Quantifying the effects of interventions for movement disorders resulting from cerebral palsy

Kinematic determinants of anterior knee pain in cerebral palsy: a case-control study

OBJECTIVE

To quantify the role patellofemoral and tibiofemoral kinematics may play in development of anterior knee pain (AKP) in individuals with cerebral palsy (CP).

DESIGN

Case-control.

SETTING

Clinical research center.

PARTICIPANTS

Knees from individuals with diagnosed CP (n=20) and control knees (n=40) were evaluated. Controls were matched for sex and age based on the group average. Matching by height and weight was a secondary priority. Subjects in the control cohort were asymptomatic with no history of lower leg abnormalities, surgery, or major injury. Only individuals who were physically capable of sustaining slow, cyclic knee flexion-extension for 2.5 minutes and had no contraindications to magnetic resonance imaging were enrolled. Both groups were samples of convenience.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Three-dimensional patellofemoral and tibiofemoral joint kinematics, acquired during active leg extension, under volitional control.

RESULTS

Participants with CP and AKP (n=8) demonstrated significantly greater patellofemoral extension, valgus rotation, and superior and posterior displacement relative to controls and to the subgroup of participants with CP and no AKP (n=12). Patellofemoral extension discriminated AKP in individuals with CP with 100% accuracy.

CONCLUSIONS

In quantifying the 3-dimensional, in vivo knee joint kinematics during a volitional extension task, kinematic markers that discriminate AKP in individuals with CP were identified. This provides an ability to predict which individuals with CP are most likely to develop AKP and could enable aggressive conservative treatment, aimed at reducing patella alta and excessive patellofemoral extension, to be prescribed before considering surgical options. The current findings will likely lead to improved clinical diagnostics and interventions for individuals with CP, with the ultimate goal of helping maintain, if not improve, functional mobility throughout the lifespan.

Definition and classification of hyperkinetic movements in childhood

Hyperkinetic movements are unwanted or excess movements that are frequently seen in children with neurologic disorders. They are an important clinical finding with significant implications for diagnosis and treatment. However, the lack of agreement on standard terminology and definitions interferes with clinical treatment and research. We describe definitions of dystonia, chorea, athetosis, myoclonus, tremor, tics, and stereotypies that arose from a consensus meeting in June 2008 of specialists from different clinical and basic science fields. Dystonia is a movement disorder in which involuntary sustained or intermittent muscle contractions cause twisting and repetitive movements, abnormal postures, or both. Chorea is an ongoing random-appearing sequence of one or more discrete involuntary movements or movement fragments. Athetosis is a slow, continuous, involuntary writhing movement that prevents maintenance of a stable posture. Myoclonus is a sequence of repeated, often nonrhythmic, brief shock-like jerks due to sudden involuntary contraction or relaxation of one or more muscles. Tremor is a rhythmic back-and-forth or oscillating involuntary movement about a joint axis. Tics are repeated, individually recognizable, intermittent movements or movement fragments that are almost always briefly suppressible and are usually associated with awareness of an urge to perform the movement. Stereotypies are repetitive, simple movements that can be voluntarily suppressed. We provide recommended techniques for clinical examination and suggestions for differentiating between the different types of hyperkinetic movements, noting that there may be overlap between conditions. These definitions and the diagnostic recommendations are intended to be reliable and useful for clinical practice, communication between clinicians and researchers, and for the design of quantitative tests that will guide and assess the outcome of future clinical trials.

Functional electrical stimulation to lower limb muscles after botox in children with cerebral palsy

PURPOSE

This study examined the effect of lower limb functional electrical stimulation (FES) after botulinum toxin injection in children with cerebral palsy on self-selected walking speed, plantar flexor and dorsiflexor muscle strength, and an optimal time frame for initiating FES after the injection.

METHODS

Five subjects participated in a single-subject design. All subjects received a single botulinum toxin injection into the calf muscle, followed by a 4-week FES home program. Three subjects followed the protocol as prescribed; 2 subjects received no FES.

RESULTS

FES after botulinum toxin increased isometric plantar flexor muscle strength, but did not produce changes in self-selected walking speeds or isometric dorsiflexor strength. A 32-day interval between botulinum toxin and the start of FES was most effective.

