Development and evaluation of a BCI-neurofeedback system with real-time EEG detection and electrical stimulation assistance during motor attempt for neurorehabilitation of children with cerebral palsy.

In the realm of motor rehabilitation, Brain-Computer Interface Neurofeedback Training (BCI-NFT) emerges as a promising strategy. This aims to utilize an individual's brain activity to stimulate or assist movement, thereby strengthening sensorimotor pathways and promoting motor recovery. Employing various methodologies, BCI-NFT has been shown to be effective for enhancing motor function primarily of the upper limb in stroke, with very few studies reported in cerebral palsy (CP). Our main objective was to develop an electroencephalography (EEG)-based BCI-NFT system, employing an associative learning paradigm, to improve selective control of ankle dorsiflexion in CP and potentially other neurological populations. First, in a cohort of eight healthy volunteers, we successfully implemented a BCI-NFT system based on detection of slow movement-related cortical potentials (MRCP) from EEG generated by attempted dorsiflexion to simultaneously activate Neuromuscular Electrical Stimulation which assisted movement and served to enhance sensory feedback to the sensorimotor cortex. Participants also viewed a computer display that provided real-time visual feedback of ankle range of motion with an individualized target region displayed to encourage maximal effort. After evaluating several potential strategies, we employed a Long short-term memory (LSTM) neural network, a deep learning algorithm, to detect the motor intent prior to movement onset. We then evaluated the system in a 10-session ankle dorsiflexion training protocol on a child with CP. By employing transfer learning across sessions, we could significantly reduce the number of calibration trials from 50 to 20 without compromising detection accuracy, which was 80.8% on average. The participant was able to complete the required calibration trials and the 100 training trials per session for all 10 sessions and post-training demonstrated increased ankle dorsiflexion velocity, walking speed and step length. Based on exceptional system performance, feasibility and preliminary effectiveness in a child with CP, we are now pursuing a clinical trial in a larger cohort of children with CP.

Attention-Based Deep Recurrent Neural Network to Estimate Knee Angle During Walking from Lower-Limb EMG.

Accurate prediction of joint angle during walking from surface electromyography (sEMG) offers the potential to infer movement intention and therefore represents a potentially useful approach for adaptive control of wearable robotics. Here, we present the use of a recurrent neural network (RNN) with gated recurrent units (GRUs) and an attention mechanism to estimate knee angle during overground walking from sEMG and its initial offline validation in healthy adolescents. Our results show that the attention mechanism improved estimation accuracy by focusing on the most relevant parts of the input dataset within each time window, particularly muscles active during knee excursion. Sensitivity analysis revealed knee extensor and flexor muscles to be most salient in accurately estimating joint angle. Additionally, we demonstrate the ability of the GRU-RNN approach to accurately estimate knee angle during overground walking in a child with cerebral palsy (CP) in the presence of exoskeleton knee extension assistance. Collectively, our findings establish the initial feasibility of using this approach to estimate user movement from sEMG, which is particularly important for developing robotic exoskeletons for children with neuromuscular disorders such as CP.

Children With Bilateral Cerebral Palsy Exhibit Bimanual Asymmetric Motor Deficits and EEG Evidence of Dominant Sensorimotor Hemisphere Overreliance During Reaching.

BACKGROUND: Reaching is a fundamental motor skill often impaired in cerebral palsy (CP). Studies on manual function, intervention, and underlying brain mechanisms largely focus on unilateral CP. This first electroencephalography (EEG) evaluation of reaching exclusively in bilateral CP aims to quantify and relate brain activation patterns to bimanual deficits in this population. METHODS: A total of 15 children with bilateral CP (13.4 ± 2.9 years) and 13 with typical development (TD: 14.3 ± 2.4 years) performed 45 reaches per hand while recording motion capture and EEG data. The Box and Blocks test was administered bilaterally. Cortical sources were identified using independent component analysis and clustered using k-means. Alpha (8-12 Hz) and beta (13-30 Hz) band event-related desynchronization (ERD) values were compared across groups and hands within clusters, between dominant and non-dominant sensorimotor clusters, and related to reach kinematics and the Box and Block test. RESULTS: The group with CP demonstrated bimanual motor deficits with slower reaches, lower Box and Blocks scores, and stronger hand preference than in TD. Beta ERD, representing motor execution, was notably higher in the dominant sensorimotor cluster in CP compared to TD. Both groups demonstrated more contralateral than ipsilateral activity in both hands and clusters, with CP showing a less lateralized (more bilateral) alpha response. Higher brain activation was generally related to better function. CONCLUSION: Bimanual deficits in bilateral CP and related EEG differences warrant more clinical and research attention particularly earlier in life when greater potential for neural and functional recovery exists.

