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Rasera A, Squintani GM, Cerruto MA. A Systematic Review of Botulinum Toxin Injection in Pediatric Dystonia. Toxins (Basel) 2024; 16:289. [PMID: 39057929 PMCID: PMC11281719 DOI: 10.3390/toxins16070289] [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: 04/30/2024] [Revised: 06/15/2024] [Accepted: 06/24/2024] [Indexed: 07/28/2024] Open
Abstract
Botulinum toxin (BT), a first-line treatment for focal dystonias in adults, has gained USA Food and Drug Administration approval for pediatric upper and lower extremity spasticity and sialorrhea, though its use in children younger than 2 years old is still considered off-label treatment for all pathologies. Dosing, treatment strategies and outcome measures lack international consensus, and they are often extrapolated from adult or spasticity guidelines. This review aims to evaluate the best available evidence on the efficacy and safety of BT therapy in pediatric dystonia (age under 21 years old), isolated or associated with other medical conditions. A comprehensive search in PubMed, Scopus and Web of Science was conducted, including only articles in English. Although no randomized controlled trials are still present, 12 articles were included with an overall of 57 patients. All the papers demonstrate that BT can improve motor function, decrease pain and ameliorate quality of life, with minimal adverse effects in pediatric patients affected by pure or mixed dystonic motor disorders. Despite the low level of evidence, our review shows that BT could be an efficacious treatment for these pediatric patients. The frequent generalized involvement, together with the heterogeneous nature of childhood dystonic forms, sometimes intermingled with spasticity, prompts further multicenter clinical trials or prospective studies with a higher level of evidence to shed light on the efficacy and safety profile of BT in pediatric dystonia.
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Affiliation(s)
- Andrea Rasera
- Neurology Unit, “Azienda Provinciale per i Servizi Sanitari”, Trento “Santa Chiara” Hospital, Largo Medaglie d’oro 9, 38122 Trento, Italy
| | - Giovanna Maddalena Squintani
- Section of Neurophysiology, Neurology Unit, “Azienda Ospedaliera Universitaria Integrata Verona”, Verona “Borgo Trento” Hospital, Piazzale Aristide Stefani 1, 37126 Verona, Italy;
| | - Maria Angela Cerruto
- Urology Clinic, Department of Surgery, Dentistry, Paediatrics and Gynaecology, University of Verona, Piazzale Aristide Stefani 1, 37126 Verona, Italy;
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Nguyen MX, Brown AM, Lin T, Sillitoe RV, Gill JS. Targeting DBS to the centrolateral thalamic nucleus improves movement in a lesion-based model of acquired cerebellar dystonia in mice. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2024:2024.05.21.595095. [PMID: 38826430 PMCID: PMC11142135 DOI: 10.1101/2024.05.21.595095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2024]
Abstract
Dystonia is the third most common movement disorder and an incapacitating co-morbidity in a variety of neurologic conditions. Dystonia can be caused by genetic, degenerative, idiopathic, and acquired etiologies, which are hypothesized to converge on a "dystonia network" consisting of the basal ganglia, thalamus, cerebellum, and cerebral cortex. In acquired dystonia, focal lesions to subcortical areas in the network - the basal ganglia, thalamus, and cerebellum - lead to a dystonia that can be difficult to manage with canonical treatments, including deep brain stimulation (DBS). While studies in animal models have begun to parse the contribution of individual nodes in the dystonia network, how acquired injury to the cerebellar outflow tracts instigates dystonia; and how network modulation interacts with symptom latency remain as unexplored questions. Here, we present an electrolytic lesioning paradigm that bilaterally targets the cerebellar outflow tracts. We found that lesioning these tracts, at the junction of the superior cerebellar peduncles and the medial and intermediate cerebellar nuclei, resulted in acute, severe dystonia. We observed that dystonia is reduced with one hour of DBS of the centrolateral thalamic nucleus, a first order node in the network downstream of the cerebellar nuclei. In contrast, one hour of stimulation at a second order node in the short latency, disynaptic projection from the cerebellar nuclei, the striatum, did not modulate the dystonia in the short-term. Our study introduces a robust paradigm for inducing acute, severe dystonia, and demonstrates that targeted modulation based on network principles powerfully rescues motor behavior. These data inspire the identification of therapeutic targets for difficult to manage acquired dystonia.
