**Neuromusculoskeletal Rehabilitation of Severe Cerebral Palsy**

[16] Stillwell, F.S. (1927). The correlation of malocclusion and scoliosis to posture and its

[17] D´Attilio, M., Filippi, M.R., Femminella, B., Festa, F., Tecco, S. (2005). The influence of an experimentally-induced malocclusion on vertebral alignment in rats: a controlled

[18] Pećina, M., Lulić-Dukić, O., Pećina-Hrncević, A. (1991). Hereditary orthodontic

[19] Saccucci, M., Tettamanti, L., Mummolo, S., Polimeni, A., Festa, F., Tecco, S. (2011).

[20] Rock, W.P., Baker, R. (1972). The effect of the Milwaukee brace upon dentofacial

[21] Hitchcock, H.P. (1969). Treatment of a malocclusion associated with scoliosis. *The Angle*

[22] Manzano, F.S., Granero, L.M., Masiero, D., dos, Maria, TB. (2004). Treatment of muscle spasticity in patients with cerebral palsy using BTX-A: a pilot study. *Special Care in*

anomalies and idiopathic scoliosis. *International Orthopedics*, 15(1), 57–59.

Scoliosis and dental occlusion: a review of the literature. *Scoliosis*, 6, 15.

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140 Cerebral Palsy - Current Steps

*Orthodontist*, 39(1), 64–68.

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growth. *The Angle Orthodontist*, 42(2), 96–102.

## Deepak Sharan, Joshua Samuel Rajkumar, Rajarajeshwari Balakrishnan and Amruta Kulkarni

Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/64642

#### **Abstract**

Persons with Gross Motor Function Classification System (GMFCS) levels IV and V are considered as severe cerebral palsy (CP) and are non-ambulatory. These persons are at a higher risk of complications such as hip displacement (sub-luxation or dislocation), spinopelvic deformities, musculoskeletal pain, low bone mineral density and low energy fracture. The recommended management strategy at present for this group is wheelchairaided mobility, with which none of these complications can be prevented. There is a strong need to evaluate alternative methods of treatment that can allow assisted ambulation in persons with severe CP. The role of Single Event Multilevel Lever Arm Restoration and AntiSpasticity Surgery (SEMLARASS) and protocol-based active rehabilitation on gross motor function and ambulation of non-ambulatory persons with CP at GMFCS levels IV and V is examined. Active rehabilitation involves making the person with severe CP active through most of the waking hours and participating actively in the rehabilitation. A wellplanned and executed SEMLARASS, followed by intensive, protocol-based, sequenced multidisciplinary active rehabilitation, provides the persons with GMFCS levels IV and V a significant functional improvement in gross motor function and mobility.

**Keywords:** cerebral palsy, neuromusculoskeletal rehabilitation, SEMLARASS, active rehabilitation, GMFCS

## **1. Introduction**

Cerebral palsy (CP) is a non-progressive disorder affecting the individual's posture, move‐ ment, and causing limitation in the activities that are permanent, caused due to damage in developing brain of neonates or infants. CP causes not only motor disturbances, but also sensory,

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cognitive, social, behaviour, speech and communication, seizure disorder, respiratory illness and other musculoskeletal disorders [1]. A total of 17 million persons are estimated to have CP worldwide and CP is one of the most common causes of physical disability among children. The prevalence of CP is currently estimated to be 2.11/1000 live births [2] and varies between 1 and 5/1000 live births in different countries. 28% of persons with CP have epilepsy, 58% have difficulties with communication, 42% have visual problems and 23–56% have learning disabilities [3].

Clinicians classify patients with CP to describe the specific problem, to predict prognosis and to guide treatment. Classification is based on the change in muscle tone, anatomical region of involvement and severity of the problem. Types of CP according to muscle tone are spastic (hemiplegia, diplegia and quadriplegia based on anatomical region of involvement), ataxic and dyskinetic (dystonia and choreoathetosis). Even though these terms do not have specific reliability among the observers, these terms are helpful for understanding the CP condition [4]. Gross Motor Function Classification System (GMFCS) is another system to classify gross motor function of children and youths with CP on the basis of their self-initiated movement with particular emphasis on sitting, walking and wheeled mobility. Children and youths with GMFCS levels IV and V are non-ambulatory and are considered as severe CP. Persons in GMFCS level IV use wheelchair, either manual or automatic, for transportation and persons in GMFCS level V are highly dependent because of the lack of balance in head, neck and trunk, and will require major assistive devices for physical assistance [5].

According to data from North India, 69% of persons with CP had spastic quadriplegia or dyskinetic CP and were non-ambulatory [6]. These persons are at a higher risk of developing complications such as hip displacement (sub-luxation or dislocation), spinopelvic deformities, musculoskeletal pain, low bone mineral density and low energy fracture. The most common and serious structural change in persons who have severe CP is hip displacement. This deformity is seldom present at birth but develops as the child grows older and experiences abnormal muscle pull from spastic muscles, increased femoral anteversion and the lack of weight bearing on the lower extremities. The reported rates of hip displacement in persons with CP vary from 1 to 75% [7]. The incidence of hip displacement in CP is related to the severity of involvement, varying from 1% in children with spastic hemiplegia up to 75% in those with spastic quadriplegia [8]. In two population studies, the rate of hip displacement was found to be one-third and was not related to the movement disorder but was directly related to gross motor function as determined by the GMFCS [9, 10].

The prevalence of hip pain in severe CP is reported to be 47.2% [11]. The common type of pain identified was provoked pain (e.g. during mobilisation, palpation and weight bearing on the lower extremities). A study of 2777 children (57% boys) at a median age of 7 years reported 32.4% children in pain, with significantly more girls than boys experiencing pain, and significantly more children at GMFCS levels III and V than GMFCS level I. The frequency of pain increased with age. Pain in the abdomen and hips was most frequent at GMFCS V, whereas knee pain was most frequent at level III and foot pain at level I [12].

Markedly low bone mass in children and adults with severe CP has been reported to place these persons at the risk of osteopenia, osteoporosis and low-energy fracture [13].

Increasing problems with reduced mobility lead to problems with daily activities especially in instrumental activities of daily living (IADL). Social participation, sexual relationships, employment and leisure activities are restricted among many youths and young adults with severe CP [14–18]. Severities of physical and/or cognitive impairment are predictors for limited participation, but limited participation is not necessarily synonymous with a poorer quality of life [14, 19, 20]. Some studies also show that pain, falling stamina and functional deterioration have a negative impact on the quality of life.

Several potential benefits exist for making a person with severe CP ambulate in a therapeutic setting:


cognitive, social, behaviour, speech and communication, seizure disorder, respiratory illness and other musculoskeletal disorders [1]. A total of 17 million persons are estimated to have CP worldwide and CP is one of the most common causes of physical disability among children. The prevalence of CP is currently estimated to be 2.11/1000 live births [2] and varies between 1 and 5/1000 live births in different countries. 28% of persons with CP have epilepsy, 58% have difficulties with communication, 42% have visual problems and 23–56% have learning

Clinicians classify patients with CP to describe the specific problem, to predict prognosis and to guide treatment. Classification is based on the change in muscle tone, anatomical region of involvement and severity of the problem. Types of CP according to muscle tone are spastic (hemiplegia, diplegia and quadriplegia based on anatomical region of involvement), ataxic and dyskinetic (dystonia and choreoathetosis). Even though these terms do not have specific reliability among the observers, these terms are helpful for understanding the CP condition [4]. Gross Motor Function Classification System (GMFCS) is another system to classify gross motor function of children and youths with CP on the basis of their self-initiated movement with particular emphasis on sitting, walking and wheeled mobility. Children and youths with GMFCS levels IV and V are non-ambulatory and are considered as severe CP. Persons in GMFCS level IV use wheelchair, either manual or automatic, for transportation and persons in GMFCS level V are highly dependent because of the lack of balance in head, neck and trunk,

According to data from North India, 69% of persons with CP had spastic quadriplegia or dyskinetic CP and were non-ambulatory [6]. These persons are at a higher risk of developing complications such as hip displacement (sub-luxation or dislocation), spinopelvic deformities, musculoskeletal pain, low bone mineral density and low energy fracture. The most common and serious structural change in persons who have severe CP is hip displacement. This deformity is seldom present at birth but develops as the child grows older and experiences abnormal muscle pull from spastic muscles, increased femoral anteversion and the lack of weight bearing on the lower extremities. The reported rates of hip displacement in persons with CP vary from 1 to 75% [7]. The incidence of hip displacement in CP is related to the severity of involvement, varying from 1% in children with spastic hemiplegia up to 75% in those with spastic quadriplegia [8]. In two population studies, the rate of hip displacement was found to be one-third and was not related to the movement disorder but was directly related to gross

The prevalence of hip pain in severe CP is reported to be 47.2% [11]. The common type of pain identified was provoked pain (e.g. during mobilisation, palpation and weight bearing on the lower extremities). A study of 2777 children (57% boys) at a median age of 7 years reported 32.4% children in pain, with significantly more girls than boys experiencing pain, and significantly more children at GMFCS levels III and V than GMFCS level I. The frequency of pain increased with age. Pain in the abdomen and hips was most frequent at GMFCS V,

Markedly low bone mass in children and adults with severe CP has been reported to place

whereas knee pain was most frequent at level III and foot pain at level I [12].

these persons at the risk of osteopenia, osteoporosis and low-energy fracture [13].

and will require major assistive devices for physical assistance [5].

motor function as determined by the GMFCS [9, 10].

disabilities [3].

142 Cerebral Palsy - Current Steps


## **2. Goals of treatment**

The goals of treatment for persons with severe CP are different from those for ambulatory persons with CP. Persons with severe CP are at increased risk of developing displacement of the hip, spinal deformities and joint contracture, which may altogether hinder and interfere with caregiving, positioning, sitting and transferring the person. Other comorbidities include cognitive disorders, visual and hearing impairment, epilepsy, difficulties in chewing and swallowing, drooling, speech, digestive disorder, respiratory illness and bowel and bladder problems [24].

The management aims [24, 25] of severe CP are to


More specific therapeutic goals [26] include the following:


## **3. Treatment options**

Management aims of severe CP are very challenging and the ultimate goal of the rehabilitation process is to make the child independent at community and household level. The primary aim is to prevent any secondary complications. The rehabilitation of severe CP is an intensive process in which the patient's goals are prioritised with the help of a team of physiotherapists, occupational therapists, speech therapists, psychologists, special educators, etc., headed by a rehabilitation physician to improve the person's function physically, mentally and socially. This process also requires active participation by the patient and caregivers. No two persons with severe CP are the same. However, the impact of rehabilitation techniques on one person must be taken for reference while rehabilitating the other.

The usual management of severe CP at present consists of physical therapy, sometimes followed by multiple, and often concurrent, medical and surgical interventions, most inten‐ sively in early childhood through pre-adolescence. While a growing list of treatments, e.g. oral antispasticity medication, alcohol, phenol or botulinum toxin injections, have been shown to individually improve some motor outcomes, few definitive practice guidelines have been proposed for the management of CP due to limited and fragmented scientific evidence to support multidisciplinary intervention approaches [27]. Persons with severe CP usually do not fulfil the selection criteria for selective dorsal rhizotomy. Intrathecal baclofen is a thera‐ peutic option in this population, but the disadvantages include high cost and serious compli‐ cations like infection, neurological injury and hip dislocation.

