Profile of children with cerebral palsy spectrum disorder and a normal MRI study

OBJECTIVE

This study looks at what profile can be expected in children with cerebral palsy spectrum disorder (CP) and a normal MRI.

METHODS

The data were excerpted from the Canadian Cerebral Palsy Registry database. Only patients who had undergone MRI were included in the analysis. Neuroimaging classification was ascertained by university-based pediatric neuroradiologists and split into 2 categories: normal and abnormal MRIs. Six factors were then compared between those 2 groups: prematurity, perinatal adversity, presence of more than 1 comorbidity, CP subtype, bimanual dexterity (Manual Ability Classification System [MACS]), and gross motor function (Gross Motor Function Classification System [GMFCS]).

RESULTS

Participants with no perinatal adversity were 5.518 times more likely to have a normal MRI (p < 0.0001, 95% confidence interval [CI] 4.153-7.330). Furthermore, participants with dyskinetic, ataxic/hypotonic, and spastic diplegic forms of CP were 2.045 times more likely to have a normal MRI than those with hemiplegia, triplegia, and quadriplegia (p < 0.0001, 95% CI 1.506-2.778). No significant difference was found in prematurity, GMFCS levels, MACS levels, and the number of comorbidities.

CONCLUSIONS

Normal MRIs were associated with lack of perinatal adversity as well as with the dyskinetic, ataxic/hypotonic, and spastic diplegic CP subtypes. As MRI normality is not strongly associated with the severity of CP, continuous follow-up in children with normal imaging appears warranted. Further advanced imaging modalities, as well as strong consideration for metabolic and genetic testing, may provide additional insights into causal pathways in this population.

Use of consensus methods to determine the early clinical signs of cerebral palsy

Objectives

To develop expert-informed content regarding the early motor attributes of cerebral palsy (CP) that should prompt physician referral for diagnostic assessment of CP, as well as concurrent referral recommendations. This content will be used in the creation of knowledge translation (KT) tools for primary care practitioners and parents.

Methods

Two nominal group processes were conducted with relevant stakeholders, representing Canadian 'content experts' and 'knowledge-users', using an integrated KT approach.

Results

Six attributes were identified that should prompt referral for diagnosis. If the child demonstrates: Early handedness <12 months; stiffness or tightness in the legs between 6 and 12 months; persistent fisting of the hands >4 months; persistent head-lag >4 months; inability to sit without support >9 months; any asymmetry in posture or movement. Five referral recommendations were agreed upon: Motor intervention specialist (physical therapy and/or occupational therapy) for ALL; speech-language pathology IF there is a communication delay; audiology IF there is parental or healthcare professional concern regarding a communication delay; functional vision specialist (e.g., optometrist or occupational therapist) IF there is a vision concern (e.g., not fixating, following, or tracking); feeding specialist (e.g., occupational therapist, speech-language pathologist) IF there are feeding difficulties (e.g., poor sucking, poor swallowing, choking, and/or not gaining weight).

Conclusion

Rigorous consensus methods provided the initial evidence necessary to inform the content of tools to assist primary care providers in the early detection of CP. Results will be validated through a Delphi process with international experts, and user-friendly formats of this KT tool will be developed collaboratively with stakeholders.

A whole new world: a qualitative investigation of parents' experiences in transitioning their preterm child with cerebral palsy to developmental/rehabilitation services

BACKGROUND

Parents' experiences transitioning their children from neonatal to developmental/rehabilitation services (DRS) are unknown.

METHODS

A qualitative descriptive approach was used, including interviews with 18 parents (13 mothers and 5 fathers) of children born preterm and diagnosed with cerebral palsy (CP), located in a large urban center in Canada. Interview data underwent thematic analysis.

RESULTS

Parents' experiences with transition to DRS were a whole new world with three key themes: Wanting to know what to expect, feeling supported in their transition, and getting there emotionally and physically. Transition broke an emotional bond with neonatal services while parents were simultaneously entering DRS, experiencing their child's CP diagnosis, and reliving prior emotional trauma.

CONCLUSIONS

The findings reveal a cumulative emotional burden for parents in the first 3 years of life; a known critical period for parenting and early childhood development. Early transition interventions should consider including enhanced supports and services for parents.

