Functional electrical stimulation during walking in children with unilateral spastic cerebral palsy: A randomized cross-over trial

AIM

To study if functional electrical stimulation (FES) of the peroneal nerve, which activates dorsiflexion, can improve body functions, activities, and participation and could be an effective alternative treatment in individuals with unilateral spastic cerebral palsy (CP).

METHOD

A randomized cross-over trial was performed in 25 children with unilateral spastic CP (classified in Gross Motor Function Classification System levels I and II) aged 4 to 18 years (median age at inclusion 9 years 8 months, interquartile range = 7 years-13 years 8 months), 15 patients were male. The study consisted of two 12-week blocks of treatment, that is, conventional treatment (ankle foot orthosis [AFO] or adapted shoes) and FES, separated by a 6-week washout period. Outcome measures included the Goal Attainment Scale (GAS), the Cerebral Palsy Quality of Life questionnaire, and a three-dimensional gait analysis.

RESULTS

Eighteen patients completed the trial. The proportion of GAS goals achieved was not significantly higher in the FES versus the conventional treatment phase (goal 1 p = 0.065; goal 2 p = 1.00). When walking while stimulated with FES, ankle dorsiflexion during mid-swing decreased over time (p = 0.006, average decrease of 4.8° with FES), with a preserved increased ankle range of motion compared to conventional treatment (p < 0.001, mean range of motion with FES +10.1° compared to AFO). No changes were found in the standard physical examination or regarding satisfaction with orthoses and feelings about the ability to dress yourself. In four patients, FES therapy failed; in 12 patients FES therapy continued after the trial.

INTERPRETATION

FES is not significantly worse than AFO; however, patient selection is critical, and a testing period and thorough follow-up are needed.

Therapeutic effects of repetitive transcranial magnetic stimulation in patients with cerebral palsy: a systematic review and network meta-analysis

The purpose of this study was to systematically evaluate the efficacy of repetitive transcranial magnetic stimulation in children with cerebral palsy and to compare the differences in efficacy of different treatment parameters. Computer searches of PubMed, Embase, Cochrane Library, Scopus, Web of Science, China Knowledge Network, Wanfang Data Knowledge Service Platform, Vipshop and China Biomedical Literature Database were conducted to collect randomized controlled trials (RCTs) of TMS to improve function in children with cerebral palsy. The search period was from the establishment of the database to April 2023. Two researchers independently screened the literature and extracted data information, and the risk of bias was assessed for the included studies using the Cochrane Systematic Evaluation Manual 5.1.0. Statistical analysis was performed using RevMan 5.4 and Stata software. A total of 18 studies containing 1675 patients with cerebral palsy were included, and r-TMS did not differ significantly from other treatments in improving language function [MD = 2.80, 95% CI (-1.51, 7.11), Z = 1.27, P = 0.20] after treatment. The results of the reticulated meta-analysis showed the best probability ranking of the effect of three different frequencies of r-TMS on motor function scores in children with cerebral palsy: combined LF-rTMS + HF-rTMS (49.8%) > LF-rTMS (45.6%) > HF-rTMS (4.6%) > conventional rehabilitation (0%). Publication bias showed no significant asymmetry in the inverted funnel plot, but the possibility of publication bias could not be excluded. The results of this study showed that r-TMS was not statistically significant in improving language function in children with cerebral palsy compared to conventional treatment. r-TMS was almost unanimously significantly effective in motor function in children with cerebral palsy according to current literature data, and the combined high- and low-frequency transcranial magnetic therapy was better than low-frequency transcranial magnetic therapy.

Safety and efficacy of non-invasive brain stimulation for the upper extremities in children with cerebral palsy: A systematic review

AIM

To evaluate available evidence examining safety and efficacy of non-invasive brain stimulation (NIBS) on upper extremity outcomes in children with cerebral palsy (CP).

METHOD

We electronically searched 12 sources up to May 2023 using JBI and Cochrane guidelines. Two reviewers selected articles with predetermined eligibility criteria, conducted data extraction, and assessed risk of bias using the Cochrane Risk of Bias criteria.

RESULTS

Nineteen studies were included: eight using repetitive transcranial magnetic stimulation (rTMS) and 11 using transcranial direct current stimulation (tDCS). Moderate certainty evidence supports the safety of rTMS and tDCS for children with CP. Very low to moderate certainty evidence suggests that rTMS and tDCS result in little to no difference in upper extremity outcomes.

INTERPRETATION

Evidence indicates that NIBS is a safe and feasible intervention to target upper extremity outcomes in children with CP, although it also indicates little to no significant impact on upper extremity outcomes. These findings are discussed in relation to the heterogeneous participants' characteristics and stimulation parameters. Larger studies of high methodological quality are required to inform future research and protocols for NIBS.

Individuals with cerebral palsy and their families need an evidence-based quality seal for interventions

This letter to the editor is on the invited review by Mayston et al. on pages 564–572 of this issue.

Transition from child to adult services for young people with cerebral palsy in Ireland: Influencing factors at multiple ecological levels

AIM

To explore the factors that influence the process of transitioning from child to adult services in Ireland among young people with cerebral palsy, their parents, and service providers.

METHOD

This study followed a qualitative descriptive approach. Semi-structured interviews were conducted with 54 participants, including young people with cerebral palsy aged 16 to 22 years (n = 13), their parents (n = 14), and service providers (n = 27). Data were analysed using the Framework Method. Findings were categorized using an ecological model across four levels: individual, microsystem, mesosystem, and exosystem.

RESULTS

Limited awareness, preparation, and access to information hindered successful transition. Microsystem factors such as family knowledge, readiness, resilience, and health professional expertise influenced transition experience. Mesosystem factors encompassed provider-family interaction, interprofessional partnerships, and interagency collaboration between child and adult services. Exosystem factors included inadequate availability and distribution of adult services, limited referral options, coordination challenges, absence of transition policies, staffing issues, and funding allocation challenges.

INTERPRETATION

Transition is influenced by diverse factors at multiple ecological levels, including interactions within families, between health professionals, and larger systemic factors. Given the complexity of transition, a comprehensive multi-level response is required, taking into account the interactions among individuals, services, and systems.

Is more always better? Effectiveness of constraint-induced movement therapy in children with high-risk or unilateral cerebral palsy (0-6 years): Systematic review and meta-analysis

BACKGROUND

While constraint-induced movement therapy is strongly recommended as an intervention for infants with unilateral cerebral palsy, the optimal dosage remains undefined. This systematic review aims to identify the most effective level of intensity of constraint-induced movement therapy to enhance manual function in infants at high risk of asymmetric brain lesions or unilateral cerebral palsy diagnosis.

METHODS

This systematic review with meta-analysis encompassed a comprehensive search across four electronic databases to identify articles that met the following criteria: randomised controlled trials, children aged 0-6 with at high risk or with unilateral cerebral palsy, and treatment involving constraint-induced movement therapy for upper limb function. Studies with similar outcomes were pooled by calculating the standardised mean difference score for each subgroup, and subgroups were stratified every 30 h of total intervention dosage (30-60, 61-90, >90 h). Risk of bias was assessed with Cochrane Collaboration's tool.

RESULTS

Seventeen studies were included. Meta-analyses revealed significant differences among subgroups. The 30-60 h subgroup showed a weak effect for spontaneous use of the affected upper limb during bimanual performance, grasp function, and parents' perception of how often children use their affected upper limb. Additionally, this subgroup demonstrated a moderate effect for the parents' perception of how effectively children use their affected upper limb.

CONCLUSIONS

Using a dosage ranging from 30 to 60 h when applying a constraint-induced movement therapy protocol holds promise as the most age-appropriate and cost-effectiveness approach for improving upper limb functional outcomes and parent's perception.

Effects of 12-week aquatic exercises on gross motor function, swimming skills and walking ability in children with cerebral palsy

BACKGROUND

Cerebral palsy (CP) is the most common cause of physical disability in childhood defined as a group of permanent disorders of movement. The aim of this study was to determine the effects of 12-week aquatic exercise program on gross motor function, swimming skills, and walking ability in children with cerebral palsy.

METHODS

Eighteen children (mean±SD age: 12.3±3 years) with cerebral palsy classified at levels I, II and III on the Gross Motor Function Classification System were allocated to one group, where the first 12 weeks were a control period while another 12 weeks were an experimental period. The participants underwent the same battery of tests focusing gross motor function, swimming skills, and walking ability on three occasions.

