Epilepsy in hemiplegic cerebral palsy due to perinatal arterial ischaemic stroke

Aim The aim of this study was to describe the frequency, risk factors, manifestations, and outcome of epilepsy in children with hemiplegic cerebral palsy (CP) due to perinatal arterial ischaemic stroke (AIS). Method The study group comprised 63 participants (41 males, 22 females) from a population‐based CP register whose brain imaging showed perinatal AIS. Information collected included occurrence of neonatal seizures, family history of epilepsy, motor function and epilepsy onset, treatment, and outcome. Electroclinical findings were classified according to seizure semiology, seizure type, and epilepsy syndrome. Results Mean age of participants at the time of study was 10 years 6 months (SD 4y 7mo, range 4–20y). Gross Motor Function Classification System levels I and II were reported in 96% of participants, and Manual Ability Classification System levels I and II were reported in 79% of children. Thirty‐four children (54%) developed epilepsy. Term delivery and more severe motor impairment were associated with epilepsy, but neonatal seizures and family history of epilepsy were not. Initial seizures were epileptic spasms, focal seizures, or myoclonic seizures. Focal seizure semiology suggested Rolandic or occipital seizure origin in the majority of children. Focal epileptic discharges in children with focal seizures had features of idiopathic partial epilepsy. Only 15% of children had active epilepsy 10 years after onset. Interpretation Despite a high incidence of epilepsy in children with hemiplegic CP due to AIS, the prognosis for seizure remission is good. Many children have clinical features, electroencephalography findings, and remission typical of idiopathic partial epilepsy.     

Association of cerebral palsy with other disabilities in children with perinatal arterial ischemic stroke

The association of cerebral palsy with other disabilities in children with perinatal stroke has not been well-studied. We examined this association in 111 children with perinatal stroke: 67 with neonatal presentation, and 44 with delayed presentation. Seventy-six children (68%) had cerebral palsy, which was hemiplegic in 66 and tri- or quadriplegic in 10. Fifty-five (72%) children with cerebral palsy had at least one other disability: 45 (59%) had a cognitive/speech impairment (moderate-severe in 20), and 36 (47%) had epilepsy (moderate-severe in 11). In children with neonatal presentation, cerebral palsy was associated with epilepsy (P = 0.0076) and cognitive impairment (P = 0.0001). These associations could not be tested in children with delayed presentation because almost all children in this group had cerebral palsy. In another analysis with multivariate logistic regression for children with cerebral palsy, children who had both neonatal presentation and history of cesarean-section delivery were more likely to have epilepsy (P = 0.001). Children with cerebral palsy after perinatal stroke who had neonatal presentation were more likely to have severe cognitive impairment (odds ratio, 7.78; 95% confidence interval, 1.80-47.32) or severe epilepsy (odds ratio, 6.64; 95% confidence interval, 1.21-69.21) than children with delayed presentation. Children with cerebral palsy after perinatal stroke are likely to have an additional disability; those with neonatal presentation are more likely to have a severe disability.     

Learning to cope with mirror movements in unilateral spastic cerebral palsy: a brief report

ABSTRACT

Purpose: Mirror movements (MM) in unilateral spastic cerebral palsy (USCP) interfere with many bimanual activities of daily living.

Methods: Here, we developed a specific bimanual therapeutic regimen, focusing on asymmetric simultaneous movements of the two hands. Twelve children (6-17 years old; complete data available in ten children) with USCP and MM were included.

Results: After three weeks of inpatient rehabilitation, we observed significant improvements for two self-defined bimanual goal activities (Goal Attainment Scaling, Canadian Occupational Performance Measure) and for bimanual performance in general (Assisting Hand Assessment). These improvements were still present 6 months later. In contrast, even immediately after therapy, the severity of MM had not changed.

Conclusions: Hence, targeted bimanual therapy improved bimanual performance, but did not lead to a reduction of MM. The results of this pilot study might suggest that children with MM benefit more from acquiring strategies to cope with MM than by an active training which aimed to reduce MM.     

