published_or_final_version / Paediatric Dentistry / Master / Master of Dental Surgery

Call number: LD2668 .P7 1973 J65

Unilateral Spastic Cerebral Palsy (USCP) is caused by an early brain lesion in which the Corticospinal Tract (CST), the primary pathway controlling upper extremity (UE) movements, is affected. The CST connectivity after early brain injury (i.e., an ipsilateral, contralateral, or bilateral connectivity) may influence treatment outcomes. Transcranial magnetic stimulation (TMS) is a common method to probe CST connectivity. However, TMS is limited to children without seizures. Mirror movements (MM), an involuntary imitation of movements by one limb during the contralateral limb voluntary movements, are common in USCP. MM may result when both UEs are controlled by the contralesional motor cortex. Here we investigated the relationship between MM and CST connectivity in children with USCP. We hypothesized that stronger MM were associated with an ipsilateral connectivity. Our secondary aim was to investigate whether the amount of MM was reduced after intensive therapy. Thirty-three children with USCP (mean age=9yrs 6mos; MACS: I-III) participated and were randomized to receive 90hrs of unimanual (n=16) or bimanual (n=17) intensive training. Assessments were measured at baseline and immediately after training. We used TMS and diffusion tensor imaging (DTI) to determine the CST connectivity. We used three approaches to quantify MM: 1) behavioral MM assessment during contralateral movements, including hand opening/closing, finger opposition, finger individuation, and finger walking, 2) involuntary grip force oscillations recorded by force transducer (FT) when the contralateral hand performed repetitive pinching, and 3) involuntary muscle contractions measured by electromyography (EMG) when the contralateral hand performed pinching. Results showed that strong MM (scores ≥3) in the more-affected hand while hand opening/closing were associated with an ipsilateral pathway (Fisher's exact test, p= 0.02). This association was not found in the remaining tasks (Fisher’s exact test, opposition, p≥ 0.99; individuation, p≥ 0.99; finger walking, p≥ 0.99). Involuntary GF oscillations were measured in a subset of 16 children. Presence of FT-measured MM in the less-affected hand (> 0.3N) was not associated with TMS-probed connectivity (Fisher’s exact test, p= 0.59). Nevertheless, presence of FT-measured MM was associated with DTI-assessed connectivity (Fisher’s exact test, p= 0.0498). Similarly, presence of EMG-measured MM in the more-affected hand was not associated with TMS-probed connectivity (Fisher’s exact test, p= 0.59). Nevertheless, presence of EMG-measured MM was associated with DTI-assessed connectivity (Fisher’s exact test, p= 0.03). The amount of MM did not change after training (p> 0.06 among all measures). In conclusion, strong MM in the more-affected hand while hand opening/closing may be indicative of an ipsilateral connectivity identified by TMS. Presence of MM measured by FT may be a predictor of DTI-assessed CST pattern. Findings of this study may help researchers and clinicians understand the relationship between the CST connectivity and its behavioral manifestation in children with USCP. Such relationship may further guide therapeutic strategies in a wider range of children with USCP.

