Pain in children with cerebral palsy: a cross‐sectional multicentre European study

Aim: To determine the prevalence and associations of self‐reported and parent‐reported pain in children with cerebral palsy (CP) of all severities. Method: Cross‐sectional design using a questionnaire; analysis using ordinal regression. Children aged 8–12 years were randomly selected from population‐based registers of children with CP in eight European regions; a further region recruited 75 children from multiple sources. Outcome measures were pain in the previous week among children who could self‐report and parents’ perception of their child’s pain in the previous 4 weeks. Results: Data on pain were available from 490 children who could self‐report and parents of 806 children (those who could and could not self‐report). The estimated population prevalence of self‐reported pain in the previous week was 60% (95% CI: 54–65%) and that of parent‐reported pain in the previous 4 weeks was 73% (95% CI: 69–76%). In self‐reporting children, older children reported more pain but pain was not significantly associated with severity of impairment. In parent reports, severity of child impairment, seizures and parental unemployment were associated with more frequent and severe pain. Conclusion: Pain in children with CP is common. Clinicians should enquire about pain and consider appropriate physical, therapeutic or psychological management.     

Communication ability in cerebral palsy: A study from the CP register of western Sweden

BackgroundCommunication is often impaired in cerebral palsy (CP). Tools are needed to describe this complex function, in order to provide effective support.AimTo study communication ability and the relationship between the Communication Function Classification System (CFCS) and CP subtype, gross motor function, manual ability, cognitive function and neuroimaging findings in the CP register of western Sweden.MethodsSixty-eight children (29 girls), 14 with unilateral spastic CP, 35 with bilateral spastic CP and 19 with dyskinetic CP, participated. The CFCS, Gross Motor Function Classification System (GMFCS) and Manual Ability Classification System (MACS) levels, cognitive impairment and neuroimaging findings were recorded.ResultsHalf the children used speech, 32% used communication boards/books and 16% relied on body movements, eye gaze and sounds. Twenty-eight per cent were at the most functional CFCS level I, 13% at level II, 21% at level III, 10% at level IV and 28% at level V. CFCS levels I–II were found in 71% of children with unilateral spastic CP, 46% in bilateral spastic CP and 11% in dyskinetic CP (p = 0.03). CFCS correlated with the GMFCS, MACS and cognitive function (p < 0.01). Periventricular lesions were associated with speech and more functional CFCS levels, while cortical/subcortical and basal ganglia lesions were associated with the absence of speech and less functional CFCS levels (p < 0.01).ConclusionCommunication function profiles in CP can be derived from the CFCS, which correlates to gross and fine motor and cognitive function. Good communication ability is associated with lesions acquired early, rather than late, in the third trimester.     

下肢康复机器人在小儿脑性瘫痪康复中的应用进展

脑性瘫痪是一组严重危害儿童身心健康的运动障碍性疾病,多数患儿需要终身康复.传统康复医学方法主要依赖康复治疗手技,给家庭社会带来长期且沉重的负担.随着生物力学及康复工程技术的高速发展,新型的康复机器人通过融合康复医学、生物力学、机械学、机械力学、电子学、计算机科学和机器人学等诸多学科,将主被动训练结合,拟合正常运动模式,达到功能康复的目的.该文重点以下肢康复机器人为例,综述儿童康复机器人在脑性瘫痪中应用研究进展,为促进儿童康复技术的发展提供新的思路.     

脑性瘫痪合并视听觉障碍的临床康复研究进展

脑性瘫痪是一组以运动障碍和姿势异常为核心表现的发育障碍综合征,可伴有言语障碍、智力障碍、视听觉障碍和行为障碍等.因其高发病率与致残率,脑性瘫痪现已成为全世界需共同攻克的难题.目前国内的研究主要是针对运动障碍、言语障碍和智力障碍,而对感知觉障碍缺乏足够的重视.感知觉障碍中发病率最高的是视听觉障碍,且后者对儿童运动、认知、语言、交流、心理等方面发育均存在影响.该文重点综述脑性瘫痪合并视听觉障碍的发病率、表现形式、对脑性瘫痪儿童发育的影响以及康复治疗进展,以提高视听觉障碍的重视度,并为促进该类儿童的全面康复奠定基础.     

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.     

