A French observational study of botulinum toxin use in the management of children with cerebral palsy: BOTULOSCOPE

BACKGROUND

Dystonia and spasticity are common symptoms in children with Cerebral Palsy (CP), whose management is a challenge to overcome in order to enable the harmonized development of motor function during growth.

AIM

To describe botulinum toxin A (BTX-A) use and efficacy as a treatment of focal spasticity in CP children in France.

METHODS

This prospective observational study included 282 CP children mostly administered according to French standards with BTX-A in lower limbs. Realistic therapeutic objectives were set with parents and children together before treatment initiation and assessed using the Visual Analogue Scale (VAS). Child management was recorded and the efficacy of injections was assessed during a 12-month follow-up period by physicians (Modified Ashworth Scale, joint range of motion, Physician Rating Scale, Gillette Functional Assessment Questionnaire and Gross Motor Function Measure-66) and by patients/parents (Visual Analogue Scale).

RESULTS

BTX-A treatment was administered in different muscle localizations at once and at doses higher than those recommended by the French Health Authorities. Children were treated in parallel by physiotherapy, casts and ortheses. Injections reduced spasticity and improved joint range of motion, gait pattern and movement capacity. Pain was reduced after injections. BTX-A administration was safe: no botulism-like case was reported. The log of injected children who were not included in the study suggested that a large population could benefit from BTX-A management.

CONCLUSIONS

We showed here the major input of BTX-A injections in the management of spasticity in CP children. The results are in favor of the use of BTX-A as conservative safe and efficient treatment of spasticity in children, which enables functional improvement as well as pain relief.

Qualité de vie de l'enfant polyhandicapé: questionnaire portant sur l'influence de l'état de santé et de l'alimentation entérale

To resort to gastrostomy feeding is a difficult decision to take in children with severe disability, the objective being better quality of life.

OBJECTIVES

To describe quality of life in children with severe disability and to look for factors which influence this quality of life, in particular gastrostomy.

METHOD

Descriptive study in 28 patients, aged 1 to 18 years, with severe motor and mental disability, with or without gastrostomy. The studied factors were: health and nutritional status and quality of life. The quality of life was evaluated with QUALIN questionnaire, specifically designed for infants.

RESULTS

This questionnaire was pertinent and well accepted by the family. Quality of life was influenced by capacity of communication (P=0.006), quality of sleeping (P=0.004), digestive problems (P<0.05) and age (P=0.031).

CONCLUSION

Gastrostomy did not impair quality of life. Its benefit was estimated as high as 8.71/10 in average by parents.

[Scoliosis outcome in cerebral palsy patients with total body involvement: a descriptive study of 61 children and adults, with or without spinal fusion]

INTRODUCTION

The literature is controversial about how to manage scoliosis in cerebral palsy patients with total body involvement. Spinal fusion is admitted as the only means to stop the evolution of the curve but remains associated with many complications.

OBJECTIVES

The aim of this descriptive study was to formulate hypotheses concerning the interest of spinal fusion in this population.

METHODS

This descriptive cross-sectional study was conducted in 61 patients aged 4 to 48 years (mean 24 years, median 20 years) with severe scoliosis (Cobb score>40 degrees ). Each patient had undergone recent X-ray of the spine and hips and a clinical exam. Data were collected on orthopaedic and functional status, health level (pulmonary, digestive, nutrition, skin parameters), pain, and subjective quality of life (sQoL).

RESULTS

Data were collected for all 61 patients (35 females, 26 males), 16 underwent spinal fusion at a mean age of 16.5 years (prevalence of 32.0%). No significant difference was found between patients with a spinal instrumentation and others in variables tested. A difference might be present with functional level, but only results from a longitudinal study would be conclusive. Pain was prevalent (19.7%), not treated sufficiently (only 50% receive treatment), and contributes to poor sQoL (p<0.042). Among the other data collected, nutritional level has the greatest influence on general health status (p<0.05).

