2025 Theses Doctoral

The Hidden Forces of Rehab: Advancing Measurement Across the ICF Domains in Children with Unilateral Spastic Cerebral Palsy

Delfing, Dalina

Background.
Unilateral spastic cerebral palsy (USCP) impairs sensorimotor function primarily on one side of the body, limiting the ability to participate in daily activities. Improving rehabilitation requires scalable and inclusive measures that capture not only outcomes but also factors that shape the processes underlying change.

Purpose.
This dissertation addressed critical measurement challenges in pediatric rehabilitation by advancing tools and methods to quantify key mediators and outcome variables across the International Classification of Functioning, Disability and Health (ICF) domains for children with USCP. To advance knowledge in this area, four studies were conducted.

Results.
The first study (Chapter 2) described the development and validation of the Rehabilitation Observation Measure of Engagement (ROME), a video-based behavioral coding tool that quantifies both person-level and between-system level engagement during treatment. ROME demonstrated strong construct validity and reliability, with responsiveness to change across therapeutic activities.

Building on this tool, the second study (Chapter 3) used ROME to examine how child characteristics influence engagement and how engagement relates to functional hand outcomes. Findings indicated that age was significantly associated with engagement, and that engagement correlated with improvements in structured hand function tasks, highlighting its importance during capacity-based motor activities.

The third study (Chapter 4) addressed proprioception, which is commonly affected in children with USCP, by designing a multi-joint assessment protocol using a marker-based 3D motion analysis system. Children with USCP showed significantly reduced symmetry across all proprioceptive position sense (PPS) metrics compared to typically developing children (TDC). Results showed the importance of assessing PPS not only at the single-joint level but also across multiple joints, as orientation symmetry, which captures coordinated alignment across joints correlated significantly with functional outcomes.

The final study (Chapter 5) explored the use of a marker-less, deep learning-based algorithm as a scalable alternative to traditional motion capture for assessing motor behavior. This approach effectively quantified changes in gross motor movements and revealed intervention-specific trunk adaptations post-treatment. Fine motor applications still require further refinement.

Conclusion.
Collectively, these studies contribute to the body of tools for assessing engagement, proprioception, and motor function, enabling evaluation of intervention effects across ICF domains. This helps to advance both clinical assessment and research methodology in pediatric rehabilitation.