Igniting Mobility in Adolescents and Young Adults With Cerebral Palsy

Study Overview
=================
Brief Summary
-----------------
The study design will consist of a cohort of adolescents and young adults with cerebral palsy (CP) that will undergo a gait training protocol. All participants will complete MEG or EEG baseline brain imaging measures of their sensorimotor cortical activity, MRI brain/spinal cord imaging (previous MRI or template brain may be substituted), neurophysiological tests of the spinal cord H-reflex, and a series of mobility clinical tests and cognitive tests. Participants with metal in their body that would interfere with the MEG (e.g., braces on teeth, permanent retainer) will not undergo the MEG tests but will undergo the EEG assessments. Those who complete the MEG assessments will not undergo the EEG assessments. After completing the baseline tests, the participants with CP will undergo the therapeutic gait training. After completing all of the therapeutic gait training sessions, the participants with CP will repeat the same assessments that were completed at baseline. Separately, a cohort of neurotypical adolescents and young adults will also complete the baseline assessments. The neurotypical participants will not undergo the therapeutic gait training, but will be used as a normative group for interpreting if the changes seen in the participants with CP after therapy are in fact moving the system toward a normative state.

Detailed Description
-----------------
Cerebral palsy (CP) results from a perinatal brain injury and is one of the most prevalent and costly pediatric neurologic conditions in the United States that often results in mobility deficits. The investigator's extensive experimental work has been focused on developing a therapeutic gait training protocol that will improve the long-term mobility of adolescents and young adults with CP. Despite the major breakthroughs, it is apparent across the investigations that some patients have vast improvements in their mobility after treatment, while others are clearly non-responders. This response variability represents one of the major Gordian knots in the treatment outcomes seen in adolescents and young adults with CP. The investigator will address this knowledge gap with a multimodal approach that blends the investigator's expertise in MEG/EEG brain imaging, MRI spinal cord imaging, and assessments of the spinal cord interneuronal circuitry to probe the neurophysiological differences in participants that are classified as responders and non-responders after therapeutic gait training. The Specific Aims of this study will: (1) identify if responders and non-responders have differences in the strength of the sensorimotor cortical oscillations involved in the planning and execution of a leg motor action, (2) determine if responders and non-responders have differences in the neural synchrony within the somatosensory cortices, following stimulation of the foot mechanoreceptors, and (3) decipher if responders and non-responders have differences in the spinal cord microstructure and circuitry dynamics. (4) Secondary aim: assess cognitive related changes induced via physical therapy. Briefly, the study design consists of a cohort of adolescents and young adults with CP that will initially undergo MEG/EEG brain imaging, MRI spinal cord imaging, neurophysiological tests of the spinal cord interneuronal circuitry, cognitive testing, and clinical mobility assessments. After completing the baseline tests, the participants will undergo the therapeutic gait training protocol. Upon completion of the treatment program, the participants will repeat the same assessments that were completed at baseline. Separation of the participants into responders and non-responders to treatment will be based on the criteria for a clinically relevant change in the 10-meter walking speed test. The new data derived from this project will provide unparalleled insight on the potential neurophysiological origins of the diverse mobility outcomes seen in adolescents and young adults with CP after treatment. Finally, an additional cohort of neurotypical adolescents and young adults of similar age and sex will also complete the mobility, MEG/EEG, spinal cord imaging, and Hoffmann reflex protocols for comparative purposes.

Official Title
-----------------
Igniting Mobility in Adolescents and Young Adults With Cerebral Palsy

Conditions
-----------------
Cerebral Palsy

Intervention / Treatment
-----------------
* Behavioral: Gait Therapy


Participation Criteria
=================
Eligibility Criteria
-----------------
Inclusion Criteria: For Cerebral Palsy participants: Cerebral Palsy diagnosis For Non-Cerebral Palsy Controls: No known atypical neurodevelopment (e.g autism, Down Syndrome, ADHD, etc.) Exclusion Criteria: No orthopedic surgery in the last 6 months or metal in their body that would preclude the use of an MRI.

