Cerebral palsy epidemiology: where are we now and where are we going?

Genetic pathways in cerebral palsy: a review of the implications for precision diagnosis and understanding disease mechanisms

ABSTRACT

Cerebral palsy is a diagnostic term utilized to describe a group of permanent disorders affecting movement and posture. Patients with cerebral palsy are often only capable of limited activity, resulting from non-progressive disturbances in the fetal or neonatal brain. These disturbances severely impact the child's daily life and impose a substantial economic burden on the family. Although cerebral palsy encompasses various brain injuries leading to similar clinical outcomes, the understanding of its etiological pathways remains incomplete owing to its complexity and heterogeneity. This review aims to summarize the current knowledge on the genetic factors influencing cerebral palsy development. It is now widely acknowledged that genetic mutations and alterations play a pivotal role in cerebral palsy development, which can be further influenced by environmental factors. Despite continuous research endeavors, the underlying factors contributing to cerebral palsy remain are still elusive. However, significant progress has been made in genetic research that has markedly enhanced our comprehension of the genetic factors underlying cerebral palsy development. Moreover, these genetic factors have been categorized based on the identified gene mutations in patients through clinical genotyping, including thrombosis, angiogenesis, mitochondrial and oxidative phosphorylation function, neuronal migration, and cellular autophagy. Furthermore, exploring targeted genotypes holds potential for precision treatment. In conclusion, advancements in genetic research have substantially improved our understanding of the genetic causes underlying cerebral palsy. These breakthroughs have the potential to pave the way for new treatments and therapies, consequently shaping the future of cerebral palsy research and its clinical management. The investigation of cerebral palsy genetics holds the potential to significantly advance treatments and management strategies. By elucidating the underlying cellular mechanisms, we can develop targeted interventions to optimize outcomes. A continued collaboration between researchers and clinicians is imperative to comprehensively unravel the intricate genetic etiology of cerebral palsy.

Comparing the Pre-writing Skills of Diplegic Cerebral Palsy Children to Those of Normal Children

INTRODUCTION

The pencil grasp and drawing patterns are specific to different age levels. So, if one knows a certain pattern for that particular age, it will guide the intervention plan for children with cerebral palsy (CP). The chances of improvement in diplegic CP are possible with the help of early intervention; therefore, early intervention is only possible if one knows the areas of delay and the age at which the intervention should be started.

MATERIAL AND METHODS

It was a cross-sectional, case-control study. A total of 60 children were selected for the study, of which 30 (50%) were normal and 30 (50%) had diplegic cerebral palsy. A convenient sampling method is used for evaluation.

RESULTS

The t-value for pencil grasp between the two groups, i.e., normal and CP diplegic, was 3.515 (P=0.001), revealing a significant difference in the grasp pattern of the two groups. Similarly, the t-value for drawing patterns between the two groups, i.e., normal and CP diplegic, was 5.796 (P = 0.001). A significant difference was found in the drawing patterns of both groups.

CONCLUSION

Our study found that diplegic CP children performed lower on the Erhardt Developmental Prehension Assessment (EDPA) and showed larger variation in the pencil grasp and drawing than the normal children.

Nutritional status of children with neurodevelopmental disorders: a cross-sectional study at a tertiary-level hospital in northern Bangladesh

BACKGROUND

Malnutrition in children with neurodevelopmental disorders (NDDs) is a significant global public health issue. Nutritional assessment combined with management or advice are essential to produce optimal outcomes.

OBJECTIVES

The objective of this study was to assess nutritional status and the sociodemographic profile of children with neurodevelopmental disorders in Bangladesh.

METHODS

A cross-sectional study was conducted from December to April 2020 among the population of children with NDDs who presented to the pediatric department of the TMSS Medical College and Rafatullah Community Hospital in Bogura during this period. Socio-demographic data along with anthropometric measurements of the children were taken. Assessment of nutritional status were made using metrics such as z-scores for weight-for-age (WAZ), height-for-age (HAZ), and body mass index-for-age (BAZ). Descriptive statistics (number and percentage) and analytical statistics (chi-square and logistic regression) were included.

RESULTS

58.6% of children displayed malnutrition, with 47.8% showing undernutrition (WHZ / BAZ - 1 SD-≤-3 SD), and 10.8% overnutrition (BAZ > 2SD). Significant negative associations were found between malnutrition and parental education level, urban residency, and monthly family income. Children diagnosed with cerebral palsy exhibited twice the likelihood to be malnourished (AOR 2.39, 95% CI 0.83-6.87). Furthermore, residing in rural regions was associated with an increased risk of experiencing malnutrition, as indicated by an adjusted odds ratio of 1.60 (95% CI 0.12-3.09).

CONCLUSIONS

While the results are cross-sectional, over half of children with NDDs were found to be malnourished, suggesting that children with NDD in Bangladesh are vulnerable to developing any form of malnutrition. Therefore, regular assessments and timely nutritional support may improve their situation.

Variables included in cerebral palsy registries globally: A scoping review

AIM

To identify cerebral palsy (CP) variables collected in CP registries from high-income countries (HICs) and low- and middle-income countries (LMICs) to assist with the development of a regional CP registry relevant to the African region.

METHOD

A systematic search of online databases to identify peer-reviewed publications and grey literature about CP risk-factor variables, using Ovid MEDLINE, Embase Ovid, CINAHL, and Google Scholar.

RESULTS

A total of 197 studies published from global CP registries between 1990 and 2023 were identified. CP registries both from HICs and from LMICs included variables on prenatal CP risk factors. LMIC registries focused more on socioeconomic factors (the physical structure of the family home [21.1%, n = 8, in LMICs vs 1.7%, n = 2, in HICs]). Prenatal modifiable and non-modifiable risk factors were emphasized in HICs. LMIC registries included more postnatal CP risk-factor variables than HIC registries, including history of postnatal jaundice (15.8%, n = 6, in LMICs vs 6.9%, n = 8, in HICs) and postnatal head trauma (10.5%, n = 4, in LMICs vs 5.2%, n = 6, in HICs).

INTERPRETATION

CP registries are currently more available in HICs than in LMICs. Differences in CP risk factors account for most of the differences in variables included in HICs and LMICs. Comparing variables used by CP registries in HICs and LMICs suggests the importance of understanding contextually relevant factors for regional registry design.

Telehealth Movement-to-Music With Arm-Based Sprint-Intensity Interval Training to Improve Cardiometabolic Health and Cardiorespiratory Fitness in Children With Cerebral Palsy: Protocol for a Pilot Randomized Controlled Trial

BACKGROUND

Children with mobility disabilities, including those with cerebral palsy, have limited options and limited time to exercise to manage their cardiometabolic health and cardiorespiratory fitness. Regular cardiovascular exercise during childhood is a critical health behavior for preventing health decline in adulthood. Thus, there is an urgent need for accessible, age-appropriate, convenient exercise modalities in this group. Sprint-intensity interval training (SIT), combined with telehealth procedures, may be ideal for children with disabilities. SIT includes repetitive bouts of maximal exercise effort combined with rest periods, which can be effective in eliciting comparable results to moderate-exercise training with very short training durations.

OBJECTIVE

This phase 1 pilot feasibility randomized controlled trial aims to investigate the potential effects of a 12-week SIT program on indicators of cardiorespiratory fitness and cardiometabolic health among children with cerebral palsy. An ancillary aim is to evaluate the feasibility of the program through several process feasibility metrics.

METHODS

This study uses a 2-armed parallel group design. A total of 50 physically inactive children with cerebral palsy (aged 6-17 years) will be randomly allocated into 1 of 2 groups: a 12-week SIT or a waitlist control group that continues habitual activity for 12 weeks. The SIT prescription includes 3 tele-supervised sessions per week with 30 repeated sequences of 4 seconds of maximal arm exercise, with active recovery, warm-up, and cooldown periods (for an approximately 20-minute total session). SIT includes guided videos with child-themed arm routines and music. The exercise sessions will be remotely supervised through a web-based videoconference application and include safety monitoring equipment. Outcomes are measured at pre- and postintervention (weeks 0 and 13, respectively). Health outcome measures include peak oxygen consumption (VO2 peak), measured by a graded exercise test; high-sensitivity C-reactive protein and blood insulin, hemoglobin A1c, triglycerides, and cholesterol using a finger stick dried blood spot test; blood pressure, using a sphygmomanometer; and body composition (total mass, total lean mass, tissue % lean, and tissue % fat) using dual x-ray absorptiometry. Feasibility will be evaluated by the following metrics: adverse events or problems experienced throughout the intervention related to participant safety; perceived enjoyment; and recruitment, enrollment, and attrition rates.

RESULTS

Recruitment procedures started in November 2023. All data are anticipated to be collected by February 2025. Full trial results are anticipated to be analyzed and submitted for publication by March 2025. Secondary analyses of data will be subsequently published.

