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No description available.

The object of this thesis was to improve our understanding of bimanual coordination and neuromuscular activation in children with and without spastic hemiparetic cerebral palsy (SHCP) and to gain insight into the contribution of visual information towards interlimb coupling. The availability of visual information was manipulated by placing a glass screen, opaque screen or a mirror ('mirror box') between the arms. Using this arrangement, visual information was available from both arms (glass condition), from one arm only (opaque screen condition), or from one arm and its mirror reflection ('mirror (box) condition) that was superimposed on the arm behind mirror. When both arms were moved simultaneously in the latter condition, children with a strong asymmetry between body-sides as a result of SHCP saw a visual perception of a zero lag, symmetric movement between the two less impaired arms. Without visual manipulation it was found that children with SHCP exhibited a similar mean coordination pattern compared to typically developing (TD) children, but had greater movement variability between the arms.

The World Health Organisation published the International Classification of Functioning, Disability and Health in 2001. It defines Participation as ‘involvement in life situations’. Instruments to measure Participation have been developed for children and adults, but none specifically for adolescents. Adolescence is a life stage with distinct patterns of Participation, and previous research has demonstrated that adolescents with disabilities have poorer Participation than the non-disabled population. Cerebral palsy (CP) is a significant cause of disability in adolescents, with affected individuals experiencing a range of different impairments of varying severity. CP was chosen as the exemplar condition for this study. The aim of this study was to develop a measure of Participation for adolescents with CP. Semi-structured interviews with 17 adolescents, 12 with CP and 5 without disability, were used to elicit views of Participation to inform item generation. Focus groups with 8 of the adolescents allowed respondent validation and feedback on possible questionnaire items. The pool of 88 proposed items was revised following review by 17 experts, resulting in 92 items with a content validity index of 93%. Cognitive interviews were carried out with adolescents and carers. Field-testing with 107 young people with CP was used to examine reliability, construct validity and to enable item reduction. For 38 of these adolescents, a proxy report was obtained because the young person did not have sufficient cognitive ability to self-report. Known-groups validity was demonstrated using correlation with impairment severity. Test-retest reliability was satisfactory for all domains, whilst internal consistency varied between domains. The instrument was shortened to 45 items. This is the first instrument developed to measure Participation for adolescents with disability. Use of the instrument in research and clinical work will enable its properties to be better understood in different settings.

Cerebral Palsy (CP) refers to a motor disorder that affects approximately one in every 400 live births in the UK. Living with CP can be challenging for both patients and their families. There are a range of established approaches used by physiotherapists to improve motor capacity in children with CP. Staffing and space allocation, however, can limit the number of rehabilitation sessions that can be offered. Treadmill training has been suggested as one approach to address some of these limitations. Walking using a treadmill can maintain or improve movement function, yet questions remain over the effectiveness of the programme and how to maintain motivation on the part of the child. The inclusion of a virtual reality (VR) environment into training is a possible approach to engage children who might otherwise lack the motivation needed to undertake rehabilitation. VR based lower extremity rehabilitation to improve standing (balance) and walking (gait) skills has been shown to be relevant for patients post stroke. VR has also been noted to help children with CP increase their self- confidence and motivation, resulting in improvements of upper extremity function. The potential for VR based lower extremity rehabilitation for CP has also been reported. It has been suggested, however, that most VR systems are not designed with rehabilitation in mind. Some have been designed specifically for use in rehabilitation, but these can be expensive which has limited their use. Consequently, VR based rehabilitation, particularly for gait assist, has not been reported or investigated in detail. The overall aim of the present work was to develop, design, and investigate the practicality of a virtual rehabilitation system (the Surrey Virtual Reality System - SVRS) suitable for routine clinical use in gait re-education for children with CP. For this work, the practicality evaluation was directed at: satisfaction (how enjoyable is it to use the SVRS); comfort (how easy is it for users to complete tasks, once they have learned the system); safety (how safe is it to use the equipment and what are side effects of using the system); and to some extent utility (to what extent the selected scenarios will benefit the rehabilitation of children with CP effectively). Therefore, pilot game scenarios were developed for training in balance and treadmill based walking. A Real-time Treadmill Speed Control Algorithm was developed as part of the SVRS, which may provide a more immersed and realistic treadmill training. The performance and the 3D presentation quality of the SVRS were first evaluated in 13 young able-bodied using questionnaires. The overall results were positive and showed that the SVRS provided safe and visually acceptable virtual training environments. The statistical results suggest that self selected 'slow' and 'normal' speeds were significantly higher when using the RTSCA. This may suggest that they walked more naturally or confidently on the treadmill when using the RTSCA as compared to the use of conventional treadmill speed control buttons. To investigate the 'practicality' of the SVRS in a clinical situation; three clinicians and two children with CP used it, the latter observed by their parent/guardian and a treating physiotherapist. Feedback was collected using both questionnaires and an open-discussion. The overall results show that the SVRS appears practical for rehabilitation purposes and the children with CP and the other able-bodied participants used the RTSCA safely. Further modification is required in the future research that should focus on formally examining the clinical effectiveness of the SVRS in children with CP. For example, providing a mechanism for clinicians to alter the virtual environment should be considered in order to meet the specific rehabilitation aims for patients.