Behavioural problems in school age children with cerebral palsy

Background

Although behavioural problems are frequent in children with Cerebral Palsy (CP), the exact nature of these difficulties and their relationship with intrinsic or extrinsic factors are just beginning to be explored.

Aim

To describe and characterize behavioural problems in children with CP and to determine the nature of any relationships with child and family characteristics.

Methods

In this cross-sectional study, children with CP between 6 and 12 years of age were recruited. Children were assessed using the Leiter Intelligence Test, the Gross Motor Function Measure, the Strengths and Difficulties Questionnaire (SDQ), the Vineland Adaptive Behavior Scales and questionnaires on demographic factors. Parents’ level of stress was measured with the Parenting Stress Index.

Results

Seventy-six parents completed the SDQ. Using the Total Difficulties Scores, 39.4% of the sample scored in the borderline to clinically abnormal range. Peer problems were the most common (55.3%). High parental stress was consistently associated with behavioural difficulties across all domains of the SDQ. Not surprisingly, better socialization skills and a lower parental stress were correlated with more positive behaviours.

Conclusion

Behavioural difficulties are common in children with CP and appear not to be associated with socio-demographic variables and physical and cognitive characteristics. These difficulties are an important correlate of parental distress. This study emphasizes the need to recognize and address behavioural difficulties that may arise so as to optimize the health and well-being of children with CP and their families.     

脑瘫患儿社会生活能力及其影响因素的分析

目的分析不同类型脑瘫患儿的社会生活能力及其相关因素。方法2005-01—2006-12采用《婴儿-初中生社会生活能力量表》和自制的相关因素调查表对大连儿童医院诊治的150例脑瘫患儿进行调查。结果以社会生活能力评分,偏瘫型最高,徐动型最低;与社会生活能力有关的因素,包括脑瘫类型、产后窒息、养育情况、现头围和母亲文化程度等。结论脑瘫患儿中偏瘫型患儿的社会生活能力最好,手足徐动型最差;影响脑瘫患儿社会生活能力的相关因素主要有脑瘫类型、产后窒息、养育情况、现头围、母亲文化程度。     

Botulinum toxin in children with cerebral palsy

Botulinum toxin is a neurotoxin that blocks the synaptic release of acetylcholine from cholinergic nerve terminals mainly at the neuromuscular junction, resulting in irreversible loss of motor end plates. It is being widely tried as a targeted antispasticity treatment in children with cerebral palsy. A number of studies have shown that it reduces spasticity and increases the range of motion and is particularly useful in cases with dynamic contractures. However improvement in function has not been convincingly demonstrated. It is an expensive mode of therapy and the injections need to be repeated after 3–6 months. Whereas Botulinum toxin can be a valuable adjunct in select cases, it should not be projected as a panacea for children with spastic cerebral palsy.     

我国六省(区)小儿脑性瘫痪患病率及临床类型的调查分析

目的：调查我国1－6岁小儿脑性瘫痪（简称脑瘫）患病率及临床各种类型的分布状况,方法：1997年5月－1998年8月,对我国黑龙江、河北、甘肃、江苏、四川省及广西壮族自治区进行调查,以乡（镇)为单位进行整体抽样,对抽样乡（镇）全部1－6岁小儿进行调查。在现场工作开始之前对所有参加调查的工作进行统一培训,经考试合格后参加现场工作。资料经双重录入和统一清理后,在Pntium133微机上用SAS6．11for Windows软件,进行统计分析。结果：共调查1－6岁小儿1047327人,其中脑瘫患儿2009人,患病率为1．92‰,在脑瘫各种类型中,痉挛型脑瘫最多见,占53．56％,以下依次为肌张力低下型（13．39％）,共济失调型（10．00％）, 手足徐动型（4．63％）,震颤型（0．85％）、强直型（0．55％）、混合型（12．44％）,分类不详（4．58％）,2009例脑瘫中、男1266例,女743例,男：女＝1．70：1。结论：本次调查结果大致能反映我国大陆地区小儿脑瘫的患病率为1．92‰。脑瘫的各种类型中以痉挛型最多见。     

Clinical features of cerebral palsy in children with symptomatic congenital cytomegalovirus infection

