Combined translational and rotational perturbations of standing balance reveal contributions of reduced reciprocal inhibition to balance impairments in children with cerebral palsy.

Balance impairments are common in cerebral palsy. When balance is perturbed by backward support surface translations, children with cerebral palsy have increased co-activation of the plantar flexors and tibialis anterior muscle as compared to typically developing children. However, it is unclear whether increased muscle co-activation is a compensation strategy to improve balance control or is a consequence of reduced reciprocal inhibition. During translational perturbations, increased joint stiffness due to co-activation might aid balance control by resisting movement of the body with respect to the feet. In contrast, during rotational perturbations, increased joint stiffness will hinder balance control as it couples body to platform rotation. Therefore, we expect increased muscle co-activation in response to rotational perturbations if co-activation is caused by reduced reciprocal inhibition but not if it is merely a compensation strategy. We perturbed standing balance by combined backward translational and toe-up rotational perturbations in 20 children with cerebral palsy and 20 typically developing children. Perturbations induced forward followed by backward movement of the center of mass. We evaluated reactive muscle activity and the relation between center of mass movement and reactive muscle activity using a linear feedback model based on center of mass kinematics. In typically developing children, perturbations induced plantar flexor balance correcting muscle activity followed by tibialis anterior balance correcting muscle activity, which was driven by center of mass movement. In children with cerebral palsy, the switch from plantar flexor to tibialis anterior activity was less pronounced than in typically developing children due to increased muscle co-activation of the plantar flexors and tibialis anterior throughout the response. Our results thus suggest that a reduction in reciprocal inhibition causes muscle co-activation in reactive standing balance in children with cerebral palsy.

Alpha oscillations during visual selective attention are aberrant in youth and adults with cerebral palsy.

Our understanding of the neurobiology underlying cognitive dysfunction in persons with cerebral palsy is very limited, especially in the neurocognitive domain of visual selective attention. This investigation utilized magnetoencephalography and an Eriksen arrow-based flanker task to quantify the dynamics underlying selective attention in a cohort of youth and adults with cerebral palsy (n = 31; age range = 9 to 47 yr) and neurotypical controls (n = 38; age range = 11 to 49 yr). The magnetoencephalography data were transformed into the time-frequency domain to identify neural oscillatory responses and imaged using a beamforming approach. The behavioral results indicated that all participants exhibited a flanker effect (greater response time for the incongruent compared to congruent condition) and that individuals with cerebral palsy were slower and less accurate during task performance. We computed interference maps to focus on the attentional component and found aberrant alpha (8 to 14 Hz) oscillations in the right primary visual cortices in the group with cerebral palsy. Alpha and theta (4 to 7 Hz) oscillations were also seen in the left and right insula, and these oscillations varied with age across all participants. Overall, persons with cerebral palsy exhibit deficiencies in the cortical dynamics serving visual selective attention, but these aberrations do not appear to be uniquely affected by age.

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.

Early intensive rehabilitation reverses locomotor disruption, decrease brain inflammation and induces neuroplasticity following experimental Cerebral Palsy.

BACKGROUND: Cerebral Palsy (CP) is a major cause of motor and cognitive disability in children due to injury to the developing brain. Early intensive sensorimotor rehabilitation has been shown to change brain structure and reduce CP symptoms severity. We combined environmental enrichment (EE) and treadmill training (TT) to observe the effects of a one-week program of sensorimotor stimulation (EETT) in animals exposed to a CP model and explored possible mechanisms involved in the functional recovery. METHODS: Pregnant Wistar rats were injected with Lipopolysaccharide (LPS - 200 µg/kg) intraperitoneally at embryonic days 18 and 19. At P0, pups of both sexes were exposed to 20' anoxia at 37 °C. From P2 to P21, hindlimbs were restricted for 16 h/day during the dark cycle. EETT lasted from P21 to P27. TT - 15 min/day at 7 cm/s. EE - 7 days in enriched cages with sensorimotor stimulus. Functional 3D kinematic gait analysis and locomotion were analyzed. At P28, brains were collected for ex-vivo MRI and histological assessment. Neurotrophins and key proteins involved in CNS function were assessed by western blotting. RESULTS: CP model caused gross and skilled locomotor disruption and altered CNS neurochemistry. EETT reversed locomotor dysfunction with minor effects over gait kinematics. EETT also decreased brain inflammation and glial activation, preserved myelination, upregulated BDNF signaling and modulated the expression of proteins involved in excitatory synaptic function in the brain and spinal cord. CONCLUSIONS: Using this translational approach based on intensive sensorimotor rehabilitation, we highlight pathways engaged in the early developmental processes improving neurological recovery observed in CP.

