1
|
Saranti A, Dragoumi P, Papavasiliou A, Zafeiriou D. Current approach to cerebral palsy. Eur J Paediatr Neurol 2024; 51:49-57. [PMID: 38824721 DOI: 10.1016/j.ejpn.2024.05.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2024] [Revised: 05/26/2024] [Accepted: 05/28/2024] [Indexed: 06/04/2024]
Abstract
This teaching review aims to provide an overview of the current approach to children with cerebral palsy (CP), retrieving the best available evidence and summarizing existing knowledge in the field of CP in children. We also highlight areas where more research is needed and novel strategies for diagnosing and treating cerebral palsy. CP includes a group of permanent disorders of movement and posture that cause activity limitation. Multiple risk factors, occurring preconceptionally, prenatally, perinatally, or postneonatally, are involved in the pathogenesis of CP, with the prenatal ones accounting for 80-90 % of cases. Due to its heterogeneity, CP has various classifications, but usually is classified based on clinical findings and motor impairment. Standardized function classification systems have been developed to address inconsistencies in previous classifications. The combination of clinical assessment and validated predictive tools is recommended for an early diagnosis, which is important for early intervention and prevention of secondary impairments. The therapeutic regimen in CP involves prevention and management of the motor and associated problems. It includes the enhancement of motor performance, the enrichment of cognition and communication skills, the prevention of secondary impairments, and the support of parents and caregivers. The care of CP children demands a multidisciplinary approach focused on improving motor skills, reducing comorbidities, enhancing the quality of life, and prolonging survival.
Collapse
Affiliation(s)
- Anna Saranti
- 1th Department of Pediatrics, Aristotle University of Thessaloniki, G. Hippokration Hospital, Thessaloniki, Greece
| | - Pinelopi Dragoumi
- 1th Department of Pediatrics, Aristotle University of Thessaloniki, G. Hippokration Hospital, Thessaloniki, Greece
| | | | - Dimitrios Zafeiriou
- 1th Department of Pediatrics, Aristotle University of Thessaloniki, G. Hippokration Hospital, Thessaloniki, Greece.
| |
Collapse
|
2
|
Chokron S, Dutton GN. From vision to cognition: potential contributions of cerebral visual impairment to neurodevelopmental disorders. J Neural Transm (Vienna) 2023; 130:409-424. [PMID: 36547695 DOI: 10.1007/s00702-022-02572-8] [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: 08/16/2022] [Accepted: 11/28/2022] [Indexed: 12/24/2022]
Abstract
Vision has a crucial role to play in human development and functioning. It is, therefore, not surprising that vision plays a fundamental role in the development of the child. As a consequence, an alteration in visual function is, therefore, likely to hinder the child's development. Although ocular disorders are well known, diagnosed and taken into account, cerebral visual impairments (CVI) resulting from post-chiasmatic damage are largely underdiagnosed. However, among the disorders resulting from an episode of perinatal asphyxia and/or associated with prematurity, or neonatal hypoglycaemia, CVIs are prominent. In this article, we focus on the role of the possible effects of CVI on a child's learning abilities, leading to major difficulty in disentangling the consequences of CVI from other neurodevelopmental disorders (NDD) such as dyslexia, dyscalculia, dysgraphia, attention-deficit/hyperactivity disorder (ADHD), developmental coordination disorder (DCD) and autism spectrum disorders (ASD). Although we focus here on the possible overlap between children with CVI and children with other NDD, De Witt et al. (Wit et al. Ear Hear 39:1-19, 2018) have raised exactly the same question regarding children with auditory processing disorders (the equivalent of CVI in the auditory modality). We underline how motor, social and cognitive development as well as academic success can be impaired by CVI and raise the question of the need for systematic evaluation for disorders of vision, visual perception and cognition in all children presenting with a NDD and/or previously born under adverse neurological conditions.
Collapse
Affiliation(s)
- Sylvie Chokron
- INCC, CNRS, UMR8002, Université de Paris-Cité, Paris, France.
- Institut de Neuropsychologie, Neurovision et Neurocognition, Hôpital-Fondation A. de Rothschild, Paris, France.
| | - Gordon N Dutton
- Department of Vision Science, Glasgow Caledonian University, Glasgow, UK
| |
Collapse
|
3
|
Hidden etiology of cerebral palsy: genetic and clinical heterogeneity and efficient diagnosis by next-generation sequencing. Pediatr Res 2021; 90:284-288. [PMID: 33177673 DOI: 10.1038/s41390-020-01250-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Revised: 09/30/2020] [Accepted: 10/16/2020] [Indexed: 12/21/2022]
Abstract
Cerebral palsy (CP) is a heterogeneous neurodevelopmental disorder that causes movement and postural disabilities. Recent research studies focused on genetic diagnosis in patients with CP of unknown etiology. The present study was carried out in 20 families with one family member affected with idiopathic CP. Chromosomal microarray and exome sequencing techniques were performed in all patients. Chromosomal microarray analysis did not show any pathological or probable pathological structural variant. However, the next-generation sequencing study showed a high diagnostic yield. We report 11/20 patients (55%) with different pathogenic or potentially pathogenic variants detected by exome sequencing analysis: five patients with mutations in genes related to hereditary spastic paraplegia, two with mutations in genes related to Aicardi-Goutières syndrome, three with mutations in genes related to developmental/epileptic encephalopathies, and one with a mutation in the PGK1 gene. The accurate and precise patients' selection, the use of a high-throughput genetic platform, the selection of adequate target genes, and the application of rigorous criteria for the clinical interpretation are the most important elements for a good diagnostic performance. Based on our findings, next-generation sequencing should be considered in patients with cryptogenic CP as the first line of genetic workup. IMPACT: Sequencing techniques in CP of uncertain etiology provides a diagnostic yield of 55%. The appropriate selection of cases optimizes the diagnostic yield. NGS facilitate better understanding of new phenotypes of certain genetic diseases.
