管型石膏结合BTX-A治疗痉挛型脑性瘫痪的临床研究

目的:观察A型肉毒毒素(BTX-A)结合管型石膏固定对痉挛型脑瘫(CP)患儿坐、站、走功能及肌肉痉挛程度的影响,为痉挛型CP的治疗提供更多依据。方法:120例痉挛型CP患儿为研究对象,将其随机分为观察组和对照组各60例,对照组采用BTX-A注射治疗后行物理治疗及家庭康复指导,观察组在对照组治疗基础上予以管型石膏固定,在治疗前、治疗后1、3及6个月时分别用粗大运动功能测试量表88项(GMFM-88)和改良Tardieu量表(MTS)参数(X)对患儿进行评定。结果:除对照组在治疗6个月后GMFM-88的D区评分较治疗前差异无统计学意义外,2组在治疗1、3及6个月后,GMFM-88各区评分均较治疗前明显提高(均P<0.05),且观察组治疗6个月后GMFM-88各区评分较对照组均明显提高(均P<0.05);治疗1、3及6个月后,2组小腿三头肌和腘绳肌的MTS参数(X)评分均较治疗前明显降低(均P<0.05),且观察组在治疗6个月后较对照组同时间点比较均更低(均P<0.05)。结论:BTX-A结合物理治疗可明显改善CP患儿的肌肉痉挛程度及提高粗大运动功能,在此基础上结合管型石膏固定可延长远期疗效。     

中药气泡浴对痉挛型双瘫脑性瘫痪患儿的疗效

目的观察中药气泡浴对痉挛型双瘫脑瘫患儿的疗效。方法痉挛型双瘫脑瘫患儿在常规康复的基础上,对照组13例患儿行单纯气泡浴;实验组14 例行中药气泡浴。治疗前和治疗10 周后,使用粗大运动功能测试量表(GMFM-66)和改良Ashworth量表(MAS)分别评定患儿的运动功能和小腿三头肌肌张力。结果治疗后,两组GMFM-66 总分均较治疗前显著增加(P<0.001),MAS 评分均较治疗前明显下降(P<0.01);实验组GMFM-66 的B、D、E 区评分高于治疗前(P<0.05),对照组无显著性差异(P>0.05)。组间比较,治疗后实验组MAS评分低于对照组(P<0.05)。结论中药气泡浴能改善痉挛型双瘫脑瘫患儿粗大运动功能,降低小腿三头肌肌张力。     

Evaluating the responsiveness of 2 versions of the gross motor function measure for children with cerebral palsy

OBJECTIVE: To compare the responsiveness to motor change of the original version of Gross Motor Function Measure (GMFM-88) and its second version (GMFM-66) in children with cerebral palsy (CP). DESIGN: Cross-sectional study. SETTING: Seven rehabilitation pediatric clinics. PARTICIPANTS: Sixty-five children with CP (age range, 0.5-9.4y; mean, 3.7+/-1.9y) were recruited. INTERVENTION: The children's motor ability was assessed twice with a mean interval of 3.5 months using all of the GMFM-88 items. A 3-category range of therapist judgments on the children's meaningful motor improvement was used as an external standard. MAIN OUTCOME MEASURES: GMFM-88 scores, GMFM-66 scores, and therapists' judgments. RESULTS: Regarding the association with the therapist judgments, the overall responsiveness of GMFM-66 is superior to that of GMFM-88. Both measures' sensitivities of the responsiveness are similar, but GMFM-66 has better specificity. CONCLUSIONS: To evaluate the motor change in a sample of children with CP over a mean interval of 3.5 months by using the 2 versions of GMFM, the GMFM-66 was more responsive than the GMFM-88 with respect to consistency with therapist clinically meaningful judgments.     

