Infants born preterm demonstrate reduced task-specific exploration during the scaffolded kick-activated mobile task.

This study quantified the spatial exploration of 13 infants born very and extremely preterm (PT) at 4 months corrected age as they learned that moving their feet vertically to cross a virtual threshold activated an infant kick-activated mobile and compared results to 15 infants born full-term (FT) from a previously published study. Spatial exploration was quantified using two general spatial exploration variables (exploration volume, exploration path), two task-specific spatial variables (duration of time in the task-specific region of interest, vertical variance of kicks), and one non-task-specific spatial variable (horizontal variance of kicks). The infants born PT, similar to FT, increased their general spatial exploration and duration in the region of interest and did not change the vertical and horizontal variances of kicks. However, the infants born PT, compared to FT, spent less time in the task-specific region of interest and had a greater non-task-specific horizontal variance throughout the task. This may indicate that infants born PT and FT exhibit similar general spatial exploration, but infants born PT exhibit less task-specific spatial exploration. Future research is necessary to determine the contribution of learning and motor abilities to the differences in task-specific exploration between infants born PT and FT.

Motivating Selective Motor Control of Infants at High Risk of Cerebral Palsy Using an In-Home Kicking-Activated Mobile Task: A Pilot Study.

OBJECTIVE: Decreased selective motor control limits gait function of children with spastic cerebral palsy (CP). Infants at high risk of CP demonstrate decreased selective motor control by 1 month of age. To motivate more selective hip-knee control, infants at high risk of CP participated in an in-home kicking-activated mobile task. The purpose of this study was to determine whether infants at high risk of CP and infants with typical development (TD) demonstrated increased selective hip-knee control during 2-minute intervals of the mobile task when they demonstrated learning of the association between their leg movement and mobile activation vs during 2-minute intervals when they did not demonstrate learning. METHODS: Participants in this cohort study included 10 infants at high risk of CP based on neuroimaging and 11 infants with TD at 3.5 to 4.5 months of age. Each infant participated in the in-home kicking-activated mobile task for 8 to 10 min/d, 5 d/wk, for 6 weeks. Over 80,000 kicks were extracted and classified for each infant as occurring during 2-minute intervals of the task when the infant demonstrated learning vs not learning based on mobile activation time above baseline. RESULTS: Infants demonstrated kicks with more selective hip-knee control during 2-minute intervals of the mobile task when they demonstrated learning compared with when they did not demonstrate learning for 4 of 6 weeks in the cohort at high risk of CP and for 2 of 6 weeks in the cohort with TD. CONCLUSION: Participation in the in-home kicking-activated mobile task may motivate more selective hip-knee control of infants at high risk of CP. IMPACT: This study is a first step toward developing an intervention to promote selective hip-knee control of infants at high risk of CP, with the ultimate goal of optimizing future walking function. LAY SUMMARY: This study showed that playing with an in-home infant kicking-activated mobile may motivate infants at high risk of CP to produce more age-appropriate leg movements.

Quantifying Infant Exploratory Learning.

Exploration is considered essential to infant learning, but few studies have quantified infants' task exploration. The purpose of this study was to quantify how infants explored task space with their feet while learning to activate a kick-activated mobile. Data were analyzed from fifteen 4-month-old infants who participated in a 10-min mobile task on 2-3 consecutive days. Infants learned that their vertical leg movements above a systematically increased threshold height activated the mobile. Five kinematic variables were analyzed: 1) exploration space volume, 2) exploration path length, 3) duration of time in the region of interest around the threshold that activated the mobile, 4) task-specific vertical variance of kicks, and 5) non-task-specific horizontal variance of kicks. The infants increased their general spatial exploration, volume and path, and the infants adapted their exploration by maintaining their feet within the region of interest although the task-specific region increased in height as the threshold increased. The infants used task-specific strategies quantified by the increased variance of kicks in the vertical direction and no change in the horizontal variance of kicks. Quantifying infants' task exploration may provide critical insights into how learning emerges in infancy and enable researchers to more systematically describe, interpret, and support learning.