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Affiliation(s)
- Megan X. Nguyen
- Department of Pediatrics, Division of Neurology and Developmental Neuroscience, Baylor College of Medicine, Houston, TX, USA
- Jan and Dan Duncan Neurological Research Institute at Texas Children’s Hospital, Houston, TX, USA
| | - Amanda M. Brown
- Jan and Dan Duncan Neurological Research Institute at Texas Children’s Hospital, Houston, TX, USA
- Department of Pathology & Immunology, Baylor College of Medicine, Houston, TX, USA
| | - Tao Lin
- Jan and Dan Duncan Neurological Research Institute at Texas Children’s Hospital, Houston, TX, USA
- Department of Pathology & Immunology, Baylor College of Medicine, Houston, TX, USA
| | - Roy V. Sillitoe
- Department of Pediatrics, Division of Neurology and Developmental Neuroscience, Baylor College of Medicine, Houston, TX, USA
- Jan and Dan Duncan Neurological Research Institute at Texas Children’s Hospital, Houston, TX, USA
- Department of Pathology & Immunology, Baylor College of Medicine, Houston, TX, USA
- Department of Neuroscience, Baylor College of Medicine, Houston, TX, USA
- Development, Disease Models & Therapeutics Graduate Program, Baylor College of Medicine, Houston, TX, USA
| | - Jason S. Gill
- Department of Pediatrics, Division of Neurology and Developmental Neuroscience, Baylor College of Medicine, Houston, TX, USA
- Jan and Dan Duncan Neurological Research Institute at Texas Children’s Hospital, Houston, TX, USA
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3
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Peri F, Magni E, Pigani F, Romoli R, Vetrella S, De Zen L, Sagredini R, Barbi E, Cozzi G. Timeline of diagnosed pain causes in children with severe neurological impairment. Front Pediatr 2024; 12:1365152. [PMID: 38510078 PMCID: PMC10950906 DOI: 10.3389/fped.2024.1365152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Accepted: 02/20/2024] [Indexed: 03/22/2024] Open
Abstract
Objective Pain's causes in children with severe cognitive impairment may be challenging to diagnose. This study aimed to investigate if there is a relationship between pain causes and the age of children. Methods We conducted a multicenter retrospective study in three Italian Pediatric Units. Eligible subjects were patients from 1 to 18 years with severe neurological impairment. We collected data regarding diagnoses, pain causes and medical or surgical procedures. The timing of pain episodes was categorized into age-related periods: infants and toddlers (0-24 months), preschool children (3-5 years), schoolchildren (6-12 years), and adolescents (13-17 years). Results Eighty children with severe neurological impairment were enrolled. The mean age was 11 years (±5.8). Gastroenterological pain was most common in the first years of life (p = 0.004), while orthopaedic and tooth pain was the most typical in schoolchildren and adolescents (p = 0.001 and p = 0.02). Concerning surgical procedures, PEG placement and gastric fundoplication were significantly more common in the first 5 years of age (p = 0.03), and heart surgery was typical of infants (p = 0.04). Orthopaedic surgery was more commonly reported in older children and adolescents (p < 0.001). Conclusions Some causes of pain are more frequent in children with severe neurological impairment in defined age-related periods. Specific age-related pain frequencies may help physicians in the diagnostic approach.