Protocol for combined N-of-1 trials to assess cerebellar neurostimulation for movement disorders in children and young adults with dyskinetic cerebral palsy.

BACKGROUND: Movement and tone disorders in children and young adults with cerebral palsy are a great source of disability. Deep brain stimulation (DBS) of basal ganglia targets has a major role in the treatment of isolated dystonias, but its efficacy in dyskinetic cerebral palsy (DCP) is lower, due to structural basal ganglia and thalamic damage and lack of improvement of comorbid choreoathetosis and spasticity. The cerebellum is an attractive target for DBS in DCP since it is frequently spared from hypoxic ischemic damage, it has a significant role in dystonia network models, and small studies have shown promise of dentate stimulation in improving CP-related movement and tone disorders. METHODS: Ten children and young adults with DCP and disabling movement disorders with or without spasticity will undergo bilateral DBS in the dorsal dentate nucleus, with the most distal contact ending in the superior cerebellar peduncle. We will implant Medtronic Percept, a bidirectional neurostimulator that can sense and store brain activity and deliver DBS therapy. The efficacy of cerebellar DBS in improving quality of life and motor outcomes will be tested by a series of N-of-1 clinical trials. Each N-of-1 trial will consist of three blocks, each consisting of one month of effective stimulation and one month of sham stimulation in a random order with weekly motor and quality of life scales as primary and secondary outcomes. In addition, we will characterize abnormal patterns of cerebellar oscillatory activity measured by local field potentials from the intracranial electrodes related to clinical assessments and wearable monitors. Pre- and 12-month postoperative volumetric structural and functional MRI and diffusion tensor imaging will be used to identify candidate imaging markers of baseline disease severity and response to DBS. DISCUSSION: Our goal is to test a cerebellar neuromodulation therapy that produces meaningful changes in function and well-being for people with CP, obtain a mechanistic understanding of the underlying brain network disorder, and identify physiological and imaging-based predictors of outcomes useful in planning further studies. TRIAL REGISTRATION: ClinicalTrials.gov NCT06122675, first registered November 7, 2023.

Baby Observational Selective Control AppRaisal (BabyOSCAR): Construct validity and test performance.

AIM: To investigate the construct validity of the Baby Observational Selective Control AppRaisal (BabyOSCAR), an assessment of independent joint motion in infants with cerebral palsy (CP). METHOD: BabyOSCAR was scored for 75 infants (45 with CP and 30 without CP). Rasch analysis was used in combination with classical test theory to assess areas of strength or improvement. Overall fit and precision, unidimensionality, local independence, reliability indices, Wright's child-item map, and differential item functioning were examined as part of Rasch analysis to investigate the item properties, internal construct validity, and reliability of BabyOSCAR. Cronbach's α was used to evaluate items' internal consistency. RESULTS: Analysis demonstrated good fit to the Rasch model, with only one erratic item. Unidimensionality results suggest two dimensions, split between arm and leg items. Item calibration reliability was between 0.84 and 0.86, with three distinct item difficulty levels. Infant measure reliability was between 0.82 and 0.91, separating infants into three ability levels. Together, the two subscales covered the full range of skills, with redundancy mostly between the same motion on both sides of the body. Cronbach's α was between 0.90 and 0.95. INTERPRETATION: BabyOSCAR's construct validity was supported. Arm and leg subscales can be translated to a logit scale. WHAT THIS PAPER ADDS: Baby Observational Selective Control AppRaisal (BabyOSCAR) has excellent construct validity with good overall fit and precision. Individual BabyOSCAR items contribute and work well together, forming an interval-level assessment. BabyOSCAR has two separate subscales, arms and legs, that complement each other. BabyOSCAR's items represent a continuum of skills with three distinct difficulty levels. BabyOSCAR's continuum of skills reliably separates infants into three ability levels.

Community-based respiratory health measures in children and young people with cerebral palsy: A scoping review.

