Management of spasticity in children with cerebral palsy

Self-reported Health-related Quality of Life in Adolescents With Cerebral Palsy

BACKGROUND

Happiness, comfort, and motor function contribute to satisfaction with life for individuals with cerebral palsy (CP). Evidence-based medical care can improve motor function and physical health of youth with CP. Less is known about medical care and its relationship to health-related quality of life (HRQOL) in adolescents and young adults with CP. This study aimed to describe HRQOL among adolescents with CP to examine differences between adolescent (self) and parent (proxy) reports of HRQOL and to explore associations of pain, age, and gross motor function with HRQOL.

METHODS

This is a retrospective study including adolescents with CP classified as Gross Motor Function Classification System levels I to V, ages 11 to 20 years, reading ≥ a fourth-grade level, and who completed the self-reported Pediatric Outcomes Data Collection Instrument (PODCI). Parents completed the PODCI concurrently or within 12 months and scores were compared. In addition, self-reported scores were compared between age bands, across Gross Motor Function Classification System levels, with typically developing youth (TDY), and between youth with/without pain.

RESULTS

PODCI scores from 102 adolescents [59 males; 15.0 (SD: 2.6) years old] were examined. Scores from 50 adolescents and parents were matched. Mean self-reported scores were significantly higher than mean parent-reported scores in 4 domains: upper extremity and physical function ( P =0.018), sports and physical function ( P =0.005), happiness ( P =0.023), and global functioning ( P =0.018). All domains, except Happiness, were significantly < TDY ( P <0.01). The presence of pain was associated with lower scores in all domains ( P <0.05).

CONCLUSION

Examining HRQOL with the PODCI revealed significant limitations in physical function and higher pain in adolescents with CP compared with TDY. Self- and parent-reported PODCI results should be considered separately. Adolescents report higher HRQOL compared with parent proxy. Recognizing and validating the perspectives of youth and their parents presents an opportunity for providers to discuss different points of view with families. Such engagement can help promote self-efficacy in youth with CP as they transition to the responsibility of guiding their own care in adulthood.

LEVEL OF EVIDENCE

III, Retrospective comparative study.

Utilization of shear wave elastography to quantify and predict response to upper extremity botulinum toxin injections in patients with cerebral palsy: A pilot study

OBJECTIVE

Shear wave elastography (SWE) was used to quantify change in upper extremity muscle stiffness in patients with unilateral spastic cerebral palsy (USCP) following botulinum toxin A (BTX-A) therapy. We hypothesized that SWE measures would decrease following ultrasound-guided BTX-A injection, and correlate with functional improvement.

METHODS

SWE measures of BTX-A treated muscles were recorded immediately pre-injection, and at 1-, 3- and 6-months post-injection. At the same timepoints, functional assessment was performed using the Modified Ashworth Scale (MAS), and passive and active range of motion (PROM and AROM) measures. Correlation of SWE with MAS, PROM and AROM, as well as the relationship between change in SWE and change in MAS, PROM and AROM was determined using Spearman's rank correlation coefficient and generalized estimating equation modeling.

RESULTS

16 muscles were injected and longitudinally assessed. SWE and MAS scores decreased following BTX-A injection (p = 0.030 and 0.004, respectively), reflecting decreased quantitative and qualitative muscle stiffness. Decreased SWE reached statistical significance at 1- and 3-months, and 1-, 3- and 6-months for MAS. When comparing relative change in SWE to relative change in AROM, larger change in SWE strongly correlated with positive change in AROM (p-value range:<0.001-0.057). BTX-A responders also demonstrated lower baseline SWE (1.4 m/s) vs. non-responders (1.9 m/s), p = 0.035.

CONCLUSION

Ultrasound-guided BTX-A injections in patients with USCP resulted in decreased quantitative and qualitative muscle stiffness. Strong correlation between change in SWE and AROM, as well as the significant difference in baseline SWE for BTX-A responders and non-responders, suggests SWE may provide a useful tool to predict and monitor BTX-A response.

Impact of Upper Extremity Impairment and Trunk Control on Self-Care Independence in Children With Upper Motor Neuron Lesions

OBJECTIVE

The purpose of this study was to evaluate the relative importance of different approaches to measure upper extremity selective voluntary motor control (SVMC), spasticity, strength, and trunk control for explaining self-care independence in children affected by upper motor neuron lesions.

