Health and social outcomes of children with cerebral palsy

Neonatal resveratrol treatment in cerebral palsy model recovers neurodevelopment impairments by restoring the skeletal muscle morphology and decreases microglial activation in the cerebellum

Cerebral Palsy (CP) is the main motor disorder in childhood resulting from damage to the developing brain. Treatment perspectives are required to reverse the primary damage caused by the early insult and consequently to recover motor skills. Resveratrol has been shown to act as neuroprotection with benefits to skeletal muscle. This study aimed to investigate the effects of neonatal resveratrol treatment on neurodevelopment, skeletal muscle morphology, and cerebellar damage in CP model. Wistar rat pups were allocated to four experimental groups (n = 15/group) according CP model and treatment: Control+Saline (CS), Control+Resveratrol (CR), CP + Saline (CPS), and CP + Resveratrol (CPR). CP model associated anoxia and sensorimotor restriction. CP group showed delay in the disappearance of the palmar grasp reflex (p < 0.0001) and delay in the appearance of reflexes of negative geotaxis (p = 0.01), and free-fall righting (p < 0.0001), reduced locomotor activity and motor coordination (p < 0.05) than CS group. These motor skills impairments were associated with a reduction in muscle weight (p < 0.001) and area and perimeter of soleus end extensor digitorum longus muscle fibers (p < 0.0001), changes in muscle fibers typing pattern (p < 0.05), and the cerebellum showed signs of neuroinflammation due to elevated density and percentage of activated microglia in the CPS group compared to CS group (p < 0.05). CP animals treated with resveratrol showed anticipation of the appearance of negative geotaxis and free-fall righting reflexes (p < 0.01), increased locomotor activity (p < 0.05), recovery muscle fiber types pattern (p < 0.05), and reversal of the increase in density and the percentage of activated microglia in the cerebellum (p < 0.01). Thus, we conclude that neonatal treatment with resveratrol can contribute to the recovery of the delay neurodevelopment resulting from experimental CP due to its action in restoring the skeletal muscle morphology and reducing neuroinflammation from cerebellum.

Numerical cognition in children with cerebral palsy

Children with Cerebral Palsy (CP) often perform poorly in mathematics. It is not yet clear to what extent mathematics difficulties in this clinical condition are similar to those observed in developmental dyscalculia. To better elucidate this issue, we conducted an exploratory cross-sectional study with a sample of children and adolescents with congenital brain injuries and educational history of problems in Mathematics. Fifty students aged 7-15 years, of both genders (28 males) participated in the study, 31 with typical development (TD) and 19 of whom diagnosed with spastic CP. Nine had hemiplegia and ten diplegia. Assessment procedures included a neuropsychological battery covering numerical cognition (ZAREKI-R) and working memory (AWMA) skills, and a computerized task for comparing non-symbolic magnitudes as a measure of number sense. Despite average intelligence coefficient, participants with CP underperformed the TD in five of the 12 ZAREKI-R subtests, as well as in the number sense and working memory tasks. scores were lower among hemiplegic children compared to diplegic, numerical cognition was impaired in all CP group, unveiling a dyscalculia secondary to neurodevelopmental impairments. Therefore, we can consider that mathematical learning difficulties in CP as being heterogeneous and associated with the immaturity of neuropsychological functions, with consequences for the development of numerical cognition.

Factors Affecting Participation of Children with Cerebral Palsy in Meaningful Activities: Systematic Review

This is a systematic review using PRISMA guidelines to review the factors affecting participation of children with cerebral palsy (CP), the most common childhood motor disability. Inclusion criteria consisted of publications in a peer-reviewed journal between 2000 and 2018, and at I, II, III, and IV levels of AOTA Evidence. After the title, abstract, and a full text screening, 31 articles met eligibility to be included. The studies examined ADLs (12), IADLs (9), play and leisure (19), and social participation (14), but only 3 in rest/sleep, 1 in work, and 8 in education. Gross motor and manual function, CP type, home, and community physical environment, were the most common factors affecting individuals' participation with CP. Results imply occupational therapists must evaluate clients on all factors shown to facilitate or inhibit participation to ensure an adequate intervention plan. However, evaluating every individual case in the occupational therapy process is time-consuming and difficult. Based on this study's findings, we suggest occupational therapists prioritize evaluating motor skills (gross and fine), the most influential of the factors in all areas of participation. Occupational therapists also could advocate for policy around community environmental barrier removal.

Valuation of Life With Disability: An International Comparison Study in Vietnam, Peru, and Haiti

The authors measured perceived quality of life for 4 disabilities among 450 adults in 3 resource-limited countries, measuring mean utilities using time trade-off, and surveying participants on 35 sociocultural characteristics to compare utilities for disabilities by country and examine associated sociocultural characteristics. Mean utilities were >0 for mild and moderate, but <0 for severe and profound. Utilities differed across countries (P = .007, .000, .017, .000 for mild, moderate, severe, profound, respectively). Vietnamese utilities correlated with residence (P = .03, moderate), education (P = .03, severe), and number of children (P = .03, moderate). Peruvian utilities correlated with education (P = .05, mild; P = .05, severe), experience with disability (P = .001, mild), gender (P = .04, moderate; P = .03, profound), number of hospitalizations (P = .04, severe). In Haiti, the only correlate was rejection (P = .02, moderate). Culture-specific variables differentially shape perceptions of disability in developing countries, thereby affecting cost-effectiveness calculations. Given substantially negative perceptions, reducing major disability would improve cost-effectiveness of health-policy decisions more than reducing mortality.

Robotic lower extremity exoskeleton use in a non-ambulatory child with cerebral palsy: a case study

PURPOSE

With few treatment options available for non-ambulatory children with cerebral palsy (CP), a robotic lower extremity gait trainer may provide a non-invasive addition to conventional treatment options. This case study investigates the usage and impact of robotic lower extremity gait trainer use in a participant with CP over the initial 3 months of use.

MATERIALS AND METHODS

This prospective case study involves a 7-year old female (GMFCS V) with CP (registered clinical trial: NCT04251390). The participant used a Trexo Home robotic gait trainer (Trexo) in the community with assessments occurring in the home and school. Trexo usage and bowel movements (BMs) were tracked daily. Postural control and lower extremity range of motion (ROM) and spasticity were evaluated prior to Trexo use and weekly to biweekly thereafter.

