Stretch hyperreflexia in children with cerebral palsy:Assessment - Contextualization - Modulation

Cerebral palsy (CP) is a neurological disorder and the most frequent cause of motor impairment in children in Europe. Around 85% of children with CP experience stretch hyperreflexia, also known as “spasticity”. Stretch hyperreflexia is an excessive response to muscle stretch, leading to increased joint resistance. The joint hyper-resistance causes limitations in activities such as walking. Multiple methods have been developed to measure stretch hyperreflexia, but evidence supporting the use of these methods for diagnostics and treatment evaluation in children with CP is insufficient. Furthermore, most methods are designed to assess stretch reflexes in passive conditions, which might not translate to the limitations encountered due to stretch reflexes during activities. Furthermore, while a broad range of stretch hyperreflexia treatments is available, many are invasive, non-specific, or temporary and might have adverse side effects. Training methods to reduce stretch reflexes using biofeedback are promising non-invasive methods with potential long-term sustained effects. Still, clinical feasibility needs to be improved before implementation in clinical rehabilitation of children with CP. This thesis aimed to develop methods to assess stretch hyperreflexia of the calf muscles during passive conditions, as well as in the context of walking. Additionally, this thesis aimed to develop clinically feasible methods to modulate stretch hyperreflexia in the calf muscle of children with CP. The outcomes are described in eight different studies presented in this thesis. All in all, the work presented in this thesis shows that sagittal plane clinical gait analysis can be performed using the human body model and can be complemented with ultrasound imaging of the calf muscle. Motorized methods to assess stretch hyperreflexia in passive conditions might be useful for evaluation in adults after SCI/Stroke. Still, limitations regarding feasibility and validity limit clinical application for children with CP. Furthermore, this thesis provides additional evidence that the deviating muscle activation patterns during walking, particularly the increased activation around initial contact, are caused by stretch hyper-reflexes in children with CP. The deviating muscle activation patterns, with increased activation during early stance and reduced activation around push-off, can be modulated within one session by several children with CP. Therefore, the next step is to develop a training program to modulate the activation pattern and potentially decrease stretch hyper-reflexes in children with CP to improve the gait patter

Development of techniques for measuring the mobility of knee joints in children with Cerebral Palsy

Cerebral Palsy, commonly referred to as CP, is a neurological disorder that results in loss or impairment of motor function, which affects body movement, muscle control, muscle coordination and balance. In Sweden, about 200 children are diagnosed with Cerebral Palsy every year and the disorder can cause imbalances between the muscles. These imbalances can lead to contractures which is equiva- lent to permanent shortening of muscles and stiffness of joints. This can severely affect the mobility of the child and the quality of life. Today, the only way for physicians or physiotherapists to evaluate the movement of the joints, is during a patient’s short visits to the hospital. The purpose of this project was to develop a device that was able to measure the range of motion of the knee during a longer period of time, which could help customize the child’s rehabilitation. The initial approach was to implement two inertial measurement units (IMUs) and find the angle between the sensors. Different solutions on finding the angle was tested without being able to obtain stable data and the project members chose a new approach. Instead of IMUs, a potentiometer was used and stable data was obtained. A prototype was developed in an iterative and incremental product development process and data was collected during different types of physical exercise. The final prototype was wireless, able to collect data during ordinary life activities and had a battery life of over 30 hours. The data was analyzed and the results were accurate but showed that the prototype probably hindered some of the natural movement of the knee. The developed prototype is a step towards being able to measure the knee range of motion during a longer period of time, and could be a tool for physicians and other medical staff when evaluating and rehabilitating children with CP.Utveckling av mätteknik för mätning av rörligheten i knäleder hos barn med Cerebral pares Cerebral pares (CP) är en neurologisk störning som kan leda till förlust eller nedsättning av de motoriska funktioner som påverkar kroppens rörelser, muskelkontroll, koordination och balans. CP kan orsaka obalanser mellan musklerna som kan leda till kontrakturer. Kontrakturer innebär att musklerna förkortas permanent och styvheten i lederna ökar. Muskelförkortning och styva leder kan drastiskt påverka barnets rörlighet och därmed även livskvaliteten. I Sverige diagnostiseras cirka 200 barn varje år med CP och i dagsläget är det enda sättet för läkaren eller fysioterapeuten att utvärdera barnens rörelsefunktion under kortare besök på sjukhuset, 1-2 gånger per år. Därför var syftet med detta projekt att utveckla en prototyp som kunde mäta knäets ledrörlighet under en längre period

