Unilateral cerebral palsy: a population-based study of gait and motor function

Aim To investigate the spectrum and relationships between gait patterns and motor function in a population‐based cross study of children with unilateral cerebral palsy (CP). Method Children identified with unilateral CP born in Victoria, Australia, from 1990 to 1992 were eligible to participate. Characteristics were reported using the Winters, Gage, and Hicks (WGH) classification for gait patterns, the Gross Motor Function Classification System (GMFCS) and Functional Mobility Scale (FMS) for gross motor function, and Manual Ability Classification System (MACS) and House classification for upper‐limb function. Results A recruitment rate of 71% was achieved (42 males, 27 females; mean age 11y 4mo, SD 2y 4mo). Children were classified in levels I and II of the GMFCS and levels I, II, and III of the MACS whereas there was a greater range of scores using the FMS and House classification. The association was moderate between categorizations of lower‐limb and upper‐limb involvement (Kendall’s τ_b=0.46–0.47, p < 0.001), accounting for around 21% of the explained variance. The proportions of gait‐pattern groups in the current cohort were rather similar to the original WGH cohort (χ²=7.07, degrees of freedom [df]=3, p = 0.070). Interpretation Unilateral CP embraces a wide spectrum of clinical phenotypes. There were only moderate associations between categorizations of upper‐ and lower‐limb function, supporting the need for separate classification systems of upper‐ and lower‐limb functioning in this diverse group of children.     

肌力训练对痉挛型脑瘫患儿运动功能影响的对照研究

目的比较肌力训练结合常规康复治疗与常规康复治疗对痉挛型脑瘫患儿运动功能的临床疗效差异。方法58例脑瘫患儿随机分为两组，即肌力训练结合常规康复治疗组（肌力训练组，30例）和常规康复治疗组（28例）。两组患儿入组后开始为期2周的康复治疗，2周后改由家长在家进行治疗。分别在治疗前，治疗后的6周、12周进行以下评定：（1）综合痉挛量表（CSS）；（2）粗大运动功能量表（GMFM）中的D和E两项；（3）步行速度。结果两组患儿的CSS、GMFM评分及步行速度治疗前差异无显著性意义（P〉0．05），治疗后6周、12周与治疗前比较差异均有显著性意义（氏0．05），GMFM评分、步行速度治疗后6周、12周两组比较差异均有显著性意义（氏0．05）。结论肌力训练结合常规康复治疗能更好地提高痉挛型脑瘫患儿的运动能力。     

Effects of the Inerventions method on gross motor function in children with spastic cerebral palsy

Aim of the study

To investigate the effect of the Inerventions method on gross motor function in children with spastic cerebral palsy (CP).

佩戴踝足矫形器对痉挛型脑性瘫痪儿童足底压力步态的作用

背景：由于设计及方法的差异,佩戴踝足矫形器对脑性瘫痪(脑瘫)儿童步行时运动学、运动力学、能耗等各方面的影响尚未取得统一的结果。 目的：观察佩戴踝足矫形器对痉挛型脑瘫患儿足底压力步态特征的影响。 方法：采用足底压力式步态分析系统对21例具有独立步行能力的痉挛型脑瘫儿童进行步态分析。分别记录同一天内、同一时间段、同一种身体状态下不佩戴踝足矫形器及佩戴踝足矫形器步行时每例脑瘫患儿足底压力式步态分析数据,包括时间参数、运动学参数以及各参数的绝对对称性指标,并进行对比。记录双足的足底压力重心偏移轨迹作为步行能力的定性直观观察指标,对比佩戴支具前后的足底压力重心偏移轨迹图并做对照描述。 结果与结论：与未佩戴踝足矫形器相比,佩戴踝足矫形器使痉挛型脑瘫患儿步态周期时间缩短,步频增加(P < 0.01)。佩戴踝足矫形器步行时脑瘫儿童单足支撑期、单侧支撑期、单足摆动期、步态周期时间的绝对对称性指标值均较未佩戴矫形器时显著减少(P < 0.05)。痉挛型脑瘫儿童步行时双足的足底压力重心偏移轨迹表现出无序的特性,不能形成左右对称的蝴蝶状轨迹图。佩戴踝足矫形器后,足底压力中心偏移轨迹比未佩戴时有序,尖足步态患儿佩戴踝足矫形器后患足的足底压力偏移轨迹起始点后移。结果提示痉挛型脑瘫儿童佩戴踝足矫形器后步态周期时间缩短,步频增加,步态对称性改善,总体步行能力得到提高。足底压力式步态分析系统能以客观精确的数据和直观的图表表达,是评定脑瘫儿童步行能力的一种新型测试手段。     

Gross motor patterns in children with cerebral palsy and spastic diplegia

Rolling, sitting, and crawling patterns were motoscopically analyzed in 72 children with cerebral palsy and spastic diplegia; the relation between these patterns and the severity of the locomotive disability was studied. In rolling, trunk rotation and elbow support were difficult for the most severely diplegic children. When sitting, most patients had a between-heel sitting pattern in which the thighs were adducted and the knees were flexed. When crawling, the reciprocal thigh movements were insufficient and accompanied by lateral bending of the trunk in many patients. In the more impaired patients, the thighs supported the weight in flexion and did not move reciprocally. Creeping on the elbows without reciprocal leg movements was demonstrated in the most severely affected children after 2 years of age.     