Collapse
|
4
|
Williams SA, Mackey A, Sorhage A, Battin M, Wilson N, Spittle A, Stott NS. Clinical practice of health professionals working in early detection for infants with or at risk of cerebral palsy across New Zealand. J Paediatr Child Health 2021; 57:541-547. [PMID: 33217101 DOI: 10.1111/jpc.15263] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2020] [Revised: 09/28/2020] [Accepted: 10/14/2020] [Indexed: 02/06/2023]
Abstract
AIM A diagnosis of cerebral palsy (CP) can, and should, be made as early as possible. This work describes current clinical practice around the awareness and use of diagnostic tools for the detection of CP in New Zealand (NZ). METHODS A purpose-developed survey distributed electronically to NZ clinicians working with young children with or at risk of CP. RESULTS A total of 159 clinicians (including paediatricians, physiotherapists and occupational therapists) participated in this cross-sectional study. Ninety-six percent were aware that a diagnosis of CP can be made by 12 months of age, with high levels of awareness of the use of magnetic resonance imaging (94%), Prechtl's qualitative assessment of general movements (GMs) (70%) and Hammersmith Infant Neurological Examination (HINE) (77%). Only 40% were aware of the HINE optimality scoring. Fifty-four clinicians provided a diagnosis of CP as part of their role: 48% never used the GMs or HINE to assess children <1 year, and 57% never used the HINE for children between 1 and 2 years. Clinicians not providing a diagnosis within their professional role (n = 104) also indicated infrequent use of assessment tools with 74% and 54% never using the GM's or HINE (respectively) in their assessment of children at risk of CP. Barriers to use included lack of time and funding, lack of clear pathways and management support. CONCLUSION Despite high awareness, current use of international best practice tools in NZ clinical practice appears low. Multiple barriers are reported to the use of these tools, which need to be addressed to improve the timeliness of diagnosis.
Collapse
Affiliation(s)
- Sîan A Williams
- School of Physiotherapy and Exercise Science, Curtin University, Perth, Western Australia, Australia.,Department of Surgery, University of Auckland, Auckland, New Zealand
| | - Anna Mackey
- New Zealand Cerebral Palsy Register, Starship Child Health, Auckland, New Zealand
| | - Alexandra Sorhage
- New Zealand Cerebral Palsy Register, Starship Child Health, Auckland, New Zealand
| | - Malcolm Battin
- Neonatal Intensive Care, Starship Child Health, Auckland, New Zealand
| | - Nichola Wilson
- Department of Surgery, University of Auckland, Auckland, New Zealand.,Department of Paediatric Orthopaedics, Starship Child Health, Auckland District Health Board, Auckland, New Zealand
| | - Alicia Spittle
- Department of Physiotherapy, University of Melbourne, Melbourne, Victoria, Australia
| | - N Susan Stott
- Department of Surgery, University of Auckland, Auckland, New Zealand.,Neonatal Intensive Care, Starship Child Health, Auckland, New Zealand
| |
Collapse
|
5
|
Allen J, Zareen Z, Doyle S, Whitla L, Afzal Z, Stack M, Franklin O, Green A, James A, Leahy TR, Quinn S, Elnazir B, Russell J, Paran S, Kiely P, Roche EF, McDonnell C, Baker L, Hensey O, Gibson L, Kelly S, McDonald D, Molloy EJ. Multi-Organ Dysfunction in Cerebral Palsy. Front Pediatr 2021; 9:668544. [PMID: 34434904 PMCID: PMC8382237 DOI: 10.3389/fped.2021.668544] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Accepted: 07/15/2021] [Indexed: 11/20/2022] Open
Abstract
Cerebral Palsy (CP) describes a heterogenous group of non-progressive disorders of posture or movement, causing activity limitation, due to a lesion in the developing brain. CP is an umbrella term for a heterogenous condition and is, therefore, descriptive rather than a diagnosis. Each case requires detailed consideration of etiology. Our understanding of the underlying cause of CP has developed significantly, with areas such as inflammation, epigenetics and genetic susceptibility to subsequent insults providing new insights. Alongside this, there has been increasing recognition of the multi-organ dysfunction (MOD) associated with CP, in particular in children with higher levels of motor impairment. Therefore, CP should not be seen as an unchanging disorder caused by a solitary insult but rather, as a condition which evolves over time. Assessment of multi-organ function may help to prevent complications in later childhood or adulthood. It may also contribute to an improved understanding of the etiology and thus may have an implication in prevention, interventional methods and therapies. MOD in CP has not yet been quantified and a scoring system may prove useful in allowing advanced clinical planning and follow-up of children with CP. Additionally, several biomarkers hold promise in assisting with long-term monitoring. Clinicians should be aware of the multi-system complications that are associated with CP and which may present significant diagnostic challenges given that many children with CP communicate non-verbally. A step-wise, logical, multi-system approach is required to ensure that the best care is provided to these children. This review summarizes multi-organ dysfunction in children with CP whilst highlighting emerging research and gaps in our knowledge. We identify some potential organ-specific biomarkers which may prove useful in developing guidelines for follow-up and management of these children throughout their lifespan.
