Best responders after intensive upper-limb training for children with unilateral cerebral palsy

Sakzewski L, Ziviani J, Boyd RN. Best responders after intensive upper-limb training for children with unilateral cerebral palsy.

Objective

To delineate characteristics of best responders in a randomized trial comparing constraint-induced movement therapy (CIMT) to bimanual training for children with unilateral cerebral palsy.

Design

Secondary analysis of a single-blind matched-pairs randomized comparison trial.

Setting

Community sporting facilities in 2 Australian capital cities.

Participants

Children (n=64; mean age, 10.2±2.7y; 52% boys), matched for age, sex, side of hemiplegia, and upper-limb function, were randomized within pairs to CIMT or bimanual training. Sixty-one children who completed CIMT (n=31) or bimanual training (n=30) were included in this study.

Interventions

Each intervention was delivered in day camps (total 60h over 10d) using a novel circus theme with goal-directed training.

Main Outcome Measures

Change between baseline, 3, and 26 weeks on the Melbourne Assessment of Unilateral Upper Limb Function (MUUL>7.4%), Assisting Hand Assessment (AHA>4 raw score points), and Canadian Occupational Performance Measure (COPM>2 points) defined best responders.

Results

Poorer baseline hand function predicted a best response for unimanual capacity of the impaired upper limb (MUUL) immediately postintervention; however, at 26 weeks the odds of achieving a favorable outcome were 21 times greater for CIMT than bimanual training. A favorable response for bimanual performance (AHA) was predicted by immediate change in Jebsen-Taylor hand function test scores. Age (older), left-sided hemiplegia, and lower-baseline COPM performance scores significantly predicted favorable individualized outcomes.

Conclusions

Secondary analysis of a randomized trial directly comparing 2 upper-limb training models, found children with poorer hand function benefited most. Favorable outcomes for bimanual performance were associated with gains in movement efficiency and older children with left-sided hemiplegia achieved more favorable gains in perceived occupational performance.     

Tactile function in children with unilateral cerebral palsy compared to typically developing children

Purpose: Tactile deficits have been understudied in children with unilateral cerebral palsy (UCP) using a limited range of tactile assessments. This study aims to characterize performance across a comprehensive battery of tactile registration and perception assessments in children with UCP and typically developing children (TDC). Methods: Fifty-two children with UCP (Gross Motor Function Classification System I = 34, II = 18; Manual Ability Classification System I = 36, II = 16) and 34 TDC were assessed using Semmes Weinstein Monofilaments (tactile registration), and single-point localization, double simultaneous, static and moving two-point discrimination, stereognosis, and texture perception (tactile perception). Results: Children with UCP performed consistently worse with their impaired hand than their unimpaired hand (Z = 2.77–5.61; p < 0.005). Both hands of children with UCP performed worse than either hand of TDC (Z = ?2.08 to 5.23; p = 0.037–< 0.001). Forty percent of children with UCP had tactile registration and perception deficits, 37% had perception deficits only and 23% had no tactile deficit. The larger the tactile registration deficit, the poorer the performance on all tactile perceptual tests (r = 0.568–0.670; p < 0.001). Conclusions: Most children with UCP demonstrate poor tactile perception and over one-third also demonstrate poor tactile registration. We contend that tactile dysfunction may contribute to functional impairment and is a possible target for intervention.

Implications for Rehabilitation:

• Cerebral palsy (CP) is the most prevalent physical disability in childhood, with an incidence of approximately 2 cases per 1000 live births; about 35% of children with CP have unilateral cerebral palsy (UCP).

• Assessment and treatment has been focused on the motor impairment; however, it is known that children with UCP are also likely to have sensory impairment.

• Understanding the nature and severity of sensory, specifically tactile, impairment in children with UCP will assist therapists to direct treatment accordingly and possibly impact the motor impairment.

