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Lewis SA, Aravamuthan B, Fehlings D, Kruer MC. Evolving understanding of CP phenotypes: the importance of dystonia. Pediatr Res 2024:10.1038/s41390-024-03327-9. [PMID: 38926549 DOI: 10.1038/s41390-024-03327-9] [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] [Received: 02/18/2024] [Accepted: 03/15/2024] [Indexed: 06/28/2024]
Abstract
Cerebral palsy (CP) is the core neurodevelopmental disorder affecting movement. Several distinct movement disorders can occur in people with cerebral palsy. Dystonia is a movement disorder that causes non-velocity-dependent hypertonia and/or abnormal, often repetitive, twisting movements, and/or postures. Dystonia occurs more frequently in patients with CP than has been recognized previously, and is treated differently than other aspects of CP. Dystonia is an important cause of chronic pain, hospitalization, and musculoskeletal complications. We describe recent advances in dystonia diagnosis in patients with cerebral palsy and highlight focus areas for ongoing research and clinical care. IMPACT: Dystonia is a movement disorder that is more common in people with cerebral palsy (CP) than previously thought. Dystonia contributes to hospitalization, chronic pain, and complications in CP patients. People with dystonic CP require different tools to diagnose and treat their condition. We summarize current state of the art in dystonia in CP and identify areas of focus for future work.
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Affiliation(s)
- Sara A Lewis
- Departments of Cellular & Molecular Medicine, Child Health, and Neurology and Program in Genetics, University of Arizona College of Medicine - Phoenix, Phoenix, AZ, USA
- Pediatric Movement Disorders Program, Barrow Neurological Institute, Phoenix Children's, Phoenix, AZ, USA
| | - Bhooma Aravamuthan
- Division of Pediatric Neurology, Department of Neurology, School of Medicine, Washington University in St Louis and St Louis Children's Hospital, St Louis, MO, USA
| | - Darcy Fehlings
- Holland Bloorview Kids Rehabilitation Hospital, Deparment of Paediatrics, University of Toronto, Toronto, ON, Canada
| | - Michael C Kruer
- Departments of Cellular & Molecular Medicine, Child Health, and Neurology and Program in Genetics, University of Arizona College of Medicine - Phoenix, Phoenix, AZ, USA.
- Pediatric Movement Disorders Program, Barrow Neurological Institute, Phoenix Children's, Phoenix, AZ, USA.
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2
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Lott E, Fehlings D, Gelineau-Morel R, Kruer M, Mink JW, Thomas SP, Wisniewski S, Aravamuthan B. Physician Approaches to the Pharmacologic Treatment of Dystonia in Cerebral Palsy. Pediatrics 2024; 154:e2023065512. [PMID: 38836309 PMCID: PMC11211688 DOI: 10.1542/peds.2023-065512] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Revised: 04/08/2024] [Accepted: 04/11/2024] [Indexed: 06/06/2024] Open
Affiliation(s)
- Emma Lott
- Division of Pediatric Neurology, Department of Neurology, Washington University School of Medicine, St Louis, Missouri
| | - Darcy Fehlings
- Division of Developmental Paediatrics, Department of Paediatrics, Holland Bloorview Kids Rehabilitation Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Rose Gelineau-Morel
- Division of Neurology, Department of Pediatrics, University of Missouri-Kansas City School of Medicine, Children’s Mercy Kansas City, Kansas City, Missouri
| | - Michael Kruer
- Barrow Neurologic Institute, Phoenix Children's Hospital, Departments of Child Health, Cellular and Molecular Medicine, Genetics, and Neurology, University of Arizona College of Medicine-Phoenix, Phoenix, Arizona
| | | | - Sruthi P. Thomas
- H. Ben Taub Department of Physical Medicine and Rehabilitation and Departments of Neurosurgery and Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Steve Wisniewski
- Department of Epidemiology, Epidemiology Data Center, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Bhooma Aravamuthan
- Division of Pediatric Neurology, Department of Neurology, Washington University School of Medicine, St Louis, Missouri
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3
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San Luciano M, Oehrn CR, Wang SS, Tolmie JS, Wiltshire A, Graff RE, Zhu J, Starr PA. Protocol for combined N-of-1 trials to assess cerebellar neurostimulation for movement disorders in children and young adults with dyskinetic cerebral palsy. BMC Neurol 2024; 24:145. [PMID: 38684956 PMCID: PMC11057158 DOI: 10.1186/s12883-024-03633-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2024] [Accepted: 04/09/2024] [Indexed: 05/02/2024] Open
Abstract
BACKGROUND Movement and tone disorders in children and young adults with cerebral palsy are a great source of disability. Deep brain stimulation (DBS) of basal ganglia targets has a major role in the treatment of isolated dystonias, but its efficacy in dyskinetic cerebral palsy (DCP) is lower, due to structural basal ganglia and thalamic damage and lack of improvement of comorbid choreoathetosis and spasticity. The cerebellum is an attractive target for DBS in DCP since it is frequently spared from hypoxic ischemic damage, it has a significant role in dystonia network models, and small studies have shown promise of dentate stimulation in improving CP-related movement and tone disorders. METHODS Ten children and young adults with DCP and disabling movement disorders with or without spasticity will undergo bilateral DBS in the dorsal dentate nucleus, with the most distal contact ending in the superior cerebellar peduncle. We will implant Medtronic Percept, a bidirectional neurostimulator that can sense and store brain activity and deliver DBS therapy. The efficacy of cerebellar DBS in improving quality of life and motor outcomes will be tested by a series of N-of-1 clinical trials. Each N-of-1 trial will consist of three blocks, each consisting of one month of effective stimulation and one month of sham stimulation in a random order with weekly motor and quality of life scales as primary and secondary outcomes. In addition, we will characterize abnormal patterns of cerebellar oscillatory activity measured by local field potentials from the intracranial electrodes related to clinical assessments and wearable monitors. Pre- and 12-month postoperative volumetric structural and functional MRI and diffusion tensor imaging will be used to identify candidate imaging markers of baseline disease severity and response to DBS. DISCUSSION Our goal is to test a cerebellar neuromodulation therapy that produces meaningful changes in function and well-being for people with CP, obtain a mechanistic understanding of the underlying brain network disorder, and identify physiological and imaging-based predictors of outcomes useful in planning further studies. TRIAL REGISTRATION ClinicalTrials.gov NCT06122675, first registered November 7, 2023.
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Affiliation(s)
- M San Luciano
- Movement Disorders and Neuromodulation Center, Department of Neurology, University of California San Francisco, Weill Institute for Neurosciences, 1651 4th Street Level 3 SW Academic Offices, Box #1838, 94158, San Francisco, CA, USA.
| | - C R Oehrn
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA, USA
| | - S S Wang
- Movement Disorders and Neuromodulation Center, Department of Neurology, University of California San Francisco, Weill Institute for Neurosciences, 1651 4th Street Level 3 SW Academic Offices, Box #1838, 94158, San Francisco, CA, USA
| | - J S Tolmie
- Movement Disorders and Neuromodulation Center, Department of Neurology, University of California San Francisco, Weill Institute for Neurosciences, 1651 4th Street Level 3 SW Academic Offices, Box #1838, 94158, San Francisco, CA, USA
| | - A Wiltshire
- Movement Disorders and Neuromodulation Center, Department of Neurology, University of California San Francisco, Weill Institute for Neurosciences, 1651 4th Street Level 3 SW Academic Offices, Box #1838, 94158, San Francisco, CA, USA
| | - R E Graff
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, CA, USA
| | - J Zhu
- Movement Disorders and Neuromodulation Center, Department of Neurology, University of California San Francisco, Weill Institute for Neurosciences, 1651 4th Street Level 3 SW Academic Offices, Box #1838, 94158, San Francisco, CA, USA
| | - P A Starr
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA, USA
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Masrour M, Zare A, Presedo A, Nabian MH. Intrathecal baclofen efficacy for managing motor function and spasticity severity in patients with cerebral palsy: a systematic review and meta-analysis. BMC Neurol 2024; 24:143. [PMID: 38678195 PMCID: PMC11055284 DOI: 10.1186/s12883-024-03647-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Accepted: 04/19/2024] [Indexed: 04/29/2024] Open
Abstract
BACKGROUND Spasticity can significantly affect a patient's quality of life, caregiver satisfaction, and the financial burden on the healthcare system. Baclofen is one of only a few options for treating spasticity. The purpose of this study is to investigate the impact of intrathecal baclofen (ITB) therapy on severe40.23 spasticity and motor function in patients with cerebral palsy. METHODS We conducted a systematic review in PubMed, Scopus, Ovid, and the Cochrane Library in accordance with the PRISMA guidelines. We included studies based on eligibility criteria that included desired participants (cerebral palsy patients with spasticity), interventions (intrathecal baclofen), and outcomes (the Ashworth scales and the Gross Motor Function Measure [GMFM]). The within-group Cohen's d standardized mean differences (SMD) were analyzed using the random effect model. RESULTS We screened 768 papers and included 19 in the severity of spasticity section and 6 in the motor function section. The pre-intervention average spasticity score (SD) was 3.2 (0.78), and the post-intervention average score (SD) was 1.9 (0.72), showing a 40.25% reduction. The SMD for spasticity reduction was - 1.7000 (95% CI [-2.1546; -1.2454], p-value < 0.0001), involving 343 patients with a weighted average age of 15.78 years and a weighted average baclofen dose of 289 µg/day. The SMD for the MAS and Ashworth Scale subgroups were - 1.7845 (95% CI [-2.8704; -0.6986]) and - 1.4837 (95% CI [-1.8585; -1.1088]), respectively. We found no relationship between the participants' mean age, baclofen dose, measurement time, and the results. The pre-intervention average GMFM (SD) was 40.03 (26.01), and the post-intervention average score (SD) was 43.88 (26.18), showing a 9.62% increase. The SMD for motor function using GMFM was 0.1503 (95% CI [0.0784; 0.2223], p-value = 0.0030), involving 117 patients with a weighted average age of 13.63 and a weighted average baclofen dose of 203 µg/day. In 501 ITB implantations, 203 medical complications were reported, including six new-onset seizures (2.96% of medical complications), seven increased seizure frequency (3.45%), 33 infections (16.26%), eight meningitis (3.94%), and 16 cerebrospinal fluid leaks (7.88%). Delivery system complications, including 75 catheter and pump complications, were also reported. CONCLUSION Despite the risk of complications, ITB has a significant impact on the reduction of spasticity. A small but statistically significant improvement in motor function was also noted in a group of patients.
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Affiliation(s)
- Mahdi Masrour
- School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
- Center for Orthopedic Trans-Disciplinary Applied Research, Tehran University of Medical Sciences, Tehran, Iran
| | - Amir Zare
- School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Ana Presedo
- Department of Pediatric Orthopedics, Robert Debré University Hospital, Paris, France.
| | - Mohammad Hossein Nabian
- Center for Orthopedic Trans-Disciplinary Applied Research, Tehran University of Medical Sciences, Tehran, Iran.
- Department of Pediatric Orthopedics, Robert Debré University Hospital, Paris, France.
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Fehlings D, Agnew B, Gimeno H, Harvey A, Himmelmann K, Lin JP, Mink JW, Monbaliu E, Rice J, Bohn E, Falck-Ytter Y. Pharmacological and neurosurgical management of cerebral palsy and dystonia: Clinical practice guideline update. Dev Med Child Neurol 2024. [PMID: 38640091 DOI: 10.1111/dmcn.15921] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Revised: 02/26/2024] [Accepted: 03/01/2024] [Indexed: 04/21/2024]
Abstract
Dystonia, typically characterized by slow repetitive involuntary movements, stiff abnormal postures, and hypertonia, is common among individuals with cerebral palsy (CP). Dystonia can interfere with activities and have considerable impact on motor function, pain/comfort, and ease of caregiving. Although pharmacological and neurosurgical approaches are used clinically in individuals with CP and dystonia that is causing interference, evidence to support these options is limited. This clinical practice guideline update comprises 10 evidence-based recommendations on the use of pharmacological and neurosurgical interventions for individuals with CP and dystonia causing interference, developed by an international expert panel following the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach. The recommendations are intended to help inform clinicians in their use of these management options for individuals with CP and dystonia, and to guide a shared decision-making process in selecting a management approach that is aligned with the individual's and the family's values and preferences.