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Affiliation(s)
- Francesca Peri
- Department of Medicine, Surgery, and Health Sciences, University of Trieste, Trieste, Italy
- Department of Pediatrics, Institute for Maternal and Child Health-IRCCS “Burlo Garofolo”, Trieste, Italy
| | - Elena Magni
- Clinical Epidemiology and Public Health Research Unit, Institute for Maternal and Child Health-IRCCS “Burlo Garofolo”, Trieste, Italy
| | - Filippo Pigani
- Department of Medicine, Surgery, and Health Sciences, University of Trieste, Trieste, Italy
| | | | - Simona Vetrella
- Department of Primary Assistance—U.O.S.D. Palliative Home-Care, A.S.L. Napoli 1 Centro, Naples, Italy
| | - Lucia De Zen
- Department of Pediatrics, Institute for Maternal and Child Health-IRCCS “Burlo Garofolo”, Trieste, Italy
| | - Raffaella Sagredini
- Institute for Maternal and Child Health-IRCCS “Burlo Garofolo”, Trieste, Italy
| | - Egidio Barbi
- Department of Medicine, Surgery, and Health Sciences, University of Trieste, Trieste, Italy
- Department of Pediatrics, Institute for Maternal and Child Health-IRCCS “Burlo Garofolo”, Trieste, Italy
| | - Giorgio Cozzi
- Department of Pediatrics, Institute for Maternal and Child Health-IRCCS “Burlo Garofolo”, Trieste, Italy
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Gemperli K, Folorunso F, Norin B, Joshua R, Hill C, Rykowski R, Galindo R, Aravamuthan BR. Mice born preterm develop gait dystonia and reduced cortical parvalbumin immunoreactivity. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2024:2024.02.01.578353. [PMID: 38352408 PMCID: PMC10862908 DOI: 10.1101/2024.02.01.578353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/25/2024]
Abstract
Preterm birth leading to cerebral palsy (CP) is the most common cause of childhood dystonia, a movement disorder that is debilitating and often treatment refractory. Dystonia has been typically associated with dysfunction of striatal cholinergic interneurons, but clinical imaging data suggests that cortical injury may best predict dystonia following preterm birth. Furthermore, abnormal sensorimotor cortex inhibition has been found in many studies of non-CP dystonias. To assess the potential for a cortical etiology of dystonia following preterm birth, we developed a new model of preterm birth in mice. Noting that term delivery in mice on a C57BL/6J background is embryonic day 19.1 (E19.1), we induced preterm birth at the limits of pup viability at embryonic day (E) 18.3, equivalent to human 22 weeks gestation. Mice born preterm demonstrate display clinically validated metrics of dystonia during gait (leg adduction amplitude and variability) and also demonstrate reduced parvalbumin immunoreactivity in the sensorimotor cortex, suggesting dysfunction of cortical parvalbumin-positive inhibitory interneurons. Notably, reduced parvalbumin immunoreactivity or changes in parvalbumin-positive neuronal number were not observed in the striatum. These data support the association between cortical dysfunction and dystonia following preterm birth. We propose that our mouse model of preterm birth can be used to study this association and potentially also study other sequelae of extreme prematurity.
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Affiliation(s)
- Kat Gemperli
- Department of Neurology, Washington University School of Medicine, St. Louis, MO
| | - Femi Folorunso
- Department of Neurology, Washington University School of Medicine, St. Louis, MO
| | - Benjamin Norin
- Department of Neurology, Washington University School of Medicine, St. Louis, MO
| | - Rebecca Joshua
- Department of Neurology, Washington University School of Medicine, St. Louis, MO
| | - Clayton Hill
- Department of Neurology, Washington University School of Medicine, St. Louis, MO
| | - Rachel Rykowski
- Department of Neurology, Washington University School of Medicine, St. Louis, MO
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Jaleel F, Rust A, Cheung S, Pearson TS, Ueda K, Robichaux‐Viehoever A, Leger K, Chintalapati K, Guez‐Barber D, Shusterman M, Aravamuthan B. Caregiver descriptions of dystonia in cerebral palsy. Ann Clin Transl Neurol 2024; 11:242-250. [PMID: 38174361 PMCID: PMC10863918 DOI: 10.1002/acn3.51941] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Revised: 09/18/2023] [Accepted: 10/18/2023] [Indexed: 01/05/2024] Open
Abstract
OBJECTIVE To determine how caregivers describe dystonia in people with cerebral palsy (CP). METHODS In this prospective cohort study, paper surveys were administered to caregivers between September 7, 2021 and October 28, 2021 during CP Center visits at a large tertiary care center. Caregivers were asked to describe involuntary movements triggered by voluntary movement or triggered by tactile stimulation in the people with CP they cared for. Their CP Center medical provider separately assessed people with CP for dystonia. Movement features described exclusively by caregivers of people with CP and dystonia were determined using conventional content analysis. RESULTS 113 caregivers responded on behalf of 56 people with and 57 people without dystonia. If caregivers noted that both voluntary movement and tactile stimulation triggered involuntary movements, that had a 92% positive predictive value for a dystonia diagnosis. Movement features exclusively described in people with CP and dystonia included: (1) stiffening, tensing, or tightening (15% of respondents); (2) involvement of the head (10%), torso (5%), or feet (5%); and (3) triggers of stretching (12.5%), excitement (5%), or transfers (5%). INTERPRETATION In addition to a thorough exam, asking caregivers of people with CP to describe involuntary movements triggered by voluntary movement or tactile stimulation may inform clinical dystonia diagnosis.
