Motor response investigation in individuals

with cerebral palsy using near infrared

spectroscopy: pilot study
Ujwal Chaudhary,1 Michael Hall,1 Jean Gonzalez,1 Leonard Elbaum,2 Martha Bloyer,2
and Anuradha Godavarty1,*
1

Optical Imaging Laboratory, Department of Biomedical Engineering, Florida International University, Miami, Florida 33174, USA
2

Department of Physical Therapy, Florida International University, Miami, Florida 33199, USA
*Corresponding author: godavart@fiu.edu
Received 14 August 2013; revised 13 November 2013; accepted 20 December 2013;
posted 23 December 2013 (Doc. ID 195717); published 20 January 2014

Cerebral palsy (CP) describes a group of motor impairment syndromes secondary to genetic that may be
due to acquired disorders of the developing brain. In this study, near infrared spectroscopy (NIRS) is used
to investigate the prefrontal cortical activation and lateralization in response to the planning and execution of motor skills in controls and individuals with CP. The prefrontal cortex, which plays a dominant
role in the planning and execution of motor skill stimulus, is noninvasively imaged using a continuous
wave-based NIRS system. During the study, 7 controls (4 right-handed and 3 left-handed) and 2 individuals with CP (1 right-handed and 1 left-handed) over 18 years of age performed 30 s of a ball throwing
task followed by 30 s rest in a 5-block paradigm. The optical signal acquired from the NIRS system was
processed to elucidate the activation and lateralization in the prefrontal region of controls and individuals with CP. The preliminary result indicated a difference in activation between the task and rest conditions in all the participant types. Bilateral dominance was observed in the prefrontal cortex of controls
in response to planning and execution of motor skill tasks, while an ipsilateral dominance was observed
in individuals with CP. In conjunction, similar contralateral dominance was observed during rest periods,
both in controls and individuals with CP. 2014 Optical Society of America
OCIS codes: (170.0110) Imaging systems; (170.1610) Clinical applications; (170.3660) Light
propagation in tissues; (300.6340) Spectroscopy, infrared.
http://dx.doi.org/10.1364/AO.53.000503

1. Introduction

Cerebral palsy (CP) is the most common movement

disorder affecting children. It occurs in approximately 0.33% of live births in the US [1]. CP is not a
single disease, but the label for a large heterogeneous
group of motor impairment syndromes that occur as
a result of a permanent, nonprogressive lesion of the
brain [2]. Etiology of the lesions include mutations in
genes that control brain development, maternal infections that affect the developing fetus, fetal stroke
1559-128X/14/030503-08$15.00/0
2014 Optical Society of America

(a disruption of blood supply to the developing brain),

lack of oxygen to the brain (asphyxia) related to difficult labor or delivery, infections that cause inflammation in or around the brain, and traumatic brain
injury to an infant from a motor vehicle accident, fall,
or child abuse [3,4]. For any individual, or group of
individuals, the type of CP is typically described by
the part(s) of the body that are affected, the nature of
the observed movement disorder, and the severity
of interference with typical development [5]. In addition to motor impairments, individuals with CP may
also present with impairments of cognition, communication, and sensation. Although there is no cure for
CP, medical interventions are provided to achieve the
20 January 2014 / Vol. 53, No. 3 / APPLIED OPTICS

503

primary goal of maximum functional independence,

and typically include regular participation in physical therapy. People with CP who participate in physical therapy programs generally demonstrate some
degree of decreased motor impairment and functional improvement, in spite of the permanent
nature of their central nervous system (CNS) lesion.
The literature strongly suggests that this improvement is due to plasticity of the viable portions of
the CNS, and that plasticity is dependent, at least
in part, on repeated activation of specific areas of
the CNS. Therefore, activities to include in physical
therapy programs for any given person with CP, or
for adults with acquired brain lesions, might best
be chosen based on the magnitude, duration, and location of CNS activation they engender, with the
assumption that these activations will facilitate plastic changes within the CNS that will ultimately yield
the best possible functional outcomes [6,7]. Several
advanced neuroimaging techniques have been used
to investigate and explicate the etiological basis of
CP. To date, none of the functional neuroimaging
techniques have been employed to investigate the
functional change in the brain of individuals with
CP as these techniques [e.g., functional magnetic
resonance imaging (f MRI) and positron emission
tomography (PET)/single-photon emission computed
tomography (SPECT)] requires the participants to be
stationary in a claustrophobic environment. Hence,
it is challenging to investigate the motor response
of the individuals with CP during an active stimulus
(for example, during their physical therapy) using
the current functional neuroimaging modalities.
Along with the above mentioned neuroimaging
modalities near infrared spectroscopy (NIRS) is an
emerging modality that uses near infrared (NIR)
light to provide functional information of the brain
in response to active tasks or during resting states.
NIRS employs NIR light in the range of 650
900 nm within which light is minimally absorbed
and preferentially scattered by the dominant chromophores [oxy-(HbO) and deoxy-hemoglobin (HbR)]
present in the brain [811]. Different wavelengths
of NIR light are used to quantify the different chromophores present in the brain. Researchers have
shown that the NIR light of wavelengths close to
690 and 830 nm provide dominant information about
HbR and HbO, respectively [10,11]. Along with these
particular wavelengths there also exists an isosbestic
point, close to 790 nm [12], at which the absorption
spectra of HbR and HbO intersect. Thus, this isosbestic point provides the information about change in
total hemoglobin concentration (HbT) [12]. NIRS is
robust to movement or motion artifacts and it can
be easily applied to monitor everyday complex tasks
in awake individuals, which makes it a reliable tool
to investigate the brains functional activity (via
measurement of cerebral oxygenation changes) in
neurologically challenged individuals in response
to appropriate physical therapies or activities.
504

