Search

Background Early diagnosis of cerebral palsy (CP) is important to enable intervention at a time when neuroplasticity is at its highest. Current mean age at diagnosis is 13 months in Denmark. Recent research has documented that an early-diagnosis set-up can lower diagnostic age in high-risk infants. The aim of the current study is to lower diagnostic age of CP regardless of neonatal risk factors. Additionally, we want to investigate if an early intervention program added to standard care is superior to standard care alone. Methods The current multicentre study CP-EDIT (Early Diagnosis and Intervention Trial) with the GO-PLAY intervention included (Goal Oriented ParentaL supported home ActivitY program), aims at testing the feasibility of an early diagnosis set-up and the GO-PLAY early intervention. CP-EDIT is a prospective cohort study, consecutively assessing approximately 500 infants at risk of CP. We will systematically collect data at inclusion (age 3–11 months) and follow a subset of participants (n = 300) with CP or at high risk of CP until the age of two years. The GO-PLAY early intervention will be tested in 80 infants with CP or high risk of CP. Focus is on eight areas related to implementation and perspectives of the families: early cerebral magnetic resonance imaging (MRI), early genetic testing, implementation of the General Movements Assessment method, analysis of the GO-PLAY early intervention, parental perspective of early intervention and early diagnosis, early prediction of CP, and comparative analysis of the Hand Assessment for Infants, Hammersmith Infant Neurological Examination, MRI, and the General Movements method. Discussion Early screening for CP is increasingly possible and an interim diagnosis of “high risk of CP” is recommended but not currently used in clinical care in Denmark. Additionally, there is a need to accelerate identification in mild or ambiguous cases to facilitate appropriate therapy early, Background: Early diagnosis of cerebral palsy (CP) is important to enable intervention at a time when neuroplasticity is at its highest. Current mean age at diagnosis is 13 months in Denmark. Recent research has documented that an early-diagnosis set-up can lower diagnostic age in high-risk infants. The aim of the current study is to lower diagnostic age of CP regardless of neonatal risk factors. Additionally, we want to investigate if an early intervention program added to standard care is superior to standard care alone. Methods: The current multicentre study CP-EDIT (Early Diagnosis and Intervention Trial) with the GO-PLAY intervention included (Goal Oriented ParentaL supported home ActivitY program), aims at testing the feasibility of an early diagnosis set-up and the GO-PLAY early intervention. CP-EDIT is a prospective cohort study, consecutively assessing approximately 500 infants at risk of CP. We will systematically collect data at inclusion (age 3–11 months) and follow a subset of participants (n = 300) with CP or at high risk of CP until the age of two years. The GO-PLAY early intervention will be tested in 80 infants with CP or high risk of CP. Focus is on eight areas related to implementation and perspectives of the families: early cerebral magnetic resonance imaging (MRI), early genetic testing, implementation of the General Movements Assessment method, analysis of the GO-PLAY early intervention, parental perspective of early intervention and early diagnosis, early prediction of CP, and comparative analysis of the Hand Assessment for Infants, Hammersmith Infant Neurological Examination, MRI, and the General Movements method. Discussion: Early screening for CP is increasingly possible and an interim diagnosis of “high risk of CP” is recommended but not currently used in clinical care in Denmark. Additionally, there is a need to accelerate identification in mild or ambiguous cases to facilitate appropriate therapy early. Most studies on early diagnosis

Background: An early diagnosis of chronic disability, such as risk of Cerebral Palsy (CP), is likely to affect the quality of parent-infant interactions by affecting both infant and parental factors. Due to adverse perinatal events, infants at high risk of CP may exhibit less engagement in interactions, while parents may experience increased mental health problems and disrupted parental representations that can have a negative effect on parental sensitivity. Recent clinical guidelines on early intervention among families with infants at risk of CP recommends supporting parental sensitivity and mutual enjoyable interactions more research is needed to inform such interventions. This includes understanding how infant and parental risk as well as resilience factors impact parent-infant interactions and how existing parenting programs developed among typical developing infants should be adapted to families with infants at risk of CP. In addition, as majority of research on infant neurohabilitation focus on improving motor and cognitive outcomes research on infant emotional development is needed. The study aim is to assess the quality of early parent-infant interactions in families with high-risk infants, compared to families with low-risk infants, and to explore how interaction quality is affected by infant and parental factors. Three potential mediating factors explaining the association between CP risk and less optimal parent-infant interactions will be explored: infant interactional capacities, parental mental health and well-being, and parents' representations of their child. Methods: The prospective, longitudinal design will follow infants at high risk for CP and their parents and a control group at three time points from 15 weeks to 15 months corrected infant age (CA). Measures comprise infant developmental assessments, questionnaires and interviews with both parents, and global ratings of video-recorded parent-infant interactions. Discussion: Study results will