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Affiliation(s)
- Fayza Jaleel
- Division of Pediatric Neurology, Department of NeurologyWashington University School of MedicineSt. LouisMissouriUSA
| | - Alyssa Rust
- Division of Pediatric Neurology, Department of NeurologyWashington University School of MedicineSt. LouisMissouriUSA
| | - Shirley Cheung
- Division of Pediatric Neurology, Department of NeurologyWashington University School of MedicineSt. LouisMissouriUSA
| | - Toni S. Pearson
- Division of Pediatric Neurology, Department of NeurologyWashington University School of MedicineSt. LouisMissouriUSA
- Division of Neurology, Nationwide Children's HospitalOhio State UniversityColumbusOhioUSA
| | - Keisuke Ueda
- Division of Pediatric Neurology, Department of NeurologyWashington University School of MedicineSt. LouisMissouriUSA
| | - Amy Robichaux‐Viehoever
- Division of Pediatric Neurology, Department of NeurologyWashington University School of MedicineSt. LouisMissouriUSA
| | - Katie Leger
- Division of Pediatric Neurology, Department of NeurologyWashington University School of MedicineSt. LouisMissouriUSA
| | - Keerthana Chintalapati
- Division of Pediatric Neurology, Department of NeurologyWashington University School of MedicineSt. LouisMissouriUSA
| | - Danielle Guez‐Barber
- Division of Child Neurology, Department of PediatricsChildren's Hospital of PhiladelphiaPhiladelphiaPennsylvaniaUSA
- Department of Neurology, Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | | | - Bhooma Aravamuthan
- Division of Pediatric Neurology, Department of NeurologyWashington University School of MedicineSt. LouisMissouriUSA
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Gilbert LA, Gandham S, Ueda K, Chintalapati K, Pearson T, Aravamuthan BR. Upper Extremity Dystonia Features in People With Spastic Cerebral Palsy. Neurol Clin Pract 2023; 13:e200207. [PMID: 37780812 PMCID: PMC10540938 DOI: 10.1212/cpj.0000000000200207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Accepted: 08/14/2023] [Indexed: 10/03/2023]
Abstract
Background and Objectives Dystonia in cerebral palsy (CP) is debilitating and common, but underdiagnosed, especially when coexistent with spasticity. With dedicated research-based assessment, dystonia is found in most people with spastic CP but is only clinically diagnosed in the minority. To begin addressing the high rates of dystonia underdiagnosis in this population, we determined the key feature experts use to assess upper extremity dystonia in people with spastic CP. Methods In this prospective cohort study, 3 pediatric movement disorder specialists assessed upper extremity dystonia in neurologic examination videos of people with spastic CP and isolated periventricular leukomalacia (PVL) on brain MRI (i.e., those with a brain injury pattern typical for spastic CP). Dystonia severity was rated using the 10-point Global Dystonia Severity Rating Scale, first by each expert independently and then again after consensus-building discussion. Conventional content analysis of these discussions revealed salient features ("codes") that experts used to assess upper extremity dystonia. Code frequency distributions were compared between dystonia severity categories using χ2 tests. Results We identified 96 people with spastic CP with isolated PVL on brain MRI seen in the St. Louis Children's Hospital CP Center between 2005 and 2018. Of them, 26 people were able and willing to be recorded while doing a standardized set of upper extremity examination maneuvers (age 4-25 years; 28% nonambulatory, 77% White). When assessing their videos, experts cited the "hand" less often and "shoulder" more often with increasing dystonia severity (p < 0.005, χ2 test). "Mirror movements" and the "hand open/close" examination maneuver were cited significantly more frequently in videos when experts were attempting to distinguish between no dystonia and mild dystonia (p < 0.005). Discussion Expert clinicians use distinct movement features to assess upper extremity dystonia in people with spastic CP and PVL. Attention to involuntary shoulder (vs hand) movements can help gauge dystonia severity. Differentiation between mirror movements and dystonia, particularly during the hand open/close examination maneuver, may help identify mild dystonia. These results can help guide upper extremity dystonia assessment in people with spastic CP, thus potentially helping mitigate dystonia underdiagnosis.