CONCLUSIONS

This trial tests an accessible and low-cost exercise program that leverages principles of high-intensity exercise to provide a convenient program for children with physical disabilities. Knowledge obtained from this study will inform the development of a larger trial for improving the cardiometabolic health, cardiorespiratory fitness, and well-being of children with physical disabilities.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05619211; https://clinicaltrials.gov/study/NCT05619211.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/56499.

Development of a Play-Based Motor Learning Approach (A.MO.GIOCO) in Children with Bilateral Cerebral Palsy: Theoretical Framework and Intervention Methodology

The early intervention of motor training based on specific tasks and parent empowerment represents the new paradigm for the rehabilitation of children with Cerebral Palsy (CP). However, most published studies address the problem of the effectiveness of rehabilitation intervention without describing the treatment methodology or briefly mentioning it. The purpose of the study is to illustrate the development of a play-based motor learning approach titled A.MO.GIOCO (Apprendimento MOtorio nel GIOCO) and its systematization. Fifteen children aged between 2 and 6 years with bilateral CP will be enrolled and treated for 6-8 weeks (48 h). Motor Teaching methods applied by senior therapists have been extensively described, starting from rehabilitation goals and proposed therapeutic play activities, tailored to the functional profile of each child. This child-friendly rehabilitative approach (A.MO.GIOCO) refers to the systemic cognitive model of learning and movement control and is implemented in the context of spontaneous play activities and in the therapist-child-family interaction. In this study the theoretical framework of the approach and the process followed by the therapists to transfer it into rehabilitative practice are highlighted. As a result, an operational guide has been created. Further studies will explore the efficacy of the proposed standardized approach.

Application of Virtual Reality-Assisted Exergaming on the Rehabilitation of Children with Cerebral Palsy: A Systematic Review and Meta-Analysis

BACKGROUND

Rehabilitation programs for children with cerebral palsy (CP) aim to improve their motor and cognitive skills through repeated and progressively challenging exercises. However, these exercises can be tedious and demotivating, which can affect the effectiveness and feasibility of the programs. To overcome this problem, virtual reality VR-assisted exergaming has emerged as a novel modality of physiotherapy that combines fun and motivation with physical activity. VR exergaming allows children with CP to perform complex movements in a secure and immersive environment, where they can interact with virtual objects and scenarios. This enhances their active engagement and learning, as well as their self-confidence and enjoyment. We aim to provide a comprehensive overview of the current state of research on VR exergaming for CP rehabilitation. The specific objectives are: To identify and describe the existing studies that have investigated the effects of VR exergaming on motor function and participation outcomes in children with CP. In addition, we aim to identify and discuss the main gaps, challenges, and limitations in the current research on VR exergaming for CP rehabilitation. Finally, we aim to provide recommendations and suggestions for future research and practice in this field.

METHODS

In June 2023, we conducted a systematic search on Scopus, Web of Science, PubMed, Cochrane, and Embase for randomized trials and cohort studies that applied VR-assisted exergaming to rehabilitating patients with CP. The inclusion criteria encompassed the following: (1) Randomized controlled trials (RCTs) and cohort studies involving the rehabilitation of children with CP; (2) the application of VR-based exergaming on the rehabilitation; (3) in comparison with conventional rehabilitation/usual care. The quality of the selected RCTs was evaluated using Cochrane's tool for risk of bias assessment bias includes. Whereas the quality of cohort studies was assessed using the National Institutes of Health (NIH) tool.

RESULTS

The systematic search of databases retrieved a total of 2576 studies. After removing 863 duplicates, 1713 studies underwent title and abstract screening, and 68 studies were then selected as eligible for full-text screening. Finally, 45 studies were involved in this review (n = 1580), and 24 of those were included in the quantitative analysis. The majority of the included RCTs had a low risk of bias regarding study reporting, participants' attrition, and generating a random sequence. Nearly half of the RCTs ensured good blinding of outcomes assessors. However, almost all the RCTs were unclear regarding the blinding of the participants and the study personnel. The 2020 retrospective cohort study conducted at Samsung Changwon Hospital, investigating the effects of virtual reality-based rehabilitation on upper extremity function in children with cerebral palsy, demonstrated fair quality in its methodology and findings. VR-assisted exergaming was more effective than conventional physiotherapy in improving the Gross Motor Function Measurement (GMFM)-88 score (MD = 0.81; 95% CI [0.15, 1.47], p-value = 0.02) and the GMFM walking and standing dimensions (MD = 1.45; 95% CI [0.48, 2.24], p-value = 0.003 and MD = 3.15; 95% CI [0.87, 5.42], p-value = 0.007), respectively. The mobility and cognitive domains of the Pediatric Evaluation of Disability Inventory score (MD = 1.32; 95% CI [1.11, 1.52], p-value < 0.001) and (MD = 0.81; 95% CI [0.50, 1.13], p-value < 0.0001) were also improved. The Canadian Occupational Performance Measure performance domain (MD = 1.30; 95% CI [1.04, 1.56], p-value < 0.001), the WeeFunctional Independence Measure total score (MD = 6.67; 95% CI [6.36, 6.99], p-value < 0.0001), and the Melbourne Assessment of Unilateral Upper Limb Function-2 score (p-value < 0.001) improved as well. This new intervention is similarly beneficial as conventional therapy in improving other efficacy measures.

CONCLUSIONS

Our findings suggest that VR-assisted exergaming may have some advantages over conventional rehabilitation in improving CP children's functioning and performance in daily life activities, upper and lower limb mobility, and cognition. VR-assisted exergaming seems to be as effective as conventional physiotherapy in the other studied function measures. With its potential efficacy, better feasibility, no reported side effects, and entertaining experience, VR-assisted exergaming may be a viable complementary approach to conventional physiotherapy in rehabilitating children with CP.

Redefining cerebral palsies as a diverse group of neurodevelopmental disorders with genetic aetiology

Cerebral palsy is a clinical descriptor covering a diverse group of permanent, non-degenerative disorders of motor function. Around one-third of cases have now been shown to have an underlying genetic aetiology, with the genetic landscape overlapping with those of neurodevelopmental disorders including intellectual disability, epilepsy, speech and language disorders and autism. Here we review the current state of genomic testing in cerebral palsy, highlighting the benefits for personalized medicine and the imperative to consider aetiology during clinical diagnosis. With earlier clinical diagnosis now possible, we emphasize the opportunity for comprehensive and early genomic testing as a crucial component of the routine diagnostic work-up in people with cerebral palsy.

Effectiveness of Neurodevelopmental Treatment and Sensory Integration Therapy on Gross Motor Function, Balance and Gait Parameters in Children With Spastic Diplegia

Background Spastic diplegic cerebral palsy is the type that is most frequently seen in clinical settings. Spastic diplegic children have trouble maintaining their balance, gait, and gross motor function. This study investigated the effects of the Neurodevelopmental Technique (NDT) and Sensory Integration Technique (SIT) on balance, gross motor function, and gait characteristics in children with spastic diplegia. Method The study's participants were 8 to 12 years old, with spastic diplegia, categorized into stages I to III of the Gross Motor Function Classification System. While individuals in group B underwent sensory integration therapy, group A's subjects received NDT for 45 minutes. Both groups received traditional physiotherapy for 15 minutes. The protocol was given for five days a week, continuously for four weeks. All 40 subjects underwent pre- and post-treatment assessments using the Gross Motor Function Measure-88 (GMFM-88), Paediatric Balance Scale, Gait Parameters, and Gross Motor Function Classification System. Results The trial involved 40 children, divided into two groups of 20 each. Statistical analysis demonstrated a substantial improvement in group B post-intervention (P>0.0001). The study's findings were drawn using the Chi-Square test, paired and unpaired t-tests, and SPSS Statistics for Windows, version 27.0 (IBM Corp., Armonk, USA).A p<0.05 and the GraphPad Prism version 7.0 (GraphPad Software, Boston, USA) were used. A total of 40 children completed the entire duration of treatment for a month. 20 subjects participated in group A (age range 8-12 years; mean age 10.3 years) and 20 subjects in group B (age range 8-12 years; mean age 10.25 years). The GMFM-88, which assesses motor function, reveals that the between-group comparison indicates a substantial difference of 7.95 (6.04-9.86) in favor of Group B, with a p-value of 0.0001, signifying statistical significance. Similarly, the Pediatric Balance Scale (PBS) outcomes significantly enhanced in both groups post-intervention. The comparison between groups yields a difference of 1.85 (1.11-2.59) in favor of Group B, with a p-value of 0.0001. Conclusion The study concluded that SIT has a positive impact on gait metrics, balance, and gross motor function in children with spastic diplegia.

Effect of Intrathecal Baclofen Pump on Scoliosis in Children With Cerebral Palsy: A Meta-Analysis

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.