Collapse
Affiliation(s)
- John Allen
- Discipline of Pediatrics, School of Medicine, Trinity College Dublin, The University of Dublin, Dublin, Ireland.,Trinity Research in Childhood Centre, Trinity College Dublin, Dublin, Ireland.,Children's Health Ireland (CHI) at Tallaght, Dublin, Ireland
| | | | - Samantha Doyle
- Department of Clinical Genetics, Birmingham Women's Hospital, Birmingham, United Kingdom
| | - Laura Whitla
- Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Zainab Afzal
- Discipline of Pediatrics, School of Medicine, Trinity College Dublin, The University of Dublin, Dublin, Ireland
| | - Maria Stack
- Children's Health Ireland at Crumlin, Dublin, Ireland.,Children's Health Ireland at Temple St. Dublin, Dublin, Ireland
| | - Orla Franklin
- Children's Health Ireland at Crumlin, Dublin, Ireland.,Children's Health Ireland at Temple St. Dublin, Dublin, Ireland
| | - Andrew Green
- Children's Health Ireland at Crumlin, Dublin, Ireland.,Children's Health Ireland at Temple St. Dublin, Dublin, Ireland
| | - Adam James
- Children's Health Ireland (CHI) at Tallaght, Dublin, Ireland.,Children's Health Ireland at Crumlin, Dublin, Ireland
| | - Timothy Ronan Leahy
- Discipline of Pediatrics, School of Medicine, Trinity College Dublin, The University of Dublin, Dublin, Ireland.,Children's Health Ireland at Crumlin, Dublin, Ireland
| | - Shoana Quinn
- Children's Health Ireland (CHI) at Tallaght, Dublin, Ireland
| | - Basil Elnazir
- Children's Health Ireland (CHI) at Tallaght, Dublin, Ireland
| | - John Russell
- Children's Health Ireland at Crumlin, Dublin, Ireland
| | - Sri Paran
- Children's Health Ireland at Crumlin, Dublin, Ireland
| | - Patrick Kiely
- Children's Health Ireland at Crumlin, Dublin, Ireland
| | - Edna Frances Roche
- Discipline of Pediatrics, School of Medicine, Trinity College Dublin, The University of Dublin, Dublin, Ireland.,Trinity Research in Childhood Centre, Trinity College Dublin, Dublin, Ireland.,Children's Health Ireland (CHI) at Tallaght, Dublin, Ireland
| | - Ciara McDonnell
- Discipline of Pediatrics, School of Medicine, Trinity College Dublin, The University of Dublin, Dublin, Ireland.,Trinity Research in Childhood Centre, Trinity College Dublin, Dublin, Ireland.,Children's Health Ireland (CHI) at Tallaght, Dublin, Ireland.,Children's Health Ireland at Temple St. Dublin, Dublin, Ireland
| | - Louise Baker
- Children's Health Ireland at Temple St. Dublin, Dublin, Ireland
| | | | - Louise Gibson
- Department of Paediatrics, Cork University Hospital, Cork, Ireland
| | - Stephanie Kelly
- Children's Health Ireland (CHI) at Tallaght, Dublin, Ireland
| | - Denise McDonald
- Children's Health Ireland (CHI) at Tallaght, Dublin, Ireland
| | - Eleanor J Molloy
- Discipline of Pediatrics, School of Medicine, Trinity College Dublin, The University of Dublin, Dublin, Ireland.,Trinity Research in Childhood Centre, Trinity College Dublin, Dublin, Ireland.,Children's Health Ireland (CHI) at Tallaght, Dublin, Ireland.,Children's Health Ireland at Crumlin, Dublin, Ireland.,Department of Neonatology, The Coombe Women and Infants University Hospital, Dublin, Ireland
| |
Collapse
|
6
|
Crichton A, Ditchfield M, Gwini S, Wallen M, Thorley M, Bracken J, Harvey A, Elliott C, Novak I, Hoare B. Brain magnetic resonance imaging is a predictor of bimanual performance and executive function in children with unilateral cerebral palsy. Dev Med Child Neurol 2020; 62:615-624. [PMID: 31965572 DOI: 10.1111/dmcn.14462] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/21/2019] [Indexed: 12/24/2022]
Abstract
AIM To examine the association between brain magnetic resonance imaging (MRI) characteristics and executive function and bimanual performance in children with unilateral cerebral palsy (CP). METHOD Clinical MRI brain scans were classified as: (1) predominant pathological pattern (normal, white matter injury [WMI]; grey matter injury; focal vascular insults [FVI]; malformations; or miscellaneous); and (2) focal lesions (frontal, basal ganglia, and/or thalamus). Assessments included: (1) bimanual performance; (2) unimanual dexterity; and (3) executive function tasks (information processing, attention control, cognitive flexibility, and goal setting) and behavioural ratings (parent). RESULTS From 131 recruited children, 60 were ineligible for analysis, leaving 71 children (47 males, 24 females) in the final sample (mean age 9y [SD 2y], 6y-12y 8mo). Brain MRIs were WMI (69%) and FVI (31%); and frontal (59%), thalamic (45%), basal ganglia (37%), and basal ganglia plus thalamic (21%). Bimanual performance was lower in FVI versus WMI (p<0.003), and with frontal (p=0.36), basal ganglia (p=0.032), and thalamic/basal ganglia lesions (p=0.013). Other than information processing, executive function tasks were not associated with predominant pattern. Frontal lesions predicted attention control (p=0.049) and cognitive flexibility (p=0.009) but not goal setting, information processing, or behavioural ratings. INTERPRETATION Clinical brain MRI predicts cognitive and motor outcomes when focal lesions and predominate lesion patterns are considered. What this paper adds Early brain magnetic resonance imaging (MRI) predicts bimanual performance and cognitive outcomes. Brain MRI may identify children requiring targeted interventions. Basal ganglia with/without thalamic lesions predicted bimanual performance. Frontal lesions were associated with attention control and cognitive flexibility. Brain MRI predominant patterns predicted motor, not cognitive outcomes, other than information processing.