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Affiliation(s)
- Laura A Gilbert
- Division of Pediatric Neurology (LAG, SG, KU, KC, BRA), Department of Neurology, Washington University School of Medicine, St. Louis, MO; and Division of Neurology (TP), Nationwide Children's Hospital, Ohio State University, Columbus
| | - Sushma Gandham
- Division of Pediatric Neurology (LAG, SG, KU, KC, BRA), Department of Neurology, Washington University School of Medicine, St. Louis, MO; and Division of Neurology (TP), Nationwide Children's Hospital, Ohio State University, Columbus
| | - Keisuke Ueda
- Division of Pediatric Neurology (LAG, SG, KU, KC, BRA), Department of Neurology, Washington University School of Medicine, St. Louis, MO; and Division of Neurology (TP), Nationwide Children's Hospital, Ohio State University, Columbus
| | - Keerthana Chintalapati
- Division of Pediatric Neurology (LAG, SG, KU, KC, BRA), Department of Neurology, Washington University School of Medicine, St. Louis, MO; and Division of Neurology (TP), Nationwide Children's Hospital, Ohio State University, Columbus
| | - Toni Pearson
- Division of Pediatric Neurology (LAG, SG, KU, KC, BRA), Department of Neurology, Washington University School of Medicine, St. Louis, MO; and Division of Neurology (TP), Nationwide Children's Hospital, Ohio State University, Columbus
| | - Bhooma R Aravamuthan
- Division of Pediatric Neurology (LAG, SG, KU, KC, BRA), Department of Neurology, Washington University School of Medicine, St. Louis, MO; and Division of Neurology (TP), Nationwide Children's Hospital, Ohio State University, Columbus
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Gelineau-Morel R, Smyser C, Leeder JS. Identifying Effective Treatments for Dystonia in Patients With Cerebral Palsy: A Precision Therapeutics Approach. Neurology 2023; 101:752-759. [PMID: 37463749 PMCID: PMC10624496 DOI: 10.1212/wnl.0000000000207593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Accepted: 05/12/2023] [Indexed: 07/20/2023] Open
Abstract
Recent focus on improving the recognition of dystonia in cerebral palsy (DCP) has highlighted the need for more effective treatments. Evidence supports improved functional outcomes with early interventions for patients with cerebral palsy, but it is not known which interventions are most effective for DCP. Current pharmacologic recommendations for DCP are based largely on anecdotal evidence, with medications demonstrating minimal to moderate improvements in dystonia and variable efficacy between patients. Patients, families, and clinicians have identified the need for new and improved treatments in DCP, naming this as the top research theme in a recent Neurology® publication. Precision therapeutics focuses on providing early effective interventions that are individualized to every patient and can guide research priorities to improve treatments for DCP. This commentary outlines current obstacles to improving treatment of DCP and addresses how precision therapeutics can address each of these obstacles through 4 key components: (1) identification of predictive biomarkers to select patients likely to develop DCP in the future and for whom early intervention may be appropriate to delay or prevent full manifestation of dystonia, (2) stratification of patients with DCP into subgroups according to shared features (clinical, functional, biochemical, etc) to provide a targeted intervention based on those shared features, (3) administration of an individualized dose of an effective intervention to ensure adequate concentrations of the therapeutic entity at the site of action, and (4) monitoring of objective biomarkers of response to intervention. With implementation of each of these components of precision therapeutics, new and more effective treatments for every person with DCP can be realized.
