Thesis (Ph.D. in Clinical Science) -- University of Colorado at Denver and Health Sciences Center, 2006. / Typescript. Includes bibliographical references (leaves 58-61). Free to UCDHSC affiliates. Online version available via ProQuest Digital Dissertations;

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.

Young children with HCP experience difficulties performing age-appropriate daily activities such as self-care and play. Research in neuroplasticity has shown that intensive, task-specific training in early development is ideal to maximize functioning in children with HCP. The aim of this study was to analyze the feasibility of a new manualized clinical guideline, Family Activity Adaptation Model (FAAM), via Telehealth to coach families to develop daily activities and routines that facilitate functional bimanual skills in young children with hemiplegic cerebral palsy (HCP). Ten caregivers and children with HCP (3-7 years) received virtual training on how to embed bimanual intensive training (HABIT) into their everyday activities and routines on their own at home for 90 minutes a day, 5 days a week over 8 weeks. Caregivers and children received virtual coaching using the FAAM method 2 times per week. FAAM Activity Analysis was used to describe manual development. Daily activity logs were used to assess family adherence and home program feasibility. Bimanual functional goal performance and satisfaction was measured using the Canadian Occupational Performance Measure (COPM). Perceived changes in overall bimanual functional skills were evaluated using the Mini-Children’s Hand Use Experience Questionnaire (Mini-CHEQ). Caregiver stress, burden and program satisfaction was monitored using the Parenting Stress Index (PSI-4-SF), the Ease of Caregiving for Children measure and a caregiver satisfaction survey. The measures were assessed immediately prior to (pretest), midpoint (burden measures only, repeated measures ANOVA) and immediately after (posttest, Wilcoxon Sign Rank Test) the intervention. All families made statistically and clinically significant improvements in goal performance (p=.008) satisfaction (p=.007), and overall bimanual hand use (p=.035). All families completed daily logs and practiced strategies for an average of 81.37 (SD=7.069) minutes a day. Caregiver burden and stress remained consistent throughout the study and all caregivers reported satisfaction with the program. This is the first study to manualize a family centered, telehealth-delivered intensive motor training program. This study adds a continuum of care and access to services for children and families with limited resources. The study supports clinicians with home program design and meets the individual needs of families using resources in their natural environment.

Postural control is essential for maintaining an upright sitting position. However, children with Cerebral Palsy (CP) Gross Motor Function Classification System (GMFCS) IV-V present with impaired postural control, often limiting their daily function and environmental interaction. Most interventions targeting postural dysfunction in CP consider the trunk as a single biomechanical segment and are challenging to use in the GMFCS IV-V population. The aim of this study was to develop the Segmental Intensive Trunk Training (SITT), which uses the segmental model of trunk control. The motor learning framework was chosen for structuring SITT to be an intensive approach, with a dosage of 2hrs/day, 3days/week for 4 weeks (24 hours). The development process included the test of feasibility and the initial evidence of effects, using a single subject research design (SSRD). An A-B-A design was used, where the first phase A included 4 baseline assessments, and phase B included the 4 weeks of SITT intervention. The second phase A was the withdrawal period including an immediate posttest, post 1 week test and a 3 month follow up evaluation. Postural control and reaching behavior were assessed during all 3 phases, using the Segmental Assessment of Trunk Control (SATCO) and Seated Postural and Reaching Control Test (SP&R-co). Hand dexterity and function was measured using the Box and Block test, and ABILHAND-kids questionnaire. Gross motor function was measured using the Gross Motor Function Measure Item Set (GMFM-IS). Performance on functional goals was assessed using the Canadian Occupational Performance Measure (COPM). Data analysis was descriptive, including visual analysis and the two standard deviation band method. One participant (11 years, GMFCS V) participated in the study with a 100% completion rate and 88% participation rate. SITT was a feasible approach for training segmental postural control and reaching behavior in children with CP GMFCS V. The improvements in postural control were associated with an improvement in manual dexterity, gross motor function, functional goal performance, and performance-related satisfaction. The gains in static control and COPM performance and satisfaction were retained at 3 months. These improvements were seen in the areas of body structure and function, and activity domains. Progress in motor performance in response to SITT was established at an individual level; however, more evidence is needed to establish the external validity of the approach.

The following work presents a novel, overground robotic gait trainer: the mobile Tethered Pelvic Assist Device, or mTPAD. The mTPAD is a parallel, cable-driven platform that can apply three-dimensional forces and moments to the user’s pelvis as they walk overground. These forces and moments applied to the pelvis can be timed to the user’s gait and motivated through gait deficits to target specific motions or gait adaptations. An overview of both traditional and robotic gait training is given as an introduction in Chapter 1. The state-of-the-art pelvic robotic gait trainers are discussed, and the need for an overground device that can apply timed forces and moments to the pelvis is highlighted. The design of the mTPAD is covered in Chapter 2. The mechanical structure and the novel controller are discussed and validated through experiments with human participants. The mTPAD device is evaluated on its transparency, accuracy of pelvic localization, and ability to apply specific forces. Chapter 3 illustrates a continuous moment that is applied to the pelvis and synchronized with the user’s gait cycle. The controller is evaluated on its accuracy and ability to alter pelvic kinematics and muscle activations in a group of neurotypical adults. Chapters 4 and 5 highlight the mTPAD’s ability to alter gait characteristics and muscle responses of two groups that exhibit gait deficits: stroke survivors and children with Cerebral Palsy. By evaluating the effects of different force and moment profiles on individuals who may benefit from gait training, this work aims to illustrate the mTPAD’s potential as an overground gait training tool.

The extent to which customers are satified with the care they receive from the health professionals has been an important area of interest for researchers, managers and health care workers. The physiotherapy cerebral palsy clinic at Mulago Hospital in Kampala Uganda provides physiotherapy services for parents/caregivers of children with cerebral palsy. The parents/caregivers visit the clinic seeking physiotherapy services that will address their problems and those of the child. The purpose of this study was to explore the satisfaction that the parents/caregivers of children with cerebral palsy get from utilising the physiotherapy services at the clinic and to identify the barriers/problems that they encounter that might affect their attendance.

The extent to which customers are satified with the care they receive from the health professionals has been an important area of interest for researchers, managers and health care workers. The physiotherapy cerebral palsy clinic at Mulago Hospital in Kampala Uganda provides physiotherapy services for parents/caregivers of children with cerebral palsy. The parents/caregivers visit the clinic seeking physiotherapy services that will address their problems and those of the child. The purpose of this study was to explore the satisfaction that the parents/caregivers of children with cerebral palsy get from utilising the physiotherapy services at the clinic and to identify the barriers/problems that they encounter that might affect their attendance.