CONCLUSIONS

Systematic spinal fusion cannot be generalized for this population of patients with cerebral palsy and total body involvement. However, health status and quality of life could be improved with better care of nutritional problems and pain.

Douleur, ostéopénie et composition corporelle chez 22 patients atteints de dystrophie musculaire progressive de Duchenne. Étude descriptive

OBJECTIVES

To study the link between pain, osteopenia and body composition in patients with Duchenne muscular dystrophy and to present a detailed questionnaire to evaluate their pain.

MATERIALS AND METHODS

Twenty-two boys with Duchenne muscular dystrophy, mean age 11.4+/-4.0 years, were examined between February and March 2003. They were asked to complete a detailed questionnaire and undergo a global assessment of pain on a visual analog scale and muscular testing. They were also asked about a history of fractures. Their bone mineral content at the lumbar spine and femoral neck levels, as well as their body composition in fat and lean mass, were assessed by dual energy absorptiometry.

RESULTS

The mean age for walking incapacity was 8.8+/-1.7 years. The youngest patients, who were still able to walk, had a higher level of pain than patients who depended on wheelchairs. No significant correlation was established between pain and osteopenia. One in 2 patients had spontaneous pain, and mobilization was painful for 21. The score obtained by detailed questioning about pain correlates with the average pain scores on visual analog scales. The bone mineral content was lower, especially in the lower limbs, had decreased before the inability to walk and was correlated with muscular weakness. Fractures were more frequent in mobile patients and usually occurred after a fall.

CONCLUSION

Although pain in Duchenne muscular dystrophy has not been extensively studied, it is frequent and significant. Twenty-one patients had moderate to severe pain. The youngest patients had intense pain, especially during mobilisation. To evaluate this pain, we propose to use the mean results of 2 visual analog scales associated with a detailed questionnaire. However, in this study, Duchenne muscular dystrophy, pain and osteopenia were not correlated. Dual X-ray absorptiometry provides interesting information about bone mineral content, fat body mass and lean body mass. The fat body mass was higher than normal in our patients. The bone mineral content and lean body mass were lower than that for normal children, because the dystrophic process advances with age. The fracture prevalence was high, especially in young patients. Falling was the most common mechanism of fracture.

[Clinical assessment of spasticity in children]

This article presents the four principle steps of assessment of children with cerebral palsy. Weakness of some muscles groups and spasticity of others and the subsequent functional impairment can be identified by observation. Analytical assessments of spasticity with the Ashworth and Tardieu scales were compared in 30 children with cerebral palsy, mean age 8.5 years. The results pointed out the complimentary nature of these two scales: The Gross Motor Function Measure, which is a validated scale, is specific for children with cerebral palsy. This measure provides a useful assessment of outcome and a convenient means of evaluating the time-course. Joint assessment is also essential to identify muscle contracture. Assessment of spasticity in children with cerebral palsy must be conducted by a multidisciplinary team to take into account all the aspects involved.

[Neurosurgical treatment of spasticity: indications in children]

Today, we have several efficient neurosurgical treatments of spasticity in children with cerebral palsy. A good indication is possible only if a consensus about the goal of the surgery is found between the surgeon, the child and his/her family, and the reeducation team. This goal is not always functional. Clinical examination is not limited to the analytical assessment of spasticity, but must take into account the general and orthopedic state of the child, and his/her functional evolution, cognitive abilities, habits and general environment. The struggle against spasticity is part of a therapeutical programme which extends over several years. It must be considered before muscular contractures. On lower limbs, in the cases of general spasticity, we propose posterior rhizotomy or intrathecal baclofen administration. Posterior rhizotomy is proposed when a more aggressive intervention is preferred for some muscular groups or when the child's general environment does not allow for the medical care imposed by intrathecal administration. In the case of localized spasticity, botulinum toxin injection permits delaying until the child reaches the age for selective neurotomy. On upper limbs, in children with quadriplegia the indication is essentially physical and occupational therapy. We cannot count on the positive side effects of rhizotomy or intrathecal administration of baclofen on the upper limbs. In children with hemiplegia, with localized or global spasticity of the upper limb, botulinum toxin is proposed as the first form of treatment. Neurotomy or rhizotomy can follow toxin, according to the efficacy of the toxin.

