椎板切开复位选择性脊神经后根切断治疗痉挛性脑瘫

目的:探讨通过显微神经外科和电生理技术,进行椎板切开复位选择性脊神经后根切断术对痉挛性脑性瘫痪的治疗效果.方法:行T11～L1椎板切开复位,显微镜下在脊髓圆锥水平将L1～S2神经后根分离成神经小枝,观察电刺激神经后根小枝所诱发的肌肉收缩和肌电图反应,切断异常反应的神经后根小枝.神经后根小枝切断数目不超过60%.结果:所有病例术后肌痉挛程度立即出现明显下降,随访发现所有患者肢体运动功能均有改善,术后未出鲻现腰椎前凸、畸形及滑脱现象.结论:T11～L1椎板切开复位,脊髓圆锥入路选择性L1～S2神经后根切断,能够有效地控制脑瘫所引起的下肢肌痉挛,改善运动功能并减少术后并发症的发生.     

小儿痉挛型脑性瘫痪的康复治疗

目的：探讨采用以训练为主、结合外科手术来治疗痉挛型脑瘫,观察其临床疗效。方法：根据患儿的年龄、功能障碍程度及智力水平制定不同的训练方案,并对２１例患儿辅以手术治疗。结果：总有效率达７３．３％,其中结合手术治疗有效率达９０．０％,与非手术组比较疗效明显较优（Ｐ＜０．０５）。结论：在功能训练的基础上选择合适的病例结合外科手术治疗,能更好地达到康复效果     

全身振动疗法对痉挛型双瘫患儿下肢运动功能的影响

目的 探讨全身振动疗法对痉挛型双瘫患儿下肢运动功能的影响。 方法 选取痉挛型双瘫患儿56例,采用随机数字表法分为治疗组和对照组,每组28例。两组均给予常规的运动康复训练,治疗组在此基础上辅以全身振动疗法,治疗频率为每周5次,每次15 min,共12周。治疗前、治疗12周后（治疗后）,记录2组患儿粗大功能评定量表（GMFM-88）D区（站立）和E区（走跑跳）评分、踝关节背屈活动度（ROM）、胫前肌和腓肠肌的表面肌电信号均方根值（RMS）和Berg平衡量表（BBS）评分。 结果 治疗前,2组患儿治疗前、后GMFCS D区（站立）和E区（走跑跳）评分、踝关节主动ROM、被动ROM、被动背屈踝关节腓肠肌RMS、主动背屈踝关节胫前肌RMS、主动趾屈踝关节腓肠肌RMS、BBS评分比较,差异无统计学意义（P>0.05）。与组内治疗前比较,除主动背屈踝关节胫前肌RMS外,2组患儿治疗后GMFCS D区（站立）和E区（走跑跳）评分、踝关节主动ROM、被动ROM、被动背屈踝关节腓肠肌RMS、主动趾屈踝关节腓肠肌RMS、BBS评分均有所改善（P<0.05）,且治疗组治疗后GMFCS D区（站立）［（36.3±2.6）分］和E区（走跑跳）［（44.1±11.3）分］评分、踝关节主动ROM［（9.36±4.12）°］、被动ROM［（19.64±6.15）°］、被动背屈踝关节腓肠肌RMS［（15.3±6.5）μV］、主动趾屈踝关节腓肠肌RMS［（82.8±13.6）μV］、BBS评分［（39.6±1.6）分］较为优异（P<0.05）。 结论 全身振动疗法能有效改善痉挛型双瘫患儿的下肢运动功能。     

A型肉毒毒素注射配合康复训练治疗痉挛型脑性瘫痪儿童下肢肌张力障碍

目的探讨A型肉毒毒素（BTX-A）在脑性瘫痪（脑瘫）治疗中的应用及疗效。方法将34例痉挛型双瘫患儿随机分为治疗组和对照组，治疗组采用BTX-A局部多点注射结合康复训练，对照组仅行康复训练，2组治疗前及治疗后3d、2周、1个月、2个月和3个月采用改良的Ashworth痉挛分级量表、粗大运动功能量表（GMFM）及印油毯足印分析进行疗效评估。结果治疗组治疗3d后，对照组治疗1个月后痉挛评分下降。与治疗前比较，差异有统计学意义（P〈0．05）；治疗2周至3个月，2组痉挛评分比较，差异有统计学意义（P〈0．05）。2组治疗1个月和3个月后GMFM评分均有提高，治疗3个月后治疗组与对照组相比，差异有统计学意义（P〈0．05）。印油毯足印分析显示，治疗组治疗3个月后步行足长、步速与治疗前及与对照组比较，差异有统计学意义（P〈0．05），步幅评分2组均有明显提高（P〈0．05），但组问差异无统计学意义（P〉0．05）。结论BTX-A注射配合康复训练可快速有效地缓解脑瘫患儿下肢痉挛及提高其步行功能，缩短住院疗程。     