Joint and muscle assessments of the separate effects of Botulinum NeuroToxin-A and lower-leg casting in children with cerebral palsy

Botulinum NeuroToxin-A (BoNT-A) injections to the medial gastrocnemius (MG) and lower-leg casts are commonly combined to treat ankle equinus in children with spastic cerebral palsy (CP). However, the decomposed treatment effects on muscle or tendon structure, stretch reflexes, and joint are unknown. In this study, BoNT-A injections to the MG and casting of the lower legs were applied separately to gain insight into the working mechanisms of the isolated treatments on joint, muscle, and tendon levels. Thirty-one children with spastic CP (GMFCS I-III, age 7.4 +/- 2.6 years) received either two weeks of lower-leg casts or MG BoNT-A injections. During full range of motion slow and fast passive ankle rotations, joint resistance and MG stretch reflexes were measured. MG muscle and tendon lengths were assessed at resting and at maximum dorsiflexion ankle angles using 3D-freehand ultrasound. Treatment effects were compared using non-parametric statistics. Associations between the effects on joint and muscle or tendon levels were performed using Spearman correlation coefficients (p < 0.05). Increased joint resistance, measured during slow ankle rotations, was not significantly reduced after either treatment. Additional joint resistance assessed during fast rotations only reduced in the BoNT-A group (-37.6%, p = 0.013, effect size = 0.47), accompanied by a reduction in MG stretch reflexes (-70.7%, p = 0.003, effect size = 0.56). BoNT-A increased the muscle length measured at the resting ankle angle (6.9%, p = 0.013, effect size = 0.53). Joint angles shifted toward greater dorsiflexion after casting (32.4%, p = 0.004, effect size = 0.56), accompanied by increases in tendon length (5.7%, p = 0.039, effect size = 0.57; r = 0.40). No associations between the changes in muscle or tendon lengths and the changes in the stretch reflexes were found. We conclude that intramuscular BoNT-A injections reduced stretch reflexes in the MG accompanied by an increase in resting muscle belly length, whereas casting resulted in increased dorsiflexion without any changes to the muscle length. This supports the need for further investigation on the effect of the combined treatments and the development of treatments that more effectively lengthen the muscle

Cerebral Palsy

Nowadays, cerebral palsy (CP) rehabilitation, along with medical and surgical interventions in children with CP, leads to better motor and postural control and can ensure ambulation and functional independence. In achieving these improvements, many modern practices may be used, such as comprehensive multidisciplinary assessment, clinical decision making, multilevel surgery, botulinum toxin applications, robotic ambulation applications, treadmill, and other walking aids to increase the quality and endurance of walking. Trainings are based on neurodevelopmental therapy, muscle training and strength applications, adaptive equipment and orthotics, communication, technological solves, and many others beyond the scope of this book. In the years of clinical and academic experiences, children with cerebral palsy have shown us that the world needs a book to give clinical knowledge to health professionals regarding these important issue. This book is an attempt to fulfill and to give “current steps” about CP. The book is intended for use by physicians, therapists, and allied health professionals who treat/rehabilitate children with CP. We focus on the recent concepts in the treatment of body and structure problems and describe the associated disability, providing suggestions for further reading. All authors presented the most frequently used and accepted treatment methods with scientifically proven efficacy and included references at the end of each chapter

Clinimetric evaluation of inertial motion sensors of the cervical spine in patients with pediatric neurological motor disorders: validity, reliability and behavior patterns