Interactive media as a tool for reducing waiting anxiety at paediatric rehabilitation hospitals: a randomized controlled trial

AIM

To investigate the efficacy of waiting room media for reducing anxiety and increasing satisfaction at a paediatric rehabilitation hospital.

METHOD

In this clustered, parallel, randomized controlled trial, 310 young people with disabilities (age range 5-19y) and their parents attending outpatient clinics were assigned to interactive media (n=113), a silent nature video (n=97), or media-free comparison (n=100) groups. Young person and parent anxiety was reported using the State-Trait Anxiety Inventory (STAI) on arrival and after 10 minutes in the waiting space. Questionnaires measured young person, parent, and staff satisfaction.

RESULTS

Young people exposed to interactive media reported a postexposure state anxiety that was 1.1 raw points (2.7 standardized points) lower on the STAI than the comparison group (95% confidence interval [CI] -1.9 to -0.22). There was no difference in postexposure state anxiety between the passive media and comparison groups (95% CI -0.64 to 1.1). Parents' state anxiety did not differ between conditions, but interactive media were associated with greater satisfaction (p=0.009). Of 120 staff, 119 reported that interactive media improved the clinic experience for families.

INTERPRETATION

Interactive media designed for accessible, hands-free play mitigate waiting anxiety and increases satisfaction. This paper provides evidence to guide design and decision-making around the use of interactive media in health care spaces.

WHAT THIS PAPER ADDS

Interactive media reduced preclinic waiting anxiety for young people with disabilities. Interactive media were accessible to young people with a range of mobility. Interactive media increased parental and staff satisfaction in the clinic. Guidelines for the design of hands-free, inclusive interactive media for health care facilities are presented.

The use of functional electrical stimulation to improve upper limb function in children with hemiplegic cerebral palsy: A feasibility study

Background

Grasping and manipulating objects are common problems for children with hemiplegic cerebral palsy. Multichannel-functional electrical stimulation may help facilitate upper limb movements and improve function.

Objective

To evaluate the feasibility of multichannel-functional electrical stimulation to improve grasp and upper limb function in children with hemiplegic cerebral palsy to inform the development of a clinical trial.

Methods

A prospective pre-/post-test/follow-up (six months) design with three children, aged 6–13 years, was used. Multichannel-functional electrical stimulation (mFES) was applied to the hemiplegic upper limb for up to 48 sessions over 16 weeks. Feasibility indicators included recruitment of participants and adherence rates, safety, and discomfort/pain. Effectiveness was assessed using the grasp domain of the Quality of Upper Extremity Skills Test, and other secondary clinical outcome measures with “success” criteria set a priori.

Results

Participant recruitment target was not met but adherence was high, and multichannel-functional electrical stimulation was found to be safe and comfortable. Of the three participants, two improved in grasp at post-test, whereas one child’s ability deteriorated. Only one child met success criteria on most outcomes at post-test.

Conclusions

Feasibility indicators met success criteria, except for participant recruitment. Treatment effectiveness was mixed. A future case comparison investigation with a larger but more selected sample is suggested.

The Association Between Maternal Age and Cerebral Palsy Risk Factors

BACKGROUND

Advanced maternal age is associated with higher frequencies of antenatal and perinatal conditions, as well as a higher risk of cerebral palsy in offspring. We explore the association between maternal age and specific cerebral palsy risk factors.

METHODS

Data were extracted from the Canadian Cerebral Palsy Registry. Maternal age was categorized as ≥35 years of age and less than 20 years of age at the time of birth. Chi-square and multivariate logistic regressions were performed to calculate odds ratios and their 95% confidence intervals.

RESULTS

The final sample consisted of 1391 children with cerebral palsy, with 19% of children having mothers aged 35 or older and 4% of children having mothers below the age of 20. Univariate analyses showed that mothers aged 35 or older were more likely to have gestational diabetes (odds ratio 1.9, 95% confidence interval 1.3 to 2.8), to have a history of miscarriage (odds ratio 1.8, 95% confidence interval 1.3 to 2.4), to have undergone fertility treatments (odds ratio 2.4, 95% confidence interval 1.5 to 3.9), and to have delivered by Caesarean section (odds ratio 1.6, 95% confidence interval 1.2 to 2.2). These findings were supported by multivariate analyses. Children with mothers below the age of 20 were more likely to have a congenital malformation (odds ratio 2.4, 95% confidence interval 1.4 to 4.2), which is also supported by multivariate analysis.

