Comparison of efficacy of Adeli suit and neurodevelopmental treatments in children with cerebral palsy

This study compared the efficacy of Adeli suit treatment (AST) with neurodevelopmental treatment (NDT) in children with cerebral palsy (CP). Twenty-four children with CP, Levels II to IV according to the Gross Motor Function Classification System (GMFCS), were matched by age and functional status and randomly assigned to the AST or NDT treatment groups. In the AST group (n=12; eight males, four females; mean age 8.3 y [SD 2.0]), six children had spastic/ataxic diplegia, one triplegia and five spastic/mixed quadriplegia. In the NDT group (n=12; nine males, three females; mean age 8.1 y [SD 2.2]), five children had spastic diplegia and seven had spastic/mixed quadriplegia. Both groups were treated for 4 weeks (2 hours daily, 5 days per week, 20 sessions). To compare treatments, the Gross Motor Function Measure (GMFM-66) and the mechanical efficiency index (EIHB) during stair-climbing were measured at baseline, immediately after 1 month of treatment, and 10 months after baseline. The small but significant time effects for GMFM-66 and EIHB that were noted after 1 month of both intensive physiotherapy courses were greater than expected from natural maturation of children with CP at this age. Improvements in motor skills and their retention 9 months after treatment were not significantly different between the two treatment modes. Post hoc analysis indicated a greater increase in EIHB after 1 month (p=0.16) and 10 months (p=0.004) in AST than that in NDT, predominantly in the children with higher motor function (GMFCS Levels II and III). The results suggest that AST might improve mechanical efficiency without a corresponding gain in gross motor skills, especially in children with higher levels of motor function.     

Medial gastrocnemius muscle volume and fascicle length in children aged 2 to 5 years with cerebral palsy

AIM: The aim of this article was to compare medial gastrocnemius muscle volume, physiological cross-sectional area (PCSA), muscle length, fascicle length, and pennation angle in children aged 2 to 5 years with spastic cerebral palsy (CP) and in typically developing children. method: Fifteen children with spastic CP (11 males, four females; mean age 45 mo [SD 15 mo]; five with hemiplega; 10 with diplega; 10 classified at Gross Motor Function Classification System (GMFCS) level I, five at GMFCS level II) and 20 typically developing children (11 males, nine females; mean age 48 mo [SD 14 mo]) participated in the study. Individuals with spastic CP were included if they had a minimum range of motion of 0° ankle dorsiflexion with the knee extended and were excluded if they had had previous botulinum toxin treatment to the calf muscles or previous calf surgery. Typically developing children were included if they were able to walk independently and were excluded if there was a history of previous lower leg injury or other developmental disorder affecting the lower limb. Freehand two-dimensional and three-dimensional ultrasound was used to assess muscle properties of the relaxed medial gastrocnemius muscle at three ankle joint angles: maximum dorsiflexion, neutral and maximum plantarflexion. PCSA was calculated as a function of muscle volume and muscle fascicle length and pennation angle was recorded at the neutral ankle joint angle. Results: Medial gastrocnemius muscle volume was 22% lower in the group with spastic CP than in the typically developing group, which in the absence of significant group differences in neutral fascicle length gave rise to an equivalent reduction in PCSA for the group with spastic CP. Significant positive correlations were found between muscle volume and age (r=0.63-0.65) and between muscle length and age (r=0.72-0.81) in both groups. Maximum ankle dorsiflexion angle was also reduced in the group with spastic CP (8°) compared with the typically developing group (26°). Interpretation: The observed reduction in muscle PCSA in the group with spastic CP would be expected to contribute to the clinically observed muscle weakness in spastic CP and suggests the need for early intervention in order to minimize loss of muscle PCSA in spastic CP.     

