Safety and efficacy of non-invasive brain stimulation for the upper extremities in children with cerebral palsy: A systematic review.

AIM: To evaluate available evidence examining safety and efficacy of non-invasive brain stimulation (NIBS) on upper extremity outcomes in children with cerebral palsy (CP). METHOD: We electronically searched 12 sources up to May 2023 using JBI and Cochrane guidelines. Two reviewers selected articles with predetermined eligibility criteria, conducted data extraction, and assessed risk of bias using the Cochrane Risk of Bias criteria. RESULTS: Nineteen studies were included: eight using repetitive transcranial magnetic stimulation (rTMS) and 11 using transcranial direct current stimulation (tDCS). Moderate certainty evidence supports the safety of rTMS and tDCS for children with CP. Very low to moderate certainty evidence suggests that rTMS and tDCS result in little to no difference in upper extremity outcomes. INTERPRETATION: Evidence indicates that NIBS is a safe and feasible intervention to target upper extremity outcomes in children with CP, although it also indicates little to no significant impact on upper extremity outcomes. These findings are discussed in relation to the heterogeneous participants' characteristics and stimulation parameters. Larger studies of high methodological quality are required to inform future research and protocols for NIBS.

Bimanual Coordination in Children with Bilateral Cerebral Palsy: A Cross-Sectional Study.

AIM: To compare bimanual coordination in children with bilateral cerebral palsy (BCP) with that of children with typical development (TD) and correlate bimanual coordination with clinical measures of hand function. METHODS: 3-D kinematic data were collected from 14 children with BCP (mean age 13 years 1 month; range 7.3-17.2 years, 5 females) and 14 age-matched children with TD (mean age 13 years 1 month, range 7.0-16.0 years, 7 females) as they opened a drawer with one hand and activated a switch inside it with the other hand at self-paced and as-fast-as-possible speeds. Hand roles varied in each condition. Participants' hand function levels were classified using the Manual Ability Classification System. Unimanual dexterity and bimanual performance were evaluated using the Box and Blocks Test and Both Hands Assessment respectively. RESULTS: Participants with BCP performed the bimanual task more slowly (p < 0.001) and sequentially, as evidenced by greater time differences between the two hands achieving the end goal (p = 0.01). Faster speeds, particularly when the less affected hand opened the drawer, facilitated time-related measures of bimanual coordination (p < 0.05). Bimanual coordination correlated with all clinical measures of hand function (p < 0.05). CONCLUSION: For children with BCP, speed and hand used for each subcomponent of the task influence bimanual coordination. Better bimanual coordination is associated with less impairment of both hands.

Mirror movements and brain pathology in children with unilateral cerebral palsy.

AIM: We systematically examined the relationship between mirror movements and brain lesion type, corticospinal tract (CST) organization, and hand function to determine the relevance between mirror movements, brain lesion, the CST pattern, and hand function in children with unilateral cerebral palsy (CP). METHOD: Forty-eight children (mean age 9y 9mo [SD 3y 3mo], range 6-18y; 30 males, 18 females) with unilateral CP participated. Mirror movements, brain lesion type, CST pattern identified by transcranial magnetic stimulation, and clinical outcomes were evaluated. Children performed four unilateral tasks: hand opening/closing, finger opposition, individuation, and finger 'walking'. Mirror movements induced in the contralateral hand were scored using standardized criteria (scores 0-4 using the Woods and Teuber scale). RESULTS: We found that children with periventricular lesion may have stronger mirror movement scores induced in either hand than those with middle cerebral artery lesion (more affected hand: p=0.02; less affected hand: p<0.01). The highest mirror movement score a child exhibits across the tested tasks (i.e. scores of 3-4 using the Woods and Teuber scoring criteria) may potentially be an indicator of an ipsilateral CST connectivity pattern (p=0.03). Significant correlations were observed between higher mirror movement scores when performing hand opening/closing as well as finger walking and better unimanual dexterity (Spearman's rank correlation coefficient rs =0.44, p=0.002; rs =0.46, p=0.002 respectively). INTERPRETATION: Brain lesions may be predictive of the strength of mirror movements in either hand in children with unilateral CP. Our findings warrant further studies to extensively investigate the relationship between mirror movements and the underlying brain pathology. WHAT THIS PAPER ADDS: Brain lesion type may be predictive of mirror movement scores induced in either hand in children with unilateral cerebral palsy. The highest mirror movement score a child exhibits across the tested tasks may indicate corticospinal tract connectivity pattern in children with unilateral cerebral palsy.

