Lifelong Fitness in Ambulatory Children and Adolescents with Cerebral Palsy I: Key Ingredients for Bone and Muscle Health.

Physical activity of a sufficient amount and intensity is essential to health and the prevention of a sedentary lifestyle in all children as they transition into adolescence and adulthood. While fostering a fit lifestyle in all children can be challenging, it may be even more so for those with cerebral palsy (CP). Evidence suggests that bone and muscle health can improve with targeted exercise programs for children with CP. Yet, it is not clear how musculoskeletal improvements are sustained into adulthood. In this perspective, we introduce key ingredients and guidelines to promote bone and muscle health in ambulatory children with CP (GMFCS I-III), which could lay the foundation for sustained fitness and musculoskeletal health as they transition from childhood to adolescence and adulthood. First, one must consider crucial characteristics of the skeletal and muscular systems as well as key factors to augment bone and muscle integrity. Second, to build a better foundation, we must consider critical time periods and essential ingredients for programming. Finally, to foster the sustainability of a fit lifestyle, we must encourage commitment and self-initiated action while ensuring the attainment of skill acquisition and function. Thus, the overall objective of this perspective paper is to guide exercise programming and community implementation to truly alter lifelong fitness in persons with CP.

Lifelong Fitness in Ambulatory Children and Adolescents with Cerebral Palsy II: Influencing the Trajectory.

Physical activity of at least moderate intensity in all children contributes to higher levels of physical and psychological health. While essential, children with cerebral palsy (CP) often lack the physical capacity, resources, and knowledge to engage in physical activity at a sufficient intensity to optimize health and well-being. Low levels of physical activity place them at risk for declining fitness and health, contributing to a sedentary lifestyle. From this perspective, we describe a framework to foster a lifelong trajectory of fitness in ambulatory children with CP (GMFCS I-III) as they progress into adolescence and adulthood, implemented in conjunction with a training program to augment bone and muscle health. First, we recommend that altering the fitness trajectory of children with CP will require the use of methods to drive behavioral change prior to adolescence. Second, to promote behavior change, we suggest embedding lifestyle intervention into fitness programming while including meaningful activities and peer socialization to foster self-directed habit formation. If the inclusion of lifestyle intervention to drive behavior change is embedded into fitness programs and found to be effective, it may guide the delivery of targeted programming and community implementation. Participation in comprehensive programming could alter the long-term trajectory of musculoskeletal health while fostering strong self-efficacy in persons with CP.

Quantifying intra- and interlimb use during unimanual and bimanual tasks in persons with hemiparesis post-stroke.

BACKGROUND: Individuals with hemiparesis post-stroke often have difficulty with tasks requiring upper extremity (UE) intra- and interlimb use, yet methods to quantify both are limited. OBJECTIVE: To develop a quantitative yet sensitive method to identify distinct features of UE intra- and interlimb use during task performance. METHODS: Twenty adults post-stroke and 20 controls wore five inertial sensors (wrists, upper arms, sternum) during 12 seated UE tasks. Three sensor modalities (acceleration, angular rate of change, orientation) were examined for three metrics (peak to peak amplitude, time, and frequency). To allow for comparison between sensor data, the resultant values were combined into one motion parameter, per sensor pair, using a novel algorithm. This motion parameter was compared in a group-by-task analysis of variance as a similarity score (0-1) between key sensor pairs: sternum to wrist, wrist to wrist, and wrist to upper arm. A use ratio (paretic/non-paretic arm) was calculated in persons post-stroke from wrist sensor data for each modality and compared to scores from the Adult Assisting Hand Assessment (Ad-AHA Stroke) and UE Fugl-Meyer (UEFM). RESULTS: A significant group × task interaction in the similarity score was found for all key sensor pairs. Post-hoc tests between task type revealed significant differences in similarity for sensor pairs in 8/9 comparisons for controls and 3/9 comparisons for persons post stroke. The use ratio was significantly predictive of the Ad-AHA Stroke and UEFM scores for each modality. CONCLUSIONS: Our algorithm and sensor data analyses distinguished task type within and between groups and were predictive of clinical scores. Future work will assess reliability and validity of this novel metric to allow development of an easy-to-use app for clinicians.