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Affiliation(s)
- Darcy Fehlings
- Department of Paediatrics, Bloorview Research Institute, Holland Bloorview Kids Rehabilitation Hospital, University of Toronto, Toronto, ON, Canada
| | - Brenda Agnew
- Family Advisor AACPDM, CP-NET, Burlington, Ontario, Canada
| | - Hortensia Gimeno
- Barts NHS Health and Queen Mary University of London, Wolfson Institute of Population Health, Centre for Preventive Neurology, London, UK
| | - Adrienne Harvey
- Neurodisability and Rehabilitation, Murdoch Children's Research Institute, Parkville, VIC, Australia
| | - Kate Himmelmann
- Department of Pediatrics, Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Jean-Pierre Lin
- Faculty of Life Sciences & Medicine, King's Health Partners, Complex Motor Disorders Service, Evelina London Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, Women's and Children's Health Institute, London, UK
| | - Jonathan W Mink
- Department of Neurology, University of Rochester, Rochester, NY, USA
| | - Elegast Monbaliu
- Neurorehabilitation Technology, Lab KU Leuven Campus Brugge, Brugge, Belgium
| | - James Rice
- Paediatric Rehabilitation Department, Women's and Children's Hospital, North Adelaide, SA, Australia
| | - Emma Bohn
- Department of Paediatrics, Bloorview Research Institute, Holland Bloorview Kids Rehabilitation Hospital, University of Toronto, Toronto, ON, Canada
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Almutairi AB, Alrashdi NZ, Vogtle L, Alotaibi MM. Effect of psychostimulant medications on physical function in children with cerebral palsy: scoping review. Pediatr Res 2024; 95:1217-1223. [PMID: 38071277 DOI: 10.1038/s41390-023-02933-3] [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: 09/19/2023] [Revised: 10/18/2023] [Accepted: 11/14/2023] [Indexed: 04/24/2024]
Abstract
The aim of this scoping review is to examine the extent and depth of the literature on effects of central nervous system (CNS) stimulant medications on physical function in children with cerebral palsy (CP). A systematic search for relevant peer-reviewed studies was conducted of PubMed, CINAHL, Cochrane, SPORTDiscus, Embase, & Scopus (January 2002 & August 2022). We included studies that examined the effects of CNS stimulants on physical function in children with CP. Four studies met our selection criteria. All studies explored the effect of Modafinil on physical function outcomes. Three studies of the four included studies reported positive effects of Modafinil on spasticity, motor performance, and gait, whereas one study reported no significant effects of Modafinil. Our findings suggest that there is very low-quality evidence that suggests that Modafinil may enhance physical improvements in body structure and function, including reduction in spasticity and improvements in gait parameters. IMPACT: Central nervous system stimulants were examined for efficacy on physical function and spasticity in children with cerebral palsy. The evidence on the effects of central nervous system stimulants on physical function in children with CP is limited and inconsistent.
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Affiliation(s)
- Anwar B Almutairi
- Department of Physical Therapy, Faculty of Allied Health, Kuwait University, Jabriya, Kuwait.
| | - Naif Z Alrashdi
- Department of Physical Therapy and Health Rehabilitation, College of Applied Medical Sciences, Majmaah University, Al-Majmaah, Saudi Arabia
| | - Laura Vogtle
- Department of Occupational Therapy, School of Health Professions, Birmingham, The University of Alabama at Birmingham, Birmingham, AL, USA
| | - Mansour M Alotaibi
- Department of Rehabilitation, Faculty of Applied Medical Sciences, Northern Border University, Arar, Saudi Arabia
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7
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San Luciano M, Oehrn CR, Wang SS, Tolmie JS, Wiltshire A, Graff RE, Zhu J, Starr PA. Protocol for combined N-of-1 trials to assess cerebellar neurostimulation for movement disorders in children and young adults with dyskinetic cerebral palsy. RESEARCH SQUARE 2024:rs.3.rs-4077387. [PMID: 38645256 PMCID: PMC11030503 DOI: 10.21203/rs.3.rs-4077387/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/23/2024]
Abstract
Background Movement and tone disorders in children and young adults with cerebral palsy are a great source of disability. Deep brain stimulation (DBS) of basal ganglia targets has a major role in the treatment of isolated dystonias, but its efficacy in dyskinetic cerebral palsy (DCP) is lower, due to structural basal ganglia and thalamic damage and lack of improvement of comorbid choreoathetosis and spasticity. The cerebellum is an attractive target for DBS in DCP since it is frequently spared from hypoxic ischemic damage, it has a significant role in dystonia network models, and small studies have shown promise of dentate stimulation in improving CP-related movement and tone disorders. Methods Ten children and young adults with DCP and disabling movement disorders with or without spasticity will undergo bilateral DBS in the dorsal dentate nucleus, with the most distal contact ending in the superior cerebellar peduncle. We will implant Medtronic Percept, a bidirectional neurostimulator that can sense and store brain activity and deliver DBS therapy. The efficacy of cerebellar DBS in improving quality of life and motor outcomes will be tested by a series of N-of-1 clinical trials. Each N-of-1 trial will consist of three blocks, each consisting of one month of effective stimulation and one month of sham stimulation in a random order with weekly motor and quality of life scales as primary and secondary outcomes. In addition, we will characterize abnormal patterns of cerebellar oscillatory activity measured by local field potentials from the intracranial electrodes related to clinical assessments and wearable monitors. Pre- and 12-month postoperative volumetric structural and functional MRI and diffusion tensor imaging will be used to identify candidate imaging markers of baseline disease severity and response to DBS. Discussion Our goal is to test a cerebellar neuromodulation therapy that produces meaningful changes in function and well-being for people with CP, obtain a mechanistic understanding of the underlying brain network disorder, and identify physiological and imaging-based predictors of outcomes useful in planning further studies. Trial registration ClinicalTrials.gov NCT06122675, first registered November 7, 2023.
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Affiliation(s)
- Marta San Luciano
- University of California, San Francisco, Weill Institute for Neurosciences
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Alotaibi M, Almutairi AB, Alhirsan S, Alkazemi A, Alharbi M, Alrashdi N, Taqi A, Alamiri B, Vogtle L, Alqahtani MM. Psychostimulant Medications for Physical Function and Spasticity in Children With Cerebral Palsy: Protocol for a Randomized Controlled Trial. JMIR Res Protoc 2024; 13:e53728. [PMID: 38441919 PMCID: PMC10951828 DOI: 10.2196/53728] [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: 10/17/2023] [Revised: 02/06/2024] [Accepted: 02/09/2024] [Indexed: 03/07/2024] Open
Abstract
BACKGROUND Cerebral palsy (CP) is a prevalent nonprogressive disorder that leads to impaired movement (ie, spasticity), posture, and balance, which affects functions such as walking and upper extremity tasks. Current medical treatments show efficacy in improving motor performance but have considerable side effects. Emerging off-label use of central nervous system (CNS) medications for improving motor performance has shown promising results in children with CP and other populations. OBJECTIVE The aim of this study is to describe a protocol for a pilot randomized controlled trial (RCT) to examine the safety, tolerability, and efficacy of methylphenidate (MPH) and modafinil on spasticity and motor performance in children with CP. METHODS This will be a protocol study for a pilot, triple-masked, placebo-controlled RCT (a class I trial following the American Academy of Neurology criteria) with blinded patients, outcome assessors, and intervention delivery team. Eligible children should be diagnosed with CP levels I or II based on the Gross Motor Function Classification System and be aged between 7 and 12 years. Thirty-six children with CP will be randomized into 3 groups to receive (1) MPH (2.5 mg of MPH + 100 mg placebo), (2) modafinil (100 mg modafinil + 2.5 mg placebo), or (3) a placebo (2.5 mg placebo + 100 mg placebo), in addition to physical therapy for 12 weeks. Primary outcomes include the Gross Motor Function Measure-66 and the Modified Ashworth Scale. Secondary outcomes include the Timed Up and Go test, 5 Time Sit to Stand test, Modified Clinical Test for Sensory Interaction of Balance, and 10-Meter Walk Test. RESULTS The protocol has been accepted by Kuwait University (VDR/EC-225) and the Ministry of Health of Kuwait (2022/2157). The inclusion of participants will start in June 2024. CONCLUSIONS The combination of CNS stimulant medications and controlling for rehabilitation has not been studied yet. The findings of this study may determine if using CNS stimulant medications is beneficial for the reduction of spasticity and improvement of physical function in children with spastic CP. TRIAL REGISTRATION ClinicalTrials.gov NCT05675098; https://clinicaltrials.gov/study/NCT05675098. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) PRR1-10.2196/53728.
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Affiliation(s)
- Mansour Alotaibi
- Department of Rehabilitation, Faculty of Applied Medical Sciences, Northern Border University, Arar, Saudi Arabia
- Center for Health Research, Northern Border University, Arar, Saudi Arabia
| | - Anwar B Almutairi
- Department of Physical Therapy, Faculty of Allied Health, Kuwait University, Kuwait City, Kuwait
| | - Saleh Alhirsan
- Department of Physical Therapy, College of Applied Medical Sciences, Jouf University, Aljouf, Saudi Arabia
| | - Afrah Alkazemi
- Department of Pharmacy Practice, College of Pharmacy, Kuwait University, Kuwait City, Kuwait
| | - Maha Alharbi
- Department of Pharmacy Practice, College of Pharmacy, Kuwait University, Kuwait City, Kuwait
| | - Naif Alrashdi
- Department of Physical Therapy and Health Rehabilitation, College of Applied Medical Sciences, Majmaah University, Al-Majmaah, Saudi Arabia
- The Health and Scientific Research Center, Majmaah University, Majmaah, Saudi Arabia
| | - Ahmad Taqi
- Department of Pharmacy Practice, College of Pharmacy, Kuwait University, Kuwait City, Kuwait
| | - Bibi Alamiri
- Kuwait Center for Mental Health, Public Authority for Disability Affairs, Almanara, Kuwait
| | - Laura Vogtle
- Department of Occupational Therapy, School of Health Professions, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Mohammed M Alqahtani
- Department of Respiratory Therapy, College of Applied Medical Sciences, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
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9
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Liu C, Lan C, Chen Y. The use of sertraline to treat an adolescent of dystonia comorbid with major depressive disorder with psychotic features. Neuropsychopharmacol Rep 2024; 44:275-279. [PMID: 37987035 PMCID: PMC10932769 DOI: 10.1002/npr2.12401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Revised: 10/21/2023] [Accepted: 11/04/2023] [Indexed: 11/22/2023] Open
Abstract
Dystonia is characterized by sustained or intermittent involuntary muscle contractions. Psychiatric symptoms are essential non-motor features of dystonia, and higher risks of depressive and anxiety disorders have been reported. The precedence of psychiatric to motor symptoms in some patients and the dopaminergic and serotonergic system involvement in both the motor and psychiatric aspects suggest these psychiatric disorders may be intrinsic to the neurobiology of dystonia. Nevertheless, psychiatric comorbidities are often construed as secondary reactions to motor disabilities and the negative bio-psycho-social impacts of dystonia, leading to underdiagnosis and undertreatment. Research on antidepressant use in dystonia is scarce, especially in children and adolescents. This report presents a 17-year-old female with dystonia comorbid with depression with psychotic features, whose motor symptoms improved but psychiatric symptoms persisted with dopaminergic pharmacotherapy. Sertraline was finally added 5 years after the onset and successfully managed her psychotic depression without worsening motor symptoms. Early detection, prompt diagnosis, and timely holistic treatment with dopaminergic agents, antidepressants, and psychosocial interventions are critical for the mental health of dystonia patients.
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Affiliation(s)
- Chia‐Chien Liu
- Department of PsychiatryTaichung Veterans General HospitalTaichungTaiwan
| | - Chen‐Chia Lan
- Department of PsychiatryTaichung Veterans General HospitalTaichungTaiwan
| | - Ying‐Sheue Chen
- Department of PsychiatryTaipei Veterans General HospitalTaipeiTaiwan
- Department of PsychiatryChina Medical University HospitalTaichungTaiwan
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10
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DeArias AL, Bamford NS. Levodopa for Dystonia in Children: A Case Series and Review of the Literature. Pediatr Neurol 2024; 152:16-19. [PMID: 38176223 DOI: 10.1016/j.pediatrneurol.2023.12.012] [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: 10/16/2023] [Revised: 12/12/2023] [Accepted: 12/14/2023] [Indexed: 01/06/2024]
Abstract
BACKGROUND Levodopa is used to treat hyperkinetic movements in children with dopa-responsive dystonia. However, levodopa may also be helpful in treating other forms of dystonia when used beyond a brief trial period. METHODS We performed a retrospective review of all children referred to our institution for evaluation of generalized dystonia and subsequently treated with carbidopa-levodopa. Motor function was assessed using video recordings and examination notes, quantified with the Burke-Fahn-Marsden Dystonia Rating Scale. RESULTS Long-term treatment with carbidopa-levodopa moderately improved motor function, whereas short-term use did not. Carbidopa-levodopa was well tolerated without untoward effects. CONCLUSIONS Dystonia is a significant cause of disability with limited effective treatment options. Published work is restricted but generally supports the findings of this review. A well-controlled study to examine the utility of carbidopa-levodopa treatment for dystonia is needed.