     

Quantifying upper-limb motor impairment in people with multiple sclerosis: A physiological profiling approach

Background. Upper-limb sensory and motor impairments are common in people with multiple sclerosis (MS), yet the current gold standard criteria for documenting functional impairment largely focuses on mobility, balance and postural stability.Objective. We aimed to determine the validity of the upper-limb Physiological Profile Assessment (PPA) in people with MS by investigating whether the included domains of muscle strength, dexterity, arm stability, position sense, skin sensation and bimanual coordination 1) are sensitive in differentiating people with MS from healthy controls and 2) correlate with a validated measure of upper-limb function and a scale for quantifying disability in MS.Methods. In a cross-sectional study, 40 participants with MS and 80 healthy controls completed all 13 of the upper-limb PPA tests within a single session.Results. People with MS were impaired across all physiological domains tested. Performance in 4 of the 13 tests was correlated with a validated measure of self-reported upper-limb function (Pearson's r or Spearman's rho -0.333–0.441), whereas 3 tests were associated with the degree of MS-specific disability (Spearman's rho -0.318; 0.456).Conclusions. The upper-limb PPA offers a valid and clinically suitable assessment of upper-limb function in people with MS. Clinicians should prioritize assessments of motor speed, fine motor control and functional tasks in their assessment of upper-limb function in people with MS because these domains are the most commonly and significantly impaired.     

Network activation during bimanual movements in humans

The coordination of movement between the upper limbs is a function highly distributed across the animal kingdom. How the central nervous system generates such bilateral, synchronous movements, and how this differs from the generation of unilateral movements, remain uncertain. Electrophysiologic and functional imaging studies support that the activity of many brain regions during bimanual and unimanual movement is quite similar. Thus, the same brain regions (and indeed the same neurons) respond similarly during unimanual and bimanual movements as measured by electrophysiological responses. How then are different motor behaviors generated? To address this question, we studied unimanual and bimanual movements using fMRI and constructed networks of activation using Structural Equation Modeling (SEM). Our results suggest that (1) the dominant hemisphere appears to initiate activity responsible for bimanual movement; (2) activation during bimanual movement does not reflect the sum of right and left unimanual activation; (3) production of unimanual movement involves a network that is distinct from, and not a mirror of, the network for contralateral unimanual movement; and (4) using SEM, it is possible to obtain robust group networks representative of a population and to identify individual networks which can be used to detect subtle differences both between subjects as well as within a single subject over time. In summary, these results highlight a differential role for the dominant and non-dominant hemispheres during bimanual movements, further elaborating the concept of handedness and dominance. This knowledge increases our understanding of cortical motor physiology in health and after neurological damage.     

Impact of dual task on postural sway during sit-to-stand movement in children with unilateral cerebral palsy

BackgroundTo verify the effect of dual-task on postural oscillation during sit-to-stand movement in children with Cerebral Palsy.Methods17 children with spastic unilateral cerebral palsy and 20 typically-developing children, aged 5 to 12 years, performed the following tasks: Simple task: sit-to-stand with arms crossed against the chest; bimanual dual-task: sit-to-stand while carrying a tray; unimanual dual-task: sit-to-stand while holding a plastic cup with one hand. For data analysis, sit-to-stand was divided in three phases: preparation (phase 1), rising (phase 2), and stabilization (phase 3). Postural control was measured using a force plate, and the variables analyzed were: area, anterior-posterior and medial-lateral velocity, and STS duration. Analysis of variance was applied to test the effects of group; task conditions and interactions.FindingsChildren with cerebral palsy presented higher values of postural oscillation when compared to their typical pairs. Bimanual and Unimanual dual tasks presented greater postural oscillation values in sit-to-stand phase 1 compared to simple task. In bimanual dual-task, children with cerebral palsy presented lower values of velocity in phases 3, and greater postural oscillation and duration of the task when compared to single-task and unimanual dual-tasks. I.InterpretationThe insertion of a secondary task seems to interfere differently children with cerebral palsy, depending on the specific demands of each task. Thus, the importance of inserting dual tasks in the interventions is emphasized, considering that they are executed extensively in the day to day, and can act as facilitators or challenge in the execution of functional tasks.     

Using Grasping Tasks to Evaluate Hand Force Coordination in Children With Hemiplegic Cerebral Palsy

Mackenzie SJ, Getchell N, Modlesky CM, Miller F, Jaric S. Using grasping tasks to evaluate hand force coordination in children with hemiplegic cerebral palsy.

Objective

To assess force coordination in children with hemiplegic cerebral palsy (CP) using a device that allows for testing both unimanual and bimanual manipulation tasks performed under static and dynamic conditions.

Design

Nonequivalent groups design.

Setting

University research laboratory for motor control.

Participants

Six children with hemiplegic CP (age, mean ± SD, 11.6±1.8y) and 6 typically developing controls (11.6±1.6y).

Interventions

Not applicable.

