Game-based training of selective voluntary motor control in children and youth with upper motor neuron lesions: protocol for a multiple baseline design study.

BACKGROUND: Impairments of selective control of joint movements can have consequences for many activities of daily life, but there are only a few interventions to improve selective voluntary motor control (SVMC). We have developed a treatment option to specifically enhance SVMC exploiting the advantages of interactive computer play technology. It targets SVMC by training selective activation of a muscle or a selective joint movement while it provides immediate feedback about involuntary muscle activations/movements at an (unwanted) joint. This study aims to investigate the effectiveness of this game-based intervention to enhance SVMC in children and youth with upper motor neuron lesions. METHODS: We will conduct a randomized, non-concurrent, multiple baseline design study. Patients aged between 6 and 20 years with reduced SVMC due to an upper motor neuron lesion will be included. During the baseline phase of random length, participants will attend their regular intensive rehabilitation program, and in the intervention phase, they will additionally complete 10 therapy sessions (à 40 min) of the game-based SVMC training. The primary outcome will be a short SVMC assessment conducted repeatedly throughout both phases, which quantifies movement accuracy and involuntary movements. Changes in clinical SVMC measures, muscle strength, cortical excitability, motor control of the inhibited/unwanted movement, and functional independence will be assessed as secondary outcomes. We will use a mixed-effect model to determine the change in the course of the primary outcome when the intervention is introduced, and we will compare changes between phases for secondary outcomes with paired tests. DISCUSSION: This study will provide first evidence whether SVMC can be improved with our game-based training. The single-case design takes into account the individualization required for this intervention, and it can help to address the challenges of intervention trials in our setting. TRIAL REGISTRATION: German Clinical Trials Register: DRKS00025184 , registered on 28.04.2021.

Validity and reliability of an accelerometer-based assessgame to quantify upper limb selective voluntary motor control.

INTRODUCTION: Current clinical assessments measure selective voluntary motor control (SVMC) on an ordinal scale. We introduce a playful, interval-scaled method to assess SVMC in children with brain lesions and evaluate its validity and reliability. METHODS: Thirty-one neurologically intact children (median [1st-3rd quartile]: 11.6 years [8.5-13.9]) and 33 patients (12.2 years [8.8-14.9]) affected by upper motor neuron lesions with mild to moderate impairments participated. Using accelerometers, they played a movement tracking game (assessgame) with isolated joint movements (shoulder, elbow, lower arm [pro-/supination], wrist, and fingers), yielding an accuracy score. Involuntary movements were recorded simultaneously and resulted in an involuntary movement score. Both scores were normalized to the performance of 33 neurologically intact adults (32.5 years [27.9; 38.3]), which represented physiological movement patterns. We correlated the assessgame outcomes with the Manual Ability Classification System, Selective Control of the Upper Extremity Scale, and a therapist rating of involuntary movements. Furthermore, a robust ANCOVA was performed with age as covariate, comparing patients to their healthy peers at the age levels of 7.5, 9, 10.5, 12, and 15 years. Intraclass correlation coefficients and smallest real differences indicated relative and absolute reliability. RESULTS: Correlations (Kendall/Spearman) for the accuracy score were τ = 0.29 (p = 0.035; Manual Ability Classification System), ρ = - 0.37 (p = 0.035; Selective Control of the Upper Extremity Scale), and ρ = 0.64 (p < 0.001; therapist rating). Correlations for the involuntary movement metric were τ = 0.37 (p = 0.008), ρ = - 0.55 (p = 0.001), and ρ = 0.79 (p < 0.001), respectively. The robust ANCOVAs revealed that patients performed significantly poorer than their healthy peers in both outcomes and at all age levels except for the dominant/less affected arm, where the youngest age group did not differ significantly. Robust intraclass correlation coefficients and smallest real differences were 0.80 and 1.02 (46% of median patient score) for the accuracy and 0.92 and 2.55 (58%) for involuntary movements, respectively. CONCLUSION: While this novel assessgame is valid, the reliability might need to be improved. Further studies are needed to determine whether the assessgame is sensitive enough to detect changes in SVMC after a surgical or therapeutic intervention.

Playfully Assessing Lower Extremity Selective Voluntary Motor Control in Children With Cerebral Palsy: Psychometric Study.

BACKGROUND: Objective measures specifically assessing selective voluntary motor control are scarce. Therefore, we have developed an interval-scaled assessment based on accelerometers. OBJECTIVE: This study provided a preliminary evaluation of the validity and reliability of this novel gamelike assessment measuring lower limb selective voluntary motor control in children with cerebral palsy (CP). METHODS: Children with CP and their neurologically intact peers were recruited for this psychometric evaluation of the assessgame. The participants played the assessgame and steered an avatar by selective hip, knee, or ankle joint movements captured with accelerometers. The assessgame's scores provide information about the accuracy of the selective movement of the target joint and the amplitude and frequency of involuntary movements occurring in uninvolved joints. We established discriminative validity by comparing the assessgame scores of the children with CP with those of the neurologically intact children, concurrent validity by correlations with clinical scores and therapists' opinions, and relative and absolute test-retest reliability. RESULTS: We included 20 children with CP (mean age 12 years and 5 months, SD 3 years and 4 months; Gross Motor Function Classification System levels I to IV) and 31 neurologically intact children (mean age 11 years and 1 month, SD 3 years and 6 months). The assessgame could distinguish between the children with CP and neurologically intact children. The correlations between the assessgame's involuntary movement score and the therapist's rating of the occurrence of involuntary movements during the game were moderate (Spearman ρ=0.56; P=.01), whereas the correlations of the assessgame outcomes with the Selective Control Assessment of the Lower Extremity and Gross Motor Function Classification System were low and not significant (|ρ|≤0.39). The intraclass correlation coefficients were >0.85 and indicated good relative test-retest reliability. Minimal detectable changes amounted to 25% (accuracy) and 44% (involuntary movement score) of the mean total scores. The percentage of children able to improve by the minimal detectable change without reaching the maximum score was 100% (17/17) for the accuracy score and 94% (16/17) for the involuntary movement score. CONCLUSIONS: The assessgame proved reliable and showed discriminative validity in this preliminary evaluation. Concurrent validity was moderate with the therapist's opinion but relatively poor with the Selective Control Assessment of the Lower Extremity. We assume that the assessment's gamelike character demanded various other motor control aspects that are less considered in current clinical assessments.

