Cerebral Palsy

Aims: To assess neurodevelopmental outcome at 2 years for neonatal intensive care unit (NICU) admissions compared with controls, and to trial a parent-reporting scheme. Methods: All infants admitted to the NICU at Christchurch Women's Hospital over a 12-month period and whose parents were domiciled in a defined geographical region were eligible for study, together with every eighth term infant not admitted (to a total of 300). Parents completed a two-page questionnaire on their child's 2nd birthday. All infants <28 weeks gestation and a random 300 NICU admissions and 108 controls underwent a paediatric examination and Bayley II assessment at 2 years of age. Results: A total of 387 NICU infants (86% eligible) and 306 controls were enrolled. At 2 years of age, 276 NICU infants (89% survivors) and 94 controls (87%) had some follow up. For infants of <33 weeks, 33-36 weeks, >/=37 weeks gestation and controls, the percentage >1 SD below the mean on the Bayley Mental Development Index scales were 33.3, 36.5, 44.6 and 24.1, respectively (P= 0.03); on the Psychomotor Developmental Index scales were 30.0, 29.1, 41.1 and 19.5 (P= 0.02) and the percentage with any cerebral palsy were 11.1, 2.8, 5.2 and 1.2. Conclusions: At 2 years of age, NICU graduates have more developmental problems than controls across a range of measures. In many cases, term NICU graduates have the least favourable outcome. There was only moderate agreement between parents' reporting of moderate or severe developmental disability by means of a questionnaire, compared with professionals (kappa statistic 0.38), with parents tending to underestimate problems.

Background For parents, receiving a diagnosis, typically in early childhood, that their child has cerebral palsy may conjure up high distress and anxiety. Resolution of these initial reactions may help parents to focus on the challenges and needs of their children. Aims of the study were to test whether parents of older children displayed resolution more often than parents of younger children, and whether parents of children with less severe cerebral palsy also showed more resolution. Method Resolution of reactions to diagnosis was assessed with the Reaction to Diagnosis Interview, in a clinic-based sample of 255 parents of children with cerebral palsy aged between 1.4 and 17.3 years. Physicians rated motor ability using the Gross Motor Function Classification System. Results Overall, the responses of 81.6% of the parents were predominantly indicative of resolution. Unresolved reactions were significantly more often found among parents of younger children and parents of children with more severe motor disabilities. Among parents of teenage children, resolution was more often apparent from a focus on action to better the lives of their children, whereas in parents of younger children, it was more apparent from their focus on constructive thoughts and information seeking. Conclusions Given time, the large majority of parents may resolve their reactions to the diagnosis that their child has cerebral palsy. Parents of the most severely affected children may need specific support which, given the age trends, might be aimed at different resolution processes for parents of younger and older children.

The protocol of Davis is widely used in children’s gait analysis, especially in cerebral palsy studies and its repeatability was evaluated primarily for adults. The aim of this research was to evaluate the uncertainty and repeatability of this protocol for children. 56 asymptomatic children aged 5-15 years performed the gait exam. Kinematics parameters and Gillette Gait Index (GGI) were calculated. 17 subjects performed the exam twice with markers replacement. Uncertainties on gait parameters were evaluated using repeatability study and Monte Carlo simulations. Uncertainty (2SD of test-retest differences) obtained on angles calculated by the protocol varied between +/-2 degrees and +/-3 degrees (for pelvis and hip in sagittal and frontal planes) and +/-14 degrees (for mean hip rotation). Uncertainty on GGI was +/-12 for healthy subjects. Monte Carlo simulations on 30 cerebral palsy children showed that the error on GGI could reach +/-100 and was correlated to GGI value (R(2)=0.92): 2SD=24+0.09xGGI.

Background Although the importance of providing disabled children with assistive devices has always been highlighted, most studies in the field of assistive device research seek the participation of adult users or adult carers. Accordingly, the opinions of young users themselves seem to be overlooked. To start to address the gap, this study aimed to understand the children’s perspectives regarding device use in school and to explore the factors related to their device utilization in this setting. Methods Semi-structured interviews were adopted as the main data collection instrument. A total of 44 participants were involved, including 15 Taiwanese children with cerebral palsy, aged between 8 and 15 years, 15 mothers and 14 teachers. Results The interview results show a high frequency of device use in school which can be attributed to children’s willingness, teachers’ attitudes, mothers’ support, physical environmental factors and device-related features. Conclusions The findings not only demonstrate the significance of child-environment interaction but also provide evidence that children’s views may be different from those of adults because they are at a different developmental stage and act out different roles in their environment.