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Affiliation(s)
- Rose Gelineau-Morel
- From the Division of Neurology (R.G.-M.), Children's Mercy Kansas City; School of Medicine (R.G.-M., J.S.L.), University of Missouri-Kansas City; Department of Pediatrics (R.G.-M., J.S.L.), University of Kansas Medical Center, Kansas City; Department of Pediatrics (C.S.), Department of Neurology (C.S.), and Mallinckrodt Institute of Radiology (C.S.), Washington University in St. Louis; and Division of Clinical Pharmacology, Toxicology & Therapeutic Innovation (J.S.L.), Children's Mercy Kansas City, MO.
| | - Christopher Smyser
- From the Division of Neurology (R.G.-M.), Children's Mercy Kansas City; School of Medicine (R.G.-M., J.S.L.), University of Missouri-Kansas City; Department of Pediatrics (R.G.-M., J.S.L.), University of Kansas Medical Center, Kansas City; Department of Pediatrics (C.S.), Department of Neurology (C.S.), and Mallinckrodt Institute of Radiology (C.S.), Washington University in St. Louis; and Division of Clinical Pharmacology, Toxicology & Therapeutic Innovation (J.S.L.), Children's Mercy Kansas City, MO
| | - J Steven Leeder
- From the Division of Neurology (R.G.-M.), Children's Mercy Kansas City; School of Medicine (R.G.-M., J.S.L.), University of Missouri-Kansas City; Department of Pediatrics (R.G.-M., J.S.L.), University of Kansas Medical Center, Kansas City; Department of Pediatrics (C.S.), Department of Neurology (C.S.), and Mallinckrodt Institute of Radiology (C.S.), Washington University in St. Louis; and Division of Clinical Pharmacology, Toxicology & Therapeutic Innovation (J.S.L.), Children's Mercy Kansas City, MO
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Aravamuthan BR, Pearson TS, Ueda K, Miao H, Zerafati-Jahromi G, Gilbert L, Comella C, Perlmutter JS. Determinants of gait dystonia severity in cerebral palsy. Dev Med Child Neurol 2023; 65:968-977. [PMID: 36701240 PMCID: PMC10392706 DOI: 10.1111/dmcn.15524] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Revised: 11/04/2022] [Accepted: 12/10/2022] [Indexed: 01/27/2023]
Abstract
AIM To determine the movement features governing expert assessment of gait dystonia severity in individuals with cerebral palsy (CP). METHOD In this prospective cohort study, three movement disorder neurologists graded lower extremity dystonia severity in gait videos of individuals with CP using a 10-point Likert-like scale. Using conventional content analysis, we determined the features experts cited when grading dystonia severity. Then, using open-source pose estimation techniques, we determined gait variable analogs of these expert-cited features correlating with their assessments of dystonia severity. RESULTS Experts assessed videos from 116 participants (46 with dystonia aged 15 years [SD 3] and 70 without dystonia aged 15 years [SD 2], both groups ranging 10-20 years old and 50% male). Variable limb adduction was most commonly cited by experts when identifying dystonia, comprising 60% of expert statements. Effect on gait (regularity, stability, trajectory, speed) and dystonia amplitude were common features experts used to determine dystonia severity, comprising 19% and 13% of statements respectively. Gait variables assessing adduction variability and amplitude (inter-ankle distance variance and foot adduction amplitude) were significantly correlated with expert assessment of dystonia severity (multiple linear regression, p < 0.001). INTERPRETATION Adduction variability and amplitude are quantifiable gait features that correlate with expert-determined gait dystonia severity in individuals with CP. Consideration of these features could help optimize and standardize the clinical assessment of gait dystonia severity in individuals with CP.
