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Saranti A, Dragoumi P, Papavasiliou A, Zafeiriou D. Current approach to cerebral palsy. Eur J Paediatr Neurol 2024; 51:49-57. [PMID: 38824721 DOI: 10.1016/j.ejpn.2024.05.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2024] [Revised: 05/26/2024] [Accepted: 05/28/2024] [Indexed: 06/04/2024]
Abstract
This teaching review aims to provide an overview of the current approach to children with cerebral palsy (CP), retrieving the best available evidence and summarizing existing knowledge in the field of CP in children. We also highlight areas where more research is needed and novel strategies for diagnosing and treating cerebral palsy. CP includes a group of permanent disorders of movement and posture that cause activity limitation. Multiple risk factors, occurring preconceptionally, prenatally, perinatally, or postneonatally, are involved in the pathogenesis of CP, with the prenatal ones accounting for 80-90 % of cases. Due to its heterogeneity, CP has various classifications, but usually is classified based on clinical findings and motor impairment. Standardized function classification systems have been developed to address inconsistencies in previous classifications. The combination of clinical assessment and validated predictive tools is recommended for an early diagnosis, which is important for early intervention and prevention of secondary impairments. The therapeutic regimen in CP involves prevention and management of the motor and associated problems. It includes the enhancement of motor performance, the enrichment of cognition and communication skills, the prevention of secondary impairments, and the support of parents and caregivers. The care of CP children demands a multidisciplinary approach focused on improving motor skills, reducing comorbidities, enhancing the quality of life, and prolonging survival.
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Affiliation(s)
- Anna Saranti
- 1th Department of Pediatrics, Aristotle University of Thessaloniki, G. Hippokration Hospital, Thessaloniki, Greece
| | - Pinelopi Dragoumi
- 1th Department of Pediatrics, Aristotle University of Thessaloniki, G. Hippokration Hospital, Thessaloniki, Greece
| | | | - Dimitrios Zafeiriou
- 1th Department of Pediatrics, Aristotle University of Thessaloniki, G. Hippokration Hospital, Thessaloniki, Greece.
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van Dijk LMM, van Zwol A, Buizer AI, van de Pol LA, Slot KM, de Wildt SN, Bonouvrié LA. Potentially Life-Threatening Interaction between Opioids and Intrathecal Baclofen in Individuals with a Childhood-Onset Neurological Disorder: A Case Series and Review of the Literature. Neuropediatrics 2024. [PMID: 38776978 DOI: 10.1055/s-0044-1787103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/25/2024]
Abstract
BACKGROUND Spasticity and dystonia are movement impairments that can occur in childhood-onset neurological disorders. Severely affected individuals can be treated with intrathecal baclofen (ITB). Concomitant use of ITB and opioids has been associated with central nervous system (CNS) depression. This study aims to describe the clinical management of this interaction, based on a case series and review of literature. METHODS Four individuals with childhood-onset CNS disorders (age 8-24) and CNS-depressant overdose symptoms after the concomitant use of ITB and opioids are described. The Drug Interaction Probability Scale (DIPS) was calculated to assess the cause-relationship (doubtful <2, possible 2-4, probable 5-8, and highly probable >8) of the potential drug-drug interaction. A literature review of similar previously reported cases and the possible pharmacological mechanisms of opioid-baclofen interaction is provided. RESULTS After ITB and opioid co-administration, three out of four patients had decreased consciousness, and three developed respiratory depression. DIPS scores indicated a possible cause-relationship in one patient (DIPS: 4) and a probable cause-relationship in the others (DIPS: 6, 6, and 8). Discontinuation or adjusting ITB or opioid dosages resulted in clinical recovery. All patients recovered completely. In the literature, two articles describing nine unique cases were found. CONCLUSION Although the opioid-ITB interaction is incompletely understood, concomitant use may enhance the risk of symptoms of CNS-depressant overdose, which are potentially life-threatening. If concomitant use is desirable, we strongly recommend to closely monitor these patients to detect interaction symptoms early. Awareness and monitoring of the potential opioid-ITB interaction is essential to reduce the risk of severe complications.
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Affiliation(s)
- Liza M M van Dijk
- Department of Rehabilitation Medicine, Amsterdam University Medical Centers, Location Vrije Universiteit, Amsterdam, the Netherlands
- Amsterdam Movement Sciences, Rehabilitation & Development, Amsterdam, The Netherlands
| | - Annelies van Zwol
- Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Annemieke I Buizer
- Department of Rehabilitation Medicine, Amsterdam University Medical Centers, Location Vrije Universiteit, Amsterdam, the Netherlands
- Amsterdam Movement Sciences, Rehabilitation & Development, Amsterdam, The Netherlands
- Emma Children's Hospital, Amsterdam University Medical Centers, Location University of Amsterdam, Amsterdam, The Netherlands
| | - Laura A van de Pol
- Department of Child Neurology, Amsterdam University Medical Centers, Location Vrije Universiteit, Amsterdam, The Netherlands
| | - K Mariam Slot
- Department of Neurosurgery, Amsterdam University Medical Centers, Location University of Amsterdam, Amsterdam, The Netherlands
- Brain Tumor Center Amsterdam, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Saskia N de Wildt
- Division of Pharmacology and Toxicology, Department of Pharmacy, Radboud University Medical Center, Nijmegen, The Netherlands
- Department of Neonatal and Pediatric Intensive Care, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Laura A Bonouvrié
- Department of Rehabilitation Medicine, Amsterdam University Medical Centers, Location Vrije Universiteit, Amsterdam, the Netherlands
- Amsterdam Movement Sciences, Rehabilitation & Development, Amsterdam, The Netherlands
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Niedzwecki C, Barbuto A, Mitchell K, Wirt S, Seymour M, Thomas S, Schwabe A. Comparison of outcomes following surgical intervention and inpatient rehabilitation stays in children with cerebral palsy. PM R 2024; 16:449-461. [PMID: 37801614 DOI: 10.1002/pmrj.13075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Revised: 07/28/2023] [Accepted: 09/01/2023] [Indexed: 10/08/2023]
Abstract
INTRODUCTION Literature is limited on functional outcomes in children with cerebral palsy (CP) following surgical procedures and a subsequent inpatient rehabilitation unit (IRU) stay. OBJECTIVE To compare functional outcomes and length of stay (LOS) in children with CP following a surgical procedure and IRU stay based on the surgical procedure performed, pattern of involvement, etiology, and Gross Motor Function Classification System (GMFCS) level. DESIGN Retrospective cohort study. SETTING Tertiary care pediatrics. PARTICIPANTS Pediatric patients with CP who underwent one of three surgical procedures followed by an IRU stay. INTERVENTIONS Selective dorsal rhizotomy (SDR), single-event multilevel orthopedic surgery (SEMLS), or intrathecal baclofen (ITB) pump implantation and subsequent IRU stay. MAIN OUTCOME MEASURES IRU LOS, Functional Independence Measure for Children (WeeFIM) total score, sub-scores, and efficiency. RESULTS Children undergoing SDR had a longer LOS (p ≤ .015). Children with spastic diplegia, GMFCS level II, and prematurity-based CP had higher WeeFIM efficiency scores (p ≤ .046, ≤.021, and .034 respectively). Greater changes in WeeFIM™ scores were associated with spastic diplegia, SDR, GMFCS level II, longer LOS, and higher admission scores (p ≤ .045). CONCLUSIONS Although statistically and functionally significant improvements in children with CP following surgical interventions and an IRU stay were seen, those with higher WeeFIM change scores tended to have spastic diplegia, to have undergone SDR, GMFCS level II, longer LOS, and higher admission scores.
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Affiliation(s)
- Christian Niedzwecki
- Department of Physical Medicine & Rehabilitation, Baylor College of Medicine, Houston, Texas, USA
| | - Amy Barbuto
- Department of Physical and Occupational Therapy, Texas Children's Hospital-The Woodlands, The Woodlands, Texas, USA
| | - Katy Mitchell
- Department of Physical Therapy, Texas Woman's University-Houston, Houston, Texas, USA
| | - Steven Wirt
- Department of Physical and Occupational Therapy, Texas Children's Hospital-Main Campus, Houston, Texas, USA
| | - Michelle Seymour
- Department of Physical Medicine & Rehabilitation, Baylor College of Medicine, Houston, Texas, USA
| | - Sruthi Thomas
- Departments of Physical Medicine & Rehabilitation and Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
| | - Aloysia Schwabe
- Department of Physical Medicine & Rehabilitation, Baylor College of Medicine, Houston, Texas, USA
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van de Pol LA, Burgert N, van Schie PEM, Slot KM, Gouw AA, Buizer AI. Surgical treatment options for spasticity in children and adolescents with hereditary spastic paraplegia. Childs Nerv Syst 2024; 40:855-861. [PMID: 37783799 PMCID: PMC10891194 DOI: 10.1007/s00381-023-06159-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 09/15/2023] [Indexed: 10/04/2023]
Abstract
PURPOSE To provide an overview of outcome and complications of selective dorsal rhizotomy (SDR) and intrathecal baclofen pump implantation (ITB) for spasticity treatment in children with hereditary spastic paraplegia (HSP). METHODS Retrospective study including children with HSP and SDR or ITB. Gross motor function measure (GMFM-66) scores and level of spasticity were assessed. RESULTS Ten patients were included (most had mutations in ATL1 (n = 4) or SPAST (n = 3) genes). Four walked without and two with walking aids, four were non-walking children. Six patients underwent SDR, three patients ITB, and one both. Mean age at surgery was 8.9 ± 4.5 years with a mean follow-up of 3.4 ± 2.2 years. Five of the SDR patients were walking. Postoperatively spasticity in the legs was reduced in all patients. The change in GMFM-66 score was + 8.0 (0-19.7 min-max). The three ITB patients treated (SPAST (n = 2) and PNPLA6 (n = 1) gene mutation) were children with a progressive disease course. No complications of surgery occurred. CONCLUSIONS SDR is a feasible treatment option in carefully selected children with HSP, especially in walking patients. The majority of patients benefit with respect to gross motor function, complication risk is low. ITB was used in children with severe and progressive disease.
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Affiliation(s)
- Laura A van de Pol
- Department of Child Neurology, Amsterdam UMC, Vrije Universiteit, De Boelelaan 1117, Amsterdam, The Netherlands.
- Emma Children's Hospital, Amsterdam UMC, Meibergdreef 9, Amsterdam, The Netherlands.
| | - Nina Burgert
- Department of Rehabilitation Medicine, Amsterdam, UMC , Vrije Universiteit, De Boelelaan 1117, Amsterdam, The Netherlands
| | - Petra E M van Schie
- Department of Rehabilitation Medicine, Amsterdam, UMC , Vrije Universiteit, De Boelelaan 1117, Amsterdam, The Netherlands
| | - K Mariam Slot
- Department of Neurosurgery, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
| | - Alida A Gouw
- Department of Neurology & Clinical Neurophysiology, Amsterdam Neuroscience, Amsterdam UMC, VU University Medical Center, De Boelelaan 1117, Amsterdam, The Netherlands
| | - Annemieke I Buizer
- Emma Children's Hospital, Amsterdam UMC, Meibergdreef 9, Amsterdam, The Netherlands
- Department of Rehabilitation Medicine, Amsterdam, UMC , Vrije Universiteit, De Boelelaan 1117, Amsterdam, The Netherlands
- Rehabilitation and Development, Amsterdam Movement Sciences, Amsterdam, The Netherlands
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Pavanello M, Ronchetti A, Barretta I, Moretti P, Piatelli G. Calcification of the pump pouch in patients receiving ITB therapy: A rare complication affecting refill procedure - Analysis of two cases. Clin Neurol Neurosurg 2023; 233:107949. [PMID: 37703618 DOI: 10.1016/j.clineuro.2023.107949] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2023] [Revised: 08/20/2023] [Accepted: 08/22/2023] [Indexed: 09/15/2023]
Abstract
BACKGROUND Intrathecal baclofen therapy (ITB) is an effective treatment for reducing spasticity but can be associated with various complications, including infection and implant malfunction. METHODS This retrospective cohort study analyzed refill reports, complications, and functional outcomes in 40 consecutive patients with intractable spasticity or dystonia undergoing ITB. RESULTS Among the 40 patients, 8 experienced complications, including two cases of calcification of the baclofen pump pouch and surrounding tissue, a rare complication not extensively described in the literature. DISCUSSION Calcification, in addition to port access difficulties, could lead to drug delivery failure. We hypothesize that calcification may result from microtrauma or needlestick injury to the subcutaneous tissue and muscle fascia. The length of time the pump stays in the pocket could also contribute to favoring this phenomenon. CONCLUSION As the number of patients receiving ITB increases, physicians must be aware of potential life-threatening complications. The risk of pouch calcification should be further investigated and considered in managing patients undergoing ITB, as it could significantly impact patient care.