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Affiliation(s)
- Alexandra Lesenskyj DeArias
- Department of Pediatrics, Yale University, New Haven, Connecticut; Department of Neurology, Yale University, New Haven, Connecticut.
| | - Nigel S Bamford
- Department of Pediatrics, Yale University, New Haven, Connecticut; Department of Neurology, Yale University, New Haven, Connecticut; Department of Cellular and Molecular Physiology, Yale University, New Haven, Connecticut; Wu Tsai Institute, Yale University, New Haven, Connecticut; Department of Neurology, University of Washington, Seattle, Washington
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11
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Lott E, Fehlings D, Gelineau-Morel R, Kruer M, Mink JW, Thomas SP, Wisniewski S, Aravamuthan B. Physician Approaches to the Pharmacologic Treatment of Dystonia in Cerebral Palsy. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2024:2024.02.01.24302121. [PMID: 38352331 PMCID: PMC10862996 DOI: 10.1101/2024.02.01.24302121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 02/19/2024]
Abstract
Objective To determine how physicians approach pharmacologic dystonia treatment in people with CP and assess physician readiness to participate in a randomized trial comparing existing pharmacologic dystonia treatments. Methods We administered a REDCap survey to physician members of the American Academy of Cerebral Palsy and Developmental Medicine and of the Child Neurology Society to assess which pharmacologic agents they use to treat dystonia in CP and their preferred indications and dosing. Results Of 479 physicians surveyed, 240 (50%) responded. Respondents treated functionally limiting (95%) and generalized (57%) dystonia and most commonly used six medications: baclofen (95%), trihexyphenidyl (79%), gabapentin (67%), carbidopa/levodopa (55%), clonazepam (55%), and diazepam (54%). Baclofen was preferred in people with co-existing spasticity (81%), gabapentin was preferred in people with co-existing pain (49%), and trihexyphenidyl was avoided in people with constipation (34%) or urinary retention (42%). Preferred dosing regimens followed published regimens for dystonia, when available, but otherwise followed published regimens for other CP symptoms (spasticity and seizures). Baclofen was preferred by 64% of respondents as first line treatment, but there was no clear consensus on second or third-line medications. Most respondents (51%) were comfortable randomizing their patients to receive any of the six most commonly used medications used to treat dystonia in CP. Conclusions This study summarizes current indications and dosing for the six most commonly used medications to treat dystonia in CP as per treating physicians in the US and Canada and also demonstrates physician support for a randomized trial comparing the effectiveness of these treatments.
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Affiliation(s)
- Emma Lott
- Division of Pediatric Neurology, Department of Neurology, Washington University School of Medicine, St. Louis, MO, USA
| | - Darcy Fehlings
- Division of Developmental Paediatrics, Department of Paediatrics, Holland Bloorview Kids Rehabilitation Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Rose Gelineau-Morel
- Division of Neurology, Department of Pediatrics, University of Missouri-Kansas City School of Medicine, Children's Mercy Kansas City, Kansas City, MO, USA
| | - Michael Kruer
- Barrow Neurological Institute, Phoenix Children's Hospital, Departments of Child Health, Cellular and Molecular Medicine, Genetics, and Neurology, University of Arizona College of Medicine-Phoenix, Phoenix, AZ, USA
| | | | - Sruthi P Thomas
- H. Ben Taub Department of Physical Medicine and Rehabilitation and Departments of Neurosurgery and Pediatrics, Baylor College of Medicine, Houston, TX, USA
| | - Steve Wisniewski
- Department of Epidemiology, Epidemiology Data Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - Bhooma Aravamuthan
- Division of Pediatric Neurology, Department of Neurology, Washington University School of Medicine, St. Louis, MO, USA
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Gemperli K, Folorunso F, Norin B, Joshua R, Hill C, Rykowski R, Galindo R, Aravamuthan BR. Mice born preterm develop gait dystonia and reduced cortical parvalbumin immunoreactivity. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2024:2024.02.01.578353. [PMID: 38352408 PMCID: PMC10862908 DOI: 10.1101/2024.02.01.578353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/25/2024]
Abstract
Preterm birth leading to cerebral palsy (CP) is the most common cause of childhood dystonia, a movement disorder that is debilitating and often treatment refractory. Dystonia has been typically associated with dysfunction of striatal cholinergic interneurons, but clinical imaging data suggests that cortical injury may best predict dystonia following preterm birth. Furthermore, abnormal sensorimotor cortex inhibition has been found in many studies of non-CP dystonias. To assess the potential for a cortical etiology of dystonia following preterm birth, we developed a new model of preterm birth in mice. Noting that term delivery in mice on a C57BL/6J background is embryonic day 19.1 (E19.1), we induced preterm birth at the limits of pup viability at embryonic day (E) 18.3, equivalent to human 22 weeks gestation. Mice born preterm demonstrate display clinically validated metrics of dystonia during gait (leg adduction amplitude and variability) and also demonstrate reduced parvalbumin immunoreactivity in the sensorimotor cortex, suggesting dysfunction of cortical parvalbumin-positive inhibitory interneurons. Notably, reduced parvalbumin immunoreactivity or changes in parvalbumin-positive neuronal number were not observed in the striatum. These data support the association between cortical dysfunction and dystonia following preterm birth. We propose that our mouse model of preterm birth can be used to study this association and potentially also study other sequelae of extreme prematurity.
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Affiliation(s)
- Kat Gemperli
- Department of Neurology, Washington University School of Medicine, St. Louis, MO
| | - Femi Folorunso
- Department of Neurology, Washington University School of Medicine, St. Louis, MO
| | - Benjamin Norin
- Department of Neurology, Washington University School of Medicine, St. Louis, MO
| | - Rebecca Joshua
- Department of Neurology, Washington University School of Medicine, St. Louis, MO
| | - Clayton Hill
- Department of Neurology, Washington University School of Medicine, St. Louis, MO
| | - Rachel Rykowski
- Department of Neurology, Washington University School of Medicine, St. Louis, MO
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Horsch A, Petzinger L, Deisenhofer J, Ghandour M, Klotz M, Renkawitz T, Putz C. The Impact of Operative Correction of Equinus in Cerebral Palsy on Gait Patterns. Foot Ankle Int 2024; 45:130-140. [PMID: 38156624 DOI: 10.1177/10711007231217273] [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] [Indexed: 01/03/2024]
Abstract
BACKGROUND This study aimed to evaluate gait outcomes and strength following the surgical correction of equinus in cerebral palsy (CP) based on different surgical procedures. We included the Baumann and Strayer procedures, as well as the Achilles tendon lengthening (ATL). METHODS A retrospective analysis was performed in patients with infantile, bilateral CP who received instrumental 3D gait analysis before and after surgical correction (18.66 months postoperatively). Patients were divided into 3 groups: Strayer surgery, Baumann surgery, and ATL. Gait performance and muscle strengths were compared between studied surgeries. RESULTS A total population of 204 patients (15.43 years) with 341 operated lower limbs (LLs) was analyzed. Dorsiflexion in swing and stance phases significantly improved in all groups postoperatively. The Strayer and the ATL group showed higher postoperative dorsiflexion than the Baumann group. However, no loss of strength was observed with the Baumann method. Maximum power improved in this group postoperatively. An 8.2% loss in calf muscle strength was recorded in the Strayer group. CONCLUSION Operative pes equinus treatment successfully improved the gait of children and adults with CP postoperatively. There were differences in postoperative results between studied operative techniques regarding range of motion and power. LEVEL OF EVIDENCE Level III, retrospective cohort study.
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Affiliation(s)
- Axel Horsch
- Department of Orthopedics, Heidelberg University Hospital, Heidelberg, Germany
| | - Lara Petzinger
- Department of Orthopedics, Heidelberg University Hospital, Heidelberg, Germany
| | - Julian Deisenhofer
- Department of Orthopedics, Heidelberg University Hospital, Heidelberg, Germany
| | - Maher Ghandour
- Department of Orthopedics, Heidelberg University Hospital, Heidelberg, Germany
| | - Matthias Klotz
- Orthopedics and Trauma Surgery, Marienkrankenhaus Soest, Soest, Germany
| | - Tobias Renkawitz
- Department of Orthopedics, Heidelberg University Hospital, Heidelberg, Germany
| | - Cornelia Putz
- Department of Orthopedics, Heidelberg University Hospital, Heidelberg, Germany
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Su TY, Huang YC, Ko JY, Hsin YJ, Yu MY, Hung PL. Therapeutic effects of extracorporeal shock wave therapy on patients with spastic cerebral palsy and Rett syndrome: clinical and ultrasonographic findings. Orphanet J Rare Dis 2024; 19:6. [PMID: 38172891 PMCID: PMC10763338 DOI: 10.1186/s13023-023-03010-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Accepted: 12/19/2023] [Indexed: 01/05/2024] Open
Abstract
BACKGROUND Extracorporeal shock wave therapy (ESWT) is reportedly effective for improving spasticity and motor function in children with cerebral palsy (CP). Because late-stage Rett syndrome has a similar presentation, this study aimed to investigate the effects of ESWT on these two diseases. MATERIAL AND METHODS Patients diagnosed with spastic CP and Rett syndrome received 1500 impulses of ESWT at 4 Hz and 0.1 mJ/mm2, on their spastic legsonce weekly for a total of 12 weeks. Outcomes were assessed before and 4 and 12 weeks after ESWT. Clinical assessments included the Modified Ashworth Scale (MAS), passive range of motion (PROM), and Gross Motor Function Measure 88 (GMFM-88). Ultrasonographic assessments included muscle thickness, acoustic radiation force impulse (ARFI), and strain elastography. RESULTS Fifteen patients with CP and six with Rett syndrome were enrolled in this study. After ESWT, patients with CP showed significant clinical improvement in the MAS (P = 0.011), ankle PROM (P = 0.002), walking/running/jumping function (P = 0.003), and total function (P < 0.001) of the GMFM-88. The patients with Rett syndrome showed improved MAS scores (P = 0.061) and significantly improved total gross motor function (P = 0.030). Under ARFI, patients with CP demonstrated decreased shear wave speed in the gastrocnemius medial head (P = 0.038). Conversely, patients with Rett syndrome show increased shear-wave speeds after ESWT. CONCLUSION Our study provides evidence that a weekly course of low-dose ESWT for 12 weeks is beneficial for children with both CP and Rett syndrome, with the clinical effects of reducing spasticity and improving the gross motor function of the lower limbs. The ARFI sonoelastography reveals improvement of muscle stiffness in patients with CP after ESWT, but deteriorated in patients with Rett syndrome. The diverse therapeutic response to ESWT may be caused by the MECP2 mutation in Rett syndrome, having a continuous impact and driving the pathophysiology differently as compared to CP, which is secondary to a static insult. Trial registration IRB 201700462A3. Registered 22March 2017, https://cghhrpms.cgmh.org.tw/HRPMS/Default.aspx .
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Affiliation(s)
- Ting-Yu Su
- Department of Pediatric Neurology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, No. 123, Dapi Rd., Niaosong Dist., Kaohsiung City, 833, Taiwan
| | - Yu-Chi Huang
- Department of Physical Medicine and Rehabilitation, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung City, Taiwan
| | - Jih-Yang Ko
- Department of Orthopedic Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung City, Taiwan
- Center for Shockwave Medicine and Tissue Engineering, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung City, Taiwan
| | - Yi-Jung Hsin
- Department of Physical Medicine and Rehabilitation, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung City, Taiwan
| | - Min-Yuan Yu
- Department of Rehabilitation, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung City, Taiwan
| | - Pi-Lien Hung
- Department of Pediatric Neurology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, No. 123, Dapi Rd., Niaosong Dist., Kaohsiung City, 833, Taiwan.
- Center for Shockwave Medicine and Tissue Engineering, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung City, Taiwan.
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Liker MA, Sanger TD, MacLean JA, Nataraj J, Arguelles E, Krieger M, Robison A, Olaya J. Stereotactic Awake Basal Ganglia Electrophysiological Recording and Stimulation (SABERS): A Novel Staged Procedure for Personalized Targeting of Deep Brain Stimulation in Pediatric Movement and Neuropsychiatric Disorders. J Child Neurol 2024; 39:33-44. [PMID: 38409793 DOI: 10.1177/08830738231224057] [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] [Indexed: 02/28/2024]
Abstract
Selection of targets for deep brain stimulation (DBS) has been based on clinical experience, but inconsistent and unpredictable outcomes have limited its use in patients with heterogeneous or rare disorders. In this large case series, a novel staged procedure for neurophysiological assessment from 8 to 12 temporary depth electrodes is used to select targets for neuromodulation that are tailored to each patient's functional needs. Thirty children and young adults underwent deep brain stimulation target evaluation with the new procedure: Stereotactic Awake Basal ganglia Electrophysiological Recording and Stimulation (SABERS). Testing is performed in an inpatient neuromodulation monitoring unit over 5-7 days, and results guide the decision to proceed and the choice of targets for permanent deep brain stimulation implantation. Results were evaluated 3-6 months postoperatively with the Burke-Fahn-Marsden Dystonia Rating Scale and the Barry-Albright Dystonia Scale. Stereotactic Awake Basal ganglia Electrophysiological Recording and Stimulation testing allowed modulation to be tailored to specific neurologic deficits in a heterogeneous population, including subjects with primary dystonia, secondary dystonia, and Tourette syndrome. All but one subject were implanted with 4 permanent deep brain stimulation leads. Results showed significant improvement on both scales at postoperative follow-up. No significant adverse events occurred. Use of the Stereotactic Awake Basal ganglia Electrophysiological Recording and Stimulation protocol with evaluation in the neuromodulation monitoring unit is feasible and results in significant patient benefit compared with previously published results in these populations. This new technique supports a significant expansion of functional neurosurgery to predict effective stimulation targets in a wide range of disorders of brain function, including those for which the optimal target is not yet known.
