Early Intervention and Postural Adjustments During Reaching in Infants at Risk of Cerebral Palsy

Purpose: To investigate postural effects of the family-centered program, COPing with and CAring for infants with special needs (COPCA), applied at 3 to 6 months' corrected age in infants at high risk of cerebral palsy. Previously, we reported postural differences between the infants at risk of CP in the control group of the current study and a group of infants developing typically. Now we focus on differences between 2 intervention groups. Methods: We explored postural adjustments during reaching in seated infants at 4, 6, and 18 months using surface electromyography of arm, neck, and trunk muscles. Infants randomly received the family-centered program or another infant physical therapy. Using videotaped intervention sessions, we investigated correlations between time spent on specific physical therapeutic actions and direction specificity, recruitment order, and anticipatory activation at 18 months. Results: Postural adjustments in both groups were similar, but development of direction specificity and anticipatory activation in COPCA infants better mimicked typical development. These 2 parameters were associated with COPCA-type physical therapeutic actions. Conclusions: Postural control was similar after both interventions. Positive outcomes were associated with fewer intervening actions of the therapist and greater allowance of spontaneous movements

Temporal and spatial localisation of general movement complexity and variation-Why Gestalt assessment requires experience

Aim: General movements’ assessment (GMA), based on Gestalt perception, identifies infants at risk of cerebral palsy. However, the requirement of ample experience to construct the assessor's inner criteria for abnormal movement hampers its widespread clinical use. This study aims to describe details of general movements (GMs) in various body parts and to investigate their association with GMA-Gestalt. Methods: Participants were 24 typically developing infants and 22 very-high-risk infants. GMs were assessed during the writhing (0-8 weeks) and/or fidgety GM phase (2-5 months) by GMA-Gestalt and a semi-quantification of the duration of simple movements and complex movements in various body parts. Results: During both GM phases, the quality of movement often varied within a single assessment, but the degree of complexity and variation of movements in trunk, arms and legs were interrelated (ρ = 0.32-0.84). Longer durations of complex movements in arms and legs (P <.042) were further associated with a better quality in GMA-Gestalt. Head movement was associated with movements in other body parts only in the writhing phase and not associated with GMA-Gestalt during both GM phases. Conclusion: Infants did not show consistently over time and across body parts simple or complex movements. Detailed description of movement characteristics may facilitate the development of computer-based GMA

Development of postural adjustments during reaching in typically developing infants from 4 to 18 months

Knowledge on the development of postural adjustments during infancy, in particular on the development of postural muscle coordination, is limited. This study aimed at the evaluation of the development of postural control during reaching in a supported sitting condition. Eleven typically developing infants participated in the study and were assessed at the ages of 4, 6, 10 and 18 months. We elicited reaching movements by presenting small toys at an arm’s length distance, whilst activity of multiple arm, neck and trunk muscles was recorded using surface EMG. A model-based computer algorithm was used to detect the onset of phasic muscle activity. The results indicated that postural muscle activity during reaching whilst sitting supported is highly variable. Direction-specific postural activity was inconsistently present from early age onwards and increased between 10 and 18 months without reaching a 100 % consistency. The dominant pattern of activation at all ages was the ‘complete pattern’, in which all direction-specific muscles were recruited. At 4 months, a slight preference for top-down recruitment existed, which was gradually replaced by a preference for bottom-up recruitment. We conclude that postural control during the ecological task of reaching during supported sitting between 4 and 18 months of age is primarily characterized by variation. Already from 4 months onwards, infants are—within the variation—sometimes able to select muscle recruitment strategies that are optimal to the task at hand

Postural control during reaching while sitting and general motor behaviour when learning to walk

AimTo study changes in muscular postural strategies and general motor behaviour during the transition to independent walking. Postural control was assessed at its two functional levels: (1) direction specificity, in which dorsal muscles are primarily activated when reaching forward; and (2) fine-tuning of direction specificity. MethodIn an explorative longitudinal study, surface electromyograms of the arm, trunk, and neck muscles of 28 typically developing infants were recorded during reaching while sitting. Each infant was assessed in three developmental phases: during pull-to-stand (T0), first independent steps (T1), and 1 month after T1 (T2). Motor behaviour was assessed using the Infant Motor Profile (IMP). The effect on developmental outcome measures (postural parameters and IMP) of the developmental phases (T0, T1, T2) was estimated using linear mixed-effects models. ResultsNone of the postural parameters changed significantly over time. However, individual developmental trajectories showed infant-specific postural reorganizational changes. Total IMP score decreased between T0 and T1 (mean IMP score 95% and 91% respectively; p InterpretationTypically developing infants do not show consistent patterns of postural reorganization but show individual muscular strategies during the transition to independent walking. However, signs of reorganization of general motor behaviour are present

Are postural adjustments during reaching related to walking development in typically developing infants and infants at risk of cerebral palsy?