Introduction Contractures are frequent causes of reduced mobility in children with cerebral palsy (CP) already at the age of 2-3 years. Reduced muscle use and muscle growth have been suggested as key factors in the development of contractures, suggesting that effective early prevention may have to involve stimuli that can facilitate muscle growth before the age of 1 year. The present study protocol was developed to assess the effectiveness of an early multicomponent intervention, CONTRACT, involving family-oriented and supervised home-based training, diet and electrical muscle stimulation directed at facilitating muscle growth and thus reduce the risk of contractures in children at high risk of CP compared with standard care. Methods and analysis A two-group, parallel, open-label randomised clinical trial with blinded assessment (n=50) will be conducted. Infants diagnosed with CP or designated at high risk of CP based on abnormal neuroimaging or absent fidgety movement determined as part of General Movement Assessment, age 9-17 weeks corrected age (CA) will be recruited. A balanced 1:1 randomisation will be made by a computer. The intervention will last for 6 months aiming to support parents in providing daily individualised, goal-directed activities and primarily in lower legs that may stimulate their child to move more and increase muscle growth. Guidance and education of the parents regarding the nutritional benefits of docosahexaenic acid (DHA) and vitamin D for the developing brain and muscle growth will be provided. Infants will receive DHA drops as nutritional supplements and neuromuscular stimulation to facilitate muscle growth. The control group will receive standard care as offered by their local hospital or community. Outcome measures will be taken at 9, 12, 18, 24, 36 and 48 months CA. Primary and secondary outcome measure will be lower leg muscle volume and stiffness of the triceps surae musculotendinous unit together with infant motor profile, respe

BACKGROUND: Cerebral palsy (CP) is a neurodevelopmental disturbance characterized by impaired control of movement. Function often decreases and 15% of adults are classified as severely affected (Gross Motor Function Classification Scale III-V). Little is known about interventions that aim to improve functional abilities in this population.OBJECTIVE: To evaluate a 12-week intervention based on motor learning principles on functional ability in adults with severe CP.METHODS: 16 adults (36±10 years, GMFCS III-V) were enrolled and divided into an intervention group (Active group) and a standard care group (Control group). Primary outcome measure was Gross Motor Function Measure (GMFM-88). Secondary measures were neurological status. The Active group were measured at baseline, after the intervention and at one-month follow-up. The Control group were measured at baseline and after one month.RESULTS: Analysis showed statistically significant improvement in GMFM-88 for the Active group from baseline to post assessment compared with the Control group (group difference: 5 points, SE 14.5, p = 0.008, CI: 1.2 to 8.7). Improvements were maintained at follow-up. Results from the neurological screening showed no clear tendencies.CONCLUSIONS: The study provides support that activities based on motor learning principles may improve gross motor function in adults with severe CP.