Investigation of brain mechanisms underlying upper limb function in bilateral cerebral palsy using EEG.

OBJECTIVE: Few studies focus on upper limbs in bilateral cerebral palsy (CP) despite potential bimanual deficits. Electroencephalography (EEG) was utilized to investigate brain mechanisms underlying upper limb tasks in bilateral CP and typical development (TD) and relationships to function. METHODS: 26 (14 CP; 12 TD) completed the Box and Blocks Test and transport task with paper, sponge or mixed blocks, while recording EEG and motion data. RESULTS: Group effects for path time, path length and Box and Blocks Test revealed bimanual deficits. Four sensorimotor-related EEG clusters were identified. Group effects were found in premotor and dominant motor clusters with greater beta event-related desynchronization (ERD) in CP. Hand and hand by group effects were found in the dominant motor cluster, showing greater ERD with the more affected hand in CP. Condition effects were prominent in the posterior parietal cluster with higher ERD reflecting greater difficulty in force modulation. CONCLUSIONS: Higher brain activation associated with greater bimanual deficits is similar to our lower limb findings but contrasts studies in TD or unilateral CP linking higher ERD to greater proficiency. SIGNIFICANCE: Bilateral CP shows overreliance on the dominant hemisphere with the less functional hand and higher brain activity presumably related to excessive intracortical connectivity.

The effects of power exercises on body structure and function, activity and participation in children with cerebral palsy: an ICF-based systematic review.

PURPOSE: To systematically review the literature for evidence of effectiveness of power exercises on physical, physiological, and functional outcomes in children and adolescents with cerebral palsy (CP). MATERIALS AND METHODS: Methodological quality and evidence synthesis were assessed with using the Cochrane Risk of Bias (RoB) Tools and Modified Bakker Scale. Using the International Classification of Functioning (ICF), outcome measures for muscle agriculture, gait, balance, motor function, aerobic/anaerobic fitness, daily living, mobility, and school participation were categorised. RESULTS: The overall RoB of four randomised clinical trials was low, one had some concerns and two were rated as high. Moderate evidence was found that power exercises increased walking speed, activities of daily living, muscle strength, and enhanced gross motor function more than a routine physical therapy program. CONCLUSIONS: The lack of stronger evidence for power training interventions to improve muscle architecture, muscle function, walking capacity, and mobility in children with CP might be explained by the differences in training protocols and degree to which these meet the physiological definition of power, different methods of measuring power, limited durations of training, and the relative effectiveness of control interventions. Future studies should include a stronger focus on child and family-centred participation goals.Implications For RehabilitationPower training can improve gross motor function, walking speed, muscle strength, and activities of daily living more than routine physical therapy.Results comparing power training versus traditional strength training were less pronounced likely because both are intensive and may have positive effects.More research is needed to investigate effects of power training on participation.

External walking environment differentially affects muscle synergies in children with cerebral palsy and typical development.

Despite external environmental changes in walking, such as manipulating gait speed, previous studies have shown that the underlying muscle synergy structures (synergy weights or vectors) rarely vary. The purpose of this study is to examine if external environmental changes to the walking task influence muscle synergies in children with cerebral palsy (CP) and/or typical development (TD). To identify muscle synergies, we extracted muscle synergies from eight children with CP and eight age-matched TD in three treadmill walking conditions, e.g., baseline (adjusted to individual comfortable walking speed), variable speed (VS), or restricted foot width (RW). Then, we grouped similar muscle synergies using k-mean clustering and discriminant analyses from all datasets of individual synergy structures. Proportion tests exhibited six clusters of muscle synergies predominantly arising from children with CP and four clusters from children with TD. Also, the proportion of muscle synergies was significantly different in four of the CP-preferred clusters across conditions. Specifically, the proportion of the baseline condition was significantly different from VS and RW conditions in one and two clusters, respectively. The proportion was significantly different between VS and RW conditions in four clusters. Cadence and step lengths differed across conditions but not groups which makes the group differences in proportion even more notable. In contrast, step width, while significantly lower in CP, did not differ across conditions. Our findings demonstrate that muscle synergies in children with CP are more sensitive to changes in the external walking environment than in typically developing children.