In ambulatory patients (GMFCS levels I, II and III), single-event multilevel surgery (SEMLS) has become widely accepted to be effective in improving gait parameters and the quality of life [28]. However, the effectiveness of orthopaedic surgery (OS) to improve and maintain mobility in children with lower functional levels (GMFCS levels IV and V) has not been ascertained. A study conducted in 2012 revealed that orthopaedic surgery in children with CP at GMFCS IV was unlikely to restore or maintain mobility. The study reported that the following results:


The authors concluded that the role of orthopaedic surgery for children with CP at GMFCS level IV is limited to the treatment and prevention of spastic hip disease and scoliosis [29].

The aims of OS in GMFCS level IV are to optimise

**1.** Adequate tone control.

144 Cerebral Palsy - Current Steps

**5.** Plantigrade feet.

following results:

post-surgery.

**3. Treatment options**

**3.** Stable, enlocated, mobile and painless hips.

**2.** Straight spine and level pelvis (to allow comfortable sitting and positioning).

Management aims of severe CP are very challenging and the ultimate goal of the rehabilitation process is to make the child independent at community and household level. The primary aim is to prevent any secondary complications. The rehabilitation of severe CP is an intensive process in which the patient's goals are prioritised with the help of a team of physiotherapists, occupational therapists, speech therapists, psychologists, special educators, etc., headed by a rehabilitation physician to improve the person's function physically, mentally and socially. This process also requires active participation by the patient and caregivers. No two persons with severe CP are the same. However, the impact of rehabilitation techniques on one person

The usual management of severe CP at present consists of physical therapy, sometimes followed by multiple, and often concurrent, medical and surgical interventions, most inten‐ sively in early childhood through pre-adolescence. While a growing list of treatments, e.g. oral antispasticity medication, alcohol, phenol or botulinum toxin injections, have been shown to individually improve some motor outcomes, few definitive practice guidelines have been proposed for the management of CP due to limited and fragmented scientific evidence to support multidisciplinary intervention approaches [27]. Persons with severe CP usually do not fulfil the selection criteria for selective dorsal rhizotomy. Intrathecal baclofen is a thera‐ peutic option in this population, but the disadvantages include high cost and serious compli‐

In ambulatory patients (GMFCS levels I, II and III), single-event multilevel surgery (SEMLS) has become widely accepted to be effective in improving gait parameters and the quality of life [28]. However, the effectiveness of orthopaedic surgery (OS) to improve and maintain mobility in children with lower functional levels (GMFCS levels IV and V) has not been ascertained. A study conducted in 2012 revealed that orthopaedic surgery in children with CP at GMFCS IV was unlikely to restore or maintain mobility. The study reported that the

**•** The Functional Mobility Scale (FMS) remained the same in 95.4% of the patients.

**•** Most children lost their ability to perform assisted walking and standing transfers at 2 years'

**4.** Mobile knees that can flex to sit and extend to brace for transfer.

must be taken for reference while rehabilitating the other.

cations like infection, neurological injury and hip dislocation.

**•** Only 36.4% of the patients achieved their goals.


The aims of OS in GMFCS level V are to optimise


None of the conventional therapeutic approaches reported so far have shown any significant improvement in gross motor function or the ability to ambulate in persons with severe CP. Consequently, the recommended rehabilitation strategy across the world at present for severe CP is wheelchair-aided mobility. Hence, there is a strong need to evaluate alternative methods of treatment that can allow assisted ambulation in persons with severe CP.

## **4. Orthopaedic selective spasticity-control surgery (OSSCS)**

OSSCS, a Japanese OS approach, has been proposed with the aims of selective reduction of a specific muscle's spasticity, dystonia and athetosis, and improvement of anti-gravity posture control and movement [30]. The principles of OSSCS are as follows:


The main surgical techniques in OSSCS are intramuscular release and controlled sliding lengthening [30].

The advantages of OSSCS over conventional OS [30, 31] are as follows:

**1.** There is no loss of anti-gravity activity and weakness of the muscles because monoartic‐ ular muscles are preserved.


## **5. Single Event Multilevel Lever Arm Restoration and Anti-Spasticity Surgery (SEMLARASS)**

SEMLARASS is an advancement of the concept of OSSCS [32]. The additional principles of SEMLARASS include the following:


**Figure 1.** Percutaneous varus derotation osteotomies with external fixators.

**Figure 2.** Tectoplasty.

**2.** Over lengthening of tendons is avoided because of the surgical technique of controlled

**3.** It controls spasticity, produces reciprocal movements to facilitate anti-gravity muscles

**4.** It leads to significant functional improvement in the severely involved spastic quadriple‐

**5. Single Event Multilevel Lever Arm Restoration and Anti-Spasticity**

SEMLARASS is an advancement of the concept of OSSCS [32]. The additional principles of

**1.** Operating between the ages of 4 and 6 years (preferably) to avoid joint decompensation and over lengthening of tendons that happen due to continued usage of deformed joints.

**2.** Simultaneous restoration of lever arm dysfunction (LAD) is essential for spasticity and contracture correction as well as to reduce chances of recurrence of deformities and repeat surgery at a later stage, and to improve the direction of pull of muscles and facilitating

**3.** Minimally invasive procedures using image intensification that do not require large skin

**4.** Use of only external fixators that do not require a second operation for removal, and are technically superior to internal fixation in enabling reduction of dislocated hips and preventing stress shielding of the bone and consequent fractures after implant removal.

**5.** All surgeries to restore LAD are extra-articular to allow for the maximum growth potential

**6.** Power generators are preserved: tendon transfers of spastic muscles may lead to further weakness and worsen, lead to an opposite deformity, e.g. genu recurvatum following

**7.** For non-reducible hip dislocation, the preferred salvage operation is redirection of femoral

**8.** The surgery is followed by a structured, intensive, institutional, physician-directed,

head and tectoplasty while preserving the femoral head (**Figure 1** and **2**).

incisions and consequent risk of blood loss and infection.

and improves functional skills and voluntary movement of the hand.

sliding tendon lengthening.

146 Cerebral Palsy - Current Steps

gia, athetoid or dystonia.

**Surgery (SEMLARASS)**

strengthening.

of children's bones.

Eggers transfer.

multidisciplinary rehabilitation protocol.

SEMLARASS include the following:

**5.** There is no loss of sensation or sense of stereognosis.

**6.** There is no increase in the occurrence of dislocations.

Following are the components of SEMLARASS:

**1.** Single event: under a single anaesthesia, requiring only one hospital admission and one period of rehabilitation, all surgeries are completed.


## **6. Rehabilitation approaches used with SEMLARASS**

SEMLARASS is followed by a protocol-based rehabilitation that has already been published [32]. This rehabilitation approach is comprehensive, and includes physiotherapy, occupational therapy, speech therapy, orthosis and other adaptive equipment, recreational activities, school and education adaptation and psychosocial support, etc. [33]. Rehabilitation in severe CP can differ due to clinical type and severity of conditions, physiological age and socioeconomic factors. In addition, visual, auditory, cognitive disorders, seizures, learning disabilities and emotional problems may influence intervention outcomes [34]. Physiotherapy plays a central role in managing the condition; it focuses on function, movement and optimal use of the person's potential. Physiotherapy uses physical approaches to promote, maintain and restore physical, psychological and social well-being. The rehabilitation occurs not only at the rehabilitation centre but also involves the functional strategies at home, community, school or work and other recreational environments, where the therapists works on making the person with CP to become independent by concentrating on gross motor activities, functional mobility and ambulation either with or without assistive devices [33].

Active rehabilitation has been the choice of functional treatment for CP according to the present evidence available in the literature [35]. The rehabilitation is focussed on a combination of aspects involving physical, mental and social functions. It involves a time-bound interaction between the patient, therapist and other persons involved in the rehabilitation process to show a reduction in the disability on the person's day-to-day activities by his or her condition [36]. Active rehabilitation involves making the person with severe CP active through most of the waking hours and participating actively in the rehabilitation. A variety of therapeutic pro‐ grammes such as aquatic therapy, virtual reality-based therapy, physiotherapy, occupational therapy, hippotherapy (HT), whole body vibration therapy (WBVT), body-weight-supported treadmill training, EMG biofeedback and functional activity training are used. In addition, supportive therapies such as psychological counselling, special education, neurotherapy, yoga therapy and relaxation exercises also form a part of the treatment regimen. In the postoperative phase, a person with severe CP undergoes 5–6 hours of the above therapies in a programmed manner through a phased multidisciplinary treatment protocol for 6–9 months and less intensively thereafter [32].

#### **6.1. Aquatic therapy**

Aquatic therapy is one of the most popular and important rehabilitation strategies in persons with severe CP [37]. Water is an equalising medium; its gravity-minimising nature reduces compressive joint forces, providing a better exercise environment for patients with medical conditions that may restrict physical training on land [38]. Adapted aquatic exercises have been particularly recommended as a part of physical activity programmes for persons with severe CP. The buoyant nature of water provides persons with severe CP the opportunity to feel their bodies free from the constraints they experience on land [39]. Aquatic exercises have benefits on joint range of motion, strength of muscles, pain, muscle spasms, circulation and respiratory function, speech, balance, coordination and posture [40]. Ease of movement and weight relief allows safe movement exploration, strengthening and functional activity training with a reduced level of joint loading and impact, providing a gentler environment for persons who experience persistent abnormal loading [39]. In addition, aquatic physical activities are important for the teaching-learning process and might promote greater independence, better manual ability and, as a consequence, increase social participation in persons with severe CP [41]. Despite the fact that swimming is one of the most frequently reported physical activities in children and adolescents with CP, there is no consensus on optimal concepts of aquatic physical activity regarding duration of intervention period, duration of a single treatment, frequency per week of treatment, individual/group work, water temperature and swimming pool size and depth [38]. In our practice, the aquatic therapy consisted of 5 minutes of light warm-up in the temperature-controlled swimming pool (forward and backward walking, jumping and other such exercises), 20 minutes of exercise on swimming techniques (prone and back gliding from the wall, prone and back floating and blowing bubbles) and 5 minutes of play (ball games, chasing games, etc.). The therapy was focused and performed individually (**Figure 3**). To ensure active participation, the intervention was customised to maximise enjoyment by each individual. Depending on the improved performance demonstrated by each person and related functional ability, the complexity of the exercises was increased. In addition, some interventions focused more on arm movements than on leg movements and vice versa. Thus, the goals and progression of each person could be followed individually, and every instructor was able to easily continue onto the next lesson with each child.

