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ORIGINAL ARTICLE
Year : 2009  |  Volume : 57  |  Issue : 4  |  Page : 411--417

Interhemispheric interaction in the motor domain in children with cerebral palsy

Nadezhda V Zaytseva1, M Sami Walid2, Elena M Berdichevskaia3,  
1 Department of Physical Education, Kuban State Medical University, Krasnodar, Russia
2 Georgia NeuroCenter, Medical Center of Central Georgia, Macon, GA, USA
3 Department of Physiology, Kuban State University of Physical Education, Sport and Tourism, Krasnodar, Russia

Correspondence Address:
Nadezhda V Zaytseva
Kuban State Medical University, 4 Sedina Street, Krasnodar - 350 063
Russia

Abstract

Background : The attention of pediatric specialists has been continuously attracted to the problem of cerebral palsy (CP) and the formation of behavioral and motor skills in the initial years of life in these patients. This work aimed at studying the specifics of intra- and interhemispheric connections in the motor domain in children with CP as well as their dynamics in the process of rehabilitation using hand/finger synkineses and and lateral profile as markers. Materials and Methods : A total of 215 children aged 4-7 years were recruited after obtaining their parents«SQ» consent, including 95 patients with the most prevalent forms of CP (spastic diplegia, hemiparetic form) who underwent complex treatment in a neuropsychological sanatorium and 120 healthy children from a kindergarten. Data were analyzed using nonparametric methods and the chi-square test with the help of the statistical program SPSS v.14. Results : Changes in the scores and types of synkinesis after rehabilitation indicated that in spastic diplegia the assumed symmetric brain defects were associated with uniform restoration of interhemispheric connections and less disturbance of intrahemispheric connections. In hemiplegia, on the contrary, misbalance in intrahemispheric connections prevailed and compensation was noticed only in left-hemispheric pathology. The magnitude, type, and improvement of hand synkineses in the course of treatment depended on the lateral phenotype. Conclusion : Hand/finger synkineses in CP children change with rehabilitation. The methods used in the study can be recommended for application in the system of medico-biological and psycho-pedagogical monitoring of children with CP.



How to cite this article:
Zaytseva NV, Walid M S, Berdichevskaia EM. Interhemispheric interaction in the motor domain in children with cerebral palsy.Neurol India 2009;57:411-417


How to cite this URL:
Zaytseva NV, Walid M S, Berdichevskaia EM. Interhemispheric interaction in the motor domain in children with cerebral palsy. Neurol India [serial online] 2009 [cited 2020 Feb 28 ];57:411-417
Available from: http://www.neurologyindia.com/text.asp?2009/57/4/411/55608


Full Text

 Introduction



The last two decades has witnessed numerous publications addressing the characteristics of coordinated activity of brain hemispheres in the course of development of human organism (ontogenesis). [1],[2],[3],[4],[5],[6] However, the mechanisms of hemispheric interaction when performing different motor activities and the role of functional asymmetry of the brain in the early stages of ontogenesis remains inadequately investigated. [7],[8] Finding answers to this question will allow viewing from new positions the central adaptational mechanisms during the growth process of children with neurological pathology. For that, physiologists and symmetry researchers have been studying the asymmetric motor problems characteristic of children's cerebral palsy (CP), [9],[10],[11] a pathology that has increased in Russia after the fall of the Soviet Union to over 3 per 1,000 births. [12] Since the basis of behavioral and motor skills form mainly in the first years of life, the analysis of particulars of interhemispheric interaction is very important in outlining a rehabilitation plan for this category of patients. [13],[14],[15] Different methods have been reported useful in investigating patterns of functional recovery, mirror movements and interlimb coordination in children with cerebral palsy, from repetitive manual squeezing tasks (grip assessment) to video recording to transcranial magnetic stimulation and motor evoked potentials. [16],[17],[18] Studying hand and finger synkineses (the involuntary movements that accompany intentional movements) has also been reported as a simple method in the methodological analysis of intra- and interhemispheric interaction in the motor sphere in normal and children with neurological pathology. [19],[20],[21] Synkineses are considered a secondary manifestation of intra- and interhemispheric interaction in the functional organization of the motor act. [7],[19],[22] This work aimed at studying the specifics of intra- and interhemispheric connections in the motor domain in children with CP as well as the dynamics of synkinetic disturbances in the process of rehabilitation.

 Materials and Methods



After obtaining the approval of the scientific Council of Kuban State University of Physical Education, Sport and Tourism, we recruited 215 children, aged between four and seven years, whose parents gave permission to include in the study. Among these children, 95 patients had the most common forms of CP of mild-to-moderate severity: Spastic diplegia (n=40), right hemiparesis/plegia (n=30) and left hemiparesis/plegia (n=25), who passed three and a half months of comprehensive treatment at Krasnodar Regional Neuropsychological Sanatorium «Solnitshko», and 120 healthy children from Kindergarten ¹ 101, an ordinary nursery school in Krasnodar. The study took place in 2003 and consisted of two evaluations of the children: in the first 2-3 weeks of arrival in the sanatorium and two weeks before leaving the sanatorium.