Assisting hand use and self-care bimanual performance of children with unilateral spastic cerebral palsy.

AIM: To examine the relationship between assisting hand use in bimanual activities and children's self-care activities and task performance. METHOD: We retrospectively analysed daily functioning (Pediatric Evaluation of Disability Inventory [PEDI]) and bimanual performance (Assisting Hand Assessment [AHA]) data from the assessment of 112 children (mean age: 8 years 10 months [SD 2 years 1 month], range 3 years 7 months-17 years 4 months; 66 males, 46 females) with unilateral spastic cerebral palsy (CP). We used Rasch analysis to examine the relationship between individual item scores from the AHA and the self-care items (functional skills, caregiver assistance) from the PEDI. RESULTS: Most self-care functional skills and caregiver-assisted tasks were located on the middle of the unidimensional continuum. These items showed similar levels of difficulty as the items from the AHA related to the effective coordination of two hands, appropriate pace, and use of the assisting hand to stabilize and release objects, as well as variations in arm movements. INTERPRETATION: The distribution of the PEDI self-care and AHA items along the unidimensional continuum illustrates the relationship between assisting hand use and self-care bimanual performance. Interpretation of the items' locations on the hierarchical unidimensional continuum may be helpful to therapists' clinical reasoning and suggest intervention goals to improve the hand function and daily functioning of children with unilateral spastic CP. Such an application needs further investigation.

"Help Me to Improve my Own Priorities!": A Feasibility Study of an Individualized Intensive Goal Training for Adolescents with Cerebral Palsy.

AIM: To investigate the feasibility and the preliminary effects of an individualized intensive goal training for adolescents with cerebral palsy (CP). METHODS: Twelve adolescents with CP (12-17 years old, MACS II-III, GMFCS I-IV) identified functional goals to be practiced three hours/day, five days/week, for two weeks. The feasibility aspects included the participant's adherence (i.e., daily logs), the adequacy of the instruments used, and the participant's satisfaction with the intervention (i.e., structured questionnaire). Outcome measures included the Canadian Occupational Performance Measure (COPM), Pediatric Evaluation of Disability Inventory (PEDI) (self-care; mobility), Children Helping Out: Responsibilities, Expectations and Supports (CHORES), Participation and Environment Measure-Children and Youth (PEM-CY) (home) and Box and Blocks Test (BBT). Assessments were conducted one month and two days before the intervention, immediately and three months after the intervention. Friedman tests were used to test time-related differences in the outcome measures. RESULTS: All adolescents completed and reported satisfaction with the proposed intervention. Significant improvements were observed in performance and satisfaction (COPM), in functional skills and caregiver assistance in self-care and in the performance of household tasks. There were no significant differences in mobility skills, independence in mobility or household tasks, home participation, or manual dexterity. CONCLUSION: The intensive training was feasible and promoted improvements in functional goals and daily functioning of adolescents with CP.

Intensive Bimanual Intervention for Children Who Have Undergone Hemispherectomy: A Pilot Study.

PURPOSE: To conduct a pilot study to assess the feasibility and effectiveness of an intensive bimanual intervention on upper limb function in children who have undergone hemispherectomy. METHODS: Thirteen children received 90 hours of intensive bimanual training (Hand-Arm Bimanual Intensive Therapy, HABIT). The Jebsen-Taylor Test of Hand Function (JTTHF), Box and Block Test (BBT), Assisting Hand Assessment (AHA), ABILHAND-Kids, and Canadian Occupational Performance Measure (COPM) were assessed by a masked clinician twice before, immediately, and 6 months after treatment. RESULTS: Significant improvements over time were found in the JTTHF, AHA, ABILHAND-Kids, and COPM. CONCLUSION: Completion of HABIT was feasible for children with hemispherectomy. Improvement of bimanual function and functional goals can be related to the nature of the activities prioritized in HABIT training.

