The changing panorama of cerebral palsy in Sweden. VII. Prevalence and origin in the birth year period 1987-90

Tools for Nutrition Assessment of Adults with Cerebral Palsy: Development of a Gold Standard

PURPOSE OF REVIEW

Cerebral palsy (CP) is a group of disorders caused by non-stabilized cerebral lesions. Individuals with this disorder are at a higher risk of suffering from malnutrition and other related detrimental effects to their quality of life. For this reason, accurate methods of nutritional assessment are vital for people suffering from this condition. While assessment of nutritional status in children with CP has been extensively studied, very few studies have been carried out on adults. These limitations are due to the great anatomical-functional variability characteristic of this syndrome. Difficulties that derive from this variability in adult patients with CP mean that there remains an urgent need for certain standards of nutritional assessment for this population. The objective of this review is to compile the latest trends in nutritional assessment in adults with CP to guide the development of a conceptual framework for future research.

RECENT FINDINGS

With this aim, relevant studies have been identified. The most commonly used technique to evaluate nutritional status is the BMI because of its ease-of-use. However, its well-known limitations fail to adequately estimate the nutritional status in this population, with measurements of patients with CP yielding results that are much less accurate than those that already exist in the general population. Although more studies are needed, kinanthropometry is considered one of the most reliable techniques; nevertheless, the anatomical limitation characteristic of CP plays a limiting factor.

The panorama of cerebral palsy in Sweden part XIII shows declining prevalence in birth-years 2011-2014

AIM

To describe epidemiology and characteristics of cerebral palsy (CP) in western Sweden 1954-2014.

METHODS

Population-based study covering 105 935 live births in the area in 2011-2014. Birth characteristics, neuroimaging findings and outcome were analysed and prevalence calculated. Non-parametric methods were used for group comparisons.

RESULTS

CP was diagnosed in 192 children. Crude prevalence had decreased to 1.81 per 1000 live births (p = 0.0067). Gestational age-specific prevalence for <28 gestational weeks was 74.8 per 1000 live births, 46.6 for 28-31 weeks, 5.8 for 32-36 weeks and 1.1 per 1000 for >36 weeks of gestation. Hemiplegia, found in 36.2%, had declined (p = 0.03). Diplegia was found in 36.2% and tetraplegia 5.3%. Dyskinetic CP accounted for 18.6% and ataxia for 3.7%. Neuroimaging revealed maldevelopments in 14%, white matter lesions in 44%, cortical/subcortical lesions in 13% and basal ganglia lesions in 17%. Prenatal aetiology was considered in 34%, peri- or neonatal in 48%, while in 18% aetiological period remained unclassified. Motor outcome in children who needed neonatal care had improved (p = 0.04). Motor function in dyskinetic CP had improved compared to previous cohorts (p = 0.008).

CONCLUSION

The prevalence of CP has declined, mainly in term-born and in hemiplegia, and motor severity has changed compared to previous cohorts.

Secondary Osteoporosis

Osteoporosis is a global public health problem, with fractures contributing to significant morbidity and mortality. Although postmenopausal osteoporosis is most common, up to 30% of postmenopausal women, > 50% of premenopausal women, and between 50% and 80% of men have secondary osteoporosis. Exclusion of secondary causes is important, as treatment of such patients often commences by treating the underlying condition. These are varied but often neglected, ranging from endocrine to chronic inflammatory and genetic conditions. General screening is recommended for all patients with osteoporosis, with advanced investigations reserved for premenopausal women and men aged < 50 years, for older patients in whom classical risk factors for osteoporosis are absent, and for all patients with the lowest bone mass (Z-score ≤ -2). The response of secondary osteoporosis to conventional anti-osteoporosis therapy may be inadequate if the underlying condition is unrecognized and untreated. Bone densitometry, using dual-energy x-ray absorptiometry, may underestimate fracture risk in some chronic diseases, including glucocorticoid-induced osteoporosis, type 2 diabetes, and obesity, and may overestimate fracture risk in others (eg, Turner syndrome). FRAX and trabecular bone score may provide additional information regarding fracture risk in secondary osteoporosis, but their use is limited to adults aged ≥ 40 years and ≥ 50 years, respectively. In addition, FRAX requires adjustment in some chronic conditions, such as glucocorticoid use, type 2 diabetes, and HIV. In most conditions, evidence for antiresorptive or anabolic therapy is limited to increases in bone mass. Current osteoporosis management guidelines also neglect secondary osteoporosis and these existing evidence gaps are discussed.

Apgar Score and Risk of Cerebral Palsy in Preterm Infants: A Population-Based Cohort Study

A low Apgar score is associated with increased risk of cerebral palsy (CP) in term infants, while such association remains controversial in preterm neonates. The objective of this study was to assess association between 5-minute Apgar scores and CP in different subcategories of preterm birth based on gestational age. The Slovenian National Perinatal Information System was used to identify singleton children without congenital malformations live-born at 22 to 37 weeks of gestation between 2002 and 2010. Data were linked to the Slovenian Registry of Cerebral Palsy in children born between 2002 and 2010. CP was diagnosed at a minimum of 5 years of age. Of 11,924 children included, 241 (2.0%) died before discharge and 153 (1.3%) were diagnosed with CP. Five-minute Apgar scores <7 were significantly associated with higher risk of death or CP (compared with scores ≥9) at all preterm gestations. CP alone was associated with Apgar scores <7 only at moderately or late preterm gestation (32-36 weeks) (adjusted relative risk [aRR]: 8.27; 95% confidence interval [CI]: 1.87-36.64 for scores 0-4 and aRR: 4.96; 95% CI 1.89-13.06 for scores 5-6). In conclusion, a low 5-minute Apgar score was associated with combined outcome of neonatal death or CP in all preterm births, while in surviving preterm infants at >32 weeks a low 5-minute Apgar score was associated with CP.

Assessment of adult patients with cerebral palsy

Objectives

The aim of this study was to evaluate health problems, accommodation, and mobility of adult patients with cerebral palsy (CP).

Patients and methods

Between September 2018 and September 2019, a total of 70 adult CP patients (37 males, 33 females; mean age 29.4±10.2 years; range, 19 to 68 years) who were admitted to our clinic were included. Accommodation, education status, mental state, comorbidities, spasticity, contracture, deformity, and mobility of the patients were evaluated.

Results

Of the patients, 24.3% were diplegic, 21.4% were hemiplegic, 32.9% were tetraplegic, 15.7% were dyskinetic, and 5.7% had mixed form of CP. Among the patient, 38.6% had normal mental ability and 21.4% had severe mental retardation. A total of 92.9% of the patients were living with their family, 85.7% were unemployed, 10% were illiterate, and 21.4% had no health problems. Speech disorder was the most common health issue in 52.9% of the patients. Other health concerns included sensory problems, epilepsy, bladder/intestinal problems, nutritional problems, and respiratory and skin problems. The ratio of pain was 31.4%. Mild deformity was present in 54.3% of the patients, 43.7% were wheelchair-dependent, and 25.7% were Gross Motor Function Classification System (GMFCS) Level V.

Conclusion

Recognition and understanding health problems and living conditions of adult patients with CP would be useful both in determining the treatment goals of pediatric CP patients and in improving the quality of life of adult CP patients.

