Cerebral palsy: a clinical approach

Spastic cerebral palsy remains a therapeutic challenge. Diagnosis, usually possible within the first year of life, is straightforward. However, its uncertain etiology frustrates attempts at prevention and its poorly defined prognosis defies attempts to evaluate therapeutic effectiveness. Treatment must be directed toward both medical and habilitation issues. The syndrome of spastic cerebral palsy includes an increased risk of multiple medical problems. These must be followed and treated as needed. Habilitation needs are more difficult to define, thus demanding open communication between families and physicians for goal setting. Once goals are defined a comprehensive management program must be devised, choosing from several available approaches. No "right" answers exist; the only overriding concern remains to promote optimal independence through the developmental years and on into adulthood.     

Gross motor function measure for children with cerebral palsy

The aim of this study was to compare the pattern of motor dysfunction in Hong Kong Chinese children with spastic diplegic and the athetoid type of cerebral palsy (CP) by the Gross Motor Function Measure (GMFM). The GMFM was first tested on its content validity in differentiating the items suitable for testing on upper and lower limb function, followed by test-retest and inter-rater reliability studies, before it was used in a within-subject experiment comparing upper and lower gross motor function in two types of CP, respectively. Children with spastic diplegia (n=18) and with athetosis (n=19) were recruited from three pre-school centres, schools for physically handicapped children and centres of the Hong Kong Spastic Association in Hong Kong. The GMFM, a standardized outcome measure of the motor function in children with CP, was used in comparing mean scores of motor tasks involving upper limbs and those not involving upper limbs in the athetoid and spastic cerebral palsied children. The scores were significantly higher for the children in the spastic diplegic group, but there was no significant difference in the performance of static and dynamic motor tasks of the GMFM between the children in the two groups.     

Cerebral palsy: incidence and clinical features in Saudi Arabia

The purpose of this work is to analyse the cerebral palsy (CP) incidence, aetiology, birthweight, types and/or subdiagnosis and associated impairments, individually or in combination, in children at Riyadh Military Hospital (RMH). The study covered the birth year period 1984 - 2003, during which 99,788 live births were recorded at Riyadh Military Hospital (RMH). Incidence ratio and clinical features of 412 positive cases of cerebral palsied children between 1 - 10 years old were investigated. Medical information was collected from patient files at the medical records department. The incidence of CP was 0.41%. The five intervals of the study period gave a pattern of decreasing percentage incidence. The case distribution according to birth weight, aetiology, duration and subdiagnoses was studied. It could be concluded that livebirth incidence of cerebral palsied patients in Saudi Arabia was relatively high as compared to most other studies. Severe disability due to cerebral palsy was associated with impairments such as mental retardation, epilepsy and visual impairments, often found in combinations.     

CT在脑性瘫痪早期诊断中的价值

目的探讨CT在小儿脑性瘫痪(脑瘫)早期诊断中的价值。方法对124例小儿脑瘫的头颅CT进行回顾性研究与分析。结果124例中96例头颅CT检查阳性,CT异常率77.42％,其中脑萎缩是最常见的表现(54.84％)。临床类型中痉挛型最多见(71.77％)。不同年龄组中,年龄越小,CT异常率越高。结论虽然CT不能作为诊断脑瘫的主要依据,但有助于早期发现病变,有助于寻找病因及定位,还可以为判断本病的预后提供依据,在脑瘫的早期诊断中具有重要价值。     

脑性瘫痪CT表现与临床症状的分析

目的：分析脑性瘫痪ＣＴ表现与临床症状的关系。方法：本组自１９９６年～１９９８年通过综合临床表现与头部ＣＴ的表现观察８８例脑瘫患儿。结果：该治疗方法效果好,疗效短,见程快,有效率高。结论：临床表现与头部ＣＴ表现相结合进行定位穴位封闭治疗,大大地提高了有效率。     

Transcranial direct current stimulation for promoting motor function in cerebral palsy: a review

Transcranial direct current stimulation (tDCS) has the potential to improve motor function in a range of neurological conditions, including Cerebral Palsy (CP). Although there have been many studies assessing tDCS in adult stroke, the literature regarding the efficacy of tDCS in CP is more limited. This review therefore focuses on the neurophysiological and clinical findings in children and adolescents with CP. Initial studies applying anodal tDCS to promote lower limb function are promising, with improvements in gait, mobility and balance reported. However, the results of upper limb studies are mixed and more research is needed. Studies investigating neurophysiological changes or predictors of response are also lacking. Large-scale longitudinal studies are needed for the lower limb to ascertain whether the initial pilot results translate into clinically meaningful improvements. Future studies of the upper limb should focus on determining the optimal stimulation parameters and consider tailoring stimulation to the individual based on the (re)organisation of their motor system.     