AIM: To identify, map, and describe outcome measurement domains and instruments used within a community setting to assess respiratory health in children and young people aged 1 to 18 years, diagnosed with cerebral palsy (CP). METHOD: A scoping review methodology informed structured searches in nine databases, grey literature, and registries, conducted in August 2021 (updated in February 2023). Articles were screened for eligibility by two independent researchers. Any outcome measurement instruments used to assess respiratory health or associated impact were extracted, categorized, and mapped to health and health-related domains of the International Classification of Functioning, Disability, and Health. RESULTS: Seventy-six outcome measurement instruments were identified across 78 articles worldwide between 1970 and 2023. These were categorized into 'Body functions and structures' (n = 20), 'Activity and performance' (n = 22), and 'Participation and quality of life' (n = 19), with a further 15 mapped to 'Health care resources use'. INTERPRETATION: No consensus of 'what' to measure and 'how' to measure respiratory health in children and young people with CP was found. Moreover, many measures were not replicable in individuals with more severe forms of CP, excluding those at increased risk of respiratory-related morbidity and mortality. Further research is required to agree important outcome domains and associated measures in research and clinical practice. WHAT THIS PAPER ADDS: A limited number and size of experimental designs were found. Seventy-six measures were identified to assess respiratory health in cerebral palsy. No consensus was found in 'what' or 'how' to measure respiratory health. Many measures were not replicable in children and young people at risk of poorer respiratory health outcomes. Children and young people with comorbidities and learning disability were frequently excluded from studies.

Visual, perceptual functions, and functional vision in children with unilateral cerebral palsy compared to children with neurotypical development.

AIM: To investigate visual (perceptual) function and functional vision in children with unilateral cerebral palsy (CP) and children with neurotypical development (NTD). METHOD: Fifty children with unilateral CP (mean age 11 years 11 months, SD 2 years 10 months, range 7-15 years; 27 males; 26 left-sided unilateral CP; Manual Ability Classification System [MACS] levels: I, 27; II, 16; III, 7) and 50 age- and sex-matched children with NTD participated in a cross-sectional study. Visual acuity, stereoacuity, and visual-perceptual functions were measured with standardized clinical tests. Functional vision was assessed in children with unilateral CP with the Flemish cerebral visual impairment questionnaire (FCVIQ). Group differences were investigated with Mann-Whitney U tests, Kruskal-Wallis tests, and the relative effect sizes r, η2 respectively. Correlations between visual assessments and the FCVIQ were investigated with Spearman's rank correlations. RESULTS: The total group of children with unilateral CP showed reduced visual acuity compared with children with NTD (p = 0.02, r = 0.23). Only children with left-sided unilateral CP scored lower than those with NTD on stereoacuity (p < 0.01, r = 0.36). Children with right/left-sided unilateral CP scored significantly lower than those with NTD on visual-perceptual functions (p = 0.001-0.02), with large effect sizes on visuomotor integration and visual closure (both r = 0.57). Children with unilateral CP classified in MACS level III showed significantly lower scores on visual-perceptual assessments than children classified in MACS level I. Stereoacuity and visual-perceptual functions negatively correlated with the FCVIQ, with the highest association with visual (dis)interest and anxiety-related behaviours. INTERPRETATION: Multi-level visual profiling is warranted in the clinical intake of children with unilateral CP to detect visual impairments that further compromise their level of functioning.

Baby Observational Selective Control AppRaisal (BabyOSCAR): Convergent and discriminant validity and reliability in infants with and without spastic cerebral palsy.

