Onabotulinum toxin-A (Botox) for spastic equinus in cerebral palsy: a prospective kinematic study

PURPOSE

Botulinum toxin-A (or Botox) is widely used for the management of equinus gait in children with cerebral palsy but few recent studies have included instrumented gait analysis.

METHODS

This was a prospective cohort study. Gait analysis was performed four weeks before and four weeks after Botulinum toxin-A injection for spastic equinus to detect the maximum effects on gait kinematics. Outcome measures included the Gait Profile Score (GPS), the Gait Variable Score (GVS) for the ankle, maximal ankle dorsiflexion and maximal knee extension at midstance.

RESULTS

In all, 37 children participated (20 boys); mean age five years seven months (4 years 1 month to 8 years 2 months); 19 with unilateral and 18 bilateral involvement. At a mean four weeks post-injection, the GPS and ankle GVS were unchanged. However maximum ankle dorsiflexion increased for the whole group; median 7.7° (confidence interval (CI) 4° to 10.6°) to 11.5° (CI 7.7° to 12.9°), p = 0.02. Maximum midstance knee extension was unchanged for the whole group, but median knee flexion increased in children with bilateral involvement; 10.9° (CI 7.4° to 20.8°) to 16.5° (CI 8.4° to 19.7°), p = 0.58.

CONCLUSION

Injections of the gastrocsoleus for spastic equinus did not result in objective improvements in overall gait. Improvements in ankle dorsiflexion for children with bilateral involvement may be offset by deterioration at the knee.

LEVEL OF EVIDENCE

II - prospective cohort study, before and after intervention.

The radiological assessment of pelvic obliquity in cerebral palsy and the impact on hip development

Pelvic obliquity is a common finding in adolescents with cerebral palsy, however, there is little agreement on its measurement or relationship with hip development at different gross motor function classification system (GMFCS) levels. The purpose of this investigation was to study these issues in a large, population-based cohort of adolescents with cerebral palsy at transition into adult services. The cohort were a subset of a three year birth cohort (n = 98, 65M: 33F, with a mean age of 18.8 years (14.8 to 23.63) at their last radiological review) with the common features of a migration percentage greater than 30% and a history of adductor release surgery. Different radiological methods of measuring pelvic obliquity were investigated in 40 patients and the angle between the acetabular tear drops (ITDL) and the horizontal reference frame of the radiograph was found to be reliable, with good face validity. This was selected for further study in all 98 patients. The median pelvic obliquity was 4° (interquartile range 2° to 8°). There was a strong correlation between hip morphology and the presence of pelvic obliquity (effect of ITDL on Sharpe's angle in the higher hip; rho 7.20 (5% confidence interval 5.59 to 8.81, p < 0.001). This was particularly true in non-ambulant adolescents (GMFCS IV and V) with severe pelvic obliquity, but was also easily detectable and clinically relevant in ambulant adolescents with mild pelvic obliquity. The identification of pelvic obliquity and its management deserves closer scrutiny in children and adolescents with cerebral palsy.

The transverse Vulpius gastrocsoleus recession for equinus gait in children with cerebral palsy

We report the results of Vulpius transverse gastrocsoleus recession for equinus gait in 26 children with cerebral palsy (CP), using the Gait Profile Score (GPS), Gait Variable Scores (GVS) and movement analysis profile. All children had an equinus deformity on physical examination and equinus gait on three-dimensional gait analysis prior to surgery. The pre-operative and post-operative GPS and GVS were statistically analysed. There were 20 boys and 6 girls in the study cohort with a mean age at surgery of 9.2 years (5.1 to 17.7) and 11.5 years (7.3 to 20.8) at follow-up. Of the 26 children, 14 had spastic diplegia and 12 spastic hemiplegia. Gait function improved for the cohort, confirmed by a decrease in mean GPS from 13.4° pre-operatively to 9.0° final review (p < 0.001). The change was 2.8 times the minimal clinically important difference (MCID). Thus the improvements in gait were both clinically and statistically significant. The transverse gastrocsoleus recession described by Vulpius is an effective procedure for equinus gait in selected children with CP, when there is a fixed contracture of the gastrocnemius and soleus muscles.

The development of Australian Standards of Care for Hip Surveillance in Children with Cerebral Palsy: how did we reach consensus?