RESULTS

Control period was stable with no significant changes in any of measurements. After the 12-week experimental program, a statistically significant improvement was determined in gross motor function (P=0.005), swimming skills (P=0.000), walking endurance and walking velocity (P=0.000). No significant differences (P>0.05) were observed for walking efficiency.

CONCLUSIONS

The 12-week aquatic exercise program (3/week, 60 minutes), combining Halliwick method, swimming and walking activities may improve the gross motor function, swimming skills, walking endurance and velocity in ambulatory children with cerebral palsy.

[Effectiveness of early motor interventions in children with cerebral palsy between 3 to 5years of age: Systematic review]

Early motor intervention is essential in children with cerebral palsy; however, it is unknown its effectiveness between 3 to 5years. The objective was to determinate the effectiveness of early motor intervention in the motor development of this population. A systematic literature search was performed in Pubmed/Medline, PEDro, OTSeeker, Embase, and LILACS. Finally, 18 articles were selected, of which 4 showed favorable changes in the experimental group in the outcomes of overall motor development and manual motor function, with sensory integration therapy and movement-induced restriction therapy, respectively; however, the results were not statistically significant, and the level of evidence was low. Early motor intervention could be cautiously considered for improving overall motor development and manual function. Higher-quality methodological studies are necessary.

The efficacy of dance interventions for the activity and participation of individuals with cerebral palsy - a systematic review and meta-analysis

PURPOSE

The aim of this review was to examine the efficacy of dance interventions for individuals with cerebral palsy (CP), measured at any level of the International Classification of Functioning, Disability and Health (ICF).

METHODS

A systematic review and meta-analysis was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). A comprehensive search of peer-reviewed articles was performed using six electronic databases.

RESULTS

Fourteen studies were included in this review, nine of which were also included in the meta-analysis. The meta-analyses yielded a large overall effect for cognitive, motor, and social-emotional function outcomes, with a high degree of heterogeneity between outcome effects, attributable to differences in study design.

CONCLUSION

Although recent studies provide support for the acceptance and efficacy of dance interventions for people with CP, the systematic review revealed significant limitations in study design (only 2 randomised control trials). High-quality research that measures outcomes across all dimensions of the ICF, and particularly at the level of participation, are needed to improve the level of empirical support for dance-based interventions.

Efficacy of Early Intervention for Infants With Cerebral Palsy in an LMIC: An RCT

OBJECTIVE

To test efficacy of a parent-delivered multidomain early intervention (Learning through Everyday Activities with Parents [LEAP-CP]) for infants with cerebral palsy (CP) compared with equal-dose of health advice (HA), on (1) infant development; and (2) caregiver mental health. It was hypothesized that infants receiving LEAP-CP would have better motor function, and caregivers better mental health.

METHODS

This was a multisite single-blind randomized control trial of infants aged 12 to 40 weeks corrected age (CA) at risk for CP (General Movements or Hammersmith Infant Neurologic Examination). Both LEAP-CP and HA groups received 15 fortnightly home-visits by a peer trainer. LEAP-CP is a multidomain active goal-directed intervention. HA is based on Key Family Practices, World Health Organization. Primary outcomes: (1) infants at 18 months CA: Pediatric Evaluation of Disability Inventory-Computer Adaptive Test (PEDI-CAT mobility); and (2) caregiver: Depression Anxiety and Stress Scale.

RESULTS

Of eligible infants, 153 of 165 (92.7%) were recruited (86 males, mean age 7.1±2.7 months CA, Gross Motor Function Classification System at 18 m CA: I = 12, II = 25, III = 9, IV = 18, V = 32). Final data were available for 118 (77.1%). Primary (PEDI-CAT mobility mean difference = 0.8 (95% CI -1.9 to 3.6) P = .54) and secondary outcomes were similar between-groups. Modified-Intention-To-Treat analysis on n = 96 infants with confirmed CP showed Gross Motor Function Classification System I and IIs allocated to LEAP-CP had significantly better scores on PEDI-CAT mobility domain (mean difference 4.0 (95% CI = 1.4 to 6.5), P = .003) compared with HA.

CONCLUSIONS

Although there was no overall effect of LEAP-CP compared with dose-matched HA, LEAP-CP lead to superior improvements in motor skills in ambulant children with CP, consistent with what is known about targeted goal-directed training.

Mapping the Current Research on Mindfulness Interventions for Individuals with Cerebral Palsy: A Scoping Review

Cerebral palsy (CP) is a chronic neurological disorder that can cause motor and cognitive disabilities. Mindfulness is a form of meditation that has gained attention as a potential therapeutic intervention for improving the health and well-being of patients with CP. Four databases were searched until January 2023. A scoping review was conducted to explore the role of mindfulness in the management of CP by reviewing the available scientific literature. Studies that examined the effects of mindfulness on motor function, communication, and quality of life in patients with CP were analyzed. The gray literature and reference lists of included articles were not identified. The results were presented in numerical and thematic forms. From an initial pool of 30 registered studies, only 3 met the inclusion criteria. These selected studies reported positive effects of mindfulness interventions on communication abilities and stress management in patients with CP. The available evidence suggests that mindfulness may have beneficial effects on motor function, communication, and quality of life in patients with CP. The findings of this review highlight the potential of mindfulness as a complementary therapy for improving the health and well-being of patients with CP.

Human amniotic mesenchymal stromal cell-derived exosomes promote neuronal function by inhibiting excessive apoptosis in a hypoxia/ischemia-induced cerebral palsy model: A preclinical study

BACKGROUND

Cerebral palsy (CP) is a condition resulting from perinatal brain injury and can lead to physical disabilities. Exosomes derived from human amniotic mesenchymal stromal cells (hAMSC-Exos) hold promise as potential therapeutic options.

OBJECTIVE

This study aimed to investigate the impact of hAMSC-Exos on neuronal cells and their role in regulating apoptosis both in vitro and in vivo.

METHODS

hAMSC-Exos were isolated via ultracentrifugation and characterized via transmission electron microscopy, particle size analysis, and flow cytometry. In vitro, neuronal damage was induced by lipopolysaccharide (LPS). CP rat models were established via left common carotid artery ligation. Apoptosis levels in cells and CP rats were assessed using flow cytometry, quantitative reverse transcription polymerase chain reaction (RT-qPCR), Western blotting, and TUNEL analysis.

RESULTS

The results demonstrated successful isolation of hAMSC-Exos via ultracentrifugation, as the isolated cells were positive for CD9 (79.7%) and CD63 (80.2%). Treatment with hAMSC-Exos significantly mitigated the reduction in cell viability induced by LPS. Flow cytometry revealed that LPS-induced damage promoted apoptosis, but this effect was attenuated by treatment with hAMSC-Exos. Additionally, the expression of caspase-3 and caspase-9 and the Bcl-2/Bax ratio indicated that excessive apoptosis could be attenuated by treatment with hAMSC-Exos. Furthermore, tail vein injection of hAMSC-Exos improved the neurobehavioral function of CP rats. Histological analysis via HE and TUNEL staining showed that apoptosis-related damage was attenuated following hAMSC-Exo treatment.

CONCLUSIONS

In conclusion, hAMSC-Exos effectively promote neuronal cell survival by regulating apoptosis, indicating their potential as a promising therapeutic option for CP that merits further investigation.

Who really decides? Feeding decisions 'made' by caregivers of children with cerebral palsy

BACKGROUND

 There are no definitive guidelines for clinical decisions for children with cerebral palsy (CP) requiring enteral feeds. Traditionally, medical doctors made enteral feeding decisions, while patients were essentially treated passively within a paternalistic 'doctor knows best' approach. Although a more collaborative approach to decision-making has been promoted globally as the favoured model among healthcare professionals, little is known about how these decisions are currently made practically.

OBJECTIVES

 This study aimed to identify the significant individuals, factors and views involved in the enteral feeding decision-making process for caregivers of children with CP within the South African public healthcare sector.

METHOD

 A single-case research design was used in this qualitative explorative study. Data were collected using semi-structured interviews and analysed using reflexive thematic analysis.

RESULTS

 Four primary individuals were identified by the caregivers in the decision-making process: doctors, speech therapists, caregivers' families and God. Four factors were identified as extrinsically motivating: (1) physiological factors, (2) nutritional factors, (3) financial factors and (4) environmental factors. Two views were identified as intrinsically motivating: personal beliefs regarding enteral feeding tubes, and feelings of fear and isolation.

