Report of a workshop on research gaps in the treatment of cerebral palsy

Adults with cerebral palsy and chronic pain experience: A cross-sectional analysis of patient-reported outcomes from a novel North American registry

BACKGROUND

Chronic pain is common among adults with cerebral palsy (CP) and an area of priority for research and treatment.

OBJECTIVE

Describe the pain experience and its functional and quality of life impact among adults with CP with chronic pain in the community.

METHODS

Cross-sectional analysis of adult patient-reported outcomes collected by the Cerebral Palsy Research Network Community Registry.

RESULTS

Among all participants in the Community Registry, n = 205 reported having chronic pain, and 73 % of those (n = 149) completed the Chronic Pain Survey Bundle (75 % female; mean age 43 years (SD 14 years); 94 % White; 91 % non-Hispanic). Back and weight-bearing joints of lower extremities were most frequently reported as painful. There were no differences in average pain severity scores between varying GMFCS levels (H = 6.25, p = 0.18) and age groups (H = 3.20, p = 0.36). Several nonpharmacologic interventions were most frequently reported as beneficial. Participants with moderate to severe average pain scores (5-10) had higher levels of pain interference (p < 0.01) and depression (p < 0.01), and lower levels of satisfaction with social roles (p < 0.01) and lower extremity function (p < 0.01). Pain interference was significantly positively correlated with depression, and negatively correlated with upper and lower extremity function and satisfaction with social roles.

CONCLUSIONS

Chronic pain is experienced by adults with CP of varying ages and functional levels and is associated with several adverse quality of life and functional outcomes. Improved understanding of chronic pain in this population will facilitate the development and study of treatment interventions optimizing health, function, participation, and quality of life.

Adults with cerebral palsy and functional decline: A cross-sectional analysis of patient-reported outcomes from a novel North American registry

BACKGROUND

Adults with cerebral palsy (CP) have unique healthcare needs and risks, including high risk of functional decline. Understanding functional decline is an area of priority for CP research.

OBJECTIVE

Describe factors associated with patient-reported changes in function among adults with CP living in the community.

METHODS

Cross-sectional analysis of adult patient-reported outcomes collected by the CP Research Network (CPRN) Community Registry.

RESULTS

Participants included 263 respondents (76% female (n = 200); mean age 42 years (SD 14); 95% White (n = 249); 92% non-Hispanic (n = 241)). Many reported functional changes, most commonly a decline in gross motor function since childhood (n = 158, 60%). Prevalence of gross motor decline varied significantly by Gross Motor Function Classification System (GMFCS) level (p < 0.001), but neither hand function decline (p = 0.196) nor communication decline (p = 0.994) differed by GMFCS. All types of decline increased with increasing age, with statistically significant differences between age groups (p < 0.001 gross motor; p = 0.003 hand function; p = 0.004 communication). Those with spastic CP (n = 178) most commonly reported gross motor functional decline (n = 108/178, 60.7%). However, the prevalence of gross motor decline did not significantly differ between those with spastic CP and those without spastic CP (p = 0.789).

CONCLUSIONS

Many adults in the CPRN Community Registry reported functional decline, most commonly in gross motor function. Functional decline across domains increased with age. Further research into risk stratification and preventive and rehabilitative measures is needed to address functional decline across the lifespan.

Cerebral palsy research network community registry adult surveys on function & pain: Successes, challenges, and future directions

NARRATIVE SUMMARY

The formation of a patient-reported outcomes registry to provide information about functional changes and pain among adults with cerebral palsy (CP) was identified as a priority to address the gap in knowledge and practice about aging and CP. The Cerebral Palsy Research Network collaborated with consumers, clinicians, and researchers to create an interactive internet platform, MyCP, to host a Community Registry. MyCP also provides educational programming, access to webinars and community forums, and fitness opportunities. The registry hosts surveys on function and pain for adults with CP, which provide cross-sectional and longitudinal data about these important issues. Surveys include previously validated measures with normative values that have been used with other populations and investigator developed questions. Enrollment in the registry is growing but needs to reflect the population of adults with CP, which limits generalizability. Future initiatives involve strategies to increase consumer engagement and enrollment.