Infants born preterm and infants born full-term generate more selective leg joint movement during the scaffolded mobile task.

Infants born very preterm (PT), prior to 32 weeks gestation, are at increased risk of developing cerebral palsy. Children with spastic cerebral palsy have impaired selective leg joint movement, which contributes to lifelong walking limitations. We investigated whether infants born PT generated more selective hip-knee joint movement (e.g., hip flexes as knee extends) while participating in a scaffolded mobile task. Infants born PT and infants born full-term (FT) at 4 months corrected age participated in a scaffolded mobile task for 2-3 consecutive days. The scaffolded mobile task required infants to raise their legs vertically over a virtual threshold. Three threshold heights (low, middle, and high) were used to test whether the middle and high heights encourage infants to move their legs more selectively. Fifteen infants born FT learned the task and showed more selective hip-knee movement at each of the three threshold heights on the day that they learned, compared with their baseline spontaneous kicking. Thirteen infants born PT learned the task and showed more selective hip-knee movement on their learning day, but only when the middle and high thresholds were used. The results show that the scaffolded mobile task effectively encouraged infants to generate more selective hip-knee joint movement.

Early Intervention for Children Aged 0 to 2 Years With or at High Risk of Cerebral Palsy: International Clinical Practice Guideline Based on Systematic Reviews.

Importance: Cerebral palsy (CP) is the most common childhood physical disability. Early intervention for children younger than 2 years with or at risk of CP is critical. Now that an evidence-based guideline for early accurate diagnosis of CP exists, there is a need to summarize effective, CP-specific early intervention and conduct new trials that harness plasticity to improve function and increase participation. Our recommendations apply primarily to children at high risk of CP or with a diagnosis of CP, aged 0 to 2 years. Objective: To systematically review the best available evidence about CP-specific early interventions across 9 domains promoting motor function, cognitive skills, communication, eating and drinking, vision, sleep, managing muscle tone, musculoskeletal health, and parental support. Evidence Review: The literature was systematically searched for the best available evidence for intervention for children aged 0 to 2 years at high risk of or with CP. Databases included CINAHL, Cochrane, Embase, MEDLINE, PsycInfo, and Scopus. Systematic reviews and randomized clinical trials (RCTs) were appraised by A Measurement Tool to Assess Systematic Reviews (AMSTAR) or Cochrane Risk of Bias tools. Recommendations were formed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework and reported according to the Appraisal of Guidelines, Research, and Evaluation (AGREE) II instrument. Findings: Sixteen systematic reviews and 27 RCTs met inclusion criteria. Quality varied. Three best-practice principles were supported for the 9 domains: (1) immediate referral for intervention after a diagnosis of high risk of CP, (2) building parental capacity for attachment, and (3) parental goal-setting at the commencement of intervention. Twenty-eight recommendations (24 for and 4 against) specific to the 9 domains are supported with key evidence: motor function (4 recommendations), cognitive skills (2), communication (7), eating and drinking (2), vision (4), sleep (7), tone (1), musculoskeletal health (2), and parent support (5). Conclusions and Relevance: When a child meets the criteria of high risk of CP, intervention should start as soon as possible. Parents want an early diagnosis and treatment and support implementation as soon as possible. Early intervention builds on a critical developmental time for plasticity of developing systems. Referrals for intervention across the 9 domains should be specific as per recommendations in this guideline.

Infants born full term and preterm increase the height of anti-gravity leg movements during a kick-activated mobile task using a scaffolded task environment.

Prior research supports that infants born very preterm (PT), compared with full term (FT), have early differences in rate of learning and motor control that may hinder their ability to learn challenging motor tasks. Four-month-old infants born FT (n = 18) and PT (n = 18) participated in an infant kick-activated mobile task that was scaffolded to motivate progressively higher kicks. We found the FT group learned the association between their leg movements and mobile activation on the second day, but the PT group learned the association on the third day. Both groups of infants increased the height of their kicks on the day they learned the task, compared with their spontaneous kicking height. These findings suggest that infants born PT have the ability to learn challenging motor tasks, such as kicking high, when participating in a task environment that uses scaffolding.

