Cognitive and academic profiles in children with cerebral palsy: A narrative review

BackgroundConsiderable effort has recently been made to improve the accurate diagnosis of cerebral palsy (CP) in childhood and to establish early intervention aiming to improve functional outcome. Besides the visible motor impairments, cognitive abilities are frequently affected but might remain unrecognised in children with mild forms. On the other hand, some severely disabled children with presumed intellectual disabilities might demonstrate normal-range reasoning capacities. Most studies on this topic have emphasized a variety of cognitive profiles (cognitive level) related to the type of cerebral palsy and the underlying brain lesions (biological level). However, little is known at the behavioural level, namely learning skills and educational achievement.ObjectiveThis narrative review aimed to discuss cognitive and scholastic skills typically affected in children with CP.MethodsOnline literature research for studies of cerebral palsy, cognition and academic achievement, extracting all relevant articles regardless of article type.ResultsIn children with CP, intellectual disability is frequent and correlated with the degree of motor impairment and early epilepsy. Speech and language problems are prevalent in all forms of CP and might hamper everyday participation on varying levels depending on the degree of motor disability. Most children with CP have neuropsychological deficits affecting predominantly visuospatial functions, attention, and/or executive functions. These problems relate to academic performance and social participation.DiscussionAn adequate interdisciplinary follow-up of children with CP requires a sensitization of clinicians to the complex topic of cognitive and academic problems in this population and a better synergy between the medical and educational worlds.     

Sequence memory skills in Spastic Bilateral Cerebral Palsy are age independent as in normally developing children

Purpose: To study the development of sequence memory skills in a group of participants with Spastic Bilateral Cerebral Palsy (CP) and their matched controls (TD). Sequence memory skills are defined as a blend of implicit and explicit competences that are crucial for the acquisition and consolidation of most adaptive skills along the lifespan. Method: A computerized sequence learning task was administered to 51 participants with CP (age range: 4.1–14.7) and their controls. General performance, accuracy and learning strategy were analyzed, as well as cognitive competencies (IQ and explicit visual spatial memory). Results: Explicit learning developed along with age in all participants. Sequence learning skills were age independent and unevenly distributed among CP participants: most TD (96.1%) and only about half (58.8%) of CP participants succeeded in sequence learning, in dynamic relation with cognitive and manipulation abilities. Conclusion: Sequence memory skills should be verified to plan therapeutic strategies. Therapeutic plans based on implicit learning (more resistant to disruption and stress) could be effective and highly advantageous for most but not for all CP children. Independently from age, many CP children could fix sequences more efficiently by explicit strategies, a more effortful but probably more effective way.

Implications for Rehabilitation

“Sequence memory skills in Spastic Bilateral Cerebral Palsy (CP) are age-independent as in normally developing children”

• Sequence memory skills (a blend of explicit and implicit components) represent a basic competence whose impairment could in a dynamic perspective affect multiple motor and non-motor developmental features.

• The prevalence and importance of implicit learning as a point of strength in therapeutic choice has been formerly emphasized: implicit learning is far more resistant to disruption and stress during rehabilitation and therefore potentially far reaching.

• Sequence memory skills are unevenly distributed in our clinical group.

• A majority of CP participants (58.8%) can rely on efficient sequence learning and therefore may specifically benefit from therapeutic programs privileging implicit learning (that is, relying on progressive and not necessarily explicit consolidation of sequences).

• In those children failing to fix sequences, sequence learning skills need to be specifically supported and explicit strategies (such as for example verbal and visual guides along the task) could be helpful to support consolidation.