AIM: To describe the development of an observational measure of spontaneous independent joint motion in infants with spastic cerebral palsy (CP), the Baby Observational Selective Control AppRaisal (BabyOSCAR), and to test its convergent validity and reliability. METHOD: A retrospective sample of 75 infants (45 with spastic CP and 30 without CP) at 3 months of age were scored with the BabyOSCAR and compared with diagnosis of spastic CP, limbs affected, and Gross Motor Function Classification level at 2 years of age or later for convergent validity using t-tests, Kruskal-Wallis tests, and Spearman's rank correlation coefficients. BabyOSCAR interrater and test-retest reliability was also evaluated using intraclass correlation coefficients. RESULTS: Infants with spastic CP had significantly lower BabyOSCAR scores than children without CP (p < 0.001) and scores were significantly correlated with Gross Motor Function Classification System levels (p < 0.001). Children with unilateral CP had significantly higher asymmetry scores than children with bilateral CP or no CP (p < 0.01). Interrater and test-retest reliabilities were good to excellent. INTERPRETATION: Reductions in independent joint control measured in infancy are a hallmark of eventual diagnosis of spastic CP, and influence gross motor function later in childhood (with or without a diagnosis of CP). WHAT THIS PAPER ADDS: Early brain injury causing spastic cerebral palsy results in fewer independent joint movements in infants. Baby Observational Selective Control AppRaisal (BabyOSCAR) score at 3 months depends on limbs affected by early brain injury. BabyOSCAR scores at 3 months correlate with Gross Motor Function Classification System level at ≥2 years. BabyOSCAR has excellent interrater reliability. BabyOSCAR, scored with a 1-minute video recording, has good to excellent test-retest reliability.

Baby Observational Selective Control AppRaisal (BabyOSCAR): Scores at 3 months predict functional ability, spastic cerebral palsy distribution, and diagnosis at 2 years.

AIM: To assess the predictive capabilities of the Baby Observational Selective Control AppRaisal (BabyOSCAR) tool, administered at 3 months corrected age, in determining spastic cerebral palsy (CP) outcome, functional abilities, and body topography at 2 years of age or later. METHOD: Independent joint motions were measured at age 10 to 16 weeks from video recordings of spontaneous movement using BabyOSCAR in a sample of 75 infants. All included infants had known 2-year outcomes (45 with spastic CP and 30 without CP) including Gross Motor Functional Classification System (GMFCS) levels and CP body distribution. Receiver operating characteristic curves and cut points indicating greatest sensitivity and specificity were generated for predictive performance. RESULTS: Total BabyOSCAR score was a strong predictor of future outcome of spastic CP (cut score of 22.5, sensitivity = 98%, specificity = 100%, area under the curve = 0.99), and was able to distinguish children classified in GMFCS levels I and II from those in III to V (cut score of 13.5, sensitivity = 92%, specificity = 89%, area under the curve = 0.94). Having an (absolute) asymmetry score on the BabyOSCAR of more than 5 was a predictor of having unilateral CP at age 2 years (sensitivity = 56%, specificity = 100%, area under the curve = 0.86). INTERPRETATION: BabyOSCAR scores are predictors of diagnosis, body distribution, and future gross motor function in infants with spastic CP at 2 years of age or later. WHAT THIS PAPER ADDS: Decreased independent joint movement at 3 months predicts spastic cerebral palsy (CP) at 2 years. Baby Observational Selective Control AppRaisal (BabyOSCAR) scores ≤13 are predictive of Gross Motor Function Classification System (GMFCS) levels III to V. BabyOSCAR scores of 14 to 22 are predictive of GMFCS levels I and II. A BabyOSCAR total asymmetry score >5 predicts unilateral CP. Stereotyped movements are more prominent in those who will be diagnosed with spastic CP at 2 years.

Circulating immune cell populations at rest and in response to acute endurance exercise in young adults with cerebral palsy.

AIM: The aim of this observational study was to determine the immune status and function in young adults with cerebral palsy (CP) in comparison to typically developing individuals. METHOD: Blood samples from 12 individuals with CP (five males, seven females; mean age: 25 years 1 month (5 years 9 months); age range: 19-38 years) and 17 typically developing individuals (eight males, nine females; mean age: 31 years 4 months (6 years 2 months); age range: 20-40 years) were collected before, immediately after, and 1 hour after 45 minutes of frame running or running respectively. Independent t-tests were used to compare heart rate, level of exertion, and baseline cell proportions between groups. Mixed model analysis of variance was utilized to investigate immune cell responses to exercise across groups. RESULTS: Baseline levels of gamma delta (TCRγδ+) T-cells were significantly higher (absolute percentage: +2.65, p = 0.028) in the individuals with CP. Several cell populations showed similar significant changes after exercise in both CP and typically developing groups. Cytotoxic (CD8+) T-cells were only significantly elevated immediately after exercise in the typically developing participants (p < 0.01). Individuals with CP exhibited significantly lower heart rates (-11.1%, p < 0.01), despite similar ratings of perceived exertion. INTERPRETATION: Elevated baseline TCRγδ+ T-cells may indicate low-grade inflammation in adults with CP. Although most of the cell populations showed typical responses to endurance exercise, the absence of response in CD8+ T-cells in individuals with CP may indicate the need for higher intensity during exercise. WHAT THIS PAPER ADDS: TCRγδ+ T-cell baseline levels are elevated in adults with cerebral palsy (CP). The CD8+ T-cell response to exercise was blunted in adults with CP. Exercise intensity is decisive for CD8+ T-cell responses in individuals with CP.