APPLIED OPTICS / Vol. 53, No. 3 / 20 January 2014

To date, NIRS has been reliably used to monitor

and investigate the cerebral oxygenation changes
in healthy and neurologically challenged adults and
children in response to various stimuli across different cortical regions [1327, selective references]. In
the area of CP research, NIRS has been applied in
limited studies [28,29] to investigate the response of
the motor cortex in individuals with CP in response
to finger tapping tasks.
The prefrontal region of the brain plays a prominent role in memory, motor set, and preparation
for movement [30]. Researchers have shown that
the initiation of motor action in response to sensory
stimuli takes place in the prefrontal cortex, where
the sensory stimuli are integrated to produce a perceivable change in the environment [31]. Thus, the
prefrontal region plays a dominant role in the planning and execution of motor skill tasks [30,31], especially in motor-challenged CP populations. Hence, in
the present study NIRS is used for the first time (to
our best knowledge) to investigate the planning and
execution of motor skill tasks in the prefrontal region
of the brain in individuals with CP, in comparison to
the controls.
2. Materials and Methods
A. Instrumentation

An in-house developed continuous wave (CW) NIRS

system was used for the study (see Fig. 1). The
NIRS system is constituted of a laser diode-based
source system, an intensified charge coupled device
(ICCD) based detector system, and a custom developed optical cap containing the source and the detector fiber bundles. The laser diode-based source
system consists of two 785 nm (close to isosbestic
point) laser light sources with variable optical power
output (controlled using a multichannel controller).
The light from the source system is delivered to the
region of the head under investigation via an optode
connected to source fibers (core diameter 400 m and
numerical aperture of 0.37). The attenuated light intensity (after it travels through the cortical surface)
is collected via an optode connected to a detector fiber
bundle (core diameter 2.5 mm and numerical aperture of 0.6). The detector fiber bundle delivers the
light to an ICCD-based detector that is operated at
an acquisition rate (I R ) of 4.76 Hz. The block diagram
of the in-house developed NIRS system is shown in
Fig. 1. The acquisition rate of the ICCD detector is
determined by the formulas shown in Eqs. (1) and (2).
IR

1
;
TI

T I
T ex  T TI ;

(1)

(2)

where I R is the acquisition rate of the ICCD detector

and T I is the total time taken to acquire a single image. The term T ex is the exposure time of the CCD

The study was approved by the universitys institutional review board, and written consent(s) were
obtained from the participants.
C.

Fig. 1. Block diagram of the in-house developed NIRS system for

performing CW-based brain imaging studies.

camera (set to 0.2 s) and T TI is the time taken to

transfer and integrate the charge on the CCD camera
(0.01 s). Thus, the acquisition rate is estimated
as 4.76 Hz.
During this study the output optical power of the
laser diodes was 5 mW and the optical cap with the
sourcedetector layout was placed on the prefrontal
region of the brain as shown in Fig. 2. The prefrontal
region plays a dominant role in the planning and
execution of motor tasks [30,31]. Hence, two different
sourcedetector pairs or channels, corresponding to
left (Fp1Fpz) and right (Fp2Fpz) prefrontal regions, were used for the study, where the placement
of the sources/detectors was based on the international 1020 electrode placement system.
B.

Participants

One left-handed and one right-handed adult male, 26

and 28 years old, respectively, with a primary diagnosis of spastic, quadriplegic CP, and seven controls
(4 right-handed and 3 left-handed) between 2130
years old, were recruited for the study. The individuals with CP were recruited via the department of
physical therapy at Florida International University
(FIU). The participants conveyed their handedness
based on the dominant use of their particular hand.