**Figure 3.** Aquatic therapy.

**2.** Multilevel: simultaneous correction of all the affected regions and all orthopaedic

**3.** Lever arm restoration: to improve the direction of pull of muscles and to facilitate muscle

SEMLARASS is followed by a protocol-based rehabilitation that has already been published [32]. This rehabilitation approach is comprehensive, and includes physiotherapy, occupational therapy, speech therapy, orthosis and other adaptive equipment, recreational activities, school and education adaptation and psychosocial support, etc. [33]. Rehabilitation in severe CP can differ due to clinical type and severity of conditions, physiological age and socioeconomic factors. In addition, visual, auditory, cognitive disorders, seizures, learning disabilities and emotional problems may influence intervention outcomes [34]. Physiotherapy plays a central role in managing the condition; it focuses on function, movement and optimal use of the person's potential. Physiotherapy uses physical approaches to promote, maintain and restore physical, psychological and social well-being. The rehabilitation occurs not only at the rehabilitation centre but also involves the functional strategies at home, community, school or work and other recreational environments, where the therapists works on making the person with CP to become independent by concentrating on gross motor activities, functional mobility

Active rehabilitation has been the choice of functional treatment for CP according to the present evidence available in the literature [35]. The rehabilitation is focussed on a combination of aspects involving physical, mental and social functions. It involves a time-bound interaction between the patient, therapist and other persons involved in the rehabilitation process to show a reduction in the disability on the person's day-to-day activities by his or her condition [36]. Active rehabilitation involves making the person with severe CP active through most of the waking hours and participating actively in the rehabilitation. A variety of therapeutic pro‐ grammes such as aquatic therapy, virtual reality-based therapy, physiotherapy, occupational therapy, hippotherapy (HT), whole body vibration therapy (WBVT), body-weight-supported treadmill training, EMG biofeedback and functional activity training are used. In addition, supportive therapies such as psychological counselling, special education, neurotherapy, yoga therapy and relaxation exercises also form a part of the treatment regimen. In the postoperative phase, a person with severe CP undergoes 5–6 hours of the above therapies in a programmed manner through a phased multidisciplinary treatment protocol for 6–9 months

Aquatic therapy is one of the most popular and important rehabilitation strategies in persons with severe CP [37]. Water is an equalising medium; its gravity-minimising nature reduces

strengthening post-operatively, LAD corrections are done simultaneously.

deformities (soft tissue and bony) as joints are interdependent.

**4.** Anti-spasticity surgery: using the principles of OSSCS.

148 Cerebral Palsy - Current Steps

and ambulation either with or without assistive devices [33].

and less intensively thereafter [32].

**6.1. Aquatic therapy**

**6. Rehabilitation approaches used with SEMLARASS**

## **6.2. Body-weight-supported treadmill training (BWSTT)**

Persons with severe CP are non-ambulatory. Treadmill training has shown positive outcomes in improving ambulation in CP [42]. Animal studies of supported treadmill training have demonstrated restoration of coordinated stepping movements in spinalised cats [43]. BWSTT is an active, repetitive, task-specific approach used to facilitate attainment of stepping and locomotion and to achieve a more normalised gait pattern. It is a method of task-oriented ambulatory training using the overhead suspension system and harness to support a percent‐ age of the person's body weight while walking on a treadmill. Other effects of BWSTT include increase in walking speed, improved balance and increased endurance [44]. We use an indigenously constructed BWSTT device to aid persons with severe CP during the gait training phase of rehabilitation (**Figure 4**). The body weight support device can facilitate walking, both on treadmill and on level ground. In addition to its effectiveness in improving the person's walking ability, it also reduces the physical workload of physiotherapists and caregivers handling the persons with severe CP.

**Figure 4.** Body-weight-supported treadmill training.

## **6.3. Functional electrical stimulation (FES)**

**6.2. Body-weight-supported treadmill training (BWSTT)**

handling the persons with severe CP.

150 Cerebral Palsy - Current Steps

**Figure 4.** Body-weight-supported treadmill training.

Persons with severe CP are non-ambulatory. Treadmill training has shown positive outcomes in improving ambulation in CP [42]. Animal studies of supported treadmill training have demonstrated restoration of coordinated stepping movements in spinalised cats [43]. BWSTT is an active, repetitive, task-specific approach used to facilitate attainment of stepping and locomotion and to achieve a more normalised gait pattern. It is a method of task-oriented ambulatory training using the overhead suspension system and harness to support a percent‐ age of the person's body weight while walking on a treadmill. Other effects of BWSTT include increase in walking speed, improved balance and increased endurance [44]. We use an indigenously constructed BWSTT device to aid persons with severe CP during the gait training phase of rehabilitation (**Figure 4**). The body weight support device can facilitate walking, both on treadmill and on level ground. In addition to its effectiveness in improving the person's walking ability, it also reduces the physical workload of physiotherapists and caregivers FES is used to stimulate targeted muscles during ambulation, especially in enhancing quad‐ riceps function, allowing for better range in knee extension. It is used to improve gait control and trunk control [45–47]. Persons with severe CP have difficulty in generating sufficient muscle force. So, combining exercise with FES programme is a good option for increasing the intensity and effectiveness of the strengthening programme. Studies show participants in an FES programme can make measurable gains in body structure and function, activity and participation. The evidence supporting the efficacy of FES in improving gait quality, gait symmetry and muscle strength and motor control in persons with CP is growing steadily [48– 51]. Given the complex nature of the gait deviations seen in children with CP, many paediatric FES studies investigate the effect of multi-channel FES systems on abnormal gait. Most multichannel systems include stimulation of the anterior tibialis muscle as a treatment for drop foot [45, 51, 52]. Two of the FES review studies investigated single-channel FES systems that operate as neuroprostheses by stimulating the peroneal nerve to alleviate drop foot [45, 48]. In our setting also, we use a single-channel FES to facilitate the activation of tibialis anterior and knee extension for gait training, especially during treadmill training (**Figure 5**).

**Figure 5.** Functional electrical stimulation.

#### **6.4. Whole body vibration therapy (WBVT)**

Studies on vibration therapy at a specific frequency and amplitude have many negative effects on humans. However, recent studies have shown that vibration therapy for humans at very low amplitude and frequency is safe and beneficial to the human musculoskeletal structures. WBVT can be used as a form of exercise targeted for improving muscle strength, power, flexibility and coordination. Persons using this tool stand on the vibrating platform so that the whole body was stimulated with a sinusoidal vibration [52]. WBVT has been utilised to deliver mechanical accelerations to the appendicular and axial skeletons to elicit increased bone mass. WBVT has been shown to be specifically effective in improving bone mineral density especially in hip and spine for persons with severe CP after plaster immobilisation [53, 54]. The advantage of WBVT lies in its ability to be applied in a low-impact manner, which is critical for persons with impaired mobility and muscle strength (**Figure 6**). In our practice, WBVT is used, initially with suspension similar to BWSTT, in persons with severe CP who are in the weight bearing phase of rehabilitation.

**Figure 6.** Whole body vibration therapy.

#### **6.5. Virtual reality-based therapy (VRBT)**

Virtual reality is the use of interactive simulations using computer hardware and software to present users with opportunities to perform rehabilitation in virtual environments that appear, sound, and less frequently, feel similar to real-world objects and events. The advantage of VRBT is that it allows a more elaborate and complex interaction between the virtual environ‐ ment and the user. We have reported on the successful use of Nintendo Wii for VRBT to improve the balance, motivation and participation of children with CP following SEMLARASS [55] (**Figure 7**). Virtual reality-based bilateral arm training shows improvement in upper limb motor skills on the affected sites and in bilateral coordination ability. It can also improve trunk control and concentration [56]. Active participation, receiving feedback and repetition of movements during the VRBT intervention, assists in motor learning that induces cortical reorganisation and neural plasticity changes in the brain [57–59]. VRBT also increases the exercise compliance level in achieving selective motor control and enhances the effectiveness of conventional physiotherapy [60]. Participants were highly motivated by the feedback, challenge, variability and other competitive factors involved in the VRBT and overall give a sense of achievement mimicking the real world [61–63]. We also use Microsoft X-Box with Kinect and virtual reality headsets in neurorehabilitation. Initially, suspension is used for nonambulatory persons.

**Figure 7.** Virtual reality-based therapy.

#### **6.6. EMG biofeedback**

**6.4. Whole body vibration therapy (WBVT)**

phase of rehabilitation.

152 Cerebral Palsy - Current Steps

**Figure 6.** Whole body vibration therapy.

**6.5. Virtual reality-based therapy (VRBT)**

Studies on vibration therapy at a specific frequency and amplitude have many negative effects on humans. However, recent studies have shown that vibration therapy for humans at very low amplitude and frequency is safe and beneficial to the human musculoskeletal structures. WBVT can be used as a form of exercise targeted for improving muscle strength, power, flexibility and coordination. Persons using this tool stand on the vibrating platform so that the whole body was stimulated with a sinusoidal vibration [52]. WBVT has been utilised to deliver mechanical accelerations to the appendicular and axial skeletons to elicit increased bone mass. WBVT has been shown to be specifically effective in improving bone mineral density especially in hip and spine for persons with severe CP after plaster immobilisation [53, 54]. The advantage of WBVT lies in its ability to be applied in a low-impact manner, which is critical for persons with impaired mobility and muscle strength (**Figure 6**). In our practice, WBVT is used, initially with suspension similar to BWSTT, in persons with severe CP who are in the weight bearing

Virtual reality is the use of interactive simulations using computer hardware and software to present users with opportunities to perform rehabilitation in virtual environments that appear,

Biofeedback uses the principle of measuring and processing normal and/or abnormal neuro‐ muscular activity in the form of auditory or visual feedback by means of an electromechanical instrument. EMG biofeedback specifically uses surface electrodes and records the muscular activity and gives the feedback that can be therapeutically used to facilitate or inhibit the muscular activity. This helps to create a better awareness about the physiological process of the abnormal body movements in specific activities of the individuals. Pressure, temperature, angular and positional systems can also be used as other modes of biofeedback similar to EMG biofeedback [64–67]. EMG biofeedback is now widely used in the rehabilitation of upper motor neuron lesions and also found that it helps in improving the spastic muscles by relaxing them [68–70]. In CP rehabilitation, EMG biofeedback has not been evaluated with any major controlled studies. Studies with small sample sizes have reported reduction in spasticity in the gastrocnemius [71] and increases in active range of motion and ankle dorsiflexion strength [72]. Although EMG is used to reduce muscle spasticity, there was no degree of changes in muscle contracture using EMG biofeedback. However, reversing muscle contracture can be achieved by combining surgical procedures that lengthen the muscles along with biofeedback training in order to maintain the lengthened muscle. [73]. In our setup, we use a single-channel EMG biofeedback device that provides an individual with supplemental information about the response of muscular activity, allowing the individual to attempt to control a given output associated with this process (**Figure 8**). Through trial and error, the person receives feedback on his or her success in adapting their behaviour to achieve the desired output (reduced spasticity or improved muscle strength). A variety of instruments are being used in research and in the clinical setting including surface EMG, computer-assisted feedback and a variety of simple auditory and visual feedback such as providing an auditory cue on the heel of a child to encourage heel-toe gait [74].