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Affiliation(s)
- Bhooma R. Aravamuthan
- Division of Pediatric Neurology, Department of Neurology, Washington University School of Medicine, St Louis, MO, USA
| | - Toni S. Pearson
- Division of Pediatric Neurology, Department of Neurology, Washington University School of Medicine, St Louis, MO, USA
| | - Keisuke Ueda
- Division of Pediatric Neurology, Department of Neurology, Washington University School of Medicine, St Louis, MO, USA
| | - Hanyang Miao
- Division of Pediatric Neurology, Department of Neurology, Washington University School of Medicine, St Louis, MO, USA
| | - Gazelle Zerafati-Jahromi
- Division of Pediatric Neurology, Department of Neurology, Washington University School of Medicine, St Louis, MO, USA
| | - Laura Gilbert
- Division of Pediatric Neurology, Department of Neurology, Washington University School of Medicine, St Louis, MO, USA
| | - Cynthia Comella
- Department of Neurological Sciences, Rush University, Chicago, IL, USA
| | - Joel S. Perlmutter
- Departments of Neurology, Radiology, Neuroscience, Physical Therapy, and Occupational Therapy, Washington University School of Medicine, St Louis, MO, USA
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Aravamuthan B, Pearson TS, Chintalapati K, Ueda K. Under-recognition of leg dystonia in people with cerebral palsy. ANNALS OF THE CHILD NEUROLOGY SOCIETY 2023; 1:162-167. [PMID: 38464792 PMCID: PMC10923506 DOI: 10.1002/cns3.20018] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/21/2023] [Accepted: 03/11/2023] [Indexed: 03/12/2024]
Abstract
Objective To determine the rates of clinical under-documentation of leg dystonia in people with cerebral palsy (CP). Methods In this prospective cohort study, we identified independently ambulatory people age 10-20yo with CP-associated spasticity seen in a tertiary care CP center between 1/1/20 to 11/4/21. Three pediatric movement disorders specialists assessed gait videos from these visits for leg dystonia using the Global Dystonia Rating Scale. We compared the gold standard expert consensus assessment for each patient with the clinical documentation of dystonia during a contemporaneous CP Center clinic visit and also with dystonia documentation longitudinally in their medical record. Results Of 116 people with CP-associated spasticity assessed in this study, 70 were found to have leg dystonia in their gait videos. Only 13% of these 70 individuals (n=9/70) had leg dystonia documented in their contemporaneous CP Center clinic visit, even though they were assessed during this visit by clinicians well-trained in CP and dystonia assessment. Even with repeated assessment, only 54% (n=38/70) of these individuals had leg dystonia documented in their medical record. Conclusions Leg dystonia is clinically under-documented in people with CP-associated spasticity, even when these people are evaluated by well-trained clinicians. Longitudinal evaluation and vigilance for leg dystonia is critical to address this diagnostic gap.
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Affiliation(s)
- Bhooma Aravamuthan
- Division of Pediatric Neurology, Department of Neurology, Washington University School of Medicine, St. Louis, MO
| | - Toni S. Pearson
- Division of Pediatric Neurology, Department of Neurology, Washington University School of Medicine, St. Louis, MO
- Division of Neurology, Nationwide Children’s Hospital, Ohio State University, Columbus, Ohio, USA
| | - Keerthana Chintalapati
- Division of Pediatric Neurology, Department of Neurology, Washington University School of Medicine, St. Louis, MO
| | - Keisuke Ueda
- Division of Pediatric Neurology, Department of Neurology, Washington University School of Medicine, St. Louis, MO
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