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.

Cognitive approach to rehabilitation in children with hyperkinetic movement disorders post-DBS.

OBJECTIVE: This proof-of-concept feasibility trial examined the potential of the Cognitive Orientation to daily Occupational Performance Approach (CO-OP) to augment deep brain stimulation (DBS) outcomes in childhood-onset hyperkinetic movement disorders (HMD) including dystonia and dyskinetic cerebral palsy. METHODS: This is a single case experimental design using multiple baseline as n-of-1 trial comprising 10 intervention sessions, with replications across participants (n = 10). Treatment focused on 3 participant-selected goals. Transfer was assessed on 2 additional untreated goals. Individuals enrolled were 6-21 years of age and had DBS in situ and sufficient manual ability. Primary outcome was functional performance change on the Performance Quality Rating Scale-Individualized (PQRS-i) measured before, during, and posttreatment, and at 3-month follow-up. Assessors of outcome were blinded to time of assessment, number of intervention session, and treatment allocation. To measure effect size, a nonoverlapping index, Tau-U, was used. Feasibility measures were captured. RESULTS: One participant withdrew before baseline assessment. Effect sizes of at least 0.66 were seen at both posttreatment and follow-up with all participants showing improvements in at least one trained goal in PQRS-i. Six participants improved on all 3 goals and 2 improved on 2 trained goals. Two children showed deterioration in one trained goal each. Transfer to untrained goals was observed in 3 participants for a total of 5 goals. CO-OP was feasible and acceptable to all participants. CONCLUSION: A cognitive-based, task-oriented approach to support performance of personally relevant functional skills enabling participation is acceptable in childhood-onset HMD post-DBS. Further, preliminary efficacy to improve outcomes and proof of concept with CO-OP has been established in this population. CLASSIFICATION OF EVIDENCE: This study provides Class IV evidence that for children with HMD who had undergone DBS, CO-OP improves performance of personally relevant functional skills.

Bilateral globus pallidus internus deep brain stimulation for dyskinetic cerebral palsy supports success of cochlear implantation in a 5-year old ex-24 week preterm twin with absent cerebellar hemispheres.

BACKGROUND: Early onset dystonia (dyskinesia) and deafness in childhood pose significant challenges for children and carers and are the cause of multiple disability. It is particularly tragic when the child cannot make use of early cochlear implantation (CI) technology to relieve deafness and improve language and communication, because severe cervical and truncal dystonia brushes off the magnetic amplifier behind the ears. Bilateral globus pallidus internus (GPi) deep brain stimulation (DBS) neuromodulation can reduce dyskinesia, thus supporting CI neuromodulation success. METHODS: We describe the importance of the order of dual neuromodulation surgery for dystonia and deafness. First with bilateral GPi DBS using a rechargeable ACTIVA-RC neurostimulator followed 5 months later by unilateral CI with a Harmony (BTE) Advanced Bionics Hi Res 90 K cochlear device. This double neuromodulation was performed in series in a 12.5 kg 5 year-old ex-24 week gestation-born twin without a cerebellum. RESULTS: Relief of dyskinesia enabled continuous use of the CI amplifier. Language understanding and communication improved. Dystonic storms abated. Tolerance of sitting increased with emergence of manual function. Status dystonicus ensued 10 days after ACTIVA-RC removal for infection-erosion at 3 years and 10 months. He required intensive care and DBS re-implantation 3 weeks later together with 8 months of hospital care. Today he is virtually back to the level of functioning before the DBS removal in 2012 and background medication continues to be slowly weaned. CONCLUSION: This case illustrates that early neuromodulation with DBS for dystonic cerebral palsy followed by CI for deafness is beneficial. Both should be considered early i.e. under the age of five years. The DBS should precede the CI to maximise dystonia reduction and thus benefits from CI. This requires close working between the paediatric DBS and CI services.

Improving Target Acquisition for Computer Users With Athetosis.

Prior work has highlighted the challenges faced by people with athetosis when trying to acquire on-screen targets using a mouse or trackball. The difficulty of positioning the mouse cursor within a confined area has been identified as a challenging task. We have developed a target acquisition assistance algorithm that features transition assistance via directional gain variation based on target prediction, settling assistance via gain reduction in the vicinity of a predicted target, and expansion of the predicted target as the cursor approaches it. We evaluated the algorithm on improving target acquisition efficiency among seven participants with athetoid cerebral palsy. Our results showed that the algorithm significantly reduced the overall movement time by about 20%. Considering the target acquisition occurs countless times in the course of regular computer use, the accumulative effect of such improvements can be significant for improving the efficiency of computer interaction among people with athetosis.

