Individualized Electrode Subset Improves the Calibration Accuracy of an EEG P300-design Brain-Computer Interface for People with Severe Cerebral Palsy.

Objective: This study examined the effect of individualized electroencephalogram (EEG) electrode location selection for non-invasive P300-design brain-computer interfaces (BCIs) in people with varying severity of cerebral palsy (CP). Approach: A forward selection algorithm was used to select the best performing 8 electrodes (of an available 32) to construct an individualized electrode subset for each participant. BCI accuracy of the individualized subset was compared to accuracy of a widely used default subset. Main Results: Electrode selection significantly improved BCI calibration accuracy for the group with severe CP. Significant group effect was not found for the group of typically developing controls and the group with mild CP. However, several individuals with mild CP showed improved performance. Using the individualized electrode subsets, there was no significant difference in accuracy between calibration and evaluation data in the mild CP group, but there was a reduction in accuracy from calibration to evaluation in controls. Significance: The findings suggested that electrode selection can accommodate developmental neurological impairments in people with severe CP, while the default electrode locations are sufficient for many people with milder impairments from CP and typically developing individuals.

Teleintervention for users of augmentative and alternative communication devices: A systematic review.

AIM: To synthesize existing evidence on the effectiveness of speech-language teleinterventions delivered via videoconferencing to users of augmentative and alternative communication (AAC) devices. METHOD: A systematic literature search was conducted in 10 electronic databases, from inception until August 2021. Included were speech-language teleinterventions delivered by researchers and/or clinicians via videoconferencing to users of AAC devices, without restrictions on chronological age and clinical diagnosis. The quality of the studies included in the review was appraised using the Downs and Black checklist and the Single-Case Experimental Design Scale; risk of bias was assessed using the Risk Of Bias In Non-Randomized Studies - of Interventions and the single-case design risk of bias tools. RESULTS: Six teleinterventions including 25 participants with a variety of conditions, such as Down syndrome, autism, Rett syndrome, and amyotrophic lateral sclerosis met the inclusion criteria. Five studies used a single-case experimental design and one was a cohort study. Teleinterventions included active consultation (n = 2), functional communication training (n = 2), brain-computer interface (n = 1), and both teleintervention and in-person intervention (n = 1). All teleinterventions reported an increase in participants' independent use of AAC devices during the training sessions compared to baseline, as well as an overall high satisfaction and treatment acceptability. INTERPRETATION: Speech-language teleinterventions for users of AAC devices show great potential for a successful method of service delivery. Future telehealth studies with larger sample sizes and more robust methodology are strongly encouraged to allow the generalization of results across different populations. WHAT THIS PAPER ADDS: Individuals can learn to use augmentative and alternative communication (AAC) devices independently during tele-AAC interventions. Service providers and recipients reported an overall high satisfaction and acceptability for AAC services delivered via teleinterventions. Speech-language teleinterventions may be an effective method of providing AAC intervention services.

Are We Getting It Right? A Scoping Review of Outcomes Reported in Cell Therapy Clinical Studies for Cerebral Palsy.

Cell therapies are an emergent treatment for cerebral palsy (CP) with promising evidence demonstrating efficacy for improving gross motor function. However, families value improvements in a range of domains following intervention and the non-motor symptoms, comorbidities and complications of CP can potentially be targeted by cell therapies. We conducted a scoping review to describe all outcomes that have been reported in cell therapy studies for CP to date, and to examine what instruments were used to capture these. Through a systematic search we identified 54 studies comprising 2066 participants that were treated with a range of cell therapy interventions. We categorized the reported 53 unique outcome instruments and additional descriptive measures into 10 categories and 12 sub-categories. Movement and Posture was the most frequently reported outcome category, followed by Safety, however Quality of Life, and various prevalent comorbidities and complications of CP were infrequently reported. Notably, many outcome instruments used do not have evaluative properties and thus are not suitable for measuring change following intervention. We provide a number of recommendations to ensure that future trials generate high-quality outcome data that is aligned with the priorities of the CP community.

A validation and acceptability study of cognitive testing using switch and eye-gaze control technologies for children with motor and speech impairments: A protocol paper.

