Important Note: The following information is provided for your education. It should not be relied upon for personal diagnosis or treatment. If you believe that a particular therapy applies to you or someone you care about, be sure to consult a doctor before trying it.
   

On Downloading (Please Read Carefully)   
To download or print the Cerebral Palsy File, point your mouse to "File" in the top bar of your Explorer or Netscape window, and click once. Now click once on either "Save As" (download), or "Print" (print), and follow the appropriate prompts.

Latest Research on Cerebral Palsy
     
Dev Med Child Neurol. 2008 Feb;50(2):123-8.
Randomized trial of botulinum toxin injections into the salivary glands to reduce drooling in children with neurological disorders.
Reid SM, Johnstone BR, Westbury C, Rawicki B, Reddihough DS.
Developmental Disability Research, Murdoch Childrens Research Institute, University of Melbourne, Victoria, Australia.

The primary aim of this randomized, controlled trial was to assess the effectiveness of botulinum toxin A (BoNT-A) injections into the submandibular and parotid glands on drooling in children with cerebral palsy (CP) and other neurological disorders. Secondary aims were to ascertain the duration of any such effect and the timing of maximal response. Of the 48 participants (27 males, 21 females; mean age 11y 4mo [SD 3y 3mo], range 6-18y), 31 had a diagnosis of CP and 15 had a primary intellectual disability; 27 children were non-ambulant. Twenty-four children randomized to the treatment group received 25 units of BoNT-A into each parotid and submandibular gland. Those randomized to the control group received no treatment. The degree and impact of drooling was assessed by carers using the Drooling Impact Scale questionnaire at baseline and at monthly intervals up to 6 months postinjection/baseline, and again at 1 year. Maximal response was at 1 month at which time there was a highly significant difference in the mean scores between the groups. This difference remained statistically significant at 6 months. Four children failed to respond to the injections, four had mediocre results, and 16 had good results. While the use of BoNT-A can help to manage drooling in many children with neurological disorders, further research is needed to fully understand the range of responses.

-----

J Pediatr Orthop. 2008 Jan-Feb;28(1):91-6.
Upper limb function after intrathecal baclofen treatment in children with cerebral palsy.
Motta F, Stignani C, Antonello CE.
Department of Paediatric Orthopaedics, V Buzzi Children's Hospital, Milan, Italy. f.motta@icp.mi.it

BACKGROUND: The literature shows that intrathecal baclofen (ITB) treatment in patients with cerebral palsy (CP) is able to reduce spasticity. The purpose of this work is to evaluate the motor function of the upper limbs in patients with CP treated with ITB. METHODS: A consecutive series of 20 patients with spastic CP (mean age at implant, 11.4 years) implanted with pumps in our center was studied. These patients were classified using the Gross Motor Function Classification System.The patients were followed up over a 12-month period for assessment of the upper limb function with the Melbourne Assessment of Unilateral Upper Limb Function scale. RESULTS: The data show a reduction of upper limb spasticity in all 20 patients (P < 0.05). The Melbourne scale shows a statistically significant improvement of the total score (P < 0.05) and an improvement of the subskills of range of movement, target accuracy, and fluency. Twenty-five percent of patients showed a clinically significant improvement. CONCLUSION: The subjects with CP of different degrees of severity had an improvement in the quality of the upper limb function and showed overall satisfaction with the results achieved.The study also shows the importance of evaluating the quality of upper limb function in children with CP treated with ITB therapy.

-----

J Bone Joint Surg Am. 2008 Jan;90(1):23-33.
Does botulinum toxin a combined with bracing prevent hip displacement in children with cerebral palsy and "hips at risk"? A randomized, controlled trial.
Graham HK, Boyd R, Carlin JB, Dobson F, Lowe K, Nattrass G, Thomason P, Wolfe R, Reddihough D.
Departments of Orthopaedics, The Royal Children's Hospital, Flemington Road, Parkville, Victoria 3052, Australia. kerr.graham@rch.org.au

BACKGROUND: Cerebral palsy is the most common cause of childhood physical disability in developed countries, affecting two children per 1000 live births. Hip displacement affects about one-third of children with cerebral palsy and may result in pain, deformity, and impaired function. The prevention of hip displacement has not been studied in a randomized trial as far as we know. METHODS: A randomized, controlled trial was conducted to examine the effect of intramuscular injections of botulinum toxin A combined with use of a variable hip abduction brace on the progression of hip displacement in children with cerebral palsy. The patients in the treatment group received injections of botulinum toxin A to the adductor and hamstring muscles every six months for three years and were prescribed a hip abduction brace to be worn for six hours per day. In the control group, no hip bracing was used nor were injections performed. The primary outcome measure was hip displacement from the acetabulum as determined by serial measurements of the migration percentage. RESULTS: Ninety children with bilateral cerebral palsy and so-called hips at risk (a migration percentage of >10% but <40%) were entered into the study. Fifty-nine patients were boys, and the mean age was three years. Progressive hip displacement, as determined by serial measurements of the migration percentage, was found in both the treatment and control groups. The rate of hip displacement was reduced in the treatment group by 1.4% per year (95% confidence interval, -0.6% to 3.4%; p = 0.16) when weighted for the uncertainty in rates due to the differing numbers of migration percentage measurements per subject. CONCLUSIONS: There may be a small treatment benefit for the combined intervention of intramuscular injection of botulinum toxin A and abduction hip bracing in the management of spastic hip displacement in children with cerebral palsy. However, progressive hip displacement continued to occur in the treatment group, and our data do not support recommending this treatment.

-----

Dev Med Child Neurol. 2007 Dec;49(12):942-7.
Systematic review of hyperbaric oxygen therapy for cerebral palsy: the state of the evidence.
McDonagh MS, Morgan D, Carson S, Russman BS.
Department of Medical Informatics and Clinical Epidemiology, Oregon Health and Science University, Portland, Oregon 97239-3098, USA. mcdonagh@ohsu.edu

A systematic review of the evidence was conducted on the benefits and adverse effects of hyperbaric oxygen treatment (HBOT) for cerebral palsy (CP). Studies of any HBOT regimen in patients with CP were included except for case reports and case series. Electronic databases (e.g. MEDLINE, EMBASE), professional society databases, and reference lists were searched to identify studies. Study quality was assessed using predefined criteria relevant to the study design. Two randomized controlled trials and four observational studies were identified. Best evidence came from a randomized controlled trial which found that HBOT at 1.75 atmospheres (atm) and 1.3 atm of room air resulted in similar improvements in motor function (5-6%). Other outcomes also indicated no difference between the HBOT and room air. Observational studies reported improvements in motor function to a similar degree. Other evidence was insufficient to clarify the benefits and/or adverse effects of HBOT for CP. Both HBOT and pressurized room air resulted in improvements in motor function compared with baseline. Similar improvements were seen in the observational studies. Children undergoing HBOT were reported to experience adverse events, including seizures and the need for ear pressure equalization tube placement, but the incidence was unclear. Future research is needed to determine the efficacy of pressurized room air or non-pressurized oxygen in equivalent amounts by mask, compared with standard treatments.

-----

Disabil Rehabil. 2007 Dec 15;29(23):1813-22.
Botulinum toxin A in the management of focal muscle overactivity in children with cerebral palsy.
Gibson N, Graham HK, Love S.
Princess Margaret Hospital, Perth.