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Affiliation(s)
- Marco Pavanello
- Department of Neurosurgery, IRCCS Istituto Giannina Gaslini, Via G. Gaslini, 5, 16147 Genoa, Italy
| | - Anna Ronchetti
- Physical Medicine and Rehabilitation Unit, IRCCS Istituto Giannina Gaslini, Via G. Gaslini, 5, 16147 Genoa, Italy
| | - Ida Barretta
- Pediatric Surgery Unit, IRCCS Istituto Giannina Gaslini, Via G. Gaslini, 5, 16147 Genoa, Italy; University of Genoa, DINOGMI, Genoa, Italy.
| | - Paolo Moretti
- Physical Medicine and Rehabilitation Unit, IRCCS Istituto Giannina Gaslini, Via G. Gaslini, 5, 16147 Genoa, Italy
| | - Gianluca Piatelli
- Department of Neurosurgery, IRCCS Istituto Giannina Gaslini, Via G. Gaslini, 5, 16147 Genoa, Italy
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Asma A, Ulusaloglu AC, Howard JJ, Rogers KJ, McManus M, Miller F, Shrader MW. Does intrathecal baclofen therapy decrease the progression of hip displacement in young patients with cerebral palsy? Dev Med Child Neurol 2023; 65:1112-1117. [PMID: 36649172 DOI: 10.1111/dmcn.15509] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Revised: 07/11/2022] [Accepted: 12/10/2022] [Indexed: 01/18/2023]
Abstract
AIM To evaluate the effects of intrathecal baclofen pump (ITBP) therapy on hip dysplasia in young patients with cerebral palsy (CP). METHOD This was a retrospective cohort series of prospectively collected data. Inclusion criteria were all patients with CP in Gross Motor Function Classification System (GMFCS) levels IV or V who underwent ITBP placement under 8 years old with at least 5 years of follow-up. Thirty-four patients were matched to a control group of 71 patients based on GMFCS level, motor type, medical comorbidities, worst hip migration percentage at ITBP placement, age, and Modified Ashworth scale scores. Patients were followed for at least 5 years or until they had hip reconstructive surgery. The primary outcome was the development of hip displacement as measured by the migration percentage at the latest follow-up or the preoperative migration percentage before hip reconstruction. RESULTS The migration percentage at last follow-up was not statistically different between groups (ITBP: 36.2%, non-ITBP: 44.4%, p = 0.14). The rates of future preventative, reconstructive, and recurrent hip surgery were not different between groups. INTERPRETATION The use of ITBP as an early treatment of spasticity did not alter the natural history of progressive hip displacement in non-ambulatory patients with CP and hip displacement is likely multifactorial, not solely due to spasticity.
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Affiliation(s)
- Ali Asma
- Department of Orthopedic Surgery, Nemours Children's Health, Delaware, USA
| | | | - Jason J Howard
- Department of Orthopedic Surgery, Nemours Children's Health, Delaware, USA
| | - Kenneth J Rogers
- Department of Orthopedic Surgery, Nemours Children's Health, Delaware, USA
| | - Maura McManus
- Division of Physical Medicine and Rehabilitation, Nemours Children's Health, Delaware, USA
| | - Freeman Miller
- Department of Orthopedic Surgery, Nemours Children's Health, Delaware, USA
| | - M Wade Shrader
- Department of Orthopedic Surgery, Nemours Children's Health, Delaware, USA
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Dekopov AV, Tomsky AA, Isagulyan ED. [Methods and results of neurosurgical treatment of cerebral palsy]. ZHURNAL VOPROSY NEIROKHIRURGII IMENI N. N. BURDENKO 2023; 87:106-112. [PMID: 37325833 DOI: 10.17116/neiro202387031106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
Treatment of spastic syndrome and muscular dystonia in patients with cerebral palsy is a complex clinical problem. Effectiveness of conservative treatment is not high enough. Modern neurosurgical techniques for spastic syndrome and dystonia are divided into destructive interventions and surgical neuromodulation. Their effectiveness is different and depends on the form of disease, severity of motor disorders and age of patients. OBJECTIVE To evaluate the effectiveness of various methods of neurosurgical treatment of spasticity and muscular dystonia in patients with cerebral palsy. MATERIAL AND METHODS We To evaluate the effectiveness of various methods of neurosurgical treatment of spasticity and muscular dystonia in patients with cerebral palsy.analyzed literature data in the PubMed database using the keywords «cerebral palsy», «spasticity», «dystonia», «selective dorsal rhizotomy», «selective neurotomy», «intrathecal baclofen therapy», «spinal cord stimulation», «deep brain stimulation». RESULTS Effectiveness of neurosurgery was higher for spastic forms of cerebral palsy compared to secondary muscular dystonia. Destructive procedures were the most effective among neurosurgical operations for spastic forms. Effectiveness of chronic intrathecal baclofen therapy decreases in follow-up due to secondary drug resistance. Destructive stereotaxic interventions and deep brain stimulation are used for secondary muscular dystonia. Effectiveness of these procedures is low. CONCLUSION Neurosurgical methods can partially reduce severity of motor disorders and expand the possibilities of rehabilitation in patients with cerebral palsy.
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Affiliation(s)
- A V Dekopov
- Burdenko Neurosurgical Center, Moscow, Russia
| | - A A Tomsky
- Burdenko Neurosurgical Center, Moscow, Russia
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HarnEnz Z, Vermilion P, Foster-Barber A, Treat L. Pediatric neuropalliative care. HANDBOOK OF CLINICAL NEUROLOGY 2023; 191:157-184. [PMID: 36599507 DOI: 10.1016/b978-0-12-824535-4.00015-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Pediatric palliative care seeks to support quality of life for children and families affected by serious illness. Children with neurological disease are among the most frequent recipients of pediatric palliative care. Several important elements distinguish pediatric palliative care from adult practice, including a longer illness duration, longitudinal relationships over the span of years, diseases characterized by chronic fragility rather than progressive pathology, and the reliance on parents as proxy decision makers. This chapter will provide an overview of pediatric neuropalliative care, with emphasis on the types of disease trajectories, symptom management, and communication principles for supporting shared decision making with families. The role of neurology expertise is highlighted throughout, with special attention toward incorporating palliative care into pediatric neurology practice.
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Affiliation(s)
- Zoe HarnEnz
- Department of Neurology, University of California San Francisco, San Francisco, CA, United States
| | - Paul Vermilion
- Department of Medicine, University of Rochester, Rochester, NY, United States
| | - Audrey Foster-Barber
- Department of Neurology, University of California San Francisco, San Francisco, CA, United States
| | - Lauren Treat
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, United States.
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Asma A, Ulusaloglu AC, Howard JJ, Rogers KJ, Miller F, Shrader MW. Does the Addition of Intrathecal Baclofen Along with or After Soft-Tissue Hip Adductor Surgery Decrease the Need for Hip Reconstruction Compared with Soft-Tissue Surgery Alone for Children with Nonambulatory Cerebral Palsy? Indian J Orthop 2022; 56:2176-2181. [PMID: 36507212 PMCID: PMC9705619 DOI: 10.1007/s43465-022-00762-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Accepted: 10/10/2022] [Indexed: 11/29/2022]
Abstract
Purpose Intrathecal baclofen (ITB) is a well-known treatment option for cerebral palsy (CP) spasticity. The combination of soft-tissue release and ITB for spasticity is common. This study compared patients who had soft-tissue release before ITB (PRE-ITB), soft-tissue release at the same time as ITB (ST-ITB), and no ITB (NON-ITB) but had soft-tissue release at a similar age as PRE-ITB. Methods Inclusion criteria were a spastic or mixed nonambulatory CP diagnosis, prior hip adductor surgery, no prior reconstructive surgery, and at least a five-year post-operative follow-up. Thirty hips were identified as PRE-ITB, 20 hips as ST-ITB, and 43 hips as NON-ITB. The primary outcome variables were the subsequent hip surgery during the study period and/or a migration percentage ≥ 50% at the final follow-up defined as "unsuccessful hip." Results The mean follow-up duration was 9.0 years (SD 2.4) for PRE-ITB, 9.4 (SD 3.6) for ST-ITB, and 9.3 (SD 3) for NON-ITB. The odds of unsuccessful outcomes were not different between NON-ITB and PRE-ITB but were lower for the ST-ITB group. The need for subsequent osteotomies or revision adductor surgery was significantly higher in ST-ITB compared with PRE-ITB (p = 0.02) or NON-ITB (p = 0.015). The incidence of surgical site infection over the whole follow-up period was higher in ST-ITB (40%) compared with PRE-ITB (13.3%, p = 0.035) and NON-ITB (0, p < 0.001). Conclusion The addition of tone management with ITB did not reduce the need for later hip surgery but did increase the risk for surgical site infection.
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Affiliation(s)
- Ali Asma
- Department of Orthopaedics, Nemours Children’s Health, Delaware Valley, 1600 Rockland Road, Wilmington, DE 19803 USA
- Investigation Performed at Nemours Children’s Hospital, Wilmington, DE USA
| | - Armagan Can Ulusaloglu
- Department of Orthopaedics, Nemours Children’s Health, Delaware Valley, 1600 Rockland Road, Wilmington, DE 19803 USA
- Investigation Performed at Nemours Children’s Hospital, Wilmington, DE USA
| | - Jason J. Howard
- Department of Orthopaedics, Nemours Children’s Health, Delaware Valley, 1600 Rockland Road, Wilmington, DE 19803 USA
- Investigation Performed at Nemours Children’s Hospital, Wilmington, DE USA
| | - Kenneth J. Rogers
- Department of Orthopaedics, Nemours Children’s Health, Delaware Valley, 1600 Rockland Road, Wilmington, DE 19803 USA
- Investigation Performed at Nemours Children’s Hospital, Wilmington, DE USA
| | - Freeman Miller
- Department of Orthopaedics, Nemours Children’s Health, Delaware Valley, 1600 Rockland Road, Wilmington, DE 19803 USA
- Investigation Performed at Nemours Children’s Hospital, Wilmington, DE USA
| | - Michael Wade Shrader
- Department of Orthopaedics, Nemours Children’s Health, Delaware Valley, 1600 Rockland Road, Wilmington, DE 19803 USA
- Investigation Performed at Nemours Children’s Hospital, Wilmington, DE USA
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Ronchetti AB, Bertamino M, Tacchino CM, Moretti P, Pavanello M. Letter to the Editor. Intrathecal baclofen pump insertion versus selective dorsal rhizotomy. J Neurosurg Pediatr 2022; 30:634-635. [PMID: 36593674 DOI: 10.3171/2022.7.peds22276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
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Tamburin S, Filippetti M, Mantovani E, Smania N, Picelli A. Spasticity following brain and spinal cord injury: assessment and treatment. Curr Opin Neurol 2022; 35:728-740. [PMID: 36226708 DOI: 10.1097/wco.0000000000001114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
PURPOSE OF REVIEW Spasticity is a common sequela of brain and spinal cord injury and contributes to disability, reduces quality of life, and increases economic burden. Spasticity is still incompletely recognized and undertreated. We will provide an overview of recent published data on the definition, assessment, and prediction, therapeutic advances, with a focus on promising new approaches, and telemedicine applications for spasticity. RECENT FINDINGS Two new definitions of spasticity have been recently proposed, but operational criteria should be developed, and test-retest and inter-rater reliability should be explored. Cannabinoids proved to be effective in spasticity in multiple sclerosis, but evidence in other types of spasticity is lacking. Botulinum neurotoxin injection is the first-line therapy for focal spasticity, and recent literature focused on optimizing its efficacy. Several pharmacological, interventional, and nonpharmacological therapeutic approaches for spasticity have been explored but low-quality evidence impedes solid conclusions on their efficacy. The recent COVID-19 pandemic yielded guidelines/recommendations for the use of telemedicine in spasticity. SUMMARY Despite the frequency of spasticity, robust diagnostic criteria and reliable assessment scales are required. High-quality studies are needed to support the efficacy of current treatments for spasticity. Future studies should explore telemedicine tools for spasticity assessment and treatment.