BackgroundHuman cytomegalovirus is the most common cause of vertically transmitted viral infection, affecting around 1% of liveborns. Infection is symptomatic in nearly 10% of infected children who are at higher risk of development of severe neurological disorders, including cerebral palsy.AimsTo study the clinical profile of children with cerebral palsy caused by symptomatic congenital cytomegalovirus infection in a multicenter study involving six countries from the Surveillance of Cerebral Palsy in Europe (SCPE) Network.MethodsData on 35 children (13 males, 22 females; mean age at last assessment 12y 6mo, age range 14y 6mo, min 4y, max 18y 6mo) on pre/peri/neonatal history and last clinical assessment were collected. Classification of cerebral palsy and associated impairments was performed according to SCPE criteria.ResultsThe majority of children had bilateral spastic cerebral palsy, 85.7%, with a confidence interval (CI) [69.7–95.2], and 71.4% [CI 53.7–85.4] were unable to walk (GMFCS levels IV–V) while fine motor function was severely affected in 62.8% [CI 44.9–78.5] (BFMF levels IV and V). Most of the children with severe CP had severe associated impairments. 11.4% of children had severe visual and 42.8% severe hearing impairment, 77.1% [CI 59.9–89.6] suffered from epilepsy, also 77.1% had severe intellectual impairment, and speech was undeveloped in 71.4%. Female:male ratio was 1.69:1 and 80% of children were term born.ConclusionsCerebral palsy following symptomatic congenital cytomegalovirus infection seems to be in most cases a severe condition and associated impairments are overrepresented.     

Identification of feeding risk factors for impaired nutrition status in paediatric patients with cerebral palsy

Aim: To assess the nutrition status of children with CP, applying WHO growth standards, to indentify feeding risk factors and to evaluate their impact on the growth of children with CP. Methods: In 42 paediatric patients (mean age 8.00 ± 4.00 years), anthropometry and food intake records were assessed. z ‐scores were calculated using WHO Anthro software. Intake to requirements ratio (I/R) was calculated, and patients were classified according to their feeding ability (PFA). Overall diet quality was assessed using the Diet Quality Index International (DQI‐I). Results: Based on WAz, 15 patients (38.1%) were undernourished. No association was found between I/R ratio and BMI z‐score, while PFA and DQI‐I displayed a significant correlation to both (p < 0.05). Diet Quality Index International was also correlated with macronutrient distribution (p < 0.05). Patients with CP were undernourished in a considerable proportion. Malnutrition in patients with CP is not associated with the intake of estimated energy requirements. Among the other feeding risk factors studied, PFA and DQI‐I represented important parameters associated with malnutrition. Conclusion: WHO z‐scores represent accurate parameters for the assessment of malnutrition in patients with CP. Together with anthropometry and PFA evaluation, the use of the DQI‐I would add prognostic value to both the initial growth assessment and the patients’ growth monitoring.     

Deep brain stimulation in cerebral palsy: Challenges and opportunities

Cerebral palsy (CP) is the most common cause for acquired dystonia in childhood. Pharmacological treatment is often unsatisfactory and side effects are frequently dose-limiting. Data on outcome of DBS in paediatric patients with dyskinetic CP is very limited and heterogeneous. Reasons for the variability in responses are not entirely known yet. Interestingly, some CP-patients seem to improve subjectively on pallidal stimulation but without measurable changes in impairment scales. Besides dystonia scales, the use of sensitive age-dependent assessments tools is therefore reasonable to capture the full effect.As the course of disease duration as well as the age at operation seem to correlate with DBS outcome in patients with dystonia, DBS at an early stage of development might be beneficial for some of these patients. For the future, well-conducted trials as well as data collection in the international registry is of major importance to increase knowledge about DBS in CP patients, especially those implanted at a young age. Furthermore, selection criteria and guidelines or treatment standards are needed to improve the service for children with dyskinetic CP – especially in light of unsatisfactory medical treatment options.     