METHODS

Thirty-one patients (mean [SD] age = 12.5 [3.2] years) with mild to moderate arm function impairments participated in this observational study. Self-care independence was evaluated with the Functional Independence Measure for children (WeeFIM). Upper extremity SVMC was quantified with the Selective Control of the Upper Extremity Scale (SCUES), a similarity index (SISCUES) calculated from simultaneously recorded surface electromyography muscle activity patterns, and an accuracy and involuntary movement score derived from an inertial-measurement-unit-based assessgame. The Trunk Control Measurement Scale was applied and upper extremity spasticity (Modified Ashworth Scale) and strength (dynamometry) were assessed. To determine the relative importance of these factors for self-care independence, 3 regression models were created: 1 included only upper extremity SVMC measures, 1 included upper extremity and trunk SVMC measures (overall SVMC model), and 1 included all measures (final self-care model).

RESULTS

In the upper extremity SVMC model (total variance explained 52.5%), the assessgame (30.7%) and SCUES (16.5%) were more important than the SISCUES (4.5%). In the overall SVMC model (75.0%), trunk SVMC (39.0%) was followed by the assessgame (21.1%), SCUES (11.0%), and SISCUES (4.5%). In the final self-care model (82.1%), trunk control explained 43.2%, upper extremity SVMC explained 23.1%, spasticity explained 12.3%, and strength explained 2.3%.

CONCLUSION

Although upper extremity SVMC explains a substantial portion of self-care independence, overall trunk control was even more important. Whether training trunk control and SVMC can translate to improved self-care independence should be the subject of future research.

IMPACT

This study highlights the importance of trunk control and selective voluntary motor control for self-care independence in children with upper motor neuron lesions.

Clinical Relevance of State-of-the-Art Analysis of Surface Electromyography in Cerebral Palsy

Surface electromyography (sEMG) can be used to assess the integrity of the neuromuscular system and its impairment in neurological disorders. Here we will consider several issues related to the current clinical applications, difficulties and limited usage of sEMG for the assessment and rehabilitation of children with cerebral palsy. The uniqueness of this methodology is that it can determine hyperactivity or inactivity of selected muscles, which cannot be assessed by other methods. In addition, it can assist for intervention or muscle/tendon surgery acts, and it can evaluate integrated functioning of the nervous system based on multi-muscle sEMG recordings and assess motor pool activation. The latter aspect is especially important for understanding impairments of the mechanisms of neural controllers rather than malfunction of individual muscles. Although sEMG study is an important tool in both clinical research and neurorehabilitation, the results of a survey on the clinical relevance of sEMG in a typical department of pediatric rehabilitation highlighted its limited clinical usage. We believe that this is due to limited knowledge of the sEMG and its neuromuscular underpinnings by many physiotherapists, as a result of lack of emphasis on this important methodology in the courses taught in physical therapy schools. The lack of reference databases or benchmarking software for sEMG analysis may also contribute to the limited clinical usage. Despite the existence of educational and technical barriers to a widespread use of, sEMG does provide important tools for planning and assessment of rehabilitation treatments for children with cerebral palsy.

Orthopedic treatment of the lower limbs in spastic paralysis

Spastic paralysis of the limb mainly results from the central lesion, in which spastic cerebral palsy is the common cause. Due to durative muscle spasm in spastic cerebral palsy, it is often accompanied by the formation of secondary musculoskeletal deformities, resulting in limb motor disability. Based on its pathogenesis, surgical treatment is currently applied: selective posterior rhizotomy (SPR) or orthopedic surgery. The primary purpose of early orthopedic surgery was simply to correct limb deformities, which usually led to the recurrence of deformity as a result of the presence of spasticity. With the application of SPR, high muscle tone was successfully relieved, but limb deformity was still present postoperatively. Therefore, this study aimed to elaborate on the management of orthopedic surgery, common deformities of the lower limb, and orthopedic operative methods; discuss the relationship between SPR and orthopedic procedure for limb deformity; and focus on the indications, timing of intervention, and postoperative outcome of different surgical methods.