踝足矫形器联合肉毒毒素治疗痉挛型脑性瘫痪儿童尖足畸形的疗效观察

目的观察踝足矫形器（AFO）联合A型肉毒毒素（BTX-A）肌肉注射治疗痉挛型脑瘫患儿尖足的疗效。 方法痉挛型脑瘫患儿尖足畸形50例,采用随机数字表法将其分为对照组和观察组,每组25例,对照组患儿采用BTX-A肌肉注射与运动康复训练,观察组在对照组基础上加用AFO训练,与其运动康复训练同步。分别于治疗前、治疗后1、3和6个月,使用量角器测量踝关节的被动背屈角（APROM）,改良Ashworth量表的评分（MAS）以及粗大运动功能量表（GMFM-88）的D区（站立）和E区（走跑跳）评分。 结果治疗前,观察组APROM、MAS和GMFM（D、E）分别为（109.25±12.38）°、（3.12±0.56）分和（55.32±11.23）分,与对照组［（107.11±13.44）°、（3.05±0.66）分和（56.21±10.81）分］比较,差异均无统计学意义（P>0.05）。2组患儿的APROM、MAS和GMFM评分在治疗后1、3和6个月时与组内与治疗前比较,差异均有统计学意义（P<0.05）;治疗后,观察组APROM、MAS和GMFM评分分别与对照组治疗比较,差异亦均有统计学意义（P<0.05）。2组治疗后各时间点之间的评估指标比较,观察组差异均有统计学意义;对照组治疗后1个月与治疗后3个月比较,差异有统计学意义（P<0.05）,治疗后3个月和治疗后6个月比较,差异无统计学意义（P>0.05）。 结论AFO联合BTX-A疗法能进一步缓解痉挛型脑瘫患儿的下肢痉挛程度,减轻尖足异常姿势,维持时间更持久。     

Geometrical adaptation in ulna and radius of cerebral palsy patients: Measures and consequences

Background

The presence of significant forearm bone torsion might affect planning and evaluating treatment regimes in cerebral palsy patients. We aimed to evaluate the influence of longstanding wrist flexion, ulnar deviation, and forearm pronation due to spasticity on the bone geometries of radius and ulna. Furthermore, we aimed to model the hypothetical influence of these deformities on potential maximal moment balance for forearm rotation.

Methods

Geometrical measures were determined in hemiplegic cerebral palsy patients (n = 5) and healthy controls (n = 5). Bilateral differences between the spastic arm and the unaffected side were compared to bilateral differences between the dominant and non-dominant side in the healthy controls. Hypothetical effects of bone torsion on potential maximal forearm rotation moment were calculated using an existing anatomical muscle model.

Findings

Patients showed significantly smaller (radius: 41.6%; ulna: 32.9%) and shorter (radius: 9.1%; ulna: 8.4%) forearm bones in the non-dominant arm than in the dominant arm compared to controls (radius: 2.4%; ulna 2.5% and radius: 1.5%; ulna: 1.0% respectively). Furthermore, patients showed a significantly higher torsion angle difference (radius: 24.1°; ulna: 26.2°) in both forearm bones between arms than controls (radius: 2.0°; ulna 1.0°). The model predicted an approximate decrease of 30% of potential maximal supination moment as a consequence of bone torsion.

Interpretation

Torsion in the bones of the spastic forearm is likely to influence potential maximal moment balance and thus forearm rotation function. In clinical practice, bone torsion should be considered when evaluating movement limitations especially in children with longstanding spasticity of the upper extremity.     

Functional Status of Patients With Cerebral Palsy According to the International Classification of Functioning, Disability and Health Model: A 20-Year Follow-Up Study After Selective Dorsal Rhizotomy

Langerak NG, Lamberts RP, Fieggen AG, Peter JC, Peacock WJ, Vaughan CL. Functional status of patients with cerebral palsy according to the International Classification of Functioning, Disability and Health Model: a 20-year follow-up study after selective dorsal rhizotomy.

Objective

To determine functional status of patients with cerebral palsy 20 years after they received selective dorsal rhizotomy (SDR).

Design

A prospective 20-year follow-up study.

Setting

Red Cross Children's Hospital (SDR operation and 1-year follow-up assessment) and at institutional or private locations nearby patients' homes (20-year follow-up assessment).

Participants

Referred sample of 14 patients with spastic diplegia (6 women, 8 men; mean age, 27y; range, 22-33y) who were preoperatively ambulant and fulfilled strict selection criteria for SDR operation in 1985.