Ages Eligible for Study
-----------------
Minimum Age: 13 Years
Maximum Age: 18 Years

Sexes Eligible for Study
-----------------
All

Accepts Healthy Volunteers
-----------------
Accepts Healthy Volunteers

Study Plan
=================
How is the study designed?
-----------------

Design Details

Primary Purpose: Treatment
Intervention Model: Parallel Assignment
Interventional Model Description: Cerebral Palsy participants will undergo baseline mobility/brain imaging/cognitive testing, receive gait therapy, and then repeat mobility/brain imaging testing. Non-Cerebral Palsy controls will undergo the same baseline testing once as a reference group to determine a normative state for mobility. No gait therapy will be conducted.
Masking: Single


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| No Intervention: Neurotypical Youth/Young Adults<br>No intervention administered. The controls will only undergo initial baseline assessments. | |
| Experimental: Cerebral Palsy Youth/Young Adults<br>Baseline and 8 week assessments; 8 week gait therapy | Behavioral: Gait Therapy<br>* The therapeutic gait training protocol will consist of 24-treatment sessions that will be performed 3 times-a-week for an 8-week period. All therapeutic exercises will be performed under the direction of a licensed pediatric physical therapist. Any sessions missed will be added on to the 8-week period. Each intervention session will consist of over-ground gait activities that will be completed in a 60 minute session with rests as needed. The key ingredients of the therapy will include: 1) activities of adequate intensity that promote gait adaptation and gait speed sustainment, 2) exploratory activities that enhance the somatosensory experience through rich/novel movement, and 3) optimally challenging activities that emphasize planning and problem solving that requires altering the leg kinematics to meet the environmental and task constraints.<br>|