Cortical Gray Matter Injury in Encephalopathy of Prematurity: Link to Neurodevelopmental Disorders

Preterm-born infants frequently suffer from an array of neurological damage, collectively termed encephalopathy of prematurity (EoP). They also have an increased risk of presenting with a neurodevelopmental disorder (e.g., autism spectrum disorder; attention deficit hyperactivity disorder) later in life. It is hypothesized that it is the gray matter injury to the cortex, in addition to white matter injury, in EoP that is responsible for the altered behavior and cognition in these individuals. However, although it is established that gray matter injury occurs in infants following preterm birth, the exact nature of these changes is not fully elucidated. Here we will review the current state of knowledge in this field, amalgamating data from both clinical and preclinical studies. This will be placed in the context of normal processes of developmental biology and the known pathophysiology of neurodevelopmental disorders. Novel diagnostic and therapeutic tactics required integration of this information so that in the future we can combine mechanism-based approaches with patient stratification to ensure the most efficacious and cost-effective clinical practice.

PREVALENCE OF EARLY SPINAL DEFORMITY IN CHILDREN WITH GMFCS V CEREBRAL PALSY

ABSTRACT Objective: Spastic cerebral palsy (sCP) is a cause of early onset scoliosis, although there are no data on its prevalence. Our objective was to determine the prevalence of early onset neuromuscular spinal deformities (SD) in severely compromised children with sCP. Methods: Cross-sectional quantitative, observational, exploratory, and descriptive study. Review of clinical records. Inclusion criteria: age 2 to 5 years, sCP, level V of the GMFCS, residents in our province. X-ray blind reading by 2 observers. The Student t test was used for parametric data and the chi-square test for non-parametric data. Level of statistical significance: p < 0.05. Results: Thirty-eight cases of 158 registered were included. Average age: 3 years 7 months (2 years – 5 years 2 months). Sex: 21 male/17 female. The predominant etiologies were perinatal: 21 (55.3%), and the prevalent nutritional status was eutrophic: 28 cases (73.7%). SD was very frequent: 32 patients (84.2%) without statistical differences between sexes; there were 20 kyphoscoliosis, 1 lordoscoliosis, 6 scoliosis, 5 hyperkyphosis. Mean angular values: 23.9° (10°- 50°) for the frontal plane deformities and 58° (9°- 92º) for the sagittal deformities. Seventeen patients (44.7%) had average pelvic obliquity of 15° (2°- 30°) without differences in patients with and without SD. There was no association between SD and etiology, digestive disorders, seizures, nutritional status, hip excentration, or limb deformities. Conclusions: The prevalence of SD in children up to 5 years old with severe sCP is high: 84.2% (32/38 cases). The orthopedic profile is children with sCP of any etiology at GMFCS level V, with multiple disabilities and independently of associated limb deformities. Level of evidence I; Diagnostic Studies - Investigating a Diagnostic Test: Testing of previously developed diagnostic criteria on consecutive patients (with universally applied reference “gold” standard).

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.

Auditory stimulation improves motor function and caretaker burden in children with cerebral palsy- A randomized double blind study

Aim

To investigate the impact of auditory stimulation on motor function in children with cerebral palsy (CP) and disabling hypertonia.

Method

9 matched pairs (age: 7y5m, SD 4y1m; 13 boys; gross-motor-functional-classification-scale: median 4; manual-ability-classification-system: median 4) were randomized to receive either auditory stimulation embedded in music (study, n = 9) or music alone (sham, control, n = 9) for at least 10 minutes 4 times a week for 4 weeks. Goal-Attainment-Scale, Care-and-Comfort-Hypertonicity-Questionnaire, Gross-Motor-Function–Measure and Quality-of-Upper-Extremity-Skills-Test (QUEST) were assessed before and 5 months following intervention.

Result

Children receiving auditory stimulation attained more goals than children who listened to music alone (p = 0.002). Parents reported improved care and comfort in children in the study group compared to a slight deterioration in controls (p = 0.002). Upper extremity skills improved in the study group compared to controls (p = 0.006). Similar gross motor function changes were documented in both groups (p = 0.41).

One participant reported increased seizure frequency; no other participants with epilepsy reported increased seizure frequency (n = 6/18) and no other adverse events were reported.

Interpretation

Auditory stimulation alleviated hypertonia and improved fine and gross motor functions.

Implementation of the International Classification of Functioning, Disability, and Health (ICF) Core Sets for Children and Youth with Cerebral Palsy: Global Initiatives Promoting Optimal Functioning

Background: The International Classification of Functioning, Disability, and Health (ICF) Core Sets for children and youth with cerebral palsy (CP) offer service providers and stakeholders a specific framework to explore functioning and disability for assessment, treatment, evaluation, and policy purposes in a global context. Objective: Describe global initiatives applying the ICF Core Sets for children and youth with CP, with a focus on contributions to clinical practice and challenges in their implementation. Methods: This is a descriptive cross-sectional study. Ongoing initiatives applying the ICF Core Sets for CP in Russia, Poland, Malawi, and Brazil are included. Results: The main contributions of applying the ICF Core Sets for children and youth with CP include: (1) an objective description of abilities and limitations in everyday activities; (2) a consistent identification of facilitators and barriers influencing functioning; (3) a practical communication tool promoting client-centered care and multidisciplinary teamwork; and, (4) a useful guideline for measurement selection. The main challenges of adopting the ICF Core Sets are related to lack of ICF knowledge requiring intense training and translating results from standardized measures into the ICF qualifiers in a consistent way. Conclusions: Global initiatives include research and clinical applications at the program, service and system levels. The ICF Core Sets for CP are useful tools to guide service provision and build profiles of functioning and disability. Global interprofessional collaboration, capacity training, and informatics (e-records) will maximize their applications and accelerate adoption.

Evaluation of hand function in patients with unilateral cerebral palsy who underwent multilevel functional surgery: a retrospective observational study

BACKGROUND

Hemiplegia is the most common form of cerebral palsy. Upper limb is generally more affected than lower one. Indeed, hemiplegic children can spontaneously acquire standing and walking ability, while manipulation remains uncertain, with severe limitations in activity and participation, which define a child's functional status (International Classification of Functioning [ICF]). Several non-surgical tools are currently available to approach upper limb impairments. Studies regarding upper limb multilevel surgery in Hemiplegic Cerebral Palsy are relatively few and inhomogeneous.

AIM

The aim of this study is to propose a surgical approach based on upper limb functional level and manipulation strategy and establish whether multilevel surgery can improve segmental alignment, performance and capacity, that ICF defines as activities and participation qualifiers.

DESIGN

This study is an observational retrospective study.

SETTING

This study involves patients who referred to the Unit of Children Rehabilitation of S. Maria Nuova Institute for Research and Care, in Reggio Emilia (Italy), over a four-year period.

POPULATION

Children affected by hemiplegic cerebral palsy who underwent upper limb multilevel surgery.

METHODS

For each patient, we previously defined functional use of affected upper limb applying the House classification and the Ferrari one of manipulation pattern. Patients are divided into three groups: synergic hand (House 4, 5), imprisoned hand (House 3), excluded hand (House 0). We recorded goals achievement through Goal Attainment Scale and unimanual and bimanual abilities through Melbourne Assessment of Unilateral Upper Limb Function and through Assisting Hand Assessment respectively.

RESULTS

We recorded 16 upper limb multilevel surgical interventions in 13 children and report their results.

CONCLUSIONS

This study suggests that surgery can induce a segmental and/or aesthetic and/or a functional change depending on manipulation pattern. It also underlines the importance to analyze results in term of spontaneous manipulation abilities and daily use.

CLINICAL REHABILITATION IMPACT

This study provides a preliminary guide to plan surgery in relation to segmental deformities and overall manipulation pattern and describes their feasible improvement measures. It also suggests the most useful tools to record goal achievements in modifying manipulation function. Further controlled, randomized and prospective studies are required to support this idea.