[Initial management of congenital varus equinus clubfoot by Ponseti's method]

The choice of first-line treatment for congenital varus equine clubfoot remains a controversial issue largely dependent on experience. In France, functional treatment predominates. In 1948, Ponseti proposed reducing the deformity with successive casts. Although cast treatment is a very old method, Ponseti's method is original because it is based on strict rules established from anatomic evidence. The goal is not to correct the apparent deformation, but on the contrary to impose a simultaneous supination and abduction of the foot. Once the calcaneopedal block has been derotated, percutaneous tenotomy of the Achilles tendon is performed. We relate our experience with this method and recall the precise technique used to make the casts. After the cast, derotation braces are worn at night but rehabilitation exercises are not required. We emphasize the quality of the clinical reduction achieved as well as the smaller number of patients who require surgery at walking age.

[Pelvic obliquity and scoliosis in non-ambulatory patients with cerebral palsy: a descriptive study of 234 patients over 15 years of age]

PURPOSE OF THE STUDY

Children with cerebral palsy who cannot walk have an oblique pelvis and scoliosis. There is a certain degree of controversy in the literature on the best way to manage this difficult situation. We present a descriptive analysis of a population of non-ambulatory adults with cerebral palsy in order to formulate hypotheses concerning the factors determining scoliosis.

MATERIAL AND METHODS

This descriptive cross-sectional study was conducted in 234 patients aged over 15 years who had cerebral palsy and could not walk. Physical examination and an x-ray of the pelvis and spine in the reclining position were obtained for all patients. The following variables were recorded: luxation and subluxation of the hip, spontaneous deviation attitude, ability or not to turn over in bed, pelvic obliquity, history of bone surgery, defective hip abduction. The statistical analysis accounted for laterality and pelvis obliquity to the scoliosis convexity and the laterality of the hip excentration.

RESULTS

Scoliosis was observed in 66.2% of the patients; it was more than 60 degrees in 34.5%. Two basic groups were distinguished: thoracolumbar scoliosis (41.6%) and lumbar scoliosis (41.6%). The prevalence of oblique pelvi was 59.9% with important difference by side: 31.6% right oblique and 68.4% left oblique pelvi. We were unable to find any relationship between the side of the pelvic obliquity and the side of the scoliosis convexity, the side of the hip excentration, or the deviation attitude, but the deviation attitude appeared to be a risk factor for pelvic obliquity, which itself was a risk factor for excentration, which was a risk factor for scoliosis.

DISCUSSION

Scoliosis is an important problem in this population. Hip luxation is a direct risk factor for scoliosis, but the deviation attitude and pelvic obliquity are intermediary stages. The prevalence of oblique pelvi was greater on the left than the right. This finding should be confirmed in other series before hypotheses can be formulated concerning this difference.

[Quality of life of a population of 54 ambulatory children with cerebral palsy. A cross-sectional study]

To evaluate the impact of handicap on quality of life in children with cerebral palsy and living in family.

METHOD

A descriptive study by investigation was conducted in children with cerebral palsy, with the ability to walk, from 4 to 12 years of age, and in their family. Quality of life was evaluated with the AUQUEI questionnaire. Another questionnaire was given to the parents to collect the different variables, which could influence quality of life of the child.

RESULTS

The mean age was 9 years. Associations between the studied variables and the quality of life were observed for motor function, number of siblings and the quantity of hours of reeducation given by the family. Parents evaluated their quality of life on the visual scale at 72.23 mm (95CI: 51.60-92.84). There was no correlation between the assessment of quality of life of parents and children.

DISCUSSION-CONCLUSION

The better the child's motor function the less satisfied he was. This result shows the poor correlation between quality of life and general condition, impairment or disability. The greater the number of children in the family the less satisfied the child was within the family and the more satisfied the child was at school. A handicapped child has perhaps a more difficult place in the close family and an easier time in a school where the environment is more neutral. The more time that is devoted by the family to reeducation the less the child is satisfied. Quality of life seems to be influenced negatively by the demands of physical therapy, which do not correspond to the reality of the abilities of the child.

