Stability of the Motor Optimality Score Revised (MOS-R) in medically complex infants

BACKGROUND

The Motor Optimality Score-Revised (MOS-R) is a clinical test of infant spontaneous movement at 3-5 months of age and has been associated with neurodevelopmental outcomes in infants with medical complexity. However the stability of the MOS-R tested at different developmental ages is not yet known.

AIM

To determine if the repeated scoring of the MOS-R remained consistent when tested at two developmental ages in young infants.

STUDY DESIGN

In this prospective cohort study, infants were tested twice with the MOS-R between 12 and 13 weeks corrected age (CA) and 14-16 weeks CA. Bland Altman Plots were used to calculate agreement between the scores. Infants were grouped as having higher or lower medical complexity. MOS-R threshold scores were analyzed to assess changes over time within each group using Fisher's exact test.

SUBJECTS

85 infants with history of hospitalization in a neonatal intensive care unit (NICU).

RESULTS

The MOS-R scores had a high agreement with negligible bias (0.058) between timepoints (95 % CI -1.10, 1.22). Using a MOS-R cut point of 19, infants with higher medical complexity were more likely to change groups between timepoints than infants with lower medical complexity (p = 0.008), but this was not significantly different using cut points of 20 or 21.

CONCLUSION

The MOS-R scores were stable when measured repeatedly in infants who were hospitalized in a NICU. Infants with high medical complexity had less stable MOS-R scores using certain cut points than infants with lower medical complexity.

Supportive mobility devices across the lifespan in Cerebral Palsy: a modified Delphi study to establish stakeholder research priorities

PURPOSE

The aim of this study was to co-develop research priorities and identify meaningful research questions with a diverse group of stakeholders representing the CP community for implementation in subsequent research activities. The overarching aim of this research was to 1) Understand the mobility experiences, supported mobility device (SMD) use, and desired participation outcomes of people with cerebral palsy (CP) across the lifespan; and 2) Describe how perspectives of rehabilitation care and professional resources may influence mobility decision-making processes and outcomes.

MATERIALS AND METHODS

A three-round modified Delphi consensus study was conducted with a stakeholder advisory panel consisting of three adults with CP, two parents of children with CP, and four SMD providers.

RESULTS

The advisory panel identified 11 unique topical categories focused on SMD selection and use, stratified by age group and stakeholder role. Questions or statements within each category were ranked, and top consensus and concordance statements were retained, reviewed, and refined for use in a co-developed focus group guide. Priorities were identified in three main groupings: (1) Age/GMFCS level/Environment-related; (2) Individual with CP/Caregiver need-related; and (3) Clinician/provider partnership-related.

DISCUSSION

A modified Delphi process was a useful tool for stakeholders in co-developing research priorities related to SMD use across the lifespan. Drawing on the lived expertise of stakeholders is important in facilitating improved research translation in the CP community.

Comparative Study of the Pain, Function, and Biomarkers of Joint Disease in the Transition to Adulthood in Individuals With and Without Cerebral Palsy

BACKGROUND

Biomarkers have potential to identify early signs of joint disease. This study compared joint pain and function in adolescents and young adults with cerebral palsy compared with individuals without.

METHODS

This cross-sectional study compared individuals with cerebral palsy ( n = 20), aged 13-30 yrs with Gross Motor Function Classification System I-III and age-matched individuals without cerebral palsy ( n = 20). Knee and hip joint pain measured using Numeric Pain Rating Scale and Knee injury and Osteoarthritis Outcome Score and Hip dysfunction and Osteoarthritis Outcome Score surveys. Objective strength and function were also measured. Biomarkers for tissue turnover (serum cartilage oligomeric matrix protein, urinary C-terminal crosslinked telopeptide of type II collagen) and cartilage degradation (serum matrix metalloproteinase 1, matrix metalloproteinase 3) were measured in blood and urinary samples.

FINDINGS

Individuals with cerebral palsy had increased knee and hip joint pain, reduced leg strength, reduced walking and standing speeds, and ability to carry out activities of daily living ( P < 0.005) compared with controls. They also had higher serum matrix metalloproteinase 1 ( P < 0.001) and urinary C-terminal crosslinked telopeptide of type II collagen levels ( P < 0.05). Individuals with cerebral palsy who were Gross Motor Function Classification System I and II demonstrated reduced hip joint pain ( P = 0.02) and higher matrix metalloproteinase 1 levels ( P = 0.02) compared with Gross Motor Function Classification System III.

INTERPRETATION

Individuals with cerebral palsy with less severe mobility deficits had higher matrix metalloproteinase 1 levels likely due to more prolonged exposure to abnormal joint loading forces but experienced less joint pain.

Relationship of anthropometric measurements and percent body fat mass to cardiovascular disease risk factors in adults with cerebral palsy

INTRODUCTION

Adults with cerebral palsy (CP) face high morbidity from cardiovascular disease (CVD). Of concern, classic screening parameters are inconsistent in identifying CVD risk in this population. Dual-energy x-ray absorptiometry (DEXA), which provides direct measurements of fat mass (FM), may be an alternative screening method.

OBJECTIVE

To evaluate whether FM measurement with DEXA is feasible in screening adults with CP and compare FM and anthropometric measures to CVD risk factors.

DESIGN

Cross-sectional study.

SETTING

Outpatient rehabilitation hospital.

PARTICIPANTS

Forty-seven adults with CP.

MAIN OUTCOME MEASURES

Weight, height, waist circumference (WC), and hip circumference (HC) were measured; waist-to-hip ratio (WHR) and body mass index (BMI) were calculated. Blood pressure (BP), FM by DEXA, hemoglobin A1c (HbA1c), and lipid measurements were obtained. Logistic regression models investigated odds ratios (ORs) and 95% confidence intervals (CIs) between anthropometric measurements/FM and CVD risk factors; correlations were assessed using Pearson correlation coefficients.

RESULTS

Elevated BP or hypertension diagnosis was present in 47.8%; HbA1c ≥5.7% in 22.2%; and high-density lipoprotein (HDL) level below optimal for 33.3%. DEXA FM was obtained in 29 of 47 participants, as surgical metal and positioning limited many studies. Excess FM was noted in 75.9% versus 41.3% overweight/obese by BMI. WC correlated with HbA1c (r = 0.46, p = .002), HDL (r = -0.36, p = .018), and triglyceride (TG) levels (r = 0.30, p = .045); however at-risk WC values were associated only with odds of elevated HbA1c (OR 8.53, 95% CI 1.46-50.05; p = .018). HC correlated with HbA1c levels (r = 0.38, p = .011) and systolic BPs (r = 0.35, p = .019); similarly, ORs for elevated HC were weakly associated with elevated HbA1c and BPs (OR 1.08, 95% CI 1.01-1.16; p = .024 and OR 1.07, 95% CI 1.01-1.14; p = .024, respectively). WHR correlated with TGs; however few TG levels were elevated. FM measures were not associated with at-risk lab values or BPs.

