REHABILITATION OF UPPER MOTOR NEURON LESION IN CHILDREN THROUGH ORIGINAL METHODS VERSUS CLASSICAL METHODS

. Various methods of approaching patients aged 0-4 years after upper motor neuron lesion have been investigated, but no conclusive results have been obtained regarding the effectiveness of these methods and the difficulty of getting a clear picture of the disease progression before starting physical therapy. On the one hand, it is very hard to rehabilitate functional motor ability as long as it is still unclear how to relieve muscle stiffness after cerebral palsy. On the other hand, there is a problem with improving muscle control because classical rehabilitation methods use passive or semi-active joint mobilisation. Consequently, it is very difficult to predict the patient ’ s evolution. The present study is based on the data collected from a representative sample during physical therapy sessions and their processing in statistical tables. The 51 patients participating in the research are divided into two groups, with 31 children assigned to the experimental group and 20 children included in the control group. They were assessed before and after 4 months of physical therapy using the proposed ‘DinaCord’ Gross Motor Development Scale. Rehabilitation is different for each group, in the sense that the original ‘DinaCord’ physical therapy method is used for the experimental group, and classical methods are used for the control group. The conclusion of the study highlights the effectiveness and perspective on the patient’s motor development due to the application of the above-mentioned original physical therapy method.


Introduction
Upper motor neuron lesion is any injury of motor neurons that reside above the cranial nerve nuclei and the anterior horn cells of the spinal cord.In the current study, we will talk about the upper motor neuron syndrome (UMNS) as the totality of symptoms that define the central motor neuron lesion, which is characterised by increased muscle stretch reflex, clonus, spasticity, synkinesis, dystonia, alteration of fine motor skills, muscle fatigue and impaired muscle control.One of the most important features of central motor neuron injury is damage to several muscle groups.
Cerebral palsy is the most common type of central motor neuron injury and the most common cause of disability in children (Morgan et al., 2021).
Recent studies have estimated that the prevalence of cerebral palsy is 1.5 to nearly 4 cases per 1000 children, depending on the geographical area (Centers for Disease Control and Prevention, 2022).In Europe, there are about 80 cases per 1000 live births between 28 and 31 weeks of gestation and 1 to 1.7 cases per 1000 live births at minimum 37 weeks of gestation (Pakula et al., 2009).
According to the study conducted by Durkin et al. (2016) in four areas of the United States, the prevalence of cases was 1 per 345 children in 2010, with a higher frequency in boys than girls and in Black non-Hispanic children compared to White non-Hispanic or Hispanic children.Although more than 58% of them were able to walk independently, a large percentage (around 77%) suffered from a spastic form.Another significant problem identified was the existence of at least one more diagnosis of major importance, with the cooccurrence of epilepsy reaching the highest percentage (over 40%).
In terms of prevalence, data collected in Europe show a downward trend from 1.9 cases per 1,000 live births in 1980 to 1.77 per 1,000 live births in 2003 (Sellier et al., 2015).
In the US, there are studies (Kancherla et al., 2012) estimating medical expenditures attributable to cerebral palsy among children enrolled in Medicaid (a joint federal and state programme for people with low income) (Figure 1).The costs over the course of a year for a child without cerebral palsy or mental retardation were $1674, the costs for a child with cerebral palsy were $16,721 (1000% of $1674), and the costs for a child with cerebral palsy and mental retardation were $43,338 (2600% of $1674).A study by Grigoriu et al. (2021) examined the gait of 41 toddlers (28 typically developing children and 13 children with unilateral cerebral palsy) aged up to 3 years and with maximum walking of 6 months in order to compare kinematic parameters, spatiotemporal parameters and lower limb control between the two groups.The above authors observed that all toddlers diagnosed with unilateral cerebral palsy showed bilateral changes in spatiotemporal parameters during gait.The largest kinematic difference between the two groups was external pelvic rotation (13.3°) on the affected side.Foot progression angle was external during the swing phase on the affected side.The conclusion of the study is that alterations in kinematic gait parameters at this age mostly occur at the pelvis in toddlers with unilateral cerebral palsy as a consequence of primary motor control disorders rather than compensatory mechanisms.The research findings suggest that early rehabilitation should focus on improving proximal motor control, balance and symmetry in order to optimise gait development.
A number of studies (Forsyth et al., 2022) on medical rehabilitation in central motor neuron syndrome describe various methods and strategies to address symptomatology over a period of at least 3 months.
Another recent study (Morgan et al., 2021) published at the University of California in the form of an international clinical practice guideline aims to systematise early interventions for children younger than 2 years of age across 9 domains promoting motor function, communication, cognitive skills, sleep, vision, muscle tone, eating and drinking, musculoskeletal health and parental support.The study considered 27 randomised clinical trials and 16 systematic reviews complying with the initial requirements that included, among other things, children aged 0-2 years with cerebral palsy or at high risk of cerebral palsy.We note in this study that the most important recommendations made by specialists with regard to the 9 domains are related to the development of motor function and cognitive skills.According to the same authors, motor function rehabilitation is a priority in 4 systematic reviews where physical therapy is recommended due to its potential of maximising functional improvement, with the specification that its effect depends on the intensity and frequency of sessions.It is worth mentioning that none of the 43 studies can demonstrate an improvement through passive movement.Instead, specialists recommend the following:  initiation of physical therapy when the first signs of UMNS appear in order to use the process of forming neuromuscular connections (Kolb et al., 2017);  stimulation of independent development;  total avoidance of passive movements performed by the physical therapist (Morgan et al., 2016);  use of the affected hemi-body or symmetrical use of both hemi-bodies.The decrease of muscle hypertonia is not scientifically analysed in detail because the collected data cannot demonstrate an obvious influence of physical therapy on this aspect, and from a pharmacological point of view, there are few studies that address the safe administration of botulinum toxin for the treatment of spasticity in children younger than 2 years of age (Pascual-Pascual & Pascual-Castroviejo, 2009).
Muscle hypertonia is one of the important symptoms that participate in generating or worsening functional disabilities, including impaired motor control, contractures, muscle cramps and deformities.These consequences of hypertonia most often encompass the alteration of neuromotor development and the onset of pain.At this point, the best solution chosen in most countries is the administration of botulinum toxin, although adverse effects are possible, according to studies conducted on children older than 2 years (Bourseul et al., 2018).
The present research is based on the hypothesis that the application of an original functional education/re-education programme consisting of active physical exercises (of higher level than the detected motor level), which are preceded by myofascial stress release and joint manipulation techniques, will accelerate the neuromotor development process in children with upper motor neuron syndrome (UMNS).