[Pelvis obliquity, hip excentration and scoliosis in a population of 120 polyhandicaped adults. Descriptive study]

The objective of this study is to give objective data about neuro-orthopaedic status of the population of polyhandicapped patients for improving both our medical and surgical practices.

MATERIAL AND METHOD

It was a multicentre, cross-sectional study to describe the population of polyhandicapped patients over 15 years of age. Each person was provided with clinical examination and X rays to detect scoliosis, pelvis obliquity and hip excentration (subluxation or dislocation) and other factors associated with polyhandicap. Polyhandicap was defined as a severe handicap linking physical and mental disability and responsible for extreme restriction of autonomy.

RESULTS

One hundred and twelve persons were studied. Mean age was 27.2 years. Etiology of the handicap was neonatal asphyxia (38.3% of patients). 69.0% of patients had no possibility to turn over in lying position. Orthopaedic status was serious : 75.9% scoliosis, 65.2% pelvis obliquity (75% left and 25% right), 19.1% hip dislocation. General condition was precarious : one patient in two had a weight judged lower than normal weight, 32.5% had bedsores, 45.2% suffered from hip pain and only 13.6% received treatment against pain.

DISCUSSION AND CONCLUSION

The description of general and neuro-orthopaedic status of these 120 people with polyhandicap cannot leave us indifferent. Although life expectancy in this population was lower than in normal populations, we are faced with life process and no with accompanying the terminally ill. We urgently need to review preventive care in terms of quality and quantity as well as surgical proposals for treating spasticity in children and adults.

Hip pain in 234 non-ambulatory adolescents and young adults with cerebral palsy: a cross-sectional multicentre study

In orthopaedic clinical practice hip pain is the main complaint of adults with cerebral palsy (CP). The aim of this descriptive study was to specify prevalence of hip pain and to propose methods of care other than surgery. The study was a cross sectional multicentre one based in the Rhĵne-Alpes region. Patients over 15 years of age, with CP who were non-ambulatory were included. Two hundred and thirty-four patients were questioned. Mean age of the patients was 27 years 10 months, median 26 years 1 month, with 59.3% males and 40.7% females. Patients were questioned about pain with precise information about the circumstances of pain, tolerance, and treatment. Pain was judged to be intolerable if it prevented usual activities. Prevalence of hip pain was 47.2%. Pain was judged to be tolerable in 35.6% of the 234 patients, i.e. in 75.5% of patients with hip pain. There were three types of pain: provoked pain, pain linked to position, and spontaneous pain. Medical treatment was given to only 13.6% of patients with hip pain. The first treatment for hip pain is to avoid circumstances where pain occurs; medical treatment is reserved for when daily life cannot be adapted sufficiently to prevent pain. Medical treatment must be appropriate with doses of adequate strength before proposing surgery.

Dispersion equations for vacuum-deposited tilted-columnar biaxial media

We consider the application of the Bragg-Pippard (BP) equations for form birefringence to a tilted-columnar biaxial thin film with columns of index n(c) and voids of known index n(v). In such a situation the three forward BP equations that express the principal refractive indices n1, n2, and n3 as functions of n(c), n(v), the packing fraction p(c), and the depolarization factors L1, L2, and L3 can be inverted. The procedure described for adding dispersion to the principal indices involves entry to the BP model via the inverted equations, modification of n(c) to allow for dispersion, and then exit from the model via the forward BP equations. We discuss the introduction of composite columns to the model to allow for angular dependence of n(c) and the selection of suitable dispersion functions for bulk tantalum oxide, titanium oxide, and zirconium oxide. Theory and experiment both show that the dispersion of the normal-incidence birefringence Deltan of the thin films is several times larger than the dispersion of the individual principal refractive indices.