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Affiliation(s)
- Stefano Tamburin
- Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Italy
| | - Mirko Filippetti
- Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Italy
| | - Elisa Mantovani
- Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Italy
| | - Nicola Smania
- Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Italy
| | - Alessandro Picelli
- Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Italy
- Canadian Advances in Neuro-Orthopaedics for Spasticity Congress (CANOSC), Kingston, Ontario, Canada
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Sheu J, Cohen D, Sousa T, Pham KLD. Cerebral Palsy: Current Concepts and Practices in Musculoskeletal Care. Pediatr Rev 2022; 43:572-581. [PMID: 36180545 DOI: 10.1542/pir.2022-005657] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Cerebral palsy is a neurologic disorder characterized by a spectrum of motor and cognitive deficits resulting from insults to the developing brain. The etiologies are numerous and likely multifactorial; an increasing portion of cases may be attributable to genetic causes, although the exact mechanisms responsible remain poorly understood. Major risk factors include intrauterine stroke and prematurity and neonatal infection, trauma, and hypoxia, which may occur in the prenatal, perinatal, or postnatal period. The Gross Motor Function Classification System (GMFCS) is a widely used tool to establish a child's level of function and to guide treatment; however, additional metrics are necessary to formulate long-term prognoses. Goals of care are to maximize function and independence, which directly correlate with overall quality of life, and family participation is key to establishing goals early in treatment. Nonpharmaceutical treatments include physical, occupational, and speech therapy, as well as bracing, equipment, and technology. There is a breadth of medical interventions for managing hypertonia, including medications, botulinum toxin injections, intrathecal baclofen pumps, and selective dorsal rhizotomy. Orthopedic interventions are indicated for symptomatic or progressive musculoskeletal sequelae. Treatments for dysplastic hips and/or hip instability range from soft tissue releases to bony procedures. Neuromuscular scoliosis is managed with posterior spinal fusion because bracing is ineffective against these rapidly progressive curves. The degree of care varies considerably depending on the child's baseline GMFCS level and functional capabilities, and early screening, diagnosis, and appropriate referrals are paramount to initiating early care and maximizing the child's quality of life.
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Affiliation(s)
- Jonathan Sheu
- Department of Orthopedic Surgery, McLaren Flint Regional Hospital, Flint, MI
| | - Dorian Cohen
- Department of Orthopedic Surgery, Renaissance School of Medicine, Stony Brook University, Stony Brook, NY
| | - Ted Sousa
- Department of Orthopedic Surgery, Shriners Hospital for Children, Spokane, WA
| | - Kelly L D Pham
- Department of Physical Medicine and Rehabilitation, Pediatric Rehabilitation Medicine, Reach Pediatric Rehab, Vienna, VA
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Mansur A, Morgan B, Lavigne A, Phaneuf-Garand N, Diabira J, Yan H, Narayanan UG, Fehlings D, Milo-Manson G, Dalziel B, Breitbart S, Mercier C, Venne D, Marois P, Weil AG, Raskin JS, Thomas SP, Ibrahim GM. Comparison of intrathecal baclofen pump insertion and selective dorsal rhizotomy for nonambulatory children with predominantly spastic cerebral palsy. J Neurosurg Pediatr 2022; 30:217-223. [PMID: 35901772 DOI: 10.3171/2022.4.peds21576] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Accepted: 04/22/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE In nonambulatory children with predominantly spastic cerebral palsy (CP), the authors compared care needs, symptom burden, and complications after surgical treatment with either intrathecal baclofen (ITB) pump insertion or selective dorsal rhizotomy (SDR). The patients were treated at two Canadian centers with variability in practice pertaining to these surgical options. METHODS The authors performed a retrospective analysis of nonambulatory children with predominantly spastic quadriplegic or diplegic CP who underwent treatment with ITB or SDR. These two strategies were retrospectively assessed by comparing patient data from the two treatment groups for demographic characteristics, outcomes, and complications. A partial least-squares analysis was performed to identify patient phenotypes associated with outcomes. RESULTS Thirty patients who underwent ITB and 30 patients who underwent SDR were included for analysis. Patients in the ITB group were older and had lower baseline functional status, with greater burdens of spasticity, dystonia, pain, deformity, bladder dysfunction, and epilepsy than patients in the SDR group. In addition, children who underwent SDR had lower Gross Motor Function Classification System (GMFCS) levels and were less likely to experience complications than those who underwent ITB. However, children treated with SDR had fewer improvements in pain than children treated with ITB. A single significant latent variable explaining 88% of the variance in the data was identified. CONCLUSIONS Considerable baseline differences exist within this pediatric CP patient population. Factors specific to individual children must be taken into account when determining whether ITB or SDR is the appropriate treatment.
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Affiliation(s)
- Ann Mansur
- 1Division of Neurosurgery, Department of Surgery, Faculty of Medicine, and
| | - Benjamin Morgan
- 2Department of Medical Imaging, Faculty of Medicine, University of Toronto, Ontario
| | - Alexandre Lavigne
- 3Neurosurgery Service, Department of Surgery, Sainte-Justine University Hospital, Montreal, Quebec
- 4Brain and Child Development Axis, CHU Sainte-Justine Research Center, Montreal, Quebec
| | - Nicolas Phaneuf-Garand
- 3Neurosurgery Service, Department of Surgery, Sainte-Justine University Hospital, Montreal, Quebec
- 4Brain and Child Development Axis, CHU Sainte-Justine Research Center, Montreal, Quebec
| | - Jocelyne Diabira
- 3Neurosurgery Service, Department of Surgery, Sainte-Justine University Hospital, Montreal, Quebec
- 4Brain and Child Development Axis, CHU Sainte-Justine Research Center, Montreal, Quebec
| | - Han Yan
- 1Division of Neurosurgery, Department of Surgery, Faculty of Medicine, and
| | - Unni G Narayanan
- 5Division of Orthopedic Surgery, Hospital for Sick Children, Toronto, Ontario
| | - Darcy Fehlings
- 6Division of Developmental Paediatrics, Department of Paediatrics, Holland Bloorview Kids Rehabilitation Hospital, University of Toronto, Ontario
| | - Golda Milo-Manson
- 6Division of Developmental Paediatrics, Department of Paediatrics, Holland Bloorview Kids Rehabilitation Hospital, University of Toronto, Ontario
| | - Blythe Dalziel
- 3Neurosurgery Service, Department of Surgery, Sainte-Justine University Hospital, Montreal, Quebec
| | - Sara Breitbart
- 7Division of Neurosurgery, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Claude Mercier
- 3Neurosurgery Service, Department of Surgery, Sainte-Justine University Hospital, Montreal, Quebec
| | - Dominic Venne
- 3Neurosurgery Service, Department of Surgery, Sainte-Justine University Hospital, Montreal, Quebec
| | - Pierre Marois
- 4Brain and Child Development Axis, CHU Sainte-Justine Research Center, Montreal, Quebec
| | - Alexander G Weil
- 3Neurosurgery Service, Department of Surgery, Sainte-Justine University Hospital, Montreal, Quebec
| | - Jeffrey S Raskin
- 8Section of Pediatric Neurosurgery, Riley Hospital for Children, Department of Neurological Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Sruthi P Thomas
- 9Department of Pediatrics and
- 10Department of Physical Medicine and Rehabilitation and Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - George M Ibrahim
- 1Division of Neurosurgery, Department of Surgery, Faculty of Medicine, and
- 7Division of Neurosurgery, Hospital for Sick Children, Toronto, Ontario, Canada
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14
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Efficacy of Rehabilitation Therapy and Pharmacotherapy on Children with Cerebral Palsy: A Meta-Analysis. COMPUTATIONAL AND MATHEMATICAL METHODS IN MEDICINE 2022; 2022:6465060. [PMID: 35855834 PMCID: PMC9288332 DOI: 10.1155/2022/6465060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Revised: 06/24/2022] [Accepted: 06/27/2022] [Indexed: 11/17/2022]
Abstract
Background. Cerebral palsy (CP) has a serious impact on children’s multiple motor functions and life behavior. Rehabilitation therapy or pharmacotherapy alone has been proven to have a good effect on patients’ strength and gait. However, the efficacy of rehabilitation combined with pharmacotherapy for CP in children needs to be further explored. This study is aimed at assessing the effectiveness of this combined method on life function and social behavior in children with CP. Methods. PubMed, China National Knowledge Infrastructure, WanFang Data, EMBASE, and Web of Science databases were searched for all kinds of literature related to the treatment of pediatric CP published between 2000 and 2021. Basic information and experimental data from the literature were screened and extracted, and a meta-analysis was performed using Stata 16. Results. A total of 605 studies were retrieved, and finally, 10 studies involving 805 pediatric patients were included in the analysis. The analysis results showed that rehabilitation combined with pharmacotherapy could improve the treatment effective rate in children with CP compared with the control group using either alone (
, 95% CI (1.102, 1.273),
). In addition, in terms of social behavior, the combined therapy could significantly improve activities of daily living (
, 95% CI (1.66, 4.22),
), motor ability (
, 95% CI (0.75, 2.96),
), adaptability behavior (
, 95% CI (0.45, 5.18),
), language behavior (
, 95% CI (0.95, 5.22),
), social behavior (
, 95% CI (2.22, 5.35),
), and fine motor behavior (
, 95% CI (1.17, 5.86),
). Conclusion. The current study shows that rehabilitation combined with pharmacotherapy can effectively improve the recovery, quality of life, and social behavior of children with CP.
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15
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Pintér H, Gál F, Molnár P. The professional network underlying cerebral palsy intervention research based on systematic reviews and meta-analyses published in international journals: authors' communities, institutional networks, and international collaboration. Heliyon 2022; 8:e09718. [PMID: 35761937 PMCID: PMC9233218 DOI: 10.1016/j.heliyon.2022.e09718] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Revised: 03/09/2022] [Accepted: 06/08/2022] [Indexed: 11/16/2022] Open
Abstract
Cerebral palsy (CP) is a well-researched area of medical science, health science and special education. The growing number of publications every year makes difficult to monitor the progress of this research domain, therefore there is a broad interest for conducting systematic reviews and meta-analyses of interventions in international peer-reviewed scientific journals. Our goal is to analyze the scientific activity of authors who published systematic reviews and meta-analyses of CP intervention studies. To identify the active researchers, institutions, and countries, we used scientometric and bibliometric indicators that assess their productivity, collaborations, and the citations (utilization/usefulness of their studies), also paying attention to the institutional background and the network structure of national and international collaboration. We used Scopus to search for articles and included systematic reviews and meta-analyses of intervention studies, a total of 180 works, in our sample. Our results showed active and large communities of prolific authors and groups of authors with diverse institutional background. Most institutions are universities, hospitals, but we found various other organizations among them. Most of the universities are leading educational institutions according to international rankings; some of them are among the top-ranking ones. In geographical terms, the North American, Australian, and European regions are the most active and most interconnected ones. We assume organizations other than scientific collaboration networks also play a major role in the productivity and dissemination of scientific knowledge in this research area. As an example, we could mention the network, including the US, Australian and European registers. Authors living and working in the Far East, the Middle East or in South America also started to publish relevant articles in the 2010s. The research network structuring scientific knowledge in this area is flourishing.
