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No comment; International audience; CCBYNCNDMovement-based video games can provide engaging practice for repetitive therapeutic gestures towards improving manual ability in youth with cerebral palsy (CP). However, home-based gesture calibration and classification is needed to personalize therapy and ensure an optimal challenge point. Nineteen youth with CP controlled a video game during a 4-week home-based intervention using therapeutic hand gestures detected via electromyography and inertial sensors. The in-game calibration and classification procedure selects the most discriminating, person-specific features using random forest classification. Then, a support vector machine is trained with this feature subset for in-game interaction. The procedure uses features intended to be sensitive to signs of CP and leverages directional statistics to characterize muscle activity around the forearm. Home-based calibration showed good agreement with video verified ground truths (0.86±0.11, 95%CI=0.93-0.97). Across participants, classifier performance (F1-score) for the primary therapeutic gesture was 0.90±0.05 (95%CI=0.87-0.92) and, for the secondary gesture, 0.82±0.09 (95%CI=0.77-0.86). Features sensitive to signs of CP were significant contributors to classification and correlated to wrist extension improvement and increased practice time. This study contributes insights for classifying gestures in people with CP and demonstrates a new gesture controller to facilitate home-based therapy gaming.

Cerebral palsy (CP) is the most common childhood disability. CP can impact a person’s motor control, perception, intellectual function, ability to perform daily activities and participation in society. Persons with CP frequently have impaired hand function affecting motor activities. Usually improving motor activities require frequent and intense use of the affected hand. Importantly, biofeedback, where a person receives information about their body state can help improve function by informing the individual to how their body is moving. This type of information can readily be delivered through interactive computer play (ICP) technologies, that is where one interacts with virtual objects using therapeutic movements, to motivate highly repetitive practice at home.In this thesis an evidence-based biofeedback strategy is identified by systematic review and embedded into a novel ICP technology via co-creation with individuals with CP and clinicians. Feasibility of the resulting technology is evaluated by 19 young people with CP during a 1-month home-based intervention.The systematic review showed generally positive but very low quality of evidence due to the number of non-controlled studies and the heterogeneity of outcome measures. While interventions consistently showed improvements in measures of motor activity pre-post-intervention, they frequently implemented characteristics of biofeedback incongruent with motor learning principles expected to facilitate sustained results. Interventions using biofeedback would be improved by using a strategy that facilitates self-regulation, varies in timing and presentation, and closely connects the game and movement goals.The co-creation process described in this thesis resulted in design recommendations and practical tools for integrating biofeedback into therapy games. These are compiled in an infographic and detailed in tables to support interdisciplinary knowledge sharing with different audiences. Participant use of the biofeedback implementation proved efficient (i.e. participants reduced compensatory arm movements by 10.2±4.0%), effective (i.e. participants made higher quality gestures over time) and engaging (i.e. participants reviewed biofeedback 65.4±22.4% of the time). Participants found the game usable and enjoyable. Home-based calibration showed good agreement with video verified true labels (0.86 ± 0.11, 95%CI = 0.93 - 0.97). Across participants, classifier accuracy in the target therapeutic gesture was 0.91±0.07, 95%CI = 0.87 - 0.94 (0.80±0.14, 95%CI = 0.73 - 0.87 and 0.75±0.23, 95%CI = 0.64 - 0.86 in secondary gestures). Features expected to be sensitive to neuromotor signs of CP were significant contributors to classification and correlated with practice wrist extension improvement.Evaluation of the a priori feasibility success criteria showed that the 1-month home-based intervention protocol was feasible with minor modifications. Recruitment response (31%) and assessment completion (84%) rates were good and 74% of participants reached self-identified practice goals and 83% of technical issues were