The panorama of cerebral palsy in Sweden part XII shows that patterns changed in the birth years 2007-2010

AIM

This was the 12th population-based study to explore the epidemiology of cerebral palsy (CP) in western Sweden.

METHODS

From 2007 to 2010, there were 104 713 live births in the area. We analysed the birth characteristics, aetiology and neuroimaging findings, calculated the prevalence and compared the results with previous study cohorts.

RESULTS

Cerebral palsy was found in 205 children, corresponding to a crude prevalence of 1.96 per 1000 live births. The gestational age-specific prevalence for <28 gestational weeks was 59.0 per 1000 live births, 45.7 for 28-31 weeks, 6.0 for 32-36 weeks and 1.2 for >36 weeks. Hemiplegia accounted for 44%, diplegia for 34%, tetraplegia for 5%, dyskinetic CP for 12% and ataxia for 3%. Neuroimaging showed maldevelopment in 12%, white matter lesions in 49%, cortical/subcortical lesions in 15% and basal ganglia lesions in 11%. The aetiology was considered prenatal in 38%, peri/neonatal in 38% and remained unclassified in 24%. CP due to term or near-term asphyxia had decreased.

CONCLUSION

A nonsignificant decrease in CP prevalence was seen in term-born children. Hemiplegia was still the most prevalent CP type, while the prevalence of dyskinetic CP had decreased. One in two children had white matter lesions, indicating late second- or early third-trimester timing.

Acupuncture for cerebral palsy: A meta-analysis of randomized controlled trials

OBJECTIVE:

To evaluate the efficacy and safety of acupuncture therapy for children with cerebral palsy.

DATA SOURCES:

We conducted electronic searches of PUBMED (1950/2017), EMBASE (1974/2017), ScienceDirect (1986/2017), Academic Source Premier (1887/2017), the Cochrane Library (Issue 4, April 2017), Science Citation Index Expanded (1900/2017), China National Knowledge Infrastructure (1915/2017), China Biological Medicine (1990/2017-04), WanFang (1980/2017), VIP (1989/2017), and Chinese Science Citation Database (1989/2017).

DATA SELECTION:

We included randomized controlled trials that aimed to compare the effect of acupuncture plus rehabilitation training versus rehabilitation training alone. Data about functional motor abilities, daily activity/social participation, effective rate, intellectual development, and adverse effects were included. We used Revman 5.2 software for statistical analysis.

OUTCOME MEASURES:

The primary outcomes included functional motor abilities, daily activity, and effective rate. The secondary outcomes included intellectual development and adverse effects.

RESULTS:

Twenty-one studies with a total of 1718 participants met the inclusion criteria. The effect size of gross motor function (SMD = 0.64, 95% CI: 0.52 to 0.76, P < 0.00001; I² = 0%, P = 0.69; in 13 studies with 1144 patients) and the total effective rate (RR = 1.28, 95% CI: 1.20 to 1.37, P < 0.00001; I² = 18%, P = 0.27; in 12 studies with 1106 patients) suggested that acupuncture plus rehabilitation produced a significant improvement in gross motor function and a high total effective rate. The pooled fine motor function (SMD = 3.48, 95% CI: 2.62 to 4.34, P < 0.00001; I² = 64%, P = 0.10; in 2 studies with 193 patients), modified Ashworth scale scores (SMD = –0.31, 95% CI: –0.52 to –0.11, P = 0.003; I² = 74%, P = 0.004; in 5 studies with 363 patients) and activities of daily living (SMD = 1.45, 95% CI: 1.20 to 1.71, P < 0.00001; I² = 78%, P = 0.004; in 4 studies with 313 patients) also indicated improvements in children with cerebral palsy. Publication bias was not observed. Only mild adverse events related to acupuncture were reported.

CONCLUSION:

Acupuncture plus rehabilitation training improved gross motor function, reduced muscle spasms, and enhanced daily life activities in children with cerebral palsy. However, this conclusion should be interpreted with caution due to the small number of randomized controlled trials available and the small sample sizes. More high-quality and large-scale studies are needed.

Neurodevelopmental Impairment in Children After Group B Streptococcal Disease Worldwide: Systematic Review and Meta-analyses

BACKGROUND

Survivors of infant group B streptococcal (GBS) disease are at risk of neurodevelopmental impairment (NDI), a burden not previously systematically quantified. This is the 10th of 11 articles estimating the burden of GBS disease. Here we aimed to estimate NDI in survivors of infant GBS disease.

METHODS

We conducted systematic literature reviews (PubMed/Medline, Embase, Latin American and Caribbean Health Sciences Literature [LILACS], World Health Organization Library Information System [WHOLIS], and Scopus) and sought unpublished data on the risk of NDI after invasive GBS disease in infants <90 days of age. We did meta-analyses to derive pooled estimates of the percentage of infants with NDI following GBS meningitis.

RESULTS

We identified 6127 studies, of which 18 met eligibility criteria, all from middle- or high-income contexts. All 18 studies followed up survivors of GBS meningitis; only 5 of these studies also followed up survivors of GBS sepsis and were too few to pool in a meta-analysis. Of meningitis survivors, 32% (95% CI, 25%-38%) had NDI at 18 months of follow-up, including 18% (95% CI, 13%-22%) with moderate to severe NDI.

CONCLUSIONS

GBS meningitis is an important risk factor for moderate to severe NDI, affecting around 1 in 5 survivors. However, data are limited, and we were unable to estimate NDI after GBS sepsis. Comparability of studies is difficult due to methodological differences including variability in timing of clinical reviews and assessment tools. Follow-up of clinical cases and standardization of methods are essential to fully quantify the total burden of NDI associated with GBS disease, and inform program priorities.

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

AIM

To estimate the number of children living with cerebral palsy (CP) in England and Wales in 2013 by severity, and to extrapolate this figure to 2020.

METHOD

Data from the North of England Collaborative Cerebral Palsy Survey for births during the period 1991 to 2000 were restricted to individuals aged at or above 3 years to estimate the prevalence of CP and to calculate 15-year survival by severity according to the number of severe impairments and lifestyle assessment score. The number of 3- to 15-year-olds with CP of different severity in England and Wales was estimated in 2013 and 2019 using actual and nationally projected births.

RESULTS

Cumulative survival estimates up to the age of 16 years in children with CP differ significantly by severity, ranging between 97 per cent and 100 per cent for children with non-severe CP, and between 64 per cent and 67 per cent for those with the most severe CP. By the end of 2013, the estimated number of children aged 3 to 15 years living with CP in England and Wales will be about 20 500 rising to approximately 22 100 by 2020, a 7.5 per cent increase.

INTERPRETATION

Owing to an increasing population, the number of children living with CP in England and Wales will increase by 2020. This will have significant implications for health and social care service planning.

Clown-care reduces pain in children with cerebral palsy undergoing recurrent botulinum toxin injections- A quasi-randomized controlled crossover study

OBJECTIVE

We investigated the impact of clown-care on pain in 45 children with cerebral palsy who underwent recurrent Botulinum-toxin injections (age 7.04± 4.68 years). Participants were randomized to receive either clown (n = 20) or standard (n = 25) -care.

METHODS

Pain Visual-Analogue-Scale (range 1-5) was reported before and after procedures. Pain assessment was lower for children undergoing Botulinum-toxin injections with clown-care (2.89± 1.36) compared to standard-care (3.85± 1.39; p = 0.036) even though pain anticipated prior to procedures was similar (~3).

