External visual and auditory feedback using a system that exercises the upper limbs may improve praxis — the ability to conceptualize, plan, and execute unfamiliar motor movements — in children with hemiplegic cerebral palsy, according to a case report.

The study, “Improvement of Praxis Skills in Children with Hemiplegic Cerebral Palsy by Using New Trend of Augmented Visual and Auditory Feedback Training: A Case Report,” was published in the Open Journal of Therapy and Rehabilitation.

Spastic hemiplegia is the most common subtype of cerebral palsy, accounting for more than 38 percent of all cases. It affects movement on only one side of the body, with the arm typically being more affected than the leg.

Children with spastic hemiplegic cerebral palsy frequently have impaired control of muscle tone, spasticity — continuous muscle contraction, which causes muscle stiffness or tightness — poor praxis, and intellectual impairment.

The processes of perception and reflection — derived from a person’s own sensory systems — that allow a person to adapt his or her movements are often impaired in children with spastic hemiplegia.

Augmented or external feedback provided by an individual or device has been shown to improve motor skills and learning, and is frequently used in the rehabilitation of people with neurological disorders. This type of feedback is thought to help the person achieve his or her goal more quickly, and increase motivation levels and the probability the person will repeat the activity.

Previous studies have shown the clinical benefits of auditory or visual external feedback in drawing tasks, upper limb performance and hand function, and calf muscle contraction in children with cerebral palsy.

In this study, researchers evaluated the effectiveness of visual and auditory external feedback using a system called the E-Link Upper Limb Exerciser in the praxis skills of a 6-year-old child with spastic hemiplegic cerebral palsy.

The Upper Limb Exerciser is a computerized interactive system that uses activities for therapeutic use, providing motivation and feedback. The activities are timed; gradable in complexity, speed, and duration; and consist of simple and exciting games in which a variety of handles are used.

One of the advantages of the Upper Limb Exerciser is that it allows the difficulty of games to be adjusted according to the individual’s motor abilities and provides step-by-step guidance.

Feedback is given through scores so that the person has an ongoing record of his or her performance, which may increase motivation.

The child used the Upper Limb Exerciser for 60 minutes, three times a week, for three months at the Disabled Child Association, in Riyadh, Saudi Arabia. No additional physical therapy exercises were included in the treatment sessions.

The child’s praxis skills and ability to integrate and process sensory inputs were assessed through the Sensory Integration and Praxis Test (SIPT) before and after treatment completion. SPIT is made up of 17 standardized tests used to measure a child’s ability to integrate sensory input for perception, motor planning, and spatial actions, and is suitable for children 4-9 years old.

SIPT scores of all subtests improved after treatment. The most prominent improvement was found in praxis skills, followed by form and space perception, and bilateral motor coordination.

Smaller improvements were observed in balance or postural reactions tests, but researchers argue the Upper Limb Exerciser does not work to improve the child’s balance and posture.

“The Upper Limb Exerciser system can be used as a method of augmented visual and auditory biofeedback to improve praxis skills in hemiplegic cerebral palsied children, and it can be used by physical and occupational therapists to improve perception, motor planning, and spatial actions of hemiplegic cerebral palsied children,” the researchers wrote.

Researchers noted this case report is part of a larger, randomized, controlled trial that is currently ongoing, and that they plan to evaluate this approach, with or without physical therapy, in a larger group of cerebral palsy children, who will then be followed after treatment.