Effects of Motor Imagery Training After Muscle Lengthening Surgery in Children with Cerebral Palsy

March 8, 2025 updated by: Meltem Çelik, Saglik Bilimleri Universitesi

Investigation of the Early Effects of Motor Imagery Training on Balance, Walking and Quality of Life After Ankle Plantar Flexor Muscle Lengthening Surgery in Children with Cerebral Palsy

In children with cerebral palsy (CP), spasticity occurs in the muscles due to upper motor neuron lesions. The muscle groups that are mostly spastic in the lower extremity are; the hip adductor and flexors, hamstrings, and ankle plantar flexors. Spasticity in the ankle plantar flexor muscles of these muscle groups causes contracture over time and restricts ankle dorsiflexion. Limitations in ankle dorsiflexion present as toe walking problems, balance loss, and various functional difficulties in children. Children with spasticity of the ankle plantar flexor muscles gastrocnemius and soleus are initially treated conservatively with exercise and positioning. However, after contracture occurs, treatment is performed using surgical methods. Surgical release of plantar flexor muscles is a method that has been proven to be effective and is frequently applied in the clinic. This surgery aims to remove the ankle dorsiflexion joint range of motion restriction, prevent toe walking, and improve the functional status of the child. However, since the plantar flexor muscles are in the antigravity muscle group, excessive release of these muscles can cause loss of balance and crouch gait. Therefore, it is important for this surgery to be performed by an experienced surgical team at the right time and to provide an exercise protocol aimed at stabilization by working both muscle groups in the postoperative period. In addition, after these surgeries, the patient is immobilized with a cast and orthosis for a while and the patient's active and passive movements are restricted with these devices. Motor Imagery; It is the process of learning a new movement or improving the quality of a known movement by visualizing it in a planned and intensive way in the mind of the person without performing any motor activity. This study hypothesized that the motor imagery training in the early rehabilitation process with movement restrictions after plantar flexor muscle relaxation operations will be effective on the patient's balance, walking, and quality of life.

Study Overview

Status

Active, not recruiting

Conditions

Intervention / Treatment

Detailed Description

Cerebral palsy (CP) is a pathology that occurs as a result of a non-progressive lesion in the brain that develops due to various risk factors that may occur before, during, or after birth. The spastic type is the most common type of CP. Children with CP experience various problems in physical, psychological, mental, and social areas depending on the affected area of the brain and the degree of involvement. Motor function losses are the primary problem in individuals with CP. Children are classified according to the level of involvement with the gross motor function scale (GMFCS). While GMFCS level 1 indicates the mildest involvement, GMFCS level 5 indicates the most severe involvement.

Spasticity that occurs in the affected areas of the body after upper motor neuron lesions directly negatively affects the child's muscle and joint functions. The muscle groups where spasticity is commonly and frequently seen in the lower extremities are the hip adductor muscles, hamstrings, and ankle plantar flexor muscles. Ankle plantar flexor muscle spasticity can be seen in children of all GMFCS levels and negatively affects the child's functional status and reduces compliance with orthosis use. Increased ankle plantar flexor spasticity causes contracture in the ankle plantar flexors over time, which restricts ankle dorsiflexion. This condition often causes toe walking in children. Toe walking disrupts the child's general body balance and also negatively affects other upper segments, especially the knee joint.

The primary treatment option in the presence of ankle plantar flexor muscle spasticity is conservative treatment. Conservative treatment includes positioning the ankle in dorsiflexion and strengthening the dorsiflexor muscles, stretching the ankle plantar flexor muscles, performing relaxation exercises on the same muscle group, transferring weight in the appropriate position, and walking exercises.

In addition, in the presence of dynamic spasticity, the effectiveness of botulinum neurotoxin injection applied to the ankle plantar flexor muscles in cases where conservative treatment is inadequate has been shown in the literature. In cases where all these methods are inadequate, plantar flexor muscle contracture is present, and the child is functionally negatively affected, lengthening surgeries performed on the plantar flexor muscles are indicated. This operation can be performed only on the gastrocnemius muscle or on the Achilles tendon, which includes both the gastrocnemius and soleus muscles.

