A coactivation strategy in anticipatory postural adjustments during voluntary unilateral arm movement while standing in individuals with bilateral spastic cerebral palsy.

Individuals with bilateral spastic cerebral palsy (BSCP) reportedly has problems with anticipatory postural adjustments (APAs) while standing. However, the use of coactivation strategy in APAs in individuals with BSCP has conflicting evidence. Hence, this study aimed to investigate postural muscle activities in BSCP during unilateral arm flexion task in which postural perturbations occur in the sagittal, frontal, and horizontal planes. We included 10 individuals with BSCP with level II on the Gross Motor Function Classification System (BSCP group) and 10 individuals without disability (control group). The participants stood on a force platform and rapidly flexed a shoulder from 0° to 90° at their own timing. Surface electromyograms were recorded from the rectus femoris, medial hamstring, tibialis anterior, and medial gastrocnemius. The control group showed a mixture of anticipatory activation and inhibition of postural muscles, whereas the BSCP group predominantly exhibited anticipatory activation with slight anticipatory inhibition. Compared with the control group, the BSCP group tended to activate the ipsilateral and contralateral postural muscles and the agonist-antagonist muscle pairs. The BSCP group had a larger disturbance in postural equilibrium, quantified by the peak displacement of center of pressure during the unilateral arm flexion, than those without disability. Individuals with BSCP may use coactivation strategy, mainly the anticipatory activation of postural muscle activity, during a task that requires a selective postural muscle activity to maintain stable posture.

A usability study on the inGAIT-VSO: effects of a variable-stiffness ankle-foot orthosis on the walking performance of children with cerebral palsy.

BACKGROUND: Ankle-foot orthoses (AFOs) are commonly used by children with cerebral palsy (CP), but traditional solutions are unable to address the heterogeneity and evolving needs amongst children with CP. One key limitation lies in the inability of current passive devices to customize the torque-angle relationship, which is essential to adapt the support to the specific individual needs. Powered alternatives can provide customized behavior, but often face challenges with reliability, weight, and cost. Overall, clinicians find certain barriers that hinder their prescription. In recent work, the Variable Stiffness Orthosis (VSO) was developed, enabling stiffness customization without the need for motors or sophisticated control. METHODS: This work evaluates a pediatric version of the VSO (inGAIT-VSO) by investigating its impact on the walking performance of children with CP and its potential to be used as a tool for assessing the effect of variable stiffness on pathological gait. Data was collected for three typical developing (TD) children and six pediatric participants with CP over two sessions involving walking/balance tasks and questionnaires. RESULTS: The sensors of the inGAIT-VSO provided useful information to assess the impact of the device. Increasing the stiffness of the inGAIT-VSO significantly reduced participants' dorsiflexion and plantarflexion. Despite reduced range of motion, the peak restoring torque increased with stiffness. Overall the participants' gait pattern was altered by reducing crouch gait, preventing drop-foot and supporting body weight. Participants with CP exhibited significantly lower (p < 0.05) physiological cost when walking with the inGAIT-VSO compared to normal condition (own AFO or shoes only). Generally, the device did not impair walking and balance of the participants compared to normal conditions. According to the questionnaire results, the inGAIT-VSO was easy to use and participants reported positive experiences. CONCLUSION: The inGAIT-VSO stiffnesses significantly affected participants' plantarflexion and dorsiflexion and yielded objective data regarding walking performance in pathological gait (e.g. ankle angle, exerted torque and restored assistive energy). These effects were captured by the sensors integrated in the device without using external equipment. The inGAIT-VSO shows promise for customizing AFO stiffness and aiding clinicians in selecting a personalized stiffness based on objective metrics.

The effect of vibration-hinged ankle foot orthoses on gait and spasticity in children with cerebral palsy: A randomized clinical trial design.