CONCLUSIONS

The risk factor profiles of children with cerebral palsy vary by maternal age. Future studies are warranted to further our understanding of the compound causal pathways leading to cerebral palsy and the observed greater prevalence of cerebral palsy with increasing maternal age.

Current Practice "Constraints" in the Uptake and Use of Intensive Upper Extremity Training: A Canadian Perspective

BACKGROUND

Intensive upper extremity training (IUET) has demonstrated efficacy in clinical and functioning outcomes in children with hemiplegia. However, implementation in the clinical context requires novel service models and knowledge translation.

AIMS

To map implementation of IUET in Canada, to identify factors associated with the implementation and best practices for implementation.

METHODS

Mixed-methods design; descriptive statistics, chi-square tests. Individual phone interviews and focus groups with purposeful sampling. Thematic analysis; telephone surveys with managers of 31 pediatric rehabilitation centers across Canada. Four focus groups across Canada and one in the Netherlands.

RESULTS

Implementation of IUET group interventions is limited in Canada (7/31). Barriers included beliefs and values related to evidence-based practice, opportunities for continuing education, researchers-clinicians partnerships, access to scientific literature, and the presence of a champion. Pressure from parents and media presenting IUET as a novel and effective therapy, support and flexibility of families, having the critical mass of clients and a managerial willingness to accommodate new ideas and restructure service provision were some facilitators.

CONCLUSIONS

Uptake of the evidence requires many steps described in the knowledge translation cycle. Factors identified in the study could be considered in most clinical settings to facilitate the uptake of research evidence for IUET.

Pharmacological and neurosurgical interventions for managing dystonia in cerebral palsy: a systematic review

AIM

To systematically review evidence for pharmacological/neurosurgical interventions for managing dystonia in individuals with cerebral palsy (CP) to inform a care pathway.

METHOD

Searches included studies with a minimum of five participants with dystonia in CP receiving oral baclofen, benzodiazepines (clonazepam, diazepam, lorazepam), clonidine, gabapentin, levodopa, trihexyphenidyl, botulinum toxin, intrathecal baclofen (ITB), or deep brain stimulation (DBS). Evidence was classified according to American Academy of Neurology guidelines.

RESULTS

Twenty-eight articles underwent data extraction: one levodopa, five trihexyphenidyl, three botulinum toxin, six ITB, and 13 DBS studies. No articles for oral baclofen, benzodiazepines, clonidine, or gabapentin met the inclusion criteria. Evidence for reducing dystonia was level C (possibly effective) for ITB and DBS; level C (possibly ineffective) for trihexyphenidyl; and level U (inadequate data) for botulinum toxin.

INTERPRETATION

For dystonia reduction, ITB and DBS are possibly effective, whereas trihexyphenidyl was possibly ineffective. There is insufficient evidence to support oral medications or botulinum toxin to reduce dystonia. There is insufficient evidence for pharmacological and neurosurgical interventions to improve motor function, decrease pain, and ease caregiving. The majority of the pharmacological and neurosurgical management of dystonia in CP is based on clinical expert opinion.

WHAT THIS PAPER ADDS

Intrathecal baclofen and deep brain stimulation are possibly effective in reducing dystonia. Current evidence does not support effectiveness of oral medications or botulinum toxin to reduce dystonia. Evidence is inadequate for pharmacological/neurosurgical interventions impact on improving motor function, pain/comfort, and easing caregiving. The majority of the care pathway rests on expert opinion.

Neonatal Infection in Children With Cerebral Palsy: A Registry-Based Cohort Study

BACKGROUND

The goal of this study was to explore the association between neonatal infection and outcomes in children with cerebral palsy.