Highlighting gaps in spinal cord injury research in activity-based interventions for the upper extremity: A scoping review.

BACKGROUND: Upper extremity activity-based therapy for neurologic disorders employs high-intensity, high repetition functional training to exploit neuroplasticity and improve function. Research focused on high-intensity upper extremity activity-based therapy for persons with spinal cord injury (SCI) is limited. OBJECTIVE: To summarize high-intensity activity-based interventions used in neurological disorders for their current or potential application to SCI. METHODS: The scoping review included articles from MEDLINE, CINAHL, Cochrane CENTRAL, and OTSeeker with the criteria: non-invasive activity-based interventions delivered at least three times/week for two weeks, upper extremity functional outcomes, age 13 years or older, English language, and neurological disorders three months post onset/injury. RESULTS: The search yielded 172 studies. There were seven studies with SCI, all in adults. Activity-based interventions in SCI included task-specific training and gaming, with and without electrical stimulation, and a robotic exoskeleton. The other populations found in the review included studies in stroke, cerebral palsy, and multiple sclerosis. Thirty-four different interventions were reported in other populations. In comparison to the extensive stroke research, work in SCI was not found for high-intensity interventions using virtual reality, brain stimulation, rehabilitation devices, and applications to the home and telerehab settings. CONCLUSION: The results highlight critical gaps within upper extremity high-intensity activity-based research in SCI.

Comparison of Machine Learning approaches for Classifying Upper Extremity Tasks in Individuals Post-Stroke.

After a stroke, individuals often exhibit upper extremity (UE) motor dysfunction, influencing the performance of everyday tasks. Characterizing UE movements is useful to track recovery and response to intervention. Yet, due to the complexity of the recovery process, UE movements may be extremely variable and person-specific. While this renders automatic recognition of these gestures challenging, machine learning methods could be used to classify UE movements in atypical populations. In the current study, we utilize data from 20 individuals post-stroke and 20 age-matched controls to identify an optimal set of sensor-extracted features for the classification of unimanual and bimanual gestures during task performance. We found that using fewer than 100 features along with a random forest classifier produced the best performance across both groups, with both user-dependent and user-independent models.

Development of Sensor-Based Measures of Upper Extremity Interlimb Coordination.

The development of motor impairment after the onset of an injury such as stroke may result in long-term compensatory behaviors. Because compensation often evolves in ambient settings (outside the purview of monitoring clinicians), there is a need for quantitative tools capable of accurately detecting the subtleties of compensation and related reduction in interlimb coordination. Improvement in interlimb coordination may serve as a marker of recovery from stroke, and rehabilitation progress. The current study investigates measures of upper extremity interlimb coordination in persons post-stroke and healthy controls. It introduces a novel algorithm for objective characterization of interlimb coordination during the performance of real-world tasks.

Innovative evaluation of dexterity in pediatrics.

STUDY DESIGN: Review paper. INTRODUCTION: Hand dexterity is multifaceted and essential to the performance of daily tasks. Timed performance and precision demands are the most common features of quantitative dexterity testing. Measurement concepts such as rate of completion, in-hand manipulation and dynamic force control of instabilities are being integrated into assessment tools for the pediatric population. PURPOSE: To review measurement concepts inherent in pediatric dexterity testing and introduce concepts that are infrequently measured or novel as exemplified with two assessment tools. METHODS: Measurement concepts included in common assessment tools are introduced first. We then describe seldom measured and novel concepts embedded in two instruments; the Functional Dexterity Test (FDT) and the Strength-Dexterity (SD) Test. DISCUSSION: The inclusion of novel yet informative tools and measurement concepts in our assessments could aid our understanding of atypical dexterity, and potentially contribute to the design of targeted therapy programs.