CONCLUSION

 Enteral feeding decision-making within the South African public healthcare sector is currently still dominated by a paternalistic approach, endorsed by a lack of caregiver knowledge, distinct patient-healthcare provider power imbalances and prescriptive multidisciplinary healthcare dialogues.Contribution: This study has implications for clinical practice, curriculum development at higher education training facilities, and institutional policy changes and development, thereby contributing to the current knowledge and clinical gap(s) in the area.

Evaluating the impact of movement tracking feedback on engagement with home exercise programmes of children with cerebral palsy using a new therapy app: a protocol for a mixed-methods single-case experimental design with alternating treatments

INTRODUCTION

Children with cerebral palsy (CP) are prescribed home exercise programmes (HEPs) to increase the frequency of movement practice, yet adherence to HEPs can be low. This paper outlines the protocol for a single-case experimental design (SCED) with alternating treatments, using a new home therapy exercise application, Bootle Boot Camp (BBCamp), offered with and without movement tracking feedback. This study will explore the impact of feedback on engagement, movement quality, lower limb function and family experiences to help understand how technology-supported HEPs should be translated and the added value, if any, of movement tracking technology.

METHODS AND ANALYSIS

In this explanatory sequential mixed-methods study using a SCED, 16 children with CP (aged 6-12 years, Gross Motor Function Classification System levels I-II) will set lower limb goals and be prescribed an individualised HEP by their physiotherapist to complete using BBCamp on their home television equipped with a three-dimensional camera-computer system. Children will complete four weekly exercise sessions over 6 weeks. Children will be randomised to 1 of 16 alternating treatment schedules where BBCamp will provide or withhold feedback during the first 4 weeks. The version of BBCamp that results in the most therapeutic benefit will be continued for 2 final weeks. Goals will be re-evaluated and families interviewed. The primary outcome is adherence (proportion of prescribed exercise repetitions attempted) as a measure of behavioural engagement. Secondary outcomes are affective and cognitive engagement (smiley face ratings), exercise fidelity, lower limb function, goal achievement and participant experiences. SCED data will be analysed using visual and statistical methods. Quantitative and qualitative data will be integrated using joint displays.

ETHICS AND DISSEMINATION

Ethical approval was obtained from the Research Ethics Boards at Bloorview Research Institute and the University of Toronto. Results will be distributed through peer-reviewed journals and scientific conferences.

TRIAL REGISTRATION NUMBER

NCT05998239; pre-results.

Impact of a National Follow-Up Program on the Age at Diagnosis for Cerebral Palsy

BACKGROUND

The Danish National Cerebral Palsy Follow-up Program (CPOP) is a nationwide program offering standardized treatment to all children with cerebral palsy (CP) since 2004. We aimed to establish if its implementation had a positive impact on the diagnostic age of CP.

METHODS

Children with validated CP diagnoses were identified from the Danish Cerebral Palsy Registry and the CPOP. We then compared the age at diagnosis and the clinical features of children with CP born in 2000 to 2003 with those born in 2010 to 2013. Differences in time to diagnosis were compared using log-rank test.

RESULTS

The age at diagnosis was not different in the two periods (P = 0.23), with identical overall median diagnostic ages at 13.0 months. The number of children with severe motor disability decreased markedly from 47.5% in 2000 to 2003 to 32.0% in 2010 to 2013 (P < 0.001). There was increased usage of cerebral magnetic resonance imaging; however, this was not associated with lower diagnostic age.

CONCLUSIONS

The diagnostic age of CP did not change after the implementation of a nationwide follow-up program, offering standardized and early assessments. However, central clinical aspects also changed significantly between the periods compared, which possibly affected the diagnostic age.

Single-pulse transcranial magnetic stimulation for assessment of motor development in infants with early brain injury

INTRODUCTION

Single-pulse transcranial magnetic stimulation (TMS) has many applications for pediatric clinical populations, including infants with perinatal brain injury. As a noninvasive neuromodulation tool, single-pulse TMS has been used safely in infants and children to assess corticospinal integrity and circuitry patterns. TMS may have important applications in early detection of atypical motor development or cerebral palsy.

AREAS COVERED

The authors identified and summarized relevant studies incorporating TMS in infants, including findings related to corticospinal development and circuitry, motor cortex localization and mapping, and safety. This special report also describes methodologies and safety considerations related to TMS assessment in infants, and discusses potential applications related to diagnosis of cerebral palsy and early intervention.

EXPERT OPINION

Single-pulse TMS has demonstrated safety and feasibility in infants with perinatal brain injury and may provide insight into neuromotor development and potential cerebral palsy diagnosis. Additional research in larger sample sizes will more fully evaluate the utility of TMS biomarkers in early diagnosis and intervention. Methodological challenges to performing TMS in infants and technical/equipment limitations require additional consideration and innovation toward clinical implementation. Future research may explore use of noninvasive neuromodulation techniques as an intervention in younger children with perinatal brain injury to improve motor outcomes.

The cost of respiratory hospitalizations in children with cerebral palsy

AIM

To establish the burden of respiratory illness in cerebral palsy (CP) on the Western Australian health care system by quantifying the costs of respiratory hospitalizations in children with CP, compared with non-respiratory hospitalizations.

METHOD

A 2-year (2014-2015) retrospective study using linked hospital data (excluding emergency department visits), in a population of children with CP in Western Australia aged 18 years and under (median age at hospitalization 7 years; interquartile range 5-12 years).

RESULTS

In 671 individuals (57% male) there were 726 emergency hospitalizations, and 1631 elective hospitalizations. Although there were more elective hospitalizations, emergency hospitalizations were associated with longer stays in hospital, and more days in an intensive care unit, resulting in a higher total cost of emergency hospitalizations than elective hospitalizations (total costs: emergency AU$7 748 718 vs elective AU$6 738 187). 'Respiratory' was the leading cause of emergency hospitalizations, contributing to 36% of all emergency admission costs. For a group of high-cost inpatient users (top 5% of individuals with the highest total inpatient costs) the most common reason for hospitalization was 'respiratory'. Where non-respiratory admissions were complicated by an additional respiratory diagnosis, length of stay was greater.

INTERPRETATION

Respiratory hospitalizations in CP are a significant driver of health care costs. In the paediatric group, they are a burden for a subgroup of children with CP.

WHAT THIS PAPER ADDS

Respiratory illness is the most costly area for unplanned, emergency hospitalizations for children and young people with cerebral palsy. The top 5% of individuals with the highest total inpatient costs account for a disproportionate amount of health care costs.

Effects of structured training on spinal posture and selective motor control in children with unilateral spastic cerebral palsy

BACKGROUND

Children with Unilateral Spastic Cerebral Palsy (USCP) have an asymmetrical postural pattern. Although functional limitations are less, deteriorations in spinal posture are observed.

RESEARCH QUESTION

What is the effect of structured training on spinal posture and selective motor control of upper extremity?

METHODS

Forty five children with USCP were included in the study. Participants were children ages 3-18 with GMFCS levels 1 and 2. Spinal posture and mobility was assessed by Spinal Mouse (SM) and the Spinal Alignment and Range of Motion Measure (SAROMM), and selective motor control of upper extremity was evaluated by the Selective Control of the Upper Extremity Scale (SCUES). Children were divided into two groups: structured training group (STG) (n = 22) and conventional physiotherapy group (CPG) (n = 23). Groups received treatment sessions lasting 45 min, 2 days a week for 8 weeks. Evaluations were made baseline and after treatment.

RESULTS

In sagittal plane, there was a significant decrease in the degree of thoracic kyphosis after treatment in the STG (p = 0.004). A significant difference was found in total spine angulation (p = 0.015) and mobility from flexion to extension in the STG group. There was a difference in total spine angulation (p = 0.014) in the CPG group, but no difference in spinal mobility. Post-training differences were found in thoracic angulation (p = 0.006) and lateral flexion mobility to the affected side in the STG in thoracic (p = 0.020), lumbar (p = 0.035) and total spine (p = 0.008) in the frontal plane. When SCUES-shoulder, elbow, wrist, total scores changes was significant in CPG (p < 0.001), SCUES-forearm (p = 0.002) and fingers (p = 0.007) changes was significant in STG.

SIGNIFICANCE

This study showed that although children with USCP are more mildly affected, there are adverse effects on their selective motor control and spinal posture. This study reveals the contribution of structured training in terms of selective movement, spinal smoothness and mobility in children.

