Neuro-imaging characteristics of sensory impairment in cerebral palsy; a systematic review.

Background: Objective: To identify and examine neural reorganization of the sensory network in terms of lesion type, somatotopic organization of the primary somatosensory area, and functional connectivity in relation to sensory function in children and young adults with cerebral palsy (CP). Methods: Design: systematic review, Prospero registration ID 342570. Data sources: PubMed; Cochrane; Web of Science; Embase; CINAHL and PEDro from inception to March 13, 2021. Eligibility criteria: All types of original studies, concerning sensory connectivity in relation to sensory outcome in patients with spastic CP, <30 years of age. No publication status or date restrictions were applied. Data extraction and synthesis: Two authors independently determined the eligibility of studies. Quality assessment was performed by a third author. Neuro-imaging/neurophysiological techniques, sensory outcomes and patient characteristics were extracted. Results: Children and young adults with periventricular leucomalacia (PVL) lesions have significantly better hand function and sensation scores than patients with cortical-subcortical/middle cerebral artery (MCA) lesions. Ipsilesional reorganization of the S1 (primary somatosensory cortex) area appears to be the primary compensation mechanism after a unilateral early brain lesion, regardless of the timing of the lesion. Interhemispheric reorganization of the sensory system after early brain lesions is rare and, when it occurs, poorly effective. Diffusion tractography shows a positive correlation between the ascending sensory tract (AST) diffusivity metrics of the more affected hemisphere and sensory test outcomes. Discussion and conclusions: Because of the large variability in study design, patient characteristics, neuroimaging/neurophysiological techniques and parameters as well as sensory assessment methods used, it is difficult to draw definite inferences on the relationship between the reorganization of the sensory network following early brain damage and sensory function in children and young adults with CP. In general, sensory function seems to be worse in cortical as opposed to white matter tract (PVL) lesions. International consensus on a clinically relevant sensory test battery is needed to enhance understanding of the intriguing compensatory mechanisms of sensory network following early brain damage and potential consequences for rehabilitation strategies. Systematic Review Registration: https://www.crd.york.ac.uk/prospero/.

Lower limb muscle fatigue after uphill walking in children with unilateral spastic cerebral palsy.

Fatigue during walking is a common complaint in cerebral palsy (CP). The primary purpose of this study is to investigate muscle fatigue from surface electromyography (sEMG) measurements after a treadmill-based fatigue protocol with increasing incline and speed in children with CP with drop foot. The secondary purpose is to investigate whether changes in sagittal kinematics of hip, knee and ankle occur after fatigue. Eighteen subjects with unilateral spastic CP performed the protocol while wearing their ankle-foot orthosis and scored their fatigue on the OMNI scale of perceived exertion. The median frequency (MF) and root mean square (RMS) were used as sEMG measures for fatigue and linear mixed effects model were applied. The MF was significantly decreased in fatigued condition, especially in the affected leg and in the tibialis anterior and peroneus longus muscle. The RMS did not change significantly in fatigued condition, while the OMNI fatigue score indicated patients felt really fatigued. No changes in sagittal kinematics of hip, knee and ankle were found using statistical non-parametric mapping. In conclusion, the current fatigue protocol seems promising in inducing fatigue in a population with CP with drop foot and it could be used to expand knowledge on muscle fatigue during walking in CP.

Barriers to recruitment of children with cerebral palsy in a trial of home-based training.

Many trials fail to include the targeted number of participants, causing scientific and ethical problems. The COAD trial of home-based training programs (HBTPs) for children with unilateral cerebral palsy (CP) encountered recruitment problems, even though the parent-delivered home-based approach complies with recent health-care developments in the Netherlands. The current project aimed to identify the barriers to recruitment in the COAD trial. This summative, multidimensional evaluation comprised informal conversational interviews in which stakeholders who had been involved reflected on the factors that impeded successful recruitment of participants into the COAD trial. Barriers to implementation and recruitment were clustered according to the constructs of the Consolidated Framework for Implementation Research (CFIR). Member checking validated the findings. A total of 41 stakeholders contributed to the evaluation. Barriers to the implementation of the HBTPs were identified within every domain of the CFIR (intervention characteristics, outer setting, inner setting, characteristics of individuals, and process). Parent-delivered home-based training was perceived as highly complex and in conflict with the pressures on and the needs of parents. Many parents preferred the alternative center-based group interventions. The involvement of a resonance group was highly valued, and opportunities for further enhancements emerged. Additionally, the importance of research consortia was emphasized. The appropriateness of the RCT as the study design was criticized. The findings of this study are summarized in a tool which provides a dozen directions for the successful recruitment of participants in pediatric rehabilitation research.