Collapse
Affiliation(s)
- Alison Crichton
- Victorian Paediatric Rehabilitation Service, Monash Children's Hospital, Clayton, Victoria, Australia.,Department of Paediatrics, Monash University, Clayton, Victoria, Australia
| | - Michael Ditchfield
- Department of Diagnostic Imaging, Monash Children's Hospital, Clayton, Victoria, Australia
| | - Stellamay Gwini
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.,Barwon Health, University Hospital Geelong, Geelong, Victoria, Australia
| | - Margaret Wallen
- School of Allied Health, Australian Catholic University, North Sydney, New South Wales, Australia
| | - Megan Thorley
- Queensland Paediatric Rehabilitation Service, Lady Cilento Children's Hospital, South Brisbane, Queensland, Australia
| | - Jenny Bracken
- Department of Diagnostic Imaging, Royal Children's Hospital, Parkville, Victoria, Australia
| | - Adrienne Harvey
- Developmental Disability and Rehabilitation Research, Murdoch Children's Research Institute, Parkville, Victoria, Australia
| | - Catherine Elliott
- School of Occupational Therapy, Social Work and Speech Pathology, Curtin University, Bentley, Western Australia, Australia
| | - Iona Novak
- Cerebral Palsy Alliance, Child and Adolescent Health, The University of Sydney, Frenchs Forest, New South Wales, Australia
| | - Brian Hoare
- Victorian Paediatric Rehabilitation Service, Monash Children's Hospital, Clayton, Victoria, Australia.,Department of Paediatrics, Monash University, Clayton, Victoria, Australia.,School of Occupational Therapy, La Trobe University, Bundoora, Victoria, Australia
| |
Collapse
|
7
|
Franki I, Mailleux L, Emsell L, Peedima ML, Fehrenbach A, Feys H, Ortibus E. The relationship between neuroimaging and motor outcome in children with cerebral palsy: A systematic review - Part A. Structural imaging. RESEARCH IN DEVELOPMENTAL DISABILITIES 2020; 100:103606. [PMID: 32192951 DOI: 10.1016/j.ridd.2020.103606] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Revised: 02/05/2020] [Accepted: 02/05/2020] [Indexed: 06/10/2023]
Abstract
BACKGROUND Conventional Structural Magnetic Resonance Imaging (sMRI) is a mainstay in Cerebral Palsy (CP) diagnosis. AIMS A systematic literature review was performed with the aim to investigate the relationship between structural brain lesions identified by sMRI and motor outcomes in children with CP. METHODS Fifty-eight studies were included. The results were analysed in terms of population characteristics, sMRI (classified according to Krägeloh-Mann & Horber, 2007), gross and fine motor function and their interrelation. OUTCOMES White matter lesions were the most common brain lesion types and were present in 57.8 % of all children with uCP, in 67.0 % of all children with bCP and in 33 % of the group of mixed subtypes. Grey matter lesions were most frequently registered in children with dyskinesia (n = 42.2 %). No structural anomalies visualized by sMRI were reported in 5.7 % of all cases. In all lesion types, an equal distribution over the different gross motor function classification system categories was present. The included studies did not report sufficient information about fine motor function to relate these results to structural imaging. CONCLUSIONS AND IMPLICATIONS The relationship between brain structure and motor outcome needs to be further elucidated in a representative cohort of children with CP, using a more standardized MRI classification system.
Collapse
Affiliation(s)
- Inge Franki
- KU Leuven, Department of Development and Regeneration, Leuven, Belgium; Universitaire Ziekenhuizen Leuven, Campus Pellenberg, Cerebral Palsy Reference Centre, Leuven, Belgium.
| | - Lisa Mailleux
- KU Leuven, Department of Rehabilitation Sciences, Leuven, Belgium; Centre For Developmental Disabilities, Leuven, Belgium
| | - Louise Emsell
- KU Leuven, Department of Imaging an Pathology, Translational MRI, Leuven, Belgium; KU Leuven, University Psychiatric Center (UPC-) Geriatric Psychiatry, Leuven, Belgium
| | | | - Anna Fehrenbach
- KU Leuven, Department of Rehabilitation Sciences, Leuven, Belgium
| | - Hilde Feys
- KU Leuven, Department of Rehabilitation Sciences, Leuven, Belgium
| | - Els Ortibus
- KU Leuven, Department of Development and Regeneration, Leuven, Belgium; Universitaire Ziekenhuizen Leuven, Campus Pellenberg, Cerebral Palsy Reference Centre, Leuven, Belgium; Centre For Developmental Disabilities, Leuven, Belgium
| |
Collapse
|
8
|
Morgan C, Fahey M, Roy B, Novak I. Diagnosing cerebral palsy in full-term infants. J Paediatr Child Health 2018; 54:1159-1164. [PMID: 30294991 DOI: 10.1111/jpc.14177] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Accepted: 07/18/2018] [Indexed: 12/25/2022]
Abstract
More than 50% of infants with cerebral palsy (CP) are born at or near term, with the vast majority having pre- or perinatally acquired CP. While some have a clinical history predictive of CP, such as neonatal encephalopathy or neonatal stroke, others have no readily identifiable risk factors. Paediatricians are often required to discriminate generalised motor delay from a variety of other diagnoses, including CP. This paper outlines known causal pathways to CP in term-born infants with a focus on differential diagnosis. Early and accurate diagnosis is important as it allows prompt access to early intervention during the critical periods of brain development. A combination of clinical history taking, standard clinical examination, neuroimaging and genetic testing should be started at the time of referral. Attention to the investigation of common comorbidities of CP, including feeding and sleep difficulties, and referral to early intervention are recommended.
