Kinematic effects of sensorimotor timing training in children with diplegic cerebral palsy

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Introduction and aim: The objective of the present study was to explore the individual effects of sensorimotor timing training with the Interactive Metronome© (IM) in young individuals with spastic diplegic cerebral palsy (DCP). IM is a multi-modal integration training method where the goal is to synchronize rhythmic movement activation with a beat. To this end, error feedback is provided via auditory and visual cues. One previous case study has shown positive effects on upper-limb kinematics of IM training in children with hemiplegic CP [1]. However, there is a need for extended scientific evaluation of the effects of existing training methods for children with CP of various types and severity. In the present study 3D movement registration technique was used to objectively evaluate training effects on goal-directed upper-limb movements. Patients/materials andmethods: Participants comprised three children with spastic DCP (two boys; one girl, age range: 12–16 years). The score on the Manual Ability Classification System was II, IV, and III and the Gross Motor Function Classification System score was III, IV, and IV for cases I–III, respectively. The spasticity severely affected arm function in cases II and III. All cases were diagnosed with intellectual disability and other comorbidities were diagnoses of autism, epilepsy, cortical visual impairment, strabismus, dysarthria, asthma and scoliosis. IM training consisted of a four week (12 sessions) individually customised program including bilateral and unilateral movements of the arms and hands. To establish shortand long-term effects, goaldirected upper-limb movements were examined by the use of a 6-camera optoelectronic recording system (240Hz, ProReflex, Qualisys Inc.) at three time points, before and at two following occasions after the IM training (post-test I, one week after completed training; post-test II, six months after post-test I). The goal-directed evaluation task consisted of pushing three buttons in a sequential order in four different directions (extension–flexion; flexion–extension; adduction–abduction; abduction–adduction). The following parameters were derived from the wrist marker; movement duration (time needed to complete the task), segmentation of the movement trajectory (number of movement units), and 3D distance. Results: The intraas well as the inter-individual variability of IM effects were large. Case I showed some improvement in timing ability with auditory error feedback at post-test I as measured by the IM equipment. Self-phased timing was not improved. Cases II and III showed no apparent improvement in timing ability. For case I, the 3D analyses of the movement trajectories during the evaluation task, showed great inconsistency with no systematic improvements at both post-test occasions. However, Case II and III improved significantly as characterized by decreased duration at post-test I. This improvement remained at post-test II. Further, the segmentations of the wrist movement trajectory in terms of the number of movement units significantly decreased at post-test I. This finding was also stable at post-test II. Few changes were detected on the 3D distance for either case. Discussion and conclusions: No substantial improvement was shown on timing ability for any of the cases, possibly due to task constraints inflicted by the severity of the CP in these children. However, the training did result in faster and smoother movements for cases II and III. The effect appeared to mainly affect temporal aspects and remained at six month follow up. For these cases, the results suggest improved motor planning and control of goal-directed upper-limb actions. Case I showed no improvements, possibly due to the complexity of comorbidity including diagnoses of autism and intellectual disability. Thus, IM appears to be a feasible and promising method to improve movement control in some children diagnosed with severe types of CP. However, future studies should include outcomemeasures pertaining to attention as the IM encompasses high attentional demand.