Neonatal well-being and timing of brain injury in persons with cerebral palsy born at term or late preterm.

AIM: To describe the distribution of neuroimaging patterns in a term/late preterm population-based cohort with cerebral palsy (CP), ascertain associations between neuroimaging patterns and neonatal well-being, estimate the proportion with antenatal or perinatal timing of neuropathology, and apply this information to the understanding of common mechanisms of brain injury and causal pathways. METHOD: The cohort for this observational study comprised 1348 persons born between 1999 and 2017 in Victoria, Australia. Using algorithms designed for the study, neonatal well-being and timing of brain injury were tabulated for the whole cohort and across neuroimaging patterns and birth epochs. RESULTS: Clinical and demographic profiles, neonatal well-being, and timing of brain injury differed across neuroimaging patterns. An estimated 57% of the cohort had a complicated neonatal period. Timing of brain injury was antenatal in 57% and perinatal in 41%. A decrease in the relative proportions of perinatal timing of brain injury was observed over a period when the rates of CP in live births at term decreased. INTERPRETATION: This study begins to bridge the knowledge gap about causation in CP, moving towards better description of the main mechanisms of brain injury and their contribution within CP cohorts, and facilitating the ability to monitor changes over time and the success of preventive measures. WHAT THIS PAPER ADDS: In a population-based, term/late preterm cohort with cerebral palsy, 57% had a complicated neonatal period. In the same cohort, 57% had presumed antenatal timing of brain injury. The relative proportion with perinatal injury decreased over time.

Training intensity of robot-assisted gait training in children with cerebral palsy.

AIM: We compared three different intensities of robot-assisted gait training (RAGT) for achieving favourable outcomes in children with cerebral palsy (CP). METHOD: This study was conducted using a randomized controlled, single-blind design. Thirty children (19 males and 11 females; mean age 6 years 1 month, SD 2 years) with CP classified in Gross Motor Function Classification System levels II and III were assigned to three different RAGT intensity groups: high-intensity (fastest walking speed and lowest body weight support [BWS]), low-intensity (slowest speed and highest BWS), and comfortable intensity (intermediate speed and intermediate BWS). The RAGT intervention was performed three times a week for 6 weeks. Outcome measures included the 88-item Gross Motor Function Measure, stability index, spatiotemporal parameters of gait analysis, paediatric functional independence measure, and the Canadian Occupational Performance Measure. RESULTS: The 88-item Gross Motor Function Measure was significantly improved after training in the high-intensity (D Δ8.3 ± 15.6; E Δ3.8 ± 4.1) and comfortable intensity (D Δ2.9 ± 3.1; E Δ1.2 ± 2.0) groups, whereas gait speed was improved in the comfortable intensity group, without statistically significant group differences. Only the low-intensity group showed improvement on the stability index (Δ -0.6 ± 0.9, p = 0.05). Everyday functional performance significantly improved in all three groups, with the comfortable intensity group showing the greatest improvement. INTERPRETATION: Different training intensities produced improvement in different areas; individualized RAGT intensity adjustment is therefore needed based on the rehabilitation goal.

Implementation and Clinical Outcomes of Blood Flow Restriction Training on Adults With Cerebral Palsy: A Case Series.