Collapse
Affiliation(s)
- Catherine Morgan
- School of Medicine, Paediatrics and Child Health, Sydney, New South Wales, Australia
- Cerebral Palsy Alliance, School of Child and Adolescent Health, University of Sydney, Sydney, New South Wales, Australia
| | - Michael Fahey
- Department of Paediatrics, Monash University, Melbourne, Victoria, Australia
| | - Bithi Roy
- School of Medicine, Paediatrics and Child Health, Sydney, New South Wales, Australia
- School of Medicine, University of Notre Dame, Sydney, New South Wales, Australia
- Special Care Nursery, Mater Hospital Sydney, Sydney, New South Wales, Australia
| | - Iona Novak
- School of Medicine, Paediatrics and Child Health, Sydney, New South Wales, Australia
- Cerebral Palsy Alliance, School of Child and Adolescent Health, University of Sydney, Sydney, New South Wales, Australia
| |
Collapse
|
9
|
Hoare B, Ditchfield M, Thorley M, Wallen M, Bracken J, Harvey A, Elliott C, Novak I, Crichton A. Cognition and bimanual performance in children with unilateral cerebral palsy: protocol for a multicentre, cross-sectional study. BMC Neurol 2018; 18:63. [PMID: 29739443 PMCID: PMC5938804 DOI: 10.1186/s12883-018-1070-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2017] [Accepted: 05/03/2018] [Indexed: 11/30/2022] Open
Abstract
Background Motor outcomes of children with unilateral cerebral palsy are clearly documented and well understood, yet few studies describe the cognitive functioning in this population, and the associations between the two is poorly understood. Using two hands together in daily life involves complex motor and cognitive processes. Impairment in either domain may contribute to difficulties with bimanual performance. Research is yet to derive whether, and how, cognition affects a child’s ability to use their two hands to perform bimanual tasks. Methods/Design This study will use a prospective, cross-sectional multi-centre observational design. Children (aged 6–12 years) with unilateral cerebral palsy will be recruited from one of five Australian treatment centres. We will examine associations between cognition, bimanual performance and brain neuropathology (lesion type and severity) in a sample of 131 children. The primary outcomes are: Motor - the Assisting Hand Assessment; Cognitive - Executive Function; and Brain – lesion location on structural MRI. Secondary data collected will include: Motor - Box and Blocks, ABILHAND- Kids, Sword Test; Cognitive – standard neuropsychological measures of intelligence. We will use generalized linear modelling and structural equation modelling techniques to investigate relationships between bimanual performance, executive function and brain lesion location. Discussion This large multi-centre study will examine how cognition affects bimanual performance in children with unilateral cerebral palsy. First, it is anticipated that distinct relationships between bimanual performance and cognition (executive function) will be identified. Second, it is anticipated that interrelationships between bimanual performance and cognition will be associated with common underlying neuropathology. Findings have the potential to improve the specificity of existing upper limb interventions by providing more targeted treatments and influence the development of novel methods to improve both cognitive and motor outcomes in children with unilateral cerebral palsy. Trial registration ACTRN12614000631606; Date of retrospective registration 29/05/2014.
Collapse
Affiliation(s)
- Brian Hoare
- Victorian Paediatric Rehabilitation Service, Monash Children's Hospital, 246 Clayton Rd, Clayton, VIC, 3168, Australia. .,School of Occupational Therapy, La Trobe University, Bundoora, VIC, 3168, Australia. .,Department of Paediatrics, Monash University, Clayton, VIC, 3168, Australia.
| | - Michael Ditchfield
- Department of Diagnostic Imaging, Monash Children's Hospital, 246 Clayton Road, Clayton, VIC, 3168, Australia
| | - Megan Thorley
- Queensland Paediatric Rehabilitation Service, Lady Cilento Children's Hospital, South Brisbane, QLD, 4101, Australia
| | - Margaret Wallen
- School of Allied Health, Australian Catholic University, North Sydney, NSW, 2060, Australia
| | - Jenny Bracken
- Department of Diagnostic Imaging, Royal Children's Hospital, 50 Flemington Rd, Parkville, Victoria, 3052, Australia
| | - Adrienne Harvey
- Developmental Disability and Rehabilitation Research, Murdoch Children's Research Institute, Parkville, VIC, 3052, Australia
| | - Catherine Elliott
- School of Occupational Therapy and Social Work, Curtin University, Bentley, 6102, Western Australia, Australia.,Department of Paediatric Rehabilitation, Princess Margaret Hospital, Washington, WA, Australia
| | - Iona Novak
- Cerebral Palsy Alliance, Child and Adolescent Health, The University of Sydney, PO Box 6427, Frenchs Forest, NSW, 2086, Australia
| | - Ali Crichton
- Victorian Paediatric Rehabilitation Service, Monash Children's Hospital, 246 Clayton Rd, Clayton, VIC, 3168, Australia.,Department of Paediatrics, Monash University, Clayton, VIC, 3168, Australia
| |
Collapse
|
10
|
Zhou J, Butler EE, Rose J. Neurologic Correlates of Gait Abnormalities in Cerebral Palsy: Implications for Treatment. Front Hum Neurosci 2017; 11:103. [PMID: 28367118 PMCID: PMC5355477 DOI: 10.3389/fnhum.2017.00103] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2016] [Accepted: 02/20/2017] [Indexed: 01/17/2023] Open
Abstract
Cerebral palsy (CP) is the most common movement disorder in children. A diagnosis of CP is often made based on abnormal muscle tone or posture, a delay in reaching motor milestones, or the presence of gait abnormalities in young children. Neuroimaging of high-risk neonates and of children diagnosed with CP have identified patterns of neurologic injury associated with CP, however, the neural underpinnings of common gait abnormalities remain largely uncharacterized. Here, we review the nature of the brain injury in CP, as well as the neuromuscular deficits and subsequent gait abnormalities common among children with CP. We first discuss brain injury in terms of mechanism, pattern, and time of injury during the prenatal, perinatal, or postnatal period in preterm and term-born children. Second, we outline neuromuscular deficits of CP with a focus on spastic CP, characterized by muscle weakness, shortened muscle-tendon unit, spasticity, and impaired selective motor control, on both a microscopic and functional level. Third, we examine the influence of neuromuscular deficits on gait abnormalities in CP, while considering emerging information on neural correlates of gait abnormalities and the implications for strategic treatment. This review of the neural basis of gait abnormalities in CP discusses what is known about links between the location and extent of brain injury and the type and severity of CP, in relation to the associated neuromuscular deficits, and subsequent gait abnormalities. Targeted treatment opportunities are identified that may improve functional outcomes for children with CP. By providing this context on the neural basis of gait abnormalities in CP, we hope to highlight areas of further research that can reduce the long-term, debilitating effects of CP.