Background: In typical development, postural adjustments during reaching change in the second half of infancy, including increasing rates of direction-specific adjustments. These changes are absent or different in infants at risk of cerebral palsy (CP). To discover whether these changes are related to acquisition of independent walking, we studied postural adjustments during reaching in infants before and after they learned to walk. Methods: Ten typically developing (TD) infants and 11 infants at very high risk (VHR) of CP were assessed before and after they learned to walk. Reaching movements were elicited during supported sitting, while surface electromyography was recorded of arm, neck, and trunk muscles. Percentages of direction-specific adjustments (first level of control), and recruitment patterns and anticipatory activation (second level of control) were calculated. Results: In both groups, postural adjustments during reaching were similar before and after acquisition of independent walking. Direction-specificity increased with age in typically developing infants but not in VHR-infants. Conclusion: Increasing age rather than the transition to independent walking is associated with increasing direction-specificity of TD-infants during reaching while sitting, while infants at very high risk of CP show no increase in direction-specificity, suggesting that they gradually grow into a postural deficit

Postural adjustments in infants at very high risk for cerebral palsy before and after developing the ability to sit independently

Background: Children with cerebral palsy (CP) have impaired postural control. Posture is controlled in two levels: direction-specificity, and fine-tuning of direction-specific adjustments, including recruitment order. Literature suggests that direction-specificity might be a prerequisite for independent sitting. Aim: To study development of postural adjustments in infants at very high risk for CP (VHR-infants) during developing the ability to sit independently. Method: In a longitudinal study surface electromyograms of the neck-, trunk- and arm muscles of 11 VHR-infants and 11 typically developing (TD) infants were recorded during reaching in sitting before and after developing the ability to sit unsupported (median ages: VFIR 8.0 and 14.9 months; TD 5.7 and 10.4 months). Sessions were video-recorded. Results: In VHR- and TD-infants the prevalence of direction-specific adjustments and recruitment order did not change when the infant learned to sit independently. In VHR-infants able to sit independently more successful reaching was associated with a higher frequency of bottom-up recruitment (Spearman's rho = 0.828, p = 0.006) and a lower frequency of simultaneous recruitment (Spearman's rho = -0.701, p = 0.035), but not with more direction-specificity. In TD-infants not able to sit independently, more successful reaching was associated with higher rates of direction-specific adjustments at the neck level (Spearman's rho = 0.778, p = 0.014), but not with recruitment order. Conclusions: In VHR- and TD-infants postural adjustments during reaching in terms of direction-specificity and recruitment order are not related to development of independent sitting. Postural adjustments are associated with success of reaching, be it in a different way for VHR- and TD-infants. (C) 2014 Elsevier Ltd. All rights reserved

Best seating condition in children with spastic cerebral palsy:One type does not fit all

Background: The effect of forward-tilting of the seat surface and foot-support in children with spastic cerebral palsy (CP) is debated. Aim: To assess the effect of forward-tilting of the seat surface and foot-support in children with CP on kinematic head stability and reaching. Methods: Nineteen children functioning at Gross Motor Function Classification System levels I-III participated [range 6-12y; ten unilateral spastic CP (US-CP) and nine bilateral spastic CP (BS-CP)]. Kinematic data were recorded of head sway and reaching with the dominant arm in four sitting conditions: a horizontal and a 15 forward (FW) tilted seat surface, each with and without foot-support. Results: Seating condition did not affect head stability during reaching, but did affect kinematic reaching quality. The major reaching parameters, i.e., the proportion of reaches with one movement unit (MU) and the size of the transport MU, were not affected by foot-support. Forward-tilting had a positive effect on these parameters in children with US-CP, whereas the horizontal condition had this effect in children with BS-CP. Implications: A 15 degrees forward-tilted seating and foot-support do not affect head stability. Reaching in children with US-CP profits from forward-tilting; in children with BS-CP forward-tilting worsens reaching - effects that are independent of foot-support

Effects of forward tilted seating and foot-support on postural adjustments in children with spastic cerebral palsy:An EMG-study