RESULTS

The participant used the device an average of 46 min/week, over 3.3 d/week. BM frequency increased from 0.4/d at baseline, to 1.2 (±0.5)/d during Trexo use. There were no diffuse systematic changes in postural stability, ROM or muscle spasticity, but specifically head control and spasticity in the knee flexors had improvements.

CONCLUSIONS

Data and anecdotal reports suggest that regular use of the Trexo Home robotic gait trainer has positive outcomes on frequency and quality of BMs, and may improve head control, and knee flexor spasticity. Larger controlled studies are needed to evaluate the impacts of Trexo use in children with CP.Implications for RehabilitationNon-ambulatory children with CP can use and may experience benefits from using a robot-assisted gait trainer (RAGT).Constipation, aspects of balance and focal spasticity may improve.

Bilateral symmetry in leg and joint stiffness in children with spastic hemiplegic cerebral palsy during gait

Deviations are often identified at individual joints in the gait analysis of patients with cerebral palsy. Previous gait studies on hemiplegic cerebral palsy (HCP) have focused mainly on deviations of the affected side. The current study aimed to quantify and compare the joint and leg stiffness, the contributions of skeletal and muscular components, and the associated joint angles and moments of the affected and nonaffected lower limbs during level walking in children with spastic HCP. A total of 12 children with spastic HCP and 12 healthy controls walked at a self-selected speed in a gait laboratory while their kinematic and forceplate data were measured and analyzed during loading response, midstance, terminal stance, and preswing. The altered joint kinematics and kinetics in the nonaffected limb in the HCP group appeared to be mainly a compensatory strategy to minimize the bilateral asymmetry in leg stiffness during the double-limb support phase and joint stiffness during the entire stance phase. The current results suggest that therapeutic planning and decision-making for children with HCP should consider not only the mechanics of the affected side but also the control of the nonaffected side.

Automatic classification of gait patterns in children with cerebral palsy using fuzzy clustering method

BACKGROUND

Subjective classification of gait pattern in children with cerebral palsy depends on the assessor's experience, while mathematical methods produce virtual groups with no clinical interpretation.

METHODS

In a retrospective study, gait data from 66 children (132 limbs) with a mean age of 9.6 (SD 3.7) years with cerebral palsy and no history of surgery or botulinum toxin injection were reviewed. The gait pattern of each limb was classified in four groups according to Rodda using three methods: 1) a team of experts subjectively assigning a gait pattern, 2) using the plantarflexor-knee extension couple index introduced by Sangeux et al., and 3) employing a fuzzy algorithm to translate the experiences of experts into objective rules and execute a clustering tool. To define fuzzy repeated-measures, 75% of the members in each group were used, and the remaining were used for validation. Eight parameters were objectively extracted from kinematic data for each group and compared using repeated measure ANOVA and post-hoc analysis was performed. Finally, the results of the clustering of the latter two methods were compared to the subjective method.

FINDINGS

The plantarflexor-knee extension couple index achieved 86% accuracy while the fuzzy system yielded a 98% accuracy. The most substantial errors occurred between jump and apparent in both methods.

INTERPRETATION

The presented method is a fast, reliable, and objective fuzzy clustering system to classify gait patterns in cerebral palsy, which produces clinically-relevant results. It can provide a universal common language for researchers.

Bone and joint complications and reduced mobility are associated with pain in children with cerebral palsy

AIM

To investigate the relationships between pain in the lower extremities and back, and spasticity, bone/joint complications and mobility.

METHODS

Retrospective population-based registry study. Participants (N = 3256) with cerebral palsy (CP), 2.5-16 years of age, participating in the Swedish Cerebral Palsy Follow-up Program were included. Spasticity was measured using scissoring and the Modified Ashworth Scale. Bone/joint complications consisted of hip displacement, range of motion, windswept posture and scoliosis. Mobility was measured using the Functional Mobility Scale (5-, 50- and 500-metres), wheelchair use (outdoors) and the ability to stand/get up from sitting/use stairs, respectively. Pain was measured as presence of pain in hips, knees, feet and back. Data were analysed using structural equation modelling.

RESULTS

Bone/joint complications had the strongest direct pathway with pain in the lower extremities (standardised regression coefficient = 0.48), followed by reduced mobility (standardised regression coefficient = -0.24). The pathways between spasticity and pain, and age and pain were not significant. The R² of the model was 0.15.

CONCLUSION

Bone/joint complications and reduced mobility were associated with pain in the lower extremities when controlling for sex. Considering the R² of the model, other factors not included in the model are also associated with pain in the lower extremities in children with CP.

The paediatric version of Wisconsin gait scale, adaptation for children with hemiplegic cerebral palsy: a prospective observational study

Background

In clinical practice there is a need for a specific scale enabling detailed and multifactorial assessment of gait in children with spastic hemiplegic cerebral palsy. The practical value of the present study is linked with the attempts to find a new, affordable, easy-to-use tool for gait assessment in children with spastic hemiplegic cerebral palsy. The objective of the study is to evaluate the Wisconsin Gait Scale (WGS) in terms of its inter- and intra-rater reliability in observational assessment of walking in children with hemiplegic cerebral palsy.

Methods

The study was conducted in a group of 34 patients with hemiplegic cerebral palsy. At the first stage, the original version of the ordinal WGS was used. The WGS, consisting of four subscales, evaluates fourteen gait parameters which can be observed during consecutive gait phases. At the second stage, a modification was introduced in the kinematics description of the knee and weight shift, in relation to the original scale. The same video recordings were rescored using the new, paediatric version of the WGS. Three independent examiners performed the assessment twice. Inter and intra-observer reliability of the modified WGS were determined.

Results

The findings show very high inter- and intra-observer reliability of the modified WGS. This was reflected by a lack of systematically oriented differences between the repeated measurements, very high value of Spearman’s rank correlation coefficient 0.9 ≤ |R| < 1, very high value of ICC > 0.9, and low value of CV < 2.5% for the specific physical therapists.