The primary goal of human locomotion is to stably translate the center of mass (CoM) over the ground with minimum expenditure of energy. Pelvic movement is crucial for walking because the human CoM is located close to the pelvic center. Because of this anatomical feature, pelvic motion directly contributes to the metabolic expenditure, as well as in the balance to keep the center of mass between the legs. An abnormal pelvic motion during the gait not only causes overexertion, but also adversely affects the motion of the trunk and lower limbs. In order to study different interventions, recently a cable-actuated robotic system called Tethered Pelvic Assist Device (TPAD) was developed at ROAR laboratory at Columbia University. The cable-actuated system has a distinct advantage of applying three dimensional forces on the pelvis at discrete points in the gait cycle in contrast to rigid exoskeletons that restrict natural pelvic motion and add extra inertia from the rigid linkages. However, in order to effectively use TPAD for rehabilitation purposes, we still need to have a better understanding of how human gait is affected by different forces applied by TPAD on the pelvis. In the present dissertation, three different control methodologies for TPAD are discussed by performing human experiments with healthy subjects and patients with gait deficits. Moreover, the corresponding changes in the biomechanics during TPAD training are studied to understand how TPAD mechanistically influences the quality of the human gait. In Chapter 2, an ‘assist-as-needed’ controller is implemented to guide and correct the pelvic motion in three dimensions. Here, TPAD applies the correction force based on the deviation of the current position of the pelvic center from a pre-defined target trajectory. This force acts on the pelvic center to guide it towards the target trajectory. A subject in the device experiences a force field, where the magnitude becomes larger when the subject deviates further away from the target trajectory. This control strategy is tested by performing the experiments on healthy subjects with different target pelvic trajectories. Chapter 3 describes a robotic resistive training study using a continuous force on the pelvis to strengthen the weak limbs so that subjects can improve their walking. This study is designed to improve the abnormal gait of children with Cerebral Palsy (CP) who have a crouch gait. Crouch gait is caused by a combination of weak extensor muscles that do not produce adequate muscle forces to keep the posture upright, coupled with contraction of muscles that limit the joint range of motion. Among the extensor muscles, the soleus muscle acts as the major weight-bearing muscle to prevent the knees from collapsing forward during the middle of the stance phase when the foot is on the ground. Electromyography, kinematics, and clinical measurements of the patients with crouch gait show significant improvements in the gait quality after the resistive TPAD training performed over five weeks. Both Chapters 2 & 3 present interventions that are bilaterally applied on both legs. Chapter 4 introduces a training strategy that can be used for patients who have impairments in only one leg which results in manifests as asymmetric weight-bearing while walking. This training method is designed to improve the asymmetric weight bearing of the hemiparetic patients who overly rely on the stronger leg. The feasibility of this training method is tested by experiments with healthy subjects, where the controller creates an asymmetric force field to bring asymmetry in weight bearing during walking. In summary, the present dissertation is devoted to developing new training methods that utilize TPAD for rehabilitation purposes and characterize the responses of different force interventions by investigating the resulting biomechanics. We believe that these methodologies with TPAD can be used to improve abnormal gait patterns that are often observed in cerebral palsy or stroke patients.

Thesis (M.Ed. (Educational Psychology)) --University of Limpopo, 2014 / Self-concept is a driving force, (Barongo & Nyamwange, 2013: 7) and Harter (1998: 559) pointed out that improved self-concept is an important means to enhance other desirable outcomes like, self-acceptance and academic improvement. The purpose of this study was therefore to explore the self-concept of adolescent learners with cerebral palsy in special schools in Limpopo Province, to check their level of selfconcept. The objectives of this study were to determine if cerebral palsy affects the self-concept of these learners, to measure their level of self-concept and to find out if intervention improves their self-concept. The sample was selected by means of random sampling. The Self Descriptive Questionnaire (SDQ) with nine subscales was administered to a group of participants, 65 adolescent learners with cerebral palsy, (30 males and 35 females) at the three special schools; Helena Franz, Letaba and Tšhilizini. The questionnaire was administered to the respondents twice, before and after intervention. Pre-test and post-test were done at Helena Franz Special School since it was the only high school among the three special schools catering for cerebral palsied learners in Limpopo Province. The empirical investigation revealed that the self-concept of adolescents with cerebral palsy in special schools in Limpopo Province is not negative but just leaning in the direction of the positive judgments. It further indicated that cerebral palsy affects the self-concept of the adolescent learners and that intervention has a positive impact on the self-concept of adolescent learners with cerebral palsy