In-Home Kicking-Activated Mobile Task to Motivate Selective Motor Control of Infants at High Risk of Cerebral Palsy: A Feasibility Study.

OBJECTIVE: Children with spastic cerebral palsy (CP) have gait impairments resulting from decreased selective motor control, an inability to move the leg joints independently of one another, relying on excessive flexion or extension coupling across the 3 joints. Infants with white matter injury are at high risk of CP and have decreased selective motor control as early as 1 month corrected age. An in-home kicking-activated mobile task was developed to motivate more selective hip-knee control of infants at high risk of CP. The purposes of this study were to determine the feasibility of the in-home mobile task and to determine whether infants at high risk of CP and infants with typical development (TD) learn the association between their leg movements and mobile activation. METHODS: Ten infants at high risk of CP based on neuroimaging and 11 infants with TD participated in this cohort study at 3.5 to 4.5 months corrected age. Each infant participated in the in-home kicking-activated mobile task for 8 to 10 min/d, 5 d/wk, for 6 weeks. Learning was assessed weekly based on an increase in the time that the infant demonstrated the reinforced leg actions when interacting with the kicking-activated mobile compared with spontaneous kicking. RESULTS: With regard to feasibility, participation averaged 92% for infants at high risk of CP and 99% for infants with TD. With regard to learning, the group at high risk of CP demonstrated learning of the task for 2 of 6 weeks, whereas the group with TD demonstrated learning for all 6 weeks. CONCLUSIONS: Infants at high risk of CP demonstrated learning of the kicking-activated mobile task but at a reduced amount compared with infants with TD. Further research is necessary to determine whether the kicking-activated mobile task has potential as an intervention to motivate more selective hip-knee control and improve walking outcomes of infants at high risk of CP. IMPACT: This study investigated the feasibility of an in-home kicking-activated mobile task, a discovery learning task designed to motivate infants at high risk of CP to engage in the intensive task practice necessary to promote their learning abilities and selective motor control. LAY SUMMARY: CP is a lifelong disorder of movement caused by abnormal development or early damage to the brain. If an in-home infant kicking-activated mobile task could be used to motivate certain types of age-appropriate leg movements of infants who are at high risk of CP, the task could help improve walking outcomes, which eventually could contribute to improving children's ability to participate in daily life. This study showed that infants at high risk of CP did learn the infant kicking-activated mobile task but at a much reduced amount compared with infants who are developing typically; so, this is a first step in determining whether the task has potential to motivate more age-appropriate leg movements in infants at high risk of cerebral palsy.

The effects of locomotor training in children with spinal cord injury: a systematic review.

PURPOSE: Discuss the effectiveness of locomotor training (LT) in children following spinal cord injury (SCI). This intervention was assessed following an exhaustive search of the literature using the Preferred Reporting Items for Systematic Reviews and Meta- Analyses: The PRISMA Statement as a guideline. METHOD: Six databases were searched including PubMed, PEDro, CINAHL, Cochrane, PsycINFO, and Web of Knowledge in January 2016 and November 2016, without date restrictions. Inclusion criteria were: studies in English and peer-reviewed and journal articles with a primary intervention of LT in children following SCI. RESULTS: Twelve articles, reporting eleven studies, were included. A systematic review assessing locomotor training in children with SCI published in April 2016 was also included. Participants were ages 15 months to 18 years old. Forms of LT included body-weight supported treadmill or over ground training, functional electrical stimulation, robotics, and virtual reality. Protocols differed in set-up and delivery mode, with improvements seen in ambulation for all 41 participants following LT. CONCLUSION: Children might benefit from LT to develop or restore ambulation following SCI. Age, completeness, and level of injury remain the most important prognostic factors to consider with this intervention. Additional benefits include improved bowel/ bladder management and control, bone density, cardiovascular endurance, and overall quality of life. Looking beyond the effects LT has just on ambulation is crucial because it can offer benefits to all children sustaining a SCI, even if restoration or development of walking is not the primary goal. Further rigorous research is required to determine the overall effectiveness of LT.