The efficacy of GMFM-88 and GMFM-66 to detect changes in gross motor function in children with cerebral palsy (CP): a literature review

Abstract

Aim: The purpose of this study was to review published research on the use of the Gross Motor Function Measure (GMFM-88) and (GMFM-66) as outcome measures to determine if these tools detect changes in gross motor function in children with cerebral palsy (CP) undergoing interventions. Methods: A comprehensive literature search was conducted using Medline and PubMed to identify studies published from January 2000 through January 2011 that reported the accuracy of GMFM-88 and GMFM-66 to measure changes over time in children with CP undergoing interventions. The keywords used for the search were “GMFM” and “CP”. Two of the authors (M.A. and S.B.) reviewed the titles and abstracts found in the databases. The methodological quality of the studies was assessed by using the Critical Review Form-Quantitative Studies. Results: Of 62 papers initially identified, 21 studies fulfilled the inclusion criteria. These articles consist of three longitudinal studies, six randomized controlled trials, four repeated measure design, six pre–post test design, a case series and one non-randomized prospective study. The included studies were generally of moderate to high methodological quality. The studies included children from a wide age range of 10?months to 16?years. According to the National Health and Medical Research Council, the study designs were level II, III-2, III-3 and IV. Conclusion: The review suggests that the GMFM-88 and GMFM-66 are useful as outcome measures to detect changes in gross motor function in children with CP undergoing interventions.

• Implications for Rehabilitation

• Accurate measurement of change in gross motor skill acquisition is important to determine effectiveness of intervention programs in children with cerebral palsy (CP).

• The Gross Motor Function Measure (GMFM-88 and GMFM-66) are common tools used by rehabilitation specialists to measure gross motor function in children with CP.

• The GMFM appears to be an effective outcome tool for measuring change in gross motor function according to a small number of randomized control studies utilizing participant populations of convenience.

     

Rasch analysis of the Gross Motor Function Measure: validating the assumptions of the Rasch model to create an interval-level measure

OBJECTIVES: To describe the Rasch analysis of the Gross Motor Function Measure (GMFM-88) and to demonstrate how the assumptions of unidimensionality, sample-free measurement, and test-free measurement were validated to create an interval level measure. DESIGN: Cross-sectional and longitudinal (12-mo) data from a prospective study of motor development in children with cerebral palsy (CP) were used for the analysis. SETTING: Motor assessments were completed at 18 children's ambulatory rehabilitation centers in Ontario, Canada, by pediatric physical therapists trained in the use of the GMFM-88. PARTICIPANTS: The first 537 of 682 children enrolled into a longitudinal study of motor development in children with CP. Children had a mean age of 6.43+/-2.75 years (range, 11mo-12y) with varying types and severity of CP. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: The GMFM-88. RESULTS: The Rasch analysis, in conjunction with clinical decisions, identified 66 items from the GMFM-88 that formed a unidimensional measure (GMFM-66). Assumptions of sample-free and test-free measurement were confirmed, and a user-friendly scoring program was developed. CONCLUSIONS: The GMFM-66 is an interval-level measure of gross motor function for children with CP; it should improve the scoring, interpretation, and overall clinical and research utility over the original GMFM.     

An individualized intermittent intensive physical therapy schedule for a child with spastic quadriparesis

Current research literature supports the use of intensive physical therapy (PT) for children with cerebral palsy (CP) but lacks consensus on the selection of a specific therapy schedule. The purpose of this case report was to describe the use of an individualized intermittent intensive PT schedule for a child with CP who was otherwise seen following a traditional, two times per week, schedule. The patient was a 4.5-year-old girl with spastic quadriparesis, GMFCS level III. The new schedule was tried over a 3-month period. Each of the 3 months included a 2-week, five times per week intensive therapy phase, followed by a 2-week resting phase. Outcomes were assessed by using the GMFM-66 and by documenting the attainment of functional gross motor skills related to the patient's PT goals. Intervention included TAMO therapy and family instruction. The patient demonstrated a gradual increase in GMFM-66 scores throughout the 9-month period covered by this case report, with the greatest mean change score obtained when the intermittent intensive therapy schedule was used. Acquired skills were retained and even improved during the resting phases. The child's parents expressed their interest in using the new PT schedule in the future.     