Hand-arm bimanual intensive therapy and daily functioning of children with bilateral cerebral palsy: a randomized controlled trial.

AIM: To examine the efficacy of Hand-Arm Bimanual Intensive Therapy (HABIT) on daily functioning, unimanual dexterity, and bimanual performance of children with bilateral cerebral palsy (CP) compared with customary care. METHOD: Forty-one children with bilateral CP, aged 4 to 16 years, classified in levels I to III of the Manual Ability Classification System, were randomly assigned to HABIT (90h) (n=21) or to customary care (4.5h) (n=20). Participants' daily functioning (Pediatric Evaluation of Disability Inventory [PEDI], Canadian Occupational Performance Measure [COPM]), unimanual dexterity (Jebsen-Taylor Test of Hand Function, Box and Blocks Test [BBT]), and bimanual performance (Both Hands Assessment) were assessed pre-, post-, and 6 months after the intervention. Linear mixed-effects models were used for inferential analysis. RESULTS: Children participating in HABIT showed greater improvements in daily functioning (COPMperformance : χ 1 2 =9.50, p<0.01; COPMsatisfaction : χ 1 2 =5.07, p<0.05; PEDIfunctional skills : χ 1 2 =6.81, p<0.01; PEDIcaregiver assistance : χ 1 2 =6.23, p<0.05) and in the dexterity of the dominant hand (BBT: χ 1 2 =3.99, p<0.05) compared with children maintaining customary care. Group or time effects did not explain any variance in bimanual performance or in the dexterity of the non-dominant hand. INTERPRETATION: HABIT may be beneficial for children with bilateral CP, with benefits evidenced for daily functioning outcomes. WHAT THIS PAPER ADDS: Hand-Arm Bimanual Intensive Therapy (HABIT) improved daily functioning of children with bilateral cerebral palsy (CP). Bimanual performance, measured by the Both Hands Assessment, did not change after HABIT in children with bilateral CP. Children with asymmetric and symmetric hand use exhibited similar improvements after HABIT.

Intensive Unimanual Training Leads to Better Reaching and Head Control than Bimanual Training in Children with Unilateral Cerebral Palsy.

AIMS: To quantify the changes in joint movement control and motor planning of the more-affected upper extremity (UE) during a reach-grasp-eat task in children with Unilateral Spastic Cerebral Palsy (USCP) after either constraint-induced movement therapy (CIMT) or hand-arm bimanual intensive therapy (HABIT). METHODS: Twenty children with USCP (average age 7.7; MACS levels I-II) were randomized into either a CIMT or HABIT group. Both groups received intensive training 6 h a day for 15 days. Children performed a reach-grasp-eat task before and after training with their more-affected hand using 3D kinematic analysis. RESULTS: Both groups illustrated shorter movement time during reaching, grasping, and eating phases after training (p < 0.05). Additionally, both intensive training approaches improved joint control with decreased trunk involvement, greater elbow, and wrist excursions during the reaching phase, and greater elbow excursion during the eating phase (p < 0.05). However, only the CIMT group decreased hand curvature during reaching, lowered hand position at grasp, and decreased head rotation during the eating phase (p < 0.05). CONCLUSIONS: The current findings showed that both CIMT and HABIT improved UE joint control, but there were greater effects of CIMT on the more-affected UE motor planning and head control for children with USCP.

The Seated Postural & Reaching Control Test in Cerebral Palsy: A Validation Study.

Aim: Children with moderate-severe cerebral palsy (CP) show postural control deficits that affect their daily activities, like reaching. The Seated Postural and Reaching Control test (SP&R-co) was developed to address the need for clinical measures that objectively identify dimensions of postural imbalance and corresponding reaching limitations in children with CP.Methods: SP&R-co documentation was designed for test validity and rater training. Rater and internal consistency were examined using Cronbach's α. Reference SP&R-co score sheets of children and rater's scores were used for absolute item-by-item, average inter-rater, and intra-rater reliability. Motor classification systems and performance tests were used for construct and concurrent validity.Results: The SP&R-co scoring showed acceptable-good consistency (α = 0.76-0.84). Interrelatedness of SP&R-co items was good-excellent (α = 0.82-0.97). The raters demonstrated fair, good, and excellent item-by-item reliability (ICC = 0.41-0.92). Inter-rater and intra-rater reliability of SP&R-co dimensions were good-excellent (ICC = 0.68-0.86 and ICC = 0.64-0.95, respectively). Construct and concurrent validity showed moderate-excellent correlations (r = 0.49-0.88).Conclusions: Results provide evidence that the SP&R-co is a reliable and valid test for therapists to objectively examine and quantify seated postural and reaching control in children with CP.