Despite the importance of knowing the cognitive capabilities of children with neurodevelopmental conditions, less than one-third of children with cerebral palsy participate in standardized assessments. Globally, approximately 50% of people with cerebral palsy have an intellectual disability and there is significant risk for domain-specific cognitive impairments for the majority of people with cerebral palsy. However, standardized cognitive assessment tools are not accessible to many children with cerebral palsy, as they require manual manipulation of objects, verbal response and/or speeded response. As such, standardised assessment may result in an underestimation of abilities for children with significant motor and/or speech impairment. The overall aim of the project is to examine and compare the psychometric properties of standardised cognitive assessment tools that have been accommodated for use with either a switch device or eye-gaze control technologies, with the specific aims to: (1) Examine the psychometric properties (measurement agreement and validity) of accommodated assessment tools by comparing the performance of typically developing children on six cognitive assessment tools administered via standardised versus accommodated (switch or eye-gaze control) administration; (2) Describe and compare the performance and user experience of children with cerebral palsy on six accommodated cognitive assessments administered via switch or eye-gaze control technologies. Secondary aims are to: (1) Describe the completion rates and time to complete assessments of participants in each group; (2) Within the group with cerebral palsy, examine the effects of condition-specific characteristics (type of cerebral palsy, functional levels, and pain) and demographics (age, socio-demographic) on participation. This protocol paper describes a two-phase validation and acceptability study that utilizes a mixed-model design. This study will collect concurrent data from 80 typically developing children and 40 children with cerebral palsy, who use switch or eye-gaze control technology as alternate access communication methods. The set of instruments will measure receptive vocabulary, fluid reasoning, sustained attention, vision perception, visuospatial working memory and executive functions. Data analyses will be conducted using SPSS v. 25 and R v 4.1.0. SPSS Sample Power 3 was used for power computation and allows for a 10% drop out rate. Quantitative descriptive statistics, measurement agreement data plotting, bivariate and multiple regressions analysis will be conducted using appropriate methods.

Challenges of brain-computer interface facilitated cognitive assessment for children with cerebral palsy.

Brain-computer interfaces (BCIs) have been successfully used by adults, but little information is available on BCI use by children, especially children with severe multiple impairments who may need technology to facilitate communication. Here we discuss the challenges of using non-invasive BCI with children, especially children who do not have another established method of communication with unfamiliar partners. Strategies to manage these challenges require consideration of multiple factors related to accessibility, cognition, and participation. These factors include decisions regarding where (home, clinic, or lab) participation will take place, the number of sessions involved, and the degree of participation necessary for success. A strategic approach to addressing the unique challenges inherent in BCI use by children with disabilities will increase the potential for successful BCI calibration and adoption of BCI as a valuable access method for children with the most significant impairments in movement and communication.

Accommodations to cognitive assessment for a child with dyskinetic cerebral palsy: case study.

PURPOSE: Despite the importance of having knowledge about a child's cognitive functioning, less than one-third of children with cerebral palsy (CP) are formally assessed. Consequently, the cognitive strengths of many children with severe CP may be underestimated or go overlooked. This case study aimed to test accommodations to cognitive assessment administration procedures to enable switch access. METHODS: A 9-year-old boy with dyskinetic CP tested a suite of cognitive assessments with accommodations for single switch access and measures of user experience. The cognitive assessment included: receptive vocabulary; non-verbal reasoning; sustained attention; executive functions of problem solving and shifting; and visual perception skills. RESULTS: The participant's ability to independently undertake assessment on the receptive vocabulary, non-verbal reasoning and the sustained attention measures indicates that accommodations made for single switch access were appropriate. Assessment took 1-2 h longer than expected for a typically developing child via standardised administration procedures, but was considerably faster than expected if undertaken via low-tech partner assisted scanning. Accessibility barriers continued to be present for the executive function and visual perception measures. Overall, the user experience was positive, both in regards to usability and cognitive load. CONCLUSIONS: This case study provides emerging data for usability and accessibility of accommodations to a battery of cognitive assessment tasks. Further research is needed to devise appropriate accommodations for executive function and visual perception measures and to determine whether the accommodations are accessible more generally for children with motor and/or speech impairments. Implications for rehabilitationAccommodations can be successfully made to receptive vocabulary, non-verbal reasoning and sustained attention assessment administration procedures for switch technologies.Cognitive assessment with switch accommodations takes considerably longer to complete than standardised administration estimates for a typically developing child. Assessment may need to be scheduled over more than one session.User experience, including usability and cognitive load, of accommodations was positive.