Participants
Between October 2017 and February 2021, we established a group of 51 participants based on the informed consent of their parents or legal guardians.The research was carried out at the Regina Maria Cotroceni and Floreasca Medical Clinics in the Paediatric Physiotherapy Department and the Psihologoland Centre, respectively.The case reports for central motor neuron lesion were assessed and treated kinetically in both locations.The selection of research participants was made following functional and myofascial assessments in order to rate each patient's level of impairment and motor ability.
Each participant was assigned a registration number (for example, '9 EG') as follows:  a number from 1 to 31 for children in the experimental group and a number from 1 to 20 for children in the control group;  the acronym 'EG' was used for children included in the experimental group, and the acronym 'CG' was used for children included in the control group.

Measurements
The research participants were assessed to identify their levels of neuromotor, somatic and osteopathic development using the complex 'DinaCord' Assessment Scale, and the sheet used for this purpose included the following data:  Motor assessment used the stages of functional motor development and focused on the degree of difficulty and the child's ability to perform a motor action or maintain a specific posture.Each motor test is assessed based on a certain score, and the sum of the points obtained represents the total score.
The motor development assessment system proposed by the 'DinaCord' Assessment Scale is divided into 6 levels (0-5) that are similar to GMFCS (Gross Motor Function Classification System, a scale accepted and adopted by the World Health Organization) as follows: 5 -ability to perform analytical movement with maximum range of motion, with deliberately opposed resistance; 4 -ability to perform analytical movement with maximum range of motion; 3 -ability to perform analytical movement with maximum range of motion but with compensatory movements; 2 -ability to passively perform partial or total analytical movement; 1 -muscle contraction is present, without the ability to perform movement; 0 -muscle contraction is absent.
The maximum possible total score that can be obtained is 240 points.Motor age is determined according to the value of minimum optimal score per motor age at 80% of maximum score of the motor age concerned.
Considering the motor age of 2 years as the final stage of the neuromotor medical rehabilitation process, we used the 'DinaCord' assessment system (Table 1) and expressed the score as a percentage by relating each patient's score to the maximum possible score (240 points).We could thus assess the recovery rate and predict the evolution of each patient.

