Technical innovations for the diagnosis and the rehabilitation of motor and perceptive impairments of the child with Cerebral Palsy

The treatment of the Cerebral Palsy (CP) is considered as the “core problem” for the whole field of the pediatric rehabilitation. The reason why this pathology has such a primary role, can be ascribed to two main aspects. First of all CP is the form of disability most frequent in childhood (one new case per 500 birth alive, (1)), secondarily the functional recovery of the “spastic” child is, historically, the clinical field in which the majority of the therapeutic methods and techniques (physiotherapy, orthotic, pharmacologic, orthopedic-surgical, neurosurgical) were first applied and tested. The currently accepted definition of CP – Group of disorders of the development of movement and posture causing activity limitation (2) – is the result of a recent update by the World Health Organization to the language of the International Classification of Functioning Disability and Health, from the original proposal of Ingram – A persistent but not unchangeable disorder of posture and movement – dated 1955 (3). This definition considers CP as a permanent ailment, i.e. a “fixed” condition, that however can be modified both functionally and structurally by means of child spontaneous evolution and treatments carried out during childhood. The lesion that causes the palsy, happens in a structurally immature brain in the pre-, peri- or post-birth period (but only during the firsts months of life). The most frequent causes of CP are: prematurity, insufficient cerebral perfusion, arterial haemorrhage, venous infarction, hypoxia caused by various origin (for example from the ingestion of amniotic liquid), malnutrition, infection and maternal or fetal poisoning. In addition to these causes, traumas and malformations have to be included. The lesion, whether focused or spread over the nervous system, impairs the whole functioning of the Central Nervous System (CNS). As a consequence, they affect the construction of the adaptive functions (4), first of all posture control, locomotion and manipulation. The palsy itself does not vary over time, however it assumes an unavoidable “evolutionary” feature when during growth the child is requested to meet new and different needs through the construction of new and different functions. It is essential to consider that clinically CP is not only a direct expression of structural impairment, that is of etiology, pathogenesis and lesion timing, but it is mainly the manifestation of the path followed by the CNS to “re”-construct the adaptive functions “despite” the presence of the damage. “Palsy” is “the form of the function that is implemented by an individual whose CNS has been damaged in order to satisfy the demands coming from the environment” (4). Therefore it is only possible to establish general relations between lesion site, nature and size, and palsy and recovery processes. It is quite common to observe that children with very similar neuroimaging can have very different clinical manifestations of CP and, on the other hand, children with very similar motor behaviors can have completely different lesion histories. A very clear example of this is represented by hemiplegic forms, which show bilateral hemispheric lesions in a high percentage of cases. The first section of this thesis is aimed at guiding the interpretation of CP. First of all the issue of the detection of the palsy is treated from historical viewpoint. Consequently, an extended analysis of the current definition of CP, as internationally accepted, is provided. The definition is then outlined in terms of a space dimension and then of a time dimension, hence it is highlighted where this definition is unacceptably lacking. The last part of the first section further stresses the importance of shifting from the traditional concept of CP as a palsy of development (defect analysis) towards the notion of development of palsy, i.e., as the product of the relationship that the individual however tries to dynamically build with the surrounding environment (resource semeiotics) starting and growing from a different availability of resources, needs, dreams, rights and duties (4). In the scientific and clinic community no common classification system of CP has so far been universally accepted. Besides, no standard operative method or technique have been acknowledged to effectively assess the different disabilities and impairments exhibited by children with CP. CP is still “an artificial concept, comprising several causes and clinical syndromes that have been grouped together for a convenience of management” (5). The lack of standard and common protocols able to effectively diagnose the palsy, and as a consequence to establish specific treatments and prognosis, is mainly because of the difficulty to elevate this field to a level based on scientific evidence. A solution aimed at overcoming the current incomplete treatment of CP children is represented by the clinical systematic adoption of objective tools able to measure motor defects and movement impairments. A widespread application of reliable instruments and techniques able to objectively evaluate both the form of the palsy (diagnosis) and the efficacy of the treatments provided (prognosis), constitutes a valuable method able to validate care protocols, establish the efficacy of classification systems and assess the validity of definitions. Since the ‘80s, instruments specifically oriented to the analysis of the human movement have been advantageously designed and applied in the context of CP with the aim of measuring motor deficits and, especially, gait deviations. The gait analysis (GA) technique has been increasingly used over the years to assess, analyze, classify, and support the process of clinical decisions making, allowing for a complete investigation of gait with an increased temporal and spatial resolution. GA has provided a basis for improving the outcome of surgical and nonsurgical treatments and for introducing a new modus operandi in the identification of defects and functional adaptations to the musculoskeletal disorders. Historically, the first laboratories set up for gait analysis developed their own protocol (set of procedures for data collection and for data reduction) independently, according to performances of the technologies available at that time. In particular, the stereophotogrammetric systems mainly based on optoelectronic technology, soon became a gold-standard for motion analysis. They have