Cerebral palsy comprises a heterogenous group of neurological disorders representing a continuum of pathologies and clinical phenotypes. Although cerebral palsy is not a focal disorder, it is appropriate to treat identified focal problems as long as the intervention is goal directed. This paper reviews principles of managing muscle imbalance in the growing, changing child using a range of complementary, carefully timed intervention options. Over the past two decades these options have increasingly included intramuscular injection of botulinum toxin-A to manage focal spasticity and dystonia. The predictable movement patterns and postures characteristic of spasticity enable a systematic clinical rationale to be developed to determine the role of botulinum toxin-A to manage the spasticity and subsequently improve function. The management of dystonia with botulinum toxin-A is more complex, particularly when spasticity and dystonia are present in combination. An active therapy programme remains central to the management of movement problems in the child with cerebral palsy, including task-specific motor training, maintenance of muscle lengths, and improved muscle strength, aiming to achieve carry over improvements that persist beyond the pharmacological effects of the botulinum toxin-A. A series of case examples are presented to highlight the role of botulinum toxin-A in the overall management of the child with focal muscle hyperactivity.

-----

Phys Occup Ther Pediatr. 2007;27(4):43-65.
Group-based task-related training for children with cerebral palsy: a pilot study.
Crompton J, Imms C, McCoy AT, Randall M, Eldridge B, Scoullar B, Galea MP.
Physiotherapy Department, Royal Children's Hospital, Melbourne.

This pilot study examined the feasibility of a 6-week group-based, task-related training program in children 6 to 14 years-old with spastic diplegia. Eight children were randomized to lower limb training and seven to an upper limb dexterity training program. There were no statistically significant differences in lower limb outcomes between children who received the lower limb training and children who received the upper limb dexterity training after completion of the interventions or at a 6-week follow-up. Children who received the upper limb training demonstrated a greater improvement on measures of manual dexterity compared with children who received the lower limb training program. Children who received the lower limb training demonstrated a trend toward walking a longer distance in 10 minutes immediately following intervention, that was not sustained at the 6-week follow-up. The group setting appeared to motivate the children and enhance their participation in the training programs. The pilot study provides data for the calculation of effect size and sample estimates for future studies.

-----

J Hand Surg [Am]. 2007 Nov;32(9):1418-22.
Surgical treatment of swan-neck deformity in hemiplegic cerebral palsy.
Carlson MG, Gallagher K, Spirtos M.
Hospital for Special Surgery, New York, NY 10021, USA. carlsonm@hss.edu

PURPOSE: Previously described surgical treatments for dynamic swan-neck deformity in cerebral palsy are technically difficult and time consuming. Typically only a few fingers could be addressed at one sitting, and postoperative swelling and stiffness were often incurred. An easy procedure of central slip tenotomy is described that allows for multiple fingers to be addressed, with minimal postoperative morbidity. METHODS: Fifteen patients (33 fingers) with hemiplegic cerebral palsy and dynamic swan-neck deformities of their fingers were treated. Only swan-neck deformities of greater than 20 degrees were considered for treatment. Pre- and postoperative measurements of swan-neck deformity were recorded. A central slip tenotomy was performed through a transverse incision proximal to the proximal interphalangeal joint. The joint was pinned in 10 degrees of flexion for 4 weeks, and then active extension was allowed to 10 degrees short of full extension and blocked with an oval-8 splint. Average patient age was 16 years (range 5-44 years). All patients had concurrent procedures performed on the extremity. Average follow-up evaluation was 23 months (+/-12 months). RESULTS: Improvement in dynamic swan-neck deformity averaged 32 degrees . Preoperative swan-neck deformity averaged 38 degrees and postoperative swan-neck deformity averaged 6 degrees . No swan-neck deformity was worse than its preoperative state, and no patient developed boutonniere deformity. No patient lost active or passive flexion after the procedure. All patients would repeat the procedure. CONCLUSION: Central slip tenotomy is a reliable treatment for dynamic swan-neck deformity in cerebral palsy in patients without dynamic metacarpophalangeal flexion deformity. Because of the simplicity of the procedure, it can easily be added to the treatment of the entire upper extremity in cerebral palsy.

-----

Dev Med Child Neurol. 2007 Nov;49(11):830-8. Comment in:
Dev Med Child Neurol. 2007 Nov;49(11):806.
Efficacy of a hand-arm bimanual intensive therapy (HABIT) in children with hemiplegic cerebral palsy: a randomized control trial.
Gordon AM, Schneider JA, Chinnan A, Charles JR.
Division of Physical Therapy, Emory University School of Medicine, Atlanta, GA, USA. ag275@columbia.edu

Children with hemiplegic cerebral palsy (CP) have impairments in bimanual coordination above and beyond their unilateral impairments. Recently we developed hand-arm bimanual intensive therapy (HABIT), using the principles of motor learning, and neuroplasticity, to address these bimanual impairments. A single-blinded randomized control study of HABIT was performed to examine its efficacy in children with hemiplegic CP with mild to moderate hand involvement. Twenty children (age range 3 y 6 mo-15 y 6 mo) were randomized to either an intervention (n=10: seven males, three females; mean age 8 y 7 mo, SD 4 y) or a delayed treatment control group (n=10: seven males, three females; mean age 6 y 10 mo, SD 2 y 4 mo). Children were engaged in play and functional activities that provided structured bimanual practice 6 hours per day for 10 days. Each child was evaluated immediately before and after the intervention, and again at 1-month post-intervention. Children in the intervention group demonstrated improved scores on the Assisting Hand Assessment, increased involved extremity use measured using accelerometry and a caregiver survey, bimanual items of the Bruininks-Oseretsky Test of Motor Proficiency, and the simultaneity of completing a draw-opening task with two hands (p<0.05 in all cases). The results suggest that for this carefully selected subgroup of children with hemiplegic CP, HABIT appears to be efficacious in improving bimanual hand use.

-----

Dev Med Child Neurol. 2007 Nov;49(11):823-9.
Repeat injection of botulinum toxin A is safe and effective for upper limb movement and function in children with cerebral palsy.
Lowe K, Novak I, Cusick A.
Department of Paediatric Rehabilitation, Sydney Children's Hospital and University of New South Wales, Randwick, Australia. kev.lowe@unsw.edu.au

The efficacy of repeated botulinum toxin A (BTX-A) injections in two and three dose regimes, together with occupational therapy, on upper limb movement and function, was studied using an evaluator blinded, randomized, controlled two-group trial. Forty-two children (31 males, 11 females; range 2-8 y, mean 4 y [SD 1 y 7 mo]) with hemiplegic cerebral palsy (Gross Motor Function Classification System Level I) longitudinally participated for 30 months, with the first 6 months reported earlier (Lowe et al. 2006). The BTX-A group (n=21) received three injections (0, 6, and 18 mo), while the delayed group had two (6 and 18 mo; dose 0.5-2.1 units/kg, mean 1.5 [SD 0.18]; dilution 100 units/0.5 ml). At 30 months, no difference existed between groups on any standardized measures. First and second injections showed significant treatment effect sizes, on Quality of Upper Extremity Skills Test (5.5 p=0.01: 4.5 p=0.03); parent Goal Attainment Scaling (GAS; 3.5 p=0.02: 3.9 p=0.01; therapist GAS 7.8 p=0.00: 4.0 p=0.03); Canadian Occupational Performance Measure (performance 0.4 p=0.05: 0.4 p=0.02; satisfaction 0.4 p=0.05: 0.37 p=0.08); and Pediatric Evaluation of Disability Inventory functional skills (1.8 p=0.00: 2.3 p=0.04). BTX-A was not linked to adverse events, suggesting repeated upper limb injections in children with hemiplegia receiving occupational therapy were safe and effective for improvement of movement and function.

-----

Dev Med Child Neurol. 2007 Sep;49(9):654-9.
Intrathecal baclofen in children with spastic cerebral palsy: a double-blind, randomized, placebo-controlled, dose-finding study.
Hoving MA, van Raak EP, Spincemaille GH, Palmans LJ, Sleypen FA, Vles JS; on behalf of the Dutch Study Group on Child Spasticity.
Department of Neurology, University Hospital Maastricht, Maastricht, The Netherlands.

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 12.5mug in one, 20mug in another, 25mug in 10, and 50mug 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.