The critical need to accelerate cerebral palsy research with consumer engagement, global networks, and adaptive designs

The prevalence of cerebral palsy (CP) varies globally, with higher rates and burden of disease in low- and middle-income countries. CP is a lifelong condition with no cure, presenting diverse challenges such as motor impairment, epilepsy, and mental health disorders. Research progress has been made but more is needed, especially given consumer demands for faster advancements and improvements in the scientific evidence base for interventions. This paper explores three strategies to accelerate CP research: consumer engagement, global clinical trial networks, and adaptive designs. Consumer engagement involving individuals with lived experience enhances research outcomes. Global clinical trial networks provide efficiency through larger and more diverse participant pools. Adaptive designs, unlike traditional randomized controlled trials, allow real-time modifications based on interim analyses, potentially answering complex questions more efficiently. The establishment of a CP Global Clinical Trials Network, integrating consumer engagement, global collaboration, and adaptive designs, marks a paradigm shift. The Network aims to address consumer-set research priorities. While challenges like ethical considerations and capacity building exist, the potential benefits for consumers, clinicians, researchers, and funding bodies are substantial. This paper underscores the urgency of transforming CP research methodologies for quicker translation of novel treatments into clinical practice to improve quality of life for those with CP.

Epilepsy and proxy-reported health-related quality of life in children and young people with non-ambulatory cerebral palsy

AIM

To assess the association between epilepsy characteristics and proxy-reported health-related quality of life (HRQoL) in children and young people with non-ambulatory cerebral palsy (CP) and seizures.

METHOD

This was a cross-sectional study of 164 children and young people (74 females, 90 males; mean age 10 years 6 months, range 2-21 years, SD 5 years 5 months). Caregivers completed the Child Health Index of Life with Disabilities (CPCHILD) in an outpatient setting. We utilized univariable linear regression and multivariable modeling to study relationships between variables and CPCHILD scores.

RESULTS

Gross Motor Function Classification System levels were 37% IV and 63% V. Sociodemographic factors included the Child Opportunity Index (median 51, interquartile range [IQR] 25-80). A median of 2 (IQR 1-3) antiseizure medications (ASMs) were used, and days with seizures ranged from 0 (30%) to 28 (20%) days in the previous 4 weeks. Total CPCHILD scores decreased 2.3 points for each ASM (95% confidence interval [CI] -4.1 to -0.42). Compared to persons with focal epilepsy, those with generalized epilepsy had lower total CPCHILD scores (-5.7; 95% CI -11 to -0.55). Number of days with seizures was not associated with total CPCHILD scores.

INTERPRETATION

Proxy-reported HRQoL was affected by epilepsy-specific features in children and young people with severe CP.

WHAT THIS PAPER ADDS

Health-related quality of life (HRQoL) was lower with increasing numbers of antiseizure medications. Overall quality of life (QoL) scores were lower by a similar amount, independent of seizure frequency. HRQoL was lower in persons with recent hospital admissions for epilepsy.

A Bibliometric and Visualization Analysis of Motor Learning in Preschoolers and Children over the Last 15 Years

Motor learning enables preschoolers and children to acquire fundamental skills that are critical to their development. The current study sought to conduct a bibliometric and visualization analysis to provide a comprehensive overview of motor-learning progress in preschoolers and children over the previous 15 years. The number of studies is constantly growing, with the United States and Australia, as well as other productive institutions and authors, at the leading edge. The dominant disciplines were Neurosciences and Neurology, Psychology, Rehabilitation, and Sport Sciences. The journals Developmental Medicine & Child Neurology, Human Movement Science, Physical Therapy, Neuropsychology, Journal of Motor Behavior, and Journal of Experimental Child Psychology have been the most productive and influential in this regard. The most common co-citations for clinical symptoms were for cerebral palsy, developmental coordination disorder, and autism. Research has focused on language impairment (speech disorders, explicit learning, and instructor-control feedback), as well as effective intervention strategies. Advances in brain mechanisms and diagnostic indicators, as well as new intervention and rehabilitation technologies (virtual reality, transcranial magnetic stimulation, and transcranial direct current stimulation), have shifted research frontiers and progress. The cognitive process is critical in intervention, rehabilitation, and new technology implementation and should not be overlooked. Overall, our broad overview identifies three major areas: brain mechanism research, clinical practice (intervention and rehabilitation), and new technology application.

The cerebral palsy research network: Building a learning health network for cerebral palsy

PURPOSE

The purpose of this study was to measure the growth of the Cerebral Palsy (CP) Research Network towards becoming a Learning Health Network in order to guide future development.