Para los profesionales sanitarios es de gran importancia la obtención de datos clínicos válidos y fiables, para establecer unos objetivos de tratamiento adecuados a las necesidades específicas de cada paciente y para poder valorar su efectividad. Los sensores inerciales de movimiento (IMU) representan un gran avance para medir la cinemática de los segmentos corporales, aplicable al ámbito sanitario, y muestran una buena fiabilidad en la medición del Rango de movimiento articular (ROM) en humanos y la columna cervical en adultos. Por otro lado, un problema común en la Parálisis Cerebral (PC) es la demora o déficit en el Control Cefálico (CC), considerado un hito motor básico, que condiciona el desarrollo y adquisición progresiva de los niveles motrices. Además, el CC se encarga de garantizar una adecuada y segura alimentación, así como, permitir desarrollar adaptaciones posturales para relacionarse, adaptarse al entorno y sus exigencias. Así, esta tesis doctoral se propone como un estudio de las propiedades métricas, en términos de validez y fiabilidad, de los IMU, como herramienta de medida del ROM y el CC en sujetos con PC. Para ello, se analiza la movilidad cervical determinada sincrónicamente con el instrumento Cervical Range of Motion (CROM) y con IMU, así como se describe el diseño y desarrollo de una nueva prueba para la evaluación del ROM y el CC cervical en la población infantil con PC. En ambos casos, además del análisis de un grupo de sujetos con PC, se ha estudiado una muestra de sujetos control. Frente a este contexto, en la primera publicación, se abordó como objetivo principal determinar las propiedades clinimétricas en términos de validez y fiabilidad de los IMU en la medición del ROM cervical en niños con PC. Para ello se diseñó un protocolo de evaluación, una hoja informativa junto con un consentimiento informado y un documento para el registro de los datos. Se emplearon un IMU y un dispositivo CROM de forma simultánea. El ROM cervical se midió mediante la realización de 3 repeticiones de cada movimiento cervical, que se reprodujeron pasados 5 minutos para valorar la fiabilidad intradía. De igual forma, la medición se repitió a los 3-5 días para la estimación de la fiabilidad interdías. Los datos se anotaron en la hoja de registro, se tomaron los valores máximos y se procedió a su análisis estadístico e interpretación. Con objeto de evaluar la validez concurrente se aplicó el coeficiente de correlación de Pearson, la prueba t pareada y se construyeron gráficos de Bland-Altman para cada ROM. Asimismo, para analizar la fiabilidad relativa se determinó calculando el Coeficiente de Correlación Intraclase (CCI) para la fiabilidad intra e interdía. Y, por último, para la fiabilidad absoluta se calculó el error estándar de medida (SEM) y el cambio mínimo detectable (MDC). Por otra parte, herramientas como las escalas y pruebas que habitualmente se utilizan para la valoración funcional de los sujetos con PC, suelen ser subjetivas y en ocasiones difíciles de aplicar en población infantil. Su desarrollo en la práctica asistencial también depende de la destreza y experiencia de cada examinador. Para tratar de ofrecer una herramienta, que potencialmente presente datos de calidad más objetivos, en un segundo artículo, se diseña una nueva prueba para determinar la postura cervical y su control motor en la población infantil con PC, basada en la tecnología inercial, con un enfoque de suficiente validez y fiabilidad para analizar el movimiento humano, con bajo coste económico, gran versatilidad, portabilidad y capacidad para adaptarse a la morfología corporal. Primero se realizó una revisión de la literatura y dos pruebas de concepto, hasta lograr la versión final de la prueba. Posteriormente, se llevó a cabo un estudio de medición clínica que evaluó su validez de constructo y de contenido, así como la fiabilidad interdías. Durante el protocolo, se empleó una silla estable que se adaptó a las características antropométricas de cada individuo, una mesa y un ordenador. Fue utilizado un IMU colocado en la frente con una cinta flexible y ajustable. El sensor capturó los movimientos en los tres planos, mientras el sujeto observaba un vídeo durante 2 minutos. Para el registro y procesamiento de los datos brutos, se conectó vía bluetooth el sensor con la aplicación móvil iUCOTRACK ©. Se repitió la prueba a los 3-5 días, siguiendo el mismo protocolo, con objetivo de estudio de la fiabilidad. Para obtener un mejor feed-back de los datos obtenidos, además de las características del movimiento, en términos de longitud del desplazamiento, velocidad y aceleración, se diseñó una elipse con los movimientos cefálicos en los planos sagital y transversal, evaluando su área y sus dimensiones anteroposterior y lateral, como variables principales. Para