between functionality, as measured by the QUEST, and active joint-position sense was not found. This might be explained by the availability of visual information during the performance of the QUEST. It is concluded that static visual feedback improves matching accuracy in children with SHCP and that the initial distance between the limbs is an influential factor which has to be taken into account when measuring joint-position sense.     

Children with spastic hemiplegia are equally able as controls in maintaining a precise percentage of maximum force without visually monitoring their performance

In this study the hypothesis was tested that children with spastic hemiplegia rely more on externally guided visual feedback when trying to keep force constant with their affected hand (AH) as compared to their non-affected hand (NAH) and as compared to controls. An isometric force task in which a cursor had to be moved to a visually specified target that disappeared half way the task, was performed by 19 children with cerebral palsy (CP), spastic hemiplegia, aged between 5 and 16 years and an aged matched control group. It was found that the absolute deterioration of performance after withdrawal of target visualization did differ between AH, NAH and controls. The absolute error was smaller and the variability was larger in the hemiplegic hand. However, the normalized force error and co-efficient of variation increased similarly between groups. Furthermore, power spectrum density analysis of the force signal showed that both hands in both groups had a similar loss in the energy in the 2-3 Hz range when target visualization was removed. These results suggest that CP children are equally able to produce stable force without visually monitoring their performance than children without CP, provided they are allowed to operate within their own force range.     

Evolution of upper limb function in children with congenital hemiplegia

Hand function deficits in hemiplegic children are a major cause of disability, but there is a lack of appropriate instruments for evaluating the evolution of this deficit over time and for verifying the efficacy of its treatment. We evaluated changes in upper limb function in relation to age and the course of individual rehabilitation treatment in 20 children (13 males and 7 females) who were first seen within the first four years of life and subsequently followed until a mean age of 13 years and four months (range, 11–17 years) in accordance with a diagnostic/rehabilitation program initiated in our division in 1989. All of the children were treated by us; those whose paretic upper limb functioned well were not treated in any specific or directed manner. The protocol involved a qualitative evaluation of the spontaneous use of the paretic hand and a quantitative evaluation of grip. Analysis of the results revealed an age-related global improvement over time, occurring within the first five years of life and more pronounced in terms of grip than spontaneous use. This finding makes our protocol more specific than those currently used because it more reliably establishes the real capacity to use the paretic hand in different situations of everyday life. The most important changes concerned the children with more impaired functional capacity, whereas the children who presented with good functional skill retained this capacity over time, thus confirming the initial decision not to treat them. Received: 5 July 2001 / Accepted in revised form: 5 October 2001     

Trunk control and functionality in children with spastic cerebral palsy

ABSTRACT

Purpose: To investigate the relationship between trunk control in sitting and functionality in children with spastic cerebral palsy (CP).

Methods: Fifty-eight children with spastic CP were included in the study. Functional abilities were evaluated with the Gross Motor Function Measurement-88 (GMFM-88) and the Pediatric Evaluation of Disability Inventory Functional Skills domain (PEDI-FSD). Trunk control in sitting was tested with the Trunk Control Measurement Scale (TCMS) and the Trunk Impairment Scale (TIS). The scores of the TCMS and TIS were compared with GMFM-88 and PEDI-FSD with Spearman correlation analysis.

Results: The total score of GMFM-88 was signi?cantly correlated with the total score of TCMS (r_ho = 0.90, p < 0.01) and TIS (r_ho = 0.78, p < 0.01). The total score of PEDI-FSD was also signi?cantly correlated with the total score of TCMS (r_ho = 0.76, p < 0.01) and TIS (r_ho = 0.72, p < 0.01).

Conclusions: The evaluation of trunk control can provide valuable information for functional abilities of children with spastic CP.     

Neurophysiologic and neuroimaging studies of brain plasticity in children with spastic cerebral palsy

Patients with cerebral palsy (CP) may have some problems other than this motor impairment: mental retardation, epilepsy and sensory disturbance. Healthy children and children with CP have an enhanced capacity for learning and memory compared to adults. There are few tools for brain plasticity investigations. The utility of the neurophysiologic and MRI techniques in the determination of brain reorganization and repair in patients with cerebral palsy is described. The authors discuss their results of quantitative EEG and spectroscopy MRI studies in children with CP. Quantitative EEG and spectroscopy MRI can be useful tools in the determination of these processes in children with CP.     