The ankle plantar flexor muscles are included in the antigravity muscle group and have an important role in general body balance. The length and strength of these muscles at a certain rate provide stabilization of the body segments. While the increased tone of these muscles disrupts this stabilization, the inability of the elongated muscle to provide sufficient core support after relaxations results in excessive dorsiflexion and suggests that it may cause walking problems and ultimately loss of balance. Therefore, when deciding on plantar flexor muscle relaxation operations applied to children with CP, it is thought that the right timing should be provided and the surgery should be performed with an experienced team in sufficient and correct amounts, and post-operative rehabilitation protocols that include intensive studies on gaining balance and stabilization in the post-operative period will increase balance and walking control.

Motor Imagery; It is the process of learning a new movement or increasing the quality of a known movement by visualizing it in a planned and intensive manner in the mind without performing any motor activity. In imagery, while not actually doing any activity; it is possible to experience it through mental imagery by seeing the image in the mind, feeling the movement as in the image, sensing the taste or smell of the image, and hearing its sound. The effectiveness of motor imagery training has been shown in children with CP. There is no study on its effectiveness in the postoperative period.

This study hypothesizes that motor imagery training, which will be applied in addition to the post-operative rehabilitation program, is effective on balance, walking, and quality of life, especially in children with CP, in the rehabilitation process where there is a mandatory restriction with plaster and orthosis after ankle plantar flexor muscle lengthening surgeries. The primary aim of this study is to examine the effect of motor imagery training, which will be applied in addition to post-operative rehabilitation after ankle plantar flexor muscle release operations in individuals with CP, on balance, gait, and quality of life.

Study Type

Interventional

Enrollment (Actual)

28

Phase

  • Not Applicable

Contacts and Locations

This section provides the contact details for those conducting the study, and information on where this study is being conducted.

Study Locations

  • Turkey
      • Istanbul, Turkey
        • University of Health Sciences

Participation Criteria

Researchers look for people who fit a certain description, called eligibility criteria. Some examples of these criteria are a person's general health condition or prior treatments.

Eligibility Criteria

Ages Eligible for Study

  • Child
  • Adult

Accepts Healthy Volunteers

No

Description

Inclusion Criteria:

  • Diagnosis with Cerebral Palsy
  • Being between the ages of 7-18
  • Being able to walk with or without support
  • Not having received botulinum toxin injections into the ankle plantar flexor muscles in the last 6 months
  • Being at the GMFCS level of 1,2 or 3
  • Having an indication for ankle muscle release surgery and having a surgical plan
  • Being receiving a developmental rehabilitation program
  • Being able to follow given commands

Exclusion Criteria:

  • Having dyskinetic, ataxic or hypotonic involvement
  • Having any neurosurgery before
  • Having any bone surgery for the foot or ankle before
  • Having a bone surgery in the same session
  • Mental retardation and not being able to take commands

Study Plan

This section provides details of the study plan, including how the study is designed and what the study is measuring.

How is the study designed?

Design Details

  • Primary Purpose: Treatment
  • Allocation: Randomized
  • Interventional Model: Parallel Assignment
  • Masking: None (Open Label)

Arms and Interventions

Participant Group / Arm
Intervention / Treatment
Active Comparator: Post-Operative Exercise Group
This group will be included in a conventional post-operative rehabilitation program that includes intensive foot intrinsic muscle balance, bilateral ankle strengthening and range of motion exercises, and general body balance studies after plantar flexor muscle relaxation operations. In the rehabilitation program of the case group, exercises are planned under the supervision of a remote physiotherapist, with the telerehabilitation method (online live sessions) 2 days and 1 face to face therapy session will be done in a week. face therapy sessions and 16 telerehabilitation sessions.
Procedure: Conventional Post-operative Exercises

This group will receive conventional exercises in the post-op process. The exercises included in the conventional exercise program are;

  • Balance board exercises
  • Balance disc exercises
  • Bosu exercises
  • Balance pad exercises
  • Wobble board exercises
  • Walking on soft ground
  • Balance exercises on soft ground
  • Apraximations and tractions
  • Target angle exercise for ankle
  • General standing balance exercises (Eyes open and closed - single foot, double foot)
  • Ankle bidirectional ROM
  • Ankle bidirectional strengthening
  • Exercises to increase foot intrinsic muscle strength and balance
  • Functional exercises
Active Comparator: Motor Imagery Training Group in Addition to Post-Operative Exercise

The study group will receive motor imagery exercises in addition to the post-op rehabilitation received by the comparison group. The exercises will given in a hibrit method (a face to face therapy session and 2 telerehabilitation session in an online platform in a week).