     

头针配合康复训练对脑瘫患儿运动功能的影响

目的:探讨头针配合康复训练治疗脑瘫(CP)患儿的疗效,为小儿CP的治疗探索新的有效方法。方法:将CP患儿106例随机分为2组,每组53例,对照组给予肢体康复训练,治疗组在肢体康复训练基础上进行头针治疗,2组均治疗12周,比较治疗前后粗大运动功能量表(GMFM-88)评分、下肢肌群肌张力评分、大脑中动脉收缩期血流速度和搏动指数、血清胰岛素样生长因子(IGF-1)、脑源性神经营养因子(BDNF)水平。结果:治疗后,2组粗大运动功能B、C、E区评分均较治疗前显著增加(P0.01),与对照组比较,治疗组各区评分均显著增加(P0.01);治疗后,2组内收肌、腘绳肌、腓肠肌肌张力均较治疗前明显降低(P0.01),治疗后治疗组与对照组比较,腘绳肌、腓肠肌张力显著降低(P0.01),内收肌张力差异无统计学意义;治疗后2组大脑中动脉血流速度升高(P0.05,0.01),搏动指数降低(P0.01),治疗组变化较对照组更为明显(P0.05,0.01);治疗后2组血清IGF-1、BDNF水平均较治疗前显著升高(P0.05,0.01),治疗组更高于对照组(P0.01)。结论:头针配合康复训练可增加脑组织血液灌注,促进损伤后脑组织修复,降低肌肉张力,改善CP患儿运动功能,治疗小儿CP效果显著。     

152例脑瘫患儿脑电图分析

目的探讨脑瘫患儿的脑电图异常分类及脑电图与脑瘫类型之间的关系。方法采用国际10/20系统电极放置法,为152例脑瘫患儿做脑电图检查并分析。结果152例脑瘫患儿的脑电图异常率为40.13%;脑瘫分型中不随意运动型的脑电图异常率较低,为8.33%,痉挛型偏瘫患儿的脑电图异常率较高,为71.43%。结论脑瘫患儿的脑电图异常率与其脑损伤部位有关。     

Relations Between Executive Functioning and Academic Performance in Adolescents with Neurofibromatosis-1

Neurofibromatosis-1 (NF1) is one of the most common single-gene autosomal dominant disorders. In addition to significant medical complications, learning and attention problems are two of the most commonly reported difficulties in the NF1 population. Given that executive dysfunction often contributes to both learning and attention problems, the goal of the current study was to examine relations between executive and academic skills for adolescents with NF1 while considering the role of intellectual functioning. Participants were 26 adolescents with NF1 and their parents. Data from laboratory-based measures and parent ratings of executive skills in day-to-day life were integrated to elucidate the factors that contribute to academic success. Elevated rates of difficulties were observed on the laboratory-based and parent report measures of executive functioning. Findings indicate that learning difficulties are pervasive in the NF1 population, and that executive dysfunction relates to academic achievement even when intellectual functioning and age are taken into account. Interventions aimed at improving executive skills may therefore improve academic performance in children with NF1.     

Development of handwriting skill in children with unilateral cerebral palsy (CP)

Aim.?To investigate the development of handwriting, fine motor skills and school marks in children with unilateral cerebral palsy (CP) and relate the performance in handwriting skill to age and IQ at a 16-month follow-up.

Method.?Data from 16 children (5 females, 11 males; mean age 11 years 4 months, SD 1 year 6 months, range 8–13 years) with left-sided hemiplegia were collected. The Minnesota Handwriting Assessment (MHA) for handwriting skill, the Bruininks-Oseretsky Test of Motor Proficiency (BOTMP) for fine motor skills, the Wechsler Intelligence Scale for Children Revised (WISC-R) for IQ, the Manual Ability Classification System (MACS) and school marks of children were used.

Results.?Handwriting quality, handwriting speed and fine motor skills improved over 16 months but the children with unilateral CP still performed below their peers. School marks did not change. The regression model (Adj. R² == 0.76) revealed that age and IQ were negatively correlated and good predictors for the improvement in handwriting quality. No relationship was found between handwriting speed and age or IQ.

Conclusion.?Children with unilateral CP continued to develop handwriting skill over a longer time period than expected. Age and IQ predicted the rate of development in handwriting quality. Children kept up school marks despite the increasing demands of the succeeding grade.     