Sit-to-stand movement in children with cerebral palsy: a critical review

Sit-to-stand (STS) movement is widely performed in daily life and an important pre requisite for acquisition of functional abilities. However, STS is a biomechanical demanding task which requires high levels of neuromuscular coordination, muscle strength and postural control. As children with cerebral palsy (CP) exhibit a series of impairments in body structures and functions, STS movement performance could be impaired in this population. Thus, this article aimed to review studies that had described how STS movement is performed by children with CP, the factors that influence it and the methodological procedures adopted in it analyses. A search was performed by one reviewer in relevant databases. In all, 12 articles were identified and 9 were selected for the present review. It was detected a large variation in sample characteristics and methodological issues among studies. In fact, standardization of the method applied to STS movement analysis is not fully established. With regard to STS performance, children with CP exhibited variations among them and also when compared with their typical peers. Moreover extrinsic factors appear to influence STS movement performance in these children and its manipulation could be incorporated into rehabilitation protocols. Moreover, the relationship between STS movement and functionality in reviewed articles was not reported. Therefore the review allowed to observe that STS movement has been under-explored in children with CP, with a lack of standardized methodologies and a not well established relationship between this movement and functionality. Thus, further studies about STS movement in CP are necessary.     

Meta-analysis of the effect of strengthening interventions in individuals with cerebral palsy

This study aimed to investigate the evidence that strengthening interventions can improve muscle strength and activity in individuals with cerebral palsy. The search focused on studies that employed strength training for children with cerebral palsy for which six electronic databases were used to extract literature published from 2001 to 2012. The key terms used in these searches were combined strength training, strengthening, weight training, weight lifting, resistance, and cerebral palsy. The quality of each study was assessed using the PEDro (Physiotherapy Evidence Database) scale. Thirteen randomized controlled trial studies were selected and divided into categories according to program type, mode, and outcome measures. The overall effect sizes of each study and types of strengthening were large. Strengthening exercise improved muscle strength to a greater degree, when practiced 3 times per week in 40–50 min sessions than in other categories of session length, and greater improvement was observed in younger children than in older. The effect size of the activities and variables related to gait, except for gait endurance, were medium to large. The effect size of individual muscles was large, but the effect sizes for ankle plantar flexor, hip abductor/adductor, and extensor were insignificant. Strengthening interventions are useful for increasing muscle strength in individuals with cerebral palsy, specifically in youth and children, and optimal exercise consisted of 40- to 50-min sessions performed 3 times per week. Although strengthening interventions may improve activities, including gait, more studies that are rigorous are needed to determine the contributions to gross motor function.     

Epilepsy in patients with spastic cerebral palsy: correlation with MRI findings at 5 years of age

The aim of this study was to determine the relationship between epilepsy and the magnetic resonance imaging (MRI) findings in patients with spastic cerebral palsy at five years of age. We studied 14 patients with congenital anomaly and 116 with perinatal injury. The patients with perinatal injury were subdivided into two groups; those with preterm type injury alone (group P), and those with term type injury with or without preterm type injury (group T). Epilepsy was found in 37 of the 130 patients. The initial type of seizures was partial in 12 patients, infantile spasms in 20 and generalized in five. Kaplan–Meier analysis demonstrated that patients with congenital anomaly had a higher incidence and an earlier onset of epilepsy than those with perinatal injury. Of the patients with perinatal injury, group T patients showed a higher incidence and a later onset of epilepsy than group P patients.     

Muscle contractile properties in children with spastic diplegia

The aim of the present study was to evaluate contractile properties of the plantarflexor muscles in children with spastic diplegia (SD) in comparison of age-matched healthy children. Twelve prepubertal children with SD aged 11-12 years (6 girls and 6 boys) and 12 age- and gender-matched healthy control children (6 girls and 6 boys) participated in this study. Subjects were seated in a custom-made dynamometric chair with the dominant leg flexed 90 degrees at the knee and ankle joints. Twitch contraction characteristics of the plantarflexor muscles were measured by supramaximal electrical stimulation of posterior tibial nerve in popliteal fossa using square-wave pulses of 1 ms duration at rest and after a brief (5 s) isometric maximal voluntary contraction (MVC), i.e., during post-activation potentiation (PAP). Children with SD had significantly lower (p<0.05) MVC force, twitch contraction peak force (PF), PAP of twitch force, and twitch maximal rates of force development and relaxation compared to control group. Twitch contraction PF:MVC force ratio was higher (p<0.05) in children with SD than in the control group. However, no significant differences in twitch contraction and half-relaxation times were observed between the measured groups. It was concluded that prepubertal children with SD in comparison of normal children are characterized by markedly reduced isometric voluntary and electrically evoked twitch contraction maximal force, capacity for twitch PAP, and rates of twitch force production and relaxation of the plantarflexor muscles. The time-course characteristics of isometric twitch contraction were similar in children with SD and normal children.     