Efficacy of upper limb strengthening in children with Cerebral Palsy: A critical review.

OBJECTIVE: This review focuses on the effects of strengthening interventions of the upper limb in children with Cerebral Palsy (CP). The strengthening intervention studies were divided in two categories: those based on stand-alone strength training, and those on strength training combined with other interventions. DATA SOURCES AND EXTRACTION: A search in all relevant databases was performed. DATA SYNTHESIS: Six articles were included: three randomized controlled trials (RCTs), two clinical trial (CT) and one case study. Effect sizes of strength training on muscle strength and function of the upper limb were calculated. CONCLUSION: There are no coherent recommendations for strength training, based on these studies. The causes include too much variety of types of training, level of intensity and duration. All of the reported upper limb strength training studies found an increase in muscle strength. In addition, the quality of these studies was not high. More RCTs on strength training according to the official strength training guidelines are necessary to assess the impact and potential of strength training of the upper limb to improve the daily activities and participation in children with CP.

ToCUEST: a task-oriented client-centered training module to improve upper extremity skilled performance in cervical spinal cord-injured persons.

OBJECTIVES: Given (a) the importance of upper extremity skill performance in persons with cervical spinal cord injury (C-SCI), (b) the limited number of studies on arm hand functioning in C-SCI and (c) the discrepancy between the importance of client centeredness and the lack of a theoretical framework and practical guidelines on how to apply client centeredness into practice, the aim of the present study is to (1) develop a training concept in which rehabilitation of the upper extremity focuses on patient's needs and wishes and (2) to put this concept into practice for tetraplegic persons. METHODS: The training concept contains two main components. The client-centered component includes both extracting individual goals and defining and objectifying these goals. The task-oriented component incorporates a task analysis and the composition of an individual training program. RESULTS: A task-oriented client-centered training aimed at improving upper extremity skilled performance in tetraplegic persons is described step by step. The Canadian Occupational Performance Measure is used to identify patient's specific needs. The Goal Attainment Scale is applied to define and objectify individual goals. A task analysis is essential to map limiting and facilitating factors of the person, the task and the environment and to identify which aspects should be trained. An individual task-oriented training program is composed, based on principles of motor learning and training physiology and the use of assistive devices. Each step is explained and illustrated using a case example.

Evaluation of a task-oriented client-centered upper extremity skilled performance training module in persons with tetraplegia.

STUDY DESIGN: Clinical intervention study. OBJECTIVE: Arm hand skilled performance (AHSP) has a major role in the rehabilitation of persons with cervical spinal cord injury (C-SCI). A task-oriented client-centered upper extremity skilled performance-training (ToCUEST) module was developed. The present study aims to evaluate effects of ToCUEST on specific and general AHSP in C-SCI, during and after rehabilitation. SETTING: Adelante Rehabilitation Centre (The Netherlands). METHODS: C-SCI persons, either during or after rehabilitation, completed the ToCUEST training; a control group of patients during rehabilitation received standard rehabilitation. The training module was focused on patient's individual needs, combining principles of motor learning and training physiology. Three self-selected goals were trained 3 days per week, in three sessions of 30 min per day for 8 weeks. Measures were taken at 3 months after the start of the active rehabilitation (T0), before training (T1), after training (T2), at follow-up (3 months post-training; T3) and at discharge. RESULTS: For both ToCUEST groups during (n=11) and after (n=12) rehabilitation, an improvement (P<0.001) on specific AHSP (using the Goal Attainment Scale and the Canadian Occupational Performance Measure (satisfaction and performance)) was found between T1-T2 and T1-T3. Also an improvement (P<0.02) in general AHSP (using the Van Lieshout Test, the QIF and the motor FIM) was found in the total ToCUEST group between T1-T2 and T1-T3. No significant difference in improvement of general AHSP was found between the ToCUEST rehab and control group. CONCLUSION: The ToCUEST module leads to improvement in AHSP, not only persons with C-SCI during rehabilitation, but also after finishing rehabilitation. These effects remain at follow-up.

Assessment of upper extremity muscle function in persons with tetraplegia.