resolved immediately. Moderate effects were observed in Body Function measures (active wrist extension: SMD = 1.82, 95%CI = 0.85 – 2.78; Grip Strength: SMD = 0.63, 95%CI = 0.65 – 1.91; Box and Blocks: Hedge’s g = 0.58, 95%CI = -0.11 – 1.27) and small-moderate effects in Activities and Participation measures (AHA: Hedge’s g = 0.29, 95%CI = -0.39 – 0.97, COPM: r = 0.60, 95%CI = 0.13 – 0.82, SEAS: r = 0.24, 95%CI = -0.25 – 0.61). A definitive RCT is warranted following improvements in technical robustness and increased clinician involvement in the protocol.This thesis provides strategies and practical tools to enhance the efficacy of ICP technologies as a home-based support to manual therapy activities.; La paralysie cérébrale (PC) est une déficience liée à une blessure ou une anomalie du cerveau survenant au moment de la naissance et qui persiste de l'enfance à l'âge adulte. La PC peut influer sur le contrôle moteur et la capacité à effectuer des activités quotidiennes, et par conséquent les liens sociaux. Les personnes atteintes de PC voient leurs fonctions manuelles perturbées, ce qui impacte l’ensemble des activités motrices. Devant la diversité des atteintes motrices que présentent les personnes atteintes de PC, il apparaît important de considérer les stratégies de rééducation fonctionnelle visant l'amélioration des capacités manuelles et des performances motrices.Ces stratégies d'intervention impliquent généralement des exercices intenses et fréquents sur le membre supérieur atteint. Cette approche traditionnelle ne facilite pas la concentration, la motivation et la réalisation du mouvement. A l’inverse, les retours sensoriels peuvent permettre d’accroître la perception et le contrôle du mouvement réalisé, ainsi que la motivation pendant la durée de l’exercice. Le retour sensoriel, ou biofeedback, est une information sur une performance motrice communiquée à l'individu. Cette information peut être transmise à travers un jeu vidéo à visée rééducative, appelé également jeu sérieux, ou serious game.Dans une première partie, une revue systématique a été conduite sur l’impact des retours sensoriels chez les personnes atteintes de PC. Cette synthèse des connaissances a montré une qualité d’éléments probants généralement positive mais très faible en raison du manque de standardisation des études ainsi que de l'hétérogénéité des mesures. Bien que ce type d’interventions ait montré des améliorations dans les mesures de l'activité motrice (avant-après), les retours sensoriels proposés ne semblent pas en adéquation avec les principes d'apprentissage moteur. Ces interventions pourraient être améliorées en utilisant des retours sensoriels qui facilitent l'autorégulation, qui varient dans la forme et dans le temps, et qui relient étroitement but du jeu et objectif thérapeutique du mouvement.Dans une seconde partie, le processus de co-construction du jeu sérieux a permis d’établir des recommandations futures pour la conception et l’intégration de retour sensoriel dans les jeux sérieux. Ces recommandations ont été détaillées dans des tableaux et compilées dans une infographie afin de partager ces connaissances scientifiques interdisciplinaires. L’étude de validation expérimentale a démontré que la méthode proposée réduisait la variabilité motrice (réduction des mouvements compensatoires des bras de 10,2±4,0%), améliorait la qualité des mouvements (meilleure qualité des gestes au fil du temps), et permettait de maintenir l’attention (les participants ont examiné ls retours sensoriels pendant 65,4±22,4% du temps). L’algorithme de reconnaissance des mouvements, calibré à domicile, est apparu suffisamment robuste suite à une étape de vérification des mouvements par vidéo (0,86±0,11, 95%CI=0,93 - 0,97). En moyenne, la précision de la reconnaissance du mouvement thérapeutique ciblé était de 0,91±0,07, de 95%CI=0,87 - 0,94. Les paramètres musculaires attendus comme sensibles aux signes neuromoteurs de la PC se sont révélés être des indicateurs significatifs pour la classification des mouvements.L'évaluation des critères de faisabilité définis a priori a montré que le protocole d'intervention à domicile d'un mois était réalisable avec des modifications mineures. Le taux de réponse au recrutement (31%) et de complétion de l'évaluation (84%) étaient bons. Des effets modérés ont été observés dans les mesures des capacités motrices et des effets faibles à modérés ont été obtenus dans les mesures de l’activité et de la participation. Bien que l’amélioration de la robustesse technique et l’implication accrue des cliniciens dans le protocole soient nécessaires, un essai contrôlé randomisé définitif peut être envisagé.