**Figure 8.** EMG biofeedback.

#### **6.7. Activity monitor (AM)**

AMs can be used for persons with severe CP as a biofeedback device, especially in rehabilita‐ tion for improving specific gait parameters. It is economical, easy to use and provides a realtime feedback [75]. Physical activity seems to be one of the most important factors in effective CP rehabilitation or prevention of functional decline in older persons [76]. Small, lightweight, body-worn accelerometers that are able to record activity over longer periods of time now are available commercially. Body positions, movement and number of steps taken by the subject are detected in the sensory systems by inbuilt pre-installed software. This pre-installed software helps to extract data of the body's movement such as no of steps taken, time, speed, kilometers travelled and calories burnt. In our setup, we use a small, lightweight AM worn on persons' body for a particular period of time and subsequently monitoring the output and fixing targets to achieve, thus acting as a biofeedback device for persons with severe CP (**Figure 9**). This accurate measurement of free-living physical activity using advanced dynamic acceleration and inclination logging technology allows medical and rehabilitation professio‐ nals to assess patient compliance with exercise and treatment protocols, and also patient response to novel treatment interventions.

**Figure 9.** Tracking the training with activity monitor.

#### **6.8. Hippotherapy**

instrument. EMG biofeedback specifically uses surface electrodes and records the muscular activity and gives the feedback that can be therapeutically used to facilitate or inhibit the muscular activity. This helps to create a better awareness about the physiological process of the abnormal body movements in specific activities of the individuals. Pressure, temperature, angular and positional systems can also be used as other modes of biofeedback similar to EMG biofeedback [64–67]. EMG biofeedback is now widely used in the rehabilitation of upper motor neuron lesions and also found that it helps in improving the spastic muscles by relaxing them [68–70]. In CP rehabilitation, EMG biofeedback has not been evaluated with any major controlled studies. Studies with small sample sizes have reported reduction in spasticity in the gastrocnemius [71] and increases in active range of motion and ankle dorsiflexion strength [72]. Although EMG is used to reduce muscle spasticity, there was no degree of changes in muscle contracture using EMG biofeedback. However, reversing muscle contracture can be achieved by combining surgical procedures that lengthen the muscles along with biofeedback training in order to maintain the lengthened muscle. [73]. In our setup, we use a single-channel EMG biofeedback device that provides an individual with supplemental information about the response of muscular activity, allowing the individual to attempt to control a given output associated with this process (**Figure 8**). Through trial and error, the person receives feedback on his or her success in adapting their behaviour to achieve the desired output (reduced spasticity or improved muscle strength). A variety of instruments are being used in research and in the clinical setting including surface EMG, computer-assisted feedback and a variety of simple auditory and visual feedback such as providing an auditory cue on the heel of a child

AMs can be used for persons with severe CP as a biofeedback device, especially in rehabilita‐ tion for improving specific gait parameters. It is economical, easy to use and provides a real-

to encourage heel-toe gait [74].

154 Cerebral Palsy - Current Steps

**Figure 8.** EMG biofeedback.

**6.7. Activity monitor (AM)**

HT is a form of physical, occupational or speech therapy utilising a trained horse. The movement of the horse affects a rider's posture, balance, coordination, strength and sensori‐ motor systems. Recently, mechanical HT devices have been used in the rehabilitation of persons with severe CP. The mechanical HT is the modern form of providing therapeutic horse riding benefits by a pre-programmed mechanically operated device, mimicking a horse riding experience (**Figure 10**). We use mechanical HT to improve head and trunk control, sitting balance, posture and promote functional activities [77–80]. HT should be avoided in the presence of hip displacement or hip osteotomies (till the stage of bony consolidation).

**Figure 10.** Mechanical Hippotherapy.

#### **6.9. Velcro platform (VP)**

Persons with CP often have difficulty in balancing post-SEMLARASS. VP is a novel method developed and designed by us for improving standing balance. The principle behind the use of Velcro for increasing the stability of base of support was that the sensory input from the varied rehabilitation strategies using Velcro for support helps in increased muscular activa‐ tion, thereby improving functional performance [81]. The majority of persons with severe CP have severe muscular weakness and fear of falling, post-SEMLARASS, and have difficulties in achieving standing balance. VP consists of a wide wooden board attached with footcontoured pads enforced with straps that accommodate the person's feet. The positive and negative pieces of a conventional Velcro form the contact surfaces of the platform base and the foot pads. The person is made to stand on the board fastening the Velcro straps. The device provides better foot contact to the ground, which aids in better weight bearing, proper biomechanical alignment and acts as an indirect psychological assistance, which can make a person stand independently without or with minimal manual assistance (**Figure 11**). It helps to reduce the gravitational insecurities, fear of falling and gives confidence to a patient. Although the pilot study reported significant improvement in balance parameters and reduction in fear of falls, a larger clinical trial investigating the effectiveness of the VP is under progress.

**Figure 11.** Balance training with Velcro platform.

persons with severe CP. The mechanical HT is the modern form of providing therapeutic horse riding benefits by a pre-programmed mechanically operated device, mimicking a horse riding experience (**Figure 10**). We use mechanical HT to improve head and trunk control, sitting balance, posture and promote functional activities [77–80]. HT should be avoided in the

Persons with CP often have difficulty in balancing post-SEMLARASS. VP is a novel method developed and designed by us for improving standing balance. The principle behind the use of Velcro for increasing the stability of base of support was that the sensory input from the varied rehabilitation strategies using Velcro for support helps in increased muscular activa‐ tion, thereby improving functional performance [81]. The majority of persons with severe CP have severe muscular weakness and fear of falling, post-SEMLARASS, and have difficulties in achieving standing balance. VP consists of a wide wooden board attached with footcontoured pads enforced with straps that accommodate the person's feet. The positive and negative pieces of a conventional Velcro form the contact surfaces of the platform base and the foot pads. The person is made to stand on the board fastening the Velcro straps. The device provides better foot contact to the ground, which aids in better weight bearing, proper

presence of hip displacement or hip osteotomies (till the stage of bony consolidation).

**Figure 10.** Mechanical Hippotherapy.

**6.9. Velcro platform (VP)**

156 Cerebral Palsy - Current Steps

#### **6.10. Head-held laser illumination device (HHLID)**

Similar to VP, HHLID is also an indigenously developed device that can be a useful tool in the post-SEMLARASS rehabilitation programme for the improvement of sitting or standing balance and head or trunk control in persons with severe CP. A Laser-pointer-based focussed trajectory exercises were found to improve the hip extensor activation in comparison to erector spinae activation during pelvic bridging exercise [82]. A laser pointer device attached to the pelvis has been used to assess impaired balance [83]. HHLID consists of a laser-emitting device that can be fixed to the person's head or pelvis and the target is to focus on a variable screen with mazes that challenges the person's balance and control abilities (**Figure 12**). HHLID works by giving visual feedback and it requires active correction of the patient, initially guided and assisted by the physiotherapist. The pilot study reported significant improvements in sitting balance, and a larger clinical trial investigating the effectiveness of the HHLID is under progress.

**Figure 12.** Child fixed with a head held laser illumination device.

#### **6.11. Gaze-assistive rehabilitation technology (GART)**

Gaze stabilisation during head motion is an important aspect of rehabilitation of individuals with severe physical impairments with problems in communication and speech disorders. For such persons, gaze stabilisation and control-based technological devices help in communica‐ tion and interaction without the use of upper or lower extremities [84]. GART works on the principle of video-based corneal reflection eye trackers [85]. A few studies have reported the use of GART in severe CP helping them perform certain activities and increase participation [86, 87]. We are currently studying the Samsung EyeCan+ eye mouse, a futuristic device that enables people with severe CP to use computers only through eye movements. The EyeCan+ is a simple portable box positioned near the computer monitor and users are not required to wear glasses or other special equipment. Users can work with the device either sitting or lying down and just need to be a couple of feet from the monitor. This device allows people to compose and edit documents as well as browse the web (click, double click, scroll, drag, etc.) through simple eye movements. Eighteen different mouse menus allow the person with severe CP to communicate, play games and participate in rehabilitation (**Figure 13**).

**Figure 13.** EyeCan+ device fixed to a personal computer.

with mazes that challenges the person's balance and control abilities (**Figure 12**). HHLID works by giving visual feedback and it requires active correction of the patient, initially guided and assisted by the physiotherapist. The pilot study reported significant improvements in sitting balance, and a larger clinical trial investigating the effectiveness of the HHLID is under

Gaze stabilisation during head motion is an important aspect of rehabilitation of individuals with severe physical impairments with problems in communication and speech disorders. For such persons, gaze stabilisation and control-based technological devices help in communica‐ tion and interaction without the use of upper or lower extremities [84]. GART works on the principle of video-based corneal reflection eye trackers [85]. A few studies have reported the use of GART in severe CP helping them perform certain activities and increase participation [86, 87]. We are currently studying the Samsung EyeCan+ eye mouse, a futuristic device that enables people with severe CP to use computers only through eye movements. The EyeCan+ is a simple portable box positioned near the computer monitor and users are not required to wear glasses or other special equipment. Users can work with the device either sitting or lying down and just need to be a couple of feet from the monitor. This device allows people to compose and edit documents as well as browse the web (click, double click, scroll, drag, etc.) through simple eye movements. Eighteen different mouse menus allow the person with severe

CP to communicate, play games and participate in rehabilitation (**Figure 13**).

progress.

158 Cerebral Palsy - Current Steps

**Figure 12.** Child fixed with a head held laser illumination device.

**6.11. Gaze-assistive rehabilitation technology (GART)**

Other supportive therapies in the rehabilitation protocol include occupational therapy involving specific goal-oriented therapies such as constraint-induced movement therapy (CIMT), mirror therapy, play therapy, music and art therapy, psychological counselling, behavioural training, special education, yoga therapy, speech therapy and dance movement therapy.

#### **6.12. Results of SEMLARASS for severe CP**

A study was conducted on 170 children with severe CP (GMFCS levels IV and V) to find out the functional outcome of SEMLARASS and rehabilitation. The mean age of the participants was 9.68 ± 4.77 years. The follow-up ranged from 2 to 10 years (mean = 4 years). The outcome measures such as component of Gross Motor Function Measure (GMFM-88), Functional Mobility Scale, Physicians Rating Scale (PRS), Manual Ability Classification System (MACS) were used to compare the functional status of the child before and after SEMLARASS.

The results showed a significant improvement in all GMFM-88 components and the values were lying and rolling (A): GMFM 5: t-9.77 (*P* < 0.001); GMFM 4: t-8.56 (*P* < 0.001); sitting (B): GMFM 5: t-20.01 (*P* < 0.001); GMFM 4: t-12.61 (*P* < 0.001); crawling and kneeling (C): GMFM 5: t-22.26 (*P* < 0.001); GMFM 4: t-21.01 (*P* < 0.001); standing (D): GMFM 5: t-20.01 (*P* < 0.001); GMFM 4: t-22.64 (*P* < 0.001); standing (D): GMFM 5: t-20.01 (*P* < 0.001); GMFM 4: t-22.64 (*P* < 0.001); walking, running and jumping (E): GMFM 5: t-12.71 (*P* < 0.001); GMFM 4: t-15.65 (*P* < 0.001) and total GMFM-88: GMFM 5: t-31.55 (*P* < 0.001); GMFM 4: t-32.86 (*P* < 0.001), respectively. The result of pre-post PRS evaluation showed a significant improvement for both sides (*P* < 0.01). Correlation studies showed median value of Functional Mobility Scale of 1 before surgery and 3 after surgery. Before surgery the median value of Gross Motor Functional Classification System was level IV and after surgery it was level II. The GMFCS improved two levels on average. Before surgery, the mean value of Pediatric QOL (PQOL) was 23.11 ± 14.02; after surgery, the mean value was 39.64 ± 17.49. Before surgery median value of Manual Ability Classification System was 3 and after surgery it was 1. No child was wheelchair bound at the end of the rehabilitation and all the children were able to walk at least with help of a walking aid. A significant improvement was noted in their participation levels, motivation and a significant improvement in the overall quality of life [88]. Over 50 patients have been followed up for 10 years and there have been no significant recurrence of deformities or significant deterioration of gross motor function.