CONCLUSIONS AND RECOMMENDATIONS FOR CLINICAL PRACTICE

FES after botulinum toxin seems to be effective in improving some gait variables, although further research is needed for substantiation.

The predictive validity of general movements--a systematic review

BACKGROUND

The assessment of general movements (GMs), introduced by Professor Heinz Prechtl and his co-workers in the early 1990s, may offer the opportunity to identify infants with neurological deficits at a very early age.

AIM

The aim of this review was to systematically assess available data in order to determine the evidence of general movements in early infancy to predict the neurodevelopmental outcome in 12- and 24-month-old infants.

METHOD

A systematic literature search was performed using the following computerised databases: Medline, CINAHL, Pedro, The Cochrane Library, Science Direct, ProQuest: Science Journals, Medical Library & Social Science Journals, Journals @ OVID and PsycINFO. The following key terms were used: general movements, spontaneous motor activity, nervous system diseases [MeSH] and developmental disabilities [MeSH]. A comprehensive author search was also conducted. The methodological quality of eligible studies was critically appraised by two reviewers using the Critical Review Form for Quantitative Studies of the McMaster University Occupational Therapy Evidence-Based Practice Research Group.

RESULTS

Seventeen studies were eligible for this review. The average score of the studies was 8.82 (73.5%) from a total of 12 (SD 0.73). Fifteen of the 17 studies found a high relationship (sensitivity > or =92%; specificity > or =82%; p<0.01) between the quality of general movements at 8-20 weeks postterm (fidgety movements' period) and the infants' neurodevelopmental outcome.

CONCLUSION

The results of this systematic review indicate that the qualitative assessment of general movements, especially during the fidgety movements' period, can be used as a prognostic tool to identify infants with neurodevelopmental disabilities.

Effects of ankle-foot orthoses for children with hemiplegia on weight-bearing and functional ability

PURPOSE

To compare the effects of a leaf spring ankle-foot orthosis (LAFO) and a hinged AFO with plantar flexion stop with that of shoe only on weight-bearing and function in children with hemiplegia.

METHODS

The study used an experimental single-subject alternating treatment design with replication. Outcomes measured were weight-bearing symmetry, weight-bearing on the hemiplegic rear foot compared with that of the forefoot, functional ability, and child and parent preference.

RESULTS

Both AFOs increased relative contact area of the hemiplegic foot. The LAFO increased relative force through the hemiplegic foot. There was increased pressure through the rear foot, time spent on the rear foot, and force through the forefoot. Rear foot contact area increased in the LAFO. Neither AFO affected function. Patient preference for AFO condition was inconsistent.

CONCLUSION

Both AFOs increased weight-bearing through the hemiplegic foot and rear foot, indicative of potential benefit to growth. Neither the LAFO nor the hinged AFO with plantar flexion stop improved function of the children.

The effect of lower limb functional electrical stimulation on gait of children with cerebral palsy

PURPOSE

To examine the effect of lower limb functional electrical stimulation (FES) in children with cerebral palsy.

METHODS

A comprehensive search yielded 37 citations. English articles included in the review applied either surface or percutaneous FES to the lower limb, if subjects were younger than 18 years old, and if the stimulator was removed or off at the time of testing.

RESULTS

Five articles were included in this review, including 3 case reports, 1 single subject, and 1 crossover design. Among the wide range of stimulation protocols, stimulation of the gastrocnemius with or without the tibialis anterior muscle may effect greater gait improvements than stimulating the tibialis anterior muscle alone.

CONCLUSIONS AND RECOMMENDATIONS FOR CLINICAL PRACTICE

Future research differentiating between optimal FES and neuromuscular electrical stimulation protocols as well as more rigorous research designs are needed to provide clinically relevant results.