Interventions

Patients were assessed before and 1 and 20 years after SDR.

Main Outcome Measures

Standardized assessments of function according to 2 dimensions of the International Classification of Functioning, Disability and Health (ICF) model: (1) body structure and function (muscle tone, joint stiffness, voluntary movement) and (2) activity (rolling, sitting, kneeling, crawling, standing, walking, transitions) were obtained. In addition, based on assessments and questionnaires, Gross Motor Function Classification System (GMFCS) levels were determined before and at 1 year after SDR retrospectively and currently at 20 years after SDR.

Results

One year after SDR, functional outcomes based on the 2 dimensions of the ICF model improved significantly, and these improvements were maintained at 20 years after surgery. Patients showed a shift in their GMFCS levels 1 and 20 years after SDR.

Conclusions

In line with our 20-year follow-up study with gait parameters as outcome measures, patients with spastic diplegia still show improvements in their functional status 20 years after SDR. We acknowledge the presence of possible confounding factors and a small sample size, but we argue that the improvements found in this study were caused mainly by SDR. Finally, changes in GMFCS levels suggest a possible role for this tool to detect changes after an intervention.     

Adjunct therapies to improve outcomes after botulinum toxin injection in children: A systematic review

BackgroundBotulinum toxin (BTX) injection alone is not sufficient to treat spasticity in children, notably those with cerebral palsy; thus, there is an emerging trend for adjunct therapies to offer greater outcomes than BTX alone.ObjectiveThe aim of this systematic review was to evaluate the general effectiveness of adjunct therapies regardless of their nature in children with spasticity.MethodsMedline, Cochrane and Embase databases were searched from January 1980 to March 15, 2018 for reports of parallel-group trials (randomized controlled trials [RCTs] and non-RCTs) assessing adjunct therapies after BTX injection for treating spasticity in children. Two independent reviewers extracted data and assessed the risk of bias by using the PEDro scale for RCTs and Downs and Black scale (D&B) for non-RCTs.ResultsOverall, 20 articles involving 662 participants met the inclusion criteria. The average quality was good for the 16 RCTs (mean PEDro score 7.4 [SD 1.6]) and poor to moderate for the 4 non-RCTs (D&B score 9 to 17). Adjunct therapies consisted of casting/posture, electrical stimulation, resistance training and rehabilitation programmes. Casting associated with BTX injection improved the range of passive and active motion and reduced spasticity better than did BTX alone (9 studies), with a follow-up of 1 year. Resistance training enhanced the quality and performance of muscles without increasing spasticity. Only 3 rehabilitation programmes were studied, with encouraging results for activities.ConclusionLower-limb posture with casting in children has a high level of evidence, but the long-term efficacy of short-leg casting needs to be evaluated. A comparison between the different modalities of casting is missing, and studies specifically devoted to testing the different kinds of casting are needed. Moreover, the delay to casting after BTX injection is not clear. Data on electrical stimulation are not conclusive. Despite the small number of studies, resistance training could be an interesting adjunct therapy notably to avoid loss of strength after BTX injection. Rehabilitation programmes after BTX injection still need to be evaluated.     

不同定位技术引导肉毒毒素治疗脑瘫患儿踝跖屈肌群痉挛的对照研究

目的 比较电刺激定位技术与经验定位引导肉毒毒素A（BTX-A）注射治疗脑瘫患儿踝跖屈肌群痉挛的临床疗效。方法 45例脑瘫患儿随机分为电刺激定位组23例，经验定位组22例。2组接受BTX-A注射后3d，开始进行10d物理治疗，之后改由家长在家治疗。患儿在治疗前和治疗后3d、2周、1个月、2个月、3个月进行以下评定：①踝关节被动活动范围（PROM）；②改良Ashworth量表（MAS）评分；③综合痉挛量表（CSS）评分；④粗大运动功能量表（GMFM）D、E项评分；⑤步行速度。结果 2组患儿的PROM、MAS评分、CSS评分、GMFM评分和步行速度，在治疗后2周、1个月、2个月、3个月分别与治疗前比较，差异均有统计学意义（P〈0．001）。PROM、CSS评分在治疗后3d、2周、1个月、2个月、3个月组间差异有统计学意义（P〈0．05）。MAS评分在治疗后3d、2个月、3个月时组间差异有统计学意义（P〈0．05）。GMFM评分在治疗后2个月、3个月组间差异有统计学意义（P〈0．05）。步行速度差值在治疗后2个月、3个月时组间差异有统计学意义（P〈0．05）。结论 电刺激定位技术较经验定位引导BTX-A注射结合物理治疗能更好地缓解脑瘫患儿踝跖屈肌群痉挛，提高患儿运动能力。