Table 1. 'DinaCord' assessment system
The motor age of a child is assessed using the total score obtained according to the 'DinaCord' Assessment Scale.This value can fall into a higher category at a difference of no more than 10%.If the total score is between two age categories and at least 40% less than the minimum optimal score of the lower category, then the child is half (1/2) above it.
A patient is considered medically recovered if their chronological age is correlated with their motor age.
An important aspect of assessment is the difference between the patient's ability to perform or maintain a specific position and its appropriateness.According to the proposed physical therapy programme, if a child has superior motor ability (whether assisted or not) but lower neuromotor level, that child can perform physical exercise going 2 or 3 stages higher.
Somatic assessment analyses the child's physical development level.The parameters measured in our study are: height, body weight, head circumference and chest circumference.All the collected data are gender-related and compared to the centile tables of physical development.This method helps us to assess the level of growth and physical development compared to a population average.
Osteopathic assessment is systematised, according to the structures on which the intervention occurs, into two categories: • osteoarticular -active or passive assessment of the range of motion in a joint or a biomechanical complex by comparing it with the other side of the body or the antagonistic movement; • soft parts -assessment of myofascial mobility/elasticity.According to the osteopathic assessment, the level of damage is divided into the following two stages: unaltered mobility; reduced mobility.

Procedure
Medical rehabilitation programmes lasted 4 months and were designed differently, depending on the group to which the patients belonged.Thus, the 31 children in the experimental group followed the 'DinaCord' programme, and the 20 children in the control group followed the programme aimed to stimulate their neuromotor development through classical methods.
We designed the 'DinaCord' rehabilitation programme based on myofascial and bone manipulations and active exercises.
The structure of the proposed programme for the experimental group was divided according to location as follows:  segmental -applications to the neck and trunk; -applications to the upper limbs; -applications to the lower limbs. global -global functional applications.Myofascial and bone manipulations are meant to relieve soft tissue tension and bone relationships.They are performed only once per session.Manipulations precede physical exercises that are designed to stimulate analytical and/or global neuromuscular control and improve muscle tone with a specific dosage.
The proposed 'DinaCord' programme included 30 types of myofascial manipulations, bone manipulations and physical exercises (Table 2).The programme to stimulate neuromotor development through classical methods was conducted over a period of 4 months, being preceded by the initial 'DinaCord' neuromotor assessment and followed by the final 'DinaCord' neuromotor assessment.It was carried out by an interdisciplinary team led by two physical therapists, with a frequency of 3-5 sessions per week.The 20 patients belonging to the control group were included in this programme.
The means of the proposed programme are passive exercise, passive-active exercise and massage.The programme to stimulate neuromotor development through classical methods included massage, which consisted of relaxation and/or toning manoeuvres (depending on muscle tone) applied to the limbs and back for 3-5 minutes, as well as 21 exercises, of which 8 were passive and 13 were passive-active.