Association of motor performance of children with cerebral palsy and burnout level of their informal caregivers in an African community

PURPOSE

The demands of caring for children with cerebral palsy (CWCP) may lead to burnout among the informal caregivers of these children. However, this subject area has not received significant research attention in Nigeria. The primary aim of this study was to investigate the association between burnout level of informal caregivers of CWCP and the motor performance of the CWCP. The association between burnout level of the informal caregivers and selected clinical variables of CWCP was also investigated.

METHODS

This is a descriptive study of 75 consecutively-sampled informal caregivers (34.76±8.7 years) of CWCP and an equal number of their CWCP. Burnout level of the caregivers and motor performance of the CWCP were assessed using the Copenhagen Burnout Inventory (CBI) and Gross Motor Function Classification System Family Questionnaire (GMFCSFQ) respectively. Descriptive and inferential statistics were used to analyse results at alpha = 0.05.

RESULTS

There was a statistically significant positive association between the CBI scores and the GMFCSFQ scores (p <  0.05). Age of the CWCP as well as type and topography of the cerebral palsy were not significantly associated with the caregivers' burnout level. Similarly, the age and sex of the caregivers had no statistically significant association with their burnout level (p >  0.05).

CONCLUSION

Caregiving for children with lower motor performance is associated with higher burnout among caregivers. This may impact negatively on the overall health of the caregivers and the quality of care for the CWCP.

Mothers' experience of having a child with cerebral palsy. A systematic review

AIM

To explore, synthesise and present findings of qualitative studies describing the experiences of mothers raising a child with cerebral palsy.

DESIGN

A systematic literature review of the qualitative evidence.

METHODS

A systematic search for qualitative studies published in the following databases: CINAHL (EBSCO), Medline via OVID, SCOPUS, and Google Scholar. The authors independently assessed eligibility, appraised methodological quality using the Critical Appraisal Skills Program tool for qualitative Research (CASP). An inductive thematic analysis method was adopted to synthesise major findings and to construct core concepts and themes.

RESULTS

Five overarching themes reflecting the experiences and perceptions of mothers raising and caring for a child with cerebral palsy are developed: 1) adapting and making sacrifices; 2) guilt and cultural blame; 3) social stigma and marginalisation; 4) physical, environmental, and financial challenges and 5) healthcare experiences.

Effect of Lower Extremity Muscle Strength on Aerobic Capacity in Adults with Cerebral Palsy

The purpose of this study is to analyze the effect of lower extremity muscle strength of HIP joint and KNEE joint on the aerobic capacity to provide the basic data for developing an exercise program that can effectively improve the aerobic capacity of adults with cerebral palsy (CP) by identifying the part of the lower extremity muscle. A total of 18 ambulant adults with CP were recruited for this study. Seven ambulant adults with CP were excluded because they did not achieve the criteria of maximal exercise. The data from 11 subjects (11 men) with CP were used for the analysis. The mean (±SD) age, height, weight, and BMI of the subjects were 37.00 ± 12.72 years, 170.45 ± 6.37 cm, 67.02 ± 8.62 kg, and 23.09 ± 2.78 kg/m2, respectively. To measure the muscle strength of HIP joint and KNEE joint in lower extremities, the variables of the isokinetic muscle strength and the muscular endurance were performed using the isokinetic equipment (Biodex Co., Shirley, NY, USA). For the isokinetic muscle strength measurement of HIP joint, the 45°/sprotocol indicating the muscle power and the 300°/s protocol indicating the muscle endurance were used. Additionally, the measurement of KNEE joint was performed once on the left and right side, using the protocol of 60°/s indicating the muscle power and 300°/s indicating the muscular endurance. Progressive exercise tests were conducted on the treadmill (Quinton model—4500) using previously developed protocols targeting CP. The initial protocol speeds were 5 km/h−1 and 2 km/h−1 for the subjects who have been classified as Gross Motor Function Classification System (GMFCS) level I and II, respectively. Using a portable cardiopulmonary indirect breath-by-breath calorimetry system (MetaMax 3B; Cortex Biophysik, Leipzig, Germany), pulmonary ventilation (VE), respiratory exchange ratio (RER), and oxygen uptake (VO2) have been persistently measured. HR monitor (Polar Electro, Kempele, Finland polar Co. RS-800) was used to measure heart rate (HR). A correlation analysis was conducted to find out how the lower extremity muscle strength and aerobic capacity with cerebral palsy are related. Therefore, as a result, VO2peak among aerobic capacity displayed a significant positive correlation in 45° and 300°/s peak torque/BW of HIP joint, and with 60° and 300°/s peak torque/BW of KNEE joint. It was the same with 60°/s Agon/Antag ratio of KNEE Joint (p < 0.05). VEpeak showed a significant positive correlation with 45° and 300°/s peak torque/BW of HIP joint, as well as correlation with 60° and 300°/s peak torque/BW and 60°/s Agon/Antag ratio of KNEE joint (p < 0.05). However, HRpeak showed a significant positive correlation only in 45°/s peak torque/BW of HIP joint (p < 0.05). The result of step-wise analysis was to find out which muscle strength significantly affects VO2peak and HRpeak among aerobic abilities in the lower extremity muscles of those disabled with cerebral palsy. Among the muscle functions of lower extremity muscle strength, 300°/s peak torque/BW of KNEE Joint was found to have the greatest effect on VO2peak (p < 0.001). As a result, 300°/s peak torque/BW of KNEE Joint was found to be the predictable factor that could explain the VO2peak in the disabled people with cerebral palsy at 67% (R2 = 0.661). In particular, among the muscle functions of lower extremity muscle strength at 45°/s peak, torque/BW of HIP Joint was found to have the greatest effect on HRpeak (p < 0.001). As a result, this factor was found to be the predictable factor that could explain the HRpeak in disabled people with cerebral palsy at 39% (R2 = 0.392). In this study, the muscle strength of the lower extremity of CP was closely related to the aerobic capacity, and the muscle endurance of KNEE Joint and the muscle power of HIP Joint were found to be important factors to predict the aerobic capacity of CP.

Muscle architecture, growth, and biological Remodelling in cerebral palsy: a narrative review

Cerebral palsy (CP) is caused by a static lesion to the brain occurring in utero or up to the first 2 years of life; it often manifests as musculoskeletal impairments and movement disorders including spasticity and contractures. Variable manifestation of the pathology across individuals, coupled with differing mechanics and treatments, leads to a heterogeneous collection of clinical phenotypes that affect muscles and individuals differently. Growth of muscles in CP deviates from typical development, evident as early as 15 months of age. Muscles in CP may be reduced in volume by as much as 40%, may be shorter in length, present longer tendons, and may have fewer sarcomeres in series that are overstretched compared to typical. Macroscale and functional deficits are likely mediated by dysfunction at the cellular level, which manifests as impaired growth. Within muscle fibres, satellite cells are decreased by as much as 40–70% and the regenerative capacity of remaining satellite cells appears compromised. Impaired muscle regeneration in CP is coupled with extracellular matrix expansion and increased pro-inflammatory gene expression; resultant muscles are smaller, stiffer, and weaker than typical muscle. These differences may contribute to individuals with CP participating in less physical activity, thus decreasing opportunities for mechanical loading, commencing a vicious cycle of muscle disuse and secondary sarcopenia. This narrative review describes the effects of CP on skeletal muscles encompassing substantive changes from whole muscle function to cell-level effects and the effects of common treatments. We discuss growth and mechanics of skeletal muscles in CP and propose areas where future work is needed to understand these interactions, particularly the link between neural insult and cell-level manifestation of CP.

Informing the development of the Canadian Neurodiversity Platform: What is important to parents of children with neurodevelopmental disabilities?

BACKGROUND

A crowd-sourced Canadian platform that collects information across neurodevelopmental disabilities (NDDs) can (1) facilitate knowledge mobilization; (2) provide epidemiological data that can benefit knowledge, treatment, and advocacy; and (3) inform policy and resource allocation decisions. We obtained input from parents of children with NDDs about relevance and feasibility of questionnaire items as a first step to inform questionnaire development of a stakeholder-driven, national platform for data collection on children with NDDs.

METHODS

A parent of a teenager with NDDs was a research partner on the project. Through four focus groups and using a guided discussion consensus process, 16 participants provided feedback on whether questionnaire items from existing instruments related to function and disability were feasible for parents to complete and important to include in the platform. Data were analysed using content analysis.

RESULTS

Participants (1) indicated that questions about medical history, general health, body functioning, self-care, access to resources, and outcomes (e.g., quality of life) are important to include in the platform and are feasible for self-completion; (2) provided various suggestions for the questionnaire ranging from additional items to include, using non-medical language, and keeping completion time from 20 to 30 min; (3) identified incentives and knowing the purpose of the platform as strong motivators to platform participation; (4) spoke about the challenges of their caregiver experience including impact of caregiving on themselves and barriers to accessing services; and (5) highlighted the isolation experienced by their children.