evaluar el estado funcional de los niños con PC, se aplicó la GMFM-88 y la PEDI. La validez de constructo se estimó determinando la capacidad discriminante del nuevo test e identificando asociaciones entre las medidas funcionales y los resultados de la nueva prueba. Para ello, se aplicaron la prueba t de Student no pareada, una curva de características operativas del receptor (ROC, en sus siglas en inglés) y el test U de Mann- Whitney para comparar subgrupos de sujetos con PC. Para la validez concurrente en el grupo PC, se calculó el coeficiente de correlación de Pearson entre los datos sociodemográficos y los resultados obtenidos el primer día, y los dominios y puntuaciones totales de las escalas GMFM- 88 y PEDI. Para la obtención de la fiabilidad relativa se determinó el CCI en el test-retest en ambos grupos. Y, por último, se evaluó la fiabilidad absoluta con el cálculo del SEM y el MDC. Los resultados obtenidos en la primera publicación mostraron altas correlaciones entre el CROM y el IMU y en ambos grupos (PC y controles), salvo en el plano trasversal. Por otra parte, los gráficos de Bland-Altman indicaron un sesgo por debajo de 5° entre ambos sistemas de medición, menos en la rotación en el grupo PC que fue de 8,2°. Los CCI fueron superiores a 0,8 entre métodos y grupos. En la fiabilidad absoluta, el SEM obtuvo valores inferiores a 8,5° y el MDC valores superiores a 20° en el movimiento rotacional en la medición entredías. En la segunda publicación, la nueva prueba para determinar la postura cervical y su control motor en niños con PC mostró una alta capacidad discriminante en el área de la elipse (Área Bajo la Curva = 0.8) y en ambas dimensiones. Las variables de la nueva prueba se asociaron de moderada a fuerte con las medidas funcionales. Los CCI fueron superiores a 0,8 para los individuos del grupo PC. El SEM para ambos grupos fue aceptablemente bajo, en los movimientos angulares por debajo de 4° para ambos grupos, y en las variables de la elipse fue mayor en el grupo PC. La gran variabilidad entre individuos reveló un MDC alto, principalmente en el grupo con PC. Concluimos que los resultados obtenidos en ambas publicaciones sugieren que los IMU son válidos y fiables para medir el ROM, así como para evaluar la postura y el control motor de la columna cervical en los niños con PC. Si bien la aplicabilidad de los hallazgos, del protocolo y de la nueva prueba se limita a muestras y procedimientos similares. Por consiguiente, se plantea la necesidad de estudios futuros con el fin de estandarizar los procedimientos y determinar datos normativos del ROM cervical en diferentes poblaciones.For healthcare professionals, obtaining valid and reliable clinical data is of great importance in order to establish treatment goals suited to the individual needs of each patient and to be able to assess their effectiveness. Inertial motion sensors (IMU) represent a breakthrough in the measurement of the kinematics of body segments, applicable to the healthcare setting, and show good reliability in measuring joint range of motion (ROM) in humans and the cervical spine in adults. A common problem in Cerebral Palsy (CP) is the delay or deficit in head control (HC), considered a basic motor milestone, which conditions the development and progressive acquisition of motor levels. In addition, HC is responsible for ensuring adequate and safe feeding, as well as enabling the development of postural adaptations to interact with others and adapt to the environment and its demands. Thus, this doctoral thesis proposes a study of the metric properties, in terms of validity and reliability, of the IMU, as a tool for measuring ROM and HC in subjects with CP. For this reason, it aims to analyze the cervical mobility determined synchronously with the Cervical Range of Motion (CROM) instrument and with IMU, in addition to describing the design and development of a new test for the evaluation of Range of Motion (ROM) and cervical HC in children with CP. In both cases, in addition to the analysis of a group of subjects with CP, a sample of control patients have been studied. In this context, the main objective of the first publication was to determine the clinimetric properties in terms of validity and reliability of the IMU in the measurement of cervical ROM in children with CP. For this purpose an evaluation protocol was designed, together with an information sheet, an informed consent form and a form for data recording. The IMU and a CROM device were used simultaneously. Cervical ROM was measured by performing 3 repetitions of each cervical movement, which were reproduced after 5 minutes to assess intraday reliability. Similarly, the measurement procedure was repeated after 3-5 days to estimate interday reliability. The results were recorded on the recording sheet, the