Main Outcome Measures

Children performed simple lifting and force-matching static ramp tasks by way of both unimanual and bimanual pulling using a device that measures grip force (force acting perpendicularly at the digits-device contact area) and load force (tangential force). Main outcome measures were grip/load force ratios (grip force scaling) and correlation coefficients (force coupling).

Results

CP subjects showed significantly higher grip/load force ratios (P<.05) and slightly lower correlation coefficients than the control group, with more pronounced differences for most tasks when using their involved hand. For subjects with CP, switching from unimanual to bimanual conditions did not bring changes in scaling or coupling for the involved hand (P>.05).

Conclusions

Compared with healthy children, the impaired hand function in the hemiplegic CP pediatric population could be reflected in excessive grip force that is also decoupled from ongoing changes in load force. Therefore, the bimanual grip load device used in this study could provide a sensitive measure of grip force coordination in CP, although nonmotor deficits should be taken into account when asking children to perform more complex tasks.     

Essential Role of Social Context and Self-Efficacy in Daily Paretic Arm/Hand Use After Stroke: An Ecological Momentary Assessment Study With Accelerometry

ObjectiveTo determine the momentary effect of social-cognitive factors, in addition to motor capability, on post-stroke paretic arm/hand use in the natural environment.DesignA 5-day observational study in which participants were sent 6 Ecological Momentary Assessment (EMA) prompts/day.SettingParticipants’ daily environment.ParticipantsCommunity-dwelling, chronic stroke survivors with right-dominant, mild-moderate upper extremity paresis (N=30).InterventionsNot applicable.Main Outcome MeasuresTime duration of bimanual and unimanual paretic arm/hand use indexed by accelerometry; social-cognitive factors (social context, self-efficacy, mood) captured by EMA; motor capability of the paretic limb measured by Fugl-Meyer Upper Extremity Motor Assessment (FM).ResultsAfter accounting for participants’ motor capability, we found that momentary social context (alone or not) and self-efficacy significantly predicted post-stroke paretic arm/hand use behavior in the natural environment. When participants were not alone, paretic arm/hand movement increased both with and without the less-paretic limb (bimanual and unimanual movements, P=.018 and P<.001, respectively). Importantly, participants were more likely to use their paretic arm/hand (unimanually) if they had greater self-efficacy for limb use (P=.042). EMA repeated-measures provide a real-time approach that captures the natural dynamic ebb and flow of social-cognitive factors and their effect on daily arm/hand use. We also observed that people with greater motor impairments (FM<50.6) increase unimanual paretic arm/hand movements when they are not alone, regardless of motor capability.ConclusionsIn addition to motor capability, stroke survivors’ momentary social context and self-efficacy play a role in paretic arm/hand use behavior. Our findings suggest the development of personalized rehabilitative interventions which target these factors to promote daily paretic arm/hand use. This study highlights the benefits of EMA to provide real-time information to unravel the complexities of the biopsychosocial (ie, motor capability and social-cognitive factors) interface in post-stroke upper extremity recovery.     

A touchy topic: tactile assessment among pediatric therapists

Purpose: Tactile impairments affect over 77% of children with unilateral cerebral palsy (CP). This study aimed to examine the current practices of pediatric therapists in relation to tactile assessment and the barriers to carrying out tactile assessment in children with CP.

Method: The study was in two parts. In part one, pediatric therapists (n?=?35) completed a questionnaire detailing their current knowledge and the use of tactile assessments in children. In part two, therapists (n?=?12) completed a questionnaire based on the Theoretical Domains Framework examining the barriers and facilitators to completing tactile assessments in clinical practice.

Results: Most therapists (over 90%) carry out tactile assessments in the minority (less than 25%) of children with CP that they treat. Therapists reported the need for improved knowledge/skills (n?=?24) and confidence (n?=?19) in carrying out tactile assessments, alongside the provision of necessary equipment (n?=?17). Qualitative reports also suggested that organizational assessment guidelines and templates may facilitate the implementation of tactile assessment.

Conclusions: A multi-faceted knowledge translation strategy to address the barriers to tactile assessment among pediatric therapists needs to be developed.

• Implications for rehabilitation

• Pediatric occupational therapists and physiotherapists may not be completing tactile assessments according to current evidence-based recommendations.

• Therapists identified five main barriers, including a lack of knowledge, skills, belief in their capabilities (confidence), behavioral regulation (organizational procedures), and environmental context (e.g., equipment).