Conclusions

The new, ordinal, paediatric version of WGS, proposed by the authors, seems to be useful as an additional tool that can be used in qualitative observational gait assessment of children with spastic hemiplegic cerebral palsy. Practical dimension of the study lies in the fact that it proposes a simple, easy-to-use tool for a global gait assessment in children with spastic hemiplegic cerebral palsy. However, further research is needed to validate the modified WGS by comparing it to other observational scales and objective 3-dimensional spatiotemporal and kinematic gait parameters.

Trial registration

anzctr.org.au, ID: ACTRN12617000436370. Registered 24 March 2017.

Correlation between the gross motor performance measurement and pediatric balance scale with respect to movement disorder in children with cerebral palsy

[Purpose] To determine whether the Gross Motor Performance Measurement is useful in predicting the future score of the Pediatric Balance Scale, this study examined the correlation between the 2 measurement tools with respect to movement disorder in children with cerebral palsy. [Subjects and Methods] A total of 38 study subjects with cerebral palsy were divided into 3 groups (spastic, dyskinetic, and ataxic) by means of systematic proportional stratified sampling in accordance with the characteristics of their movement disorders. [Results] The spastic Pediatric Balance Scale had an intermediate level of positive correlation with dissociated movement (r=0.411), alignment (r=0.518), and weight shift (r=0.461). The dyskinetic Pediatric Balance Scale had a strong positive correlation with dissociated movement (r=0.905), coordination (r=0.882), alignment (r=0.930), and stability (r=0.924). The ataxic Pediatric Balance Scale had an intermediate level of positive correlation with the overall Gross Motor Performance Measurement (r=0.636), and a strong positive correlation with dissociated movement (r=0.866), coordination (r=0.871) and stability (r=0.984). [Conclusion] Gross Motor Performance Measurement is important in evaluating the quality of movement, and can be considered an excellent supplementary tool in predicting functional balance.

Activities and participation of 9- to 13-year-old children with cerebral palsy

Objective: To describe the activities and participation of children with cerebral palsy and to examine the relationship with personal factors and disease characteristics.

Design: Cross-sectional study.

Setting: Department of Rehabilitation Medicine of a University Medical Center in The Netherlands.

Subjects: One hundred and ten children: 70 boys, 40 girls, mean (SD) age 11 years and 3 months (20 months).

Outcome measures: Activities and participation, described in the domains of mobility, self-care, domestic life, social life and communication, measured with the Gross Motor Function Measure, the Pediatric Evaluation of Disability Inventory and the Vineland Adaptive Behavior Scales.

Results: Multiple linear regression models showed that the Gross Motor Function Classification System (GMFCS) was strongly associated with mobility (explained variance 87-92%), self-care and domestic life. Apart from the GMFCS, cognitive impairment and limb distribution were less important but also significantly associated with self-care and domestic life (explained variance 65-81%). Cognitive impairment and epilepsy were the most important factors associated with social life and communication (explained variance 54-75%).

Conclusion: Activities and participation can, to a large extent, be explained by only a few associated factors.

The Prevalence of Cerebral Palsy in British Columbia, 1991-1995

Objective:

To quantify the prevalence of cerebral palsy (CP) in British Columbia within a four-year birth cohort.

Methods:

The study was a population-based record linkage study of a birth cohort of British Columbian children born between April 1, 1991 and March 31, 1995. Cases were identified by the presence of International Classification of Diseases, Version 9 (ICD-9) diagnostic code “343” recorded at three years of age or older or by having the ICD-9 diagnostic code “343” recorded prior to the third birthday with two confirmatory diagnoses within the first three years of life through a record search of the BC Medical Services Plan billing files for the fiscal years 1991 to 1995.

Results/Conclusion:

This research has provided an estimate of the prevalence of CP in the four-year birth cohort 1991 to 1995 in British Columbia. An aggregate prevalence rate of CP was measured as 2.68 per 1000 live births, and a congenital rate was measured at 2.57 for the same population. Birth weight and gestational age demonstrated a significant relationship with the development of CP. This study should lend credence to the establishment of a CP register in British Columbia.

Social support provided to caregivers of children with cerebral palsy

OBJECTIVE

To describe the perception of caregivers of children with cerebral palsy (CP) concerning social support received and to verify how the characteristics of the children (i.e. type of CP and severity of motor impairment) and those of their caregivers (i.e. age, level of education, occupation, income and number of children) are significantly related to this perception.

METHOD

A total of 50 children with CP aged between 3 and 12 years and their respective caregivers participated in this study. Children were grouped in terms of type of CP and according to the severity of motor impairment through the Gross Motor Function Classification System (GMFCS). The Social Support Questionnaire (SSQ) was used to evaluate the perception of caregivers concerning the social support they receive (number of people offering support - SSQ-N index, and level of satisfaction concerning such support - SSQ-S index).

RESULTS

The caregivers reported receiving support from a mean of 1.67 people. Core and extended family members (i.e. husband, mother, siblings) and friends are the most common providers of support. In regard to level of satisfaction, caregivers considered the support they received to be positive, obtaining a mean of 5.52 out of a total of six points. Children's and caregivers' characteristics were not significantly related to the SSQ-N and SSQ-S indexes.

CONCLUSION

Family members are the caregivers' primary source of social support and caregivers reported being satisfied with the support they received.

A path model for evaluating dosing parameters for children with cerebral palsy

Dosing of pediatric rehabilitation services for children with cerebral palsy (CP) has been identified as a national priority. Establishing dosing parameters for pediatric physical therapy interventions is critical for informing clinical decision making, health policy, and guidelines for reimbursement. The purpose of this perspective article is to describe a path model for evaluating dosing parameters of interventions for children with CP. The model is intended for dose-related and effectiveness studies of pediatric physical therapy interventions. The premise of the model is: Intervention type (focus on body structures, activity, or the environment) acts on a child first through the family, then through the dose (frequency, intensity, time), to yield structural and behavioral changes. As a result, these changes are linked to improvements in functional independence. Community factors affect dose as well as functional independence (performance and capacity), influencing the relationships between type of intervention and intervention responses. The constructs of family characteristics; child characteristics (eg, age, level of severity, comorbidities, readiness to change, preferences); plastic changes in bone, muscle, and brain; motor skill acquisition; and community access warrant consideration from researchers who are designing intervention studies. Multiple knowledge gaps are identified, and a framework is provided for conceptualizing dosing parameters for children with CP.