Augmented Biofeedback Training with Physical Therapy Improves Visual-Motor Integration, Visual Perception, and Motor Coordination in Children with Spastic Hemiplegic Cerebral Palsy: A Randomised Control Trial

Aim: The aim of this study is to investigate the efficacy of combining augmented biofeedback training and standard therapy for improving visual-motor integration (VMI), visual perception (VP), and motor coordination (MC) in children with spastic cerebral palsy (CP).Methods: Participants were 45 children, 5-8 years of age, with spastic hemiplegic CP. They were randomized into three groups: group A followed a 3-month specially designed program physical therapy intervention to facilitate VMI and VP. Group B received augmented biofeedback training. Group C received augmented biofeedback training and the physical therapy program provided to group A. The treatment sessions lasted 60 min, three times a week for three months. The Beery-Buktenica Developmental Test of VMI and its supplemental tests were used to evaluate the children before and after the program.Results: After a 3-month treatment, standard scores and age equivalent scores for VMI, VP, and MC were significantly higher in group C compared with group A.Conclusion: The combination of augmented biofeedback and physical therapy could be used to improve VMI, VP, and MC in children with spastic hemiplegic CP.

The Impact of Repetitive Transcranial Magnetic Stimulation on Affected and Unaffected Sides of a Child with Hemiplegic Cerebral Palsy

The purpose of this study was to investigate the therapeutic effects of neuro-navigated repetitive transcranial magnetic stimulation (rTMS) combined with occupational therapy (OT) on gait impairment of a child (male, age: 13.2) with spastic hemiplegic cerebral palsy (CP). The treatment included 4 days a week of rTMS sessions for 3 weeks and 4 days of rTMS and OT sessions per week for 3 weeks. Transcranial magnetic stimulation (TMS) was used to evaluate corticospinal tract (CST) activities and H-reflex test was used to assess reflex hyper-excitability. Common clinical tests demonstrate the clinical status of the patient. Evaluations were performed in 4 time steps: baseline, 3 weeks after the beginning of the treatment, at the end of the treatment, and 1 month after the end of the treatment. The patient did not receive any specific treatment after the end of the treatment up to the follow up evaluations. The tests' results were compared between the affected and unaffected legs of the patient. Four parameters of the TMS test were calculated (motor evoked potential (MEP) latency, MEP peak-to-peak amplitude, cortical silent period (cSP), and stimulation intensity). These parameters were all improved for the affected side and cSP improved for the unaffected side, but MEP p-p amplitude and intensity got worse slightly for the unaffected side. Recruitment curves of H response and M-wave of the H-reflex test for both sides were obtained. Improvements could be seen after the treatment for both sides. Max H response on max M-wave (H/M) and H response latency got better after the treatment for both sides. Walking speed for self and fast velocity, timed up and go, and walking endurance improved during and after the treatment. All the improvements persisted after one month of the end of the treatment in the follow up evaluations. These findings indicate that rTMS combined with OT can have effective and long-lasting impact on neuromuscular impairments in spastic CP children.

The efficacy of botulinum toxin A lower limb injections in addition to physiotherapy approaches in children with cerebral palsy: A systematic review

BACKGROUND

To assess treatment effect of lower limb botulinum toxin type A (BTX-A) in combination with physiotherapy approaches on gross motor functions in children with cerebral palsy compared with only physiotherapy treatment.

OBJECTIVE

The purpose of this review was to analyze the efficacy botulinum toxin a lower limb injections in addition to physiotherapy approaches in children with cerebral palsy.

METHODS

A literature search was conducted in the following databases: Cochrane, PEDro, PubMed, MEDLINE, AMED and EMBASE. The searches were limited to the period from July 2009 to July 2015. The intervention had to contain BTX-A into the lower limb plus physiotherapy approaches and be compared with only physiotherapy. The methodological quality and clinical relevance were independently assessed by the authors.

RESULTS

The database search resulted in a total of 1521 studies, of which 4 (Level II of evidence) trials were included in this review. The population represented by were age between from 11 month to 15 years. Overall there were 153 children all diagnosed with CP (87 Male, 66 Female).

CONCLUSIONS

The use of BTX-A injections in addition to physiotherapy approaches seems to have positive effect on spasticity and ROM. However, the question of whether the treatment of BTX-A plus physiotherapy has a greater improvement on functional capacity, such as gross motor function or gait parameter than only physiotherapy treatments, was inconclusive. Further investigation by rigorous studies is required.