Eye movements and stress during eye-tracking gaming performance in children with dyskinetic cerebral palsy.

AIM: This study aimed to explore eye movements and stress during eye-tracking gaming performance in children with dyskinetic cerebral palsy (CP) compared with typically developing children, and associations between eye-tracking performance, eye movements, stress, and participants' characteristics. METHOD: This cohort study included 12 children with dyskinetic CP aged 5 to 12 years (mean age 8 years 7 months, standard deviation [SD] 2 years 3 months) and 23 typically developing children aged 5 to 13 years (mean age 9 years 0 months, SD 2 years 7 months). Participants played 10 eye-tracking games. Tobii X3-120 and Tobii Pro Lab were used to record and analyse eye movements. Stress was assessed through heart rate variability (HRV), recorded during rest, and eye-tracking performance using the Bittium Faros360° ECG Holter device. Eye-tracking performance was measured using gaming completion time. Fixation and saccade variables were used to quantify eye movements, and time- and frequency-domain variables to quantify HRV. Non-parametric statistics were used. RESULTS: Gaming completion time was significantly different (p < 0.001) between groups, and it was negatively correlated with experience (rs  = -0.63, p = 0.029). No significant differences were found between groups in fixation and saccade variables. HRV significantly changed from rest to eye-tracking performance only in typically developing children and not in children with dyskinetic CP. INTERPRETATION: Children with dyskinetic CP took longer to perform the 10 games, especially the inexperienced users, indicating the importance of the early provision of eye-tracking training opportunities. It seems that eye-tracking tasks are not a source of increased stress and effort in children with dyskinetic CP. WHAT THIS PAPER ADDS: Participants with dyskinetic cerebral palsy (CP) took twice as long to perform 10 eye-tracking games than typically developing peers. Participants with dyskinetic CP with previous eye-tracking experience performed the games faster. Fixation and saccade variables were not significantly different between children with and without dyskinetic CP. Heart rate variability showed no differences between rest and performance in participants with dyskinetic CP. Gross Motor Function Classification System, Manual Ability Classification System, and Viking Speech Scale levels were not correlated to the eye movements or stress variables.

Brain-Computer Interfaces for Children With Complex Communication Needs and Limited Mobility: A Systematic Review.

Brain-computer interfaces (BCIs) represent a new frontier in the effort to maximize the ability of individuals with profound motor impairments to interact and communicate. While much literature points to BCIs' promise as an alternative access pathway, there have historically been few applications involving children and young adults with severe physical disabilities. As research is emerging in this sphere, this article aims to evaluate the current state of translating BCIs to the pediatric population. A systematic review was conducted using the Scopus, PubMed, and Ovid Medline databases. Studies of children and adolescents that reported BCI performance published in English in peer-reviewed journals between 2008 and May 2020 were included. Twelve publications were identified, providing strong evidence for continued research in pediatric BCIs. Research evidence was generally at multiple case study or exploratory study level, with modest sample sizes. Seven studies focused on BCIs for communication and five on mobility. Articles were categorized and grouped based on type of measurement (i.e., non-invasive and invasive), and the type of brain signal (i.e., sensory evoked potentials or movement-related potentials). Strengths and limitations of studies were identified and used to provide requirements for clinical translation of pediatric BCIs. This systematic review presents the state-of-the-art of pediatric BCIs focused on developing advanced technology to support children and youth with communication disabilities or limited manual ability. Despite a few research studies addressing the application of BCIs for communication and mobility in children, results are encouraging and future works should focus on customizable pediatric access technologies based on brain activity.

Early Intervention for Children Aged 0 to 2 Years With or at High Risk of Cerebral Palsy: International Clinical Practice Guideline Based on Systematic Reviews.

