Effects of Piano Training in Unilateral Cerebral Palsy Using Probabilistic and Deterministic Tractography: A Case Report.

Cerebral palsy (CP) is an umbrella term encompassing motor and often additional disabilities, resulting from insult to the developing brain and remaining throughout life. Imaging-detected alterations in white matter microstructure affect not only motor but also sensorimotor pathways. In this context, piano training is believed to promote sensorimotor rehabilitation for the multiplicity of skills and neuronal processes it involves and integrates. However, it remains unknown how this contribution may occur. Here, effects of 1.5 years of piano training in an adolescent with unilateral CP were investigated through tests of manual function and by comparing fractional anisotropy, mean diffusivity, radial and axial diffusivity in neuronal pathways pre- vs. post-training. In the absence of a control condition and of data from a larger cohort, both probabilistic neighborhood and deterministic tractography were employed to reduce bias associated with a single-case analysis and/or with user-input. No changes in manual function were detected with the tests performed. In turn, the two tractography methods yielded similar values for all studied metrics. Furthermore, post-hoc analyses yielded increased fractional anisotropy accompanied by decreases in mean diffusivity in the bilateral dorsal cingulate that were at least as large as and more consistent than in the bilateral corticospinal tract. This suggests contributions of training to the development of non-motor processes. Reduced anisotropy and correspondingly high mean diffusivity were observed for the bilateral corticospinal tract as well as for the right arcuate and the inferior longitudinal fasciculus, two sensory processing-related pathways, confirming the importance of sensorimotor rehabilitation in CP.

Assessment of adolescent idiopathic scoliosis from body scanner image by finite element simulations.

Adolescent idiopathic scoliosis, is a three-dimensional spinal deformity characterized by lateral curvature and axial rotation around the vertical body axis of the spine, the cause of which is yet unknown. The fast progression entails regular clinical monitoring, including X-rays. Here we present an approach to evaluate scoliosis from the three-dimensional image of a patient's torso, captured by an ionizing radiation free body scanner, in combination with a model of the ribcage and spine. A skeletal structure of the ribcage and vertebral column was modelled with computer aided designed software and was used as an initial structure for macroscopic finite element method simulations. The basic vertebral column model was created for an adult female in an upright position. The model was then used to simulate the patient specific scoliotic spine configurations. The simulations showed that a lateral translation of a vertebral body results in an effective axial rotation and could reproduce the spinal curvatures. The combined method of three-dimensional body scan and finite element model simulations thus provide quantitative anatomical information about the position, rotation and inclination of the thoracic and lumbar vertebrae within a three-dimensional torso. Furthermore, the simulations showed unequal distributions of stress and strain profiles across the intervertebral discs, due to their distortions, which might help to further understand the pathogenesis of scoliosis.

Assessing haemorrhage-critical values of cerebral blood flow by modelling biomechanical stresses on capillaries in the immature brain.

The development of intraventricular haemorrhages (IVH) in preterm newborns is triggered by a disruption of the vessels responsible for cerebral microcirculation. Analysis of the stresses exerted on vessel walls enables the identification of the critical values of cerebral blood flow (CBF) associated with the development of IVH in preterm infants. The purpose of the present study is the estimation of these critical CBF values using the biomechanical stresses obtained by the finite element modelling of immature brain capillaries. The properties of the endothelial cells and basement membranes employed were selected on the basis of published nanoindentation measurements using atomic force microscopes. The forces acting on individual capillaries were derived with a mathematical model that accounts for the peculiarities of microvascularity in the immature brain. Calculations were based on clinical measurements obtained from 254 preterm infants with the gestational age ranging from 23 to 30 weeks, with and without diagnosis of IVH. No distinction between the affected and control groups with the gestational age of 23 to 26 weeks was possible. For infants with the gestational age of 27 to 30 weeks, the CBF value of 17.03 ml/100 g/min was determined as the critical upper value, above which the likelihood of IVH increases.

Assessing key clinical parameters before and after intraventricular hemorrhage in very preterm infants.