The telerehabilitation sessions will given under the supervision of a remote physiotherapist. This group will take therapy sessions during 8 weeks. All the patients will have totally 8 face to face therapy sessions and 16 telerehabilitation sessions.
Procedure: Conventional Post-operative Exercises

This group will receive conventional exercises in the post-op process. The exercises included in the conventional exercise program are;

  • Balance board exercises
  • Balance disc exercises
  • Bosu exercises
  • Balance pad exercises
  • Wobble board exercises
  • Walking on soft ground
  • Balance exercises on soft ground
  • Apraximations and tractions
  • Target angle exercise for ankle
  • General standing balance exercises (Eyes open and closed - single foot, double foot)
  • Ankle bidirectional ROM
  • Ankle bidirectional strengthening
  • Exercises to increase foot intrinsic muscle strength and balance
  • Functional exercises
Procedure: Motor Imagery Training
The study group will receive motor imagery training in addition to control group's exercise program. This process will proceed as follows; In motor imagery training videos taken with a 9-year-old healthy child will be watched.• The content of the videos will include exercises such as ankle dorsiflexion, heel tapping while walking, climbing and descending stairs, walking on a ramp, standing on a ramp, walking on soft ground, and walking on a treadmill.• The patients will watch these videos and then the relaxation, imagination and return to environment phases of motor imagery will be applied respectively.

What is the study measuring?

Primary Outcome Measures

Outcome Measure
Measure Description
Time Frame
Range of Motion Measurement
Time Frame: Baseline, week 4, week 8
Range of Motion will be measured with using an universal goniometer for knee and ankle.
Baseline, week 4, week 8
Muscle Strength
Time Frame: Baseline, week 4, week 8
Manuel muscle testing will be done. It will graded 0 to 5. Five represents full strength.
Baseline, week 4, week 8
Gait Assessment
Time Frame: Baseline and week 8

It will be asseessed with using Edinburg Visual Gait Scorring (EVGS). EVGS is a video based gait scorring system. It consist of 17 items. A gait video will be taken from sagital and coronal plan. It will scorred later.

Additionally, pedobarographic measurements for temporospatial gait parameters will be obtained with Enertor foot scanning system (RSscan Lab Ltd; UK).

The temporospatial gait parameters are; step length, stride length, Step width, cadance, double support time, single support time.
Baseline and week 8
Balance Assessment
Time Frame: Baseline, week 8

It will done by using Pediatric Balance Scale. There are 14 items in this scale. The Pediatric Balance Scale is a modified version of the Berg Balance Scale that is used to assess functional balance skills during tasks that mimic experiences of everyday living in school-aged children. The scale consists of 14 balance-related test items that are scored from 0 points (lowest function) to 4 points (highest function) with a maximum score of 56 points.

Additionally, pedobarographic measurements for static balance assessment will be obtained with Enertor foot scanning system (RSscan Lab Ltd; UK).
Baseline, week 8
Quality of Life Assessment
Time Frame: Baseline and week 8
Quality of life assessments of patients will be made using the Quality of Life Scale for Children. The first version of the scale (PedsQL TM 1.0) is a general quality of life scale developed for use in various pediatric populations. The most powerful version, the fourth version's core scale (PedsQL TM 4.0 Generic Core Scale), is a scale that evaluates the basic physical, mental and social health components determined by the World Health Organization in healthy children or those with acute or chronic diseases, together with school functionality. This scale consists of a total of 23 items and 4 subscales, including 8 items measuring physical functionality, 5 items measuring emotional functionality, 5 items measuring social functionality and 5 items evaluating school functionality.
Baseline and week 8