OBJECTIVE: To evaluate the effect of 15° forward (FW) seat inclination and foot-support in children with cerebral palsy (CP) on postural adjustments during reaching. DESIGN: Observational study repeated-measures design; step two of two-step-project. SETTING: Laboratory unit within University Hospital and two special education schools. PARTICIPANTS: 19 children (ten unilateral spastic CP (US-CP); nine bilateral spastic CP (BS-CP); Gross Motor Function Classification System levels I-III; 6-12 years old). Participants were able to take part for one one-hour session. INTERVENTION: Reaching while sitting in four seating conditions (FW or horizontal seat; with or without foot-support) applied in randomized order. OUTCOME MEASURES: Simultaneously, surface electromyography (EMG) of neck, trunk and arm muscles and kinematics of head and reaching arm (step one of two-step-project) were recorded. Primary outcome parameters were the ability to modulate EMG-amplitudes at baseline and during reaching (phasic muscle activity). Other EMG-parameters were direction-specificity (1st control level), and 2nd level of control parameters: recruitment order, and anticipatory postural activity. Motor behaviour measures: ability to modulate EMG-amplitudes to kinematic characteristics of reaching and head stability. RESULTS: Only foot-support was associated with increased tonic background EMG-amplitudes and decreased phasic EMG-amplitudes of the trunk extensors in children with US-CP and BS-CP (mixed-models analyses; p-values <0.01). The foot-support effect was also associated with better kinematics of reaching (Spearman's Rho; p-values <0.01). CONCLUSION: In terms of postural adjustments during forward reaching, foot-support enhanced the children's capacity to modulate trunk extensor activity, which was associated with improved reaching quality. FW-tilting did not affect postural muscle activity

Development of the quality of reaching in infants with cerebral palsy:a kinematic study

AIM: To assess development of reaching and head stability in infants at very high risk (VHR-infants) of cerebral palsy (CP) who did and did not develop CP. METHOD: This explorative longitudinal study assessed the kinematics of reaching and head sway in sitting in 37 VHR-infants (18 CP) one to four times between 4.7 months and 22.6 months corrected age. Developmental trajectories were calculated using linear mixed effect models. Motor function was evaluated with the Infant Motor Profile (IMP) around 13 months corrected age. RESULTS: Throughout infancy, VHR-infants with CP had a worse reaching quality than infants without CP, reflected for example by more movement units (factor 1.52, 95% CI 1.16-1.99) and smaller transport movement units (factor 1.86, 95% CI 1.20-2.90). Total head sway of infants with and without CP was similar, but infants with CP used more head movement units to achieve stability. The rate of developmental change in infants with and without CP was similar. Around 13 months, head control and reaching quality were interrelated; both were associated with IMP-scores. INTERPRETATION: Infants with CP showed a worse kinematic reaching quality and head stability throughout infancy from early age onwards than VHR-infants without CP, implying that kinematically they do not grow into a deficit, but exhibit deficits from early infancy on. WHAT THIS PAPER ADDS: Reaching quality improves throughout infancy in all infants at high risk (VHR-infants). Infants with cerebral palsy (CP) show a worse reaching quality than VHR-infants without CP. Infants with CP achieve head stability differently from infants without CP. Infants with CP exhibit kinematic reaching problems from early age onwards

Development of postural control in infancy in cerebral palsy and cystic periventricular leukomalacia

Background: Development of postural problems in Cerebral Palsy (CP) is largely unknown. Postural muscle activity is organized into two levels: 1) direction-specificity; 2) fine-tuning of direction-specific activity. Aim: To study development of postural control until 21 months corrected age in subgroups of infants at very high-risk (VHR) of CP: a) with and without CP at 21 months; b) with and without cystic periventricular leukomalacia (cPVL), the brain lesion with highest risk of CP. Methods and procedures: Longitudinal electromyography recordings of postural muscles during reaching were made in 38 VHR-infants (severe brain lesion or clear neurological signs) between 4.7 and 22.6 months (18 CP, of which 8 with cPVL). Developmental trajectories were calculated using linear mixed effect models. Outcomes and results: VHR-infants with and without CP showed virtually similar postural development throughout infancy. The subgroup of VHR-infants with cPVL improved performance in direction-specificity with increasing age, while they performed throughout infancy worse in fine-tuning of postural adjustments than infants without cPVL. Conclusions and implications: VHR-infants with and without CP have a similar postural development that differs from published trajectories of typically developing infants. Infants with cPVL present from early age onwards dysfunctions in fine-tuning of postural adjustments; they focus on direction-specificity