Selective dorsal rhizotomy in cerebral palsy spasticity - a newly established operative technique in Slovenia: A case report and review of literature

BACKGROUND

Spasticity affects a large number of children, mainly in the setting of cerebral palsy, however, only a few paediatric neurosurgeons deal with this problem. This is mainly due to the fact that until 1979, when Fasano has published the first series of selective dorsal rhizotomy (SDR), neurosurgeons were able to provide such children only a modest help. The therapy of spasticity has made a great progress since then. Today, peroral drugs, intramuscular and intrathecal medicines are available, that may limit the effects of the disease. In addition, surgical treatment is gaining importance, appearing in the form of deep brain stimulation, peripheral nerve procedures and SDR. All these options offer the affected children good opportunities of improving the quality of life.

CASE SUMMARY

A 15-year old boy is presented that was surgically treated for spasticity as a result of cerebral palsy. Laminotomy at L1 level was performed and L1 to S1 nerve roots were isolated and divided in smaller fascicles. Then, the SDR was made.

CONCLUSION

We describe a patient report and surgical technique of SDR that was performed in Slovenia for the first time.

Effectiveness of electrical stimulation after administration of botulinum toxin in children with spastic diplegic cerebral palsy: A prospective, randomized clinical study

Objectives

The aim of the study was to investigate the effectiveness of electrical stimulation to agonist muscles after injection of Botulinum toxin A (BTX-A) in children with spastic diplegic cerebral palsy (SDCP).

Patients and methods

Between October 2009 and October 2010, 38 patients with SDCP (19 males, 19 females; mean age 6.3 years; range, 4 to 10 years) were included. The patients were able to walk independently or with minimal assistance by foot equine and had spasticity in the calf muscles between Grades 1+ and 3 according to the Modified Ashworth Scale (MAS). The patients received either BTX-A injection + electrical stimulation (Group 1, n=19) or BTX-A injection alone (Group 2, n=19). All patients were evaluated using the MAS, Penn Spasm Frequency Scale (PSFS), Gross Motor Function Measure-88 (GMFM-88) (Dimensions D and E), and walking velocity.

Results

A decrease in spasticity was evident for the right, left, and bilateral lower extremities for both groups (p<0.05). There were no statistically significant differences in the MAS, PSFS, GMFM-88 (Dimensions D and E), and walking velocity between the groups.

Conclusion

Our study results showed that both patient groups benefited from the treatment and the administration of electrical stimulation to the gastrocnemius motor points produced no additional benefit for patients with SDCP.

Cerebral Palsy: An Overview

Cerebral palsy (CP) is a neurodevelopmental disorder characterized by abnormalities of muscle tone, movement and motor skills, and is attributed to injury to the developing brain. The clinical features of this entity evolve over time and the specific CP syndrome may be recognizable only after 3-5 y of age; although suggestive signs and symptoms may be present at an earlier age. The management involves neurological rehabilitation (addressing muscle tonal abnormalities, and devising physical and occupational therapies) and diagnosis and management of co-morbidities (including epilepsy, impairment of cognition, vision, hearing, and disturbances of growth and gastrointestinal function). The management, therefore, is multidisciplinary involving the treating physician working with a team of rehabilitation-, orthopedic-, psychologic-, and social care- providers.

Influence of Spinal Manipulation on Muscle Spasticity and Manual Dexterity in Participants With Cerebral Palsy: Randomized Controlled Trial

Objectives

The aim of this study was to investigate the short-term effects of spinal manipulation (SM) on wrist muscle spasticity and manual dexterity in participants with cerebral palsy (CP).

Methods

After baseline examination, 78 participants with spastic CP (7-18 years) without contractures or hyperkinetic syndrome were randomly allocated into 2 groups. The experimental group underwent SM to the cervical, thoracic, and lumbar spine, and the control group received sham SM. A second evaluation was performed 5 minutes postintervention. Wrist muscle spasticity was measured quantitatively with NeuroFlexor (Aggero MedTech AB, Solna, Sweden), a device assessing resistance to passive movements of different velocities. Between-group difference was calculated using the Mann-Whitney U test. Manual dexterity was evaluated by the Box and Block test.

Results

In the experimental group, muscle spasticity was reduced by 2.18 newton from median 5.53 with interquartile range 8.66 to median 3.35 newton with interquartile range 7.19; the difference was statistically significant (P = .002). In the control group, reduction in spasticity was negligible. The between-group difference in change of muscle spasticity was statistically significant (P = .034). Improvement of manual dexterity was not statistically significant (P = .28).