Voluntary toe walking in adults is characterized by feedforward control of ankle muscles in order to ensure optimal stability of the ankle joint at ground impact. Toe walking is frequently observed in children with cerebral palsy, but the mechanisms involved have not been clarified. Here, we investigated maturation of voluntary toe walking in typically-developing children and typically-developed adults and compared it to involuntary toe walking in children with cerebral palsy. Twenty-eight children with cerebral palsy (age 3-14 years), 24 typically-developing children (age 2-14 years) and 15 adults (mean age 30.7 years) participated in the study. EMG activity was measured from the tibialis anterior and soleus muscles together with knee and ankle joint position during treadmill walking. In typically-developed adults, low step-to-step variability of the drop of the heel after ground impact was correlated with low tibialis anterior and high soleus EMG with no significant coupling between the antagonist muscle EMGs. Typically-developing children showed a significant age-related decline in EMG amplitude reaching an adult level at 10-12 years of age. The youngest typically-developing children showed a broad peak EMG-EMG synchronization (>100 ms) associated with large 5-15 Hz coherence between antagonist muscle activities. EMG coherence declined with age and at the age of 10-12 years no correlation was observed similar to adults. This reduction in coherence was closely related to improved step-to-step stability of the ankle joint position. Children with cerebral palsy generally showed lower EMG levels than typically-developing children and larger step-to-step variability in ankle joint position. In contrast to typically-developing children, children with cerebral palsy showed no age-related decline in tibialis anterior EMG amplitude. Motor unit synchronization and 5-15 Hz coherence between antagonist EMGs was observed more frequently in children with cerebral palsy w

AIM: If increased muscle stiffness and contractures in children with cerebral palsy (CP) are related to impaired muscle growth, reduced muscle growth should precede or coincide with increased muscle stiffness during development. Here, we compared the volume of the medial gastrocnemius muscle and the passive (non-neural) stiffness of the triceps surae musculotendinous unit in typically developing children and children with CP from birth until 4 years of age.METHOD: Forty-one children with CP and 45 typically developing children were included. Freehand three-dimensional ultrasound was used to evaluate the volume of the medial gastrocnemius muscle. Biomechanical and electrophysiological measures were used to determine passive and reflex mediated stiffness of the triceps surae musculotendinous unit.RESULTS: Medial gastrocnemius muscle volume increased with the same rate in typically developing and children with CP until 12 months of age, when a significant smaller rate of growth was observed in children with CP. Passive stiffness of the triceps surae musculotendinous unit showed a linear increase with age in typically developing children. Children with CP older than 27 months showed a significant increase in passive stiffness. Reflex mediated stiffness was only pathologically increased in four children with CP.INTERPRETATION: The deviation of medial gastrocnemius muscle volume, earlier than musculotendinous unit stiffness, is consistent with the hypothesis. The data also point out that muscle atrophy and muscle stiffness already develops within the first 1 to 2 years. This emphasizes the necessity of early interventions to promote lower limb muscle growth in this population.WHAT THIS PAPER ADDS: Medial gastrocnemius muscle growth is reduced in children with cerebral palsy (CP) around 12 months after birth. Triceps surae musculotendinous unit stiffness is increased in children with CP around 27 months after birth. Reflex excitability is rar

The neural motor circuitries in the spinal cord receive information from our senses and the rest of the nervous system and translate it into purposeful movements, which allow us to interact with the rest of the world. In this review, we discuss how these circuitries are established during early development and to what extent they are shaped according to the demands of the body that they control and the environment that the body has to interact with. We also discuss how ageing processes and physiological changes in our body are reflected in adaptations of activity in the spinal cord motor circuitries. The complex, multi-facetted connectivity of the spinal cord motor circuitries allow that they can be used to generate vastly different movements and that their activity can be adapted to meet new challenges imposed by bodily changes or a changing environment. There are thus plenty of possibilities for adaptive changes in the spinal motor circuitries both early and late in life.

The early postnatal development of functional corticospinal connections in human infants is not fully clarified. We used EEG and EMG to investigate the development of corticomuscular and intramuscular coherence as indicators of functional corticospinal connectivity in healthy infants aged 1–66 weeks. EEG was recorded over leg and hand area of motor cortex. EMG recordings were made from right ankle dorsiflexor and right wrist extensor muscles. Quantification of the amount of corticomuscular coherence in the 20–40 Hz frequency band showed a significantly larger coherence for infants aged 9–25 weeks compared to younger and older infants. Coherence between paired EMG recordings from tibialis anterior muscle in the 20–40 Hz frequency band was also significantly larger for the 9–25 week age group. A low-amplitude, broad-duration (40–50 ms) central peak of EMG–EMG synchronization was observed for infants younger than 9 weeks, whereas a short-lasting (10–20 ms) central peak was observed for EMG–EMG synchronization in older infants. This peak was largest for infants aged 9–25 weeks. These data suggest that the corticospinal drive to lower and upper limb muscles shows significant developmental changes with an increase in functional coupling in infants aged 9–25 weeks, a period which coincides partly with the developmental period of normal fidgety movements. We propose that these neurophysiological findings may reflect the existence of a sensitive period where the functional connections between corticospinal tract fibres and spinal motoneurones undergo activity-dependent reorganization. This may be relevant for the timing of early therapy interventions in infants with pre- and perinatal brain injury.

