Predicting the prevalence of cerebral palsy by severity level in children aged 3 to 15 years across England and Wales by 2020

A core outcome set for lower limb orthopaedic surgery for children with cerebral palsy: An international multi-stakeholder consensus study

AIM

To develop a core set of outcome domains to be measured in clinical studies on lower limb orthopaedic surgery for ambulant children with cerebral palsy (CP) that represents the priorities of an international multi-stakeholder group (children, parent/carers, and health professionals).

METHOD

Potential outcome domains were identified through literature review and qualitative interviews with key stakeholders. These were scored in an international two-round Delphi survey, using a 9-point Likert scale. A final consensus meeting with key stakeholders agreed on the most important outcome domains and refined the core outcome set (COS).

RESULTS

One hundred and sixty-one health professionals and 36 individuals with CP and their parents/carers rated 21 of 41 outcomes as important in the Delphi survey. The final consensus group agreed 19 outcomes within eight domains to be included in the final COS: pain and fatigue, lower limb structure, motor function, mobility (daily life activities), gait-related outcomes, physical activity, independence, and quality of life.

INTERPRETATION

A COS for lower limb orthopaedic surgery for children with CP was developed. Incorporating this in the design of future clinical studies will provide a more holistic assessment of the impact of treatment while allowing meaningful comparisons and future synthesis of results from primary studies.

WHAT THIS PAPER ADDS

Eight core outcome domains were identified as important to measure in future clinical research. Key stakeholders perceived pain, balance and fall, and independence as very important outcomes. Six contextual factors were identified as essential in surgical decision-making.

Exploring the factors that influence stakeholders' expectations and subsequent perception of lower limb orthopaedic surgical outcomes for ambulant children with cerebral palsy - a qualitative study

PURPOSE

To explore the perspectives of children with CP, their parents or carers, and health professionals on factors affecting expectations and perceptions of surgical outcomes for lower limb orthopaedic surgery.

MATERIALS AND METHODS

Semi-structured interviews were conducted with 10 healthcare professionals, 10 children and young people with CP, and 8 parents. Interview data were analysed by content analysis supported by the Framework Approach using the International Classification of Functioning, Disability, and Health (ICF-CY).

RESULTS

A comprehensive list of 10 factors including facilitators, barriers, motivational and demotivational factors were identified and categorized into two overreaching themes (Environmental and Personal factors): interdisciplinary collaboration, communication and information resources, holistic care, and shared goal setting are reported as environment facilitators of outcomes expectations. In contrast, reported barriers include lack of time and resources and divergent expectations. Personal motivators include family encouragement, patient's self-determination, and previous experiences, whereas personal demotivators include fear of a new environment.

CONCLUSION

The recognition of potential factors influencing expectations and perceptions of surgical outcomes could assist clinical reasoning when planning surgical interventions for ambulant children with CP. If these factors are integrated into the healthcare practice, it will most likely enhance the positive stakeholders' experiences postoperatively.IMPLICATION FOR REHABILITATIONUnderstanding relevant stakeholders' experiences offer a positive contribution to holistic and person-centred approaches in healthcare.People with cerebral palsy and their caregivers require adequate information on surgery and post-surgical rehabilitation regime in order to reach informed decisions.Previous experiences can influence surgical expectations and subsequent perceptions of the outcome.

Outcomes of importance to children and young adults with cerebral palsy, their parents and health professionals following lower limb orthopaedic surgery: A qualitative study to inform a Core Outcome Set

Introduction

Although several outcomes are commonly measured to assess the effect of surgery for young people with cerebral palsy (CP), these are selected mainly by health professionals and researchers. Including the perspectives of a broader range of stakeholders is an essential step towards determining important outcomes for assessment. This qualitative study involves the development of a core outcome set (COS) for lower limb orthopaedic surgery for ambulant children with CP.

Objective

This study aimed to identify outcomes that matter to children and young people with CP, their parents and healthcare professionals following lower limb orthopaedic surgery.

Methods

Semi‐structured interviews were conducted with 10 healthcare professionals, 10 children and young people with CP and 8 parents. Interview data were analysed by content analysis supported by the International Classification of Functioning, Disability and Health (ICF‐CY) supplemented by thematic analysis.

Findings

Thirty‐one outcomes were identified in total, which were linked to eleven second‐level ICF‐CY categories. There were differences between stakeholder groups in preferences and expectations from surgical outcomes. Healthcare professionals and children with their parents identified 31 and 25 outcomes, respectively. Health outcomes valued by participants were lower limb alignment and symmetry, flexibility and muscle strength, mental health, fatigue, pain, function in life, mobility, participation, being independent, quality of life and adverse events. Compared to previous published trials, 10 new outcomes were revealed by this study.