BACKGROUND AND PURPOSE: Cerebral palsy (CP) is a congenital neurological disorder that causes musculoskeletal weakness and biomechanical dysfunctions. Strength training guidelines recommend at least 70% of 1-repetition maximum to increase muscle strength and mass. However, individuals with CP may not tolerate such high exercise intensity. Blood flow restriction (BFR) can induce similar gains in strength and muscle mass using loads as low as 20% to 30% 1-repetition maximum. This case series described the safety, feasibility, and acceptability of BFR in adults with CP and examined changes in muscle mass and strength. CASE DESCRIPTION: Three male participants with gross motor function classification system level 3 CP underwent strength training using a periodized 8-week BFR protocol. Outcomes included: Safety via blood pressure during and post-BFR exercises in addition to adverse event tracking; Feasibility via number of support people and time-duration of BFR exercises; Acceptability via rate of perceived discomfort (0-10) and qualitative interviews; Muscle Mass via ultrasonographic cross-sectional area of the quadriceps and hamstring; and Strength via (1) 3-repetition maximum in the leg press and knee extension, (2) isometric knee flexor and extensor muscle force measured with a hand-held dynamometer, and (3) 30-second sit-to-stand test. INTERVENTION: Participants replaced 2 exercises from their current regimen with seated knee extension and leg press exercises using progressively higher limb occlusion pressure and exercise intensity. Limb occlusion pressure started at 60%, by week 4 progressed to 80%, and then remained constant. The exercise repetition scheme progressed from fixed nonfailure repetition sets to failure-based repetition sets. OUTCOMES: Blood pressure never exceeded safety threshold, and no adverse events were reported. The BFR training was time-consuming and resource-intensive, but well-tolerated by participants (rate of perceived discomfort with a mean value of 5.8, 100% protocol adherence). Strength, as measured by 3-repetition maximum testing and 30-second sit-to-stand test, increased, but isometric muscle force and muscle mass changes were inconsistent. DISCUSSION: Blood flow restriction may be an effective means to increase strength in adults with CP who cannot tolerate high-intensity resistance training. Future research should compare BFR to traditional strength training and investigate mediators of strength changes in this population. VIDEO ABSTRACT AVAILABLE: for more insights from the authors (see the Video, Supplemental Digital Content available at: http://links.lww.com/JNPT/A473 ).

Measurement of surface electromyography activity during swallowing in paediatrics: a scoping literature review.

Surface electromyography (sEMG) could be used for diagnostic and therapeutic purposes in various health conditions. For example, sEMG biofeedback is shown to be beneficial in adults with swallowing disorders (dysphagia), whereas there are no easily identifiable studies to support such evidence in paediatrics. The current review aimed to evaluate the feasibility of implementing sEMG during swallowing tasks in paediatric populations with various diagnoses. Additionally, the review aimed to describe findings in publications involving participants with cerebral palsy (CP) and dysphagia. Paediatric-related publications were sourced using English keywords and phrases across the following seven databases: PubMed, EMBASE, CINAHL, Web of Science, PsycINFO, and ProQuest Dissertations and Theses Global. The search included all available publications without language and date restrictions. Publications using sEMG during chewing tasks were also accepted in the review as chewing is considered to be part of the act of swallowing. The feasibility of measuring sEMG during swallowing in children with various health conditions was supported by 116 publications (n = 6 literature reviews) that met the inclusion criteria for the final full-text review. However, a few publications described some difficulties occurring directly during the sEMG data collection sessions. The review identified 15 publications involving 177 participants with CP who underwent sEMG while swallowing (n = 1 publication focused solely on the assessment of chewing). Ten publications described studies that recruited children with dysphagia. Children with CP who had dysphagia were recruited in five of these studies. CONCLUSIONS: The acquisition of sEMG measurements while performing swallowing tasks was shown to be feasible in children with various diagnoses including those who have CP and dysphagia. Future studies should investigate the implementation of sEMG as a part of paediatric dysphagia therapy alongside biofeedback swallowing skill training. WHAT IS KNOWN: • Surface electromyography (sEMG) could be implemented for diagnostic and therapeutic purposes in various health conditions. • Biofeedback using sEMG is beneficial in adults with swallowing disorders (dysphagia). WHAT IS NEW: • Implementation of sEMG was shown to be feasible during swallowing tasks in paediatric populations with various diagnoses, including dysphagia and cerebral palsy. • The usage of sEMG biofeedback as a part of paediatric dysphagia management should be investigated in future studies.

Therapeutic effects of repetitive transcranial magnetic stimulation in patients with cerebral palsy: a systematic review and network meta-analysis.