• Therapists recommended several potential facilitators, including access to necessary equipment, procedures, record sheets, training in tactile assessments, and research supporting related interventions.

• Service providers are encouraged to develop multi-faceted knowledge translation strategies that address these barriers and maximize facilitators.

     

Skill transfer from symmetric and asymmetric bimanual training using a robotic system to single limb performance

ABSTRACT: BACKGROUND: Humans are capable of fast adaptation to new unknown dynamics that affect their movements. Such motor learning is also believed to be an important part of motor rehabilitation. Bimanual training can improve post-stroke rehabilitation outcome and is associated with interlimb coordination between both limbs. Some studies indicate partial transfer of skills among limbs of healthy individuals. Another aspect of bimanual training is the (a)symmetry of bimanual movements and how these affect motor learning and possibly post-stroke rehabilitation. METHODS: A novel bimanual 2-DOF robotic system was used for both bimanual and unimanual reaching movements. 35 young healthy adults participated in the study. They were divided into 5 test groups that performed movements under different conditions (bimanual or unimanual movements and symmetric or asymmetric bimanual arm loads). The subjects performed a simple tracking exercise with the bimanual system. The exercise was developed to stimulate motor learning by applying a velocity-dependent disturbance torque to the handlebar. Each subject performed 255 trials divided into three phases: baseline without disturbance torque, training phase with disturbance torque and evaluation phase with disturbance torque. RESULTS: Performance was assessed with the maximal values of rotation errors of the handlebar. After exposure to disturbance torque, the errors decreased for both unimanual and bimanual training. Errors in unimanual evaluation following the bimanual training phase were not significantly different from errors in unimanual evaluation following unimanual training. There was no difference in performance following symmetric or asymmetric training. Changing the arm force symmetry during bimanual movements from asymmetric to symmetric had little influence on performance. CONCLUSIONS: Subjects could adapt to an unknown disturbance torque that was changing the dynamics of the movements. The learning effect was present during both unimanual and bimanual training. Transfer of learned skills from bimanual training to unimanual movements was also observed, as bimanual training also improved single limb performance with the dominant arm. Changes of force symmetry did not have an effect on motor learning. As motor learning is believed to be an important mechanism of rehabilitation, our findings could be tested for future post-stroke rehabilitation systems.     

Development of the assisting hand assessment for adults following stroke: a Rasch-built bimanual performance measure

Aims: To describe the development of a new test of bimanual performance for adults following Stroke, the Adult-Assisting Hand Assessment Stroke, and to report the evidence of internal and external validity.

Methods: Scale development included: (i) establishing the test situation; (ii) constructing test items; (iii) evaluating internal construct validity by use of Rasch measurement analysis on 144 assessments of adults with hemiparesis, mean age 53?years (SD11.45); and (iv) investigating external validity by correlation to the Jebsen and Taylor Test of Hand Function and the ABILHAND Stroke.

Results: The Adult-Assisting Hand Assessment Stroke scale, scored on 19 items using a four-point rating scale, provided a valid measure of bimanual performance. The rating scale structure, goodness of fit, and principal component analysis demonstrated evidence of a unidimensional construct. The strong reliability and high person separation ratio indicated high probability for the scale to be responsive to change. Correlation to outcomes of the Jebsen and Taylor Test of Hand Function and the ABILHAND Stroke indicated strong external validity.

Conclusion: Using two hands together is a critical aspect for performance of most daily life tasks. However, assessments of hand function commonly focus on measuring aspects of unimanual function. The Adult-Assisting Hand Assessment Stroke has the potential to contribute new and clinically important knowledge to stroke rehabilitation by providing an observation-based valid functional measure of bimanual performance.

• Implications for rehabilitation

• Hand function assessments commonly focus on unimanual aspects, although the use of two hands together is critical to perform most daily life tasks.

• The Adult-Assisting Hand Assessment Stroke measures how effectively a patient with a hemiparesis uses his/her affected hand together with the unaffected hand to perform bimanual tasks.

• The Adult-Assisting Hand Assessment Stroke contributes a new and clinically important aspect to stroke rehabilitation by providing a valid bimanual observation-based measure to guide intervention and measure change over time.

     

Bimanual versus unimanual coordination: what makes the difference?