Physical therapy for a child with sudden-onset choreoathetosis: a case report.

PURPOSE: This case report describes the physical therapy examination, intervention, and outcomes for a 5-year-old girl who developed choreoathetosis following mitral valve repair. CASE DESCRIPTION: This child was admitted to an inpatient short-term rehabilitation program with marked choreoathetosis and dependence for all functional mobility. She received physical therapy twice a day for 5 weeks. Physical therapy intervention included therapeutic exercise emphasizing stabilization and closed chain exercises, aquatic therapy, and functional training to improve gross motor skills and mobility. Tests and measures included the Selective Control Assessment of the Lower Extremity, 66-item Gross Motor Function Measure, and Pediatric Evaluation of Disability Inventory. OUTCOMES: At discharge, this child demonstrated improvements in her Selective Control Assessment of the Lower Extremity, Gross Motor Function Measure, and Pediatric Evaluation of Disability Inventory scores. She was independent in all functional mobility tasks. SUMMARY: This case study describes physical therapy tests and measures, intervention, and positive outcomes for a child with sudden-onset choreoathetosis.

Toward filtering of athetoid motion with neural networks.

People with athetoid cerebral palsy (CP) have difficulty using computers due to unintentional involuntary movements in the upper extremities. A neural network-based system has been developed to cancel the undesired motion, and speed up the movements and accuracy in target acquisition and path tracking tasks while using an isometric joystick (IJ). Nonlinear filtering algorithms were created with neural networks using nonlinear models to help people with athetoid CP to access the computer. This paper presents unfiltered test data that have been collected from patients, and describes the planned filtering approach.

Gross motor function measure for children with cerebral palsy.

The aim of this study was to compare the pattern of motor dysfunction in Hong Kong Chinese children with spastic diplegic and the athetoid type of cerebral palsy (CP) by the Gross Motor Function Measure (GMFM). The GMFM was first tested on its content validity in differentiating the items suitable for testing on upper and lower limb function, followed by test-retest and inter-rater reliability studies, before it was used in a within-subject experiment comparing upper and lower gross motor function in two types of CP, respectively. Children with spastic diplegia (n=18) and with athetosis (n=19) were recruited from three pre-school centres, schools for physically handicapped children and centres of the Hong Kong Spastic Association in Hong Kong. The GMFM, a standardized outcome measure of the motor function in children with CP, was used in comparing mean scores of motor tasks involving upper limbs and those not involving upper limbs in the athetoid and spastic cerebral palsied children. The scores were significantly higher for the children in the spastic diplegic group, but there was no significant difference in the performance of static and dynamic motor tasks of the GMFM between the children in the two groups.

Melbourne Assessment of Unilateral Upper Limb Function: construct validity and correlation with the Pediatric Evaluation of Disability Inventory.

The Melbourne Assessment of Unilateral Upper Limb Function (Melbourne Assessment) is an evaluation tool that objectively measures upper-extremity function in children with cerebral palsy (CP). This study investigates how well performance on the Melbourne Assessment relates to the child's actual performance in functional tasks. Eighteen children with CP (5 to 14 years of age; nine males, nine females) were assessed using the Melbourne Assessment and the Pediatric Evaluation of Disability Inventory (PEDI). Five children had spastic quadriplegia, eight had spastic diplegia, two had spastic hemiplegia and diplegia, two had athetosis, and one had hypotonic quadriplegia with mobile ventilator dependence. Children's performances were statistically correlated using Spearman's rho to establish the relation between these tools. Very high correlation coefficients were calculated between the Melbourne Assessment and self-care (0.939) and mobility domains (0.783) of the PEDI and the overall functional skills section of the PEDI (0.718). The Melbourne Assessment demonstrates excellent construct validity for upper limb functioning.

A measurement system for the recognition of arm gestures using accelerometers.

This paper describes a strategy to measure arm movements using accelerometers for the computer recognition of arm gestures. Gesture recognition is being investigated as an alternative method of computer input for people with severe speech and motor impairment; the emphasis is on the needs of people with athetoid cerebral palsy who have difficulties with existing computer input devices. An initial model-based approach to estimate the kinematic motion of the arm from acceleration measurements is given, followed by the chosen measurement scheme. The current system considers the forearm as a rigid body and uses two data streams derived from four linear accelerometers. By treating these signals as outputs from postulated mechanical models, the data are reduced to two series of step inputs that are appropriate for pattern classification and recognition. Although this does not in any way model the arm, the concepts used are based on the type of driving signals expected in the control of arm gestures. Initial experimental results show that the information content of gestures is preserved by this data parameterization.