METHODS

We conducted a retrospective cohort study using the Canadian CP Registry. Neonatal infection was defined as meeting one of the following criteria: (1) septicemia, (2) septic shock, or (3) administration of antibiotics for ≥10 days. Phenotypic profiles of children with cerebral palsy with and without an antecedent neonatal infection were compared. Subgroup analysis was performed, stratified by gestational age (term versus preterm).

RESULTS

Of the 1229 registry participants, 505 (41.1%) were preterm, and 192 (15.6%) met the criteria for neonatal infection with 29% of preterm children having a neonatal infection compared with 6.5% in term-born children. Children with prior neonatal infection were more likely to have a white matter injury (odds ratio 2.2, 95% confidence interval 1.5 to 3.2), spastic diplegic neurological subtype (odds ratio 1.6, 95% confidence interval 1.1 to 2.3), and sensorineural auditory impairment (odds ratio 2.1, 95% confidence interval 1.4 to 3.3). Among preterm children, neonatal infection was not associated with a difference in phenotypic profile. Term-born children with neonatal infection were more likely to have spastic triplegia or quadriplegia (odds ratio 2.4, 95% confidence interval 1.3 to 4.3), concomitant white matter and cortical injury (odds ratio 4.1, 95% confidence interval 1.6 to 10.3), and more severe gross motor ability (Gross Motor Function Classification System IV to V) (odds ratio 2.6, 95% confidence interval 1.4 to 4.8) compared with preterm children.

CONCLUSIONS

Findings suggest a role of systemic infection on the developing brain in term-born infants, and the possibility to develop targeted therapeutic and preventive strategies to reduce cerebral palsy morbidity.

Optimization of fMRI methods to determine laterality of cortical activation during ankle movements of children with unilateral cerebral palsy

Measurement of laterality of motor cortical activations may provide valuable information about lower limb control in children with unilateral cerebral palsy (UCP). Evidence from upper limb research suggests that increased contralateral activity may accompany functional gains. However, lower limb areas of activation and associated changes have been underexplored due to challenges with imaging motor cortical leg representations. In this study, methods for a task-based functional magnetic resonance imaging (fMRI) ankle dorsiflexion paradigm were refined with three pilot groups of participants: (i) adults (n = 5); (ii) typically developing (TD) children (n = 5) and; (iii) children with UCP (n = 4). Parameters of experimental design, task resistance, reproducibility, and pre-scan procedures were tested/refined using a staged development approach with additions or changes introduced if image quality did not meet pre-defined standards. When image quality was acceptable for two consecutive participants, the next participant group was recruited to test/refine the next parameter. The final paradigm involved an event-related design of a single dorsiflexion movement against individualized resistance, with two runs per leg. It included a pre-scan session to increase child comfort and determine task resistance. This paradigm produced valid data for laterality index (LI) calculations to determine the ratio of activity in each hemisphere. Ventricle and lesion masks were used in non-linear image registration, and individual thresholds were used for extent-based LI calculations. LI of dominant ankle movements were contralateral (LI ≥ +0.2) for TD children (mean LI = +0.89, std = 0.27) and children with UCP (mean LI = +0.86, std = 0.26). For the affected ankle of children with UCP, LI values indicated ipsilateral and/or contralateral activation (mean LI = +0.02, std = 0.71, range -0.92 to +1.00). This fMRI paradigm will support investigations of cortical activation and mechanisms of skill improvement following lower limb interventions.

Identification and measurement of dystonia in cerebral palsy

AIM

To establish the prevalence and severity of dystonia in a population of children with cerebral palsy (CP) with hypertonia assessment and measurement tools.

METHOD

A cross-sectional study of 151 children (84 males, 67 females) with CP who were assessed with the Hypertonia Assessment Tool (HAT) and Barry-Albright Dystonia scale (BAD) for identification and measurement of severity of dystonia. HAT dystonia items were assessed for construct and convergent validity.

RESULTS

Distribution by predominant motor type (PMT) was: 85% spastic, 14% dyskinetic, and 1% ataxic. Spastic and dyskinetic groups showed widespread evidence of dystonia according to HAT profiles and BAD scores. The dyskinetic PMT group had a higher mean BAD score than the spastic group (difference of 13 units, 95% CI 9.1-16.4). Dystonia severity (BAD score) increased linearly across gross motor (p<0.001), manual ability (p<0.001) and communication functional levels (p<0.001). Divergence was noted in how HAT item six identified dystonia compared to items one and two.