Collapse
Affiliation(s)
- Joanne Zhou
- Department of Orthopaedic Surgery, Stanford UniversityStanford, CA, USA; Motion and Gait Analysis Lab, Lucile Packard Children's HospitalPalo Alto, CA, USA
| | - Erin E Butler
- Thayer School of Engineering, Dartmouth CollegeHanover, NH, USA; Neukom Institute for Computational Sciences, Dartmouth CollegeHanover, NH, USA
| | - Jessica Rose
- Department of Orthopaedic Surgery, Stanford UniversityStanford, CA, USA; Motion and Gait Analysis Lab, Lucile Packard Children's HospitalPalo Alto, CA, USA
| |
Collapse
|
11
|
Abstract
Cerebral palsy has always been known as a disorder of movement and posture resulting from a non-progressive injury to the developing brain; however, more recent definitions allow clinicians to appreciate more than just the movement disorder. Accurate classification of cerebral palsy into distribution, motor type and functional level has advanced research. It also facilitates appropriate targeting of interventions to functional level and more accurate prognosis prediction. The prevalence of cerebral palsy remains fairly static at 2-3 per 1000 live births but there have been some changes in trends for specific causal groups. Interventions for cerebral palsy have historically been medical and physically focused, often with limited evidence to support their efficacy. The use of more appropriate outcome measures encompassing quality of life and participation is helping to deliver treatments which are more meaningful for people with cerebral palsy and their carers.
Collapse
Affiliation(s)
- Neil Wimalasundera
- Department of Paediatric Neurodisability, Clinical lead for the Wolfson Neurodisability Service, The Wolfson Neurodisability Service, London, UK
| | | |
Collapse
|
12
|
Horridge K, Tennant PWG, Balu R, Rankin J. Variation in health care for children and young people with cerebral palsies: a retrospective multicentre audit study. Dev Med Child Neurol 2015; 57:844-51. [PMID: 25808699 DOI: 10.1111/dmcn.12740] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/24/2015] [Indexed: 11/27/2022]
Abstract
AIM To explore the provision and variations in care for children and young people with cerebral palsies (CP) registered with the population-based North of England Collaborative Cerebral Palsy Survey (NECCPS). METHOD This is a retrospective multicentre record audit of 389 children with CP (220 males, 148 females, 21 no data; median age at time of audit 12y 3mo), born between 1995 and 2002. Data were collected on cranial magnetic resonance imaging (MRI), hip and spine surveillance and management, and pain presence and management. Variations over time and between the districts in the north of England (Northumberland, North and West Cumbria, North and South Tyneside, Newcastle-upon-Tyne, Gateshead, Sunderland, Durham, Darlington, Bishop Auckland, Hartlepool, Stockton-on-Tees, Middlesbrough, Redcar, and Cleveland), and by socio-economic status (SES) (estimated from the Index of Multiple Deprivation [IMD] 2004) were estimated by generalized estimating equations. RESULTS There was significant variation between districts in access to MRI (p<0.001), orthopaedic surgeons (p=0.005), recording state of spine (p<0.001), and discussions about pain (p<0.001). Fifty-seven per cent (95% CI 52-62) had evidence of a reported MRI brain scan, the proportion of which increased over time (p<0.001). Sixty-seven per cent (95% CI 62-71) had a discussion about pain recorded. Of those in pain, 87% (95% CI 80-93) had a pain management plan. The proportion with documented discussion about pain increased with increasing SES (p=0.04). INTERPRETATION The provision of care for children with CP in the north of England varies between districts. Internationally agreed, evidence-based standards are urgently needed to ensure more equitable health care and improved outcomes for all.
Collapse
Affiliation(s)
- Karen Horridge
- City Hospitals Sunderland NHS Foundation Trust, Sunderland Royal Hospital, Sunderland, UK
| | - Peter W G Tennant
- Institute of Health & Society, Newcastle University, Newcastle upon Tyne, UK
| | - Rajesh Balu
- County Durham and Darlington NHS Foundation Trust, Durham, UK
| | - Judith Rankin
- Institute of Health & Society, Newcastle University, Newcastle upon Tyne, UK.,PHE: Regional Maternity Survey Office, Newcastle upon Tyne, UK
| |
Collapse
|
13
|
Hurley DS, Sukal-Moulton T, Gaebler-Spira D, Krosschell KJ, Pavone L, Mutlu A, Dewald JPA, Msall ME. Systematic Review of Cerebral Palsy Registries/Surveillance Groups: Relationships between Registry Characteristics and Knowledge Dissemination. INTERNATIONAL JOURNAL OF PHYSICAL MEDICINE & REHABILITATION 2015; 3:266. [PMID: 27790626 PMCID: PMC5079705 DOI: 10.4172/2329-9096.1000266] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
The aims of this study were to provide a comprehensive summary of the body of research disseminated by Cerebral Palsy (CP) registries and surveillance programs from January 2009 through May 2014 in order to describe the influence their results have on our overall understanding of CP. Secondly, registries/surveillance programs and the work they produced were evaluated and grouped using standardized definitions and classification systems. METHOD A systematic review search in PubMed, CINAH and Embase for original articles published from 1 January 2009 to 20 May 2014 originating from or supported by population based CP registries and surveillance programs or population based national registries including CP were included. Articles were grouped by 2009 World CP Registry Congress aim, registry/surveillance program classification, geographical region, and the International Classification of Function, Disability and Health (ICF) domain. Registry variables were assessed using the ICF-CY classification. RESULTS Literature searches returned 177 articles meeting inclusion criteria. The majority (69%) of registry/surveillance program productivity was related to contributions as a Resource for CP Research. Prevention (23%) and Surveillance (22%) articles were other areas of achievement, but fewer articles were published in the areas of Planning (17%) and Raising the Profile of CP (2%). There was a range of registry/surveillance program classifications contributing to this productivity, and representation from multiple areas of the globe, although most of the articles originated in Europe, Australia, and Canada. The domains of the ICF that were primarily covered included body structures and function at the early stages of life. Encouragingly, a variety of CP registry/surveillance program initiatives included additional ICF domains of participation and environmental and personal factors. INTERPRETATION CP registries and surveillance programs, including novel non-traditional ones, have significantly contributed to the understanding of how CP affects individuals, families and society. Moving forward, the global CP registry/surveillance program community should continue to strive for uniformity in CP definitions, variables collected and consistency with international initiatives like the ICF so that databases can be consolidated for research use. Adaptation to new technologies can improve access, reduce cost and facilitate information transfer between registrants, researchers and registries/surveillance programs. Finally, increased efforts in documenting variables of individuals with CP into adulthood should be made in order to expand our understanding of CP across the lifespan.