Functional and Structural Brain Connectivity in Children With Bilateral Cerebral Palsy Compared to Age-Related Controls and in Response to Intensive Rapid-Reciprocal Leg Training.

Background: Compared to unilateral cerebral palsy (CP), less is known about brain reorganization and plasticity in bilateral CP especially in relation or response to motor training. The few trials that reported brain imaging results alongside functional outcomes include a handful of studies in unilateral CP, and one pilot trial of three children with bilateral CP. This study is the first locomotor training randomized controlled trial (RCT) in bilateral CP to our knowledge reporting brain imaging outcomes. Methods: Objective was to compare MRI brain volumes, resting state connectivity and white matter integrity using DTI in children with bilateral CP with PVL and preterm birth history (<34 weeks), to age-related controls, and from an RCT of intensive 12 week rapid-reciprocal locomotor training using an elliptical or motor-assisted cycle. We hypothesized that connectivity in CP compared to controls would be greater across sensorimotor-related brain regions and that functional (resting state) and structural (fractional anisotropy) connectivity would improve post intervention. We further anticipated that baseline and post-intervention imaging and functional measures would correlate. Results: Images were acquired with a 3T MRI scanner for 16/27 children with CP in the trial, and 18 controls. No conclusive evidence of training-induced neuroplastic effects were seen. However, analysis of shared variance revealed that greater increases in precentral gyrus connectivity with the thalamus and pons may be associated with larger improvements in the trained device speed. Exploratory analyses also revealed interesting potential relationships between brain integrity and multiple functional outcomes in CP, with functional connectivity between the motor cortex and midbrain showing the strongest potential relationship with mobility. Decreased posterior white matter, corpus callosum and thalamic volumes, and FA in the posterior thalamic radiation were the most prominent group differences with corticospinal tract differences notably not found. Conclusions: Results reinforce the involvement of sensory-related brain areas in bilateral CP. Given the wide individual variability in imaging results and clinical responses to training, a greater focus on neural and other mechanisms related to better or worse outcomes is recommended to enhance rehabilitation results on a patient vs. group level.

Evaluation of Multi-layer Perceptron Neural Networks in Predicting Ankle Dorsiflexion in Healthy Adults using Movement-related Cortical Potentials for BCI-Neurofeedback Applications.

Brain computer interface (BCI) systems were initially developed to replace lost function; however, they are being increasingly utilized in rehabilitation to restore motor functioning after brain injury. In such BCI-mediated neurofeedback training (BCI-NFT), the brain-state associated with movement attempt or intention is used to activate an external device which assists the movement while providing sensory feedback to enhance neuroplasticity. A critical element in the success of BCI-NFT is accurate timing of the feedback within the active period of the brain state. The overarching goal of this work was to develop a reliable deep learning model that can predict motion before its onset, and thereby deliver the sensory stimuli in a timely manner for BCI-NFT applications. To this end, the main objective of the current study was to design and evaluate a Multi-layer Perceptron Neural Network (MLP-NN). Movement-related cortical potentials (MRCP) during planning and execution of ankle dorsiflexion was used to train the model to classify dorsiflexion planning vs. rest. The accuracy and reliability of the model was evaluated offline using data from eight healthy individuals (age: 26.3 ± 7.6 years). First, we evaluated three different epoching strategies for defining our 2 classes, to identify the one which best discriminated rest from dorsiflexion. The best model accuracy for predicting ankle dorsiflexion from EEG before movement execution was 84.7%. Second, the effect of various spatial filters on the model accuracy was evaluated, demonstrating that the spatial filtering had minimal effect on model accuracy and reliability.

Determining optimal mobile neurofeedback methods for motor neurorehabilitation in children and adults with non-progressive neurological disorders: a scoping review.