Cerebral palsy and sleep: nonpharmacological treatment and impact on the life of caregivers - an integrative review

BACKGROUND

 Children with cerebral palsy have a higher prevalence of sleep disorders, with numerous factors associated with a negative impact on the quality of life of caregivers.

OBJECTIVE

 To identify factors related to sleep disorders, nonpharmacological treatment, and the impact on the lives of caregivers.

METHODS

 The present literature review was carried out in the Latin American and Caribbean Center on Health Sciences Information (BIREME), the Cochrane Library, Scopus, PubMed, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), PsycInfo, WorldCat, Web of Science, Latin American Literature on Health Sciences (LILACS), and Excerpta Medica Database (EMBASE), with the descriptors sleep, child, cerebral palsy, parents, and nursing. Studies available in Portuguese, English, or Spanish, published between 2010 and 2020, were our inclusion criteria. A total of 29 articles were included in the present review.

RESULTS

 We considered nonpharmacological interventions effective support measures to drug-based treatments. The main sleep disorders in children with cerebral palsy are insomnia, parasomnias, nightmares, sleep bruxism, sleepwalking, sleep talking, disorders of initiation and maintenance of sleep, and sleep hyperhidrosis. Most studies point to a reduction in the quality of life of caregivers whose children have sleep disorders.

CONCLUSION

 Our review suggests the effectiveness of nonpharmacological treatments combined with the use of medications. Measures such as changes in sleep environment and routine are favorable strategies to improve sleep quality. In addition, children with sleep disorders negatively impact the quality of life of their caregivers.

Effects of a full-body electrostimulation garment application in a cohort of subjects with cerebral palsy, multiple sclerosis, and stroke on upper motor neuron syndrome symptoms

OBJECTIVES

Dysfunction of the central nervous system may inflict spastic movement disorder (SMD). Electrical stimuli were identified as promising therapeutic option. Electrical stimulation provided by a 58-electrode full body garment was investigated based on data from regular trial fittings.

METHODS

Data from 72 testees were investigated. Age averages 36.6 (19.8) ys with 44 females. The cohort spans infantile cerebral paresis (CP) (n=29), multiple sclerosis (MS) (n=23) and stroke (n=20). Data were stratified by etiology and an entry BBS Score<45.

RESULTS

Effect sizes (Cohen`s d) related BBS, TUG, FGA, 10mWT, WMFT, EQ5D5L and Pain. Significance levels are indicated by *: p<0.05, **: p<0.01, ***: p<0.001, (t): p<0.1: CP: 1.64***, 0.29*, 1.59***, 0.76(t), 1.00***, 0.5*, 1.28***; MS: 1.83***, 0.83***, 1.28**, 1.07***, 0.93*, 1,11**, 0.78*; Stroke: 1.28**, 0.78**, 0.89, 0.92**, 0.71, 1.26*, 0.78*.

CONCLUSIONS

Multi-site transcutaneous electrical stimulation may increase ambulation related skills in subjects with SMD stemming from CP, MS and stroke. The results indicate effects on static and dynamic balance, fall risk, mobility, upper extremity improvement and an overall increase in health utility and a reduction in spasticity related pain. Effects are immediate as well as sustained. These results may inspire individual trial fittings and inform further controlled trials.

Does somatosensory discrimination therapy alter sensorimotor upper limb function differently compared to motor therapy in children and adolescents with unilateral cerebral palsy: study protocol for a randomized controlled trial

BACKGROUND

Besides motor impairments, up to 90% of the children and adolescents with unilateral cerebral palsy (uCP) present with somatosensory impairments in the upper limb. As somatosensory information is of utmost importance for coordinated movements and motor learning, somatosensory impairments can further compromise the effective use of the impaired upper limb in daily life activities. Yet, intervention approaches specifically designated to target these somatosensory impairments are insufficiently investigated in children and adolescents with uCP. Therefore, the aim of this randomized controlled trial (RCT) is to compare the effectiveness of somatosensory discrimination therapy and dose-matched motor therapy to improve sensorimotor upper limb function in children and adolescents with uCP, who experience somatosensory impairments in the upper limb. We will further explore potential behavioral and neurological predictors of therapy response.

METHODS

A parallel group, evaluator-blinded, phase-II, single-center RCT will be conducted for which 50 children and adolescents with uCP, aged 7 to 15 years, will be recruited. Participants will be randomized to receive 3 weekly sessions of 45 minutes of either somatosensory discrimination therapy or upper limb motor therapy for a period of 8 weeks. Stratification will be performed based on age, manual ability, and severity of tactile impairment at baseline. Sensorimotor upper limb function will be evaluated at baseline, immediately after the intervention and after 6 months follow-up. The primary outcome measure will be bimanual performance as measured with the Assisting Hand Assessment. Secondary outcomes include a comprehensive test battery to objectify somatosensory function and measures of bimanual coordination, unimanual motor function, and goal attainment. Brain imaging will be performed at baseline to investigate structural brain lesion characteristics and structural connectivity of the white matter tracts.

DISCUSSION

This protocol describes the design of an RCT comparing the effectiveness of somatosensory discrimination therapy and dose-matched motor therapy to improve sensorimotor upper limb function in children and adolescents with uCP. The results of this study may aid in the selection of the most effective upper limb therapy, specifically for children and adolescents with tactile impairments.

TRIAL REGISTRATION

ClinicalTrials.gov (NCT06006065). Registered on August 8, 2023.

Therapeutic hypothermia after perinatal asphyxia in Vietnam: medium-term outcomes at 18 months - a prospective cohort study

AIM

To determine neurodevelopmental outcome at 18 months after therapeutic hypothermia for hypoxic-ischaemic encephalopathy (HIE) infants in Vietnam, a low-middle-income country.

METHOD

Prospective cohort study investigating outcomes at 18 months in severely asphyxiated outborn infants who underwent therapeutic hypothermia for HIE in Hanoi, Vietnam, during the time period 2016-2019. Survivors were examined at discharge and at 6 and 18 months by a neonatologist, a neurologist and a rehabilitation physician, who were blinded to the infants' clinical severity during hospitalisation using two assessment tools: the Ages and Stages Questionnaire (ASQ) and the Hammersmith Infant Neurological Examination (HINE), to detect impairments and promote early interventions for those who require it.

RESULTS

In total, 130 neonates, 85 (65%) with moderate and 45 (35%) with severe HIE, underwent therapeutic hypothermia treatment using phase change material. Forty-three infants (33%) died during hospitalisation and in infancy. Among the 87 survivors, 69 (79%) completed follow-up until 18 months. Nineteen children developed cerebral palsy (8 diplegia, 3 hemiplegia, 8 dyskinetic), and 11 had delayed neurodevelopment. At each time point, infants with a normal or delayed neurodevelopment had significantly higher ASQ and HINE scores (p<0.05) than those with cerebral palsy.

CONCLUSION

The rates of mortality and adverse neurodevelopment rate were high and comparable to recently published data from other low-middle-income settings. The ASQ and HINE were useful tools for screening and evaluation of neurodevelopment and neurological function.

Modification of the Paediatric Gastro-oesophageal Reflux Disease Symptom and Quality of Life Questionnaire (PGSQ) for children with cerebral palsy: a preliminary study

OBJECTIVE

Gastro-oesophageal reflux disease (GORD) is a common condition affecting children, characterised by the passage of gastric contents into the oesophagus causing pain, vomiting and regurgitation. Children with neurodisability (such as cerebral palsy; CP) are predisposed to more severe GORD due to coexisting gut dysmotility and exclusive/supplementary liquid diet; however, there are no existing tools or outcome measures to assess the severity of GORD in this patient group. For children without CP, the 'Paediatric Gastro-oesophageal Symptom and Quality of Life Questionnaire' (PGSQ) assesses symptoms and response to treatment, but the questions are not suitable for children with significant cognitive impairment. We aimed to adapt the existing PGSQ assessment tool to enable use in evaluating children with CP and GORD.

PATIENTS/INTERVENTIONS

Cognitive interviews were conducted by the research team with six parents/carers of children (aged 3-15) with CP (Gross Motor Function Classification System level V) who have current or past symptoms of reflux. They were asked to interpret the questionnaire using a 'think-aloud technique,' and offer suggestions on alterations to questions. Reasons for changing questions included confusing/difficult to understand questions, differing interpretations of questions and response choices not applying to the patient group.

