Gait & Posture

Cerebral palsy (CP) is characterized by neuromusculoskeletal impairments, including reduced muscle fiber lengths, which alter muscle-tendon unit (MTU) lengths and contribute to gait deviations. Estimation of MTU length reliability using musculoskeletal modeling is essential for guiding interventions such as muscle lengthening. This study aims to assess within-assessor (WA) and between-assessor (BA) reliability of MTU length estimation during gait in CP and non-impaired (NI) individuals. 38 individuals (19CP,19TD) participated in 3 3DGA sessions (2 by the same assessor). Normalized MTU length, MTU lengthening, and maximum lengthening range of the rectus femoris, semitendinosus, and gastrocnemius medialis were reported. Reliability was quantified through the standard error of measurement (SEM) and minimal detectable change (MDC). The mean SEM (MDC) during the gait ranged from 1.0-2.1% (2.5-5.7%) for normalized MTU length, from 3.6-8.7 mm (10.1-24.1 mm) for MTU lengthening, and from 2.9-8.0 mm (8.0-22.1 mm) for MTU lengthening range in individuals with CP. In NI individuals, the mean SEM (MDC) during the cycle ranged from 0.6-1.3% (1.8-3.7%) for normalized MTU length, from 2.6-5.0 mm (7.3-13.9 mm) for MTU lengthening, and from 2.7-5.0 mm (7.5-12.4 mm) for MTU lengthening range. Results suggest reliable estimations by the same assessor, supporting therapeutic decision-making and patient progress monitoring.

Three-dimensional gait analysis is widely used to support clinical decision-making in neuromuscular disorders, with the Conventional Gait Model (CGM) being the most commonly applied biomechanical model in clinical practice. Recent developments of the CGM, grouped under the open-source CGM2 framework, introduced methodological updates intended to improve robustness while preserving backward compatibility. However, the reliability of these successive CGM2 iterations has not been comprehensively evaluated, particularly in pathological gait populations. This study investigated within- and between-assessor reliability of lower-limb kinematics across three CGM2 versions (2.1, 2.2, and 2.3) in asymptomatic participants and individuals with cerebral palsy. Reliability was quantified using standard error of measurement and minimal detectable change across the gait cycle. Overall measurement error remained low and consistent across models and participant groups, with standard errors close to 2{degrees} and minimal detectable changes around 6{degrees}. Introducing kinematic fitting had minimal influence on reliability, while adding tracking markers on the thigh and shank produced a modest reduction in hip transverse rotation error. These findings indicate that methodological refinements implemented in CGM2 preserve the reliability of the original CGM while providing incremental improvements for clinically relevant parameters, supporting its use in both asymptomatic and pathological gait analysis and longitudinal clinical assessments

BackgroundThree-dimensional gait analysis (3DGA) is widely used to support clinical decision-making in individuals with motor impairments. However, kinematic outputs depend strongly on the underlying biomechanical model. The open-source Conventional Gait Model II (CGM2) integrates updates to joint centre estimation (CGM2.1), inverse kinematics (CGM2.2), and cluster-based segment tracking (CGM2.3). While previous work demonstrated consistency among CGM2 variants in typically developing children, their effect in clinical populations remains unknown. This study quantified how CGM2 variants influence gait kinematics in individuals with cerebral palsy (CP). MethodsTwenty-one individuals with CP (GMFCS I-II) underwent 3DGA using a 12-camera motion capture system and a CGM2.3 marker set. Hip, knee, and ankle kinematics from 487 gait cycles were computed using pyCGM2. Differences between CGM2.1, CGM2.2, and CGM2.3 were evaluated using Mean Absolute Deviation (MAD) and the adjusted coefficient of determination (R2). ResultsOverall, small differences were observed between model variants. MAD values were typically below 5{degrees} for most joints and planes, with high correlation between curves (R2>0.7). Hip rotation showed the largest discrepancies, with maximum MAD up to 7.7{degrees} when comparing CGM2.2 and CGM2.3. Differences between CGM2.1 and CGM2.3 were greater in the transverse and frontal planes but remained within acceptable limits (<5{degrees}), except for hip rotation. ConclusionThe CGM2 variant selection has limited impact on gait kinematics in individuals with CP, and most differences fall within known repeatability error. However, transverse-plane kinematics, particularly hip rotation, should be interpreted with caution when comparing data across CGM2 variants.