Home programs are widely used by occupational therapists as a strategy to address health and development needs of children with cerebral palsy. Experts believe they are essential. Despite wide-spread clinical use there is no high quality research evidence proving home program effectiveness. Further there is no information that provides a parent perspective on home programs. The aim of this research was to evaluate the effectiveness of occupational therapy home program intervention for school-aged children with cerebral palsy and identify factors perceived to be important in home program practice from a parent perspective. A double blind randomised controlled trial design was used to evaluate effectiveness, where parents and evaluators were blinded to intervention. Children were randomised to three groups, home program intervention for eight weeks (“8WEEKS”), home program intervention for four weeks (“4WEEKS”), and a control group, that did not receive home program intervention (“NoHP”). The primary end-point was change in performance of functional activities and satisfaction with function as measured by the Canadian Occupational Performance Measure (COPM), after eight weeks. Secondary endpoints were change in COPM scores after four weeks, goal achievement at four and eight weeks as measured by Goal Attainment Scale (GAS), quality of arm movement at four and eight weeks measured on the Quality of Upper Extremity Skills Test (QUEST) and participation levels at four and eight weeks measured on the Children’s Assessment of Participation and Enjoyment (CAPE). Parent experience was explored through semistructured interviews of parents who participated in the home program trial. Content analysis of interview data was conducted to the level of “open coding” to identify factors. Results for the primary outcome measure at the primary end point (eight weeks) - Effect of an 8WEEK or 4WEEK home program on COPM scores: comparison between the three groups was conducted using a linear regression model with baseline COPM performance/satisfaction scores, participant age and severity of cerebral palsy as measured by the GMFCS entered into the model as covariates. Overall, there were statistically significant and clinically important differences in performance of activities and satisfaction with function on COPM when comparing either home program group to the NoHP group at eight weeks. There was no difference between 4WEEKS versus 8WEEKS on COPM performance or satisfaction scores at eight weeks. Results on secondary outcome measures: compared to NoHP, receiving a home program for either 4WEEKs or 8WEEKs increased COPM performance scores and GAS measures at four weeks, and increased COPM performance and satisfaction scores, GAS measures, and QUEST scores at eight weeks. There were no differences within or between groups on the CAPE at either four week or eight weeks. There were no statistically significant between-group differences between the 4WEEK and 8WEEK home program groups on any secondary outcome measures. This was most likely the result of a protocol implementation flaw that occurred in the study where 4WEEK group participants continued program activity for the final four weeks when they should have suspended it. Parents perceived their experience of implementing home programs as characterised by five features: ����guidance for the journey”, practice makes perfect, they were a necessary “way of life”, they maximised progress and something that made it easier to juggle competing demands. Positive home program experiences were characterised by: support, realistic expectations, flexibility, motivation from goals, activities that translated to real-life, reminders to practice, progress updates and role clarity. Parents advised other parents to: accept the disability, never refuse help, be honest, consider home programs essential, develop routines and view programs as a way of improving the child and parents’ life. No negative experiences were reported. Parents advised professionals that they wanted: support, interdisciplinary co-ordination of programs, advice without pressure and prognostic guidance for future planning. This dissertation presents new information about occupational therapy home programs. Until this study, there was little research evidence to inform therapist or parent decision-making regarding the therapeutic value of home programs or the parent perspective on home programs. Findings from this dissertation can inform clinical practice and parent decisions regarding the use of home program interventions for children with cerebral palsy. / Doctor of Philosophy (PhD)