Clinical assessment of the infant and child following perinatal brachial plexus injury.

STUDY DESIGN: Literature review. INTRODUCTION: After perinatal brachial plexus injury (PBPI), clinicians play an important role in injury classification as well as the assessment of recovery and secondary conditions. Early assessment guides the initial plan of care and influences follow-up and long-term outcome. PURPOSE: To review methods used to assess, classify and monitor the extent and influence of PBPI with an emphasis on guidelines for clinicians. METHODS: We use The International Classification of Functioning, Disability, and Health (ICF) model to provide a guide to assessment after PBPI for rehabilitation clinicians. DISCUSSION: With information gained from targeted assessments, clinicians can design interventions to increase the opportunities infants and children have for optimal recovery and to attain skills that allow participation in areas of interest.

Interrater reliability of the Wolf Motor Function Test-Functional Ability Scale: why it matters.

BACKGROUND: One important objective for clinical trialists in rehabilitation is determining efficacy of interventions to enhance motor behavior. In part, limitation in the precision of measurement presents a challenge. The few valid, low-cost observational tools available to assess motor behavior cannot escape the variability inherent in test administration and scoring. This is especially true when there are multiple evaluators and raters, as in the case of multisite randomized controlled trials (RCTs). One way to enhance reliability and reduce variability is to implement rigorous quality control (QC) procedures. OBJECTIVE: This article describes a systematic QC process used to refine the administration and scoring procedures for the Wolf Motor Function Test (WMFT)-Functional Ability Scale (FAS). METHODS: The QC process, a systematic focus-group collaboration, was developed and used for a phase III RCT, which enlisted multiple evaluators and an experienced WMFT-FAS rater panel. RESULTS: After 3 staged refinements to the administration and scoring instructions, we achieved a sufficiently high interrater reliability (weighted κ = 0.8). CONCLUSIONS AND IMPLICATIONS: A systematic focus-group process was shown to be an effective method to improve reliability of observational assessment tools for motor behavior in neurorehabilitation. A reduction in noise-related variability in performance assessments will increase power and potentially lower the number needed to treat. Improved precision of measurement can lead to more cost-effective and efficient clinical trials. Finally, we suggest that improved precision in measures of motor behavior may provide more insight into recovery mechanisms than a single measure of movement time alone.

Applying principles of motor learning and control to upper extremity rehabilitation.

The purpose of this article is to provide a brief review of the principles of motor control and learning. Different models of motor control from historical to contemporary are presented with emphasis on the Systems model. Concepts of motor learning including skill acquisition, measurement of learning, and methods to promote skill acquisition by examining the many facets of practice scheduling and use of feedback are provided. A fictional client case is introduced and threaded throughout the article to facilitate understanding of these concepts and how they can be applied to clinical practice.

The impact of left hemisphere stroke on force control with familiar and novel objects: neuroanatomic substrates and relationship to apraxia.

Fingertip force scaling for lifting objects frequently occurs in anticipation of finger contact. An ongoing question concerns the types of memories that are used to inform predictive control. Object-specific information such as weight may be stored and retrieved when previously encountered objects are lifted again. Alternatively, visual size and shape cues may provide estimates of object density each time objects are encountered. We reasoned that differences in performance with familiar versus novel objects would provide support for the former possibility. Anticipatory force production with both familiar and novel objects was assessed in six left hemisphere stroke patients, two of whom exhibited deficient actions with familiar objects (ideomotor apraxia; IMA), along with five control subjects. In contrast to healthy controls and stroke participants without IMA, participants with IMA displayed poor anticipatory scaling with familiar objects. However, like the other groups, IMA participants learned to differentiate fingertip forces with repeated lifts of both familiar and novel objects. Finally, there was a significant correlation between damage to the inferior parietal and superior and middle temporal lobes and impaired anticipatory control for familiar objects. These data support the hypotheses that anticipatory control during lifts of familiar objects in IMA patients are based on object-specific memories and that the ventro-dorsal stream is involved in the long-term storage of internal models used for anticipatory scaling during object manipulation.