Importance: Cerebral palsy (CP) is the most common childhood physical disability. Early intervention for children younger than 2 years with or at risk of CP is critical. Now that an evidence-based guideline for early accurate diagnosis of CP exists, there is a need to summarize effective, CP-specific early intervention and conduct new trials that harness plasticity to improve function and increase participation. Our recommendations apply primarily to children at high risk of CP or with a diagnosis of CP, aged 0 to 2 years. Objective: To systematically review the best available evidence about CP-specific early interventions across 9 domains promoting motor function, cognitive skills, communication, eating and drinking, vision, sleep, managing muscle tone, musculoskeletal health, and parental support. Evidence Review: The literature was systematically searched for the best available evidence for intervention for children aged 0 to 2 years at high risk of or with CP. Databases included CINAHL, Cochrane, Embase, MEDLINE, PsycInfo, and Scopus. Systematic reviews and randomized clinical trials (RCTs) were appraised by A Measurement Tool to Assess Systematic Reviews (AMSTAR) or Cochrane Risk of Bias tools. Recommendations were formed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework and reported according to the Appraisal of Guidelines, Research, and Evaluation (AGREE) II instrument. Findings: Sixteen systematic reviews and 27 RCTs met inclusion criteria. Quality varied. Three best-practice principles were supported for the 9 domains: (1) immediate referral for intervention after a diagnosis of high risk of CP, (2) building parental capacity for attachment, and (3) parental goal-setting at the commencement of intervention. Twenty-eight recommendations (24 for and 4 against) specific to the 9 domains are supported with key evidence: motor function (4 recommendations), cognitive skills (2), communication (7), eating and drinking (2), vision (4), sleep (7), tone (1), musculoskeletal health (2), and parent support (5). Conclusions and Relevance: When a child meets the criteria of high risk of CP, intervention should start as soon as possible. Parents want an early diagnosis and treatment and support implementation as soon as possible. Early intervention builds on a critical developmental time for plasticity of developing systems. Referrals for intervention across the 9 domains should be specific as per recommendations in this guideline.

Stakeholder consensus for decision making in eye-gaze control technology for children, adolescents and adults with cerebral palsy service provision: findings from a Delphi study.

BACKGROUND: Limited research exists to guide clinical decisions about trialling, selecting, implementing and evaluating eye-gaze control technology. This paper reports on the outcomes of a Delphi study that was conducted to build international stakeholder consensus to inform decision making about trialling and implementing eye-gaze control technology with people with cerebral palsy. METHODS: A three-round online Delphi survey was conducted. In Round 1, 126 stakeholders responded to questions identified through an international stakeholder Advisory Panel and systematic reviews. In Round 2, 63 respondents rated the importance of 200 statements generated by in Round 1. In Round 3, 41 respondents rated the importance of the 105 highest ranked statements retained from Round 2. RESULTS: Stakeholders achieved consensus on 94 of the original 200 statements. These statements related to person factors, support networks, the environment, and technical aspects to consider during assessment, trial, implementation and follow-up. Findings reinforced the importance of an individualised approach and that information gathered from the user, their support network and professionals are central when measuring outcomes. Information required to support an application for funding was obtained. CONCLUSION: This Delphi study has identified issues which are unique to eye-gaze control technology and will enhance its implementation with people with cerebral palsy.

Efficacy of a knowledge translation approach in changing allied health practitioner use of evidence-based practices with children with cerebral palsy: a before and after longitudinal study.

PURPOSE: To investigate the effect of a knowledge translation intervention on knowledge and frequency of routine evidence-based assessment behaviours of healthcare professionals working with children with cerebral palsy. METHODS: A before-and-after longitudinal study was conducted in five disability organisations. Four organisations (Commencing Knowledge Translation group) implemented a multifaceted intervention: knowledge brokers, targeted education, electronic-evidence library, and clinical outcomes database. These strategies were already in place at the fifth organisation (Comparison group). Outcomes evaluated at 0, 6, 12, and 24 months were health-professional knowledge and routine assessment behaviours (self-report and "completeness" of clinical assessment). Generalised estimating equations determined longitudinal changes. RESULTS: Four hundred and forty-seven professionals involved 861 children in the study. The Comparison group had higher knowledge and routine assessment behaviours at baseline. Professional knowledge in both groups remained stable (differences in change from baseline to 24 months: 0.3 units, 95%CI: -0.76 to 1.36). Assessment completeness of the Comparison group was stable (baseline mean 68 units, 95%CI: 65-71); the Commencing Knowledge Translation group improved from baseline mean 35 units (95%CI: 33-36), peaking at 12 months (mean 68 (95%CI: 65-71). CONCLUSIONS: Multifaceted organisational support improved health-professional routine evidence-based assessment behaviours with children with cerebral palsy, despite no change in knowledge. TRIAL REGISTRATION: This trial was not a controlled health care intervention and was registered retrospectively: ACTRN12616001616460. The protocol of the trial was published in 2015 as follows: Imms et al. [6].Implications for rehabilitationA multifaceted knowledge translation intervention increased allied health professionals' assessment behaviours.Knowledge translation strategies can be chosen to target change in knowledge and/or change in behaviour.Knowledge translation interventions should be designed to address organisational barriers and enhance organisational supports.Interventions that target healthcare professionals' behaviour directly can be effective even if their knowledge does not change.