In Russia, the widely used classification of CP forms suggested by Semenova (1999) takes into consideration the maturity of the motor, intellectual, psychological, emotional and speech aspects of the child.[23] According to this classification, the following forms can be distinguished: Spastic forms (60%), [24] including dual (spastic) hemiplegia, in which the functions of upper and lower extremities are disturbed to equal degrees or the upper extremities suffer mainly from markedly tonic reflexes and muscle rigidity, and spastic diplegia (little syndrome) in which the lower extremities are most affected. The hyperkinetic form is characterized by the presence of involuntary uncontrolled movements in the form of chorea (quick movements vaguely comparable to dancing) or athetosis (slow writhing movements) or cheaoathetosis (combination of both). The atonic-astatic form is distinguished by wide-range movements of the extremities with problems in balance and possible hand tremor. In the hemiparetic/plegic form (15%), [25] there is severe disturbance in the basic functions of one upper and one lower extremity on the same side. In all the abovementioned forms of CP three degrees of severity can be noticed: Mild when the physical defect allows ambulation and self-care but causes clumsiness of movements, moderate when patients need some help from surrounding people in walking and self-service, and a severe form when children can not walk independently. In Russia, physicians dealing with CP patients often combine the first and second degrees of severity together and write the diagnosis as "CP of mild-to-moderate severity." This corresponds to levels 1-3 of the Gross Motor Function Classification System for CP. [26]

The complex treatment of children with CP in the neuropsychological sanatorium was individualized and dependent on age, form and severity of the disease. It included medical treatment, orthopedic regime, gradual splinting, acupuncture, physiotherapy, massage (classical therapeutic, segmental, punctual, sedative and tonic), logopedic and physical education exercises. Special attention was paid to physical exercises in the reflex-loading apparatus Gravistat (Cosmic Costume) designed by the constructors of the scientific research center Ogonek ( www.ogonek.org ) in Moscow for the rehabilitation of children with CP. Exercises using hand finger synkineses were conducted individually under the supervision of a qualified instructor. The structure of the costume allows the calculation and distribution of load which can be directed along the longitudinal axis of the body. It was specifically designed for the application of the dynamic propioceptive correction method described later in the works of Semenova (1999) in which steady suppression of tonic reflexes and restoration of adjusting reflexes take place during exercises with functional correction of the pathologic posture. [23]

For the assessment of the functional mechanisms of intra-and interhemispheric interaction in the organization of motor activity we used the hand/finger synkinesis probe [Figure 1]. [19],[20],[21],[22],[27] Results were assessed on a scale from 1 to 5, as suggested by Zeigarnik (1987).[27] Thus, the more optimal interhemispheric connections worked the less synkineses were manifested, and the higher the score was. Bilateral synkineses of fingers, performed separately or simultaneously in both hands by different fingers (asynchronous, crossed) were scored as one; synchronous, crossed synkineses as two; unilateral, consistent synkineses as three; unilateral occasional synkineses as four; and absence of synkinesis as five [Figure 2]. Crossed synkineses reflected the function of interhemispheric connections, while the remaining variants intrahemispheric connections. [7]

The Individual Profile of Asymmetry (IPA), or the Lateral Phenotype, was determined using the method of Bragina and Dobrokhotova (1988), which we modified to fit the specifics of perception in preschool children. [28] It consists of 25 tests that check preferences in vision, hearing and motor activity of the upper and lower extremities. The asymmetry coefficient is calculated using the same author's formula: CoefAsym5100*(TR-TL/TR1TL1TO), where CoefAsym is the Coefficient of Asymmetry, TR is the number of tests of a paired organ with right dominance; TL is the number of tests with left dominance; and TO is the number of tests with no dominance. When CoefAsym is > +15% the right dominates, when CoefAsym isThe average synkinesis scores and types of synkineses in normal and CP children and changes from baseline due to rehabilitation;Changes from baseline in the average score and types of synkineses in normal and CP children with different lateral phenotypes due to rehabilitation.

Experimental data were processed using non-parametric methods (the Wilcoxon-Mann-Whitney test) and the chi-square test for categorical variables with the help of the statistical program SPSS v.14. The arithmetic average (m), standard deviation (± σ), and significance value (P) were calculated.

 Results and Discussion



Before rehabilitation, children with spastic diplegia had the lowest average score of synkineses, 1.3 vs. 3.6 for healthy children. In the hemiparetic form, it was significantly higher than in spastic diplegia (0.05), 2.0 and 2.2 for left or right brain hemisphere pathology (corresponding to right and left hemiparesis), respectively [Figure 3].

After treatment, the amount of synkineses decreased in spastic diplegia by 38% and in right hemiparesis by 35% ( [29],[30] On the contrary, in hemiparesis, [25],[31],[32] with the lesion mainly cortical in one hemisphere, misbalance in intrahemispheric connections predominates and compensation is noted only in left-hemispheric pathology. In our study, the magnitude, character, and positive changes in synkineses in the course of treatment depended on the lateral phenotype of the ill child. Moreover, it was characteristic for every form of CP to impact IPA and the dynamics of rehabilitation. In «absolute» rightist children with spastic diplegia the number of synkineses was less before the beginning of treatment; therefore, the end result of treatment concerning the positive dynamics of synkineses reflecting interhemispheric connections was better than in «partial» leftists despite the smaller ranges of restoration of impaired interhemispheric connections. In «absolute» leftists with right hemiparesis, a better picture of the character of synkineses before the beginning of treatment and their positive dynamics in the process of rehabilitation was noted, in comparison with «partial» leftists, despite the less scopes of restoration of impaired intercentral relationships.

On the basis of the results above, a conclusion can be made that hand and finger synkinesis tests can be added to the grip assessment test when evaluating the disability of CP-affected hands during their functional recovery. Methods for elucidation of pathologic synkineses, including those described in this paper for investigating motor function in children with CP, can also be recommended for application in the system of medico-biological and psycho-pedagogical monitoring. They represent objective criteria for evaluating tempos of maturation of the central nervous system in healthy children and adaptive-compensatory transformations in the presence of neurological pathology. In the presence of motor and, especially, crossed synkineses, we need to pay attention to the value of performing additional therapeutic measures aiming at improving manual coordination and the activation of recuperation of functional capacities in the course of rehabilitation of patients with CP.

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