FINDINGS

Children who underwent the first procedure with clown-care reported lower pain even after they crossed-over to the following procedure which was standard (p = 0.048). Carryover effect was more prominent in injection-naïve children (p = 0.019) and during multiple procedures (p = 0.009). Prior pain experience correlated with pain in subsequent procedures only when first experience was standard-care (p = 0.001).

CONCLUSIONS

Clown-care alleviated pain sensation during Botulinum-toxin injections and initial clown-care experience reduced pain during subsequent injections even though clowns were not present.

TRIAL REGISTRATION

clinicaltrials.gov ID # NCT01377883.

The Role of Prematurity in Patients With Hemiplegic Cerebral Palsy

A multicenter retrospective study was conducted to investigate the perinatal factors, imaging findings and clinical characteristics of hemiplegic cerebral palsy with a particular focus on children born prematurely. Our cohort included 135 patients of whom 42% were born prematurely; 16% were extreme premature infants who were born at 30 weeks or earlier. Nineteen (14%) were twins. Right hemiplegia was slightly more common and accounted for 59% of the patients. Imaging findings of intraventricular hemorrhage and periventricular leukomalacia were more prevalent in premature children whereas stroke, porencephaly, cerebral hemorrhage and cerebral atrophy were more evenly distributed in both term-born and prematurely-born children (p< 0.01). The overall prevalence of epilepsy in the cohort was 26% with no differences in full-term compared to prematurely-born children. Regardless of the gestational birth age, intellectual deficits were more common in the presence of comorbidity of both hemiplegia and epilepsy (p< 0.05).

Antecedents of cerebral palsy according to severity of motor impairment

INTRODUCTION

The purpose of this study was to determine whether antecedents and neuroimaging patterns vary according to the severity of motor impairment in children with cerebral palsy.

MATERIAL AND METHODS

A population-based study in which all 309 term-born children with spastic and dyskinetic cerebral palsy born between 1983 and 1994 and 618 matched controls were studied. Antecedents were retrieved from obstetric records. Information on neuroimaging was retrieved from the cerebral palsy Register of Western Sweden. Cases were grouped by severity of motor impairment: mild (walks without aids), moderate (walks with aids) or severe (dependent on wheelchair). Binary logistic regression, the Cochran-Armitage test for trends, interaction analyses and interrelationship analyses were performed.

RESULTS

Antecedents associated with mild motor impairment were antepartum (placental weight, maternal weight and antibiotic therapy) or intrapartum and postpartum adverse events (meconium-stained amniotic fluid, low Apgar score, admission to neonatal intensive care unit and neonatal encephalopathy). Antecedents associated with severe motor impairment were antepartum (congenital infection, small head circumference and brain maldevelopment) or intrapartum and postpartum (emergency cesarean section and maternal antibiotic therapy). Comparisons between mild and severe motor impairment revealed congenital infection, maldevelopment, neonatal encephalopathy and meconium aspiration syndrome significantly more often in the group with severe motor impairment (p < 0.05). White matter injury was the most common neuroimaging pattern in mild motor impairment, whereas maldevelopment and cortical/subcortical lesions were most common in the severe motor impairment group.

CONCLUSIONS

Our results suggest a variation in antecedents associated with cerebral palsy, related to severity of motor impairment. Timing of antecedents corresponded to neuroimaging patterns.

Survival with cerebral palsy over five decades in western Sweden

AIM

The life expectancy of individuals with cerebral palsy (CP) is often reduced compared with the general population. Long-term survival with CP is rarely reported. The aim of this study was to investigate survival and the causes of death in relation to CP type and motor and accompanying impairments documented in the CP register of western Sweden over five decades.

METHOD

All individuals born between 1959 and 2002 were included in the study. CP was classified according to Hagberg and the Surveillance of Cerebral Palsy in Europe (SCPE). Motor and accompanying impairments were documented. Causes of death were derived from the National Board of Health and Welfare, and population data were obtained from Statistics Sweden. Log-rank tests with Kaplan-Meier plots were used for statistical analyses.

RESULTS

Of the 1856 individuals (1033 males, 823 females) with CP included in the study, 180 (9.6%) had died by 31 December 2009. Tetraplegia, dyskinetic CP, severe cognitive impairment, and epilepsy were associated with decreased survival rates. At Gross Motor Function Classification System (GMFCS) level V, survival rates among individuals with spastic CP were lower than among those with dyskinetic CP. However, compared with the general population, there was an elevated death rate among individuals with CP for all age groups and CP types. At all ages, females with CP had a larger excess risk of death than males. Respiratory failure caused 53% of deaths. For individuals with hemiplegia, as in the general population, 20% of deaths were accidental.

INTERPRETATION

Survival rates are influenced by CP type but there is an elevated risk of death for individuals with any type of CP, compared with those without CP.

Clinical profile, predisposing factors, and associated co-morbidities of children with cerebral palsy in South India

INTRODUCTION

Cerebral palsy (CP) is the most common physical disorder of children. Causes like jaundice and birth injury though are decreasing; complications resulting from the survival of low birth weight babies are replacing some of the older etiologies. Hence, this study was planned.

OBJECTIVES

The objective was to study the clinical patterns, predisposing factors, and co-morbidities in children with CP.

MATERIALS AND METHODS

The present study is a hospital based prospective study conducted from January 2012 to January 2013 in children presenting to neurodevelopmental clinic at a tertiary care teaching hospital in India. Hundred cases with clinical features suggestive of CP were included in the study. Cases were evaluated by history, clinical examination, and necessary investigations.

RESULTS

Results of the study showed 81% of spastic, 12% of hypotonic, 5% of dystonic, and 2% of mixed CP cases. The mean age of presentation was 2 year, 2 month, and male to female ratio of 1:2. Pregnancy-induced hypertension (PIH) was the most common antenatal complication observed in 6%. Four percent had neonatal sepsis and 19% were born premature. Associated co-morbidities were mental retardation (55%), seizure disorder (46%), visual problems (26%), hearing problems (19%), and failure to thrive (47%).

DISCUSSION

Sex distribution observed in our study was male to female ratio of 1.2, which was comparable with a multicenter study in Europe. PIH was observed in 6% of cases, which was comparable with prior studies. Birth asphyxia was observed in 43% of cases. Eighty-one percent of the cases constituted a spastic variety of CP which was comparable to other studies.

CONCLUSION

Perinatal asphyxia was the important etiological factor. We found preventable intranatal causes (60%) and antenatal causes (20%) forming a significant proportion. Co-morbidities were significantly observed in our study.

The Prevalence of Cerebral Palsy in British Columbia, 1991-1995

Objective:

To quantify the prevalence of cerebral palsy (CP) in British Columbia within a four-year birth cohort.

Methods:

The study was a population-based record linkage study of a birth cohort of British Columbian children born between April 1, 1991 and March 31, 1995. Cases were identified by the presence of International Classification of Diseases, Version 9 (ICD-9) diagnostic code “343” recorded at three years of age or older or by having the ICD-9 diagnostic code “343” recorded prior to the third birthday with two confirmatory diagnoses within the first three years of life through a record search of the BC Medical Services Plan billing files for the fiscal years 1991 to 1995.

Results/Conclusion:

This research has provided an estimate of the prevalence of CP in the four-year birth cohort 1991 to 1995 in British Columbia. An aggregate prevalence rate of CP was measured as 2.68 per 1000 live births, and a congenital rate was measured at 2.57 for the same population. Birth weight and gestational age demonstrated a significant relationship with the development of CP. This study should lend credence to the establishment of a CP register in British Columbia.

