Cerebral Palsy

Objective: To describe the differences in intraoperative opioid dosing and associated outcomes in children with and without cerebral palsy (CP). Background: Previous work on children with cognitive impairment has suggested that they receive less intraoperative opioid than children without cognitive impairment. This finding may be due to a common concern that impaired children are hypersensitive to the adverse effects of opioids. Patterns in intraoperative opioid dosing have yet to be studied in children with motor impairment (e.g. CP). Methods: We examined the medical records of pediatric patients with CP who underwent orthopedic surgery over the last decade at our institution, as well as the records of a randomly selected group of pediatric orthopedic patients without CP (non-CP). Outcome variables were intraoperative opioid dosing, postoperative intensive care unit (ICU) admission, and postoperative oxygen desaturation. We collected demographic, surgical, and medical data for covariate analysis. A stepwise multivariate regression was used for each outcome. Results: Seventy-one (71) CP and 77 non-CP charts were included in the study. CP children received significantly less intraoperative opioid (3.26 +/- 3.01 mug.kg(-1) fentanyl dose equivalents) than non-CP children (4.58 +/- 3.79 mug.kg(-1)) (P = 0.02), and this difference was corroborated by the regression analysis, which significantly associated CP with decreased opioid dosing (P < 0.001). In addition, intraoperative opioid dosing, but not CP, predicted ICU admission (odds ratio: 1.463, 95% CI: 1.042-2.054, P = 0.03) and postoperative oxygen desaturation (odds ratio: 1.174, 95% CI: 1.031-1.338, P = 0.02). Conclusions: Similar to prior research on children with cognitive impairment, a reduction in intraoperative opioid dosing was found in children with CP. Given the discrepant doses of intraoperative opioid between groups, it is unclear whether children with CP are at any greater risk for untoward opioid-related events.

Cerebral palsy is a common static encephalopathy and can present as multiple musculoskeletal problems. Increased peripheral muscle tone causes joint contractures and decreased functional capacity. The risk for scoliosis increases parallel with the severity of musculoskeletal involvement. Scoliosis adversely affects the functional capacity, daily care, and nutrition in disabled children. Conservative treatments including physical therapy, bracing, and botulinum toxin injections do not prevent the progression of scoliosis in most of the patients and surgical treatment becomes mandatory. With the use of pedicle screws, three-plane fixation is possible, making posterior instrumentation and fusion effective in correction of severe curves and obviating anterior surgery.

Upper extremity deformities in cerebral palsy are caused by the imbalance between spastic and weak muscles acting on unstable joints. The basic goals of surgical treatment of spastic hands and upper extremities of patients with cerebral palsy can be summarized as reducing the strength of spastic muscles, strengthening the antagonist muscles, and permanent stabilization of unstable joints. Surgical techniques to achieve these goals include lengthening of spastic muscles, tendon transfers, release or plication of the joint capsule, joint arthrodesis, neurectomies, and skin procedures. Amongst these surgical treatment options, this article will present, in more detail, tendon transfers which are performed especially to achieve balance and restore motor functions.