Cerebral palsy (CP) is the most common childhood disability. CP can impact a person’s motor control, perception, intellectual function, ability to perform daily activities and participation in society. Persons with CP frequently have impaired hand function affecting motor activities. Usually improving motor activities require frequent and intense use of the affected hand. Importantly, biofeedback, where a person receives information about their body state can help improve function by informing the individual to how their body is moving. This type of information can readily be delivered through interactive computer play (ICP) technologies, that is where one interacts with virtual objects using therapeutic movements, to motivate highly repetitive practice at home.In this thesis an evidence-based biofeedback strategy is identified by systematic review and embedded into a novel ICP technology via co-creation with individuals with CP and clinicians. Feasibility of the resulting technology is evaluated by 19 young people with CP during a 1-month home-based intervention.The systematic review showed generally positive but very low quality of evidence due to the number of non-controlled studies and the heterogeneity of outcome measures. While interventions consistently showed improvements in measures of motor activity pre-post-intervention, they frequently implemented characteristics of biofeedback incongruent with motor learning principles expected to facilitate sustained results. Interventions using biofeedback would be improved by using a strategy that facilitates self-regulation, varies in timing and presentation, and closely connects the game and movement goals.The co-creation process described in this thesis resulted in design recommendations and practical tools for integrating biofeedback into therapy games. These are compiled in an infographic and detailed in tables to support interdisciplinary knowledge sharing with different audiences. Participant use of the biofeedback implementation proved efficient (i.e. participants reduced compensatory arm movements by 10.2±4.0%), effective (i.e. participants made higher quality gestures over time) and engaging (i.e. participants reviewed biofeedback 65.4±22.4% of the time). Participants found the game usable and enjoyable. Home-based calibration showed good agreement with video verified true labels (0.86 ± 0.11, 95%CI = 0.93 - 0.97). Across participants, classifier accuracy in the target therapeutic gesture was 0.91±0.07, 95%CI = 0.87 - 0.94 (0.80±0.14, 95%CI = 0.73 - 0.87 and 0.75±0.23, 95%CI = 0.64 - 0.86 in secondary gestures). Features expected to be sensitive to neuromotor signs of CP were significant contributors to classification and correlated with practice wrist extension improvement.Evaluation of the a priori feasibility success criteria showed that the 1-month home-based intervention protocol was feasible with minor modifications. Recruitment response (31%) and assessment completion (84%) rates were good and 74% of participants reached self-identified practice goals and 83% of technical issues were resolved immediately. Moderate effects were observed in Body Function measures (active wrist extension: SMD = 1.82, 95%CI = 0.85 – 2.78; Grip Strength: SMD = 0.63, 95%CI = 0.65 – 1.91; Box and Blocks: Hedge’s g = 0.58, 95%CI = -0.11 – 1.27) and small-moderate effects in Activities and Participation measures (AHA: Hedge’s g = 0.29, 95%CI = -0.39 – 0.97, COPM: r = 0.60, 95%CI = 0.13 – 0.82, SEAS: r = 0.24, 95%CI = -0.25 – 0.61). A definitive RCT is warranted following improvements in technical robustness and increased clinician involvement in the protocol.This thesis provides strategies and practical tools to enhance the efficacy of ICP technologies as a home-based support to manual therapy activities., La paralysie cérébrale (PC) est une déficience liée à une blessure ou une anomalie du cerveau survenant au moment de la naissance et qui persiste de l'enfance à l'âge adulte. La PC peut influer sur le contrôle moteur et la capacité à effectuer des activités quotidiennes, et par conséquent les liens sociaux. Les personnes atteintes de PC voient leurs fonctions manuelles perturbées, ce qui impacte l’ensemble des activités motrices. Devant la diversité des atteintes motrices que présentent les personnes atteintes de PC, il apparaît important de considérer les stratégies de rééducation fonctionnelle visant l'amélioration des capacités manuelles et des performances motrices.Ces stratégies d'intervention impliquent généralement des exercices intenses et fréquents sur le membre supérieur atteint. Cette approche traditionnelle ne facilite pas la concentration, la motivation et la réalisation du mouvement. A l’inverse, les retours sensoriels peuvent permettre d’accroître la perception et le contrôle du mouvement réalisé, ainsi que la motivation pendant la durée de l’exercice. Le retour sensoriel, ou biofeedback, est une information sur une performance motrice communiquée à l'individu. Cette information peut être transmise à travers un jeu vidéo à visée rééducative, appelé également jeu sérieux, ou serious game.Dans une première partie, une revue systématique a été conduite sur l’impact des retours sensoriels chez les personnes atteintes de PC. Cette synthèse des connaissances a montré une qualité d’éléments probants généralement positive mais très faible en raison du manque de standardisation des études ainsi que de l'hétérogénéité des mesures. Bien que ce type d’interventions ait montré des améliorations dans les mesures de l'activité motrice (avant-après), les retours sensoriels proposés ne semblent pas en adéquation avec les principes d'apprentissage moteur. Ces interventions pourraient être améliorées en utilisant des retours sensoriels qui facilitent l'autorégulation, qui varient dans la forme et dans le temps, et qui relient étroitement but du jeu et objectif thérapeutique du mouvement.Dans une seconde partie, le processus de co-construction du jeu sérieux a permis d’établir des recommandations futures pour la conception et l’intégration de retour sensoriel dans les jeux sérieux. Ces recommandations ont été détaillées dans des tableaux et compilées dans une infographie afin de partager ces connaissances scientifiques interdisciplinaires. L’étude de validation expérimentale a démontré que la méthode proposée réduisait la variabilité motrice (réduction des mouvements compensatoires des bras de 10,2±4,0%), améliorait la qualité des mouvements (meilleure qualité des gestes au fil du temps), et permettait de maintenir l’attention (les participants ont examiné ls retours sensoriels pendant 65,4±22,4% du temps). L’algorithme de reconnaissance des mouvements, calibré à domicile, est apparu suffisamment robuste suite à une étape de vérification des mouvements par vidéo (0,86±0,11, 95%CI=0,93 - 0,97). En moyenne, la précision de la reconnaissance du mouvement thérapeutique ciblé était de 0,91±0,07, de 95%CI=0,87 - 0,94. Les paramètres musculaires attendus comme sensibles aux signes neuromoteurs de la PC se sont révélés être des indicateurs significatifs pour la classification des mouvements.L'évaluation des critères de faisabilité définis a priori a montré que le protocole d'intervention à domicile d'un mois était réalisable avec des modifications mineures. Le taux de réponse au recrutement (31%) et de complétion de l'évaluation (84%) étaient bons. Des effets modérés ont été observés dans les mesures des capacités motrices et des effets faibles à modérés ont été obtenus dans les mesures de l’activité et de la participation. Bien que l’amélioration de la robustesse technique et l’implication accrue des cliniciens dans le protocole soient nécessaires, un essai contrôlé randomisé définitif peut être envisagé.

