Sleep problems in children with cerebral palsy and their relationship with maternal sleep and depression

Abstract Aim: To compare sleep problems in children with cerebral palsy to typically developing children. To study the relationship between sleep problems in children with cerebral palsy and maternal sleep quality and depression. Methods: Fifty‐seven children with cerebral palsy aged 4–12 years were identified from a UK disability database. Maternal sleep disturbance and mood were assessed using the Pittsburgh Sleep Quality Index and the Major Depression Inventory. Child sleep problems, assessed with the Children’s Sleep Habits Questionnaire, but not maternal variables, were compared to 102 typically developing children. Results: Forty children (70%) were recruited with a mean age of 7.8 (SD 2.4). Sleep anxiety, night wakings, parasomnias and sleep‐disordered breathing sub‐scales indicated significantly more difficulties than in typically developing children. 40% of mothers of children with cerebral palsy had poor sleep quality of whom 44% had depressed mood. Child and maternal sleep disturbance were significantly correlated. Maternal sleep quality predicted 50% of the variance in maternal depression. Conclusions: Children with cerebral palsy have more sleep problems than typically developing peers. Their mothers also have disturbed sleep that correlates with maternal depression. Childhood sleep problems can be treated and should be identified in routine clinical practice.     

Anaerobic endurance and peak muscle power in children with spastic cerebral palsy.

The aim of this study was to provide information on anaerobic muscle endurance (mean power) and peak muscle power in children with spastic cerebral palsy. We measured peak power and mean power of the upper and lower limbs in 29 boys and 20 girls, aged from 6 to 14 years, by means of the Wingate Anaerobic Test. In addition, the physical components (physical capacity, upper limb, and lower limb) of a system used for evaluating function in the physically disabled were assessed. Of the 49 subjects, 46 and 37 successfully completed the arm and leg Wingate Anaerobic Test, respectively. Compared with norms for age and gender (healthy, nonathletic children), peak and mean power in the patients, even when corrected for body weight, were distinctly subnormal. The performance of subjects with quadriplegia was 3 to 4 SDs below the mean for controls. Twenty-five of diplegic and hemiplegic subjects had values below 2 SDs. When the data were analyzed according to the severity of the cerebral palsy, with the use of the physical capacity, upper limb, and lower limb score, those children with moderate to severe cerebral palsy had values for mean and peak power of the arm and leg 3 to 4 SDs below the normal mean. Values for children with only mild cerebral palsy also fell below the mean, but the data were more scattered, especially for the leg. The lower muscle performance may reflect both quantitative and qualitative differences in the upper- and lower-limb muscles, due to altered innervation and, in the more severely affected children, disuse.     

Sleep quality and respiratory function in children with severe cerebral palsy using night-time postural equipment: a pilot study

Background:  Night-time postural equipment (NTPE) prevents contractures and hip subluxation in children with severe physical disabilities. However, impact on sleep quality and respiratory function has not been objectively studied.
Methods:  Ten children with severe cerebral palsy (CP), mean age of 10.9 (range: 5.3–16.7) years, were recruited from a community population. Polysomnography was undertaken on two nights, once with the child sleeping in their NTPE and once sleeping unsupported. Randomization to first night condition controlled for first night effects.
Results:  Night-time postural equipment use was associated with higher mean overnight oxygen saturation for three children but lower values for six children compared with sleeping unsupported. There were no differences in sleep quality between the conditions. The study group had lower overnight oxyhaemoglobin saturation values, less rapid eye movement (REM) sleep and higher arousal indices compared with typically developing children.
Conclusion:  This pilot study indicated that children with severe CP risk respiratory compromise in sleep irrespective of positioning. Further study will determine if the observed trend for mean overnight oxygen saturation to be lower within positioning equipment reflects random night-to-night variation or is related to equipment use. We suggest that respiratory function is assessed when determining optimal positioning for children using night-time positioning equipment.     

Follow-up study of children with hypoxia following pneumothorax

A group of 23 children suffering from neonatal hypoxia (pO2 less than 50 mm Hg) due to pneumothorax was examined at an average age of 14 months. Evaluation at this early developmental stage was accomplished by combination of "Motoscopy", "Vojta's postural reactions" and the "Concept of provocation of normal behaviour under adverse conditions". Development of the group as a whole was found to be unexpectedly good: Two children with cerebral palsy, and seven with yet undefinable developmental course versus fourteen obviously normally developing children. Pneumothorax and drainage did not cause the frequent transient postural asymmetries in this group.     