CONCLUSIONS

DEXA FM measurements may not be feasible for CVD screening in many adults with CP. Although CVD risk factors are frequently present, anthropometric measurements commonly used for general population screening may not translate well to adults with CP.

Adult outcomes for children who sustained firearm-related spinal cord injuries

OBJECTIVE

To describe the adult functional, participation, education, employment, and quality of life outcomes of children who incurred spinal cord injury (SCI) as the result of gun injuries vs. non-violent etiologies, as well as their utilization of health services.

DESIGN

Retrospective-cohort study. Eligibility criteria were current age at least 18 years, at least 5 years after SCI, and injury prior to 19 years of age. After enrolling the gun injury group, we matched individuals with non-violent etiologies from the Midwest Regional SCI Model System database to the gun injury group's demographic characteristics. Adult outcomes included education level, employment, income, involvement with the criminal justice system, quality of life indicators using PROMIS and SCI-QOL item banks, and utilization of health services.

PARTICIPANTS

Twenty-six participants with gun injury SCI matched with 19 participants with non-violent etiologies.

RESULTS

Average age at injury was 15 years and current age was 44 years for both cohorts. Individuals from racial minority groups were over-represented in the gun injury cohort. The gun-injury cohort had lower educational attainment. Though employment rates were similar, the gun injury group had a lower income level. Both groups endorsed high average levels of function and quality of life on the PROMIS and SCI-QOL short forms.

CONCLUSIONS

SCI etiology reflects racial characteristics of the sample and is associated with subsequent educational attainment and income. Rehabilitation planning should consider gun injury etiology in children not as a characteristic that determines a poor outcome, but as a risk factor for reduced educational attainment and lifetime income.

Measuring the inch stones for progress: Gross motor function in the developmental and epileptic encephalopathies

OBJECTIVE

Developmental and epileptic encephalopathies (DEE) entail moderate to profound impairments in gross motor skills and mobility, which are poorly quantified with clinical outcomes assessments (COA) used in neuro-typical populations. We studied the motor domain of the Adaptive Behavior Assessment System-3 for ages 0-5 years (ABAS) used outside of its intended age range with a focus on raw scores.

METHODS

In a cross-sectional survey, 117 parents of children with a variety of DEEs (ages 1-35 years, median = 9) completed the motor domain section of the ABAS. Floor and ceiling effects and associations with epilepsy-related factors were assessed with appropriate parametric and nonparametric statistical techniques. The sensitivity of the ABAS and additional measures of mobility borrowed from the cerebral palsy literature (Functional Activities Questionnaire (FAQ-22) walking level (FAQ-WL)) to different levels of the Functional Mobility Scale was determined.

RESULTS

ABAS motor scores corresponded to a median age equivalent of 20.5 months (Inter-Quartile Range (IQR) 8-34). Most raw scores corresponded to standardized scores > 2 standard deviations below the ABAS standardization sample mean. ABAS raw scores demonstrated minimal floor and ceiling effects (<5%). In linear regression models, scores increased with age under 6 years (p < 0.0001) but flattened out thereafter. Scores varied substantially by DEE group (p < 0.001) and decreased with higher convulsive seizure frequency (<0.0001) and number of seizure medications (p < 0.001). ABAS and other motor scores were sensitive to important differences in mobility as represented by the FMS at 5 yards. Further, they correlated with declines in mobility function from 5 to 500 yards.

SIGNIFICANCE

An out-of-range COA with raw scores may provide a measure of motor ability and mobility sensitive within the range of moderate to profound impairment seen in patients with DEE. This approach could shorten the time to appropriate COA development and ensure timely clinical trial readiness for novel therapies for rare DEEs.

Supportive mobility device use across the life span by individuals with cerebral palsy: A qualitative study

AIM

To understand the mobility experiences, supportive mobility device (SMD) use, and desired participation outcomes of individuals with cerebral palsy (CP) across the life span, and describe how perspectives of rehabilitation care and professional resources may influence mobility decision-making processes and outcomes.

METHOD

In the second phase of an overarching study, focus groups were conducted with 164 participants (68 individuals with CP; 32 females, 36 males; mean age 17y 8mo, SD 11y 11mo, range 3-68y), 74 caregivers (50 females, 24 males), and 22 healthcare providers (14 females, eight males) across four US cities. Sessions were audio-recorded, transcribed, and analysed using constant comparison.

RESULTS

Six themes emerged. Five presented across all stakeholder groups: (1) the system is broken; (2) equipment is simultaneously liberating and restricting; (3) adaptation across the life span; (4) designed for transport, not for living; and (5) sharing our stories and sharing resources. One theme (theme 6) was specific to healthcare providers: caught in the middle.

INTERPRETATION

This qualitative study underscores the simultaneous value and frustration associated with SMDs as described by the community with CP, and recognition among all stakeholders of the need to improve connections and resource networks within the community with CP to improve SMD design and provision processes across device types and across the life span for individuals with CP.

WHAT THIS PAPER ADDS

Supportive mobility devices (SMDs) were most often equated with freedom, participation, and independence. Frustration with SMDs across the life span persisted with regard to design, function, cost, and maintenance. Stakeholders in the community with cerebral palsy are seeking greater networking and resource sharing to enhance SMD provision processes. Access to appropriate SMDs across the life span and the need for system improvement are critical.

Physical and Environmental Barriers to Mobility and Participation in Children With Medical Complexity: A Qualitative Study

This qualitative study evaluated barriers and facilitators to mobility in the homes of children with medical complexity (CMC) and the subsequent impact on CMC and their families. Eighteen caregivers of CMC were interviewed. Parents described that accessibility barriers impaired delivery of care at home and impacted the child's participation in family life. The most inaccessible areas were stairs and bathrooms. Mobility and transfers became more difficult as children grew larger. Parents and children sustained injuries from performance of activities of daily living (ADLs). When available, durable medical equipment (DME) and home modifications improved home access and typically were funded using insurance and state Title V funds. However, parents reported that larger home modifications, such as bathroom modifications, were cost prohibitive. A pediatrician's inquiry about mobility barriers may reveal crucial information about delivery of home care to CMC. CMC may be referred to rehabilitation specialists to address mobility needs.