CONCLUSION

Through the focus groups, parent stakeholders contributed to questionnaire development and shared their caregiver experiences. Obtaining feedback from youths with NDDs and healthcare providers on the questionnaire is a next step to validating findings. Stakeholder engagement is fundamental to developing a platform that will inform research that is relevant to the needs of children with NDDs and their families.

Determinants of Cerebral Palsy in Pediatric Patients in Northern Ethiopia: A Hospital-Based Study

Introduction

Cerebral palsy is the most common neurologic disorder of childhood with lifelong implications in majority of patients. Knowledge of the determinants of cerebral palsy is important for accurate mobilization of resources in obstetric, perinatal, and infant care besides implementation of prevention systems. In Ethiopia, however, this knowledge gap exists as there are no published studies on determinants of cerebral palsy in the country.

Objective

To assess the determinants of cerebral palsy in pediatric patients attending Ayder Comprehensive Specialized Referral Hospital between April 2019 and August 2019.

Methods

An unmatched case-control study was conducted among 50 pediatric cerebral palsy patients and 100 controls, pediatric patients without cerebral palsy or other motor or central nervous system illnesses, attending Ayder Comprehensive Specialized Hospital, Mekelle, Ethiopia. The data were analyzed using SPSS version 27.

Results

Significant factors were operative vaginal delivery (AOR: 9.49, 95% CI: 1.31-68.88), central nervous system infections (AOR: 0.02, 95% CI: 0-0.58), neonatal admissions (AOR: 0.13, 95% CI: 0.03-0.61), and unknown maternal education status (AOR: 18.64, 95% CI: 2.15-161.73).

Conclusion

Operative vaginal delivery, central nervous system infections in infancy, neonatal hospital admissions, and unknown maternal education status were found to be significant determinants for cerebral palsy. This knowledge aids focused hospital and regional health bureau development and implementation of prevention strategies for cerebral palsy, besides improvement of obstetric and neonatal healthcare services, and provides baseline data to the scientific community for further research.

Analysis of Selected Risk Factors Depending on the Type of Cerebral Palsy

Background: Cerebral palsy (CP) is not a defined, separate disease classification, but a set of etiologically diverse symptoms that change with the child's age. According to the up-to-date definition, CP is a group of permanent but not unchanging disorders of movement and/or posture and motor function, which are due to a nonprogressive interference, lesion, or abnormality of the developing/immature brain. CP is one of the most frequent causes of motor disability in children. The aim of the present study was to analyze whether selected risk factors may vary depending on particular types of CP. Methods: 181 children with CP (aged 4-17 years), hospitalized at the Department of Pediatrics and Developmental Age Neurology in Katowice in the years 2008-2016 were retrospectively analyzed in the present study. The assumed risk factors of CP were divided into two groups: 1-pre-conception and prenatal (mother's age, family history of epilepsy, burdened obstetric history, mother's systemic diseases, pregnancy order, multiple pregnancy, duration of pregnancy, bleedings from the genital tract during gestation, arterial hypertension during pregnancy, infections during pregnancy, preterm contractions, maintained pregnancy, premature rupture of membranes, abruptio placentae, and others), 2-perinatal and postnatal (mode of delivery, birth weight, Apgar score at the first and fifth minute, neonatal convulsions, respiratory failure, infections in neonatal and infant period, and intraventricular bleeding). The division into particular CP types was based on Ingram's classification. Results: The following risk factors were the most frequent in the total group: respiratory failure, infections, intraventricular bleeding, and prematurity. Among the analyzed preconception and prenatal factors, the duration of pregnancy and preterm contractions during pregnancy significantly differentiated the subgroups of patients depending on the type of CP. The prevalence of almost all analyzed perinatal, neonatal, and infant-related risk factors (i.e., birth weight, Apgar score at the first and fifth minute, neonatal convulsions, respiratory failure, infections in neonatal and infant period, and intraventricular bleeding) significantly differed between CP types, apart from the mode of delivery. However, in multivariate regression, only intraventricular bleeding was an independent predictor for tetraplegic CP type when compared to joined extrapyramidal and ataxic types (OR = 2.801, p = 0.028). Conclusions: As CP is a syndrome of multifactorial etiology, the identification of CP risk factors entails the need for careful observation and comprehensive care of children in the risk group. The presence of certain risk factors may be a prognostic indicator for particular types of CP. The knowledge about the association between the risk factor(s) and the CP type could be a very useful tool for pediatricians looking after the child at risk of developmental disorders.

Upper extremity rehabilitation using video games in cerebral palsy: a randomized clinical trial

INTRODUCTION

The aim of the present study was to compare the effects of neurodevelopmental therapy (NDT)-based upper extremity rehabilitation and video game-based therapy (VGBT) using Nintendo^® wii and leap motion controller (LMC) games on upper extremity function in patients with cerebral palsy (CP). The 30 patients included in the present study were randomized to two groups: VGBT group (VGBT using Nintendo® Wii and LMC games) and control group (NDT-based upper extremity rehabilitation). Both groups trained 3 days a week for 8 weeks. Manual dexterity was evaluated using the "Minnesota Manual Dexterity Test (MMDT)", functional ability using the "Childhood Health Assessment Questionnaire (CHAQ)" and the "Duruoz Hand Index (DEI)" and grip and pinch strengths using a dynamometer. Following treatment, significant changes were found, MMDT, grip and pinch strength, CHAQ, and DHI scores in both groups (p < 0.05); however, VGBT group was statistically superior to group II with respect to changes in MMDT (p < 0.05). VGBT using Nintendo^®Wii and LMC games had slightly superior effects on manual dexterity in patients with CP while compared with NDT-based upper extremity rehabilitation. Futhermore, the effects of both treatment programs on grip strengths and functional ability were similar beneficial.

The respiratory problems of patients with cerebral palsy requiring hospitalization: Reasons and solutions

OBJECTIVE

Recurrent respiratory problems are common in patients with cerebral palsy (CP). Detection of risk factors could prevent respiratory problems and reduce permanent lung damage. We aimed to provide a multidisciplinary approach for the causes, frequency, and concomitant problems and solutions of respiratory problems of these patients.

METHOD

Medical records of CP patients who were followed-up and treated due to respiratory problems requiring hospitalization were examined retrospectively, and factors affecting the frequency and duration of hospitalization in wards and in the intensive care unit (ICU) were evaluated.

RESULTS

Among 292 hospitalizations of 83 CP patients, 91% of them were hospitalized for pneumonia, and only 15.4% of them had major aspiration-related pneumonia in the history. 97.4% of the hospitalized patients had swallowing dysfunction in detailed history, but videofluoroscopic swallowing studies could be performed only to 24 patients and aspiration had been demonstrated in 96%. Patients who had been hospitalized more than two times during the oral feeding period, before switching to artificial feeding (nasogastric tube, gastric tube +/- fundoplication), had higher total and ICU hospitalization frequency/duration than the patients who had been hospitalized twice or less (0.12 vs. 0.17/0.005106 vs. 0.005353).

CONCLUSION

The most common pulmonary complication in patients with CP is pneumonia due to chronic aspiration. To prevent recurrent lung infections and consequently chronic respiratory failure, it is necessary to evaluate these patients in terms of feeding difficulties in the early period with appropriate methods and apply interventions before affecting the lung parenchyma.

Evaluation of risk factors for cerebral palsy

Background

Cerebral palsy (CP) has been identified as one of the most important and common causes of childhood disabilities worldwide and is often accompanied by multiple comorbidities. CP is defined as a group of disorders of the development of movement and posture, causing activity limitation that are attributed to non-progressive disturbances that occurred in the developing fetal or infant brain. The objective of our study was to describe main clinical pattern and motor impairments of our patients, and to evaluate the presence of risk factors and if there is a relation to the type of cerebral palsy.

Methods

Children with cerebral palsy were retrospectively enrolled over 2 years from the neurology outpatient clinics. Cerebral palsy risk factors and motor impairments were determined through caregiver interviews, review of medical records, and direct physical examination.

Results

One thousand children with cerebral palsy were enrolled. Subjects were 64.4% male, with a median age of 2.5 years. The risk factors for cerebral palsy in our study were antenatal (21%), natal and post-natal (30.5%), post-neonatal (17.1%), and unidentified (31.4%). Antenatal as CNS malformation (26.6%), maternal DM (17.6%), prolonged rupture of membrane (11.9%), maternal hemorrhage (10.4%), and pre-eclampsia (4.7%). Natal and post-natal as hypoxic ischemic encephalopathy (28.5%), infection (16.3%), hyperbilirubinemia (12.7%), cerebrovascular accidents (8.8%), meconium aspiration (6.2%), and intracranial hemorrhage. Post-neonatal as CNS infection (34.5%), cerebrovascular accidents (28.6%), sepsis (23.9%), and intracranial hemorrhage (8.7%).