右利手右大脑半球卒中患者的镜像书写研究

目的探讨右利手患者右大脑半球卒中时的镜像书写发生情况及其发生机制。方法对经ＣＴ确诊的右利手右大脑半球卒中患者按《汉语失语症检查法（草案）》进行检查，其中１３例左侧轻瘫者进行左手书写检查，并检查了左右定向力和视空间能力。结果１３例左手书写的患者中，６例出现镜像书写，占４６．１％，２例为中度，４例为轻度。２例中度镜像书写者左右定向差，６例患者均无视空间障碍。间隔２周以上复查，均有明显恢复或消失。结论①非优势半球病变可引起镜像书写，其发生率与优势半球卒中相仿；②认为右半球卒中阻断了左侧书写运动－图式对右侧镜像书写运动－图式的抑制及对右侧运动区书写运动的主导作用而产生镜像书写，提出镜像书写运动联系通路理论。左右定向障碍对镜像书写的发生也有一定作用；③视空间障碍与镜像书写似无明显关系。     

Gait pattern differences in children with unilateral cerebral palsy

Children with cerebral palsy (CP) often have atypical body posture patterns and abnormal gait patterns resulting from functional strategies to compensate for primary anomalies that are directly attributable to damage to the central nervous system. Our previous study revealed two different postural patterns in children with unilateral CP: (1) a pattern with overloading of the affected body side and (2) a pattern with under-loading of the affected side.The purpose of present study was to test whether different gait patterns dependent on weight distribution between the affected and unaffected body sides could be detected in these children. The study included 45 outpatients with unilateral CP and 51 children with mild scoliosis (reference group). The examination consisted of two inter-related parts: paedobarographic measurements of the body mass distribution between the body sides and three-dimensional instrumented gait analysis.Using cluster analysis based on the Gillette Gait Index (GGI) values, three gait patterns were described: a scoliotic gait pattern and two hemiplegic gait patterns, corresponding to overloading/under-loading of the hemi-side, which are the pro-gravitational gait pattern (PGP) and the anti-gravitational gait pattern (AGP), respectively. The results of this study showed that subjects with AGP presented a higher degree of deviation from the normal gait than children with PGP. This proof that there are differences in the GGI between the AGP and PGP could be a starting point to identify kinematic differences between these gaits in a follow-up study.     

Prospective open-label clinical trial of trihexyphenidyl in children with secondary dystonia due to cerebral palsy

Although trihexyphenidyl is used clinically to treat both primary and secondary dystonia in children, limited evidence exists to support its effectiveness, particularly in dystonia secondary to disorders such as cerebral palsy. A prospective, open-label, multicenter pilot trial of high-dose trihexyphenidyl was conducted in 23 children aged 4 to 15 years with cerebral palsy judged to have secondary dystonia impairing function in the dominant upper extremity. All children were given trihexyphenidyl at increasing doses over a 9-week period up to a maximum of 0.75 mg/kg/d. Trihexyphenidyl was subsequently tapered off over the next 5 weeks. Objective motor assessments were performed at baseline, 9 weeks, and 15 weeks. The primary outcome measure was the Melbourne Assessment of Unilateral Upper Limb Function, tested in the dominant arm. Tolerability and safety were monitored closely throughout the trial. Of the 31 children who agreed to participate in the study, 5 failed to meet entry criteria and 3 withdrew due to nonserious adverse events (chorea, drug rash, and hyperactivity). Three children required a dosage reduction because of nonserious adverse events but continued to participate. The 23 children who completed the study showed a significant improvement in arm function at 15 weeks (P = .045) but not at 9 weeks (P = .985). Post hoc analysis showed that a subgroup (n = 10) with hyperkinetic dystonia (excess involuntary movements) worsened at 9 weeks (P = .04) but subsequently returned to baseline following taper of the medicine. The authors conclude that scientific evidence for the clinical use of trihexyphenidyl in cerebral palsy remains equivocal. Trihexyphenidyl may be a safe and effective for treatment for arm dystonia in some children with cerebral palsy if given sufficient time to respond to the medication. Post hoc analyses based on the type of movement disorder suggested that children with hyperkinetic forms of dystonia may worsen. A larger, randomized prospective trial stratified by the presence or absence of hyperkinetic movements is needed to confirm these results.     

Bimanual force coordination in children with spastic unilateral cerebral palsy

In this study bimanual grip-force coordination was quantified using a novel “Gripper” system that records grip forces produced while holding a lower and upper unit, in combination with the lift force necessary to separate these units. Children with unilateral cerebral palsy (CP) (aged 5-14 years, n = 12) were compared to age matched typically developing (TD) children (n = 23). Compared to TD, the CP-group is much slower and takes 50% more time to generate grip and lift forces with more fixating force before lifting the upper unit. In addition the coordination between forces in both hands is reduced. The CP-group increases the lift force in the upper hand 2.5 times more than the holding force when pulling the two units apart, while this is only 1.5 times in TD. Moreover, the correlation between forces generated in both hands in the CP-group is lower. The lack of fine tuning of the forces, measured by the linearity error is increased, especially when the magnet load keeping the unit together is low. The results indicate an impaired pull-hold synergy between upper and lower hand and the lift force. Bimanual tasks evaluating bimanual grip and lift forces in children with CP and can give us new insights in the underlying force control mechanisms of the spastic hand.     