A型肉毒毒素对脑性瘫痪患儿腘绳肌痉挛的疗效

目的观察A型肉毒毒素(BTX-A)注射缓解脑瘫患儿腘绳肌痉挛的疗效。方法39 例存在腘绳肌痉挛的脑瘫患儿分为对照组(n=20)和观察组(n=19),对照组采用常规康复训练,观察组在常规康复训练的基础上予BTX-A局部注射。治疗前后采用改良Ashworth 量表(MAS)、粗大运动功能测试(GMFM-88)、膝关节屈曲角度进行评定。结果治疗6 周后,观察组患儿腘绳肌MAS评分、膝关节屈曲角度、GMFM-88 评分均较治疗前改善(P<0.05),且均优于对照组(P<0.05);对照组GMFM-88 较治疗前改善(P<0.05)。结论BTX-A注射可以有效缓解脑瘫患儿腘绳肌痉挛,有助于纠正异常步态,提高患儿运动功能。     

An individualized intermittent intensive physical therapy schedule for a child with spastic quadriparesis

Current research literature supports the use of intensive physical therapy (PT) for children with cerebral palsy (CP) but lacks consensus on the selection of a specific therapy schedule. The purpose of this case report was to describe the use of an individualized intermittent intensive PT schedule for a child with CP who was otherwise seen following a traditional, two times per week, schedule. The patient was a 4.5-year-old girl with spastic quadriparesis, GMFCS level III. The new schedule was tried over a 3-month period. Each of the 3 months included a 2-week, five times per week intensive therapy phase, followed by a 2-week resting phase. Outcomes were assessed by using the GMFM-66 and by documenting the attainment of functional gross motor skills related to the patient's PT goals. Intervention included TAMO therapy and family instruction. The patient demonstrated a gradual increase in GMFM-66 scores throughout the 9-month period covered by this case report, with the greatest mean change score obtained when the intermittent intensive therapy schedule was used. Acquired skills were retained and even improved during the resting phases. The child's parents expressed their interest in using the new PT schedule in the future.     

步态诱发功能性电刺激改善痉挛型双瘫型脑瘫患儿下肢运动功能的疗效观察

摘要 目的：探讨功能性电刺激（FES）对痉挛型双瘫型脑瘫患儿下肢功能的影响。 方法：25例痉挛型双瘫型脑瘫患儿随机分为FES组（n=14）及对照组（n=11）,两组均进行运动训练、物理疗法等。对照组在此基础上进行步行训练30min,每天1次,每周5d,共12周。前6周FES组在此基础上应用FES对双侧腓总神经进行神经肌肉电刺激（NMES）治疗,同时进行步行训练30min,每天1次,每周5d。后6周FES组在此基础上进行步行训练30min,每天1次,每周5d。在治疗前、治疗6周和治疗12周后,分别进行腓肠肌痉挛评分（改良Ashworth 分值,MAS）、踝关节主动背屈活动度（ROM）和粗大运动功能量表（GMFM-88）之D区（站立）、E区（走跑跳）评定。 结果：两组患儿治疗6周和12周后,踝关节ROM增加,GMFM之D区（站立）评分提高,与各自治疗前相比,差异均有显著性意义(P<0.05或0.01);FES组患儿治疗6周和12周后,对照组患儿治疗12周后,MAS评分及GMFM-88之E区分值均优于治疗前(P<0.05或0.01)。治疗6周和12周后,FES组MAS、踝关节ROM及GMFM-88之D区（站立）、E区（走跑跳）等指标均优于对照组,差异有显著性意义（P<0.05或0.01）。 结论：FES配合康复功能训练能降低痉挛型双瘫型脑瘫患儿的下肢肌张力,增加踝关节活动度,提高下肢运动功能。     

