Constraint-Induced Movement Therapy and Action Observation Training in Children With Unilateral Cerebral Palsy

The AHA, a Rasch-based performance scale, measures how effectively the affected hand is spontaneously used during performance of bimanual tasks.

The Melbourne Assessment evaluates quality of movement in 16 functional unimanual tasks.

The Jebsen-Taylor hand function test measures manual dexterity in six unimanual tasks, by means of movement time expressed in seconds for both hands.

The Tyneside pegboard test is an adapted 9-hole pegboard test and assesses unimanual and bimanual dexterity.

PROM of shoulder flexion, abduction, external and internal rotation, elbow extension, forearm supination and wrist extension is measured using a universal goniometer.

Muscle tone is evaluated in 11 muscle groups using the Modified Ashworth Scale (MAS), ranging from 0 to 4.

Muscle strength is evaluated in nine muscle groups using manual muscle testing (MMT), ranging from 0 to 5.

Grip strength is assessed with a Jamar dynamometer®. The average of three consecutive maximum contractions is recorded for both hands.

Muscle fatigability during an isometric grip strength task is assessed based on a 30 second sustained contraction with E-link software.

The Abilhand- Kids questionnaire is a Rasch-based inventory of 21 mostly bimanual activities that the parents are asked to judge as: 0 (impossible), 1 (difficult), and 2 (easy), irrespective of the limb(s) actually used to do the activity.

CHEQ is a questionnaire to evaluate the experience of children and adolescents in using the affected hand in activities where usually two hands are needed.

This quantitative assessment comprises upper limb kinematics during functionally relevant aiming and grasping tasks.

LIFE-H Kids assesses the quality of social participation of children with disabilities by estimating how a client accomplishes activities of daily living and social roles

CP-QOL is a parent report that assesses the wellbeing across various domains of life in children with cerebral palsy.

Structural images are acquired using three-dimensional fluid-attenuated inversion recovery (3D FLAIR) with following parameters: 321 sagittal slices, slice thickness 1.2, slice gap 0.6, repetition time=4800 ms, echo time=353 ms, field of view=250 x 250 mm², 1.1 x 1.1 x 0.56 mm³ voxel size, acq time = 5'02". Brain lesions will be first classified according to the timing of the lesion and the predominant pattern of damage as described by Kragelöh-mann (2007): cortical malformations (first and second trimester of pregnancy), periventricular white matter (PWM) lesions (from late second till early third trimester) and cortical and deep greymatter (CDGM) lesions (around term age) and acquired brain lesions (between 28 days 3 years postnatally). Second, a more detailed evaluation of the brain lesion (i.e. location and extent) will be performed using the semi-quantitative MRI (sqMRI) scale developed by Fiori et al. (2014).

rsfMRI images are acquired using a T2*-weighted gradient-echo planar imaging (GE-EPI) sequence with the following parameters: TR = 1700 ms; TE = 30 ms; matrix size = 64x64; FOV = 230 mm; flip angle = 90º; slice thickness = 4 mm; no gap; axial slices = 30; number of functional volumes = 250; acquisition time = 7 min. rsfMRI will be pre-processed with Statistical Parametric Mapping version 12 (SPM12) software. Functional connectivity analysis will be computed with the CONN toolbox v17b.

Diffusion weighted images will be acquired using a single shot spin echo sequence with the following parameters: slice thickness = 2.5 mm, TR = 8700 ms, TE = 116 ms, number of diffusion directions = 150, number of sagittal slices = 58, voxel size = 2.5 x 2.5 x 2.5 mm³, acq time = 18'. Implemented b values are 700, 1000, and 2800 s/mm², applied in 25, 40, and 75 uniformly distributed directions, respectively. In addition, 11 non-diffusion weighted images are obtained. Diffusion data will be pre-processed and analyzed in ExploreDTI toolbox, version 4.8.6. Diffusion metrics, such as fractional anisotropy and mean diffusivity of white matter tracts of interest (i.e. corpus callosum, corticospinal tract, superior thalamic radiations, medial lemniscus) will be calculated for both hemispheres.

TMS was performed using a MagStim 200 Stimulator (Magstim Ltd, Whitland, Wales, UK) equipped with a focal 70mm figure-eight coil and a Bagnoli electromyography (EMG) system with two single differential surface electrodes (Delsys Inc, Natick, MA, USA). A Micro1401-3 acquisition unit and Spike software version 4.11 (Cambridge Electronic Design Limited, Cambridge, UK) were used to synchronize the TMS stimuli and the EMG data acquisition. Motor Evoked Potentials (MEPs) were bilaterally recorded, using single differential surface EMG electrodes attached on the muscles adductor pollicis brevis of both hands.