BACKGROUND: Hinged ankle foot orthoses (HAFO) are commonly prescribed for children with cerebral palsy (CP) to improve their ambulatory function. OBJECTIVES: The aim of this study was to compare the effect of vibration-HAFO with that of the same orthosis without vibration on gait, function, and spasticity in hemiplegic CP children. STUDY DESIGN: Randomized Control Trial Design (a pilot study). METHODS: Twenty-three children with hemiplegic CP participated in this study. The control group (n = 12) used HAFO, and the intervention group (n = 11) used vibration-HAFO for four weeks. Pre-post three-dimensional gait analysis was done. Calf muscle spasticity and function were also measured. RESULTS: Results showed significant differences between the two groups in the one-minute walking test (p = 0.023) and spasticity (after intervention [p = 0.022], after follow-up [p = 0.020]). Also, significant differences were detected between the two groups in the step width (p = 0.042), maximum hip abduction (p = 0.008), stance maximum dorsiflexion (p = 0.036) and mean pelvic tilt (p = 0.004) in the barefoot condition. Gait cycle time (p = 0.005), maximum hip abduction (p = 0.042), and cadence (p = 0.001) were different between groups in the braced condition. We couldn't find any significant within and between groups differences in knee kinematic parameters. The mean time of using vibration was 16.83 minutes per day. CONCLUSIONS: The vibration-hinged AFO is feasible, safe, and acceptable for children with hemiplegic CP to be integrated into practice. Temporospatial and clinical parameters, especially spasticity, were improved. There were slight trends toward improvement in pelvic and knee kinematics. Vibration-HAFO is of benefit to ambulatory CP children with mild and moderate spasticity. It improved the walking capacity of the children.

Robotic assessment of bilateral and unilateral upper limb functions in adults with cerebral palsy.

BACKGROUND: Children with unilateral cerebral palsy (CP) exhibit motor impairments predominantly on one side of the body, while also having ipsilesional and bilateral impairments. These impairments are known to persist through adulthood, but their extent have not been described in adults with CP. This study's aim is to characterize bilateral and unilateral upper limbs impairments in adults with CP. METHODS: Nineteen adults with CP (34.3 years old ± 11.5) performed three robotic assessments in the Kinarm Exoskeleton Lab, including two bilateral tasks (Object Hit [asymmetric independent goals task] and Ball on Bar [symmetric common goal task]) and one unilateral task (Visually Guided Reaching, performed with the more affected arm [MA] and less affected arm [LA]). Individual results were compared to sex, age and handedness matched normative data, describing the proportion of participants exhibiting impairments in each task-specific variable (e.g., Hand speed), each performance category (e.g., Feedforward control) and in global task performance. Associations were assessed using Spearman correlation coefficients between: 1: the results of the MA and LA of each limb in the unilateral task; and 2: the results of each limb in the unilateral vs. the bilateral tasks. RESULTS: The majority of participants exhibited impairments in bilateral tasks (84%). The bilateral performance categories (i.e., Bimanual) identifying bilateral coordination impairments were impaired in the majority of participants (Object Hit: 57.8%; Ball on Bar: 31.6%). Most of the participants were impaired when performing a unilateral task with their MA arm (63%) and a smaller proportion with their LA arm (31%). The Feedforward control was the unilateral performance category showing the highest proportion of impaired participants while displaying the strongest relationship between the MA and LA arms impairments (rs = 0.93). Feedback control was the unilateral performance category most often associated with impairments in bilateral tasks (6 out of 8 performance categories). CONCLUSIONS: Adults with CP experienced more impairment in bilateral tasks while still having substantial impairments in unilateral tasks. They frequently display Feedforward control impairments combined with a higher reliance on Feedback control during both bilateral and unilateral tasks, leading to poorer motor performance.

Repeated Transcranial Magnetic Stimulation Combined with Action Observation Training in Children with Spastic Cerebral Palsy.

This study presents the results of a randomized controlled trial utilizing a 2 x 2 factorial design, comparing the effects of repeated transcranial magnetic stimulation (rTMS) and action observation training (AOT) intervention methods on spasticity, balance function, and motor function in children with spastic cerebral palsy (SCP). The study aimed to investigate whether the combination of the two interventions produces greater improvement than either treatment alone or conventional treatment. Subject children in this study, in accordance with the random number table, were randomly divided into four groups: conventional group, rTMS group, AOT group, and combined intervention group. All the children in the four groups received conventional rehabilitation treatment, on the basis of which they were given different therapeutic programs of rehabilitation measures. The conventional group had no other treatment while the rTMS group received rTMS, the AOT group received AOT and the combined intervention group was given a combined intervention of rTMS and AOT. They were trained five days per week for 12 weeks. Changes in scores of spasticity, balance function, walking ability, and gross motor function were assessed at the onset of the training program and upon completion of 12 weeks of treatment. A total of 64 Children with SCP completed the study, and their results were analyzed. The total gross motor function efficiency of 87.50% in the experimental group was significantly higher than that of 25.00% in the conventional group, 62.50% in the rTMS group, and 68.75% in the AOT group. The preliminary results showed that combined intervention of rTMS and AOT could effectively improve the balance function and motor function of children, and the therapeutic effect of the combined intervention was better than that of conventional treatment, rTMS or AOT alone. Finally, clinical efficacy and optimal treatment parameters of the combined intervention were clarified to provide a clinical basis for therapists to conduct lower limb function rehabilitation for children with SCP.