The early postnatal development of functional corticospinal connections in human infants is not fully clarified. We used EEG and EMG to investigate the development of corticomuscular and intramuscular coherence as indicators of functional corticospinal connectivity in healthy infants aged 1-66 weeks. EEG was recorded over leg and hand area of motor cortex. EMG recordings were made from right ankle dorsiflexor and right wrist extensor muscles. Quantification of the amount of corticomuscular coherence in the 20-40 Hz frequency band showed a significantly larger coherence for infants aged 9-25 weeks compared to younger and older infants. Coherence between paired EMG recordings from tibialis anterior muscle in the 20-40 Hz frequency band was also significantly larger for the 9-25 week age group. A low-amplitude, broad-duration (40-50 ms) central peak of EMG-EMG synchronization was observed for infants younger than 9 weeks, whereas a short-lasting (10-20 ms) central peak was observed for EMG-EMG synchronization in older infants. This peak was largest for infants aged 9-25 weeks. These data suggest that the corticospinal drive to lower and upper limb muscles shows significant developmental changes with an increase in functional coupling in infants aged 9-25 weeks, a period which coincides partly with the developmental period of normal fidgety movements. We propose that these neurophysiological findings may reflect the existence of a sensitive period where the functional connections between corticospinal tract fibres and spinal motoneurones undergo activity-dependent reorganization. This may be relevant for the timing of early therapy interventions in infants with pre-and perinatal brain injury.

Human bipedal gait requires supraspinal control and gait is consequently severely impaired in most persons with spinal cord injury (SCI). Little is known of the contribution of lesion of specific descending pathways to the clinical manifestations of gait deficits. Here, we assessed transmission in descending pathways using imaging and electrophysiological techniques and correlated them with clinical measures of impaired gait in persons with SCI. Twenty-five persons with SCI participated in the study. Functional assessment of gait included the Walking Index for Spinal Cord Injury (WISCI), the Timed-Up and Go (TUG), the 6-Min Walking Test (6MWT), and the maximal treadmill gait speed. Balance was evaluated clinically by the Berg Balance Scale (BBS). The amplitude of tibialis anterior (TA) motor-evoked potentials (MEPs) at rest elicited by transcranial magnetic stimulation as a measure of corticospinal transmission showed a moderately good correlation with all clinical measures (r(2)~0.5), whereas the latency of the MEPs showed less good correlation (r(2)~0.35). Interestingly, the MEP amplitude was correlated to atrophy in the ventrolateral rather than the dorsolateral section of the spinal cord where the main part of the corticospinal tract is located. TA intramuscular coherence in the beta and gamma frequency range has been suggested to reflect corticospinal transmission and was, consistent with this, found to be correlated to atrophy in the dorsolateral and ventrolateral sections of the spinal cord. Coherence was found to correlate to all clinical measures to the same extent as the MEP amplitude. The latency and duration of medium-latency responses in the soleus muscle to galvanic stimulation as measures of vestibulospinal transmission showed very good correlation to BBS (r(2)=-0.8) and moderately good correlation to the assessments of gait function (r(2)~0.4). 6MWT and gait speed were correlated to atrophy of the lateral sections of the spinal cord bilaterally, w

ABSTRACT Neuroscience has fundamentally changed the understanding of learning and memory within recent years. Here, the authors discuss a number of specific areas where they believe new understanding of the CNS from basic science is having a fundamental impact on neurorehabilitation and is leading to new therapeutic approaches. These areas have constituted a basis for development of some basic principles for neurorehabilitation: Optimal rehabilitation should involve (a) active (patient) participation in the training, (b) training that does not only involve many repetitions, but also continues to challenge the skill of the training person, (c) motivation and reward, (d) intensive training and practice over a long time, (e) careful organization of the training in relation to other activities, and (f) incorporation of other potentially beneficial parameters such as sleep and diet. It should in this relation also be pointed out that albeit neurorehabilitation may be predicted to have the most optimal effect early in life and as soon after injury as possible, there is no reason to believe that beneficial effects of training may not be obtained late in life or several years after injury.