Hand forces and placement are modulated and covary during anticipatory control of bimanual manipulation.

Dexterous object manipulation relies on the feedforward and feedback control of kinetics (forces) and kinematics (hand shaping and digit placement). Lifting objects with an uneven mass distribution involves the generation of compensatory moments at object lift-off to counter object torques. This is accomplished through the modulation and covariation of digit forces and placement, which has been shown to be a general feature of unimanual manipulation. These feedforward anticipatory processes occur before performance-specific feedback. Whether this adaptation is a feature unique to unimanual dexterous manipulation or general across unimanual and bimanual manipulation is not known. We investigated the generation of compensatory moments through hand placement and force modulation during bimanual manipulation of an object with variable center of mass. Participants were instructed to prevent object roll during the lift. Similar to unimanual grasping, we found modulation and covariation of hand forces and placement for successful performance. Thus this motor adaptation of the anticipatory control of compensatory moment is a general feature across unimanual and bimanual effectors. Our results highlight the involvement of high-level representation of manipulation goals and underscore a sensorimotor circuitry for anticipatory control through a continuum of force and placement modulation of object manipulation across a range of effectors. NEW & NOTEWORTHY This is the first study, to our knowledge, to show that successful bimanual manipulation of objects with asymmetrical centers of mass is performed through the modulation and covariation of hand forces and placements to generate compensatory moments. Digit force-to-placement modulation is thus a general phenomenon across multiple effectors, such as the fingers of one hand, and both hands. This adds to our understanding of integrating low-level internal representations of object properties into high-level task representations.

Intraspecific variation in soy across the leaf economics spectrum.

Background and Aims: Intraspecific trait variation (ITV) is an important dimension of plant ecological diversity, particularly in agroecosystems, where phenotypic ITV (within crop genotypes) is an important correlate of key agroecosystem processes including yield. There are few studies that have evaluated whether plants of the same genotype vary along well-defined axes of biological variation, such as the leaf economics spectrum (LES). There is even less information disentangling environmental and ontogenetic determinants of crop ITV along an intraspecific LES, and whether or not a plant's position along an intraspecific LES is correlated with reproductive output. Methods: We sought to capture the extent of phenotypic ITV within a single cultivar of soy (Glycine max) - the world's most commonly cultivated legume - using a data set of nine leaf traits measured on 402 leaves, sampled from 134 plants in both agroforestry and monoculture management systems, across three distinct whole-plant ontogenetic stages (while holding leaf age and canopy position stable). Key Results: Leaf traits covaried strongly along an intraspecific LES, in patterns that were largely statistically indistinguishable from the 'universal LES' observed across non-domesticated plants. Whole-plant ontogenetic stage explained the highest proportion of phenotypic ITV in LES traits, with plants progressively expressing more 'resource-conservative' LES syndromes throughout development. Within ontogenetic stages, leaf traits differed systematically across management systems, with plants growing in monoculture expressing more 'resource-conservative' trait syndromes: trends largely owing to an approximately ≥50% increases in leaf mass per area (LMA) in high-light monoculture vs. shaded agroforestry systems. Certain traits, particularly LMA, leaf area and maximum photosynthetic rates, correlated closely with plant-level reproductive output. Conclusions: Phenotypic ITV in soy is governed by constraints in trait trade-offs along an intraspecific LES, which in turn (1) underpins plant responses to managed environmental gradients, and (2) reflects shifts in plant functional biology and resource allocation that occur throughout whole-plant ontogeny.

Modulation of gait inter-limb coordination in children with unilateral spastic cerebral palsy after intensive upper extremity intervention.