METHODS

Thirteen CP Research Network leaders completed the Network Maturity Grid (NMG) which consists of six domains with eight to 10 components each. The six domains are Systems of Leadership, Governance and Management, Quality Improvement, Engagement and Community, Data and Analytics, and Research. Radar mapping was utilized to display mean scores on a 5-point ordinal scale (1 = not started to 5 = idealized state) across domains and for individual components within domains. Consensus was reached for top priorities for the next 3-5 years.

RESULTS

Domain scores ranged from 2.4 in Quality Improvement to 3.2 in System of Leadership. The lowest scoring component was clinician clinical decision support and the highest was common purpose. The following priority areas of focus were agreed upon moving forward: development of leaders, financial sustainability, quality improvement education and training, patient reported data, data quality and validation, and primary data collection.

CONCLUSION

Results from this project will be utilized for strategic planning to improve the network. Conducting regular self-assessments of the network with the NMG will be useful in achieving the network's ultimate goal to improve care and outcomes for individuals with CP.

miR-135b-dependent downregulation of S100B promotes neural stem cell differentiation in a hypoxia/ischemia-induced cerebral palsy rat model

Cerebral palsy (CP) is frequently caused by brain injury during pregnancy, delivery, or the immediate postnatal period. The differentiation potential of neural stem cell (NSC) makes them effective in restoring injured tissues and organs with minimal risks of side effects. In this study, we identified a novel microRNA-135b (miR-135b) in CP and investigated its functional role in mediating NSC differentiation. CP models were established in Wistar rats and validated with the Y-maze test. Gain- and loss-of-function experimentation was performed on CP rats. Then NSCs were isolated and the expression patterns of miR-135b and S100B were altered in NSCs. S100B exhibited high expression in the hippocampus tissues of CP models, which was targeted by miR-135b. miR-135b elevation or S100B silencing resulted in promoted NSC differentiation, alleviated brain injury, and inhibited NSC apoptosis in hippocampus tissues of CP rats. S100B downregulation targeted by miR-135b overexpression contributed to the inactivation of the signal transducer and activator of transcription-3 (STAT3) pathway, which promoted NSC differentiation and proliferation but inhibited NSC apoptosis. Our results highlight the suppressor role played by miR-135b in CP by inducing NSC differentiation via inactivation of S100B-dependent STAT3 pathway.

Cerebral Palsy Research Network Clinical Registry: Methodology and Baseline Report

Objective

To apply practice-based evidence to clinical management of cerebral palsy (CP). The process of establishing purpose, structure, logistics, and elements of a multi-institutional registry and the baseline characteristics of initial enrollees are reported.

Design

A consensus-building process among consumers, clinicians, and researchers used a participatory action process.

Setting

Community, hospitals, and universities.

Participants

More than 100 clinicians, researchers, and consumers and more than 1858 enrollees in the registry.

Main Outcome Measures

Not applicable.

Results

Consensus was that the purpose of registry was to (1) quantify practice variation, (2) facilitate quality improvement (QI), and (3) perform comparative effectiveness research (CER). Collecting data during routine clinical care using the electronic medical record was determined to be a sustainable plan for data acquisition and management. Clinicians from multiple disciplines defined salient characteristics of individuals and interventions for the registry elements. The registry was central to the clinical research network, and a leadership structure was created. A leading electronic health record platform adopted the registry elements. Twenty-four sites have initiated the data collection process and agreed to export data to the registry. Currently 12 are collecting data. Number of enrollees and characteristics were similar to other population registers.

Conclusions

This is the first multi-institutional CP registry that contains the patient and treatment characteristics needed for QI and CER. The Cerebral Palsy Research Network registry elements are implemented in a versatile electronic platform and minimize burden to clinicians. The resultant registry is available for any institution to participate and is growing rapidly.

Cerebral palsy in Canada, 2011-2031: results of a microsimulation modelling study of epidemiological and cost impacts

INTRODUCTION

The objective of our study was to present model-based estimates and projections on current and future health and economic impacts of cerebral palsy in Canada over a 20-year time horizon (2011-2031).