OBJECTIVES: We investigated how foot pressure pattern and foot progression relate to power generation from the ankle joint in children with spastic hemiplegic cerebral palsy (CP). METHODS: The study included 35 children (13 girls, 22 boys; mean age 8.8 years; range 4 to 19.8) with CP, all having independent ambulation. The children underwent three-dimensional gait analysis and a set of pedobarographic data were obtained. The pedobarographs were analyzed by dividing the foot into five segments. RESULTS: The mean power generation from the ankle was 7.6 watts/kg on the hemiplegic side, and 15.9 watts/kg on the uninvolved side (p=0.000). Based on the pedobarographic data, hemiplegic feet exhibited significantly less heel pressure/impulse (8.0 vs. 24.7; p=0.000), time to heel rise (32.1% of stance phase vs. 61.9%; p=0.000), and decreased pressure of the medial forefoot segment (40.8 vs. 52.2; p=0.009). The children were divided into two groups depending on the ankle power generated on the hemiplegic side (<8.0 watts/kg and =/>8.0 watts/kg). Those with an ankle power generation of =/>8.0 watts/kg had significantly longer step length (49 cm vs. 41 cm; p=0.001) and increased velocity (109 cm/sec vs. 89 cm/sec; p=0.000) in gait analysis, and in pedobarographic measurements, increased heel impulse (11.6 vs. 4.4; p=0.047), time to heel rise (46.6% vs. 17.1%; p=0.000), and less varus/valgus positioning (11.1 degrees vs. -34.6 degrees ; p=0.013). In bivariate correlation analysis, ankle power generation on the hemiplegic side demonstrated a significant association with time to heel rise (r=0.574; p=0.000) and varus/valgus positioning (r=0.420; p=0.017), and almost a significant association with heel pressure (r=0.342; p=0.052). CONCLUSION: Deviations in the pedobarographic data are reflected in the power generation of the ankle joint and can be of help in decision making of treatment in spastic hemiplegic CP. We speculate that efforts to normalize the heel segment pattern may result in decreased power generation differences.

OBJECTIVES: This study aimed to assess the results of knee capsulotomy for correcting fixed knee flexion contracture in children with cerebral palsy (CP). METHODS: Thirty-five children (20 boys, 15 girls; mean age 13.5+/-2.5 years) with CP underwent posterior knee capsulotomy for 59 knees. Eleven patients had diplegia, one patient had hemiplegia, and 23 patients had quadriplegia. There were two community ambulators (3 knees), 19 household ambulators (33 knees), and 14 nonambulators (23 knees). Posterior knee capsulotomy was combined with hamstring lengthening (50 knees, 84.8%), rectus femoris transfer (10 knees, 17%), Achilles tendon lengthening (12 knees, 20.3%), and posterior cruciate ligament release (eight knees, 13.6%). The mean follow-up was 3.5+/-1.7 years. RESULTS: Fixed knee flexion contracture significantly improved from 26.5+/-15.4 degrees to 17.0+/-15.5 degrees after posterior knee capsulotomy (p<0.0001). The mean improvement was 9.5 degrees. Popliteal angle significantly improved from 70.6+/-18.7 degrees to 48.2+/-19.9 degrees (p<0.0001). Ankle dorsiflexion did not differ significantly. At the end of follow-up, 38 knees (64.4%) had improved knee flexion contracture and 21 knees (35.6%) had recurrent flexion contracture (failure). Age and male gender were significantly associated with failure rate (adjusted odds ratio 0.78, 95% CI: 0.62-0.99 and 12.1, 95% CI: 2.37-61.7, respectively). Complications included transient sciatic nerve palsy in seven knees (11.9%), and wound dehiscence in two knees (3.4%). Revision was required in two knees (3.4%), and posterolateral corner reconstruction in one knee (1.7%). CONCLUSION: Posterior knee capsulotomy is another option for the treatment of knee contracture in CP, resulting in a significant decrease in knee contracture with acceptable complications. However, failure rate is higher in boys, patients who are marginal ambulators, and in younger age group.

The knee is the most affected joint in children with cerebral palsy. Flexion contracture of the knee is the cause of crouch gait pattern, instability in stance phase of gait, and difficulties during standing and sitting, and for daily living activities. It may also cause patella alta, degeneration of the patellofemoral joint, and stress fractures of the patella and tibial tubercle in young adults. Children with cerebral palsy may even give up walking due to its high energy demand in the adult period. The purpose of this article is to review the causes of the knee flexion contractures, clinical and radiological evaluations, and treatment principles in children with cerebral palsy. The biomechanical reasons of knee flexion deformity are discussed in detail in the light of previous studies and gait analysis data.