been successfully applied especially for scientific purposes. Nowadays the optoelectronic systems have significantly improved their performances in term of spatial and temporal resolution, however many laboratories continue to use the protocols designed on the technology available in the ‘70s and now out-of-date. Furthermore, these protocols are not coherent both for the biomechanical models and for the adopted collection procedures. In spite of these differences, GA data are shared, exchanged and interpreted irrespectively to the adopted protocol without a full awareness to what extent these protocols are compatible and comparable with each other. Following the extraordinary advances in computer science and electronics, new systems for GA no longer based on optoelectronic technology, are now becoming available. They are the Inertial and Magnetic Measurement Systems (IMMSs), based on miniature MEMS (Microelectromechanical systems) inertial sensor technology. These systems are cost effective, wearable and fully portable motion analysis systems, these features gives IMMSs the potential to be used both outside specialized laboratories and to consecutive collect series of tens of gait cycles. The recognition and selection of the most representative gait cycle is then easier and more reliable especially in CP children, considering their relevant gait cycle variability. The second section of this thesis is focused on GA. In particular, it is firstly aimed at examining the differences among five most representative GA protocols in order to assess the state of the art with respect to the inter-protocol variability. The design of a new protocol is then proposed and presented with the aim of achieving gait analysis on CP children by means of IMMS. The protocol, named ‘Outwalk’, contains original and innovative solutions oriented at obtaining joint kinematic with calibration procedures extremely comfortable for the patients. The results of a first in-vivo validation of Outwalk on healthy subjects are then provided. In particular, this study was carried out by comparing Outwalk used in combination with an IMMS with respect to a reference protocol and an optoelectronic system. In order to set a more accurate and precise comparison of the systems and the protocols, ad hoc methods were designed and an original formulation of the statistical parameter coefficient of multiple correlation was developed and effectively applied. On the basis of the experimental design proposed for the validation on healthy subjects, a first assessment of Outwalk, together with an IMMS, was also carried out on CP children. The third section of this thesis is dedicated to the treatment of walking in CP children. Commonly prescribed treatments in addressing gait abnormalities in CP children include physical therapy, surgery (orthopedic and rhizotomy), and orthoses. The orthotic approach is conservative, being reversible, and widespread in many therapeutic regimes. Orthoses are used to improve the gait of children with CP, by preventing deformities, controlling joint position, and offering an effective lever for the ankle joint. Orthoses are prescribed for the additional aims of increasing walking speed, improving stability, preventing stumbling, and decreasing muscular fatigue. The ankle-foot orthosis (AFO), with a rigid ankle, are primarily designed to prevent equinus and other foot deformities with a positive effect also on more proximal joints. However, AFOs prevent the natural excursion of the tibio-tarsic joint during the second rocker, hence hampering the natural leaning progression of the whole body under the effect of the inertia (6). A new modular (submalleolar) astragalus-calcanear orthosis, named OMAC, has recently been proposed with the intention of substituting the prescription of AFOs in those CP children exhibiting a flat and valgus-pronated foot. The aim of this section is thus to present the mechanical and technical features of the OMAC by means of an accurate description of the device. In particular, the integral document of the deposited Italian patent, is provided. A preliminary validation of OMAC with respect to AFO is also reported as resulted from an experimental campaign on diplegic CP children, during a three month period, aimed at quantitatively assessing the benefit provided by the two orthoses on walking and at qualitatively evaluating the changes in the quality of life and motor abilities. As already stated, CP is universally considered as a persistent but not unchangeable disorder of posture and movement. Conversely to this definition, some clinicians (4) have recently pointed out that movement disorders may be primarily caused by the presence of perceptive disorders, where perception is not merely the acquisition of sensory information, but an active process aimed at guiding the execution of movements through the integration of sensory information properly representing the state of one’s body and of the environment. Children with perceptive impairments show an overall fear of moving and the onset of strongly unnatural walking schemes directly caused by the presence of perceptive system disorders. The fourth section of the thesis thus deals with accurately defining the perceptive impairment exhibited by diplegic CP children. A detailed description of the clinical signs revealing the presence of the perceptive impairment, and a classification scheme of the clinical aspects of perceptual disorders is provided. In the end, a functional reaching test is proposed as an instrumental test able to disclosure the perceptive impairment. References 1. Prevalence and characteristics of children with cerebral palsy in Europe. Dev Med Child Neurol. 2002 Set;44(9):633-640. 2. Bax M, Goldstein M, Rosenbaum P, Leviton A, Paneth N, Dan B, et al. Proposed definition and classification of cerebral palsy, April 2005. Dev Med Child Neurol. 2005 Ago;47(8):571-576. 3. Ingram TT. A study of cerebral palsy in the childhood population of Edinburgh. Arch. Dis. Child. 1955 Apr;30(150):85-98. 4. Ferrari A, Cioni G. The spastic forms of cerebral palsy : a guide to the assessment of adaptive functions. Milan: Springer; 2009. 5. Olney SJ, Wright MJ. Cerebral Palsy. Campbell S et al. Physical Therapy for Children. 2nd Ed. Philadelphia: Saunders. 2000;:533-570. 6. Desloovere K, Molenaers G, Van Gestel L, Huenaerts C, Van Campenhout A, Callewaert B, et al. How can push-off be preserved during use of an ankle foot orthosis in children with hemiplegia? A prospective controlled study. Gait Posture. 2006 Ott;24(2):142-151.