Factors related to psychosocial quality of life for children with cerebral palsy

Background. Current health services interventions focus on the treatment of the musculoskeletal impairments of cerebral palsy (CP). The goal of this study was to explore whether the severity of physical symptoms correlates with psychosocial quality of life (QOL) among pediatric patients with CP. Methods. A sample of 53 caregivers of children with CP was surveyed and health status information was extracted from patient medical records. Descriptive analysis explored the association between the main outcome variable, psychosocial QOL (CP QOL-child), and patient demographics, comorbidity (e.g., visual, hearing and feeding impairments, language delays, and epilepsy), CP severity (GMFCS), and the receipt of family centered care (MPOC-20). Results. Child psychosocial QOL decreased with increasing comorbidity but was not associated with CP symptom severity or any measured demographic factors. Reporting high levels of family centered care (FCC) was associated with higher psychosocial QOL in univariate analysis but was not significant when controlling for comorbidities. Conclusion. There is no clear connection between symptom severity and psychosocial QOL in children with CP. Comorbidity however is strongly associated with psychosocial QOL. Focusing on reducing CP comorbidities could have a positive impact on psychosocial QOL.

Deficit in implicit motor sequence learning among children and adolescents with spastic cerebral palsy

Skill learning (SL) is learning as a result of repeated exposure and practice, which encompasses independent explicit (response to instructions) and implicit (response to hidden regularities) processes. Little is known about the effects of developmental disorders, such as Cerebral Palsy (CP), on the ability to acquire new skills. We compared performance of CP and typically developing (TD) children and adolescents in completing the serial reaction time (SRT) task, which is a motor sequence learning task, and examined the impact of various factors on this performance as indicative of the ability to acquire motor skills. While both groups improved in performance, participants with CP were significantly slower than TD controls and did not learn the implicit sequence. Our results indicate that SL in children and adolescents with CP is qualitatively and quantitatively different than that of their peers. Understanding the unique aspects of SL in children and adolescents with CP might help plan appropriate and efficient interventions.

Identification of facilitators and barriers to physical activity in children and adolescents with cerebral palsy

OBJECTIVE

To explore facilitators and barriers to participation in physical activity and sport in youth with cerebral palsy (CP).

STUDY DESIGN

This was a qualitative study involving in-depth focus group interviews with 33 ambulatory youth with CP and their parents. The interviews were conducted until informational redundancy was achieved.

RESULTS

Youth with CP and their parents reported personal and environmental facilitators and barriers to participation in physical activity. Seven major themes related to personal and environmental factors were identified.

CONCLUSIONS

This study suggests that various personal and environmental factors play a key role in determining the extent to which youth with CP participate in physical activity. The facilitators and barriers identified provide important theoretical insights into how and why youth with CP and their parents might change their physical activity behavior.

Comparison of the prevalence and impact of health problems of pre-school children with and without cerebral palsy

BACKGROUND

The range of health problems associated with children with cerebral palsy (CP) is well documented in the literature; however, the existing data are often either reported for samples of children with all types of CP, or stratified by typology of motor disorder, rather than using the Gross Motor Function Classification System (GMFCS), which has been shown to be the most reliable way of classifying children with CP. Furthermore, availability of research on pre-school-aged children (under 5 years) is sparse. The aim of this study is to compare the prevalence and impact of health problems in pre-school children with and without CP, stratified by the GMFCS.

METHODS

Parents of 430 pre-school-aged children with CP (243 boys, 187 girls; mean age = 3 years 2 months, SD = 11 months) and 107 typically developing (TD) children (56 boys, 51 girls; mean age = 3 years 4 months, SD = 11 months) participated. Using the consensus definition of CP and the World Health Organization's International Classification of Functioning, Disability and Health, a parent survey was developed to assess the prevalence and impact of 16 health problems. The measure demonstrates good test-retest reliability (ICC > 0.80) and discriminant validity across GMFCS levels (P < 0.001).

RESULTS

Both the prevalence and impact of health problems is greater in children with CP compared with TD children (P < 0.001). The number and impact of health problems increase with ascending GMFCS level (P ≤ 0.01), except for the impact of health problems between groups GMFCS I and GMFCS II/III (P= 0.19). Children with CP have an average of between 3.4 and 6.7 health problems, compared with fewer than one in TD children.

CONCLUSIONS

Service providers working with pre-school-aged children with CP need to consider health problems and their impact when planning care.

Cognitive correlates of mathematical achievement in children with cerebral palsy and typically developing children

BACKGROUND

Remarkably few studies have investigated the nature and origin of learning difficulties in children with cerebral palsy (CP).

AIMS

To investigate math achievement in terms of word-problem solving ability in children with CP and controls. Because of the potential importance of reading for word-problem solving, we investigated reading as well.

SAMPLE

Children with CP attending either special (n= 41) or mainstream schools (n= 16) and a control group of typically developing children in mainstream schools (n= 16).

METHOD

Group differences in third grade math and reading, controlled for IQ, were tested with analyses of co-variance (ANCOVAs). Hierarchical regression was used to investigate cognitive correlates of third grade math and reading. Predictors included verbal and non-verbal IQ measured in first grade, components of working memory (WM) and executive function (EF) measured in second grade, and arithmetic fact fluency and reading measured in third grade.

RESULTS

Children with CP in special schools performed significantly worse than their peers on word-problem solving and reading. There was a trend towards worse performance in children with CP in mainstream schools compared to typically developing children.

CONCLUSIONS

Impairments of non-verbal IQ and WM updating predicted future difficulties in both word-problem solving and reading. Impairments of visuospatial sketchpad and inhibition predicted future word-problem, but not reading difficulty. Conversely, deficits of phonological loop predicted reading but not word-problem difficulty. Concurrent arithmetic fact fluency and reading ability were both important for word-problem solving ability. These results could potentially help to predict which children are likely to develop specific learning difficulties, facilitating early intervention.

[The Battelle developmental inventory screening test for early detection of developmental disorders in cerebral palsy]

INTRODUCTION

Cerebral palsy is usually associated with motor, cognitive, and language deficits, and with other disorders that cause disability in daily living skills, personal independence, social interaction and academic activities. Early detection of these deficits in the clinical setting is essential to anticipate and provide the child with the necessary support for adapting to the environment in all possible areas. The main objective of this study is to demonstrate that these deficits can be detected at an early age and comprehensively through the use of a brief development scale.