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Affiliation(s)
- Mark A Liker
- Divison of Neurosurgery, Children's Hospital of Orange County, Orange, CA, USA
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Terence D Sanger
- Samueli School of Engineering, University of California Irvine, Irvine, CA, USA
- Research Institute, Children's Hospital of Orange County, Orange, CA, USA
- Department of Pediatrics, School of Medicine, University of California Irvine, Irvine, CA, USA
- Department of Neurology, Children's Hospital of Orange County, Orange, CA, USA
| | - Jennifer A MacLean
- Research Institute, Children's Hospital of Orange County, Orange, CA, USA
- Department of Neurology, Children's Hospital of Orange County, Orange, CA, USA
| | - Jaya Nataraj
- Samueli School of Engineering, University of California Irvine, Irvine, CA, USA
| | - Enrique Arguelles
- Department of Biomedical Engineering, University of Southern California, Los Angeles, CA, USA
| | - Mark Krieger
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
- Department of Surgery, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Aaron Robison
- Department of Neurosurgery, School of Medicine, Loma Linda University, Loma Linda, CA, USA
| | - Joffre Olaya
- Divison of Neurosurgery, Children's Hospital of Orange County, Orange, CA, USA
- Department of Neurological Surgery, School of Medicine, University of California Irvine, Irvine, CA, USA
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16
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Gill JS, Nguyen MX, Hull M, van der Heijden ME, Nguyen K, Thomas SP, Sillitoe RV. Function and dysfunction of the dystonia network: an exploration of neural circuits that underlie the acquired and isolated dystonias. DYSTONIA 2023; 2:11805. [PMID: 38273865 PMCID: PMC10810232 DOI: 10.3389/dyst.2023.11805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/27/2024]
Abstract
Dystonia is a highly prevalent movement disorder that can manifest at any time across the lifespan. An increasing number of investigations have tied this disorder to dysfunction of a broad "dystonia network" encompassing the cerebellum, thalamus, basal ganglia, and cortex. However, pinpointing how dysfunction of the various anatomic components of the network produces the wide variety of dystonia presentations across etiologies remains a difficult problem. In this review, a discussion of functional network findings in non-mendelian etiologies of dystonia is undertaken. Initially acquired etiologies of dystonia and how lesion location leads to alterations in network function are explored, first through an examination of cerebral palsy, in which early brain injury may lead to dystonic/dyskinetic forms of the movement disorder. The discussion of acquired etiologies then continues with an evaluation of the literature covering dystonia resulting from focal lesions followed by the isolated focal dystonias, both idiopathic and task dependent. Next, how the dystonia network responds to therapeutic interventions, from the "geste antagoniste" or "sensory trick" to botulinum toxin and deep brain stimulation, is covered with an eye towards finding similarities in network responses with effective treatment. Finally, an examination of how focal network disruptions in mouse models has informed our understanding of the circuits involved in dystonia is provided. Together, this article aims to offer a synthesis of the literature examining dystonia from the perspective of brain networks and it provides grounding for the perspective of dystonia as disorder of network function.
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Affiliation(s)
- Jason S. Gill
- Division of Neurology and Developmental Neuroscience, Department of Pediatrics, Baylor College of Medicine, Houston, TX, United States
- Jan and Dan Duncan Neurological Research Institute at Texas Children’s Hospital, Houston, TX, United States
| | - Megan X. Nguyen
- Division of Neurology and Developmental Neuroscience, Department of Pediatrics, Baylor College of Medicine, Houston, TX, United States
- Jan and Dan Duncan Neurological Research Institute at Texas Children’s Hospital, Houston, TX, United States
| | - Mariam Hull
- Division of Neurology and Developmental Neuroscience, Department of Pediatrics, Baylor College of Medicine, Houston, TX, United States
| | - Meike E. van der Heijden
- Jan and Dan Duncan Neurological Research Institute at Texas Children’s Hospital, Houston, TX, United States
- Department of Pathology and Immunology, Baylor College of Medicine, Houston, TX, United State
| | - Ken Nguyen
- Jan and Dan Duncan Neurological Research Institute at Texas Children’s Hospital, Houston, TX, United States
- Department of Pathology and Immunology, Baylor College of Medicine, Houston, TX, United State
| | - Sruthi P. Thomas
- H. Ben Taub Department of Physical Medicine and Rehabilitation, Baylor College of Medicine, Houston, TX, United States
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX, United States
| | - Roy V. Sillitoe
- Jan and Dan Duncan Neurological Research Institute at Texas Children’s Hospital, Houston, TX, United States
- Department of Pathology and Immunology, Baylor College of Medicine, Houston, TX, United State
- Department of Neuroscience, Baylor College of Medicine, Houston, TX, United States
- Development, Disease Models and Therapeutics Graduate Program, Baylor College of Medicine, Houston, TX, United States
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Gilbert LA, Gandham S, Ueda K, Chintalapati K, Pearson T, Aravamuthan BR. Upper Extremity Dystonia Features in People With Spastic Cerebral Palsy. Neurol Clin Pract 2023; 13:e200207. [PMID: 37780812 PMCID: PMC10540938 DOI: 10.1212/cpj.0000000000200207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Accepted: 08/14/2023] [Indexed: 10/03/2023]
Abstract
Background and Objectives Dystonia in cerebral palsy (CP) is debilitating and common, but underdiagnosed, especially when coexistent with spasticity. With dedicated research-based assessment, dystonia is found in most people with spastic CP but is only clinically diagnosed in the minority. To begin addressing the high rates of dystonia underdiagnosis in this population, we determined the key feature experts use to assess upper extremity dystonia in people with spastic CP. Methods In this prospective cohort study, 3 pediatric movement disorder specialists assessed upper extremity dystonia in neurologic examination videos of people with spastic CP and isolated periventricular leukomalacia (PVL) on brain MRI (i.e., those with a brain injury pattern typical for spastic CP). Dystonia severity was rated using the 10-point Global Dystonia Severity Rating Scale, first by each expert independently and then again after consensus-building discussion. Conventional content analysis of these discussions revealed salient features ("codes") that experts used to assess upper extremity dystonia. Code frequency distributions were compared between dystonia severity categories using χ2 tests. Results We identified 96 people with spastic CP with isolated PVL on brain MRI seen in the St. Louis Children's Hospital CP Center between 2005 and 2018. Of them, 26 people were able and willing to be recorded while doing a standardized set of upper extremity examination maneuvers (age 4-25 years; 28% nonambulatory, 77% White). When assessing their videos, experts cited the "hand" less often and "shoulder" more often with increasing dystonia severity (p < 0.005, χ2 test). "Mirror movements" and the "hand open/close" examination maneuver were cited significantly more frequently in videos when experts were attempting to distinguish between no dystonia and mild dystonia (p < 0.005). Discussion Expert clinicians use distinct movement features to assess upper extremity dystonia in people with spastic CP and PVL. Attention to involuntary shoulder (vs hand) movements can help gauge dystonia severity. Differentiation between mirror movements and dystonia, particularly during the hand open/close examination maneuver, may help identify mild dystonia. These results can help guide upper extremity dystonia assessment in people with spastic CP, thus potentially helping mitigate dystonia underdiagnosis.
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Affiliation(s)
- Laura A Gilbert
- Division of Pediatric Neurology (LAG, SG, KU, KC, BRA), Department of Neurology, Washington University School of Medicine, St. Louis, MO; and Division of Neurology (TP), Nationwide Children's Hospital, Ohio State University, Columbus
| | - Sushma Gandham
- Division of Pediatric Neurology (LAG, SG, KU, KC, BRA), Department of Neurology, Washington University School of Medicine, St. Louis, MO; and Division of Neurology (TP), Nationwide Children's Hospital, Ohio State University, Columbus
| | - Keisuke Ueda
- Division of Pediatric Neurology (LAG, SG, KU, KC, BRA), Department of Neurology, Washington University School of Medicine, St. Louis, MO; and Division of Neurology (TP), Nationwide Children's Hospital, Ohio State University, Columbus
| | - Keerthana Chintalapati
- Division of Pediatric Neurology (LAG, SG, KU, KC, BRA), Department of Neurology, Washington University School of Medicine, St. Louis, MO; and Division of Neurology (TP), Nationwide Children's Hospital, Ohio State University, Columbus
| | - Toni Pearson
- Division of Pediatric Neurology (LAG, SG, KU, KC, BRA), Department of Neurology, Washington University School of Medicine, St. Louis, MO; and Division of Neurology (TP), Nationwide Children's Hospital, Ohio State University, Columbus
| | - Bhooma R Aravamuthan
- Division of Pediatric Neurology (LAG, SG, KU, KC, BRA), Department of Neurology, Washington University School of Medicine, St. Louis, MO; and Division of Neurology (TP), Nationwide Children's Hospital, Ohio State University, Columbus
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Hunziker S, Morosoli F, Zuercher K, Tscherter A, Grunt S. Prescription Practices of Cannabinoids in Children with Cerebral Palsy Worldwide-A Survey of the Swiss Cerebral Palsy Registry. CHILDREN (BASEL, SWITZERLAND) 2023; 10:1838. [PMID: 38136040 PMCID: PMC10742030 DOI: 10.3390/children10121838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Revised: 11/21/2023] [Accepted: 11/22/2023] [Indexed: 12/24/2023]
Abstract
Cannabinoids are prescribed to children with cerebral palsy despite limited evidence. We aimed to assess cannabinoid prescribing practices in children with cerebral palsy, focusing on indications, types of preparations used, and tolerability. Furthermore, we investigated how physicians acquire knowledge about cannabinoid medication. We asked physicians with expertise in the care of children with cerebral palsy about their prescribing practices for cannabinoids. Data were collected through an online survey, which was distributed by email. In addition to the demographic information of participants, we also inquired about the indications for the prescription of cannabinoids, experiences regarding efficacy, and observed side effects of the therapy. Seventy physicians from Europe, North America, and Australia completed the survey. Forty-seven participants were experienced in treating of children with cerebral palsy with cannabinoids. The most common indication was epilepsy (69%), followed by spasticity (64%) and pain (63%). The preparations and doses prescribed varied considerably. Half of the participants evaluated the effect of the cannabinoids as moderate. Twenty-nine physicians reported side effects, most frequently, drowsiness (26%), somnolence (19%), fatigue (13%), and diarrhea (13%). Despite the lack of evidence to date, cannabinoids are used to treat children with cerebral palsy in a wide variety of indications. Randomized controlled trials in this vulnerable patient group are therefore of utmost importance.
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Affiliation(s)
- Sandra Hunziker
- Institute of Social and Preventive Medicine, University of Bern, Mittelstrasse 43, CH-3012 Bern, Switzerland
| | - Federico Morosoli
- Division of Neuropediatrics, Development and Rehabilitation, Children’s University Hospital, Inselspital, University of Bern, Freiburgstr. 15, CH-3010 Bern, Switzerland
| | - Kathrin Zuercher
- Institute of Social and Preventive Medicine, University of Bern, Mittelstrasse 43, CH-3012 Bern, Switzerland
| | - Anne Tscherter
- Institute of Social and Preventive Medicine, University of Bern, Mittelstrasse 43, CH-3012 Bern, Switzerland
| | - Sebastian Grunt
- Division of Neuropediatrics, Development and Rehabilitation, Children’s University Hospital, Inselspital, University of Bern, Freiburgstr. 15, CH-3010 Bern, Switzerland
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Chintalapati K, Pearson TS, Ueda K, Aravamuthan BR. Brain Region Size Differences Associated With Dystonia in People With Cerebral Palsy Born Premature. Pediatr Neurol 2023; 148:8-13. [PMID: 37633215 DOI: 10.1016/j.pediatrneurol.2023.07.011] [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: 09/26/2022] [Revised: 03/21/2023] [Accepted: 07/14/2023] [Indexed: 08/28/2023]
Abstract
BACKGROUND Dystonia in cerebral palsy (CP) is classically associated with deep gray matter injury at term gestation, but the patterns of injury associated with dystonia following premature birth are unclear. We examined whether there were brain regional size differences associated with dystonia in people with CP born premature. METHODS In this retrospective cohort study, we identified subjects with CP born premature (<37 weeks gestational age) seen at a tertiary care CP center between February 1, 2017, to February 1, 2021, who had T1-weighted brain magnetic resonance imaging (MRI) done between ages one and five years available in the clinical record. We measured the following on these brain MRI images per the 2013 Kidokoro criteria: interhemispheric distance, biparietal width, lateral ventricle diameter, transcerebellar diameter, deep gray matter area, and corpus callosum thickness. We then compared the sizes of these structures between those with and without dystonia correcting for gestational age at birth and gross motor functional ability (univariate general linear models). RESULTS Fifty-five subjects met the inclusion and exclusion criteria. Interhemispheric distance was significantly greater in those with dystonia, suggesting decreased cortical volume (P = 0.005). There was no significant difference in the other measured structures between those with and without dystonia, including deep gray matter area. CONCLUSIONS Increased interhemispheric distance, not measures of deep gray matter size, correlate with the presence of dystonia in people with CP born premature.
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Affiliation(s)
- Keerthana Chintalapati
- Division of Pediatric Neurology, Department of Neurology, Washington University School of Medicine and St. Louis Children's Hospital, St. Louis, Missouri
| | - Toni S Pearson
- Division of Pediatric Neurology, Department of Neurology, Washington University School of Medicine and St. Louis Children's Hospital, St. Louis, Missouri; Nationwide Children's Hospital, Columbus, Ohio
| | - Keisuke Ueda
- Division of Pediatric Neurology, Department of Neurology, Washington University School of Medicine and St. Louis Children's Hospital, St. Louis, Missouri
| | - Bhooma R Aravamuthan
- Division of Pediatric Neurology, Department of Neurology, Washington University School of Medicine and St. Louis Children's Hospital, St. Louis, Missouri.
