A review of the effectiveness of lower limb orthoses used in cerebral palsy

To produce this review, a systematic literature search was conducted for relevant articles published in the period between the date of the previous ISPO consensus conference report on cerebral palsy (1994) and April 2008. The search terms were 'cerebral and pals* (palsy, palsies), 'hemiplegia', 'diplegia', 'orthos*' (orthoses, orthosis) orthot* (orthotic, orthotics), brace or AFO

Upper limb function in children with cerebral palsy : range of motion, botulinum neurotoxin A and accelerometry metrics

Cerebral palsy (CP) is the most common cause of movement disorders in children and may result in diverse levels of severity of the disability, from very mild to very severe. The underlying neurological pathology in CP is by definition not progressive, but motor symptoms may cause permanent and progressive secondary movement complications, which often change over time. Movement disorders are a prominent component in individuals with CP and treatments are often aimed at affecting movement disorders. Since CP is caused by a permanent lesion to the brain, the lesion will affect the individual in different ways throughout life and in daily life activities. Thus, it is particularly important to understand how secondary complications develop from early childhood until adulthood in this population. Measurement tools that are evaluating individuals’ daily life need to be psychometrically evaluated, and we also need to evaluate the treatments outcome of the secondary complications within CP efficiently. Gaining more knowledge about secondary complications to CP is a priority in CP research. This thesis focuses on upper limb (UL) passive range of motion (pROM) and contracture development over time, botulinum neurotoxin A (BoNT-A) and on accelerometry based metrics evaluated in daily life in children and adolescents. Upper limb passive range of motion change over time and BoNT-A treatment were investigated by population-based data sourced from the Swedish national CP registry. Upper limb clinical assessments and accelerometry based metrics were obtained from 20 children and adolescents, who were residents of Sörmland or Västmanland in Sweden. Results show that one-third of children and adolescents with CP developed upper limb contractures and the pROM deteriorated over time. The contracture development started already at preschool age. The first and most severe contractures were found in wrist extension with extended fingers. Children with the most affected level of manual ability were at highest risk for contracture development. One-fifth of children with spastic or dyskinetic CP had been treated with BoNT-A in the ULs, 45% of them early at age, 1–3 years. Children with lower levels of manual ability or full pROM with resistance at the end of the movement range were most likely to receive a first UL BoNT-A treatment. At the first treatment occasion, thumb and forearm muscles were the most targeted. Interestingly, a first UL BoNT-A treatment at an early age, 1-3 years implied a favourable pROM development over time compared to children treated first time at a later age, 4-15 years. Early detection of a first sign of muscle shortening and thus early intervention before contractures are manifested can be one of the keys to successful outcomes. In daily life, during sedentary time and light-intensity physical activity, accelerometry metrics provide objective information about UL asymmetry and relative use. Thus, accelerometry metrics may provide complementary information to clinical assessments in daily life

PREDICT-CP: study protocol of implementation of comprehensive surveillance to predict outcomes for school-aged children with cerebral palsy

Objectives: Cerebral palsy (CP) remains the world’s most common childhood physical disability with total annual costs of care and lost well-being of $A3.87b. The PREDICT-CP (NHMRC 1077257 Partnership Project: Comprehensive surveillance to PREDICT outcomes for school age children with CP) study will investigate the influence of brain structure, body composition, dietary intake, oropharyngeal function, habitual physical activity, musculoskeletal development (hip status, bone health) and muscle performance on motor attainment, cognition, executive function, communication, participation, quality of life and related health resource use costs. The PREDICT-CP cohort provides further follow-up at 8–12 years of two overlapping preschool-age cohorts examined from 1.5 to 5 years (NHMRC 465128 motor and brain development; NHMRC 569605 growth, nutrition and physical activity). Methods and analyses: This population-based cohort study undertakes state-wide surveillance of 245 children with CP born in Queensland (birth years 2006–2009). Children will be classified for Gross Motor Function Classification System; Manual Ability Classification System, Communication Function Classification System and Eating and Drinking Ability Classification System. Outcomes include gross motor function, musculoskeletal development (hip displacement, spasticity, muscle contracture), upper limb function, communication difficulties, oropharyngeal dysphagia, dietary intake and body composition, participation, parent-reported and child-reported quality of life and medical and allied health resource use. These detailed phenotypical data will be compared with brain macrostructure and microstructure using 3 Tesla MRI (3T MRI). Relationships between brain lesion severity and outcomes will be analysed using multilevel mixed-effects models. Ethics and dissemination: The PREDICT-CP protocol is a prospectively registered and ethically accepted study protocol. The study combines data at 1.5–5 then 8–12 years of direct clinical assessment to enable prediction of outcomes and healthcare needs essential for tailoring interventions (eg, rehabilitation, orthopaedic surgery and nutritional supplements) and the projected healthcare utilisation