BackgroundInertial measurement units (IMUs) have potential to be inexpensive, portable sensors for collecting gait parameters and joint kinematics. Current validation protocols generally do not investigate IMU accuracy in measuring altered gait; therefore, they cannot assess an IMUs ability to detect pathologies. The Stridelink IMU-based gait analysis device is intended for use in detecting and monitoring gait abnormalities, thus there is a need to evaluate the devices accuracy under abnormal gait conditions. Research questionHow well do measurements from the StrideLink IMU agree with motion capture (MoCap), particularly when gait is mechanically altered to simulate pathology? MethodsTwenty-eight healthy participants (ages 18-40) were analyzed during a one-minute tread-mill walk with Vicon MoCap and StrideLink. Tests were performed under normal and mechanically induced abnormal conditions (knee brace, walking boot). Equivalence testing and correlation analysis evaluated StrideLinks accuracy against MoCap. ResultsStrideLink showed statistical equivalence (within 5%) for average cadence, stride, swing, and stance times but not double support time. Many metrics were statistically equivalent (p < .001) despite induced abnormalities. Correlation analysis showed almost perfect agreement with MoCap for stride times, cadence, and stance. However, the abnormal gait protocol revealed nuances not observed in normal gait; specifically, the device underestimated swing time by [~]10 ms in knee brace restricted limbs. SignificanceThis study utilized mechanically induced gait abnormalities to assess the robustness of IMU measurements. Results indicate StrideLink yields valid temporal gait measurements comparable to reference systems, even under conditions of significant deviation, supporting the utility of using induced abnormalities for sensor validation.

Sound- and music-based gait training (SM-GT), including rhythmic auditory stimulation and music-based movement approaches, has been shown to improve gait and functional outcomes in people with Parkinsons disease (PD). However, little is known about how such interventions are recognized and implemented in real-world settings. This study investigated awareness and actual use of SM-GT among people with PD in Japan across inpatient rehabilitation, home-based rehabilitation, and daily-life contexts. A cross-sectional questionnaire survey was conducted among 62 people with PD recruited from public lectures and exercise programs. Participants reported their awareness of SM-GT, experiences of use in different contexts, types of auditory cues employed, and functional status including activities of daily living, gait and balance, and freezing of gait. Overall, 57.4% of participants reported being aware of SM-GT, whereas actual use remained limited across contexts (26.1% in inpatient rehabilitation, 9.1% in home-based rehabilitation, and 31.1% in daily-life contexts). Awareness was higher among participants with inpatient rehabilitation experience than among those with home-based rehabilitation experience; however a substantial gap between awareness and actual use was observed across all settings. While metronomes were the most frequently recognized auditory cue, hand clapping or verbal cueing and music were more commonly used in practice. Awareness and use of SM-GT also varied according to functional status, with relatively higher implementation among individuals with mild functional impairment. These findings reveal a pronounced discrepancy between recognition and real-world implementation of SM-GT in Japan, highlighting the need for strategies that facilitate translation of evidence-based auditory interventions into routine rehabilitation and everyday walking for people with PD.