Improved scaling of the gross motor function measure for children with cerebral palsy: evidence of reliability and validity

BACKGROUND AND PURPOSE: This study examined the reliability, validity, and responsiveness to change of measurements obtained with a 66-item version of the Gross Motor Function Measure (GMFM-66) developed using Rasch analysis. SUBJECTS AND METHODS: The validity of measurements obtained with the GMFM-66 was assessed by examining the hierarchy of items and the GMFM-66 scores for different groups of children from a stratified random community-based sample of 537 children with cerebral palsy (CP). A subset of 228 children who had been reassessed at 12 months was used to test the hypothesis that children who are young (<5 years of age) and have "mild" CP will demonstrate greater change in GMFM-66 scores than children who are older ((5 years of age) and whose CP is more severe. Data from an additional 19 children with CP who were assessed twice, one week apart, were used to examine test-retest reliability. RESULTS: The overall changes in GMFM-66 scores over 12 months and a time ( severity ( age interaction supported our hypotheses. Test-retest reliability was high (intraclass correlation coefficient=.99). CONCLUSION AND DISCUSSION: This study demonstrated that the GMFM-66 has good psychometric properties. By providing a hierarchical structure and interval scaling, the GMFM-66 can provide a better understanding of motor development for children with CP than the 88 item GMFM and can improve the scoring and interpretation of data obtained with the GMFM.     

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。     

步态诱发功能性电刺激对痉挛型脑瘫足下垂患儿的疗效

目的:观察应用功能性电刺激(FES)治疗痉挛型脑瘫偏瘫患儿足下垂的疗效.方法:痉挛型脑瘫偏瘫患儿24例分为观察组和对照组各12例,2组均进行运动训练、物理因子等治疗.观察组在此基础上应用FES对偏瘫侧腓总神经进行神经肌肉电刺激治疗(NMES),同时进行步行训练.治疗前后分别用改良的Ashworth量表测定患儿腓肠肌肌张力的变化、关节量角器法测量下肢踝关节主动背屈角度和粗大运动功能量表(GMFM-88)之D区(站立)、E区(走跑跳)分值.结果:治疗12周后,2组患儿患侧腓肠肌肌张力评分均较治疗前显著降低(P＜0.01),且观察组更低于对照组(P＜0.05);2组GMFM-88之D、E区评分及踝关节主动背屈角度均高于治疗前(P＜0.01),且观察组更高于对照组(P＜0.05).结论:FES配合康复功能训练能改善痉挛型脑瘫偏瘫患儿的踝关节活动范围,提高下肢运动功能.     

A型肉毒毒素配合药浴对脑性瘫痪患儿痉挛的疗效

目的探讨A型肉毒毒素注射与康复训练和药浴相结合治疗脑瘫患儿痉挛的效果。方法80 例痉挛型和混合型脑瘫患儿分为两组,每组40 例。对照组采用运动疗法;观察组采用A型肉毒毒素注射后进行康复训练和药浴。治疗前后采用改良Ashworth评定量表(MAS)、粗大运动功能测试量表(GMFM-88)进行评定。结果治疗3 个月后,两组患儿MAS评分、GMFM评分均优于治疗前(P<0.05),观察组疗效优于对照组(P<0.05)。结论A型肉毒毒素注射配合康复训练和药浴能降低肌张力,有效提高痉挛型和混合型脑瘫患儿的粗大运动功能。     

The change of intrinsic stiffness in gastrocnemius after intensive rehabilitation with botulinum toxin a injection in spastic diplegic cerebral palsy

A recent study claimed that botulinum toxin A (BTX-A) injection into the calf muscle of cerebral palsy (CP) children did not change the intrinsic stiffness. Contrary to this recent report, in our case, decreased muscle spasticity, which was measured using a modified Ashworth scale, and increased Gross Motor Function Measure score were demonstrated at 4 weeks after intensive rehabilitation treatment (IRT) with BTX-A injection to the medial gastrocnemius muscle in a child with spastic CP. Additionally, we indentified decreased muscle stiffness which was demonstrated by a decrease in the color-coded scale and shear velocity, and an increase in the strain ratio using dynamic sonoelastography.     