The focus of the current study is to investigate how

the planning and execution of motor skill tasks manifests itself in the prefrontal cortex in individuals
with CP in comparison to the controls. During the
study the individuals with CP remained on their
wheel chair that was wheeled into a quiet imaging
room. The custom built optical cap was placed on
the prefrontal region of their head and the tasks
to be performed during the study were explained
to them by the physical therapist. In the case of control participants, they were seated comfortably in an
upright chair in the same imaging room and the custom built optical cap was also placed on the prefrontal region of their head during the imaging studies.
The study began with a 30 s rest period, followed by
30 s of a ball throwing task (T), and 30 s of rest (R).
The TR block was repeated for five times by each
participant. During the rest period, the participants
were asked to close their eyes and try not to think
about anything. The rest period, which entails closing of eyes and trying not to think about anything,
serves as a baseline to the actual stimulus. During
the ball throwing task period the participants were
asked to throw balls into a container placed at a distance of four feet from their palms. The balls used for
this study were soft and spongy with grooves on their
surface and the size of a golf ball (4 cm in diameter).
The task of throwing the ball in the container involved picking up the ball from the box containing
the ball, aiming the ball at the container placed at
a distance of four feet, and finally releasing the ball
at such a trajectory that it lands in the container. The
task may seem to be easy for controls but for individuals with CP who have impairment in muscular
mobility (in upper extremities), the task of picking
up and throwing the ball in the container was challenging. During the study it was observed that individuals with CP had difficulty in grabbing the ball
from the container even before attempting to throw
it 4 feet away. Hence, for individuals with CP, the
container was placed right below their hand and they
were asked to pick up the ball from the box containing the balls and drop it in the container, which was
still challenging for them. The participants performed the task with their dominant hand.
D.

Fig. 2. Source detector placement is same as the 1020 system of

electrode placement for the prefrontal region of the brain. Each
sourcedetector pair is called a channel. Fp1 and Fp2 represent
the detector placed on the left and right prefrontal, respectively.
Fpz represents the source placed on the mid prefrontal.

Experimental Procedure

Data Processing and Analysis

The raw NIR optical intensity data was postprocessed using the following steps in order to obtain
relative changes in total hemoglobin concentration
[HbTt] as a function of time.
Step 1Filtering. The optical intensity data (arbitrary units) acquired from the surface of head is
contaminated by systemic signals like heartbeat,
respiratory signal, and Mayer waves [10,11]. Hence,
a band pass filter of 0.30.0016 Hz based on the
20 January 2014 / Vol. 53, No. 3 / APPLIED OPTICS

505

frequency range of other signals was used to remove

this noise [10].
Step 2Normalizing. The filtered optical intensity
data was normalized to remove the instrument effect
and provide the relative change in intensity by dividing the filtered optical intensity data by its mean, as
shown in Eq. (3),
I N t

It
;
I0

(3)

where I N t is the normalized optical intensity data

as a function of time, It is the raw optical intensity
data as a function of time, and I 0 is the mean of the
raw optical intensity data acquired during a given
stimulus (either task or rest period as described in
Section 2.D) and a given sourcedetector channel.
Step 3Relative change in total hemoglobin,
HbT. Negative logarithm of the normalized optical
intensity data [32] calculated based on the modified
BeerLambert law to calculate change in optical density (OD) as shown in Eq. (4),
ODt
logI N t:

(4)

Since the NIRS study was performed at 785 nm,

which is close to the isosbestic point at 790 nm [12],
the change in optical density is equivalent to relative
change in HbT (HbTt), as shown in Eq. (5),
ODtIsosbestic point
HbTt;

(5)

where ODtIsosbestic point is the change in optical

density at the isosbestic point (same as OD in
Eq. (4). Equation (5) provides the relative changes
in HbT without giving any information about the
changes in HbO or HbR in the brain.
Step 4Averaging. The HbT is averaged across
the 5 blocks (i
1 to 5) and across all participants
within the subject group ( j
1 to m subjects) used
in the study to obtain the change in HbT across a single block of ball throwing tasks (T) and rest (R)
period (TR), and a given sourcedetector channel
as shown in Eq. (6),
Pm hPn
HbTtAvg

j
1

i
1

(6)

where HbTti corresponds to the relative change in

HbT across the ith block and jth participant within
the subject group, n
5 blocks for all experiments,
m
4 for right-handed controls, m
3 for lefthanded controls, and m
1 for individuals with
the CP group.
The differences in the brain activation and cortical
lateralization was calculated across the different
subject groups using the HbTtAvg data, as described below.
506