BackgroundChildren with unilateral spastic cerebral palsy (USCP) often rely on trunk compensation due to impaired upper limb control, but current clinical tools do not directly capture trunk involvement. Marker-based systems are challenging to use with children, while computer vision methods like OpenPose offer a promising, scalable alternative for kinematic analysis but need to be validated. PurposeWe validated OpenPose for quantifying trunk recruitment during bimanual play in children with USCP and examined how the interventions Constraint-Induced Movement Therapy (CIMT) and Hand-Arm Bimanual Intensive Therapy (HABIT) influence trunk use. MethodsWe analyzed videos of children with USCP who underwent CIMT or HABIT. OpenPose was used to extract trunk displacement angle (TDA) and trunk rotation angle (TRA), which were compared to hand function scores. OpenPose was validated against a 3D motion analysis system in typically developing adults. Reach-phase kinematic variables were also assessed. ResultsOpenPose showed high validity for TDA and lower validity for multi-planar TRA. TDA and TRA did not correlate with baseline hand function. HABIT reduced TDA, while CIMT slightly increased it. No significant changes were found in velocity, movement time, or variability. ConclusionsOpenPose is a viable tool for capturing gross trunk motion. Trunk recruitment patterns differed by intervention, supporting the need for personalized approaches.

PurposeFalls are common in adults with cerebral palsy (CP) and remain a significant concern. The study examined whether fall risk, fall incidence, and fall-related injuries differ by GMFCS level, CP type, age, and gender in adults with CP. Materials and MethodsA cross-sectional, retrospective chart review was conducted for adults 18 years or older with CP who received outpatient specialty care between December 2022 to May 2023. CP diagnosis and type were determined using ICD-10 codes; GMFCS level was extracted from electronic medical record notes. Fall risk was determined using the Morse Fall Scale (MFS), with scores [&ge;]45 indicating high fall risk. ResultsAmong 647 adults with CP, ambulatory individuals (GMFCS II-III) had significantly higher MFS scores and fall incidence than non-ambulatory individuals (p < 0.001). CP type and gender showed significant group differences, whereas age did not. Individuals with spastic diplegia and unspecified CP showed higher fall risk. Females were twice as likely as males to report a recent fall, although MFS scores did not differ by gender. Five injuries were reported among ambulatory individuals in the past three months. ConclusionsFindings highlight the importance of refining fall-risk assessment and prevention strategies for higher-risk groups.

Centre of mass (COM) is a key measurement used to assess balance and mobility. Marker-based motion capture systems have traditionally been used to measure COM, but they are time-consuming and prone to marker error. Markerless motion capture systems offer a potential alternative, reducing setup time while maintaining accuracy. The ease of collecting markerless data may be particularly beneficial when study participants have limited mobility, such as those with stroke. This study aimed to determine the differences in COM measurements between marker-based and markerless motion capture systems during balance and mobility tasks in individuals with sub-acute stroke. Seventeen participants completed the following tasks: walking, quiet standing, sit-to-stand, rise on toes, and backward reactive stepping. COM data were analyzed using two markerless models, a default with 17 segments and a fit model with 11 segments to match the marker-based model to be compared as the reference. The results showed high correlations (R2 = 0.75 to 0.999) and low root-mean-square differences (< 2 cm) in the anterior-posterior and medial-lateral directions. Larger differences (> 4 cm) were observed in the superior-inferior direction, particularly with the default model. These findings suggest that markerless motion capture can be used to measure COM in people with stroke, and that model selection plays an important role in COM estimates.

BackgroundFreezing of gait (FOG) affects up to 80% of people with advanced Parkinsons disease and is difficult to elicit reliably during clinical assessments. Augmented reality (AR) offers potential for standardized FOG provocation by presenting virtual triggers in any environment. ObjectiveTo evaluate whether an AR-based turning task could elicit FOG in a graded, dose-dependent manner and assess user experience with the technology. MethodsThirteen people with Parkinsons disease (8 freezers, 5 non-freezers) completed an AR pillar-turning protocol across two cohorts: clinic-based (n=4, all freezers) and laboratory-based (n=9, mixed). Participants performed 360{degrees} turns around a virtual pillar presented at three diameters (0.6, 0.4, 0.2 m) using a Microsoft HoloLens 2, manipulating turning radius to vary task difficulty. FOG episodes were video-recorded and independently annotated. Participants completed perception questionnaires and the New Freezing of Gait Questionnaire (NFOG-Q). ResultsAll clinic freezers exhibited FOG during AR pillar turns, with a clear dose-response relationship: mean episodes increased from 2.3 at 0.6 m to 5.3 at 0.4 m to 8.5 at 0.2 m diameter. No laboratory participants experienced FOG during pillar turns, though one lab freezer froze during return turns. NFOG-Q profiles indicated comparable daily-life FOG severity between clinic and laboratory freezers, suggesting environmental factors drove differential outcomes. Participants reported positive experiences with AR quality, safety, naturalness of movement, and rapid adaptation, though clinic participants reported higher immersion than laboratory participants. ConclusionsAR-based pillar-turning successfully elicited graded FOG in susceptible individuals within a FOG-provoking environment, demonstrating proof-of-concept for scalable virtual trigger paradigms. Effectiveness depends on matching environmental context to individual FOG susceptibility, with implications for standardized clinical FOG assessment.

