Cerebral Palsy

PURPOSE: The purpose of this report is to review our experience with talonavicular joint arthrodesis for the treatment of severe valgus foot deformities in older children and adolescents with cerebral palsy (CP). METHODS: The clinical, radiographic, and gait parameters results after talonavicular joint arthrodesis were retrospectively reviewed in 32 patients (59 feet) with valgus deformities of the foot. The surgery was performed as part of multiple simultaneous surgeries for the treatment of gait disorders. The mean age of the patients was 13.9 years (range 9-20 years) and the mean follow-up was 40 months (range 18.3-66.7 months). RESULTS: The clinical and radiographic measurements improved significantly (P = 0.000). There were no significant changes in gait parameters. Symptoms were relieved in most patients with symptomatic preoperative feet. The most frequent complication was pseudoarthrosis, which occurred in seven feet. We found a high rate of satisfaction of patients (or parents) and most of them recommended the procedure to other patients with the same condition. CONCLUSION: Talonavicular joint arthrodesis is a reliable technique that provides both functionally and cosmetically good results with a low rate of complications in the treatment of severe pes planus valgus in older children and adolescents with CP. Careful examination should rule out concomitant ankle valgus deformities. A stable fixation of the arthrodesis is recommended.

OBJECTIVES: Neurodevelopmental outcomes associated with preterm birth are of major health and educational concern. This study examined the neuromotor, cognitive, language and emotional/behavioural outcomes of a regional cohort of 4 year old children born extremely preterm (EPT: 23-27 weeks gestation), very preterm (VPT: 28-33 weeks) and full term (FT: 38-41 weeks). Of particular interest were children's risks of impairment across multiple neurodevelopmental domains. METHODS: Data were gathered as part of a prospective longitudinal study of 105 very preterm (<33 weeks gestation) and 107 full term children born during 1998-2000. At 4 years corrected age, children underwent a comprehensive, multidisciplinary assessment that included a paediatric neurological examination, cognitive and language testing, and an assessment of child emotional and behavioural adjustment. RESULTS: At age 4 years, compared to full term children, EPT and VPT children had increased risks of cerebral palsy (EPT 18%, VPT 15%, FT 1%), cognitive delay (EPT 33%, VPT 36%, FT 13%), language delay (EPT 29%, VPT 29%, FT 10%) and emotional/behavioural adjustment problems (EPT 37%, VPT 13%, FT 11%). EPT and VPT children were three times more likely to have multiple domain impairments than full term children (EPT 30%, VPT 29%, FT 10%). CONCLUSIONS: A substantial proportion of preschool children born very preterm show clinically significant problems in at least one neurodevelopmental domain, with impairment in multiple domains being common. There is a need to monitor preschool development across a range of functional domains and to consider the likely cascading effects of multiple impairments on later development.

BACKGROUND: Postoperative pancreatitis is a recognized complication after spine fusion surgery in scoliosis management. There are established risk factors for the development of postoperative pancreatitis for patients with scoliosis in general, but no such factors have been established in patients with cerebral palsy (CP) who have scoliosis. The aim of this study was to assess the association between preoperative comorbidities and other parameters in the development of pancreatitis after spinal fusion surgery in a sample of children with CP. METHODS: A retrospective cohort design was used to assess the association between postoperative pancreatitis and preoperative comorbidities and other covariates that might predispose to pancreatitis. The study participants included 355 patients, with a mean age of 13.8 years (range, 5.6-21 years) with CP, who received spine fusion with rod instrumentation. We used the chi statistic, mean, and SD to describe study variables that were categorical and continuous, respectively. To test the null hypothesis of no association between our outcome variable (postoperative pancreatitis) and comorbidities and other covariates as predictors, we used a binomial regression model. To simultaneously adjust for confounding effects in the relationship between our outcome and the independent or predictor variables, we used a multivariable binomial regression model. RESULTS: Of the 355 patients who underwent spine fusion, 109 developed postoperative pancreatitis (prevalence, 30.1%). Patients who developed pancreatitis had prolonged number of fasting days (until oral or G-tube feeding initiated; 7.9 vs 5.2 days) and longer hospital stay (23.1 vs 15.6 days). In the univariable binomial regression model, patients with CP who had gastroesophageal reflux disease (GERD) and feeding difficulty were more likely to develop pancreatitis than those without this condition (risk ratio [RR], 1.57; 95% confidence interval [CI], 1.10-2.28, respectively). Likewise, in this model, gastrointestinal tube and reactive airway disease (RAD) were statistically significantly associated with postoperative pancreatitis. Patients with CP who had gastrointestinal tube were 61% more likely to develop postoperative pancreatitis, whereas those with RAD were 54% (RR, 1.61; 95% CI, 1.01-2.55 and RR, 1.54; 95% CI, 1.13-2.10, respectively). However, there was a clinically relevant but nonstatistically significant association between seizure and postoperative pancreatitis (RR, 1.72; 95% CI, 0.96-3.06). After adjustment for the confounding variables in the multivariable model, GERD with feeding difficulties persisted as a single most significant and potent predictor of postoperative pancreatitis (adjusted RR, 1.52; 95% CI, 1.01-2.29). Consequently, patients with CP who had GERD were 52% more likely to develop postoperative pancreatitis. Likewise, there was a statistically significant 49% increase in the risk of postoperative pancreatitis in patients with CP who had RAD (adjusted RR, 1.49; 95% CI, 1.10-2.04). CONCLUSIONS: Pancreatitis is a major cause of morbidity after spinal fusion surgery in patients with CP. Patients with preoperative GERD with feeding difficulties and RAD had a higher risk of developing postoperative pancreatitis. Postoperative pancreatitis causes delays in feeding and increases the duration of hospitalization. Clinicians should be aware of the roles of GERD and RAD, as well as seizure and/or antiepileptics in the development of postoperative pancreatitis in patients with CP undergoing spinal fusion. LEVEL OF EVIDENCE: Level III.

