Cerebral Palsy

BACKGROUND: Children with cerebral palsy (CP) expend more energy when walking than do their typically developing peers. The effect this has on physical activity levels (PALs) and on total energy expenditure (TEE) will have important implications when determining energy requirements. OBJECTIVES: This study aimed to investigate the components of TEE in children with CP in comparison with typically developing children and to determine what effect the higher energy expenditure during walking has in ambulatory children with CP on PAL and on TEE. DESIGN: Sixteen children with mild CP and 16 typically developing children, aged 5-12 y, were recruited for the study. Resting energy expenditure (REE) and the energy expenditure during walking were measured by using indirect calorimetry. TEE was determined by using the doubly labeled water technique. PAL was calculated as the ratio of TEE to REE. Body composition was estimated by using oxygen-18. RESULTS: TEE was lower in children with CP (7012 +/- 1268 kJ/d) than in typically developing children (8309 +/- 2088 kJ/d) because of a lower PAL (1.57 +/- 0.23 compared with 1.79 +/- 0.26). The children with CP expended significantly more energy when walking than did the typically developing children (13.8 +/- 4.9 compared with 10.3 +/- 2.3 kJ/min) while walking at a lower velocity (61 +/- 10 compared with 72 +/- 8 m/min). Correlations between energy expenditure during walking and PAL were not statistically significant for either group. CONCLUSIONS: Children with CP expend more energy during walking and have a lower PAL and lower energy requirements than do typically developing children. This has important implications when estimating the energy requirements of children with CP.

Time trends for cerebral palsy (CP) prevalence in children born >/=2,500 g vary across studies and scarce data exist on trends by subtype of CP. The objective of this study was to describe changes in prevalence of CP in infants born >/=2,500 g between 1980 and 1998 in Europe. Data were collated from the SCPE (Surveillance of Cerebral Palsy in Europe collaboration) common database. Poisson regression was used to test for change in prevalence over time. Birth year and register effects were explored and trends in prevalence were estimated by CP subtype and severity. Four thousand and two children with CP and birthweight >/=2,500 g were recorded in 15 population based-registers. The overall prevalence of CP was 1.16 per 1,000 live births (99% CI, 0.88-1.48) in 1980 and 0.99 (CI, 0.80-1.20) in 1998. The trend was not significant (P = .14), except in two registers. However, there were significant changes in the prevalence of spastic CP subtypes, with a decrease in the bilateral spastic form (P < .001), and an increase in the unilateral spastic form (P = .004). There was a concurrent reduction in neonatal mortality of children with birthweight >/=2,500 g: from 1.7 (CI, 1.4-2.1) to 0.9 (CI, 0.7-1.1) per 1,000 live births. In conclusion, for children born with birthweight >/=2,500 g, the prevalence of CP in Europe was stable in spite of changes by subtype and a significant decrease in neonatal mortality.

Achievement of urinary continence is an important developmental step that most children attain with the assistance of their parents and caregivers. Debate continues as to the best time to toilet train; in some Asian and African cultures children are trained as infants, while training at age 2-3 years is more typical in Western cultures. Infant voiding is not merely a spinal reflex, as the sensation of bladder filling is relayed to the brain. However, the ability of the brain to inhibit bladder contractions, and to achieve coordinated bladder contraction with sphincter relaxation, matures over time. While there is a concern that later toilet training may be responsible for an increase in urinary incontinence in children, no controlled studies on early versus late toilet training exist to evaluate this hypothesis. A number of medical conditions such as spina bifida, posterior urethral valves, cerebral palsy and autism can cause incontinence and difficulties in toilet training. The decision to start toilet training a child should take into account both the parents’ expectation of how independent the child will be in terms of toileting, and the child’s developmental readiness, so that a realistic time course for toilet training can be implemented.

Objective: To evaluate the effects of constraint-induced movement therapy on the use of the affected arm and on daily functioning in children with hemiplegic cerebral palsy.Design: A single-blinded randomized clinical trial.Subjects: Sixteen children with cerebral palsy randomized to intervention (n = 8, 4 males, 4 females, mean age 5 years and 6 months) and control groups (n = 8, 4 males, 4 females, mean age 6 years and 7 months).Interventions: Non-affected arm of intervention group was restricted for 10 hours/day and the affected arm intensively trained for 3 hours/day for two weeks. The intervention protocol included one week of bimanual functional training following constraint therapy. The control group maintained usual rehabilitation throughout the intervention period. MAIN MEASURES: Pediatric Evaluation of Disability Inventory (self-care domain) and an adapted version of the Jebsen-Taylor test were administered before and after intervention, and at one month follow-up. General linear models tested differences in gain scores and the number needed to treat estimated relative effectiveness of intervention protocol for functional skills and independence in self-care.Results: Results are reported for 15 children who completed assessments and intervention. Higher gains were observed in the intervention group for functional skills and independence post intervention (dfunctional skills = 1.61, P = 0.0134; dindependence=1.37; P = 0.0001) and follow-up (dfunctional skills = 2.08, P = 0.004; dindependence = 0.85; P = 0.0016). No group difference in manual dexterity gains was observed. Low indices of number needed to treat (1.75 and 2.33) illustrate clinical relevance of intervention.Conclusions: The protocol associating constraint-induced movement therapy and bimanual functional training was effective in promoting daily living functioning among children with cerebral palsy.