脑性瘫痪儿童腰骶脊髓背根的电生理研究

目的：探讨脑性瘫痪儿童腰骶脊髓Ｉα背根兴奋性与肌肉痉挛的关系。方法：在１２例患儿选择性脊神经背根切断术中，直接电刺激Ｌ２～Ｓ１节段的４０８条Ｉα背根小束，观察其兴奋阈值和传导潜伏期等值的改变，并比较５例患儿１３条背根的术后电生理变化。结果：各节段脊小束兴奋阈高低不均，但传导潜伏期值在正常范围。术后残余Ｉα背根的兴奋阈明显提高（Ｐ＜０．０５），其它电生理值无改变（Ｐ＞０．０５）。结论：脑瘫患儿脊髓ｒ－环路的外周传入不均衡；手术通过减少Ｉα背根传入纤维的异常兴奋性而缓解肌痉挛     

Effects of the Inerventions method on gross motor function in children with spastic cerebral palsy

Aim of the study

To investigate the effect of the Inerventions method on gross motor function in children with spastic cerebral palsy (CP).

The development of anticipatory action planning in children with unilateral cerebral palsy

Background Previous studies suggest that compromised bimanual performance experienced by children with unilateral cerebral palsy (CP) is not only due to difficulties in action execution but may also be a result of impaired anticipatory action planning.Aims The effect of age and side of hemiplegia were examined and the relationship between anticipatory action planning, unimanual capacity and bimanual performance was explored.Methods and procedures Using a multi-centre, prospective, cross-sectional observational design, anticipatory action planning was analyzed in 104 children with unilateral cerebral palsy, aged 6–12 years, using the sword task.Outcomes and results Anticipatory action planning did not improve with age in children with unilateral CP, aged between 6–12 years. No differences were found between children with left or right hemiplegia. Finally, anticipatory action planning was not related to unimanual capacity or bimanual performance.Conclusion and implications This study demonstrates anticipatory action planning, measured using the sword task, does not improve with age in children with unilateral CP and is not related to bimanual performance or laterality. Future studies of anticipatory action planning in children with unilateral CP should consider using measures that require effective anticipatory action planning for successful task completion rather than end state comfort.     

CBTX-A治疗痉挛性脑性瘫痪临床研究

目的研究国产A型肉毒毒素(CBTX-A)局部注射治疗小儿痉挛性脑瘫的疗效,副作用。方法选择1000例痉挛性小儿脑性瘫痪患儿,以每组肌肉2.5U/kg用量进行痉挛肌肉局部注射。应用PRS(physicianratingscale)法比较治疗前及治疗后1个月时运动姿势的改善情况。观察治疗中及治疗后的副作用。结果绝大多数患儿治疗后其PRS疗效指标均有不同程度的改善,其有效率为99.7%,P<0.01。除5例(0.5%)注射后短期内患肢无力外,其他均无明显副作用发生。结论CBTX-A局部注射是一种安全、有效、方便灵活、较少副作用的治疗小儿痉挛性脑瘫的好方法。     

Gaze behaviour during interception in children with spastic unilateral cerebral palsy

Anticipatory gaze behaviour during interceptive movements was investigated in children with Spastic Unilateral Cerebral Palsy (SUCP), and related to the side of the intracerebral lesion. Five children with lesions of the right hemisphere (RHL) and five children with lesions of the left hemisphere (LHL) had to walk towards and intercept a ball that moved perpendicular to the walking path. Interception accuracy and gaze patterns were measured in a no-occlusion and occlusion condition, in which the ball was occluded from view for half of its trajectory. There was a clear support for a relationship between gaze behaviour and success in interception performance, with some evidence for the presence of anticipatory gaze behaviour. There were also differences in gaze behaviour between children with RHL and children with LHL that might be related to planning, but these did not affect interception accuracy. It is concluded that gaze behaviour during interceptive movements is anticipatory, and at least partly dependent on the lesional side.