Spasticity-related pain in children/adolescents with cerebral palsy. Part 2 IncobotulinumtoxinA efficacy results from a pooled analysis

PURPOSE

This pooled analysis of data from three Phase 3 studies investigated the effects of incobotulinumtoxinA on spasticity-related pain (SRP) in children/adolescents with uni-/bilateral cerebral palsy (CP).

METHODS

Children/adolescents (ambulant and non-ambulant) were evaluated for SRP on increasingly difficult activities/tasks 4 weeks after each of four incobotulinumtoxinA injection cycles (ICs) using the Questionnaire on Pain caused by Spasticity (QPS; six modules specific to lower limb [LL] or upper limb [UL] spasticity and respondent type [child/adolescent, interviewer, or parent/caregiver]). IncobotulinumtoxinA doses were personalized, with all doses pooled for analysis.

RESULTS

QPS key item responses were available from 331 and 155 children/adolescents with LL- and UL-spasticity, respectively, and 841/444 (LL/UL) of their parents/caregivers. IncobotulinumtoxinA efficacy was evident with the first IC. Efficacy was sustained and became more robust with further subsequent ICs. By Week 4 of the last (i.e. fourth) IC, 33.8-53.3% of children/adolescents reported complete SRP relief from their baseline pain for respective QPS items. Children/adolescents reported reductions in mean LL SRP intensity at levels that surpassed clinically meaningful thresholds. Similarly, parents/caregivers observed complete SRP relief and less frequent SRP with incobotulinumtoxinA. Similar results were found for UL SRP.

CONCLUSION

These findings indicate that incobotulinumtoxinA could bring considerable benefit to children/adolescents with spasticity by reducing SRP, even during strenuous activities.

Development and Validation of a Deep Learning Method to Predict Cerebral Palsy From Spontaneous Movements in Infants at High Risk

IMPORTANCE

Early identification of cerebral palsy (CP) is important for early intervention, yet expert-based assessments do not permit widespread use, and conventional machine learning alternatives lack validity.

OBJECTIVE

To develop and assess the external validity of a novel deep learning-based method to predict CP based on videos of infants' spontaneous movements at 9 to 18 weeks' corrected age.

DESIGN, SETTING, AND PARTICIPANTS

This prognostic study of a deep learning-based method to predict CP at a corrected age of 12 to 89 months involved 557 infants with a high risk of perinatal brain injury who were enrolled in previous studies conducted at 13 hospitals in Belgium, India, Norway, and the US between September 10, 2001, and October 25, 2018. Analysis was performed between February 11, 2020, and September 23, 2021. Included infants had available video recorded during the fidgety movement period from 9 to 18 weeks' corrected age, available classifications of fidgety movements ascertained by the general movement assessment (GMA) tool, and available data on CP status at 12 months' corrected age or older. A total of 418 infants (75.0%) were randomly assigned to the model development (training and internal validation) sample, and 139 (25.0%) were randomly assigned to the external validation sample (1 test set).

EXPOSURE

Video recording of spontaneous movements.

MAIN OUTCOMES AND MEASURES

The primary outcome was prediction of CP. Deep learning-based prediction of CP was performed automatically from a single video. Secondary outcomes included prediction of associated functional level and CP subtype. Sensitivity, specificity, positive and negative predictive values, and accuracy were assessed.

RESULTS

Among 557 infants (310 [55.7%] male), the median (IQR) corrected age was 12 (11-13) weeks at assessment, and 84 infants (15.1%) were diagnosed with CP at a mean (SD) age of 3.4 (1.7) years. Data on race and ethnicity were not reported because previous studies (from which the infant samples were derived) used different study protocols with inconsistent collection of these data. On external validation, the deep learning-based CP prediction method had sensitivity of 71.4% (95% CI, 47.8%-88.7%), specificity of 94.1% (95% CI, 88.2%-97.6%), positive predictive value of 68.2% (95% CI, 45.1%-86.1%), and negative predictive value of 94.9% (95% CI, 89.2%-98.1%). In comparison, the GMA tool had sensitivity of 70.0% (95% CI, 45.7%-88.1%), specificity of 88.7% (95% CI, 81.5%-93.8%), positive predictive value of 51.9% (95% CI, 32.0%-71.3%), and negative predictive value of 94.4% (95% CI, 88.3%-97.9%). The deep learning method achieved higher accuracy than the conventional machine learning method (90.6% [95% CI, 84.5%-94.9%] vs 72.7% [95% CI, 64.5%-79.9%]; P < .001), but no significant improvement in accuracy was observed compared with the GMA tool (85.9%; 95% CI, 78.9%-91.3%; P = .11). The deep learning prediction model had higher sensitivity among infants with nonambulatory CP (100%; 95% CI, 63.1%-100%) vs ambulatory CP (58.3%; 95% CI, 27.7%-84.8%; P = .02) and spastic bilateral CP (92.3%; 95% CI, 64.0%-99.8%) vs spastic unilateral CP (42.9%; 95% CI, 9.9%-81.6%; P < .001).

CONCLUSIONS AND RELEVANCE

In this prognostic study, a deep learning-based method for predicting CP at 9 to 18 weeks' corrected age had predictive accuracy on external validation, which suggests possible avenues for using deep learning-based software to provide objective early detection of CP in clinical settings.

Use of Frame Running for Adolescent Athletes With Movement Challenges: Study of Feasibility to Support Health and Participation

Children and adolescents with movement challenges have lower instances of physical activity and longer time spent in sedentary behaviors compared to children with typical development. The purpose of this study was to investigate the feasibility of a sport-based youth development running program modified for accessibility using a running frame and to evaluate initial evidence for its efficacy on endurance and functional strength. We completed four 8-week seasons (2–3 times per week) in a combination of 3 different formats by season: online remote (winter and spring), in person in a community park (winter, spring, and summer), and in person in an afterschool setting (autumn). Participants included 13 athletes (average age 14.46 years, range 8–18 years, 4 females), who collectively completed 22 season blocks. Diagnoses included cerebral palsy (n = 10), arthrogryposis (n = 1), Dandy-Walker malformation (n = 1), and transverse myelitis (n = 1). In all settings, participants engaged in activities of social emotional learning, cardiovascular endurance, and muscle strengthening in a progressive manner. We found that each season format was feasible to administer with high attendance rates (76–97%) and positive qualitative feedback from athletes. In addition, promising average improvements in motor performance across a season (6 min frame running test, 170 m; timed up and go test, 8.44 s; five times sit to stand, 14.1 s; and Goal Attainment Scale, t = 65.01) were identified in the pilot data of this non-randomized cohort. Training in any of the proposed settings with an overall goal of completing a community race in a running frame is feasible and warrants further study.