AimTo determine the mechanistic relationship between segmental trunk control in the neutral vertical posture (NVP), assessed using the Segmental Assessment of Trunk Control (SATCo), and the Gross Motor Function Classification System (GMFCS); and hence to identify the means to enhance function in children with cerebral palsy (CP). MethodThis cross-sectional study included 101 children with CP (34 female, 10y(3y8m), 1.32(0.27)m, 33.4(18.4)kg) classified across GMFCS Levels I-V and tested with SATCo. Association and variation between GMFCS Levels and SATCo results were examined. ResultsSATCo results differed significantly (p<.05) between GMFCS Levels in static, active and reactive tests of trunk control. As neuro-ability increases through GMFCS Levels V-I, ability to control the head and trunk in NVP increases ({rho}(99)=-0.61 to -1,p<.0001) and variation in head and trunk control increases ({rho}(3)=-0.9 to -1,p<.05). InterpretationSATCo provides mechanistic insights supporting its use following GMFCS. In severe CP, NVP control is minimal across all children. In mild CP, large variation in results shows that SATCo discriminates between the use of full trunk control from compensatory strategies to achieve function. For each GMFCS Level, SATCo identifies the training required to improve trunk control in NVP, thus improving functional performance and reducing long-term risk of deformity. What this paper addsO_LISATCo results are related to GMFCS Levels, and complements GMFCS C_LIO_LISATCo provides the mechanistic explanation for what is observed in GMFCS C_LIO_LISATCo-GMFCS reveals if function is attained with trunk control or compensatory strategies C_LIO_LICompensatory strategies often used in mild CP are not captured by GMFCS C_LIO_LISATCo identifies the training required to improve function and reduce deformity risk C_LI Graphical abstract O_FIG O_LINKSMALLFIG WIDTH=200 HEIGHT=115 SRC="FIGDIR/small/26344472v2_ufig1.gif" ALT="Figure 1"> View larger version (19K): org.highwire.dtl.DTLVardef@3e97cdorg.highwire.dtl.DTLVardef@1603bdcorg.highwire.dtl.DTLVardef@fa21a4org.highwire.dtl.DTLVardef@1b6a1c4_HPS_FORMAT_FIGEXP M_FIG C_FIG O_LIExample above: GMFCS Level I child leaning backwards when tested for lower thoracic NVP trunk control. Same child showing compensatory lordotic lumbar posture while standing. C_LIO_LISATCo can be used in combination with GMFCS to identify specific training targets to improve postural control, enhance function, and reduce deformity risk. C_LI