Collapse
Affiliation(s)
- Donna S Hurley
- Department of Physical Therapy and Human Movement Sciences, Northwestern University, Chicago, IL, USA
| | - Theresa Sukal-Moulton
- Functional and Applied Biomechanics Section, Rehabilitation Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD, USA
| | | | - Kristin J Krosschell
- Department of Physical Therapy and Human Movement Sciences, Northwestern University, Chicago, IL, USA
| | | | - Akmer Mutlu
- Department of Physiotherapy and Rehabilitation, Faculty of Health Sciences, Hacettepe University, Ankara, Turkey
| | - Julius PA Dewald
- Department of Physical Therapy and Human Movement Sciences, Northwestern University, Chicago, IL, USA
| | - Michael E Msall
- University of Chicago Comer Children’s Hospital and Kennedy Research Center on Intellectual and Neurodevelopmental Disabilities, Chicago, IL, USA
| |
Collapse
|
14
|
A diagnostic approach for cerebral palsy in the genomic era. Neuromolecular Med 2014; 16:821-44. [PMID: 25280894 DOI: 10.1007/s12017-014-8331-9] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2014] [Accepted: 09/24/2014] [Indexed: 12/12/2022]
Abstract
An ongoing challenge in children presenting with motor delay/impairment early in life is to identify neurogenetic disorders with a clinical phenotype, which can be misdiagnosed as cerebral palsy (CP). To help distinguish patients in these two groups, conventional magnetic resonance imaging of the brain has been of great benefit in "unmasking" many of these genetic etiologies and has provided important clues to differential diagnosis in others. Recent advances in molecular genetics such as chromosomal microarray and next-generation sequencing have further revolutionized the understanding of etiology by more precisely classifying these disorders with a molecular cause. In this paper, we present a review of neurogenetic disorders masquerading as cerebral palsy evaluated at one institution. We have included representative case examples children presenting with dyskinetic, spastic, and ataxic phenotypes, with the intent to highlight the time-honored approach of using clinical tools of history and examination to focus the subsequent etiologic search with advanced neuroimaging modalities and molecular genetic tools. A precise diagnosis of these masqueraders and their differentiation from CP is important in terms of therapy, prognosis, and family counseling. In summary, this review serves as a continued call to remain vigilant for current and other to-be-discovered neurogenetic masqueraders of cerebral palsy, thereby optimizing care for patients and their families.
Collapse
|
15
|
Kruer MC, Jepperson T, Dutta S, Steiner RD, Cottenie E, Sanford L, Merkens M, Russman BS, Blasco PA, Fan G, Pollock J, Green S, Woltjer RL, Mooney C, Kretzschmar D, Paisán-Ruiz C, Houlden H. Mutations in γ adducin are associated with inherited cerebral palsy. Ann Neurol 2014; 74:805-14. [PMID: 23836506 PMCID: PMC3952628 DOI: 10.1002/ana.23971] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2013] [Revised: 05/27/2013] [Accepted: 06/07/2013] [Indexed: 12/22/2022]
Abstract
OBJECTIVE Cerebral palsy is estimated to affect nearly 1 in 500 children, and although prenatal and perinatal contributors have been well characterized, at least 20% of cases are believed to be inherited. Previous studies have identified mutations in the actin-capping protein KANK1 and the adaptor protein-4 complex in forms of inherited cerebral palsy, suggesting a role for components of the dynamic cytoskeleton in the genesis of the disease. METHODS We studied a multiplex consanguineous Jordanian family by homozygosity mapping and exome sequencing, then used patient-derived fibroblasts to examine functional consequences of the mutation we identified in vitro. We subsequently studied the effects of adducin loss of function in Drosophila. RESULTS We identified a homozygous c.1100G>A (p.G367D) mutation in ADD3, encoding gamma adducin in all affected members of the index family. Follow-up experiments in patient fibroblasts found that the p.G367D mutation, which occurs within the putative oligomerization critical region, impairs the ability of gamma adducin to associate with the alpha subunit. This mutation impairs the normal actin-capping function of adducin, leading to both abnormal proliferation and migration in cultured patient fibroblasts. Loss of function studies of the Drosophila adducin ortholog hts confirmed a critical role for adducin in locomotion. INTERPRETATION Although likely a rare cause of cerebral palsy, our findings indicate a critical role for adducins in regulating the activity of the actin cytoskeleton, suggesting that impaired adducin function may lead to neuromotor impairment and further implicating abnormalities of the dynamic cytoskeleton as a pathogenic mechanism contributing to cerebral palsy.