Hyperactive stretch reflexes, co-contraction, and muscle weakness in children with cerebral palsy

The aim of this study was to examine the repeatability of and relationships among spasticity, co-contraction of agonist–antagonist, and muscle strength in children with cerebral palsy (CP). Eight children with spastic diplegic CP (five males, three females; Gross Motor Function Classification System [GMFCS] Levels I–III; mean age 10y 2mo [SD 2y 9mo], range 6–13y) and nine children in a comparison group (six males, three females; mean age 8y 10mo [SD 2y 4mo], range 6y to 12y 6mo) were assessed twice to examine repeatability of Composite Spasticity Scale, soleus stretch reflexes, electromyography (EMG) co-contraction ratio, and torque recorded during maximal isometric voluntary contraction of ankle dorsiflexors and plantarflexors. Sixty-one children with spastic CP, (54 diplegic, seven hemiplegic; 32 males, 29 females; GMFCS levels I–III; mean age 10y 8mo [SD 2y 9mo], range 6–15y) were then assessed to delineate possible correlations among these measures. Intraclass correlation coefficients (0.78–0.97) showed high data repeatability in both groups. Children with spastic CP demonstrated significantly larger soleus stretch reflex/M-response areas smaller torques, but larger EMG co-contraction ratios during both voluntary dorsiflexion and plantarflexion (all p <0.05). Children with spastic CP who had larger soleus stretch reflex/M-response areas demonstrated larger plantarflexion co-contraction ratio ( r = 0.28), and produced smaller plantarflexion and dorsiflexion torques ( r = –0.48 and –0.27 respectively). However, no correlation was noted between soleus stretch reflex and clinical spasticity. Our findings demonstrated that hyperactive soleus stretch reflex affected torque production of ankle muscles. Moreover, the severity of spasticity may not be fully described by either stretch reflex or tone measure alone.     

Predictive value of definitely abnormal general movements in the general population

Aim Definitely abnormal general movements in populations of high‐risk infants predict serious neurodevelopmental impairment. This study aimed to assess predictive values of definitely abnormal general movements at 3 months for serious neurodevelopmental impairment in a representative sample of the general population. Method A prospective cohort study of 455 3‐month‐old infants was performed (241 females, 214 males; mean birthweight 3452g, SD 604g; mean gestational age 39.4wks, SD 1.96; n=32 born preterm). At enrolment, general movement quality was assessed by means of video recording. At 4 years, all participants were reassessed by well‐baby health clinicians; if serious neurodevelopmental impairment was identified, clinical records were reviewed. Predictive values of definitely abnormal general movement quality for major neurodevelopmental impairment were calculated. Results Five children were diagnosed as having a major neurodevelopmental disorder with serious implications for daily life, including three children with cerebral palsy (CP). Three out of the five had shown definitely abnormal general movements; they had lesions involving the periventricular white matter. Two children did not show definitely abnormal general movements; one had unilateral spastic CP due to a cortical lesion and the other had ataxia due to cerebellar atrophy. The positive predictive value of definitely abnormal general movements for major neurodevelopmental impairment was 18/100, and for CP it was 12/100. Negative predictive values approached 100%. Interpretation The good predictive value of general movement assessment in high‐risk populations cannot be generalized to the general population.     

Everyday functioning in young children with cerebral palsy: functional skills,caregiver assistance,and modifications of the environment

Everyday functioning is described in 95 children with cerebral palsy (CP; 55 males and 40 females; mean age 58 months, SD 18 months, range 25 to 87 months) using the three scales of the Pediatric Evaluation of Disability Inventory (PEDI): Functional Skills, Caregiver Assistance, and Modifications of the Environment. Types of CP in the children were hemiplegia, (n=19), spastic/ataxic diplegia, (n=44), spastic quadriplegia, (n=16), dyskinetic, (n=9), and mixed (n=7). Symptoms were grouped by severity according to the Gross Motor Function Classification System (GMFCS): 23% were classified at level I, 21% at level II, 10% at level III, 23% at level IV, and 23% level V. A large variability in functioning in mobility, self-care, and social function was seen because of the heterogeneity of children with CP. Limitations in achievement of activities, need for assistance, and use of assistive devices increased progressively with GMFCS level. Furthermore, these children differed to a great extent from the normative sample of the PEDI. Stepwise regression analysis showed that the GMFCS was a good predictor of everyday functioning with age and learning problems as significantly contributing factors, particularly in self-care and social function. In conclusion, the three scales of the PEDI represent different but strongly related aspects of everyday functioning in young children with CP.     

