Peripheral sensory neuropathy observed in children with cerebral palsy: is chronic afferent excitation from muscle spindles a possible cause?

Somatosensory deficits and neural correlates in cerebral palsy: a scoping review

AIM

To synthetize studies assessing somatosensory deficits and alterations in cerebral responses evoked by somatosensory stimulation in individuals with cerebral palsy (CP) compared to typically developing individuals.

METHOD

A scoping review of the literature was performed in the MEDLINE, Embase, PsycInfo, CINAHL, Evidence-Based Medicine Reviews, and Web of Science databases (last search carried out on 6th and 7th August 2020) with a combination of keywords related to CP and somatosensory functions. Somatosensory deficits were measured with clinical tests and alterations in cerebral responses were measured with functional magnetic resonance imaging, electroencephalography, and magnetoencephalography.

RESULTS

Forty-eight articles were included. Overall, 1463 participants with CP (mean [SD] age 13y 1mo [4y 11mo], range 1-55y; 416 males, 319 females, sex not identified for the remaining participants) and 1478 controls (mean [SD] age 13y 1mo [5y 8mo], range 1-42y; 362 males, 334 females, sex not identified for the remaining participants) were included in the scoping review. For tactile function, most studies reported registration (8 out of 13) or perception (21 out of 21) deficits in participants with CP. For proprioception, most studies also reported registration (6 out of 8) or perception (10 out of 15) deficits. Pain function has not been studied as much, but most studies reported registration (2 out of 3) or perception (3 out of 3) alterations. Neuroimaging findings (18 studies) showed alterations in the somatotopy, morphology, latency, or amplitude of cortical responses evoked by somatosensory stimuli.

INTERPRETATION

Despite the heterogeneity in the methods employed, most studies reported somatosensory deficits. The focus has been mainly on tactile and proprioceptive function, whereas pain has received little attention. Future research should rigorously define the methods employed and include a sample that is more representative of the population with CP. What this paper adds Most of the papers reviewed found tactile registration and perception deficits in the upper limbs. Proprioceptive deficits were generally observed in cerebral palsy but results were heterogeneous. Pain has received little attention compared to tactile and proprioceptive functions. Neuroimaging studies supported behavioral observations. Alterations were observed for both the most and least affected limb.

Pathophysiology of chronic pain in cerebral palsy: implications for pharmacological treatment and research

The high prevalence of chronic pain in individuals with cerebral palsy (CP) across the lifespan has been well documented, as has its negative impact on quality of life. However, without an understanding of the underlying (possibly unique) pathophysiology of pain in CP, identification of more effective management options, such as innovative and individualized pharmacological approaches to non-opioid pain treatment, will be significantly hindered. We review, briefly, what is known about chronic pain in CP and present what we need to know with respect to the neurobiology of pain and new developments in pain treatment research that might be applied to CP.

WHAT THIS PAPER ADDS

Pain conditions in cerebral palsy have differing mechanisms and will not respond to the same treatments. Novel analgesics under development include inhibitors of ion channels, nerve growth factor, and calcitonin gene-related peptide.

Synaptic-like vesicles and candidate transduction channels in mechanosensory terminals

