The positive effect of mirror visual feedback on arm control in children with Spastic Hemiparetic Cerebral Palsy is dependent on which arm is viewed

Mirror visual feedback has previously been found to reduce disproportionate interlimb variability and neuromuscular activity in the arm muscles in children with Spastic Hemiparetic Cerebral Palsy (SHCP). The aim of the current study was to determine whether these positive effects are generated by the mirror per se (i.e. the illusory perception of two symmetrically moving limbs, irrespective of which arm generates the mirror visual feedback) or by the visual illusion that the impaired arm has been substituted and appears to move with less jerk and in synchrony with the less-impaired arm (i.e. by mirror visual feedback of the less-impaired arm only). Therefore, we compared the effect of mirror visual feedback from the impaired and the less-impaired upper limb on the bimanual coupling and neuromuscular activity during a bimanual coordination task. Children with SHCP were asked to perform a bimanual symmetrical circular movement in three different visual feedback conditions (i.e. viewing the two arms, viewing only one arm, and viewing one arm and its mirror image), combined with two head orientation conditions (i.e. looking from the impaired and looking from the less-impaired body side). It was found that mirror visual feedback resulted in a reduction in the eccentric activity of the Biceps Brachii Brevis in the impaired limb compared to the condition with actual visual feedback from the two arms. More specifically, this effect was exclusive to mirror visual feedback from the less-impaired arm and absent when mirror visual feedback from the impaired arm was provided. Across conditions, the less-impaired arm was the leading limb, and the nature of this coupling was independent from visual condition or head orientation. Also, mirror visual feedback did not affect the intensity of the mean neuromuscular activity or the muscle activity of the Triceps Brachii Longus. It was concluded that the positive effects of mirror visual feedback in children with SHCP are not just the result of the perception of two symmetrically moving limbs. Instead, in order to induce a decrease in eccentric neuromuscular activity in the impaired limb, mirror visual feedback from the ‘unaffected’ less-impaired limb is required

Determinants of muscle preservation in individuals with cerebral palsy across the lifespan: a narrative review of the literature

In individuals with cerebral palsy (CP), smaller muscle and atrophy are present at young age. Many people with CP also experience a decline in gross motor function as they age, which might be explained by the loss of muscle mass. The clinical observation of muscle wasting has prompted a comparison with sarcopenia in older adults, and the term accelerated musculoskeletal ageing is often used to describe the hallmark phenotype of CP through the lifespan. However, there has been very little research emphasis on the natural history of ageing with CP and even less with respect to the determinants or prevention of muscle loss with CP. Considering the burgeoning interest in the science of muscle preservation, this paper aims to (i) describe the characteristics of accelerated musculoskeletal ageing in people with CP, (ii) describe the pathophysiology of sarcopenia and parallels with CP, and (iii) discuss possible therapeutic approaches, based on established approaches for sarcopenia

Combined transcranial direct current stimulation and robotic upper limb therapy improves upper limb function in an adult with cerebral palsy

BACKGROUND: Robotic therapy can improve upper limb function in hemiparesis. Excitatory transcranial direct current stimulation (tDCS) can prime brain motor circuits before therapy. OBJECTIVE: We tested safety and efficacy of tDCS plus robotic therapy in an adult with unilateral spastic cerebral palsy (USCP). METHODS: In each of 36 sessions, anodal tDCS (2 mA, 20 min) was applied over the motor map of the affected hand. Immediately after tDCS, the participant completed robotic therapy, using the shoulder, elbow, and wrist (MIT Manus). The participant sat in a padded chair with affected arm abducted, forearm supported, and hand grasping the robot handle. The participant controlled the robot arm with his affected arm to move a cursor from the center of a circle to each of eight targets (960 movements). Motor function was tested before, after, and six months after therapy with the Wolf Motor Function Test (WMFT) and Fugl-Meyer (FM). RESULTS: Reaching accuracy on the robot task improved significantly after therapy. The WMFT and FM improved clinically meaningful amounts after therapy. The motor map of the affected hand expanded after therapy. Improvements were maintained six months after therapy. CONCLUSIONS: Combined tDCS and robotics safely improved upper limb function in an adult with USCP

Does Corticospinal Tract Connectivity Influence the Response to Intensive Bimanual Therapy in Children With Unilateral Cerebral Palsy?

Background Reorganization of the corticospinal tract (CST) can occur in unilateral spastic cerebral palsy (USCP). The affected hand can be controlled via (1) typical contralateral projections from the lesioned hemisphere, (2) ipsilateral projections from the nonlesioned hemisphere, and (3) a combination of contralateral and ipsilateral projections (ie, bilateral). Intensive bimanual therapy and constraint-induced movement therapy (CIMT) improve hand function of children with USCP. Earlier it was suggested that the CST connectivity pattern may influence the efficacy of CIMT. Objective To examine whether CST projection pattern influences the efficacy of intensive bimanual therapy in children with USCP. Participants Thirty-three children with USCP (age 8.9 ± 2.6 years, 16 females). Methods Bimanual therapy was provided in a day-camp setting (90 hours). Participants were involved in different bimanual play and functional activities actively engaging both hands. Hand function was tested before and after the intervention with the Jebsen-Taylor Test of Hand Function, Assisting Hand Assessment, ABILHAND-Kids, and the Canadian Occupational Performance Measure. Single-pulse transcranial magnetic stimulation (TMS) was used to determine each child's CST projection pattern (ie, ipsilateral, contralateral, or bilateral). Results Children whose affected hand was controlled only by ipsilateral CST projections had worse Jebsen-Taylor Test of Hand Function and Assisting Hand Assessment scores than children in the contralateral group at baseline. Bimanual hand use and functional hand use was independent of CST projection pattern. After bimanual therapy, improvements on all outcome measures were observed, and these improvements were independent of the CST connectivity pattern. Conclusion The efficacy of bimanual therapy on hand function in children with USCP appears to be independent of CST connectivity pattern