Quantifying age-related differences in selective voluntary motor control in children and adolescents with three assessments.

BACKGROUND: Neurophysiological development of selective voluntary motor control (SVMC) is assumed but has not been quantified objectively. We assessed SVMC with (i) clinical assessments, (ii) a combination of these assessments with surface electromyography (sEMG) and, (iii) a playful computer game. The aim of this study was to describe and compare age-related differences in SVMC, quantified with these tools, in neurologically intact children, adolescents, and adults. METHODS: We measured upper and lower extremity SVMC with three assessments in 31 children and adolescents. A sample of 33 and 31 adults provided reference values for the upper and lower extremity assessments, respectively. The Selective Control of the Upper Extremity Scale (SCUES) or the Selective Control Assessment of the Lower Extremity (SCALE) were combined with simultaneous sEMG recordings. We quantified SVMC by a similarity index that compared an individual's muscle activation pattern with those of an adult reference group. The SVMC Assessgame required isolated joint movements to steer an avatar and quantified the accuracy of the selective movement and the extent of involuntary movements occurring in not involved joints. RESULTS: Results from the conventional clinical assessments correlated low to moderately with age (SCUES: r = 0.55, p = 0.013; SCALE: r = 0.44, p = 0.001), while the correlation between the sEMG based similarity index and age was negligible (r ≤ 0.25). The outcomes of the Assessgame correlated highly with age (r ≥ 0.80, p ≤ 0.001). Older children and adolescents performed movements more accurately and with fewer involuntary movements compared to younger participants. CONCLUSIONS: The tools assess and quantify SVMC differently, affecting the way they capture age-related differences in SVMC. Some assessments require reference values from neurologically intact children and adolescents to correctly classify impairments of SVMC in patients with neuromotor disorders.

Effectiveness of interactive computer play on balance and postural control for children with cerebral palsy: A systematic review.

BACKGROUND: Interactive computer play (ICP) becomes popular in rehabilitation for children with cerebral palsy (CP). With the nature of ICP, it could be an effective intervention specifically to improve balance and postural control for children with CP. The present paper aimed to review the effectiveness of ICP on postural control and balance for children with CP. METHODS: Electronic databases including Medline, AMED, EBSCOhost, PsycINFO, Embase, the Cochrane Library and the DARE were searched up to September 2018. Studies were included if (1) participants were aged under 18 and had CP, (2) ICP intervention was performed, (3) an explicit objective was postural control and balance of the participants, and (4) results were fully published in English-language peer-reviewed journals. Characteristics of study participants, ICP protocols and study results were extracted. Level of evidence of each studies was graded using the guidelines from the American Academy of Cerebral Palsy and Developmental Medicine. Methodological quality was graded using the Physiotherapy Evidence Database (PEDro) scale. Effect sizes were calculated on available data. RESULTS: Twenty studies were included, with nine of level I or II evidence. Most studies had fair methodological rigor. Huge variations in the study designs and protocols of ICP were found among the studies. CONCLUSIONS: ICP seemed to be more effective than conventional therapy in improving postural control and balance, with medium to large effect sizes for children with mild to moderate severity of CP. Future studies of high methodological rigour are required to verify the role of on-site guidance of the children during ICP and the effect on children with more severe CP.

An innovative cycling exergame to promote cardiovascular fitness in youth with cerebral palsy.

OBJECTIVE: To evaluate the effects of an internet-platform exergame cycling programme on cardiovascular fitness of youth with cerebral palsy (CP). METHODS: In this pilot prospective case series, eight youth with bilateral spastic CP, Gross Motor Functional Classification System (GMFCS) level III, completed a six-week exergame programme. Outcomes were obtained at baseline and post-intervention. The primary outcome measure was the GMFCS III-specific shuttle run test (SRT-III). Secondary outcomes included health-related quality of life (HQL) as measured by the KIDSCREEN-52 questionnaire, six-minute walk test, Wingate arm cranking test and anthropomorphic measurements. RESULTS: There were significant improvements in the SRT-III (t = -2.5, p = 0.04, d = 0.88) post-intervention. There were no significant changes in secondary outcomes. CONCLUSION: An exergame cycling programme may lead to improvement in cardiovascular fitness in youth with CP. This study was limited by small sample size and lack of a comparison group. Future research is warranted.