Conclusion

The researchers identified outcomes that are important to all stakeholders following lower limb orthopaedic surgery for ambulant CP. Including these outcomes in future studies would promote patient‐centred care for children and young adults with CP. Findings will be used to inform an international Delphi survey and develop a COS in this field.

Patient and Public Contribution

This study was informed by an advisory group including a young adult with CP and a parent of a child with CP. This group engaged in the design of the study and the information material to support the interview (information sheet and interview topic guide).

Optimization of an Intranasal Route for the Delivery of Human Neural Stem Cells to Treat a Neonatal Hypoxic-Ischemic Brain Injury Rat Model

OBJECTIVE

Stem cell administration via the intranasal route has shown promise as a new therapy for hypoxic-ischemic encephalopathy (HIE). In this study, we aimed to improve the intranasal delivery of stem cells to the brain.

METHODS

Human neural stem cells (hNSCs) were identified using immunofluorescence, morphological, and flow cytometry assays before transplantation, and cell migration capacity was examined using the transwell assay. Cerebral hypoxia-ischemia (HI) was induced in 7-day-old rats, followed by the intranasal transplantation of CM-Dil-labeled hNSCs. We examined various experimental conditions, including preconditioning hNSCs with hypoxia, catheter method, multiple low-dose transplantation, head position, cell appropriate concentration, and volume. Rats were sacrificed 1 or 3 days after the final intranasal administration, and parts of the nasal tissue and whole brain sections were analyzed under a fluorescence microscope.

RESULTS

The isolated hNSCs met the characteristics of neural stem cells. Hypoxia (5% O₂, 24 h) enhanced the surface expression of CXC chemokine receptor 4 (CXCR4) (9.21 ± 1.9% ~ 24.76 ± 2.24%, P < 0.01) on hNSCs and improved migration (toward stromal cell-derived factor 1 [SDF-1], 0.54 ± 0.11% ~ 8.65 ± 1.76%, P < 0.001; toward fetal bovine serum, 8.36 ± 0.81% ~ 21.74 ± 0.85%, P < 0.0001). Further improvement increased the number of surviving cell distribution with increased uniformity on the olfactory epithelium and allowed the cells to stay in the nasal cavity for at least 72 h, but they did not survive for longer than 48 h. Optimization of pre-transplantation conditions augmented the success rate of intranasally delivered cells to the brain (0-41.6%). We also tentatively identified that hNSCs crossed the olfactory epithelium into the tissue space below the lamina propria, with cerebrospinal fluid entering the cribriform plate into the subarachnoid space, and then migrated toward injured areas along the brain blood vessels.

CONCLUSION

This study offers some helpful advice and reference for addressing the problem of repeatability in the intranasal delivery of stem cells.

Long-term effect of botulinum toxin A on the hip and spine in cerebral palsy: A national retrospective cohort study in Taiwan

Objectives

To investigate the effect of botulinum toxin A (BTA) on the development of hip dislocation and scoliosis, surgical rates for hip and spine, and mortality in cerebral palsy (CP).

Study design

A cohort study was conducted using CP data from a Taiwan National Insurance Health Research Database. Diagnoses were defined using the International Classification of Diseases codes, 9th revision. Adjusted hazard ratios for outcomes were calculated using Cox regression analysis and adjusted for the following variables: BTA injection, sex, age, severities of CP, comorbidities, location, urbanization level, and level of care.

Results

A total of 1,405 CP children (670 female vs. 735 male), 281 in the BTA group and 1,124 in the controls, were followed-up for a mean of 5 years 4 months. There were no significant differences in the outcomes in both groups, in the incidence rates of hip dislocation and scoliosis, nor in the surgical rates for hip and spine surgery. Mortality rate in the BTA group was 0.49 times lower than that in the controls (p = 0.001). Moderate to severe types of CP had higher incidence rates of hip dislocation, scoliosis, hip surgery, spine surgery, and mortality.

Conclusion

Moderate to severe types of CP had poorer outcomes in all aspects, including a higher risk of hip dislocation, scoliosis, surgical rate for hip and spine, and mortality. Although BTA injection in children with CP proved to not significantly reduce hip dislocation and scoliosis, it is considered safe as an anti-spasticity treatment and may be beneficial for survival.

Healthcare use by children and young adults with cerebral palsy

AIM

To link routinely collected health data to a cerebral palsy (CP) register in order to enable analysis of healthcare use by severity of CP.