METHODS

We studied 100 children between 4 and 70 months old, half of them with cerebral palsy and the other half without any disorder. All subjects were evaluated using the Battelle Developmental Inventory screening test. We compared the developmental quotients in both groups and between the subjects with different motor impairments, using a simple prospective ex post facto design.

RESULTS

The test detected statistically significant differences between the clinical group and the control group at all age levels. Statistically significant differences were also found between tetraplegia and other motor disorders. There were no differences by gender.

DISCUSSION

The deficit in development associated with cerebral palsy can be quantified at early ages through the use of a brief development scale, thus we propose that the systematic implementation of protocols with this screening tool would be helpful for treatment and early intervention. This would also help in anticipating and establishing the means for the multidisciplinary actions required, and could provide guidance to other health professionals, to provide adequate school, social, and family support,.

Feasibility and reliability of classifying gross motor function among children with cerebral palsy using population-based record surveillance

For conditions with wide-ranging consequences, such as cerebral palsy (CP), population-based surveillance provides an estimate of the prevalence of case status but only the broadest understanding of the impact of the condition on children, families or society. Beyond case status, information regarding health, functional skills and participation is necessary to fully appreciate the consequences of the condition. The purpose of this study was to assess the feasibility and reliability of enhancing population-based surveillance by classifying gross motor function (GMF) from information available in medical records of children with CP. We assessed inter-rater reliability of two GMF classification methods, one the Gross Motor Function Classification System (GMFCS) and the other a 3-category classification of walking ability: (1) independently, (2) with handheld mobility device, or (3) limited or none. Two qualified clinicians independently reviewed abstracted evaluations from medical records of 8-year-old children residing in southeast Wisconsin, USA who were identified as having CP (n = 154) through the Centers for Disease Control and Prevention's Autism and Developmental Disabilities Monitoring Network. Ninety per cent (n = 138) of the children with CP had information in the record after age 4 years and 108 (70%) had adequate descriptions of gross motor skills to classify using the GMFCS. Agreement was achieved on 75.0% of the GMFCS ratings (simple kappa = 0.67, 95% confidence interval [95% CI 0.57, 0.78], weighted kappa = 0.83, [95% CI 0.77, 0.89]). Among case children for whom walking ability could be classified (n = 117), approximately half walked independently without devices and one-third had limited or no walking ability. Across walking ability categories, agreement was reached for 94% (simple kappa = 0.90, [95% CI 0.82, 0.96], weighted kappa = 0.94, [95% CI 0.89, 0.98]). Classifying GMF in the context of active records-based surveillance is feasible and reliable. Future surveillance efforts that include functional level among children with cerebral palsy may provide important information for monitoring the impact of the condition for programmatic and policy purposes.

Utility of language comprehension tests for unintelligible or non-speaking children with cerebral palsy: a systematic review

AIM

to identify the use and utility of language comprehension tests for unintelligible or non-speaking children with severe cerebral palsy (CP).

METHOD

severe CP was defined as severe dysarthria (unintelligible speech) or anarthria (absence of speech) combined with severe limited mobility, corresponding to Gross Motor Function Classification System levels IV to V. An electronic search in the databases of PubMed, PsychInfo, Embase, and CINAHL was made of studies published between January 1965 and December 2008. Indexing terms and free-text terms for 'cerebral palsy', 'language', and 'instrumentation' were used. Studies were included when (1) the focus was to investigate comprehension of spoken language of children (0-18 y) with severe CP, and (2) language tests were described.

RESULTS

twelve standardized tests and five experimental instruments were identified. All standardized tests were developed for children without limited mobility. Only the Peabody Picture Vocabulary Test - Revised was frequently used and feasible for older children with severe CP (> 9 y). The other tests were used occasionally. To establish utility, adaptations of standardized test procedures were necessary.

INTERPRETATION

language comprehension tests for children with severe CP are scarce. A language comprehension test specifically designed for these children is warranted.

Gait patterns in hemiplegic children with Cerebral Palsy: comparison of right and left hemiplegia

The aims of this study are to compare quantitatively the gait strategy of the right and left hemiplegic children with Cerebral Palsy (CP) using gait analysis. The gait strategy of 28 right hemiparetic CP (RHG) and 23 left hemiparetic CP (LHG) was compared using gait analysis (spatio-temporal and kinematic parameters) and considering the hemiplegic classification based on four gait strategies. Our results demonstrated that velocity was a significant parameter to differentiate RHG and LHG: all hemiplegic types revealed in fact that RHG walked with higher velocity than LHG. The ankle strategy displayed an increased number of differences between RHG and LHG from hemiplegia of Type I to Type III. In all the comparison, the LHG showed the less physiological gait pattern. As for knee kinematics, differences between right and left hemiplegic gait pattern were evidenced only in children with hemiplegia Type II: the LHG walked with a more flexed knee at initial contact, marked hyperextension in midstance and reduced knee flexion ability in the swing phase. The hip strategy was quite normal in both groups in hemiplegia Type I. In the other two types, LHG showed a limited extension ability in midstance in comparison to RHG. In conclusion, our data revealed that RHG and LHG were in general characterised by different gait patterns, evidencing a general a progression of involvement in the different types of hemiplegia; in particular in all the hemiplegic types the LHG patients revealed a more severe involvement than the RHG individuals and the differences were more evident at the distal joints, especially at the ankle joint.

The relationship between motor abilities and early social development in a preschool cohort of children with cerebral palsy

AIM

To investigate the relationship between motor ability and early social development in a cohort of preschool children with cerebral palsy (CP).

DESIGN

Population-based cohort study.

METHODS

Participants were 122 children with CP assessed at 18, 24 and 30 months, corrected age (ca). Motor ability was measured by the Gross Motor Function Classification System (GMFCS) with classification assigned by physiotherapists. The sample was representative of a population-based cohort (I=48, 38.4%, II=19, 15.2%, III=17, 13.6%, IV=22, 17.6% and V=19, 15.2%). Social development was measured by the Paediatric Evaluation of Disability Inventory (PEDI) and included capabilities in social interaction, social communication, interactive play and household/community tasks.