Muscle Strengthening in Children with Cerebral Palsy

Muscle strengthening as a therapeutic technique for cerebral palsy is controversial. Many therapists have been trained to avoid muscle strengthening in children with cerebral palsy because of the belief that overflow to the antagonist muscle might increase muscle tone or spasticity and therefore increase abnormal movement. Recently some clinicians have become interested in resisted exercise as a treatment for children with cerebral palsy. This review summarizes the few published studies relating to progressive resistive exercise in children and young adults with cerebral palsy. The results of these studies indicate that resistive exercise increased strength in individuals with mild cerebral palsy and none of the studies showed any deleterious effects on level of spasticity or range of motion. Some studies showing that strength measurement instruments can be reliable under certain conditions are also reviewed.     

Behavioral responses to tactile stimuli in children with cerebral palsy

Children with cerebral palsy often have difficulty processing tactile information. Assessment of tactile processing in children with cerebral palsy frequently relies on the use of informal clinical observations, checklists, and sensory histories without established psychometric properties. It is proposed that a formal approach to the assessment of behavioral responses to tactile stimuli will provide a better understanding of the tactile processing of children with cerebral palsy. This approach also has potential to assist with the development of intervention strategies and the evaluation of progress. The purposes of this article are to review the literature on the tactile processing difficulties of children with cerebral palsy, examine the suitability of existing assessments of tactile processing for children with cerebral palsy, and provide a rationale for a new assessment tool being developed by the authors.     

Physiologic neurocirculatory patterns in the head-up tilt test in children with orthostatic intolerance

Background: Orthostatic intolerance (OI) is a common clinical manifestation in clinical pediatrics. The head‐up tilt (HUT) table test is considered the standard of orthostatic assessment, but the physiologic neurocirculatory profile during HUT has not been fully realized in children with OI. The present study, therefore, was designed to investigate the physiologic patterns that occur during HUT in children with OI. Methods: Ninety children (56 girls; mean age, 11.6 ± 2.3 years) with OI underwent HUT under quiet circumstances. Blood pressure and heart rate were monitored simultaneously. Results: Forty‐nine children with OI (54.4%) had vasovagal response with HUT testing; 33 (36.7%), vasodepressor response; six (6.7%), cardioinhibitory response; and 10 (11.1%), mixed response. Twenty‐eight children (31.1%) had postural orthostatic tachycardia; one (1.1%), orthostatic hypotension (OH); and 12 (13.3%), normal physiologic response. Patterns of cerebral syncope response and chronotropic incompetence were not observed. Conclusions: Classical vasovagal response was the major physiologic pattern seen in children with OI during HUT testing, and postural orthostatic tachycardia response ranked second.     

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.     

Comparison of abilities of preterm and maturely born children at 5 years of age

This study investigated whether the development of 5 year old preterm born children was appropriate for age and equivalent to or different from their peers who were full term at birth. At the adjusted age of 5 years, the development of 106 children born 5 or more weeks before term was compared with the development of 103 children who were born at term. This latter group of children were matched to the preterm group in sex, year of birth, birthplace, race and residential location. No cerebral palsy children were included in either subject group. The results indicated a significant difference between the two groups. Factors distinguishing the preterm children from their full term peers included small involuntary hand movements, less competent gross motor ability, poorer verbal performance and more variability in behaviour, postural response and balance. A higher than average incidence of minor motor, speech, behaviour and learning problems in early school years is probable.     

Comparison of abilities of preterm and maturely born children at 5 years of age

This study investigated whether the development of 5 year old preterm born children was appropriate for age and equivalent to or different from their peers who were full term at birth.
At the adjusted age of 5 years, the development of 106 children born 5 or more weeks before term was compared with the development of 103 children who were born at term. This latter group of children were matched to the preterm group in sex, year of birth, birthplace, race and residential location. No cerebral palsy children were included in either subject group.
The results indicated a significant difference between the two groups. Factors distinguishing the preterm children from their full term peers included small involuntary hand movements, less competent gross motor ability, poorer verbal performance and more variability in behaviour, postural response and balance. A higher than average incidence of minor motor, speech, behaviour and learning problems in early school years is probable.     