largest results were selected and were statistically analyzed and interpreted. In order to assess concurrent validity, the Pearson correlation coefficient, paired t-test and Bland-Altman plots were drawn for each ROM. Likewise, to analyze relative reliability, this was determined by calculating the Intraclass Correlation Coefficient (ICC) for intra- and inter-day reliability. Finally, for achieve absolute reliability, the standard error of measurement (SEM) and the minimum detectable change (MDC) were calculated. In addition, tools such as scales and tests commonly used for the functional assessment of patients with CP are usually subjective and sometimes difficult to apply in children. Their development in healthcare practice also depends on the skill and experience of each examiner. In order to provide a tool that shows more objective results, in a second scientific article, a new procedure has been designed to determine cervical posture and its motor control in children with CP, based on inertial technology, with an approach of sufficient validity and reliability to analyze human movement, with a low cost, great versatility, portability and capacity to adapt to body morphology. First, a literature review and two proofs of concept were carried out to obtain the final version of the test. Subsequently, a clinical measurement study was performed to evaluate its construct and content efficacy, and its inter-day reliability. During the protocol, a fixed chair adapted to the anthropometric characteristics of each patient, a table, and a computer were used. Furthermore, an IMU was placed on the forehead with a flexible and adjustable strap. The sensor captured movements in all three planes, while the subject watched a video for two minutes. For the registration and processing of raw data, the sensor was connected via bluetooth with the iUCOTRACK mobile app ©. The test was repeated at 3-5 days, following the same protocol, with the aim of studying reliability. To obtain a better feed-back of the data obtained, in addition to the characteristics of the movement, in terms of displacement length, speed and acceleration, an ellipse was designed with the head movements in the sagittal and transverse planes, evaluating its area and its anteroposterior and lateral dimensions, as main variables. To assess the functional status of children with CP GMFM-88 and PEDI were applied. Construct validity was estimated by determining the discriminant capacity of the new test and identifying associations between the functional measures and the results of the new test. For this purpose, the unpaired Student t-test, a receiver operating characteristic (ROC) and the Mann- Whitney U-test were applied to compare subgroups of subjects with CP. For concurrent validity in the CP group, the Pearson's correlation coefficient was calculated between the sociodemographic data and the results obtained on the first day, and the total domains and scores of the GMFM-88 and PEDI scales. To obtain the relative reliability, the ICC was determined in the test-retest in both groups. Finally, absolute reliability was assessed by calculating the SEM and the MDC. The results obtained in the first publication showed high correlations between CROM and IMU and in both groups (CP and controls), except in the transverse plane. Furthermore, the Bland- Altman charts indicated a bias below 5 degrees between the two measurement systems, except for rotation in the CP group which was 8.2°. The ICC were higher than 0.8 between methods and groups. Regarding absolute reliability, the SEM achieved values less than 8.5 degrees and the MDC obtained values greater than 20° in rotational motion in the interday measurement. In the second publication, the new test to determine cervical posture and motor control in children with CP showed a high discriminatory capacity in the ellipse area (Area Under the Curve 0.8) and in both dimensions. The variables of the new test were moderately to strongly associated with the functional measures. The ICCs were greater than 0.8 for individuals in the CP group. The SEM for both groups was acceptably low, in angular movements below 4° for both groups, whereas in the ellipse variables it was higher in the CP group. The great variability between individuals revealed a high MDC, mainly in the CP group. In conclusion, the results obtained in both publications suggest that IMU is valid and reliable for measuring ROM, as well as for the assessment of the posture and motor control of the cervical spine in children with CP. However, the applicability of the findings, the protocol and these findings are limited to similar samples and procedures. Therefore, future studies are needed to standardize procedures and determine normative cervical ROM data in different populations