This article summarises progress to date over an exciting and very enjoyable first 15 years of collaboration with Bob Banks. Our collaboration began when I contacted him with (to me) an unexpected observation that a dye used to mark recycling synaptic vesicle membrane at efferent terminals also labelled muscle spindle afferent terminals. This observation led to the re-discovery of a system of small clear vesicles present in all vertebrate primary mechanosensory nerve terminals. These synaptic-like vesicles (SLVs) have been, and continue to be, the major focus of our work. This article describes our characterisation of the properties and functional significance of these SLVs, combining our complementary skills: Bob’s technical expertise and encyclopaedic knowledge of mechanosensation with my experience of synaptic vesicles and the development of the styryl pyridinium dyes, of which the most widely used is FM1-43. On the way we have found that SLVs seem to be part of a constitutive glutamate secretory system necessary to maintain the stretch-sensitivity of spindle endings. The glutamate activates a highly unusual glutamate receptor linked to phospholipase D activation, which we have termed the PLD-mGluR. It has a totally distinct pharmacology first described in the hippocampus nearly 20 years ago but, like the SLVs that were first described over 50 years ago, has since been little researched. Yet, our evidence and literature searches suggest this glutamate/SLV/PLD-mGluR system is a ubiquitous feature of mechanosensory endings and, at least for spindles, is essential for maintaining mechanosensory function. This article summarises how this system integrates with the classical model of mechanosensitive channels in spindles and other mechanosensory nerve terminals, including hair follicle afferents and baroreceptors controlling blood pressure. Finally, in this time when there is an imperative to show translational relevance, I describe how this fascinating system might actually be a useful therapeutic drug target for clinical conditions such as hypertension and muscle spasticity. This has been a fascinating 15-year journey in collaboration with Bob who, as well as having an astute scientific mind, is also a great enthusiast, motivator and friend. I hope this exciting and enjoyable journey will continue well into the future.

Treadmill training induces plasticity in spinal motoneurons and sciatic nerve after sensorimotor restriction during early postnatal period: new insights into the clinical approach for children with cerebral palsy

The aim of the present study was to investigate whether locomotor stimulation training could have beneficial effects on the morphometric alterations of spinal cord and sciatic nerve consequent to sensorimotor restriction (SR). Male Wistar rats were exposed to SR from postnatal day 2 (P2) to P28. Control and experimental rats underwent locomotor stimulation training in a treadmill for three weeks (from P31 to P52). The cross-sectional area (CSA) of spinal motoneurons innervating hind limb muscles was determined. Both fiber and axonal CSA of myelinated fibers were also assessed. The growth-related increase in CSA of motoneurons in the SR group was less than controls. After SR, the mean motoneuron soma size was reduced with an increase in the proportion of motoneurons with a soma size of between 0 and 800 μm(2). The changes in soma size of motoneurons were accompanied by a reduction in the mean fiber and axon CSA of sciatic nerve. The soma size of motoneurons was reestablished at the end of the training period reaching controls level. Our results suggest that SR during early postnatal life retards the growth-related increase in the cell body size of motoneurons in spinal cord and the development of sciatic nerve. Additionally, three weeks of locomotor stimulation using a treadmill seems to have a beneficial effect on motoneurons' soma size.

Histological evidence of intraoperative monitoring efficacy in selective dorsal rhizotomy

PURPOSE

It has been advocated that intraoperative electrophysiological monitoring is mandatory in selective dorsal rhizotomy (SDR). However, it is still uncertain whether the monitoring procedure effectively differentiates dysfunctional rootlets. We histologically analyzed sectioned rootlets in SDR, in order to confirm the efficacy of the monitoring.

METHODS

Seven children with cerebral palsy underwent SDR on the same protocol. The pieces of their sectioned nerve rootlets from L5 were examined histologically using an electron microscope. In each patient, two nerve rootlets, one with the most abnormal response to intraoperative electrical stimulation and the other with the least abnormal response, were examined. The electron microscope findings of the rootlets were compared with the electromyography (EMG) findings in the intraoperative stimulation.

RESULTS

Among 14 examined nerve rootlets, definite abnormal EMG findings were seen in 5, which were 4 clonuses and one bilateral spread. All five rootlets with abnormal EMG findings showed axonal degenerations except one case, whose finding was dysmyelination. On the contrary, in the nine rootlets with normal EMG findings, eight rootlets had histologically minimum changes limited to the myelin sheath and one rootlet had dysmyelination without axonal degeneration.

CONCLUSIONS

The nerve rootlets with abnormal EMG findings in the intraoperative stimulation have definite histological abnormalities. This indicates that intraoperative monitoring is a meaningful method for identifying the nerve rootlets to be sectioned. This finding should be reminded as a precaution when considering nonselective dorsal rhizotomy, especially, for children who are expected to stand up after the surgery.