BackgroundCommercially-available microprocessor-controlled prosthetic knees are unable to fully replicate the biomechanical function of the missing biological limb. While powered prostheses have the capacity to restore joint level kinetics, current systems rely on intrinsic control schemes that do not allow the user to volitionally modulate movement under neural commands. This limitation may compromise functional performance and hinder prosthetic embodiment, the sense that the device is part of the users body. In a case study on one test participant, we evaluate the functional and perceptual benefits of a bone-anchored, neurally-controlled knee prosthesis by comparing it to the participants microprocessor-controlled prosthesis. MethodsWe conducted a within-subject study on an individual with a transfemoral amputation, with an osseointegrated implant and surgically reconstructed agonist-antagonist muscle pairs. We tested a neurally-controlled powered knee and conventional microprocessor knee across a set of activities, including seated volitional control tasks, sit-to-stand transitions, squatting, level-ground walking, stair ascent, and uninstructed standing. Performance metrics included knee kinematics, prosthesis-generated mechanical power, and functional outcomes such as gait speed, stair ascent time, and weight-bearing symmetry derived from ground reaction forces. Functional mobility and control were complemented by self-reported embodiment, assessed through a questionnaire targeting agency, ownership, and body representation. ResultsThe neurally-controlled prosthesis enabled intuitive and responsive control. Compared to the subjects prescribed prosthesis, the prosthesis yielded improved temporal gait symmetry during walking (symmetry index: 0.93 vs. 0.59, with 1 indicating perfect stance time symmetry), increased prosthetic-side weight-bearing during sit-to-stand and squatting, and successful execution of a step-over-step stair ascent strategy--an outcome not achievable with the subjects prescribed device. Embodiment scores were consistently higher with the neurally-controlled prosthesis compared to the prescribed device across multiple domains, including agency, ownership and body representation. ConclusionsThis study is the first to directly compare a prescribed microprocessor knee with a bone-anchored, neurally-controlled powered prosthesis. By combining osseointegration, surgically reconstructed agonist-antagonist muscle pairs, and powered actuation, the system improved gait symmetry, greater prosthetic-side loading, and step-over-step stair ascent. These results demonstrate the novelty and promise of integrating surgical and mechatronic innovations to restore both functional mobility and embodied control after transfemoral amputation. Trial registrationThis study was approved by the Institutional Review Board at MIT (Protocol No. 2503001589).

Stroke can affect sensorimotor control, impairing balance and locomotion. These impairments increase the risk of falls, limit patient independence, and reduce their quality of life. In this study, we investigated how stroke affects the bilateral coordination of soleus motor units during standing, in individuals undergoing subacute rehabilitation. Fourteen participants (n=7 females; time since stroke=19{+/-}8 days; age=60.2{+/-}15.9 years) were recruited after admission for inpatient rehabilitation together with sixteen age- and sex-matched controls (n=8 females; age=61.2{+/-}14.7 years). Both groups attended the laboratory for two sessions separated by one week, during which high-density EMG signals were recorded from soleus muscles during quiet standing on force plates. Patients also performed the Berg Balance Scale in their clinical rehabilitation. To investigate the neural control of soleus muscles during quiet standing, the EMG signals were decomposed into motor unit spike trains, from which peristimulus time histograms and EMG waveform averages were computed in relation to peaks in the center of pressure (COP). The amplitude of motor unit and EMG activity around COP peaks, their directional tuning, and bilateral synchronization were estimated. Individuals post-stroke demonstrated improved scores on the Berg Balance Scale between visits, but the amplitudes of their COP displacement and speed were still greater than controls. In controls, the activity of soleus from both limbs exhibited an anteriorly-oriented tuning. In individuals post-stroke, while the activity of the soleus from the unaffected limb exhibited the same anteriorly-oriented directional tuning, the activity of the soleus from the affected limb was tuned laterally. Synchronization of soleus activities, quantified by computing the amplitude of motor unit and EMG activation in one soleus time-locked to prominent peaks in activity in the contralateral muscle, were also reduced in the affected limb compared to controls. Furthermore, cross correlation demonstrated a greater lag in motor unit and EMG activation between limbs in individuals post-stroke compared to controls. The absolute lag between limbs, measured through peristimulus time histograms, decreased between visits in individuals post-stroke (p=0.008), and this metric was the sole predictor of Berg Balance Scale with forward regression (R2=0.582, P<0.001). These results highlight the importance of bilateral motor unit coordination in balance, which is disrupted in both spatial and temporal domains following stroke.