Using fMRI, we investigated the neuronal structures controlling bimanual coordination applying a visuomotor coordination task. Recent studies suggest the existence of a widespread network for the neuronal control of bimanual coordination including primary sensorimotor cortices (M1/S1), lateral and medial premotor cortices (PMC, SMA), cingulate motor area (CMA), and cerebellum (CB). In the present study, subjects performed bimanual and unimanual tasks requiring the coordination of two fingers at a time to navigate a cursor on a computer screen. Thus, in contrast to previous studies, we are using appropriate unimanual control (UNI) tasks. By using this new motor task, we identified a similar activation network for uni- and bimanual movements. Subjects exhibited bilateral activations in PMC, SMA, posterior-parietal cortex (PPC), occipital, and inferiotemporal cortex, as well as in the contralateral M1/S1 and ipsilateral CB. We did not find any additional activation when comparing bimanual with unimanual conditions. The lack of significant activation in the comparison "bimanual > unimanual" gives reason to suggest that this network is not limited to the control of bimanual motor actions, but responsible for unimanually coordinated movements as well. Interestingly, we found stronger activations for unimanual as compared to bimanual coordination. We hypothesize that task difficulty (degrees of freedom to control, e.g., number of limbs) is more important in determining which network components are activated and to what extent, compared to the factor of bimanuality. It even seemed to be less demanding for the motor system to control the cursor bimanually compared to the unimanual performance with two adjacent fingers.     

Assessment of bimanual performance in 3-D movement analysis: Validation of a new clinical protocol in children with unilateral cerebral palsy

BackgroundThe “Be an Airplane Pilot” (BE-API) protocol is a novel 3-D movement analysis (3DMA) protocol assessing the bimanual performance of children during a game.ObjectiveThis study aimed to investigate the reliability and validity of this protocol in children with unilateral cerebral palsy (uCP).MethodsAngular waveforms (WAVE), maximum angles (MAX) and range of motion (ROM) of the trunk, shoulder, elbow and wrist joints were collected in children with uCP and in typically developing children (TDC) during 4 tasks of the BE-API protocol designed to explore specific degrees of freedom (DoF). The inter-trial reliability for children with uCP was assessed with the coefficient of multiple correlation (CMC) for WAVE and the intraclass correlation coefficient (ICC) and standard error of measurement (SEM) for MAX and ROM. Clinical performance-based measures, including the Assisting Hand Assessment (AHA) and ABILHAND-Kids scores, were used to explore correlations between clinical measures and kinematic parameters in children with uCP.Results20 children with uCP (13 boys; mean age 12.0 [SD 3.2] years) and 20 TDC (11 boys; mean age 11.9 [SD 3.4] years) were included. In children with uCP, most kinematic parameters showed high reliability (WAVE: CMC ≥ 0.82; MAX and ROM: ICC ≥ 0.85, SEM ≤ 4.7°). Elbow extension, forearm supination, and wrist adduction were reduced and wrist flexion was increased for children with uCP versus TDC (P < 0.01). In children with uCP, MAX and ROM values were moderately correlated with clinical assessments (AHA score: r = 0.48–0.65; ABILHAND-Kids score: r = 0.48–0.49).ConclusionsThe BE-API protocol is a 3DMA-bimanual performance-based assessment that is highly reliable in children with uCP. Children with uCP and TDC significantly differed in some clinically relevant kinematic parameters. The BE-API is a promising playful tool, helpful for better understanding upper-limb motor movement abnormalities in bimanual conditions and for tailoring treatments to individual deficits.     

Getting inTOUCH: outcomes of a knowledge translation intervention for tactile assessment knowledge,barriers, and practice in paediatric therapists working with children with cerebral palsy

Background: Tactile impairments are common in children with cerebral palsy (CP), however assessment is not routinely carried out by therapists. We investigated a multi-faceted Knowledge Translation intervention to improve Knowledge, remove Barriers and enhance Practice of tactile assessments by paediatric therapists.

Method: Twelve therapists from a state-wide service for children with CP (seven physiotherapists, five occupational therapists; 12 female) received: written information, demonstration videos, a face-to-face workshop, equipment provision, and on-call mentoring. Therapists completed pre–post-intervention questionnaires reporting their perceived tactile assessment Knowledge, current Practices and implementation Barriers.