The panorama of cerebral palsy in Sweden. XI. Changing patterns in the birth-year period 2003-2006

AIM

To describe the epidemiology of cerebral palsy (CP) in western Sweden.

METHODS

A population-based study covering 94 466 live births in the area in 2003-2006. Birth characteristics and neuroimaging findings were recorded, prevalence was calculated and aetiology was analysed.

RESULTS

CP was found in 206 children, including postneonatal cases, corresponding to a crude prevalence of 2.18 per 1000 live births. The gestational age-specific prevalence for <28 gestational weeks was 71.4 per 1000 live births, while it was 39.6 for 28-31 weeks, 6.4 for 32-36 weeks and 1.41 per 1000 for >36 weeks. Hemiplegia accounted for 44%, diplegia for 29% and tetraplegia for 6%, while 16% had dyskinetic CP and 5% had ataxia. Neuroimaging was available in 95% of the children. This showed maldevelopment in 13%, white matter lesions in 36%, cortical/subcortical lesions in 23% and basal ganglia lesions in 14%. The aetiology was considered to be prenatal in 36% and perinatal/neonatal in 46% and remained unclassified in 18%.

CONCLUSION

The overall prevalence of CP in western Sweden was stable. However, the distribution of CP types changed and the term hemiplegia increased significantly. Among children with CP born extremely preterm, the percentage born before 26 weeks of gestation had increased.

Cerebral palsy and perinatal infection in children born at term

OBJECTIVE

To investigate the link between infection-related risk factors for cerebral palsy subtypes in children born at term.

METHODS

A case-control study was performed in a population-based series of children with cerebral palsy born at term (n=309) matched with a control group (n=618). The cases were divided into cerebral palsy subtypes: spastic hemiplegia, spastic diplegia, spastic tetraplegia, and dyskinetic cerebral palsy. All forms of spastic cerebral palsy were also analyzed together. All records were examined for maternal and neonatal signs of infection. Univariate and adjusted analyses were performed.

RESULTS

Infection-related risk factors were shown to be independent risk factors for spastic cerebral palsy in the adjusted analyses. This was especially pronounced in the subgroup with spastic hemiplegia in which bacterial growth in urine during pregnancy (n=11 [7.5%], odds ratio [OR] 4.7, 95% confidence interval [CI] 1.5-15.2), any infectious disease during pregnancy (n=57 [39.0%], OR 2.9, 95% CI 1.7-4.8), severe infection during pregnancy (n=12 [8.2%], OR 15.4, 95% CI 3.0-78.1), antibiotic therapy once during pregnancy (n=33 [22.6%], OR 6.3, 95% CI 3.0-15.2) as well as several times during pregnancy (n=9 [6.2%], OR 15.6, 95% CI 1.8-134.2) constituted strong independent risk factors. However, only neonatal infection (n=11 [9.1%], OR 14.7, 95% CI 1.7-126.5) was independently significantly associated with an increased risk of spastic diplegia and tetraplegia.

CONCLUSIONS

Infection-related factors are strong independent risk factors for the subgroup with spastic hemiplegia in children with cerebral palsy born at term. The finding is less pronounced in the subgroups with spastic diplegia or tetraplegia.

LEVEL OF EVIDENCE

II.

The psychosocial impact on standing devices

PURPOSE

The aim of this study was to explore the psychosocial impact of standing devices as experienced by users.

METHOD

This is the second part of a comprehensive survey in five counties in Sweden where all the subjects with standing devices were invited to participate. The impact of standing devices on functional independence, quality of life and wellbeing was assessed using a questionnaire, Psychosocial Impact of Assistive Devices Scale (PIADS).

RESULTS

The psychosocial impact of the standing devices was perceived as positive. The highest PIADS scores in relation to age were found in the oldest group, aged 65 years and older. The ability to walk and independence in ambulation resulted in higher scores than the use of a wheelchair and/or dependence on others. Those who stood often awarded higher scores in the PIADS questionnaire compared to those who used the device less frequently. When standing was integrated in various activities, its psychosocial impact received high scores.

CONCLUSION

The psychosocial impact of standing devices was generally experienced positively. The main results indicated that standing in a standing device had a value and we as professionals should ask the users about the intended purpose of their standing in order to prescribe the optimal device.

IMPLICATIONS FOR REHABILITATION

Standing in standing devices has positive psychosocial impact for the user. As professionals we should broaden our view of the use of standing devices, i.e. to see the standing device as an aid that not only treats the body's structures or improves the user's abilities in activities, but also provides a psychosocial impact on the user's daily life, and to find meaningful goals for the user from a psychosocial perspective.

Intensive upper extremity training for children with hemiplegia: from science to practice

For children with hemiplegic cerebral palsy, bimanual abilities are central to independent function. Over the last decade, considerable attention has been given to 2 forms of extended practice therapy for the upper limb, constraint-induced movement therapy and intensive bimanual training. This article reviews the varying nature of these 2 approaches and the existing scientific rationale supporting them. Comparisons between these 2 intensive upper extremity training approaches indicate similar improvements in unimanual capacity and bimanual performance outcomes; however, when considering participant and caregiver goal achievement, evidence favors a bimanual approach. Careful selection of either therapy for this population requires consideration of individual and contextual factors in relation to treatment goals. The key ingredients and dose responses remain unknown. Treatment intensity, intrinsic motivation, and individualization of treatment are hypothesized as requisite in either approach.

An update on the prevalence of cerebral palsy: a systematic review and meta-analysis

AIMS

The aim of this study was to provide a comprehensive update on (1) the overall prevalence of cerebral palsy (CP); (2) the prevalence of CP in relation to birthweight; and (3) the prevalence of CP in relation to gestational age.

METHOD

A systematic review and meta-analysis was conducted and reported, based on the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) statement. Population-based studies on the prevalence of CP in children born in 1985 or after were selected. Statistical analysis was carried out using computer package R, version 2.14.

RESULTS

A total of 49 studies were selected for this review. The pooled overall prevalence of CP was 2.11 per 1000 live births (95% confidence interval [CI] 1.98-2.25). The prevalence of CP stratified by gestational age group showed the highest pooled prevalence to be in children weighing 1000 to 1499g at birth (59.18 per 1000 live births; 95% CI 53.06-66.01), although there was no significant difference on pairwise meta-regression with children weighing less than 1000g. The prevalence of CP expressed by gestational age was highest in children born before 28 weeks' gestation (111.80 per 1000 live births; 95% CI 69.53-179.78; p<0.0327).

INTERPRETATION

The overall prevalence of CP has remained constant in recent years despite increased survival of at-risk preterm infants.

Prognostic value of brain proton MR spectroscopy and diffusion tensor imaging in newborns with hypoxic-ischemic encephalopathy treated by brain cooling

INTRODUCTION

MRI, proton magnetic resonance spectroscopy (¹H-MRS), and diffusion tensor imaging (DTI) have been shown to be of great prognostic value in term newborns with moderate-severe hypoxic-ischemic encephalopathy (HIE). Currently, no data are available on ¹H-MRS and DTI performed in the subacute phase after hypothermic treatment. The aim of the present study was to assess their prognostic value in newborns affected by moderate-severe HIE and treated with selective brain cooling (BC).

METHODS

Twenty infants treated with BC underwent conventional MRI and (1)H-MRS at a mean (SD) age of 8.3 (2.8) days; 15 also underwent DTI. Peak area ratios of metabolites and DTI variables, namely mean diffusivity (MD), axial and radial diffusivity, and fractional anisotropy (FA), were calculated. Clinical outcome was monitored until 2 years of age.

