Piia Haakana

Background: Maintaining and improving motor function is essential in the rehabilitation of children with cerebral palsy (CP). Stretching is traditionally used to prevent muscle tightness and contractures to improve movement patterns in children with CP. Fascial manipulation (FM) is an increasingly used manual therapy method for movement difficulties associated with CP. However, evidence for FM remains limited, and its benefits over conventional stretching are unclear. A pilot randomized controlled trial (RCT) is warranted to assess the feasibility and acceptability of a definitive trial comparing FM with stretching. This study protocol describes a pilot randomized controlled feasibility trial comparing FM and stretching in children with CP to inform the design and conduct of a future definitive RCT. Objective: The primary objective is to assess the feasibility and acceptability of the trial procedures and interventions. This includes evaluating recruitment and retention rates, intervention adherence, completion rates for outcome assessments, and the perceived impact of the interventions on children’s daily functioning and participation. The secondary objective is to explore the preliminary acute and longitudinal effects of FM, compared with traditional stretching, on walking performance, gait biomechanics, joint mobility, and the variability in these outcome measures. Methods: This pilot RCT will include 20 children aged 7 to 14 years with spastic CP, randomized to an FM intervention group (n=10) and a stretching group (n=10). Both groups will receive 1 treatment session per week for 8 weeks. Feasibility and acceptability will be assessed using quantitative measures of recruitment and retention, intervention adherence, and completion of outcome assessments, complemented by semistructured interviews with caregivers and the children’s regular physiotherapists to explore perceived changes in the children’s daily functioning and participation, and their experiences of the interventions. Secondary outcomes include the 6-minute walk test (6MWT), walking metabolic cost, gait biomechanics, ankle spasticity, muscle activity, joint stiffness, and functional mobility in daily life. Acute outcomes will be assessed before and after the first intervention session, while longitudinal outcomes will be assessed at baseline and following the 8-week intervention period. Results: Recruitment of participants began in October 2024, with 3 additional participants required to reach the target sample size. Results are expected to be published in 2027. Conclusions: This pilot RCT will provide essential feasibility data and preliminary estimates of potential treatment effects to inform the design of a future adequately powered RCT. To our knowledge, evidence regarding the effects of FM on gait, mobility, and function in children with CP remains limited. This study aims to contribute to the development of evidence-based rehabilitation strategies for children with CP.

Paired associative stimulation (PAS) is a combination of transcranial magnetic stimulation (TMS) and peripheral nerve stimulation (PNS). PAS can induce long‐term potentiation (LTP)‐like plasticity in humans, manifested as motor‐evoked potential (MEP) enhancement. We have developed a variant of PAS (“high‐PAS”), which consists of high‐frequency PNS and high‐intensity TMS and targets spinal plasticity and promotes rehabilitation after spinal cord injury (SCI). Vagus nerve stimulation (VNS) promotes LTP‐like plasticity and enhances recovery in SCI and stroke in humans and animals when combined with repetitive motor training. We combined high‐PAS with simultaneous noninvasive transcutaneous auricular VNS (aVNS) to determine if aVNS enhances the extent of PAS‐induced MEP amplitude increase. Sixteen healthy participants were stimulated for 20 min in four different sessions (PAS, PAS + aVNS, PAS + shamVNS, and aVNS) in a randomized single‐blind setup. MEPs were measured before, immediately after, and at 30, 60, and 90 min post‐stimulation. Stimulation protocols with PAS significantly potentiated MEPs (p = 0.005) when compared with aVNS (p = 0.642). Although not significant, MEP enhancement observed after PAS (43.5%) is further increased by aVNS (49.7%) and electrical earlobe stimulation (63.9%). Our aVNS setup failed to significantly enhance the effect of PAS, but sham VNS revealed a trend towards enhanced plasticity. Optimization of auricular VNS stimulation setup is required for possible tests of patients with SCI.

Healthy people can walk nearly effortlessly thanks to their instinctively adaptive gait patterns that tend to minimize metabolic energy consumption. However, the economy of gait is severely impaired in many neurological disorders such as stroke or cerebral palsy (CP). Moreover, self-selected asymmetry of impaired gait does not seem to unequivocally coincide with the minimal energy cost, suggesting the presence of other adaptive origins. Here, we used hemiparetic CP gait as a model to test the hypothesis that pathological asymmetric gait patterns are chosen to equalize the relative muscle efforts between the affected and unaffected limbs. We determined the relative muscle efforts for the ankle and knee extensors by relating extensor joint moments during gait to maximum moments obtained from all-out hopping reference test. During asymmetric CP gait, the unaffected limb generated greater ankle (1.36±0.15 vs 1.17±0.16 Nm/kg, p = 0.002) and knee (0.74±0.33 vs 0.44±0.19 Nm/kg, p = 0.007) extensor moments compared with the affected limb. Similarly, the maximum moment generation capacity was greater in the unaffected limb versus the affected limb (ankle extensors: 1.81±0.39 Nm/kg vs 1.51±0.34 Nm/kg, p = 0.033; knee extensors: 1.83±0.37 Nm/kg vs 1.34±0.38 Nm/kg, p = 0.021) in our force reference test. As a consequence, no differences were found in the relative efforts between unaffected and affected limb ankle extensors (77±12% vs 80±16%, p = 0.69) and knee extensors (41±17% vs 38±23%, p = 0.54). In conclusion, asymmetric CP gait resulted in similar relative muscle efforts between affected and unaffected limbs. The tendency for effort equalization may thus be an important driver of self-selected gait asymmetry patterns, and consequently advantageous for preventing fatigue of the weaker affected side musculature.