Clinical Classification of Cerebral Palsy

The classification of cerebral palsy (CP) remains a challenge; hence the presence of so many classifications and a lack of consensus. Each classification used alone is incomplete. Therefore, a multiaxial classification gives a more comprehensive description of a child with CP. The recent WHO International Classification of Functioning, Disability and Health (ICF) emphasizes the importance of focusing on the functional consequences of various states of health and has stimulated the development of newer functional scales in CP. It is widely accepted that the functional classification is the best classification for the patient because it guides management. The objectives of this chapter are to review the various classifications of CP, to highlight the clinical features used in the various classifications, to outline the recent functional classifications of CP and to highlight how these recent classifications guide current management. It is expected that at the end of this chapter, the reader should be able to understand the difficulties in classifying CP, enumerate and discuss the various classifications of CP, understand the merits and shortcomings of each classification scheme, clinically evaluate and classify a child with CP multiaxially and understand how functional scales predict current and future needs of children with CP

Développement d’un outil automatique d’aide au diagnostic pour les enfants atteints de paralysie cérébrale en réadaptation robotique

La paralysie cérébrale représente l’infirmité la plus courante chez les enfants, affectant le mouvement, la coordination et la tonicité musculaire. Cette atteinte peut avoir des effets dévastateurs sur le développement des enfants, s’accompagnant d’une grande difficulté pour accomplir les tâches de la vie quotidienne. Les interventions médicamenteuses, psychothérapeutiques et l’adoption de nouvelles technologies d’assistance robotisée, sont des moyens qui permettent d’améliorer la qualité de vie et procurer une indépendance maximale aux enfants dont les capacités mentales le permettent. Les résultats de ces prises en charge sont généralement basés sur des outils d’évaluation subjectives qui dépendent grandement de l’avis de l’évaluateur et des facteurs environnementaux. Dans le but d’améliorer l’efficacité de ces interventions, l’objectif de cette thèse est de développer un outil de catégorisation des comportements musculaires dynamiques et les habilités motrices des enfants atteints de paralysie cérébrale. Cet objectif global est subdivisé en trois objectifs spécifiques: (1) tester la validité d’une méthode assistée par ordinateur pour la classification des niveaux fonctionnels des enfants avec paralysie cérébrale à partir des mouvements simples d’extension-flexion et de supination-pronation; (2) explorer d’autres techniques d’apprentissage machine plus avancées pour la catégorisation des habilités motrices à partir des mouvements effectués avec un dispositif d’assistance robotisé REAplan; et (3) comparer les comportements musculaires dynamiques aux membres supérieurs entre les enfants atteints de paralysie cérébrale avant et après la rééducation afin de valider l’efficacité du REAPlan comme outil de réadaptation. Parmi les résultats, une bonne corrélation a été trouvée entre les niveaux de sévérité établis par l’échelle « Manuel Ability Classification System » (MACS) et les niveaux de sévérité issus de la méthode de classification. En outre, il a été possible de différencier les enfants avec un développement normal, des enfants avec paralysie cérébrale pré-thérapie et post-thérapie, avec une précision globale de 97,6%. Par la suite, un indice quantitatif « Upper Limb Motor Function Index » (ULMFI) a été calculé à partir des paramètres électromyographiques et accélérométriques les plus pertinents pour distinguer les trois groupes d’enfants. L'ULMFI a montré des différences significatives entre le groupe avec un développement normal et les enfants avec paralysie cérébrale pré et post-thérapie assistée par robot. Les résultats de cette thèse suggèrent que les coûts et les efforts nécessaires pour évaluer et caractériser le niveau de limitation d'un enfant atteint de paralysie cérébrale, peuvent être davantage réduits avec des techniques d'apprentissage machine. Comme perspective, cette méthode pourra aussi être appliquée à d’autres populations atteintes de maladies neuromusculaires et de déficits moteurs cérébraux, afin de mieux cibler les muscles atteints avec des traitements spécifiques et d'améliorer le diagnostic médical.----------ABSTRACT Cerebral palsy is the most common disability in children, affecting movement, coordination and muscle tone. This disability has a devastating effect on children development, on their quality of life and impacts their ability to perform everyday tasks. The use of appropriate combinations of medical and psychotherapeutic interventions and the adoption of the assistive robotic devices could improve the independence and quality of life of children with cerebral palsy whose mental abilities allow it. The effects of these interventions are generally assessed based on the perspective of the therapist evaluating the child and the environmental factors. To improve the effectiveness of these interventions, the aim of this thesis was to develop a computerized method to estimate the disability levels of children with cerebral palsy. To do so our three specific objectives were: (1) validating a computerized method to classify disability levels of children with cerebral palsy during two main movements of upper extremity: extension-flexion and supination-pronation; (2) testing a more advanced machine learning techniques to categorize motor skills using an assistive robotic device REAplan; and (3) comparing dynamic muscle behavior in upper limbs between children with cerebral palsy before and after the intervention to validate the effectiveness of REAPlan as a rehabilitation tool. A good correlation was found between the severity levels fixed by the « Manual Ability Classification System » (MACS) and the obtained classes. In addition, it was possible to differentiate children with typical development from children with cerebral palsy pre-therapy and post-therapy, with an overall accuracy of 97.6%. Thereafter, a quantitative « Upper Limb Motor Function Index » (ULMFI) was calculated from the most relevant electromyographic and accelerometric parameters to distinguish between the three groups of children. The ULMFI was able to differentiate between children with typical development and children with cerebral palsy pre and post Robot-Assisted Therapy (Robot-AT). The results of this thesis suggest that the cost and effort needed to assess and characterize the disability level of a child with cerebral palsy can be further reduced using machine learning techniques. As a perspective, the proposed assessment method can also be applied to other populations with neuromuscular diseases and cerebral motor deficits, to identify the muscles to target with specific treatments and improve medical diagnosis

Development and evaluation of an evidence-based and individually defined physical therapy approach for ambulant children with bilateral spastic cerebral palsy

status: publishe

Playfully Assessing Lower Extremity Selective Voluntary Motor Control in Children With Cerebral Palsy: Psychometric Study