Conclusions

Cerebral palsy has different etiologies and risk factors. Further studies are necessary to determine optimal preventative strategies in these patients.

Causes, functional outcomes and healthcare utilisation of people with cerebral palsy in Singapore

Introduction: A voluntary cerebral palsy (CP) registry was established in 2017 to describe the clinical characteristics and functional outcomes of CP in Singapore. Methods: People with CP born after 1994 were recruited through KK Women’s and Children’s Hospital, National University Hospital and Cerebral Palsy Alliance Singapore. Patient-reported basic demographics, service utilisation and quality of life measures were collected with standardised questionnaires. Clinical information was obtained through hospital medical records. Results: Between 1 September 2017 and 31 March 2020, 151 participants were recruited. A majority (n=135, 89%) acquired CP in the pre/perinatal period, where prematurity (n=102, 76%) and the need for emergency caesarean section (n=68, 50%) were leading risk factors. Sixteen (11%) of the total participants had post-neonatally acquired CP. For predominant CP motor types, 109 (72%) had a spastic motor type; 32% with spastic mono/hemiplegia, 41% diplegia, 6% triplegia and 21% quadriplegia. The remaining (42, 27.8%) had dyskinetic CP. Sixty-eight (45.0%) participants suffered significant functional impairment (Gross Motor Functional Classification System levels IV–V). Most participants (n=102, 67.5%) required frequent medical follow-up (≥4 times a year). Conclusion: Optimisation of pre- and perinatal care to prevent and manage prematurity could reduce the burden of CP and their overall healthcare utilisation. Keywords: Cerebral palsy, functional outcomes, neonatal, registry

Population-based study on the prevalence and clinical profile of adults with cerebral palsy in Northern Ireland

OBJECTIVES

This study aimed to report the prevalence and clinical characteristics of adults with cerebral palsy (CP) in a geographically defined region of the UK.

DESIGN AND SETTING

Cross-sectional study using the Northern Ireland Cerebral Palsy Register (NICPR).

PARTICIPANTS

All validated cases known to the NICPR, born 1981-2001 and alive and resident in Northern Ireland at age 19 years were included.

RESULTS

The study included 1218 persons with CP aged 19-39 years, 46 of whom died in adulthood. The prevalence of CP was 2.38 per 1000. The majority of cases had spastic CP (n=1132/1218, 93%) and could walk (n=949/1218, 78%). Those that died in adulthood typically had bilateral spastic CP (n=39/46) and used a wheelchair (n=40/46).

CONCLUSION

The prevalence of CP in adults is similar to other common neurological conditions such as multiple sclerosis and Parkinson's disease. The needs of adults with CP vary widely with almost half having two or more associated impairments that may require multiprofessional and multiagency coordination. Results from this study can be used to inform transformation of health and care services for adults with CP.

No support that early selective dorsal rhizotomy increase frequency of scoliosis and spinal pain - a longitudinal population-based register study from four to 25 years of age

Abstract

Spasticity interfering with gross motor development in cerebral palsy (CP) can be reduced with selective dorsal rhizotomy (SDR). Although reported, it is unknown if SDR surgery causes later spine problems. Using CP-registry data from a geographically defined population, the objectives were to compare frequency and time to scoliosis, and spinal pain up to adult age after SDR-surgery or not in all with same medical history, functional abilities, CP-subtype and level of spasticity at 4 years of age. Variables associated with scoliosis at 20 years of age were explored.

Method

In the total population with CP spastic diplegia in Skåne and Blekinge, born 1990–2006, 149 individuals had moderate to severe spasticity and no medical contraindications against SDR at 4 years of age and were included; 36 had undergone SDR at a median age of 4.0 years (range 2.5–6.6 years), and 113 had not.

Frequency of scoliosis and age when scoliosis was identified, and frequency of spinal pain at 10, 15, 20 and 25 years of age were analysed using Kaplan-Meier survival curves and Fisher’s exact test. Multivariable logistic regression was performed to identify variables to explain scoliosis at 20 years of age. Gross Motor Function Classification System (GMFCS) levels at 4 years of age were used for stratification.

Result

Frequency of scoliosis did not significantly differ between groups having had early SDR surgery or not. In GMFCS IV, the SDR group had later onset and lower occurrence of scoliosis (p = 0.004). Frequency of spinal pain did not differ between the groups (p- levels > 0.28). GMFCS level was the background variable that in the logistic regression explained scoliosis at 20 years of age.

Conclusion

Frequency of back pain and scoliosis in adulthood after early SDR are mainly part of the natural development with age, and not a surgery complication.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-020-03782-5.

Definition and diagnosis of cerebral palsy in genetic studies: a systematic review

AIM

To conduct a systematic review of phenotypic definition and case ascertainment in published genetic studies of cerebral palsy (CP) to inform guidelines for the reporting of such studies.

METHOD

Inclusion criteria comprised genetic studies of candidate genes, with CP as the outcome, published between 1990 and 2019 in the PubMed, Embase, and BIOSIS Citation Index databases.

RESULTS

Fifty-seven studies met the inclusion criteria. We appraised how CP was defined, the quality of information on case ascertainment, and compliance with international consensus guidelines. Seven studies (12%) were poorly described, 33 studies (58%) gave incomplete information, and 17 studies (30%) were well described. Missing key information precluded determining how many studies complied with the definition by Rosenbaum et al. Only 18 out of 57 studies (32%) were compliant with the Surveillance of Cerebral Palsy in Europe (SCPE) international guidelines on defining CP.

INTERPRETATION

Limited compliance with international consensus guidelines on phenotypic definition and mediocre reporting of CP case ascertainment hinders the comparison of results among genetic studies of CP (including meta-analyses), thereby limiting the quality, interpretability, and generalizability of study findings. Compliance with the SCPE guidelines is important for ongoing gene discovery efforts in CP, given the potential for misclassification of unrelated neurological conditions as CP.

Engaging children and adolescents with acquired brain injury and their families in goal setting: The clinician perspective

This paper explored clinicians' experiences of the goal setting process with children and adolescents with acquired brain injuries (ABI) and their families in paediatric neurorehabilitation. Semi-structured interviews were conducted with 13 clinicians, all members of an interdisciplinary paediatric rehabilitation service, who work with children and adolescents with ABI and their families. Interview transcripts and additional data were analysed using constructivist grounded theory methods. Three main themes and sub-themes were developed: (1) Seeing the bigger picture: Goals change over time; Families set bigger picture goals; Need-to-dos: Goals that the child/adolescent needs to achieve; and Want-to-dos: Goals that the child/adolescent wants to achieve; (2) Collaborating as a team: Everyone needs to be on the same page; Hearing the child's/adolescent's voice; and Parents as advocates; and (3) Recognizing and navigating challenges: Child-/adolescent- and family-related challenges and Time as a service-related challenge. Participants perceived the clinician's role during goal setting as that of an active collaborator, enabling children and adolescents with ABI and their families to generate meaningful goals. These findings demonstrate insights into goal setting in paediatric ABI neurorehabilitation from clinicians' perspectives, and highlight the importance of collaboration, flexibility and anticipation of challenges in facilitating children's, adolescents' and families' involvement in this process.

A perspective on the development of hemispheric specialization, infant handedness, and cerebral palsy

Cerebral Palsy (CP), a common form of neurological pediatric disability, results from pre- or perinatal brain injury. Although there is growing evidence of the efficacy of motor learning-based therapies, several factors interact to produce variability in impairment and limit the effectiveness of these therapies. The variability of hand function present in children with CP indicates that a range of developmental pathways must contribute to the manifestation of individually unique characteristics of impairment. Despite two decades of progress using therapies derived from understanding the mechanisms controlling hand function, very little is known about the sensorimotor experiences occurring during development that likely shape later functional problems for children with CP. In this "perspective" paper, we propose that the study of the development of motor skills in typically developing infants may reveal experiential factors potentially important for creating remedial therapies for children with CP. Specifically, we use the development of infant handedness, a model of hemispheric specialization of function, as an example of how self-generated experiences and sensorimotor feedback can shape the development of limb control and hemispheric specialization. We illustrate how early sensorimotor asymmetries concatenate into pronounced differences in skill between the two hands. We suggest that this model of infant handedness provides a framework for studying the individual differences manifested in children with CP. These differences likely arise from aberrant sensorimotor experiences created by sensorimotor circuits disrupted by the early brain injury. We conclude that knowledge of the developmental events, including subtle motor behaviors, that shape sensorimotor pathways, can improve treatment options for children with CP.

Walking through life with cerebral palsy: reflections on daily walking by adults with cerebral palsy

Purpose: Walking is a major target in childhood physiotherapy for children with cerebral palsy (CP). Little information exists on the importance or value of walking when these children grow up. The aim of this study was to explore personal reflections on daily walking by adults with CP.

Method: Semi-structured individual interviews were conducted and analysed with systematic text condensation, a four-step thematic cross-case analysis.

