脑瘫患儿继发髋关节脱位的防治研究进展

脑性瘫痪是一组持续存在的姿势异常及功能障碍症候群,而髋关节脱位是其常见的伴随症状。本文就脑瘫患儿继发髋关节脱位流行病学特征、髋关节发育监测方案、治疗手段等研究进展进行概述。     

综合康复治疗脑瘫患儿的临床效果

目的：探讨脑瘫儿童接受不同康复治疗的临床效果，并观察年龄、瘫痪程度和智力对功能恢复的影响。方法：81例脑瘫患儿分为2组，综合组58例采用以Bobath技术为主的综合康复治疗；传统组23例采用针灸、按摩等传统康复技术治疗。治疗前后依据脑瘫儿童综合功能评定表进行疗效评定。结果：康复训练6个月后，2组患儿综合功能均显著提高（P〈0．01），综合组优于传统组（P〈0．05）。年龄、瘫痪程度、智力水平对疗效有负性影响。结论：采用综合康复治疗脑瘫优于传统治疗；患儿的年龄、瘫痪程度和智力对功能恢复有一定影响。     

痉挛型脑瘫患儿髋关节半脱位的相关因素分析

目的:观察痉挛型脑瘫患儿髋关节半脱位的发生情况,探讨相关因素对半脱位的影响。方法:对我院康复治疗的脑瘫患儿248名采用拍摄骨盆正位片的方式,测量髋关节股骨头外移百分比(MP)。并采用MP分级、粗大运动功能分级、改良Ashworth量表对患儿进行评定。结果:髋关节半脱位发生率为32.7%,不同分型患儿的发生率差异有统计学意义(χ^2=23.626,P=0.001),相关性分析发现粗大运动功能分级(GMFCS)、内收肌改良Ashworth量表(MAS)评分与MP值具有相关性(P<0.01)。结论:痉挛型脑瘫患儿的髋关节半脱位的相关因素是分型、粗大运动功能、内收肌肌张力。     

痉挛型脑瘫患儿髋关节脱位的风险预测

目的 研究脑瘫患儿髋关节脱何的预测因素.方法 对90例脑瘫患儿进行中文版脑瘫粗大运动功能分级系统(GMF-CS)分级和脑瘫类型区分,并测定股骨头外移百分比.结果 四肢瘫患儿发生髋关节脱位的风险最大,偏瘫患儿的风险最小;GMF-CS Ⅰ级发生髋关节脱位的风险最小,GMFCS Ⅴ级风险最大.结论 痉挛型脑瘫患儿的髋关节异常发育与脑瘫类型和脑瘫粗大运动功能有相关性.     

脑瘫患儿髋关节脱位的系统管理

2005年国际脑瘫新定义认为，脑性瘫痪是指一组运动和姿势发育障碍综合征，这种导致活动受限的综合征是由于发育中的胎儿或婴儿脑部受到非进行性损伤而引起的。脑性瘫痪的运动障碍常伴随感觉、认知、交流、感知、和／或行为障碍，和／或抽搐障碍。由于肌张力和姿势的异常发育，导致脑瘫患儿极易出现肌肉骨骼系统的畸形发育，而髋脱位是脑瘫患儿中除了马蹄内翻足外的第二常见骨骼的畸形问题，在严重的脑瘫患儿中髋关节半脱位或全脱位的比例在2．5％-45％之间。如果早期没有进行科学的监测和干预，会进行性地演变成髋关节半脱位、二次髋臼发育不良、股骨头畸形、髋关节全脱位以及疼痛髋，所以对于脑瘫患儿髋脱位应予高度关注。     

家庭康复对脑瘫患儿的影响

目的 探讨脑瘫患儿家庭康复的方式及作用.方法 脑性瘫痪患儿60例分为医院康复组及医院一家庭康复组,2组分别给予医院康复及医院-家庭康复治疗1年.治疗前后采用贝利婴幼儿发展量表(BSID)进行评定,对治疗前后智力发展指数(MDI)及精神运动发展指数(PDI)的平均值和平均增长值进行比较.结果 治疗1年后,两组MDI及PDI均有增长(P《0.05),医院-家庭康复组平均增长值优于医院康复组(P《0.05).结论 家庭康复是脑瘫患儿康复治疗不可缺少的过程.     