脑性瘫痪儿童脑电图纺锤波变化分析

目的了解脑性瘫痪(CerebralPalsy,CP)儿童脑电图纺锤波变化与临床表现关系。方法检查179例CP儿童脑电图并对其中有纺锤波变化者进行分析。结果CP儿童纺锤波变化中缺失占72％，且双侧痉挛型纺锤波双侧缺失占83％。结论儿童纺锤波的变化可作为观察CP儿童脑器质性损害的指征之一。     

Postnatal cerebral infection leading to hemiplegic cerebral palsy: clinical description of 13 children in Stockholm, Sweden

Purpose. The aim of this research was to estimate the prevalence of postnatal cerebral infection leading to hemiplegic cerebral palsy (CP) in Stockholm County and to describe the motor impairments, associated impairments and involvement of the non hemiplegic side.

Method. Children with hemiplegic CP subsequent to a cerebral infection in the perinatal period up to the age of seven years were identified. The assessments of child psychologists and speech therapists and EEG-studies, CT-scan or MRI of the brain were extracted from the children's files. Thirteen children, with a mean age of 9.5 years, participated. The prevalence was 0.03/1000.

Results. Nine children suffered from mental retardation, seven took antiepileptic drugs and six had bilateral radiological anomalies. The non-hemiplegic side was involved in six of the children.

Conclusion. Cerebral infection at an early age can cause hemiplegic CP with a high frequency of associated impairments and with involvement of the non-hemiplegic side. The infectious origin probably gives rise to a more widespread brain injury.     

脑性瘫痪MRI研究进展

MRI技术是目前明确脑部结构损伤的重要诊断技术,对确定脑瘫的病理类型、病因及损伤时间有重要意义,其改变与脑瘫类型、出生胎龄、病因及损伤时间密切相关。作者就不同类型脑瘫的MRI影像学改变及其与出生胎龄、损伤时间、病因相关性的研究进展做一综述。     

Mu rhythm: State of the art with special focus on cerebral palsy

Various specific early rehabilitation strategies are proposed to decrease functional disabilities in patients with cerebral palsy (CP). These strategies are thought to favour the mechanisms of brain plasticity that take place after brain injury. However, the level of evidence is low. Markers of brain plasticity would favour validation of these rehabilitation programs. In this paper, we consider the study of mu rhythm for this goal by describing the characteristics of mu rhythm in adults and children with typical development, then review the current literature on mu rhythm in CP. Mu rhythm is composed of brain oscillations recorded by electroencephalography (EEG) or magnetoencephalography (MEG) over the sensorimotor areas. The oscillations are characterized by their frequency, topography and modulation. Frequency ranges within the alpha band (∼10 Hz, mu alpha) or beta band (∼20 Hz, mu beta). Source location analyses suggest that mu alpha reflects somatosensory functions, whereas mu beta reflects motor functions. Event-related desynchronisation (ERD) followed by event-related (re-)synchronisation (ERS) of mu rhythm occur in association with a movement or somatosensory input. Even if the functional role of the different mu rhythm components remains incompletely understood, their maturational trajectory is well described. Increasing age from infancy to adolescence is associated with increasing ERD as well as increasing ERS. A few studies characterised mu rhythm in adolescents with spastic CP and showed atypical patterns of modulation in most of them. The most frequent findings in patients with unilateral CP are decreased ERD and decreased ERS over the central electrodes, but atypical topography may also be found. The patterns of modulations are more variable in bilateral CP. Data in infants and young children with CP are lacking and studies did not address the questions of intra-individual reliability of mu rhythm modulations in patients with CP nor their modification after motor learning. Better characterization of mu rhythm in CP, especially in infants and young children, is warranted before considering this rhythm as a potential neurophysiological marker of brain plasticity.     

Postnatal cerebral infection leading to hemiplegic cerebral palsy: Clinical description of 13 children in Stockholm,Sweden

Purpose. The aim of this research was to estimate the prevalence of postnatal cerebral infection leading to hemiplegic cerebral palsy (CP) in Stockholm County and to describe the motor impairments, associated impairments and involvement of the non hemiplegic side.