BACKGROUND: Progressive hip flexion deformity is a common problem in ambulatory children with spastic cerebral palsy, causing static and dynamic deformity. The iliopsoas muscle is recognized as a major deforming force in the development of this problem. Many clinicians address this problem by lengthening the iliopsoas, either in an intramuscular location at the pelvic brim or by complete tenotomy at the lesser trochanter. The goal of this study was to compare the outcomes of patients with ambulatory cerebral palsy who had intramuscular lengthening at the pelvic brim to those who underwent complete release of the iliopsoas tendon at the level of the lesser trochanter. METHODS: Twenty patients were included in the study, 11 of whom had iliopsoas release at the lesser trochanter (group 1) and 9 of whom had intramuscular lengthening at the pelvic brim (group 2). All patients had physical examinations, plus kinematic and kinetic analyses in our gait laboratory before and 1 year after surgery. RESULTS: Hip flexion contracture was decreased significantly only in group 1, although there was a trend of decrease in group 2. There was a significant increase in maximum hip extension in terminal stance and a reciprocal decrease in maximum swing phase hip flexion in group 1, with a similar trend that did not reach significance in group 2. Stride length increased significantly in both groups. There was no significant change in power generation of hip flexion during the swing phase in either group. CONCLUSIONS: We found improved static and dynamic parameters of hip extension after iliopsoas lengthening and did not detect any adverse kinematic or kinetic change in hip function after surgery. The improvement was more robust in the group who underwent release at the lesser trochanter. Because there are no adverse effects of iliopsoas release from the lesser trochanter and the improvement in hip extension is greater, this approach should be considered in ambulatory patients with spastic diplegia when a hip flexor weakening procedure is considered. LEVEL OF EVIDENCE: Comparative cohort study, level III, case-control study.

BACKGROUND: It has been observed in children with cerebral palsy (CP) that the femoral head rests in a valgus position as compared to the proximal neck and/or shaft. The purpose of this study was to compare the head-shaft angle (HSA) as a measure of femoral head valgus in children with CP (group 1) with a subset of children with CP who have more significant hip subluxation (group 2, as demonstrated by the need for surgery to correct the deformity), with age-matched (group 3) and historical controls. METHODS: There were a total of 39 patients (70 hips), 15 patients in group 1, 10 in group 2, and 14 in group 3. The HSA was measured as described by Southwick (Southwick WO. Osteotomy of the lesser trochanter for slipped capital femoral epiphysis. J Bone Joint Surg Am. 1967;49A:803-835). Interrater and intrarater reliabilities and the variation of these measures with rotation were assessed. RESULTS: The mean HSA in group 1 was 160.8 degrees; group 2, 170.3 degrees; group 3, 152.5 degrees; and historical control, 146.7 degrees. The difference was statistically significant between groups 1 and 2 and between both CP groups and the control groups. Intrarater and interrater reliabilities were found to be low, and variation with rotation was found to be minimal. CONCLUSIONS: This study demonstrates that HSA is greater in children with CP than in typically developing children and that this is more pronounced in children with CP who are at risk for eventual subluxation. Evaluation of the HSA may be prudent in children with CP.

This study assessed the effects of continuous intrathecal infusion of baclofen on the gait of ambulant children with cerebral palsy. Details, collected retrospectively before and after pump implantation, included Gillette Functional Assessment Questionnaire score, use of walking aids, Ashworth Scale score, and joint angle at which the stretch reflex was triggered. Twenty-one ambulant children and young adults with cerebral palsy were included. Their mean age was 11 years and 10 months (standard deviation, 4 years and 10 months; range, 6-22 years). The mean length of treatment was 25.8 months (range, 5-75 months). After treatment, the lower-limb Ashworth score decreased by 1.4 points (standard deviation, 0.52), and the Gillette Functional Assessment Questionnaire score increased significantly, from 5.04 (standard deviation, 2.08) to 6.09 (standard deviation, 2.05) (P < 0.05). Seven children were able to use less supportive walking aids. Continuous intrathecal baclofen infusion appears to decrease spasticity and improve the gait capacity of children with cerebral palsy. Prospective, controlled studies are necessary to prove the functional effect of intrathecal baclofen infusion.