Collapse
|
16
|
Reid SM, Dagia CD, Ditchfield MR, Carlin JB, Reddihough DS. Population-based studies of brain imaging patterns in cerebral palsy. Dev Med Child Neurol 2014; 56:222-32. [PMID: 23937113 DOI: 10.1111/dmcn.12228] [Citation(s) in RCA: 68] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/13/2013] [Indexed: 01/12/2023]
Abstract
AIM The aim of this study was to review the distribution of neuroimaging findings from a contemporary population cohort of individuals with cerebral palsy (CP) and to facilitate standardization of imaging classification. METHOD Publications from 1995 to 2012 reporting imaging findings in population cohorts were selected through a literature search, and review of the titles, abstracts, and content of studies. Relevant data were extracted, including unpublished data from Victoria, Australia. The proportions for each imaging pattern were tabulated, and heterogeneity was assessed for all individuals with CP, and for subgroups based on gestational age, CP subtype, and Gross Motor Function Classification System level. RESULTS Studies from three geographic regions met the inclusion criteria for individuals with CP, and two additional studies reported on specific CP subtypes. Brain abnormalities were observed in 86% of scans, but were observed least often in children with ataxia (24-57%). White matter injury was the most common imaging pattern (19-45%), although the proportions showed high heterogeneity. Additional patterns were grey matter injury (21%), focal vascular insults (10%), malformations (11%), and miscellaneous findings (4-22%). INTERPRETATION This review suggests areas where further dialogue will facilitate progress towards standardization of neuroimaging classification. Standardization will enable future collaborations aimed at exploring the relationships among magnetic resonance imaging patterns, risk factors, and clinical outcomes, and, ultimately, lead to better understanding of causal pathways and opportunities for prevention.
Collapse
Affiliation(s)
- Susan M Reid
- Developmental Disability & Rehabilitation Research, Murdoch Childrens Research Institute, Parkville, Vic., Australia
| | | | | | | | | |
Collapse
|
17
|
Reid SM, Dagia CD, Ditchfield MR, Carlin JB, Meehan EM, Reddihough DS. An Australian population study of factors associated with MRI patterns in cerebral palsy. Dev Med Child Neurol 2014; 56:178-84. [PMID: 24428267 DOI: 10.1111/dmcn.12331] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/17/2013] [Indexed: 11/30/2022]
Abstract
AIM The aim of this study was to describe the distribution of magnetic resonance imaging (MRI) patterns in a large population sample of children with cerebral palsy (CP) and to examine associations between MRI patterns, and antenatal and perinatal variables. METHOD Data were retrieved from the Victorian CP Register for 884 children (527 males, 357 females) born between 1999 and 2006. Postneonatal MRI was classified for 594 children. For 563 children (329 males, 234 females) for whom classification was to a single MRI pattern, the frequency of each variable was compared between patterns and with the population frequency. RESULTS White matter injury was the most common MRI pattern (45%), followed by grey matter injury (14%), normal imaging (13%), malformations (10%), focal vascular insults (9%), and miscellaneous patterns (7%). Parity, birth gestation, level of neonatal care, Apgar score, and time to established respiration varied between MRI patterns (p<0.01). Nulliparity was most strongly associated with focal vascular insults, whereas multiparity was associated only with malformations. Grey matter injury was not associated with birth in a tertiary unit, but was strongly associated with severe perinatal compromise. The frequency of neonatal seizures and of nursery admissions was lowest among children with malformations. INTERPRETATION As known risk factors for CP are differentially associated with specific MRI patterns, future exploration of causal pathways might be facilitated when performed in pathogenically defined groups.
Collapse
Affiliation(s)
- Susan M Reid
- Developmental Disability and Rehabilitation Research, Murdoch Childrens Research Institute, Melbourne, Australia; Department of Paediatrics, University of Melbourne, Melbourne, Australia
| | | | | | | | | | | |
Collapse
|
18
|
Arnfield E, Guzzetta A, Boyd R. Relationship between brain structure on magnetic resonance imaging and motor outcomes in children with cerebral palsy: a systematic review. RESEARCH IN DEVELOPMENTAL DISABILITIES 2013; 34:2234-2250. [PMID: 23643774 DOI: 10.1016/j.ridd.2013.03.031] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/18/2012] [Revised: 03/19/2013] [Accepted: 03/25/2013] [Indexed: 06/02/2023]
Abstract
Magnetic resonance imaging (MRI) is recommended in all children with cerebral palsy (CP) where the aetiology has not been established, and the major presenting problem in CP is reduced motor capacity. A systematic review of the literature was performed to investigate the relationship between brain structure on MRI and motor outcomes in children with CP. A total of 37 studies met inclusion criteria, and were analysed in terms of (a) population characteristics, (b) MRI data, (c) motor outcome data, and (d) the relationship between MRI data and motor outcomes. All studies used a qualitative system to classify brain lesions; however, few reported information about the location and extent of lesions. Valid and reliable classifications of motor abilities were not always used, and three studies did not link motor findings to MRI features. There was, however, a relationship between the type of brain lesion on MRI and two specific motor outcomes, namely gross motor functional classification (using GMFCS) and motor type. This relationship could aid in the prediction and optimisation of early interventions for children with CP. There is also need for a quantitative MRI classification measure which includes detailed information about the location and severity of lesions.
Collapse
Affiliation(s)
- Evyn Arnfield
- Queensland Cerebral Palsy and Rehabilitation Research Centre, School of Medicine, The University of Queensland, Brisbane, QLD, Australia
| | | | | |
Collapse
|
19
|
Whitehouse WP. Metabolic testing in children with cerebral palsy: yield could be up to 20%. Dev Med Child Neurol 2011; 53:1160; author reply 1161. [PMID: 21933175 DOI: 10.1111/j.1469-8749.2011.04104.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
|
20
|
Affiliation(s)
- Florian Heinen
- University Hospital - Paediatric Neurology and Developmental Medicine, Munich, Germany
| |
Collapse
|