Method. Children with hemiplegic CP subsequent to a cerebral infection in the perinatal period up to the age of seven years were identified. The assessments of child psychologists and speech therapists and EEG-studies, CT-scan or MRI of the brain were extracted from the children's files. Thirteen children, with a mean age of 9.5 years, participated. The prevalence was 0.03/1000.

Results. Nine children suffered from mental retardation, seven took antiepileptic drugs and six had bilateral radiological anomalies. The non-hemiplegic side was involved in six of the children.

Conclusion. Cerebral infection at an early age can cause hemiplegic CP with a high frequency of associated impairments and with involvement of the non-hemiplegic side. The infectious origin probably gives rise to a more widespread brain injury.     

小儿脑瘫矫形器治疗应用的研讨

本文以探讨脑瘫等肢残患儿应用矫形器治疗效果为目的,对４６名患儿通过步态分析、平衡测试及综合能力ＡＤＬ的评定等方法进行矫形器穿戴前后对比。结果综合有效率达９４．２５％。结论对脑瘫等肢残患儿有必要辅以矫形器治疗以提高疗效。文中阐明了应用矫形器治疗时应注意的问题及踝足矫形器的制作经验     

Adaptive ability,behavior and quality of life pre and posttraumatic brain injury in childhood

Context: Traumatic brain injury (TBI) is a common, acquired childhood disability, which has been shown to have a significant impact on children’s cognitive and educational function. While behavioral problems are also noted, there is ongoing debate about the contribution of preinjury factors in this domain. Few studies have attempted to measure the impact of these preinjury functions on postinjury behavior. Objective: To compare pre and postinjury adaptive ability, behavior, executive function and quality of life (QOL) and to identify factors that contribute to outcomes in these domains including injury severity, socio-demographic and preinjury characteristics. Design: Consecutive recruitments to a prospective, longitudinal study, utilizing a between factor design, with injury severity as the independent variable. Participants and methods: Children admitted to hospital with a diagnosis of TBI aged between 6 and 14 years (n = 205) were divided according to injury severity (mild, moderate and severe). Adaptive behavior (Vineland Adaptive Behavior Scales), child behavior (Child Behavior Checklist), everyday executive functions (Behavior Rating Inventory of Executive Function) and QOL (Child Health Questionnaire) assessed at 6 months post-TBI. Results and conclusions: Severity by time interactions were identified across a range of outcome domains demonstrating that more severe injury is associated with a decrease in functional ability at 6 months post-TBI. This effect was most pronounced for everyday executive skills, social function and internalizing aspects of child behavior. Preinjury function was a consistent predictor of postinjury status. Injury severity contributed little to the prediction of functional outcomes once preinjury functioning was accounted for in the model. Age at injury and family cohesion were relevant to specific outcome domains only. Socio-economic status did not contribute significantly to outcome at 6 months. Preinjury functioning as reported by parents in the acute phase may be a useful predictive tool for identifying children who may be at risk of functioning difficulties 6 months post-TBI.

Implications for Rehabilitation

Childhood traumatic brain injury

• Priorities for intervention: (i) more severe injury; (ii) presence of pre-injury impairment; (iii) younger age at injury and (iv) evidence of family dysfunction.

• Level of functional impairment postinjury rarely meets criteria for a frank diagnosis (e.g. intellectual impairment and psychiatric disorder) and thus children are frequently ineligible for routine community supports.

• Reduced executive skills and social competence and elevated behavioral disturbances indicate that evidence-based interventions addressing these domains are a priority.