Results: Eight ambulatory adults (26–60 years, four women and four men) with CP were interviewed. Almost all had experienced deteriorated walking ability in adulthood and reported that walking was restricted and affected by intrinsic features, such as pain, fatigue, reduced balance and fear of falling. Extrinsic features such as being looked at due to walking abnormality and environmental factors, such as seasonal changes affected their free walking and was common. Some had accepted using mobility aids for energy conservation.

Conclusions: Both intrinsic and extrinsic factors influence walking in adults with CP. Reflections by the adults with CP suggest these features may reduce participation in public spaces and potentially increase acceptance and use of mobility aids.

Pattern of Cerebral Palsy Among Sudanese Children Less Than 15 Years of Age

BACKGROUND

Cerebral palsy (CP) is a non-progressive, everlasting neurological disorder of movement, posture, and physical activities, with a prevalence of 2.2-3.3/1,000. CP is a condition that occurs globally, with a similar prevalence in both developed and undeveloped countries. However, the etiology differs according to the socioeconomic status of the countries. The objective is to determine the pattern and the contributing factors of CP among Sudanese children.

METHODS

This was a retrospective hospital-based study conducted over a period of three years in a pediatric referral hospital in Khartoum, Sudan. One hundred and eight patients of CP were enrolled, of whom 59 (54.6%) were males and 49 (45.4%) were females.

RESULTS

Spastic quadriplegic CP was the most common type. Most cases were from lower social classes. Prenatal, antenatal, and unclassified CP were found in 45 (41.7%), 31 (28.7.%), 23 (21.3%), and 9 (8.3%) cases, respectively. Birth asphyxia, neonatal jaundice, Toxoplasma gondii, rubella virus, cytomegalovirus, herpes simplex virus infections (TORCH), and sepsis (acquired) were the main causative factors.

CONCLUSION

Spastic quadriplegia is the most common type of CP. Most of the cases had a direct positive relationship with socioeconomic status. The prenatal period was the most common period for the development of CP.

Understanding the impact of bilateral brain injury in children with unilateral cerebral palsy

The presence of bilateral brain injury in patients with unilateral cerebral palsy (CP) may impact neuroplasticity in the ipsilateral hemisphere; however, this pattern of injury is typically under‐analyzed due to the lack of methods robust to severe injury. In this study, injury‐robust methods have been applied to structural brain magnetic resonance imaging (MRI) data of a cohort of 91 children with unilateral CP (37 with unilateral and 54 with bilateral brain injury, 4–17 years) and 44 typically developing controls (5–17 years), to determine how brain structure is associated with concurrent motor function, and if these associations differ between patients with unilateral or bilateral injury. Regression models were used to associate these measures with two clinical scores of hand function, with patient age, gender, brain injury laterality, and interaction effects included. Significant associations with brain structure and motor function were observed (Pearson's r = .494–.716), implicating several regions of the motor pathway, and demonstrating an accurate prediction of hand function from MRI, regardless of the extent of brain injury. Reduced brain volumes were observed in patients with bilateral injury, including volumes of the thalamus and corpus callosum splenium, compared to those with unilateral injury, and the healthy controls. Increases in cortical thickness in several cortical regions were observed in cohorts with unilateral and bilateral injury compared to controls, potentially suggesting neuroplasticity might be occurring in the inferior frontal gyrus and the precuneus. These findings identify prospective useful target regions for transcranial magnetic stimulation intervention.

Cerebral Palsy: Current Opinions on Definition, Epidemiology, Risk Factors, Classification and Treatment Options

Cerebral palsy (CP) is one of the most frequent causes of motor disability in children. According to the up-to-date definition, CP is a group of permanent disorders of the development of movement and posture, causing activity limitations that are attributed to non-progressive disturbances that occurred in the developing foetal or infant brain. The CP definition has evolved over time; the problem is aetiologically and clinically very heterogeneous. According to European data, the average frequency of CP is 2.08 per 1000 live births, but in the group of children born with a body weight below 1500 g, the frequency is 70 times higher when compared with the group of children with a body weight over 2500 g at birth. The risk factors for CP can be divided into pre-conception, prenatal, perinatal and postnatal ones. CP commonly co-exists with epilepsy, in particular drug-resistant epilepsy, but also with mental retardation, visual and hearing impairment, as well as feeding and behavioral disorders. The degree of motor problem varies from mild to very severe making the child totally dependent on caregivers. Cerebral palsy is divided into forms depending on the type of motor disorders which dominate the clinical presentation; the traditional classifications by Ingram and Hagberg have now been replaced by the Surveillance of Cerebral Palsy in Europe classification which divides CP into spastic, dyskinetic and ataxic forms. Although cerebral palsy is a clinical diagnosis, modern diagnostic imaging provides information that allows the division of the results of magnetic resonance imaging in children with cerebral palsy into five groups according to the magnetic resonance imaging classification system. Just as the clinical presentation and the factors predisposing for CP are very diverse, treatment is also a very complex problem. Modern treatment of spasticity includes both botulinum toxin therapies and surgical techniques, eg, rhizotomy. The authors present current views on definitions, risk factors, diagnostics and treatment of CP as well as comorbid problems, eg, drug-resistant epilepsy.

Frequency distribution in intraoperative stimulation-evoked EMG responses during selective dorsal rhizotomy in children with cerebral palsy-part 2: gender differences and left-biased asymmetry

INTRODUCTION

Spinal reflexes reorganize in cerebral palsy (CP), producing hyperreflexia and spasticity. CP is more common among male infants, and gender might also influence brain and spinal-cord reorganization. This retrospective study investigated the frequency of higher-graded EMG responses elicited by electrical nerve-root stimulation during selective dorsal rhizotomy (SDR), prior to partial nerve- root deafferentation, considering not only segmental level and body side, but also gender.

METHODS

Intraoperative neuromonitoring (IOM) was used in SDR to pinpoint the rootlets most responsible for exacerbated stimulation-evoked EMG patterns recorded from lower-limb muscle groups. Responses were graded according to an objective response-classification system, ranging from no abnormalities (grade 0) to highly abnormal (grade 4+), based on ipsilateral spread and contralateral involvement. Non-parametric analysis of data with repeated measures was primarily used in investigating the frequency distribution of these various EMG response grades. Over 7000 rootlets were stimulated, and the results for 65 girls and 81 boys were evaluated, taking changes in the composition of patient groups into account when considering GMFCS levels.

RESULTS

The distribution of graded EMG responses varied according to gender, laterality, and level. Higher-graded EMG responses were markedly more frequent in the boys and at lower segmental levels (L5, S1). Left-biased asymmetry in higher-graded rootlets was also more noticeable in the boys and in patients with GMFCS level I. A close link was observed between higher-grade assessments and left-biased asymmetry.

CONCLUSIONS

Detailed insight into the patient's initial spinal-neurofunctional state prior to deafferentation suggests that differences in asymmetrical spinal reorganization might be attributable to a hemispheric imbalance.

Losing a diagnosis of cerebral palsy: a comparison of variables at 2 and 5 years

AIM

This study aims to identify characteristics at 2 years of age that differ between children with confirmed cerebral palsy (CP) and a non-CP diagnosis by 5 years of age.

METHOD

This was a retrospective cohort analysis. A CP diagnosis may be considered a 'probable' diagnosis at 2 years, which is often 'confirmed' at 4 or 5 years, particularly in the context of CP registries. A total of 1683 children with a diagnosis of CP or probable CP at 2 years of age were identified from the Canadian Cerebral Palsy Registry, of whom 48 received a non-CP diagnosis at 5 years ('non-confirmed CP'). Perinatal adversity, preterm birth status, Gross Motor Function Classification System (GMFCS) level, presence of comorbidities, magnetic resonance imaging (MRI) findings, and initial CP motor type were compared between the two groups by univariate and logistic regression analyses.

RESULTS

χ² analysis and multivariate analysis both confirmed that children with a non-CP diagnosis by 5 years of age were more likely to have a normal MRI (χ² odds ratio [OR]=7.8, 95% confidence interval [CI]=3.8-16.1; OR=5.4, 95% CI=2.4-12.5), ataxic-hypotonic (χ² OR=10.1, 95% CI=4.9-21.2; OR=6.1, 95% CI=2.2-16.2) or dyskinetic CP (χ² OR=2.7, 95% CI=1.2-5.9; OR=2.9, 95% CI=1.0-7.6), born at term (χ² OR=3.7, 95% CI=1.7-8.0; OR=3.6, 95% CI=1.0-12.1), and lack perinatal adversity (χ² OR=4.1, 95% CI=1.6-10.7; OR=3.4, 95% CI=1.0-11.7).

INTERPRETATION

Normal MRI, ataxic-hypotonic or dyskinetic CP, lack of perinatal adversity, and term birth are associated with a higher odds of non-CP diagnosis by 5 years of age, thus potentially enhancing diagnostic work-up.