Foot deformities are common in children with cerebral palsy diplegia. One such deformity is midfoot break where movement occurs in the midfoot region during mid to late stance. This deformity is thought to be associated with hindfoot valgus with the abnomial movement in the midfoot contributing to the maintenance of the ground reaction force behind the knee and thus increasing crouch gait (Gage 2004). There are no reports in the literature of any studies examining the link between midfoot break and crouch in cerebral palsy. The two objectives of this study were 1) to provide a descriptor to identify midfoot break from close up sagittal video in order that the deformity could be recorded and classified and 2) to confirm whether midfoot break was associated with crouch gait. Retrospective close up sagittal and coronal video of children with cerebral palsy diplegia, who had attended for routine gait analysis, where clinical examination, kinematic and kinetic data were available, were analyzed. Ten children with moderate midfoot break were identified using the new descriptor and ten children, with no midfoot break were selected at random for comparison. None of the subjects had had any previous foot/ankle surgery. Hindfoot position was recorded using the Edinburgh Visual Gait Score stance phase hindfoot descriptor (Read et al 2003). Mann-Whitney U non-parametric tests were used to identify significant differences.

Background Impairment of the upper limb (UL) is a common consequence of cerebral palsy (CP), and results in difficulties completing daily activities. Methods Literature reviews evaluated UL classification systems and measures of impairment for children with CP. Cross-sectional surveys were mailed to paediatric therapists and families of children with CP to describe the perceived severity of UL problems and current therapy management of such problems. Seven children aged 8-15 years with hemiplegic CP were recruited to a mixed methods study (single subject research design and semi-structured interviews) evaluating the efficacy and feasibility of constraint induced movement therapy (CIMT). Results Five classification systems were recommended for clinical use; two classified function, and three, deformities. Continued use of the Modified Ashworth Scale, manual muscle testing and goniometry when measuring UL impairments in clinical practice was supported. Families and therapists perceived muscle weakness, decreased grip strength, reduced coordination and impaired fine motor function as having a moderate or great impact on the UL in children with the condition. Therapists commonly assessed joint range of motion and muscle strength, however standardised measurement of activity was rare. Current therapy management reflected training received by therapists with neurodevelopmental therapy and positioning being most often reported in managing the UL of children with CP. CIMT resulted in significant improvements in unimanual capacity in four participants, two of whom also significantly improved on UL active range of motion, although UL strength, tone and participation remained largely unchanged. Conclusions This programme of work identified issues regarding assessment and treatment of UL dysfunction in the paediatric CP population. Recommendations regarding UL assessment methods and CIMT, pertinent to clinical practice and research, have stemmed from the completed studies. This thesis has increased understanding of the complexity of UL problems and provides a basis for further research in the area.