BackgroundUpper limb (UL) deficits in children with unilateral cerebral palsy (uCP) have traditionally been targeted with motor execution treatment models, such as modified Constraint-Induced Movement Therapy (mCIMT). However, new approaches based on a neurophysiological model such as Action-Observation Training (AOT) may provide new opportunities for enhanced motor learning. The aim of this study is to describe a randomised controlled trial (RCT) protocol investigating the effects of an intensive treatment model, combining mCIMT and AOT compared to mCIMT alone on UL function in children with uCP. Additionally, the role of neurological factors as potential biomarkers of treatment response will be analysed.MethodsAn evaluator-blinded RCT will be conducted in 42 children aged between 6 and 12 years. Before randomization, children will be stratified according to their House Functional Classification Scale, age and type of corticospinal tract wiring. A 2-week day-camp will be set up in which children receive intensive mCIMT therapy for 6 hours a day on 9 out of 11 consecutive days (54 h) including AOT or control condition (15 h). During AOT, these children watch video sequences showing goal-directed actions and subsequently execute the observed actions with the more impaired UL. The control group performs the same actions after watching computer games without human motion. The primary outcome measure will be the Assisting Hand Assessment. Secondary outcomes comprise clinical assessments across body function, activity and participation level of the International Classification of Function, Disability and Health. Furthermore, to quantitatively evaluate UL movement patterns, a three-dimensional motion analysis will be conducted. UL function will be assessed at baseline, immediately before and after intervention and at 6 months follow up. Brain imaging comprising structural and functional connectivity measures as well as Transcranial Magnetic Stimulation (TMS) to evaluate corticospinal tract wiring will be acquired before the intervention.DiscussionThis paper describes the methodology of an RCT with two main objectives: (1) to evaluate the added value of AOT to mCIMT on UL outcome in children with uCP and (2) to investigate the role of neurological factors as potential biomarkers of treatment response.Trial registrationNCT03256357 registered on 21st August 2017 (retrospectively registered).Electronic supplementary materialThe online version of this article (10.1186/s12887-018-1228-2) contains supplementary material, which is available to authorized users.

BackgroundDiffusion magnetic resonance imaging (dMRI) is able to detect, localize and quantify subtle brain white matter abnormalities that may not be visible on conventional structural MRI. Over the past years, a growing number of studies have applied dMRI to investigate structure-function relationships in children with cerebral palsy (CP). AimsTo provide an overview of the recent literature on dMRI and motor function in children with CP. MethodsA systematic literature search was conducted in PubMed, Embase, Cochrane Central Register of Controlled trials, Cinahl and Web of Science from 2012 onwards. ResultsIn total, 577 children with CP in 19 studies were included. Sixteen studies only included unilateral CP, while none included dyskinetic CP. Most studies focused on specific regions/tracts of interest (n=17) versus two studies that investigated the whole brain. In unilateral and bilateral CP, white matter abnormalities were widespread including non-motor areas. In unilateral CP, consistent relationships were found between white matter integrity of the corticospinal tract and somatosensory pathways (e.g. thalamocortical projections, medial lemniscus) with upper limb sensorimotor function. The role of commissural and associative tracts remains poorly investigated. Also results describing structurefunction relationships in bilateral CP are scarce (n=3). ConclusionsThis review underlines the importance of both the motor and somatosensory tracts for upper limb sensorimotor function in unilateral CP. However, the exact contribution of each tract requires further exploration. In addition, research on the relevance of non-motor pathways is warranted, as well as studies including other types of CP. What this paper adds• An overview of the current literature investigating the relationship between diffusion MRI based measures of white matter tract integrity and motor function in CP.• Current gaps and future recommendations to further improve our insights into these structurefunction relationships. Highlights• In unilateral and bilateral CP, white matter microstructural abnormalities are widespread including non-motor areas.• In unilateral CP, dMRI reveals a relationship between the microstructural properties of motor and somatosensory tracts and upper limb sensorimotor function.• The contribution of motor versus somatosensory tracts needs further clarification.• There are limited studies in bilateral spastic CP and in children with dyskinetic CP.

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