Movement disorders after status epilepticus and other brain injuries.

A retrospective medical record review was conducted of 173 consecutive children hospitalized for acquired brain injuries on a specialized pediatric rehabilitation service. The chart review identified children who developed movement disorders with acquired brain injuries: 8 with status epilepticus, 2 with trauma, and 1 with anoxia. Movement disorders were observed more frequently following status epilepticus (8 of 12) than following other causes of acquired brain injury (3 of 161; P = .0001). Four additional children had severe neurologic deficits following status epilepticus but did not develop movement disorders. The 11 patients who developed movement disorders had choreiform movements predominantly. Even though status epilepticus is a clinical phenomenon resulting from a variety of etiologies, the features of movement disorders in these children were strikingly similar. The pathophysiology of this complication is unknown.

Comparison of three computer scanning modes as an interface method for persons with cerebral palsy.

Occupational therapists are becoming increasingly involved with interface assessments. This involvement is improving the ability of persons with physical disabilities to interact with computers, augmentative communication aids, and other devices. The ability to use these devices facilitates participation in activities that would otherwise be much more difficult to pursue, such as communication, education, work, and recreation. The purpose of the present study was to systematically compare three basic modes of scanning--automatic, inverse, and step--with the use of a single-subject experimental design. Six subjects--3 with spastic and 3 with athetoid cerebral palsy--from a local school volunteered for the study. Results indicated that the 3 subjects with spastic cerebral palsy had the greatest difficulty using the automatic scanning mode. The 3 subjects with athetoid cerebral palsy had the most difficulty using the step scanning mode. The results of this study suggest that clients should attempt each scanning mode and that their performance with each mode be compared to ensure the most appropriate recommendations.

Nondominant arm restraint and dominant arm function in a child with athetoid cerebral palsy: electromyographic and functional evaluation.

This single case study was designed to determine the effect of restraining the nondominant arm on the function of the dominant arm of a child with athetoid cerebral palsy. Performance time of shoulder horizontal adduction was computed with and without the restraint. Electromyographic (EMG) activity of selected muscles was simultaneously monitored by surface electrodes. Performance time was less when the arm restraint was applied. Generally, tonic and phasic EMG activity decreased in all muscles monitored. The results show that upper extremity motor function improved in the dominant arm when the nondominant arm was restrained and that myoelectric activity was not adversely affected when the restraint was applied.

[Motor goals of therapeutic horseback riding for cerebral palsied children (author's transl)]. / Motorische Zielsetzungen beim therapeutischen Reiten mit zerebralparetischen Kindern. Eine kritische Analyse.

The article reviews in a critical survey the current opinions on the possibilities of improving the motor functions of cerebral palsied children with the help of riding therapy. Furthermore, the essential motor difficulties with spasm, athetosis and ataxia are described. It is demonstrated that only a small number of these typical difficulties can be tackled by means of riding therapy and that some key problems, particularly encountered by the spastics, cannot be solved. If, despite these facts, the favourable effects of riding on the cerebral palsied cannot be denied, then this must be attributed, first of all, to the unique psychological motivation derived from riding. Credit is given to the effects on the autonomic nervous system, the psyche, the world of experience and the behaviour.

Contingent feedback for training children to propel their wheelchairs.

Three multiply handicapped children were taught self-movement of their wheelchairs. This behavior was established through the use of contingent reinforcement within 30-minute therapy sessions. When a high number of self-movement responses were obtained, the reinforcement was systematically withdrawn to allow the responses to come under the control of the natural environmental consequences.

[Trampoline therapy with brain-injured children and adolescents (author's transl)]. / Trampolin- Therapie bei hirngeschdigten Kindern und Jugendlichen

Trampoline therapy is a useful part of the medical rehabilitation treatment of brain-injured children and adolescents, if the basic principles of accident prevention are observed. The therapy should only consist of systematically organised exercise series and be carried out by adequately trained sport teachers, medical paedagogues or physical therapists. In the "Jugendwerk Gailingen" an improvement of the standing balance and movement co-ordination was achieved in more than 20 patients with hemiparesis and tetraparesis. Only little progress was achieved in atactic and athetoid patients. It is important to stress the positive psychological effects of the trampoline therapy.