BACKGROUND: Brain-computer interfaces (BCI), initially designed to bypass the peripheral motor system to externally control movement using brain signals, are additionally being utilized for motor rehabilitation in stroke and other neurological disorders. Also called neurofeedback training, multiple approaches have been developed to link motor-related cortical signals to assistive robotic or electrical stimulation devices during active motor training with variable, but mostly positive, functional outcomes reported. Our specific research question for this scoping review was: for persons with non-progressive neurological injuries who have the potential to improve voluntary motor control, which mobile BCI-based neurofeedback methods demonstrate or are associated with improved motor outcomes for Neurorehabilitation applications? METHODS: We searched PubMed, Web of Science, and Scopus databases with all steps from study selection to data extraction performed independently by at least 2 individuals. Search terms included: brain machine or computer interfaces, neurofeedback and motor; however, only studies requiring a motor attempt, versus motor imagery, were retained. Data extraction included participant characteristics, study design details and motor outcomes. RESULTS: From 5109 papers, 139 full texts were reviewed with 23 unique studies identified. All utilized EEG and, except for one, were on the stroke population. The most commonly reported functional outcomes were the Fugl-Meyer Assessment (FMA; n = 13) and the Action Research Arm Test (ARAT; n = 6) which were then utilized to assess effectiveness, evaluate design features, and correlate with training doses. Statistically and functionally significant pre-to post training changes were seen in FMA, but not ARAT. Results did not differ between robotic and electrical stimulation feedback paradigms. Notably, FMA outcomes were positively correlated with training dose. CONCLUSION: This review on BCI-based neurofeedback training confirms previous findings of effectiveness in improving motor outcomes with some evidence of enhanced neuroplasticity in adults with stroke. Associative learning paradigms have emerged more recently which may be particularly feasible and effective methods for Neurorehabilitation. More clinical trials in pediatric and adult neurorehabilitation to refine methods and doses and to compare to other evidence-based training strategies are warranted.

Early intervention for very young children with or at high likelihood for autism spectrum disorder: An overview of reviews.

AIM: To identify which interventions are supported by evidence and the quality of that evidence in very young children with or at high likelihood for autism spectrum disorder (ASD) to improve child outcomes. METHOD: We conducted an overview of reviews to synthesize early intervention literature for very young children with or at high likelihood for ASD. Cochrane guidance on how to perform overviews of reviews was followed. Comprehensive searches of databases were conducted for systematic reviews and meta-analyses between January 2009 and December 2020. Review data were extracted and summarized and methodological quality was assessed. Primary randomized controlled trial evidence was summarized and risk of bias assessed. This overview of reviews was not registered. RESULTS: From 762 records, 78 full texts were reviewed and seven systematic reviews and meta-analyses with 63 unique studies were identified. Several interventional approaches (naturalistic developmental behavioral intervention, and developmental and behavioral interventions) improved child developmental outcomes. Heterogeneity in design, intervention and control group, dose, delivery agent, and measurement approach was noted. Inconsistent methodological quality and potential biases were identified. INTERPRETATION: While many early interventional approaches have an impact on child outcomes, study heterogeneity and quality had an impact on our ability to draw firm conclusions regarding which treatments are most effective. Advances in trial methodology and design, and increasing attention to mitigating measurement bias, will advance the quality of the ASD early intervention evidence base. WHAT THIS PAPER ADDS: Naturalistic developmental behavioral interventions, as well as developmental and behavioral interventions, improve child outcomes in autism spectrum disorder (ASD). If only randomized controlled trials are considered, guidelines for early intensive behavioral intervention in younger children should be revisited. The greatest intervention impacts were on proximal, intervention-specific outcomes. Inadequacies in the quality of the early ASD intervention evidence base were observed.

Interleaved Assistance and Resistance for Exoskeleton Mediated Gait Training: Validation, Feasibility and Effects.

Strength and selective motor control are primary determinants of pathological gait in children with cerebral palsy (CP) and other neuromotor disorders. Emerging evidence suggests robotic application of task-specific resistance to functional movements may provide the opportunity to strengthen muscles and improve neuromuscular function during walking in children with CP. Such a strategy could be most beneficial to children who are more severely affected by the pathology but their ability to overcome such resistance and maintain functional ambulation remains unclear. The goal of this study was to design, validate and evaluate initial feasibility and effects of a novel exoskeleton strategy that provides interleaved assistance and resistance to knee extension during overground walking. One participant with CP (GMFCS III) was recruited and completed ten total visits, nine walking with the exoskeleton. Our results validated the controller's ability to parse the gait cycle into five discrete phases (mean accuracy 91%) and provide knee extension assistance during stance and resistance during swing. Following acclimation to the interleaved strategy, peak knee extension was significantly improved in both the left (mean 7.9 deg) and right (15.2 deg) limbs when walking with the exoskeleton. Knee extensor EMG during late swing phase increased to 2.7 (left leg) and 1.7 (right leg) times the activation level during baseline exoskeleton walking without resistance. These results indicate that this interleaved strategy warrants further investigation in a longitudinal intervention study, particularly in individuals who may be more severely affected such that they are unable to ambulate overground using an exoskeleton training strategy that only deploys targeted resistance to limb motion.

Effect of muscle strength training in children and adolescents with spastic cerebral palsy: A systematic review and meta-analysis.