ASSOCIATION BETWEEN DAILY PHYSICAL ACTIVITY AND CLINICAL ANTHROPOMORPHIC MEASURES IN ADULTS WITH CEREBRAL PALSY

OBJECTIVE

To describe the relationship between activity level and cardiovascular risk measures as well as describe general activity patterns of adults with cerebral palsy Design: Cross-Sectional Setting: Academic Outpatient Rehabilitation Clinic.

PARTICIPANTS

47 adults with cerebral palsy (CP) Interventions: Not applicable Main Outcome Measures: Gross Motor Functional Classification System (GMFCS) level was determined by validated self-report questionnaire. Activity (daily step count, walk time, sitting time, standing time, and transitional movements) over 6 days recorded using an activPAL. Weight, body mass index (BMI), and waist to hip ratio (WHR) were measured. Bivariate relationships between anthropomorphic and activity measures were assessed.

RESULTS

38 participants completed all measurements. Nine were excluded due to incomplete activPAL data. The median age was 28.50 years [interquartile range 24.25,47.00], range 18-77 years. Participants' GMFCS levels were I:13%, II:16%, III:21%, IV:34%, and V:16%. Median steps/day for GMFCS I/II participants were 5258.3[3606.8, 6634.7], while median steps/day were 1681.3 [657.2, 2751.8] and 30.0 [6.8, 54.2] for GMFCS level III and IV/V participants, respectively. Significantly greater steps/day were found for GMFCS I/II or III participants compared to those GMFCS IV/V (p<0.001 and p=0.0074, respectively). 60.5% of the subjects had a BMI in the normal range, 10.5% were obese, 23.6% were overweight, and 5.3% were underweight. For subjects with GMFCS I/II, the Spearman's rank correlation coefficient for time standing and waist circumference was -0.73 (0.01). Subjects GMFCS III and GMFCS IV/V had respective correlations of -0.16 (0.71) and -0.01 (0.98). For subjects with GMFCS I/II, the Spearman's rank correlation coefficient for standing time and BMI was -0.55 (p= 0.08). For the GMFCS III and GMFCS IV/V groups the respective correlation was -0.19 (0.67) and 0.00 (1.00).

CONCLUSIONS

Subjects with GMFCS level I or II who engaged in more activity tended to have more favorable anthropometric profiles. Subjects GMFCS III, IV, or V did not have a similar trend. Our findings suggest factors beyond activity patterns affect anthropometrics to a greater degree in those with higher GMFCS levels.

Safety and efficacy of repeat long-term incobotulinumtoxinA treatment for lower limb or combined upper/lower limb spasticity in children with cerebral palsy

PURPOSE

The open-label phase 3 "Treatment with IncobotulinumtoxinA in Movement Open-Label" (TIMO) study investigated longer-term safety and efficacy of incobotulinumtoxin A in children/adolescents with cerebral palsy (CP).

METHODS

Patients on standard treatment, with unilateral or bilateral lower limb (LL) or combined upper limb (UL)/LL spasticity received four incobotulinumtoxinA injection cycles (16 or 20 Units/kg bodyweight total [maximum 400 or 500 Units] per cycle depending on ambulatory status/clinical pattern treated), each followed by 12-16 weeks' observation. Treatment for pes equinus was mandatory; flexed knee or adducted thigh were options for unilateral treatment and/or ULs for unilateral/bilateral treatment. The primary endpoint was safety; changes in Ashworth Scale and Gross Motor Function Measure-66 scores, and Global Impression of Change Scale scores at week 4 of each injection cycle were also evaluated.

RESULTS

IncobotulinumtoxinA (≤500 Units for ≤98 weeks) was safe, well-tolerated, and effective across all endpoints for multipattern treatment of LL and combined LL/UL spasticity in ambulant/nonambulant children/adolescents with CP. Treatment effects increased with each injection cycle. No new/unexpected safety concerns were identified.

CONCLUSION

IncobotulinumtoxinA showed a good safety and tolerability profile, with efficacy over multiple clinical presentations. As an adjunct treatment, it offers an effective, individualized treatment option for pediatric CP-related spasticity.

The next generation of peer review

Peer review is an important process that produces the evidence-based medicine that guides the standards by which we provide care. We all have a role to contribute to the advancement of our field through involvement in this process. Opportunities and guidance to the next generation of reviewers is essential to continue to move our field forward and is supported by the JPRM Residents and Fellows Program.

Spasticity-related pain in children/adolescents with cerebral palsy. Part 1: Prevalence and clinical characteristics from a pooled analysis

PURPOSE

A large prospective database from three Phase 3 studies allowed the study of spasticity-related pain (SRP) in pediatric cerebral palsy (CP).

METHODS

Baseline (pretreatment) SRP data occurring during different activities in children/adolescents (aged 2-17 years, ambulant/nonambulant) with uni-/bilateral spastic CP was obtained using the Questionnaire on Pain caused by Spasticity (QPS; six modules specific to spasticity level [lower limb (LL) or upper limb (UL)] and type of respondent [child/adolescent, interviewer, or parent/caregiver]).

RESULTS

At baseline, 331 children/adolescents with LL- and 155 with UL-spasticity completed at least one key item of their modules; LL/UL QPS modules of parent/caregivers were at least partially completed (key items) by 841/444 parents/caregivers. SRP with at least one activity at baseline was self-reported in 81.9% /69.7% (LLs/ULs) of children/adolescents with spasticity. Parents/caregivers observed LL/UL SRP behaviors in 85.9% /77.7% of their children, with multiple body regions affected. SRP negatively affected the great majority of the children in various ways. Child/adolescent-reported mean SRP intensity and parent/caregiver-observed mean SRP behavior frequencies were higher for LLs than ULs, and the level of SRP increased with more physically demanding activities.

CONCLUSION

These data suggest SRP is more common and intense in pediatric CP than generally thought, emphasizing the need for effective, long-term pain management.

Dysautonomia and functional impairment in rare developmental and epileptic encephalopathies: the other nervous system

AIM

To determine whether functional impairments and autonomic symptoms are correlated in young people with developmental and epileptic encephalopathies (DEEs).

METHOD

Cross-sectional, online surveys (2018-2020) of parents recruited from family groups obtained information on several aspects of children's conditions including functional abilities (mobility, hand use, eating, and communication), 18 autonomic symptoms in six groups (cardiac, respiratory, sweating, temperature, gastrointestinal, and other), and parental stress. Bivariate and multivariable logistic regression analyses examined associations of dysautonomias with functional impairment, adjusted for type of DEE and age.