Motor function difficulties associated with unilateral spastic cerebral palsy (USCP) impact gait inter-limb coordination between the upper and lower extremities. Two motor learning based, upper extremity treatments, Constraint Induced Movement Therapy (CIMT) and Hand Arm Bimanual Therapy (HABIT), have resulted in improvements in coordination and function between the arms in children with USCP. However, no study has investigated whether coordination between the upper and lower extremities improves after either intervention during a functional task, such as walking. Gait analysis was performed before and after participation in intensive (3 weeks, 90 h total) CIMT and HABIT interventions to determine if intensive upper extremity treatment can improve inter-limb coordination between the upper and lower extremities of children (n = 20, 6-17 years old) with USCP. While upper extremity clinical evaluations indicated hand function improvements, there were no changes in lower extremity parameters for either treatment. However, we found that 10 out of 11 children with a 2:1 arm swing-to-stride ratio at pre-test improved to a 1:1 ratio at post-test. Temporal synchronicity of contralateral limbs, swing displacement of the more affected arm, and arm swing side symmetry unexpectedly decreased. Positive changes in coordination were observed in children who demonstrated poor coordination during walking at pre-test, yet the changes were not robust. Principle component analysis did not indicate changes in limb coupling. While more coordinated, gross-motor training of the upper and lower extremity may reveal greater changes, lower extremity gait patterns were not improved in high functioning children with USCP.

Reliability and responsiveness of the Jebsen-Taylor Test of Hand Function and the Box and Block Test for children with cerebral palsy.

AIM: To assess the reliability and to evaluate the responsiveness of both the Jebsen-Taylor Test of Hand Function (JTTHF) and the Box and Block Test (BBT) in children with cerebral palsy (CP). METHOD: In this retrospective study, the reliability analyses were conducted with paired t-tests considering a short (mean 14d) and a long (mean 120d) time in between two assessment periods. In addition, an intraclass correlation coefficient (ICC) was used to assess the level of congruency. The responsiveness to therapy was conducted with a paired t-test in the whole sample regarding the age, the manual ability level as classified with the Manual Ability Classification System (MACS), and the topography. RESULTS: Our main results confirmed the tests' reliability in a short time period for the JTTHF in both hands and for the BBT on the less affected hand. These results were consistent with the ICC. The responsiveness was confirmed, except on the less affected hand for the JTTHF, with similar results for age, MACS, and topography approach. INTERPRETATION: This study supports the use of the JTTHF and the BBT to examine changes after short-term interventions for children with CP. These results should be interpreted with association to normative values or with a control group when used over long assessment periods. WHAT THIS PAPER ADDS: The Box and Block Test (BBT) is reliable in a brief period of assessment in children with cerebral palsy (CP). The Jebsen-Taylor Test of Hand Function (JTTHF) is reliable in a brief period of assessment in children with CP. The JTTHF and BBT are responsive to changes in a brief period of intensive therapy in children with CP. The reliability and responsiveness of the JTTHF and BBT are weak over long assessment periods.

CONFIABILIDAD Y SENSIBILIDAD DE LA PRUEBA JEBSEN-TAYLOR TEST OF HAND FUNCTIÓN Y LA PRUEBA BOX AND BLOCK TEST EN NIÑOS CON PARÁLISIS CEREBRAL: OBJETIVO: Evaluar la confiabilidad y la sensibilidad de las pruebas Jebsen-Taylor Test of Hand Function (JTTHF) y Box and Block Test (BBT) en niños con parálisis cerebral (PC). MÉTODO: En este estudio retrospectivo, los análisis de confiabilidad fueron realizados con pruebas t para muestras relacionadas, considerando un tiempo corto (media de 14 días) y largo (media de 120 días) entre dos períodos de evaluación. Además, se utilizó el coeficiente de correlación intraclase (CCI) para evaluar el grado de congruencia. La sensibilidad de la terapia fue evaluada con prueba t en toda la muestra, respecto a la edad, nivel de habilidad manual, según el sistema de clasificación de la habilidad manual (MACS), y la topografía. RESULTADOS: Nuestros principales resultados confirman la confiabilidad a corto plazo para la prueba JTTHF en ambas manos y para la prueba BBT en la mano menos afectada. Estos resultados fueron consistentes, de acuerdo con el CCI. La sensibilidad fue confirmada, excepto en la mano menos afectada para la prueba JTTHF, con resultados similares respecto a la edad, MACS y topografía. INTERPRETACIÓN: Este estudio sustenta el uso de las pruebas JTTFH y BBT para evaluar cambios luego de intervenciones de corto plazo para niños con PC. Estos resultados debieran ser interpretados en asociación a valores de normalidad o con un grupo control cuando sean utilizados para evaluar períodos de intervención de largo plazo.

