Cerebral Palsy

The currently accepted definition classifies Cerebral Palsy (CP) as a mere posture and movement disorder. Conversely, some authors have recently associated the presence of several motor dysfunctions exhibited by diplegic children with CP to an impairment in the perceptive system. The aim of the present study was to investigate the influence of the Perceptive Impairment (PI) on motor control and to appraise if the PI can be revealed by a reaching task. A functional reach and touch experiment was accomplished from sitting posture considering different directions and distances. Typically developing and diplegic children with CP were enrolled and, the latter, a priori divided in two subgroups considering a positive or negative diagnosis of PI. The reaching trials were quantified by means of centre of pressure analysis in terms of the overall quality of the task, and accuracy and effectiveness of postural adjustments and Anticipatory Postural Adjustments (APAs). The three groups showed statistically significant differences in terms of percentage of touched target, and of time spent and maximum distance covered to reach the target. In particular, PI caused a major difficulty in accomplishing the reaching tasks, thus a lower autonomy level in action. Overall, the PI strongly affected the anticipatory control system. Children with PI, rarely recruited APAs, each of which was characterized by small amplitude and inaccuracy in direction. The lack of effective APAs indicated how PI strongly influenced the motor control strategy. The present study demonstrates that the PI is a primary syndrome responsible for the long-term prognosis beside the motor and the postural disorders in CP. Copyright © 2010 Elsevier B.V. All rights reserved.

OBJECTIVE: To quantify dynamic spasticity, i.e. the coupling between muscle-tendon stretch velocity and muscle activity during gait, of the gastrocnemius and soleus muscles in children with spastic cerebral palsy. DESIGN: Prospective, cross-sectional study. SUBJECTS: Seventeen ambulatory children with cerebral palsy with spastic calf muscles, and 11 matched typically developing children. METHODS: The children walked at 3 different speeds. Three-dimensional kinematic and electromyographic data were collected. Muscle-tendon velocities of the gastrocnemius medialis and soleus were calculated using musculoskeletal modelling. RESULTS: In typically developing children, muscles were stretched fast in swing without subsequent muscle activity, while spastic muscles were stretched more slowly for the same walking speed, followed by an increase in muscle activity. The mean ratio between peak activity and peak stretch velocity in swing was approximately 4 times higher in spastic muscles, and increased with walking speed. In stance, the stretch of muscles in typically developing children was followed by an increase in muscle activity. Spastic muscles were stretched fast in loading response, but since muscle activity was already built up in swing, no clear dynamic spasticity effect was present. CONCLUSION: Spastic calf muscles showed increased coupling between muscle-tendon stretch velocity and muscle activity, especially during the swing phase of gait.

ABSTRACT: BACKGROUND: Use of Botulinum toxin-A (BoNT-A) for treatment of upper limb spasticity in children with cerebral palsy has become routine clinical practice in many paediatric treatment centres worldwide. There is now high-level evidence that upper limb BoNT-A injection, in combination with occupational therapy, improves outcomes in children with cerebral palsy at both the body function/structure and activity level domains of the International Classification of Functioning, Disability and Health. Investigation is now required to establish what amount and specific type of occupational therapy will further enhance functional outcomes and prolong the beneficial effects of BoNT-A. METHODS: A randomised, controlled, evaluator blinded, prospective parallel-group trial. Eligible participants were children aged 18 months to 6 years, diagnosed with spastic hemiplegic cerebral palsy and who were able to demonstrate selective motor control of the affected upper limb. Both groups received upper limb injections of BoNT-A. Children were randomised to either the modified constraint-induced movement therapy group (experimental) or bimanual occupational therapy group (control). Outcome assessments were undertaken at pre-injection and 1, 3 and 6 months following injection of BoNT-A. The primary outcome measure was the Assisting Hand Assessment. Secondary outcomes include: the Quality of Upper Extremity Skills Test; Pediatric Evaluation of Disability Inventory; Canadian Occupational Performance Measure; Goal Attainment Scaling; Pediatric Motor Activity Log; modified Ashworth Scale and; the modified Tardieu Scale. DISCUSSION: The aim of this paper is to describe the methodology of a randomized controlled trial comparing the effects of modified constraint-induced movement therapy (a uni-manual therapy) versus conventional occupational therapy (a bimanual therapy) on improving bimanual upper limb performance of children with hemiplegic cerebral palsy following upper limb injection of BoNT-A. The paper outlines the background to the study, the study hypotheses, outcome measures and trial methodology. It also provides a comprehensive description of the interventions provided. Trial Registration ACTRN12605000002684.