脑瘫儿童选择脊神经后根切断术术前爬行能力与术后下肢功能改善的关联分析

目的：分析术前爬行能力与术后下肢功能,特别是独立行走能力的关系。方法：以量化功能的方式评估选择性脊神经后根据切术PSR）后下肢功能,将爬行功能分为A－D4个等级,同时将下肢功能分别量化,观察各级患儿手术前、后的功能变化,并统计分析手术前、后功能差异,结果：脑送信患者SPR术后肌张力明显降低,下肢各项功能显著改善;订前爬行能力良好的患儿术后下肢各项功能及独立行走与爬行能力差的患者有显著差异。结论：术前评三爬行能力对判断手术预后具有参考价值。     

脑性瘫痪患儿术前爬行能力与选择性脊神经后根切断术后下肢功能改善的相关分析

目的分析术前爬行能力与术后下肢功能特别是独立行走能力的关联。方法以量化功能的方式评估选择性脊神经后根切断术后下肢功能。将爬行功能分为A～D4个等级,同时将下肢功能分别量化,观察各级患儿手术前、后的功能变化,并统计分析术前、后的功能差异。结果术后肌张力明显降低,下肢各项功能显著改善;术前爬行能力良好的患儿术后下肢各项功能与独立行走与爬行能力差的患者有显著性差异。结论术前爬行能力对判断手术预后具有参考价值。     

Postoperative phrenic nerve palsy: early clinical implications and management

Objective We examined the clinical impact of diaphragmatic palsy (DP) as a result of phrenic nerve injury following cardiothoracic surgery, specifically its effects on morbidity and mortality, early regeneration capacity of the phrenic nerve, and role of surgical diaphragmatic plication.Methods A retrospective case control study was performed in 74 children with DP and 74 matched controls after cardiothoracic surgery within the past 14 years.Results Following 5,128 surgical procedures in children (aged under 18 years) we found an incidence of DP of 1.4%. There were no differences in mortality between the groups, and the cause of death was not related to DP or plication in any of the patients. However, patients with diaphragm impairment had significantly longer duration of mechanical ventilation (median 3 days vs. 1), ICU stay (7 days vs. 3.5), duration of hospital stay (16 days vs. 12), and for antibiotic treatment (16 days vs. 7). Because of prolonged respiratory problems 40 children (54%) underwent surgical diaphragmatic plication to flatten the diaphragm in its inspiratory position. In children with DP younger age was a strong predictor for plication (median 3.8 months vs. 12.1).Conclusions Especially in newborns and young infants with DP the length of mechanical ventilation, ICU stay, and hospital stay are prolonged. Early spontaneous recovery of the phrenic nerve is rare. In cases of respiratory impairment early transthoracic diaphragmatic plication is an effective means of treatment.This article is discussed in the editorial available at:     

痉挛型脑性瘫痪运动功能的康复现状

痉挛性脑性瘫痪(CP)患儿的运动功能的临床治疗和康复已取得了相当的进展。痉挛型CP的康复首选功能训练,主要是采用Bobath法、Vojta法、上田疗法及Peto引导式教育等方法改善患儿的肢体运动功能、生活自理能力和社会适应能力。在功能训练的基础上,早期应用矫形支具可以帮助患儿开发残存功能和代偿功能。目前神经阻滞技术和肉毒杆菌毒素的应用在降低CP患儿肌张力、缓解肌痉挛方面取得了显著的治疗效果。而各种矫形手术的日趋完善也为痉挛型CP患儿最大限度地恢复肢体运动功能带来了希望。     

踝足矫形器对脑性瘫痪患儿步态功能的改善作用

脑性瘫痪丰要影响患儿的行走功能,出现异常低效的步态模式,矫形器足用于改变神经肌肉和骨骼系统的机能特性或结构的体外使用装置,在矫形器治疗中使用最多的是踝足矫形器.踝足矫形器能够在踝足矢状面、碰状面、水平面3个平面提供合理的运动控制,保持关节的力线排列,促进功能,改善步态,是脑瘫患儿改善步态较为理想的矫形器.踝足矫形器在使用时也存在一些问题,比如关节活动范围受限,导致肌肉功能受限,因为加重了局部皮肤受压,容易引起感染等.正因为有这些不足,多年来临床医生与科研工作者一直在寻求各种各样的改良方式,如在现有标准踝足矫形器作用的基础上.附加某些治疗或保护性功能,以期获得更好的临床效果.为患者设计与装配最为合适的、个性化的踝足矫形器,是矫形器制作和设计的发展发向.     