RESULTS

Of 313 participants with full information on function and dysautonomias, 156 (50%) were females. The median age was 8 years (interquartile range 4-12y); 255 (81%) participants had symptoms in at least one autonomic symptom group; 283 (90%) had impairment in at least one functional domain. The number of functional impairment domains and of autonomic symptom groups varied significantly across DEE groups (both p<0.001). The number of functional impairment domains and of autonomic symptom groups were correlated (Spearman's r=0.35, p<0.001) on bivariate and multivariable analysis adjusted for DEE group and age. Parental stress was also independently correlated with dysautonomias (p<0.001).

INTERPRETATION

Parent-reported dysautonomias are common in children with DEEs. They correlate with extent of functional impairment and may contribute to caregiver stress. What this paper adds Dysautonomic symptoms are common in young people with developmental and epileptic encephalopathies (DEEs). Burden of dysautonomias is strongly correlated with burden of functional impairments. Aspects of dysautonomic function may provide biomarkers of DEE disease severity.

IncobotulinumtoxinA Efficacy/Safety in Upper-Limb Spasticity in Pediatric Cerebral Palsy: Randomized Controlled Trial

BACKGROUND

This randomized phase 3 study with double-blind main period (MP) and open-label extension (OLEX; NCT02002884) assessed incobotulinumtoxinA safety and efficacy for pediatric upper-limb spasticity treatment in ambulant/nonambulant (Gross Motor Function Classification System [GMFCS] I-V) patients, with the option of combined upper- and lower-limb treatment.

METHODS

Patients were aged two to 17 years with unilateral or bilateral spastic cerebral palsy (CP) and Ashworth Scale (AS) score ≥2 in treatment-selected clinical patterns. In the MP, patients were randomized (2:1:1) to incobotulinumtoxinA 8, 6, or 2 U/kg body weight (maximum 200, 150, 50 U/upper limb), with optional lower-limb injections in one of five topographical distributions (total body dose ≤16 to 20 U/kg, maximum 400 to 500 U, depending on body weight and GMFCS level). In the OLEX, patients received three further treatment cycles, at the highest MP doses (8 U/kg/upper limb group). Outcomes included AS, Global Impression of Change Scale (GICS), and adverse events (AEs).

RESULTS

AS scores improved from baseline to week 4 in all MP dose groups (n = 350); patients in the incobotulinumtoxinA 8 U/kg group had significantly greater spasticity improvements versus the 2 U/kg group (least-squares mean [standard error] for upper-limb main clinical target pattern -1.15 [0.06] versus -0.93 [0.08]; P = 0.017). Investigator's, child/adolescent's, and parent/caregiver's GICS scores showed improvements in all groups. Treatment benefits were sustained over further treatment cycles. AE incidence did not increase with dose or repeated treatment across GMFCS levels.

CONCLUSIONS

Data provide evidence for sustained efficacy and safety of multipattern incobotulinumtoxinA treatment in children and adolescents with upper-limb spasticity.

Breast Health Experiences in Women with Cerebral Palsy: A Qualitative Approach

Background: All women, regardless of disability status, should receive screening for breast cancer. In 2010, only 61.4% of women with disabilities (WWD) received a mammogram in the past 2 years compared to 75% of women without disabilities. The purpose of this study is to explore breast cancer screening experiences of women with cerebral palsy (CP) with the aim of identifying factors that could improve screening rates for WWD.

Methods: Thirty women with CP, 22–72 years of age, residing in New York, Chicago, or Los Angeles areas participated in individual or group interviews about breast health. Twenty-five of the participants identified themselves as white, and one self-identified as Hispanic or Latina. Facilitators used a semistructured guide across the three sites. Qualitative analysis utilized an iterative coding process to generate themes related to breast health.

Results: We identified six predominant themes in these interviews, which revolved around physical, environmental, and emotional barriers and facilitators. Within each theme, we identified subthemes. Physical barriers included the most highly identified subthemes of age, pain, holding breath, holding still, spasticity, standing, fatigue, and positioning. Self-advocacy and communication between the health care professional and the patient were the most common subthemes identified among the emotional facilitators.

Conclusion: Women with CP perceive a variety of issues impacting breast health. These findings are multifaceted and suggest that improving screening rates for women with CP should address these barriers and facilitators.

Clinical Characteristics Associated with Reduced Selective Voluntary Motor Control in the Upper Extremity of Individuals with Spastic Cerebral Palsy

BACKGROUND

Selective voluntary motor control (SVMC) in the upper extremity is often impaired in individuals with cerebral palsy (CP) and can be assessed quantitatively and qualitatively using the Test of Arm Selective Control (TASC).

METHODS

Fifty-six individuals with spastic CP (5-18 years old) were included. Descriptors associated with administration of the TASC were analyzed according to the type of CP and arm joint using Chi-square and Kruskal-Wallis tests. ABILHAND-Kids scores were compared between participants with and without mirror movements using a t-test.

RESULTS

All groups of children with spastic CP had incidence of TASC movement descriptors. There was a main effect of topography of CP on extra movements, decreased active range of motion, tightness, spasticity, and mirroring, and an additional main effect of joint on mirroring. Participants with mirroring had lower ABILHAND-Kids scores than those without mirroring.

CONCLUSIONS

Systematically observing arm movements using the TASC revealed differences across participants.

An autosomal dominant neurological disorder caused by de novo variants in FAR1 resulting in uncontrolled synthesis of ether lipids

PURPOSE

In this study we investigate the disease etiology in 12 patients with de novo variants in FAR1 all resulting in an amino acid change at position 480 (p.Arg480Cys/His/Leu).

METHODS

Following next-generation sequencing and clinical phenotyping, functional characterization was performed in patients' fibroblasts using FAR1 enzyme analysis, FAR1 immunoblotting/immunofluorescence, and lipidomics.

RESULTS

All patients had spastic paraparesis and bilateral congenital/juvenile cataracts, in most combined with speech and gross motor developmental delay and truncal hypotonia. FAR1 deficiency caused by biallelic variants results in defective ether lipid synthesis and plasmalogen deficiency. In contrast, patients' fibroblasts with the de novo FAR1 variants showed elevated plasmalogen levels. Further functional studies in fibroblasts showed that these variants cause a disruption of the plasmalogen-dependent feedback regulation of FAR1 protein levels leading to uncontrolled ether lipid production.

CONCLUSION

Heterozygous de novo variants affecting the Arg480 residue of FAR1 lead to an autosomal dominant disorder with a different disease mechanism than that of recessive FAR1 deficiency and a diametrically opposed biochemical phenotype. Our findings show that for patients with spastic paraparesis and bilateral cataracts, FAR1 should be considered as a candidate gene and added to gene panels for hereditary spastic paraplegia, cerebral palsy, and juvenile cataracts.