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20
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Gelineau-Morel R, Smyser C, Leeder JS. Identifying Effective Treatments for Dystonia in Patients With Cerebral Palsy: A Precision Therapeutics Approach. Neurology 2023; 101:752-759. [PMID: 37463749 PMCID: PMC10624496 DOI: 10.1212/wnl.0000000000207593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Accepted: 05/12/2023] [Indexed: 07/20/2023] Open
Abstract
Recent focus on improving the recognition of dystonia in cerebral palsy (DCP) has highlighted the need for more effective treatments. Evidence supports improved functional outcomes with early interventions for patients with cerebral palsy, but it is not known which interventions are most effective for DCP. Current pharmacologic recommendations for DCP are based largely on anecdotal evidence, with medications demonstrating minimal to moderate improvements in dystonia and variable efficacy between patients. Patients, families, and clinicians have identified the need for new and improved treatments in DCP, naming this as the top research theme in a recent Neurology® publication. Precision therapeutics focuses on providing early effective interventions that are individualized to every patient and can guide research priorities to improve treatments for DCP. This commentary outlines current obstacles to improving treatment of DCP and addresses how precision therapeutics can address each of these obstacles through 4 key components: (1) identification of predictive biomarkers to select patients likely to develop DCP in the future and for whom early intervention may be appropriate to delay or prevent full manifestation of dystonia, (2) stratification of patients with DCP into subgroups according to shared features (clinical, functional, biochemical, etc) to provide a targeted intervention based on those shared features, (3) administration of an individualized dose of an effective intervention to ensure adequate concentrations of the therapeutic entity at the site of action, and (4) monitoring of objective biomarkers of response to intervention. With implementation of each of these components of precision therapeutics, new and more effective treatments for every person with DCP can be realized.
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Affiliation(s)
- Rose Gelineau-Morel
- From the Division of Neurology (R.G.-M.), Children's Mercy Kansas City; School of Medicine (R.G.-M., J.S.L.), University of Missouri-Kansas City; Department of Pediatrics (R.G.-M., J.S.L.), University of Kansas Medical Center, Kansas City; Department of Pediatrics (C.S.), Department of Neurology (C.S.), and Mallinckrodt Institute of Radiology (C.S.), Washington University in St. Louis; and Division of Clinical Pharmacology, Toxicology & Therapeutic Innovation (J.S.L.), Children's Mercy Kansas City, MO.
| | - Christopher Smyser
- From the Division of Neurology (R.G.-M.), Children's Mercy Kansas City; School of Medicine (R.G.-M., J.S.L.), University of Missouri-Kansas City; Department of Pediatrics (R.G.-M., J.S.L.), University of Kansas Medical Center, Kansas City; Department of Pediatrics (C.S.), Department of Neurology (C.S.), and Mallinckrodt Institute of Radiology (C.S.), Washington University in St. Louis; and Division of Clinical Pharmacology, Toxicology & Therapeutic Innovation (J.S.L.), Children's Mercy Kansas City, MO
| | - J Steven Leeder
- From the Division of Neurology (R.G.-M.), Children's Mercy Kansas City; School of Medicine (R.G.-M., J.S.L.), University of Missouri-Kansas City; Department of Pediatrics (R.G.-M., J.S.L.), University of Kansas Medical Center, Kansas City; Department of Pediatrics (C.S.), Department of Neurology (C.S.), and Mallinckrodt Institute of Radiology (C.S.), Washington University in St. Louis; and Division of Clinical Pharmacology, Toxicology & Therapeutic Innovation (J.S.L.), Children's Mercy Kansas City, MO
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Hernandez-Martin E, Vidmark JSL, MacLean JA, Sanger TD. What is the effect of benzodiazepines on deep brain activity? A study in pediatric patients with dystonia. Front Neurol 2023; 14:1215572. [PMID: 37638186 PMCID: PMC10457157 DOI: 10.3389/fneur.2023.1215572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Accepted: 08/01/2023] [Indexed: 08/29/2023] Open
Abstract
Introduction Benzodiazepines (BDZs) are commonly used to treat the symptoms of movement disorders; however, deep brain stimulation (DBS) has become a popular treatment for these disorders. Previous studies have investigated the effects of BDZ on cortical activity, no data are currently available on their effects on deep brain regions, nor on these regions' responses to DBS. How the BDZ affects the thalamus and basal ganglia in dystonia patients remains unknown. Methods DBS recordings were performed in ventral oralis anterior/posterior (VoaVop), ventral intermediate (VIM) and ventral anterior (VA) thalamic subnuclei, as well as globus pallidus interna (GPi) and subthalamic nucleus (STN). Evoked potentials (EP) and frequency domain analysis were performed to determine the BDZ effect on neural activities compared to the control condition (off-BDZ). Three male pediatric patients with dystonia treated with BDZ and undergoing depth electrode evaluation for clinical targeting were recruited for the study. Stimulation was administered at 25 and 55 Hz frequencies and recordings were simultaneously gathered through pairs of externalized stereoelectroencephalography (sEEG) electrodes. EP amplitude and the effect of stimulation on the frequency spectrum of activity were compared at baseline and following clinical administration of BDZ. Results Frequency analysis showed consistent reductions in activity during BDZ treatment in all studied brain regions for all patients. Evoked potential (EP) analysis showed increased subthalamic nucleus (STN) EP amplitude and decreased ventral intermediate (VIM) and STN EP amplitude during BDZ treatment. Interpretation BDZs reduce thalamic and basal ganglia activity in multiple regions and alter the efficacy of transmission between these regions. While the mechanism is unknown our results confirm the known widespread effects of this class of medications and identify specific areas within the motor system that are directly affected.
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Affiliation(s)
- Estefania Hernandez-Martin
- Department of Electrical Engineering and Computer Science, University of California, Irvine, CA, United States
| | - Jessica S. L. Vidmark
- Department of Biomedical Engineering, University of California, Irvine, CA, United States
| | - Jennifer A. MacLean
- Department of Neurology, Children’s Health Orange County (CHOC), Orange, CA, United States
| | - Terence D. Sanger
- Department of Electrical Engineering and Computer Science, University of California, Irvine, CA, United States
- Department of Biomedical Engineering, University of California, Irvine, CA, United States
- Department of Neurology, Children’s Health Orange County (CHOC), Orange, CA, United States
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Aravamuthan B, Pearson TS, Chintalapati K, Ueda K. Under-recognition of leg dystonia in people with cerebral palsy. ANNALS OF THE CHILD NEUROLOGY SOCIETY 2023; 1:162-167. [PMID: 38464792 PMCID: PMC10923506 DOI: 10.1002/cns3.20018] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/21/2023] [Accepted: 03/11/2023] [Indexed: 03/12/2024]
Abstract
Objective To determine the rates of clinical under-documentation of leg dystonia in people with cerebral palsy (CP). Methods In this prospective cohort study, we identified independently ambulatory people age 10-20yo with CP-associated spasticity seen in a tertiary care CP center between 1/1/20 to 11/4/21. Three pediatric movement disorders specialists assessed gait videos from these visits for leg dystonia using the Global Dystonia Rating Scale. We compared the gold standard expert consensus assessment for each patient with the clinical documentation of dystonia during a contemporaneous CP Center clinic visit and also with dystonia documentation longitudinally in their medical record. Results Of 116 people with CP-associated spasticity assessed in this study, 70 were found to have leg dystonia in their gait videos. Only 13% of these 70 individuals (n=9/70) had leg dystonia documented in their contemporaneous CP Center clinic visit, even though they were assessed during this visit by clinicians well-trained in CP and dystonia assessment. Even with repeated assessment, only 54% (n=38/70) of these individuals had leg dystonia documented in their medical record. Conclusions Leg dystonia is clinically under-documented in people with CP-associated spasticity, even when these people are evaluated by well-trained clinicians. Longitudinal evaluation and vigilance for leg dystonia is critical to address this diagnostic gap.
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Affiliation(s)
- Bhooma Aravamuthan
- Division of Pediatric Neurology, Department of Neurology, Washington University School of Medicine, St. Louis, MO
| | - Toni S. Pearson
- Division of Pediatric Neurology, Department of Neurology, Washington University School of Medicine, St. Louis, MO
- Division of Neurology, Nationwide Children’s Hospital, Ohio State University, Columbus, Ohio, USA
| | - Keerthana Chintalapati
- Division of Pediatric Neurology, Department of Neurology, Washington University School of Medicine, St. Louis, MO
| | - Keisuke Ueda
- Division of Pediatric Neurology, Department of Neurology, Washington University School of Medicine, St. Louis, MO
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Gelineau-Morel R, Kim YM, O'Malley JA, Wilson JL, Aravamuthan BR. The Role of Child Neurologists in the Management of Motor Disability in Cerebral Palsy: Establishing the Path Forward. Pediatr Neurol 2023; 144:33-38. [PMID: 37121109 DOI: 10.1016/j.pediatrneurol.2023.03.018] [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: 07/07/2022] [Revised: 01/20/2023] [Accepted: 03/29/2023] [Indexed: 05/02/2023]
Abstract
BACKGROUND Cerebral palsy (CP) is the most common motor disability of childhood, and yet the role of child neurologists and neurodevelopmentalists (CN/NDDs) in the management of children with CP is unclear. Although previous surveys showed that CN/NDDs believe they are uniquely expert in CP motor phenotyping and should be involved in CP management, others have demonstrated that training in CP management among CN/NDD residency programs is inadequate. METHODS In this article, we surveyed a group of CN/NDDs at the Child Neurology Society Cerebral Palsy Special Interest Group meeting on January 27, 2022. Questions addressed provider comfort with CP tone management including motor phenotyping, pharmacologic and surgical management, barriers and solutions to improving practice, and the use of systems-based care. RESULTS Responses from 42 participants demonstrated that CN/NDDs lack experience with CP tone management, with 48% and 58% of respondents reporting little to no experience in pharmacologic or surgical management, respectively. Primary barriers identified to improving comfort with CP tone management included lack of knowledge and ineffective treatment options, while most solutions centered on improving collaborations between CN/NDDs and other specialties. Only 50% of respondents reported currently using systems-based care in the management of patients with CP. CONCLUSIONS An interdisciplinary, systems-based care model would allow for collaboration and knowledge sharing between involved specialties and provide high-value goal-directed care to maximize the functional outcomes for every individual with CP.
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Affiliation(s)
- Rose Gelineau-Morel
- Division of Pediatric Neurology, Department of Pediatrics, University of Missouri- Kansas City School of Medicine, Kansas City, Missouri.
| | - Young-Min Kim
- Division of Pediatric Neurology, Department of Pediatrics, Loma Linda University School of Medicine, Loma Linda, California
| | - Jennifer A O'Malley
- Division of Child Neurology, Department of Neurology, Stanford University School of Medicine, Palo Alto, California
| | - Jenny L Wilson
- Division of Pediatric Neurology, Oregon Health & Science University, Portland, Oregon
| | - Bhooma R Aravamuthan
- Division of Pediatric Neurology, Department of Neurology, School of Medicine, Washington University in St Louis and St Louis Children's Hospital, St Louis, Missouri
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Towards functional improvement of motor disorders associated with cerebral palsy. Lancet Neurol 2023; 22:229-243. [PMID: 36657477 DOI: 10.1016/s1474-4422(23)00004-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Revised: 11/29/2022] [Accepted: 11/29/2022] [Indexed: 01/18/2023]
Abstract
Cerebral palsy is a lifelong neurodevelopmental condition arising from non-progressive disorders occurring in the fetal or infant brain. Cerebral palsy has long been categorised into discrete motor types based on the predominance of spasticity, dyskinesia, or ataxia. However, these motor disorders, muscle weakness, hypotonia, and impaired selective movements should also be discriminated across the range of presentations and along the lifespan. Although cerebral palsy is permanent, function changes across the lifespan, indicating the importance of interventions to improve outcomes in motor disorders associated with the condition. Mounting evidence exists for the inclusion of several interventions, including active surveillance, adapted physical activity, and nutrition, to prevent secondary and tertiary complications. Avenues for future research include the development of evidence-based recommendations, low-cost and high-quality alternatives to existing therapies to ensure universal access, standardised cerebral palsy registers to harmonise epidemiological and clinical information, improved adult screening and check-up programmes to facilitate positive lived experiences, and phase 3 trials for new interventions.