发育性髋关节脱位患儿的髋关节康复指导

目的 探讨康复指导对发育性髋关节脱位患儿术后康复的作用。方法 在术前和术后，根据手术特点，对48例(63髋)发育性髋关节脱位患儿进行髋关节康复指导。结果 经1-2．5年随访，48例患儿(63髋)的康复优良率达95％。结论 康复指导可促进发育性髋关节脱位患儿术后髋关节的康复。     

脑瘫康复中的外科矫形治疗

1手术治疗的目的与原则脑瘫是一种上运动神经原性损害的疾病 ,由于病变程度和大脑病损部位的不同 ,临床表现也不同。对于痉挛型脑瘫 ,受累部位肌肉的主动或被动收缩均可引起拮抗肌的收缩 ,严重地影响相关动作的完成 ,尤其是协调性强 ,比较精细的动作 ,如手的精细动作。因此 ,上肢痉挛的外科矫形治疗效果远不如下肢痉挛的好。外科手术并不是痉挛型脑瘫的主要治疗手段 ,只有当长期的其他治疗方法无效时 ,才能根据患者的要求考虑手术治疗。1.1手术治疗的目的　进一步改善患者的肢体功能 ,补充非手术疗法的不足 ,为运动训练创造条件 ,提高患者的…     

脑瘫患儿家庭康复护理指导

脑瘫患儿的康复是一个长期艰苦的工作,对患儿的父母来说,做好日常生活护理是非常重要的.脑瘫患儿的康复主要是三分治疗七分护理,由患儿家长根据在院时制定的护理计划进行康复护理.良好的家庭康复护理可促进脑瘫患儿护理目标的实现,并可获得更为理想的康复治疗效果.     

脑瘫患儿常用康复器械

脑瘫患儿在康复治疗过程中 ,常常需要使用一些康复器械。这些康复器械在脑瘫患儿的康复训练中起着非常重要的作用。1楔形垫 (见封 3图 1)楔形垫最初的用途是作为头部控制能力、坐位平衡能力和体位变换能力差的脑瘫患儿坐位时的辅助物。随着康复训练的普及 ,楔形垫在脑瘫康复中的训练价值越来越受到重视。不同大小的楔形垫有不同的训练效果。楔形垫的长度主要取决于患儿的身长 ,一般应能容纳患儿俯卧位时的身体 ,最短也不应短于患儿胸骨到膝盖的长度。楔形垫的高度主要取决于患儿所要开展的训练项目。使用楔形垫的训练主要有以下几种 :①头部…     

Test-Retest repeatability of gluteus maximus strength testing using a fixed digital dynamometer in children with cerebral palsy

OBJECTIVE: To investigate the test-retest repeatability of the measurement of the gluteus maximus strength using a fixed digital dynamometer. DESIGN: Test-retest design. The strength of the gluteus maximus was measured in prone position during 2 sessions an average of 6 days apart. SETTING: Gait analysis laboratory. PARTICIPANTS: Eleven children with spastic diplegic (n=10) and hemiplegic (n=1) cerebral palsy (CP), age 6 to 14 years, and 11 aged-matched children. All were able to walk independently, but 2 in the CP group used walking aids. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: On 2 occasions, gluteus maximus strength was measured 3 times in 2 positions of the hip joint. Repeatability of the measurements was assessed by intraclass correlation coefficients (ICCs), coefficients of variation, and the coefficient of repeatability. RESULTS: When normalized to body mass, children with CP had significantly less gluteus maximus strength compared with the controls. The ICCs for the control group ranged from .76 to .85 and from .75 to .83 for the involved leg in the CP group. CONCLUSIONS: The reliability of measurement of gluteus maximus strength was good for both control group and the involved leg of the CP group. The normalized values for gluteus maximus strength and measures of reproducibility can be used when measuring gluteus maximus strength in children with CP.     

肉毒杆菌毒素肌肉注射疗法在小儿脑瘫康复训练中的应用

目的观察肉毒杆菌毒素Ａ（ＢＴＸ－Ａ）肌肉注射矫治小儿脑瘫功能畸形的疗效和副作用,及其在康复训练中的应用意义。方法ＢＴＸ－Ａ剂量为１～２ＩＵ／ｋｇ痉挛肌运动点注射。注射后１个月不出现效果,则增加剂量重复注射。结果１２例不能行走或走不稳的患儿,治疗后２个月内,５例能平稳行走,５例扶物自行,上肢畸形７例中３例恢复,３例改善;１例无效。随防２～１７个月未见复发和副作用。结论该法实用、安全、有效、无组织损害。适用于痉挛型或伴有痉挛的徐动型脑瘫患儿。     

Incidence and risk factors of hip joint pain in children with severe cerebral palsy

Purpose.?Pain is a serious complication associated with hip dislocation in cerebral palsy (CP), limiting patient independence and quality of life. This study aimed to determine the frequency of pain in severe CP patients with hip dislocation and to reveal factors associated with the hip pain.