Partial body-weight-supported treadmill training can improve walking in children with cerebral palsy: a clinical controlled trial

This matched-pairs, clinical controlled trial evaluated the effects of a school-based, partial body-weight-supported treadmill training (PBWSTT) programme, conducted twice a week for 6 weeks, on the walking speed and endurance of children with cerebral palsy (CP). Pairs of children (10 males, four females; mean age 8 y 10 mo [SD 2 y 6 mo], range 5-14 y) matched for sex, age, type of CP (athetoid quadriplegia, n=6; spastic quadriplegia, n=6; spastic diplegia, n=2), and Gross Motor Function Classification System level (10 at Level I V, four at Level III) were allocated to the experimental or control group. Compared with the control group, the seven treadmill-training participants increased their self-selected walking speed over 10 metres (Mann-Whitney U=9.00, z=-1.98, p=0.048; mean difference 4.21 m/min). A trend was also found for increased distance walked over ground in 10 minutes (t[12]=1.88, p=0.083; mean difference 19.81 m). A relatively short PBWSTT programme can improve the walking speed of children with CP and moderate to severe disabilities. Walking endurance might also improve in some children. Treadmill training seems to be a useful gait training option for children with C P, and it seems feasible to conduct such a programme within a school environment.     

Remodeling of the proximal femur after varus osteotomy in children with cerebral palsy

The purpose of this study was to determine and measure the factors that affect the remodeling of the proximal femur after varus osteotomy in children with spastic cerebral palsy (CP). Seventy-five varus proximal osteotomies were performed on 44 children (26 females, 18 males) for hip dysplasia. Thirty-nine patients had spastic CP and five had spastic diplegia; 35 patients used a wheelchair for mobility and nine could walk. Mean age at time of surgery was 8 years (SD 4 years), range 2 years 6 months to 15 years. Preoperative, immediate postoperative, and follow-up (0 to 6 months, 6 months to <1 year, 1 year to <2 years, 2 years to <4 years, 4 years to <6 years, and 6 years to <8 years) radiographs were reviewed. Neck-shaft angles were measured. Correlations to examine the relationship between age at time of surgery and ambulatory status with postoperative changes in neck-shaft angles were reviewed. Remodeling of the proximal femur does occur after varus osteotomy as long as the physes of the proximal femur show growth potential. Remodeling was quite variable between patients: children younger than 4 years old at the time of surgery remodeled more than children who were older than 4 years. Ambulatory status has little effect on the magnitude of remodeling. This study reinforces the need to follow these patients with periodic hip radiographs until completion of growth.     

Altered skeletal maturation in moderate to severe cerebral palsy

Abnormalities of growth and development are prevalent in children with cerebral palsy (CP). The purpose of this study was to assess skeletal maturation ('bone age') in this population and to identify those factors related to alterations in this aspect of development. The study group was a convenience sample of 80 participants (47 males, 33 females; age range 2 y 6 mo to 21 y 1 mo; mean age 10 y 10 mo, SD 4 y 2 mo). All had moderate to severe spastic or mixed spastic CP at Gross Motor Function Classification System level III (n=8, 10%); level IV (n=21, 26%); or level V (n=51, 64%). Skeletal maturation was assessed by the detailed Fels method of scoring hand-wrist radiographs. Each evaluation included clinical and anthropometric assessments, Tanner staging, bone density measurements, and the Children's Health Status Questionnaire. Follow-up evaluations were obtained for 41 participants, providing a total of 143 evaluations. Median interval between first and last evaluations was 24.7 months (range 11.9 to 45mo). For the study group as a whole there was no significant difference between a child's skeletal age and chronological age. However, there was a high prevalence of individual participants in whom skeletal age was advanced (7%) or delayed (10%), relative to chronological age, by more than 2 years. In multivariant analyses it was found that diminished linear growth (height), low lumbar-spine bone density, and low body fat as measured by triceps skinfolds were all independently associated with delays in skeletal maturation. Multiple aspects of skeletal growth and development, including skeletal maturation, are frequently altered in children with moderate to severe CP.     