Definition and classification of negative motor signs in childhood

In this report we describe the outcome of a consensus meeting that occurred at the National Institutes of Health in Bethesda, Maryland, March 12 through 14, 2005. The meeting brought together 39 specialists from multiple clinical and research disciplines including developmental pediatrics, neurology, neurosurgery, orthopedic surgery, physical therapy, occupational therapy, physical medicine and rehabilitation, neurophysiology, muscle physiology, motor control, and biomechanics. The purpose of the meeting was to establish terminology and definitions for 4 aspects of motor disorders that occur in children: weakness, reduced selective motor control, ataxia, and deficits of praxis. The purpose of the definitions is to assist communication between clinicians, select homogeneous groups of children for clinical research trials, facilitate the development of rating scales to assess improvement or deterioration with time, and eventually to better match individual children with specific therapies. "Weakness" is defined as the inability to generate normal voluntary force in a muscle or normal voluntary torque about a joint. "Reduced selective motor control" is defined as the impaired ability to isolate the activation of muscles in a selected pattern in response to demands of a voluntary posture or movement. "Ataxia" is defined as an inability to generate a normal or expected voluntary movement trajectory that cannot be attributed to weakness or involuntary muscle activity about the affected joints. "Apraxia" is defined as an impairment in the ability to accomplish previously learned and performed complex motor actions that is not explained by ataxia, reduced selective motor control, weakness, or involuntary motor activity. "Developmental dyspraxia" is defined as a failure to have ever acquired the ability to perform age-appropriate complex motor actions that is not explained by the presence of inadequate demonstration or practice, ataxia, reduced selective motor control, weakness, or involuntary motor activity.

Brachial plexus dorsal rhizotomy in hemiplegic cerebral palsy

Brachial plexus dorsal rhizotomy releases spasticity, improving the functional use of the hand. Grasping and pinch strength are augmented, together with movement speed and dexterity. Even when four dorsal roots have been sectioned, hand sensibility is largely preserved. Movement control is improved and equally advantageous in athetotic patients. Brachial plexus dorsal rhizotomy does not exclude the use of tendon lengthening or transfer procedures, but it is the authors' opinion that orthopedic procedures should be performed after dorsal rhizotomy. Children aged 5-6 years without muscle contractures are the ideal candidates to benefit fully from dorsal rhizotomy.

Classification and definition of disorders causing hypertonia in childhood

OBJECTIVE

This report describes the consensus outcome of an interdisciplinary workshop that was held at the National Institutes of Health in April 2001. The purpose of the workshop and this article are to define the terms "spasticity," "dystonia," and "rigidity" as they are used to describe clinical features of hypertonia in children. The definitions presented here are designed to allow differentiation of clinical features even when more than 1 is present simultaneously.

METHODS

A consensus agreement was obtained on the best current definitions and their application in clinical situations.

RESULTS

"Spasticity" is defined as hypertonia in which 1 or both of the following signs are present: 1) resistance to externally imposed movement increases with increasing speed of stretch and varies with the direction of joint movement, and/or 2) resistance to externally imposed movement rises rapidly above a threshold speed or joint angle. "Dystonia" is defined as a movement disorder in which involuntary sustained or intermittent muscle contractions cause twisting and repetitive movements, abnormal postures, or both. "Rigidity" is defined as hypertonia in which all of the following are true: 1) the resistance to externally imposed joint movement is present at very low speeds of movement, does not depend on imposed speed, and does not exhibit a speed or angle threshold; 2) simultaneous co-contraction of agonists and antagonists may occur, and this is reflected in an immediate resistance to a reversal of the direction of movement about a joint; 3) the limb does not tend to return toward a particular fixed posture or extreme joint angle; and 4) voluntary activity in distant muscle groups does not lead to involuntary movements about the rigid joints, although rigidity may worsen.

CONCLUSION

We have provided a set of definitions for the purpose of identifying different components of childhood hypertonia. We encourage the development of clinical rating scales that are based on these definitions, and we encourage research to relate the degree of hypertonia to the degree of functional ability, change over time, and societal participation in children with motor disorders.

Functional performance following selective posterior rhizotomy: long-term results determined using a validated evaluative measure

Object. Selective posterior rhizotomy (SPR) may result in considerable benefit for children with spastic cerebral palsy. To date, however, there have been few studies in which validated functional outcome measures have been used to report surgical results beyond 3 years. The authors analyzed data obtained from the McGill Rhizotomy Database to determine long-term functional performance outcomes in patients who underwent lumbosacral dorsal rhizotomy performed using intraoperative electrophysiological monitoring.