Kinematic characteristics of postural control during reaching in preterm children with cerebral palsy

The relationships between kinematic characteristics of sitting posture during reaching movements of the dominant arm and 1) the kinematics of the reaching movement itself and 2) functional performance during daily life activities (PEDI) were assessed in 51 sitting preterm children with cerebral palsy (CP). The children were 2-11 y, 33 had spastic hemiplegia (SH) and 18 bilateral CP (Bi-CP). The data were compared with those of 26 typically developing children (TD). Sitting posture before the onset of reaching of children with CP differed from that of TD children: they sat with a more reclined pelvis and a more collapsed trunk. The more reclined pelvic position was associated with a better quality of reaching movements. The different sitting postures of pelvis and trunk were not related to functional performance during daily life activities. Displacement of the head, trunk, and pelvis of the children with CP did not differ from that of the TD children. Nevertheless, in the children with CP a more stable head, a more mobile trunk, and a more stable pelvis were related to better functional performance and/or a better quality of reaching. This suggests that physiotherapeutic guidance of children with CP should focus rather on the latter postural parameters than on the different sitting posture of pelvis and trunk.     

24-Hour postural care and use of sleep systems in cerebral palsy

The purpose of this article is to explain the impact of secondary musculoskeletal problems in cerebral palsy and the impact with growth on body posture and how postural care and use of sleep systems can help protect and preserve body shape. Successful postural care relies on a family's engagement of the programme. To engage them education staff and health care workers require the awareness of the impact of body shape distortion and the fact it can be reduced or avoided through good postural care. A failure to provide good postural care increases the risks of physical changes in the bones and muscles and joints, which can lead to severe issues on an individual's respiration, circulation and their digestion. This can lead to compromising the internal organs and has the potential to lead to premature death. It is important for everyone involved in the care of children with CP to have knowledge and understanding of the importance of postural care. The child needs a team around them empowering the family through education and support. All clinicians should be able to identify who will need it, know how they can refer on to access assessment of the child and training for the family and be aware off the postural care plan as it is developed to get the right equipment in place. The benefits of an improved posture can result in reduced muscle tone, increased comfort, improved functioning and participation, and better sleeping patterns. This leads to an improved quality of life for the child and the family.     

Kinematic characteristics of reaching movements in preterm children with cerebral palsy

Kinematic characteristics of reaching movements of the dominant arm were assessed in 51 sitting preterm children who were aged 2-11 y and had cerebral palsy (CP), including 33 with spastic hemiplegia and 18 with bilateral CP (Bi-CP). Reference data of 29 typically developing children were present. The results indicated that the quality of reaching movements from the dominant arm of children with CP was significantly worse than that of typically developing children. This held true in particular for the children with Bi-CP. For example, reaching movements of children with CP took more time and consisted less often of one movement unit. The quality of reaching was related to the severity of lesion present on the neonatal ultrasound scan of the brain, the severity of motor disorder, the degree of spasticity, and the ability to perform activities of daily life. The last indicates that movements of the dominant arm in children with spastic hemiplegia and Bi-CP deserve clinical attention.     

Relationships between lower limb muscle strength and locomotor capacity in children and adolescents with cerebral palsy who walk independently

This study aimed to quantify relationships between lower limb muscle strength and locomotor capacity for children and adolescents with cerebral palsy (CP) to identify key muscle groups for strength training. Fifty 6- to 16-year-olds with CP (Gross Motor Function Classification System level I or II) participated. Isometric muscle strength of hip flexor and abductor, knee flexor and extensor, and ankle dorsiflexor muscles was measured using hand-held dynamometry. Ankle plantar flexor concentric muscle strength was assessed as the maximal number of unilateral heel rises. Locomotor capacity was evaluated by the 6-min walk test (6MWT), 10-meter Shuttle Run Test (10mSRT), and Timed Up and Down Stairs Test (TUDS). With control for age, sex, and height, hip flexor and ankle plantar flexor strength explained 47.8% of the variance in the 6MWT and 32.9% of variance in the TUDS and hip abductor isometric strength explained 43.5% of the variance in the 10mSRT. Avenues for future research include randomized controlled trials that specifically target hip flexor muscles, as this has not previously been done, and determining factors other than strength that are likely related to locomotor capacity of children and adolescents with CP.     