## **7. Discussion**

The currently practised treatment options have little impact on gross motor function and mobility in non-ambulatory persons with spastic quadriplegia and dyskinetic CP, which constitute nearly 70% of all cases of CP. In particular, OS is considered to have minimal role in this patient population. A retrospective cohort study of 107 children with bilateral spastic CP, classified as GMFCS level II or III, who underwent surgery at a single tertiary institution in Australia between 1997 and 2008, reported that the GMFCS levels remained stable and unchanged in 95% of children and improved by one level in 5% of children [89]. Khan reported a series of previously untreated 85 non-walker children with diplegic CP who underwent multilevel surgery. All patients improved and became walkers. However, since the GMFCS was not used, their cohort cannot be compared to this study [90]. Blumetti et al. found a low rate of success after surgery in patients with GMFCS level IV with only 36.4% of the patients achieving their goals. The FMS scores remained the same in 95.4% of the patients. Only one patient maintained an FMS score of 2, 1, 1 at 2 years' follow-up. Most children lost their ability to do supported walking and standing transfers at 2 years' post-surgery [29]. Some external factors are known to influence the outcomes after OS, including post-operative rehabilitation, use of orthotic devices, pain-controlling strategies, adequate tone control, and presence of comorbidities [91]. However, all patients in this series received a standardised rehabilitation programme as described previously and were closely monitored by the team of medical and rehabilitation professionals. Unlike previous studies the current study showed that GMFCS levels improved at least by two levels and significant improvement in gross motor function and mobility was recorded. The main limitation of the study was the lack of a control group.

## **8. Conclusion**

A well-planned and executed SEMLARASS, followed by intensive, protocol-based, sequenced multidisciplinary active rehabilitation, provides the person with severe CP, a significant functional improvement in gross motor function and mobility. SEMLARASS is the only documented treatment for CP till date that has been able to address all the three key problems in CP—selective reduction of spasticity, dyskinetic movements and LAD. The best age for SEMLARASS is 4–6 years before the LAD become severe or joints become decompensated. Intensive, protocol-based and medically supervised rehabilitation for several years and close follow-up are needed at least till skeletal maturity. SEMLARASS provides a patient with severe CP with the best hope for a dramatic, predictable and lasting functional improvement.

## **9. Case study 1**

levels on average. Before surgery, the mean value of Pediatric QOL (PQOL) was 23.11 ± 14.02; after surgery, the mean value was 39.64 ± 17.49. Before surgery median value of Manual Ability Classification System was 3 and after surgery it was 1. No child was wheelchair bound at the end of the rehabilitation and all the children were able to walk at least with help of a walking aid. A significant improvement was noted in their participation levels, motivation and a significant improvement in the overall quality of life [88]. Over 50 patients have been followed up for 10 years and there have been no significant recurrence of deformities or significant

The currently practised treatment options have little impact on gross motor function and mobility in non-ambulatory persons with spastic quadriplegia and dyskinetic CP, which constitute nearly 70% of all cases of CP. In particular, OS is considered to have minimal role in this patient population. A retrospective cohort study of 107 children with bilateral spastic CP, classified as GMFCS level II or III, who underwent surgery at a single tertiary institution in Australia between 1997 and 2008, reported that the GMFCS levels remained stable and unchanged in 95% of children and improved by one level in 5% of children [89]. Khan reported a series of previously untreated 85 non-walker children with diplegic CP who underwent multilevel surgery. All patients improved and became walkers. However, since the GMFCS was not used, their cohort cannot be compared to this study [90]. Blumetti et al. found a low rate of success after surgery in patients with GMFCS level IV with only 36.4% of the patients achieving their goals. The FMS scores remained the same in 95.4% of the patients. Only one patient maintained an FMS score of 2, 1, 1 at 2 years' follow-up. Most children lost their ability to do supported walking and standing transfers at 2 years' post-surgery [29]. Some external factors are known to influence the outcomes after OS, including post-operative rehabilitation, use of orthotic devices, pain-controlling strategies, adequate tone control, and presence of comorbidities [91]. However, all patients in this series received a standardised rehabilitation programme as described previously and were closely monitored by the team of medical and rehabilitation professionals. Unlike previous studies the current study showed that GMFCS levels improved at least by two levels and significant improvement in gross motor function and mobility was recorded. The main limitation of the study was the lack of a control group.

A well-planned and executed SEMLARASS, followed by intensive, protocol-based, sequenced multidisciplinary active rehabilitation, provides the person with severe CP, a significant functional improvement in gross motor function and mobility. SEMLARASS is the only documented treatment for CP till date that has been able to address all the three key problems in CP—selective reduction of spasticity, dyskinetic movements and LAD. The best age for SEMLARASS is 4–6 years before the LAD become severe or joints become decompensated.

deterioration of gross motor function.

**7. Discussion**

160 Cerebral Palsy - Current Steps

**8. Conclusion**

#### **9.1. Pre-op status**

(A) A 13-year-old girl with spastic quadriplegia was confined to bed and completely depend‐ ent on caregivers for all her daily activities. She had no neck control or sitting balance. When held upright by an adult, there was severe crouching at hips and knees. Her GMFCS level was V.

## **9.2. Treatment**

She underwent SEMLARASS in two stages: the first stage with OSCSS of bilateral hamstring, psoas, rectus femoris and gracilis along with femoral derotation and tibial derotation osteot‐ omies and the second stage (after 8 weeks) with OSCSS of bilateral forearm flexors, pronators and hand intrinsics.

#### **9.3. Current functional status**

At a follow-up of 13 months, she was able to walk with the assistance of walker with forearm gutter. She was able to sit independently either long or cross sitting and able to perform some of her daily activities such as feeding, brushing and upper body dressing on her own. Her present GMFCS score was III (**Figure 14**).

**Figure 14.** Pre- and post-rehabilitation status of child A.

'Our daughter, till the age of 12, could only sit with maximal support. But after SEMLARASS and intensive rehabilitation in RECOUP, our daughter is now able to sit without support in both cross sitting and long sitting and now she is able to stand and walk with walking frame with minimum support. She now feels more confident'—parents of A.

## **10. Case study 2**

## **10.1. Pre-op status**

(S) A 12-year-old boy with spastic diplegia was not able to walk and perform his daily activities. His GMFCS level was IV.

#### **10.2. Treatment**

He underwent SEMLARASS with OSCSS of bilateral hamstring, psoas and rectus femoris along with bilateral femoral varus derotation osteotomy.

#### **10.3. Current functional status**

At a follow-up of 12 months, he was able to walk independently for over 100 metres and able to climb up stairs by holding the hand rails and started going to school independently. Current GMFCS score was 2 (**Figure 15**).

**Figure 15.** Pre- and post-rehabilitation status of child S.

'Our son, born with Spastic Diplegia, could not walk and needed constant support even for few steps and frequent falls and imbalance were a constant issue. Now, after the treatment at RECOUP, he started walking independently with lot of confidence and enthusiasm'—parents of S.

## **11. Case study 3**

'Our daughter, till the age of 12, could only sit with maximal support. But after SEMLARASS and intensive rehabilitation in RECOUP, our daughter is now able to sit without support in both cross sitting and long sitting and now she is able to stand and walk with walking frame

(S) A 12-year-old boy with spastic diplegia was not able to walk and perform his daily activities.

He underwent SEMLARASS with OSCSS of bilateral hamstring, psoas and rectus femoris

At a follow-up of 12 months, he was able to walk independently for over 100 metres and able to climb up stairs by holding the hand rails and started going to school independently. Current

'Our son, born with Spastic Diplegia, could not walk and needed constant support even for few steps and frequent falls and imbalance were a constant issue. Now, after the treatment at

with minimum support. She now feels more confident'—parents of A.

along with bilateral femoral varus derotation osteotomy.

**10. Case study 2**

162 Cerebral Palsy - Current Steps

**10.1. Pre-op status**

**10.2. Treatment**

His GMFCS level was IV.

**10.3. Current functional status**

GMFCS score was 2 (**Figure 15**).

**Figure 15.** Pre- and post-rehabilitation status of child S.

#### **11.1. Pre-op status**

(D) A 6-year-old girl with spastic quadriplegia and bilateral hip dislocations was confined to bed and could only bunny hop or creep from one point to other and was totally dependent on caregivers. Her GMFCS level was IV.

## **11.2. Treatment**

She underwent SEMLARASS in two stages: the first stage with OSCSS of bilateral hamstring, psoas, rectus femoris, gracilis and tibialis anterior along with femoral varus derotation and tibial derotation osteotomies and the second stage (after 8 weeks) with OSCSS of bilateral forearm flexors and pronators.

#### **11.3. Current functional status**

After 12 months of follow-up, she was able to walk independently with walker and able to sit up in bed by herself and stand to sit with support. She was able to carry out some basic activities of daily living by her own. Her current GMFCS score was III (**Figure 16**).

**Figure 16.** Pre- and post-rehabilitation status of child D.

'The SEMLARASS surgery and rehabilitation at RECOUP had made a lot of difference in her and now she can walk with a walker'—parents of D.

## **12. Case study 4**

#### **12.1. Pre-op status**

(MA) A 13-year-old boy with spastic dystonic quadriplegia could not walk, even with support. His GMFCS level was IV.

## **12.2. Treatment**

He underwent SEMLARASS in two stages: the first stage with OSCSS of bilateral hamstring, psoas, rectus femoris and gracilis along with bilateral femoral derotation and tibial derotation osteotomies and the second stage (after 8 weeks) with OSCSS of bilateral forearm flexors and pronators.

## **12.3. Current functional status**

At a follow-up of 10 months, he was able to walk independently using walking frame. He is now able to climb up stairs with 50% assistance. His current GMFCS status was III (**Figure 17**).

**Figure 17.** Pre- and post-rehabilitation status of child MA.

'Our son could only walk on toes with his knee bent and used to get a lot of pain and confined to bed. But now, after the surgery and intensive rehabilitation at RECOUP, he started walking independently with a walker and looking for a brighter future ahead'—parents of MA.

## **13. Case study 5**

#### **13.1. Pre-op status**

(R) A 5-year-old boy with spastic athetoid quadriplegia with bilateral dislocated hips was not able to sit or stand or use his hands. His GMFCS level was V.

