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CorticalControlofHandMovement:Impacton
ClinicalCareofPeoplewithCerebralPalsy
KathleenM.Friel,Ph.D.
CorticalControlofHandMovement• PrimarymethodsofevaluatingcorticalcontrolofhandmovementinpeoplewithCP– Singlepulsetranscranialmagneticstimulation(TMS)– Diffusiontensorimaging(DTI)
• Whocares?– Whatistheclinicalrelevanceofthisinformation?– Howdoescorticalwiringimpacthandfunction,responsivenesstotherapies?
• Howcanthisinformationbeassessedmeaningfullyintheclinic?
Hemiplegic(Unilateral)CerebralPalsy• Motordeficitsprimarilyononesideofthebody.
• Handfunctionismostimpactedimpairment.
• Aschildrenwithhemiplegiaage,theyoftenfailtodevelopgoodmotorskillsononesideofbody.
• Affectsabilitytoperformactivitiesofdailyliving.
CorticalControlofHandMovement• BestunderstoodinchildrenwithunilateralCP.• Moststudiedinolderchildren(age>6yr).
• Assessmentschallengingformoreseverelyimpairedchildrenandyoungerchildren.
• Muchworkstillneedstobedone:differenttypesofCP,differentpartsofbody,differentages(veryyoungchildren,adults,agerelatedchangesacrosslifespan).
MotorSystemDysfunctioninChildrenwithUnilateralCP
• Single-pulseTMStomapbraincircuits
• RepetitiveTMStochangeactivityofbraincircuits
Ingaetal.,2009 NIMH
Videosaresharedwithconsentofparticipants&theirfamilies.
TMSwithKids:ACollaborativeEffort!
• [VIDEO]
UsingTMStoStudyCPNeurophysiology• Howdoesmotorsystemdevelopafterperinatalbraininjury?
Staudt etal,2002
”Contralateral” ”Bilateral” ”Ipsilateral”
Ipsi,contra-->Samelatency
UsingTMStoStudyCPNeurophysiology• Howdoesmotorsystemdevelopafterperinatalbraininjury?
Staudt etal,2002
”Contralateral” ”Bilateral” ”Ipsilateral”
Ipsi,contra-->Samelatency
UsingTMStoStudyCPNeurophysiology• Howdoesmotorsystemdevelopafterperinatalbraininjury?
Staudt etal,2002
”Contralateral” ”Bilateral” ”Ipsilateral”
Ipsi,contra-->Samelatency
• HowdoesCSTpatternimpacthandfunction?”Contralateral” ”Bilateral” ”Ipsilateral”
Contralateral
Bilateral
Ipsilateral
0
500
1000
JTTH
F (S
EC)
Jebsen-TaylorTestofHandFunction:Timetakentocompletefinemotortasks(higherscore-->moreimpaired)
KidswithipsilateralCSThavepoorerhandfunctionthanothergroups(p<0.05).
~20%ofkids ~40%ofkids ~40%ofkids
UsingTMStoStudyCPNeurophysiology
c c Ipsilateralprojections:• Maladaptiveafterstrokeinadults.• Previouslyassumedtoonlycontrol
proximalgrossmovements.• Markerofpoorfunction/prognosis?
Contralateral
Bilateral
Ipsilateral
0
500
1000
JTTH
F (S
EC)
c
Highvariability:Why??
UsingTMStoStudyCPNeurophysiology
~40%ofkids
c cIpsilateralprojectionsinCP:• Possiblyadaptiveafterdevelopmental
braininjury.• Cancontrolfinemotor(digit/wrist)
movements.• Motormapsofbothhandssharethesame
corticalspace.• Inmanykids,themapsofthetwohands
arehighlyoverlapped.• Moreoverlapà betterhandfunction
(r=0.51,p<0.05).• “Adaptiveyoking”ofmotorcontrolofthe
twohands.
