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Early Intensive Leg Training to Enhance Walking in Children With Perinatal Stroke: Protocol for a Randomized
Caitlin Hurd1, Donna Livingstone1, Kelly Brunton1
1Department of Physical Therapy, University of Alberta.
Insights
Early, intensive activity may improve motor function in children with perinatal stroke. This child-initiated intervention shows promise for enhancing motor pathway connectivity and physical therapy approaches.
Area of Science:
- Neuroscience
- Pediatric Neurology
- Rehabilitation Medicine
Background:
- Motor pathway development is activity-dependent during critical periods.
- Perinatal stroke impairs motor function by damaging corticospinal tracts and reducing activity.
- Current interventions for lower limb hemiparesis are often passive.
Purpose of the Study:
- To evaluate intensive, early, child-initiated activity for enhancing motor pathway connectivity in perinatal stroke.
- To compare early vs. delayed intervention timing during the critical period.
- To assess differences in intervention delivery by therapists vs. parents.
Main Methods:
- Prospective, single-blind, randomized controlled trial (RCT) and parallel cohort study.
- Participants: Children aged 8 months to 3 years with MRI-confirmed perinatal ischemic stroke and hemiparesis.
- Intervention: 12 weeks of daily, intensive, play-based leg activity with weights.
Main Results:
- Primary outcome: Gross Motor Function Measure-66 score.
- Secondary outcomes: Gait analysis, step counts, motor evoked potentials, and reflexes.
- Intervention delivery and assessment were standardized to minimize bias.
Conclusions:
- Intensive, early, child-initiated activity may offer a novel approach to physical therapy for pediatric stroke.
- The findings suggest a potential shift from passive to active interventions.
- Further research can explore optimizing this intervention for improved motor outcomes.
Background:
Development of motor pathways is modulated by activity in these pathways, when they are maturing (ie, critical period). Perinatal stroke injures motor pathways, including the corticospinal tracts, reducing their activity and impairing motor function. Current intervention for the lower limb emphasizes passive approaches (stretching, braces, botulinum toxin injections). The study hypothesis was that intensive, early, child-initiated activity during the critical period will enhance connectivity of motor pathways to the legs and improve motor function.
Objective:
The study objective was to determine whether early intervention with intensive activity is better than standard care, intervention delivered during the proposed critical period is better than after, and the outcomes are different when the intervention is delivered by a physical therapist in an institution vs. a parent at home.
Design:
A prospective, delay-group, single-blind, randomized controlled trial (RCT) and a parallel, cohort study of children living beyond commuting distance and receiving an intervention delivered by their parent.
Setting:
The RCT intervention was provided in university laboratories, and parent training was provided in the childs home.
Participants:
Children 8 months to 3 years old with MRI-confirmed perinatal ischemic stroke and early signs of hemiparesis.
Intervention:
Intensive, play-based leg activity with weights for the affected leg and foot, 1 hour/day, 4 days/week for 12 weeks.
Measurements:
The primary outcome was the Gross Motor Function Measure-66 score. Secondary outcomes were motion analysis of walking, full-day step counts, motor evoked potentials from transcranial magnetic stimulation, and patellar tendon reflexes.
Limitations:
Inter-individual heterogeneity in the severity of the stroke and behavioral differences are substantial but measurable. Differences in intervention delivery and assessment scoring are minimized by standardization and training.
Conclusions:
The intervention, contrary to current practice, could change physical therapy interventions for children with perinatal stroke.
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