不同时机开始康复干预对2岁前脑瘫高危儿粗大运动疗效的影响

目的 探讨不同时机开始康复干预对2岁前脑瘫高危儿粗大运动疗效的影响。 方法 将我院出生后14d、有脑瘫高危因素、新生儿行为神经测定（NBNA）评分<35分的新生儿（225例）作为脑瘫高危儿纳入研究对象,剔除失访、死亡及被诊断为其它疾病患儿11例,最后完成本研究214例,其中男117例,女97例。根据患儿开始接受正规康复干预时的月龄分为Ⅰ组（42例）、Ⅱ组（47例）、Ⅲ组（37例）和Ⅳ组（25例）,分别于出生后月龄≤3个月、3～6个月、6～12个月、12～24个月开始接受正规康复干预（包括住院康复干预和家庭康复干预）,以住院康复干预（2～3周）-家庭康复干预（4～6周）-住院康复干预（2～3周）的模式进行,在患儿整体发育接近或达到正常发育水平时,则停止住院康复干预改为单一的家庭康复干预;将未接受正规康复干预仅接受家庭康复干预的63例脑瘫高危儿作为家庭康复干预组（Ⅴ组）。住院康复干预措施主要是根据患儿症状及体征合理应用营养神经药物、物理因子疗法、手法治疗、运动疗法、认知训练、引导式教育、支具及矫形器;家庭康复干预措施主要是由康复医师和康复治疗师共同制订详细、规范、个体化的运动方案,教会家长正确执行运动处方及简单的手法治疗,并要求家长在家庭完成康复干预,每日1～2次按运动处方做运动同时进行手法治疗,每次35～45min,每1～2个月到门诊定期复诊。分别于脑瘫高危儿出生后3、6、12、24个月时,采用粗大运动功能测试量表（GMFM）检测患儿的粗大运动发育能力,并记录各时间点GMFM评分;统计各组住院总时间以及临床诊断为脑瘫和运动发育迟缓的例数;统计各组脑瘫高危儿2岁时的预后（优、良、一般、差）例数,计算各组预后优良率。 结果 ①月龄3个月时,Ⅰ组至Ⅴ组的GMFM评分依次明显增高,分别为(5.00±1.89)、(6.80±1.55)、(8.44±1.26)、(11.10±1.72)和(12.70±1.64)分,各组间两两比较,差异均有统计学意义（P<0.05）;月龄6个月时,Ⅰ组、Ⅱ组、Ⅲ组的GMFM评分分别为（39.10±7.95）、（40.60±3.68）和（43.40±3.84）分,组间两两比较,差异均无统计学意义（P>0.05）,且显著低于Ⅳ组［（49.90±3.32）分］和Ⅴ组［（52.40±1.48）分］,组间差异均有统计学意义（P<0.01）;月龄12个月时,Ⅰ组至Ⅴ组的GMFM评分分别为（177.20±16.92）、（172.10±13.81）、（157.50±18.93）、（163.00±9.04）和（178.50±4.72）分,其中Ⅰ组与Ⅱ组、Ⅰ组与Ⅴ组比较,组间差异均无统计学意义（P>0.05）,而Ⅰ组、Ⅱ组、Ⅴ组均显著高于Ⅲ组和Ⅳ组（P<0.05）;月龄24个月时,Ⅰ组至Ⅴ组的GMFM评分依次逐渐降低,分别为(218.64±16.07)、(211.10±13.14)、(201.80±11.54)、(193.20±12.33)和(185.40±10.74)分,组间差异均有统计学意义(P<0.05)。②Ⅲ组住院总时间最长,其次为Ⅰ组和Ⅱ组,Ⅳ组住院总时间最短,Ⅴ组未住院;Ⅰ组住院总时间与Ⅱ组比较,差异无统计学意义（P>0.05）,其余组间两两比较,差异均有统计学意义（P<0.05）。③Ⅰ组和Ⅱ组的脑瘫发生率（38.10%和29.79%）明显高于Ⅲ组（21.62%）、Ⅳ组（12.00%）和Ⅴ组（3.17%）,且组间差异均有统计学意义（P<0.05）;Ⅰ组和Ⅱ组的运动发育迟缓发生率（7.14%和10.64%）显著低于Ⅲ组（56.76%）、Ⅳ组（68.00%）和Ⅴ组（36.51%）,除Ⅰ组与Ⅱ组、Ⅲ组与Ⅳ组间差异无统计学意义（P>0.05）外,其余组间差异均有统计学意义（P<0.01）。④Ⅰ组至Ⅴ组在脑瘫高危儿2岁时的预后优良率依次显著下降（Ⅰ组88.10%、Ⅱ组78.72%、Ⅲ组62.16%、Ⅳ组48.00%、Ⅴ组31.75%）,组间两两比较,差异均有统计学意义（P<0.01）。 结论 脑瘫高危儿及早进行正规康复干预尤其重要,在出生后3个月内开始正规康复干预的治疗效果最佳;出生后3～6个月开始正规康复干预的治疗效果次之,但仍较理想;而在出生后6～12个月和出生后12～24个月才开始正规康复干预的治疗效果依次显著递减。     