     

340例脑瘫患儿脑电图分析

目的：探讨脑瘫患儿脑电图与脑瘫型别、合并损伤及高危因素的关系。方法：采用国际10／20导系统电极放置法对340例脑瘫患儿行脑电图检查和分析。结果：340例患儿中脑电图异常率为81．5％，伴有智力低下和癫痫发作患儿脑电图异常率明显增高，分别为82．4％（P〈0．05）和96．6％（P〈0．05）；高危因素中颅内出血、早产、出生低体重、颅内感染与脑电图异常发生有密切关系，但各高危因素对脑电图异常发生的影响均没达到显著差异。结论：脑瘫患儿脑电图异常率高，且脑功能障碍越明显，脑电图异常率越高。     

痉挛型脑性瘫痪MRI研究

目的探讨颅脑MRI与脑瘫类型、患儿胎龄之间的关系。方法回顾性分析224例痉挛型脑瘫患儿的MRI检查和临床资料。结果224例患儿痉挛型偏瘫27例、双瘫149例、四肢瘫48例；MRI异常201例（89.7%），其中偏瘫、双瘫、四肢瘫的异常率分别为100%、87.2%和91.7%。痉挛型双瘫以脑室周围白质软化（PVL）最常见，发生率79.2%，其他类型脑损伤少见。痉挛型四肢瘫脑损伤多种多样，以PVL、足月儿类型脑损伤、先天发育畸形为主要表现，发生率分别为45.8%、20.8%和18.8%。足月儿痉挛型偏瘫以半侧损伤为主，临床表现为一侧肢体运动障碍，上肢重，下肢轻；未成熟儿痉挛型偏瘫表现为单侧或双侧PVL，临床表现为下肢重、上肢轻的偏瘫。152例PVL患儿中，发生于未成熟儿108例（71.1%）、足月儿44例（28.9%）。足月儿类型脑损伤22例，发生于足月儿20例（90.9%）。未成熟儿脑损伤类型主要为PVL，主要见于未成熟儿脑瘫，也可发生于足月儿脑瘫。足月儿类型脑损伤主要见于足月儿脑瘫，未成熟儿少见。结论颅脑MRI表现与脑瘫的类型、出生胎龄密切相关。     

小儿脑瘫常见并发症的临床分析

目的：对脑瘫患儿常见并发症的发生率进行分析，为临床的早期治疗和预防提供资料。方法：脑瘫患儿108例,神经学检查评价脑瘫类型以及并发症诊断，并进行头部MRI检查、视听诱发电位检测及脑电图检测。结果：①108例中不同类型脑瘫并发症81例（75%），其中摄食困难、智力低下、语言障碍等并发症占多数。②混合型脑瘫的并发症发生率最高（90%）。③头部MRI异常率75.9%，以脑室周围白质软化症最多（45.1%）。结论：小儿脑瘫并发症严重影响患儿营养物质的摄取和体格发育，增加其融入社会的难度。早期注重婴幼儿摄食技能的发育监测，干预和改善其智能水平，促进语言发育，积极控制癫痫发作，可以降低并发症的发生率。     