Intraventricular cerebral hemorrhage (IVH) is one of the most severe complications of premature birth, potentially leading to lifelong disability. The purpose of this paper is the assessment of the evolution of three of the most relevant parameters, before and after IVH: mean arterial pressure (MAP), arterial carbon dioxide pressure (pCO2), and cerebral blood flow (CBF). Clinical records of 254 preterm infants with a gestational age of 23-30 weeks, with and without a diagnosis of IVH, were reviewed for MAP and arterial pCO2 in the period up to 7 days before and 3 days after IVH or during the first 10 days of life in cases without IVH.Conclusion: A statistically significant increase in pCO2 and decrease in MAP in patients with IVH compared with those without were detected. Both the mean values and the mean absolute deviations of CBF were computed in this study, and the latter was significantly higher than in control group. High deviations of CBF, as well as hypercapnia and hypotension, are likely to contribute to the rupture of cerebral blood vessels in preterm infants, and consequently, to the development of IVH.What is Known:• The origin of IVH is multifactorial, but mean arterial pressure, carbon dioxide partial pressure, and cerebral blood flow are recognized as the most important parameters.• In premature infants, the autoregulation mechanisms are still underdeveloped and cannot compensate for cerebral blood flow fluctuations.What is New:• The numerical simulation of CBF is shown to be a promising approach that may be useful in the care of preterm infants.• The mean values of CBF before and after IVH in the affected group were similar to those in the control group, but the mean absolute deviations of CBF in the affected group before and after IVH were significantly higher than that in the control group.

Machine learning models for identifying preterm infants at risk of cerebral hemorrhage.

Intracerebral hemorrhage in preterm infants is a major cause of brain damage and cerebral palsy. The pathogenesis of cerebral hemorrhage is multifactorial. Among the risk factors are impaired cerebral autoregulation, infections, and coagulation disorders. Machine learning methods allow the identification of combinations of clinical factors to best differentiate preterm infants with intra-cerebral bleeding and the development of models for patients at risk of cerebral hemorrhage. In the current study, a Random Forest approach is applied to develop such models for extremely and very preterm infants (23-30 weeks gestation) based on data collected from a cohort of 229 individuals. The constructed models exhibit good prediction accuracy and might be used in clinical practice to reduce the risk of cerebral bleeding in prematurity.

A Noninvasive 3D Body Scanner and Software Tool towards Analysis of Scoliosis.

PURPOSE: Children with neurological disorders, such as cerebral palsy (CP), have a high risk of developing scoliosis during growth. The fast progression of scoliosis implies in several cases frequent clinical and X-ray examinations. We present an ionizing radiation-free, noncontacting method to estimate the trajectory of the vertebral column and to potentially facilitate medical diagnosis in cases where an X-ray examination is not indicated. METHODS: A body scanner and corresponding analysis software tools have been developed to get 3D surface scans of patient torsos and to analyze their spinal curvatures. The trajectory of the vertebral column has been deduced from the body contours at different transverse sectional planes along the vertical torso axis. In order to verify the present methods, we have analyzed twenty-five torso contours, extracted from computer tomography (CT) images of patients who had a CT scan for other medical reasons, but incidentally also showed a scoliosis. The software tools therefore process data from the body scanner as well as X-ray or CT images. RESULTS: The methods presented show good results in the estimations of the lateral deviation of the spine for mild and moderate scoliosis. The partial mismatch for severe cases is associated with a less accurate estimation of the rotation of the vertebrae around the vertical body axis in these cases. In addition, distinct torso contour shapes, in the transverse sections, have been characterized according to the severity of the scoliosis. CONCLUSION: The hardware and software tools are a first step towards an ionizing radiation-free analysis of progression of scoliosis. However, further improvements of the analysis methods and tests on a larger number of data sets with diverse types of scoliosis are necessary, before its introduction into clinical application as a supplementary tool to conventional examinations.