Background Objective measures specifically assessing selective voluntary motor control are scarce. Therefore, we have developed an interval-scaled assessment based on accelerometers. Objective This study provided a preliminary evaluation of the validity and reliability of this novel gamelike assessment measuring lower limb selective voluntary motor control in children with cerebral palsy (CP). Methods Children with CP and their neurologically intact peers were recruited for this psychometric evaluation of the assessgame. The participants played the assessgame and steered an avatar by selective hip, knee, or ankle joint movements captured with accelerometers. The assessgame’s scores provide information about the accuracy of the selective movement of the target joint and the amplitude and frequency of involuntary movements occurring in uninvolved joints. We established discriminative validity by comparing the assessgame scores of the children with CP with those of the neurologically intact children, concurrent validity by correlations with clinical scores and therapists’ opinions, and relative and absolute test-retest reliability. Results We included 20 children with CP (mean age 12 years and 5 months, SD 3 years and 4 months; Gross Motor Function Classification System levels I to IV) and 31 neurologically intact children (mean age 11 years and 1 month, SD 3 years and 6 months). The assessgame could distinguish between the children with CP and neurologically intact children. The correlations between the assessgame’s involuntary movement score and the therapist’s rating of the occurrence of involuntary movements during the game were moderate (Spearman ρ=0.56; P=.01), whereas the correlations of the assessgame outcomes with the Selective Control Assessment of the Lower Extremity and Gross Motor Function Classification System were low and not significant (|ρ|≤0.39). The intraclass correlation coefficients were >0.85 and indicated good relative test-retest reliability. Minimal detectable changes amounted to 25% (accuracy) and 44% (involuntary movement score) of the mean total scores. The percentage of children able to improve by the minimal detectable change without reaching the maximum score was 100% (17/17) for the accuracy score and 94% (16/17) for the involuntary movement score. Conclusions The assessgame proved reliable and showed discriminative validity in this preliminary evaluation. Concurrent validity was moderate with the therapist’s opinion but relatively poor with the Selective Control Assessment of the Lower Extremity. We assume that the assessment’s gamelike character demanded various other motor control aspects that are less considered in current clinical assessments

Methods and metrics for the improvement of the interaction and the rehabilitation of cerebral palsy through inertial technology