CONFIABILIDADE E RESPONSIVIDADE DO TESTE DA FUNÇÃO MANUAL DE JEBSEN-TAYLOR E DO TESTE DA CAIXA E BLOCOS PARA CRIANÇAS COM PARALISIA CEREBRAL: OBJETIVO: Avaliar a confiabilidade e a responsividade do Teste da Função Manual de Jebsen-Taylor (TFMJT) e do Teste da Caixa e Blocos (TCB) para crianças com paralisia cerebral (PC). MÉTODO: Neste estudo retrospectivo, análises de confiabilidade foram realizadas com testes t pareados considerando um tempo curto (média 14d) e longo (média 120d) entre dois períodos de avaliação. Adicionalmente, coeficiente de correlacão intraclasse (CCI) foi usado para avaliar o nível de conguência. A responsividade a terapia foi conduzida com um teste t pareado em uma amostra considerando a idade, o nível de habilidade manual classificado pelo Sistema de Classificação da Habilidade Manual (MACS), e a topografia. RESULTADOS: Nossos principais resultados confirmaram a confiabilidade dos testes em um curto período de tempo para o TFMJT em ambas as mãos e para o TCB na mão menos afetada. Estes resultados foram consistentes com o CCI. A responsividade foi confirmada, exceto na mão menos afetada para o TFMJT, com resultados similares para a abordagem por idade, MACS e topografia. INTERPRETAÇÃO: Este estudo apóia o uso do TFMJT e do TCB para examinar mudanças após intervenções de curto prazo em crianças com PC. Estes resultados devem ser interpretados em associação com valores normativos ou um grupo controle quando usados em longos períodos de avaliação.

Voluntary Cough and Clinical Swallow Function in Children with Spastic Cerebral Palsy and Healthy Controls.

Dysphagia and resulting pulmonary sequelae are frequently observed in children with spastic cerebral palsy (SCP). However, physiological evidence regarding airway protective behaviors (specifically swallowing and cough function) in these children is sparse. The aim of this investigation was to quantify specific feeding, swallowing, and cough impairments in children with SCP compared to controls. Eleven children with SCP (mean age: 7 ± 2 years; GMFCS: I-V; MACS: I-V) and 10 age-matched controls participated. Clinical feeding and swallowing performance was evaluated with the dysphagia disorder survey (DDS) using standardized liquid, puree, and chewable solid consistencies. Suprahyoid muscle activity and respiratory-swallow patterns were assessed with simultaneous surface electromyography and respiratory inductance plethysmography as children swallowed the various consistencies. Voluntary cough airflow measures were also obtained. Nonparametric tests were used for group comparisons and correlational analyses. Compared to controls, children with SCP demonstrated more signs of clinical feeding and swallowing impairment (p < 0.0001, η2 = 0.771), heightened suprahyoid muscle activity for puree (p = 0.014, η2 = 0.305) and chewable solids (p = 0.001, η2 = 0.528), more frequent post-swallow inhalation across liquid (p = 0.005, η2 = 0.401), puree (p = 0.014, η2 = 0.304), and chewable solids (p = 0.035, η2 = 0.223), and lower cough volume acceleration (p = 0.019, η2 = 0.289). Post-swallow inhalation for chewable solids was correlated with the DDS Part 1 (rs = 0.734, p = 0.010), DDS Part 2 (rs = 0.610, p = 0.046) and the DDS Total scores (rs = 0.673, p = 0.023). This study is the first to provide evidence of specific physiological deficits of both swallowing and voluntary cough in children with SCP. Potential hypotheses explaining these deficits and implications for physiologically driven management are explored.

Effect of sensory and motor connectivity on hand function in pediatric hemiplegia.