RESULTS

Adverse outcome was observed in 6/20 newborns. Both ¹H-MRS and DTI variables showed higher prognostic accuracy than conventional MRI. N-acetylaspartate/creatine at a basal ganglia localisation showed 100% PPV and 93% NPV for outcome. MD showed significantly decreased values in many regions of white and gray matter, axial diffusivity showed the best predictive value (PPV and NPV) in the genu of corpus callosum (100 and 91%, respectively), and radial diffusivity was significantly decreased in fronto white matter (FWM) and fronto parietal (FP) WM. The decrement of FA showed the best AUC (0.94) in the FPWM.

CONCLUSION

Selective BC in HIE neonates does not affect the early and accurate prognostic value of ¹H-MRS and DTI, which outperform conventional MRI.

Prophylactic maternal N-acetylcysteine in rats prevents maternal inflammation-induced offspring cerebral injury shown on magnetic resonance imaging

OBJECTIVE

Maternal infection or inflammation may induce fetal inflammatory responses associated with fetal injury and cerebral palsy. We sought to assess the inflammation-associated neuroprotective potential of prophylactic N-acetyl-cysteine (NAC). We examined the effect of NAC on prevention of maternal lipopolysaccharide (LPS)-induced neonatal brain injury using magnetic resonance imaging.

STUDY DESIGN

Pregnant Sprague Dawley dams (n = 5-8) at embryonic day 18 received intraperitoneal injection of LPS or saline at time 0. Animals were randomized to receive 2 intravenous injections of NAC or saline (time -30 and 120 minutes). Pups were delivered spontaneously and allowed to mature until postnatal day 25. Female offspring were examined by magnetic resonance brain imaging and analyzed using voxel-based analysis after spatial normalization. T2 relaxation time was used to assess white matter injury and diffusion tensor imaging for apparent diffusion coefficient (ADC) to assess white and gray matter injury.

RESULTS

Offspring of LPS-treated dams exhibited significantly increased T2 levels and increased ADC levels in white and gray matter (eg, hypothalamus, motor cortex, corpus callosum, thalamus, hippocampus), consistent with diffuse cerebral injury. In contrast, offspring of NAC-treated LPS dams demonstrated similar T2 and ADC levels as control in both white and gray matter.

CONCLUSION

Maternal NAC treatment significantly reduced evidence of neonatal brain injury associated with maternal LPS. These studies suggest that maternal NAC therapy may be effective in human deliveries associated with maternal/fetal inflammation.

Early predictors of short term neurodevelopmental outcome in asphyxiated cooled infants. A combined brain amplitude integrated electroencephalography and near infrared spectroscopy study

BACKGROUND

Brain Cooling (BC) represents the elective treatment in asphyxiated newborns. Amplitude Integrated Electroencephalography (aEEG) and Near Infrared Spectroscopy (NIRS) monitoring may help to evaluate changes in cerebral electrical activity and cerebral hemodynamics during hypothermia.

OBJECTIVES

To evaluate the prognostic value of aEEG time course and NIRS data in asphyxiated cooled infants.

METHODS

Twelve term neonates admitted to our NICU with moderate-severe Hypoxic-Ischemic Encephalopathy (HIE) underwent selective BC. aEEG and NIRS monitoring were started as soon as possible and maintained during the whole hypothermic treatment. Follow-up was scheduled at regular intervals; adverse outcome was defined as death, cerebral palsy (CP) or global quotient <88.7 at Griffiths' Scale.

RESULTS

2/12 Infants died, 2 developed CP, 1 was normal at 6 months of age and then lost at follow-up and 7 showed a normal outcome at least at 1 year of age. The aEEG background pattern at 24 h of life was abnormal in 10 newborns; only 4 of them developed an adverse outcome, whereas the 2 infants with a normal aEEG developed normally. In infants with adverse outcome NIRS showed a higher Tissue Oxygenation Index (TOI) than those with normal outcome (80.0±10.5% vs 66.9±7.0%, p=0.057; 79.7±9.4% vs 67.1±7.9%, p=0.034; 80.2±8.8% vs 71.6±5.9%, p=0.069 at 6, 12 and 24 h of life, respectively).

CONCLUSIONS

The aEEG background pattern at 24h of life loses its positive predictive value after BC implementation; TOI could be useful to predict early on infants that may benefit from other innovative therapies.

Short and long-term analysis and comparison of neurodegeneration and inflammatory cell response in the ipsilateral and contralateral hemisphere of the neonatal mouse brain after hypoxia/ischemia

Understanding the evolution of neonatal hypoxic/ischemic is essential for novel neuroprotective approaches. We describe the neuropathology and glial/inflammatory response, from 3 hours to 100 days, after carotid occlusion and hypoxia (8% O₂, 55 minutes) to the C57/BL6 P7 mouse. Massive tissue injury and atrophy in the ipsilateral (IL) hippocampus, corpus callosum, and caudate-putamen are consistently shown. Astrogliosis peaks at 14 days, but glial scar is still evident at day 100. Microgliosis peaks at 3–7 days and decreases by day 14. Both glial responses start at 3 hours in the corpus callosum and hippocampal fissure, to progressively cover the degenerating CA field. Neutrophils increase in the ventricles and hippocampal vasculature, showing also parenchymal extravasation at 7 days. Remarkably, delayed milder atrophy is also seen in the contralateral (CL) hippocampus and corpus callosum, areas showing astrogliosis and microgliosis during the first 72 hours. This detailed and long-term cellular response characterization of the ipsilateral and contralateral hemisphere after H/I may help in the design of better therapeutic strategies.

Classification of topographical pattern of spasticity in cerebral palsy: a registry perspective

This study used data from a population-based cerebral palsy (CP) registry and systematic review to assess the amount of heterogeneity between registries in topographical patterns when dichotomised into unilateral (USCP) and bilateral spastic CP (BSCP), and whether the terms diplegia and quadriplegia provide useful additional epidemiological information. From the Victorian CP Register, 2956 individuals (1658 males, 1298 females), born 1970-2003, with spastic CP were identified. The proportions with each topographical pattern were analysed overall and by gestational age. Binary logistic regression analysis was used to assess temporal trends. For the review, data were systematically collected on topographical patterns from 27 registries. Estimates of heterogeneity were obtained, overall and by region, reporting period and definition of quadriplegia. Among individuals born <32 weeks, 48% had diplegia, whereas the proportion for children born ≥ 32 weeks was 24% (p < 0.001). Evidence was weak for a temporal trend in the relative proportions of USCP and BSCP (p = 0.038), but much clearer for an increase in the proportion of spastic diplegia relative to quadriplegia (p < 0.001). The review revealed wide variations across studies in the proportion of diplegia (range 34-90%) and BSCP (range 51-86%). These findings argue against a topographical classification based solely on laterality.

Bimanuality is improved by hand surgery in children with brain lesions: preliminary results in 18 children

The present study was performed to investigate if, in a short term perspective, bimanual hand function in children with brain damage improves as an effect of hand surgery. Assisting Hand Assessment (AHA), Goal Achievement Scale, consolidated House Functional Classification, Zancolli Classification, and the active range of motion were measured before surgery and 5-14 months after surgery in 18 children, aged 6-16 years, mean of 11 years. AHA improved from 44.5 AHA units (range 20-66) to 52.5 AHA units (range 25-69) (P<0.005) on a 0-100 AHA unit scale. Active motion improved (P<0.005). Rating of selected goals improved from 2.6 to 6.4, on a 10-grade scale. On a short term, hand surgery improved not only the grip, but also the ability to use the hemiplegic hand in bimanual activities.