The PURPLE N study: objective and perceived nutritional status in children and adolescents with cerebral palsy

Purpose: To obtain information on characteristics, management, current objective nutritional status and perception of nutritional status of children with cerebral palsy (CP) from healthcare professionals (HCPs) and caregivers

Quantification of functional abilities in Rett syndrome: a comparison between stages III and IV

We aimed to evaluate the functional abilities of persons with Rett syndrome (RTT) in stages III and IV. The group consisted of 60 females who had been diagnosed with RTT: 38 in stage III, mean age (years) of 9.14, with a standard deviation of 5.84 (minimum 2.2/maximum 26.4); and 22 in stage IV, mean age of 12.45, with a standard deviation of 6.17 (minimum 5.3/maximum 26.9). The evaluation was made using the Pediatric Evaluation of Disability Inventory, which has 197 items in the areas of self-care, mobility, and social function. The results showed that in the area of self-care, stage III and stage IV RTT persons had a level of 24.12 and 18.36 (P=0.002), respectively. In the area of mobility, stage III had 37.22 and stage IV had 14.64 (P<0.001), while in the area of social function, stage III had 17.72 and stage IV had 12.14 (P=0.016). In conclusion, although persons with stage III RTT have better functional abilities when compared with stage IV, the areas of mobility, self-care, and social function are quite affected, which shows a great functional dependency and need for help in basic activities of daily life.Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP

The Relationship Between Hand Function and Overlapping Motor Representations of the Hands in the Contralesional Hemisphere in Unilateral Spastic Cerebral Palsy

BACKGROUND: In many children with unilateral spastic cerebral palsy (USCP), the corticospinal tract to the affected hand atypically originates in the hemisphere ipsilateral to the affected hand. Such ipsilateral connectivity is on average a predictor of poor hand function. However, there is high variability in hand function in these children, which might be explained by the complexity of motor representations of both hands in the contralesional hemisphere. OBJECTIVE: To measure the link between hand function and the size and excitability of motor representations of both hands, and their overlap, in the contralesional hemisphere of children with USCP. METHODS: We used single-pulse transcranial magnetic stimulation to measure the size and excitability of motor representations of both hands, and their overlap, in the contralesional hemisphere of 50 children with USCP. We correlated these measures with manual dexterity of the affected hand, bimanual performance, and mirror movement strength. RESULTS: The main and novel findings were (1) the large overlap in contralesional motor representations of the 2 hands and (2) the moderate positive associations of the size and excitability of such shared-site representations with hand function. Such functional associations were not present for overall size and excitability of representations of the affected hand. CONCLUSIONS: Greater relative overlap of the affected hand representation with the less-affected hand representation within the contralesional hemisphere was associated with better hand function. This association suggests that overlapping representations might be adaptively "yoked," such that cortical control of the child's less-affected hand supports that of the affected hand

The PURPLE N study: objective and perceived nutritional status in children and adolescents with cerebral palsy

Purpose: To obtain information on characteristics, management, current objective nutritional status and perception of nutritional status of children with cerebral palsy (CP) from healthcare professionals (HCPs) and caregivers. Materials and methods: A detailed survey of several items on eight main topics (general characteristics, motor function, comorbidities, therapies, anthropometry, feeding mode and problems and perceived nutritional status) was developed and tested for the study. Correlation between nutritional status and Gross Motor Function Classification System (GMFCS) levels was assessed using continuous variables (Z-scores for weight-for-age, height-for-age, weight-for-height, and body mass index-for-age), and categorical variables (being malnourished, stunted, or wasted). HCP and caregiver perceptions of the child&apos;s nutritional status as well as agreement between perceived and objective nutritional status and agreement between perceived nutritional status and concerns about the nutritional status were analyzed. Results: Data were available for 497 participants from eight European countries. Poorer nutritional status was associated with higher (more severe) GMFCS levels. There was minimal agreement between perceived and objective nutritional status, both for HCPs and caregivers. Agreement between HCP and caregiver perceptions of the child&apos;s nutritional status was weak (weighted kappa 0.56). However, the concerns about the nutritional status of the child were in line with the perceived nutritional status. Conclusions: The risk of poor nutritional status is associated with more severe disability in children and adolescents with CP. There is a mismatch between HCP and caregiver perceptions of participants&apos; nutritional status as well as between subjective and objective nutritional status. Our data warrant the use of a simple and objective screening tool in daily practice to determine nutritional status in children and adolescents with CP