UsingTMStoStudyCPNeurophysiology
AlternativetoTMSfordeterminingCSTlaterality
• TMSequipmentisexpensive,contraindicatedforchildrenwhohaveseizuredisorders.
• DiffusionTensorImaging(DTI)canbeusedtovisualizebrainpathways.
DTI:AlternativetoTMSfordeterminingCSTlaterality
• CanbedoneonmostMRIscanners(~6min).
• IsaccuratesurrogatemeasureofCSTlaterality(Kuo etal.,2017).
Contralateral Bilateral Ipsilateral
MirrorMovements:AQuickClinicalAssessmentofCSTLateralty?
• EventhoughDTIismoreaccessibletomostkidsthanTMS,itstillrequiresanMRI,andinterpretationofscans.
• Mirrormovements(MMs)à whenchildmovesonehandvoluntarily,theotherhandinvoluntarilymirrorsthemovement.
• SevereMMsassociatedwithipsilateralCST.
• Mostkidshavemild/moderateMMs– unclearhowmildMMsrelatetoCSTlaterality.
Summary:NeurophysiologyinChildrenwithUnilateralCP
• ConnectionpatternofCSTisrelatedtoseverityofhandfunctiondeficits.
• SinglePulseTMSandDTIcanbeusedtoassessCSTlaterality.
• SeveremirrormovementsmaypointtoanipsilateralCST.
Activity-BasedTreatmentsforUnilateralCP
§ Unimanualtraining:slingover“good”arm,intensivetrainingofimpairedarm- game-playing,arts/crafts,practicingfunctionalmovements.(Gordonetal.)
§ Bimanualtraining:childrenusebothhandsintensively,efficacynotdifferentfromunimanualtraining,bettertranslatesintoimprovementoffunctionalgoals.(Hand-ArmBimanualArmTraining,HABIT)(Gordonetal.)
Unimanual Bimanual-100
-50
0
50
100
Therapy Type
Perc
ent I
mpr
ovem
ent
Affe
cted
Han
d Fu
nctio
n
High Variability in Treatment Response
High Variability in Treatment Response-
Why??
Affected Hand Affected Hand
§ Single pulse TMS -
determine corticospinal
tract (CST) organization
§ 90 hrs. of unimanual or
bimanual therapy
§ Goal: Determine if CST
organization relates to
improvements in
dexterity following
unimanual vs. bimanual
therapy
Contralateral Ipsilateral
High Variability in Treatment Response-
Why??
Affected Hand Affected Hand
§ Constraint therapy –
drives down activity in
the hemisphere
controlling the less-
affected arm.
§ If both hands are
controlled by the less-
affected hemisphere,
driving down activity
may not be best.
§ Bimanual therapy à“yoking” of both hands.
Contralateral Ipsilateral
§ Children with contralateral CST improve more
than children with ipsilateral CST in CIMT
(unimanual therapy)
§ Children with ipsilateral and contralateral improve
equally in HABIT (bimanual therapy)
§ Understanding an individual’s brain
wiring can help prescribe the most
effective therapy.
UpperLimbRehabinPeopleWithCP:LessonsandFuture
• TMSandDTIeffectivetoolsformeasuringCSTlaterality.
• CSTlateralityaffectshandfunction:– ContralateralCSTassociatedwithbetterhandfunction.
– IpsilateralCSTassociatedwithpoorerhandfunction.• CSTlateralityappearstoimpactefficacyofintensivehandtherapy:– CIMTbestforkidswithcontralateralCS.
• Muchisstillunknown!
EarlyBrainInjuryRecoveryProgram
Funding: NINDS,NICHD,BurkeFoundation,CarvelFoundation,Blythedale Children’sHospital
LabMembers:TalitaCamposKarenChin,MSClaudioFerre,PhDDisha Gupta,PhD
Collaborators:AndyGordon,PhDMarom Bikson,PhDDylanEdwards,PTPhDYannickBleyenheuft,PhDJasonCarmel,MDPhDSusanDuff,EdD PTOT/RCHTBernadetteGillick,PhDPT
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