Secondary Outcome Measures

Outcome Measure
Measure Description
Time Frame
Functional Mobility
Time Frame: Baseline, week 4, week 8
Functional status and ambulation assessment of patients will be made with the Functional Mobility Scale (FMS). The Functional Mobility Scale is a scale that evaluates how patients walk 5, 50 and 500 meters and ultimately divides them into 6 groups.
Baseline, week 4, week 8
Foot pressure measurement
Time Frame: Baseline and week 8
The pedobarograph is a device displaying and recording the instantaneous distribution of the pressure under the entire surface of the soles of the feet. The subject stands or walks on a transparent plate, in which light is conducted by total internal reflections. For the assessment of foot pressure, pedobarographic measurements will be obtained with the Enertor foot scanning system (RSscan Lab Ltd; UK).
Baseline and week 8
Movement imagery
Time Frame: Baseline, week 8
It will be assessed by usisng Movement imagery questionnaire for children-MIQ-C. This questionnaire was used to measure visual (internal, external skills) and kinesthetic imagery. It contains a total of 12 items, 4 items internal, 4 items external, and 4 items kinesthetic imagery skills. Within the scope of the questionnaire, the individual is asked to imagine 4 different movements from 3 different visual perspectives. During this test applied with the evaluator, the individual is asked to do the movement in the instructions once in reality and then to imagine doing the movement, and the clarity of this imagery is scored using a Likert-type scale between 1 (very difficult to feel) and 7 (very easy to feel). The questionnaire was developed by Martini et al..
Baseline, week 8
Motor Imagery Training Fun and Clarity
Time Frame: After each therapy sessions
An additional evaluation will be made with the Motor Imagery Training Fun and Clarity Scale. The fun level of motor imagery sessions and imagery training for individuals will be evaluated using a 0-10 point numerical rating scale (fun scale). There will be numbers from 0 to 10 on a 10 cm horizontal line. On the scale, 0 on the line means "not fun at all" and 10 means "very fun". The degree of fun will be recorded numerically between 0 and 10. Similarly, how clearly they can visualize the tasks imagined during the imagery sessions will be evaluated with a 0-10 point numerical rating scale (clarity scale). Individuals will be asked to evaluate clarity by stating that 0 on a 10 cm horizontal line means that imagery is not clear at all, and 10 means it is very clear.
After each therapy sessions

Collaborators and Investigators

This is where you will find people and organizations involved with this study.

Sponsor

Saglik Bilimleri Universitesi

Investigators

  • Study Director: Zuhal Didem Takinacı, PhD, Saglik Bilimleri Universitesi

Publications and helpful links

The person responsible for entering information about the study voluntarily provides these publications. These may be about anything related to the study.

General Publications

Study record dates

These dates track the progress of study record and summary results submissions to ClinicalTrials.gov. Study records and reported results are reviewed by the National Library of Medicine (NLM) to make sure they meet specific quality control standards before being posted on the public website.

Study Major Dates

Study Start (Actual)

March 1, 2024

Primary Completion (Actual)

May 5, 2024

Study Completion (Estimated)

March 15, 2025

Study Registration Dates

First Submitted

February 16, 2025

First Submitted That Met QC Criteria

February 16, 2025

First Posted (Actual)

March 25, 2025

Study Record Updates

Last Update Posted (Actual)

March 25, 2025

Last Update Submitted That Met QC Criteria

March 8, 2025

Last Verified

February 1, 2025

More Information

Terms related to this study

Keywords

Additional Relevant MeSH Terms

Other Study ID Numbers

  • MCDT-2025

Plan for Individual participant data (IPD)

Plan to Share Individual Participant Data (IPD)?

NO

Drug and device information, study documents

Studies a U.S. FDA-regulated drug product

No

Studies a U.S. FDA-regulated device product

No

product manufactured in and exported from the U.S.

No

This information was retrieved directly from the website clinicaltrials.gov without any changes. If you have any requests to change, remove or update your study details, please contact register@clinicaltrials.gov. As soon as a change is implemented on clinicaltrials.gov, this will be updated automatically on our website as well.

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