Sleep disorders in children with cerebral palsy: neurodevelopmental and behavioral correlates

ObjectivesWe aimed to estimate the frequency of sleep disorders in children with cerebral palsy (CP) using the Sleep Disturbance Scale for Children (SDSC) and to evaluate the relations between sleep disorders and motor, cognitive, and behavioral problems.MethodsOne hundred and sixty-five children with CP ages 6–16 years (mean age, 11 years) were assessed using the SDSC, the Gross Motor Function Classification System (GMFCS), the Wechsler Intelligence Scale for Children and the Child Behavior Check List (CBCL) to assess sleep, motor, cognitive, and behavioral problems, respectively.ResultsAn abnormal total sleep score was found in 19% of children with CP; more than 40% of children had an abnormal score on at least one SDSC factor. The SDSC total score was significantly associated (P < .01) with mental retardation, epilepsy, CBCL scores, and level 5 on the GMFCS.ConclusionsOur results confirm that sleep disorders are common in children with cerebral palsy. The relationship between motor and cognitive behavior and epilepsy should be further explored to better understand how these factors influence one another to identify effective treatments and to improve the well-being of the child.     

Longitudinal development of hand function in children with unilateral cerebral palsy

Aim  The aim of this study was to describe how the usefulness of the hemiplegic hand develops in children with unilateral cerebral palsy (CP) aged between 18 months and 8 years. Method  A prospective longitudinal study of 43 children (22 males, 21 females) with unilateral CP was conducted. Inclusion age was 18 months to 5 years 4 months (mean 2y 8mo [SD 1y 1mo]). Children were assessed with the Assisting Hand Assessment (AHA) 3 to 11 times per child over a mean period of 4 years 6 months. Two models were used for grouping children: by AHA score at 18 months and by Manual Ability Classification System (MACS) levels. Estimated average motor development curves were fitted with a nonlinear mixed‐effects model. Results  Children with a high AHA score (high ability level) at 18 months reached a significantly higher ability level and at a higher progression rate than children with a low 18‐month AHA score. Limits of development differed between the three MACS levels. Interpretation  Results indicate that the AHA score at 18 months can be used to discuss future development of affected hand use in bimanual tasks in children with unilateral CP.     

Object/wrist movements during manipulation in children with cerebral palsy

The kinematics of the wrist and a manipulated object were studied in a posting task in 30 control, eight hemiplegic and 10 diplegic children. Statistical analyses using ‘mixed’ models examined the effects of subject group, hand, object shape and repeated trials, together with all possible interaction terms. During transport to the posting hole, the number of significant peaks/troughs in the velocity/time profile of the wrist in the transport (‘z’) direction were increased in subjects with cerebral palsy, as were adjustment error and the distances moved by the object relative to the wrist, reflecting more unpredictable object movement. In the placing phase, relative object/wrist normalized ‘z’ distances and number of wrist ‘z’ velocity peaks increased with increasing object complexity, reflecting the need for more adjustment movements. The number of wrist ‘z’ velocity peaks/troughs and adjustment error were increased in cerebral palsy subjects, reflecting ineffective adjustment. Relative object/wrist distances and number of wrist ‘z’ velocity troughs were reduced in both phases with repeated trials. It is suggested that such variables may provide a quantitative measure of poor movement ‘quality’ in children with Cerebral Palsy and that these findings reflect reduced mechanical stability of the hand and arm during movement.     

Gaze behaviour during interception in children with spastic unilateral cerebral palsy

Anticipatory gaze behaviour during interceptive movements was investigated in children with Spastic Unilateral Cerebral Palsy (SUCP), and related to the side of the intracerebral lesion. Five children with lesions of the right hemisphere (RHL) and five children with lesions of the left hemisphere (LHL) had to walk towards and intercept a ball that moved perpendicular to the walking path. Interception accuracy and gaze patterns were measured in a no-occlusion and occlusion condition, in which the ball was occluded from view for half of its trajectory. There was a clear support for a relationship between gaze behaviour and success in interception performance, with some evidence for the presence of anticipatory gaze behaviour. There were also differences in gaze behaviour between children with RHL and children with LHL that might be related to planning, but these did not affect interception accuracy. It is concluded that gaze behaviour during interceptive movements is anticipatory, and at least partly dependent on the lesional side.