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Abdulbaki A, Jijakli A, Krauss JK. Deep brain stimulation for hemidystonia: A meta-analysis with individual patient data. Parkinsonism Relat Disord 2023; 108:105317. [PMID: 36813584 DOI: 10.1016/j.parkreldis.2023.105317] [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: 11/02/2022] [Revised: 01/27/2023] [Accepted: 02/05/2023] [Indexed: 02/17/2023]
Abstract
BACKGROUND Deep brain stimulation (DBS) is now well established for the treatment of dystonic movement disorders. There is limited data, however, on the efficacy of DBS in hemidystonia. This meta-analysis aims to summarize the published reports on DBS for hemidystonia of different etiologies, to compare different stimulation targets, and to evaluate clinical outcome. METHODS A systematic literature review was performed on PubMed, Embase and Web of Science to identify appropriate reports. The primary outcome variables were the improvement in the Burke-Fahn-Marsden Dystonia Rating Scale movement (BFMDRS-M) and disability (BFMDRS-D) scores for dystonia. RESULTS Twenty-two reports (39 patients; 22 with pallidal stimulation, 4 with subthalamic stimulation, 3 with thalamic stimulation, and 10 with combined target stimulation) were included. Mean age at surgery was 26.8 years. Mean follow-up time was 31.72 months. An overall mean improvement of 40% in the BFMDRS-M score was achieved (range 0%-94%), which was paralleled by a mean improvement of 41% in the BFMDRS-D score. When considering a 20% cut-off for improvement, 23/39 patients (59%) would qualify as responders. Hemidystonia due to anoxia did not significantly improve with DBS. Several limitations of the results must be considered, most importantly the low level of evidence and the small number of reported cases. CONCLUSION Based on the results of the current analysis, DBS can be considered as a treatment option for hemidystonia. The posteroventral lateral GPi is the target used most often. More research is needed to understand the variability in outcome and to identify prognostic factors.
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Affiliation(s)
- Arif Abdulbaki
- Department of Neurosurgery, Hannover Medical School, Hannover, Germany.
| | - Amr Jijakli
- Department of Neurology, Tufts Medical Center, Boston, MA, USA
| | - Joachim K Krauss
- Department of Neurosurgery, Hannover Medical School, Hannover, Germany
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Lee S, Hyun C, KIM K, Kwon HE, Woo M, Koh SE. Effect of Intrathecal Baclofen Pump on Scoliosis in Children With Cerebral Palsy: A Meta-Analysis. Ann Rehabil Med 2023; 47:11-18. [PMID: 36599295 PMCID: PMC10020052 DOI: 10.5535/arm.22108] [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: 07/25/2022] [Accepted: 10/17/2022] [Indexed: 01/06/2023] Open
Abstract
OBJECTIVE To systematically review the effect of intrathecal baclofen pump insertion in children with cerebral palsy (CP) with respect to scoliosis. METHODS A systematic literature search was conducted in PubMed, Embase, Cochrane Library, and Google Scholar databases up to June 2022. The inclusion criteria were as follows: (1) studies with a quantitative study design; (2) studies with a study group of children with CP; (3) studies comparing scoliosis in children with and without an intrathecal baclofen pump; and (4) studies with Cobb's angle as a parameter. RESULTS Of the 183 studies found, four studies, all of which were retrospective comparative studies, met the aforementioned inclusion criteria. All studies were homogeneous (I2=0%, p=0.53) and intrathecal baclofen pump insertion accelerated the progression of scoliosis (standard mean difference=0.27; 95% confidence interval=0.07-0.48). CONCLUSION Intrathecal baclofen pumps have been used to alleviate spasticity in children with CP, thus aiding their daily activities and movements. However, their advantages and disadvantages should be reviewed after sufficient time considering the pumps' negative effect on the course of scoliosis.
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Affiliation(s)
- Soolim Lee
- Department of Rehabilitation Medicine, Konkuk University School of Medicine & Konkuk University Medical Center, Seoul, Korea
| | - Cheolhwan Hyun
- Department of Rehabilitation Medicine, Konkuk University School of Medicine & Konkuk University Medical Center, Seoul, Korea
| | - Kyungmin KIM
- Department of Rehabilitation Medicine, Konkuk University School of Medicine & Konkuk University Medical Center, Seoul, Korea
| | - Hyo Eun Kwon
- Department of Rehabilitation Medicine, Konkuk University School of Medicine & Konkuk University Medical Center, Seoul, Korea
| | - Minwoo Woo
- Department of Rehabilitation Medicine, Konkuk University School of Medicine & Konkuk University Medical Center, Seoul, Korea
| | - Seong-Eun Koh
- Department of Rehabilitation Medicine, Konkuk University School of Medicine & Konkuk University Medical Center, Seoul, Korea
- Corresponding author: Seong-Eun Koh Department of Rehabilitation Medicine, Konkuk University School of Medicine & Konkuk University Medical Center, 120-1 Neungdong-ro, Gwangjingu, Seoul 05030, Korea. Tel: +82-2-2030-5346, Fax: +82-2-2030-5375, E-mail:
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Qian G, Cai X, Xu K, Tian H, Meng Q, Ossowski Z, Liang J. Which gait training intervention can most effectively improve gait ability in patients with cerebral palsy? A systematic review and network meta-analysis. Front Neurol 2023; 13:1005485. [PMID: 36703638 PMCID: PMC9871496 DOI: 10.3389/fneur.2022.1005485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2022] [Accepted: 11/30/2022] [Indexed: 01/11/2023] Open
Abstract
Background A vital objective to treat people with cerebral palsy (CP) is to increase gait velocity and improve gross motor function. This study aimed to evaluate the relative effectiveness of gait training interventions for persons with CP. Methods Studies published up to October 26, 2022 were searched from four electronic databases [including Medline (via PubMed), Web of Science, Embase and Cochrane]. Studies with randomized controlled trials (RCTs), people with CP, comparisons of different gait training interventions and outcomes of gait velocity and gross motor function measures (GMFM) were included in this study. The quality of the literature was evaluated using the risk of bias tool in the Cochrane Handbook, the extracted data were analyzed through network meta-analysis (NMA) using Stata16.0 and RevMan5.4 software. Results Twenty RCTs with a total of 516 individuals with CP were included in accordance with the criteria of this study. The results of the NMA analysis indicated that both external cues treadmill training (ECTT) [mean difference (MD) = 0.10, 95% confidence interval CI (0.04, 0.17), P < 0.05] and partial body weight supported treadmill training (BWSTT) [MD = 0.12, 95% CI (0.01, 0.23), P < 0.05] had better gait velocity than over ground gait training (OGT), BWSTT [MD = 0.09, 95%CI(0.01,0.18), P < 0.05] had a better gait velocity than robot-assisted gait training (RAGT), BWSTT [MD = 0.09, 95% CI (0.06, 0.13) P < 0.05] had a better gait velocity than treadmill training (TT), and BWSTT [MD = 0.14, 95% CI (0.07, 0.21), P < 0.05] had a better gait velocity than conventional physical therapy (CON). The SUCRA ranking indicated that BWSTT optimally improved the gait velocity, and the other followed an order of BWSTT (91.7%) > ECTT (80.9%) > RAGT (46.2%) > TT (44%) > OGT (21.6%) > CON (11.1%). In terms of GMFM, for dimension D (GMFM-D), there was no statistical difference between each comparison; for dimension E (GMFM-E), RAGT [MD = 10.45, 95% CI (2.51, 18.40), P < 0.05] was significantly more effective than CON. Both SUCRA ranking results showed that RAGT improved GMFM-D/E optimally, with rankings of RAGT (69.7%) > TT (69.3%) > BWSTT (67.7%) > OGT (24%) > CON (20.3%), and RAGT (86.1%) > BWSTT (68.2%) > TT (58%) > CON (20.1%) > OGT (17.6%) respectively. Conclusion This study suggested that BWSTT was optimal in increasing the gait velocity and RAGT was optimal in optimizing GMFM in persons with CP. Impacted by the limitations of the number and quality of studies, randomized controlled trials with larger sample sizes, multiple centers, and high quality should be conducted to validate the above conclusion. Further studies will be required to focus on the total duration of the intervention, duration and frequency of sessions, and intensity that are optimal for the promotion of gait ability in this population. Systematic review registration https://doi.org/10.37766/inplasy2022.10.0108, identifier: INPLASY2022100108.
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Affiliation(s)
- Guoping Qian
- Department of Sport, Gdansk University of Physical Education and Sport, Gdańsk, Poland
| | - Xiaoye Cai
- Department of General Education, Shanghai Normal University Tianhua College, Shanghai, China
| | - Kai Xu
- Department of Sport, Gdansk University of Physical Education and Sport, Gdańsk, Poland,Department of Art and Sports, Huanghe Science and Technology University, Zhengzhou, Henan, China
| | - Hao Tian
- Department of Sport, Gdansk University of Physical Education and Sport, Gdańsk, Poland,Department of Physical Education and Humanities, Nanjing Sport Institute, Nanjing, China
| | - Qiao Meng
- Department of Sport, Gdansk University of Physical Education and Sport, Gdańsk, Poland
| | - Zbigniew Ossowski
- Department of Sport, Gdansk University of Physical Education and Sport, Gdańsk, Poland,*Correspondence: Zbigniew Ossowski ✉
| | - Jinghong Liang
- Department of Maternal and Child Health, School of Public Health, Medical College of Sun Yat-sen University, Guangzhou, China,Jinghong Liang ✉
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Bertoncelli CM, Latalski M, Bertoncelli D, Bagui S, Bagui SC, Gautier D, Solla F. Prediction Model for Identifying Computational Phenotypes of Children with Cerebral Palsy Needing Neurotoxin Treatments. Toxins (Basel) 2022; 15:20. [PMID: 36668840 PMCID: PMC9867395 DOI: 10.3390/toxins15010020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Revised: 12/19/2022] [Accepted: 12/20/2022] [Indexed: 12/29/2022] Open
Abstract
Factors associated with neurotoxin treatments in children with cerebral palsy (CP) are poorly studied. We developed and externally validated a prediction model to identify the prognostic phenotype of children with CP who require neurotoxin injections. We conducted a longitudinal, international, multicenter, double-blind descriptive study of 165 children with CP (mean age 16.5 ± 1.2 years, range 12−18 years) with and without neurotoxin treatments. We collected functional and clinical data from 2005 to 2020, entered them into the BTX-PredictMed machine-learning model, and followed the guidelines, “Transparent Reporting of a Multivariable Prediction Model for Individual Prognosis or Diagnosis”. In the univariate analysis, neuromuscular scoliosis (p = 0.0014), equines foot (p < 0.001) and type of etiology (prenatal > peri/postnatal causes, p = 0.05) were linked with neurotoxin treatments. In the multivariate analysis, upper limbs (p < 0.001) and trunk muscle tone disorders (p = 0.02), the presence of spasticity (p = 0.01), dystonia (p = 0.004), and hip dysplasia (p = 0.005) were strongly associated with neurotoxin injections; and the average accuracy, sensitivity, and specificity was 75%. These results have helped us identify, with good accuracy, the clinical features of prognostic phenotypes of subjects likely to require neurotoxin injections.
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Affiliation(s)
- Carlo M. Bertoncelli
- Department of Computer Science, Hal Marcus College of Science & Engineering, University of West Florida, Pensacola, FL 32514, USA
- EEAP H Germain and Department of Pediatric Orthopaedic Surgery, Lenval Foundation, University Pediatric Hospital of Nice, 06000 Nice, France
- Department of Information Engineering Computer Science and Mathematics, Computer Science and Mathematics, University of L’Aquila, 67100 L’Aquila, Italy
| | - Michal Latalski
- Children Orthopaedic Department, Medical University, 20-059 Lublin, Poland
| | - Domenico Bertoncelli
- Department of Computer Science, Hal Marcus College of Science & Engineering, University of West Florida, Pensacola, FL 32514, USA
- Department of Information Engineering Computer Science and Mathematics, Computer Science and Mathematics, University of L’Aquila, 67100 L’Aquila, Italy
| | - Sikha Bagui
- Department of Computer Science, Hal Marcus College of Science & Engineering, University of West Florida, Pensacola, FL 32514, USA
| | - Subhash C. Bagui
- Department of Computer Science, Hal Marcus College of Science & Engineering, University of West Florida, Pensacola, FL 32514, USA
| | - Dechelle Gautier
- EEAP H Germain and Department of Pediatric Orthopaedic Surgery, Lenval Foundation, University Pediatric Hospital of Nice, 06000 Nice, France
| | - Federico Solla
- EEAP H Germain and Department of Pediatric Orthopaedic Surgery, Lenval Foundation, University Pediatric Hospital of Nice, 06000 Nice, France
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Hu J, Wang X, Liu X, Xia T, Liu Q, Zhang X, Hu Y. Effectiveness and safety of acupuncture for children with cerebral palsy: An overview of systematic reviews. Eur J Integr Med 2022. [DOI: 10.1016/j.eujim.2022.102199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Butchereit K, Manzini M, Polatajko HJ, Lin JP, McClelland VM, Gimeno H. Harnessing cognitive strategy use for functional problems and proposed underlying mechanisms in childhood-onset dystonia. Eur J Paediatr Neurol 2022; 41:1-7. [PMID: 36108454 DOI: 10.1016/j.ejpn.2022.08.007] [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: 03/03/2022] [Revised: 08/09/2022] [Accepted: 08/22/2022] [Indexed: 10/31/2022]
Abstract
BACKGROUND There is a significant gap in knowledge about rehabilitation techniques and strategies that can help children and young people with hyperkinetic movement disorders (HMD) including dystonia to successfully perform daily activities and improve overall participation. A promising approach to support skill acquisition is the Cognitive Orientation to daily Occupational Performance (CO-OP) intervention. CO-OP uses cognitive strategies to help patients generate their own solutions to overcome self-identified problems encountered in everyday living. PURPOSE 1. To identify and categorize strategies used by children with HMD to support skill acquisition during CO-OP; 2. To review the possible underlying mechanisms that might contribute to the cognitive strategies, in order to facilitate further studies for developing focused rehabilitation approaches. METHODS A secondary analysis was performed on video-recorded data from a previous study exploring the efficacy of CO-OP for childhood onset HMD, in which CO-OP therapy sessions were delivered by a single occupational therapist. For the purpose of this study, we reviewed a total of 40 randomly selected hours of video footage of CO-OP sessions delivered to six participants (age 6-19 years) over ten intervention sessions. An observational recording sheet was applied to identify systematically the participants' or therapist's verbalizations of cognitive strategies during the therapy. The strategies were classified into six categories in line with published literature. RESULTS Strategies used by HMD participants included distraction, externally focussed attention, internally focussed attention, emotion self-regulation, motor imagery and mental self-guidance. We postulate different underlying working mechanisms for these strategies, which have implications for the therapeutic management of children and young people with HMD including dystonia. CONCLUSIONS Cognitive strategy training can fundamentally change and improve motor performance. On-going work will address both the underlying neural mechanisms of therapeutic change and the mediators and moderators that influence how change unfolds.
