Cerebral Palsy

Clinical experience plays an important role in the development of expertise, particularly when coupled with reflection on practice. There is debate, however, regarding the amount of clinical experience that is required to become an expert. Various lengths of practice have been suggested as suitable for determining expertise, ranging from five years to 15 years. This study aimed to investigate the association between length of experience and therapists’ level of expertise in the field of cerebral palsy with upper limb hypertonicity using an empirical procedure named Cochrane-Weiss-Shanteau (CWS). The methodology involved re-analysis of quantitative data collected in two previous studies. In Study 1, 18 experienced occupational therapists made hypothetical clinical decisions related to 110 case vignettes, while in Study 2, 29 therapists considered 60 case vignettes drawn randomly from those used in Study 1. A CWS index was calculated for each participant’s case decisions. Then, in each study, Spearman’s rho was calculated to identify the correlations between the duration of experience and level of expertise. There was no significant association between these two variables in both studies. These analyses corroborated previous findings of no association between length of experience and judgemental performance. Therefore, length of experience may not be an appropriate criterion for determining level of expertise in relation to cerebral palsy practice.

AIM: The aim of this study was to evaluate if the robot-mediated therapy (RMT) can yield positive outcomes in children with acquired or congenital upper extremity movement disorders. METHODS: This was an uncontrolled pilot study with pre-post treatment outcome comparison carried out by the Pediatric Rehabilitation Department of a Children’s Hospital. The study enrolled 12 children, aged 5 to 15 years, suffering from acquired (at least 12 months post-onset) or congenital upper limb motor impairment. Etiology: 4 stroke, 6 traumatic brain injuries, and 2 hemiplegic cerebral palsy. RMT was provided 3 times a week for an hour during 6 weeks for a total of 18 robot therapy sessions. The Melbourne Scale (MS) and the upper-extremity subsection of the Fugl-Meyer Assessment (FMA) were used for measurement of impairment. Secondary outcome measurements were made through the Modified Ashworth Scale (MAS); the Reaching Performance Scale (RPS); Parent’s Questionnaire, and robot-based evaluation measurements. Specifically, authors compared the smoothness, as measured by the jerk metric, and average speed of unconstrained reaching movements. RESULTS: Pre-post clinical evaluation revealed statistically significant gains for all primary and secondary metrics. In addition, significant improvement of robot-based metrics was observed. The primary outcome measurement mean (SEM) gains were 6.71 (1.29) for MS and 3.33 (0.80) for the FMA. RMT led to spasticity decreases in chronic cases, as shown by the reduction of MAS. It led to improved trunk-upper extremity postural attitude as demonstrated by improved RPS, and it was well accepted by parents and children as observed in the Parent’s Questionnaire. CONCLUSIONS: This study suggests that RMT may hold rehabilitative benefits in children suffering from acquired and congenital hemiparesis.

OBJECTIVE: To study the efficacy of conductive education combined with Frenkel training in the improvement of balance function in children with cerebral palsy. METHODS: One hundred and fifteen children with cerebral palsy were randomly administered with conductive education and Frenkel training (study group, n=60) or conventional training (control group, n=55). Activities of daily living (ADL) scale and gross motor function measurement (GMFM) of physical performances were used to assess the balance function. RESULTS: The scores of ADL scale and GMFM of physical performances in both the study and the control groups increased after training. The study group showed higher scores of ADL scale (37.91+/-10.12 vs 34.18+/-6.13; p<0.05)and GMFM (62.93+/-15.00 vs 54.53+/-14.11) than the control group (p<0.05). CONCLUSIONS: Conductive education combined with Frenkel training is more effective for the improvement of balance function in children cerebral palsy.

The management of cerebral palsy and spinal deformity can be challenging for the spine surgeon. The presence of large, structural deformities oftentimes detracts from the subtle changes in neurological status and necessitates a thorough neurologic examination. Scoliosis is the most common spinal deformity associated with cerebral palsy, but the development of thoracic lordoscoliosis is rare. Cervical kyphosis has been noted to occur in cerebral palsy patients, but primarily is associated with the athetoid variant of the disorder. We present a case report of a 17 year-old male, spastic quadriplegic cerebral palsy patient with progressive myelopathy and concurrent cervical kyphosis and thoracic lordoscoliosis. The patient’s condition and symptoms were managed via two-stages. The cervical spine was managed by a sequential, circumferential one-stage procedure, which entailed a two-level cervical corpectomy of C5 and C6 with multi-level laminectomies, lateral mass plating, and wire fixation. Approximately 3 months following cervical spine surgery, a simultaneous, anteroposterior approach was used to correct the thoracic deformity and entailed a combined anterior spinal release of the thoracic spine with posterior spinal segmental instrumentation and sublaminar wiring. No complications were noted. The patient was successfully returned to independent ambulation. On follow-up, the spinal correction and instrumentation was maintained. The occurrence of concurrent cervical kyphosis and thoracic lordoscoliosis in patients with cerebral palsy is rare, but can be managed successfully with combined anteroposterior approaches.

Little babies have a disability at birth, most of which were brought to the doctor between 3 and 18 months by their concerned parents. Although there is no blood test for chemical or cerebral palsy, there are several clinical tests that help establish the diagnosis. As it exists in many children with cerebral palsy a strong dominance of one member over another, these children are likely to express a preference (to be left-handed or right) much earlier than the healthy babies that have no preference in the first year. When a baby always takes the objects of the right hand, even when the object is placed much closer to the left hand is a possible sign of cerebral palsy.