Validation of a model of gross motor function for children with cerebral palsy

BACKGROUND AND PURPOSE: Development of gross motor function in children with cerebral palsy (CP) has not been documented. The purposes of this study were to examine a model of gross motor function in children with CP and to apply the model to construct gross motor function curves for each of the 5 levels of the Gross Motor Function Classification System (GMFCS). SUBJECTS: A stratified sample of 586 children with CP, 1 to 12 years of age, who reside in Ontario, Canada, and are known to rehabilitation centers participated. METHODS: Subjects were classified using the GMFCS, and gross motor function was measured with the Gross Motor Function Measure (GMFM). Four models were examined to construct curves that described the nonlinear relationship between age and gross motor function. RESULTS: The model in which both the limit parameter (maximum GMFM score) and the rate parameter (rate at which the maximum GMFM score is approached) vary for each GMFCS level explained 83% of the variation in GMFM scores. The predicted maximum GMFM scores differed among the 5 curves (level I=96.8, level II=89.3, level III=61.3, level IV=36.1, and level V=12.9). The rate at which children at level II approached their maximum GMFM score was slower than the rates for levels I and III. The correlation between GMFCS levels and GMFM scores was (.91. Logistic regression, used to estimate the probability that children with CP are able to achieve gross motor milestones based on their GMFM total scores, suggests that distinctions between GMFCS levels are clinically meaningful. CONCLUSION AND DISCUSSION: Classification of children with CP based on functional abilities and limitations is predictive of gross motor function, whereas age alone is a poor predictor. Evaluation of gross motor function of children with CP by comparison with children of the same age and GMFCS level has implications for decision making and interpretation of intervention outcomes.     

MRI征象及定量测量坏死体积对非创伤性股骨头坏死的预测价值

目的:探讨分析影响非创伤性股骨头坏死(Osteonecrosis of the femoral head,ONFH)塌陷的危险因素,评估其预测ONFH塌陷的临床应用价值.方法:收集经影像学检查诊断为早期ONFH(ARCOⅠ、Ⅱ)的患者共计112例(152髋),对以上患者进行随访观察.利用X线图像观察股骨头的塌陷情况;利用MRI图像观察髋关节的关节腔积液、骨髓腔水肿、坏死区信号特点、坏死部位及坏死形态等指标,并测量股骨头坏死体积,计算其坏死体积百分比.对分类变量采用卡方检验;对计量资料采用独立样本T检验.对有统计学意义的影像学指标采用Logistic回归分析其危险因素.结果:112例(152髋)患者发生股骨头塌陷者62髋,未塌陷者90髋.除塌陷组与未塌陷组间性别(P=0.078)、年龄(P=0.631)、病因(P=-0.604)和坏死信号比较(P=0.071)之外,其他各项指标均有显著的统计学意义.塌陷组及未塌陷组总的坏死体积百分比平均值分别为40.1％±20.1％、18.3％±19.8％;除塌陷组与未塌陷组后内下(PIM)象限比较(P=0.143)之外,其他各象限值均具有统计学意义.ARCO分期、坏死形态、骨髓水肿、总坏死体积百分比、前外上(ASL)象限坏死体积百分比、后外上(PSL)象限坏死体积百分比均具有统计学意义(P值＜0.05).结论:MRI检查和测量在ONFH的定量评价和预测塌陷中具有重要的临床价值,但预测股骨头塌陷时亦应综合考虑各种临床因素影响,从而进一步提高预测的准确性.     

A single serum test for measuring early pregnancy outcome with high predictive value

OBJECTIVES: Current testing to determine a failing pregnancy requires two separate clinic visits to measure the hCG doubling rate. Diagnosing a failing pregnancy is often done in emergency departments where simplified and accelerated testing methods are needed. Here, we investigated hyperglycosylated hCG (hCG-H) for predicting pregnancy failure. DESIGN AND METHODS: We studied two independent sets of patient samples collected in the early weeks of gestation. One set was urine samples, and the other was serum samples. In all cases, hCG and hCG-H were measured using automated chemiluminescence immunoassays. Concentrations of hCG and hCG-H were plotted on a scattergram, and levels in failing pregnancies were compared to those in continuing pregnancies. RESULTS: Data indicated that a threshold level of hCG-H (13 microg/L) in both serum and urine samples defined the concentration below where pregnancies were likely to fail. This cut-off corresponded to 73% detection of failures at a 2.9% false positive rate using serum and 75% detection at a 15% false positive rate using urine. Using an hCG cut-off that corresponded to the same false positive rates, hCG detected only 42% of failures using serum and 43% of failures using urine. CONCLUSIONS: Our data indicate that hCG-H provides a much more accurate single test than hCG for assessing pregnancy outcome. Compatible with the use of serum or urine samples, a single hCG-H test might provide simpler, faster, and more accurate results for predicting the progress of a pregnancy than standard hCG testing.