Progressive hip displacement is the second most common deformity in children with cerebral palsy (CP). For many decades, the methods of monitoring hip health and development in children with CP varied widely between facilities. Recently, systematic population based studies have identified some of the factors and characteristics of children with CP who would most benefit from hip surveillance. Health services providing hip surveillance within Australia identified a need for clinical guidelines to assist in provision of comprehensive and best practice health care for children with CP across all patient demographics. Guidelines providing clear, evidence based information on specific timing for commencement, frequency, and discharge have not previously been published. This article analyses the supportive evidence for comprehensive hip surveillance, discusses the development of draft guidelines in Australia, and describes the process for achieving national consensus resulting in the Consensus Statement on Hip Surveillance for Children with Cerebral Palsy: Australian Standards of Care. These standards of care are being followed in clinical facilities across Australia and are endorsed by the Australasian Academy of Cerebral Palsy and Developmental Medicine (AusACPDM).

The Consensus Statement on Hip Surveillance for Children with Cerebral Palsy: Australian Standards of Care

The 'Consensus Statement on Hip Surveillance for Children with Cerebral Palsy: Australian Standards of Care' ('Standards of Care') provides a clear and concise guideline for inclusion of hip surveillance into current services. The 'Standards of Care' have been developed by a multidisciplinary working group for the education and information of all health professionals working with children with CP and their families. The 'Standards of Care' were developed through extensive review of the literature and garnering of expert opinion from professionals working in the area within Australia and New Zealand. A formalized external consensus process was conducted from 2007 to 2008 and the 'Consensus Statement on Hip Surveillance for Children with Cerebral Palsy: Australian Standards of Care' became the basis for best practice around Australia in 2008. It has been endorsed by The Australasian Academy of Cerebral Palsy and Developmental Medicine (AusACPDM). Prospective longitudinal study will evaluate both effectiveness and cost/benefit outcomes of this recommended hip surveillance standard of care.

A randomized controlled trial of the impact of therapeutic horse riding on the quality of life, health, and function of children with cerebral palsy

This randomized controlled trial examined whether therapeutic horse riding has a clinically significant impact on the physical function, health and quality of life (QoL) of children with cerebral palsy (CP). Ninety-nine children aged 4 to 12 years with no prior horse riding experience and various levels of impairment (Gross Motor Function Classification System Levels I-III) were randomized to intervention (10wks therapeutic programme; 26 males, 24 females; mean age 7y 8mo [SD 2y 5mo] or control (usual activities, 27 males, 22 females; mean age 8y 2mo [SD 2y 6mo]). Pre- and post-measures were completed by 72 families (35 intervention and 37 control). Children's gross motor function (Gross Motor Function Measure [GMFM]), health status (Child Health Questionnaire [CHQ]), and QoL (CP QoL-Child, KIDSCREEN) were assessed by parents and QoL was assessed by children before and after the 10-week study period. On analysis of covariance, there was no statistically significant difference in GMFM, CP QoL-Child (parent report and child self-report), and CHQ scores (except family cohesion) between the intervention and control group after the 10-week study period, but there was weak evidence of a difference for KIDSCREEN (parent report). This study suggests that therapeutic horse riding does not have a clinically significant impact on children with CP. However, a smaller effect cannot be ruled out and the absence of evidence might be explained by a lack of sensitivity of the instruments since the QoL and health measures have not yet been demonstrated to be sensitive to change for children with CP.

Eukaryotic signal transduction via histidine-aspartate phosphorelay

Transmembrane signal transduction is a feature common to all eukaryotic and prokaryotic cells. We now understand that a subset of the signalling mechanisms used by eukaryotes and prokaryotes are not just similar in principle, but actually use homologous proteins. These are the histidine-aspartate phosphorelays, signalling systems of eubacterial origin, now known to be widespread in eukaryotes outside the animal kingdom. Genome projects are revealing that His-Asp phosphorelays are present as multigene families in lower eukaryotes and in plants. A major challenge is to understand how these ‘novel’ signal transduction systems form integrated networks with the more familiar signalling mechanisms also present in eukaryotic cells. Already, phosphorelays have been characterised that regulate MAP kinase cascades and the cAMP/PKA pathway. The probable absence of His-Asp phosphorelays from animals has generated interest in their potential as targets for anti-microbial therapy, including antifungals. Recent findings suggest that this approach holds promise.

Taking the plunge. Terminal differentiation in Dictyostelium

During the last stage of Dictyostelium development a motile, cylindrical slug transforms into an immotile, stalked fruiting body and the constituent cells change from amoebae to either refractile spores or vacuolated stalk cells. Analysis of this process using genetics and simple culture techniques is becoming a powerful way of investigating a number of conserved signal transduction processes. A common pathway activating cAMP-dependent protein kinase (PKA) triggers the maturation of spore cells and those stalk cells forming the stalk. It uses a eukaryotic version of the 'bacterial' two-component phospho-relay system to control cAMP breakdown. A second pathway, inhibiting the GSK3 protein kinase, might control the maturation of a distinct set of stalk cells at the base of the fruiting body.