OBJECTIVE: This systematic review and meta-analysis investigates the effects of strength training program in children and adolescents with cerebral palsy to improve function, activity, and participation. DATA SOURCES: Five electronic databases (MEDLINE-Pubmed, Cochrane Library, PEDro, CINAHL, and SPORTDiscus) were systematically searched for full-text articles published from inception to 30 June 2021. REVIEW METHODS: Randomized controlled trials were included, who compared: (i) child population with spastic cerebral palsy population between 0 and 22 years; (ii) studies in which a muscle strength training program was performed and included dosing information; (iii) studies comparing strength training with other physical therapy technique(s) or untreated control group. Studies with similar outcomes were pooled by calculating standardized mean differences. Risk of bias was assessed with Cochrane Collaboration's tool for assessing the risk of bias and PROSPERO's registration number ID: CRD42020193535. RESULTS: Twenty-seven studies, comprising 847 participants with spastic cerebral palsy. The meta-analyses demonstrated significant standardized mean differences in favor of strength training program compared to other physical therapy technique(s) or untreated control group(s) for muscle strength at the knee flexors, at the knee extensor, at the plantarflexors, maximum resistance, balance, gait speed, GMFM (global, D and E dimension) and spasticity. CONCLUSION: A strength training program has positive functional and activity effects on muscle strength, balance, gait speed, or gross motor function without increasing spasticity for children and adolescents with cerebral palsy in Gross Motor Function Classification System levels I, II, and III when adequate dosage and specific principles are utilized.

NCS Assessments of the Motor, Sensory, and Physical Health Domains.

As part of the National Children's Study (NCS) comprehensive and longitudinal assessment of the health status of the whole child, scientific teams were convened to recommend assessment measures for the NCS. This manuscript documents the work of three scientific teams who focused on the motor, sensory, or the physical health aspects of this assessment. Each domain team offered a value proposition for the importance of their domain to the health outcomes of the developing infant and child. Constructs within each domain were identified and measures of these constructs proposed. Where available extant assessments were identified. Those constructs that were in need of revised or new assessment instruments were identified and described. Recommendations also were made for the age when the assessments should take place.

A Pediatric Knee Exoskeleton With Real-Time Adaptive Control for Overground Walking in Ambulatory Individuals With Cerebral Palsy.

Gait training via a wearable device in children with cerebral palsy (CP) offers the potential to increase therapy dosage and intensity compared to current approaches. Here, we report the design and characterization of a pediatric knee exoskeleton (P.REX) with a microcontroller based multi-layered closed loop control system to provide individualized control capability. Exoskeleton performance was evaluated through benchtop and human subject testing. Step response tests show the averaged 90% rise was 26 ± 0.2 ms for 5 Nm, 22 ± 0.2 ms for 10 Nm, 32 ± 0.4 ms for 15 Nm. Torque bandwidth of P.REX was 12 Hz and output impedance was less than 1.8 Nm with control on (Zero mode). Three different control strategies can be deployed to apply assistance to knee extension: state-based assistance, impedance-based trajectory tracking, and real-time adaptive control. One participant with typical development (TD) and one participant with crouch gait from CP were recruited to evaluate P.REX in overground walking tests. Data from the participant with TD were used to validate control system performance. Kinematic and kinetic data were collected by motion capture and compared to exoskeleton on-board sensors to evaluate control system performance with results demonstrating that the control system functioned as intended. The data from the participant with CP are part of a larger ongoing study. Results for this participant compare walking with P.REX in two control modes: a state-based approach that provided constant knee extension assistance during early stance, mid-stance and late swing (Est+Mst+Lsw mode) and an Adaptive mode providing knee extension assistance proportional to estimated knee moment during stance. Both were well tolerated and significantly improved knee extension compared to walking without extension assistance (Zero mode). There was less reduction in gait speed during use of the adaptive controller, suggesting that it may be more intuitive than state-based constant assistance for this individual. Future work will investigate the effects of exoskeleton assistance during overground gait training in children with neurological disorders and will aim to identify the optimal individualized control strategy for exoskeleton prescription.

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.

Akwenda intervention programme for children and youth with cerebral palsy in a low-resource setting in sub-Saharan Africa: protocol for a quasi-randomised controlled study.