Microsoft word document. PRISMA-P 2015 Checklist. This additional file is the completed PRISMA-P checklist used for the development of the protocol. (DOCX 31.7 kb)

Determining tendon tension in the finger is essential to understanding forces that may be detrimental to hand function. Direct measurement is not feasible, making biomechanical modelling the best way to estimate these forces. In this study, the intrinsic muscles and extensor mechanism were added to an existing model of the index finger, and as such, it has been named the Intrinsic model. The Intrinsic model of the index finger has 4 degrees of freedom and 7 muscles (with 14 components). Muscle properties and paths for all extrinsic and intrinsic muscles were derived from the literature. Two models were evaluated, the Intrinsic model and the model it was adapted from (identified in this thesis as the Extrinsic-only model). To complement the model, multiple static optimization solution methods were also developed that allowed for EMG-constrained solutions and applied objective functions to promote co-contraction. To test the models and solution methods, 10 participants performed 9 static pressing tasks at 3 force levels, and 5 free motion dynamic tasks at 2 speeds. Kinematics, contact forces, and EMG (from the extrinsic muscles and first dorsal interosseous) were collected. For all solution methods, muscle activity predicted using the Intrinsic model was compared to activity from the model currently available through open-source software (OpenSim). Just by using the Intrinsic model, co-contraction increased by 16% during static palmar pressing tasks. The EMG-constrained solution methods gave a smaller difference between predicted and experimental activity compared to the optimization-only approach (p < 0.03). The model and solution methods developed in this thesis improve co-contraction and tendon tension estimates in the finger. As such, this work contributes to our understanding of the control of the hand and the forces that may be detrimental to hand function. Thesis Master of Science (MSc)

Purpose: The purpose of this study is to evaluate the quality of evidence of biofeedback interventions aimed at improving motor activities in people with Cerebral Palsy (CP). Second, to describe the relationship between intervention outcomes and biofeedback characteristics. Methods: Eight databases were searched for rehabilitation interventions that provided external feedback and addressed motor activities. Two reviewers independently assessed and extracted data. The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework was used to evaluate quality of evidence for outcome measures related to two International Classification of Functioning, Disability and Health (ICF) chapters. Results: Fifty-seven studies were included. There were 53 measures related Activities and Participation and 39 measures related to Body Functions. Strength of evidence was “Positive, Very-Low” due to the high proportion of non-controlled studies and heterogeneity of measures. Overall, 79% of studies and 63% of measures showed improvement post-intervention. Counter to motor learning theory recommendations, most studies provided feedback consistently and concurrently throughout the intervention regardless of the individual’s desire or progress. Conclusion: Heterogeneous interventions and poor study design limit the strength of biofeedback evidence. A thoughtful biofeedback paradigm and standardized outcome toolbox can strengthen the confidence in the effect of biofeedback interventions for improving motor rehabilitation for people with CP.Implications for RehabilitationBiofeedback can improve motor outcomes for people with Cerebral Palsy.If given too frequently, biofeedback may prevent the client from learning autonomously.Use consistent and concurrent feedback to improve simple/specific motor activities.Use terminal feedback and client-directed feedback to improve more complex/general motor activities. Biofeedback can improve motor outcomes for people with Cerebral Palsy. If given too frequently, biofeedback may prevent the client from learning autonomously. Use consistent and concurrent feedback to improve simple/specific motor activities. Use terminal feedback and client-directed feedback to improve more complex/general motor activities.