Methods.?Seventy-three consecutive new-intervention CP patients admitted to authors' institution with spastic quadriplegia, mean age 10.8 years (range 4.0–18.0 years) were enrolled: 31 females and 42 males, totally 99 dislocated hips. All patients were assessed level IV or V according to the Gross Motor Function Classification Scale (GMFCS) and had poor communication skills. Pain severity was evaluated according to the Numeric Rating Scale (NRS-11). Data concerning previously applied physiotherapy was collected to divide the patients into subgroups: A – no abduction therapy (n == 24), B – abduction therapy (n == 35) and C – abduction therapy and horse-back riding (n == 13). On the pelvic antero-posterior radiographs head migration percentage was measured to reveal hip dislocation. Femoral head cartilage degenerative lesions were evaluated for size and location in 45 hips undergoing surgical treatment.

Results.?Overall pain prevalence was 56%%. The appearance of pain was associated with the patient age (p == 0.048), previous abduction physiotherapy (p < 0.00001), previous horse-back riding therapy (p < 0.00001) and anterior location of degenerative changes of the femoral head (p == 0.03). Pain intensity was related to the size of the degenerative cartilage lesions (p == 0.004) and to the degree of femoral anteversion (p < 0.0001).

Conclusions.?Extensive abduction exercises, hippotherapy and presence of degenerative cartilage lesions on the anterior part of femoral head may be considered risk factors for hip pain appearance in the dislocated hip of a child with severe spastic CP. Other associated factors are abduction exercise intensity, age, excessive femoral anteversion and size of degenerative cartilage lesions.     

Hip migration percentage in children with cerebral palsy treated with botulinum toxin type A

OBJECTIVE: To determine hip radiographic findings in children with cerebral palsy (CP) treated with botulinum toxin type A (BTX-A). DESIGN: Retrospective chart review with correlation to radiographic findings. SETTING: Academic center. PARTICIPANTS: Sixteen subjects with CP. INTERVENTION: BTX-A treatment to adductor muscles. MAIN OUTCOME MEASURE: The Reimers hip migration percentage before and after BTX-A. RESULTS: Thirty-two hips in 16 children with CP were treated. We examined the effect of initial migration percentage and initial migration percentage age on the change in migration percentage after BTX-A injection. A significant effect for initial migration percentage (<30% or >/=30%; F=19.05, P <.001) and a significant interaction between initial migration percentage and initial migration percentage age (F=7.5, P <.01) was noted. Initial migration percentage age (24 mo) was not significant (F=.95, P =.34). Patients who had an initial migration percentage of 30% or more and were less than 24 months old were more likely to have a decrease in migration percentage after BTX-A injection compared with patients who were older than 24 months and who had an initial migration percentage of 30% or more. CONCLUSIONS: Improvement in hip migration percentage after BTX-A injection is a function of age and the initial migration percentage. BTX-A injections to adductor muscles may be beneficial for some children with CP.     

Patterns of hip migration in non-ambulant children with cerebral palsy: A prospective cohort study

BackgroundIn children with cerebral palsy (CP), we have little information on when hip migration (HM) starts, what causes hip displacement, how HM changes over time, and how to halt this migration to avoid surgery.ObjectivesWe aimed to estimate the prevalence of HM percentage (HMP) >4 0% in a homogeneous population of non-ambulant children with CP and model the changes in HMP over a 2.6-year mean follow-up.MethodsFrom September 2009 to September 2015, this observational, prospective, multicenter cohort study recruited 235 children from 51 centers who were 3 to 10 years old and had levels IV and V of the Gross Motor Function Classification System for CP. The outcomes were yearly HMP measurements by the Reimers index. Only children with at least one hip with HMP ≤ 40% at baseline were included in trajectory modeling. Comparisons of chidren's characteristics between trajectory groups were adjusted by the false discovery rate method.ResultsThe prevalence of children with at least one hip with HMP > 40% was estimated at 24.3% (95% confidence interval 18.6–30.0). Pelvic obliquity was observed in 51.4% and 24.4% of children with asymmetric and symmetric HMP (P = 0.002). The trajectory modelling identified 3 types of MP changes over time. Many children (67.4% and 79.3% for the right and left hip) could be assigned to the “stable” trajectory group.ConclusionsIn non-ambulant children with CP, the prevalence of HM requiring surgery is low and most hips remain practically stable over time.     

The role for hip surveillance in children with cerebral palsy

Spastic hip displacement is the second most common deformity seen in children with cerebral palsy (CP), and the long-term effects can be debilitating. Progressive hip displacement leading to dislocation can result in severe pain as well as impaired function and quality of life. Recent population-based studies have demonstrated that a child’s Gross Motor Functional Classification System (GMFCS) level is most predictive for identifying hips “at-risk” for progressive lateral displacement. As a result, in many developed countries, hip surveillance has now been adopted as an integral piece of the comprehensive care puzzle for the management of children with spastic hip displacement. This paper reviews the spectrum of treatments available for progressive hip displacement, examines the current literature on the success of hip surveillance, and illustrates an example of a current hip surveillance program stratified by the GMFCS level.     