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Affiliation(s)
- Kailee Butchereit
- University of Toronto, Department of Occupational Science and Occupational Therapy, Toronto, Canada
| | - Michael Manzini
- University of Toronto, Department of Occupational Science and Occupational Therapy, Toronto, Canada
| | - Helene J Polatajko
- University of Toronto, Department of Occupational Science and Occupational Therapy, Toronto, Canada
| | - Jean-Pierre Lin
- Complex Motor Disorders Service, Paediatric Neurosciences, Evelina London Children's Hospital, Guy's & St Thomas' NHS Foundation Trust, London, UK; Women and Children's Institute, Faculty of Life Sciences and Medicine, King's College London, UK
| | - Verity M McClelland
- Complex Motor Disorders Service, Paediatric Neurosciences, Evelina London Children's Hospital, Guy's & St Thomas' NHS Foundation Trust, London, UK; Women and Children's Institute, Faculty of Life Sciences and Medicine, King's College London, UK
| | - Hortensia Gimeno
- Complex Motor Disorders Service, Paediatric Neurosciences, Evelina London Children's Hospital, Guy's & St Thomas' NHS Foundation Trust, London, UK; Barts Health NHS Trust, Royal London Hospital and Tower Hamlets Community Therapy Services, London, UK; Wolfson Institute of Population Medicine, Preventive Neurology Institute, Queen Mary University of London, London, UK.
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O’Malley JA. Diagnosing Common Movement Disorders in Children. Continuum (Minneap Minn) 2022; 28:1476-1519. [DOI: 10.1212/con.0000000000001187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Gilbert LA, Fehlings DL, Gross P, Kruer MC, Kwan W, Mink JW, Shusterman M, Aravamuthan BR. Top 10 Research Themes for Dystonia in Cerebral Palsy: A Community-Driven Research Agenda. Neurology 2022; 99:237-245. [PMID: 35715199 PMCID: PMC9442618 DOI: 10.1212/wnl.0000000000200911] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2021] [Accepted: 05/16/2022] [Indexed: 11/15/2022] Open
Abstract
Dystonia in cerebral palsy (DCP) is a common, debilitating, but understudied condition. The CP community (people with CP and caregivers) is uniquely equipped to help determine the research questions that best address their needs. We developed a community-driven DCP research agenda using the well-established James Lind Alliance methodology. CP community members, researchers, and clinicians were recruited through multiple advocacy, research, and professional organizations. To ensure shared baseline knowledge, participants watched webinars outlining our current knowledge on DCP prepared by a Steering Group of field experts (cprn.org/research-cp-dystonia-edition). Participants next submitted their remaining uncertainties about DCP. These were vetted by the Steering Group and consolidated to eliminate redundancy to generate a list of unique uncertainties, which were then prioritized by the participants. The top-prioritized uncertainties were aggregated into themes through iterative consensus-building discussions within the Steering Group. 166 webinar viewers generated 67 unique uncertainties. 29 uncertainties (17 generated by community members) were prioritized higher than their randomly matched pairs. These were coalesced into the following top 10 DCP research themes: (1) develop new treatments; (2) assess rehabilitation, psychological, and environmental management approaches; (3) compare effectiveness of current treatments; (4) improve diagnosis and severity assessments; (5) assess the effect of mixed tone (spasticity and dystonia) in outcomes and approaches; (6) assess predictors of treatment responsiveness; (7) identify pathophysiologic mechanisms; (8) characterize the natural history; (9) determine the best treatments for pain; and (10) increase family awareness. This community-driven research agenda reflects the concerns most important to the community, both in perception and in practice. We therefore encourage future DCP research to center around these themes. Furthermore, noting that community members (not clinicians or researchers) generated the majority of top-prioritized uncertainties, our results highlight the important contributions community members can make to research agendas, even beyond DCP.
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Affiliation(s)
- Laura A Gilbert
- From the Department of Neurology (L.A.G., B.R.A.), Washington University School of Medicine and St. Louis Children's Hospital, MO; Department of Pediatrics (D.L.F.), University of Toronto and Holland Bloorview Kids Rehabilitation Hospital, Ontario, Canada; Department of Population Health Sciences (P.G., W.K.), University of Utah, Salt Lake City; Departments of Child Health, Neurology, Genetics, and Cellular and Molecular Medicine (M.C.K.), College of Medicine-Phoenix, University of Arizona and Cerebral Palsy and Pediatric Movement Disorders Program, Barrow Neurological Institute, Phoenix Children's Hospital; Department of Neurology (J.W.M.), University of Rochester School of Medicine and Dentistry, NY; and The Cerebral Palsy Research Network (P.G., M.S.), Salt Lake City, UT
| | - Darcy L Fehlings
- From the Department of Neurology (L.A.G., B.R.A.), Washington University School of Medicine and St. Louis Children's Hospital, MO; Department of Pediatrics (D.L.F.), University of Toronto and Holland Bloorview Kids Rehabilitation Hospital, Ontario, Canada; Department of Population Health Sciences (P.G., W.K.), University of Utah, Salt Lake City; Departments of Child Health, Neurology, Genetics, and Cellular and Molecular Medicine (M.C.K.), College of Medicine-Phoenix, University of Arizona and Cerebral Palsy and Pediatric Movement Disorders Program, Barrow Neurological Institute, Phoenix Children's Hospital; Department of Neurology (J.W.M.), University of Rochester School of Medicine and Dentistry, NY; and The Cerebral Palsy Research Network (P.G., M.S.), Salt Lake City, UT
| | - Paul Gross
- From the Department of Neurology (L.A.G., B.R.A.), Washington University School of Medicine and St. Louis Children's Hospital, MO; Department of Pediatrics (D.L.F.), University of Toronto and Holland Bloorview Kids Rehabilitation Hospital, Ontario, Canada; Department of Population Health Sciences (P.G., W.K.), University of Utah, Salt Lake City; Departments of Child Health, Neurology, Genetics, and Cellular and Molecular Medicine (M.C.K.), College of Medicine-Phoenix, University of Arizona and Cerebral Palsy and Pediatric Movement Disorders Program, Barrow Neurological Institute, Phoenix Children's Hospital; Department of Neurology (J.W.M.), University of Rochester School of Medicine and Dentistry, NY; and The Cerebral Palsy Research Network (P.G., M.S.), Salt Lake City, UT
| | - Michael C Kruer
- From the Department of Neurology (L.A.G., B.R.A.), Washington University School of Medicine and St. Louis Children's Hospital, MO; Department of Pediatrics (D.L.F.), University of Toronto and Holland Bloorview Kids Rehabilitation Hospital, Ontario, Canada; Department of Population Health Sciences (P.G., W.K.), University of Utah, Salt Lake City; Departments of Child Health, Neurology, Genetics, and Cellular and Molecular Medicine (M.C.K.), College of Medicine-Phoenix, University of Arizona and Cerebral Palsy and Pediatric Movement Disorders Program, Barrow Neurological Institute, Phoenix Children's Hospital; Department of Neurology (J.W.M.), University of Rochester School of Medicine and Dentistry, NY; and The Cerebral Palsy Research Network (P.G., M.S.), Salt Lake City, UT
| | - Wendy Kwan
- From the Department of Neurology (L.A.G., B.R.A.), Washington University School of Medicine and St. Louis Children's Hospital, MO; Department of Pediatrics (D.L.F.), University of Toronto and Holland Bloorview Kids Rehabilitation Hospital, Ontario, Canada; Department of Population Health Sciences (P.G., W.K.), University of Utah, Salt Lake City; Departments of Child Health, Neurology, Genetics, and Cellular and Molecular Medicine (M.C.K.), College of Medicine-Phoenix, University of Arizona and Cerebral Palsy and Pediatric Movement Disorders Program, Barrow Neurological Institute, Phoenix Children's Hospital; Department of Neurology (J.W.M.), University of Rochester School of Medicine and Dentistry, NY; and The Cerebral Palsy Research Network (P.G., M.S.), Salt Lake City, UT
| | - Jonathan W Mink
- From the Department of Neurology (L.A.G., B.R.A.), Washington University School of Medicine and St. Louis Children's Hospital, MO; Department of Pediatrics (D.L.F.), University of Toronto and Holland Bloorview Kids Rehabilitation Hospital, Ontario, Canada; Department of Population Health Sciences (P.G., W.K.), University of Utah, Salt Lake City; Departments of Child Health, Neurology, Genetics, and Cellular and Molecular Medicine (M.C.K.), College of Medicine-Phoenix, University of Arizona and Cerebral Palsy and Pediatric Movement Disorders Program, Barrow Neurological Institute, Phoenix Children's Hospital; Department of Neurology (J.W.M.), University of Rochester School of Medicine and Dentistry, NY; and The Cerebral Palsy Research Network (P.G., M.S.), Salt Lake City, UT
| | - Michele Shusterman
- From the Department of Neurology (L.A.G., B.R.A.), Washington University School of Medicine and St. Louis Children's Hospital, MO; Department of Pediatrics (D.L.F.), University of Toronto and Holland Bloorview Kids Rehabilitation Hospital, Ontario, Canada; Department of Population Health Sciences (P.G., W.K.), University of Utah, Salt Lake City; Departments of Child Health, Neurology, Genetics, and Cellular and Molecular Medicine (M.C.K.), College of Medicine-Phoenix, University of Arizona and Cerebral Palsy and Pediatric Movement Disorders Program, Barrow Neurological Institute, Phoenix Children's Hospital; Department of Neurology (J.W.M.), University of Rochester School of Medicine and Dentistry, NY; and The Cerebral Palsy Research Network (P.G., M.S.), Salt Lake City, UT
| | - Bhooma R Aravamuthan
- From the Department of Neurology (L.A.G., B.R.A.), Washington University School of Medicine and St. Louis Children's Hospital, MO; Department of Pediatrics (D.L.F.), University of Toronto and Holland Bloorview Kids Rehabilitation Hospital, Ontario, Canada; Department of Population Health Sciences (P.G., W.K.), University of Utah, Salt Lake City; Departments of Child Health, Neurology, Genetics, and Cellular and Molecular Medicine (M.C.K.), College of Medicine-Phoenix, University of Arizona and Cerebral Palsy and Pediatric Movement Disorders Program, Barrow Neurological Institute, Phoenix Children's Hospital; Department of Neurology (J.W.M.), University of Rochester School of Medicine and Dentistry, NY; and The Cerebral Palsy Research Network (P.G., M.S.), Salt Lake City, UT.
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Home-Based Measurements of Dystonia in Cerebral Palsy Using Smartphone-Coupled Inertial Sensor Technology and Machine Learning: A Proof-of-Concept Study. SENSORS 2022; 22:s22124386. [PMID: 35746168 PMCID: PMC9231145 DOI: 10.3390/s22124386] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Revised: 05/30/2022] [Accepted: 06/07/2022] [Indexed: 02/06/2023]
Abstract
Accurate and reliable measurement of the severity of dystonia is essential for the indication, evaluation, monitoring and fine-tuning of treatments. Assessment of dystonia in children and adolescents with dyskinetic cerebral palsy (CP) is now commonly performed by visual evaluation either directly in the doctor’s office or from video recordings using standardized scales. Both methods lack objectivity and require much time and effort of clinical experts. Only a snapshot of the severity of dyskinetic movements (i.e., choreoathetosis and dystonia) is captured, and they are known to fluctuate over time and can increase with fatigue, pain, stress or emotions, which likely happens in a clinical environment. The goal of this study was to investigate whether it is feasible to use home-based measurements to assess and evaluate the severity of dystonia using smartphone-coupled inertial sensors and machine learning. Video and sensor data during both active and rest situations from 12 patients were collected outside a clinical setting. Three clinicians analyzed the videos and clinically scored the dystonia of the extremities on a 0–4 scale, following the definition of amplitude of the Dyskinesia Impairment Scale. The clinical scores and the sensor data were coupled to train different machine learning models using cross-validation. The average F1 scores (0.67 ± 0.19 for lower extremities and 0.68 ± 0.14 for upper extremities) in independent test datasets indicate that it is possible to detected dystonia automatically using individually trained models. The predictions could complement standard dyskinetic CP measures by providing frequent, objective, real-world assessments that could enhance clinical care. A generalized model, trained with data from other subjects, shows lower F1 scores (0.45 for lower extremities and 0.34 for upper extremities), likely due to a lack of training data and dissimilarities between subjects. However, the generalized model is reasonably able to distinguish between high and lower scores. Future research should focus on gathering more high-quality data and study how the models perform over the whole day.