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Affiliation(s)
- Henriett Pintér
- Semmelweis University, Andras Pető Faculty, Research Group on Communication Teaching and Learning, Hungary
| | - Franciska Gál
- Semmelweis University, Andras Pető Faculty, Research Group on Communication Teaching and Learning, Hungary
| | - Pál Molnár
- Semmelweis University, Andras Pető Faculty, Research Group on Communication Teaching and Learning, Hungary
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16
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Puertas M V, de Noriega Echevarria I, Errasti V I, Perez M M, Alba R. Intrathecal baclofen therapy as treatment for spasticity and dystonia: Review of cases in a pediatric palliative care unit. Neurologia 2022. [DOI: 10.1016/j.nrl.2022.04.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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17
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Bonouvrié LA, Lagendijk KE, Beckerman H, Slot KM, van de Pol LA, Buizer AI. Surgical complications of intrathecal baclofen in children: A single centre, 20-year retrospective cohort study. Eur J Paediatr Neurol 2022; 37:94-97. [PMID: 35180559 DOI: 10.1016/j.ejpn.2022.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Revised: 08/18/2021] [Accepted: 02/10/2022] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Complications of intrathecal baclofen treatment (ITB) with an implanted pump can be severe and require surgery. Surgical implantation techniques and catheter materials for continuous ITB treatment have improved over the past years with the aim to reduce complications. OBJECTIVE To assess: 1) the type and rate of complications of ITB that require surgical intervention, 2) which risk factors influence the occurrence of complications, and, specifically, 3) whether complication rate is influenced by type of catheter used. METHODS A retrospective cohort study was conducted including all children (<18 years old) in one university medical center with pump implantation between 2001 and 2017. All complications requiring surgery were recorded. Risk factors for surgical intervention were determined using multiple logistic regression analysis. Catheter related complications between two types of catheters (silicone vs coated) were compared. RESULTS In total, 88 complications of ITB treatment requiring surgery were found in 47 (36.2%) out of 130 children. These included catheter-related complications (55.7% of all complications), infections (21.6%), cerebrospinal fluid leakage (14.8%), and pump-related complications (7.9%). The silicone catheter type, used until 2012, was found to be a significant risk factor for complications (Odds Ratio 3.75; 95% CI: 1.30-10.83). Since the introduction of the coated catheter type, in 2012, the rate of catheter-related complications decreased, from 0.15 to 0.10 complications per pump year. CONCLUSION The rate of surgical complications of intrathecal baclofen in children is high, and most frequently catheter-related. The number of complications decreased since the introduction of a new, coated, catheter in 2012. This study helps to inform children and their caregivers about the risk of possible complications of ITB, and to identify directions for future improvement of ITB care.
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Affiliation(s)
- Laura A Bonouvrié
- Department of Rehabilitation Medicine, Amsterdam UMC, Vrije Universiteit, Amsterdam Movement Sciences Research Institute, Amsterdam, the Netherlands.
| | - Karen E Lagendijk
- Department of Rehabilitation Medicine, Amsterdam UMC, Vrije Universiteit, Amsterdam Movement Sciences Research Institute, Amsterdam, the Netherlands
| | - Heleen Beckerman
- Department of Rehabilitation Medicine, Amsterdam UMC, Vrije Universiteit, Amsterdam Movement Sciences Research Institute, Amsterdam, the Netherlands
| | - K Mariam Slot
- Department of Neurosurgery, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Laura A van de Pol
- Department of Child Neurology, Amsterdam UMC, Vrije Universiteit, Amsterdam Neuroscience Research Institute, Amsterdam, the Netherlands
| | - Annemieke I Buizer
- Department of Rehabilitation Medicine, Amsterdam UMC, Vrije Universiteit, Amsterdam Movement Sciences Research Institute, Amsterdam, the Netherlands; Emma Children's Hospital, Amsterdam UMC, Amsterdam, the Netherlands
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18
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Danzig JA, Katz EB. Musculoskeletal and skin considerations in children with medical complexity: Common themes and approaches to management. Curr Probl Pediatr Adolesc Health Care 2021; 51:101074. [PMID: 34656455 DOI: 10.1016/j.cppeds.2021.101074] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The term "children with medical complexity" (CMC) describes a population of heterogeneous genetic and metabolic disorders with multi-system involvement, with shared common abnormalities within the musculoskeletal system. Disorders that affect the central nervous system (CNS) result in abnormal muscular tone, ranging from dystonia and spasticity, to hypotonia, to combinations of both (axial hypotonia with appendicular hypertonia). Abnormal tone can impair movement and function and contribute to development of contractures, progressive scoliosis and hip dislocation. Impaired mobility, chronic illness and polypharmacy can result in fragile bones and increased risk of fracture, which can be difficult to diagnose and associated with pain. Additionally, CMC with impaired ability to communicate, total dependence on caregivers and frequent use of support devices can develop unintended skin injuries. There are a variety of treatments available for CMC with musculoskeletal disorders ranging from physical supports to pharmacologic treatments to surgeries. Medical and surgical treatments can promote changes in tone and support bone health to improve comfort, hygiene and proper positioning. These therapies may also carry significant risk in medically fragile patients. It is important for CMC to have a care team with a good understanding of the patient's overall health and goals of care and that can advocate for the patient to balance optimization of function and reduction of pain while also minimizing risk.
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Affiliation(s)
- Jennifer A Danzig
- Division of General Pediatrics, The Children's Hospital of Philadelphia and Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, 3401 Civic Center Boulevard, Philadelphia, PA 19104, United States.
| | - Elana B Katz
- Center for Rehabilitation, The Children's Hospital of Philadelphia and Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104, United States
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19
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Mohon RT, Sawyer K, Pickett K, Bothwell S, Brinton JT, Sobremonte-King M, DelRosso LM. Sleep-related breathing disorders associated with intrathecal baclofen therapy to treat patients with cerebral palsy: A cohort study and discussion. NeuroRehabilitation 2021; 48:481-491. [PMID: 33967066 DOI: 10.3233/nre-210012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Patients with cerebral palsy and other static encephalopathies (CP) are known to be at increased risk of sleep-related breathing disorders (SRBD). Few studies have reviewed whether intrathecal baclofen (ITB) can contribute to SRBD. OBJECTIVE To assess the prevalence of SRBD in patients with CP receiving ITB by using nocturnal polysomnography (NPSG). METHODS We performed a retrospective chart review of patients receiving ITB who had NPSG at Children's Hospital Colorado (CHCO) and Seattle Children's Hospital (SCH) from 1995 to 2019. The Gross Motor Function Classification System (GMFCS) measured the severity of motor disability. Screening sleep questionnaires collected subjective data and NPSG provided objective data of SRBD. RESULTS All patients except one were GMFCS 4 or 5 with median age at ITB pump placement of 9.7 years. The screening questionnaire for SRBD detected one or more nighttime symptoms in > 82% of all patient groups. Pre-ITB criteria for a SRBD was met in 83% of patients at CHCO and 91% at SCH. Post-ITB prevalence remained similarly high. CONCLUSIONS NPSG identified a high prevalence of SRBD in these cohorts from CHCO and SCH. Our study showed neither improvement nor worsening of SRBD in patients receiving ITB.
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Affiliation(s)
- Ricky T Mohon
- Children's Hospital Colorado and Division of Pulmonary and Sleep Medicine, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA
| | - Kim Sawyer
- Children's Hospital Colorado, Department of Rehabilitation, University of Colorado School of Medicine, Aurora, CO, USA
| | - Kaci Pickett
- Colorado School of Public Health, Department of Biostatistics and Informatics, University of Colorado, Aurora, CO, USA
| | - Samantha Bothwell
- Colorado School of Public Health, Department of Biostatistics and Informatics, University of Colorado, Aurora, CO, USA
| | - John T Brinton
- Department of Pediatrics, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, CO, USA
| | - Michelle Sobremonte-King
- Seattle Children's Hospital and Division of Pulmonary and Sleep Medicine, University of Washington, Seattle, WA, USA
| | - Lourdes M DelRosso
- Seattle Children's Hospital and Division of Pulmonary and Sleep Medicine, University of Washington, Seattle, WA, USA
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20
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Musculoskeletal Pain Outcomes Pre- and Post Intrathecal Baclofen Pump Implant in Children With Cerebral Palsy: A Prospective Cohort Study. Arch Rehabil Res Clin Transl 2021; 2:100049. [PMID: 33543076 PMCID: PMC7853392 DOI: 10.1016/j.arrct.2020.100049] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Objective To characterize musculoskeletal pain intensity, duration, frequency, and interference with activities of daily living in children with cerebral palsy (CP) before and after intrathecal baclofen pump placement. Design Prospective cohort study. Setting Children's tertiary hospital. Participants Participants were children with CP (N=32; 53% male; mean age, 9.9y; age range, 4-17y). The majority of participants had a CP diagnosis of quadriplegia (76%) and relied on wheeled mobility (91%). Interventions Assessments were completed pre- and post intrathecal baclofen pump implant. Main Outcome Measures Because of considerable patient heterogeneity, both pain measures (Brief Pain Inventory, Dalhousie Pain Interview) were completed by proxy (parent) report at the time of the procedure and approximately 6 months after intrathecal baclofen (ITB) pump placement. Results Prior to implant, 31% of participants were living with constant pain, which reduced to 6% post ITB implant (P<.001). Based on Wilcoxon signed rank tests, pain duration significantly decreased post ITB pump implant (P<.01). Conclusions This prospective analysis supports the anecdotal and retrospective evidence that musculoskeletal pain decreases in CP following ITB pump implant. The greatest effect appears to be on the duration of pain experience. Pain did not decrease for all individuals, and it would be worth further investigation to better understand the relation between patient characteristics and pain outcomes.
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21
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Tyack L, Copeland L, McCartney L, Waugh MC. Adverse events associated with paediatric intrathecal baclofen in Australia: 5 years of data collection. J Paediatr Child Health 2021; 57:258-262. [PMID: 32975337 DOI: 10.1111/jpc.15194] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2020] [Revised: 08/09/2020] [Accepted: 08/14/2020] [Indexed: 12/01/2022]
Abstract
AIM This study aims to examine the adverse event (AE) rate for intrathecal baclofen (ITB) therapy in an Australian paediatric population and to clarify type and frequency of AEs. METHODS AE data were extracted from the Australian Paediatric ITB Research Group national database, to include the first 5 years of data collection. Raw data were collated and analysed descriptively. RESULTS Data were collected for 40 patients. Forty-seven AEs in 23 patients were reported. Ten (25%) patients required surgical intervention related to their AE. Five patients (12.5%) required pump removal. The most frequent ITB-related AEs were catheter dysfunction (24%), drug overdose, withdrawal or sensitivity (19%), seromas and haematomas (15%) and infections (13%). CONCLUSIONS The AE rate for ITB therapy is high and needs to be considered when counselling patients regarding ITB as a therapeutic option.