INTERPRETATION

The HAT provided an estimate of the prevalence of both spasticity and dystonia in a large CP population, beyond predominant motor type. Dystonia is a common finding in the spastic PMT group, and its severity increases as motor function worsens.

WHAT THIS PAPER ADDS

Dystonia is readily identified in cerebral palsy (CP) using the Hypertonia Assessment Tool, regardless of the predominant motor type. Spasticity and dystonia frequently coexist in the CP population. Severity of dystonia is inversely related to motor function.

Parents' early healthcare transition experiences with preterm and acutely ill infants: a scoping review

BACKGROUND

Parents undergo multiple transitions following the birth of an ill infant: their infant's illness-health trajectory, neonatal intensive care unit hospitalization and transfers from one healthcare setting to another, while also transitioning to parenthood. The objective of this review was to map and synthesize evidence on the experiences and needs of parents of preterm or ill infants as they transition within and between healthcare settings following birth.

METHODS

The scoping review followed Arskey and O'Malley's () framework, enhanced by Levac et al. (). Relevant studies were identified through a comprehensive search strategy of scientific and grey literature databases, online networks, Web of Science and citation lists of relevant articles. Inclusion criteria encompassed a focus on infants undergoing a healthcare transition, and the experiences and needs of parents during transition. Studies were appraised for design quality, and data relevant to parent experiences were extracted and underwent thematic analysis.

RESULTS

A total of 7773 records were retrieved, 90 full texts reviewed and 11 articles synthesized that represented a total sample of 435 parents of preterm or ill infants. Parents reported on their experiences in response to their infant's transition within and between hospitals and across levels of neonatal intensive care unit, intermediate and community hospital care. Ten studies used qualitative research methods, while one employed quantitative survey methods. Four key themes were identified: that of parent distress throughout transition, parenting at a distance, sources of stress and sources of support. Parents' stress resulted from not being informed or involved in the transition decision, inadequate communication and perceived differences in cultures of care across healthcare settings.

CONCLUSIONS

Opportunities to improve parents' early transition experiences include enhanced engagement, communication, information-sharing and shared decision-making between health care providers and parents. Future areas of research should focus on early transition interventions to advance parent capacity, confidence and closeness as the primary nurturer.

Early, Accurate Diagnosis and Early Intervention in Cerebral Palsy: Advances in Diagnosis and Treatment

IMPORTANCE

Cerebral palsy describes the most common physical disability in childhood and occurs in 1 in 500 live births. Historically, the diagnosis has been made between age 12 and 24 months but now can be made before 6 months' corrected age.

OBJECTIVES

To systematically review best available evidence for early, accurate diagnosis of cerebral palsy and to summarize best available evidence about cerebral palsy-specific early intervention that should follow early diagnosis to optimize neuroplasticity and function.

EVIDENCE REVIEW

This study systematically searched the literature about early diagnosis of cerebral palsy in MEDLINE (1956-2016), EMBASE (1980-2016), CINAHL (1983-2016), and the Cochrane Library (1988-2016) and by hand searching. Search terms included cerebral palsy, diagnosis, detection, prediction, identification, predictive validity, accuracy, sensitivity, and specificity. The study included systematic reviews with or without meta-analyses, criteria of diagnostic accuracy, and evidence-based clinical guidelines. Findings are reported according to the PRISMA statement, and recommendations are reported according to the Appraisal of Guidelines, Research and Evaluation (AGREE) II instrument.