OBJECTIVE: We tested the hypothesis that somatosensory system injury would more strongly affect movement than motor system injury in children with unilateral cerebral palsy (USCP). This hypothesis was based on how somatosensory and corticospinal circuits adapt to injury during development; whereas the motor system can maintain connections to the impaired hand from the uninjured hemisphere, this does not occur in the somatosensory system. As a corollary, cortical injury strongly impairs sensory function, so we hypothesized that cortical lesions would impair hand function more than subcortical lesions. METHODS: Twenty-four children with unilateral cerebral palsy had physiological and anatomical measures of the motor and somatosensory systems and lesion classification. Motor physiology was performed with transcranial magnetic stimulation and somatosensory physiology with vibration-evoked electroencephalographic potentials. Tractography of the corticospinal tract and the medial lemniscus was performed with diffusion tensor imaging, and lesions were classified by magnetic resonance imaging. Anatomical and physiological results were correlated with measures of hand function using 2 independent statistical methods. RESULTS: Children with disruptions in the somatosensory connectivity and cortical lesions had the most severe upper extremity impairments, particularly somatosensory function. Motor system connectivity was significantly correlated with bimanual function, but not unimanual function or somatosensory function. INTERPRETATION: Both sensory and motor connectivity impact hand function in children with USCP. Somatosensory connectivity could be an important target for recovery of hand function in children with USCP. Ann Neurol 2017;82:766-780.

Neurophysiological mechanisms and functional impact of mirror movements in children with unilateral spastic cerebral palsy.

Children with unilateral spastic cerebral palsy (CP) often have mirror movements, i.e. involuntary imitations of unilateral voluntary movements of the contralateral upper extremity. The pathophysiology of mirror movements has been investigated in small and heterogeneous cohorts in the literature. Specific pathophysiology of mirror movements and their impact on upper extremity function require systematic investigation in larger and homogeneous cohorts of children with unilateral spastic CP. Here we review two possible neurophysiological mechanisms underlying mirror movements in children with CP and those with typical development: (1) an ipsilateral corticospinal tract projecting from the contralesional motor cortex (M1) to both upper extremities; (2) insufficient interhemispheric inhibition between the two M1s. We also discuss clinical implications of mirror movements in children with unilateral CP and suggest that a thorough examination of the relationship between the pathophysiology and clinical manifestations of mirror movements is warranted. We suggest two premises: (1) the presence of mirror movements is indicative of an ipsilateral corticospinal tract reorganization; and (2) the corticospinal tract organization may affect patients' responses to certain treatment. If these premises are supported through future research, mirror movements should be clinically evaluated for patient selection to maximize benefits of therapy, hence promoting individualized medicine in this population. WHAT THIS PAPER ADDS: Mirror movements may be indicative of the underlying corticospinal tract reorganization in children with unilateral spastic cerebral palsy (CP). Future research will benefit from systematic investigations of the relationship between mirror movements and its pathophysiology. Mirror movements may be a potential biomarker for individualized medicine in children with unilateral spastic CP.

Uso da mão de assistência e o desempenho bimanual no autocuidado de crianças com paralisia cerebral unilateral espástica.

OBJETIVO: Examinar a relação entre o uso da mão de assistência em atividades bimanuais e o desempenho de crianças nas atividades e tarefas de autocuidado. MÉTODO: Analisamos retrospectivamente dados da funcionalidade diária (Inventário de Avaliação Pediátrica de Incapacidade [PEDI]) e do desempenho bimanual (Avaliação da Mão de Assistência [AHA]) de 112 crianças (idade média: 8 anos 10 meses [DP 2 anos 1 mês], amplitude 3 anos 7 meses-17 anos 4 meses; 66 meninos, 46 meninas) com paralisia cerebral (PC) unilateral espástica. Nós usamos análise Rasch para examinar a relação entre os escores individuais nos itens do AHA e nos itens de autocuidado (habilidades funcionais e assistência do cuidador) do PEDI. RESULTADOS: A maioria das habilidades funcionais e das tarefas de assistência do cuidador de autocuidado ficaram localizadas no meio do contínuo unidimensional. Estes itens apresentaram níveis de dificuldade semelhantes aos itens do AHA relacionados à coordenação efetiva das duas mãos, cadência, e uso da mão de assistência para estabilizar e soltar objetos, bem como variações nos movimentos dos braços. INTERPRETAÇÃO: A distribuição dos itens de autocuidado do PEDI e itens do AHA ao longo do contínuo unidimensional ilustra a relação entre o uso da mão de assistência e o desempenho bimanual em autocuidado. Interpretação sobre a localização dos itens na hierarquia do contínuo unidimensional pode ajudar no raciocínio clínico dos terapeutas e na sugestão de objetivos de intervenção para melhorar a função manual e a funcionalidade diária de crianças com PC unilateral espástica. Tais aplicações necessitam de investigação futura.