RESULTS

Cross-sectional analyses indicated a significant relationship between motor ability and social development at 18 months, F(4, 56)=11.44, p<.0001, η(2)=.45, at 24 months, F(4, 79)=15.66, p<.0001, η(2)=.44 and at 30 months, F(4, 76)=16.06, p<.0001, η(2)=.49. A longitudinal analysis with a subset of children (N=24) indicated a significant interaction between age at assessment and GMFCS, F(2, 21)=7.02, p=.005, η(2)=.40. Comparison with community norms indicated that at 18 months corrected age, 44.3% of the cohort was greater than two standard deviations below the mean (>2SD) for social development and a further 27.9% of the cohort was greater than one standard deviation below the mean (>1SD).

INTERPRETATION

There is a relationship between motor ability and social development in preschool children with CP. Children with CP may require support for social development in additional to physical interventions, from as early as 18 months.

Enabling self-directed computer use for individuals with cerebral palsy: a systematic review of assistive devices and technologies

AIM

The purpose of this study was to systematically review published evidence on the development, use, and effectiveness of devices and technologies that enable or enhance self-directed computer access by individuals with cerebral palsy (CP).

METHODS

Nine electronic databases were searched using keywords 'computer', 'software', 'spastic', 'athetoid', and 'cerebral palsy'; the reference lists of articles thus identified were also searched. Thirty articles were selected for review, with 23 reports of development and usability testing of devices and seven evaluations of algorithms to increase computer recognition of input and cursor movements.

RESULTS

Twenty-four studies had fewer than 10 participants with CP, with a wide age range of 5 to 77 years. Computer task performance was usually tested, but only three groups sought participant feedback on ease and comfort of use. International standards exist to evaluate effectiveness of non-keyboard devices, but only one group undertook this testing. None of the study designs were higher than American Academy for Cerebral Palsy and Developmental Medicine level IV.

INTERPRETATION

Access solutions for individuals with CP are in the early stages of development. Future work should include assessment of end-user comfort, effort, and performance as well as design features. Engaging users and therapists when designing and evaluating technologies to enhance computer access may increase acceptance and improve performance.

Social functioning and communication in children with cerebral palsy: association with disease characteristics and personal and environmental factors

AIM

The objective of this longitudinal study was to describe the course of social functioning and communication in children with cerebral palsy (CP) over a 3-year period, its difference with the normative course, and its relationship with disease characteristics and personal and environmental factors.

METHOD

Participants in this study were 110 children with CP (70 males, 40 females) with a mean age of 11 years and 3 months (SD 1y 8mo). Social functioning and communication were measured with the Vineland Adaptive Behavior Scales. Comparisons were made with normative data; data were analysed with generalized estimating equations. According to the Gross Motor Function Classification System (GMFCS), 50 of the 110 children were categorized as GMFCS level I, 16 as level II, 13 as level III, 13 as level IV, and 18 as level V.

RESULTS

The course of social functioning over a 3-year period showed an increase in restrictions in children with CP (p<0.001). Restrictions in communication increased more in children with the most severe forms of CP (p<0.001). In addition to disease characteristics (GMFCS category, presence of epilepsy, and speech problems), personal factors (externalizing behaviour problems) and environmental factors (having no siblings, low parental level of education, and parental stress) were associated with greater restrictions in social functioning and communication.

INTERPRETATION

The results indicate that it is important to focus not only on the medical treatment of children with CP, but also on their behavioural problems and social circumstances, and to support the parents so that social functioning and communication in these children may be improved.

The updated European Consensus 2009 on the use of Botulinum toxin for children with cerebral palsy

An interdisciplinary European group of clinical experts in the field of movement disorders and experienced Botulinum toxin users has updated the consensus for the use of Botulinum toxin in the treatment of children with cerebral palsy (CP). A problem-orientated approach was used focussing on both published and practice-based evidence. In part I of the consensus the authors have tabulated the supporting evidence to produce a concise but comprehensive information base, pooling data and experience from 36 institutions in 9 European countries which involves more than 10,000 patients and over 45,000 treatment sessions during a period of more than 280 treatment years. In part II of the consensus the Gross Motor Function Measure (GMFM) and Gross Motor Function Classification System (GMFCS) based Motor Development Curves have been expanded to provide a graphical framework on how to treat the motor disorders in children with CP. This graph is named "CP(Graph) Treatment Modalities - Gross Motor Function" and is intended to facilitate communication between parents, therapists and medical doctors concerning (1) achievable motor function, (2) realistic goal-setting and (3) treatment perspectives for children with CP. The updated European consensus 2009 summarises the current understanding regarding an integrated, multidisciplinary treatment approach using Botulinum toxin for the treatment of children with CP.

‘I am what I am because of who we all are’: International perspectives on rehabilitation: South Africa

This article provides an overview of some of the important factors that impinge on people with cerebral palsy and their families, on medical and rehabilitation personnel, and on systems of healthcare and education in South Africa. Information is provided with regard to the national contextual variables that influence intervention in the country. The incidence of cerebral palsy is related to some of the more prominent aetiological variables including poverty, malaria, HIV/Aids and premature birth. Health care systems available for children with cerebral palsy are discussed, including the role of traditional healers. Access to education, training and care of children with cerebral palsy is described, including a brief history of specialized education in South Africa. An overview of the personnel, approaches and work contexts involved in rehabilitation highlights the unique nature of intervention in South Africa. The article concludes with recommendations for interventionists with reference to lessons that can be learned in terms of adapting skills and knowledge to local needs, in order to work successfully with children with cerebral palsy and to develop the resilience of their families. In addition, it is suggested that the definition of cerebral palsy needs to reflect the context in which the person lives.

Participation in life situations of 8-12 year old children with cerebral palsy: cross sectional European study

OBJECTIVES

To evaluate how involvement in life situations (participation) in children with cerebral palsy varies with type and severity of impairment and to investigate geographical variation in participation.

DESIGN

Cross sectional study. Trained interviewers visited parents of children with cerebral palsy; multilevel multivariable regression related participation to impairments, pain, and sociodemographic characteristics.

SETTING

Eight European regions with population registers of children with cerebral palsy; one further region recruited children from multiple sources.