“痉挛三针”对痉挛型脑瘫儿童运动功能的影响

目的观察"痉挛三针"对痉挛型脑瘫儿童运动功能的影响。方法选择我院治疗的86例痉挛型脑瘫患儿,依据随机数字表法分为观察组与对照组各43例。对照组采用头针针灸结合康复训练治疗,观察组在对照组的治疗基础上加用"痉挛三针"。比较2组治疗前后的改良Ashworth评分、GMFM-88中D区与E区评分及治疗效果。结果治疗后2组改良Ashworth评分均不同程度降低,GMFM-88中D区与E区评分均有所提高,观察组显著优于对照组;观察组总有效率(90.7%)显著优于对照组(81.4%),差异有统计学意义(P0.05)。结论 "痉挛三针"可有效降低痉挛型脑瘫儿童内收肌肌张力,使患儿获得更好的独立行走及跑跳等运动功能。     

Intrathecal baclofen therapy in children with intractable spastic cerebral palsy: a cost-effectiveness analysis

In a Dutch national study, we recently established the effectiveness and safety of continuous intrathecal baclofen infusion (CITB) in children with intractable spastic cerebral palsy (CP). Because prospective studies on the cost-effectiveness of CITB in children with spastic CP are lacking, we conducted a cost-effectiveness analysis alongside our prospective national study. We compared the costs and health effects of CITB with those of standard treatment only, from the health care perspective for a 1-year period. Health effects were expressed in terms of a visual analogue scale for individual problems and quality-adjusted life years (QALYs). We included eight females and seven males, aged between 7 and 17 years (mean age 13y 8mo [SD 3y]). Eleven children had spastic CP and four had spastic-dyskinetic CP. One child was clsssified on the Gross Motor Function Classification System at Level III, two at Level IV, and 12 at Level V. CITB was more effective and more costly than standard treatment only. Gaining one QALY cost on average 32,737 euros. We conclude that based on the threshold-willingness to pay for one QALY in the Netherlands (80,000 euros), our results confirm the cost-effectiveness of CITB for carefully selected children with intractable spastic CP.     

Effect of cerebrolysin on gross motor function of children with cerebral palsy: a clinical trial

Gross motor dysfunction is considered as the most challenging problem in cerebral palsy (CP). It is proven that improvement of gross motor function could reduce CP-related disabilities and provide better quality of life in this group of patients. Therefore, the aim of this trial is to evaluate the effectiveness of cerebrolysin (CBL) on gross motor function of children with CP who are undergoing treatment. In this clinical trial study, paediatric patients aged 18–75 months with spastic diplegic or quadriplegic cerebral palsy, who were under rehabilitation therapy, were selected and randomly allocated in control and CBL groups. Patients in CBL group underwent treatment with standard rehabilitation therapy plus CBL. The latter was administrated intramuscularly as a single daily dose of 0.1 cc/kg for 10 days and then continued weekly for 4 months. Gross motor function of participants in the two studied groups, before and after trial, was evaluated and compared using the validated Persian version of gross motor function classification system-expanded and revised (GMFCS-E&R). During this trial, 108 patients with CP were evaluated for eligibility. From these, 50 patients were enrolled and randomly allocated in the CBL and control groups. Four months after trial, the mean level of GMFCS decreased significantly in the two groups (P < 0.05). However, it was significantly lower in the CBL group than in the control group (2.1 vs. 3.16, P < 0.05). The results of this trial indicated that CBL could improve gross motor function in patients with CP. This finding is consistent with neurotrophic and neuroprotective effects of CBL, which have been reported in various clinical trials in other neurological disorders. Further studies are recommended to establish the value of continued neuroprotection and to determine the pharmacokinetics/dynamics of CBL in this group of patients.     