Objective: To assess the efficacy of botulinum toxin A injection for the management of spastic calf muscles in children with cerebral palsy.Data sources: We reviewed all relevant literature indexed in MEDLINE, CINAHL, EMBASE, PEDro and the Cochrane Registered Trials, and also hand reviewed abstracts.Methods: Eligible studies were randomized controlled trials that compared botulinum toxin A injection with any type of treatment or no treatment with identical conditions. We extracted data on calf muscle tone, passive ankle range of motion, gait speed, ankle kinematics and Gross Motor Function Measure, and assessed methodological qualities.Results: Fifteen studies met our inclusion criteria. When botulinum injection was compared with a non-sham control, it was found to be effective at improving calf muscle tone (one month: -2.73 (confidence interval (CI) -3.42 to -2.04), three months: -1.72 (-2.68 to -0.76)), passive ankle range of motion (one month: 3.29 (CI 2.52 to 4.05), three months: 1.00 (CI 0.44 to 1.56)) and gait speed (one month: 0.91 (CI 0.29 to 1.53), three months: 0.61 (CI 0.01 to 1.21)) for four months, as well as Gross Motor Function Measure (2.02 (CI 1.30 to 2.75)) for two months. When compared with sham injection, botulinum injection was only effective on Gross Motor Function Measure (0.98 (CI 0.28 to 1.69)) after four months.Conclusions: Although we found evidence supporting the efficacy of botulinum toxin A in studies comparing botulinum injection with non-sham controls, we did not find clear evidence of support in studies comparing botulinum injection with sham injection.

Compared to automatic postural responses to external perturbation, little is known about anticipatory postural adjustments in individuals with spastic diplegic cerebral palsy. In this study, we examined whether anticipatory activation of postural muscles would be observed before voluntary arm movement while standing in individuals with spastic diplegia. Seven individuals with spastic diplegia (SDCP(group), 12-22 years) and 7 age- and gender-matched individuals without disability (Control(group)) participated in this study. Participants performed bilateral arm flexion at maximum speed at their own timing while standing, during which electromyographic (EMG) activities of focal and postural muscles were recorded. In both groups, the erector spinae (ES) and medial hamstring (MH) muscles were activated in advance of the anterior deltoid muscle (AD), which is a focal muscle of arm flexion. Although start times of ES and MH with respect to AD were similar in the 2 groups, increases in EMG amplitudes of ES and MH in the anticipatory range from-150ms to +50ms, with respect to burst onset of AD, were significantly smaller in the SDCP(group) than in the Control(group). These findings suggest that individuals with spastic diplegia have the ability to anticipate the effects of disturbance of posture and equilibrium caused by arm movement and to activate postural muscles in advance of focal muscles. However, it is likely that the anticipatory increase in postural muscle activity is insufficient in individuals with spastic diplegia. Copyright © 2010. Published by Elsevier Ireland Ltd.

The authors describe specific effects of prolonged epidural blockade in treatment of contractures of the lower extremity joints in children with cerebral palsy. The method was used in 5 patients aged from 11 to 16 years. The prolonged epidural blockade during 4-5 weeks allowed adequate motor rehabilitation and conditions for learning to walk.

Objective To ascertain mortality from 1 to 18 years, and predictors of mortality. Design Long-term follow-up of population cohort born 1989-1992. Setting Births in South East Thames Region. Patients 346 children with bilateral cerebral palsy (CP). Interventions Not applicable. Main outcome measures Mortality; predictors of mortality. Results 98% of the cohort were traced. 61/340 (17.9%) had died by age 16-18 years at a steady mortality. The main predictive factor was severity of impairment of functional ability (hazard ratio 5.7, 95% CI 2.1 to 15.0 for poor hand manipulation; 6.8 (1.9 to 23.9).for severe communication problems). Conclusions Although there were deaths throughout the childhood and teenage years, the majority of children with bilateral CP are likely to survive to adulthood, especially if they do not have major functional impairment at 2 years. This confirms findings of other studies of children with CP.

The objective is to study the effect of disport injections on the clinical and electromyographic changes in 35 patients (mean age 5,3+/-2,0 years) with spastic forms of cerebral palsy (26 with spastic diplegia, 9 with hemiparetic form) with equinus and equinovarus deformity. Depending on the clinical situation, disport was injected in a total dose of 20-30 u per 1 kg of the body mass. Gastrocnemius muscles were injected more frequently than soleus and posterior tibial muscles. The treatment resulted in the significant reduction of spasticity on the Ashworth scale, decrease of equinus deformity, positive changes in the parameters of stepping on flat foot, independent standing and walking, the beginning of support period from the heel. During the arbitrary contraction, the amplitude of bioelectrical activity of target muscles of low extremities reduced, though not to the extent of the motor activity loss; the reciprocity coefficient decreased from 0,69+/-0,32 to 0,47+/-0,28 in patients with spastic diplegia and from 0,45+/-0,34 to 0,34+/-0,25 in patients with hemiparetic form. The effect of disport was higher in hemiparetic form compared to spastic diplegia. The best results for spastic diplegia were revealed in patients with isolated spasticity without severe disturbances of reciprocal relations in shin muscles and pathological synkinesia.