Effects of forward tilted seating and foot-support on postural adjustments in children with spastic cerebral palsy: An EMG-study

ObjectiveTo evaluate the effect of 15° forward (FW) seat inclination and foot-support in children with cerebral palsy (CP) on postural adjustments during reaching.DesignObservational study repeated-measures design; step two of two-step-project.SettingLaboratory unit within University Hospital and two special education schools.Participants19 children (ten unilateral spastic CP (US-CP); nine bilateral spastic CP (BS-CP); Gross Motor Function Classification System levels I-III; 6–12 years old). Participants were able to take part for one one-hour session.InterventionReaching while sitting in four seating conditions (FW or horizontal seat; with or without foot-support) applied in randomized order.Outcome measuresSimultaneously, surface electromyography (EMG) of neck, trunk and arm muscles and kinematics of head and reaching arm (step one of two-step-project) were recorded. Primary outcome parameters were the ability to modulate EMG-amplitudes at baseline and during reaching (phasic muscle activity). Other EMG-parameters were direction-specificity (1st control level), and 2nd level of control parameters: recruitment order, and anticipatory postural activity. Motor behaviour measures: ability to modulate EMG-amplitudes to kinematic characteristics of reaching and head stability.ResultsOnly foot-support was associated with increased tonic background EMG-amplitudes and decreased phasic EMG-amplitudes of the trunk extensors in children with US-CP and BS-CP (mixed-models analyses; p-values <0.01). The foot-support effect was also associated with better kinematics of reaching (Spearman's Rho; p-values <0.01).ConclusionIn terms of postural adjustments during forward reaching, foot-support enhanced the children's capacity to modulate trunk extensor activity, which was associated with improved reaching quality. FW-tilting did not affect postural muscle activity.     

Development and reorganization of descending motor pathways in children with hemiplegic cerebral palsy

Reorganization of descending motor pathways was explored in 33 subjects with hemiplegic cerebral palsy. Subjects were assessed neurologically and surface electromyographic recordings were taken from homologous muscles of both hands. Functional corticospinal projections were assessed using focal magnetic stimulation of the motor cortex. In control subjects this evokes EMG responses in the contralateral hand at short latency. Similar results were seen in 12 of the hemiplegic subjects following stimulation of the undamaged motor cortex. In the remaining 22 subjects novel corticospinal pathways were demonstrated arising from the undamaged cortex, where stimulation evoked short latency EMG responses in both hands. Cross-correlation analysis performed from EMGs recorded between the two hands revealed short duration central peaks in 11 of these subjects, all of whom had strong mirror movements of the hands. These findings suggested that two patterns of central reorganization may follow early unilateral cortical insult. Examination further indicated that hand function in hemiplegic subjects could be related to the neurophysiological results.     

脑性瘫痪常见膝关节步态异常及治疗进展

脑性瘫痪患儿的步态异常通常是由于附着在关节两端的肌肉痉挛或者挛缩引起,抑或是不能够自主平衡协作肌与拮抗肌导致。膝关节异常是最常影响脑性瘫痪患儿步态的因素,主要发生在矢状面。该文通过对于脑性瘫痪患儿常见膝关节步态异常的临床表现进行分型,介绍国外对于各型治疗的临床进展和指证。     