PARTICIPANTS

1174 children aged 8-12 with cerebral palsy randomly selected from the population registers, 743 (63%) joined in the study; the further region recruited 75 children.

MAIN OUTCOME MEASURE

Children's participation assessed by the Life-H questionnaire covering 10 main areas of daily life. Scoring ignored adaptations or assistance required for participation.

RESULTS

Children with pain and those with more severely impaired walking, fine motor skills, communication, and intellectual abilities had lower participation across most domains. Type of cerebral palsy and problems with feeding and vision were associated with lower participation for specific domains, but the sociodemographic factors examined were not. Impairment and pain accounted for up to a sixth of the variation in participation. Participation on all domains varied substantially between regions: children in east Denmark had consistently higher participation than children in other regions. For most participation domains, about a third of the unexplained variation could be ascribed to variation between regions and about two thirds to variation between individuals.

CONCLUSIONS

Participation in children with cerebral palsy should be assessed in clinical practice to guide intervention and assess its effect. Pain should be carefully assessed. Some European countries facilitate participation better than others, implying some countries could make better provision. Legislation and regulation should be directed to ensuring this happens.

Health status of children with cerebral palsy living in Europe: a multi-centre study

AIM

The aim of this report is to describe the health status of 8-12-year-old children with cerebral palsy (CP) of all severities in Europe using the Child Health Questionnaire (CHQ).

METHOD

A total of 818 children with CP from nine centres in defined geographical areas participated. CP type, gross and fine motor function, additional impairments were classified and family data were obtained. The CHQ was used to measure the parent's perception of their child's physical (PHY) and psychosocial (PSY) health.

RESULTS

PHY scores were lower than the reference samples with a median of 46. The severity of gross motor function influenced the CHQ scores significantly in the PHY scale with the lowest scores for children with least gross motor function. There were significant differences between the CP types in PHY with the higher scores for children with unilateral spastic and the lowest scores for children with bilateral spastic and dyskinetic CP type. Fine motor function severity significantly affected both the PHY and PSY scales. The severity of intellectual impairment was significantly associated with CHQ scores in most dimensions with higher scores for higher IQ level in PHY and PSY. Children with seizures during the last year had a significantly lower health compared with children without seizures. The results of the multivariate regression analyses (forward stepwise regression) of CHQ scores on CP subtype, gross and fine motor function, cognitive function, additional impairments, seizures, parental education and employment revealed gross motor function, cognitive level and type of school attended were significant prognostic factors.

CONCLUSION

This report is based on the largest sample to date of children with CP. Health status as measured using the CHQ was affected in all children and was highly variable. Gross motor function level correlates with health from the PHY well-being perspective but the PSY and emotional aspects do not appear to follow the same pattern.

Cerebral palsy: orthopedic aspects and rehabilitation

Cerebral palsy is the most common chronic disability of childhood today. The concept of management rather than cure forms the basis of intervention. Therapy programs should be integrated with summer camps, home activities, and school, enabling the child and the family to live as close to normal as possible. Successful rehabilitation should prevent additional problems, minimize disability, and create a happy child.

Cognitive profile in young Icelandic children with cerebral palsy

We describe the cognitive profile in a complete national cohort of children with cerebral palsy (CP). One hundred and twenty-seven Icelandic children (67 females, 60 males) with CP, born between 1985 and 2000 and assessed between the ages of 4 and 6 years 6 months (mean age 5y 5mo, SD 6mo), were included in the study. IQ was measured using the Wechsler Preschool and Primary Scale of Intelligence (WPPSI) and developmental quotient (DQ) was obtained using various developmental scales. Physiological classification of CP in the children was: spasticity, n=104 (82%); dyskinesia, n=14 (11%); ataxia, n=six (4.7%), and unclassified CP, n=3 (2.3%). Spastic diplegia was the most prevalent subtype (35%) followed by hemiplegia and quadriplegia. Forty-five per cent of the group were at Level I of the Gross Motor Function Classification System, 32% were at Levels II and III, and 23% were at Levels IV and V. Sixty per cent of the children had an IQ or DQ >70. Median scores on the WPPSI were Full-scale IQ 84, Verbal IQ (VIQ) 92, and Performance IQ (PIQ) 77. Children with spastic diplegia and quadriplegia had a significantly lower PIQ than VIQ. Of the children who failed to complete the WPPSI, 20% had DQ >85. Thus, cognitive skills can be masked by limitations of movement and motor control in children with CP.

Impact of neonatal asphyxia and hind limb immobilization on musculoskeletal tissues and S1 map organization: implications for cerebral palsy

Cerebral palsy (CP) is a complex disorder of locomotion, posture and movements resulting from pre-, peri- or postnatal damage to the developing brain. In a previous study (Strata, F., Coq, J.O., Byl, N.N., Merzenich, M.M., 2004. Comparison between sensorimotor restriction and anoxia on gait and motor cortex organization: implications for a rodent model of cerebral palsy. Neuroscience 129, 141-156.), CP-like movement disorders were more reliably reproduced in rats by hind limb sensorimotor restriction (disuse) during development rather than perinatal asphyxia (PA). To gain new insights into the underpinning mechanisms of CP symptoms we investigated the long-term effects of PA and disuse on the hind limb musculoskeletal histology and topographical organization in the primary somatosensory cortex (S1) of adult rats. Developmental disuse (i.e. hind limb immobilization) associated with PA induced muscle fiber atrophy, extracellular matrix changes in the muscle, and mild to moderate ankle and knee joint degeneration at levels greater than disuse alone. Sensorimotor restricted rats with or without PA exhibited a topographical disorganization of the S1 cortical hind limb representation with abnormally large, multiple and overlapping receptive fields. This disorganization was enhanced when disuse and PA were associated. Altered cortical neuronal properties included increased cortical responsiveness and a decrease in neuronal selectivity to afferent inputs. These data support previous observations that asphyxia per se can generate the substrate for peripheral tissue and brain damage, which are worsened by aberrant sensorimotor experience during maturation, and could explain the disabling movement disorders observed in children with CP.