Rates of cerebral palsy in Victoria, Australia, 1970 to 2004: has there been a change?

AIM

The aim of this study was to assess overall and gestational age-specific trends in the rate of cerebral palsy (CP) in Victoria, Australia, and to compare these findings with other population data.

METHOD

Individuals born in Victoria from 1970 to 2004 with non-postneonatally acquired CP were identified from a population register; 3491 were included in the study (1963 males, 1528 females). After a literature review, comparison data were extracted from publications using previously devised inclusion criteria. Rates were calculated per 1000 live births for all CP and by gestational age group: these were tabulated and plotted by year of birth.

RESULTS

Data from nine registries, including the Victorian register, showed an increase in the rates of CP over the 1970s and 1980s, consistently seen in extremely preterm (<28 wks) survivors but also in those born at term (≥37 wks). Since the early 1990s, CP rates either stabilized or decreased, particularly for children born extremely preterm.

INTERPRETATION

Increases in the rates of CP during the 1970s and 1980s are in part because of the increasing survival of extremely preterm infants that occurred without a concomitant improvement in neurological outcomes. Evidence from population samples now suggests that this trend has been reversed since the mid- to late 1990s.

Follow-up studies of very low birthweight children in Sweden

Follow-up studies are essential to our knowledge of outcome in very low birthweight (VLBW) or extremely preterm (EPT) infants because those children have a greater risk for developing neurosensory disabilities and behavioural and educational problems and have decreased probability for an optimal transition into adulthood compared to term controls. Outcome data are of interest not only to healthcare professionals but also to parents, schoolteachers and society. The aim of this review is to describe the follow-up studies of seven populations of VLBW or EPT infants performed in Sweden and published between 1995 and 2009.

CONCLUSION

 The time has come to implement evident data from these Swedish follow-up studies into clinical practice and to perform regular and specific follow-up examinations during childhood for all VLBW and EPT children. These assessments, specially designed for high-risk infants, should consider the potential outcomes for neurological, visual, auditory function and cognitive function as well as behaviour and growth, from birth to school-start.

Upper limb children action-observation training (UP-CAT): a randomised controlled trial in hemiplegic cerebral palsy

BACKGROUND

Rehabilitation for children with hemiplegic cerebral palsy (HCP) aimed to improve function of the impaired upper limb (UL) uses a wide range of intervention programs. A new rehabilitative approach, called Action-Observation Therapy, based on the recent discovery of mirror neurons, has been used in adult stroke but not in children. The purpose of the present study is to design a randomised controlled trial (RCT) for evaluating the efficacy of Action-Observation Therapy in improving UL activity in children with HCP.

METHODS/DESIGN

The trial is designed according to CONSORT Statement. It is a randomised, evaluator-blinded, match-pair group trial. Children with HCP will be randomised within pairs to either experimental or control group. The experimental group will perform an Action-Observation Therapy, called UP-CAT (Upper Limb-Children Action-Observation Training) in which they will watch video sequences showing goal-directed actions, chosen according to children UL functional level, combined with motor training with their hemiplegic UL. The control group will perform the same tailored actions after watching computer games. A careful revision of psychometric properties of UL outcome measures for children with hemiplegia was performed. Assisting Hand Assessment was chosen as primary measure and, based on its calculation power, a sample size of 12 matched pairs was established. Moreover, Melbourne and ABILHAND-Kids were included as secondary measures. The time line of assessments will be T0 (in the week preceding the onset of the treatment), T1 and T2 (in the week after the end of the treatment and 8 weeks later, respectively). A further assessment will be performed at T3 (24 weeks after T1), to evaluate the retention of effects. In a subgroup of children enrolled in both groups functional Magnetic Resonance Imaging, exploring the mirror system and sensory-motor function, will be performed at T0, T1 and T2.

DISCUSSION

The paper aims to describe the methodology of a RCT for evaluating the efficacy of Action-Observation Therapy in improving UL activity in children with hemiplegia. This study will be the first to test this new type of treatment in childhood. The paper presents the theoretical background, study hypotheses, outcome measures and trial methodology.

TRIAL REGISTRATION

NCT01016496.

Distribution of motor types in cerebral palsy: how do registry data compare?

AIM

The aim of this study was to describe the distribution of types of motor disorder (motor type) in a population-based registry of children with cerebral palsy (CP), to examine any trends in motor type distribution over time, and to make comparisons with other populations.

METHOD

Individuals born in Victoria, Australia, between 1970 and 2003 with congenital CP were identified from the Victorian Cerebral Palsy Register, 3297 of whom were included in the study (1840 males, 1457 females). Those who had a hypotonic motor type, those whose brain abnormality was believed to have developed after 28 days of life, and those with missing data were excluded from the study. The proportions of each motor type were calculated and plotted by year of birth. Logistic regression analyses were used to assess the mean change in odds per year of birth. A systematic review of the international literature was undertaken and comparison data were extracted based on previously devised criteria. The degree of heterogeneity was assessed and comparisons were made according to geographical region and reporting period.

RESULTS

In Victoria, the predominant motor types for individuals with CP born between 1970 and 2003 were spasticity (91%), ataxia (5%), and dyskinesia (4%). There was no clear trend for any motor type over time. The mean proportions from two other large data sets were similar but there was considerable heterogeneity between 29 individual CP registries, mainly because of differences in the classification of mixed motor types.

INTERPRETATION

A more objective method for determining the predominant motor type is required to make the classification of motor type in CP more consistent and reliable.

Pediatric anklebot

In this paper we present the alpha-prototype of a novel pediatric ankle robot. This lower-extremity robotic therapy module was developed at MIT to aid recovery of ankle function in children with cerebral palsy ages 5 to 8 years old. This lower-extremity robotic module will commence pilot testing with children with cerebral palsy at Blythedale Childrens Hospital (Valhalla, NY), Bambino Gesu Children's Hospital (Rome, Italy), Riley Children's Hospital (Indianapolis, IN). Its design follows the same guidelines as our upper-extremity robots and adult anklebot designs, i.e. it is a low friction, backdriveable device with intrinsically low mechanical impedance. We show the ankle robot characteristics and stability range. We also present pilot data with healthy children to demonstrate the potential of this device.

A combined a-EEG and MR spectroscopy study in term newborns with hypoxic-ischemic encephalopathy

OBJECTIVES

Brain damage following a perinatal hypoxic-ischemic (HI) insult has been documented by different diagnostic techniques. The aim of the present study was to relate a-EEG time course during the first 24h of life to brain metabolic changes detected by proton MR spectroscopy ((1)H-MRS) at 7-10days of life and to evaluate their correlation with outcome.

METHODS

Thirty-two patients with any grade HI encephalopathy were studied. Thirty-one out of 32 patients survived and underwent (1)H-MRS examination at 7-10days of life; a-EEG was recorded during the first 24h of life in 27/32 newborns; 26 patients underwent both examinations. Griffiths test, evaluation of motor skills, visual and hearing function were performed at regular intervals until the age of 2years.

RESULTS

a-EEG at 6, 12 and 24h of life showed a significant correlation with outcome. N-acetyl-aspartate/creatine (Cr), Lactate/Cr and myo-inositol differed significantly between patients with normal or poor outcome. a-EEG time course during the first 24h of life showed improvement in newborns with normal (1)H-MRS and good outcome and a deterioration in those with abnormal (1)H-MRS and poor outcome.

CONCLUSIONS

a-EEG time course may be able to document the severity and the evolution of the cerebral damage following an HI event. a-EEG is related to the severity of cerebral injury as defined by (1)H-MRS and both examinations showed a good correlation with outcome. These data, obtained in non-cooled infants, may represent reference data for future investigations in cooled infants.