The purpose of this study was to systematically evaluate the efficacy of repetitive transcranial magnetic stimulation in children with cerebral palsy and to compare the differences in efficacy of different treatment parameters. Computer searches of PubMed, Embase, Cochrane Library, Scopus, Web of Science, China Knowledge Network, Wanfang Data Knowledge Service Platform, Vipshop and China Biomedical Literature Database were conducted to collect randomized controlled trials (RCTs) of TMS to improve function in children with cerebral palsy. The search period was from the establishment of the database to April 2023. Two researchers independently screened the literature and extracted data information, and the risk of bias was assessed for the included studies using the Cochrane Systematic Evaluation Manual 5.1.0. Statistical analysis was performed using RevMan 5.4 and Stata software. A total of 18 studies containing 1675 patients with cerebral palsy were included, and r-TMS did not differ significantly from other treatments in improving language function [MD = 2.80, 95% CI (-1.51, 7.11), Z = 1.27, P = 0.20] after treatment. The results of the reticulated meta-analysis showed the best probability ranking of the effect of three different frequencies of r-TMS on motor function scores in children with cerebral palsy: combined LF-rTMS + HF-rTMS (49.8%) > LF-rTMS (45.6%) > HF-rTMS (4.6%) > conventional rehabilitation (0%). Publication bias showed no significant asymmetry in the inverted funnel plot, but the possibility of publication bias could not be excluded. The results of this study showed that r-TMS was not statistically significant in improving language function in children with cerebral palsy compared to conventional treatment. r-TMS was almost unanimously significantly effective in motor function in children with cerebral palsy according to current literature data, and the combined high- and low-frequency transcranial magnetic therapy was better than low-frequency transcranial magnetic therapy.

Impact of Wheelchair Seating Systems on Scoliosis Progression for Children With Neurologic and Neuromuscular Disorders: A Retrospective Study of Custom-Contoured Wheelchair Seating and Modular Wheelchair Seating.

OBJECTIVES: To retrospectively evaluate the comparative effect of 2 wheelchair seating systems, Custom-Contoured Wheelchair Seating (CCS) and Modular Wheelchair Seating (MWS), on scoliosis progression in children with neuromuscular and neurologic disorders and to determine any predictors for scoliosis progression. DESIGN: Longitudinal, retrospective cohort study. SETTING: A national health service regional posture and mobility service. PARTICIPANTS: Nonambulant pediatric wheelchair users with neuromuscular and neurologic disorders (N=75; 36 men, 39 women; mean age at seating intervention, 10.50±3.97y) issued CCS and MWS by the South Wales Posture and Mobility Service from 2012-2022. INTERVENTIONS: Two specialized wheelchair seating systems, CCS and MWS. MAIN OUTCOME MEASURES: A generalized least squares model was used to estimate the effect of seat type on Cobb angle over time. RESULTS: Of the 75 participants enrolled, 51% had cerebral palsy. Fifty were issued CCS and 25 were issued MWS. Baseline Cobb angle was 32.9±18.9° for the MWS group and 48.0±31.0° for the CCS group. The generalized least squares model demonstrated that time since seating intervention (χ2=122, P<.0001), seating type (χ2=52.5, P<.0001), and baseline scoliosis severity (χ2=41.6, P<.0001) were predictive of scoliosis progression. Condition was not a strong predictor (χ2=9.96, P =.0069), and sex (χ2=5.67, P=.13) and age at intervention (χ2=4.47, P=.35) were not predictive. Estimated contrasts of medical condition with seat type over time demonstrated smaller differences between MWS and CCS over time. Predicted scoliosis velocity was found to attenuate with use of CCS over time compared with MWS, although scoliosis deteriorated regardless of intervention. CONCLUSIONS: Our findings showed pediatric wheelchair users with neurologic and neuromuscular disorders prescribed CCS showed greater mitigation of scoliosis progression over time compared with those issued MWS.

Motor function and gait decline in individuals with cerebral palsy during adulthood: a narrative review of potential physiological determinants.