BACKGROUND: Foot drop and toe walking are frequent concerns in children with cerebral palsy (CP). Increased stiffness of the ankle joint muscles may contribute to these problems.OBJECTIVE: Does four weeks of daily home based treadmill training with incline reduce ankle joint stiffness and facilitate heel strike in children with CP?METHODS: Seventeen children with CP (4-14 years) were recruited. Muscle stiffness and gait ability were measured twice before and twice after training with an interval of one month. Passive and reflex-mediated stiffness were measured by a dynamometer which applied stretches below and above reflex threshold. Gait kinematics were recorded by 3-D video-analysis during treadmill walking. Foot pressure was measured by force-sensitive foot soles during treadmill and over-ground walking.RESULTS: Children with increased passive stiffness showed a significant reduction in stiffness following training (P = 0.01). Toe lift in the swing phase (P = 0.014) and heel impact (P = 0.003) increased significantly following the training during both treadmill and over-ground walking.CONCLUSIONS: Daily intensive gait training may influence the elastic properties of ankle joint muscles and facilitate toe lift and heel strike in children with CP. Intensive gait training may be beneficial in preventing contractures and maintain gait ability in children with CP.

It is commonly assumed that exaggerated stretch reflex activity and the resulting increased muscle tone in ankle plantar flexors contribute to reduced ankle joint movement during gait in children with cerebral palsy (CP). We investigated the contribution of sensory feedback mechanisms to ankle plantar flexor muscle activity during treadmill walking in 20 children with CP and 41 control children. Stretch responses in plantar flexor muscles evoked in stance by dorsiflexion perturbations showed an age-related decline in control children but not in children with CP. In swing responses were abolished in control children, but not in children with CP. Removal of sensory feedback to the soleus muscle in stance by shortening the plantar flexors produced a drop in soleus EMG activity of a similar size and latency in control children and children with CP. Soleus EMG activity was observed in swing in a similar proportion in both groups. Shortening of the plantar flexors in swing caused a larger drop in Soleus EMG in control children than in children with CP. The lack of age related decline in stretch reflexes in the stance phase and the inability to suppress the reflex in the swing phase is likely related to lack of maturation of corticospinal control in children with CP. However, since they did not show soleus EMG activity to a larger extent than control children in swing and since sensory afferent feedback did not contribute more to their muscle activity, spasticity is unlikely to contribute to foot drop and toe walking.

During the past 30 years spasticity research has raised fundamental concerns regarding the definition, evaluation and functional significance of spasticity. The present thesis is a direct continuation of this work. The aim of the thesis was to evaluate reflex mediated stiffness (spasticity) and passive stiffness (changes in the elastic properties of muscles) of ankle joint muscles at rest, during gait and in relation to gait training in children with cerebral palsy (CP). In study I we found that reflex mediated stiffness is difficult to distinguish clinically from changes in passive muscle stiffness and notably that passive muscle stiffness rather than increased reflex stiffness (spasticity) is the most frequent explanation of ankle muscle hyper tonicity in children with CP. These findings emphasises the importance of properly distinguishing different contributions to muscle stiffness in order to avoid unnecessary antispastic treatment. Findings from study II suggested that spasticity is not the main functional limitation for movement of the ankle joint during gait in children with CP. Despite relative exaggeration of reflexes during gait, unloading of the active plantar flexors produced a similar or in some cases a smaller drop in the soleus EMG activity in the children with CP compared to control children. This indicates that sensory feedback mechanisms contribute less to the soleus EMG activity in children with CP than in control children. We thus argue that exaggeration of reflex activity is unlikely to contribute to foot drop and toe walking in the children with CP. Antispastic treatment is therefore unlikely to benefit the children functionally and we argue that therapy and treatment strategies should rather be directed at passive muscle changes. Study III was performed in order to explore whether intensive gait training on a treadmill with incline could reduce passive muscle stiffness in the ankle joint and maybe facilitate a more approp