Results: Following intervention, therapists improved Knowledge of correct (1) tactile impairment prevalence in children with CP (pre 3/12; post 9/12), (2) tactile assessment items (e.g. Registration – pre 1/12; post 9/12; Localisation – pre 2/12; post 10/12), and (3) equipment choice (e.g. Monofilaments – pre 1/12; post 10/12). Tactile assessment Practice improved slightly. All major clinician-level implementation Barriers were resolved and less obvious organisational-level Barriers were identified for follow-up.

Conclusion: A 12-month multi-faceted Knowledge Translation intervention can improve tactile assessment Knowledge, resolve major clinician-level implementation Barriers, and identify less obvious organisational-level Barriers to be addressed to achieve maximum Practice improvement. Ongoing multi-faceted knowledge translation processes are essential for high-performing organisations.

• Implications for rehabilitation

• A multi-faceted knowledge translation intervention significantly improved paediatric therapists’ knowledge of the items and equipment necessary for tactile assessment.

• A 12-month intervention can address clinician-level barriers of knowledge, confidence, and access to equipment and assist in the identification of less obvious organisational-level barriers.

• Consideration of motivational readiness for change, intervention timelines, monitoring of emergent barriers, and fitting tactile assessment into a broader assessment framework are critical for improving uptake of tactile assessment in practice.

     

Hand function and Disability of the Arm,Shoulder and Hand in Charcot-Marie-Tooth disease

Purpose. The aim of the present study was to examine hand function and disability in persons with Charcot-Marie-Tooth disease (CMT) and to evaluate the possible correlations between hand function and disability.

Methods. Nine male, 11 female (24–73 yrs) persons with CMT in northern Sweden and a matched control group of 18 men, 22 women (21–73 yrs) participated in the study. Measurements applied were tests of dexterity (Box and Block Test; Nine-Hole Peg test), grip strength (Grippit®), tactile gnosis (Shape Texture Identification test) and upper-limb disability (Disabilities of the Arm Shoulder and Hand questionnaire, DASH).

Results. Hand function in CMT was reduced (p < 0.001) to about 60% of normal, as indicated by each of the separate outcome measures as well as by a constructed summary index of hand function. DASH score median was 38.8 (range 0–66.7) and was clearly related to hand function (r = 0.64–0.83).

Conclusion. Reduced hand function in CMT was found at different dimensions according to the International Classification of Functioning, Disability and Health (ICF). We suggest that DASH can be used in persons with CMT, though clinicians should be aware that patients might score lower than expected, possibly because of a long process of adaptation when learning to live with a slowly progressive disease.     

The role of the medial wall and its anatomical variations for bimanual antiphase and in-phase movements

The medial wall of the frontal cortex is thought to play an important role for bimanual coordination. However, there is uncertainty regarding the exact neuroanatomical regions involved. We compared the activation patterns related to bimanual movements using functional magnetic resonance imaging in 12 healthy right-handed subjects, paying special attention to the anatomical variability of the frontal medial wall. The subjects performed unimanual right and left and bimanual antiphase and in-phase flexion and extension movements of the index finger. Activation of the right supplementary motor area (SMA) proper, right and left caudal cingulate motor area (CMA), and right and left premotor cortices was significantly stronger during bimanual antiphase than bimanual in-phase movements, indicating an important function of these areas with bimanual coordination. A frequent anatomical variation is the presence of the paracingulate sulcus (PCS), which might be an anatomical landmark to determine the location of activated areas. Seven subjects had a bilateral, three a unilateral right, and two a unilateral left PCS. Because the area around the PCS is functionally closer coupled to the CMA than to the SMA, activation found in the area around the PCS should be attributed to the CMA. With anatomical variations such as the presence of a PCS or a vertical branch of the cingulate sulcus, normalization and determination of the activation with the help of stereotaxic coordinates can cause an incorrect shift of CMA activation to the SMA. This might explain some of the discrepancies found in previous studies.     