Health professionals' perceptions of feeding-related quality of life in children with quadriplegic cerebral palsy

BACKGROUND

Our aim was to identify the major determinants of feeding-related quality of life (QoL) in children with quadriplegic cerebral palsy (QCP) from the perspective of health professionals to provide a framework for comprehensive clinical evaluation of health status in this group.

METHODS

A trained facilitator conducted five semi-structured focus groups during September and November 2003. Participants were recruited through the two paediatric hospitals in Sydney and community-based services, and included general and specialist paediatricians (n = 18), nurses (n = 15) and allied health professionals (n = 13), with an 80% response rate. All sessions were audio- and videotaped. NVIVO software was used to facilitate thematic analysis of the transcribed audiotapes.

RESULTS

Responses clustered into five themes: delivery of health services, parent-child interaction, the child's physical and emotional well-being, and social participation. Participants thought the QoL of child and parent was inseparable. Parent-child interaction, delivery of services and physical well-being were the topics which prompted most participant interaction. These findings did not vary across disciplines.

CONCLUSIONS

Health professionals identified five domains which provide a framework within which clinicians may comprehensively evaluate the health status of children with QCP and feeding difficulties. These five domains may also be used to inform a new feeding-related QoL instrument for use in this group of patients.

Primary care of the child with cerebral palsy: a review of systems (part II)

Cerebral palsy (CP) is a disorder of movement and posture with additional potential to affect cognitive status. Thus, the goals for management of the child with CP include the following: to promote optimal function; to maintain general health; to foster acquisition of new skills; to assist and educate parents and caregivers; and to anticipate, prevent, and treat the complications of this disorder. Pediatric management of the child with CP should begin at the time of diagnosis. This article is the second of two articles on CP. The first article focused on the diagnosis of CP, and this article will focus on a review of systems approach for management as well as resources for the family and the nurse practitioner.

Reliability of Greek version Gross Motor Function Classification System

The Gross Motor Function Classification System for Cerebral Palsy (GMFCS), a reliable and valid system, has been widely utilized for objective classification of the patterns of motor disability in children with cerebral palsy. The objective of this study was to produce a Greek version of the instrument, with the same construct as the original one and to investigate the reliability of application of the Greek version GMFCS. Translation and back translation was made by two of the authors, one of whom did not know the original English text. The final translation was fixed by consensus. Two physicians were trained and given practice in the use of the GMFCS and its application to clinical documentation. The raters classified children with cerebral palsy according to GMFCS - Greek version. The reliability was assessed with the weighted kappa statistic. The sample consisted of 47 boys and 47 girls, mean age 5.4 years. The overall weighted Kappa was 0.80 (95% CI=0.67-0.94). Weighted Kappa for level I was 0.91 (95% CI=0.74-1.09), for level II, 0.78 (95% CI=0.62-0.95), for level III, 0.85 (95% CI=0.68-1.02), for level IV, 0.85 (95% CI=0.67-1.03) and for level V, 0.84 (95% CI=0.66-1.03). The inter-rater reliability was lowest at level II. Percent agreement was 75%. Results of this study suggest that GMFCS - Greek version can be used reliably to classify patients with CP from clinical documentation. These results further support use of the GMFCS in clinical settings and for research. Investigation is needed to further assess the reliability and to determine the validity of the Greek version of the GMFCS.

Handicaps, recours aux soins et conditions de vie des Adultes atteints de paralysie cérébrale infantile en Bretagne (APIB) : premiers résultats

Cerebral palsy is defined as a nonprogressive brain lesion that occurs during prenatal or perinatal development. The Breizh IMC health network objective is to improve the knowledge about the way of life and the health status of adults with cerebral palsy.

OBJECTIVE

To describe disabilities, way of life and access to medical care for older teens and adults with cerebral palsy.

METHOD

We conducted a descriptive study using health insurance data to contact patients. A questionnaire was addressed to people with cerebral palsy who were older than 16 years. Data were then compared to data of a general population sample.

RESULTS

In total, 562 persons responded: 56% male and 44% female, mean age 36. Motor disability was more important with age (50% at age 20 and 70% after 60). A total of 66% of the sample? had cognitive impairment or mental retardation, 60% needed help when going outside, and 40% required assistance with eating, bathing and dressing. The level of education was variable. Health problems were more frequent in patients with cerebral palsy than in the general population and were progressive. Of the sample, 75% experienced pain and half felt depressed or lonely. Medication use was higher in the sample than in the general population.

CONCLUSION

More study is needed to improve the knowledge of the health status of patients with cerebral palsy. This study highlights health problems that may be considered a basis for the development of care programs.

Gait classification in children with cerebral palsy: a systematic review

This systematic review of the literature evaluates the validity of existing classifications of gait deviations in children with cerebral palsy (CP). Numerous efforts have been made to develop classification systems for gait in CP to assist in diagnosis, clinical decision-making and communication. The internal and external validity of gait classifications in 18 studies were examined, including their sampling methods, content validity, construct validity, reliability and clinical utility. Half of the studies used qualitative pattern recognition to construct the gait classification and the remainder used statistical techniques such as cluster analysis. Few adequately defined their samples or sampling methods. Most classifications were constructed using only sagittal plane gait data. Many did not provide adequate guidelines or evidence of reliability and validity of the classification system. No single classification addressed the full magnitude or range of gait deviations in children with CP. Although gait classification in CP can be useful in clinical and research settings, the methodological limitations of many classifications restrict their clinical and research applicability.

European consensus table 2006 on botulinum toxin for children with cerebral palsy

An interdisciplinary group of experienced botulinum toxin users and experts in the field of movement disorders was assembled, to develop a consensus on best practice for the treatment of cerebral palsy using a problem-orientated approach to integrate theories and methods. The authors tabulated the supporting evidence to produce a condensed but comprehensive information base, pooling data and experience from nine European countries, 13 institutions and more than 5500 patients. The consensus table summarises the current understanding regarding botulinum toxin treatment options in children with CP.

Disorders of attention or learning in neurodevelopmental disorders

Disorders of attention or learning commonly accompany neurodevelopmental disorders. The evaluation and diagnosis of these disorders is complex and does not always follow techniques used for typically developing children. These disorders are often underappreciated and inadequately addressed because they are overshadowed by the neurodevelopmental disorder. Nevertheless, failure to recognize, diagnose, and manage these disorders may result in unsuccessful community integration.