Evaluation of cervical posture improvement of children with cerebral palsy after physical therapy based on head movements and serious games

Background: This paper presents the preliminary results of a novel rehabilitation therapy for cervical and trunk control of children with cerebral palsy (CP) based on serious videogames and physical exercise. Materials: The therapy is based on the use of the ENLAZA Interface, a head mouse based on inertial technology that will be used to control a set of serious videogames with movements of the head. Methods: Ten users with CP participated in the study. Whereas the control group (n=5) followed traditional therapies, the experimental group (n=5) complemented these therapies with a series of ten sessions of gaming with ENLAZA to exercise cervical flexion-extensions, rotations and inclinations in a controlled, engaging environment. Results: The ten work sessions yielded improvements in head and trunk control that were higher in the experimental group for Visual Analogue Scale, Goal Attainment Scaling and Trunk Control Measurement Scale (TCMS). Significant differences (27% vs. 2% of percentage improvement) were found between the experimental and control groups for TCMS (p<0.05). The kinematic assessment shows that there were some improvements in the active and the passive range of motion. However, no significant differences were found pre- and post-intervention. Conclusions:Physical therapy that combines serious games with traditional rehabilitation could allow children with CP to achieve larger function improvements in the trunk and cervical regions. However, given the limited scope of this trial (n=10) additional studies are needed to corroborate this hypothesis

Biomechanics

Biomechanics is a vast discipline within the field of Biomedical Engineering. It explores the underlying mechanics of how biological and physiological systems move. It encompasses important clinical applications to address questions related to medicine using engineering mechanics principles. Biomechanics includes interdisciplinary concepts from engineers, physicians, therapists, biologists, physicists, and mathematicians. Through their collaborative efforts, biomechanics research is ever changing and expanding, explaining new mechanisms and principles for dynamic human systems. Biomechanics is used to describe how the human body moves, walks, and breathes, in addition to how it responds to injury and rehabilitation. Advanced biomechanical modeling methods, such as inverse dynamics, finite element analysis, and musculoskeletal modeling are used to simulate and investigate human situations in regard to movement and injury. Biomechanical technologies are progressing to answer contemporary medical questions. The future of biomechanics is dependent on interdisciplinary research efforts and the education of tomorrow’s scientists

Enabling self-directed computer use for individuals with cerebral palsy: a systematic review of available assistive devices and technologies

Aim  The purpose of this study was to systematically review published evidence on the development, use, and effectiveness of devices and technologies that enable or enhance self-directed computer access by individuals with cerebral palsy (CP). Methods  Nine electronic databases were searched using keywords ‘computer’, ‘software’, ‘spastic’, ‘athetoid’, and ‘cerebral palsy’; the reference lists of articles thus identified were also searched. Thirty articles were selected for review, with 23 reports of development and usability testing of devices and seven evaluations of algorithms to increase computer recognition of input and cursor movements. Results  Twenty-four studies had fewer than 10 participants with CP, with a wide age range of 5 to 77 years. Computer task performance was usually tested, but only three groups sought participant feedback on ease and comfort of use. International standards exist to evaluate effectiveness of non-keyboard devices, but only one group undertook this testing. None of the study designs were higher than American Academy for Cerebral Palsy and Developmental Medicine level IV. Interpretation  Access solutions for individuals with CP are in the early stages of development. Future work should include assessment of end-user comfort, effort, and performance as well as design features. Engaging users and therapists when designing and evaluating technologies to enhance computer access may increase acceptance and improve performance

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

Positive and negative motor signs of head motion in cerebral palsy: assessment of impairment and task performance

This paper analyzes the presence of positive and negative motor signs in people with cerebral palsy (CP). Positive motor signs are those that lead to involuntarily increased frequency or magnitude of muscle activity. Negative motor signs describe insufficient muscle activity or insufficient control of muscle activity. In this paper, a head-mounted alternative computer interface based on inertial technology was used to assess motor signs in seven users with CP. Task performance and control of posture was related to the impairment. There are no significant differences between users with CP and healthy control participants in the frequency domain of the head movement. Results suggest that this kind of motor disorders is not related to positive motor signs. Moreover, a control mode based on posture more than on movements is not optimum; an alternative control mode must be specially designed for users with poor postural control

The use of computers and augmentative and alternative communication devices by children and young with cerebral palsy

[Abstract] The purpose of the study was to determine the use of computers and assistive devices amongst children with cerebral palsy (CP) and establish the satisfaction level of both users and educational staff. The study was carried out with 30 children with cerebral palsy. A questionnaire was designed to characterize the use of new technologies and assistive devices. Some of the questions were reserved for the teachers. Even though 29 users show some type of communication difficulty, only 4 users dispose of a computer-aided communication device, with the static symbolic board being the most widely used device (4). More than half of the participants (17) regularly use a computer, 16 of them requiring some type of assistive device. The perception of the teachers with regard to the use of Information and Communications Technologies (ICTs) in the classrooms is positive in 5 out of 6 cases. ICTs only provide assistance if their application is accompanied by the involvement of professionals and the child's social environment. The low use of Augmentative and Alternative Communication techniques along with the absence of communication codes reveal the need to establish training protocols. The inclusion of social, physical, and personal factors is considered essential in order to evaluate the needs for assistive technology

A Robust Kalman Algorithm to Facilitate Human-Computer Interaction for People with Cerebral Palsy, Using a New Interface Based on Inertial Sensors

This work aims to create an advanced human-computer interface called ENLAZA for people with cerebral palsy (CP). Although there are computer-access solutions for disabled people in general, there are few evidences from motor disabled community (e.g., CP) using these alternative interfaces. The proposed interface is based on inertial sensors in order to characterize involuntary motion in terms of time, frequency and range of motion. This characterization is used to design a filtering technique that reduces the effect of involuntary motion on person-computer interaction. This paper presents a robust Kalman filter (RKF) design to facilitate fine motor control based on the previous characterization. The filter increases mouse pointer directivity and the target acquisition time is reduced by a factor of ten. The interface is validated with CP users who were unable to control the computer using other interfaces. The interface ENLAZA and the RKF enabled them to use the computer

Access to Eye-Gaze Control Technology for Children with Cerebral Palsy

Children with cerebral palsy (CP), whose disability may limit speech production and motor skills, are often considered good candidates for the use of eye-gaze technology to access communication, learning and play. At present, little is known about the skills needed to control this technology, which can make it difficult for clinicians to make decisions, or to manage expectations around progress. This is further complicated by the emergence of “teaching” software packages, claiming to improve basic skills such as cause and effect. Children with CP are known to be at a higher risk of vision disorders, including those related to functional vision – how a child functions in vision related activities. These skills (in particular fixation and gaze switching) are similar to those required to make use of eye-gaze technology, so are likely to impact on children’s performance. This thesis uses typically developing children to provide baseline information and to observe how they respond to tasks which were incrementally lowered in terms of cognitive demand. Over three rounds of experiments a pattern emerged that children aged 32 months were able to use it with only minimal instruction. The impact of teaching on performance was also investigated in this section of the study. A group of children with CP were recruited to investigate the most effective way of assessing functional vision skills in this group, with results indicating behavioural measures were most effective. A final study with children with CP used the activities above to look at the performance of this group on eye-gaze tasks. Results suggested good functional gaze control skills were related to better performance on a novel eye-gaze task. The findings suggest that some children may be at a “developmental advantage” if their functional vision and cognitive skills are more developed

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