FINDINGS

Six systematic reviews and 2 evidence-based clinical guidelines met inclusion criteria. All included articles had high methodological Quality Assessment of Diagnostic Accuracy Studies (QUADAS) ratings. In infants, clinical signs and symptoms of cerebral palsy emerge and evolve before age 2 years; therefore, a combination of standardized tools should be used to predict risk in conjunction with clinical history. Before 5 months' corrected age, the most predictive tools for detecting risk are term-age magnetic resonance imaging (86%-89% sensitivity), the Prechtl Qualitative Assessment of General Movements (98% sensitivity), and the Hammersmith Infant Neurological Examination (90% sensitivity). After 5 months' corrected age, the most predictive tools for detecting risk are magnetic resonance imaging (86%-89% sensitivity) (where safe and feasible), the Hammersmith Infant Neurological Examination (90% sensitivity), and the Developmental Assessment of Young Children (83% C index). Topography and severity of cerebral palsy are more difficult to ascertain in infancy, and magnetic resonance imaging and the Hammersmith Infant Neurological Examination may be helpful in assisting clinical decisions. In high-income countries, 2 in 3 individuals with cerebral palsy will walk, 3 in 4 will talk, and 1 in 2 will have normal intelligence.

CONCLUSIONS AND RELEVANCE

Early diagnosis begins with a medical history and involves using neuroimaging, standardized neurological, and standardized motor assessments that indicate congruent abnormal findings indicative of cerebral palsy. Clinicians should understand the importance of prompt referral to diagnostic-specific early intervention to optimize infant motor and cognitive plasticity, prevent secondary complications, and enhance caregiver well-being.

Re-Evaluation of Serum Ferritin Cut-Off Values for the Diagnosis of Iron Deficiency in Children Aged 12-36 Months

An ongoing challenge has been determining clinically relevant serum ferritin cut-offs in the diagnosis of iron deficiency in children aged 1-3 years. We identified 2 potential clinically relevant serum ferritin cut-off values through their association with clinically important cut-off of hemoglobin as the indicator of anemia.

Centres for Leadership: a strategy for academic integration

Purpose

The purpose of this paper is to describe how an Academic Health Science Centre, providing pediatric rehabilitation services, research, and education, developed a Centres for Leadership (CfL) initiative to integrate its academic functions and embrace the goal of being a learning organization.

Design/methodology/approach

Historical documents, tracked output information, and staff members’ insights were used to describe the ten-year evolution of the initiative, its benefits, and transformational learnings for the organization.

Findings

The evolutions concerned development of a series of CfLs, and changes over time in leadership and management structure, as well as in operations and targeted activities. Benefits included enhanced clinician engagement in research, practice-based research, and impacts on clinical practice. Transformational learnings concerned the importance of supporting stakeholder engagement, fostering a spirit of inquiry, and fostering leaderful practice. These learnings contributed to three related emergent outcomes reflecting “way stations” on the journey to enhanced evidence-informed decision making and clinical excellence: enhancements in authentic partnerships, greater innovation capacity, and greater understanding and actualization of leadership values.

Practical implications

Practical information is provided for other organizations interested in understanding how this initiative evolved, its tangible value, and its wider benefits for organizational collaboration, innovation, and leadership values. Challenges encountered and main messages for other organizations are also considered.

Originality/value

A strategy map is used to present the structures, processes, and outcomes arising from the initiative, with the goal of informing the operations of other organizations desiring to be learning organizations.

Change in pain status in children with cerebral palsy

AIM

To identify factors associated with a change in pain over time in children with cerebral palsy (CP).

METHOD

Pain was assessed at two time-points by physicians and caregiver-rated Health Utilities Index 3 (HUI3) pain scores.

RESULTS

One hundred and forty-eight children out of 179 approached from outpatient clinics (83% response; 104 males, 44 females mean age 8y 8mo, range 3y-16y) across all Gross Motor Function Classification System (GMFCS) levels were included. Fifty-five percent had changes in caregiver-reported HUI3 pain. A backward stepwise multiple linear regression retained HUI3 pain score at visit 1 and GMFCS level (F_[2,144] =23.40, R² =0.35; p<0.001) as variables associated with a change in pain status (HUI3 pain at visit 1: β=0.61, p<0.001; GMFCS level: β=-0.17, p<0.015). The association between HUI3 pain at visit 1 and GMFCS level was significant (β=-0.15, p<0.036). There was an association between pain etiology and pain trajectory (F_[3,144] =5.39, p=0.002). Post-hoc testing revealed musculoskeletal pain had the greatest improvements compared with the no pain group (p=0.006).

INTERPRETATION

Children with CP with more severe initial pain and higher gross motor function have lower pain at follow-up indicating an improvement in pain status over time.

