Levetiracetam in children and adolescents with epilepsy and hemiplegic cerebral palsy

Aim: To monitor the effect of adding levetiracetam in paediatric patients with hemiplegic cerebral palsy and uncontrolled epilepsy. Methods: A case series of eight patients with hemiplegic cerebral palsy whose focal seizures were not adequately controlled by their current anticonvulsants were monitored after levetiracetam was added to their medications. If there was a 50% reduction in seizure frequency, then the other anticonvulsants were discontinued. Prolonged follow‐up occurred for a minimum of 2 years. Results: There were seven males and one female whose ages ranged from 4 years to 17 years. All had focal onset seizures, while seven also had secondarily generalised tonic clonic seizures. Levetiracetam resulted in at least a 50% reduction in seizure frequency in seven, with no change in one. Three were able to wean successfully to monotherapy and remained seizure free for over 2 years. They had a prior history of infrequent seizures, one to six per year. Those who continued to require multiple anticonvulsants had a prior history of more frequent seizures, 6–50/year. Levetiracetam was well tolerated, and none ceased this because of side effects. Conclusion: Levetiracetam is likely to be an effective anticonvulsant in children and adolescents with hemiplegic cerebral palsy and infrequent but persistent focal seizures.     

Parent‐perceived barriers to participation in children and adolescents with cerebral palsy

Aim: To pilot the use of the Craig Hospital Inventory of Environmental Factors (CHIEF) questionnaire to ascertain information regarding barriers to participation experienced by a sample of New Zealand children with cerebral palsy. Methods: The CHIEF questionnaire was administered to parents/caregivers of a consecutive sample of 32 children with cerebral palsy attending a paediatric tertiary clinic in Auckland. Twenty‐three children walked independently, 5 used walking aides and four used a wheelchair. Twenty‐four of the 32 parent‐respondents provided contextual feedback for their responses and wider issues relating to the topic. Results: The barriers to participation most commonly reported by parents were attitudes at school (72%) and in the community (56%), difficulties accessing personal equipment (59%), and the natural environment and built surroundings (56%). Contextual information from families generally supported their answers to the questionnaire but highlighted that some parents had confused the ‘not applicable’ and ‘never’ options. Discrepancy between scores on the policy‐related questions and later contextual feedback suggested that the policy subscale did not fully capture family concerns about limited availability of public funding for equipment, therapy, and educational support. Conclusions: The CHIEF instrument proved easy to use in a clinic setting. However, parent‐respondent feedback highlighted the difficulties in interpreting responses to some items when the instrument is used in isolation to quantify environmental barriers to participation. The results highlight the need to develop research approaches and tools that can explore barriers to participation by children with cerebral palsy taking account of socio‐economic and other relevant contextual information.     

Robotic-assisted treadmill therapy improves walking and standing performance in children and adolescents with cerebral palsy

ObjectiveTask-specific body-weight-supported treadmill therapy improves walking performance in children with central gait impairment. The aim of the study was to investigate the effect of robotic-assisted treadmill therapy on standing and walking performance in children and adolescents with cerebral palsy and to determine parameters influencing outcome.Methods20 Patients (mean age 11.0 ± 5.1, 10 males and 10 females) with cerebral palsy underwent 12 sessions of robotic-assisted treadmill therapy using the driven gait orthosis Lokomat. Outcome measures were the dimensions D (standing) and E (walking) of the Gross Motor Function Measure (GMFM).ResultsSignificant improvements in dimension D by 5.9% (±5.2, p = 0.001) and dimension E by 5.3% (±5.6, p < 0.001) of the GMFM were achieved. Improvements in the GMFM D and E were significantly greater in the mildly affected cohort (GMFCS I and II) compared to the more severely affected cohort (GMFCS III and IV). Improvement of the dimension E but not of D correlated positively with the total distance and time walked during the trial (r_s = 0.748, p < 0.001).ConclusionsChildren and adolescents with bilateral spastic cerebral palsy showed improvements in the functional tasks of standing and walking after a 3-week trial of robotic-assisted treadmill therapy. The severity of motor impairment affects the amount of the achieved improvement.     