Feeding problems in children with cerebral palsy

OBJECTIVE: To determine the magnitude and extent of feeding problems in children with cerebral palsy (CP) and to evaluate the effectiveness of nutritional interventions. DESIGN: Prospective hospital based interventional study. METHOD: Children with cerebral palsy of either sex were enrolled randomly and their parents were interviewed for their perception about feeding problems, nutritional status and for their views about the expected outcome of feeding problems. Each case was assessed for feeding problems based on Gisel and Patrick feeding skill score; for nutritional status by measurement of weight, skinfold thickness (at biceps, triceps, suprailiac and subscapular), mid arm circumference and caloric intake; neurologically for type and severity of cerebral palsy and for developmental age by Gasell s developmental scale. Equal number of age and sex matched controls were included for comparison of nutritional status and developmental quotient. Various rehabilitation procedures were applied and their response was observed in the followup ranging from 3-10 months. RESULTS: One hundred children (76 boys and 24 girls) with cerebral palsy of mean age 2.5 years (range 1 to 9 years) and mean developmental age of 7.6 months (range 1 to 36 months) were included in the study. Oral motor dysfunction (OMD) was found in all cases and in each category. Spastic quadriplegic cerebral palsy (SQCP) and hypotonic patients had significantly poor feeding skill score (p < 0.001). Mean duration of feeding session was 31.5 minutes (range 10-60 minutes). Main food of children with cerebral palsy consisted of liquid and semisolid diet. Children with poor OMD were unable to take solid food. Cases with seizures had significantly more feeding problems than those without seizures (p < 0.001). Parental awareness about feeding problems of their children was significantly low and they overestimated the nutritional status of their children. Anthropometric indicators were significantly lower than controls (p < 0.001). Spastic quadreparesis, hypotonia and poor feeding skill score had negative effect on nutritional status. Thirty per cent parents of cerebral palsy patients were pessimistic about the possibility of any improvement in feeding problems. After nutritional rehabilitation, good improvement was seen in feeding problems, OMD and nutritional status. CONCLUSION: Nutritional status of children with cerebral palsy is poor due to summation of several factors. Therefore, they should be thoroughly assessed for feeding problems and nutritional status in order to start timely nutritional rehabilitation which can significantly improve their nutritional status and quality of life.     

The effect of intrathecal baclofen on muscle co-contraction in children with spasticity of cerebral origin

AIM: Investigation of the effect of intrathecal baclofen administration on the time course of electrical patterns of muscle activation in patients with spasticity due to upper motor neuron syndrome. METHODS: Six children with clinical signs of upper motor neuron syndrome resulting from an acquired cerebral hypoxic injury were tested. Simultaneous multichannel acquisition of surface EMG activity from flexor/extensor muscle groups of the upper and lower limbs was recorded. Investigated muscle group pairs included biceps/triceps brachii, wrist flexors/extensors, rectus/biceps femoris and tibialis anterioris/gastrocnemius. Time-frequency analysis of EMG activity at rest and while eliciting a stretch reflex was performed. The non-linear cross-correlation coefficient and time lag estimation were computed between paired channel groups both for baseline and post-intrathecal baclofen injection conditions for epochs consisting of 2 s prior to and 2 s after voluntary contraction. The effect of baclofen was assessed 3 h following single-bolus intrathecal injections of 25 or 50 microg during the baclofen trial and 6 months after baclofen pump implantation. RESULTS: In the baseline condition, the stretch reflex resulted in a synchronous increase in spectral EMG power in both the agonist and the antagonist muscles. The mean correlation coefficient between agonist and antagonist muscles was 0.948 (SD = 0.034), and the mean time lag was 4.64 ms (SD = 1.84 ms). After intrathecal administration of baclofen, a dramatic decrease in the correlation coefficient between agonist and antagonists (mean value = 0.342) during voluntary contraction was observed. This corresponded to a significant reduction of tone and spasticity in all four limbs, and reduction of the Ashworth score by 2 points on average. CONCLUSION: After intrathecal baclofen administration, we observed a significant decrease in the co-contraction pattern typically associated with upper motor neuron spasticity. This was evident clinically and was quantitatively expressed by the significantly decreased degree of coupling in EMG activity of agonist/antagonist muscles. Although a relatively small sample was investigated in this study, we were able to demonstrate the efficacy of this procedure in restoring selective activation of agonists during voluntary contraction. This is one of the prerequisites of an improvement of motor function in patients with spasticity.     

脑瘫髋内收痉挛性内收肌组织化学和超微结构研究

目的研究小儿脑性瘫痪痉挛性髋内收肌肌纤维分型和肌细胞超微结构损害。 方法对16例脑性瘫痪痉挛性髋内收患儿的内收大肌用肌球蛋白ATP酶染色方法，对肌纤维进行分型和超微结构观察。 结果痉挛组内收大肌Ⅰ型肌纤维(慢缩纤维)比例70．92％，比对照组(57．43％)明显增高，并可见同型肌纤维聚集。超微结构显示肌纤维内线粒体和肌纤维结构受到损害。 结论提示Ⅰ型肌纤维增多和肌纤维的超微结构损害是脑瘫痉挛性髋内收手术治疗效果不佳的原因之一，引起肌纤维型改变的确切原因尚需进一步研究。