What is the study measuring?
-----------------
Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Change in Mobility Test Time | The participant will be asked to perform a series of timed (in seconds) 10-meter walking tasks. | Baseline (CP and Neurotypical) and 8 weeks (CP) | 
| Change in Time for Community Ambulation | The participants will walk along a 400 meter course laid out on the Boys Town campus that incorporates uphill/downhill grades, stairs, curbs, grass and uneven surfaces. The time (in seconds) to complete the course will be used as an outcome variable. | Baseline (CP and Neurotypical) and 8 weeks (CP) | 
| Change in Time for Timed Up and Go | The participant will start the test by sitting on a bench. The time (in seconds) it takes the participant to stand-up, walk to a line on the floor that is 3-meters away and return back to sitting on the bench will be the outcome measure. | Baseline (CP and Neurotypical) and 8 weeks (CP) | 
| Change in Selective Control Assessment of the Lower Extremity | This is a clinical assessment where the participant is asked to isolate and move the lower extremity joints. The examiner grades the amount of movement and the ability of the participant to isolate the control. A grade of 0 indicates the participant cannot move the joint, 1 indicates the participant can move the joint but it is impaired, and 2 indicates normal movement of the joint. | Baseline (CP and Neurotypical) and 8 weeks (CP) | 
| Change in Level of Spasticity | Modified Ashworth: This is a clinical assessment where the therapist passively moves the participant's joints and rates the level of spasticity. Scores range from 0-5, where 0 indicates no tone, 5 indicates rigidity. | Baseline (CP and Neurotypical) and 8 weeks (CP) | 
| Change in Isolation of Movement | This is a clinical assessment where the participant is asked to isolate and move the lower extremity joints. The examiner grades the amount of movement and the ability of the participant to isolate the control. A grade of 0 indicates the participant cannot move the joint, 1 indicates the participant can move the joint but it is impaired, and 2 indicates normal movement of the joint. | Baseline (CP and Neurotypical) and 8 weeks (CP) | 
| Change in Brain Activity in Sensory Cortices | Magnetoencephalogram (MEG) or electroencephalogram (EEG) scan: The frequency bands of interest include theta (4-8 Hz), alpha (8-12 Hz), beta(15-30 Hz) and gamma (>30 Hz). | Baseline (CP and Neurotypical) and 8 weeks (CP) | 
| Change in Motor Response | Percutaneous electrical stimulations of the femoral nerve applied via an anode that is positioned on the patella and a cathode that is positioned on the popliteal fossa will be applied to the right leg. A wireless surface EMG sensor positioned on the soleus will measure the motor response. The muscular (M-wave) will be assessed while resting and walking. | Baseline (CP and Neurotypical) and 8 weeks (CP) | 
| Change in Hoffmann Reflex | Percutaneous electrical stimulations of the femoral nerve applied via an anode that is positioned on the patella and a cathode that is positioned on the popliteal fossa will be applied to the right leg. A wireless surface EMG sensor positioned on the soleus will measure the Hoffmann reflex. The spinal reflexes (H-wave) will be assessed while resting and walking. | Baseline (CP and Neurotypical) and 8 weeks (CP) | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Cognitive related changes induced via physical therapy -Wide Range Assessment of Memory and Learning (WRAML) | Subtests: Finger Windows, Picture Memory, Symbolic Working Memory: A standardized test that measures memory functioning, evaluating both immediate and delayed memory ability in addition to the acquisition of new learning. Viable for young children and adults. | Baseline (CP and Neurotypical) and 8 weeks (CP) | 
| Cognitive related changes induced via physical therapy - D2 - Test of Attention | A neuropsychological measure of selective and sustained attention in addition to visual scanning speed. Participants are tasked with crossing out any letter d with two marks around above it or below it in any order, in a mix of other letters and with various numbers of marks around them. Viable for young children and adults. | Baseline (CP and Neurotypical) and 8 weeks (CP) | 
| Cognitive related changes induced via physical therapy - Trail Making A+B | A neuropsychological test of visual attention and task switching. The subject is tasked to connect a set of numbered 25 dots as quickly as possible while still maintaining accuracy, with the second test increasing in cognitive load by introducing letters as well. Viable for young children and adults. | Baseline (CP and Neurotypical) and 8 weeks (CP) | 
| Cognitive related changes induced via physical therapy - WAIS-IV Digit Span - Youth + Adult | A subtest of the Wechsler Memory Scales (WMS), subjects are read a sequence of numbers and asked to repeat the same sequence back to the examiner in order (forward span) or in reverse order (backward span) to measure short term memory capacity in young children and adults. | Baseline (CP and Neurotypical) and 8 weeks (CP) | 
| Cognitive related changes induced via physical therapy - Stroop Test - Youth + Adult | A neuropsychological test that assesses the ability to inhibit cognitive interference during the processing of a specific stimulus feature impedes the simultaneous processing of a second stimulus attribute (the Stroop Effect). The Stroop Effect is the delay in reaction time between congruent and incongruent stimuli, Such that a mismatch between the name of a color (e.g., blue, green, or red) and the color it is printed on (i.e., the word red printed in blue ink instead of red ink). | Baseline (CP and Neurotypical) and 8 weeks (CP) | 
| Cognitive related changes induced via physical therapy - Caregiver Priorities & Child Health Index of Life with Disabilities (CPCHILD) Questionnaire | Children with severe developmental disabilities are often dependent on parents/caregivers for much of their daily needs. These children often have multiple co-morbid conditions which can have a significant impact on their overall health and quality of life. Interventions are aimed at preserving or improving their health, comfort and quality of life and to facilitate caregiving. CP CHILD is an instrument that aims to measure these phenomena. Respondents rate a number of areas including the difficulty of activities for their child (Scale ranging from 0-Not Possible to 6-No problem at all) and choose the level of assistance needed to perform these activities (Scale ranging from 0-Total to 3-Independent), how often their child experience pain or discomfort (Scale ranging from 0-Every day to 5-None of the time) and intensity (0-Severe to 3-None), importance of items in child's quality of life (0-Least Important to 5-Most Important), and overall health of child (0-Very Poor to 5-Excellent). | Baseline (CP) and 8 weeks (CP) | 
| Cognitive related changes induced via physical therapy - Silver Linings Questionnaire - Adapted for CP | A survey measure that examines the extent to which people believe their illness - in this case the questionnaire has been adapted to individuals with CP, has had a positive benefit despite the negative consequences of having CP. Participants indicate the extent to which they agree or disagree with each statement by circling a number between 5 strongly agree and 1 strongly disagree | Baseline (CP) and 8 weeks (CP) | 
| Cognitive related changes induced via physical therapy - Child and Adolescent Sleep Checklist (CASC) | Tool designed to identify sleep habits and to make a screening of sleep problems among preschoolers, elementary school children, and high school students. | Baseline (CP and Neurotypical) and 8 weeks (CP) | 
| Cognitive related changes induced via physical therapy - PEDS QL Fatigue Questionnaire (Acute) | The PedsQL Multidimensional Fatigue Scale is a symptom-specific instrument to measure fatigue across pediatric populations. It measures cognitive fatigue which focuses on problems with memory and attention, areas known to be affected in children with CP, on a scale ranging from 0-if it is never a problem and 4-if it is almost always a problem. | Baseline (CP and Neurotypical) and 8 weeks (CP) | 
| Cognitive related changes induced via physical therapy - Pittsburgh Sleep Quality Index (PSQI) | An effective instrument used to measure the quality and patterns of sleep in adults. | Baseline (CP and Neurotypical) and 8 weeks (CP) | 
| Cognitive related changes induced via physical therapy - MacArthur Scale of Subjective Social Status Youth + Adult | Adult Version: This tool for adults, uses a pictorial representation of a symbolic ladder, developed to capture the common sense of social status based on usual socioeconomic status indicators. It has the additional advantage to allow comparisons between studies conducted in different populations. Youth Version: This tool is a two-item instrument that measures a how a young person perceives their family's and their own social standing The symbolic ladder has 10 rungs. The higher the rung, the higher the perceived social status. | Baseline (CP and Neurotypical) and 8 weeks (CP) | 

 Terms related to the study
=================
Keywords Provided by Centre Hospitalier Valida
-----------------
Cerebral Palsy, Gait therapy, Mobility