Conclusions

These findings suggest that SM may, in the short term, help to reduce spasticity in participants with CP. Long-term effects of SM on muscle spasticity have yet to be studied.

Hidden Medical Devices in the School Setting: What the School Nurse Needs to Know About the Safe Use of Baclofen Pumps

One of the "hidden" medical devices in the school setting is the baclofen pump, which is used for the treatment of spasticity. The goals of spasticity treatment are to decrease muscle tone, deformity, and pain in order to maximize function and ease of care for both child and caregiver. The use of an intrathecal baclofen pump, often for children with cerebral palsy, spinal cord injury, brain injury, or stroke, has been effective in spasticity treatment. It is important for school nurses to be aware of the safety implications associated with this type of device. The Specialized Health Needs Interagency Collaboration (SHNIC) program at the Kennedy Krieger Institute has complied education and materials that explain the use of baclofen pumps in children with spasticity and the role of the school nurse in providing staff training, developing emergency care plans, and creating a safe school environment for children with special health needs.

Serial Casting as an Adjunct to Botulinum Toxin Type A Treatment in Children With Cerebral Palsy and Spastic Paraparesis With Scissoring of the Lower Extremities

The purpose of this study was to examine whether combination therapy of serial casting and botulinum toxin type A injection can further enhance the effects of botulinum toxin type A in children with cerebral palsy with scissoring of both legs. This study was a prospective and randomized trial. The children were divided into 2 groups, one of which received serial casting after botulinum toxin type A (n = 40), and the other which only received botulinum toxin type A (n = 40). Serial casting started 3 weeks after the botulinum toxin type A. Both groups received physiotherapy. Groups were assessed at baseline then compared at 6 and 12 weeks following the intervention. Significant improvements in Gross Motor Function Measure-66 and Caregiver Health Questionnaire were recorded in both groups ( P < .001). The modified Ashworth scale improved significantly following botulinum toxin type A in the serial casting group ( P < .05), but not in botulinum toxin type A only group. These results suggest that serial casting after botulinum toxin type A can enhance the benefits of botulinum toxin type A in children with cerebral palsy.

Changes in Muscle Spasticity in Patients With Cerebral Palsy After Spinal Manipulation: Case Series

OBJECTIVE

The purpose of this case series was to report quantitative changes in wrist muscle spasticity in children with cerebral palsy after 1 spinal manipulation (SM) and a 2-week course of treatment.

METHODS

Twenty-nine patients, aged 7 to 18 years, with spastic forms of cerebral palsy and without fixed contracture of the wrist, were evaluated before initiation of treatment, after 1 SM, and at the end of a 2-week course of treatment. Along with daily SM, the program included physical therapy, massage, reflexotherapy, extremity joint mobilization, mechanotherapy, and rehabilitation computer games for 3 to 4 hours' duration. Spasticity of the wrist flexor was measured quantitatively using a Neuroflexor device, which calculates the neural component (NC) of muscle tone, representing true spasticity, and excluding nonneural components, caused by altered muscle properties: elasticity and viscosity.

RESULTS

Substantial decrease in spasticity was noted in all patient groups after SM. The average NC values decreased by 1.65 newtons (from 7.6 ± 6.2 to 5.9 ± 6.5) after 1 SM. Another slight decrease of 0.5 newtons was noted after a 2-week course of treatment. In the group of patients with minimal spasticity, the decrease in NC after the first SM was almost twofold-from 3.93 ± 2.9 to 2.01 ± 1.0. In cases of moderate spasticity, NC reduction was noted only after the 2-week course of intensive treatment.

CONCLUSIONS

In this sample of patients with cerebral palsy, a decrease in wrist muscle spasticity was noted after SM. Spasticity reduction was potentiated during the 2-week course of treatment.

Spastic Paralysis of the Elbow and Forearm

As the physiologic recovery period concludes, the patient is evaluated for surgical procedures that may rebalance muscle function and correct deformity. Upper extremity function is the product of complex and highly sophisticated mechanisms working in unison, and a careful, systematic preoperative evaluation is critical. A good function of the hand cannot be achieved without adequate position of the shoulder, elbow, forearm, and wrist. The goals of surgery must be practical and clearly understood by the patient and the family.