2. Cortical Lateralization
A cortical lateralization study was performed to
understand the hemispherical dominance of planning and execution tasks in the frontal cortex and
its variation with each stimulus (task and rest) and
participant type (controls and individuals with CP).
The laterality index was computed for the left versus
right frontal cortex of each stimulus using the
grand averaged relative change in total hemoglobin
(HbTtAvg ) obtained from the two channels: Fp1
Fpz versus Fp2Fpz (see Fig. 2). The NIR laterality
index, L, was calculated according to the formula
shown in Eq. (7),
Lt

HbTtleft HbTtright 
;
jHbTtleft j  jHbTtright j

(7)

where HbTtleft and HbTtright are the relative

changes in total hemoglobin concentration in the left
and right channel, respectively, of the frontal cortex
with respect to time (t) and for each the 30 s stimulus.
A laterality index of value greater than 0.25 indicates left side dominance, and a laterality index of
value less than 0.25 indicates right side dominance
in the brain activation of the given channel pair [33].
A laterality index value between 0.25 and 0.25 indicates no dominance between the channel pairs, and
is also termed as bilateral activation [33].
3. Result and Discussion

HbTti
n
j

1. Brain Activation
A mean of the averaged relative change in total
hemoglobin (HbTtAvg ) that varied with time
was determined across the central 20 s time window
across each stimulus (i.e., 30 s task and 30 s rest
period) for each participant type, denoted as
(HbT). Of the 30 s stimulus period, only the central
20 s period of each stimulus was employed so as to
negate the confounding effect of one stimulus over
the other. The activation analysis elucidates the extent of the relative change in total hemoglobin without giving any information about the hemispherical
dominance during a stimulus. Hence, to explicate the
dominance feature of the cortical lateralization is
performed as described below.

APPLIED OPTICS / Vol. 53, No. 3 / 20 January 2014

A. Brain Activation

The grand averaged relative change in total hemoglobin, HbTtAvg across the task and rest time
periods in the prefrontal cortex is shown in Fig. 3
for each participant type. It can be observed from
Figs. 3A and 3B, which correspond to HbTtAvg
in right-handed and left-handed controls, respectively, that there is a difference in the relative change
in total hemoglobin between tasks and rest across
both the channels (Fp1Fpz and Fp2Fpz). The
HbTtAvg increases during the ball throwing task
period in both the controls and the individuals with
CP. The HbTtAvg decreases during the rest

Fig. 3. Relative changes in total hemoglobin [HbTt] as a function of time across the right (Fp1Fpz, shown by dashed black) and left
(Fp2Fpz, shown by solid red) prefrontal cortex obtained from A, right-handed controls; B, left-handed controls; C, right-handed individual
with CP; and D, left-handed individual with CP. In all the plots, the first 30 s corresponds to the relative change in total hemoglobin during
the ball throwing task (T) and the last 30 s during the rest period (R).

period, which returns toward the baseline by the end

of the rest period in both the controls and individuals
with CP. This indicates that there is a similarity in
the trend of relative change in total hemoglobin
across both the subject groups (i.e., controls and individuals with CP).
The mean of the relative change in total hemoglobin (HbT) over the central 20 s time period of each
stimulus and channel is shown as bar plots in Fig. 4
for all participant types. The figure quantitatively
estimates that there is a relative increase in change
in total hemoglobin (HbT) during the task in comparison to the rest in both the right- and left-handed
controls as well as right- and left-handed individuals
with CP. Comparing the quantitative change in
total hemoglobin across the tasks and rest periods
between the controls and individuals with CP, no
definitive trend can be stated because of the less
number of participants enrolled for this study,
thereby limiting the statistical significance of the result. Although the study was performed on a smaller
number of participants, the results of the activation

during the ball throwing and rest periods in the controls and individuals with CP showed that there was
a similarity in the trend of activation between controls and individuals with CP. Thus, the relative
change in total hemoglobin across the Fp1Fpz and
Fp2Fpz channels for all the participant types indicates that the change in total hemoglobin during the
task is greater than the change in HbT during the
rest. The relatively greater change of total hemoglobin during the task over rest indicates an increase in
the blood flow to the prefrontal cortex to support the
increased metabolic activity during the planning and
execution of motor skill tasks over rest conditions.
B. Cortical Lateralization