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Gober J, Seymour M, Miao H, Curry DJ, Thomas SP. Management of severe spasticity with and without dystonia with intrathecal baclofen in the pediatric population: a cross-sectional study. WORLD JOURNAL OF PEDIATRIC SURGERY 2022; 5:e000407. [DOI: 10.1136/wjps-2021-000407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Accepted: 04/19/2022] [Indexed: 11/04/2022] Open
Abstract
ObjectiveTo investigate the differences in delivery mode, daily dose, and catheter tip location in pediatric patients using intrathecal baclofen (ITB) pumps with spasticity plus dystonia versus spasticity alone.MethodsA single-center, cross-sectional study was performed by collecting retrospective data from electronic medical records. Demographic and diagnostic information was obtained, comparing patients with spasticity with or without dystonia. The data were analyzed for group differences using a two-tailed Student’s t-test. Categorical data were analyzed for group differences using Pearson’s χ2 test.ResultsA total of 137 patients met the criteria. The majority (114) had spasticity plus dystonia whereas only 23 were documented as spasticity alone. Simple continuous dosing was the most common delivery mode, but flex dosing was used more than twice as frequently with spasticity plus dystonia compared with spasticity alone (42% vs 17%). Patients with spasticity plus dystonia also had more rostral catheter tip locations.ConclusionsWhile it has been discussed anecdotally, this study confirms the supposition that patients with spasticity plus dystonia have increased dose requirements when compared with those with spasticity alone. Although there are no clear standards of care when managing these patients, they are often on higher daily dosages, are more likely to require flexed dosing method, and have higher catheter placements. Still, there are few studies that demonstrate improvements in dystonia with the use of ITB. In general, these patients would benefit from the development of universal standardizations as well as the confirmation that this is an appropriate treatment.
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Saini AG, Hassan I, Sharma K, Muralidharan J, Dhawan S, Saini L, Suthar R, Sahu J, Sankhyan N, Singhi P. Status Dystonicus in Children: A Cross-Sectional Study and Review of Literature. J Child Neurol 2022; 37:441-450. [PMID: 35253510 DOI: 10.1177/08830738221081593] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: Status dystonicus is a life-threatening, underrecognized movement disorder emergency. We aimed to ascertain the etiology, clinical presentation, complications, and outcomes of status dystonicus in children and reviewed the literature for similar studies. Methods: Records of all children aged <14 years admitted to a single center with status dystonicus between 2014 and 2018 were reviewed. Results: Twenty-four children (75% male) were identified with status dystonicus. The annual incidence rate was 0.05 per 1000 new admissions <12 years of age. The mean age at presentation was 6.3 ± 3.6 years. Median duration of hospital stay was 10.5 days (interquartile range 5-21.7). The severity of dystonia at presentation was grade 3 (n = 9; 37.5%) and 4 (n = 9; 37.5%). The most common triggering factor was intercurrent illness/infection (n = 18; 75%). The most common underlying etiologies were cerebral palsy (n = 8; 33.3%), complicated tubercular meningitis (n = 3; 12.5%), and mitochondrial disorders (n = 3; 12.5%). Basal ganglia involvement was seen in 15 cases (62.5%). Respiratory and/or bulbar compromise (n = 20; 83.3%) and rhabdomyolysis (n = 15; 62.5%) were most commonly seen. Oral trihexyphenidyl (96%) followed by oral or intravenous diazepam (71%), oral baclofen (67%), and midazolam infusion (54%) were the most common drugs used. Clonidine was used in 33% cases, without any significant side effects. Three children died owing to refractory status dystonicus and its complications; the mortality rate was 12.5%. Conclusion Status dystonicus is a neurologic emergency in children with severe dystonia, with significant complications and a high mortality rate. Static and acquired disorders are more common than heredo-familial causes. Identification and treatment of infection in children is important as the majority of cases are triggered by an intercurrent infection.
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Affiliation(s)
- Arushi Gahlot Saini
- Pediatric Neurology Unit, Department of Pediatrics, 29751Postgraduate Institute of medical Education and Research (PGIMER), Chandigarh, India
| | - Ijas Hassan
- Department of Pediatrics, 29751Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Kanika Sharma
- Department of Pediatrics, 29751Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Jayashree Muralidharan
- Pediatric Emergency and Intensive Care Units, Department of Pediatrics, 29751Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Sumeet Dhawan
- Department of Pediatrics, 29751Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Lokesh Saini
- Pediatric Neurology Unit, Department of Pediatrics, 29751Postgraduate Institute of medical Education and Research (PGIMER), Chandigarh, India
| | - Renu Suthar
- Pediatric Neurology Unit, Department of Pediatrics, 29751Postgraduate Institute of medical Education and Research (PGIMER), Chandigarh, India
| | - Jitendra Sahu
- Pediatric Neurology Unit, Department of Pediatrics, 29751Postgraduate Institute of medical Education and Research (PGIMER), Chandigarh, India
| | - Naveen Sankhyan
- Pediatric Neurology Unit, Department of Pediatrics, 29751Postgraduate Institute of medical Education and Research (PGIMER), Chandigarh, India
| | - Pratibha Singhi
- Pediatric Neurology Unit, Department of Pediatrics, 29751Postgraduate Institute of medical Education and Research (PGIMER), Chandigarh, India
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Miao H, Mathur AM, Aravamuthan BR. Spasticity and Dystonia are Underidentified in Young Children at High Risk for Cerebral Palsy. J Child Neurol 2022; 37:105-111. [PMID: 34866453 PMCID: PMC9650959 DOI: 10.1177/08830738211059683] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Early spasticity and dystonia identification in cerebral palsy is critical for guiding diagnostic workup and prompting targeted treatment early when it is most efficacious. However, differentiating spasticity from dystonia is difficult in young children with cerebral palsy. METHODS We sought to determine spasticity and dystonia underidentification rates in children at high risk for cerebral palsy (following neonatal hypoxic-ischemic encephalopathy) by assessing how often child neurologists identified hypertonia alone versus specifying the hypertonia type as spasticity and/or dystonia by age 5 years. RESULTS Of 168 children, 63 developed cerebral palsy and hypertonia but only 19 (30%) had their hypertonia type specified as spasticity and/or dystonia by age 5 years. CONCLUSIONS Child neurologists did not specify the type of hypertonia in a majority of children at high risk of cerebral palsy. Because early tone identification critically guides diagnostic workup and treatment of cerebral palsy, these results highlight an important gap in current cerebral palsy care.
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Affiliation(s)
- Hanyang Miao
- Department of Neurology, Division of Pediatric Neurology, Washington University School of Medicine and St. Louis Children’s Hospital, St. Louis, Missouri, USA
| | - Amit M. Mathur
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, St. Louis University and Cardinal Glennon Children’s Hospital, St. Louis, Missouri, USA
| | - Bhooma R. Aravamuthan
- Department of Neurology, Division of Pediatric Neurology, Washington University School of Medicine and St. Louis Children’s Hospital, St. Louis, Missouri, USA
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Singh J, Lanzarini E, Nardocci N, Santosh P. Movement disorders in patients with Rett syndrome: A systematic review of evidence and associated clinical considerations. Psychiatry Clin Neurosci 2021; 75:369-393. [PMID: 34472659 PMCID: PMC9298304 DOI: 10.1111/pcn.13299] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Revised: 07/28/2021] [Accepted: 08/20/2021] [Indexed: 12/18/2022]
Abstract
AIM This systematic review identified and thematically appraised clinical evidence of movement disorders in patients with Rett syndrome (RTT). METHOD Using PRISMA criteria, six electronic databases were searched from inception to April 2021. A thematic analysis was then undertaken on the extracted data to identify potential themes. RESULTS Following the thematic analysis, six themes emerged: (i) clinical features of abnormal movement behaviors; (ii) mutational profile and its impact on movement disorders; (iii) symptoms and stressors that impact on movement disorders; (iv) possible underlying neurobiological mechanisms; (v) quality of life and movement disorders; and (vi) treatment of movement disorders. Current guidelines for managing movement disorders in general were then reviewed to provide possible treatment recommendations for RTT. CONCLUSION Our study offers an enriched data set for clinical investigations and treatment of fine and gross motor issues in RTT. A detailed understanding of genotype-phenotype relationships of movement disorders allows for more robust genetic counseling for families but can also assist healthcare professionals in terms of monitoring disease progression in RTT. The synthesis also showed that environmental enrichment would be beneficial for improving some aspects of movement disorders. The cerebellum, basal ganglia, alongside dysregulation of the cortico-basal ganglia-thalamo-cortical loop, are likely anatomical targets. A review of treatments for movement disorders also helped to provide recommendations for treating and managing movement disorders in patients with RTT.
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Affiliation(s)
- Jatinder Singh
- Department of Child and Adolescent Psychiatry, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK.,Centre for Interventional Paediatric Psychopharmacology and Rare Diseases, South London and Maudsley NHS Foundation Trust, London, UK.,Centre for Personalised Medicine in Rett Syndrome, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Evamaria Lanzarini
- Child and Adolescent Neuropsychiatry Unit, Infermi Hospital, Rimini, Italy
| | - Nardo Nardocci
- Department of Paediatric Neurology, Fondazione IRCCS Istituto Neurologico "Carlo Besta", Milan, Italy
| | - Paramala Santosh
- Department of Child and Adolescent Psychiatry, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK.,Centre for Interventional Paediatric Psychopharmacology and Rare Diseases, South London and Maudsley NHS Foundation Trust, London, UK.,Centre for Personalised Medicine in Rett Syndrome, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
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Bates L, Taylor M, Lin JP, Gimeno H, Kingston J, Rudebeck SR. Mental health and behaviour in children with dystonia: Anxiety, challenging behaviour and the relationship to pain and self-esteem. Eur J Paediatr Neurol 2021; 35:40-48. [PMID: 34600412 DOI: 10.1016/j.ejpn.2021.09.002] [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: 05/24/2021] [Revised: 08/13/2021] [Accepted: 09/06/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE To ascertain whether young people with dystonia are more likely than the general population to have mental health and/or behavioural difficulties, and to explore factors that may contribute to these difficulties. METHOD Using a quasi-experimental design, 50 young people with dystonia aged 7-17 and their carers were recruited from the Evelina London Children's Hospital. Young people completed the Beck Youth Inventories and the Strengths and Difficulties Questionnaire. Carers completed the Strengths and Difficulties Questionnaire-Parent version and the Paediatric Pain Profile. Important medical factors, such as age of onset, motor severity and manual function were obtained from medical records. RESULTS One sample z tests showed young people with dystonia self-reported significantly higher levels of anxiety (p < .001) and prosocial difficulties (p < .01), with 48% experiencing clinically significant anxiety levels. They experienced significantly lower levels of anger, disruptive behaviour and conduct problems (all p ≤ .01). Carers reported significantly higher rates of emotional problems, hyperactivity and peer problems, and significantly lower prosocial behaviours (all p ≤ .01). Pearson's correlation coefficients showed lower levels of self-esteem were related to higher levels of anxiety (p = .015). High levels of pain were related to parent-rated conduct problems (p = .004). Age of dystonia onset and motor severity did not correlate with any of the psychological or behavioural measures. INTERPRETATION/CONCLUSIONS Our study suggests high rates of anxiety and behaviours that challenge in children with dystonia. Screening in movement clinics would be helpful in early identification and signposting for support.
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Affiliation(s)
- Lauren Bates
- Department of Clinical Psychology, Royal Holloway, University of London, Egham, Surrey, TW20 0EX, UK.
| | - Michelle Taylor
- Department of Clinical Psychology, Royal Holloway, University of London, Egham, Surrey, TW20 0EX, UK.
| | - Jean-Pierre Lin
- Complex Motor Disorders Service, Evelina London Children's Hospital, Guy's & St Thomas' NHS Foundation Trust, Westminster Bridge Road, London, SE17 7EH, UK; Women and Children's Health Institute, Faculty of Life Sciences and Medicine, King's College London, St Thomas' Hospital, Westminster Bridge Road, London, SE1 7EH, UK.
| | - Hortensia Gimeno
- Complex Motor Disorders Service, Evelina London Children's Hospital, Guy's & St Thomas' NHS Foundation Trust, Westminster Bridge Road, London, SE17 7EH, UK; Women and Children's Health Institute, Faculty of Life Sciences and Medicine, King's College London, St Thomas' Hospital, Westminster Bridge Road, London, SE1 7EH, UK.
| | - Jessica Kingston
- Department of Clinical Psychology, Royal Holloway, University of London, Egham, Surrey, TW20 0EX, UK.
| | - Sarah R Rudebeck
- Complex Motor Disorders Service, Evelina London Children's Hospital, Guy's & St Thomas' NHS Foundation Trust, Westminster Bridge Road, London, SE17 7EH, UK.
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The importance of dystonia in cerebral palsy. Eur J Paediatr Neurol 2021; 32:A3. [PMID: 33966981 DOI: 10.1016/j.ejpn.2021.05.003] [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: 11/22/2022]
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