WHAT THIS PAPER ADDS

Normal magnetic resonance imaging (MRI) at 2 years was associated with a non-cerebral palsy (CP) diagnosis by 5 years. Diagnosis of ataxic-hypotonic or dyskinetic CP motor subtype at 2 years was associated with a non-CP diagnosis by 5 years. Perinatal adversity and preterm birth were rarer with a non-CP diagnosis by 5 years.

Transition-Age Young Adults with Cerebral Palsy: Level of Participation and the Influencing Factors

Background and Objectives: The aim of this study was to identify the level of participation in the context of the developmental transition from adolescence to adult life for young adults with cerebral palsy (CP) and the factors that had an influence on participation. Materials and Methods: Eighty-one young adults (16-21 years old) with CP and with normal or slightly decreased cognitive function participated in this study. Assessments were made using the Rotterdam Transition Profile (RTP) and the WHO Disability Assessment Schedule 2.0 (WHODAS 2.0). In the binary regression model, levels of participation (RTP scores) were set as dependents and the level of disability (WHODAS 2.0 scores), age, and level of gross motor function were set as independent variables. Results: In the age group <18 years, in three out of seven RTP domains, less than 10% of participants were in phase 2 (experimenting and orientating toward the future), i.e., finance-7%, housing-7%, sexuality-4%. In the age group ≥18 years, 21% (education and employment), 56% (intimate relationships), and 59% (sexuality) of the participants were in phase 0 (no experience). Higher scores in WHODAS 2.0 domains showed positive associations with RTP domains, i.e., cognition with social activities, mobility with transportation, self-care with sexuality and transportation, and life activities with transportation. Age was positively associated with education and employment, finance, housing, and sexuality. Low motor function according to the Gross Motor Function Classification System (GMFCS) had negative associations with autonomy in social activities, sexuality, and transportation. Conclusions: Young adults with cerebral palsy showed low levels of autonomy in all domains of participation. When addressing a person's improvement in terms of their participation, the promotion of abilities in cognition, mobility, self-care, and life activities should be attempted. Age and gross motor function influenced autonomy in participation, but not in all domains.

Effectiveness of interactive computer play on balance and postural control for children with cerebral palsy: A systematic review

BACKGROUND

Interactive computer play (ICP) becomes popular in rehabilitation for children with cerebral palsy (CP). With the nature of ICP, it could be an effective intervention specifically to improve balance and postural control for children with CP. The present paper aimed to review the effectiveness of ICP on postural control and balance for children with CP.

METHODS

Electronic databases including Medline, AMED, EBSCOhost, PsycINFO, Embase, the Cochrane Library and the DARE were searched up to September 2018. Studies were included if (1) participants were aged under 18 and had CP, (2) ICP intervention was performed, (3) an explicit objective was postural control and balance of the participants, and (4) results were fully published in English-language peer-reviewed journals. Characteristics of study participants, ICP protocols and study results were extracted. Level of evidence of each studies was graded using the guidelines from the American Academy of Cerebral Palsy and Developmental Medicine. Methodological quality was graded using the Physiotherapy Evidence Database (PEDro) scale. Effect sizes were calculated on available data.

RESULTS

Twenty studies were included, with nine of level I or II evidence. Most studies had fair methodological rigor. Huge variations in the study designs and protocols of ICP were found among the studies.

CONCLUSIONS

ICP seemed to be more effective than conventional therapy in improving postural control and balance, with medium to large effect sizes for children with mild to moderate severity of CP. Future studies of high methodological rigour are required to verify the role of on-site guidance of the children during ICP and the effect on children with more severe CP.

From congenial paralysis to post-early brain injury developmental condition: Where does cerebral palsy actually stand?

Cerebral palsy (CP), an umbrella term for a developmental motor disorder caused by early brain injury (EBI)/interference, remains debated. In this essay, we present a narrative, beginning with the original anatomical-clinical description of the so-called paralysie congéniale (congenial paralysis) by the French psychiatrist Jean-Baptiste Cazauvieilh. We then discuss how the concept has evolved over the last 2 centuries. We aim to illustrate these ideas with the biopsychosocial model of health, especially in light of the current neuroscientific and sociological knowledge of human development. We endeavour to integrate 3 connected but distinct entities: (1) the EBI as a seminal turning point of the individual's story; (2) the clinical findings we call CP, when motor impairment and activity limitation related to post-EBI (or other early non-progressive brain interference) appears, and; (3) a post-EBI developmental condition that encompasses the overall consequences of an EBI. This framework should guide individual, familial and collective care discussions and research strategies beyond the scope of CP.

Investigation of the relationship between quality of life, activity-participation and environmental factors in adolescents with cerebral palsy

BACKGROUND AND OBJECTIVE

The aim of this study is to examine the relationship between quality of life, activity-participation and environmental factors in adolescents with cerebral palsy.

METHODS

Seventy-five adolescents (M:45, F:30) ages between 14-18 yrs (mean: 15.52±1.60 yrs) were included in the study. Participants were divided into three groups: Level I, Level II and Level III according to the Gross Motor Function Classification System. Gross Motor Function Classification System, Gross Motor Function Measure, Functional Independence Scale, Manuel Ability Classification System, Pediatric Quality of Life Inventory and International Classification of Functioning, Disability and Health Child-Youth version Short Form (ICF-CY) (14-18 yrs) were used for assessments.

RESULTS

It is found that there is a moderate and high level of correlation between quality of life and activity participation and body functions; moderate and high level of correlation between quality of life and activity participation and body functions with the gross motor function levels; moderate and low level correlation between environmental factors and gross motor function levels (p < 0,05).

CONCLUSIONS

The fact that the ICF-CY short form used for cerebral palsied children is compatible with other assessment scales suggests that the use of ICF-CY short forms may be useful in assessing the health status of individuals.

Genetic or Other Causation Should Not Change the Clinical Diagnosis of Cerebral Palsy

High throughput sequencing is discovering many likely causative genetic variants in individuals with cerebral palsy. Some investigators have suggested that this changes the clinical diagnosis of cerebral palsy and that these individuals should be removed from this diagnostic category. Cerebral palsy is a neurodevelopmental disorder diagnosed on clinical signs, not etiology. All nonprogressive permanent disorders of movement and posture attributed to disturbances that occurred in the developing fetal and infant brain can be described as "cerebral palsy." This definition of cerebral palsy should not be changed, whatever the cause. Reasons include stability, utility and accuracy of cerebral palsy registers, direct access to services, financial and social support specifically offered to families with cerebral palsy, and community understanding of the clinical diagnosis. Other neurodevelopmental disorders, for example, epilepsy, have not changed the diagnosis when genomic causes are found. The clinical diagnosis of cerebral palsy should remain, should prompt appropriate genetic studies and can subsequently be subclassified by etiology.

Emerging Issues in Cerebral Palsy Associated With Aging: A Physiatrist Perspective

The population of adults diagnosed with cerebral palsy (CP) is increasing along with the survival rate of children born with the disability. Adults with CP need health services for the continued monitoring and management of their condition. Moreover, the development of additional health problems in adulthood increases the need for ongoing access to health services. Adults with CP manifest a higher rate of chronic health conditions and eventual decline in strength and functional reserve, deterioration in physical activity, increased risk of musculoskeletal complications, and gradual changes in swallowing ability. They are also reported to exhibit difficulty engaging socially and have a low health-related quality of life (QOL). However, there are a large number of adults with CP who cannot access medical services adequately and are therefore not effectively treated. To overcome these apparent challenges, we need to fully comprehend the healthcare needs of adults with CP to develop adult-focused health services. Further research is needed regarding the impact of physical activity, nutrition, sarcopenia, myeloradiculopathy, and swallowing function on QOL.

Strabismus Is Correlated with Gross Motor Function in Children with Spastic Cerebral Palsy

Purpose: To investigate the correlation between clinical features of strabismus and motor dysfunction classified according to the Gross Motor Function Classification System (GMFCS) in patients with spastic cerebral palsy (CP).Methods: In this retrospective, cross-sectional study in single tertiary medical center, 62 patients who are diagnosed with spastic CP who had an ophthalmic examination between 2006 and 2014 were included. Only patients with vision sufficient to fixate were included and patients with restrictive or paralytic strabismus were excluded. The types of CP were classified as diplegia, hemiplegia, or quadriplegia for distribution of motor impairment. The GMFCS was used to grade gross motor dysfunction, which was then classified as mild (grade 1, 2 and 3) or severe (grade 4 and 5) motor impairment. Strabismus was investigated in terms of direction, constancy, and deviation angle. The relationship between strabismus characteristics and the level of GMFCS and type of CP were assessed.Results: Thirty-eight and 24 patients had mild or severe motor deficit, respectively. Forty patients had strabismus, which was more frequent in patients with severe motor impairment.(P = .014) Exotropia and esotropia occurred with similar frequency. Constant and large-angle strabismus was frequently observed in patients with severe motor impairment.(P < .005, 0.027) The topographical subtype of CP was not related to clinical features of strabismus.Conclusions: The prevalence of strabismus is higher in severe motor impairment. The constancy and angle of strabismus was related to the severity of motor impairment while the topographical subtype of CP has no significant relationship.