Liu W-Y, Hou Y-J, Wong AMK, Lin P-S, Lin Y-H, Chen C-L: Relationships between gross motor functions and health-related quality of life of Taiwanese children with cerebral palsy. OBJECTIVE:: To examine the relationships between gross motor functions and physical and psychosocial components of the health-related quality of life of children with cerebral palsy. DESIGN:: Participants comprising 90 children (53 boys, 37 girls; mean age +/- SD = 8.2 +/- 2.4 yrs) with cerebral palsy were enrolled by a cross-sectional design. Gross motor function measure was used to quantify their gross motor functions. Their health-related quality of life was determined by the Child Health Questionnaire-Parent Form 50 (traditional Chinese version), completed by their caregivers. RESULTS:: A significant moderate positive correlation (r = 0.73, P < 0.01) existed between the physical summary scores of the Child Health Questionnaire-Parent Form 50 and gross motor function measure, 66 scores in Taiwanese children with cerebral palsy. There was no significant correlation between the psychosocial summary scores of Child Health Questionnaire-Parent Form 50 and gross motor function measure, 66 scores in cerebral palsy (r = -0.13, P = 0.23). CONCLUSIONS:: Gross motor functions may be good predictors of the physical component of health-related quality of life, but they are poor predictors of the psychosocial component of health-related quality of life in children with cerebral palsy. In the future, more comprehensive information regarding children's comorbidities may need to be objectively gathered to provide professionals a better understanding of their health-related quality of life.

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.

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.

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.

PURPOSE: A pilot study with short-term outcomes of a combined surgical and medical intervention for management of generalized lower limb spasticity, hip displacement and contractures of adductors in children with bilateral spastic cerebral palsy. METHODS: A prospective cohort study of 16 children (9 boys and 7 girls) aged 2-6 years with bilateral spastic cerebral palsy was performed. At entry, 5 were classified as level III and 11 as level IV, according to the Gross Motor Function Classification System (GMFCS). The intervention consisted of surgical lengthening of adductor longus and gracilis combined with the phenolization of the anterior branch of the obturator nerve, using 1 ml of 6% phenol, applied under direct vision at the time of lengthening of adductor longus. The hamstring and calf muscles were each injected with Botulinum neurotoxin A at a dose of 4 U/kg/muscle. Serial clinical (hip, knee, ankle joint range of motion), radiographic (migration percentage) and functional data-taken from a functional mobility scale (FMS) or GMFCS-were collected at 3, 6, 12 and 24 months post-operatively. RESULTS: There was a significant increase in hip abduction, knee extension (popliteal angle) and ankle dorsiflexion, maintained for 24 months; mean hip migration percentage decreased from 29 to 21% (P < 0.001). Using a validated mobility scale, significant improvements were noted in gross motor function. There were no complications related to the intervention. CONCLUSIONS: The combined surgical-medical intervention resulted in a reduction of spastic hip subluxation and improvements in gross motor function, as determined by the FMS. The combined intervention is, thus, useful as a temporizing measure, before definitive decisions are made considering such interventions as dorsal rhizotomy, intrathecal baclofen and single-event, multilevel surgery.

INTRODUCTION: In patients with cerebral palsy, the prevention of hip dislocation should be the “primum momens” of early surgery. The surgery consists of a myotomy of the adductor medium, mayor and gracilis, and, in non-ambulatory cases, a neurectomy of the second branch of the obturator nerve. The purpose of this study was to examine whether the adductor myotomy should be performed on the contralateral side at one sitting. MATERIALS AND METHODS: In a study performed by our team on 1,474 patients, 792 patients (53.7%) had a unilateral procedure and 682 a bilateral procedure. RESULTS: The non-myotomized spastic adductors alter the movement of forces on the femoral head and, thus, 78.20% required a secondary contralateral procedure. The dislocation of the hip in patients whose operations were performed at two different sittings occurred in 20% of cases, and in those with a bilateral procedure at one sitting only in 1%. The increase in the cervicodiaphyseal angle occurred in 23.1% of patients with surgeries performed at two sittings and only in 10% of patients with bilateral procedures at one sitting. CONCLUSIONS: Our results suggest that the bilateral surgical procedure at one sitting should be recommended to equalize the movements of force in spastic hips.