[Truncared abstract] Introduction: The assessment of any therapy requires not only an understanding of how that therapy works but also how it affects health related quality of life (HRQOL). Botulinum Toxin A(BoNT-A) therapy for upper limb spasticity management in children with hemiplegic cerebral palsy(CP) is currently under trial. Despite its use for over a decade for lower limb spasticity, little is known about the mechanisms involved in improving motor function and the effect on the child and their familys HRQOL. Both central and peripheral mechanisms are hypothesised[1]. Whilst evidence of improved quality of movement and ability to perform tasks is emerging[2-4], this cannot be directly correlated with an improvement in HRQOL. In addition, the traditional method of assessing child HRQOL by parent proxy reports has come under question[5, 6]. The World Health Organisation now recommends the collection of both parent proxy and child self-reports[7]. Aims: 1. Investigate the corticomotor projections to the upper limb in school aged children with hemiplegic CP and the changes that occur with BoNT-A therapy by transcranial magnetic stimulation (TMS). 2. Investigate the effect of upper limb BoNT-A therapy on HRQOL of school aged children with hemiplegic CP by completion of the PedsQL 4.0 Generic Core Scales and 3.0 CP Module. 3. Determine the concordance between Child Self-Report and Parent Proxy Report scores for the PedsQL 4.0 Generic Core Scales and 3.0 CP Module. 4. Determine the concordance between PedsQL scores and function as assessed by the Melbourne Assessment of Unilateral Upper Limb Function (MUUL). Methods: Design: Prospective randomised pilot study. Setting: Department of Paediatric Rehabilitation, Princess Margaret Hospital, and Centre for Neurological and Neuromuscular Disorders, Perth. Participants: 22 school aged children with hemiplegic CP aged 7yr 0mth-13yr 11mth (12 treatment, 10 control). 3 Treatment: One episode BoNT-A injections (dose 1-2U/kg/muscle) into the upper limb for treatment group. The control group received usual care. ... Conclusion: This pilot study provides preliminary evidence of the effects of upper limb BoNT-A therapy at both a central physiological and a broader quality of life level in school aged children with hemiplegic CP. At a central level, corticomotor pathway reorganisation occurs in the setting of BoNT-A. However the reorganisation is not limited to the affected side pathways suggesting a systemic BoNT-A effect or developmental changes. Similarly, in this pilot study, there was no statistically significant effect of upper limb BoNT-A on the childs HRQOL as assessed by the PedsQL although positive trends were observed 4 for a number of physical and psychosocial domains. The collection of both child self-report and parent proxy reports when assessing HRQOL is recommended, and function needs to be assessed independently. Larger studies across the broader CP population, the design of CP specific HRQOL tools appropriate for use in the higher functioning CP cohort, and alternative better tolerated methods of investigating the motor system in children with movement disorders are recommended.

Previous research has shown that fundamental movement skills (FMS) proficiency influences physical activity (PA) in children, such that those who are more proficient tend to be more active. Sufficient PA engagement in childhood has been associated with positive health outcomes, but little is known about PA levels in children with disabilities. Children with cerebral palsy (CP) represent the largest diagnostic group in pediatric rehabilitation. In one systematic review and six studies, FMS proficiency and PA levels among children with CP were measured, analyzed, and compared with typically developing children. The lack of a valid objective PA measurement method for children with CP was determined in the systematic review, and the first study (Chapter 2) validated the Actigraph accelerometer as a valid objective PA measurement instrument in this population group. FMS measurement in children with CP was addressed in the second study (Chapter 3), which showed that process-and product-oriented measurement are both important in characterizing FMS proficiency in a holistic manner. With the said measurement techniques validated, the third study (Chapter 4) utilized a cross- sectional study design to examine FMS proficiency and PA in children with and without CP. It was found that children were less active and more sedentary during weekends than weekdays. FMS proficiency was negatively associated with sedentary time and positively associated with time spent in moderate to vigorous PA in both groups of children. Process-oriented FMS measures were found to have a stronger influence on PA in children with CP than in typically developing children. With the intention to examine these relationships in a cause-effect study design, a theoretical model for FMS training programs was tested in children with and without disabilities in the fourth and fifth studies (Chapter 5). A movement training approach that minimized the amount of practice errors was found to facilitate improvements in FMS proficiency. This approach was then utilized in the sixth study (Chapter 6), wherein the relationship of FMS proficiency and PA were examined in a quasi-experimental design. It was found that by training FMS, weekend PA was heightened and weekend sedentary time was decreased among children with CP. In comparison, typically developing children manifested decreased weekend sedentary time after FMS training. The findings from these studies contribute to understanding the measurement of FMS and PA in children with CP, the implementation of FMS training in children in general, and the relationship between FMS and PA in children with and without disabilities. / published_or_final_version / Human Performance / Doctoral / Doctor of Philosophy

Thesis (Ph.D.)--University of Western Australia, 2005.

Thesis (Ed. D.)--Virginia Polytechnic Institute and State University, 1992. / Vita. Abstract. Includes bibliographical references (leaves 203-214). Also available via the Internet.