Validation of the Kinematic Assessment Protocol Used in the Technology-Supported Neurorehabilitation System, Rehabilitation Technologies for Hand and Arm (R3THA™), in Children and Teenagers with Cerebral Palsy.

This study evaluates the R3THA™ assessment protocol (R3THA-AP™), a technology-supported testing module for personalized rehabilitation in children with cerebral palsy (CP). It focuses on the reliability and validity of the R3THA-AP in assessing hand and arm function, by comparing kinematic assessments with standard clinical assessments. Conducted during a 4-week summer camp, the study assessed the functional and impairment levels of children with CP aged 3-18. The findings suggest that R3THA is more reliable for children aged 8 and older, indicating that age significantly influences the protocol's effectiveness. The results also showed that the R3THA-AP's kinematic measurements of hand and wrist movements are positively correlated with the Box and Blocks Test Index (BBTI), reflecting hand function and dexterity. Additionally, the R3THA-AP's accuracy metrics for hand and wrist activities align with the Melbourne Assessment 2's Range of Motion (MA2-ROM) scores, suggesting a meaningful relationship between R3THA-AP data and clinical assessments of motor skills. However, no significant correlations were observed between the R3THA-AP and MA2's accuracy and dexterity measurements, indicating areas for further research. These findings validate the R3THA-AP's utility in assessing motor abilities in CP patients, supporting its integration into clinical practice.

Rectus femoris electromyography signal clustering: Data-driven management of crouch gait in patients with cerebral palsy.

This study aimed to investigate how electromyography (EMG) cluster analysis of the rectus femoris (RF) could help to better interpret gait analysis in patients with cerebral palsy (CP). The retrospective gait data of CP patients were categorized into two groups: initial examination (E1, 881 patients) and subsequent examination (E2, 377 patients). Envelope-formatted EMG data of RF were collected. Using PCA and a combined PSO-K-means algorithm, main clusters were identified. Patients were further classified into crouch, jump, recurvatum, stiff and mild gait for detailed analysis. The clusters (labels) were characterized by a significant peak EMG activity during mid-swing (L1), prolonged EMG activity during stance (L2), and a peak EMG activity during loading response (L3). Notably, L2 contained 76% and 92% of all crouch patients at E1 and E2, respectively. Comparing patients with a crouch gait pattern in L2-E1 and L2-E2, two subgroups emerged: patients with persistent crouch (G1) and patients showing improvement at E2 (G2). The minimum activity of RF during 20-45% of the gait was significantly higher (p = 0.025) in G1 than in G2. A greater chance of improvement from crouch gait might be associated with lower RF activity during the stance phase. Using our findings, we could potentially establish an approach to improve clinical decision-making regarding treatment of patients with CP.

Effects of Video-Based Exercises and Conventional Physiotherapy on Upper Extremity Functionality, Selective Motor Control, and Proprioception in Unilateral Cerebral Palsy: A Randomized Controlled Trial.