Altered reward-related effective connectivity in obsessive-compulsive disorder: an fMRI study

Background: Obsessive­compulsive disorder (OCD) is characterized by anxiety-provoking, obsessive thoughts. Patients usually react to these thoughts with repetitive behaviours that reduce anxiety and are perceived as rewarding. Hence, reward plays a major role in the psychopathology of OCD. Previous studies showed altered activation in frontostriatal networks, among others, in association with the processing of reward in patients with OCD. Potential alterations in connectivity within these networks have, however, barely been explored. Methods: We investigated a sample of patients with OCD and healthy controls using functional MRI and a reward learning task presented in an event-related design. Dynamic causal modelling (DCM) was used to estimate effective connectivity. Results: Our sample included 37 patients with OCD and 39 healthy controls. Analyses of task-related changes in connectivity showed a significantly altered effective connectivity between the ventromedial prefrontal cortex (vmPFC) and the orbitofrontal cortex (OFC), among others, both in terms of endogenous connectivity as well as modulatory effects under positive feedback. Clinical measures of compulsion correlated with the effect of feedback input on visual sensory areas. Limitations: The reported alterations should be interpreted within the context of the task and the a priori­defined network considered in the analysis. Conclusion: This disrupted connectivity in parts of the default mode network and the frontostriatal network may indicate increased rumination and self-related processing impairing the responsiveness toward external rewards. This, in turn, may underlie the general urge for reinforcement accompanying compulsive behaviours.

Postnatal Paraclinical Parameters Associated to Occurrence of Intracerebral Hemorrhage in Preterm Infants.

Intracerebral hemorrhage (ICH) is the most frequent complication in postnatal development of preterm infants. The purpose of the present work is the statistical evaluation of seven standard paraclinical parameters and their association to the development of ICH. Clinical records of 265 preterm infants with gestational age (GA) 23 to 30 weeks were analyzed. According to ICH status, patients were divided into control (without ICH) and affected (with ICH) groups. Mean values of paraclinical parameters at each week of gestation were compared. Different ICH grades, periods before and after ICH were considered separately. Lower hematocrit, SaO2, and pH were statistically significant for preterm infants with 23 to 30 weeks GA and diagnosis of ICH relative to infants without ICH. Additionally, for preterm infants with 27 to 30 weeks GA, higher C-reactive protein, as well as lower values of thrombocytes were associated with the occurrence of ICH. Preterm infants with 23 to 26 weeks GA showed C-reactive protein values similar to those in the group without ICH and lower levels of thrombocytes after bleeding. Significant differences in paraclinical parameters between preterm infants with and without ICH may constitute useful indicators for closer clinical observation of preterm infants at risk of ICH.

Piano jacket for perceiving and playing music for patients with cerebral palsy.

PURPOSE: Patients with cerebral palsy with severe motor disabilities are limited not only in everyday life activities but also in choice of their hobbies. Playing a musical instrument is for the majority not possible, even though music constitutes a central component of many relaxation activities for people with disabilities. To give affected patients the opportunity to make music and to learn piano playing through somatosensory perception, a prototype of piano jacket was developed. METHOD: A cycling jacket was equipped with boxes, each representing a musical note, incorporated into the sleeves. Each box contains vibration motors and LEDs. These can be used to translate the sequences of piano key presses performed at an external E-piano. An additional operation mode allows the user to actively play a melody himself by touching the same boxes that also incorporate touch sensor components. RESULTS: A working prototype of the piano jacket was developed. CONCLUSION: The sensory piano jacket provides patients with cerebral palsy and contractures the possibility to develop sensorimotor skills, motor abilities and participation in music-related activities. The jacket is planned to be used in music lessons. Implications for Rehabilitation The system is suitable even for patients with severe motor disabilities and especially joint contractures. Excellent handling through large easily accessible communication buttons. All building blocks are held in a garment, which allows for easy portability and gripping comfort.

Modeling Cerebral Blood Flow Dependence on Carbon Dioxide and Mean Arterial Blood Pressure in the Immature Brain With Accounting for the Germinal Matrix.

Intraventricular hemorrhage (IVH) is one of the most critical complications in the development of preterm infants. The likelihood of IVH is strongly associated with disturbances in cerebral blood flow (CBF) and with microvascular fragility in the germinal matrix (GM). The CBF value and its reactivity to changes in arterial carbon dioxide pressure (pCO 2 ) and mean arterial blood pressure (MABP) are relevant indicators in the clinical assessment of preterm infants. The objective of the present study is mathematical modeling of the influence of pCO 2 and MABP on CBF in immature brain, based on clinical data collected from 265 preterm infants with 23-30 gestational weeks. The model was adapted to the peculiarities of immature brain by taking into account the morphological characteristics of the GM capillary network and vascular reactivity, according to gestational and postnatal age. An analysis of model based values of CBF and its reactivity to changes in MABP and pCO 2 was performed separately for each gestational week and for the first two days of life both for preterm infants with and without IVH. The developed model for the estimation of CBF was validated against equivalent experimental measurements taken from the literature. A good agreement between the estimated values of CBF, as well as its reaction on changes in MABP and pCO 2 and the equivalent values obtained in experimental studies was shown.