PurposeTo evaluate the feasibility, impacts, and perspectives of a family-led robotic walking intervention. Materials & MethodsThis single-arm interventional study recruited participants aged [&ge;]4 years with pediatric-onset neuromotor disorders. Participants were lent a robotic walker and recommended to use at least 150min/week for 12-weeks. Robotic walking use, acceptability, practicality and adverse events were tracked. Family goals were measured before and after training period using Canadian Occupational Performance Measure (COPM). Quality of life was examined using EQ-5D-Y, Carer-QoL, and CP-CHILD. Quantitative data were analyzed using descriptive statistics (median (25th-75th percentile)) and Wilcoxon signed-rank tests. Qualitative interviews captured family perspectives and were analyzed using thematic analysis. Results15 participants aged 4-23 completed this study. Participants trained 5 (3.5-6) times for 150(82-181) minutes and took 7,544(4,640 - 9,575) steps each week. Adverse events occurred in <1% (16 minor, 1 moderate) of robotic walking sessions. Performance (3.5 (1.9-4.5), p=<0.001) and satisfaction (3.3(3.0-5.0), p=<0.001) of goals increased. Parents described positive changes in social experiences and family interactions and difficulties with the logistics of robotic walking. ConclusionsThis family-led robotic walking intervention resulted in improvements in individual goals, though families did struggle with some logistics of robotic walking, such as; transport and difficulties with the device.

Musculoskeletal simulations and experiments in young adults without knee pain have demonstrated that reducing gastrocnemius muscle activity can reduce knee contact force, which may reduce pain and progression of knee osteoarthritis. This study investigated whether individuals with knee osteoarthritis could reduce gastrocnemius electromyography (EMG) when provided with haptic biofeedback and consequently reduce late-stance knee contact force. Individuals with tibiofemoral osteoarthritis walked on a treadmill with adaptive biofeedback instructing them to reduce gastrocnemius EMG. Thirteen of eighteen participants reduced their average gastrocnemius EMG by at least 10% during an initial 30-minute training session and thereby qualified for a second session. During the second session, participants received the same biofeedback, and we estimated knee contact force using musculoskeletal models and static optimization. With feedback, participants reduced gastrocnemius EMG by 25{+/-}15% (p<0.001) and reduced the late-stance peak of knee contact force by 12%, or 0.38{+/-}0.47 times body weight (p=0.01). However, the average EMG of the vasti muscles increased by 38{+/-}34% (p=0.004), which contributed to an increase in early-stance knee contact force in some participants. Ten out of thirteen reduced their knee contact force impulse with the feedback. While additional work is needed to mitigate increases in vasti EMG, our data demonstrates that individuals with knee osteoarthritis can reduce gastrocnemius EMG and late-stance knee contact force in a brief period of training, suggesting the potential of muscle coordination retraining as a non-surgical intervention for knee osteoarthritis.

IntroductionTraditional clinical motor function assessment scales, despite their importance, often fail to identify the underlying neurophysiological mechanisms of postural control disorders. In this regard, stabilography, as an objective quantitative method, acquires particular diagnostic value. The aim of this study was to identify and compare frequency markers of postural control disorders in adults with cerebral palsy (CP) and healthy subjects using stabilographic signal power analysis in narrow frequency ranges. MethodsStabilograms were recorded while performing a visual feedback task and its combination with additional cognitive loads in two groups: adults with CP (n=8) and a control group (n=8). For the analysis, the stabilographic signal power was calculated in ten narrow frequency ranges (0.05-12.0 Hz). ResultsBased on the analysis of the stabilographic signal power, individual postural control profiles were identified, defined by three key patterns: <<hyperactivation>>, <<exhaustion>>, and <<optimization>>. The obtained data were interpreted within the framework of N.A. Bernsteins level theory of movement construction, where the identified patterns reflect an imbalance or synergy of various postural regulation circuits--from subspinal to corticocerebellar. ConclusionsThe proposed method for analyzing stabilogram power enables the identification of individual neurophysiological profiles of postural control disorders. The identified <<optimization>> marker indicates preserved neuroplastic potential. The results of the work open the way to a well-founded personalized rehabilitation, the strategy of which consists of transforming a pathological pattern (<<hyperactivation>>, <<exhaustion>>) into an optimal one (<<normalization>>) through targeted modulating effects on specific levels of movement construction.