The objective was to investigate the actual level of muscle function impairment in tetraplegic persons and, inextricably related to this, the possibilities to compensate function loss using new muscle coalitions. In this cross-sectional group study, 20 persons with a cervical spinal cord injury (SCI) at segmental levels C5C6 or C7C8 and 10 control persons participated. Activity from 21 upper extremity and trunk muscles was recorded during standardised gross upper extremity task performance. No substantial differences in main activation patterns were found between C7C8 and control subjects. In contrast, main activation patterns in C5C6 persons showed an absence of selectivity, which may be explained by the participants activating every controllable muscle in an attempt to perform maximally. In order to identify more intricate differences in muscle activation between control and C7C8 persons a fine motor function task may be necessary. Muscle activation patterns during arm task performance were stable in all three groups.

Measuring change in arm hand skilled performance in persons with a cervical spinal cord injury: responsiveness of the Van Lieshout Test.

OBJECTIVES: To asses whether the Van Lieshout Test (VLT) is responsive to measure changes in arm hand skilled performance (AHSP) over time during active rehabilitation in persons with cervical spinal cord injury (C-SCI) and in different subgroups of persons with C-SCI according to lesion completeness and to lesion level. STUDY DESIGN: Longitudinal cohort study. SETTING: Spinal Cord Injury Units in eight rehabilitation centres across the Netherlands. METHODS: In the present study, data from a national SCI cohort study are used. Data from the VLT, the Grasp Release Test (GRT), the Functional Independence Measure (FIM) and the Quadriplegia Index of Function (QIF) were recorded at three moments during active rehabilitation: at the start of active rehabilitation (t1), 3 months after t1 (t2) and at discharge (t3). Data have been analysed using three responsiveness measures, that is, the standardized response mean, the effect size and comparison of test scores measured at different times. RESULTS: The VLT is responsive for the intervals t1-3, t1-2 and t2-3. The VLT can be used to measure changes in AHSP in persons with a C-SCI with an American Spinal Injury Association Impairment Scale (AIS) A or B score or an AIS C or D score, as well as in persons with a C3-C6 lesion or a C7-T1 lesion. The responsiveness of the VLT is significantly correlated to the GRT, but not to the FIM and the QIF. CONCLUSION: The VLT is responsive in measuring changes in AHSP during rehabilitation in persons with C-SCI.

Botulinum toxin A and upper limb functional skills in hemiparetic cerebral palsy: a randomized trial in children receiving intensive therapy.

The objective of this study was to determine whether the use of intramuscular botulinum toxin A (BTX-A) increases upper limb function and skills in the context of a specific therapy programme in children with hemiparetic cerebral palsy. Twenty children (nine females, 11 males) aged 4 to 16 years who were thought likely to benefit from BTX-A treatment were included. After matched pairs were made, on the basis of Zancolli grade and age, randomization took place. All patients were given structured rehabilitation (physiotherapy and occupational therapy three times a week for 6 months), and half of the patients received intramuscular BTX-A. No placebo injections were given in the control group. Participants were assessed at baseline, at 2 and 6 weeks, and at 3, 6, and 9 months after injection. The Ashworth scale, active range of motion of arm joints, the Melbourne assessment of upper limb function, the Pediatric Evaluation of Disability Inventory, and the nine-hole peg test were used for outcome measurement. Observers were blinded for treatment allocation only for scoring the Melbourne test. The children in the treatment group showed a clinically relevant increase in active dorsal flexion, and tone reduction of the wrist. For the functional outcome measures, no statistically significant differences between the groups could be demonstrated. Intramuscular BTX-A added to an intensive therapy programme reduces impairment for at least 9 months; the effect on activity level is still uncertain.

Evaluation of upper extremity motor function tests in tetraplegics.

OBJECTIVE: To provide an overview of arm-hand function tests useful in tetraplegic subjects. Considerations for selection of an appropriate test are also provided. DATA SOURCES: A Medline literature search was conducted covering the period from 1967 to March 2001. Relevant references cited in the selected papers were also considered, regardless of the year of publication. STUDY SELECTION: This review was restricted to strength tests, functional and ADL tests. Only general tests and tests designed specifically to test tetraplegic persons written in English, or in Dutch were included in the review. RESULTS: Information is provided on four types of strength tests, 10 general and five specific functional tests and eight ADL tests. CONCLUSION: Many tests are available to measure upper extremity motor function in tetraplegics. Selection of a test is at first determined by the outcome value in which the investigator is interested. When the type of outcome value has been determined, the most suitable test has to be selected from the range of available tests. When two tests appear to be equally suitable, the availability of information on psychometric properties of the test when used in tetraplegic patients is a decisive factor. When information on the reliability, validity and sensitivity of a test is missing, it should be gathered before using the test.