Characteristics of Lower Leg Muscle Activity in Patients with Cerebral Palsy during Cycling on an Ergometer.

PURPOSE: Cycling on ergometer is often part of rehabilitation programs for patients with cerebral palsy (CP). The present study analyzed activity patterns of individual lower leg muscle during active cycling on ergometer in patients with CP and compared them to similar recordings in healthy participants. METHODS: Electromyographic (EMG) recordings of lower leg muscle activity were collected from 14 adult patients and 10 adult healthy participants. Activity of the following muscles was recorded: Musculus tibialis anterior, Musculus gastrocnemius, Musculus rectus femoris, and Musculus biceps femoris. Besides qualitative analysis also quantitative analysis of individual muscle activity was performed by computing the coefficient of variation of EMG signal amplitude. RESULTS: More irregular EMG patterns were observed in patients in comparison to healthy participants: agonist-antagonist cocontractions were more frequent, muscle activity measured at specific points of the cycle path was more variable, and dynamic range of muscle activity along the cycle path was narrower in patients. Hypertonicity was also more frequent in patients. CONCLUSION: Muscle activity patterns during cycling differed substantially across patients. It showed irregular nature and occasional sharp high peaks. Dynamic range was also narrower than in controls. Observations underline the need for individualized cycling training to optimize rehabilitation effects.

Mobile communication jacket for people with severe speech impairment.

PURPOSE: Cerebral palsy is a movement disorder caused by damage to motor control areas of the developing brain during early childhood. Motor disorders can also affect the ability to produce clear speech and to communicate. The aim of this study was to develop and to test a prototype of an assistive tool with an embedded mobile communication device to support patients with severe speech impairments. METHODS: A prototype was developed by equipping a cycling jacket with a display, a small keyboard, a LED and an alarm system, all controlled by a microcontroller. Functionality of the prototype was tested in six participants (aged 7-20 years) with cerebral palsy and global developmental disorder and three healthy persons. A patient questionnaire consisting of seven items was used as an evaluation tool. RESULTS: A working prototype of the communication jacket was developed and tested. The questionnaire elicited positive responses from participants. Improvements to correct revealed weaknesses were proposed. Enhancements like voice output of pre-selected phrases and enlarged display were implemented. CONCLUSIONS: Integration in a jacket makes the system mobile and continuously available to the user. The communication jacket may be of great benefit to patients with motor and speech impairments. Implications for Rehabilitation The communication jacket developed can be easily used by people with movement and speech impairment. All technical components are integrated in a garment and do not have to be held with the hands or transported separately. The system is adaptable to individual use. Both expected and unexpected events can be dealt with, which contributes to the quality of life and self-fulfilment.

Effects of short-term piano training on measures of finger tapping, somatosensory perception and motor-related brain activity in patients with cerebral palsy.

Playing a musical instrument demands the integration of sensory and perceptual information with motor processes in order to produce a harmonic musical piece. The diversity of brain mechanisms involved and the joyful character of playing an instrument make musical instrument training a potential vehicle for neurorehabilitation of motor skills in patients with cerebral palsy (CP). This clinical condition is characterized by motor impairments that can affect, among others, manual function, and limit severely the execution of basic daily activities. In this study, adolescents and adult patients with CP, as well as a group of typically developing children learned to play piano for 4 consecutive weeks, having completed a total of 8 hours of training. For ten of the participants, learning was supported by a special technical system aimed at helping people with sensorimotor deficits to better discriminate fingers and orient themselves along the piano keyboard. Potential effects of piano training were assessed with tests of finger tapping at the piano and tests of perception of vibratory stimulation of fingers, and by measuring neuronal correlates of motor learning in the absence of and after piano training. Results were highly variable especially among participants with CP. Nevertheless, a significant effect of training on the ability to perceive the localization of vibrations over fingers was found. No effects of training on the performance of simple finger tapping sequences at the piano or on motor-associated brain responses were registered. Longer periods of training are likely required to produce detectable changes.