Continuous inter-limb coordination deficits in children with unilateral spastic cerebral palsy

BackgroundContinuous inter-limb coordination and the ability to offset perturbations to a movement pattern (i.e., stability) are important factors in efficient motor performance. Patients with movement disorders often show deficits in coordination and stability, although little is known about these features in children with cerebral palsy. The purpose of this study was to identify the continuous inter-limb coordination and stability deficits in children with cerebral palsy and determine if improvement occurs with upper extremity intervention.MethodsChildren with cerebral palsy participated in bimanual or unimanual intensive therapy. Continuous inter-limb coordination between the arms and between the more-affected arm and leg was evaluated using relative phase analysis during four gross motor tasks, including in-place marching and standing with asymmetric and symmetric arm swing. A control group of children with cerebral palsy and a group of typically developing children were also evaluated.FindingsChildren with cerebral palsy displayed coordination deficits compared to typically developing children (p<0.01), yet both groups presented similarly poor levels of stability (p=0.39). Compared to standing, adding legs to the task negatively impacted the coordination (p<0.01) and stability (p<0.01) of all children. Both groups improved coordination between the arms post-intervention (p<0.05 for all cases), however neither group improved stability (p>0.05 for all cases).InterpretationRelative phase analysis successfully provided a sensitive measurement of coordination and stability in pathologic and non-pathologic populations. Findings indicate that all children have difficulty producing consistent movement patterns and suggest that both bimanual and unimanual interventions can improve continuous coordination in children with cerebral palsy.     

Effectiveness of virtual reality in children and young adults with cerebral palsy: a systematic review of randomized controlled trial

BackgroundCerebral palsy (CP) is one of the main causes of disability in childhood. Virtual reality (VR) has been used as a treatment option in this population, however its effectiveness is unclear.ObjectiveTo evaluate the effectiveness of VR in patients with CP.MethodsWe conducted electronic searches in EMBASE, MEDLINE, Cochrane library, PEDro, AMED, PsycoINFO, and LILACS databases and trial site registries such as ClinicalTrials.gov and ICTRP. We included randomized controlled trials that tested the use of VR alone or in combination with other interventions compared to more conventional rehabilitation or usual care in individuals with CP. The primary outcomes were upper and lower limb function, postural control, and balance. The secondary outcomes included global motor function, perception, cognition and spatial functions, motivation, motor learning, and adverse events. Two independent reviewers extracted and assessed included articles for risk of bias using the Cochrane risk of bias tool. We use a meta-analysis with random effect model whenever possible. We analyzed the quality of evidence using theGRADE approach.ResultsWe included 38 trials (pooled n = 1233 participants) in this review. There is very low quality of evidence that VR plus conventional rehabilitation is better than conventional rehabilitation for upper limb function. There is also very low quality evidence that VR alone is no better than conventional rehabilitation for upper and lower limb function. No adverse events were observed among the 10 trials that provided information on this outcome.ConclusionAt present we have very limited to limited confidence in effect estimation for utilization of VR in this population. Future studies may change our confidence in results and effect estimates.Protocol registrationPROSPERO CRD 42018102759.     

The co-ordination of bimanual rapid aiming movements following stroke

OBJECTIVE: To determine the role of anticipatory and movement control processes for the coordination of bimanual target aiming in individuals post stroke. SUBJECTS: Thirty adults with chronic stroke and 30 individuals without stroke history. DESIGN: A two-group (stroke, control) by two-aiming type (unimanual, bimanual) by two-limb (paretic, nonparetic; left, right for controls) design with repeated measures on the last two factors. OUTCOME MEASURES: Kinematic analyses of performance and psychometric measures of reaction time, movement time, peak resultant velocity, time to and after peak resultant velocity and interlimb timing for movement initiation and target impact. RESULTS: Compared with unimanual aiming, the nonparetic limb exhibited a prolonged movement time in the bimanual condition; the locus for prolongation was primarily in the deceleration phase. This adaptive response allowed for a nearly simultaneous (both limbs) target impact in 81% of trials. Compared with the unimanual condition, the nonparetic limb exhibited a lower peak velocity (10%) in the bimanual condition. Conversely, compared with the unimanual condition, the paretic limb exhibited a higher peak velocity (4%) in the bimanual condition. This disociation between limb and condition was observed for the stroke group but not the control group. CONCLUSIONS: The interlimb coordination that emerged for the stroke group revealed a complex and asymmetric contribution from each limb mediated through anticipatory and motor control processes. We suggest that this coordination may be harnessed for future bimanual intervention approaches to rehabilitation of upper limb function after stroke.     