Recent studies suggest that in addition to low-level motor impairments, individuals with Hemiparetic Cerebral Palsy (HCP) are characterized by anticipatory action planning deficits as well. In the present EEG study we investigated the neural and temporal dynamics of action planning in participants with right-sided HCP (n=10) and in left-handed control subjects (n=10). An anticipatory planning task was used in which participants were required to grasp and rotate a hexagonal knob over different angles (60 degrees , 120 degrees or 180 degrees ). At a behavioral level, participants with HCP were slower in their movements and often selected an inappropriate grip when grasping the object. At a neural level, individuals with HCP showed a strong reduction in the amplitude of the P2 component, likely reflecting an impaired process of action selection. In addition, a strong correlation was observed between the P2 amplitude and grasping and rotation times. The P2 component was localized to sources in the dorsal posterior cingulate cortex (dPCC), an area that is known to be involved in orienting visual body parts in space. Together these findings suggest that anticipatory planning deficits in cerebral palsy arise mainly due to an impaired process of action selection. Copyright © 2010. Published by Elsevier B.V.

OBJECTIVE: To evaluate neurodevelopment after necrotizing enterocolitis (NEC) and late bacteremia, alone and together. STUDY DESIGN: Sample included 1155 infants born at 23 to 27 weeks' gestation. NEC was classified by the modified Bell's staging criteria and grouped as medical NEC or surgical NEC. Late bacteremia was defined as a positive blood culture result after the first postnatal week. Neurodevelopment was assessed at 24 months corrected age. Multivariable models estimated the risk of developmental dysfunction and microcephaly associated with medical or surgical NEC with and without late bacteremia. RESULTS: Children who had surgical NEC unaccompanied by late bacteremia were at increased risk of psychomotor developmental indexes <70 (OR = 2.7 [1.2, 6.4]), and children who had both surgical NEC and late bacteremia were at increased risk of diparetic cerebral palsy (OR = 8.4 [1.9, 39]) and microcephaly (OR = 9.3 [2.2, 40]). In contrast, children who had medical NEC with or without late bacteremia were not at increased risk of any developmental dysfunction. CONCLUSION: The risk of neurodevelopmental dysfunction and microcephaly is increased in children who had surgical NEC, especially if they also had late bacteremia. These observations support the hypothesis that bowel injury might initiate systemic inflammation potentially affecting the developing brain. (J Pediatr 2010;157:***). Copyright © 2010 Mosby, Inc. All rights reserved.

OBJECTIVE: To examine adverse birth events on the development of cerebral palsy in California. STUDY DESIGN: A retrospective population-based study of children with cerebral palsy (as of Nov. 30, 2006), matched to their maternal/infant delivery records (Jan. 1, 1991 to Dec. 31, 2001) was performed. Demographic data and intrapartum events were examined. Six adverse birth-related events were chosen. Children without cerebral palsy were controls. RESULTS: There were 7242 children who had cerebral palsy (59% term) and 31.3% had 1 or more of the 6 adverse intrapartum events (12.9% in controls P < .0001). This held for both term (28.3% vs 12.7% controls) and preterm (36.8% vs 15.9%, controls) neonates (both P < .0001). Maternal (15.1% vs 6.6%) and neonatal (0.9% vs 0.1%) infection were increased in cerebral palsy cases (P < .0001). CONCLUSION: Almost one-third of children with cerebral palsy had at least 1 adverse birth-related event. Higher rates in the preterm group may partially explain the higher rates of cerebral palsy in this group. Copyright © 2010 Mosby, Inc. All rights reserved.

Developmental Coordination Disorder (DCD) is a movement disorder affecting between 1.7% and 6% of children aged 5-11years. The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition Text Revision codes DCD as an Axis I Clinical Disorder. If there is neurological involvement, as is the case for cerebral palsy, the movement disorder would be coded as an Axis III General Medical Condition. What little is known of the aetiology of DCD implicates neurological involvement. In a previous co-twin control study of monozygotic twins concordant and discordant for DCD, seven of the nine twins who met criteria for DCD on the McCarron Assessment of Neuromuscular Development experienced perinatal oxygen perfusion problems, while another experienced prenatal complications. This supported findings in an earlier study of a relationship between environmental factors and DCD, and strengthened the hypothesis that DCD and cerebral palsy have similar causal pathways and may fall on a continuum of movement disorder rather than being discrete categories. In the present paper, this hypothesis is tested by application of the nine principles identified by Sir Austin Bradford Hill as important when considering observed associations between two variables. Implications for prevention, clinical intervention, policy, and classification systems are discussed. Copyright © 2010. Published by Elsevier B.V.