Objective: The present study was conducted to evaluate the effects of video-based exercises added to conventional physiotherapy (CPT) on upper extremity functionality, selective motor control, and proprioception in individuals with unilateral cerebral palsy (UCP). Materials and Methods: Thirty patients with UCP were randomized into two groups: the intervention group (15 individuals with a mean age of 9.2 ± 3.8 years) and the control group (15 individuals with a mean age of 8.3 ± 4.1 years). The intervention group received 8 weeks of video-based exercises, and the control group received 8 weeks of conventional physiotherapy. Upper extremity functional abilities, upper extremity selective motor control, proprioception, and entertainment levels were evaluated before and after the intervention for all groups. Results: While a significant change was observed in the mean scores of the ABILHAND-Kids, Selective Control of the Upper Extremity Scale right-left scores, shoulder flexion, shoulder abduction, and elbow flexion proprioception angles after the video-based exercises in the intervention group (P < 0.05), a significant change was observed only in the 60-degree flexion angle in the control group (P = 0.001). In the comparison between the groups, there were significant differences in post-intervention value only in shoulder flexion and abduction angles, whereas there was no difference between the groups in elbow flexion angles (P > 0.05). Conclusion: Incorporating video-based exercises into the upper extremity rehabilitation processes of individuals with UCP is beneficial in terms of upper extremity functionality, selective motor control, and proprioception.

Markerless motion analysis to assess reaching-sideways in individuals with dyskinetic cerebral palsy: A validity study.

This study aimed to evaluate clinical utility of 2D-markerless motion analysis (2DMMA) from a single camera during a reaching-sideways-task in individuals with dyskinetic cerebral palsy (DCP) by determining (1) concurrent validity by correlating 2DMMA against marker-based 3D-motion analysis (3DMA) and (2) construct validity by assessing differences in 2DMMA features between DCP and typically developing (TD) peers. 2DMMA key points were tracked from frontal videos of a single camera by DeepLabCut and accuracy was assessed against human labelling. Shoulder, elbow and wrist angles were calculated from 2DMMA and 3DMA (as gold standard) and correlated to assess concurrent validity. Additionally, execution time and variability features such as mean point-wise standard deviation of the angular trajectories (i.e. shoulder elevation, elbow and wrist flexion/extension) and wrist trajectory deviation by mean overshoot and convex hull were calculated from key points. 2DMMA features were compared between the DCP group and TD peers to assess construct validity. Fifty-one individuals (30 DCP;21 TD; age:5-24 years) participated. An accuracy of approximately 1.5 cm was reached for key point tracking. While significant correlations were found for wrist (ρ = 0.810;p < 0.001) and elbow angles (ρ = 0.483;p < 0.001), 2DMMA shoulder angles were not correlated (ρ = 0.247;p = 0.102) to 3DMA. Wrist and elbow angles, execution time and variability features all differed between groups (Effect sizes 0.35-0.81;p < 0.05). Videos of a reaching-sideways-task processed by 2DMMA to assess upper extremity movements in DCP showed promising validity. The method is especially valuable to assess movement variability.

The relation between visual functions, functional vision, and bimanual function in children with unilateral cerebral palsy.

BACKGROUND: Accurate visual information is needed to guide and perform efficient movements in daily life. AIMS: To investigate the relation between visual functions, functional vision, and bimanual function in children with unilateral cerebral palsy (uCP). METHODS AND PROCEDURES: In 49 children with uCP (7-15 y), we investigated the relation between stereoacuity (Titmus Stereo Fly test), visual perception (Test of Visual Perceptual Skills), visuomotor integration (Beery Buktenica Test of Visual-Motor Integration) and functional vision (Flemish cerebral visual impairment questionnaire) with bimanual dexterity (Tyneside Pegboard Test), bimanual coordination (Kinarm exoskeleton robot, Box opening task), and functional hand use (Children's Hand-use Experience Questionnaire; Assisting Hand Assessment) using correlations (rs) and elastic-net regularized regressions (d). OUTCOMES AND RESULTS: Visual perception correlated with bimanual coordination (rs=0.407-0.436) and functional hand use (rs=0.380-0.533). Stereoacuity (rs=-0.404), visual perception (rs=-0.391 to -0.620), and visuomotor integration (rs=-0.377) correlated with bimanual dexterity. Functional vision correlated with functional hand use (rs=-0.441 to -0.458). Visual perception predicted bimanual dexterity (d=0.001-0.315), bimanual coordination (d=0.004-0.176), and functional hand use (d=0.001-0.345), whereas functional vision mainly predicted functional hand use (d=0.001-0.201). CONCLUSIONS AND IMPLICATIONS: Visual functions and functional vision are related to bimanual function in children with uCP highlighting the importance of performing extensive visual assessment to better understand children's difficulties in performing bimanual tasks. WHAT THIS PAPER ADDS: Previous findings showed that up to 62 % of children with unilateral cerebral palsy (uCP) present with visual impairment, which can further compromise their motor performance. However, the relation between visual and motor function has hardly been investigated in this population. This study makes a significant contribution to the literature by comprehensively investigating the multi-level relation between the heterogenous spectrum of visual abilities and bimanual function in children with uCP. We found that mainly decreased visual perception was related to decreased bimanual dexterity, bimanual coordination, and functional hand use while impairments in functional vision were only related to decreased functional hand use. Additionally, elastic-net regression models showed that visual assessments can predict bimanual function in children with uCP, however, effect sizes were only tiny to small. With our study, we demonstrated a relation between visual functions and bimanual function in children with uCP. These findings suggest the relevance of thoroughly examining visual functions in children with uCP to identify the presence of visual impairments that may further compromise their bimanual function.