Drooling in children with cerebral palsy: effect of salivary flow reduction on daily life and care

The purpose of this study was to investigate the effect of salivary flow reduction on daily life and provision of care in children with cerebral palsy (CP). Parents of children with CP were asked to fill in a questionnaire on the impact of drooling on the daily life of their children and their families and the data were then analyzed. Forty-five children with severe drooling (28 males, 17 females; mean age 9y 5mo [SD 3y 7mo]; range 3 to 16y) were monitored before and after receiving medication (scopolamine and botulinum toxin) to reduce salivary flow. Type of CP included hypotonia (n = 1), spastic paresis (n = 27), and mixed motor disorders with spastic and dyskinetic paresis (n = 17). Eight children were independently ambulant and 37 children were wheelchair users. Thirty-four children had learning disability with a developmental age of below 6 years. Six participants dropped out of the study; data on 39 children were analyzed. Results showed that anticholinergic agents effectively reduced salivary flow. Drooling diminished substantially and this was accompanied by a significant reduction in care needs, making daily care less demanding. The amount of reported damage to communication devices and computers decreased. In addition to the evaluation of primary variables, such as the salivary flow rate, investigation of impact of drooling on daily life provides useful information about the outcome of treatment for reduction in drooling.     

Testing of the spinal alignment and range of motion measure: a discriminative measure of posture and flexibility for children with cerebral palsy

In this study we describe the development and preliminary psychometric testing of the Spinal Alignment and Range of Motion Measure (SAROMM). Through consultation with pediatric physiotherapists, the items were refined. Subsequently 25 children and adolescents with cerebral palsy (CP; 17 males, 8 females) with a mean age of 9 years 8 months (SD 4y 4mo), stratified by the Gross Motor Function Classification System (GMFCS, n=5 in each group), were recruited. Twenty-two children had spastic CP, and one each was also diagnosed with hypotonic, athetoid, and mixed CP. Three children had hemiplegia, 12 had diplegia, and 10 had quadriplegia. These participants were examined by two physiotherapists on one occasion and by the primary physiotherapist again two weeks later. The intraclass correlation coefficients reflecting interrater and test-retest reliabilities for the spine and range of motion subscales and the total scores were all above 0.80. Validity was supported by a significant contribution of GMFCS level and age to the SAROMM score (r2=0.44). The SAROMM has sufficient reliability and validity for use with children with CP in clinical and research settings by rehabilitation therapists.     

Neuroimpairments, activity performance, and participation in children with cerebral palsy mainstreamed in elementary schools

Participation and activity performance (motor and cognitive or behavioural) were examined in 148 children with cerebral palsy (CP; 87 males, 61 females; mean age 9y 8mo, SD 1y 11mo; range 6y 1mo to 13y 7mo), mainstreamed in fully inclusive (n=100) and in self-contained classes (n=48) within general schools in Israel, using the School Function Assessment. Differences in participation within these groups were analyzed in relation to the type of CP (mainly spastic hemiplegia, spastic diplegia, and spastic tetraplegia), the level of impairment according to the Gross Motor Function Classification System (GMFCS; level II 55%, level III 37%, and level IV 8%), and additional neuroimpairments. Univariate analyses of variance revealed significant differences in levels of participation and levels of activity performance between different types of CP and GMFCS levels. With regard to additional neuroimpairments, significant differences in participation were found for fully included children with speech and language impairments and those with learning disability within the self-contained group. Physical activity performance partly accounted for differences in participation between children with different types of CP and different levels of motor impairment. These findings suggest that within the mainstreamed environment, participation and activity performance increase as motor disability and/or additional neuroimpairments (speech and language impairments and learning disability) decrease.     