[Prevalence and morbidity of hip excentration in cerebral palsy: review of the literature]

PURPOSE OF THE STUDY

Excentration of the hip is one of the main orthopedic complications of ante and perinatal cerebral palsy. Excentration can progress to dislocation even if tenotomy is performed. What is the prevalence and morbidity of hip excentration?

METHODS

We reviewed the pertinent literature on the prevalence and morbidity of hip excentration in patients with cerebral palsy based on the Medline and Reedoc databases.

RESULTS

Data presented in the literature vary greatly. Populations are representative of the referral network of the teams reporting the study rather than the cerebral palsy population in general. Signs reported were pain, difficult nursing procedures, difficult sitting position, pressure sores and fractures, but only one sign can be taken fully into account: 50 p. cent of the dislocated hip joints were painful.

DISCUSSION

No one study gives a precise assessment of the prevalence of hip excentration and displacement and its consequences in patients with cerebral palsy. In a population of quadriplegic patients who do not walk, the question is whether complementary tenotomy should be performed, knowking the difficult operative and postoperative situation of such procedures. In this population, walking is an exceptional goal of bone surgery, pain relief and patient comfort are more common goals. Data in this literature (50 p. 100 of the dislocated hips are painful) suggest a prudent approach. However, there is no known marker which can be used to distinguish hips which will become painful from those which will remain pain free. In addition, irreversible cartilage degeneration can cause pain contraindicating reconstructive surgery.

Vacuum deposition of chiral sculptured thin films with high optical activity

We present the technique of bideposition to realize thin-film helicoidal bianisotropic mediums (TFHBM's) that exhibit high optical activity. We show, by experiment as well as by simulation, that the optical rotation produced by these chiral sculptured thin films is roughly proportional to the square of the local linear birefringence. Experimental measurements on bideposited TFHBM's of titanium oxide yield a typical value of 5 degrees /mum for the effective specific rotation in the short-wavelength regime; the corresponding value determined for the standard unideposited TFHBM's is 1 degrees /mum. Both types of TFHBM's are highly optically active in comparison with quartz, fluorite films, and cholesteric liquid crystals. Bideposited TFHBM's will lend themselves to many different types of optical devices.

Serial bideposition of anisotropic thin films with enhanced linear birefringence

We describe a serial bideposition technique in which a tilted substrate is rotated stepwise by half a turn about a normal axis during the evaporation of a metal oxide from a single electron-beam source. Coatings formed by the new method develop a columnar nanostructure that is perpendicular to the substrate and has greatest width or bunching perpendicular to the common deposition plane. With appropriate choice of deposition parameters, the method produces biaxial films with large birefringence, principal axes aligned parallel and perpendicular to the substrate, and improved uniformity. Measured phase retardances for light incident normally on the films are double the corresponding values for tilted-columnar films.

Anisotropic antireflection coatings: design and fabrication

We discuss the design and fabrication of coatings that are antireflecting for p -polarized light at normal incidence and are purposely reflecting for s -polarized light. A single birefringent material, such as obliquely deposited zirconium oxide, forms the layers of the coating. Typical experimental results for a six-layer zirconium oxide anisotropic antireflection coating are R(p) = 0.2% and R(s) = 4.9%. Potential applications of the coatings include polarization-selection devices for lasers.

Selective dorsal rhizotomy in children with cerebral palsy. Results in 18 cases at one year postoperatively

OBJECTIVE

Effects of selective dorsal rhizotomy (SDR) were studied in children with spastic cerebral palsy in orthopaedic and functional fields.

METHODS

In a prospective study, we compared the same population before SDR and 1 year after SDR. This population included children with spastic cerebral palsy, when spasticity was responsible for a halt in the motor skill acquisitions or for orthopaedic complications. All the children had intensive physiotherapy for 6 months postoperatively. We observed spasticity by a 4-point scale, isolation of movement by a 3-point scale, and orthopaedic status by the measure of range of motion, hip migration on the radiography, and function by Gross Motor Function Measure (GMFM) and Abbott scale. All the assessments were done by the same physiotherapist. We compared the results with a Wilcoxon statistic test.