踝足矫形器对脑性瘫痪患儿步态功能的改善作用

脑性瘫痪主要影响患儿的行走功能,出现异常低效的步态模式，矫形器是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、冠状面、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。     

Modified constraint-induced movement therapy for young children with hemiplegic cerebral palsy: a pilot study

The objective of the study was to evaluate the effectiveness of modified constraint-induced movement therapy in young children with hemiplegia. It was a single-case experimental design using children as their own controls. Assessment was at entry to the study and subsequently at 4-weekly intervals. A 4-week baseline period with no hand treatment, controlling for maturation, was followed by a 4-week treatment period and a second 4-week period with no hand treatment to measure carry-over. Treatment consisted of twice-weekly 1-hour sessions of structured activities with a therapist and a home programme for non-treatment days. Only verbal instruction and gentle restraint of the unaffected arm were used to encourage use of the affected arm. Nine children (six males, three females; median age 31 mo, age range 21 to 61 mo) presenting with congenital spastic hemiplegia (five right side, four left side) were involved in the study. Changes in hand function were evaluated with the Quality of Upper Extremity Skills Test. Improvement was seen throughout the study with statistical significance, using the Wilcoxon signed rank test, of 0.01 immediately after treatment. Results of this pilot study suggest that this modification of constraint-induced movement therapy may be an effective way of treating young children with hemiplegia. Future work is planned to consolidate and develop these results.     

Effect of upper limb deformities on gross motor and upper limb functions in children with spastic cerebral palsy

The aims of this study were to investigate the nature and extent of upper limb deformities via the use of various classifications, and to analyze the relationship between upper limb deformities and gross motor or upper limb functionality levels. Upper extremity data were collected from 234 children with spastic cerebral palsy (CP) who were admitted to the university hospital for intensive rehabilitation. Upper limb deformities were classified according to the Zancolli classification for finger and wrist extension ability, the Gshwind and Tonkin classification for supination ability, and the House classification for thumb-in-palm deformity. Digital deformity was also classified. Upper limb function was assessed using the Upper Extremity Rating Scale (UERS) and the Upper Limb Physician's Rating Scale (ULPRS). Gross motor function was assessed using the Gross Motor Functional Classification System (GMFCS). Among the 234 children observed, 70.5% had a limitation in forearm supination, and 62.8% had problems with wrist and finger extension in at least one limb. Thumb-in-palm deformity of at least one hand was found in 47.0% of patients. Swan neck deformity was the most common finger deformity. Upper limb functional measures, the ULPRS and the UERS, significantly correlated with the degree of upper limb deformity, as assessed by the Gschwind and Tonkin, Zancolli, and House classifications. Further, the degree of upper limb deformity was significantly related to the GMFCS level in children with bilateral CP, but not in children with unilateral CP. Limitation of forearm supination was the most common upper limb deformity in children with spastic CP. The degree of upper limb deformity significantly affected upper limb function in these children.     

Intermittent intensive physiotherapy in children with cerebral palsy: a pilot study

The aims of the study were: (1) to determine the feasibility of a rehabilitation program combining intensive therapy periods (4 times/week for 4 weeks) with periods without therapy (8 weeks) over a 6-month period in severely impaired children with cerebral palsy (CP); and (2) to measure changes in gross motor function after intensive therapy periods (immediate effects) and rest periods (retention). A convenient sample included five children (two females, three males; mean age 22.6 months [SD 9.9]) with severe forms of CP with impairment of four limbs and trunk (GMFCS levels IV and V). A multiple-baseline design was used. Changes in motor performance were assessed by a blind evaluator using the Gross Motor Function Measure. Visual and statistical analyses followed. Level of compliance during intensive therapy was 93.1%. Children received a mean of 30 treatments over the 24 weeks of the experimental phase compared with the 48 treatments they would have received routinely. Increases in GMFM scores (mean 9.2%; range 3 to 15%) were significant in three children (p<0.05) and all participants maintained their motor performance during the two 8-week rest periods. Results showed that four treatments per week over a 4-week period were well tolerated when separated by rest periods. The intermittent program led to improvements in motor function that were maintained over the rest periods. Results underline the need to reconsider the organization of physical rehabilitation programs. A regime that is intensive enough without being tiring and one that provides practice conditions for consolidating motor skills learned during the intensive therapy period may best optimize motor training.     

Effect of functional electrical stimulation, applied during walking, on gait in spastic cerebral palsy

This study investigated the effect of functional electrical stimulation (FES), applied during walking, on the gait of children with spastic cerebral palsy (CP). Eight children (five males, three females; mean age 13y 2mo, SD 2y 2m; range 8y 11mo to 17y 6mo) diagnosed with diplegic (n=6) or hemiplegic (n=2) spastic CP completed the study. All participants were ambulant. Core FES strategies based on common CP gait deviations were developed and tailored for each child. FES strategies for each child were evaluated in two separate test sessions. Effects of FES on gait were monitored with three-dimensional motion analysis. Within each test session each child's gait was assessed when walking without FES (phase A) and with FES (phase B). An A-B-A-B test sequence was employed allowing the effects of the withdrawal and reinstatement of FES to be assessed. All children performed 10 consecutive walks in each phase. Replication of this sequence on a separate day allowed the repeatability of the intervention to be evaluated. Outcome measures, including summary variables of kinematic data, temporal-spatial variables, and mode of initial contact, were predefined for each child and targets for clinical significance were set for these outcome measures. Comparisons were performed between these targets and the actual outcomes. Consistent clinically significant improvements were recorded for three children: one child showed some improvement that was statistically significant but not clinically significant. Results for one child were mixed. There was no change in the remaining three children. Gait analysis proved to be a useful tool in both developing and determining the effectiveness of FES strategies.     