Eye Gaze Gaming Intervention in Children with Dyskinetic Cerebral Palsy: A Pilot Study of Task Performance and Its Relation with Dystonia and Choreoathetosis.

OBJECTIVES: To investigate the operational competences screen navigation and dwell function underlying eye gaze performance, and the relation of dystonia and choreoathetosis with eye gaze performance in children with dyskinetic cerebral palsy (DCP). METHODS: During a 5-week intervention, ten participants with DCP played eye gaze video games daily for 30 minutes. Six games were used to assess task performance, fixation count, and eye movement accuracy during four measurements. Dystonia and choreoathetosis were evaluated using the Dyskinesia Impairment Scale. RESULTS: Eye gaze performance improved over time (p = .013). Moderate to strong within-subject correlations were found between eye movement accuracy and task performance, and between eye movement accuracy and fixation count. No significant correlations were found with the movement disorders. CONCLUSIONS: Eye gaze technology shows great potential to be a successful computer interface for children with severe DCP, thereby potentially improving their communication skills, participation levels, and quality of life.

Eyes on communication: trialling eye-gaze control technology in young children with dyskinetic cerebral palsy.

PURPOSE: This study aims to identify eye-gaze control technology outcomes, parent perception of the technology and support received, and gauge the feasibility of available measures. METHODS: Five children with dyskinetic cerebral palsy, mean age 4 years, 4 months (1 year, 0 months); n = 4 males; trialled two eye-gaze control technology systems, each for six weeks. Parents completed pre- and post-questionnaires. RESULTS: Parents found the 6-week home-based trial period to be the right length. Written guidelines and instructions about set-up, calibration, and play and learning activities were perceived as important. Children demonstrated improvements in goal achievement and performance. Parents found questionnaires on quality of life, participation, behaviours involved in mastering a skill and communication outcomes challenging to complete resulting in substantial missing data. CONCLUSION: Eye-gaze control technology warrants further investigation for young children with dyskinetic cerebral palsy in a large international study.

Eye-gaze control technology for children, adolescents and adults with cerebral palsy with significant physical disability: Findings from a systematic review.

PURPOSE: The primary objective of this systematic review was to examine the effectiveness of eye-gaze control technology for facilitating communication across different social contexts for people with cerebral palsy and significant physical disability. METHODS: Systematic review. RESULTS: The search identified 756 potentially eligible articles, of which two, low level articles were eligible. One study reported positive results for achieving communication goals for children with cerebral palsy. The second concluded that eye-gaze control technology resulted in greater quality of life and less depression for adults with late stage amyotrophic lateral sclerosis when compared to non-users. DISCUSSION: Research regarding the effectiveness of eye-gaze control technology used to access a laptop, tablet or computer on communication outcomes, participation, quality of life and self-esteem in children, adolescents and adults with cerebral palsy and significant physical disability is sparse. A scoping review to fully identify issues to inform clinical practice and future research is required.

Influences on students' assistive technology use at school: the views of classroom teachers, allied health professionals, students with cerebral palsy and their parents.