-----

J Pediatr Orthop. 2007 Sep;27(6):668-70.
Effects of early weight bearing on the functional recovery of ambulatory children with cerebral palsy after bilateral proximal femoral osteotomy.
Schaefer MK, McCarthy JJ, Josephic K.
From the Shriners Hospitals for Children, Philadelphia, Pennsylvania.

This study evaluates the effects of early versus delayed weight bearing on the functional recovery of ambulatory children with cerebral palsy (CP) after they have undergone proximal femoral osteotomies (PFOs). We retrospectively reviewed the cases of 25 ambulatory children with CP who underwent PFO to correct excessive hip internal rotation and intoeing. Thirteen children were permitted to weight-bear as tolerated (WBAT) immediately after surgery, and 12 were placed on non-weight bearing restrictions for 3 to 7 weeks (mean +/- SD, 30 +/- 6.7 days). There were no major complications. The children in the WBAT group initiated standing 26 days sooner and returned to baseline walking almost 4 months sooner than those on non-weight bearing restrictions. Pain at 8 days postoperatively was significantly less for the WBAT group, but pain at the time of initial standing and walking was not significantly different between groups. In conclusion, early mobilization after PFOs in children with CP is safe, with reduced recovery time, and with decreased pain.

-----

J Pediatr Orthop. 2007 Sep;27(6):658-667.
Kinematic and Kinetic Outcomes After Identical Multilevel Soft Tissue Surgery in Children With Cerebral Palsy.
Adolfsen SE, Ounpuu S, Bell KJ, Deluca PA.
From the *Department of Orthopaedics and Rehabilitation, Yale-New Haven Hospital, and †Center for Motion Analysis, Connecticut Children's Medical Center, University of Connecticut School of Medicine, CT.

This study evaluates the outcomes of multilevel soft tissue surgery in 31 ambulatory children (n = 39 sides) with cerebral palsy. All children had undergone rectus femoris transfer, hamstring lengthening, and gastrosoleus lengthening for the purpose of correcting sagittal plane abnormalities. There were no simultaneous bony surgeries. Preoperative and postoperative evaluation consisted of clinical assessment and gait analysis, including 3-dimensional kinematics and kinetics. Results demonstrated improvements in knee and ankle function. At the knee, there was a decrease in mean flexion at initial contact (from 31 degrees [SD, +/-8 degrees] to 21 degrees [SD, +/-10 degrees]) and in stance (mean stance, 22 degrees [SD, +/-12 degrees] to 16 degrees [SD, +/-11 degrees]) associated with a decreased mean internal extensor moment in stance (from 0.09 Nm/kg [SD, +/-0.24 Nm/kg] to -0.03 [SD, +/-0.22 Nm/kg]). At the same time, knee flexion was preserved in swing and occurred earlier. At the ankle, mean dorsiflexion improved at the time of examination (from 8 degrees [SD, +/-9 degrees] to 14 degrees [SD, +/-11 degrees] with the knee in extension), in terminal stance (peak from 7 degrees [SD, +/-9 degrees] to 12 degrees [SD, +/-8 degrees]), and in swing. Peak ankle power generation in stance was preserved and shifted later in stance toward push-off, with no functional weakening of the ankle plantar flexors. A longer-term assessment of a subset of patients with a second postoperative gait analysis at a mean of 4 years after surgery showed that gains measured at 1 year were maintained during the longer term. A subgroup demonstrating a jump knee gait pattern (as defined by excessive knee flexion at initial contact followed by rapid knee extension to full knee extension in midstance) had a tendency to go into knee hyperextension in stance with resultant net knee flexor moment after surgery. This raises concern about the indications for hamstring lengthening in this patient group.

-----

J Pediatr Orthop. 2007 Sep;27(6):653-657.
Health-Related Quality of Life Outcomes Improve After Multilevel Surgery in Ambulatory Children With Cerebral Palsy.
Cuomo AV, Gamradt SC, Kim CO, Pirpiris M, Gates PE, McCarthy JJ, Otsuka NY.
From the *University of California, Los Angeles; †Department of Orthopaedic Surgery, Harbor-University of California, Los Angeles, Torrance, CA; ‡Shriners Hospital for Children-Los Angeles, CA; §Shriners Hospital for Children-Shreveport, LA; and ?Shriners Hospital for Children-Philadelphia, PA.

BACKGROUND:: Studies evaluating multilevel surgery to treat spastic deformity and functional deficits in cerebral palsy (CP) usually focus on data from instrumented gait analysis and clinical examination without examining functional and health-related quality of life (HRQOL) outcomes. Recently, outcome measures for well-being in children with a variety of musculoskeletal disorders have also been validated specifically for CP. Therefore, this study aimed to investigate the impact of multilevel surgery on the function and HRQOL in a group of ambulatory children with CP. METHODS:: In a multicenter prospective trial, 57 ambulatory children with CP, mean age 9.5 years, underwent multilevel soft tissue surgery to correct sagittal imbalance. Validated clinical outcome measures for HRQOL were administered preoperatively and postoperatively with an average follow-up time of 15.2 months. The functional and psychosocial components of the Pediatric Outcomes Data Collection Instrument (PODCI), Pediatric Quality of Life Questionnaire (PedsQL), and the Functional Assessment Questionnaire Walking Score were used. RESULTS:: Significant improvements in outcome scores occurred postoperatively in the following: PedsQL parent-total (17.6%; P < 0.001) and parent-physical sections (25.0%; P < 0.001), the Functional Assessment Questionnaire Walking Score (15.3%; P < 0.001), and the PODCI sections for transfers and basic mobility (15.8%; P < 0.001), sports and physical function (23.9%; P = 0.012), and global (12.9%; P < 0.001). Improvements also occurred in the PedsQL child-total (8.4%; P = 0.104) and child-physical sections (8.6%; P = 0.189), but these were not statistically significant. There were no significant changes in the PODCI parent-derived pain (-3.2%; P = 0.504) and happiness sections (1.9%; P = 0.645). CONCLUSIONS:: Multilevel surgery in ambulatory patients with CP improves function and HRQOL. However, improved functional well-being does not imply improved psychosocial well-being, and patients and their families should be counseled accordingly. LEVEL OF EVIDENCE:: Therapeutic Level II. See Instructions to Authors for a complete description of levels of evidence.

-----

Acta Neurochir Suppl. 2007;97(Pt 1):193-203.
Surgical management of spasticity of cerebral origin in children.
Sgouros S.
Department of Neurosurgery, Birmingham Children's Hospital, Birmingham, UK. S.Sgouros@bham.ac.uk

In children, spasticity is commonly seen in the context of cerebral palsy
(CP), but also following head injury, cerebral infarct or other brain insults. CP is a wide term used to describe a constellation of symptoms that characterise the physical impairment of movement due to abnormal brain development. The management of spasticity is tailored according to the clinical picture of the child. Ambulatory mild spastic diplegics tend to reach the maximum of their disability in the first few years of life, and change little after the age of 5-7 years. Such patients who are between 3-5 years and who attempt to mobilise with walking frames are often good candidates for either dorsal rhizotomy or intrathecal baclofen (ITB) administration with the implantation of an indwelling pump. Non-ambulatory mild spastic diplegics and spastic quadriplegics have more profound spasticity, painful spasms, orthopaedic deformities, and difficulties with daily care and posture. ITB has become established as the first line of surgical treatment for these patients. In the last decade, there has been a definite trend away from ablative treatments and towards reversible stimulation and infusion systems. Current pumps have practical limitations but, in the next decade, it is anticipated that technological improvements will render the pumps more patient friendly.