Effects of the standing program with hip abduction on hip acetabular development in children with spastic diplegia cerebral palsy

Purpose: Early identification and intervention with conservative measures is important to help manage hip dysplasia in children with a high adductor and iliopsoas tone and delay in weight bearing. The effect of a daily standing program with hip abduction on hip acetabular development in ambulatory children with cerebral palsy was studied. Method: The participants were 26 children with spastic diplegia cerebral palsy (CP), classified at Level III according to the Gross Motor Function Classification System (GMFCS). Thirteen children stood with hip abduction at least 1 h daily from 12 to 14 months of age to 5 years with an individually fabricated standing frame with hip abduction. Results: At the age of 5 years, radiologic results of the study group were compared with a comparison group of 13 children with spastic diplegia CP who had not taken part in a standing program. The migration percentage in all children who stood with abduction remained within stable limits (13–23%) at 5 years of age, in comparison to children who did not stand in abduction (12–47%) (p?Conclusions: The results indicate that a daily standing program with hip abduction in the first 5 years may enhance acetabular development in ambulatory children with spastic diplegia CP.

• Implications for Rehabilitation

• Abnormal acetabular development is a problem related to mobility problems and spasticity muscles around the hip.

• The literature suggests that postural management and standing programs could reduce levels of hip subluxation and increase function in children with cerebral palsy.

• A standing program with hip abduction can be a beneficial to develop more stable hips in children with spastic diplegic GMFCS level III.

     

The interaction between executive attention and postural control in dual-task conditions: children with cerebral palsy

Reilly DS, Woollacott MH, van Donkelaar P, Saavedra S. The interaction between executive attention and postural control in dual-task conditions: children with cerebral palsy.

Objective

To investigate the interference between a secondary task and a postural task in children with cerebral palsy (CP).

Design

In this exploratory study, a dual-task paradigm was used in which children stood in either a wide or a narrow stance position while simultaneously performing a visual working memory task calibrated to be of equitable attentional demand between groups.

Setting

Study data were gathered in a university motor control laboratory.

Participants

Children with CP (n=8; age range, 10−14y) were compared with typically developing older children (n=6; age range, 7−12y), and typically developing young children (n=5; age range, 4−6y).

Interventions

Not applicable.

Main Outcome Measures

Proficiency in postural control was measured by the range and root mean square of the velocity of center of pressure displacement in the mediolateral and anteroposterior directions, calculated from forceplate data. Accuracy of response was used as a measure of cognitive task performance. Capacity of the executive attention system was determined by assessing visual working memory capacity.

Results

Children with CP, like the typically developing young children, were more unstable and had less executive attention capacity compared with older children, and like the typically developing young children, experienced dual-task interference in postural control in both stance positions. Children with ataxic CP also experienced decreased cognitive task performance in narrow stance.

Conclusions

In designing therapeutic interventions for children with CP, it would be beneficial for clinicians to assess postural control in both single- and dual-task environments.     

Comparison of botulinum toxin type A injection and soft-tissue surgery to treat hip subluxation in children with cerebral palsy

Yang EJ, Rha D-W, Kim HW, Park ES. Comparison of botulinum toxin type A injection and soft-tissue surgery to treat hip subluxation in children with cerebral palsy.

Objective

To compare the effects of botulinum toxin type A (BTX-A) injection into the hip adductor muscles on hip displacement with soft-tissue surgery and assess the factors related to a favorable outcome after intervention in children with bilateral spastic cerebral palsy (CP).

Design

Retrospective chart review with regard to radiographic findings.

Setting

University hospital.

Participants

Children with CP (N=194).

Interventions

BTX-A injection and soft-tissue surgery into the hip adductor muscles.

Main Outcome Measure

The Reimers hip migration percentage (MP).

Results

Sixty-nine children did not receive any therapeutic intervention for hip displacement, whereas 60 children underwent soft-tissue surgery and 65 children took BTX-A injection for the spasticity of their hip muscles. MP was measured on each radiograph of the pelvis. The annual change of MP was improved in both the soft-tissue surgery and BTX-A groups, whereas it worsened in the nonintervention group. The annual improvement of MP in the BTX-A group did not differ significantly from that of the soft-tissue surgery group. The improvement in hip displacement after therapeutic intervention was greater in young children and high-functioning groups compared with older children and low-functioning groups. Hip displacement was progressive in the severely hip subluxated group despite therapeutic intervention.

Conclusions

Comparable effects of BTX-A injection to soft-tissue surgery in our study suggest that BTX-A injection, if timely reinjected, may replace soft-tissue surgery as a prophylactic procedure against progressive hip subluxation or dislocation in children. Age at intervention, functional level, and initial MP before therapeutic intervention were the factors affecting the outcomes.