PURPOSE: This study explored how classroom teachers, allied health professionals, students with cerebral palsy, and their parents view high-tech assistive technology service delivery in the classroom. METHODS: Semi-structured interviews with six classroom teachers and six parents and their children were conducted. Additionally, two focus groups comprising 10 occupational therapists and six speech pathologists were carried out. Ethical and confidentiality considerations meant that the groups were not matched. RESULTS: Results revealed that it is often untrained staff member who determine students' educational needs. The participants' experiences suggested that, particularly in mainstream settings, there is a need for support and guidance from a professional with knowledge of assistive technology who can also take a lead and guide classroom teachers in how to meet students' needs. Students' motivation to use the technology was also found to be critical for its successful uptake. CONCLUSIONS: The study points to the need for classroom teachers to be given sufficient time and skill development opportunities to enable them to work effectively with assistive technology in the classroom. The participants' experiences suggest that such opportunities are not generally forthcoming. Only in this way can it be ensured that students with disabilities receive the education that is their right. Implications for Rehabilitation Classroom teachers, allied health professionals, students, parents need ongoing support and opportunities to practise operational, strategic and linguistic skills with the assistive technology equipment. System barriers to the uptake of assistive technology need to be addressed. To address the lack of time available for training, programing and other support activities around assistive technology, dedicated administrative support is crucial. Professional development around the use of the quality low cost ICF-CY checklist is recommended for both school and allied health staff.

Parent Perception of Two Eye-Gaze Control Technology Systems in Young Children with Cerebral Palsy: Pilot Study.

Eye-gaze control technology enables people with significant physical disability to access computers for communication, play, learning and environmental control. This pilot study used a multiple case study design with repeated baseline assessment and parents' evaluations to compare two eye-gaze control technology systems to identify any differences in factors such as ease of use and impact of the systems for their young children. Five children, aged 3 to 5 years, with dyskinetic cerebral palsy, and their families participated. Overall, families were satisfied with both the Tobii PCEye Go and myGaze® eye tracker, found them easy to position and use, and children learned to operate them quickly. This technology provides young children with important opportunities for learning, play, leisure, and developing communication.

Early, Accurate Diagnosis and Early Intervention in Cerebral Palsy: Advances in Diagnosis and Treatment.

Importance: Cerebral palsy describes the most common physical disability in childhood and occurs in 1 in 500 live births. Historically, the diagnosis has been made between age 12 and 24 months but now can be made before 6 months' corrected age. Objectives: To systematically review best available evidence for early, accurate diagnosis of cerebral palsy and to summarize best available evidence about cerebral palsy-specific early intervention that should follow early diagnosis to optimize neuroplasticity and function. Evidence Review: This study systematically searched the literature about early diagnosis of cerebral palsy in MEDLINE (1956-2016), EMBASE (1980-2016), CINAHL (1983-2016), and the Cochrane Library (1988-2016) and by hand searching. Search terms included cerebral palsy, diagnosis, detection, prediction, identification, predictive validity, accuracy, sensitivity, and specificity. The study included systematic reviews with or without meta-analyses, criteria of diagnostic accuracy, and evidence-based clinical guidelines. Findings are reported according to the PRISMA statement, and recommendations are reported according to the Appraisal of Guidelines, Research and Evaluation (AGREE) II instrument. Findings: Six systematic reviews and 2 evidence-based clinical guidelines met inclusion criteria. All included articles had high methodological Quality Assessment of Diagnostic Accuracy Studies (QUADAS) ratings. In infants, clinical signs and symptoms of cerebral palsy emerge and evolve before age 2 years; therefore, a combination of standardized tools should be used to predict risk in conjunction with clinical history. Before 5 months' corrected age, the most predictive tools for detecting risk are term-age magnetic resonance imaging (86%-89% sensitivity), the Prechtl Qualitative Assessment of General Movements (98% sensitivity), and the Hammersmith Infant Neurological Examination (90% sensitivity). After 5 months' corrected age, the most predictive tools for detecting risk are magnetic resonance imaging (86%-89% sensitivity) (where safe and feasible), the Hammersmith Infant Neurological Examination (90% sensitivity), and the Developmental Assessment of Young Children (83% C index). Topography and severity of cerebral palsy are more difficult to ascertain in infancy, and magnetic resonance imaging and the Hammersmith Infant Neurological Examination may be helpful in assisting clinical decisions. In high-income countries, 2 in 3 individuals with cerebral palsy will walk, 3 in 4 will talk, and 1 in 2 will have normal intelligence. Conclusions and Relevance: Early diagnosis begins with a medical history and involves using neuroimaging, standardized neurological, and standardized motor assessments that indicate congruent abnormal findings indicative of cerebral palsy. Clinicians should understand the importance of prompt referral to diagnostic-specific early intervention to optimize infant motor and cognitive plasticity, prevent secondary complications, and enhance caregiver well-being.