Implicit Learning of a Finger Motor Sequence by Patients with Cerebral Palsy After Neurofeedback.

Facilitation of implicit learning of a hand motor sequence after a single session of neurofeedback training of alpha power recorded from the motor cortex has been shown in healthy individuals (Ros et al., Biological Psychology 95:54-58, 2014). This facilitation effect could be potentially applied to improve the outcome of rehabilitation in patients with impaired hand motor function. In the current study a group of ten patients diagnosed with cerebral palsy trained reduction of alpha power derived from brain activity recorded from right and left motor areas. Training was distributed in three periods of 8 min each. In between, participants performed a serial reaction time task with their non-dominant hand, to a total of five runs. A similar procedure was repeated a week or more later but this time training was based on simulated brain activity. Reaction times pooled across participants decreased on each successive run faster after neurofeedback training than after the simulation training. Also recorded were two 3-min baseline conditions, once with the eyes open, another with the eyes closed, at the beginning and end of the experimental session. No significant changes in alpha power with neurofeedback or with simulation training were obtained and no correlation with the reductions in reaction time could be established. Contributions for this are discussed.

Development of congenital clubfoot during growth: a long-term study on the basis of pedobarography, biomechanics, and magnetic resonance imaging measurements of muscle volumes.

The aim of this study was to clarify the degree to which the operated congenital asymptomatic clubfoot still shows malpositions or whether it approaches a physiological development with increasing age. Clubfeet of 12 children were examined repeatedly over up to 10 years using pedobarography. The muscle volumes of the lower legs were investigated with MRI and compared with those of a healthy control group. Although some characteristics of clubfoot remained in the plantar pressure distribution, a gradual decrease in the heel and metatarsus load accompanied by an increase in the forefoot load could be registered as is typical for a developing healthy child's foot. The MRI showed a reduced volume of all muscles of the affected lower leg. A correlation was detected between the measured moments in the upper and lower ankle joints and the volumes of the muscles that move these joints. Even though a functional and anatomical separation between the two groups existed, the general developmental changes during growth were similar. The combination of pedobarographic data and derived joint moments with MRI-measured muscle volumes indicated that higher ankle joint moments in clubfoot were associated with smaller muscle volume and were therefore generated by higher joint rigidity.

The Case for Musical Instrument Training in Cerebral Palsy for Neurorehabilitation.

Recent imaging studies in cerebral palsy (CP) have described several brain structural changes, functional alterations, and neuroplastic processes that take place after brain injury during early development. These changes affect motor pathways as well as sensorimotor networks. Several of these changes correlate with behavioral measures of motor and sensory disability. It is now widely acknowledged that management of sensory deficits is relevant for rehabilitation in CP. Playing a musical instrument demands the coordination of hand movements with integrated auditory, visual, and tactile feedback, in a process that recruits multiple brain regions. These multiple demands during instrument playing, together with the entertaining character of music, have led to the development and investigation of music-supported therapies, especially for rehabilitation with motor disorders resulting from brain damage. We review scientific evidence that supports the use of musical instrument playing for rehabilitation in CP. We propose that active musical instrument playing may be an efficient means for triggering neuroplastic processes necessary for the development of sensorimotor skills in patients with early brain damage. We encourage experimental research on neuroplasticity and on its impact on the physical and personal development of individuals with CP.

Altered lower leg muscle activation patterns in patients with cerebral palsy during cycling on an ergometer.