Results
The participants of this study were diagnosed with infantile cerebral palsy, met the inclusion criteria and did not meet the exclusion criteria.
The total score is represented by the sum of the points obtained in each of the 48 motor tests (Table 3 and Table 5).
The percentage is the percentage value of the total score obtained compared to the maximum possible score (240 points).This parameter shows the recovery rate and the evolution of each patient.
Motor age represents a patient's neuromotor development level and is related to chronological age.The t-test applied to the total scores obtained by the experimental group (Table 4) shows a statistically significant difference between the initial assessment (M = 88.45,SD = 46.75)and the final assessment (M = 139.42,SD = 49.75).The null hypothesis is rejected (p < 0.001).The Wilcoxon test was applied to the control group, and the results demonstrated that there was a significant difference between the initial and final assessments (Table 6).Z-value is -3.91, p-value is less than 0.01, and the effect size index is r = 0.87, highlighting a very large difference between the results (Predoiu, 2020), meaning that the results are conclusive.After analysing the differences between the parameters obtained in the initial and final assessments, higher values are observed for the experimental group compared to the control group in terms of total score, percentage and motor age (Table 7).
The difference between the mean total scores achieved by the experimental group (51) in the initial and final assessments is higher than that of the control group (19.1).
The difference between the mean motor age in the initial and final assessments is higher for the experimental group (4.6 months) compared to the control group (1 month).The difference between the mean percentages obtained by the experimental group (21.1%) in the initial and final assessments is higher than that of the control group (7.9%).The minimum/maximum value for the experimental group is 7/54 with a range of 47, while for the control group, it is 1/16 with a range of 15 (Table 8).The difference between the mean percentage scores achieved by the two groups in the initial and final assessments has a value 2.67 times higher for the experimental group (21.1%) compared to the control group (7.9%).The intergroup t-test demonstrated that there was no significant difference between the experimental group and the control group in the initial assessment -p = 0.75 (Table 9).The intergroup t-test showed that there was a significant difference between the experimental and control groups in the final assessment (Table 10).P-value is 0.008, indicating that the null hypothesis is rejected.The mean score of the experimental group (139.41) is significantly higher than that of the control group (103.55), which demonstrates that the 'DinaCord' method is more effective in terms of both the rehabilitation level reached and the time interval required for this.

Discussion and Conclusion
The present research has clarified the issue of applying the typology of treatment to patients diagnosed with central motor neuron lesion, whose motor age is 0-2 years and chronological age is 0-3 years and 3 months.The results of the proposed original 'DinaCord' physiotherapeutic method of active functional type with myofascial stress release and bone relationship improvement were superior to the classical rehabilitation method aimed to stimulate neuromotor development through massage, passive and passive-active mobilisation and passive-active and active exercises.
Analysis of the processed data for the percentage scores obtained between the initial and final assessments reveals the superior efficiency of the 'DinaCord' rehabilitation programme compared to the classical programme aimed to stimulate neuromotor development.
The experimental group reached a higher functional level as a result of applying the original 'DinaCord' treatment method compared to the control group that was applied the classical method of stimulating neuromotor development.The quantification tool was the 'DinaCord' Assessment Scale through which the values were calculated as the difference between the mean values obtained in the initial and final assessments.After comparing the mean values of the total scores achieved by the two groups, we can conclude that 'DinaCord', as a functional rehabilitation method based on myofascial manipulations and bone alignment improvement, is more effective than the proposed classical methods.
The importance of myofascial stress release as part of the 'DinaCord' method is also highlighted by Sulowska-Daszyk and Skiba (2022), who argue that it increases muscle flexibility and range of motion.
The few eligible studies on bone manipulation that we identified had low-quality evidence.According to Driehuis et al. (2019), studies on the effectiveness and safety of specific manual therapy techniques for children of different ages are lacking, so further research is needed in this regard.
In general, we found no studies about the dosage of myofascial stress release, bone relationship improvement and active exercise.We provide suggestions for future research to better understand the variables concerned.

Institutional Review Board Statement:
The study was conducted in accordance with the Declaration of Helsinki and approved by the Ethics Committee of the National University of Physical Education and Sports in Bucharest, Romania (ID:1009/03.30).

Informed Consent Statement:
The participants provided their written informed consent to participate in this study.

Figure 1 .
Figure 1.Costs for a child without cerebral palsy versus a child with cerebral palsy name, registration number, gender, chronological age and date of completion;  evaluation score for each intermediate stage of motor development;  total evaluation score for the intermediate stages of motor development;  percentage of the neuromotor development level, with the maximum percentage being at the level of neuromotor development for 2 years of age (maximum score: 240 points -100%, minimum optimal score: 192 points -80%);  neuromotor age (considering the value of minimum optimal score per motor age at 80% of maximum score per motor age);  osteopathic assessment;  somatic assessment.

Table 2 .
Means applied in 'DinaCord' method according to location

Table 3 .
Motor assessment results -Experimental group

Table 4 .
T-test results -Initial and final total scores for the experimental group

Table 5 .
Motor assessment results -Control group

Table 6 .
Wilcoxon test results -Initial and final total scores for the control group

Table 8 .
Intergroup descriptive statistical analysis of the difference between the initial and final assessments of percentage scores

Table 9 .
Intergroup t-test results -Initial scores for the experimental and control groups

Table 10 .
Intergroup t-test results -Final scores for the experimental and control groups