Babies have special reflexes that they lose after a few months, but these reflexes persist longer in children with cerebral palsy. Several tests to assess these reflexes. For example, the Moro reflex pushes the baby to move both arms when lying on his back and that raises his legs above his head. If a baby keeps this reaction well beyond six months is a sign of developmental delay that may evoke cerebral palsy.

Sometimes, medical imaging techniques like magnetic resonance imaging (MRI) and computed tomography (CT) may show an abscess or other physical brain damage. We must exclude the possibility of a progressive neurological disease. There are also intelligence tests and eye exams and hearing to determine if cerebral palsy is accompanied by other problems.

Typically, parents first noticed symptoms of cerebral palsy in their child from the age of six months. Among the first symptoms include:

* A failure to thrive, the child not reaching milestones such as the ability to sit, smile or walk;
* Unusual positions, excessive rigidity or lack of exaggerated tone, continuous bending of the joints;
* Seizures;
* A muscle wasting, slow growth or asymmetric;
* A convergent squint (child ladle);
* A sense of drowsiness or apparent deafness.

There is no set profile of symptoms in cerebral palsy, because it is a broad term that encompasses many symptoms. However, there are some broad categories that distinguish the various motor symptoms (muscle).

The spastic form category is the most common symptom, affecting about three quarters of people with cerebral palsy. The muscles tend to be contracted, which may be serious enough for the joint remains bent permanently or to cause paralysis. The spasticity may affect both legs, both arms, the four members, or one leg and one arm. In addition, growth in affected members may be slower than that of healthy members, with the result of the feet, legs and abnormally small hands. For those affected, but able to walk, often have a scissors in which, at every step, knees almost touching, and the feet cross inwards beyond an imaginary line through the middle of body.

The form athetosis affects one in ten people with cerebral palsy. It is characterized by slow movements, such as convulsions, usually in the limbs, but may also affect facial muscles including the tongue. This form may cause the patient to drool, produce at home facial expressions and unusual ability to pronounce certain words or sounds. One must distinguish speech disorders due to muscle damage (dysarthria) and those caused by mental retardation, an entirely different matter.

The ataxic form is the form of cerebral palsy the less common and affects less than one in ten. In case of ataxia, poor coordination and poor depth perception makes unsteady gait with a broader base of sustenance. Ataxia also makes it difficult for the execution of rapid movements and fine, like writing. People may suffer from intention tremor: tremor that affects the arm or hand during a voluntary movement to grasp an object and empire as the main approach of the object.

The objective of this study was to identify the predictors of outcome of distal rectus femoris transfer in cerebral palsy. Preoperative and postoperative gait data for 81 patients were examined, focusing on knee flexion/extension range. Outcome was 'good' for 46 patients and 'poor' for 35. The poor outcome group had no improvement in knee range because of increased crouch postoperatively. Outcome was unrelated to quadriceps strength, crouch, velocity, or type of cerebral palsy. Gross Motor Function Classification System was predictive of outcome, with poor results in all level IV patients (P</=0.008). In conclusion, Gross Motor Function Classification System IV patients may not benefit from distal rectus femoris transfer because of increased postoperative crouch.

OBJECTIVE: To assess perinatal and long-term outcomes for pregnancies complicated by early onset, severe fetal growth restriction with absent or reverse end-diastolic flow velocity waveform (AREDF) in the umbilical artery. METHODS: A retrospective cohort study of 36 singleton pregnancies with AREDF when the estimated fetal weight (EFW) is less than 501 g at presentation. RESULTS: At presentation, the median gestational age and EFW were 24 (18-29) weeks and 364 (167-496) g, respectively. The median interval between presentation and live birth or diagnosis of intrauterine fetal death (IUFD) was 13 (0-60) days. Delivery was for IUFD in 19 cases (53%), fetal indications in 13 cases (36%) and maternal indications in four cases (11%). Caesarean section (CS) was performed for the 17 live births of which 10 (59%) were by classical CS. Of the total cohort, five infants survived to hospital discharge giving an overall perinatal survival rate of 14%. All survivors had short-term morbidity. The cognitive function in four children was assessed as normal at two years of age. One survivor had developmental delay. None of the surviving children had any evidence of cerebral palsy. CONCLUSION: The overall perinatal survival rate for pregnancies complicated by early onset, severe growth restriction with an EFW of < 501 g and AREDF is low. When delivery occurs for fetal indications, the majority of these women require classical CS. Short-term neonatal morbidity is high though none of the survivors had cerebral palsy.

Despite advances in non-invasive ventilation techniques, tracheostomy is still indicated in children with serious airway obstruction or with the need for long-term ventilation. Alternatives should be studied before deciding to tracheostomise as complications exist, despite the simple procedure. The aims of this study were the identification of tracheostomised children followed in a tertiary care paediatric department, the characterisation of primary disease, the indications leading to tracheostomy and any complications. We present a case review of tracheostomised children followed in our department. Sixteen tracheostomised children were followed, median age of 4.5 months, neuromuscular disease – 5, cerebral palsy – 3 and pulmonary or airway disease – 7. Indications were long-term invasive ventilation – 12, subglottic or tracheal stenosis – 3 and laryngomalacia – 1. The most frequent complications found were persistent bacterial colonisation, accidental decannulation and obstruction. There was a tracheostomy- related death in 1 child. Outcome: 9 children maintained tracheostomy, 5 were successfully decannulated and 2 children died while on tracheostomy. Tracheostomised children usually have complex disease that requires a multidisciplinary team and should be followed-up at a specialised reference centre. Rev Port Pneumol 2009; XV (2): 227-239 Key-words: Tracheostomy, child, complications, indications.