Botulinum Toxin in Pediatric Neurology: Switching Lanes From Death to Life

Botulinum neurotoxins are natural molecules produced by anaerobic spore-forming bacteria called Clostradium boltulinum. The toxin has a peculiar mechanism of action by preventing the release of acetylcholine from the presynaptic membrane. Consequently, it has been used in the treatment of various neurological conditions related to muscle hyperactivity and/or spasticity. Also, it has an impact on the autonomic nervous system by acting on smooth muscle, leading to its use in the management of pain syndromes. The use of botulinum toxin in children separate from adults has received very little attention in the literature. This review presents the current data on the use of botulinum neurotoxin to treat various neurological disorders in children.

Multidimensional outcome measure of selective dorsal rhizotomy in spastic cerebral palsy

BACKGROUND

One of the treatment option to reduce spasticity in cerebral palsy children is selective dorsal rhizotomy. Several studies have demonstrated short and long term improvements in gait and other activities after rhizotomy but this surgery still remains a controversial procedure and patient outcome indicators measures are not uniform.

AIMS

To describe our assessment and outcome evaluation protocol and to verify by this protocol short term results of rhizotomy.

METHODS

We recruited 9 cerebral palsy children (mean age 7.9 years ± 3.2) affected by mild to moderate spastic diplegia and operated by rhizotomy. Patients were studied preoperatively and at 12 months after surgery by the following clinical and instrumental measures correlated to the International Classification of Functioning: modified Ashworth Scale, passive Range of Motion, Medical Research Council Scale, Selective Motor Control Scale, 3D-motion analysis and energy cost of locomotion measurements (indicators of "body functions"); Gross Motor Functional Measure and Motor Functional Independence Measure (indicators of "activities and participation").

RESULTS

Our data showed, after rhizotomy, reduction of spasticity specially in plantarflexors muscles (p < 0.01), increase of strength of knee flexors/extensors and foot plantar/dorsiflexion muscles (p < 0.01), improvement of selective motor control (p < 0.05), more similar spatio-temporal parameters of gait analysis to healthy subjects, reduced equinus foot and knees hyperflexion as energy cost.

CONCLUSION

The complementary use of multiple indicators may improve the evaluation of the results of dorsal rhizotomy. A beneficial outcome measured by these indicators has been found in our spastic diplegic children one year after rhizotomy.

Indwelling intrathecal catheter with subcutaneous abdominal reservoir: a viable baclofen delivery system in severely cachectic patients

Intrathecal baclofen (ITB) is a reversible treatment that reduces muscle tone to ameliorate spasticity and dystonia in patients with cerebral palsy (CP). The resulting decrease in energy expenditure allows patients to gain much-needed weight, albeit temporarily. Modern techniques require sufficient abdominal musculature and subcutaneous fat to permit the implantation of an indwelling pump. In patients with extremely low muscle bulk, visceral pumps may be impractical or impossible, with increased risks of dehiscence and infection. The authors describe a variation of the classical procedure in a young patient with severe cachexia. A 10-year-old boy with spastic-dystonic quadriplegic CP was admitted to the neuromedical unit. Numerous drug trials had failed, and surgical intervention was deemed necessary but was complicated by his cachectic body habitus. The authors inserted a lumbar intrathecal catheter and subcutaneously tunneled it to the anterolateral abdomen, where it was connected to a subcutaneous injection port. Baclofen was continuously infused into the subcutaneous port using a noncoring needle connected to an external pump. The needle and line were changed every 5 days to minimize the risk of sepsis. Although other techniques, such as intraventricular baclofen delivery, have been described, these are largely dependent upon sufficient musculature to support a visceral pump. A subcutaneous injection port system represents an alternative approach that reduces the risk of sepsis and may be better tolerated in cachectic patients.

Pediatric palliative care for children with complex chronic medical conditions

Children with complex chronic medical conditions are at risk for significant distress during multiple points in their life. Pediatric palliative care can meaningfully assist in providing support to the child and family throughout their complex care, managing distressing symptoms, anticipating future decision points, and helping the child and family to thrive in their local community.

Effect of a trunk-targeted intervention using vibration on posture and gait in children with spastic type cerebral palsy: a randomized control trial

AIM

This study aimed to determine whether strengthening trunk muscles using vibration can improve posture and gait in children with spastic-type cerebral palsy (STCP).

METHODS

A total of 27 children (6-13 years) participated in a single-blinded pre-post crossover experimental trial. The 1-Minute Walk Test, 2D-posturography, ultrasound imaging and sit-ups in one minute were used to assess effect on gait, posture, resting abdominal muscle thickness and functional strength.