Impairments of Visuospatial Attention in Children with Unilateral Spastic Cerebral Palsy.

Aim: This observational study aimed at assessing the prevalence of visuospatial attention deficits in children with unilateral spastic cerebral palsy (USCP), taking into consideration the affected hemibody and the localization of the brain lesion. Method: Seventy-five children with USCP were assessed with four visuospatial attention tests: star cancellation, Ogden figure copy, line bisection, and proprioceptive pointing. Results: A majority (64%) of children with USCP presented a deficit in at least one test compared to the reference values. The alterations observed in children with left or right USCP were related to egocentric or allocentric neglect, respectively. Children with cortico/subcortical lesion presented more often visuospatial attention deficits than children with periventricular lesion. Visuospatial attention deficits were not associated with brain lesion locations. Interpretation: Visuospatial attention deficits are prevalent in children with USCP and should be taken into account during their rehabilitation process. The present results shed new light on the interpretation of motor impairments in children with USCP as they may be influenced by the frequent presence of visuospatial deficits.

Improvements in Kinematic Performance After Home-Based Bimanual Intensive Training for Children with Unilateral Cerebral Palsy.

AIMS: To evaluate the effects of home-based intensive bimanual training for children with unilateral spastic cerebral palsy (USCP) on bimanual coordination using 3-D kinematic analyses. METHODS: Seven children with USCP (aged 29-54 months, MACS level: I-III) received 90 hours (2 hrs/day, 5days/week for 9 weeks) of Home Hand-Arm Bimanual Intensive Training (H-HABIT) provided by trained caregivers. A bimanual drawer-opening task was evaluated with eight infrared cameras using VICON workstation4.6 before and after training to assess improvements in bimanual coordination. RESULTS: H-HABIT training significantly decreased the time between one hand opening the drawer and the other hand manipulating its contents (p < 0.05) and increased the percentage of time when both hands were moving simultaneously (p = 0.001), which are indicators of improved temporal bimanual coordination. In addition, participants demonstrated a 26% decrease in trunk displacement (p < 0.05), a 30% increase in upper arm joint excursion (p < 0.01), and a 25% increase in elbow extension (p < 0.05) for the affected side. All the improvements were maintained at 6-month posttest. CONCLUSIONS: H-HABIT improved not only temporal, but also quality of movement during a bimanual task for seven children with USCP. Thus, H-HABIT could be an alternative or adjunctive treatment for children with USCP.

Current Practice "Constraints" in the Uptake and Use of Intensive Upper Extremity Training: A Canadian Perspective.

BACKGROUND: Intensive upper extremity training (IUET) has demonstrated efficacy in clinical and functioning outcomes in children with hemiplegia. However, implementation in the clinical context requires novel service models and knowledge translation. AIMS: To map implementation of IUET in Canada, to identify factors associated with the implementation and best practices for implementation. METHODS: Mixed-methods design; descriptive statistics, chi-square tests. Individual phone interviews and focus groups with purposeful sampling. Thematic analysis; telephone surveys with managers of 31 pediatric rehabilitation centers across Canada. Four focus groups across Canada and one in the Netherlands. RESULTS: Implementation of IUET group interventions is limited in Canada (7/31). Barriers included beliefs and values related to evidence-based practice, opportunities for continuing education, researchers-clinicians partnerships, access to scientific literature, and the presence of a champion. Pressure from parents and media presenting IUET as a novel and effective therapy, support and flexibility of families, having the critical mass of clients and a managerial willingness to accommodate new ideas and restructure service provision were some facilitators. CONCLUSIONS: Uptake of the evidence requires many steps described in the knowledge translation cycle. Factors identified in the study could be considered in most clinical settings to facilitate the uptake of research evidence for IUET.