RESULTS

The PGSQ was modified iteratively following each interview. Overall, parents/carers reported that it was acceptable to recall information over the past 7 days. In the final version, it was felt the questions were relevant, useful and related to symptoms that they observed. It was easy to comprehend with no uncomfortable questions. Suggestions for future work included a section specifically focusing on the school day answered by school staff and home life answered by carers who assist them in the home.

CONCLUSIONS

We have adapted the PGSQ to improve relevance and acceptability for families/carers of children with symptoms of GORD and neurodisability. Further work is needed to validate the questionnaire for this patient group.

Baby HABIT-ILE intervention: study protocol of a randomised controlled trial in infants aged 6-18 months with unilateral cerebral palsy

INTRODUCTION

Research using animal models suggests that intensive motor skill training in infants under 2 years old with cerebral palsy (CP) may significantly reduce, or even prevent, maladaptive neuroplastic changes following brain injury. However, the effects of such interventions to tentatively prevent secondary neurological damages have never been assessed in infants with CP. This study aims to determine the effect of the baby Hand and Arm Bimanual Intensive Therapy Including Lower Extremities (baby HABIT-ILE) in infants with unilateral CP, compared with a control intervention.

METHODS AND ANALYSIS

This randomised controlled trial will include 48 infants with unilateral CP aged (corrected if preterm) 6-18 months at the first assessment. They will be paired by age and by aetiology of the CP, and randomised into two groups (immediate and delayed). Assessments will be performed at baseline and at 1 month, 3 months and 6 months after baseline. The immediate group will receive 50 hours of baby HABIT-ILE intervention over 2 weeks, between first and second assessment, while the delayed group will continue their usual activities. This last group will receive baby HABIT-ILE intervention after the 3-month assessment. Primary outcome will be the Mini-Assisting Hand Assessment. Secondary outcomes will include behavioural assessments for gross and fine motricity, visual-cognitive-language abilities as well as MRI and kinematics measures. Moreover, parents will determine and score child-relevant goals and fill out questionnaires of participation, daily activities and mobility.

ETHICS AND DISSEMINATION

Full ethical approval has been obtained by the Comité d'éthique Hospitalo-Facultaire/Université catholique de Louvain, Brussels (2013/01MAR/069 B403201316810g). The recommendations of the ethical board and the Belgian law of 7 May 2004 concerning human experiments will be followed. Parents will sign a written informed consent ahead of participation. Findings will be published in peer-reviewed journals and conference presentations.

TRIAL REGISTRATION NUMBER

NCT04698395. Registered on the International Clinical Trials Registry Platform (ICTRP) on 2 December 2020 and NIH Clinical Trials Registry on 6 January 2021. URL of trial registry record: https://clinicaltrials.gov/ct2/show/NCT04698395?term=bleyenheuft&draw=1&rank=7.

Can RESPiratory hospital Admissions in children with cerebral palsy be reduced? A feasibility randomised Controlled Trial pilot study protocol (RESP-ACT)

INTRODUCTION

The most common cause of morbidity and mortality in children with severe cerebral palsy (CP) is respiratory disease. BREATHE-CP (Better REspiratory and Airway Treatment and HEalth in Cerebral Palsy) is a multidisciplinary research team who have conducted research on the risk factors associated with CP respiratory disease, a systematic review on management and a Delphi study on the development of a consensus for the prevention and management of respiratory disease in CP. These strategies have not been investigated; therefore, it is not known if implementation is feasible, if they improve patient outcomes or if they are acceptable for families.

METHODS AND ANALYSIS

Mixed-method feasibility pilot randomised controlled trial with economic analysis. Twenty children with CP aged 0-12 years who are at risk of respiratory disease will be followed up for 1 year. All children will receive baseline assessments for comparison. The control group will receive usual care from their treating teams. The intervention group will receive comprehensive assessments from physiotherapy, speech pathology and respiratory medicine. An individualised investigation and treatment plan will then be made. Participants in both groups will complete fortnightly patient-reported outcome surveys to assess symptoms and health service use. Analysis will include assessments of acceptability through qualitative interviews, implementation by ability to recruit, randomise and retain, practicality including costs of intervention and hospitalisation, and explore efficacy through quality-of-life surveys and decreased health service use for respiratory-related symptoms.

ETHICS AND DISSEMINATION

Ethics and governance approvals have been obtained through Child and Adolescent Health Service Human Research Ethics Committee. At completion, this study will lead to the design of the definitive protocol to test intervention efficacy that maximises recruitment, retention and adherence to interventions.

TRIAL REGISTRATION NUMBER

Australian New Zealand Clinical Trials Registry (ACTRN12620000114943).

Fast needling combined with occupational therapy for hand dysfunction of spastic cerebral palsy : a randomized controlled trial

OBJECTIVES

To compare the clinical effect of fast needling (without needle retaining), needle retaining acupuncture combined with occupational therapy and simple occupational therapy for hand dysfunction of spastic cerebral palsy in children.

METHODS

A total of 75 children with spastic cerebral palsy were randomly divided into an occupational therapy group (25 cases), a fast needling group (25 cases, 1 case dropped out) and a needle retaining group (25 cases, 1 case dropped out). The patients in the occupational therapy group were only treated with occupational therapy for 20 min each time. The patients in the fast needling group were treated with acupuncture (without needle retaining) combined with occupational therapy, and the needle retaining group was treated with acupuncture (needle retaining) combined with occupational therapy, and acupuncture was taken at Hegu (LI 4), Houxi (SI 3), Yuji (LU 10), Waiguan (SJ 5), Jianyu (LI 15) and so on. The needles were retained for 30 min in patients of the needle retaining group. All the above treatments were performed once a day, 5 times a week for 12 weeks. The scores of fine motor function measure (FMFM) and Peabody developmental motor scale 2 (PDMS-2) were observed in patients of the three groups before and after treatment, and the safety of the fast needling group and the needle retaining group was compared.

RESULTS

After treatment, the scores of FMFM and PDMS-2 in patients of the three groups were higher than those before treatment (P<0.01), and the scores of FMFM and PDMS-2 in the fast needling group and the needle retaining group were higher than those in the occupational therapy group (P<0.05, P<0.01). The incidence of acupuncture abnormalities in the fast needling group was 0.3% (5/1 440), which was lower than 1.4% (20/1 440) in the needle retaining group (P<0.05).

CONCLUSIONS

Acupuncture combined with occupational therapy has better clinical effect than occupational therapy alone in improving hand dysfunction in children with spastic cerebral palsy, and there is no statistical difference in effect between fast needling acupuncture and needle retaining acupuncture, but fast needling has better safety than needle retaining acupuncture.

Enhancing the Development and Growth of Infant Cerebral Palsy Rats Using Selective Spinal Manipulations

Cerebral palsy (CP) is a refractory pediatric disease with a high prevalence, high disability rate, and difficult treatment. A variety of treatments are currently used for CP. The treatment involves drug and non-drug therapy. Traditional Chinese medicine external therapy is a very distinctive treatment method in non-drug therapy. As one of the external therapies of traditional Chinese medicine, massage is used in treating cerebral palsy and has good efficacy, small side effects, and strong operability. As a part of TCM external therapy, selective spinal manipulation can effectively promote the growth and development of infant rats with cerebral palsy.The operation was mainly divided into four steps: first, the rubbing method was applied to the spine and both sides of the spine for 1 min. The pressing and kneading method was applied to the spine for 5 min, and the muscles on both sides of the spine for 5 min. Second, pressing and kneading the sensitive local acupoints in the spine for 2 min were performed. Thirdly, the affected limb was treated by twisting method for 1 min. Fourth, the rubbing method was applied to a midline from the forehead to the back of the brain for 1 min. This study aimed to use selective spinal manipulation to treat infant rats with cerebral palsy. The weight, Rotarod test, Foot-fault score, and growth hormone of infant rats with cerebral palsy were detected to understand the effect of selective spinal manipulation on the growth and development of infant rats with cerebral palsy. The results showed that it can promote weight gain, improve balance ability and motor function, promote growth and development of infant cerebral palsy rats, promote growth hormone secretion, and increase the temperature of sensitive parts of the back.

Early cerebral palsy motor therapies research: Hope springs and science matters

This commentary is on the original article by Prosser et al. on pages 233–243 of this issue.