Sleep disorders in children with cerebral palsy

To determine the frequency and predictors of sleep disorders in children with cerebral palsy (CP) we analyzed the responses of 173 parents who had completed the Sleep Disturbance Scale for Children. The study population included 100 males (57.8%) and 73 females (42.2%; mean age 8y 10mo [SD 1y 11mo]; range 6y-11y 11mo). Eighty-three children (48.0%) had spastic diplegia, 59 (34.1%) congenital hemiplegia, 18 (10.4%) spastic quadriplegia, and 13 (7.5%) dystonic/dyskinetic CP. Seventy-three children (42.2%) were in Gross Motor Function Classification System Level I, 33 (19.1%) in Level II, 30 (17.3%) in Level III, 23 (13.3%) in Level IV, and 14 (8.1%) in Level V. Thirty children (17.3%) had epilepsy. A total sleep problem score and six factors indicative of the most common areas of sleep disorder in childhood were obtained. Of the children in our study, 23% had a pathological total sleep score, in comparison with 5% of children in the general population. Difficulty in initiating and maintaining sleep, sleep-wake transition, and sleep breathing disorders were the most frequently identified problems. Active epilepsy was associated with the presence of a sleep disorder (odds ratio [OR]=17.1, 95% confidence interval [CI] 2.5-115.3), as was being the child of a single-parent family (OR=3.9, 95% CI 1.3-11.6). Disorders of initiation and maintenance of sleep were more frequent in children with spastic quadriplegia (OR=12.9, 95% CI 1.9-88.0), those with dyskinetic CP (OR=20.6, 95% CI 3.1-135.0), and those with severe visual impairment (OR=12.5, 95% CI 2.5-63.1). Both medical and environmental factors seem to contribute to the increased frequency of chronic sleep disorders in children with CP.     

The influence of age at single-event multilevel surgery on outcome in children with cerebral palsy who walk with flexed knee gait

Aim Information on the timing and long‐term outcome of single‐event multilevel surgery in children with bilateral spastic cerebral palsy (CP) walking with flexed knee gait is limited. Based on our clinical experience, we hypothesized that older children with bilateral spastic CP would benefit more from single‐event multilevel surgery than younger children. Moreover, any improvement in older children could be maintained with fewer additional surgery events. Method We performed a retrospective analysis of the long‐term outcomes of single‐event multilevel surgery. Thirty‐two children (17 males, 15 females) who had received single‐event multilevel surgery between 1995 and 2000 with a mean age at the time of surgery of 10 years 6 months (range 5y 8mo–15y 6mo; SD 3y 1mo) and in Gross Motor Function Classification System level II (n=12) or III (n=20) were included in the study. The inclusion criteria required that all children were ambulatory with spastic bilateral CP, had a flexed knee gait, had a full set of data for single‐event multilevel surgery preoperatively and at 1 year and 10 years postoperatively, had not had previous surgery on their lower limbs, had not had any treatment with botulinum toxin A before gait assessment, and had not received intrathecal baclofen medication. The follow‐up time lasted for over 10 years until the participants reached adulthood (mean age at the last follow‐up 21 years 4 months, SD 3y 4mo). Data were collected on six separate occasions: preoperatively, at 1 year, at 2 to 3 years, at 5 years, at 7 to 8 years, and at 10 or more years postoperatively. The primary outcome was the Gait Deviation Index, and the secondary outcomes were the number and type of initial and additional surgeries. A linear mixed model and Spearman’s rank correlation coefficient were used to prove the hypothesis. Results The older the child was at the time of the surgery, the better the long‐term result (_Age,Time=0.15; p=0.03). We did not find any correlation between age at the time of surgery and the number of bony or soft‐tissue procedures performed initially as well as during the 10 years of follow‐up. Interpretation Children with CP who require single‐event multilevel surgery at an older age fare better in the long term than those who are younger at the time of surgery. The pubertal growth spurt is discussed as a contributing factor to gait deterioration.     