INTRODUCTION: Cerebral palsy (CP) is the most common childhood-onset motor disorder accompanied by associated impairments, placing a heavy burden on families and health systems. Most children with CP live in low/middle-income countries with little access to rehabilitation services. This study will evaluate the Akwenda CP programme, a multidimensional intervention designed for low-resource settings and aiming at improving: (1) participation, motor function and daily activities for children with CP; (2) quality of life, stress and knowledge for caregivers; and (3) knowledge and attitudes towards children with CP in the communities. METHODS: This quasi-randomised controlled clinical study will recruit children and youth with CP aged 2-23 years in a rural area of Uganda. Children will be allocated to one of two groups with at least 44 children in each group. Groups will be matched for age, sex and motor impairment. The intervention arm will receive a comprehensive, multidimensional programme over a period of 11 months comprising (1) caregiver-led training workshops, (2) therapist-led practical group sessions, (3) provision of technical assistive devices, (4) goal-directed training and (5) community communication and advocacy. The other group will receive usual care. The outcome of the intervention will be assessed before and after the intervention and will be measured at three levels: (1) child, (2) caregiver and (3) community. Standard analysis methods for randomised controlled trial will be used to compare groups. Retention of effects will be examined at 12-month follow-up. ETHICS AND DISSEMINATION: The study has been approved by the Uganda National Council for Science and Technology (SS 5173) and registered in accordance with WHO and ICMJE standards. Written informed consent will be obtained from caregivers. Results will be disseminated among participants and stakeholders through public engagement events, scientific reports and conference presentations. TRIAL REGISTRATION NUMBER: Pan African Clinical Trials Registry (PACTR202011738099314) Pre-results.

Early intervention evidence for infants with or at risk for cerebral palsy: an overview of systematic reviews.

AIM: To perform an overview of systematic reviews and more recent randomized controlled trials (RCTs) on early motor interventions in infants aged 0 to 3 years with or at risk of cerebral palsy to inform current clinical and research efforts and provide a benchmark to assess future interventions ideally initiated within the first 6 months. METHOD: Standardized searches of the PubMed, Embase, Scopus, and Web of Science databases were conducted for systematic reviews (2009-2020) and RCTs (2015-2020). RESULTS: From 840 unique records, 31 full texts were reviewed, yielding three systematic reviews encompassing 46 studies, 16 with comparison groups, and six additional RCTs that met the criteria. Two enrichment- and activity-based approaches had medium effect sizes on motor development, only one with low risk of bias; two others had large task-specific effect sizes but some bias concerns; and three enriched environment studies with some bias concerns had medium effect sizes on cognitive development. Most had small or no effect sizes, bias concerns, and uncertain diagnostic determinations. INTERPRETATION: Data synthesis revealed limited data quantity and quality, and suggest, although not yet confirmed, greater benefit from early versus later intervention. Research efforts with greater early diagnostic precision and earlier intervention are accelerating, which may transform future outcomes and practices. What this paper adds For over 50% of trials within the reviews, the intervention was compared to standard care with only two showing efficacy. Similar to results in older children, constraint-induced movement therapy (CIMT) emerged as efficacious with high effect sizes. CIMT was not superior to similarly intense bimanual training or occupational therapy. Goals-Activity-Motor Enrichment intervention initiated before 5 months of age was superior to equally intense standard care. Several other enriched environment strategies promoted cognitive and/or motor development.

Greater Reliance on Cerebral Palsy-Specific Muscle Synergies During Gait Relates to Poorer Temporal-Spatial Performance Measures.

Children with cerebral palsy typically exhibit reduced complexity of muscle coordination patterns during walking; however, the specific patterns that characterize their gait abnormalities are still not well documented. This study aimed to identify the specific repertoire of muscle coordination patterns in children with CP during walking compared to same-aged peers without CP and their relationships to gait performance. To identify muscle coordination patterns, we extracted muscle synergies from 10 children with CP and 10 age-matched typically developing children (TD). K-mean clustering and discriminant analyses of all extracted synergies were used to group similar synergies. Then, weight-averaged z-scores were quantified for each cluster to determine their group-specific level. In this cohort, 10 of the 17 distinct clusters were largely CP-specific while six clusters were seen mainly in TD, and one was non-specific. CP-specific clusters generally showed merging of two TD synergies, excessive antagonist co-activation, decreased muscle activation compared to TD, and complex or atypical pattern. Significant correlations were found between weight-averaged z-scores and step length asymmetry, cadence asymmetry, self-selected treadmill speed and AP-COM displacement of the pelvis such that greater CP-specificity of muscle synergies was related to poorer performance, thus indicating that CP-specific synergies can influence motor dysfunction.