Feeding problems,growth and nutritional status in children with cerebral palsy

Aim: The aim was to estimate the prevalence of feeding and nutritional problems in children with cerebral palsy (CP) in Norway. Methods: Data were abstracted from the Norwegian CP Register for 661 (368 boys) children born 1996–2003 (mean age 6 years 7 months; SD: 1.5). For children born from 1999 to 2003, weight and height were available. Body mass index (BMI) (kg/m²) was used to assess nutritional status. Results: One hundred and thirty‐two (21%) children with CP were completely dependent on assistance during feeding. The prevalence of gastrostomy tube feeding was 14%. Longer duration of gastrostomy tube feeding was associated with higher weight and BMI, but not with height. Only 63% of the children with CP had normal BMI, 7% had grade 3 thinness, while the prevalence of overweight and obesity in our study was 16%. In all, 20% of the children had mean z‐scores for weight and/or height below – 2 SD. Conclusion: Feeding problems in children with CP were common and associated with poor linear growth. A high proportion of the children were undernourished. Moreover, our results suggest that gastrostomy tube feeding may have been introduced too late in some children.     

Micronutrient status in children with cerebral palsy

AIM: To investigate micronutrient status in a group of children with cerebral palsy (CP). METHODS: Thirty-six children with CP, aged 1.5-17 years, completed a 4-day food diary, underwent anthropometric measurements and delivered blood for analysis of micronutrient concentrations. RESULTS: Low intake of iron, folate, niacin, calcium, vitamin E and vitamin D was common, even among those who were receiving nutritional supplements. Laboratory tests revealed low serum concentration of folate in eight children, alpha-tocopherol in six children, ferritin in five children and pyridoxal-5-phosphate in three children. Two participants were low in zinc and one was low in selenium. Severely disabled children received nutrition supplements more frequently than those with less severe disability (71% vs.16%, p = 0.01). Tube feeding and use of nutrition supplements was reflected in higher concentrations of micronutrients in blood and serum. CONCLUSION: Low intake of micronutrients as well as low micronutrient concentrations was common in this heterogenic group of children with CP. Children with neurological disabilities should have their nutritional status evaluated in order to ascertain sufficient intake of micronutrients.     

Intrauterine growth in children with cerebral palsy

The risk of cerebral palsy in connection with intrauterine growth retardation has been analysed in a case-control study. The case series comprised 519 children with cerebral palsy born in 1967-1982 in the west health-care region of Sweden and the control series 445 children born during the same years in the same region. The risk of cerebral palsy in small-for-gestational-age infants was significantly increased in term and moderately preterm infants. The highest proportion among infants with cerebral palsy born at term was found in tetraplegia, followed by diplegia and dyskinetic cerebral palsy. It was concluded that small for gestational age on the one hand reflects early prenatal brain damage, and on the other mediates prenatal risk factors compatible with foetal deprivation of supply and also potentiates adverse effects of birth asphyxia and neonatal hypoxia.     

脑瘫患儿口运动与进食和营养问题

目的　分析脑瘫患儿口运动与进食障碍的发生率与症状学 ,并对营养状况进行初步评价。方法　 2 0 0 2年 3月～ 2 0 0 3年 3月住院康复的脑瘫患儿 5 9例 ,男 39例 ,女 2 0例 ,平均年龄 31个月 (2 0～ 72个月 )。父母问卷调查了解高危因素、喂养史 ,神经病学检查评价脑瘫类型 ,Gesell发育评分评价运动发育年龄 ,测体重、身高评价营养状况 ,对所有患儿进行口运动与进食技能评分与现场观察 ,按年龄、性别匹配对照组进行对比分析。结果　 5 9例患儿中口运动障碍 5 1例 ,所有徐动型和痉挛型四肢瘫、16例痉挛型双瘫患儿存在口运动异常 ,脑瘫组平均口运动评分为 (2 5± 15 )分 ,低于对照组儿童 (t=11 5 87,P <0 0 0 1)。口运动异常涉及下颌、唇、舌的各个运动测试亚项。 5 5例患儿存在进食方面问题 ,绝大多数患儿进食过程中需要家长帮助 ,半数患儿仅能进食流质和 (或 )半流质 ,不能进食固体食物。进食技能障碍主要表现在口相和口前相 ,脑瘫组进食技能分平均 (35± 11)分 ,亦明显低于对照儿童 (t=4 5 5 2 ,P <0 0 0 1) ,徐动型总分较低 ,其次是痉挛型四肢瘫。脑瘫组 13例患儿体重低于第 2 5百分位数 ,19例患儿身高低于第 2 5百分位数 ,提示体格发育存在受阻现象。结论　绝大多数脑瘫患儿存在口运动和进食障碍 ,