A resource guide to understanding cerebral palsy: Commentary on collaboration to support health literacy and shared decision making

BACKGROUND

Shared decision-making is a newer model of patient-centered healthcare; it is particularly important for people with chronic conditions including cerebral palsy. Health literacy is the ability of an individual to obtain, communicate, process, and understand health information and is a crucial component to shared decision-making. With the abundance of information that can be found on the internet, it can be difficult to navigate and determine which websites contain reliable information.

OBJECTIVE

Provide a commentary article aimed to provide healthcare professionals a current, annotated list of reliable online resources in regards to cerebral palsy throughout the lifespan with the goal of supporting health literacy and therefore improving shared decision-making and reducing disparity.

CONCLUSION

Access to accurate and reliable information is an important aspect of health literacy, which in turn will optimize outcomes and build the foundation for shared decision-making between the provider and the patient. Educational materials should be easy to navigate and utilize. This article serves as a guide for reliable CP resources.

IncobotulinumtoxinA for the treatment of lower-limb spasticity in children and adolescents with cerebral palsy: A phase 3 study

PURPOSE

Investigate the efficacy and safety of multipattern incobotulinumtoxinA injections in children/adolescents with lower-limb cerebral palsy (CP)-related spasticity.

METHODS

Phase 3 double-blind study in children/adolescents (Gross Motor Function Classification System - Expanded and Revised I-V) with unilateral or bilateral spastic CP and Ashworth Scale (AS) plantar flexor (PF) scores ⩾ 2 randomized (1:1:2) to incobotulinumtoxinA (4, 12, 16 U/kg, maximum 100, 300, 400 U, respectively) for two 12- to 36-week injection cycles. Two clinical patterns were treated. Pes equinus (bilateral or unilateral) was mandatory; if unilateral, treatment included flexed knee or adducted thigh.

ENDPOINTS

Primary: AS-PF change from baseline to 4 weeks; Coprimary: investigator-rated Global Impression of Change Scale (GICS)-PF at 4 weeks; Secondary: investigator's, patient's, and parent's/caregiver's GICS, Gross Motor Function Measure-66 (GMFM-66).

RESULTS

Among 311 patients, AS-PF and AS scores in all treated clinical patterns improved from baseline to 4-weeks post-injection and cumulatively across injection cycles. GICS-PF and GICS scores confirmed global spasticity improvements. GMFM-66 scores indicated better motor function. No significant differences between doses were evident. Treatment was well-tolerated, with no unexpected treatment-related adverse events or neutralising antibody development.

CONCLUSION

Children/adolescents with lower-limb spasticity experienced multipattern benefits from incobotulinumtoxinA, which was safe and well-tolerated in doses up to 16 U/kg, maximum 400 U.

Women with cerebral palsy: A qualitative study about their experiences with sexual and reproductive health education and services

PURPOSE

To explore the recalled experiences of women with CP regarding sexual health education and services they received.

METHODS

Semi-structured interviews and focus groups were conducted at four academic tertiary hospitals with 33 adult women with CP. Templates were used to ask about four key content domains: appointment planning (including planning for a gynecologic exam), accessibility of services, experiences with providers, and recommendations for improvement. Sessions were transcribed verbatim and analyzed to generate a coding dictionary. Blinded coding was carried out for each transcript, with duplicate coding used to confirm identified themes. Iterative analysis was used to identify and consolidate coding and key themes.

RESULTS

Similar barriers were discussed at the four sites, including lack of accessible exam tables, hospital staff unfamiliar with physical disabilities, and assumptions that women with CP are not sexually active. Many described the sexual education they received as brief, omitted, or mistimed. Self-advocacy was crucial, and recommended strategies ranged from pre-gynecologic exam medication to visit checklists.

CONCLUSION

Reproductive health education for young women with CP is frequently inadequate. Medical professionals lack relevant knowledge and awareness; medical facilities lack necessary infrastructure. Recommendations for improvements are made.

Nonseizure consequences of Dravet syndrome, KCNQ2-DEE, KCNB1-DEE, Lennox-Gastaut syndrome, ESES: A functional framework

RATIONALE

Developmental epilepsies and encephalopathies (DEEs) are characterized by many severe developmental impairments, which are not well-described. A functional framework could facilitate understanding of their nature and severity and guide the selection instruments to measure improvements in therapeutic trials.

METHODS

An online survey administered through several parent-organized foundations utilized accepted functional classifications and questionnaires derived from common instruments to determine levels of mobility, fine motor, communication, and feeding functions. Statistical analyses focused on overall levels of function and across-group comparisons adjusted for age.

RESULTS

From 6/2018 to 2/2020, 252 parents provided information for one or more functional domains. Median age was 7.2 years (interquartile range (IQR): 3.9 to 11.8), and 128 (51%) were females. DEE groups were Dravet syndrome (N = 72), KCNQ2-DEE (N = 80), KCNB1-DEE, (N = 33), Lennox-Gastaut syndrome (LGS; N = 26), electrographic status epilepticus in sleep (ESES; N = 15), and others (N = 26). Overall, functional hand grasp was absent in 48 (20%). Of children ≥2 years old, 60/214 (28%) could not walk independently, 85 (40%) were dependent on someone else for feeding, and 153 (73%) did not effectively communicate with unfamiliar people. Impairments entailing absence or near absence of independent function (profound impairment) were observed in 0, 1, 2, 3, and 4 domains for 58 (25%), 78 (34%), 40 (17%), 33 (14%), and 22 (10%) children, respectively. After adjustment for age, impairment levels varied substantially across DEE group for mobility (p < 0.0001), feeding (p < 0.0001), communication (p < 0.0001), hand grasp (p < 0.0001), and number of profoundly impaired domains (p < 0.0001). Three or four profoundly affected domains were reported in 44% of KCNQ2-DEE participants, followed by LGS (29%), KCNB1-DEE (27%), ESES (7%), and Dravet syndrome (6%).

CONCLUSIONS

Many children with DEEs experience severe functional impairments, and few children have typical function. As precision therapies will emphasize nonseizures consequences of DEEs, understanding the nature of abilities and impairments will be critical to selecting appropriate outcome measures in therapeutic trials.

Neural and non-neural contributions to ankle spasticity in children with cerebral palsy

AIM

To assess the neural and non-neural contributions to spasticity in the impaired ankle of children with cerebral palsy (CP).