Methods. The study population was composed of children with debilitating spasticity who underwent SPR and were evaluated by a multidisciplinary team preoperatively and at 6 months and 1 year postoperatively. Quantitative standardized assessments of activities of daily living (ADL) were obtained using the Pediatric Evaluation of Disability Inventory (PEDI). Of 57 patients who met the entry criteria for the study, 41 completed the 3-year assessments and 30 completed the 5-year assessments.

Statistical analysis demonstrated significant improvement in the mobility and self-care domains of the functional skills dimension at 1 year after SPR. The preoperative and 1-, 3-, and 5-year postoperative scaled scores for the mobility domain were 56, 64, 77.2, and 77.8, respectively. The scaled score for the self-care domain increased from 59 presurgery to 67.9, 81.6, and 82.4 at the 1-, 3-, and 5-year postoperative assessments, respectively.

Conclusions. The results of this study support the presence of significant improvements in functional performance, based on PEDI scores obtained 1 year after SPR. The improvements persisted at the 3- and 5-year follow-up examinations. The authors conclude that SPR performed using intraoperative stimulation is valuable in the augmentation of motor function and self-care skills essential to the performance of ADL.

Using the berg balance scale to distinguish balance abilities in children with cerebral palsy

PURPOSE

This study was designed to evaluate the use of the Berg Balance Scale (BBS) to assess the balance abilities of children with cerebral palsy.

METHODS

Thirty-six ambulatory children with cerebral palsy and 14 children with no motor impairment (ages eight to 12 years) were assessed on the BBS and the Gross Motor Function Measure (GMFM). Participants with cerebral palsy comprised three groups based on diagnosis (spastic hemiplegia, spastic diplegia who ambulated without aids, and spastic diplegia who ambulated with aids). A fourth group consisted of control subjects with no motor impairment. It was hypothesized that these four groups demonstrated a hierarchy of balance abilities. A one-way ANOVA was used to detect significant differences in test scores among the four groups. The analysis was repeated categorizing children on the Gross Motor Function Classification System (GMFCS) instead of diagnosis.

RESULTS

The ability to use scores on the GMFM was slightly better than using BBS scores to distinguish among the groups when children were classified using diagnosis. Significant pair-wise differences among the groups were present on both the BBS and the GMFM when the children were grouped on the GMFCS.

CONCLUSIONS

The results suggest that the BBS can be considered as a clinical measure of balance for children with cerebral palsy, and a functional classification system can be used to group children more homogeneously than traditional classification by diagnosis.

Medium-term functional benefits in children with cerebral palsy treated with botulinum toxin type A: 1-year follow-up using gross motor function measure

One of the main goals when treating spasticity is to relieve pain and improve function. Intramuscular injection of botulinum toxin type A (BTX-A) has gained widespread acceptance in the treatment of spastic cerebral palsy. Several studies have clearly shown the short-term functional benefit of BTX-A treatment. Information is limited, however, on the efficacy of medium and long-term regimens, using repeated injection of BTX-A. The aim of the present open-label, prospective study was to evaluate functional outcome in children with spastic cerebral palsy after 1 year of treatment with BTX-A, using the Gross Motor Function Measure (GMFM) as a validated outcome measure. Patients (n=25, age 1.5--15.5 years) were treated with BTX-A for adductor spasm (n=12) or pes equinus (n=13). The local effect was evaluated using passive range of motion and modified Ashworth Scale. Apart from a significant improvement in joint mobility and reduction of spasticity compared to pretreatment values (P < 0.01), we demonstrated a significant improvement of gross motor function after 12 months of treatment, with a median gain of 6% in total and goal scores (P < 0.001). An increase in GMFM scores was particularly evident in younger and moderately impaired children (Gross Motor Function Classification System level III). Whether the observed improvement in gross motor function in children with cerebral palsy is specifically related to therapy with BTX-A or represents at least in part the natural course of motor development still needs clarification.

Randomised double blind placebo controlled trial of the effect of botulinum toxin on walking in cerebral palsy

BACKGROUND

Cerebral palsy is the commonest cause of severe physical disability in childhood. For many years treatment has centred on the use of physiotherapy and orthotics to overcome the problems of leg spasticity, which interferes with walking and can lead to limb deformity. Intramuscular botulinum toxin (BT-A) offers a targeted form of therapy to reduce spasticity in specific muscle groups.