METHOD

The Northern Ireland Cerebral Palsy Register was linked to hospital data. Data for those on the CP register born between 1st January 1981 and 31st December 2009 and alive in 2004 were extracted, forming a CP cohort (n=1684; 57% males, 43% females; aged 0-24y). Frequencies of healthcare events, and the reasons for them, were reported according to CP severity and compared with those without CP who had had at least one hospital attendance in Northern Ireland within the study period.

RESULTS

Cases of CP represented 0.3% of the Northern Ireland population aged 0 to 24 years but accounted for 1.6% of hospital admissions and 1.6% of outpatient appointments. They had higher rates of elective admissions and multi-day hospital stays than the general population. Respiratory conditions were the most common reason for emergency admissions. Those with most severe CP were 10 times more likely to be admitted, and four times more likely to attend outpatients, than those with mild CP.

INTERPRETATION

Linkage between a register and routinely collected healthcare data provided a confirmed cohort of cases of CP that was sufficiently detailed to analyse healthcare use by disease severity.

Patients' and parents' views about lower limb orthopaedic surgery for ambulant children and young people with cerebral palsy: a qualitative evidence synthesis

PURPOSE

The article identifies the aspects of health and outcomes that are considered important from the perspective of ambulatory children with cerebral palsy (CP) and their parents regarding lower limb orthopaedic surgery and explores how they experience surgical interventions.

METHODS

Four databases (Embase, MEDLINE (Ovid), CINAHL and PsycINFO) were searched from inception to 11 April 2020. Studies were included if they: 1) they involved children or young adults diagnosed with ambulant CP or their family, 2) participants had experience with lower limb orthopaedic surgery and 3) studies employed qualitative research methods. The Critical Appraisal Skills Programme was used to appraise identified studies. The 'Best-fit framework' synthesis approach was used by applying the International Classification of Functioning-Children and Youth (ICF-CY) linking rules and thematic synthesis. The review process was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

RESULTS

Six studies were included. Four themes were generated which were linked to the ICF-CY framework: Body function and structure, Activity and participation, Environmental factors, Personal factors, as well as non-ICF-CY themes including Emotional well-being and Goal setting. Important surgical outcomes identified were pain, fatigue, movement-related function, mobility, walking ability, community life, emotional well-being, and adequate provision of public and health services.

CONCLUSION

These findings are important for understanding patient-centred outcomes in lower limb ortho-paedics surgery and providing focus for future interventional studies aimed at improving outcomes of importance to children with CP. These findings highlight the importance of long-term support to help people negotiate the challenge of surgical regimes and to achieve good outcomes after orthopaedic surgery. The outcomes identified will contribute to the development of a core outcome set in this field.

LEVEL OF EVIDENCE

III.

Outcome domains and measures after lower limb orthopaedic surgery for ambulant children with cerebral palsy: an updated scoping review

AIM

To determine the reported outcome domains and measures used to assess lower limb orthopaedic surgery of ambulant children and young people with cerebral palsy (CP) and map these outcomes to the International Classification of Functioning, Disability and Health - Children and Youth (ICF-CY) framework.

METHOD

This updated scoping review included studies published between January 2016 and July 2019 in five databases: MEDLINE, PubMed, EMBASE, CINAHL, and the Cochrane Central Register of Controlled Trials. Studies were included if participants were ambulant individuals with CP aged between 0 and 20 years who had undergone lower limb orthopaedic surgery. Health outcome domains and measures were identified and classified using the ICF-CY framework.

RESULTS

Forty-four eligible studies were identified with a total of 40 different outcome domains recorded. Among eligible studies, 44 (100%) measured body function and structural impairment and seven (16%) measured activity limitation and participation restriction. The most frequently reported outcome was gait pattern (n=37, 84%). Few studies reported adverse effects of surgery (n=13, 30%). Twenty-nine different outcome measures were identified. Patient-reported outcomes measures were used in 10 studies (23%).

INTERPRETATION

The review highlights a heterogeneity in the reported outcome domains and measures used in CP studies. The majority of the reported outcomes focus on the ICF-CY domain of body function and structure. The review also highlights a notable shift towards patient-reported outcomes in recent years. Development of a core outcome set for lower limb orthopaedic surgery would guide researchers to use more consistent and complete measurement sets.

Development of a core outcome set for lower limb orthopaedic surgical interventions in ambulant children and young people with cerebral palsy: a study protocol

INTRODUCTION

Musculoskeletal deformities and gait deviations are common features in ambulatory cerebral palsy (CP). Deformity correction through lower limb orthopaedic surgery is the standard form of care aimed at improving or preserving motor function. Current research on CP care does not always take into account individual patients' expectations and needs. There is a wide range of outcome domains and outcome measures used to assess outcome from treatment. This can lead to reporting bias and make it difficult to compare and contrast studies. A core outcome set (COS) would enhance the efficiency, relevance and overall quality of CP orthopaedic surgery research. The aim of this study is to establish a standardised COS for use in evaluating lower limb orthopaedic surgery for ambulatory children and young people with CP.