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Affiliation(s)
- Louise Tyack
- Queensland Paediatric Rehabilitation Service, Queensland Children's Hospital, Brisbane, Queensland, Australia
| | - Lisa Copeland
- Queensland Paediatric Rehabilitation Service, Queensland Children's Hospital, Brisbane, Queensland, Australia
| | - Lynn McCartney
- Kids Rehab, The Sydney Children's Hospitals Network Randwick and Westmead, Sydney, New South Wales, Australia
| | - Mary-Clare Waugh
- Kids Rehab, The Sydney Children's Hospitals Network Randwick and Westmead, Sydney, New South Wales, Australia
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22
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Stewart K, Copeland L, Lewis J. The Impact of Intrathecal Baclofen Therapy on Health-related Quality of Life for Children with Marked Hypertonia. Dev Neurorehabil 2020; 23:542-547. [PMID: 32338172 DOI: 10.1080/17518423.2020.1753841] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Purpose: To investigate the effects of intrathecal baclofen therapy (ITB) on health-related quality of life for children with cerebral palsy and neurological conditions. Method: This study is part of a longitudinal, multicentre audit. The primary outcome measure, the Caregiver Priorities and Child Health Index of Life with Disabilities, was completed at baseline, 6 and 12 months post ITB implant. Results: Forty subjects with cerebral palsy and other neurological conditions demonstrated significant improvement in aspects of health-related quality of life following ITB therapy, mean change 42.3 (SD 14.9) at baseline to 53.3 (SD 14.7) at 12 months (p< .001). Conclusion: Evidence to demonstrate the utility of ITB in pediatric populations beyond spasticity and dystonia reduction is limited. Our findings suggest that ITB improves aspects of quality of life, comfort, and ease of caregiving in children with cerebral palsy and other neurological conditions.
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Affiliation(s)
- Kirsty Stewart
- Kids Rehab, The Children's Hospital at Westmead , Sydney, Australia.,Faculty of Medicine and Health, The University of Sydney , Sydney, Australia
| | - Lisa Copeland
- Queensland Children's Hospital , Brisbane, Australia
| | - Jennifer Lewis
- Kids Rehab, The Children's Hospital at Westmead , Sydney, Australia.,Queensland Children's Hospital , Brisbane, Australia.,Royal Children's Hospital , Melbourne, Australia.,Monash Children's Health , Melbourne, Australia.,Women and Children's Hospital , Adelaide, South Australia.,Perth Children's Hospital , Perth, Australia
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23
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Peck J, Urits I, Kassem H, Lee C, Robinson W, Cornett EM, Berger AA, Herman J, Jung JW, Kaye AD, Viswanath O. Interventional Approaches to Pain and Spasticity Related to Cerebral Palsy. PSYCHOPHARMACOLOGY BULLETIN 2020; 50:108-120. [PMID: 33633421 PMCID: PMC7901135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
Purpose of Review This review will cover seminal and emerging evidence on interventional therapy chronic pain in cerebral palsy (CP). It will cover the background and burden of disease, present the current options, and then weigh the evidence that is available to support interventional therapy and the current indications. Recent Findings CP is a permanent posture and movement disorder from in-utero brain development defects with a 3-4/1,000 incidence in the US. The cost of care for each child is estimated at $921,000. Pain in CP is attributed to musculoskeletal deformities, spasticity, increased muscle tone, dislocations, and GI dysfunction. First-line treatments include physical and occupational therapy and oral pharmacological agents; however, a significant amount of patients remain refractory to these and require further therapy. Injection therapy includes botulinum toxin A (BTA) injections and intrathecal baclofen. BTA injections were shown to control chronic pain effectively and are FDA approved for spastic pain; intra-thecal baclofen, in contrast, was only shown to improve comfort and quality of life with a focus on the pain. Surgical intervention includes selection dorsal rhizotomy (SDR). It may increase range of motion and quality of life and reduce spasticity and pain; however, most evidence is anecdotal, and more research is required. Summary Interventional therapy, including injection and surgical, is the last line of therapy for chronic pain in CP. It extends the possibility of therapy in hard-to-treat individuals; however, more data is required to provide strong evidence to the efficacy of these treatments and guide proper patient selection.
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Affiliation(s)
- Jacquelin Peck
- Peck, MD, Kassem, MD, Berger, MD, PhD, Herman, DO, Mount Sinai Medical Center, Department of Anesthesiology, Miami Beach, FL. Urits, MD, Department of Anesthesiology, Louisiana State University School of Medicine, Shreveport, LA; Beth Israel Deaconess Medical Center, Department of Anesthesiology, Critical Care and Pain Medicine, Harvard Medical School, Boston, MA. Lee, BS, Creighton University School of Medicine, Phoenix, Arizona. Robinson, BS, Georgetown University School of Medicine, Washington DC. Cornett, PhD, Louisiana State University Health Sciences Center, Department of Anesthesiology, New Orleans, LA. Jung, BS, Georgetown University School of Medicine, MedStar Georgetown University Hospital, Washington, DC. Kaye, Departments of Anesthesiology and Pharmacology, Toxicology and Neurosciences, Louisiana State University School of Medicine, Shreveport, LA. Viswanath, MD, Department of Anesthesiology, Louisiana State University School of Medicine, Shreveport, LA; Valley Pain Consultants - Envision Physician Services, Phoenix, AZ; University of Arizona College of Medicine-Phoenix, Department of Anesthesiology, Phoenix, AZ; Creighton University School of Medicine, Department of Anesthesiology, Omaha, NE
| | - Ivan Urits
- Peck, MD, Kassem, MD, Berger, MD, PhD, Herman, DO, Mount Sinai Medical Center, Department of Anesthesiology, Miami Beach, FL. Urits, MD, Department of Anesthesiology, Louisiana State University School of Medicine, Shreveport, LA; Beth Israel Deaconess Medical Center, Department of Anesthesiology, Critical Care and Pain Medicine, Harvard Medical School, Boston, MA. Lee, BS, Creighton University School of Medicine, Phoenix, Arizona. Robinson, BS, Georgetown University School of Medicine, Washington DC. Cornett, PhD, Louisiana State University Health Sciences Center, Department of Anesthesiology, New Orleans, LA. Jung, BS, Georgetown University School of Medicine, MedStar Georgetown University Hospital, Washington, DC. Kaye, Departments of Anesthesiology and Pharmacology, Toxicology and Neurosciences, Louisiana State University School of Medicine, Shreveport, LA. Viswanath, MD, Department of Anesthesiology, Louisiana State University School of Medicine, Shreveport, LA; Valley Pain Consultants - Envision Physician Services, Phoenix, AZ; University of Arizona College of Medicine-Phoenix, Department of Anesthesiology, Phoenix, AZ; Creighton University School of Medicine, Department of Anesthesiology, Omaha, NE
| | - Hisham Kassem
- Peck, MD, Kassem, MD, Berger, MD, PhD, Herman, DO, Mount Sinai Medical Center, Department of Anesthesiology, Miami Beach, FL. Urits, MD, Department of Anesthesiology, Louisiana State University School of Medicine, Shreveport, LA; Beth Israel Deaconess Medical Center, Department of Anesthesiology, Critical Care and Pain Medicine, Harvard Medical School, Boston, MA. Lee, BS, Creighton University School of Medicine, Phoenix, Arizona. Robinson, BS, Georgetown University School of Medicine, Washington DC. Cornett, PhD, Louisiana State University Health Sciences Center, Department of Anesthesiology, New Orleans, LA. Jung, BS, Georgetown University School of Medicine, MedStar Georgetown University Hospital, Washington, DC. Kaye, Departments of Anesthesiology and Pharmacology, Toxicology and Neurosciences, Louisiana State University School of Medicine, Shreveport, LA. Viswanath, MD, Department of Anesthesiology, Louisiana State University School of Medicine, Shreveport, LA; Valley Pain Consultants - Envision Physician Services, Phoenix, AZ; University of Arizona College of Medicine-Phoenix, Department of Anesthesiology, Phoenix, AZ; Creighton University School of Medicine, Department of Anesthesiology, Omaha, NE
| | - Christopher Lee
- Peck, MD, Kassem, MD, Berger, MD, PhD, Herman, DO, Mount Sinai Medical Center, Department of Anesthesiology, Miami Beach, FL. Urits, MD, Department of Anesthesiology, Louisiana State University School of Medicine, Shreveport, LA; Beth Israel Deaconess Medical Center, Department of Anesthesiology, Critical Care and Pain Medicine, Harvard Medical School, Boston, MA. Lee, BS, Creighton University School of Medicine, Phoenix, Arizona. Robinson, BS, Georgetown University School of Medicine, Washington DC. Cornett, PhD, Louisiana State University Health Sciences Center, Department of Anesthesiology, New Orleans, LA. Jung, BS, Georgetown University School of Medicine, MedStar Georgetown University Hospital, Washington, DC. Kaye, Departments of Anesthesiology and Pharmacology, Toxicology and Neurosciences, Louisiana State University School of Medicine, Shreveport, LA. Viswanath, MD, Department of Anesthesiology, Louisiana State University School of Medicine, Shreveport, LA; Valley Pain Consultants - Envision Physician Services, Phoenix, AZ; University of Arizona College of Medicine-Phoenix, Department of Anesthesiology, Phoenix, AZ; Creighton University School of Medicine, Department of Anesthesiology, Omaha, NE
| | - Wilton Robinson
- Peck, MD, Kassem, MD, Berger, MD, PhD, Herman, DO, Mount Sinai Medical Center, Department of Anesthesiology, Miami Beach, FL. Urits, MD, Department of Anesthesiology, Louisiana State University School of Medicine, Shreveport, LA; Beth Israel Deaconess Medical Center, Department of Anesthesiology, Critical Care and Pain Medicine, Harvard Medical School, Boston, MA. Lee, BS, Creighton University School of Medicine, Phoenix, Arizona. Robinson, BS, Georgetown University School of Medicine, Washington DC. Cornett, PhD, Louisiana State University Health Sciences Center, Department of Anesthesiology, New Orleans, LA. Jung, BS, Georgetown University School of Medicine, MedStar Georgetown University Hospital, Washington, DC. Kaye, Departments of Anesthesiology and Pharmacology, Toxicology and Neurosciences, Louisiana State University School of Medicine, Shreveport, LA. Viswanath, MD, Department of Anesthesiology, Louisiana State University School of Medicine, Shreveport, LA; Valley Pain Consultants - Envision Physician Services, Phoenix, AZ; University of Arizona College of Medicine-Phoenix, Department of Anesthesiology, Phoenix, AZ; Creighton University School of Medicine, Department of Anesthesiology, Omaha, NE
| | - Elyse M Cornett
- Peck, MD, Kassem, MD, Berger, MD, PhD, Herman, DO, Mount Sinai Medical Center, Department of Anesthesiology, Miami Beach, FL. Urits, MD, Department of Anesthesiology, Louisiana State University School of Medicine, Shreveport, LA; Beth Israel Deaconess Medical Center, Department of Anesthesiology, Critical Care and Pain Medicine, Harvard Medical School, Boston, MA. Lee, BS, Creighton University School of Medicine, Phoenix, Arizona. Robinson, BS, Georgetown University School of Medicine, Washington DC. Cornett, PhD, Louisiana State University Health Sciences Center, Department of Anesthesiology, New Orleans, LA. Jung, BS, Georgetown University School of Medicine, MedStar Georgetown University Hospital, Washington, DC. Kaye, Departments of Anesthesiology and Pharmacology, Toxicology and Neurosciences, Louisiana State University School of Medicine, Shreveport, LA. Viswanath, MD, Department of Anesthesiology, Louisiana State University School of Medicine, Shreveport, LA; Valley Pain Consultants - Envision Physician Services, Phoenix, AZ; University of Arizona College of Medicine-Phoenix, Department of Anesthesiology, Phoenix, AZ; Creighton University School of Medicine, Department of Anesthesiology, Omaha, NE
| | - Amnon A Berger
- Peck, MD, Kassem, MD, Berger, MD, PhD, Herman, DO, Mount Sinai Medical Center, Department of Anesthesiology, Miami Beach, FL. Urits, MD, Department of Anesthesiology, Louisiana State University School of Medicine, Shreveport, LA; Beth Israel Deaconess Medical Center, Department of Anesthesiology, Critical Care and Pain Medicine, Harvard Medical School, Boston, MA. Lee, BS, Creighton University School of Medicine, Phoenix, Arizona. Robinson, BS, Georgetown University School of Medicine, Washington DC. Cornett, PhD, Louisiana State University Health Sciences Center, Department of Anesthesiology, New Orleans, LA. Jung, BS, Georgetown University School of Medicine, MedStar Georgetown University Hospital, Washington, DC. Kaye, Departments of Anesthesiology and Pharmacology, Toxicology and Neurosciences, Louisiana State University School of Medicine, Shreveport, LA. Viswanath, MD, Department of Anesthesiology, Louisiana State University School of Medicine, Shreveport, LA; Valley Pain Consultants - Envision Physician Services, Phoenix, AZ; University of Arizona College of Medicine-Phoenix, Department of Anesthesiology, Phoenix, AZ; Creighton University School of Medicine, Department of Anesthesiology, Omaha, NE