Abstract 8: Functional and societal limitation and disability outcomes in a randomized control trial of botulinum toxin type a for children with spastic diplegic cerebral palsy.

Objectives: To document the functional and societal limitation and disability level effects (National Center for Medical Rehabilitation Research framework) of gastrocnemius botulinum toxin type A (BTX) injections in children with spastic diplegic cerebral palsy (CP). Design: Randomized double-masked placebo controlled trial. Setting: Tertiary care children’s hospital. Participants: 33 children with spastic diplegic CP, (mean age, 5.5y; range, 3.0-11.9y), of whom 19 were boys (subjects’ Gross Motor Function Classification System levels: level I=12; level II=15; level III=6). Intervention: All participants were randomized to receive either 12U/kg BTX or placebo saline injections. Main Outcome Measures: Functional limitation and disability: Gross Motor Function Measure (GMFM-88, GMFM-66), energy cost index (ECI), and Canadian Occupational Performance Measure (COPM) performance scores were collected at selected weeks postinjection. Societal limitation: COPM satisfaction scores and Goal Attainment Scaling (GAS) were obtained at 12 and 24 weeks. Results: GMFM-88 total score (P=.00) and the GMFM-66 (P=.03) significantly increased for the treatment group compared with the placebo group at 24 weeks. No significant group differences were found for the ECI at any follow-up point. The COPM performance scores were significantly greater for the treatment group at 12 weeks (P=.04) and approached a significant difference at 24 weeks (P=.06). COPM satisfaction scores and GAS did not differ significantly by group at any follow-up point. Conclusions: The GMFM-88 and -66 scores and COPM performance scores demonstrated a significant difference at 12 weeks, with a diminishing effect noted at 24 weeks. In contrast, satisfaction with performance as measured by the COPM satisfaction scores and performance and importance of goals set as measured by the GAS did not differ significantly between treatment groups. These data documented consistent changes on the functional limitation and disability levels up to 6 months posttreatment, but not on the societal outcome level.     

不同剂量A型肉毒毒素注射治疗痉挛型脑性瘫痪儿童尖足的疗效研究

目的 观察不同剂量A型肉毒毒素（BTX-A）注射联合康复治疗对痉挛型脑性瘫痪患儿尖足的影响。 方法 选取脑性瘫痪患儿107例,按照随机数字表法将其分为A组（35例）、B组（36例）、C组（36例）。BTX-A注射在彩色多普勒超声引导下进行,注射剂量分别为3 U/kg、4 U/kg、5 U/kg,注射后每组均给予4个疗程的康复训练。治疗前及治疗后1、3、6个月,采用改良Tardieu量表（MTS）评定腓肠肌痉挛程度,采用粗大运动功能量表-88（GMFM-88）及儿童平衡量表（PBS）评估患儿粗大运动D、E区及平衡功能。 结果 治疗后,3组患儿MTS、关节角度R1及R2、PBS、GMFM的D区及E区评分均较组内治疗前有不同程度改善,但组间比较差异无统计学意义（P＞0.05）。3组患儿注射BTX-A不良反应率比较,差异无统计学意义（P>0.05）。 结论 3 U/kg、4 U/kg、5 U/kg的BTX-A注射联合康复训练均能改善痉挛型脑瘫患儿的尖足状态,但不同剂量的疗效差异无统计学意义,推荐剂量为3 U/kg。     

Standing activity intervention and motor function in a young child with cerebral palsy: A case report