-----

J Pediatr. 2007 Aug;151(2):161-6. Epub 2007 Jun 22.
Growth and nutritional status in residential center versus home-living children and adolescents with quadriplegic cerebral palsy.
Henderson RC, Grossberg RI, Matuszewski J, Menon N, Johnson J, Kecskemethy HH, Vogel L, Ravas R, Wyatt M, Bachrach SJ, Stevenson RD.
Department of Orthopaedics, University of North Carolina, Chapel Hill, North Carolina 27599, USA. rchh@med.unc.edu

OBJECTIVE: To describe growth and nutrition in nonambulatory youth (<19 years of age) with cerebral palsy (CP) living in residential centers compared with similar youth living at home. STUDY DESIGN: A multicenter, cross-sectional, single observational assessment of 75 subjects living in a residential care facility compared with 205 subjects living at home. Primary outcome measures included anthropometric measures of height, weight, triceps, and subscapular skinfolds, and mid-upper-arm muscle area. Z scores were calculated from reference values for healthy children. Age, use of a feeding tube, and Gross Motor Functional Classification System (GMFCS) level were included as important confounders. RESULTS: Use of a feeding tube was associated with higher skinfold Z scores, and a significantly higher percentage of the residential subjects had a feeding tube. Height, weight, and arm-muscle area Z scores all diverged (negatively) from reference values with age, and the residential subjects were on average older than the home-living subjects. After controlling for age, GMFCS level and use of a feeding tube, residential living was associated with significantly greater weight, height, skinfold thicknesses, and mid-arm muscle area Z scores. CONCLUSION: Poor growth and nutrition in children with CP is a prevalent, important, and complex problem. Although factors intrinsic to the condition of CP likely play a significant role, it is also clear that environmental factors, including the living situation of the child, can have an impact.

-----

Am J Occup Ther. 2007 Jul-Aug;61(4):463-8.
A pilot study on the impact of occupational therapy home programming for young children with cerebral palsy.
Novak I, Cusick A, Lowe K.
Cerebral Palsy Institute, PO. Box 184, Brookvale NSW 2100 Sydney, Australia. inovak@tscnsw.org.au

Occupational therapy home programs are a common approach used to provide interventions for children with cerebral palsy, but there is little evidence to demonstrate the effectiveness of such programs. This single-group pretest-posttest design pilot study evaluated the impact of an occupational therapy home program implemented with 20 children who had spastic hemiplegic cerebral palsy (ages 2-7 years, mean 3.8). We measured impact using Goal Attainment Scaling (GAS), the Pediatric Evaluation of Disability Inventory (PEDI), and the Quality of Upper Extremity Skills Test (QUEST). We measured participation amount through a parent self-report log. Significant changes following intervention occurred in scores on the GAS, the PEDI Functional Skills and Caregiver Assistance Scales, and the QUEST, but has found no relationship between participation amount and outcome using the same measures. These promising results suggest that further investigation of the impact of occupational therapy home programs is warranted.

-----

Zhongguo Zhen Jiu. 2007 Jun;27(6):395-7.
[Scalp-acupuncture plus body-acupuncture for treatment of spastic cerebral palsy and its effects on bone density and trace elements in the diseased children]
[Article in Chinese]
Huang M, Fan HF, Lei SE.
Department of Human Sciences, Hebei Sports College, Shijiazhuang 050041, China. huangma680211@163.com

OBJECTIVE: To observe therapeutic effect of scalp-acupuncture plus body-acupuncture on spastic cerebral palsy and its effects on bone density and blood trace elements Ca, Cu, Zn, and Fe in the children with spastic cerebral palsy. METHODS: Eighty children of spastic cerebral palsy were randomly divided into an observation group and a control group, 40 cases in each group. The observation group were treated with scalp-acupuncture plus body-acupuncture combined with body therapy and performance therapy, and the control group with simple body therapy and performance therapy, once each day, for 3 courses, 30 days constituting one course. Changes of bone density and the trace elements were compared before and after treatment. RESULTS: The total effective rate was 87.5% in the observation group and 67.5% in the control group with a significant difference between the two groups (P < 0.05); after treatment, the bone density and blood Ca, Cu, Zn and Fe contents in the two groups significantly increased (P < 0.05, P < 0.01) with the observation group being superior to the control group (P < 0.05, P < 0.01). CONCLUSION: The scalp-acupuncture plus body-acupuncture combined with body therapy and performance therapy can improve bone density and contents of trace elements in the children of spastic cerebral palsy, and has a definite therapeutic effect on spastic cerebral palsy.

-----

J Child Neurol. 2007 May;22(5):530-7.
Prospective open-label clinical trial of trihexyphenidyl in children with secondary dystonia due to cerebral palsy.
Sanger TD, Bastian A, Brunstrom J, Damiano D, Delgado M, Dure L, Gaebler-Spira D, Hoon A, Mink JW, Sherman-Levine S, Welty LJ; Child Motor Study Group.
Stanford University, Stanford, California, USA. sanger@stanford.edu

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.

-----

ANZ J Surg. 2007 May;77 Suppl 1:A34.
Hs03 botulinum toxin a in the upper limb in cerebral palsy.
Johnstone BR, Coombs C, McCombe D, Duncan J.
Royal Childrens Hospital, Victoria, Australia.

Purpose To evaluate patients with cerebral palsy treated with botulinum toxin A injections to assist with the management of contracted muscles and joints as well as co-contraction. Methods Since 1998, 40 limbs have been treated. The average age was 14 years (range 4 to 33 years) and the average dose given was 107 units (range 50 to 200 units). Digital flexors were injected in 26 limbs, elbow flexors in 18, wrist flexors in 17, thumb adductors in 13, pronator teres in 9, intrinsics in 3, shoulder abductors in 2 and ECU in one limb. All patients were injected under a general anaesthetic, allowing for an assessment of fixed contractures. Padded plaster casts were applied, putting the injected muscles on full stretch before the reversal of anaesthesia and were maintained for approximately 3 weeks. Thermoplastic splits were then wore 23 hrs per day for a further three weeks. Splints were serially modified to achieve progressively more extension as the flexion contractures were corrected. Simultaneous surgical procedures such as tendon lengthening and transfers were performed in 14 limbs. Results The results in the elbow flexors were disappointing. The finger, thumb and wrist flexors have responded extremely well, despite fixed flexion deformities being documented under anaesthesia in the majority of patients. Conclusion It is estimated that the muscle bellies have been elongated by 3 to 4 cm either by the lengthening of, or addition to the sarcomeres. The results in these patients are vastly superior to that which could be obtained surgically.

-----

Dev Med Child Neurol. 2007 May;49(5):390-4.
A descriptive analysis of studies on behavioural treatment of drooling (1970-2005).
Van der Burg JJ, Didden R, Jongerius PH, Rotteveel JJ.
Department of Special Education, Radboud University Nijmegen, The Netherlands. j.vanderburg@pwo.ru.nl

A descriptive analysis was conducted on studies on the behavioural treatment of drooling (published between 1970 and 2005). The 17 articles that met the inclusion criteria described 53 participants (mean age 14y 7mo, [SD 4y 9mo]; range 6-28y). Sex of 87% of the participants was reported: 28 male, 18 female. For 60% of the participants the degree of learning disability was reported, varying from severe/profound (n=24, 75%), moderate (n=4, 13%), to mild (n=2, 6%), while two participants (6%) had no learning disabilities. Forty-two participants (79%) were diagnosed with cerebral palsy. Behavioural procedures included instruction, positive and negative reinforcement, overcorrection and restitution, verbal and automatic cueing, and/or self-management. Effective behavioural procedures are reported in children with and without learning disability and/or motor impairment. Even participants with profound learning disability may benefit from behavioural intervention. However, the evidence base in terms of number of studies in this area is limited. Fifteen studies used a single participant design; two studies implemented an experimental-comparison group design. Some of these studies were poorly designed and methodological flaws were identified. Therefore, conclusions about efficacy of behaviour therapy for drooling and/or best practice cannot be drawn, although our analysis suggests that this approach is promising. However, future research on this topic is needed. After years of research focused on medical treatment, the option of behavioural treatment to reduce drooling should be reconsidered in relation to the medical management of this problem.