La questione percettiva in semiotica. Linee fondamentali e sviluppi della ricerca

This dissertation deals with the problems and the opportunities of a semiotic approach to perception. Is perception, seen as the ability to detect and articulate an coherent picture of the surrounding environment, describable in semiotic terms? Is it possibile, for a discipline wary of any attempt to reduce semiotic meaning to a psychological and naturalized issue, to come to terms with the cognitive, automatic and genetically hard-wired specifics of our perceptive systems? In order to deal with perceptive signs, is it necessary to modify basic assumptions in semiotics, or can we simply extend the range of our conceptual instruments and definitions? And what if perception is a wholly different semiotic machinery, to be considered as sui generis, but nonetheless interesting for a general theory of semiotics? By exposing the major ideas put forward by the main thinkers in the semiotic field, Mattia de Bernardis gives a comprehensive picture of the theoretical situation, adding to the classical dichotomy between structuralist and interpretative semiotics another distinction, that between homogeneist and etherogeneist theories of perception. Homogeneist semioticians see perception as one of many semiotic means of sign production, totally similar to the other ones, while heterogeneist semioticians consider perceptive meaning as essentially different from normal semiotic meaning, so much so that it requires new methods and ideas to be analyzed. The main example of etherogeneist approach to perception in semiotic literature, Umberto Eco’s “primary semiosis” is then presented, critically examined and eventually rejected and the homogeneist stance is affirmed as the most promising path towards a semiotic theory of perception.

Language and Embodiment: sensory-motor and linguistic-social experience. Evidence on sentence comprehension