RESULTS

18 quadriplegic children had spastic cerebral palsy; their mean age was 9 years (5.5-16.5 years). We observed a decrease in spasticity in all the muscular groups; increase in range of motion only on abduction and extension of the hips; no evolution of hip migration; an increase of 3.2% in the total GMFM score; 1 child was classified IV before SDR and V after SDR on the Abbott scale; 3 children had planned orthopaedic surgery in the year after SDR; 16 children and their families were highly satisfied with the result of the surgery.

CONCLUSIONS

The decrease in spasticity does not entail prevention of orthopaedic problems in children with quadriplegic spastic cerebral palsy. However, we observed an improvement in qualitative function that is outside the scope of current assessment scales.

Empirical equations for the principal refractive indices and column angle of obliquely deposited films of tantalum oxide, titanium oxide, and zirconium oxide

Values of the transmittance T(s) and the phaseretardation D were recorded in situ at two angles duringthe growth of thin films of tantalum oxide, titanium oxide, andzirconium oxide for deposition angles theta(nu) in the range40 degrees -70 degrees . Column angles for the same films were determinedex situ from scanning electron microscopy photographs ofdeposition-plane fractures. We show that the experimental columnangles are smaller than the corresponding values predicted by thetangent-rule equation psi = tan(-1)(0.5 tan theta(nu)) and that the experimental values fit a modifiedform of the equation psi = tan(-1)(E(1) tan theta(nu)) where E(1) is less than 0.5. We also show that theprincipal refractive indices are represented well by quadraticfunctions of the deposition angle, for example, n(1)(theta(nu)) = A(0) + A(2) theta(nu)(2).

Anisotropic scatter patterns and anomalous birefringence of obliquely deposited cerium oxide films

Cerium oxide films formed by electron-beam evaporation onto oblique substrates are shown to scatter light strongly into spatially anisotropic distributions and to exhibit large normal-incidence birefringence Δ n = n(s) - n(p). The apparatus for direct recording of a useful projection of the scatter distributions is described. Characteristic differences in scatter patterns recorded for cerium oxide, relative to those from tilted columnar titania and zirconia films, are believed to be associated with unusual microstructures recorded for cerium oxide films by scanning electron microscopy. With increasing angle of deposition, the microstructure of cerium oxide was observed to change from densely packed columns to partially isolated needlelike columns at angles that do not obey the tangent rule. In particular, deposition at 55° yielded columns nearly perpendicular to the substrate, yet the normal-incidence birefringence was large. The retardation of the films was recorded as a function of angle of incidence for propagation in the deposition plane. A turning point near 0° incidence for the 55° film confirmed that one principal axis is perpendicular to the substrate. Significant bunching of columns into rows running perpendicular to the deposition plane was recorded by scanning electron microscopy and may account for both the scatter and the birefringence.

Modal contours for biaxial thin-film waveguides

The modal characteristics of a general tilted columnar biaxial thin-film waveguide are displayed by the plots of both Snell's law quantity β = n sin θ and the polarization of the evanescent field at the cover interface on a polar diagram. The association of characteristic features in the modal diagram with the basis fields is demonstrated, and the mechanism that allows p and s modes propagating in the deposition plane to overlap, without the modal contours crossing, is explored.

Anisotropy in thin films: modeling and measurement of guided and nonguided optical properties: application to TiO(2) films

The main purpose of this research is to study the anisotropic behavior of dielectric material in thin-film form. First we present a theory based on a 4 × 4 transfer matrix linking tangential components of the electromagnetic field on one interface to the tangential components of the electromagnetic field on the other interface of an anisotropic thin film. A biaxial model is associated with the columnar structure of the layer. The comparison between measurements of the transmission in normal incidence in cross-polarized light and of guided-mode propagation constants with the calculations allows us to study the biaxial behavior of TiO(2) films. The excellent consistency between measurements and computations demonstrates the validity of the model based on the columnar structure.