A Relook at Cerebral Palsy Beyond Motor Pathology: A Cross-Sectional Study of Sensory Processing Abilities.

BACKGROUND: Sensory processing refers to receiving, organizing, and interpreting sensory stimuli from the sensory system. Unlike other neurodevelopmental disorders, knowledge about the sensory processing abilities of children with cerebral palsy (CP) is lacking. OBJECTIVE: To study the difference in sensory processing abilities of children with cerebral palsy in comparison to age matched typically developing children (TDC). METHODS AND MATERIAL: A cross-sectional analysis of sensory processing abilities of children with CP and TDC was performed from July 2018 through February 2020. The child sensory profile2 (CSP2) caregiver questionnaire was used to detect sensory processing differences (SPD) across nine sensory domains and four sensory processing patterns. A comparison was made between the two study groups as well as between the CP subtypes. RESULT: Around 226 children with CP and 58 TDC were screened. Finally, 150 children with CP and 50 TDC were enrolled. Probable SPD (>1SD) was observed in (121/150) 80.7% of children with CP compared to (13/50) 26% in TDC (p < 0.001). Definite SPD (>2SD) was seen in 40.7% (61/150) of children with CP vs. none in TDC (p < 0.001). The body position domain which tests the vestibular and proprioceptive processing was primarily affected in CP. Most children with CP fell under the "bystander" pattern suggesting poor registration of sensory stimuli. No significant difference in the pattern of sensory processing was observed between the CP subtypes. Prevalence of definite SPD positively correlated with the gross motor functional classification system level. CONCLUSION: Sensory processing abilities of children with CP differ significantly from TDC. Proprioceptive and vestibular sensory processing is primarily affected in CP.

HABIT training in unilateral spastic cerebral palsy children having mirror movement disorder.

The single-arm feasibility study was planned to evaluate the therapeutic effect of hand arm bimanual intensive training in improving the fine and gross motor functions of hand, and in the reduction of intensity with respect to mirror movement disorder. The sample comprised unilateral spastic cerebral palsy children aged 6-16 years who were having mirror movement disorder and were able to make a gross grip. The hand arm bimanual intensive training was provided to the participants for 6 hours per day for 15 days for a total of 90 hours. Comparison of baseline and post-intervention showed that the functional independence level of children had improved, with improvement in unimanual and bimanual hand performance (p˂0.05). However, there was no improvement seen in the severity of mirror movements (p>0.05). Hence, hand arm bimanual intensive training was found to be effective in increasing the functional independence of cerebral palsy children by improving the hand function, but there was no effect on mirror movement disorder.

Collagen architecture and biomechanics of gracilis and adductor longus muscles from children with cerebral palsy.