Cerebral palsy (CP) is the most common childhood-onset disability. The evolution of gait according to severity is well known amongst children and thought to peak between 8 and 12 years of age among those walking without assistive devices. However, among adults, clinical experience as well as scientific studies report, through clinical assessments, questionnaires and interviews, increasing walking difficulties leading to an increased dependency of assistive devices in everyday ambulation. For many individuals with CP, this change will occur around 30-40 years, with the risk of losing mobility increasing with age. This narrative review aims to first provide objective evidence of motor function and gait decline in adults with CP when ageing, and then to offer mechanistic hypotheses to explain those alterations. Many studies have compared individuals with CP to the typically developing population, yet the evolution with ageing has largely been understudied. Comorbid diagnoses comprise one of the potential determinants of motor function and gait decline with ageing in people with CP, with the first manifestations happening at an early age and worsening with ageing. Similarly, ageing appears to cause alterations to the neuromuscular and cardiovascular systems at an earlier age than their typically developing (TD) peers. Future studies should, however, try to better understand how the physiological particularities of CP change with ageing that could pave the way for better strategies for maintaining function and quality of life in people with CP.

Identifying the most representative actigraphy variables reflecting standardized hand function assessments for remote monitoring in children with unilateral cerebral palsy.

BACKGROUND: Accurate assessment of physical activity and motor function in children with cerebral palsy is crucial for determining the effectiveness of interventions. This study aimed to investigate the correlation between real-world activity monitoring outcomes and in-laboratory standardized hand function assessments in children with unilateral cerebral palsy. METHODS: Actigraphy data were collected over 3 days from children aged 4-12 years with unilateral cerebral palsy before in-laboratory assessments. To tackle the high dimensionality and collinearity of actigraphy variables, we first applied hierarchical clustering using the Pearson correlation coefficient as the distance metric and then performed a principal component analysis (PCA) to reduce the dimensionality of our data. RESULTS: Both hierarchical clustering and PCAs revealed a consistent pattern in which magnitude ratio variables (ln[affected side magnitude/less-affected side magnitude]) were more strongly associated with standardized assessments of hand function than with activity time and distance domain variables. Hierarchical clustering analysis identified two distinct clusters of actigraphy variables, with the second cluster primarily consisting of magnitude ratio variables that exhibited the strongest correlation with Melbourne Assessment 2, Pediatric Motor Activity Log, Assisting Hand Assessment, and Manual Ability Classification System level. Principal component 2, primarily representing the magnitude ratio domain, was positively associated with a meaningful portion of subcategories of standardized measures, whereas principal component 1, representing the activity time and distance component, showed limited associations. CONCLUSIONS: The magnitude ratio of actigraphy can provide additional objective information that complements in-laboratory hand function assessment outcomes in future studies of children with unilateral cerebral palsy. TRIAL REGISTRATION IN CLINICALTRIALS.GOV: NCT04904796 (registered prospectively; date of registration: 23/05/2021).

Sit-to-stand performance in children with cerebral palsy: a population-based cross-sectional study.

BACKGROUND: Sit-to-stand (STS) is one of the most commonly performed functional movements in a child's daily life that enables the child to perform functional activities such as independent transfer and to initiate walking and self-care. Children with cerebral palsy (CP) often have reduced STS ability. The aim of this study was to describe STS performance in a national based total population of children with CP and its association with age, sex, Gross Motor Function Classification System (GMFCS) level, and CP subtype. METHODS: This cross-sectional study included 4,250 children (2,503 boys, 1,747 girls) aged 1-18 years from the Swedish Cerebral Palsy Follow-Up Program (CPUP). STS performance was classified depending on the independence or need for support into "without support," "with support," or "unable." "With support" included external support from, e.g., walls and furniture. Physical assistance from another person was classified as "unable" (dependent). Ordinal and binary logistic regression analyses were used to identify associations between STS and age, GMFCS level, and CP subtype. RESULTS: 60% of the children performed STS without support, 14% performed STS with support, and 26% were unable or needed assistance from another person. STS performance was strongly associated with GMFCS level and differed with age and subtype (p < 0.001). For all GMFCS levels, STS performance was lowest at age 1-3 years. Most children with GMFCS level I (99%) or II (88%) performed STS without support at the age of 4-6 years. In children with GMFCS level III or IV, the prevalence of independent STS performance improved throughout childhood. CP subtype was not associated with STS performance across all GMFCS levels when adjusted for age. CONCLUSIONS: Independent STS performance in children with CP is associated with GMFCS level and age. Children with CP acquire STS ability later than their peers normally do. The proportion of children with independent STS performance increased throughout childhood, also for children with GMFCS level III or IV. These findings suggest the importance of maintaining a focus on STS performance within physiotherapy strategies and interventions for children with CP, including those with higher GMFCS level.