Infantile cerebral palsy Prepared by: Legnica Herrera Degree in Physiotherapy UdelaR 2009 Panama
INTRODUCTION When this occurs specifically in the brain may appear motor, mental, behavioral, auditory, optical or language, rising to form a group of syndromes that cause psychomotor developmental delay including cerebral palsy . Cerebral palsy is the leading cause of disability in childhood The child who suffers from this disorder show motor effects that prevent a normal development. Multiple factors produce the largest per cent occurs in the time of birth that can happen for various reasons a hypoxia of the brain, injuring the same area. This injury causes various disabilities such as disorders of posture and movement that may be with or without seizures, mental retardation, visual problems, hearing and language. (more…)

There is no cure for cerebral palsy, because brain cells do not replace them. Treatment aims to make life as normal as possible and provide maximum independence for patients whose mental abilities permit.

The primary objective is to minimize disability, which means above all to prevent muscle contractures or remedy. They are less likely to occur if you exercise the affected limb as much as possible. Physiotherapy aims to prevent contractures and poor growth due to atrophy. Although there is not enough studies demonstrating the effectiveness of physiotherapy, most doctors agree that the exercise affected members is clearly the best way to preserve their health and to draw as much as possible. If contractures, it is generally necessary to resort to surgery. It can take several months for the muscle to recover from such an operation. It is therefore much better to prevent than cure. Sometimes administered injections of Botulinum Toxin against contractures serious. The toxin paralyzes the muscle, allowing it to relax.

When school age approach, the treatment focuses on improving communication and reducing the symptoms that constitute a problem in social terms, as was done drooling. No effort is spared to put the children of normal intelligence in schools. Parents are responsible for much of the therapy once they have learned the techniques.

Convulsions and spasticity can often be controlled by an anticonvulsant drug or a muscle relaxant (muscle relaxant), and most children with cerebral palsy after drug treatment in one form or another. When the symptoms can not be eliminated, their effects can be minimized by using modern devices such as computerized prostheses that help to speak and electric wheelchairs.

Although the total elimination of cerebral palsy is probably impossible, many measures enable women to avoid this type of congenital malformations. Any factor that increases the risk of premature delivery, such as tobacco, alcohol and illicit drugs increases the risk of cerebral palsy. Birth defects are the more likely that the mother smokes or drinks during pregnancy.

Vaccination against rubella is one of the easiest to take a woman. As this vaccine can not be administered during pregnancy, any woman who intends to have a child should be vaccinated immediately.

Any measure reducing the risk of head injury in a baby or an infant also reduces the risk of cerebral palsy. In this regard, the most important step that parents can take is to install the car seat for their child. On the other hand, it is not always possible to prevent meningitis, but we can reduce the risk by taking the child to the doctor every time he is suffering from an ear infection or a bad headache accompanied by fever. Any child under the age of 4 to 6 months has a fever should be seen by a doctor.

The split anterior tibial tendon transfer is a procedure commonly used to correct equinovarus deformity of the foot, primarily in children with spastic cerebral palsy. The procedure has been reported to yield satisfactory results; it can be combined with other soft tissue lengthening. Typically, the transferred tendon can be fixed by either button, staple, metal screw, or anchored into two bony tunnels. Occasionally, failure to maintain transferred tendon fixation may result from conventional surgical methods and therefore lead to undesirable results. The technique of using bioabsorbable interference screw has been proved to be effective in securing the graft as anterior cruciate ligament reconstruction in knee joint. To our knowledge, only few literatures have reported on the use of bioabsorbable screw in the treatment of tendon transfers around the foot. From 2004 to 2006, split anterior tibial tendon transfers with concomitant tendo-Achilles lengthening were applied to 13 patients (16 feet) who had a dynamic equinovarus deformity secondary to spastic cerebral palsy. Mean age at surgery was 8 years and the average follow-up period was 16 months (range, 12-28 months). A 7 x 23 mm cannulated bioabsorbable interference screw was used to fix the transferred tendon. Postoperatively, we used the rating system of Kling et al. to assess the clinical results. Our findings showed that there were 10 excellent, six good, and no poor results. All patients had improved gait at their latest follow-ups. At final follow-up, there was no graft failures or postoperative complications related to the bioabsorbable screw in our series. Although the study is based on a small number of cases, we suggest this technique is an additional armamentarium in fixation for tendon transfers in children’s feet.

The current mechanism for obtaining financial support for families with neurologically impaired infants is seriously flawed. It relies on payment awarded through the tort system based on a claim that medical negligence was responsible for the infant’s condition. The system is extraordinarily inefficient and expensive, as well as being unfair to many families with affected children and to physicians who are unjustly accused of contributing to outcomes they could not have prevented. Furthermore, the exorbitant malpractice premiums necessary to support the system are threatening the future of obstetric practice in the United States. This article describes a two-pronged program designed to correct these inequities and to assess each case for the occurrence of medical negligence, which has been submitted to the New York State legislature as a proposed bill entitled the Neurologically Impaired Program for New York State (S7748).