METHODS/ANALYSIS

A set of outcomes domains and outcome measures will be developed as follows: (1) a qualitative evidence synthesis to identify relevant outcomes from children and young people and family perspective; (2) a scoping review to identify relevant outcomes and outcome measures; (3) qualitative research to explore the experience of key stakeholders; (4) prioritisation of outcome domains will be achieved through a two-round Delphi process with key stakeholders; (5) a final COS will be developed at a consensus meeting with representation from key stakeholder groups.

ETHICS AND DISSEMINATION

Ethical approval for this study was granted in the UK by the Oxfordshire Research Ethics Committee B (REC reference 19/SC/0357). Informed consent will be obtained from participants taking part in the qualitative research and Delphi process. Study findings will be published in an open access journal and presented at relevant national and international conferences. Charities and associations will be engaged to promote awareness of the project COS results.

TRIAL REGISTRATION NUMBER

COMET registration: 1236.

PROSPERO REGISTRATION NUMBER

CRD42018089538.

Identifying cerebral palsy from routinely-collected data in England and Wales

Purpose: An observational study using routinely-collected health care data to describe the extent to which children and young people (CYP) with cerebral palsy (CP) can be identified and the prevalence of CP can be estimated.

Patients and methods: Routinely-collected anonymized data, for CYP (aged 0–25 years old between 1 January 2004 and 31 December 2014) were analyzed in two linked datasets, from England and Wales respectively. Datasets included National Health Service; General Practitioner (GP), inpatients, outpatients, and national mortality records. CP was identified using ICD-10 codes G80.0–G83.3 and equivalent Read v2 codes. Ascertainment rates of CP were identified for each data source and compared between countries. Frequency and consistency of coding were investigated, and prevalence of CP estimated.

Results: A total of 7,113 and 5,218 CYP with CP were identified in the English and Welsh datasets respectively. Whilst the majority of CYP with CP would be expected to attend their GP, 65.3% (4,646/7,113) of English and 65.1% (3,396/5,218) of Welsh cases were ascertained from GP datasets. Further cases were identified solely in inpatient datasets (2,410 in England, 1,813 in Wales). Few cases were coded for CP within outpatient datasets. Four character codes that specified CP type were rarely used; one in five health care records were coded both with G80 codes (explicitly CP) and with G81–83 codes (other paralytic syndromes) or equivalent Read codes. Estimated period prevalence of CYP with CP was 2.5–3.4 per 1,000 in England and 2.4–3.2 per 1,000 in Wales.

Conclusion: In England and Wales, coding of CP in routine data is infrequent, inconsistent, non-specific, and difficult to isolate from conditions with similar physical signs. Yet the prevalence estimates of CP were similar to those reported elsewhere. To optimize case recognition we recommend improved coding quality and the use of both primary and secondary care datasets as a minimum.

The risk, burden, and management of non-communicable diseases in cerebral palsy: a scoping review

AIM

To examine the risk, burden, and management of non-communicable diseases (NCDs) among people with cerebral palsy (CP).

METHOD

Databases (Ovid MEDLINE, Embase Ovid, CINAHL Plus) were systematically searched up to August 2017. Data on the prevalence of risk factors for, and the burden and management of, cardiovascular diseases, diabetes, cancers, and respiratory diseases were extracted.

RESULTS

Thirty-six studies that examined the prevalence of risk factors among people with CP were identified. There was inconsistent evidence that people with CP had higher prevalence of metabolic risk factors such as hypertension, hyperlipidaemia, and obesity, but strong evidence that they participated in low levels of physical activity, compared with people without CP. Seven studies reported on the burden of NCDs. Adults with CP had a higher risk of NCDs, including stroke, chronic obstructive pulmonary disease, and other heart conditions, and death due to NCDs, including cancers, chronic obstructive pulmonary disease, stroke, and ischaemic heart disease, compared with the general population. Only one study reported on the management of NCD, specifically the uptake of breast cancer screening among females.

INTERPRETATION

The burden of NCDs is higher among adults with CP compared with the general population. Further research is required to determine the prevalence of metabolic risk factors and management of NCDs among people with CP.