In this work I address the study of language comprehension in an “embodied” framework. Firstly I show behavioral evidence supporting the idea that language modulates the motor system in a specific way, both at a proximal level (sensibility to the effectors) and at the distal level (sensibility to the goal of the action in which the single motor acts are inserted). I will present two studies in which the method is basically the same: we manipulated the linguistic stimuli (the kind of sentence: hand action vs. foot action vs. mouth action) and the effector by which participants had to respond (hand vs. foot vs. mouth; dominant hand vs. non-dominant hand). Response times analyses showed a specific modulation depending on the kind of sentence: participants were facilitated in the task execution (sentence sensibility judgment) when the effector they had to use to respond was the same to which the sentences referred. Namely, during language comprehension a pre-activation of the motor system seems to take place. This activation is analogous (even if less intense) to the one detectable when we practically execute the action described by the sentence. Beyond this effector specific modulation, we also found an effect of the goal suggested by the sentence. That is, the hand effector was pre-activated not only by hand-action-related sentences, but also by sentences describing mouth actions, consistently with the fact that to execute an action on an object with the mouth we firstly have to bring it to the mouth with the hand. After reviewing the evidence on simulation specificity directly referring to the body (for instance, the kind of the effector activated by the language), I focus on the specific properties of the object to which the words refer, particularly on the weight. In this case the hypothesis to test was if both lifting movement perception and lifting movement execution are modulated by language comprehension. We used behavioral and kinematics methods, and we manipulated the linguistic stimuli (the kind of sentence: the lifting of heavy objects vs. the lifting of light objects). To study the movement perception we measured the correlations between the weight of the objects lifted by an actor (heavy objects vs. light objects) and the esteems provided by the participants. To study the movement execution we measured kinematics parameters variance (velocity, acceleration, time to the first peak of velocity) during the actual lifting of objects (heavy objects vs. light objects). Both kinds of measures revealed that language had a specific effect on the motor system, both at a perceptive and at a motoric level. Finally, I address the issue of the abstract words. Different studies in the “embodied” framework tried to explain the meaning of abstract words The limit of these works is that they account only for subsets of phenomena, so results are difficult to generalize. We tried to circumvent this problem by contrasting transitive verbs (abstract and concrete) and nouns (abstract and concrete) in different combinations. The behavioral study was conducted both with German and Italian participants, as the two languages are syntactically different. We found that response times were faster for both the compatible pairs (concrete verb + concrete noun; abstract verb + abstract noun) than for the mixed ones. Interestingly, for the mixed combinations analyses showed a modulation due to the specific language (German vs. Italian): when the concrete word precedes the abstract one responses were faster, regardless of the word grammatical class. Results are discussed in the framework of current views on abstract words. They highlight the important role of developmental and social aspects of language use, and confirm theories assigning a crucial role to both sensorimotor and linguistic experience for abstract words.

Il ruolo della metafora nella comunicazione della fisica contemporanea

Il presente lavoro si rivolge all’analisi del ruolo delle forme metaforiche nella divulgazione della fisica contemporanea. Il focus è sugli aspetti cognitivi: come possiamo spiegare concetti fisici formalmente complessi ad un audience di non-esperti senza ‘snaturarne’ i significati disciplinari (comunicazione di ‘buona fisica’)? L’attenzione è sulla natura stessa della spiegazione e il problema riguarda la valutazione dell’efficacia della spiegazione scientifica a non-professionisti. Per affrontare tale questione, ci siamo orientati alla ricerca di strumenti formali che potessero supportarci nell’analisi linguistica dei testi. La nostra attenzione si è rivolta al possibile ruolo svolto dalle forme metaforiche nella costruzione di significati disciplinarmente validi. Si fa in particolare riferimento al ruolo svolto dalla metafora nella comprensione di nuovi significati a partire da quelli noti, aspetto fondamentale nel caso dei fenomeni di fisica contemporanea che sono lontani dalla sfera percettiva ordinaria. In particolare, è apparsa particolarmente promettente come strumento di analisi la prospettiva della teoria della metafora concettuale. Abbiamo allora affrontato il problema di ricerca analizzando diverse forme metaforiche di particolare rilievo prese da testi di divulgazione di fisica contemporanea. Nella tesi viene in particolare discussa l’analisi di un case-study dal punto di vista della metafora concettuale: una analogia di Schrödinger per la particella elementare. I risultati dell’analisi suggeriscono che la metafora concettuale possa rappresentare uno strumento promettente sia per la valutazione della qualità delle forme analogiche e metaforiche utilizzate nella spiegazione di argomenti di fisica contemporanea che per la creazione di nuove e più efficaci metafore. Inoltre questa prospettiva di analisi sembra fornirci uno strumento per caratterizzare il concetto stesso di ‘buona fisica’. Riteniamo infine che possano emergere altri risultati di ricerca interessanti approfondendo l’approccio interdisciplinare tra la linguistica e la fisica.