The laterality index calculated for each participant

type during tasks and rest periods is given in Table 1.
The laterality index value for right- and left-handed
controls indicates that there is a bilateral (or no)
dominance during the task, and contralateral dominance during the rest in the prefrontal cortex. The
laterality index value for right- and left-handed
20 January 2014 / Vol. 53, No. 3 / APPLIED OPTICS

507

Fig. 4. Bar plots depicting the mean relative changes in HbT across the central 20 s window of each of the 30 s stimulus (ball throwing
task and rest) performed by A, right- and left-handed controls; and B, right- and left-handed individuals with CP. The black and gray bars
represent the data from a ball throwing task and a rest task, respectively, and are provided along with mean relative changes in HbT
values. A depicts the histogram plot corresponding to the right-handed and left-handed controls across the sourcedetector pair Fp1Fpz
and Fp2Fpz. B depicts the histogram plot corresponding to the right-handed and left-handed individuals with CP across the source
detector pair Fp1Fpz and Fp2Fpz.

individuals with CP indicates that there is an ipsilateral dominance during the tasks, and contralateral
dominance during the rests in the prefrontal cortex
of individual with CP (left/right-handed).
From the brain activation (in terms of
HbTtAvg ) and cortical lateralization results, it
can be seen that, although there was a difference
in HbTtAvg between tasks and rest periods across
all participant types, the cortical lateralization
differed between controls and individuals with CP
during the task periods. In other words, there is contralateral dominance of the prefrontal cortex during
rests across any participant type. However, the prefrontal cortical dominance changes during the planning and execution of motor tasks in individuals with
CP (with ipsilateral dominance) in comparison to the
controls (with bilateral or no dominance).
The present study was performed on a small number of participants because of which no statistically
significant conclusion can be drawn. However, preliminary results suggest differences in the functional
response of the prefrontal cortex across the two subject groups. Currently studies are ongoing in imaging
a larger sample of subjects (both controls and individuals with CP) toward understanding the planning
and execution of motor skills. These studies may

Table 1. Prefrontal Cortical Lateralization or Dominance in Response

to Planning and Execution of Motor Skill Task and Rest Task in
Controls and Individual(s) with CP

Laterality Index (Dominance)

Participant Type
Right-handed control
Left-handed control
Right-handed
individual with CP
Left-handed
individual with CP

508

Ball Throwing

Rest

0.02 (bilateral)
0.38 (contralateral)
0.1 (bilateral)
0.29 (contralateral)
0.75 (ipsilateral) 0.29 (contralateral)
0.26 (ipsilateral) 0.35 (contralateral)

APPLIED OPTICS / Vol. 53, No. 3 / 20 January 2014

have the potential to elucidate the neural basis of

cognition in individuals with CP during the execution of motor tasks prior to understanding the neuronal connectivity in the motor regions of the brain.
4. Conclusion

Motor skill tasks were performed by controls and

individuals with CP and the NIR optical signal was
measured using a CW-based NIRS system. The preliminary results show a greater activation during the
ball throwing tasks in comparison to the rest periods
in both the controls and individuals with CP. However, it was observed that the prefrontal cortical lateralization showed bilateral dominance in controls
and contralateral dominance in individuals with
CP during the task periods. The main aim of the
present work was to demonstrate the feasibility of
NIRS toward the investigation of the differences, if
any, in the planning and execution of simple motor
tasks in controls versus CP, such that it can be developed as a reliable tool to aid in the rehabilitation of
individuals with CP. Extensive work is currently
being carried out to statistically validate the preliminary observations by recruiting and performing the
studies on more controls and individuals with CP.
The immediate future work is to perform the NIRS
study in an effort to understand the hemodynamic
responses for planning/execution from both the frontal and motor cortices in order to determine synchrony, if any, across these two regions in controls
versus CPs. The current state of the art in the field
of physical therapy for individuals with CP is that
they are trained in certain motor tasks to help them
in their everyday activity. The motor task is determined using trial and error methods; i.e., the physical therapists use many different tasks until they
find one task that would help the individual to effectively reduce their muscular motor impairment. If
the brain activation in individuals with CP can be
monitored during their training routines, then an

effective and customized training routine could possibly be designed appropriately. This may involve
simultaneous monitoring of brain activation (via
NIRS) and kinematics of the limb movement during
a given motor task (a parallel research focus of our
group). The combined NIRS and kinematics study
can be synchronized for a better understanding
and intervention options can be offered by physical
therapists to individuals with CP during their rehabilitation regimes.
The authors would like to thank the funding
support from the dissertation evidence acquisition
fellowship (DEA) and dissertation year fellowship
(DYF) provided to the first author by Florida
International University, and partial support from
NIH (R15CA119253).

14.

15.

16.

17.

18.

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