Cerebral palsy (CP) is one of the most limiting disabilities in childhood, with 2.2 cases per 1000 1-year survivors. It is a disorder of movement and posture due to a defect or lesion of the immature brain during the pregnancy or the birth. These motor limitations appear frequently in combination with sensory and cognitive alterations generally result in great difficulties for some people with CP to manipulate objects, communicate and interact with their environment, as well as limiting their mobility. Over the last decades, instruments such as personal computers have become a popular tool to overcome some of the motor limitations and promote neural plasticity, especially during childhood. According to some estimations, 65% of youths with CP that present severely limited manipulation skills cannot use standard mice nor keyboards. Unfortunately, even when people with CP use assistive technology for computer access, they face barriers that lead to the use of typical mice, track balls or touch screens for practical reasons. Nevertheless, with the proper customization, novel developments of alternative input devices such as head mice or eye trackers can be a valuable solution for these individuals. This thesis presents a collection of novel mapping functions and facilitation algorithms that were proposed and designed to ease the act of pointing to graphical elements on the screen—the most elemental task in human-computer interaction—to individuals with CP. These developments were implemented to be used with any head mouse, although they were all tested with the ENLAZA, an inertial interface. The development of such techniques required the following approach: Developing a methodology to evaluate the performance of individuals with CP in pointing tasks, which are usually described as two sequential subtasks: navigation and targeting. Identifying the main motor abnormalities that are present in individuals with CP as well as assessing the compliance of these people with standard motor behaviour models such as Fitts’ law. Designing and validating three novel pointing facilitation techniques to be implemented in a head mouse. They were conceived for users with CP and muscle weakness that have great difficulties to maintain their heads in a stable position. The first two algorithms consist in two novel mapping functions that aim to facilitate the navigation phase, whereas the third technique is based in gravity wells and was specially developed to facilitate the selection of elements in the screen. In parallel with the development of the facilitation techniques for the interaction process, we evaluated the feasibility of use inertial technology for the control of serious videogames as a complement to traditional rehabilitation therapies of posture and balance. The experimental validation here presented confirms that this concept could be implemented in clinical practice with good results. In summary, the works here presented prove the suitability of using inertial technology for the development of an alternative pointing device—and pointing algorithms—based on movements of the head for individuals with CP and severely limited manipulation skills and new rehabilitation therapies for the improvement of posture and balance. All the contributions were validated in collaboration with several centres specialized in CP and similar disorders and users with disability recruited in those centres.La parálisis cerebral (PC) es una de las deficiencias más limitantes de la infancia, con un incidencia de 2.2 casos por cada 1000 supervivientes tras un año de vida. La PC se manifiesta principalmente como una alteración del movimiento y la postura y es consecuencia de un defecto o lesión en el cerebro inmaduro durante el embarazo o el parto. Las limitaciones motrices suelen aparecer además en compañía de alteraciones sensoriales y cognitivas, lo que provoca por lo general grandes dificultades de movilidad, de manipulación, de relación y de interacción con el entorno. En