OBJECTIVE: Cerebral palsy (CP) is a disability that affects individuals throughout their lifespan. This study was conducted to evaluate the clinical status of adults with cerebral palsy. METHODS: A cross-sectional study was carried out during the period of February 2001 to June 2002, in Baghdad, Iraq. Fifty young adult men with cerebral palsy were evaluated by reviewing their medical records and present clinical status. RESULTS: Antenatal maternal medical problems were recorded in 17 (34%) cases. Kernicterus was the most common possible cause occurring in 14 (28%) cases. Spastic hemiplegia was reported in 16 (32%) patients. Various forms of combinations occured in 14 (28%) cases. Of the secondary disabilities, musculoskeletal disorders were the most common (60%), followed by epilepsy (42%), mental retardation (40%), speech disorders (30%), bladder dysfunction (4%) and visual impairment (2%). Relationships between musculoskeletal deformities and the development of mental retardation were statistically significant (P value 0.0001) . CONCLUSION: Adults with CP are at risk of many highly preventable secondary conditions that cause loss of function and deterioration of quality of life.

CONTEXT. Rehabilitation for children with congenital hemiplegia to improve function in the impaired upper limb and enhance participation may be time-consuming and costly. OBJECTIVES. To systematically review the efficacy of nonsurgical upper-limb therapeutic interventions for children with congenital hemiplegia. METHODS. The Cochrane Central Register of Controlled Trials, Medline, CINAHL (Cumulative Index to Nursing and Allied Health Literature), AMED (Allied and Complementary Medicine), Embase, PsycINFO, and Web of Science were searched up to July 2008. Data sources were randomized or quasi-randomized trials and systematic reviews. RESULTS. Twelve studies and 7 systematic reviews met our criteria. Trials had strong methodologic quality (Physiotherapy Evidence Database [PEDro] scale >/= 5), and systematic reviews rated strongly (AMSTAR [Assessment of Multiple Systematic Reviews] score >/= 6). Four interventions were identified: intramuscular botulinum toxin A combined with upper-limb training; constraint-induced movement therapy; hand-arm bimanual intensive training; and neurodevelopmental therapy. Data were pooled for upper-limb, self-care, and individualized outcomes. There were small-to-medium treatment effects favoring intramuscular botulinum toxin A and occupational therapy, neurodevelopmental therapy and casting, constraint-induced movement therapy, and hand-arm bimanual intensive training on upper-limb outcomes. There were large treatment effects favoring intramuscular botulinum toxin A and upper-limb training for individualized outcomes. No studies reported participation outcomes. CONCLUSIONS. No one treatment approach seems to be superior; however, injections of botulinum toxin A provide a supplementary benefit to a variety of upper-limb-training approaches. Additional research is needed to justify more-intensive approaches such as constraint-induced movement therapy and hand-arm bimanual intensive training.

Pediatric rehabilitation requires a multidisciplinary team approach to disabilities or handicaps caused by physical, mental, sensory-perceptional, or cognitive disorders due to prenatal, natal, or postnatal causes. Cerebral palsy (CP) is defined as persistent but not progressive disorder of posture and movement system, associated with functional activity limitations and sensorial, cognitive, communication problems, epilepsy, and musculoskeletal system problems. Physiotherapy approaches in rehabilitation applications aim to normalize sensorial and motor functions, provide normal posture and independent functional activity, regulate muscle tone, improve visual and auditory reactions, support normal motor development and motor control, improve ambulation and endurance, increase the quality of the existing movements, prevent soft tissue, joint and postural disorders, support orthopedic and surgical procedures, and finally to prepare the child for the adolescent and adult periods. Setting realistic goals, determination of the priorities, informing the family and enhancing family participation in physiotherapy programs will increase the success of physiotherapy. This article reviews current rehabilitation approaches and physiotherapy applications for children with CP.

Children with cerebral palsy (CP) may have many musculoskeletal deformities depending on the type of CP. These deformities may result from (i) lack of motor control, (ii) abnormal biomechanical alignment, (iii) impairment in timing of muscle activation, (iv) impairment in normal agonist/antagonist muscle balance, (v) lack of power generation, and (vi) balance disorder. Rehabilitation, orthopedic surgical intervention, and additional orthotic management can prevent and correct these deformities. In this review, mainly lower extremity orthoses are described, with brief explanation on upper and spinal orthotic applications.