Objective:Maximum toe elevation during walking is an objective measure of foot drop and reflects the impairment of the corticospinal tract (CST) in persons with spinal cord injury (SCI). To determine if this measurement is functionally relevant to ambulatory abilities, we correlated maximum toe elevation with clinical physiotherapy tests.Setting:Cross-sectional study, laboratory and clinical settings.Methods:A total of 24 individuals with SCI (American Spinal Injury Association (ASIA) Impairment Scale D) were recruited. Maximum toe elevation during the swing phase of treadmill gait was measured with a kinematic system. CST function was assessed in a sitting position by measuring the motor-evoked potentials (MEPs) induced in tibialis anterior muscle with transcranial magnetic stimulation over the motor cortex. Clinical tests performed were 10-m and 6-min walk test (6MWT), Timed-Up and Go (TUG), Walking Index for Spinal Cord Injury, Berg Balance Scale, Lower Extremity Motor Score (LEMS) and sensory score of the L4, L5 and S1 dermatomes.Results:Participants with lower toe elevation during gait walked at a slower speed, took more time to perform the TUG test, and covered a shorter distance in the 6MWT. They also scored lower on the LEMS and showed impaired superficial sensitivity of the dermatomes around the ankles. Few correlations were observed between CST function and clinical tests, but the presence of MEP at rest was indicative of faster speed and longer distance in the 6MWT.Conclusion:These results indicate that maximum toe elevation, which is directly correlated with CST impairment, is functionally relevant as it also correlates with timed clinical tests, LEMS and sensory scores.Spinal Cord advance online publication, 13 August 2013; doi:10.1038/sc.2013.84.

En gennemgang af medicineringens hæmmende effekter på indlæring og genoptræning.

Indirect evidence that the motor cortex and the corticospinal tract contribute to the control of walking in human subjects has been provided in previous studies. In the present study we used coherence analysis of the coupling between EEG and EMG from active leg muscles during human walking to address if activity arising in the motor cortex contributes to the muscle activity during gait. Nine healthy human subjects walked on a treadmill at a speed of 3.5–4 km h(-1). Seven of the subjects in addition walked at a speed of 1 km h(-1). Significant coupling between EEG recordings over the leg motor area and EMG from the anterior tibial muscle was found in the frequency band 24–40 Hz prior to heel strike during the swing phase of walking. This signifies that rhythmic cortical activity in the 24–40 Hz frequency band is transmitted via the corticospinal tract to the active muscles during walking. These findings demonstrate that the motor cortex and corticospinal tract contribute directly to the muscle activity observed in steady-state treadmill walking.

Montréal, Canada. *in english ACFAS means french canadian association for the advancement of sciences

Rehabilitation following spinal cord injury is likely to depend on recovery of corticospinal systems. Here we investigate whether transmission in the corticospinal tract may explain foot drop (inability to dorsiflex ankle) in persons with spinal cord lesion. The study was performed in 24 persons with incomplete spinal cord lesion (C1 to L1) and 15 healthy controls. Coherence in the 10-20 Hz frequency band between paired tibialis anterior muscle (TA) electromyographic recordings obtained in the swing phase of walking, which is taken as a measure of motor unit synchronization, was significantly correlated with the degree of foot drop, as measured by toe elevation and ankle angle excursion in the first part of swing. Transcranial magnetic stimulation (TMS) was used to elicit motor evoked potentials (MEPs) in the TA. The amplitude of the MEPs at rest and their latency during contraction were correlated to the degree of foot drop. Spinal cord injured participants who exhibited a large foot drop had little or no MEP at rest in the TA muscle and had little or no coherence in the same muscle during walking. Gait speed was correlated to foot drop, and was the lowest in participants with no MEP at rest. The data confirm that transmission in the corticospinal tract is of importance for lifting the foot during the swing phase of human gait.