Objective: To determine the underlying brain reorganization that occurs in children with hemiplegic cerebral palsy before and after pediatric Constraint-Induced therapy. Background: A promising new therapy for adults with hemiparesis consequent to stroke, known as Constraint-Induced Movement (CI) therapy, has recently been modified for use in children with cerebral palsy. Children with cerebral palsy treated with CI therapy show significant gains in motor skills after receiving this intensive and extended treatment. There is evidence to suggest that, after an acute stroke in adults, the undamaged motor cortex exerts greater control over movements in the affected hand than is normally seen in neurologically intact subjects. While this might seem to be an advantage, combined functional magnetic resonance imaging (fMRI) and transcranial magnetic stimulation (TMS) studies demonstrate that it is associated with poor motor recovery in adults after a stroke and impaired hand function in patients with cerebral palsy. Thus, anomalous motor control of the affected hand by the unaffected cortex may reflect a less efficient cortical reorganization process. There is controversy about how CI therapy produces an improvement in motor function. Conflicting evidence from fMRI and TMS studies in adult patients with stroke have shown that patients may have either an increase in ipsilateral motor cortical activation or an increase in activation in the damaged hemisphere. The answer to this controversy may be related to the presence of ipsilateral projections. Since ipsilateral projections are associated with worse functional outcome, determining the type of response to CI therapy may give insights into those patients who need more intense therapy. Subject Population: Children with hemiplegic subtype of cerebral palsy; age-matched children with no neurological abnormalities Design: We will assess motor cortex activation before and after CI therapy using fMRI and neurophysiologic tests including TMS and muscle reflex studies in children with hemiplegic cerebral palsy with and without evidence for ipsilateral projections. Outcome measures: Patients will be stratified by the presence of mirror movements. Primary outcome measure will be laterality index on cortical activation of the fMRI before and after CI therapy. Secondary outcome measures will be standardized measures of sensory and motor function. We will examine the relationship between the presence of anomalous ipsilateral motor control and cortical reorganization following CI therapy. Significance: Understanding this relationship is essential for planning large randomized controlled trials. Since anomalous ipsilateral cortical reorganization reflects an inefficient cortical reorganization process, treatment outcome of CI therapy may also be worse in this group. In this case, future studies may need to stratify children on study entry according to types of brain reorganization.
- INCLUSION CRITERIA: 1. Children 9 to 17 years of age. Cerebral palsy patients: 2. Children previously diagnosed with spastic hemiplegia subtype of cerebral palsy 3. Children with non-progressive cerebral lesions acquired pre-, peri- or post-natally, before 1 year of age. Typically Developing subjects: 1. Scores below 60 on Connor's attention deficit/hyperactivity disorder (ADHD) checklist. 2. Normal neurological history and examination EXCLUSION CRITERIA: 1. Any child who is pregnant 2. Patients with Development Quotient (DQ) or Intelligence Quotient (IQ) below 50 on standardized tests Cerebral palsy patients: 3. Children with subtypes of cerebral palsy that are not hemiplegia. 4. Children with uncontrolled seizures within the last 6 months 5. Children with progressive or neurodegenerative disorders; underlying known genetic or chromosomal disorders, familial or non-familial syndromes (without known chromosomal or genetic defect) 6. Patients with cerebral lesions caused by sickle cell disease or by emboli associated with congenital cardiac lesions 7. Patients incapable of voluntary movement or with severe cognitive deficits who cannot follow simple verbal commands Typically Developing Children: 1. Children with chronic medical disorders or any neurological and /or psychiatric disorder including attention deficit hyperactivity disorder or learning disorder 2. Children taking regular medications, including medications for allergies, hormonal oral contraceptives, or over-the-counter medications 3. Children born before 36 weeks gestation as estimated by dates, ultrasound or other methods (if a discrepancy exists, then the ultrasound estimation will be taken as definitive) Exclusionary criteria for clinical MRI studies: 1. Any child with metal objects in the body such as pacemakers, aneurysm clips (metal clips on the wall of a large artery), metallic prostheses, cochlear implants, or shrapnel fragments). 2. Any child with permanent tattoos on the eyelids (ferromagnetic iron oxide-based) tattoo pigments can interact with the static magnetic field of an MRI imager. Exclusionary criteria for TMS: 1. Children with hearing loss (greater than 15 dB at any individual frequency) in either ear (as evaluated in the Audiology Department, CC, NIH).