| | - Jared Herman
- Peck, MD, Kassem, MD, Berger, MD, PhD, Herman, DO, Mount Sinai Medical Center, Department of Anesthesiology, Miami Beach, FL. Urits, MD, Department of Anesthesiology, Louisiana State University School of Medicine, Shreveport, LA; Beth Israel Deaconess Medical Center, Department of Anesthesiology, Critical Care and Pain Medicine, Harvard Medical School, Boston, MA. Lee, BS, Creighton University School of Medicine, Phoenix, Arizona. Robinson, BS, Georgetown University School of Medicine, Washington DC. Cornett, PhD, Louisiana State University Health Sciences Center, Department of Anesthesiology, New Orleans, LA. Jung, BS, Georgetown University School of Medicine, MedStar Georgetown University Hospital, Washington, DC. Kaye, Departments of Anesthesiology and Pharmacology, Toxicology and Neurosciences, Louisiana State University School of Medicine, Shreveport, LA. Viswanath, MD, Department of Anesthesiology, Louisiana State University School of Medicine, Shreveport, LA; Valley Pain Consultants - Envision Physician Services, Phoenix, AZ; University of Arizona College of Medicine-Phoenix, Department of Anesthesiology, Phoenix, AZ; Creighton University School of Medicine, Department of Anesthesiology, Omaha, NE
| | - Jai Won Jung
- Peck, MD, Kassem, MD, Berger, MD, PhD, Herman, DO, Mount Sinai Medical Center, Department of Anesthesiology, Miami Beach, FL. Urits, MD, Department of Anesthesiology, Louisiana State University School of Medicine, Shreveport, LA; Beth Israel Deaconess Medical Center, Department of Anesthesiology, Critical Care and Pain Medicine, Harvard Medical School, Boston, MA. Lee, BS, Creighton University School of Medicine, Phoenix, Arizona. Robinson, BS, Georgetown University School of Medicine, Washington DC. Cornett, PhD, Louisiana State University Health Sciences Center, Department of Anesthesiology, New Orleans, LA. Jung, BS, Georgetown University School of Medicine, MedStar Georgetown University Hospital, Washington, DC. Kaye, Departments of Anesthesiology and Pharmacology, Toxicology and Neurosciences, Louisiana State University School of Medicine, Shreveport, LA. Viswanath, MD, Department of Anesthesiology, Louisiana State University School of Medicine, Shreveport, LA; Valley Pain Consultants - Envision Physician Services, Phoenix, AZ; University of Arizona College of Medicine-Phoenix, Department of Anesthesiology, Phoenix, AZ; Creighton University School of Medicine, Department of Anesthesiology, Omaha, NE
| | - Alan D Kaye
- Peck, MD, Kassem, MD, Berger, MD, PhD, Herman, DO, Mount Sinai Medical Center, Department of Anesthesiology, Miami Beach, FL. Urits, MD, Department of Anesthesiology, Louisiana State University School of Medicine, Shreveport, LA; Beth Israel Deaconess Medical Center, Department of Anesthesiology, Critical Care and Pain Medicine, Harvard Medical School, Boston, MA. Lee, BS, Creighton University School of Medicine, Phoenix, Arizona. Robinson, BS, Georgetown University School of Medicine, Washington DC. Cornett, PhD, Louisiana State University Health Sciences Center, Department of Anesthesiology, New Orleans, LA. Jung, BS, Georgetown University School of Medicine, MedStar Georgetown University Hospital, Washington, DC. Kaye, Departments of Anesthesiology and Pharmacology, Toxicology and Neurosciences, Louisiana State University School of Medicine, Shreveport, LA. Viswanath, MD, Department of Anesthesiology, Louisiana State University School of Medicine, Shreveport, LA; Valley Pain Consultants - Envision Physician Services, Phoenix, AZ; University of Arizona College of Medicine-Phoenix, Department of Anesthesiology, Phoenix, AZ; Creighton University School of Medicine, Department of Anesthesiology, Omaha, NE
| | - Omar Viswanath
- Peck, MD, Kassem, MD, Berger, MD, PhD, Herman, DO, Mount Sinai Medical Center, Department of Anesthesiology, Miami Beach, FL. Urits, MD, Department of Anesthesiology, Louisiana State University School of Medicine, Shreveport, LA; Beth Israel Deaconess Medical Center, Department of Anesthesiology, Critical Care and Pain Medicine, Harvard Medical School, Boston, MA. Lee, BS, Creighton University School of Medicine, Phoenix, Arizona. Robinson, BS, Georgetown University School of Medicine, Washington DC. Cornett, PhD, Louisiana State University Health Sciences Center, Department of Anesthesiology, New Orleans, LA. Jung, BS, Georgetown University School of Medicine, MedStar Georgetown University Hospital, Washington, DC. Kaye, Departments of Anesthesiology and Pharmacology, Toxicology and Neurosciences, Louisiana State University School of Medicine, Shreveport, LA. Viswanath, MD, Department of Anesthesiology, Louisiana State University School of Medicine, Shreveport, LA; Valley Pain Consultants - Envision Physician Services, Phoenix, AZ; University of Arizona College of Medicine-Phoenix, Department of Anesthesiology, Phoenix, AZ; Creighton University School of Medicine, Department of Anesthesiology, Omaha, NE
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Reilly M, Liuzzo K, Blackmer AB. Pharmacological Management of Spasticity in Children With Cerebral Palsy. J Pediatr Health Care 2020; 34:495-509. [PMID: 32861428 DOI: 10.1016/j.pedhc.2020.04.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Revised: 03/02/2020] [Accepted: 04/20/2020] [Indexed: 11/16/2022]
Abstract
Cerebral palsy (CP), a nonprogressive disease of the central nervous system, is the most common motor disability in childhood. Patients with CP often have a multitude of associated comorbidities, including impact on muscle tone. There are four main types of CP, with spastic as the most commonly diagnosed. Reduction in spasticity is important because it can affect not only the patient's quality of life, functional abilities, and well-being but also the lives of caregivers. The American Academy of Neurology and Child Neurology Society released a practice parameter regarding the pharmacological management of CP-related spasticity in 2010. Since then, data have been published evaluating the safety and efficacy of oral and parenteral medications to manage spasticity. This continuing education review evaluates the available safety and efficacy evidence for oral and parenteral pharmacological agents used to reduce spasticity in children with CP and provides a reference for practitioners managing these patients.
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25
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Okata Y, Bitoh Y, Aida Y, Miyauchi H, Nakatani T, Tomioka Y. Laparoscopic fundoplication for a child with abdominal intrathecal Baclofen pump. Asian J Endosc Surg 2020; 13:441-443. [PMID: 31430037 DOI: 10.1111/ases.12752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Revised: 05/31/2019] [Accepted: 07/31/2019] [Indexed: 11/30/2022]
Abstract
This is the first case report describing a laparoscopic fundoplication in a child with an intrathecal Baclofen pump which was inserted because of severe spasticity secondary to cerebral palsy. The child had symptoms of gastroesophageal reflux with recurrent episodes of aspiration pneumonia. These were managed with a gastrostomy and conservative therapy with no success. The presence of an intrathecal Baclofen pump makes abdominal surgery challenging and carries the risk of pump infection with its associated sequelae. However, we performed a successful laparoscopic fundoplication with no intraoperative complications and the child was asymptomatic at 18 months follow-up.
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Affiliation(s)
- Yuichi Okata
- Division of Pediatric Surgery, Department of Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Yuko Bitoh
- Division of Pediatric Surgery, Department of Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Yosuke Aida
- Division of Pediatric Surgery, Department of Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Harunori Miyauchi
- Division of Pediatric Surgery, Department of Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Taichi Nakatani
- Division of Pediatric Surgery, Department of Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Yuichiro Tomioka
- Division of Pediatric Surgery, Department of Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
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26
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Hagemann C, Schmitt I, Lischetzki G, Kunkel P. Intrathecal baclofen therapy for treatment of spasticity in infants and small children under 6 years of age. Childs Nerv Syst 2020; 36:767-773. [PMID: 31399764 DOI: 10.1007/s00381-019-04341-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Accepted: 08/05/2019] [Indexed: 11/27/2022]
Abstract
PURPOSE The aim of this study is to prove the efficacy and safety of intrathecal baclofen therapy in infants and children below 6 years of age by retrospective analysis of our pediatric cohort of 135 primary pump implantations. METHODS Between 2007 and 2018, 17 patients with pump implantations were below 6 years of age. Data were acquired retrospectively with a follow-up of 12 months to 11 years regarding complications. RESULTS The youngest infant was 11 months at implantation with a bodyweight of 6, 4 kg, and 63 cm length. Surgical complications were comparable to published literature and mainly involved the catheter (2 catheter dislocations and 1 catheter transection) and one pump infection resulting in 4 revision surgeries in 3 patients. One baclofen-related apnea during titration and an overdose after refill were treated conservatively. Using a subfascial implantation technique, we observed neither skin ulceration nor pump infection since 2007. In a growing child, catheter slides are common and related to growth, scoliosis, spine surgery, and surgical failure. CONCLUSION Intrathecal baclofen therapy in infants and small children is as safe and effective as published for older pediatric patients; therefore, intrathecal baclofen can be considered in all infants as long as an 8-cm incision fits into the triangle of the anterior superior iliac spine, costal margin of the 10th rib, and navel. We suggest the utilization of subfascial surgical technique for implantation pump and catheter. Titration of intrathecal baclofen should be performed slowly to avoid bradycardia in infants. This is a retrospective study (level of evidence 4).
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Affiliation(s)
- Christian Hagemann
- Department of Pediatric Neurosurgery, Altona Children's Hospital, Bleickenallee 38, 22763, Hamburg, Germany.
| | - Ilka Schmitt
- Department of Pediatric Neurosurgery, Altona Children's Hospital, Bleickenallee 38, 22763, Hamburg, Germany
| | - Grischa Lischetzki
- Department of Pediatric Neurology, Altona Children's Hospital, Bleickenallee 38, 22763, Hamburg, Germany
| | - Philip Kunkel
- Department of Pediatric Neurosurgery, Altona Children's Hospital, Bleickenallee 38, 22763, Hamburg, Germany
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27
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Novak I, Morgan C, Fahey M, Finch-Edmondson M, Galea C, Hines A, Langdon K, Namara MM, Paton MC, Popat H, Shore B, Khamis A, Stanton E, Finemore OP, Tricks A, Te Velde A, Dark L, Morton N, Badawi N. State of the Evidence Traffic Lights 2019: Systematic Review of Interventions for Preventing and Treating Children with Cerebral Palsy. Curr Neurol Neurosci Rep 2020; 20:3. [PMID: 32086598 PMCID: PMC7035308 DOI: 10.1007/s11910-020-1022-z] [Citation(s) in RCA: 427] [Impact Index Per Article: 106.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
PURPOSE OF REVIEW Cerebral palsy is the most common physical disability of childhood, but the rate is falling, and severity is lessening. We conducted a systematic overview of best available evidence (2012-2019), appraising evidence using GRADE and the Evidence Alert Traffic Light System and then aggregated the new findings with our previous 2013 findings. This article summarizes the best available evidence interventions for preventing and managing cerebral palsy in 2019. RECENT FINDINGS Effective prevention strategies include antenatal corticosteroids, magnesium sulfate, caffeine, and neonatal hypothermia. Effective allied health interventions include acceptance and commitment therapy, action observations, bimanual training, casting, constraint-induced movement therapy, environmental enrichment, fitness training, goal-directed training, hippotherapy, home programs, literacy interventions, mobility training, oral sensorimotor, oral sensorimotor plus electrical stimulation, pressure care, stepping stones triple P, strength training, task-specific training, treadmill training, partial body weight support treadmill training, and weight-bearing. Effective medical and surgical interventions include anti-convulsants, bisphosphonates, botulinum toxin, botulinum toxin plus occupational therapy, botulinum toxin plus casting, diazepam, dentistry, hip surveillance, intrathecal baclofen, scoliosis correction, selective dorsal rhizotomy, and umbilical cord blood cell therapy. We have provided guidance about what works and what does not to inform decision-making, and highlighted areas for more research.