INTRODUCTION: Primary cerebral vasculitis in children is a newly recognized, rare inflammatory condition affecting the vessels of the brain. It is characterized by newly acquired neurological deficit(s) with angiographic or histological evidence of central nervous system (CNS) vasculitis, in the absence of other known diseases with these findings. MATERIAL AND METHODS: We performed a retrospective review of children below 15 years submitted with CNS vasculitis to the department between 1999 and 2008. RESULTS: Six (two boys, four girls) of ten children with clinical and vascular imaging findings detected by magnetic resonance were diagnosed with primary CNS vasculitis. Age at onset was three to 12 years. Acutely acquired hemiparesis was seen in five children, two had facial palsy. Among other symptoms were headache, ataxia, dysarthria, loss of consciousness and seizures. Only modest changes in blood and spinal fluid values were seen. On magnetic resonance angiography, varying segmental stenoses were found. All had supratentorial lesions, and in two patients infratentorial lesions were also detected by MRI. Monthly treatment with high-dose intravenous corticosteroids for six months was successful in most of the patients. In two patients with progressive CNS vasculitis, the treatment was supplemented by intravenous cyclophosphamide and azathioprin, respectively. CONCLUSION: Primary CNS vasculitis is an acutely acquired inflammatory disease with severe neurological deficits and sequelae which may have a fatal outcome. Despite this the prognosis is acceptable since event-free survival can be achieved in almost 70% if early immunosuppressive therapy is initiated.

ABSTRACT: BACKGROUND: Overweight is reported as a side effect of SDR. The aims were to study the development of weight, height and body mass index (BMI) during five years after SDR. METHODS: This prospective, longitudinal and practice-based study included all 56 children with CP spastic diplegia undergoing SDR from the start in March 1993 to April 2003 in our hospital. The preoperative Gross Motor Function Classification System (GMFCS) levels were I-II in 17, III in 15, IV-V in 24 children. Median age at SDR was 4.3 years (range 2.4-7.4 years). Weight and height/recumbent length were measured. Swedish growth charts for typically developing children generated weight, height and BMI z-scores for age and gender. RESULTS: The preoperative median z-scores were for height -1.92 and for body mass index (BMI) -0.22. Five years later, the median BMI z-score was increased by +0.57 (p<0.05). The occurrence of thinness (BMI < -2 SD) was decreased (n.s.) and obesity (BMI > +2 SD) increased (p<0.05). Baseline BMI and age at the start of follow-up influenced the BMI change during the five years (p<0.001 and p<0.05 respectively). The individual growth was highly variable, but a tendency towards increasing stunting with age was seen in severe gross motor dysfunction (GMFCS levels IV-V) and the opposite, a slight catch-up of height in children with walking ability (GMFCS levels I-III). CONCLUSIONS: These are the first available subtype- and GMFCS-specific longitudinal growth data for children with CP spastic diplegia. Their growth potential according to these data should be regarded as a minimum, as some children were undernourished. It is unknown whether the spasticity reduction through SDR increased the weight gain velocity, or if the relative weight increase was part of the general "obesity epidemic". For some children the weight increase was highly desirable. In others, it resulted in overweight and obesity with risk of negative health effects. Weight and height should be monitored to enable early prevention of weight aberrations also causing problems with mobility, activity and participation.

Purpose. To determine the type of visual information used by children with spastic unilateral cerebral palsy (SUCP) in order to intercept a ball and to verify whether this information was dependent on the side of the lesion. More specifically, it was examined whether the interception was controlled on the basis of a time or a distance strategy, initiating the catch when the ball is at a fixed time interval or at a fixed distance from the point of interception. Methods. Three groups of children were included. Children with either a left sided (LHL) or a right sided lesion (RHL) and children without a lesion [typically developing (TD)] intercepted a ball from a conveyor belt. In order to intercept the ball successfully they had to walk and to reach for the ball at the interception point 4 m away. Results. Children with LHL had a longer decision time and started their reach movement earlier. In 56% of the children with LHL a distance strategy was observed, while in the TD and the children with RHL predominantly a time strategy was found. Conclusions. The side of the lesion influences the visual information used to initiate interceptive actions.