-----

Dev Med Child Neurol. 2007 May;49(5):385-9.
Does surgical management of the hand in children with spastic unilateral cerebral palsy affect functional outcome?
van Munster JC, Maathuis KG, Haga N, Verheij NP, Nicolai JP, Hadders-Algra M.
Centre for Rehabilitation, University Medical Center Groningen, Groningen, The Netherlands.

The aim of this review was to examine the literature on the effects of surgery of the spastic hand in children with cerebral palsy on functional outcome and muscle coordination. We performed a search of the relevant literature in Medline, Embase, and Biological Abstracts from 1966 to June 2006. The search resulted in eight studies on the effect of surgery on functional outcome and three studies on the effect of surgery on muscle coordination. Heterogeneity in outcome measures precluded meta-analysis. The studies revealed that -- at the level of impairment -- surgery has a positive effect on supination and dorsiflexion of the wrist. At the level of function, surgery might improve grip strategy and induce an increase of the repertoire of grips and spontaneous use of the hand. The evidence for the functional effects is, however, limited. Whether the possibly improved function is mediated by alterations in muscle coordination patterns remains unclear. The muscle coordination studies provided inconclusive results. We concluded that surgery improves the position of the hand and there are indications that it might improve hand function. Future research should address the question: does surgery improve hand function and, if so, is this due solely to a better hand position or does change in muscle coordination play an additional role?

-----

Dev Med Child Neurol. 2007 May;49(5):331-7.
A randomized controlled trial comparing botulinum toxin A dosage in the upper extremity of children with spasticity.
Kawamura A, Campbell K, Lam-Damji S, Fehlings D.
Department of Paediatrics, Bloorview Research Institute, Bloorview Kids Rehab, University of Toronto, Toronto, ON, Canada.

This study compared the effects of low and high doses of botulinum toxin A (BTX-A) to improve upper extremity function. Thirty-nine children (22 males, 17 females) with a mean age of 6 years 2 months (SD 2y 9mo) diagnosed with spastic hemiplegia or triplegia were enrolled into this double-blind, randomized controlled trial. The high-dose group received BTX-A in the following doses: biceps 2U/kg, brachioradialis 1.5U/kg, common flexor origin 3U/kg, pronator teres 1.5U/kg, and adductor/opponens pollicis 0.6U/kg to a maximum of 20U. The low-dose group received 50% of this dosage. Outcomes were measured at baseline and at 1 and 3 months after injection, and results were analyzed with a repeated-measures analysis of variance. There was no significant difference between the low-dose and high-dose groups in upper extremity function over the 3-month period as measured by the Quality of Upper Extremity Skills Test (F[1,37]=0.18, p=0.68). There was no difference between the groups in the Pediatric Evaluation of Disability Inventory Self Care Domain (F[1,37]=0.05, p=0.83). Although grip strength decreased over the 3-month period, there was no difference between groups (F[1,32]=0.45, p=0.51). These findings indicate that there is no difference in hand and arm function between a low dose and a high dose of BTX-A at 1 and 3 months after injection. This information can be used to guide dosage of BTX-A for the management of upper extremity spasticity in children.

-----

Arch Dis Child. 2007 May 2; [Epub ahead of print]
Selective dorsal rhizotomy for children with cerebral palsy: The Oswestry experience.
Cole GF, Farmer SE, Roberts AP, Stewart C, Patrick JH.
ORLAU, United Kingdom.

BACKGROUND: Although three randomised control trials have shown that SDR reduces spasticity in children with cerebral palsy, a meta-analysis of the results demonstrated that the procedure conferred only small functional benefit on the patient. AIM: To determine whether applying strict criteria for patient selection as practised in Oswestry leads to improved outcomes, using gait analysis as an outcome measure. METHODS: Ambulant children with cerebral palsy were selected for selective dorsal rhizotomy using very strict clinical criteria and instrumented gait analysis was used as the main outcome measure. RESULTS: Of 53 children referred for the procedure only 19 (35%) fulfilled our strict criteria for selection. These children underwent surgery and when pre and post SDR data were compared they showed improvement in cosmesis of gait, clinical examination, temporal, kinetic and kinematic parameters of gait. Post SDR the children walked, on average, 0.15m/s faster, with a step length improvement of 0.11m. Changes were seen at hip, knee and ankle, but those at the knee were most marked. A 0.3 grade improvement in knee extensor power on clinical examination led to a 13 degrees improvement in stance phase knee extension. Knees also became less stiff, with an 82 degrees /s improvement in the rate of flexion into swing phase. A functional tool (GMFCS) applied retrospectively also confirmed post operative improvement, with 15 of the 19 children improving by at least one level. CONCLUSION: Application of strict selection criteria when considering children for SDR leads to encouraging results as demonstrated by gait analysis and other measures.

-----

Phys Ther. 2007 May 1; [Epub ahead of print]
Effect of Seat Surface Inclination on Postural Control During Reaching in Preterm Children With Cerebral Palsy.
Hadders-Algra M, van der Heide JC, Fock JM, Stremmelaar E, van Eykern LA, Otten B.
Neurology, Department of Developmental Neurology, University Medical Centre Groningen, University of Groningen, Hanzeplein 1, 9713 GZ Groningen, the Netherlands.

BACKGROUND AND PURPOSE:/b> Because it is debatable whether seat surface inclination improves motor function in children with cerebral palsy (CP), the effect of seat surface tilting on postural control and quality of reaching was studied. SUBJECTS:/b> The subjects were 58 children with CP aged 2 to 11 years (34 with unilateral spastic CP, 24 with bilateral spastic CP). METHODS:/b> During the task of reaching movements, surface electromyographic and kinematic data were recorded for posture and reaching with the dominant arm in 3 sitting conditions: horizontal seat surface, seat surface tilted forward 15 degrees, and seat surface tilted backward 15 degrees. RESULTS: /b> In the children with unilateral spastic CP, forward tilting improved postural efficiency and quality of reaching. In the children with bilateral spastic CP, both forward and backward tilting of the seat surface was associated with more postural instability and did not affect the quality of reaching. DISCUSSION AND CONCLUSION:/b> The results suggest that, in terms of postural control and quality of reaching, children with unilateral spastic CP benefit from a forward-tilted position and children with bilateral spastic CP benefit from a horizontal sitting position.

-----

Health Technol Assess. 2007 May;11(16):1-90.
Additional therapy for young children with spastic cerebral palsy: a randomised controlled trial.
Weindling AM, Cunningham CC, Glenn SM, Edwards RT, Reeves DJ.
School of Reproductive and Developmental Medicine, University of Liverpool, UK.