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Affiliation(s)
- Iona Novak
- Cerebral Palsy Alliance Research Institute, Discipline of Child & Adolescent Health, Faculty of Medicine & Health, The University of Sydney, PO Box 6427, Frenchs Forest, Sydney, NSW, 2086, Australia.
| | - Catherine Morgan
- Cerebral Palsy Alliance Research Institute, Discipline of Child & Adolescent Health, Faculty of Medicine & Health, The University of Sydney, PO Box 6427, Frenchs Forest, Sydney, NSW, 2086, Australia
| | - Michael Fahey
- Department of Paediatric Neurology, Monash Health, Clayton, Victoria, Australia
- Department of Paediatrics, Monash University, Clayton, Victoria, Australia
| | - Megan Finch-Edmondson
- Cerebral Palsy Alliance Research Institute, Discipline of Child & Adolescent Health, Faculty of Medicine & Health, The University of Sydney, PO Box 6427, Frenchs Forest, Sydney, NSW, 2086, Australia
| | - Claire Galea
- Cerebral Palsy Alliance Research Institute, Discipline of Child & Adolescent Health, Faculty of Medicine & Health, The University of Sydney, PO Box 6427, Frenchs Forest, Sydney, NSW, 2086, Australia
- Grace Centre for Newborn Care, Children's Hospital at Westmead, Westmead, New South Wales, Australia
| | - Ashleigh Hines
- Cerebral Palsy Alliance Research Institute, Discipline of Child & Adolescent Health, Faculty of Medicine & Health, The University of Sydney, PO Box 6427, Frenchs Forest, Sydney, NSW, 2086, Australia
| | - Katherine Langdon
- Department of Paediatric Rehabilitation, Kids Rehab WA, Perth Children's Hospital, Perth, Australia
| | - Maria Mc Namara
- Cerebral Palsy Alliance Research Institute, Discipline of Child & Adolescent Health, Faculty of Medicine & Health, The University of Sydney, PO Box 6427, Frenchs Forest, Sydney, NSW, 2086, Australia
| | - Madison Cb Paton
- Cerebral Palsy Alliance Research Institute, Discipline of Child & Adolescent Health, Faculty of Medicine & Health, The University of Sydney, PO Box 6427, Frenchs Forest, Sydney, NSW, 2086, Australia
| | - Himanshu Popat
- Cerebral Palsy Alliance Research Institute, Discipline of Child & Adolescent Health, Faculty of Medicine & Health, The University of Sydney, PO Box 6427, Frenchs Forest, Sydney, NSW, 2086, Australia
- Grace Centre for Newborn Care, Children's Hospital at Westmead, Westmead, New South Wales, Australia
| | - Benjamin Shore
- Department of Orthopedic Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Amanda Khamis
- Cerebral Palsy Alliance Research Institute, Discipline of Child & Adolescent Health, Faculty of Medicine & Health, The University of Sydney, PO Box 6427, Frenchs Forest, Sydney, NSW, 2086, Australia
| | - Emma Stanton
- Cerebral Palsy Alliance Research Institute, Discipline of Child & Adolescent Health, Faculty of Medicine & Health, The University of Sydney, PO Box 6427, Frenchs Forest, Sydney, NSW, 2086, Australia
| | - Olivia P Finemore
- Cerebral Palsy Alliance Research Institute, Discipline of Child & Adolescent Health, Faculty of Medicine & Health, The University of Sydney, PO Box 6427, Frenchs Forest, Sydney, NSW, 2086, Australia
| | - Alice Tricks
- Cerebral Palsy Alliance Research Institute, Discipline of Child & Adolescent Health, Faculty of Medicine & Health, The University of Sydney, PO Box 6427, Frenchs Forest, Sydney, NSW, 2086, Australia
| | - Anna Te Velde
- Cerebral Palsy Alliance Research Institute, Discipline of Child & Adolescent Health, Faculty of Medicine & Health, The University of Sydney, PO Box 6427, Frenchs Forest, Sydney, NSW, 2086, Australia
| | - Leigha Dark
- Allied and Public Helath, Faculty of Health Sciences, Western Sydney University, Sydney, New South Wales, Australia
| | - Natalie Morton
- Allied and Public Helath, Faculty of Health Sciences, Western Sydney University, Sydney, New South Wales, Australia
- School of Allied Health, Australian Catholic University, North Sydney, New South Wales, Australia
| | - Nadia Badawi
- Cerebral Palsy Alliance Research Institute, Discipline of Child & Adolescent Health, Faculty of Medicine & Health, The University of Sydney, PO Box 6427, Frenchs Forest, Sydney, NSW, 2086, Australia
- Grace Centre for Newborn Care, Children's Hospital at Westmead, Westmead, New South Wales, Australia
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Davidson B, Schoen N, Sedighim S, Haldenby R, Dalziel B, Breitbart S, Fehlings D, Milo-Manson G, Narayanan UG, Drake JM, Ibrahim GM. Intrathecal baclofen versus selective dorsal rhizotomy for children with cerebral palsy who are nonambulant: a systematic review. J Neurosurg Pediatr 2020; 25:69-77. [PMID: 31628286 DOI: 10.3171/2019.8.peds19282] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Accepted: 08/01/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Cerebral palsy (CP) is the most common childhood physical disability. Historically, children with hypertonia who are nonambulatory (Gross Motor Function Classification System [GMFCS] level IV or V) were considered candidates for intrathecal baclofen (ITB) therapy to facilitate care and mitigate discomfort. Selective dorsal rhizotomy (SDR) was often reserved for ambulant children to improve gait. Recently, case series have suggested SDR as an alternative to ITB in selected children functioning at GMFCS level IV/V. The objective for this study was to systematically review the evidence for ITB and SDR in GMFCS level IV or V children. METHODS Medline, Embase, Web of Science, and Cochrane databases were systematically searched. Articles were screened using the following inclusion criteria: 1) peer-reviewed articles reporting outcomes after SDR or ITB; 2) outcomes reported using a quantifiable scale or standardized outcome measure; 3) patients were < 19 years old at the time of operation; 4) patients had a diagnosis of CP; 5) patients were GMFCS level IV/V or results were reported based on GMFCS status and included some GMFCS level IV/V patients; 6) article and/or abstract in English; and 7) primary indication for surgery was hypertonia. Included studies were assessed with the Risk of Bias in Non-Randomized Studies - of Interventions (ROBINS-I) tool. RESULTS Twenty-seven studies met inclusion criteria. The most commonly reported outcomes were spasticity (on the Mean Ashworth Scale) and gross motor function (using the Gross Motor Function Measure), although other outcomes including frequency of orthopedic procedures and complications were also reported. There is evidence from case series that suggests that both ITB and SDR can lower spasticity and improve gross motor function in this nonambulatory population. Complication rates are decidedly higher after ITB due in part to the ongoing risk of device-related complications. The heterogeneity among study design, patient selection, outcome selection, and follow-up periods was extremely high, preventing meta-analysis. There are no comparative studies, and meaningful health-related quality of life outcomes such as care and comfort are lacking. This review is limited by the high risk of bias among included studies. Studies of SDR or ITB that did not clearly describe patients as being GMFCS level IV/V or nonambulatory were excluded. CONCLUSIONS There is a lack of evidence comparing the outcomes of ITB and SDR in the nonambulatory CP population. This could be overcome with standardized prospective studies using more robust methodology and relevant outcome measures.
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Affiliation(s)
| | - Nathan Schoen
- 2University of Miami, Miller School of Medicine, Miami, Florida
| | - Shaina Sedighim
- 2University of Miami, Miller School of Medicine, Miami, Florida
| | - Renée Haldenby
- 3Department of Pediatrics, University of Toronto, Ontario, Canada
| | - Blythe Dalziel
- 3Department of Pediatrics, University of Toronto, Ontario, Canada
| | - Sara Breitbart
- 4Division of Orthopaedics, Hospital for Sick Children, University of Toronto; and
| | - Darcy Fehlings
- 3Department of Pediatrics, University of Toronto, Ontario, Canada
| | | | - Unni G Narayanan
- 4Division of Orthopaedics, Hospital for Sick Children, University of Toronto; and
| | - James M Drake
- 1Division of Neurosurgery, Department of Surgery, and
- 5Division of Neurosurgery, Hospital for Sick Children, Program in Neuroscience and Mental Health, Hospital for Sick Children Research Institute, University of Toronto, Ontario, Canada
| | - George M Ibrahim
- 1Division of Neurosurgery, Department of Surgery, and
- 5Division of Neurosurgery, Hospital for Sick Children, Program in Neuroscience and Mental Health, Hospital for Sick Children Research Institute, University of Toronto, Ontario, Canada
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29
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Imerci A, Rogers KJ, Pargas C, Sees JP, Miller F. Identification of complications in paediatric cerebral palsy treated with intrathecal baclofen pump: a descriptive analysis of 15 years at one institution. J Child Orthop 2019; 13:529-535. [PMID: 31695821 PMCID: PMC6808077 DOI: 10.1302/1863-2548.13.190112] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
PURPOSE Intrathecal baclofen (ITB) treatment is used with increasing frequency in the cerebral palsy population. We describe the complications of ITB treatment, the incidence of complications, and our experience with their treatment. METHODS In a period of 15 years, 341 paediatric patients with cerebral palsy treated with ITB were evaluated. Device problems associated with the catheter or pump, or infection and complications such as cerebrospinal fluid (CSF) leak and postdural spinal headache, were reviewed. Infection was classified as early (≤ 90 days) or late (> 90 days) according to the time of onset. RESULTS The infection rate was 6.9% per procedure (50/720) and 14.6% per patient (50/341) over a mean 6.3 ± 3.9 years. There was a positive correlation between the risk of infection and preoperative comorbidities including epilepsy/seizure history, feeding tube, and mixed type cerebral palsy (p < 0.05, p = 0.03, p = 0.01, respectively). Eighty-five (24.9%) patients experienced 90 CSF leak episodes; 61 of these 85 patients had headache complaints as a result of CSF leak. There was a positive correlation between the risk of early infection and CSF leak (p < 0.05). CONCLUSIONS The most common complication related to ITB was associated with pump and catheter problems. The rate of complications with the use of ITB is relatively high; however, based on the literature reports, it is the most effective treatment for severe spasticity and dystonia in patients with severe cerebral palsy. LEVEL OF EVIDENCE III.