Epilepsy in children with cerebral palsy

This article deals with the clinical profile of children with cerebral palsy and epilepsy, and to study the clinical predictors of response to anti-epileptic drugs. It is a prospective hospital based follow-up study. All the children who presented with cerebral palsy and history of seizure (other than neonatal seizures) over a period of one year were included. Seizures were classified according to ILAE classification. An EEG was obtained in all cases. Neuroimaging was done in all patients. Eighty-five patients were studied and followed for minimum of 12 months. Perinatal factors accounted for 62 (72.3%) cases. The motor deficits seen were quadriparesis (n = 64), hemiplegia (n = 12) and diplegia (n = 9). Associated mental retardation was seen in 80.9% patients with quadriparesis. A predominance of generalised epilepsy was seen with generalised tonic clonic seizures (32.9%) followed by mycolonic seizures (30.6%) and localisation related epilepsy (24.7%). The patients with quadriparesis were more likely to have generalised epilepsy and 52.4% of them required two or more anti-epileptic drugs for control of seizures. Patients with hemiplegia had localisation related epilepsy in 83.3% of cases. On multivariate analysis presence of quadriparesis, microcephaly, mental retardation and myoclonic epilepsy were found to predict the poor response to AED. Epilepsy in patients with cerebral palsy is of severe nature and difficult to control. Presence of quadriparesis, mental retardation and myoclonic seizures was predictive of poor response to anti- epileptic drugs.     

Longitudinal changes in bone density in children and adolescents with moderate to severe cerebral palsy

OBJECTIVE: To assess the natural history of "growth" in bone mineral density (BMD) in children and adolescents with moderate to severe cerebral palsy (CP). STUDY DESIGN: A prospective, longitudinal, observational study of BMD in 69 subjects with moderate to severe spastic CP ages 2.0 to 17.7 years. Fifty-five subjects were observed for more than 2 years and 40 subjects for more than 3 years. Each evaluation also included assessments of growth, nutritional status, Tanner stage, general health, and various clinical features of CP. RESULTS: Lower BMD z-scores at the initial evaluation were associated with greater severity of CP as judged by gross motor function and feeding difficulty, and with poorer growth and nutrition as judged by weight z-scores. BMD increased an average of 2% to 5%/y in the distal femur and lumbar spine, but ranged widely from +42%/y to -31%. In spite of increases in BMD, distal femur BMD z-scores decrease with age in this population. CONCLUSIONS: Children with severe CP develop over the course of their lives clinically significant osteopenia. Unlike elderly adults, this is not primarily from true losses in bone mineral, but from a rate of growth in bone mineral that is diminished relative to healthy children. The efficacy of interventions to increase BMD can truly be assessed only with a clear understanding of the expected changes in BMD without intervention.     

Effectiveness of physical therapy interventions for children with cerebral palsy: A systematic review

Background  

To assess the effectiveness of physical therapy (PT) interventions on functioning in children with cerebral palsy (CP).     

Uroflowmetry in the management of lower urinary tract symptoms of children and adolescents with cerebral palsy

ObjectiveTo evaluate uroflow measurements in the initial management of lower urinary tract dysfunction in children and adolescents with cerebral palsy.Materials and methodsA total of 54 patients was enrolled in this study. All patients reported their urinary symptoms and underwent a physical examination, renal and urinary tract ultrasonography, and uroflow assessment.ResultsTwenty-three patients were female. Mean age was 9 years and 6 months (SD: 2 years and 10 months), with a range of 5–18 years. Twenty-eight of the patients (51.8%) were symptomatic. Urgency (42.6%), urge incontinence (40.7%), and enuresis (16.7%) were the most frequently observed symptoms. No association was found between gender, ambulatory status, or distribution of the paralysis and uroflow parameters. Symptomatic patients presented a statistically lower maximum flow (Q_max) than asymptomatic patients (17.2 ± 7.8 ml/s vs 22.6 ± 7.5 ml/s, p = 0.013, respectively). Normal bell-shaped curves were observed more frequently in asymptomatic patients, while abnormal curves were observed more frequently in symptomatic patients (p = 0.022).ConclusionsGender, ambulatory status, and the distribution of the paralysis do not affect Q_max rate or flow pattern. Symptomatic patients present lower Q_max and may also have an abnormal uroflow curve. Uroflowmetry may be useful in the initial urological evaluation.