An innovative cycling exergame to promote cardiovascular fitness in youth with cerebral palsy

OBJECTIVE

To evaluate the effects of an internet-platform exergame cycling programme on cardiovascular fitness of youth with cerebral palsy (CP).

METHODS

In this pilot prospective case series, eight youth with bilateral spastic CP, Gross Motor Functional Classification System (GMFCS) level III, completed a six-week exergame programme. Outcomes were obtained at baseline and post-intervention. The primary outcome measure was the GMFCS III-specific shuttle run test (SRT-III). Secondary outcomes included health-related quality of life (HQL) as measured by the KIDSCREEN-52 questionnaire, six-minute walk test, Wingate arm cranking test and anthropomorphic measurements.

RESULTS

There were significant improvements in the SRT-III (t = -2.5, p = 0.04, d = 0.88) post-intervention. There were no significant changes in secondary outcomes.

CONCLUSION

An exergame cycling programme may lead to improvement in cardiovascular fitness in youth with CP. This study was limited by small sample size and lack of a comparison group. Future research is warranted.

Informing evidence-based clinical practice guidelines for children with cerebral palsy at risk of osteoporosis: an update

AIM

To investigate the impact of new evidence for weight-bearing, bisphosphonates, and vitamin D and calcium interventions, towards updating the systematic review and clinical practice guidelines for osteoporosis in children with cerebral palsy (CP) published in 2011.

METHOD

Computer-assisted literature searches were conducted for articles published from 2010 to 2016. Searches focused on children with CP functioning at Gross Motor Function Classification System levels III to V and limited to weight-bearing activities, bisphosphonates, and vitamin D and/or calcium supplementation. Articles were classified according to the American Academy of Neurology guidelines to update the grading of the evidence for improving bone mineral density (BMD) and decreasing fragility fractures.

RESULTS

Six new articles underwent full-text review and data abstraction. These included one weight-bearing, three bisphosphonate, and two mixed intervention studies (bisphosphonate and vitamin D/calcium supplementation). Overall, there continues to be 'probable' evidence for bisphosphonates, 'possible' evidence for vitamin D/calcium, and 'insufficient' evidence for weight-bearing activities as effective interventions to improve low BMD in children with CP. There is 'possible' evidence for bisphosphonates in reducing fragility fractures.

INTERPRETATION

The grading of evidence to support the use of weight-bearing activities, bisphosphonates, and vitamin D and calcium supplementation in pediatric CP osteoporosis clinical practice guidelines remained the same.

Improving Transition Practices: Understanding Family Experiences and Needs in Transitioning Their Child to Developmental/Rehabilitation Services

BACKGROUND: Children born preterm (&lt;37 weeks) with cerebral palsy (CP) have long-term complex medical needs that require transitions between multiple healthcare services, necessitating parental support. The experiences of parents undergoing early transitions from the neonatal intensive care unit (NICU) to neonatal follow-up clinics (NFUC) to home are well-documented. Our prior research conducted found parents described positive transitions as: access to information, feeling involved in care and witnessing improvement in their child’s health outcomes post-transition. Negative experiences entail: unanticipated differences between healthcare services, feeling separated from their child and having inadequate information. Unfortunately, the next transition from children with CP born preterm (&lt;37 weeks) to developmental/rehabilitation services (DRS) is grossly under-studied and knowledge from well-studied healthcare transitions has yet to be applied to this population.

OBJECTIVES: To identify and describe the experience and needs of parents of children with CP born preterm, as they transition from NFUC to DRS. Additionally, to make recommendations building upon characteristics of supportive/positive transition experiences to meet the emotional, informational, and instrumental needs of parents during transition to DRS.

DESIGN/METHODS: A descriptive qualitative study was conducted recruiting English-speaking parents of children born preterm with CP that required NICU hospitalization, and DRS post CP diagnosis. Purposeful and maximum variation strategies were used to recruit a sample of 15 parents. To ensure rigor, sampling continued until data saturation was reached. Interviews were audio-recorded, transcribed verbatim, coded using NVivo 10 software and underwent thematic analysis. Data collection and analyses were performed concurrently, with themes from early interviews incorporated, collapsed and used to inform later interviews.