Cerebral palsy (CP) describes some upper motoneuron disorders due to non-progressive disturbances occurring in the developing brain that cause progressive changes to muscle. While longer sarcomeres increase muscle stiffness in patients with CP compared to typically developing (TD) patients, changes in extracellular matrix (ECM) architecture can increase stiffness. Our goal was to investigate how changes in muscle and ECM architecture impact muscle stiffness, gait and joint function in CP. Gracilis and adductor longus biopsies were collected from children with CP undergoing tendon lengthening surgery for hamstring and hip adduction contractures, respectively. Gracilis biopsies were collected from TD patients undergoing anterior cruciate ligament reconstruction surgery with hamstring autograft. Muscle mechanical testing, two-photon imaging and hydroxyproline assay were performed on biopsies. Corresponding data were compared to radiographic hip displacement in CP adductors (CPA), gait kinematics in CP hamstrings (CPH), and joint range of motion in CPA and CPH. We found at matched sarcomere lengths muscle stiffness and collagen architecture were similar between TD and CP hamstrings. However, CPH stiffness (R2 = 0.1973), collagen content (R2 = 0.5099) and cross-linking (R2 = 0.3233) were correlated to decreased knee range of motion. Additionally, we observed collagen fibres within the muscle ECM increase alignment during muscular stretching. These data demonstrate that while ECM architecture is similar between TD and CP hamstrings, collagen fibres biomechanics are sensitive to muscle strain and may be altered at longer in vivo sarcomere lengths in CP muscle. Future studies could evaluate the impact of ECM architecture on TD and CP muscle stiffness across in vivo operating ranges. KEY POINTS: At matched sarcomere lengths, gracilis muscle mechanics and collagen architecture are similar in TD patients and patients with CP. In both TD and CP muscles, collagen fibres dynamically increase their alignment during muscle stretching. Aspects of muscle mechanics and collagen architecture are predictive of in vivo knee joint motion and radiographic hip displacement in patients with CP. Longer sarcomere lengths in CP muscle in vivo may alter collagen architecture and biomechanics to drive deficits in joint mobility and gait function.

Use of computational modeling to examine fingertip force production in children with hemiplegic cerebral palsy.

Most children with hemiplegic cerebral palsy (HCP), one of the most prevalent subtypes of cerebral palsy, struggle with grasping and manipulating objects. This impairment may arise from a diminished capacity to properly direct forces created with the finger pad due to aberrant force application. Children with HCP were asked to create maximal force with the index finger pad in the palmar (normal) direction with both the paretic and non-paretic hands. The resulting forces and finger postures were then applied to a computational musculoskeletal model of the hand to estimate the corresponding muscle activation patterns. Subjects tended to create greater shear force relative to normal force with the paretic hand (p < 0.05). The resultant force was directed 33.6°±10.8° away from the instructed palmar direction in the paretic hand, but only 8.0°±7.3° in the non-paretic hand. Additionally, participants created greater palmar force with the non-paretic hand than with the paretic hand (p < 0.05). These differences in force production are likely due to differences in muscle activation pattern, as our computational models showed differences in which muscles are active and their relative activations when recreating the measured force vectors for the two hands (p < 0.01). The models predicted reduced activation in the extrinsic and greater reductions in activation in the intrinsic finger muscles, potentially due to reduced voluntary activation or muscle atrophy. As the large shear forces could lead to objects slipping from grasp, muscle activation patterns may provide an important target for therapeutic treatment in children with HCP.

Overground Gait Training With a Wearable Robot in Children With Cerebral Palsy: A Randomized Clinical Trial.

Importance: Cerebral palsy (CP) is the most common developmental motor disorder in children. Robot-assisted gait training (RAGT) using a wearable robot can provide intensive overground walking experience. Objective: To investigate the effectiveness of overground RAGT in children with CP using an untethered, torque-assisted, wearable exoskeletal robot. Design, Setting, and Participants: This multicenter, single-blind randomized clinical trial was conducted from September 1, 2021, to March 31, 2023, at 5 rehabilitation institutions in Korea. Ninety children with CP in Gross Motor Function Classification System levels II to IV were randomized. Intervention: The RAGT group underwent 18 sessions of RAGT during 6 weeks, whereas the control group received standard physical therapy for the same number of sessions during the same period. Main Outcome and Measures: The primary outcome measure was the Gross Motor Function Measure 88 (GMFM-88) score. Secondary outcome measures were the GMFM-66, Pediatric Balance Scale, selective control assessment of the lower extremity, Pediatric Evaluation of Disability Inventory-Computer Adaptive Test (PEDI-CAT), 6-minute walking test scores (distance and oxygen consumption), muscle and fat mass via bioelectrical impedance analysis, and gait parameters measured via 3-dimensional analysis. All assessments were performed for all patients at baseline, at the end of the 6-week intervention, and after the 4-week follow-up. Results: Of the 90 children (mean [SD] age, 9.51 [2.48] years; 49 [54.4%] male and 41 [45.6%] female) in the study, 78 (86.7%) completed the intervention, with 37 participants (mean [SD] age, 9.57 [2.38] years; 19 [51.4%] male) and 41 participants (mean [SD] age, 9.32 [2.37] years; 26 [63.4%] male) randomly assigned to the RAGT and control groups, respectively. Changes in the RAGT group significantly exceeded changes in the control group in GMFM-88 total (mean difference, 2.64; 95% CI, 0.50-4.78), GMFM-E (mean difference, 2.70; 95% CI, 0.08-5.33), GMFM-66 (mean difference, 1.31; 95% CI, 0.01-2.60), and PEDI-CAT responsibility domain scores (mean difference, 2.52; 95% CI, 0.42-4.63), indicating independence in daily living at postintervention assessment. At the 4-week follow-up, the RAGT group showed significantly greater improvements in balance control (mean difference, 1.48; 95% CI, 0.03-2.94) and Gait Deviation Index (mean difference, 6.48; 95% CI, 2.77-10.19) compared with the control group. Conclusions and Relevance: In this randomized clinical trial, overground RAGT using a wearable robot significantly improved gross motor function and gait pattern. This new torque-assisted wearable exoskeletal robot, based on assist-as-needed control, may complement standard rehabilitation by providing adequate assistance and therapeutic support to children with CP. Trial Registration: CRIS Identifier: KCT0006273.