RESULTS

Significant increase in distance walked (p < 0.001), more upright posture, an increase in sit-ups executed (p < 0.001) and an increase in resting thicknesses of all the four abdominal muscles--transversus abdominis (p = 0.047), obliquus internus (p = 0.003), obliquus externus (p = 0.023) and the rectus abdominis (p = 0.001) was recorded. Strength and posture were maintained at 4-weeks post-intervention.

CONCLUSION

A trunk-targeted intervention using vibration can improve posture and gait in children with STCP without any known side effects. It is recommended that vibration and specific trunk strengthening is included in training or rehabilitation programmes. Effects of vibration on force generation and spasticity need further investigation.

Inflammatory, vascular, and infectious myelopathies in children

Acute nontraumatic myelopathies of childhood include inflammatory, infectious, and vascular etiologies. Inflammatory immune-mediated disorders of the spinal cord can be categorized as idiopathic isolated transverse myelitis, neuromyelitis optica, and multiple sclerosis. In recent years, human T-cell lymphotropic virus type 1, West Nile virus, enterovirus-71, and Lyme disease have been increasingly recognized as infectious etiologies of myelopathy, and poliomyelitis remains an important etiology in world regions where vaccination programs have not been universally available. Vascular etiologies include vasculopathies (systemic lupus erythematosus, small vessel primary angiitis of the central nervous system), arteriovenous malformations, and spinal cord infarction (fibrocartilaginous embolism, diffuse hypoxic ischemia-mediated infarction). Vascular myelopathies are less common than inflammatory and infectious myelopathies, but are more likely to lead to devastating clinical deficits. Current therapeutic strategies include acute anti-inflammatory treatment and rehabilitation. Stem cell transplantation, nerve graft implantation, and stimulation of endogenous repair mechanisms represent promising strategies for spinal cord repair.

Toxina botulínica e fisioterapia em crianças com paralisia cerebral espástica: revisão bibliográfica

INTRODUÇÃO: A paralisia cerebral (PC) é definida como uma condição neurológica não progressiva originada em razão de uma lesão no encéfalo imaturo que compromete os movimentos e a postura. A espasticidade está presente em 75% dos casos. Essa patologia tem incidência na população de aproximadamente 2 em cada 1.000 nascidos vivos e pode chegar a até 7 por 1.000 em países em desenvolvimento. O objetivo do estudo foi realizar uma revisão bibliográfica por meio da seleção e análise criteriosa de artigos científicos que relatem os efeitos da aplicação da toxina botulínica tipo A associada à fisioterapia em crianças com paralisia cerebral espástica. MATERIAIS E MÉTODOS: Foi realizada uma revisão bibliográfica nas bases de dados eletrônicas MEDLINE, LILACS e SciELO, no período de 1997 a 2009. Os descritores utilizados foram: "paralisia cerebral" e "espasticidade muscular", combinados com "toxina botulínica tipo A" e "fisioterapia". RESULTADOS: Somando-se todos os bancos de dados, um total de 50 artigos que continham os desfechos de interesse dessa revisão foram encontrados, no entanto, alguns artigos aparecem em mais de uma busca e em duplicidade de idioma. Então, 23 artigos foram utilizados neste estudo. DISCUSSÃO: Vários estudos demonstram que, para maior efetividade da toxina botulínica tipo A, esta deve ser associada a um programa fisioterapêutico que sempre deve considerar as etapas do desenvolvimento motor da criança. CONSIDERAÇÕES FINAIS: De acordo com a revisão bibliográfica apresentada, a TBA associada à fisioterapia para o controle da espasticidade se mostra bastante eficaz. Contudo, novas pesquisas acerca deste assunto são necessárias.

Assessment and treatment of movement disorders in children with cerebral palsy

Cerebral palsy is the most common motor disability in childhood. Orthopedic care depends on the appreciation and the identification of muscle tone abnormalities and how they affect growth and development of the child. Abnormal muscle tone is a common diagnostic feature of cerebral palsy and can include hypotonia or hypertonia. Hypertonia is the most frequent tone abnormality in children with cerebral palsy. This article reviews hypertonia and provides information on discriminating between spasticity, dystonia, and rigidity. Medication and neurosurgical options for the management of hypertonia are presented and compared.