las últimas décadas, el ordenador personal se ha extendido como herramienta para la compensación de parte de estas limitaciones motoras y como medio de promoción de la neuroplasticidad, especialmente durante la infancia. Desafortunadamente, cerca de un 65% de las personas PC que son diagnosticadas con limitaciones severas de manipulación son incapaces de utilizar ratones o teclados convencionales. A veces, ni siquiera la tecnología asistencial les resulta de utilidad ya que se encuentran con impedimentos que hacen que opten por usar dispositivos tradicionales aun sin dominar su manejo. Para estas personas, los desarrollos recientes de ratones operados a través de movimientos residuales con la cabeza o la mirada podrían ser una solución válida, siempre y cuando se personalice su manejo. Esta tesis presenta un conjunto de novedosas funciones de mapeo y algoritmos de facilitaci ón que se han propuesto y diseñado con el ánimo de ayudar a personas con PC en las tareas de apuntamiento de objetos en la pantalla —las más elementales dentro de la interacción con el ordenador. Aunque todas las contribuciones se evaluaron con la interfaz inercial ENLAZA, desarrollada igualmente en nuestro grupo, podrían ser aplicadas a cualquier ratón basado en movimientos de cabeza. El desarrollo de los trabajos se resume en las siguientes tareas abordadas: Desarrollo de una metodología para la evaluación de la habilidad de usuarios con PC en tareas de apuntamiento, que se contemplan como el encadenamiento de dos sub-tareas: navegación (alcance) y selección (clic). Identificación de los tipos de alteraciones motrices presentes en individuos con PC y el grado de ajuste de éstos a modelos estándares de comportamiento motriz como puede ser la ley de Fitts. Propuesta y validación de tres técnicas de facilitación del alcance para ser implementadas en un ratón basado en movimientos de cabeza. La facilitación se ha centrado en personas que presentan debilidad muscular y dificultades para mantener la posición de la cabeza. Mientras que los dos primeros algoritmos se centraron en facilitar la navegación, el tercero tuvo como objetivo ayudar en la selección a través de una técnica basada en pozos gravitatorios de proximidad. En paralelo al desarrollo de estos algoritmos de facilitación de la interacción, evaluamos la posibilidad de utilizar tecnología inercial para el control de videojuegos en rehabilitación. Nuestra validación experimental demostró que este concepto puede implementarse en la práctica clínica como complemento a terapias tradicionales de rehabilitación de la postura y el equilibrio. Como conclusión, los trabajos desarrollados en esta tesis vienen a constatar la idoneidad de utilizar sensores inerciales para el desarrollo de interfaces de accesso alternativo al ordenador basados en movimientos residuales de la cabeza para personas con limitaciones severas de manipulación. Esta solución se complementa con algoritmos de facilitación del alcance. Por otra parte, estas soluciones tecnológicas de interfaz con el ordenador representan igualmente un complemento de terapias tradicionales de rehabilitación de la postura y el equilibrio. Todas las contribuciones se validaron en colaboración con una serie de centros especializados en parálisis cerebral y trastornos afines contando con usuarios con discapacidad reclutados en dichos centros.This thesis was completed in the Group of Neural and Cognitive Engineering (gNEC) of the CAR UPM-CSIC with the financial support of the FP7 Framework EU Research Project ABC (EU-2012-287774), the IVANPACE Project (funded by Obra Social de Caja Cantabria, 2012-2013), and the Spanish Ministry of Economy and Competitiveness in the framework of two projects: the Interplay Project (RTC-2014-1812-1) and most recently the InterAAC Project (RTC-2015-4327-1)Programa Oficial de Doctorado en Ingeniería Eléctrica, Electrónica y AutomáticaPresidente: Juan Manuel Belda Lois.- Secretario: María Dolores Blanco Rojas.- Vocal: Luis Fernando Sánchez Sante