OBJECTIVES: To investigate whether, in the short and medium term, additional support by (a) a physiotherapy assistant improved physical function in young children with spastic cerebral palsy and (b) a family support worker improved family functioning. DESIGN: This was a multi-centre randomised controlled trial (RCT) with blinded assessments and a cost-effectiveness analysis. The children studied had spastic cerebral palsy that was the consequence of perinatal adversity. All were less than 4 years old on entry to the study. SETTING: In the child development centre and in the home. PARTICIPANTS: Seventy-six families completed the intervention period. Forty-three families were reassessed 6 months after the end of the intervention and 34 of these after a further 6-month period. INTERVENTIONS: Randomisation was to: (a) a group who received extra physiotherapy from a physiotherapy assistant; (b) a group who received standard physiotherapy; and (c) a group where the child received standard physiotherapy and the family was also visited by a family support worker. Children in all groups continued to receive standard physiotherapy in addition to the study interventions. MAIN OUTCOME MEASURES: The child outcome measures were motor functioning, developmental status and adaptive functioning. The family outcome measures were self-reported maternal stress, level of family needs and parental satisfaction. RESULTS: There was no evidence that additional physical therapy for 1 hour per week for 6 months by a physiotherapy assistant improved any child outcome measure in the short or medium term. Intervention by a family support worker did not have a clinically significant effect on parental stress or family needs. Over the 6-month period the total cost of services for each child ranged from pound250 to pound6750, with higher costs associated with children with more severe impairments. No significant relationship was found between measures of intensity of services received by the children and families and the main outcome measures. Low-functioning children, in terms of both motor and cognitive function, were more likely to receive more services in terms of range and frequency. Parents generally reported high satisfaction ratings after all interventions and some stated that the interventions had benefited the child and/or the family. There was therefore a discrepancy between the perceptions of these parents and the objective, quantitative measurements. The family support workers identified a small number of families who were experiencing considerable family problems, but who had not been referred for appropriate support by any other agency. CONCLUSIONS: The findings of this study provide support for the current literature that there was no evidence that additional intervention (in this case by a physiotherapy assistant or family support worker) helped the motor or general development of young children with spastic cerebral palsy. Nor was there any quantitative evidence that providing extra family support helped levels of parental stress and family needs. The implication was that the provision of extra physical therapy does not necessarily improve the motor function of a young child with cerebral palsy and additional family support should not automatically be assumed to be beneficial. In addition, no significant association was found between the intensity of the local services provided and any outcome measure, other than a slight association with lowered family needs. The provision of local services was related to the severity of the child's impairments and not to family difficulties. A small group of families with complex family problems needed more service input. There was a wide range in the costs of services. Research is needed to examine what 'sufficient' levels of provision or therapy might be for which children and which families. A time series of different levels of input and outcomes would provide valuable information for practitioners. It is also recommended that future assessments of therapies of this type adopt a similar multifaceted approach, which is likely to be more suitable than a simple RCT for the evaluation of clinical interventions where the effects are complex. The most appropriate measures of outcome should be used, including assessment of provision of information and emotional support for families.

-----

Pediatrics. 2007 May;119(5):e1149-58. Epub 2007 Apr 23.
Upper-limb botulinum toxin A injection and occupational therapy in children with hemiplegic cerebral palsy identified from a population register: a single-blind, randomized, controlled trial.
Russo RN, Crotty M, Miller MD, Murchland S, Flett P, Haan E.
Flinders University Department of Rehabilitation and Aged Care, Repatriation General Hospital, Daw Park, South Australia, Australia. ray.russo@cywhs.sa.gov.au

OBJECTIVES: The purpose of this work was to assess the effect of botulinum toxin A and occupational therapy compared with occupational therapy alone on body structure, activities participation, and self-perception in a sample of children (aged 3-16 years) with hemiplegic cerebral palsy recruited from a statewide register. PATIENTS AND METHODS: Participants of this single-blind, randomized, controlled trial identified from a population-based cerebral palsy register received either an individually prescribed and localized injection of botulinum toxin A with 4 sessions of occupational therapy over 4 weeks (intervention) or occupational therapy alone (control). Outcomes were assessed from 2 domains of the World Health Organization International Classification of Functioning, Disability, and Health: body structure (Modified Ashworth Scale and Tardieu Scale) and activities participation (Assessment of Motor and Process Skills, Goal Attainment Scale, Pediatric Evaluation of Disability Inventory, and Pediatric Quality of Life Inventory). Self-perception was also measured. RESULTS: All of the participants (intervention: n = 21; control: n = 22) provided data at baseline and 3 and 6 months. Mean age was 8.6 years; 23 were boys and 20 were girls. At 3 months, children allocated to receive the intervention performed significantly better in terms of body structure and activities participation. They reported improvements in self-perception for the global self-worth domain. At 6 months, the differences between the intervention and control groups persisted for the measures of body structure but not for activities participation or self-perception. CONCLUSION: Botulinum toxin A injection combined with a low-intensity occupational therapy program achieves significant improvements in body structure, activity participation, and self-perception.

-----

Phys Occup Ther Pediatr. 2007;27(2):5-23.
Horseback riding as therapy for children with cerebral palsy: is there evidence of its effectiveness?
Snider L, Korner-Bitensky N, Kammann C, Warner S, Saleh M.
, School of Physical and Occupational Therapy, 3654 Promenade Sir William Osler, Montreal, Quebec, Canada. laurie.snider@mcgill.ca

A systematic review of the literature on horseback riding therapy as an intervention for children with cerebral palsy (CP) was carried out. The terms horse, riding, hippotherapy, horseback riding therapy, equine movement therapy, and cerebral palsy were searched in electronic databases and hand searched. Retrieved articles were rated for methodological quality using PEDro scoring to assess the internal validity of randomized trials and the Newcastle Ottawa Quality Assessment Scale to assess cohort studies. PICO questioning (Population, Intervention, Comparison, and Outcomes) was used to identify questions of interest to clinicians for outcomes within the context of the International Classification of Functioning, Disability and Health. Levels of evidence were then accorded each PICO question. There is Level 2a evidence that hippotherapy is effective for treating muscle symmetry in the trunk and hip and that therapeutic horseback riding is effective for improved gross motor function when compared with regular therapy or time on a waiting list. No studies addressed participation outcomes.

-----

Cochrane Database Syst Rev. 2007 Apr 18;(2):CD004149.
Constraint-induced movement therapy in the treatment of the upper limb in children with hemiplegic cerebral palsy.
Hoare B, Wasiak J, Imms C, Carey L.

BACKGROUND: Children with hemiplegic cerebral palsy learn strategies to manage daily tasks (for example play) using one hand and often the affected limb is disregarded or not used. Constraint-induced movement therapy (CIMT) is emerging as a treatment approach for use with children with hemiplegic cerebral palsy. It aims to increase spontaneous use of the affected upper limb and thereby limit the effects of developmental disregard. CIMT is based on two fundamental principles: constraint of the non-affected limb and massed practice of therapeutic tasks with the affected limb. OBJECTIVES: The objective of this review was to evaluate the effectiveness of CIMT, modified CIMT or Forced Use in the treatment of the affected upper limb in children with hemiplegic cerebral palsy. SEARCH STRATEGY: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2006, Issue 3), MEDLINE (1966 to August Week 4 2006), CINAHL (1982 to July Week 3 2006), EMBASE (1980 to August 2006), PsychInfo (1985 to August Week 4 2006) and reference lists of all relevant articles. SELECTION CRITERIA: All randomised controlled trials (RCTs) and controlled clinical trials (CCTs) comparing CIMT, modified CIMT and Forced Use with traditional services such as occupational therapy, physiotherapy or no treatment were selected. DATA COLLECTION AND ANALYSIS: Two review authors extracted the data independently using standardised forms. Each trial was assessed for internal validity with differences in ratings resolved by discussion. Data were extracted and entered into Review Manager 4.2 where appropriate. MAIN RESULTS: Three studies met the inclusion criteria. The results of one RCT showed a trend for positive treatment effect favouring CIMT using the Dissociated Movement subscale of the Quality of Upper Extremity Skills Test (QUEST). Other outcome measures, that were without reported psychometric properties, showed significant treatment effects. A CCT demonstrated a significant treatment effect favouring modified CIMT at two and six months using the Assisting Hand Assessment (AHA). Another trial with inaccurate reporting and ambiguous methodology, showed a significant treatment effect at 6 weeks on the self care component of the WeeFIM using a Forced Use protocol. All other measures showed no significant treatment effect. AUTHORS' CONCLUSIONS: This systematic review found a significant treatment effect using modified CIMT in a single trial. A positive trend favouring CIMT and Forced Use was also demonstrated. Given the limited evidence, the use of CIMT, modified CIMT and Forced Use should be considered experimental in children with hemiplegic cerebral palsy. Further research using adequately powered RCTs, rigorous methodology and valid and reliable outcome measures is essential to provide higher level support of the effectiveness of CIMT for children with hemiplegic cerebral palsy.