WHAT THIS PAPER ADDS

Adults with cerebral palsy (CP) have an increased risk of non-communicable diseases (NCDs) and increased risk of death because of NCDs. Evidence is inconsistent about the elevated prevalence of metabolic risk factors for NCDs. Evidence is consistent that people with CP participate in reduced physical activity. Only one study reported on management of NCD among people with CP. Available evidence suggests people with CP are less likely to receive preventive medicine.

Seasonal Variations in Cerebral Palsy Births

INTRODUCTION

Previous studies of cerebral palsy (CP) suggest that it seasonal variations in the incidence of CP. The purpose of this paper was to compare seasonal variations in the incidence of cerebral palsy (CP) in Podlaskie Province, Poland, between 1990-1999 (study 2005) and 2000-2014 (study 2017) in a retrospective case-controlled study.

MATERIALS AND METHODS

Data were obtained from the hospital database. We compared CP births between January 1, 1990, and December 31, 1999, n = 212 (116 boys, 96 girls) and January 1, 2000, and December 31, 2014, n = 205 (114 boys, 91 girls). We used Cosinor analysis to examine the seasonality of CP births.

RESULTS

The highest number of CP births occurred in spring and the lowest in winter, with intermediate values in summer and autumn. This seasonal pattern was significant for spring vs. winter. The peaks in the numbers of CP births occurred in May and August; the lowest numbers of CP births occurred in February, December, and November. In the 2017 study, we observed a slight increase in spastic tetraplegia and a decrease in mixed CP. No significant corrections between mean temperature and Apgar score, low birth weight, and asphyxia were found.

CONCLUSIONS

Our study confirmed the existence of seasonal patterns for CP births.

The impact of neurological disorders on hospital admissions for children and young people: a routine health data study

Introduction

Neurological conditions are a major and increasing cause of hospitalisation among children and young people, but little is known about the impact of neurological conditions on hospital services in England, nor the factors that influence length of stay and bed days per year.

Objectives

To quantify the hospital usage in children and young people related to neurological conditions, trends over time and variation by ethnicity and deprivation status.

Methods

An ICD10 coding framework identified a cohort of individuals aged 0-19 years with neurological conditions from linked routinely collected healthcare data from England (The Hospital Episode Statistics Admitted Patient Care dataset), from 1 April 2003 to 31 March 2015. Linked outpatient and accident and emergency data were used to supplement missing demographic data. Length of stay and bed days per year per person were calculated. These were separately modelled using random intercept multivariable negative binomial regressions with gender, age, ethnic group, diagnostic group, region of residence and deprivation category as predictors.

Results

524,442 individuals were identified over the study period, increasing from 49,928 in 2003/04 to 102,840 in 2014/15. Neurological conditions account for 8.8% of inpatient bed days in the 0-14 year old age group. Length of stay and bed days per year vary primarily by age group - e.g. Under 1 year olds had 1.85 times (95%CI 1.83-1.86%) longer stays and over double (2.36 times, 95%CI 2.34-2.37 times) the number of bed days per person per year compared to 5 to 9 year olds - and main diagnostic group, with smaller variations by ethnic group, deprivation and region.

Conclusions

Neurological conditions in children and young people have a significant and increasing impact on the NHS in England. Falls in length of stay and bed days per person are more than offset by increasing numbers of children and young people with neurological diagnoses. Variations in length of stay and bed days per year by diagnostic group, ethnic group, age group, deprivation category and region should be taken into account in resource planning.

Future perspectives of cell therapy for neonatal hypoxic-ischemic encephalopathy

Neonatal ischemic brain injury causes permanent motor-deficit cerebral palsy. Hypoxic-ischemic encephalopathy (HIE) is a very serious condition that can result in death and disability. In 1997, we reported that irreversible neuronal cell damage is induced by the elevation of intracellular Ca ion concentration that has occurred in sequence after excess accumulation of the excitatory neurotransmitter glutamate during ischemia. We also reported that hypothermia was effective in treating ischemic brain damage in rats by suppressing energy loss and raising intracellular Ca ion concentration. Following the 2010 revised International Liaison Committee on Resuscitation guideline, our group developed the Guideline for the treatment of Hypothermia in Japan, and we started online case registry in January 2012. However, therapeutic hypothermia must be initiated within the first 6 h after birth. By contrast, cell therapy may have a much longer therapeutic time window because it might reduce apoptosis/oxidative stress and enhance the regenerative process. In 2014, we administered autologous umbilical cord blood stem cell (UCBC) therapy for neonatal HIE, for the first time in Japan. We enrolled five full-term newborns with moderate-to-severe HIE. Our autologous UCBC therapy is leading to new protocols for the prevention of ischemic brain damage.