The changing panorama of cerebral palsy in Sweden. X. Prevalence and origin in the birth-year period 1999-2002

AIM

The aim of the study was to describe the prevalence and origin of cerebral palsy (CP), which is the tenth report from the western Swedish study.

METHODS

A population-based study covering 85,737 live births in the area in 1999-2002. Birth characteristics and neuroimaging findings were recorded, prevalence of CP was calculated and aetiology was analysed.

RESULTS

CP was found in 186 children. The crude prevalence was 2.18 per 1000 live births. The gestational age-specific prevalence for <28 gestational weeks was 55.6 per 1000 live births, whereas it was 43.7 for 28-31 weeks, 6.1 for 32-36 weeks and 1.43 per 1000 for >36 weeks. There was a female majority among children born at term and a male predominance in children born preterm. Hemiplegia accounted for 38%, diplegia for 32%, tetraplegia for 7%, whereas 17% had dyskinetic CP and 5% ataxia. Neuroimaging showed white-matter lesions in 31% and cortical/subcortical lesions in 29%. The aetiology was considered to be prenatal in 36%, peri/neonatal in 42%, whereas it remained unclassified in 21%.

CONCLUSION

The decrease in CP prevalence observed since the 1980s had ceased. An increase in children born at term and in dyskinetic CP was found. In children born before 28 weeks of gestation, the prevalence decreased significantly. White-matter and cortical/subcortical lesions dominated on neuroimaging.

Influence of gestational age on nosologic CP characteristics in a high-risk population

The aim of this study is to investigate the interrelationship between gestational age (GA) and nosologic characteristics (type, distribution and severity) of cerebral palsy (CP) in a cohort of high-risk infants. One thousand ninety-nine consecutively neonatal intensive care unit-admitted high-risk infants (i.e., all infants with a GA less than 30 weeks and specified infants with GA >or= 30 weeks with a complicated neonatal course and/or brain lesion) were prospectively assessed up to the corrected age of 2 years or more. In 177 (16%) of these infants, CP was diagnosed. Of these infants, 26 were extremely preterm infants (GA 23-27 weeks), 62 very preterm (28-31 weeks), 36 moderately preterm (32-36) and 53 term infants (GA >or= 37 weeks). Spastic CP was significantly more present in the three preterm groups (77%, 90% and 72%, respectively) compared with the term ones (42%). At variance, dyskinetic CP was present in nearly half of the term group (47%) and remarkably less in all three preterm age groups (12%, 7% and 22%, respectively). Ataxic CP (7%) was of rare occurrence in all age groups. Distributive classification showed that bilateral spastic CP gradually dropped from 100% in the extremely preterm group down to 50% in the term infants. Inversely, unilateral spastic CP rises steeply with advancing GA. Severity of CP was significantly associated with birth year period in favour of mild CP. In high-risk neonates, dyskinetic CP increases steeply with increasing GA, whereas spastic CP decreases. Bilateral and unilateral involvements are gradually and oppositely changing with gestational age. It is tempting to explain the maturity-related association by gestational age-specific brain injuries.

Socio-economic inequalities in cerebral palsy prevalence in the United Kingdom: a register-based study

Evidence is unclear as to whether there is a socio-economic gradient in cerebral palsy (CP) prevalence beyond what would be expected from the socio-economic gradient for low birthweight, a strong risk factor for CP. We conducted a population-based study in five regions of the UK with CP registers, to investigate the relationship between CP prevalence and socio-economic deprivation, and how it varies by region, by birthweight and by severity and type of CP. The total study population was 1 657 569 livebirths, born between 1984 and 1997. Wards of residence were classified into five quintiles according to a census-based deprivation index, from Q1 (least deprived) to Q5 (most deprived). Socio-economic gradients were modelled by Poisson regression, and region-specific estimates combined by meta-analysis. The prevalence of postneonatally acquired CP was 0.14 per 1000 livebirths overall. The mean deprivation gradient, expressed as the relative risk in the most deprived vs. the least deprived quintile, was 1.86 (95% confidence interval [95% CI 1.19, 2.88]). The prevalence of non-acquired CP was 2.22 per 1000 livebirths. For non-acquired CP the gradient was 1.16 [95% CI 1.00, 1.35]. Evidence for a socio-economic gradient was strongest for spastic bilateral cases (1.32 [95% CI 1.09, 1.59]) and cases with severe intellectual impairment (1.59 [95% CI 1.06, 2.39]). There was evidence for differences in gradient between regions. The gradient of risk of CP among normal birthweight births was not statistically significant overall (1.21 [95% CI 0.95, 1.54]), but was significant in two regions. There was non-significant evidence of a reduction in gradients over time. The reduction of the higher rates of postneonatally acquired CP in the more socioeconomically deprived areas is a clear goal for prevention. While we found evidence for a socio-economic gradient for non-acquired CP of antenatal or perinatal origin, the picture was not consistent across regions, and there was some evidence of a decline in inequalities over time. The steeper gradients in some regions for normal birthweight cases and cases with severe intellectual impairment require further investigation.

Microbiologic and histologic characteristics of the extremely preterm infant's placenta predict white matter damage and later cerebral palsy. the ELGAN study

Inflammatory phenomena seem to contribute to the occurrence of perinatal cerebral white matter damage and CP. The stimulus that initiates the inflammation remains obscure. One thousand two hundred forty-six infants born before the 28th postmenstrual week had a protocol ultrasound scan of the brain read concordantly by two independent sonologists. Eight hundred ninety-nine of the children had a neurologic examination at approximately 24-mo postterm equivalent. The placenta of each child had been biopsied under sterile conditions and later cultured. Histologic slides of the placenta were examined specifically for this study. Recovery of a single microorganism predicted an echolucent lesion, whereas polymicrobial cultures and recovery of skin flora predicted both ventriculomegaly and an echolucent lesion. Diparetic CP was predicted by recovery of a single microorganism, multiple organisms, and skin flora. Histologic inflammation predicted ventriculomegaly and diparetic CP. The risk of ventriculomegaly associated with organism recovery was heightened when accompanied by histologic inflammation, but the risk of diparetic CP was not. Low-virulence microorganisms isolated from the placenta, including common skin microflora, predict ultrasound lesions of the brain and diparetic CP in the very preterm infant. Organism recovery does not seem to be needed for placenta inflammation to predict diparetic CP.

Long-term outcome of preterm infants and the role of neuroimaging

Preterm birth has been defined as one of the major public health problems of this decade, preterm neonates being at high risk for neurodevelopmental disabilities. As preterm survival rates increase, the next great imperative for perinatal medicine is to understand and prevent the serious adverse neurodevelopmental outcomes of preterm birth. The challenge for neonatologists and neurologists alike is identifying early markers of outcome in the prematurely born. This article reviews current trends in prevalence, mortality, and morbidity, and the present status of outcome data for cognitive and neurosensory neurodevelopmental dysfunctions in preterm infants. New neuroimaging modalities and analysis tools are contributing to the understanding of neurologic sequelae of preterm birth by providing microstructural evidence of injury sustained by the preterm brain.

Robot-assisted task-specific training in cerebral palsy

Our goal was to examine the feasibility of applying therapeutic robotics to children and adults with severe to moderate impairment due to cerebral palsy (CP). Pilot results demonstrated significant gains for both groups. These results suggest that robot-mediated therapy may be an effective tool to ameliorate the debilitating effects of CP and provide new opportunities for reducing impairment and improving coordination.