## **13.2. Treatment**

**12. Case study 4**

164 Cerebral Palsy - Current Steps

**12.1. Pre-op status**

**12.2. Treatment**

pronators.

His GMFCS level was IV.

**12.3. Current functional status**

**Figure 17.** Pre- and post-rehabilitation status of child MA.

able to sit or stand or use his hands. His GMFCS level was V.

**13. Case study 5**

**13.1. Pre-op status**

(MA) A 13-year-old boy with spastic dystonic quadriplegia could not walk, even with support.

He underwent SEMLARASS in two stages: the first stage with OSCSS of bilateral hamstring, psoas, rectus femoris and gracilis along with bilateral femoral derotation and tibial derotation osteotomies and the second stage (after 8 weeks) with OSCSS of bilateral forearm flexors and

At a follow-up of 10 months, he was able to walk independently using walking frame. He is now able to climb up stairs with 50% assistance. His current GMFCS status was III (**Figure 17**).

'Our son could only walk on toes with his knee bent and used to get a lot of pain and confined to bed. But now, after the surgery and intensive rehabilitation at RECOUP, he started walking independently with a walker and looking for a brighter future ahead'—parents of MA.

(R) A 5-year-old boy with spastic athetoid quadriplegia with bilateral dislocated hips was not

He underwent SEMLARASS with OSCSS of bilateral hamstring, psoas and rectus femoris along with femoral varus derotation osteotomy.

### **13.3. Current functional status**

After 7 years of follow-up, he was able to stand with minimal support and walk with rollator independently. He was now able to climb up stairs with assistance and able to walk on ramp with rollator. His current GMFCS was III (**Figure 18**).

**Figure 18.** Pre- and post-rehabilitation status of child R.

'Our son born with spastic athetoid quadriplegia till the age of 5 and was not able to sit, stand or walk; after surgery and intensive rehabilitation in RECOUP, our son is now able to sit and stand independently and walk with rollator more confidently'—parents of R.

## **Author details**

Deepak Sharan\* , Joshua Samuel Rajkumar, Rajarajeshwari Balakrishnan and Amruta Kulkarni

\*Address all correspondence to: deepak.sharan@recoup.in

RECOUP Neuromusculoskeletal Rehabilitation Centre, Bangalore, Karnataka, India

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## **Assistive and Adaptive Technology in Cerebral Palsy**

Alejandro Rafael Garcia Ramirez, Cleiton Eduardo Saturno, Mauro José Conte, Jéferson Fernandes da Silva, Mísia Farhat, Fabiana de Melo Giacomini Garcez Garcez, Ana Carolina Savall and Elaine Carmelita Piucco

Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/64767

#### **Abstract**

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172 Cerebral Palsy - Current Steps

10.3109/17518423.2015.1132281

10–13, 2012.

Verlag, Inc. 2007, ISBN:1846286085

Children who suffer from cerebral palsy (CP) face specific challenges, which arise due to motor dysfunction and communication disorders. In some cases, communication is only possible through eye movements and blink, as well as, low amplitude move‐ ments of the fingers and toes. Augmentative and alternative communication (AAC) strategies can be used to promote communication in these complex cases. This chapter discusses our experience developing AAC computer's solutions for children with motor and communication disorders. Software and hardware approaches are discussed. This chapter describes solutions developed for desktop computers and mobile devices. These solutions act as complements of therapist's activities, helping disabled people to communicate, and promoting social inclusion.

**Keywords:** augmentative and alternative communication, cerebral palsy, humancomputer interaction

#### **1. Introduction**

People with disabilities, such as people who suffer from cerebral palsy (CP), face several challenges in their daily lives. These individuals face specific problems, which arise due to motor dysfunction and communication disorders. These disorders are commonly related to a non-progressive brain damage in early life. CP is also responsible for senses of sight, hear‐ ing, speech and language dysfunctions [1].

© 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

In addition, cognitive development and communication problems are associated with CP. Like stated in [2], language is affected by brain injury and, therefore, the lack of communication in earlier stages of life can irreversibly impair intellectual ability.

Augmentative and alternative communication (AAC) solutions emerge as solutions to supplement spoken communication or to replace it completely, helping these individuals [3].

AAC solutions can be classified as low-tech or high-tech [2]. The low-tech solutions involve gestures, hand signals and sign language. It also includes the usage of supplementary materials, such as communication boards based on letters, symbols or pictures. It may also be related to picture books, or textured cards using Braille [4].

On the other hand, high-tech solutions involve software and electronic components for standard computers or mobile devices. Dynamic communication displays are examples of high-tech solutions.

However, despite the amount of available technologies, there is not enough guidance available on how to directly collaborate with disabled children and specialists as partners in the design process of assistive technology [5].

This work presents solutions and the methodological aspect of creating, developing and evaluating assistive technologies. These works are based on user centric-design principles [6].

Bibliographic, documentary and experimental research was conducted to achieve our goals. In addition, human-computer solutions designed for severe physical disabilities and lack of speech were studied. The documentary research aimed to analyse the professionals' feedback, verifying the progress using the proposed technologies. On the other hand, the experimental research aimed to use the developed human-computer interfaces, collecting quantitative and qualitative assessments guiding our future works.

## **2. Assistive technology**

Disability is a complex phenomenon, reflected because of the interaction between the indi‐ viduals and the society in which it lives. It is the result of a deterrent and it can be physical, cognitive, mental, sensory, emotional, developmental, or some combination of these limita‐ tions [2]. Disability might be present at birth or arise during life.

Disability is closely related to sensory limitations and emerges when some barriers (physical, communication and information) constrain the participation of individuals in society.

The term "assistive technology" is relatively new and it is used to identify resources, technol‐ ogy and services that contribute to provide or enhance functional abilities of people with disabilities. It includes a wide range of equipment, services and strategies aiming to mitigate the problems faced by individuals with disabilities [2].

In [2], the authors explore the role of assistive technologies in the lives of people with disabil‐ ities. They define a HAAT model that means Human Activity Assistive Technology model. The HAAT model is based on the interaction of four basic components, namely: the activity, the human factor, the assistive technologies and the context in which this interaction occurs (**Figure 1**).

**Figure 1.** HAAT model. Source: Adapted with permission from [2].

In addition, cognitive development and communication problems are associated with CP. Like stated in [2], language is affected by brain injury and, therefore, the lack of communication in

Augmentative and alternative communication (AAC) solutions emerge as solutions to supplement spoken communication or to replace it completely, helping these individuals [3]. AAC solutions can be classified as low-tech or high-tech [2]. The low-tech solutions involve gestures, hand signals and sign language. It also includes the usage of supplementary materials, such as communication boards based on letters, symbols or pictures. It may also be

On the other hand, high-tech solutions involve software and electronic components for standard computers or mobile devices. Dynamic communication displays are examples of

However, despite the amount of available technologies, there is not enough guidance available on how to directly collaborate with disabled children and specialists as partners in the design

This work presents solutions and the methodological aspect of creating, developing and evaluating assistive technologies. These works are based on user centric-design principles [6]. Bibliographic, documentary and experimental research was conducted to achieve our goals. In addition, human-computer solutions designed for severe physical disabilities and lack of speech were studied. The documentary research aimed to analyse the professionals' feedback, verifying the progress using the proposed technologies. On the other hand, the experimental research aimed to use the developed human-computer interfaces, collecting quantitative and

Disability is a complex phenomenon, reflected because of the interaction between the indi‐ viduals and the society in which it lives. It is the result of a deterrent and it can be physical, cognitive, mental, sensory, emotional, developmental, or some combination of these limita‐

Disability is closely related to sensory limitations and emerges when some barriers (physical, communication and information) constrain the participation of individuals in society.

The term "assistive technology" is relatively new and it is used to identify resources, technol‐ ogy and services that contribute to provide or enhance functional abilities of people with disabilities. It includes a wide range of equipment, services and strategies aiming to mitigate

In [2], the authors explore the role of assistive technologies in the lives of people with disabil‐ ities. They define a HAAT model that means Human Activity Assistive Technology model.

earlier stages of life can irreversibly impair intellectual ability.

related to picture books, or textured cards using Braille [4].

high-tech solutions.

174 Cerebral Palsy - Current Steps

process of assistive technology [5].

**2. Assistive technology**

qualitative assessments guiding our future works.

tions [2]. Disability might be present at birth or arise during life.

the problems faced by individuals with disabilities [2].

The components of the HAAT model play an important role to understand the methodologies to design assistive technologies. First, a person needs to perform a certain activity, for example, to communicate. In addition, that activity happens in a particular context, for example, in school. For that particular context, and taking into account the activity, may exist an assistive technology that could assist the individual, such as AAC solutions.

The combination between the activity and its context will determine which skills are required to fully realize the activity, so guiding the design of assistive technologies. This model allows understanding the role of assistive technologies, guiding the design process.

## **3. AAC tool desktop solution**

In this section, we describe the solution presented in [7]. The AAC tool solution, as it was named, was based on communication boards and iconographic symbols, commonly found in AAC. It was designed to help the speech therapist intervention. **Figure 3** shows the software interface. The images shown in this figure are merely illustrative.

This interface works as follows. First, a user selects a desired symbol. Next, it is vocalized and, after that, added to the upper left side of the software interface, **Figure 2**. The symbols' library could be customized for each user.

**Figure 2.** AAC tool desktop interface.

**Figure 3.** Precedence relationship between symbols and categories.

The software adopts strategies to facilitate the symbols choice. Therefore, symbols commonly used are present first, such as people and greetings. Then, the software suggests other symbols according to the previous ones selected. This feature aims to improve communication speed. Suggestions are based on the previous usage of the tool, and it also depends on the settings performed by the therapist or a caregiver.

It is important to notice that the user could autonomously navigate using the automatic scanning feature, selecting the desired symbols. In addition, the automatic scanning time rate can be settled, according to the users' skills.

The symbols are based on categories, allowing constructing a logical sequence according to the syntax of the user's language (i.e. person, action and feelings). A possible sequence of symbols is based on the syntactic Portuguese language, as illustrated in **Figure 3**.

The software uses the "I + WANT + PLAY" structure, because this grammatical construction is commonly employed by specialists in Brazil. However, some other approaches, for example, based on the verb PLAY + I structure could be used instead.

The tool also features predicting sentences based on graph theory [8]. In addition, it considered important guidelines for human-computer interfaces, adapted from WEB content accessibility guidelines, such as in [7].

This way, pictures have text and oral descriptions. This is very important because CP indi‐ viduals have difficulties keeping attention on what happens on the computer screen. In addition, the tool lets to resize letters, according to the user's skills, helping to a better understanding of symbols and texts. Border colours and backgrounds are also configurable, according to the user's needs. This is also very important to facilitate symbols recognition.

The buttons located at the bottom right of the software interface emulate mouse and keyboard functions. For this reason, new hardware interfaces could be added without the need to install specific drivers.

Other issues could be conceived, like a vocabulary with numbers and arithmetic operators for a math class or a specific vocabulary for a chemical class containing the elements of the periodic table, for example.

## **3.1. Evaluation**

**Figure 2.** AAC tool desktop interface.

176 Cerebral Palsy - Current Steps

**Figure 3.** Precedence relationship between symbols and categories.

performed by the therapist or a caregiver.

can be settled, according to the users' skills.