RESULTS: A majority of participants were mothers, whose child had received DRS for the past one to 12 years. Preliminary themes iterated by parents’ transition experiences included: Poor communication of diagnosis caused anxiety surrounding transition of care; a lack of timely access to appropriate care and resources negatively affected parents’ experiences; continuity and consistency of healthcare providers improved families’ perception of accessibility to care; and social support was desired throughout the transition period.

CONCLUSION: The transition between NFUC and DRS for families with CP is significant, but lacks best practice research to advise care. Preliminary recommendations derived from data reveal the need to better support families earlier on in the transition process, beginning at the NFUC. Further research is required to identify best practices to strengthen communication, family involvement, continuity of care, and timely access to informational supports for parents.

Canadian stroke best practice recommendations: Stroke rehabilitation practice guidelines, update 2015

Stroke rehabilitation is a progressive, dynamic, goal-orientated process aimed at enabling a person with impairment to reach their optimal physical, cognitive, emotional, communicative, social and/or functional activity level. After a stroke, patients often continue to require rehabilitation for persistent deficits related to spasticity, upper and lower extremity dysfunction, shoulder and central pain, mobility/gait, dysphagia, vision, and communication. Each year in Canada 62,000 people experience a stroke. Among stroke survivors, over 6500 individuals access in-patient stroke rehabilitation and stay a median of 30 days (inter-quartile range 19 to 45 days). The 2015 update of the Canadian Stroke Best Practice Recommendations: Stroke Rehabilitation Practice Guidelines is a comprehensive summary of current evidence-based recommendations for all members of multidisciplinary teams working in a range of settings, who provide care to patients following stroke. These recommendations have been developed to address both the organization of stroke rehabilitation within a system of care (i.e., Initial Rehabilitation Assessment; Stroke Rehabilitation Units; Stroke Rehabilitation Teams; Delivery; Outpatient and Community-Based Rehabilitation), and specific interventions and management in stroke recovery and direct clinical care (i.e., Upper Extremity Dysfunction; Lower Extremity Dysfunction; Dysphagia and Malnutrition; Visual-Perceptual Deficits; Central Pain; Communication; Life Roles). In addition, stroke happens at any age, and therefore a new section has been added to the 2015 update to highlight components of stroke rehabilitation for children who have experienced a stroke, either prenatally, as a newborn, or during childhood. All recommendations have been assigned a level of evidence which reflects the strength and quality of current research evidence available to support the recommendation. The updated Rehabilitation Clinical Practice Guidelines feature several additions that reflect new research areas and stronger evidence for already existing recommendations. It is anticipated that these guidelines will provide direction and standardization for patients, families/caregiver(s), and clinicians within Canada and internationally.

Investigating the impact of pain, age, Gross Motor Function Classification System, and sex on health-related quality of life in children with cerebral palsy

AIM

To explore whether health-related quality of life (HRQOL) can be predicted by pain, age, Gross Motor Function Classification System (GMFCS) level, and sex in children with cerebral palsy (CP) and whether different pain etiologies have varying effects on HRQOL.

METHODS

Children with CP aged 3 to 19 years and their caregivers were consecutively recruited. Caregivers reported their child's pain (Health Utilities Index 3 [HUI3] pain subset) and HRQOL (DISABKIDS questionnaires). Physicians identified pain etiologies. A multiple linear regression model determined whether pain, GMFCS level, sex, and age predicted HRQOL. An ANOVA evaluated the effects of pain etiologies on HRQOL.

RESULTS

Three hundred and forty-four participants were approached and 87% (n=300) participated. Sufficient data were available on 248 (72% of total sample). Sixty-six participants (27%) formed the pain group with HUI3 pain scores of at least 3. The presence of pain and increasing age significantly negatively predicted HRQOL (p<0.001, R(2) =0.141), while GMFCS and sex did not. Musculoskeletal deformity (24%) and hypertonia (18%) were the most frequent pain causes. HRQOL statistically differed depending on the pain etiology (p=0.028) with musculoskeletal deformity showing the lowest mean HRQOL.

INTERPRETATION

The presence of pain and increasing age negatively predict HRQOL in CP. musculoskeletal deformity has the greatest negative impact on HRQOL.