ObjectiveAccurate stride length measurement is essential for assessing functional mobility, yet gold-standard methods remain confined to laboratory settings. This study aimed to develop and validate a computationally efficient, interpretable linear model for predicting stride length using thigh- and shank-mounted inertial measurement units integrated into a wearable neuromodulation sleeve. MethodsData from the sleeve were collected from 29 healthy adults performing walking bouts at four self-selected speeds. Participants traversed a pressure-sensitive gait mat, providing gold standard labels. A linear regression model was developed from engineered features from the kinematics data streams and validated against a held-out test set (n = 6) using leaveone-participant-out cross-validation. ResultsThe final linear model utilized five predictors: participant height, shank range of motion (ROM), thigh ROM, and thigh swing duration metrics. It achieved high predictive accuracy with a mean absolute error (MAE) of 5.98 cm, a mean absolute percentage error (MAPE) of 4.53%, and an R2 of 0.89. The model significantly outperformed naive baseline models (p < 0.05) and performed similarly to more complex non-linear architectures, such as neural networks and random forests. Notably, 88.4% of strides were predicted within 10% of the ground truth. ConclusionA parsimonious linear model leveraging proximal limb kinematics provides accurate and biomechanically interpretable stride length estimation. Low computational demand makes it suitable for real-time, ondevice gait monitoring in wearable assistive technologies, facilitating clinical assessments in real-world environments.

AIMExecutive functions (EF) are advanced cognitive processes that play an essential role in daily functioning and may be of increased importance in cerebral palsy (CP), given the complexity of primary and associated impairments. This study aims to synthesize existing evidence on the relation between EF and domains of the International Classification of Functioning, Disability and Health (ICF) in individuals with CP, and to quantify the magnitude of these associations through meta-analysis. METHODA systematic literature search was conducted in eight electronic databases up to 14 July 2025, examining associations between EF and ICF domains in CP. EF outcomes were classified into inhibitory control, working memory, cognitive flexibility, higher-order EF, and EF composite scores. Outcome measures were mapped onto ICF domains: Body Functions and Structures, Activity, Participation, and Contextual factors, using the CP Core Sets. Correlation coefficients were transformed to Fishers z and entered into three-level meta-analyses to estimate pooled effect sizes. Single moderator analyses examined CP subtype, EF domain, EF assessment type, and mean age. Risk of bias was assessed using the Quality in Prognosis Studies (QUIPS) tool. RESULTSFrom 4637 identified records, 38 studies were included, comprising a total sample of 1633 participants with CP. There was substantial heterogeneity in CP subtype, participant age, and EF conceptualization, while the ICF Contextual factors domain was underrepresented. A medium-to-large association was found between EF and functioning across all ICF domains combined (r=0.26, p<0.001). Domain-specific analyses showed a medium association of EF with Body Functions and Structures (r=0.21, p<0.01), a medium-to-large association with Activity (r=0.38, p<0.001) and Participation (r=0.26, p<0.01). CP subtype and mean age significantly moderated the overall EF-functioning association, with mixed CP and younger age associated with stronger effects. INTERPRETATIONEF are meaningfully associated with multiple domains of functioning in individuals with CP. These findings support the relevance of routine EF assessment and suggest that EF are an important cognitive correlate to consider when addressing broader aspects of daily functioning. WHAT THIS PAPER ADDSO_LIExecutive functions (EF) showed medium-to-large associations with all ICF domains in people with cerebral palsy (CP) C_LIO_LIThe strongest and most consistent associations were found between EF and ICF Activity C_LIO_LIOverall associations highlight the relevance of EF as a meaningful intervention target in CP C_LI