METHOD

Instrumented tapping of the Achilles tendon was done isometrically to minimize non-neural contributions and elicit neural contributions. Robot-controlled ankle stretching was done at various velocities, including slow stretching, with minimized neural contributions. Spasticity was assessed as having neural (phasic and tonic stretch reflex torque, tendon reflex gain, contraction rate, and half relaxation rate) and non-neural origin (elastic stiffness and viscous damping) in 17 children with CP (six females and 11 males; mean age [SD] 10y 8mo [3y 11mo], range 4y-18y) and 17 typically developing children (six females and 11 males; mean age [SD] 12y 7mo [2y 9mo], range 7y-18y). All torques were normalized to weight×height.

RESULTS

Children with CP showed increased phasic and tonic stretch reflex torque (p=0.004 and p=0.001 respectively), tendon reflex gain (p=0.02), contraction rate (p=0.038), half relaxation rate (p=0.02), elastic stiffness (p=0.01), and viscous damping (p=0.01) compared to typically developing children.

INTERPRETATION

Controlled stretching and instrumented tendon tapping allow the systematic quantification of various neural and non-neural changes in CP, which can be used to guide impairment-specific treatment.

WHAT THIS PAPER ADDS

Ankle spasticity is associated with increased phasic and tonic stretch reflexes, tendon reflex gain, and contraction and half relaxation rates. Ankle spasticity is also associated with increased elastic stiffness and viscous damping.

Understanding children with cerebral palsy and bullying: A mixed methods approach

AIM

The study aims to explore the views of children with cerebral palsy (CP) regarding their experiences being bullied and their perceptions of their primary bully.

METHOD

Forty-three children aged 10-18 with CP were given the California Bullying Victimization Scale. Fourteen of the children shared a bullying experience orally or written after the survey. Using a mixed methods analysis, the survey answers were tabulated with descriptive statistics and analysed by Gross Motor Function Classification System (GMFCS) level. The comments were coded to determine qualitative responses.

RESULTS

Most bullied children viewed the bully as less than or at least equal to them regarding popularity (73%), performance in schoolwork (85%), and physical strength (56%). Bullied children preferentially told an adult at home. Code words and common categories of bullying were determined from their experiences.

INTERPRETATION

Children with CP experience bullying but do not view themselves as inferior to their bully in popularity, intelligence, or physical strength. Most bullied participants confided in an adult at home. Children with GMFCS Levels 1, 2, and 3 seem to be at greater risk for bullying than children with GMFCS Levels 4 and 5. Children with CP demonstrate individualized strategies for resilience with reliance on adults for resources.

Spasticity and pain in adults with cerebral palsy

AIM

To evaluate whether spasticity measures are related to pain in adults with cerebral palsy (CP).

METHOD

This cross-sectional study recruited individuals aged 16 to 89 years with a diagnosis of CP. Participants completed the Penn Spasm Frequency Scale (PSFS), Brief Pain Inventory (BPI), and PROMIS Pain Interference measures. The Modified Ashworth Scale (MAS) and Tardieu spasticity angles of six joints were rated and summed to composite MAS and Tardieu scores for each participant. Associations between spasticity and pain measures were evaluated.

RESULTS

Forty-seven participants (27 females, 20 males) with a mean age of 35 years 7 months (range 18-77y) spanning all Gross Motor Function Classification System (GMFCS) levels were included. Twenty-six participants reported their average pain level on BPI as greater than 0 over the past week (median pain level 4.0). Median PSFS was 1.0 (range 0.0-1.0) and this correlated with average BPI and Pain Interference T scores (median 40.7; ρ=0.33 and ρ=0.31 respectively [both p=0.01]). When adjusted for pain medication use and age, MAS correlated with BPI (ρ=0.30; p=0.04). Other pain and spasticity measures, or GMFCS level, were not significantly related with pain interference or BPI rating. Age was weakly associated with BPI (slope=0.10; p<0.01).

INTERPRETATION

PROMIS Pain Interference was lower than population-based norms. Patient-rated spasm frequency demonstrated better association with pain levels and interference than physician-rated MAS and Tardieu.

WHAT THIS PAPER ADDS

Pain was not associated with Gross Motor Function Classification System level. Pain increased with age, as anticipated. Self-reported spasm scores were associated with increased pain in contrast to clinical examination scales. Adjusted, summed spasticity on the Modified Ashworth Scale was associated with pain scores on the Brief Pain Inventory. Although pain is experienced by adults with cerebral palsy, pain did not interfere with activities.

The association of hepatoblastoma, prematurity and cerebral palsy: Case reports

PURPOSE

Hepatoblastoma is the most common primary liver tumor in children and has a greater incidence in children with a history of prematurity and very low birth weight. To increase awareness of the association between prematurity and hepatoblastoma for health care providers who treat children with Cerebral Palsy (CP), we present two case reports.

METHODS

Two case reports of premature, very low birth weight infants with hepatoblastoma are described and a literature review of hepatoblastoma in the setting of prematurity and cerebral palsy is performed.

RESULTS

Each patient had a history of 26-28 week prematurity, very low birth weight, and CP. Both presented with worsening constipation and abdominal distension that did not respond to oral medications. Appropriate referrals to the ER were made which lead to a diagnosis of hepatoblastoma. Pediatric rehabilitation was a source of referral for diagnosis in one patient and aided in the rehabilitation course following treatment for both patients.

CONCLUSIONS

Hepatoblastoma is the most common primary liver tumor in children and has an increased incidence in children with a history of prematurity and very low birth weight. Providers who frequently care for the very low birth weight and premature children with CP should be aware of this correlation and include hepatoblastoma in the differential when managing patients with suddenly worsening constipation or abdominal distension. Pediatric physiatrists and other providers for these patients could be a source of referrals and diagnosis leading to timely treatment.

Machine Learning of Infant Spontaneous Movements for the Early Prediction of Cerebral Palsy: A Multi-Site Cohort Study

BACKGROUND

Early identification of cerebral palsy (CP) during infancy will provide opportunities for early therapies and treatments. The aim of the present study was to present a novel machine-learning model, the Computer-based Infant Movement Assessment (CIMA) model, for clinically feasible early CP prediction based on infant video recordings.

METHODS

The CIMA model was designed to assess the proportion (%) of CP risk-related movements using a time-frequency decomposition of the movement trajectories of the infant's body parts. The CIMA model was developed and tested on video recordings from a cohort of 377 high-risk infants at 9-15 weeks corrected age to predict CP status and motor function (ambulatory vs. non-ambulatory) at mean 3.7 years age. The performance of the model was compared with results of the general movement assessment (GMA) and neonatal imaging.