AIMS

To determine whether intramuscular BT-A can improve walking in children with cerebral palsy.

DESIGN

Randomised, double blind, placebo controlled trial.

METHODS

Forty patients with spastic diplegia or hemiplegia were enrolled. Twenty two received botulinum toxin and 18 received placebo. The primary outcome measure was video gait analysis and secondary outcome measures were gross motor function measure (GMFM), physiological cost index (PCI), and passive ankle dorsiflexion.

RESULTS

Video gait analysis showed clinically and statistically significant improvement in initial foot contact following BT-A at six weeks and 12 weeks compared to placebo. Forty eight per cent of BT-A treated children showed clinical improvement in VGA compared to 17% of placebo treated children. The GMFM (walking dimension) showed a statistically significant improvement in favour of the botulinum toxin treated group. Changes in PCI and passive ankle dorsiflexion were not statistically significant.

CONCLUSION

The study gives further support to the use of intramuscular botulinum toxin type A as an adjunct to conventional physiotherapy and orthoses to reduce spasticity and improve functional mobility in children with spastic diplegic or hemiplegic cerebral palsy.

Cerebral Palsy

The neurorehabilitation program for cerebral palsy changes over time. During the first 2 years of life, an infant stimulation program with an emphasis on more than just improving motor deficits is emphasized. The importance of involvement of a knowledgeable therapist cannot be overemphasized. Realistic expectations must be articulated firmly. Rather then cautiously attempting to correct a dysfunction that cannot be corrected, the therapist should help the patient develop compensation techniques; the severity of the disability frequently militates against the development of "normal" motor control. Educating the parents about cerebral palsy, showing how positioning can be an effective way of helping the child be mobile, and encouraging parent-child interaction are aspects of an infant stimulation program. The therapist should serve as a coach to the parents, who implement much of the actual treatment on a daily basis at home. From 2 to 5 years of age, rapid growth occurs, and muscle tone will either develop or worsen--the latter leading not only to the development of contracture but also to a decrease in mobility. In developing a program to control this muscle tone, the most important question to be answered is, Can I improve the patient's function and decrease the patient's disability by altering muscle tone? It is not uncommon for the real problem preventing the patient from performing certain functions to be lack of motor control or lack of sensation and not the abnormal muscle tone. Between 5 and 10 years of age, the child begins to approach adult height. At this time, definitive orthopedic intervention can be considered; as already noted, contracture development occurs as a result of abnormal muscle tone in combination with growth. Finally, as the child approaches the teen years, issues of sitting and hygiene are important considerations, especially in the nonambulatory patient. The problem of pain secondary to spasticity or dystonia must be addressed.

Intrathecal baclofen for intractable cerebral spasticity: a prospective placebo-controlled, double-blind study

OBJECTIVE

To conduct a placebo-controlled prospective study of the effectiveness of intrathecal bolus injections and continuous administration of baclofen on functional parameters in patients with severe spasticity of cerebral origin. To compare this functional evaluation with spasticity scores in different muscle groups.

METHODS

In 11 patients with spasticity of cerebral origin (mainly cerebral palsy), double-blind scoring of spasticity (Ashworth scale score and visual analog score), spasms, pain, and functional abilities was performed during tests with bolus injections including a placebo control. Eight patients were considered good responders and received a subcutaneous device for intrathecal drug delivery. Six of these patients were followed up for 2 years, during which they underwent the same scoring procedures as after their bolus injections. These patients were subjected to a blinded dose reduction test.

RESULTS

There was a noticeable placebo effect on spasticity scores during tests with bolus injections. Eight patients demonstrated a significant beneficial effect of intrathecal bolus injections compared with this placebo effect. Functional improvements were noted in most patients. During continuous infusion, Ashworth scale scores were less favorable but still significantly lower than at baseline. Subjective evaluation (visual analog scores) remained positive, functional improvements were maintained, and patient comfort was invariably and significantly improved.

CONCLUSION

Intrathecal administration of baclofen is a safe and effective treatment for spasticity of cerebral origin. Functional improvement was demonstrated. The presence of a placebo effect on the spasticity scores suggests the need for double-blind screening in each patient.