The effects of ankle mulligan mobilisation in children with cerebral palsy: A randomized single blind control study.

OBJECTIVE: To assess the impact of range of motion changes before and after Mulligan mobilisation with ankle movement interventions on the daily lives of children with diplegic cerebral palsy. METHODS: The single blind randomised controlled study was conducted from July 30, 2022, to January 10, 2023, at 3 rehabilitation centres in Hebron, Palestine, after approval from the ethics review committee of Eastern Mediterranean University, Northern Cyprus, and comprised children with cerebral palsy, who were randomised into intervention group IG and control group CG. All the subjects received regular physiotherapy sessions, overseen by their parents, while those in group IG received mobilisation with ankle movement treatment 3 times per week for 4 weeks. Post-intervention assessment of ankle range of motion, balance, functional performance and quality of life was done using a goniometer, the timed up and go test, 88-item gross motor function measure, 6-minute walk test and the cerebral palsy quality of life questionnaire. Data was analysed using SPSS 24. RESULTS: Of the 64 patients, 40(63%) were girls, and 24(37%) were boys. The overall age range was aged 4-12 years. There were 32(50%) patients in each of the two groups. Mobilisation with movement had a significant effect on active and passive range of motion for the left and right ankles (p<0.05) as well as on balance, gross motor function and quality of life (p>0.05). However, mobilisation with movement had no significant effect on the the distance covered during the 6-minute walk test (p>0.05). CONCLUSIONS: Mobilisation with movement had a significant impact on active and passive ankle range of motion, balance and quality of life in diplegic children with cerebral palsy, but it had no impact on gait function. Clinical trial registration number: The study was registered at the United States National Institutes of Health (ClinicalTrials.gov) with registration number NCT05500924.

Kinematic upper limb analysis outperforms electromyography at grading the severity of dystonia in children with cerebral palsy.

BACKGROUND: Severity of dyskinesia in children with cerebral palsy is often assessed using observation-based clinical tools. Instrumented methods to objectively measure dyskinesia have been proposed to improve assessment accuracy and reliability. Here, we investigated the technique and movement features that were most suitable to objectively measure the severity of dystonia in children with cerebral palsy. METHODS: A prospective observational study was conducted with 12 participants with cerebral palsy with a predominant motor type of dyskinesia, spasticity, or mixed dyskinesia/spasticity who had upper limb involvement (mean age: 12.6 years, range: 6.7-18.2 years). Kinematic and electromyography data were collected bilaterally during three upper limb tasks. Spearman rank correlations of kinematic or electromyography features were calculated against dystonia severity, quantified by the Dyskinesia Impairment Scale. FINDINGS: Kinematic features were more influential compared to electromyography features at grading the severity of dystonia in children with cerebral palsy. Kinematic measures quantifying jerkiness of volitional movement during an upper limb task with a reaching component performed best (|rs| = 0.78-0.9, p < 0.001). INTERPRETATION: This study provides guidance on the types of data, features of movement, and activity protocols that instrumented methods should focus on when objectively measuring the severity of dystonia in children with cerebral palsy.