The software adopts strategies to facilitate the symbols choice. Therefore, symbols commonly used are present first, such as people and greetings. Then, the software suggests other symbols according to the previous ones selected. This feature aims to improve communication speed. Suggestions are based on the previous usage of the tool, and it also depends on the settings

It is important to notice that the user could autonomously navigate using the automatic scanning feature, selecting the desired symbols. In addition, the automatic scanning time rate

The symbols are based on categories, allowing constructing a logical sequence according to the syntax of the user's language (i.e. person, action and feelings). A possible sequence of

symbols is based on the syntactic Portuguese language, as illustrated in **Figure 3**.

Students from Special Education Foundation of Santa Catarina—FCEE participated in the study. The volunteers who participated suffer from choreoathetosis, which is a nervous disorder characterized by involuntary and uncontrollable movements. They have preserved the intellectual ability and act as minds trapped into the body [7].

The research sought to analyse the student's performance through a dialogue with and without using the AAC tool. First, the system was presented to the students, enabling them to under‐ stand how to use the tool. Then the efficiency and satisfaction using the AAC software were studied.

To evaluate the system, the speech therapist prepared a dialogue, talking about things that are part of the child's routine, such as family, leisure, friends, etc. The speech therapist initiated the dialogue using the low-tech technologies available at FCEE, such as communication boards. In a second stage, the therapist performed the same dialogue but using the software, instead. This procedure was repeated several times, changing the dialogues.

It should be highlighted that the students answered what they want, but it is expected that the answer should be closely related to the one previously given by using the physical board.

Concerning to the hardware resources, students at FCEE commonly use the devices showed in **Figure 4**. Mouse and keyboard devices are commonly used to interact with computers. Besides the usefulness of such suitable devices, they require considerable effort to be actuated and can cause an earlier fatigue.

**Figure 4.** Adapted devices.

**Figure 5** shows a stapler device, which was adapted to improve the computer access. The adapted stapler was well suited, because of the shape of the child's hands. It considerably diminishes the spent time to select the symbols on the screen, also reducing the fatigue. This device emulates the click and double clicks functions of the mouse.

**Figure 5.** The adapted stapler was a suitable solution.

Symbols selection time rates and errors committed were computed. Typically, students attempt an average rate of 15 symbols selections per minute, when using low-tech communi‐ cation boards. When using the system, those rates were worse, even though, on several occasions, the students achieved similar result. In addition, sometimes no coherent phrases were constructed, but it was observed that error rates gradually decrease with the usage of the interface [7].

In addition, an evaluation was carried out to demonstrate the symbol prediction feature, which is based on previous symbols selections. The goal was to build a phrase and to repeat it several times. Then the spent time to construct each phrase was verified. The tests used an automatic scanning rate of 1 s. **Figure 6** shows that it is possible to decrease the time required to construct new phrases.

**Figure 6.** Performance of the symbol prediction feature.

**Figure 4.** Adapted devices.

178 Cerebral Palsy - Current Steps

**Figure 5** shows a stapler device, which was adapted to improve the computer access. The adapted stapler was well suited, because of the shape of the child's hands. It considerably diminishes the spent time to select the symbols on the screen, also reducing the fatigue. This

Symbols selection time rates and errors committed were computed. Typically, students attempt an average rate of 15 symbols selections per minute, when using low-tech communi‐ cation boards. When using the system, those rates were worse, even though, on several occasions, the students achieved similar result. In addition, sometimes no coherent phrases were constructed, but it was observed that error rates gradually decrease with the usage of the

In addition, an evaluation was carried out to demonstrate the symbol prediction feature, which is based on previous symbols selections. The goal was to build a phrase and to repeat it several times. Then the spent time to construct each phrase was verified. The tests used an automatic scanning rate of 1 s. **Figure 6** shows that it is possible to decrease the time required to construct

device emulates the click and double clicks functions of the mouse.

**Figure 5.** The adapted stapler was a suitable solution.

interface [7].

new phrases.

In addition, speech therapists at FCEE performed qualitative assessments. Interviews evaluate issues related to student's behaviour and performance. Aspects such as simplicity, software interaction, configurability, images quality, screen navigation resources and students' evolution were evaluated as good, following the recommendations in [9].

The specialists conclude that it is easy to understand the operation and principles of the tool. In addition, according to [7], "they registered that a more efficient interaction with the software will be directly related to the complexity of the student needs and, according to their opinion, this represents the greatest challenge".

This software is opened to developers and can be accessed at https://sourceforge.net/projects/ aact/?source=navbar [Accessed: March 26, 2016].

## **4. AAC mobile solution**

After developing the AAC solution for desktops, we think about enhancing the same idea to tablets, applying the solution at Association of Parents and Friends of Exceptional Children (APAE). This section discusses our experience developing the AAC solution for mobile devices.

The problem faced at APAE is that the students with CP also suffer from severe intellectual disability. Therefore, the software AAC tool, developed for desktops, was useless in that context.

For this reason, we redirect our proposal, guided by the HAAT model. Then, a new tool for mobile devices interaction focusing users having intellectual disabilities was designed. The solution concerned about the presentation and organization of content based on accessibility standards [9].

It is worth noting that the development considered accessibility recommendations, according to the W3C Group, July 9, 2009, in particular, the Mobile Web Best Practices (MWBP) [10].

## **4.1. Interface**

The new software guides the work of professionals at APAE. It was designed as an educational strategy, contributing, booth, as a tool to study the intellectual disability and as an AAC strategy.

The app is not by itself decisive to diagnostic a sort of intellectual disability, but it helps in the professional's decision. It should be used along with other international validated tools and theoretical references founded at Diagnostic and Statistical Manual of Mental Disorders (DSM) [11] and American Association of Intellectual Disability (AAIDI), for example.

**Figure 7** shows the initial screen. In order to login, the professional informs its identification and a password. Selecting the "keep connected" option, the specialist may choose to store the password, so that it will no longer be necessary to re-enter it in future accesses.


**Figure 7.** Welcome screen.

When accessing the system, the specialist can create and configure the student profile (**Figure 8**). It is important to notice that the database involves personal data, so it must be treated with all the necessary integrity and security.

**Figure 8.** Students profile.

For this reason, we redirect our proposal, guided by the HAAT model. Then, a new tool for mobile devices interaction focusing users having intellectual disabilities was designed. The solution concerned about the presentation and organization of content based on accessibility

It is worth noting that the development considered accessibility recommendations, according to the W3C Group, July 9, 2009, in particular, the Mobile Web Best Practices (MWBP) [10].

The new software guides the work of professionals at APAE. It was designed as an educational strategy, contributing, booth, as a tool to study the intellectual disability and as an AAC

The app is not by itself decisive to diagnostic a sort of intellectual disability, but it helps in the professional's decision. It should be used along with other international validated tools and theoretical references founded at Diagnostic and Statistical Manual of Mental Disorders (DSM)

**Figure 7** shows the initial screen. In order to login, the professional informs its identification and a password. Selecting the "keep connected" option, the specialist may choose to store the

When accessing the system, the specialist can create and configure the student profile (**Figure 8**). It is important to notice that the database involves personal data, so it must be treated with

[11] and American Association of Intellectual Disability (AAIDI), for example.

password, so that it will no longer be necessary to re-enter it in future accesses.

standards [9].

180 Cerebral Palsy - Current Steps

**4.1. Interface**

strategy.

**Figure 7.** Welcome screen.

all the necessary integrity and security.

The main activity conceived for this app is to study the student's cognitive ability. This is done by selecting and grouping symbols from different categories such as clothing, food, animals, transportation, etc., grouping them according to their relationship within each category.

Before this app, the students had to select, by hand, symbols and context cards randomly spread in a round table. This made the task of selecting them difficult for CP users.

**Figure 9** shows the default categories and symbols configured for this app. The professionals at APAE could add new categories and symbols. In this screen, the student's name can be heard through the speakers.

**Figure 9.** Categories and symbols.

Actions, foods, animals, toys, communication devices, colours, fruits, liquid foods, furniture, vegetables, clothing and means of transportation are the chosen categories (**Figure 9**). In **Figure 8**, a link to the student profile and activities was highlighted in black squares.

The About option, located at the bottom in **Figure 9**, gives information about the student, the APAE professionals and the institutions who collaborate with this research. It is important to remark that all the symbols, feedbacks, texts and sounds can be configured by the professio‐ nals.

**Figure 10** shows the main activity conceived for this app, named Drag and Drop. The main purpose of this activity is to test the cognitive ability of the student by selecting symbols from different categories such as clothing, food, animals, etc., grouping them according to their relationship within each category.

**Figure 10.** Symbols and the related categories in the Drag and Drop activity.

When performing this activity, the student should drag the symbols from different categories, pictured at the top of the screen, dropping them inside the boxes that appear in the lower part of the screen. To this end, the app uses the touch feature, commonly available in mobile devices.

The professionals can configure both the symbols shown at the top of the screen and the symbols that appear at the bottom of the screen. At the end of this activity, the symbols are properly grouped into their respective categories, or not. This test contributes to evaluate intellectual disability.

**Figure 11** shows the symbols used in the Foods category. An auditory feedback can be associated to each symbol.


**Figure 11.** Symbols related to the Foods category.

Actions, foods, animals, toys, communication devices, colours, fruits, liquid foods, furniture, vegetables, clothing and means of transportation are the chosen categories (**Figure 9**). In **Figure**

The About option, located at the bottom in **Figure 9**, gives information about the student, the APAE professionals and the institutions who collaborate with this research. It is important to remark that all the symbols, feedbacks, texts and sounds can be configured by the professio‐

**Figure 10** shows the main activity conceived for this app, named Drag and Drop. The main purpose of this activity is to test the cognitive ability of the student by selecting symbols from different categories such as clothing, food, animals, etc., grouping them according to their

When performing this activity, the student should drag the symbols from different categories, pictured at the top of the screen, dropping them inside the boxes that appear in the lower part of the screen. To this end, the app uses the touch feature, commonly available in mobile devices.

The professionals can configure both the symbols shown at the top of the screen and the symbols that appear at the bottom of the screen. At the end of this activity, the symbols are properly grouped into their respective categories, or not. This test contributes to evaluate

**Figure 11** shows the symbols used in the Foods category. An auditory feedback can be

**8**, a link to the student profile and activities was highlighted in black squares.

nals.

182 Cerebral Palsy - Current Steps

relationship within each category.

intellectual disability.

associated to each symbol.

**Figure 10.** Symbols and the related categories in the Drag and Drop activity.

**Figure 12** shows an activity specially conceived for CP users. This activity was named Hit the Target and aims to analyse the motor skills of the student.

**Figure 12.** Hit the Target activity.

The goal of this activity is to measure the time the user spent to select the letter at the upper left of the screen, hitting the same letter at the lower centre of the screen.

To this end it was used the Touch Listener feature in the Android operating system [12]. The Touch Listener feature allows the programmer to create new functions for each move classi‐ fication, which are then processed whenever a movement event occurs. Among them are the touch itself, identified by the action ACTION\_DOWN code and dragging, identified by ACTION\_MOVE code.