The development of spasticity with age in 4,162 children with cerebral palsy: a register-based prospective cohort study

Background and purpose - Spasticity is often regarded as a major cause of functional limitation in children with cerebral palsy (CP). We analyzed the spasticity development with age in the gastrosoleus muscle in children with CP. Children and methods - This is a longitudinal cohort study of 4,162 children (57% boys) with CP born in 1990-2015, monitored using standardized follow-up examinations in the Swedish surveillance program for CP. The study is based on 57,953 measurements of spasticity of the gastrosoleus muscle assessed using the Ashworth scale (AS) in participants between 0 and 15 years of age. The spasticity was analyzed in relation to age, sex, and Gross Motor Function Classification System (GMFCS) levels using a linear mixed model. Development of spasticity with age was modeled as a linear spline. Results - The degree of spasticity increased in most children over the first 5 years of life. At 5 years of age, 38% had an AS level of ≥ 2. The spasticity then decreased for 65% of the children during the remaining study period. At 15 years of age only 22% had AS ≥ 2. The level of spasticity and the rate of increase and decrease before and after 5.5 years of age were higher in children at GMFCS IV-V. Interpretation - The degree of spasticity of the gastrosoleus muscle often decreases after 5 years of age, which is important for long-term treatment planning and should be considered in spasticity management.

Combined predictors of neurodevelopment in very low birth weight preterm infants

OBJECTIVE

To evaluate the combined prognostic value of neurological examination, head circumference and cranial ultrasound for neurodevelopmental delay (NDD) in very low birth weight (VLBW, <1500 g) preterm infants.

METHODS

Prospective follow-up study. Preterm infants with VLWB were assessed for NDD using the Mullen Scales of Early Learning test at 24 months of corrected age. Abnormal neurological examination (≥2 deviant items of Hammersmith neurological examination), microcephaly and major ultrasound abnormalities, each performed at term age, were evaluated as predictors of NDD in a multivariable Poisson model.

RESULTS

35/132 infants (26.5%) had NDD. In the multivariable analysis, microcephaly (RR, 3.2; 95% CI, 1.6-6.7) and major ultrasound abnormalities (RR, 2.7; 95% CI, 1.3-5.7) were associated to NDD. The combination of the two tests showed the highest positive predictive value (100%; 95% CI, 51%-100%), while the combination of normal neurological examination, no major US findings and normal head size at term showed the highest negative predictive value (89%; 95% CI, 78%-95%). The maximum under receiver operating characteristic curve area was for microcephaly or major ultrasound abnormalities (AUC 0.74 (0.65-0.83)).

CONCLUSION

The combination of head circumference, cranial ultrasound and neurological examination at term age is useful to predict NDD in VLBW preterm infants.

Cerebral palsy trends in Australia (1995-2009): a population-based observational study

AIM

To investigate trends in birth prevalence of cerebral palsy (CP) overall and by gestational age, and examine the distribution of motor type, spastic topography, and severity using Australian CP Register data from 1995 to 2009.

METHOD

Prenatal and perinatal CP data were collated from state/territory CP registers. Birth prevalence estimates per 1000 live births and per 1000 neonatal survivors (NNS) were calculated in five epochs. Data from three state registers with population-level ascertainment were used to investigate birth prevalence trends by gestational age using Poisson regression. Distribution of motor type, spastic topography, and moderate to severe disability (IQ≤50 and/or Gross Motor Function Classification System levels III-V) were evaluated within birthweight categories.

RESULTS

Birth prevalence of CP varied across population-level states but within each state declined significantly over time (p<0.05). Birth prevalence per 1000 neonatal survivors declined amongst children born before 28 weeks (South Australia, Victoria p<0.001) and those born at or after 37 weeks (Victoria p<0.001, Western Australia p<0.002). Across Australia the percentage of children with bilateral spastic CP declined amongst those born less than 1000g. The percentage of children with moderate to severe disability decreased (48%-34%, p<0.001).

INTERPRETATION

Birth prevalence of CP declined. Encouragingly, the percentage of children with CP whose disability was moderate to severe also decreased.

WHAT THIS PAPER ADDS

Birth prevalence of cerebral palsy (CP) differed but declined across Australian states (1995-2009). Australian CP birth prevalence declined significantly amongst children born before 28 weeks and those born at or after 37 weeks. The percentage of children with moderate to severe disability decreased.

Cerebral Palsy in North Indian Children: Clinico-etiological Profile and Comorbidities

Aims and Objectives

Cerebral palsy (CP) is a common motor disability in children. This study aimed at elaborating various comorbidities and etiologies and also at correlating motor disability with other disabilities.

Material and Methods

This hospital-based study was conducted in the outpatient department of a tertiary care hospital in Delhi on 160 children with CP in the age group 2-15 years. A detailed history taking and examination were conducted for each patient and appropriate investigations were performed.

Results

Most patients, that is 64.4%, were younger than 5 years of age and 72.5% were males. Most common etiology was birth asphyxia (41.9%). Maximum patients were of bilateral spastic (spastic quadriplegic) CP accounting 43.1%. Intellectual disability was the most common comorbidity across all subtypes of CP followed by epilepsy. Comorbidities such as epilepsy and all visual problems except optic atrophy were more common in spastic quadriplegic CP. Hearing, speech impairment, and optic atrophy were more common in dyskinetic CP. Chewing, swallowing, and drooling problems were more common in spastic quadriplegic CP.

Conclusion

Most common risk factor of CP is birth asphyxia; thus, by improving health care facilities, its incidence can be reduced. CP affects not only motor functions but also other important functions of body as well, and the more severe the motor disabilities, the more are other comorbidities and their intensity also increases with that of the intensity of brain insult.

Effects of live and video form action observation training on upper limb function in children with hemiparetic cerebral palsy

PURPOSE

The purpose of this study was to investigate the effects of live and video form action observation training (AOT) on upper limb (UL) movement acceleration and function in children with cerebral palsy (CP).

METHODS

In total, 12 children (7 boys, 5 girls) with CP participated in this study. The children were allocated randomly to live (experimental) and video (control) AOT groups. All children completed 20 treatment sessions, each 30 minutes in duration, 5 days per week for a month. Mediolateral (ML) and vertical (VT) acceleration data, Jebsen-Taylor Hand Function (JTHF) scores, and Box and Block Test (BBT) scores were obtained at baseline and at 4 weeks after the intervention.

RESULTS

ML and VT movement acceleration and JTHF scores were significantly lower in the live group (p< 0.05). The BBT score was significantly higher in the live than in the video group (p< 0.05).

CONCLUSIONS

Our findings suggest that live AOT is more effective than video AOT for improving UL movement acceleration and function. Clinically, our findings offer important insights for clinicians when planning AOT interventions to reduce UL movement acceleration and improve UL function.

Outcome reporting across randomized trials and observational studies evaluating treatments for twin-twin transfusion syndrome: systematic review

OBJECTIVE

Twin-twin transfusion syndrome (TTTS) is associated with significant mortality and morbidity. Potential treatments for the condition require robust evaluation. The aim of this study was to evaluate outcome reporting across observational studies and randomized controlled trials assessing treatments for TTTS.

METHODS

Cochrane Central Register of Controlled Trials, EMBASE and MEDLINE were searched from inception to August 2016. Observational studies and randomized controlled trials reporting outcome following treatment for TTTS in monochorionic-diamniotic twin pregnancy and monochorionic-triamniotic or dichorionic-triamniotic triplet pregnancy were included. Outcome reporting was systematically extracted and categorized.

RESULTS

Six randomized trials and 94 observational studies were included, reporting data from 20 071 maternal participants and 3199 children. Six different treatments were evaluated. Included studies reported 62 different outcomes, including six fetal, seven offspring mortality, 25 neonatal, six early childhood and 18 maternal/operative outcomes. Outcomes were reported inconsistently across trials. For example, when considering offspring mortality, 31 (31%) studies reported live birth, 31 (31%) reported intrauterine death, 49 (49%) reported neonatal mortality and 17 (17%) reported perinatal mortality. Four (4%) studies reported respiratory distress syndrome. Only 19 (19%) studies were designed for long-term follow-up and 11 (11%) of these reported cerebral palsy.

CONCLUSIONS

Studies evaluating treatments for TTTS have often neglected to report clinically important outcomes, especially neonatal morbidity outcomes, and most are not designed for long-term follow-up. The development of a core outcome set could help standardize outcome collection and reporting in TTTS studies. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.