[Therapies, bonds and quality of life of children and adolescents with cerebral palsy: experiences and perceptions of their caregivers during the pandemic]

The COVID-19 pandemic affected the health of children and adolescents (CA). Isolation-related conditions could have impacted not only the functionality of children and adolescents with cerebral palsy (CP) but also their social and emotional well-being, affecting their health-related quality of life (HRQoL).

OBJECTIVE

To analyze perceptions of impairment during the pandemic and differences in HRQoL dimensions compared with a previous registry in Argentinean children and adolescents diagnosed with CP from the perspective of their caregivers.

SUBJECTS AND METHOD

Cross-sectional observational study at two time points (2019 and 2021) where 98 caregivers participated. We used the KIDSCREEN-27 and CP-QOL questionnaires for the assessment of HRQoL and an open-ended question regarding the impact of the pandemic on the health of children and adolescents, including in 2021. We compared mean scores of the dimensions of the questionnaires in both stages (significant differences: Cohen's d≥0.3). Responses to the open-ended question were analyzed via "open" and "axial" coding.

RESULTS

The scores of the dimensions Participation, Emotional well-being, Social well-being, and School environment (CP-QOL) and Psychological well-being, Friends, School environment, and General HRQoL index (KIDSCREEN-27) were lower during the pandemic (2021) compared with 2019 (d>0.3). Regarding perceived affectation during the pandemic, we identified three main recurrences: "impairment due to interruption of therapies and treatments", "deterioration of peer bonding", and "increased and positive appraisal of self-care".

CONCLUSIONS

The pandemic affected the psychosocial dimensions of health. Qualitative data highlight the positive assessment of self-care.

The upper limb in children with cerebral palsy. Evaluation and treatment

Management of the upper limb in children with cerebral palsy is often complex and must be carried out by a team experienced in this field. Several clinical parameters must be taken into consideration, such as higher functions, visual problems, overall upper limb function, motor control, sensitivity, presence of hemineglect or synkinesis, limb position at rest and during walking. And last but not least, a complete analysis of the upper limb is required. It is only after this exhaustive assessment - which often includes occupational therapy, physiotherapy and in some cases, video and electromyography evaluations - that a treatment indication can be discussed with the patient's family. Other than baseline treatment consisting of rehabilitation, occupational therapy and bracing, botulinum toxin injections could be an option, targeting specific muscle groups. Surgical treatments, which are often indicated in severe forms with contractures, are proposed after the patient's case is presented at a multidisciplinary meeting. These include selective neurotomy, muscle-tendon release, transfer or lengthening, and procedures on bone and joints (osteotomy, arthrodesis). LEVEL OF EVIDENCE: Expert opinion.

Neurological and Visual Outcomes in Infants and Toddlers Following Therapeutic Hypothermia for Neonatal Hypoxic-Ischemic Encephalopathy

BACKGROUND

The majority of studies have investigated neurodevelopmental outcomes, whereas visual impairment is less explored in children with a history of neonatal (hypoxic-ischemic) encephalopathy. Our aim was to perform a detailed neurological and visual assessment and also to investigate the presence of cerebral visual impairment in infants and toddlers with neonatal encephalopathy.

METHODS

Thirty participants with a history of neonatal encephalopathy, who had been hospitalized for therapeutic hypothermia, underwent a detailed neurological examination at age five to 36 months. Age-matched, 30 healthy children were also enrolled as a control group. All children in the study and control groups received neurological and a comprehensive ophthalmologic examination, including visual field and visual acuity. Presence of cerebral visual impairment was also evaluated clinically.

RESULTS

Rates of cerebral palsy, severe motor impairment, cognitive impairment, epilepsy, and cerebral visual impairment were found to be 20%, 10%, 15.3%, 10%, and 20%, respectively. When compared with healthy controls, oculomotor functions, pupillary light response, refractive parameters, anterior/posterior segment examinations, ocular visual impairment rates, and last, visual acuities were found similar. However, we found a statistically significant increase in visual field defects in our study group.

CONCLUSIONS

It could be better to perform a comprehensive ophthalmologic examination including visual field, visual acuity, and oculomotor functions by a pediatric ophthalmologist to accurately diagnose neurovisual deficits in infants following therapeutic hypothermia. Early identification and rehabilitation of the visual deficits might improve the neurodevelopment in these children.

Hip displacements and correctable scoliosis were prevalent in children with cerebral palsy registered in a Danish follow-up programme from 2010 to 2020

AIM

We need a better understanding of non-surgical interventions for hip dislocations and scoliosis. This study estimated the cumulative incidence of problems among children with cerebral palsy and described the type and frequency of therapist-led interventions.

METHODS

The study comprised 1482 children (58% male) aged 0-15 years, with a mean age of 3.6 years, who were registered in the Danish Cerebral Palsy Follow-up Programme from 2010 to 2020. We used the Kaplan-Meier estimator to examine the cumulative incidence of hip displacement, hip dislocation, correctable scoliosis and non-correctable scoliosis. The type and frequency of therapist-led interventions are reported descriptively.

RESULTS

The cumulative incidence of hip displacement and hip dislocation were 15.8% and 3.5%, respectively, and 39.0% and 13.9% for correctable and non-correctable scoliosis. The most frequently reported type of therapist-led intervention was a joint range of motion exercise. We found that 60.5% with hip displacements and 43.8% with correctable scoliosis used a standing aid. A further 5.4% used a spinal orthosis to prevent deformity and 8.1% for stabilisation.

CONCLUSION

Hip displacement and correctable scoliosis were prevalent in children with cerebral palsy, whereas the occurrence of hip dislocations and non-correctable scoliosis was low. The use of assistive aids was low.

Therapeutic effects of extracorporeal shock wave therapy on patients with spastic cerebral palsy and Rett syndrome: clinical and ultrasonographic findings

BACKGROUND

Extracorporeal shock wave therapy (ESWT) is reportedly effective for improving spasticity and motor function in children with cerebral palsy (CP). Because late-stage Rett syndrome has a similar presentation, this study aimed to investigate the effects of ESWT on these two diseases.

MATERIAL AND METHODS

Patients diagnosed with spastic CP and Rett syndrome received 1500 impulses of ESWT at 4 Hz and 0.1 mJ/mm2, on their spastic legsonce weekly for a total of 12 weeks. Outcomes were assessed before and 4 and 12 weeks after ESWT. Clinical assessments included the Modified Ashworth Scale (MAS), passive range of motion (PROM), and Gross Motor Function Measure 88 (GMFM-88). Ultrasonographic assessments included muscle thickness, acoustic radiation force impulse (ARFI), and strain elastography.

RESULTS

Fifteen patients with CP and six with Rett syndrome were enrolled in this study. After ESWT, patients with CP showed significant clinical improvement in the MAS (P = 0.011), ankle PROM (P = 0.002), walking/running/jumping function (P = 0.003), and total function (P < 0.001) of the GMFM-88. The patients with Rett syndrome showed improved MAS scores (P = 0.061) and significantly improved total gross motor function (P = 0.030). Under ARFI, patients with CP demonstrated decreased shear wave speed in the gastrocnemius medial head (P = 0.038). Conversely, patients with Rett syndrome show increased shear-wave speeds after ESWT.

CONCLUSION

Our study provides evidence that a weekly course of low-dose ESWT for 12 weeks is beneficial for children with both CP and Rett syndrome, with the clinical effects of reducing spasticity and improving the gross motor function of the lower limbs. The ARFI sonoelastography reveals improvement of muscle stiffness in patients with CP after ESWT, but deteriorated in patients with Rett syndrome. The diverse therapeutic response to ESWT may be caused by the MECP2 mutation in Rett syndrome, having a continuous impact and driving the pathophysiology differently as compared to CP, which is secondary to a static insult. Trial registration IRB 201700462A3. Registered 22March 2017, https://cghhrpms.cgmh.org.tw/HRPMS/Default.aspx .

Satisfaction survey toward an innovative orthosis for children with cerebral palsy with pes planovalgus

BACKGROUND

Pes planovalgus (PPV) is common in children with cerebral palsy and can cause pain and gait alterations over time. Initial treatment of flexible PPV includes orthotics, despite a lack of consensus on the type of orthosis. We developed an innovative ankle-foot orthosis (RAFO). RAFO is a one-piece orthosis designed to correct both the valgus and the flat of the foot. Its conception situated above the malleolar enables a moderate anti equinus effect. Its precise description and fabrication's process is detailed.