Purpose: There is limited evidence to fully justify the use of standing interventions for children with cerebral palsy (CP). This case report describes the impact of an 8-week standing program on motor function in a child with severe CP living in western Africa. Methods: The subject was diagnosed with ischemic – hypoxic encephalopathy shortly after birth and with CP at 12 months of age. Gross Motor Function Classification of CP was level IV. Early attempts at physical therapy were interrupted by limited access to medical services. At 18 months, a standing program using a locally constructed standing frame was initiated. The standing intervention was completed at home 5 times a week for 8 weeks. Motor skills were assessed at baseline and post-intervention using the Gross Motor Function Measure (GMFM-66). Results: Scores on the GMFM-66 increased from 28 at baseline to 37.4 in 8 weeks. Improvements in motor function included improved head control, improved upper extremity function, and increased sitting ability. Conclusions: Implementation of a home-based standing program may have contributed to improved motor skills for this child. Further research is needed to determine the effect of standing interventions on functional motor development for children with severe CP.     

Functional outcomes of intramuscular botulinum toxin type a and occupational therapy in the upper limbs of children with cerebral palsy: a randomized controlled trial

OBJECTIVE: To investigate the functional outcomes of botulinum toxin type A (BTX-A) injections to the upper limb in combination with occupational therapy (OT) in children with cerebral palsy (CP). DESIGN: Randomized controlled trial with follow-up at 2 weeks, 3 months, and 6 months. SETTING: Specialist outpatient physical disabilities clinic within a public pediatric teaching hospital. PARTICIPANTS: Eighty children with spastic quadriplegic, triplegic, or hemiplegic CP from these clinics were randomly assigned to BTX-A plus OT, BTX-A alone, OT alone, or a no-treatment control group. INTERVENTIONS: Single set of BTX-A (Botox) injections and 12 weeks of OT. MAIN OUTCOME MEASURES: Canadian Occupational Performance Measure (COPM) and Goal Attainment Scale (GAS). RESULTS: The combination of BTX-A and OT resulted in accelerated attainment of functional goals measured by the COPM and GAS. There were no differences between groups on the Melbourne Assessment of Unilateral Upper Limb Function, Quality of Upper Extremity Skills Test, Pediatric Evaluation of Disability Inventory, Child Health Questionnaire, or active and passive range of motion. As expected, there was a significant reduction in muscle tone at follow-up 2 weeks after injection, which returned to baseline level by 6 months. CONCLUSIONS: OT enhanced individualized functional outcomes following BTX-A injections in the upper limbs of children with CP.     

康复治疗联合A型肉毒毒素局部注射治疗痉挛型脑性瘫痪的疗效

目的观察康复治疗联合A型肉毒毒索（BTX-A）局部注射治疗痉挛型脑性瘫痪的疗效。方法60例脑性瘫痪患儿随机分为治疗组和对照组各30例。治疗组采用康复治疗联合BTX-A局部注射；对照组采用单纯康复治疗。治疗12周后比较两组患儿的关节屈曲度、步态等临床指标。结果治疗组患儿各项临床评价指标的改善优于对照组（P〈0．05）。结论康复治疗联合BTX—A局部注射可提高脑性瘫痪的疗效。     

肉毒毒素A治疗痉挛型脑瘫探讨

目的 探讨肉毒毒素A(botulinum toxin A,BTX-A)在脑瘫康复治疗中的应用价值。方法 将47例痉挛型脑瘫儿童随机分为治疗组(32例)和对照组(15例)，两组均接受正规康复训练，治疗组辅以痉挛肌注射BTX-A，观察商组患儿的内收肌角与回常生活活动能力(activities of daily living,ADL)变化。结果 治疗3个月和6个月后，治疗组患儿的内收肌角、ADL改善精况明显优于对照组(P＜0．01)。结论 康复训练仍是有效的脑瘫治疗手段，BTX-A局部注射作为一种重要的输助方法，可为康复训练提供良好时机，两者结合可明显缩短疗程、提高疗效，在脑瘫康复治疗中具有应用价值。