-----

Dev Med Child Neurol. 2007 Feb;49(2):101-5.
Partial body-weight-supported treadmill training can improve walking in children with cerebral palsy: a clinical controlled trial.
Dodd KJ, Foley S.
Musculoskeletal Research Centre, School of Physiotherapy, Faculty of Health Sciences, La Trobe University, Victoria, Australia.

This matched-pairs, clinical controlled trial evaluated the effects of a school-based, partial body-weight-supported treadmill training (PBWSTT) programme, conducted twice a week for 6 weeks, on the walking speed and endurance of children with cerebral palsy (CP). Pairs of children (10 males, four females; mean age 8y 10mo [SD 2y 6mo], range 5-14y) matched for sex, age, type of CP (athetoid quadriplegia, n=6; spastic quadriplegia, n=6; spastic diplegia, n=2), and Gross Motor Function Classification System level (10 at Level I V, four at Level III) were allocated to the experimental or control group. Compared with the control group, the seven treadmill-training participants increased their self-selected walking speed over 10 metres (Mann-Whitney U=9.00, z=-1.98, p=0.048; mean difference 4.21m/min). A trend was also found for increased distance walked over ground in 10 minutes (t[12]=1.88, p=0.083; mean difference 19.81m). A relatively short PBWSTT programme can improve the walking speed of children with CP and moderate to severe disabilities. Walking endurance might also improve in some children. Treadmill training seems to be a useful gait training option for children with C P, and it seems feasible to conduct such a programme within a school environment.

-----

Dev Med Child Neurol. 2007 Jan;49(1):68-73.
Does horseback riding therapy or therapist-directed hippotherapy rehabilitate children with cerebral palsy?
Sterba JA.
Research Assistant Professor of Pediatrics, Department of Pediatrics, Division of Developmental Pediatrics and Rehabilitation, Robert Warner Rehabilitation Center, Women and Children's Hospital of Buffalo, NY, USA.

Quantitative (not qualitative) studies were sought investigating whether horseback riding used as therapy improves gross motor function in children with cerebral palsy (CP). Eleven published studies on instructor-directed, recreational horseback riding therapy (HBRT) and licensed-therapist-directed hippotherapy were identified, reviewed, and summarized for research design, methodological quality, therapy regimen, internal/external validity, results, and authors'conclusions. Methodological quality was moderate to good for all studies; some studies were limited by small sample size or lack of non-riding controls. HBRT improved gross motor function in five of six studies (one study was inconclusive); hippotherapy improved gross motor function in all five studies. The studies found that during HBRT and hippotherapy: (1) the three-dimensional, reciprocal movement of the walking horse produced normalized pelvic movement in the rider, closely resembling pelvic movement during ambulation in individuals without disability; (2) the sensation of smooth, rhythmical movements made by the horse improved co-contraction, joint stability, and weight shift, as well as postural and equilibrium responses; and (3) that HBRT and hippotherapy improved dynamic postural stabilization, recovery from perturbations, and anticipatory and feedback postural control. The evidence suggests that HBRT and hippotherapy are individually efficacious, and are both medically indicated as therapy for gross motor rehabilitation in children with CP. Recommendations for future research are discussed.

-----

Dev Med Child Neurol. 2007 Jan;49(1):56-61.
Motor function following multilevel botulinum toxin type A treatment in children with cerebral palsy.
Desloovere K, Molenaers G, De Cat J, Pauwels P, Van Campenhout A, Ortibus E, Fabry G, De Cock P.
Clinical Motion Analysis Laboratory, Department of Rehabilitation Sciences, University Hospital Pellenberg, Catholic University of Leuven, Belgium. kaat.desloovere@uz.kuleuven.ac.be

This study evaluated the effects of multilevel botulinum toxin type A (BTX-A) treatments on the gait pattern of children with spastic cerebral palsy (Gross Motor Function Classification System Levels I-III). In this nested case-control design, 30 children (mean age 6y 11mo [SD 1y 5mo]; 21 males, nine females; 19 with hemiplegia, 11 with diplegia) were treated according to best practice guidelines in paediatric orthopaedics, including BTX-A injections. A matched control group of 30 children (mean age 7y 8mo [SD 1y 10mo]; 13 males, 17 females; 19 with hemiplegia, 11 with diplegia) were treated identically, but without BTX-A. Motor development status at 5 to 10 years of age was assessed by means of three-dimensional gait analysis at a mean time of 1 year 10 months (SD 10mo) after the last BTX-A treatment. The control group showed a significantly more pronounced pathological gait pattern than the BTX-A group. Major differences were found for pelvic anterior tilt, maximum hip and knee extension, and internal hip rotation. These results provide evidence for a prolonged effect of BTX-A and suggest that BTX-A injections, in combination with common conservative treatment options, result in a gait pattern that is less defined by secondary problems (e.g. bony deformities) at 5 to 10 years of age, minimizing the need for complex surgery at a later age and enhancing quality of life.

-----

Pediatr Neurol. 2007 Jan;36(1):30-9.
Effect of multilevel botulinum toxin a and comprehensive rehabilitation on gait in cerebral palsy.
Scholtes VA, Dallmeijer AJ, Knol DL, Speth LA, Maathuis CG, Jongerius PH, Becher JG.
Department of Rehabilitation Medicine and Institute for Research in Extramural Medicine, VU University Medical Center, Amsterdam, The Netherlands. vab.scholtes@vumc.nl <vab.scholtes@vumc.nl>

To evaluate the effect of multilevel botulinum toxin A and comprehensive rehabilitation on gait pattern, muscle length, and spasticity, a multicenter randomized trial was performed in 46 children with spastic cerebral palsy who walk with flexed knees. Their mean age was 8.0 years (range 4 to 11 years). They were randomly allocated to the intervention group (multilevel botulinum toxin A and comprehensive rehabilitation) or the control group (usual care). After 6 weeks, a significant treatment effect in the intervention group was observed on: improved knee extension during midstance and terminal swing (7 degrees and 5 degrees , P < 0.01, respectively); hip rotation during terminal swing (4 degrees , P = 0.02); gait score (1.7, P < 0.01); decreased spasticity in hamstrings (11 degrees , P < 0.01), gastrocnemius (6 degrees , P = 0.01), and soleus (5 degrees , P = 0.02); and increased muscle length in hamstrings (9 degrees , P < 0.01) and gastrocnemius (5 degrees , P < 0.01). The improved muscle length was maintained up to 24 weeks. This study demonstrated that multilevel botulinum toxin A and comprehensive rehabilitation improves knee extension during gait, increases muscle length, and decreases spasticity in injected muscles after 6 weeks in children who walk with flexed knees. Although the effect on muscle length was maintained after 24 weeks, the effect on gait and spasticity had disappeared.

-----

J Clin Endocrinol Metab. 2006 Dec 19; [Epub ahead of print]
Growth Hormone Therapy Improves Bone Mineral Density in Children with Cerebral Palsy: A preliminary pilot study.
Ali O, Shim M, Fowler E, Greenberg M, Perkins D, Oppenheim W, Cohen P.
David Geffen School of Medicine at UCLA, Los Angeles, CA 90095; Southern California Permanente Medical Group, Los Angeles, CA; Medical College of Wisconsin, Milwaukee, WI.

