J.L. Pons et al. (Eds.): Converging Clinical & Engi. Research on NR, BIOSYSROB 1, pp. 11291132.

DOI: 10.1007/978-3-642-34546-3_185 Springer-Verlag Berlin Heidelberg 2013

Sound and Rehabilitation Robotics for Pediatric
Cerebral Palsy
*

Citlali Lopez-Ortiz
**

Rehabilitation Institute of Chicago/ Northwestern University, Chicago, IL, USA
c-lopez-ortiz@northwestern.edu
Abstract. Robots for pediatric rehabilitation are expected to have sensory-motor
components and mixed media elements to enhance rehabilitation outcomes and
make robotic therapy amenable to children. We have investigated the effect of
sound in voluntary movement trajectory formation of children with cerebral palsy.
The results indicate that including a musical melody during the execution of
movement may be beneficial in robotic applications designed for the treatment of
children with spastic cerebral palsy.
1 Introduction
Children with cerebral palsy (CP) have abnormalities in muscle tone that interfere
with movement and posture. Muscle tone may be hypertonic or hypotonic.
Hypertonia may cause spasticity, rigidity and dystonia. Hypotonia manifests
manly as weakness [1]. Other negative motor signs include reduced selective
motor controlinability to activate a specific pattern of muscles--, ataxia --
inability to activate the correct pattern of muscles for movement--, and apraxia --
inability to activate the correct pattern of muscles to accomplish a task[2].
These deficits combined compromise function and participation in social
activities. It is necessary to improve our understanding of the sensory-motor
factors that can be manipulated to enhance rehabilitation outcomes, as well as
stimulating active participation in social activities. The inclusion of sound in the
form of a beat or a melody in pediatric rehabilitation can be could be easily
implemented if desirable. Thus we investigated the effect of a simple beat and a
familiar melody in trajectory formation of typically developing children (TD) and
children with CP. Research in adult humans suggests that synchronizing
movement to a beat stabilizes movement trajectories that in other conditions
would be unstable via rhythmic entrainment [3]. We hypothesized that a rhythmic
beat and a musical melody of the same tempo would enhance trajectory formation
in similar ways in control children and children with CP [4].



*
Supported in part by The Coleman Foundation, Chicago IL and the Lavin Pediatric Fund.
**
Corresponding author.
1130 C. Lopez-Ortiz

2 Materials and Methods
The Institutional Review Board of Northwestern University approved all
procedures. Eight TD children (4 male, 4 female, ages 7 to 15 mean age = 10) and
seven children with CP (4 male, 3 female, ages 6 to 16 mean age = 10, GMFCS
=II, IV). The children were instructed to make a sequence of point-to-point
reaching movements extracted from canonical classical ballet movements. The
movements were executed in the same sequence ten times under four sound
conditions in random order: melody (M), fast beat (FB), slow beat (SB), and
silence (S). The trajectories of the end-points -distal phalanx of the middle fingers-
were traced with a motion tracking system (Vicon motion tracking system by
Vicon, Colorado). The data sampled at 120Hz. The data files were resampled at 40
Hz and filtered by a fifth order Butterworth filter with a cutoff frequency of 2Hz.
The effect of the sound condition on the trajectories generated was analyzed using
segmentation analysis [5]. Statistical analyses were performed on the mean
segment lengths under the various sound conditions. The statistical t-tests were
performed on the data set of the mean segment length after performing a Box-Cox
transformation to correct for skewedness of the distributions. Within subject
analyses were also performed n the Box-Cox transformed data. Statistical
significance was considered for p<0.05.
3 Results
The means of the segment lengths in the control group showed a trend towards
longer segments from SB, to FB, to S, to M (Fig. 1). Only the difference in mean
length of M condition as compared to SB was statistically significant (p<0.05).
The means of the segment lengths in the CP group were not statistically
significant. Within child analyses revealed that in four children in the control


Fig. 1 Significant difference in mean segment length for M vs. SB in the control group of
TD children
Sound and Rehabilitation Robotics for Pediatric Cerebral Palsy 1131

group the aspect ratio and duration were statistically smaller in the melody
condition as compared to silence (p<0.05) (Fig. 2) Within child analyses in the CP
group revealed two subgroups that coincided with the subtype of CP. In one
group, children with spastic CP had significantly longer segments lengths with M
as compared to S similarly to the typically developing control group. In the other
group, children with mixed presentation of spastic and dystonic CP showed no
statistical differences among sound conditions with exception of one child with
dystonia that exhibited the longest trajectories with FB.

Fig. 2 Example of one child with spastic CP. The length of the segments in M is
significantly longer as compares to S.
4 Discussion
The results indicate that only TD children and children with spastic cerebral palsy
enhance the segment lengths in point-to-point reaching movements in free space
with melody (M) as compared to silence (S). The children with dystonic motor
control did not show improvements with sound and, in fact, the silence condition
was best for most. This result suggests that separate mechanisms underlie the
neural processing of a beats and melody during movement execution. Thus, the
process rhythmic entrainment is not readily generalizable to rhythmic melody or
to the coordination of movement in spastic and dystonic cerebral palsy. A
plausible interpretation of our results rests on evidence form functional magnetic
resonance imaging that has revealed activity in the frontal cortex with melody
processing, while basal ganglia, and cerebellum show activity only in rhythm
processing. The more direct connection between frontal cortex and motor cortex
may enhance descending cortico-spinal signals that produce, in turn, enhanced
trajectory formation. This mechanism is likely to be at play in TD children and
children with spastic CP. Children with dystonic CP typically have deficits in
basal ganglia and cerebellum which would not be affected by melody. One would
expect that the beat condition could be beneficial for these children but an
immediate effect was not detected in this preliminary study.
1132 C. Lopez-Ortiz

5 Conclusion
The inclusion of sensory-motor modalities and mixed media elements to enhance
robotic rehabilitation outcomes in pediatric CP is still in its infancy. Research in
this area holds promise not only for better adherence to robotic rehabilitation
treatments but for the augmentation of neural plasticity by increasing
appropriately the cognitive load during therapy. The use of sound is only one
possible sensory modality to be considered in the filed of pediatric robotic
rehabilitation.
Acknowledgment. We aknowledge insightful discussions with Professors Ferdinando A.
Mussa-Ivaldi, PhD and Robert Scheidt., PhD.
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