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Affiliation(s)
- A. Imerci
- Department of Orthopaedic Surgery, Alfred I. duPont Hospital for Children Wilmington, Delaware, USA
| | - K. J. Rogers
- Department of Orthopaedic Surgery, Alfred I. duPont Hospital for Children Wilmington, Delaware, USA
| | - C. Pargas
- Department of Orthopaedic Surgery, Alfred I. duPont Hospital for Children Wilmington, Delaware, USA
| | - J. P. Sees
- Department of Orthopaedic Surgery, Alfred I. duPont Hospital for Children Wilmington, Delaware, USA
| | - F. Miller
- Department of Orthopaedic Surgery, Alfred I. duPont Hospital for Children Wilmington, Delaware, USA,Correspondence should be sent to F. Miller, Alfred I. duPont Hospital for Children, Department of Orthopaedics, 1600 Rockland Road, Wilmington, DE 19803, USA. E-mail:
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Abstract
During the past 25 years, botulinum toxin type A (BoNT-A) has become the most widely used medical intervention in children with cerebral palsy. In this review we consider the gaps in our knowledge in the use of BoNT-A and reasons why muscle morphology and function in children with cerebral palsy are impaired. We review limitations in our knowledge regarding the mechanisms underlying the development of contractures and the difficulty in preventing them. It is clear from this review that injection of BoNT-A in the large muscles of both the upper and lower limbs of children with cerebral palsy will result in a predictable decrease in muscle activity, which is usually reported as a reduction in spasticity, for between 3 and 6 months. These changes are noted by the use of clinical tools such as the Modified Ashworth Scale and the Modified Tardieu Scale. Decreased muscle over-activity usually results in improved range of motion in distal joints. Injection of the gastrocnemius muscle for toe-walking in a child with hemiplegia or diplegia usually has the effect of increasing the passive range of dorsiflexion at the ankle. In our review, we found that this may result in a measurable improvement in gait by the use of observational gait scales or gait analysis, in some children. However, improvements in gait function are not always achieved and are small in magnitude and short lived. We found that some of the differences in outcomes in clinical trials may relate to the use of adjunctive interventions such as serial casting, orthoses, night splints and intensive therapy. We note that the majority of clinical trials of the use of BoNT-A in children with cerebral palsy have focussed on a single injection cycle and this is insufficient to understand the balance between benefit and harm. Most outcomes were reported in terms of changes in muscle tone and there were fewer studies with robust methodology that reported improvements in function. Changes in the domains of activities and participation have rarely been reported in studies to date. There were no clinical reviews to date that consider the findings of studies in human volunteers and in experimental animals and their relevance to clinical protocols. In this review we found that studies in human volunteers and in experimental animals show muscle atrophy after an injection of BoNT-A for at least 12 months. Muscle atrophy was accompanied by loss of contractile elements in muscle and replacement with fat and connective tissue. It is not currently known if these changes, mediated at a molecular level, are reversible. We conclude that there is a need to revise clinical protocols by using BoNT-A more thoughtfully, less frequently and with greatly enhanced monitoring of the effects on injected muscle for both short-term and long-term benefits and harms.
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Affiliation(s)
- Iqbal Multani
- Royal Children's Hospital, 50 Flemington Road, Parkville, VIC, 3052, Australia
- Orthopaedic Department, Royal Children's Hospital, 50 Flemington Road, Parkville, VIC, 3052, Australia
| | - Jamil Manji
- Royal Children's Hospital, 50 Flemington Road, Parkville, VIC, 3052, Australia
- Orthopaedic Department, Royal Children's Hospital, 50 Flemington Road, Parkville, VIC, 3052, Australia
| | - Tandy Hastings-Ison
- Royal Children's Hospital, 50 Flemington Road, Parkville, VIC, 3052, Australia
- Hugh Williamson Gait Laboratory, Royal Children's Hospital, 50 Flemington Road, Parkville, VIC, 3052, Australia
| | - Abhay Khot
- Royal Children's Hospital, 50 Flemington Road, Parkville, VIC, 3052, Australia
- Orthopaedic Department, Royal Children's Hospital, 50 Flemington Road, Parkville, VIC, 3052, Australia
- Hugh Williamson Gait Laboratory, Royal Children's Hospital, 50 Flemington Road, Parkville, VIC, 3052, Australia
| | - Kerr Graham
- Royal Children's Hospital, 50 Flemington Road, Parkville, VIC, 3052, Australia.
- Orthopaedic Department, Royal Children's Hospital, 50 Flemington Road, Parkville, VIC, 3052, Australia.
- Hugh Williamson Gait Laboratory, Royal Children's Hospital, 50 Flemington Road, Parkville, VIC, 3052, Australia.
- University of Melbourne, Parkville, Australia.
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Nguyen L, Cross A, Rosenbaum P, Gorter JW. Use of the International Classification of Functioning, Disability and Health to support goal-setting practices in pediatric rehabilitation: a rapid review of the literature. Disabil Rehabil 2019; 43:884-894. [PMID: 31345067 DOI: 10.1080/09638288.2019.1643419] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
INTRODUCTION The International Classification of Functioning, Disability and Health (referred to as the ICF) is the World Health Organization's framework for health. It can be used to identify goals that capture all aspects of a person's life and to inform clinical goal-setting processes. This review aims to report how healthcare providers are using the ICF framework to support goal-setting practices in pediatric rehabilitation services. METHODS A rapid review was conducted using scoping review principles in the following databases: CINAHL, Medline and PsycINFO. Key terms included: "ICF", "goal-setting" and "pediatrics". RESULTS Sixteen studies met the inclusion criteria. Three main themes emerged about the use of the ICF in pediatric rehabilitation: 1) match the content of goals to the ICF domains; 2) implement with existing tools for goal-setting; and 3) inform the development of new tools for goal-setting. Healthcare providers often use a combination of goal-setting tools. The SMART approach is used to frame goals, while the Canadian Occupational Performance Measure and Goal Attainment Scale have been used to document and evaluate goals. CONCLUSION The ICF framework can be used with current goal-setting practices and offers a common lens and language with which to facilitate collaborative goal-setting with families and healthcare providers.Implications for RehabilitationThe International Classification of Functioning, Disability and Health (ICF) provides a common framework and language to support collaborative goal-setting between families and healthcare providersDespite the opportunity for the ICF to be used as a framework with goal-setting approaches, to date the ICF has mainly been used to match the content of goals to ICF domains for documentation purposesThe ICF should be incorporated into the established clinical routines in order to promote its use among healthcare providersThe ICF can be used with existing goal-setting tools in clinical practice and to inform the ongoing development of new tools to support the goal-setting process in family-centred services.
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Affiliation(s)
- Linda Nguyen
- CanChild Centre for Childhood Disability Research, McMaster University, Hamilton, Ontario, Canada.,School of Rehabilitation Science, McMaster University, Hamilton, Ontario, Canada
| | - Andrea Cross
- CanChild Centre for Childhood Disability Research, McMaster University, Hamilton, Ontario, Canada.,School of Rehabilitation Science, McMaster University, Hamilton, Ontario, Canada
| | - Peter Rosenbaum
- CanChild Centre for Childhood Disability Research, McMaster University, Hamilton, Ontario, Canada.,School of Rehabilitation Science, McMaster University, Hamilton, Ontario, Canada.,Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada
| | - Jan Willem Gorter
- CanChild Centre for Childhood Disability Research, McMaster University, Hamilton, Ontario, Canada.,School of Rehabilitation Science, McMaster University, Hamilton, Ontario, Canada.,Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada
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Lizarraga KJ, Al-Shorafat D, Fox S. Update on current and emerging therapies for dystonia. Neurodegener Dis Manag 2019; 9:135-147. [PMID: 31117876 DOI: 10.2217/nmt-2018-0047] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Treatment strategies for dystonia depend on the focal, segmental or generalized distribution of symptoms. Chemodenervation with botulinum toxin remains the treatment of choice for focal- or select-body regions in generalized and segmental dystonia. A potentially longer acting formulation of botulinum toxin is being investigated besides the currently available formulations. Electromyography increases toxin injection accuracy and may reduce injection number, frequency, side effects and costs by identifying dystonic muscle activity. Oral anticholinergics, baclofen and clonazepam are used off-label, but novel drugs in development include sodium oxybate, zonisamide and perampanel. Characterizing dystonia as a sensorimotor circuit disorder has prompted the use of noninvasive neuromodulation procedures. These techniques need further study but simultaneous rehabilitation techniques appear to also improve outcomes. Pallidal deep-brain stimulation is beneficial for medication-refractory primary generalized and possibly focal dystonia such as cervical dystonia. Certain genetic conditions are amenable to specific therapies and future gene-targeted therapies could benefit selected dystonia patients.
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Affiliation(s)
- Karlo J Lizarraga
- The Edmond J Safra Program in Parkinson's Disease & the Morton & Gloria Shulman Movement Disorders Clinic, Division of Neurology, Department of Medicine, Toronto Western Hospital, University of Toronto, Toronto, M5T2S8 ON, Canada
| | - Duha Al-Shorafat
- The Edmond J Safra Program in Parkinson's Disease & the Morton & Gloria Shulman Movement Disorders Clinic, Division of Neurology, Department of Medicine, Toronto Western Hospital, University of Toronto, Toronto, M5T2S8 ON, Canada
| | - Susan Fox
- The Edmond J Safra Program in Parkinson's Disease & the Morton & Gloria Shulman Movement Disorders Clinic, Division of Neurology, Department of Medicine, Toronto Western Hospital, University of Toronto, Toronto, M5T2S8 ON, Canada
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Bonouvrié LA, Becher JG, Vles JSH, Vermeulen RJ, Buizer AI. The Effect of Intrathecal Baclofen in Dyskinetic Cerebral Palsy: The IDYS Trial. Ann Neurol 2019; 86:79-90. [PMID: 31050023 PMCID: PMC6617761 DOI: 10.1002/ana.25498] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Revised: 05/01/2019] [Accepted: 05/01/2019] [Indexed: 01/04/2023]
Abstract
Objective Intrathecal baclofen treatment is used for the treatment of dystonia in patients with severe dyskinetic cerebral palsy; however, the current level of evidence for the effect is low. The primary aim of this study was to provide evidence for the effect of intrathecal baclofen treatment on individual goals in patients with severe dyskinetic cerebral palsy. Methods This multicenter, randomized, double‐blind, placebo‐controlled trial was performed at 2 university medical centers in the Netherlands. Patients with severe dyskinetic cerebral palsy (Gross Motor Functioning Classification System level IV–V) aged 4 to 24 years who were eligible for intrathecal baclofen were included. Patients were assigned by block randomization (2:2) for treatment with intrathecal baclofen or placebo for 3 months via an implanted microinfusion pump. The primary outcome was goal attainment scaling of individual treatment goals (GAS T score). A linear regression model was used for statistical analysis with study site as a covariate. Safety analyses were done for number and type of (serious) adverse events. Results Thirty‐six patients were recruited from January 1, 2013, to March 31, 2018. Data for final analysis were available for 17 patients in the intrathecal baclofen group and 16 in the placebo group. Mean (standard deviation) GAS T score at 3 months was 38.9 (13.2) for intrathecal baclofen and 21.0 (4.6) for placebo (regression coefficient = 17.8, 95% confidence interval = 10.4‐25.0, p < 0.001). Number and types of (serious) adverse events were similar between groups. Interpretation Intrathecal baclofen treatment is superior to placebo in achieving treatment goals in patients with severe dyskinetic cerebral palsy. ANN NEUROL 2019
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Affiliation(s)
- Laura A Bonouvrié
- Amsterdam University Medical Center, Free University Amsterdam, Department of Rehabilitation Medicine, Amsterdam Neuroscience, Amsterdam, the Netherlands
| | - Jules G Becher
- Amsterdam University Medical Center, Free University Amsterdam, Department of Rehabilitation Medicine, Amsterdam Movement Sciences, Amsterdam, the Netherlands
| | - Johan S H Vles
- Maastricht University Medical Center, Department of Child Neurology, Maastricht, the Netherlands
| | - R Jeroen Vermeulen
- Maastricht University Medical Center, Department of Child Neurology, Maastricht, the Netherlands.,Amsterdam University Medical Center, Free University Amsterdam, Department of Child Neurology, Amsterdam Neuroscience, Amsterdam, the Netherlands
| | - Annemieke I Buizer
- Amsterdam University Medical Center, Free University Amsterdam, Department of Rehabilitation Medicine, Amsterdam Movement Sciences, Amsterdam, the Netherlands
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Scheinberg A. Beyond body structure in intrathecal baclofen therapy. Dev Med Child Neurol 2019; 61:110. [PMID: 30221771 DOI: 10.1111/dmcn.14042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Adam Scheinberg
- Murdoch Children's Research Institute, Parkville, Victoria, Australia
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