OBJECTIVES

We wanted to assess user's satisfaction after several months of use and looked for clinical criteria of satisfaction.

STUDY DESIGN

Retrospective.

METHODS

We conducted a satisfaction study through a telephonic QUEST (Quebec User Evaluation of Satisfaction with Assistive Technology) survey analysing the device and the process in children and parents. 24 parents were contacted, whose child was wearing RAFO on a daily basis for at least 4 months. 20 parents answered the questionnaire. The results were then related to clinical data to research satisfaction' criteria.

RESULTS

Mean QUEST satisfaction was 4.25/5 (4.18/5 for device and 4.38/5 for process). Advantages reported concerned weight and dimensions (95%), although 20% reported the necessity to change to a shoe size above, ease of use (90%) and level of comfort (80%). Parent's satisfaction regarding perceived effectiveness was 80%. Children with equinus due to triceps surae spasticity were more susceptible to develop pain with our orthosis.

CONCLUSIONS

Parents were overall very satisfied with the orthosis. Its technical characteristics allowing both to be a corrector of flat foot and valgus and at the same time to be comfortable and discreet makes it innovative. The presence of spastic equinus is a limit for its utilization.

Design and fabrication of a novel 4D-printed customized hand orthosis to treat cerebral palsy

This research study is dedicated to additive manufacturing of the shape memory polymer hand orthosis to treat patients with cerebral palsy. The treatment process for cerebral palsy is a step-by-step process that needs different adjustments for the spastic hand to stretch it towards a normal posture, whereas meeting these requirements using conventional methods or complicated mechanisms is expensive, less flexible, time-consuming, and less practical. A comprehensive investigation was conducted to design and fabricate novel thermally actuated customized hand orthosis via digital light processing (DLP). The highly precise scanning device was used to derive the hand model, and subsequently, the Blender software was used to design the customized orthosis. The results showed that fabricated orthosis could represent a strong potential to become an alternative treatment for cerebral palsy. The shape memory actuation of the orthosis indicated that 100 % shape recovery is achievable in different actuating conditions with recovery temperatures higher than 55°C. Besides, it was found that the response time and shape recovery percentage could be tailored in the range of 5 to 40 s and 45 to 100%, respectively, by adjusting programming and actuation temperatures. Further, the repeatability of the shape memory effects in the printed orthosis was investigated as well, which proved that until 17 repetitions, 100 % shape recovery was achievable.

Individualized orthotic alignment and footwear for balance and mobility in children with bilateral spastic cerebral palsy: A randomized trial

AIM

To examine whether designed-to-be-rigid ankle-foot orthoses and footwear combinations with individualized alignment and footwear designs (AFO-FC/IAFD) would be more effective than designed-to-be-rigid AFO with non-individualized alignment and footwear designs (AFO-FC/NAFD) in children with cerebral palsy (CP).

METHOD

Nineteen children with bilateral spastic CP were randomized to AFO-FC/NAFD (n = 10) or AFO-FC/IAFD (n = 9) groups. Fifteen were male, average age 6 years 11 months (range 4 years 2 months-9 years 11 months), classified in Gross Motor Function Classification System levels II (n = 15) and III (n = 4). The Pediatric Balance Scale (PBS), Gait Outcomes Assessment List (GOAL), Patient-Reported Outcomes Measurement Information System (PROMIS), and Orthotic and Prosthetic Users' Survey (OPUS) measures of satisfaction were collected at baseline and after 3 months' wear.

RESULTS

Compared with the AFO-FC/NAFD group, those with AFO-FC/IAFD demonstrated greater change in PBS total scores (mean 12.8 [standard deviation 10.5] vs 3.5 [5.8]; p = 0.03) and GOAL total scores (3.5 [5.8] vs -0.44 [5.5]; p = 0.03). There were no significant changes in OPUS or PROMIS scores.

INTERPRETATION

After 3 months, individualized orthosis alignment and footwear designs had a greater positive effect on balance and parent-reported mobility than a non-individualized approach. No effect was documented for the PROMIS and OPUS. Results may inform orthotic management for ambulatory children with bilateral spastic CP.

WHAT THIS PAPER ADDS

Balance and parent-reported mobility increased more over time for the ankle-foot orthoses and footwear combinations with individualized alignment and footwear designs (AFO-FC/IAFD) group. Changes in balance over time suggest a therapeutic effect of the AFO-FC/IAFD approach.

[Early differential diagnosis and restorative treatment of cerebral palsy]

The article is devoted to an urgent problem of modern neurology - early diagnosis and complex restorative treatment of cerebral palsy (cerebral palsy). Etiological factors and pathogenetic aspects of the formation of various forms of cerebral palsy are considered in detail, as well as modern possibilities of differential diagnosis in children of the first years of life of cerebral palsy and a wide range of pathological conditions (somatic, endocrine, hereditary-conditioned, including hereditary-metabolic and neuromuscular diseases). The leading directions of complex rehabilitation of cerebral palsy are widely presented, taking into account modern standards and clinical recommendations. The high efficacy of the drug Cortexin has been shown, due to its positive multimodal action (stimulation of the processes of neuropreparation, neuroprotection, neuroplasticity) in the treatment of motor, cognitive and autonomic disorders in children with perinatal lesions of the central nervous system and cerebral palsy.

[Hippotherapy versus hippotherapy simulators as a treatment option in children with cerebral palsy: A systematic review]

INTRODUCTION AND OBJECTIVE

Hippotherapy (HPOT) and hippotherapy simulators (SHPOT) are used in children with cerebral palsy to achieve their maximum functionality and independence. The aim is to find out if HPOT and SHPOT produce the same effects on balance, gross motor function, and postural control in children under 18 years old with cerebral palsy.

MATERIALS AND METHODS

The keywords used were: hippotherapy, equine-assisted therapy and cerebral palsy. The databases used were PeDro, Scopus, LILACS, ScienceDirect, Cochrane Library, Web of Science and CINAHL Complete (Ebsco). Studies were included if they were randomized clinical trials that studied the effect of HPOT and/or SHPOT on the variables mentioned in these patients.

RESULTS

Four studies assessed balance, 4 studied gross motor function, and 2 investigated postural control. Both HPOT and SHPOT produced benefits in all of them.

CONCLUSIONS

According to the studied variables both interventions produce similar improvements. Although, they increase with HPOT possibly due to greater sensory stimulation.

Could cremaster muscle spasticity cause retractile or undescended testis in cerebral palsy? Implications for assessment and management

This commentary is on the original article by Bortnick et al. on pages 82–86 of this issue.

F-words and early intervention ingredients for non-ambulant children with cerebral palsy: A scoping review

AIM

To explore the ingredients of early interventions provided to young children with cerebral palsy (CP) who are classified in Gross Motor Function Classification System (GMFCS) levels IV and V, and to identify the 'F-words' addressed by the interventions.

METHOD

Searches were completed in four electronic databases. Inclusion criteria were the original experimental studies that fitted the following PCC components: population, young children (aged 0-5 years, at least 30% of the sample) with CP and significant motor impairment (GMFCS levels IV or V, at least 30% of the sample); concept, non-surgical and non-pharmacological early intervention services measuring outcomes from any of the International Classification of Functioning, Disability and Health domains; and context, studies published from 2001 to 2021, from all settings and not limited to any specific geographical location.

RESULTS

Eighty-seven papers were included for review, with qualitative (n = 3), mixed-methods (n = 4), quantitative descriptive (n = 22), quantitative non-randomized (n = 39), and quantitative randomized (n = 19) designs. Fitness (n = 59), family (n = 46), and functioning (n = 33) ingredients were addressed by most experimental studies, whereas studies on fun (n = 6), friends (n = 5), and future (n = 14) were scarce. Several other factors (n = 55) related to the environment, for example, service provision, professional training, therapy dose, and environmental modifications, were also relevant.

INTERPRETATION

Many studies positively supported formal parent training and use of assistive technology to promote several F-words. A menu of intervention ingredients was provided, with suggestions for future research, to incorporate them into a real context within the family and clinical practice.

WHAT THIS PAPER ADDS

Family-centred care (including coaching and caregiver-delivered interventions) and formal parental training are effective strategies for children in GMFCS levels IV and V. Assistive technology ingredients (power, mobility, supported, sitting, stepping, and standing) may promote several 'F-words' (functioning, fitness, family, fun, friends, and future). The lowest level of evidence was found for fun, friends, and future. Other factors (service provision, professional training, therapy dose, environmental modifications) are relevant for young children in GMFCS levels IV and V.