These data may subsequently be considered in the Drag and Drop activity in order to allow users with motor disorders use the application with autonomy.

**Figure 13** shows other kind of activities that can be done using the app. In this case, a speech therapist can work with isolated symbols to develop speech and auditory cognitive abilities, such as in speech therapy sessions, for example. It should be remarked that new symbols and sounds could be included or configured to attend users in different situations.

**Figure 13.** Working with the Foods category.

#### **4.2. Evaluation**

Nowadays, the app is being evaluated at APAE, using the system usability scale (SUS) questionnaire [13]. The APAE specialists are registering their perception about the student's performance using the tool. The SUS will highlight the positives and negatives aspects of the system.

According to [13], (at least) ten statements, being evaluated on a scale from 1 to 5, should compose the survey by establishing a balance between positive and negative assertions. "The Software operation is simple" and "The Software often induce errors" are examples of these assertions.

Other assertions are related to the complexity and, confidence using the system, and other usability issues. This questionnaire is under evaluation at APAE.

The app will indicate the degree of physical and cognitive involvement of each child, com‐ puting separately the questionnaires and grouping them according to similar cognitive and motor skills.

Preliminary evaluation shows the following contributions: easy handling application, good images contrast, easy calibration and automatic adjust of the touch screen time; useful for AAC; several language stimulation possibilities, including voice recording; and rich in visual stimuli.

Still, we have to improve images resolution, enhance the resources for speech therapy activities and insert new basic functions of the language.

The AAC mobile software is also opened to developers and can be accessed at https:// sourceforge.net/projects/aact-mobile/?source=navbar [Accessed: March 26, 2016].

## **5. New study**

**Figure 13** shows other kind of activities that can be done using the app. In this case, a speech therapist can work with isolated symbols to develop speech and auditory cognitive abilities, such as in speech therapy sessions, for example. It should be remarked that new symbols and

Nowadays, the app is being evaluated at APAE, using the system usability scale (SUS) questionnaire [13]. The APAE specialists are registering their perception about the student's performance using the tool. The SUS will highlight the positives and negatives aspects of the

According to [13], (at least) ten statements, being evaluated on a scale from 1 to 5, should compose the survey by establishing a balance between positive and negative assertions. "The Software operation is simple" and "The Software often induce errors" are examples of these

Other assertions are related to the complexity and, confidence using the system, and other

The app will indicate the degree of physical and cognitive involvement of each child, com‐ puting separately the questionnaires and grouping them according to similar cognitive and

Preliminary evaluation shows the following contributions: easy handling application, good images contrast, easy calibration and automatic adjust of the touch screen time; useful for AAC; several language stimulation possibilities, including voice recording; and rich in visual stimuli.

Still, we have to improve images resolution, enhance the resources for speech therapy activities

usability issues. This questionnaire is under evaluation at APAE.

and insert new basic functions of the language.

sounds could be included or configured to attend users in different situations.

**Figure 13.** Working with the Foods category.

**4.2. Evaluation**

184 Cerebral Palsy - Current Steps

system.

assertions.

motor skills.

A new study is being performed using a brain-computer interface (BCI) [14]. The development is based on the Emotiv Epoc [15]. In particular, we are using EEG signals [16]. This new usercomputer interaction is being integrated with the two software solutions previously described, emulating mouse and keyboard commands.

At this moment, a software pilot solution was designed to test the computer interaction with CP individuals (**Figure 14**). Our goal is to find metrics, such as success, errors, time rates, number of phrases construction, satisfaction and others parameters that will be identified when performing the next stages of this research.


**Figure 14.** PhraseForm software interface.

The PhraseForm software validates the basic headset functions of the Emotiv Epoc SDK (Software Development Kit). The SDK links users and the Emotiv Epoc, processing the electrical signals coming from the headset. The PhraseForm software emulates mouse and keyboard commands, as delete or line break, for example, also selecting characters on the screen in order to form sentences.

The software looks for the best actions to be captured using the EEG signals. Based on this interface, the BCI technique is being validated by CP individuals.

**Figure 14** shows the FraseForm user-application interface. Actions such as blink, show teeth, eyebrow, frowning, laugh, neutral, smile, etc., could be configured to interact with the software, selecting or deleting characters. Speech therapist is guiding the process of select the best actions choice for each student.

Nowadays this study is performed at FCEE. Preliminary results promise the access to com‐ puter resources with autonomy by CP individuals. **Figure 15** shows a CP volunteer using the system.

**Figure 15.** CP volunteer testing the BCI.

## **6. Conclusions**

This work discusses our experience developing AAC solutions for students with motor and communication disorders, which is commonly found in cases of cerebral palsy. The students attend the Special Education Foundation of Santa Catarina—FCEE and Association of Parents and Friends of Exceptional Children (APAE) in Brazil.

Our first experience was developed at FCEE. The AAC tool solution features characteristics that are considered relevant to the design of AAC systems. It considered several recommended guidelines to develop human-computer interfaces, adapted from WEB content accessibility.

Using the software, symbols can be selected from a pre-configured vocabulary, inserting them in a designated area. Phrases constructions are based on symbols and their respective catego‐ ries. This allows mounting a logical sequence according to the syntax of the user's language. We adopt a sequence based on syntactic Portuguese language. Iconographic symbols convey needs, wishes, desires and ideas.

The study validates symbol suggestion features, demonstrating the efficiency of this approach for assisting sentences construction. There are also presented qualitative assessments from speech therapists.

The second study was developed at APAE, together with the professionals and students who attend this institution. Educators, speech therapists, psychologists and occupational therapists took part in this new study.

The app features an alternative and augmentative communication tool for children having CP, but not restricted to this public. The solution was designed to assist professionals who act in special education assessing the intellectual disability. The app is based on the MWBP accessi‐ bility recommendations.

The AAC mobile supports the assessment of students with suspected disabilities. It encom‐ passes various activities/strategies within just one application. It also explores basic functions of language and its categories such as colours, animals and everyday objects, for example, contributing to the speech therapy.

The evaluation process using the system usability scale (SUS) is still under construction, but preliminary results showed its usefulness to study the intellectual disability, which is also useful as an alternative and augmentative communication tool.

This app cannot be considered, by itself, as the only key to diagnose intellectual disability, because there are internationally validated tools to this end. Instead, it configures a new way to interact with children with CP using the technological advances. Nowadays, we are studying new ways of interaction with computers and mobile devices using eye tracking and electroencephalography.

This research deals with a set of accessibility guidelines that benefit researchers and practi‐ tioners, giving more evidence about the design of AAC computer-based solutions for people with limited speech or language skills, who are the centre of these solutions. In this work, the HAAT model guides the design of such assistive resources.

Preliminary results in this field promise alternative ways to access computer resources, promoting autonomy, giving more evidence about the design of AAC computer and hard‐ ware-based solutions devoted to people having reduced language skills and motor disorders. It is important to remark that the AAC tools we presented are intended to be used in the school, according to the ethics protocol of this research.

## **Acknowledgements**

**Figure 14** shows the FraseForm user-application interface. Actions such as blink, show teeth, eyebrow, frowning, laugh, neutral, smile, etc., could be configured to interact with the software, selecting or deleting characters. Speech therapist is guiding the process of select the

Nowadays this study is performed at FCEE. Preliminary results promise the access to com‐ puter resources with autonomy by CP individuals. **Figure 15** shows a CP volunteer using the

This work discusses our experience developing AAC solutions for students with motor and communication disorders, which is commonly found in cases of cerebral palsy. The students attend the Special Education Foundation of Santa Catarina—FCEE and Association of Parents

Our first experience was developed at FCEE. The AAC tool solution features characteristics that are considered relevant to the design of AAC systems. It considered several recommended guidelines to develop human-computer interfaces, adapted from WEB content accessibility.

Using the software, symbols can be selected from a pre-configured vocabulary, inserting them in a designated area. Phrases constructions are based on symbols and their respective catego‐ ries. This allows mounting a logical sequence according to the syntax of the user's language. We adopt a sequence based on syntactic Portuguese language. Iconographic symbols convey

best actions choice for each student.

**Figure 15.** CP volunteer testing the BCI.

needs, wishes, desires and ideas.

and Friends of Exceptional Children (APAE) in Brazil.

**6. Conclusions**

system.

186 Cerebral Palsy - Current Steps

The National Council of Scientific and Technological Development (CNPq) support this research under the 458672 process. In addition, the Foundation for Supporting Research and Innovation in Santa Catarina (FAPESC) supported this research under grant 2015TR300. It is also been covered by the Ethics Committee on Human Research.

## **Author details**

Alejandro Rafael Garcia Ramirez1\*, Cleiton Eduardo Saturno1 , Mauro José Conte1 , Jéferson Fernandes da Silva1 , Mísia Farhat2 , Fabiana de Melo Giacomini Garcez Garcez3 , Ana Carolina Savall2 and Elaine Carmelita Piucco2

\*Address all correspondence to: garcia.ramirez@gmail.com

1 Applied Computing Department, University of Vale de Itajaí, Itajaí, Brazil

2 Assistive Technology Department, Foundation for Special Education in Santa Catarina – FCEE, São José, Brazil

3 Augmentative and Alternative Communication Department, Association of Parents and Friends of Exceptional Children, Florianópolis, Brazil

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**Author details**

188 Cerebral Palsy - Current Steps

Ana Carolina Savall2

FCEE, São José, Brazil

**References**

Jéferson Fernandes da Silva1

Alejandro Rafael Garcia Ramirez1\*, Cleiton Eduardo Saturno1

\*Address all correspondence to: garcia.ramirez@gmail.com

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, Mísia Farhat2

and Elaine Carmelita Piucco2

1 Applied Computing Department, University of Vale de Itajaí, Itajaí, Brazil

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3 Augmentative and Alternative Communication Department, Association of Parents and

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,


## *Edited by Mintaze Kerem Gunel*

Nowadays, cerebral palsy (CP) rehabilitation, along with medical and surgical interventions in children with CP, leads to better motor and postural control and can ensure ambulation and functional independence. In achieving these improvements, many modern practices may be used, such as comprehensive multidisciplinary assessment, clinical decision making, multilevel surgery, botulinum toxin applications, robotic ambulation applications, treadmill, and other walking aids to increase the quality and endurance of walking. Trainings are based on neurodevelopmental therapy, muscle training and strength applications, adaptive equipment and orthotics, communication, technological solves, and many others beyond the scope of this book.

In the years of clinical and academic experiences, children with cerebral palsy have shown us that the world needs a book to give clinical knowledge to health professionals regarding these important issue. This book is an attempt to fulfill and to give ''current steps'' about CP. The book is intended for use by physicians, therapists, and allied health professionals who treat/rehabilitate children with CP. We focus on the recent concepts in the treatment of body and structure problems and describe the associated disability, providing suggestions for further reading. All authors presented the most frequently used and accepted treatment methods with scientifically proven efficacy and included references at the end of each chapter.

Cerebral Palsy - Current Steps

Cerebral Palsy

Current Steps

*Edited by Mintaze Kerem Gunel*

Photo by Mukhina1 / iStock