Controlled study of the effects of continuous intrathecal baclofen infusion in non-ambulant children with cerebral palsy

Aim To measure changes in children with severe spastic cerebral palsy (CP) after continuous intrathecal baclofen (ITB) infusion over 18 months and to compare the results with those of a comparison group awaiting treatment. Method Thirty‐eight children with severe spastic CP considered suitable for ITB were assessed when first seen, just before insertion of an intrathecal pump, and 9 months and 18 months later. Eighteen children waited around 9 months for a pump (group 1: nine males, nine females; mean age 9y 11mo [SD 3y 7mo], nine in Gross Motor Function Classification System [GMFCS] level IV, nine in level V). This baseline period was used as a control for comparison with the first and second 9‐month periods after the pump for the remaining 20 children (group 2: 11 males, nine females; mean age 10y 2mo [SD 3y 1mo], nine in GMFCS level IV, 11 in level V). The main outcome measure was the Pediatric Evaluation of Disability Inventory (PEDI); other assessments were of function, ease of care, quality of life, and costs of new equipment. Results No significant change was found in the PEDI between group 1 while awaiting treatment and group 2 in the two periods afterwards, nor in the Lifestyle Assessment Questionnaire or the cost of new equipment. Significant changes were found in group 2 in the first 9 months according to the modified Ashworth score (difference between mean values for groups −1.7, standard error 0.58; p=0.008), Penn Spasm score (−1.3, 0.37; p=0.001), mean joint range of movement (8.3°, 2.8; p=0.005), and Caregiver Questionnaire (−19.7, 5.1; p=0.01), and in the second 9 months for the Modified Ashworth Scale score (−0.62, 0.12; p=0.001). Interpretation ITB in children with severe spastic CP over the first 18 months improves their quality of life in terms of comfort and ease of care. It has less effect on function, participation in society, or the overall cost of new equipment.     

Magnetic resonance imaging findings in a population-based cohort of children with cerebral palsy

The purpose of this study was to investigate the frequency and spectrum of magnetic resonance imaging (MRI) abnormalities in a population of children with cerebral palsy (CP) who were born in the years 2000 and 2001 in Victoria, Australia. In 2000 and 2001, 221 children (126 males, 95 females; mean age 6y [SD 7mo], range 5–7y) with CP, excluding those with CP due to postneonatal causes (6% of all cases), were identified through the Victorian Cerebral Palsy Register. All medical records were systematically reviewed and all available brain imaging was comprehensively evaluated by a single senior MRI radiologist. MRI was available for 154 (70%) individuals and abnormalities were identified in 129 (84%). The study group comprised 88% with a spastic motor type CP; the distribution was hemiplegia in 33.5%, diplegia in 28.5%, and quadriplegia in 37.6% of children. Overall, pathological findings were most likely to be identified in children with spastic hemiplegia (92%) and spastic quadriplegia (84%). Abnormalities were less likely to be identified in non-spastic motor types (72%) and spastic diplegia (52%). The most common abnormalities identified on MRI were periventricular white matter injury (31%), focal ischaemic/haemorrhagic lesions (16%), diffuse encephalopathy (14%), and brain malformations (12%). Dual findings were seen in 3% of patients. This is the first study to document comprehensively the neuroimaging findings of all children identified with CP born over a consecutive 24-month period in a large geographical area.     