Proceedings SIAMOC 2019

Il congresso annuale della Società Italiana di Analisi del Movimento in Clinica, giunto quest'anno alla sua ventesima edizione, ritorna a Bologna, che già ospitò il terzo congresso nazionale nel 2002. Il legame tra Bologna e l'analisi del movimento è forte e radicato, e trova ampia linfa sia nel contesto accademico che nel ricco panorama di centri clinici d'eccellenza. Il congresso SIAMOC, come ogni anno, è l’occasione per tutti i professionisti dell’ambito clinico, metodologico ed industriale di incontrarsi, presentare le proprie ricerche e rimanere aggiornati sulle più recenti innovazioni nell’ambito dell’applicazione clinica dei metodi di analisi del movimento. Questo ha contribuito, in questi venti anni, a fare avanzare sensibilmente la ricerca italiana nel settore, conferendole un respiro ed un impatto internazionale, e a diffonderne l'applicazione clinica per migliorare la valutazione dei disordini motori, aumentare l'efficacia dei trattamenti attraverso l'analisi quantitativa dei dati e una più focalizzata pianificazione dei trattamenti, ed inoltre per quantificare i risultati delle terapie correnti

Proceedings SIAMOC 2019

Il congresso annuale della Società Italiana di Analisi del Movimento in Clinica, giunto quest'anno alla sua ventesima edizione, ritorna a Bologna, che già ospitò il terzo congresso nazionale nel 2002. Il legame tra Bologna e l'analisi del movimento è forte e radicato, e trova ampia linfa sia nel contesto accademico che nel ricco panorama di centri clinici d'eccellenza. Il congresso SIAMOC, come ogni anno, è l’occasione per tutti i professionisti dell’ambito clinico, metodologico ed industriale di incontrarsi, presentare le proprie ricerche e rimanere aggiornati sulle più recenti innovazioni nell’ambito dell’applicazione clinica dei metodi di analisi del movimento. Questo ha contribuito, in questi venti anni, a fare avanzare sensibilmente la ricerca italiana nel settore, conferendole un respiro ed un impatto internazionale, e a diffonderne l'applicazione clinica per migliorare la valutazione dei disordini motori, aumentare l'efficacia dei trattamenti attraverso l'analisi quantitativa dei dati e una più focalizzata pianificazione dei trattamenti, ed inoltre per quantificare i risultati delle terapie correnti

Effectiveness of intensive physiotherapy for gait improvement in stroke: systematic review

Introduction: Stroke is one of the leading causes of functional disability worldwide. Approximately 80% of post-stroke subjects have motor changes. Improvement of gait pattern is one of the main objectives of physiotherapists intervention in these cases. The real challenge in the recovery of gait after stroke is to understand how the remaining neural networks can be modified, to be able to provide response strategies that compensate for the function of the affected structures. There is evidence that intensive training, including physiotherapy, positively influences neuroplasticity, improving mobility, pattern and gait velocity in post-stroke recovery. Objectives: Review and analyze in a systematic way the experimental studies (RCT) that evaluate the effects of Intensive Physiotherapy on gait improvement in poststroke subjects. Methodology: Were only included all RCT performed in humans, without any specific age, that had a clinical diagnosis of stroke at any stage of evolution, with sensorimotor deficits and functional gait changes. The databases used were: Pubmed, PEDro (Physiotherapy Evidence Database) and CENTRAL (Cochrane Center Register of Controlled Trials). Results: After the application of the criteria, there were 4 final studies that were included in the systematic review. 3 of the studies obtained a score of 8 on the PEDro scale and 1 obtained a score of 4. The fact that there is clinical and methodological heterogeneity in the studies evaluated, supports the realization of the current systematic narrative review, without meta-analysis. Discussion: Although the results obtained in the 4 studies are promising, it is important to note that the significant improvements that have been found, should be carefully considered since pilot studies with small samples, such as these, are not designed to test differences between groups, in terms of the effectiveness of the intervention applied. Conclusion: Intensive Physiotherapy seems to be safe and applicable in post-stroke subjects and there are indications that it is effective in improving gait, namely speed, travelled distance and spatiotemporal parameters. However, there is a need to develop more RCTs with larger samples and that evaluate the longterm resultsN/