Context: Cerebral palsy is associated with osteopenia, increased fracture risk, short stature and decreased muscle mass, while GH therapy is associated with increased BMD, linear growth and improvement in body composition. Objective: Pilot study to evaluate the effect of 18 months of GH therapy on spinal BMD, linear growth, biochemical markers and functional measures, in children with CP. Design: Randomized control trial, conducted 2002 to 2005 Setting: UCLA Orthopedic Hospital's Center for Cerebral Palsy. Patients: 12 male patients with CP, age 4.5 to 15.4 years Intervention: 18 months of GH (50 mcg qd) vs. no treatment. Primary outcome measures: Spinal BMD (DXA scan), height, growth factors and bone markers. Results: 10 subjects (5 in each group) completed the study. Pre and post average height z-scores were -1.47+/- 0.23 and 0.8 +/- 0.2 (GH treated group) vs. -1.35 +/- 1.26 and -1.36 +/- 1.27 (control group) (delta SDS 0.67 vs. -0.01, p= 0.01). Average change in spinal BMD z-score (delta SDS corrected for height) was 1.169 +/- 0.614 vs. 0.24 +/- 0.25, in the treated and control groups respectively, p = 0.03). Osteocalcin, IGF-I and IGFBP-3 levels increased during GH therapy. There was no change in quality of life scores as measured by the PODCI. Conclusions: This small pilot study suggests that 18 months of GH therapy is associated with statistically significant improvement in spinal BMD and linear growth.

-----

J Child Neurol. 2006 Dec;21(12):1090-2.
Oral baclofen and clonidine for treatment of spasticity in children.
Lubsch L, Habersang R, Haase M, Luedtke S.
Department of Pharmacy Practice, School of Pharmacy, Southern Illinois University Edwardsville, Edwardsville, Illinois 62026-2000, USA. llubsch@siue.edu

Few data exist in the literature to support the use of high dosages of oral baclofen and clonidine that are frequently required to treat children with spasticity. This study was a retrospective chart review of baclofen and clonidine dosages used in children diagnosed with cerebral palsy or traumatic brain injury. The primary objective was to calculate the mean dosages of baclofen and clonidine based on the duration of spasticity postinjury. Secondary objectives included determining correlations between dosage and age, injury type, location of spasticity, comorbid seizures, or concomitant antispasticity medications. Eighty-seven children receiving baclofen and/or clonidine were included in this study. Mean dosages of 40 mg/day (n = 86) and 0.4 mg/day (n = 31) were required for baclofen and clonidine, respectively. The maximum dosage was 240 mg/day for baclofen and 3.6 mg/day for clonidine. Duration postinjury, age, and concomitant antispasticity medications were the most predictive variables for baclofen dosage as a model (r = .522; P = .000). Duration postinjury and location of spasticity were the most predictive variables for clonidine dosage as a model (r = .523; P = .000). The average dosages of baclofen and clonidine used in this population of children with cerebral palsy or traumatic brain injury were similar to those reported in the literature, with higher maximum dosages found in this investigation.

-----

Arch Phys Med Rehabil. 2006 Dec;87(12):1551-8.
The combined effect of lower-limb multilevel botulinum toxin type a and comprehensive rehabilitation on mobility in children with cerebral palsy: a randomized clinical trial.
Scholtes VA, Dallmeijer AJ, Knol DL, Speth LA, Maathuis CG, Jongerius PH, Becher JG.
Department of Rehabilitation Medicine, VU University Medical Center, Amsterdam, The Netherlands. vab.scholtes@vumc.nl

OBJECTIVE: To evaluate the combined effect on mobility of treatment with multilevel botulinum toxin type A (BTX-A) and comprehensive rehabilitation in children with cerebral palsy (CP). DESIGN: Randomized clinical trial using a multiple baseline design. The intervention group was treated 6 weeks after randomization. The control group was treated after a longer period of 18 to 30 weeks. Repeated measurements in both groups were continued throughout the process, before and up to 48 weeks after treatment. SETTING: Four departments of rehabilitation medicine in The Netherlands. PARTICIPANTS: Forty-six children with spastic CP (mean age +/- standard deviation, 8.0+/-2.1y). INTERVENTION: The intervention group (n=23) was treated with multilevel BTX-A and comprehensive rehabilitation. Control group subjects (n=23) continued with their usual physical therapy (PT) for 18 to 30 weeks, and then also received multilevel BTX-A and comprehensive rehabilitation. MAIN OUTCOME MEASURES: The primary outcome measure was the Gross Motor Function Measure (GMFM-66); the secondary measures were problem score and energy cost. RESULTS: The treatment effect during the first 24 weeks of follow-up in the intervention group was compared with the effect of usual PT in the control group. Treatment with multilevel BTX-A and comprehensive rehabilitation provided a significantly greater improvement at 12 and 24 weeks in both the GMFM-66 (2.1 points, P=.02; and 3.5 points, P<.01, respectively) and problem score (1.8 and 1.7 points, P<.001, respectively) compared with usual PT. No difference was found in energy cost. Before-after analysis of the total group (n=46) showed a significant long-term improvement (48wk) on all outcome measures. CONCLUSIONS: Treatment with multilevel BTX-A and comprehensive rehabilitation significantly improves mobility as measured by the GMFM-66 and problem score in children with CP.

-----

Eur J Neurol. 2006 Dec;13 Suppl 4:35-40.
Safety and efficacy of botulinum toxin type A following long-term use.
Naumann M, Albanese A, Heinen F, Molenaers G, Relja M.
Department of Neurology, Academic Hospital Klinikum Augsburg, Augsburg, Germany.

Botulinum toxin serotype A (BoNT-A) has long heritage of use leading to confidence in its safety and efficacy. The application of BoNT-A does not lead to persistent histological changes in the nerve terminal or the target muscle. Clinical trials defined the safety and tolerability profile of BoNT-A across common therapeutic indications and showed an incidence of adverse events of approximately 25% in the BoNT-A-treated group compared with 15% in the control group. Focal weakness was the only adverse event to occur more often following BoNT-A treatment. Long-term BoNT-A administration has been assessed in various treatment settings, with the level and duration of BoNT-A efficacy response being maintained over repeated rounds of injection with no major safety concerns. The treatment of children with cerebral palsy often require long-term, repeated, multimuscle BoNT-A injections that lead to the administration of comparably higher toxin doses. Despite the high total body doses used, their distribution over multiple muscles and injection sites means that systemic side effects are rare. Recent formulation changes have reduced the incidence of antibody development following treatment with BOTOX((R)). These findings show long-term BoNT-A treatment to be both safe and efficacious for a wide variety of indications.

-----

Pediatr Phys Ther. 2006 Winter;18(4):245-52.
The effects of therapeutic taping on gross motor function in children with cerebral palsy.
Footer CB.
Department of Physical Therapy, Regis University, Denver, Colorado 80221-1099, USA. cfooter@regis.edu

PURPOSE: Therapeutic taping to address dysfunctional sitting control in children with cerebral palsy (CP) was investigated in this study. METHODS: Eighteen children with quadriplegic CP, Gross Motor Function Classification System for Cerebral Palsy levels IV (n = 9) and V (n = 9) participated in the 12-week program. Subjects were assigned randomly to one of two groups: therapeutic taping + physical therapy or physical therapy only. Therapeutic taping was applied for periods of up to 72 hours over the paraspinal region. The effects were assessed with the Gross Motor Function Measure (GMFM-88) at baseline, six weeks, and 12 weeks. A factorial analysis of variance was used to examine group differences over time. RESULTS: No significant differences were found for the GMFM-88 scores between groups over time. CONCLUSION: Therapeutic taping does not evoke a positive functional change in the seated postural control of children with quadriplegic cerebral palsy. Subjective observation, however, suggested that one child with athetosis benefited from therapeutic taping over the paraspinal region.
 

The Cerebral Palsy FileSM Compiled and Maintained by    The Center for Current Research, Inc. 708 Aubrey Avenue • Ardmore PA USA 19003 Phone: 610-649-3165 Email: customerservice@lifestages.com Website: www.lifestages.com

©Copyright 1992-date by The Center for Current Research. The Cerebral Palsy File is a proprietary compilation of the Center for Current Research. The information in the File is solely for your use, and the use of your family, friends, and doctors. The information is the property of the individual researchers and institutions that produced it. It is an infringement of copyright law to attempt to "resell" the information as it is presented here.