The Cerebral Palsy Kinematic Assessment Tool (CPKAT): feasibility testing of a new portable tool for the objective evaluation of upper limb kinematics in children with cerebral palsy in the non-laboratory setting

Purpose: Efficacy of treatment to improve upper-limb activity of children with cerebral palsy (CP) is typically evaluated outside clinical/laboratory environments through functional outcome measures (e.g. ABILHAND kids). This study evaluates CPKAT, a new portable laptop-based tool designed to objectively measure upper-limb kinematics in children with CP. Methods: Seven children with unilateral CP (2 females; mean age 10 years 2 months (SD 2 years 3 months), median age 9 years 6 months, range 6 years 5 months, MACS II–IV) were evaluated on copying, tracking and tracing tasks at their homes using CPKAT. CPKAT recorded parameters relating to spatiotemporal hand movement: path length, movement time, smoothness, path accuracy and root mean square error. The Wilcoxon signed ranks test explored whether CPKAT could detect differences between the affected and less-affected limb. Results: CPKAT detected intra-limb differences for movement time and smoothness (aiming), and path length (tracing). No intra-limb tracking differences were found, as hypothesised. These findings are consistent with other studies showing that movements of the impaired upper limb in unilateral CP are slower and less smooth. Conclusion: CPKAT provides a potential solution for home-based assessment of upper limb kinematics in children with CP to supplement other measures and assess functional intervention outcomes. Further validation is required.

• Implications for Rehabilitation

• This paper demonstrates the feasibility of evaluating upper limb kinematics in home using CPKAT, a portable laptop-based evaluation tool.

• We found that CPKAT is easy to set-up and use in home environments and yields useful kinematic measures of upper limb function.

• CPKAT can complement less responsive patient reported or subjectively evaluated functional measures for a more complete evaluation of children with cerebral palsy.

• Thus, CPKAT can help guide a multi-disciplinary team to more effective intervention and rehabilitation for children with cerebral palsy.

     

Assessing physical function in adult acquired major upper-limb amputees by combining the Disabilities of the Arm, Shoulder and Hand (DASH) Outcome Questionnaire and clinical examination

Østlie K, Franklin RJ, Skjeldal OH, Skrondal A, Magnus P. Assessing physical function in adult acquired major upper-limb amputees by combining the Disabilities of the Arm, Shoulder and Hand (DASH) Outcome Questionnaire and clinical examination.

Objectives

To describe physical function in adult acquired major upper-limb amputees (ULAs) by combining self-assessed arm function and physical measures obtained by clinical examinations; to estimate associations between background factors and self-assessed arm function in ULAs; and to assess whether clinical examination findings may be used to detect reduced arm function in unilateral ULAs.

Design

Survey: postal questionnaires and clinical examinations.

Setting

Norwegian ULA population. Clinical examinations performed at 3 clinics.

Participants

Questionnaires: population-based sample (n=224; 57.4% response rate). Clinical examinations: combined referred sample and convenience sample of questionnaire responders (n=70; 83.3% of those invited). Survey inclusion criteria: adult acquired major upper-limb amputation, resident in Norway, mastering of spoken and written Norwegian.

Interventions

Not applicable.

Main Outcome Measures

The Disabilities of the Arm, Shoulder and Hand (DASH) Outcome Questionnaire, and clinical examination of joint motion and muscle strength with and without prostheses.

Results

Mean DASH score was 22.7 (95% confidence interval [CI], 20.3–25.0); in bilateral amputees, 35.7 (95% CI, 23.0–48.4); and in unilateral amputees, 22.1 (95% CI, 19.8–24.5). A lower unilateral DASH score (better function) was associated with paid employment (vs not in paid employment: adjusted regression coefficient [aB]=−5.40, P=.033; vs students: aB=−13.88, P=.022), increasing postamputation time (aB=−.27, P=.001), and Norwegian ethnicity (aB=−14.45, P<.001). At clinical examination, we found a high frequency of impaired neck mobility and varying frequencies of impaired joint motion and strength at the shoulder, elbow, and forearm level. Prosthesis wear was associated with impaired joint motion in all upper-limb joints (P<.006) and with reduced shoulder abduction strength (P=.002). Impaired without-prosthesis joint motion in shoulder flexion (ipsilateral: aB=12.19, P=.001) and shoulder abduction (ipsilateral: aB=12.01, P=.005; contralateral: aB=28.82, P=.004) was associated with increased DASH scores.

Conclusions

Upper-limb loss clearly affects physical function. DASH score limitation profiles may be useful in individual clinical assessments. Targeted clinical examination may indicate patients with extra rehabilitational needs. Such examinations may be of special importance in relation to prosthesis function.