Health care resource utilization and costs among patients with spasticity or cervical dystonia

BACKGROUND

Spasticity and cervical dystonia (CD) are movement disorders with considerable direct and indirect health care cost implications. Although several studies have discussed their clinical impact, few have calculated the economic burden of these disorders.

OBJECTIVE

To assess the all-cause health care resource utilization (HCRU) and costs in adults and children with spasticity or CD.

METHODS

This retrospective, observational cohort-based study was conducted using administrative insurance claims from the IQVIA PharMetrics Plus database from October 1, 2015, to December 31, 2019. Patients were selected based on International Classification of Diseases, Tenth Revision, Clinical Modification diagnosis codes for first evidence of spasticity (associated with a spasticity etiology) or CD (index date) during the selection window, from April 1, 2016, through December 31, 2018. Cases were stratified into 3 mutually exclusive cohorts: adult patients with spasticity, pediatric patients with spasticity, and patients with CD; those with spasticity who had a history of stroke or cerebral palsy were also evaluated in subcohorts. Patients without evidence of spasticity or CD during the study period were identified as a matched comparator group and were randomly assigned an index date. Patients with spasticity were matched 1:1 to the comparator group based on age, sex, index year, and payer type using descriptive analyses.

RESULTS

215,739 adult patients with spasticity, 29,644 pediatric patients with spasticity, and 9,035 adult patients with CD were identified after matching. Adult patients with spasticity and CD had mean (SD) ages of 48.4 (15.6) years and 48.0 (13.1) years, respectively. Stroke was identified in 31.9% (n = 68,928) of adult patients with spasticity, and cerebral palsy was identified in 11.3% (n = 3,364) of pediatric patients with spasticity. Adult and pediatric patients with spasticity and patients with CD had significantly higher HCRU (including mean number of outpatient, emergency department, and inpatient visits and proportions of patients with prescription fills) and higher mean total health care costs per patient (adult patients with spasticity $29,912 vs $7,464; pediatric patients with spasticity $16,089 vs $2,963; and patients with CD $20,168 vs $7,141) than matched comparators (all P<0.0001).

CONCLUSIONS

The management of patients with spasticity or CD results in considerably higher health care expenses. Within managed health care systems, more effective management of spasticity and CD in adult and pediatric patients represents a significant opportunity for cost savings.

Effects of voluntary exercise on muscle structure and function in cerebral palsy

Linked Article: https://onlinelibrary.wiley.com/doi/10.1111/dmcn.15173

Therapeutic effect of the new multilevel brace orthosis on cerebral palsy gait: a case report

Background

Infantile spastic bilateral cerebral palsy (CP) is the most common form of CP. Diplegia (with ambulatory ability) is mostly a chronic condition that impairs the ability to walk. Standard orthotic management includes hip-knee-ankle-foot orthosis (HKAFO) as a pri-mary conservative treatment option to contrast spasticity and stabilise gait through partial immobilisation of the body structure. Multilevel brace orthosis (MLB) (Registered Trademark) is a specific type of light HKAFO designed to improve functional alignment and dynamic gait stability without limb immobilisation. Aim of the case report is to verify the effects of the MLB on the diplegic gait cycle.

Case

A child with a bilateral spastic gait due to CP diplegia is described. Gait analyses were performed to investigate the therapeutic effects of the MLB on walking.

Discussion

The MLB improved the gross motor function measure of walking and gait temporal parameters (velocity), compared with barefoot condition. During the swing phase, we observed a reduction in plantar and knee flexion, and the orthosis increased the width and length of the step.

Conclusion

Use of this specific type of HKAFO in children with diplegia improved gait symmetry and stability.

Walking outcomes in cerebral palsy: What is the GOAL?

This commentary is on the original articles by Stout et al. and Munger et al. on pages 61–69 and 70–81 of this issue.

Stem Cell Treatment and Cerebral Palsy: A Systematic Review and Meta-Analysis

OBJECTIVE

We designed this systematic review and meta-analysis to estimate the pooled efficacy and safety profile of different types of stem cells in treating patients with cerebral palsy (CP).

METHODS

We systematically searched PubMed, Scopus, EMBASE, Web of Science, Google Scholar, and also gray literature, including references of the included studies which were published before November 2021. We extracted data regarding the total number of participants, first author, publication year, country of origin, mean age, cell type, cell dose, cell source, method of transplantation, duration of follow-up, Gross motor function, Ashworth scale, and adverse events.

RESULTS

We found 2073 articles by literature search; after deleting duplicates, 1194 remained. Nine articles remained for meta-analysis. The SMD of GMF-66 score (after-before) treatment was 1.5 (95% CI:0.7-2.3) (I2 = 89.9%, P < 0.001). The pooled incidence of Gastrointestinal (GI) complications after transplantation was 21% (95% CI:9-33%) (I2 = 56%, P = 0.08). The pooled incidence of fever after transplantation was 18 % (95% CI:6-30%) (I2 = 87.9%, P = 0.08 < 0.001) Conclusion: The result of this systematic review and meta-analysis show that stem cell therapy in cerebral palsy has neuroprotective properties from anti-inflammatory and anti-apoptotic activities. Stem cell therapy seems to be a promising adjunct to traditional therapies for cerebral palsy patients.

Changes Induced by Early Hand-Arm Bimanual Intensive Therapy Including Lower Extremities in Young Children With Unilateral Cerebral Palsy: A Randomized Clinical Trial

Importance

Intensive interventions are provided to young children with unilateral cerebral palsy (UCP), classically focused on the upper extremity despite the frequent impairment of gross motor function. Hand-Arm Bimanual Intensive Therapy Including Lower Extremities (HABIT-ILE) effectively improves manual dexterity and gross motor function in school-aged children.

Objective

To verify if HABIT-ILE would improve manual abilities in young children with UCP more than usual motor activity.

Design, Setting, and Participants

This prospective randomized clinical trial (November 2018 to December 2021), including 2 parallel groups and a 1:1 allocation, recruitment took place at European university hospitals, cerebral palsy specialized centers, and spontaneous applications at 3 sites: Brussels, Belgium; Brest, France; and Pisa, Italy. Matched (age at inclusion, lesion type, cause of cerebral palsy, and affected side) pairs randomization was performed. Young children were assessed at baseline (T0), 2 weeks after baseline (T1), and 3 months after baseline (T2). Health care professionals and assessors of main outcomes were blinded to group allocation. At least 23 young children (in each group) aged 12 to 59 months with spastic/dyskinetic UCP and able to follow instructions were needed. Exclusion criteria included uncontrolled seizures, scheduled botulinum toxin injections, orthopedic surgery scheduled during the 6 months before or during the study period, severe visual/cognitive impairments, or contraindications to magnetic resonance imaging.

Interventions

Two weeks of usual motor activity including usual rehabilitation (control group) vs 2 weeks (50 hours) of HABIT-ILE (HABIT-ILE group).

Main Outcomes and Measures

Primary outcome: Assisting Hand Assessment (AHA); secondary outcomes: Gross Motor Function Measure-66 (GMFM-66), Pediatric Evaluation of Disability Inventory-Computer Adaptive Test (PEDI-CAT), and Canadian Occupational Performance Measure (COPM).

Results

Of 50 recruited young children (26 girls [52%], median age; 35.3 months for HABIT-ILE group; median age, 32.8 months for control group), 49 were included in the final analyses. Change in AHA score from T0 to T2 was significantly greater in the HABIT-ILE group (adjusted mean score difference [MD], 5.19; 95% CI, 2.84-7.55; P < .001). Changes in GMFM-66 (MD, 4.72; 95% CI, 2.66-6.78), PEDI-CAT daily activities (MD, 1.40; 95% CI, 0.29-2.51), COPM performance (MD, 3.62; 95% CI, 2.91-4.32), and satisfaction (MD, 3.53; 95% CI, 2.70-4.36) scores were greater in the HABIT ILE group.

Conclusions and Relevance

In this clinical trial, early HABIT-ILE was shown to be an effective treatment to improve motor performance in young children with UCP. Moreover, the improvements had an impact on daily life activities of these children.

Trial registration

ClinicalTrials.gov Identifier: NCT04020354.

Moving forward: The importance of tailored orthotic management in children with cerebral palsy

This commentary is on the original article by Bjornson et al. on pages 52–60 of this issue.