脑性瘫痪对患儿生存质量的影响研究

目的探讨脑性瘫痪对患儿生存质量的影响。方法采用儿童生存质量测定量表体系（the pediatric quality of life inventory measurement models,PedsQL）4.0作为儿童生存质量的测定工具,分别对脑性瘫痪患儿、一般疾病患儿及正常儿童进行生存质量测定,比较各组之间的差异性。结果脑性瘫痪患儿113例,男68例,女45例,平均年龄为（3.65±2.15）岁;一般疾病患儿52例,男30例,女22例,平均年龄为（3.77±1.83）岁;正常儿童314例,男177例,女137例,平均年龄为（4.46±1.13）岁。脑性瘫痪组患儿的生理功能得分为（27.80±22.61）分,情感功能得分为（55.88±22.02）分,社交功能得分为（37.17±23.44）分,PedsQL总分为（39.05±17.20）分;一般疾病组患儿的生理功能得分为（89.12±11.99）分,情感功能得分为（76.44±15.81）分,社交功能得分为（88.46±13.98）分,PedsQL总分为（83.12±10.54）分;正常对照组儿童的生理功能得分为（91.42±36.58）分,情感功能得分为（83.28±80.61）分,社交功能得分为（84.91±16.25）分,PedsQL总分为（86.57±24.83）分。脑性瘫痪组患儿在生理功能得分、社交功能得分及PedsQL总分方面均较一般疾病组和正常对照组儿童低,差异有统计学意义（P〈0.01）;脑性瘫痪组患儿的情感功能得分较正常儿童低,差异有统计学意义（P〈0.05）。脑性瘫痪组患儿的学校表现得分[（55.00±18.95）分]低于一般疾病组[（68.39±13.65）分]和正常对照组[（83.66±11.29）分]儿童,差异有显著统计学意义（P〈0.01）。结论脑性瘫痪患儿的生理功能、社交功能及总体生存质量明显低于一般疾病患儿及正常儿童,其情感功能低于正常儿童,但是与一般疾病患儿无明显差异,提示脑性瘫痪患儿生存质量存在明显的损害,而对情感功能的损害相对较小;脑性瘫痪患儿的学校表现较一般疾病组和正常对照组儿童差,提示疾病对脑性瘫痪患儿的学校表现有严重影响。因此,对脑性瘫痪患儿的康复应是对其生存质量的全面提高。     

脑性瘫痪合并癫痫的康复治疗原则探讨

目的探讨小儿脑瘫（CP）合并癫痫的康复治疗方法。方法从1402例CP中筛查出140例癫痫进行CP类型、癫痫类型、MRI或CT、脑干听觉诱发电位（BAEP）分析，并进行康复治疗，方法包括抗癫痫药物、电刺激、针灸、封闭、脑蛋白水解物、功能训练、按摩、中药熏蒸、脑苷肌肽的应用等，观察患儿的疗效。结果本组合并EP的CP患儿以痉挛型为主，癫痫类型以婴儿痉挛、肌阵挛多见；98％MRI或CT异常，90％BAEP异常；抗癫痫药物治疗均有效；电刺激、针灸、封闭、脑蛋白水解物均能加重癫痫发作；功能训练、按摩、中药熏蒸、脑苷肌肽不会加重癫痫发作。结论小儿CP合并癫痫的康复治疗原则为及早、长期应用抗癫痫药物，避免电刺激、针灸、封闭、脑蛋白水解物等治疗，提倡功能训练、按摩、中药熏蒸、脑苷肌肽等治疗。     

The Neurocognitive Effects of Type 1 Diabetes Mellitus in Children and Young Adults With and Without Hypoglycemia

Type 1 Diabetes Mellitus is one of the most common illnesses found in children under the age of 18 as well as in young adults. Symptoms of this disease, including those with and without severe hypoglycemia, create abnormal blood glucose levels along with abnormal insulin levels. These abnormal chemical levels have been associated with neurocognitive deficits in memory, attention, motor skills, visuospatial abilities and executive functioning. In this paper, available literature on the central nervous system changes associated with the effects of insulin-dependent diabetes on school-aged children and young adults is reviewed. Implications for learning as well as a neurobiological cause of executive function deficits are discussed.     

340例脑瘫患儿脑干听觉诱发电位的临床分析

目的:探讨脑瘫患儿脑干听觉诱发电位(BAEP)与脑瘫类型、合并损伤及高危因素的关系。方法:采用神经肌电诱发电位仪对340例脑瘫患儿行BAEP检查和分析。结果:脑瘫患儿BAEP异常率为22.9%,并发智力低下的异常率明显高于无智力低下的患儿(P<0.01);高危因素中宫内感染、黄疸和颅内出血与BAEP异常发生有密切关系,其中黄疸和宫内感染是高度危险因素;脑瘫并发听神经通路损伤的发生率较普遍,其中混合型和手足徐动型发生率更高。结论:宫内感染和病理性黄疸是脑瘫患儿听神经通路损伤的高度危险因素,BAEP应作为脑瘫患儿常规检查。