Relationship between gross motor capacity and daily‐life mobility in children with cerebral palsy

Aim The aim of this study was to examine the relationship between gross motor capacity and daily‐life mobility in children with cerebral palsy (CP) and to explore the moderation of this relationship by the severity of CP. Method Cross‐sectional analysis in a cohort study with a clinic‐based sample of children with CP (n=116; 76 males, 40 females; mean age 6y 3mo, SD 12mo, range 4y 8mo–7y 7mo) was performed. Gross motor capacity was assessed by the Gross Motor Function Measure (GMFM‐66). Daily‐life mobility was assessed using the Pediatric Evaluation of Disability Inventory (PEDI): Functional Skills Scale (FSS mobility) and Caregiver Assistance Scale (CAS mobility). Severity of CP was classified by the Gross Motor Function Classification System (48% level I, 17% level II, 15% level III, 8% level IV, 12% level V), type of motor impairment (85% spastic, 12% dyskinetic, 3% ataxic), and limb distribution (36% unilateral, 49% bilateral spastic). Results Scores on the GMFM‐66 explained 90% and 84% respectively, of the variance of scores on PEDI‐FSS mobility and PEDI‐CAS mobility. Limb distribution moderated the relationship between scores on the GMFM‐66 and the PEDI‐FSS mobility, revealing a weaker relationship in children with unilateral spastic CP (24% explained variance) than in children with bilateral spastic CP (91% explained variance). Interpretation In children aged 4 to 7 years with unilateral spastic CP, dissociation between gross motor capacity and daily‐life mobility can be observed, just as in typically developing peers.     

The natural history of gross motor development in children with cerebral palsy aged 1 to 15 years

The aim of this study was to explore motor development in children with cerebral palsy (CP) using developmental curves for CP, subtypes, and the five severity levels of the Gross Motor Function Classification System (GMFCS). The Gross Motor Function Measure (GMFM) and the GMFCS were applied to 317 children (145 females, 172 males) with CP, aged between 1 and 15 years. The CP type distribution was spastic diplegia in 157 (49%), spastic hemiplegia in 101 (33%), spastic tetraplegia in 11 (3%), dyskinesia in 38 (12%), and ataxia in 10 (3%). Forty-five physiotherapists were trained in the GMFM and intra- and interrater reliability was tested. The GMFM was measured prospectively every 6 months up to the age of 4 years and once a year thereafter. Developmental curves were constructed for 258 children with spastic CP. About three-quarters of the children at GMFCS Level I reached 90% of the maximum GMFM score at 5 years of age. The performance peaked at 7 years of age. Children at GMFCS Level II reached 90% at a median age of 5 years, which was also the upper limit, reached by about three-quarters at 7 years of age. The majority of children at GMFCS Level III reached 80% of the GMFM by 7 years of age and most of the children at GMFCS Level IV reached 30% at 5 years and remained there. The median score for children at GMFCS Level V was 20%. The intra- and interrater reliability for the GMFM 88 among physiotherapists were Spearman's rank correlation coefficient 0.91 and 0.99 respectively. There were 931 measurements with a median of 2 (1-11) per child. The gross motor development was demonstrated for the five GMFCS levels in children with spastic CP. These kind of curves may be useful for monitoring and predicting motor development, for planning treatment, and for evaluating outcome after interventions.     

Horseback riding in children with cerebral palsy: effect on gross motor function

The effects of recreational horseback riding therapy (HBRT) on gross motor function in children with cerebral palsy (CP: spastic diplegia, spastic quadriplegia, and spastic hemiplegia) were determined in a blinded study using the Gross Motor Function Measure (GMFM). Seventeen participants (nine females, eight males; mean age 9 years 10 months, SE 10 months) served as their own control. Their mean Gross Motor Function Classification System score was 2.7 (SD 0.4; range 1 to 5). HBRT was 1 hour per week for three riding sessions of 6 weeks per session (18 weeks). GMFM was determined every 6 weeks: pre-riding control period, onset of HBRT, every 6 weeks during HBRT for 18 weeks, and 6 weeks following HBRT. GMFM did not change during pre-riding control period. GMFM Total Score (Dimensions A-E) increased 7.6% (p<0.04) after 18 weeks, returning to control level 6 weeks following HBRT. GMFM Dimension E (Walking, Running, and Jumping) increased 8.7% after 12 weeks (p<0.02), 8.5% after 18 weeks (p<0.03), and remained elevated at 1.8% 6 weeks following HBRT (p<0.03). This suggests that HBRT may improve gross motor function in children with CP, which may reduce the degree of motor disability. Larger studies are needed to investigate this further, especially in children. with more severe disabilities. Horseback riding should be considered for sports therapy in children with CP.     