OBJECTIVE: Cycling on a recumbent ergometer constitutes one of the most popular rehabilitation exercises in cerebral palsy (CP). However, no control is performed on how muscles are being used during training. Given that patients with CP present altered muscular activity patterns during cycling or walking, it is possible that an incorrect pattern of muscle activation is being promoted during rehabilitation cycling. This study investigated patterns of muscular activation during cycling on a recumbent ergometer in patients with CP and whether those patterns are determined by the degree of spasticity and of mobility. METHODS: Electromyographic (EMG) recordings of lower leg muscle activation during cycling on a recumbent ergometer were performed in 14 adult patients diagnosed with CP and five adult healthy participants. EMG recordings were done with an eight-channel EMG system built in the laboratory. The activity of the following muscles was recorded: Musculus rectus femoris, Musculus biceps femoris, Musculus tibialis anterior, and Musculus gastrocnemius. The degree of muscle spasticity and mobility was assessed using the Modified Ashworth Scale and the Gross Motor Function Classification System, respectively. Muscle activation patterns were described in terms of onset and duration of activation as well as duration of cocontractions. RESULTS: Muscle activation in CP was characterized by earlier onsets, longer periods of activation, a higher occurrence of agonist-antagonist cocontractions, and a more variable cycling tempo in comparison to healthy participants. The degree of altered muscle activation pattern correlated significantly with the degree of spasticity. CONCLUSION: This study confirmed the occurrence of altered lower leg muscle activation patterns in patients with CP during cycling on a recumbent ergometer. There is a need to develop feedback systems that can inform patients and therapists of an incorrect muscle activation during cycling and support the training of a more physiological activation pattern.

Relating approach-to-target and detection tasks in animal psychoacoustics.

Psychophysical experiments seek to measure the limits of perception. While straightforward in humans, in animals they are time consuming. Choosing an appropriate task and interpreting measurements can be challenging. We investigated the localization of high-frequency auditory signals in noise using an "approach-to-target" task in ferrets, how task performance should be interpreted in terms of perception, and how the measurements relate to other types of tasks. To establish their general ability to localize, animals were first trained to discriminate broadband noise from 12 locations. Subsequently we tested their ability to discriminate between band-limited targets at 2 or 3 more widely spaced locations, in a continuous background noise. The ability to discriminate between 3 possible locations (-90°, 0°, 90°) of a 10-kHz pure tone decreased gradually over a wide range (>30 dB) of signal-to-noise ratios (SNRs). Location discrimination ability was better for wide band noise targets (0.5 and 2 octave). These results were consistent with localization ability limiting performance for pure tones. Discrimination of pure tones at 2 locations (-90/left, 90/right) was robust at positive SNRs, yielding psychometric functions which fell steeply at negative SNRs. Thresholds for discrimination were similar to previous tone-in-noise thresholds measured in ferrets using a yes/no task. Thus, using an approach-to-target task, sound "localization" in noise can reflect detectability or the ability to localize, depending on the stimulus configuration. Signal-detection-theory-based models were able to account for the results when discriminating between pure tones from 2- and 3-source locations. (PsycINFO Database Record

Behavioural estimates of auditory filter widths in ferrets using notched-noise maskers.

Frequency selectivity is a fundamental property of hearing which affects almost all aspects of auditory processing. Here auditory filter widths at 1, 3, 7, and 10 kHz were estimated from behavioural thresholds using the notched-noise method [Patterson, Nimmo-Smith, Weber, and Milroy, J. Acoust. Soc. Am. 72, 1788-1803 (1982)] in ferrets. The mean bandwidth was 21% of the signal frequency, excluding wider bandwidths at 1 kHz (65%). They were comparable although on average broader than equivalent measurements in other mammals (∼11%-20%), and wider than bandwidths measured from the auditory nerve in ferrets (∼18%). In non-human mammals there is considerable variation between individuals, species, and in the correspondence with auditory nerve tuning.

Piano training in youths with hand motor impairments after damage to the developing brain.

Damage to the developing brain may lead to impairment of the hand motor function and negatively impact on patients' quality of life. Development of manual dexterity and finger and hand motor function may be promoted by learning to play the piano. The latter brings together music with the intensive training of hand coordination and fine finger mobility. We investigated if learning to play the piano helped to improve hand motor skills in 18 youths with hand motor disorders resulting from damage during early brain development. Participants trained 35-40 minutes twice a week for 18 months with a professional piano teacher. With the use of a Musical Instrument Digital Interface piano, the uniformity of finger strokes could be objectively assessed from the timing of keystrokes. The analysis showed a significant improvement in the uniformity of keystrokes during the training. Furthermore, the youths showed strong motivation and engagement during the study. This is nevertheless an open study, and further studies remain needed to exclude effects of growth and concomitant therapies on the improvements observed and clarify which patients will more likely benefit from learning to play the piano.