Conventional therapy after stroke focuses on reducing physical impairments. However, the decisions that guide peoples movements may have far-reaching consequences towards recovery. We lack the tools to characterize these decisions. Recently, researchers have created a quantitative behavioral assessment of effort-based decision-making and applied it to some clinical populations. The purpose of this paper is to examine the feasibility of evaluating effort-based decision-making during walking after stroke. We recruited five neurotypical participants in an initial study. We conducted a subjective effort valuation on the neurotypical individuals with and without a knee immobilizer to simulate the biomechanics of reduced knee flexion during post-stroke gait. Participants cleared obstacles of varying heights during overground walking, followed by rating their perceived effort and then completing an effort choice paradigm to calculate subjective effort value. In a second experiment, we recruited five individuals with stroke to perform a similar protocol without an immobilizer during harnessed treadmill walking. We found that rated perceived effort increased monotonically with obstacle height across groups, that individuals could recall obstacle heights without cues, and that subjective effort value increased with knee immobilization in the control group as expected. We conclude that adapting an effort-based decision-making assessment to a walking context in people with stroke is feasible.

Background/ObjectivesWorking memory (WM) is a core component of cognition, supporting learning, reasoning, and daily functioning. In severe dyskinetic cerebral palsy (CP), profound motor impairments and involuntary movements make reliable cognitive assessment and access to cognitive interventions difficult. Eye-tracking technology offers an optimal computer interface for administering computerized cognitive assessments and training programs. This study explored the feasibility and efficacy of an adaptive, eye-tracking WM training in young people with severe dyskinetic CP. MethodsFour individuals with severe dyskinetic CP (age range 10-20 years old, 4 female) completed a 5-week intensive Cogmed WM training (five 30-45-minute sessions per week). Primary outcome was the Cogmed Improvement Index, reflecting near-transfer on trained WM tasks. Secondary outcomes included tests from the Wechsler Intelligence Scale for Children-Fifth Edition (WISC-V) to assess near-transfer on untrained WM tasks (Picture Span) and far-transfer to fluid reasoning (Matrix Reasoning, Figure Weights) and visual-spatial reasoning and planning (Visual Puzzles). Language comprehension was evaluated using the Computer-Based instrument for Low motor Language Testing (C-BiLLT), and executive functions behaviour using the Behavior Rating Inventory of Executive Function-2 (BRIEF-2). Descriptive statistics were used. ResultsParticipants completed 23-25 sessions (100% adherence). Cogmed Improvement Index increased by +10.5 to +27, and Picture Span by +12 to +21 post-intervention, mostly retained at 3-month follow-up. Far-transfer effects were variable, except language comprehension which improved consistently and remained stable. ConclusionsThese preliminary findings suggest the feasibility and potential cognitive benefits of adaptive eye-tracking WM training in severe dyskinetic CP. Randomized controlled trials are needed to confirm efficacy and generalisation effects.

Pusher syndrome is a disorder of postural control, characterized by an altered perception of upright body orientation. While visual verticality perception remains intact, patients incorrectly perceive their tilted body posture as upright, resulting in active resistance to posture correction. This perceptual mismatch offers a potential target for therapeutic interventions. We evaluated a newly developed Tilted Reality Device (TRD) designed to recalibrate body verticality perception by subtly tilting the patients real-time visual environment towards the ipsilesional side in a series of four patients with pusher syndrome. We implemented a three-phase experimental design: pre-manipulation (normal view), manipulation (TRD tilted 20{degrees} ipsilesionally), and post-manipulation (normal view). Passive body tilts were performed while we recorded body orientation. Fifteen healthy older adults served as controls. The behavioral changes were assessed via tilt angle analysis and were statistically compared using Crawford-Garthwaite Bayesian methods. Two of the four patients showed reduced resistance to ipsilesional body tilts during the TRD manipulation. Two patients also demonstrated an aftereffect. Our findings only partly confirmed our expectations; possible limitations are discussed. Further research is needed to evaluate our TRD in its potential treatment effects in pusher syndrome and better understand the mechanisms involved in the recalibration of upright body orientation perception in patients with pusher syndrome.