Sensory and motor deficits in children with cerebral palsy born preterm correlate with diffusion tensor imaging abnormalities in thalamocortical pathways

Aim  Cerebral palsy (CP) is frequently linked to white matter injury in children born preterm. Diffusion tensor imaging (DTI) is a powerful technique providing precise identification of white matter microstructure. We investigated the relationship between DTI-observed thalamocortical (posterior thalamic radiation) injury, motor (corticospinal tract) injury, and sensorimotor function.
Method  Twenty-eight children born preterm (16 males, 12 females; mean age 5y 10mo, SD 2y 6mo, range 16mo–13y; mean gestational age at birth 28wks, SD 2.7wks, range 23–34wks) were included in this case–control study. Twenty-one children had spastic diplegia, four had spastic quadriplegia, two had hemiplegia, and one had ataxic/hypotonic CP; 15 of the participants walked independently. Normative comparison data were obtained from 35 healthy age-matched children born at term (19 males, 16 females; mean age 5y 9mo, SD 4y 4mo, range 15mo–15y). Two-dimensional DTI color maps were created to evaluate 26 central white matter tracts, which were graded by a neuroradiologist masked to clinical status. Quantitative measures of touch, proprioception, strength (dynamometer), and spasticity (modified Ashworth scale) were obtained from a subset of participants.
Results  All 28 participants with CP had periventricular white-matter injury on magnetic resonance imaging. Using DTI color maps, there was more severe injury in the posterior thalamic radiation pathways than in the descending corticospinal tracts. Posterior thalamic radiation injury correlated with reduced contralateral touch threshold, proprioception, and motor severity, whereas corticospinal tract injury did not correlate with motor or sensory outcome measures.
Interpretation  These findings extend previous research demonstrating that CP in preterm children reflects disruption of thalamocortical connections as well as descending corticospinal pathways.     

Metabolite profile in the basal ganglia of children with cerebral palsy: a proton magnetic resonance spectroscopy study

This prospective study determined metabolite profile in the left and right basal ganglia of children with spastic cerebral palsy (CP) compared with children without disabilities, by using proton magnetic resonance spectroscopy (1HMRS). Twenty-three patients with spastic CP (12 males, 11 females; mean age 11y 9mo [SD 4y 2mo], range 4-17y) were examined. Twenty children had spastic diplegia and three had quadriplegia. Twenty-four normally developing children (13 females, 11 males; mean age 10y 3mo [SD 4y 8mo], range 4-17y) served as a comparison group. The relative concentrations of N-acetylaspartate (NAA), choline (Cho), myo-inositol (mI), and gamma-aminobutyric acid (GABA) were measured relative to creatine (Cr) and different combinations of metabolites within 8cm3 brain voxels. Children with CP showed reduced ratios of NAA:Cr, NAA:Cho, NAA:mI, and GABA:Cr in the basal ganglia relative to a matched comparison group. Patients demonstrated a significant age-dependent increase in NAA:Cr and NAA:Cho in the basal ganglia. No sex-dependent difference was shown in children with CP nor in the comparison group for all tested metabolite ratios. Significant correlation between Apgar score and ratio of mI:Cr in the group with CP was found. None of the tested metabolite ratios were correlated with the severity scale of CP in children with CP. NAA:Cr ratios were negatively correlated with learning disability in patients with CP. Results indicate the association of the metabolite ratios in basal ganglia with learning disability.