Effects of oral motor therapy in children with cerebral palsy

Aim:

Oral motor dysfunction is a common issue in children with cerebral palsy (CP). Drooling, difficulties with sucking, swallowing, and chewing are some of the problems often seen. In this study, we aimed to research the effect of oral motor therapy on pediatric CP patients with feeding problems.

Materials and Methods:

Included in this single centered, randomized, prospective study were 81 children aged 12-42 months who had been diagnosed with CP, had oral motor dysfunction and were observed at the Pediatric Neurology outpatient clinic of the Children''s Health and Diseases Department, Istanbul Medical Faculty, Istanbul University. Patients were randomized into two groups: The training group and the control group. One patient from the training group dropped out of the study because of not participating regularly. Following initial evaluation of all patients by a blinded physiotherapist and pedagogue, patients in the training group participated in 1 h oral motor training sessions with a different physiotherapist once a week for 6 months. All patients kept on routine physiotherapy by their own physiotherapists. Oral motor assessment form, functional feeding assessment (FFA) subscale of the multidisciplinary feeding profile (MFP) and the Bayley scales of infant development (BSID-II) were used to evaluate oral motor function, swallowing, chewing, the gag reflex, the asymmetrical tonic neck reflex, tongue, jaw, and mouth function, severity of drooling, aspiration, choking, independent feeding and tolerated food texture during the initial examination and 6 months later.

Results:

When the initial and post-therapy FFA and BSID-II scores received by patients in the training and the study group were compared, the training group showed a statistically significant improvement (P < 0.05).

Conclusion:

Oral motor therapy has a beneficial effect on feeding problems in children with CP.     

Improving upper limb motor functions through action observation treatment: a pilot study in children with cerebral palsy

Aim The aim of this randomized controlled trial was to assess whether action observation treatment may improve upper limb motor functions in children with cerebral palsy (CP). Method All children with CP admitted to our unit for rehabilitation from May 2009 to May 2010 were eligible. Inclusion criteria were age between 6 years and 11 years, an IQ of at least 70, and no major visual and/or auditory deficits. Fifteen children were enrolled and randomly assigned to either a case group (n=8; four males, four females; median age 7y 6mo) or control group (n=7; five males, two females; median age 8y). Six participants had left‐sided hemiplegia, six right‐sided hemiplegia, and three had tetraplegia; 10 were independent walkers. Those in the case group were asked to observe video clips showing daily age‐appropriate actions, and afterwards to imitate them. Participants in the control group were asked to observe video clips with no motor content and afterwards to execute the same actions as cases. The primary outcome measure was the Melbourne Assessment Scale. Children were scored twice at baseline (2wks apart), and at the end of treatment, by a physician blind to group assignment. Results At baseline groups did not differ on functional evaluation. After treatment, the functional score gain (Δ) was significantly different in the case and control groups (p=0.026). Interpretation The present results support the notion that action observation treatment can be an effective part of the rehabilitation programme in children with CP.     

Intrathecal baclofen in children with spastic cerebral palsy: a double-blind, randomized, placebo-controlled, dose-finding study

Intrathecal baclofen (ITB) therapy can be very effective in the treatment of intractable spasticity, but its effectiveness and safety have not yet been thoroughly studied in children with cerebral palsy (CP). The aims of this double-blind, randomized, placebo-controlled, dose-finding study were to select children eligible for continuous ITB infusion, to assess the effective ITB bolus dose, and to evaluate the effects, side effects, and complications. Outcome measures included the original Ashworth scale and the Visual Analogue Scale for individually formulated problems. We studied nine females and eight males, aged between 7 and 16 years (mean age 13y 2mo [SD 2y 9mo]). Twelve children had spastic CP and five had spastic-dyskinetic CP. One child was classified on the Gross Motor Function Classification System at Level III, two at Level I V, and 14 at Level V. The test treatment worked successfully for all 17 children with an effective ITB bolus dose of 12.5 microg in one, 20 microg in another, 25 microg in 10, and 50 microg in five children. ITB significantly reduced muscle tone, diminished pain, and facilitated ease of care. The placebo did not have these effects. Nine side effects of ITB were registered, including slight lethargy in seven children. Fourteen children had symptoms of lowered cerebrospinal fluid pressure. We conclude that ITB bolus administration is effective and safe for carefully selected children with intractable spastic CP.