Asymmetrical shoulder kinematics in children with brachial plexus birth palsy.

BACKGROUND: Shoulder movement patterns differ between limbs of children with unilateral brachial plexus birth palsy. To better understand the interlimb differences we examined the glenohumeral and scapulothoracic joint contributions to arm elevation. METHODS: Sixteen children with brachial plexus birth palsy, 4-12 years of age participated. Shoulder 3D kinematic data were collected using a magnetic tracking device during arm elevation with the involved and non-involved limbs for three trials each at a fixed rate. Based on maximum arm elevation in the involved limb the children were divided into two groups: group one 75 degrees . FINDINGS: During arm elevation from 15 to 75 degrees the involved limb of group one displayed lower glenohumeral joint excursion than the non-involved and both limbs of group two. Scapular upward rotation was higher in the involved limb of both groups. For group one, the glenohumeral:scapulothoracic ratio for 15-75 degrees arm elevation was lower in the involved (0.6:1) than the non-involved (2.2:1) limb and both limbs of group two: involved (1.7:1); non-involved (1.9:1). During 15-135 degrees arm elevation for group two, the glenohumeral:scapulothoracic ratio was more similar between limbs: involved (1.5:1) and non-involved (2:1). INTERPRETATION: The scapulothoracic joint made a greater contribution to arm elevation than the glenohumeral joint only in the involved limb of group one, altering the scapulohumeral rhythm. Musculoskeletal and neural factors may account for the group and limb differences. Routine 3D kinematic analysis of shoulder joint rotation may aid treatment planning and better quantify outcomes in this group.

Lateralization of motor adaptation reveals independence in control of trajectory and steady-state position.

We recently provided evidence that the dominant and nondominant arms are specialized for controlling different aspects of reaching movements. In this study, we test whether these specializations lead to qualitatively different adaptive mechanisms, when exposed to novel inertial dynamics. Two groups of six right-handed adults performed a reaching task toward a single target with either the dominant or nondominant arm. After 39 trials of task familiarization without a load, subjects performed 180 trials with a 1.5 kg mass, positioned 25 cm lateral to the forearm. To assess the time course of adaptation, we quantified changes in movement direction and linearity, and to assess the quality of adaptation, we randomly interspersed aftereffect trials and generalization trials. The former were assessed by removing the mass and the latter by changing the location of the movement in the workspace. Whereas, final position accuracy improved to the same extent for both arms, initial movement direction improved only for the dominant arm. In contrast, nondominant arm adaptation occurred mainly by making more effective corrections for persistent errors in initial direction. Consistent with these findings, aftereffect trials, an indicator of feedforward control processes, showed progressive increases in error for only the dominant arm. In addition, substantial generalization only occurred for the dominant arm. These results support our hypothesis that interlimb differences in control mechanisms produce different patterns of adaptation to novel inertial dynamics.

Does motor lateralization have implications for stroke rehabilitation?

Recent findings on motor lateralization have revealed consistent differences in the control strategies of the dominant and nondominant hemisphere/limb systems that could have implications for hemiplegic stroke patients. Studies in stroke patients have demonstrated deficiencies in the ipsilesional arm that reflect these distinctions; patients with right-hemisphere damage tend to show deficits in positional accuracy, and patients with left-hemisphere damage show deficits in trajectory control. Such deficits have been shown to impede functional performance; yet patients with severe dominant-side hemiplegia must often use the nondominant arm as the primary manipulator for activities of daily living. Nevertheless, the nondominant arm may not spontaneously become efficient as a dominant manipulator, as indicated by the persistence of deficits in chronic stroke patients. More research is necessary to determine whether motor therapy can facilitate a more effective transition of this arm from a nondominant to a dominant controller.