RESULTS

The CIMA model had sensitivity (92.7%) and specificity (81.6%), which was comparable to observational GMA or neonatal cerebral imaging for the prediction of CP. Infants later found to have non-ambulatory CP had significantly more CP risk-related movements (median: 92.8%, p = 0.02) compared with those with ambulatory CP (median: 72.7%).

CONCLUSION

The CIMA model may be a clinically feasible alternative to observational GMA.

Combined Ankle/Knee Stretching and Pivoting Stepping Training for Children With Cerebral Palsy

Although various treatment methods have been investigated to reduce spasticity and intoeing gait in children with cerebral palsy (CP), methods to concurrently reduce an intoeing gait and associated ankle/knee stiffness and spasticity according to a child's specific needs are lacking. This study aimed to develop a training program to improve walking function and transverse-plane (pivoting) neuromuscular control and reduce spasticity and intoeing gait deviations. Eight children with diplegic CP and intoeing gait participated in this 6-week combined robotic ankle and/or knee intelligent stretching and pivoting neuromuscular control training program (Subject-specific Stretching and Pivoting Off-axis Neuromuscular control Training, [SS-POINT]). The effects of SS-POINT were evaluated using neuromechanical, functional, and clinical outcome measures and compared to those for eight children with CP and intoeing gait who participated in pivoting neuromuscular control training (POINT) alone in a previous study.

RESULTS

After the SS-POINT program, subjects with CP showed reduced knee stiffness and intoeing angle, and improvements in both joint and leg functions in terms of ankle and knee active range of motion, ankle dorsiflexor strength, proprioception, walking speed, balance, and minimum pivoting angle. Furthermore, improvements in proprioceptive acuity and minimum pivoting angle after the SS-POINT were greater than those after the POINT.

CONCLUSION

The SS-POINT approach can be used as a subject-specific training program for improving leg and walking functions and reducing intoeing during gait.

SIGNIFICANCE

This approach can serve as an individualized intervention at the joint and walking levels to maximize intervention effects by adjusting training targets, sequences, and intensities to meet the individual needs of children with CP.

Nonsurgical Treatment Options for Upper Limb Spasticity

There are many nonsurgical treatment options for patients with upper limb spasticity. This article presents an algorithmic approach to management, encompassing evidence-based rehabilitation therapies, medications, and promising new orthotic and robotic innovations.

The development of Bayesian integration in sensorimotor estimation

Examining development is important in addressing questions about whether Bayesian principles are hard coded in the brain. If the brain is inherently Bayesian, then behavior should show the signatures of Bayesian computation from an early stage in life. Children should integrate probabilistic information from prior and likelihood distributions to reach decisions and should be as statistically efficient as adults, when individual reliabilities are taken into account. To test this idea, we examined the integration of prior and likelihood information in a simple position-estimation task comparing children ages 6-11 years and adults. Some combination of prior and likelihood was present in the youngest sample tested (6-8 years old), and in most participants a Bayesian model fit the data better than simple baseline models. However, younger subjects tended to have parameters further from the optimal values, and all groups showed considerable biases. Our findings support some level of Bayesian integration in all age groups, with evidence that children use probabilistic quantities less efficiently than adults do during sensorimotor estimation.

Advanced Robotic Therapy Integrated Centers (ARTIC): an international collaboration facilitating the application of rehabilitation technologies

Background

The application of rehabilitation robots has grown during the last decade. While meta-analyses have shown beneficial effects of robotic interventions for some patient groups, the evidence is less in others. We established the Advanced Robotic Therapy Integrated Centers (ARTIC) network with the goal of advancing the science and clinical practice of rehabilitation robotics. The investigators hope to exploit variations in practice to learn about current clinical application and outcomes. The aim of this paper is to introduce the ARTIC network to the clinical and research community, present the initial data set and its characteristics and compare the outcome data collected so far with data from prior studies.

Methods

ARTIC is a pragmatic observational study of clinical care. The database includes patients with various neurological and gait deficits who used the driven gait orthosis Lokomat® as part of their treatment. Patient characteristics, diagnosis-specific information, and indicators of impairment severity are collected. Core clinical assessments include the 10-Meter Walk Test and the Goal Attainment Scaling. Data from each Lokomat® training session are automatically collected.

Results

At time of analysis, the database contained data collected from 595 patients (cerebral palsy: n = 208; stroke: n = 129; spinal cord injury: n = 93; traumatic brain injury: n = 39; and various other diagnoses: n = 126). At onset, average walking speeds were slow. The training intensity increased from the first to the final therapy session and most patients achieved their goals.

Conclusions

The characteristics of the patients matched epidemiological data for the target populations. When patient characteristics differed from epidemiological data, this was mainly due to the selection criteria used to assess eligibility for Lokomat® training. While patients included in randomized controlled interventional trials have to fulfill many inclusion and exclusion criteria, the only selection criteria applying to patients in the ARTIC database are those required for use of the Lokomat®. We suggest that the ARTIC network offers an opportunity to investigate the clinical application and effectiveness of rehabilitation technologies for various diagnoses. Due to the standardization of assessments and the use of a common technology, this network could serve as a basis for researchers interested in specific interventional studies expanding beyond the Lokomat®.

Breast cancer screening in women with cerebral palsy: Could care delivery be improved?

BACKGROUND

Women with disabilities (WWD) have reported lower mammography rates than the general population, however rates for women with cerebral palsy (CP) have not been specifically studied.

OBJECTIVE

To evaluate mammography rates in women with CP and to identify strengths and barriers with their screening experience.

METHODS

Women with CP 40 years or older (n = 118) participating in a prospective cross-sectional survey were queried regarding screening status, imaging modality, and accommodation needs and availability. Categorical variables were summarized and Chi-square testing used to assess factors contributing to screening compliance. The effect of functional factors on screening was evaluated using logistic regression.

RESULTS

77 women (65.3%) had mammograms within the past two years; 56 (47.5%) were screening mammograms. Severity of fine motor deficits was associated with lack of screening (OR 0.559, p = 0.019). 85 (72.0%) experienced positive staff attitudes. Facilities most often met needs for ramps, elevators, and/or wide doorways (92.9%), exam explanations (84.4%), and accessible parking (82.5%). Needs least often met included accommodations for standing (59.3%) or for difficulties with arm/shoulder positioning (57.1%), and wheelchair-accessible mammogram machines (59.1%).

CONCLUSIONS

The screening compliance rate for women with CP is low, although the 2-year mammography rate is comparable to that reported for WWD and the general female U.S.

POPULATION

Women were usually offered respectful care. Adequate physical accommodations during the procedure were reported less often than overall facility environmental accommodations. These findings demonstrate the need for improved screening rates in women with CP, and highlight areas for improving their screening experience.