METHODS

We used Statistics Canada's Population Health Model (POHEM)-Neurological to simulate individuals' disease states, risk factors and health determinants and to describe and project health outcomes, including disease incidence, prevalence, life expectancy, health-adjusted life expectancy, health-related quality of life and health care costs over the life cycle of Canadians. Cerebral palsy cases were identified from British Columbia's health administrative data sources. A population-based cohort was then used to generate the incidence and mortality rates, enabling the projection of future incidence and mortality rates. A utility-based measure (Health Utilities Index Mark 3) was also included in the model to reflect various states of functional health to allow projections of health-related quality of life. Finally, we estimated caregiving parameters and health care costs from Canadian national surveys and health administrative data and included them as model parameters to assess the health and economic impact of cerebral palsy.

RESULTS

Although the overall crude incidence rate of cerebral palsy is projected to remain stable, newly diagnosed cases of cerebral palsy will rise from approximately 1800 in 2011 to nearly 2200 in 2031. In addition, the number of people with the condition is expected to increase from more than 75 000 in 2011 to more than 94 000 in 2031. Direct health care costs in constant 2010 Canadian dollars were about $11 700 for children with cerebral palsy aged 1-4 years versus about $600 for those without the condition. In addition, people with cerebral palsy tend to have longer periods in poorer health-related quality of life.

CONCLUSION

Individuals with cerebral palsy will continue to face challenges related to an ongoing need for specialized medical care and a rising need for supportive services. Our study offers important insights into future costs and impacts associated with cerebral palsy and provides valuable information that could be used to develop targeted health programs and strategies for Canadians living with this condition.

Deep brain stimulation for dystonia due to cerebral palsy: A review

Cerebral palsy (CP) is a heterogeneous group of syndromes that cause a non-progressive disorder of early onset, with abnormal control of movement and posture. Various aetiologies can cause the CP clinical spectrum, but all have a disruption of motor control in common. CP can be divided into four major types based on the motor disability: predominant spastic, dyskinetic, ataxic and mixed form. Dyskinetic CP (DCP) is the most common cause of acquired dystonia in children. The treatment of DCP is challenging because most individuals have mixed degrees of chorea, athetosis and dystonia. Pharmacological treatment is often unsatisfactory. Functional neurosurgery, in particular deep brain stimulation targeting the basal ganglia or the cerebellum, is emerging as a promising therapeutic approach in selected patients with DCP. We evaluated herein the effects of DBS on patients with DCP in a review of published patient data in the largest available studies.

Stem cells and cell-based therapies for cerebral palsy: a call for rigor

Cell-based therapies hold significant promise for infants at risk for cerebral palsy (CP) from perinatal brain injury (PBI). PBI leading to CP results from multifaceted damage to neural cells. Complex developing neural networks are injured by neural cell damage plus unique perturbations in cell signaling. Given that cell-based therapies can simultaneously repair multiple injured neural components during critical neurodevelopmental windows, these interventions potentially offer efficacy for patients with CP. Currently, the use of cell-based interventions in infants at risk for CP is limited by critical gaps in knowledge. In this review, we will highlight key questions facing the field, including: Who are optimal candidates for treatment? What are the goals of therapeutic interventions? What are the best strategies for agent delivery, including timing, dosage, location, and type? And, how are short- and long-term efficacy reliably tracked? Challenges unique to treating PBI with cell-based therapies, and lessons learned from cell-based therapies in closely related neurological disorders in the mature central nervous system, will be reviewed. Our goal is to update pediatric specialists who may be counseling families about the current state of the field. Finally, we will evaluate how rigor can be increased in the field to ensure the safety and best interests of this vulnerable patient population.

Pediatric Rehabilitation Services for Children With Cerebral Palsy: What Can Existing Data Sources Tell Us?

Knowledge about associated service utilization patterns and positive outcomes in children with cerebral palsy (CP) of varying levels of severity is a national priority. Families, clinicians, program directors, and policy makers need this information for clinical decision-making and service planning. Existing data sources in the United States that contain information about children with CP, their health, function, well being, and utilization of health services may add to our existing knowledge. We provide a summary of fourteen national, state, and local sources' data: where the data come from, challenges and/or specific considerations when using or accessing information, and specific data elements included. Currently available sources of data can provide meaningful information for policy, practice, and program development. We propose questions for future inquiry and suggest elements that may be useful for when developing data sources specific to physical therapy and individuals with CP. A physical therapy specific registry is warranted.