Cerebral Palsy Research:
2002-2006
     
Dev Med Child Neurol. 2006 Oct;48(10):855-62.
The effectiveness of passive stretching in children with cerebral palsy.
Pin T, Dyke P, Chan M.
University of Melbourne, Victoria, Australia.

Passive stretching is widely used for individuals with spasticity in a belief that tightness or contracture of soft tissues can be corrected and lengthened. Evidence for the efficacy of passive stretching on individuals with spasticity is limited. The aim of this review was to evaluate the evidence on the effectiveness of passive stretching in children with spastic cerebral palsy. Seven studies were selected according to the selection criteria and scored against the Physiotherapy Evidence Database scale. Effect size and 95% confidence intervals were calculated for comparison. There was limited evidence that manual stretching can increase range of movements, reduce spasticity, or improve walking efficiency in children with spasticity. It appeared that sustained stretching of longer duration was preferable to improve range of movements and to reduce spasticity of muscles around the targeted joints. Methods of passive stretching were varied. Further research is required given the present lack of knowledge about treatment outcomes and the wide use of this treatment modality.

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J Pediatr Orthop. 2006 Sep-Oct;26(5):617-23.
High reoperation rates after early treatment of the subluxating hip in children with spastic cerebral palsy.
Schmale GA, Eilert RE, Chang F, Seidel K.
Department of Orthopaedics, Children's Hospital and Regional Medical Center, Seattle, WA 98105, USA. gschmale@u.washington.edu

Hip subluxation and dislocation are well-recognized complications of spastic cerebral palsy. Alternatives for treatment include observation, bracing, or surgery. The purpose of this study is to compare the rates of reoperation and acetabular development after early soft tissue procedures with those of varus derotational osteotomies performed to maintain reduced hips in severely involved children. A series of 60 patients with spastic cerebral palsy and hip subluxation younger than 6 years who underwent primary bilateral hip surgery at one hospital between 1980 and 1996, with a minimum of 4 years of follow-up, were retrospectively reviewed. Fifty-two patients had spastic tetraplegia and 47 were nonambulators. Measures of proximal femoral and acetabular development were made via radiographic analysis. Twenty-two patients underwent primary bilateral soft tissue procedures. At a mean 6-year follow-up, there was modest improvement seen in mean femoral head coverage and little improvement seen in mean indices of acetabular development. Seventeen of these 22 patients (77%) underwent reoperation. Thirty-eight patients underwent primary bilateral varus derotational osteotomies. At a mean follow-up of 5 years, there was also modest improvement noted in mean femoral head coverage with little change in the mean indices of acetabular development. Twenty-eight of these 38 patients (74%) underwent reoperation. In this population of severely involved patients with spastic cerebral palsy, the reoperation rate was high. Acetabular remodeling did not reliably occur as a result of either early soft tissue or proximal femoral procedures when performed at an average age of 4 years.

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Neuromolecular Med. 2006;8(4):435-50.
Cerebral palsy.
Johnston MV, Hoon AH.
Kennedy Krieger Institute and Departments of Neurology and Pediatrics, Johns Hopkins University School of Medicine, 707 North Broadway, Baltimore, MD 21205.

Cerebral palsy (CP) is a group of disorders of movement and posture resulting from nonprogressive disturbances of the fetal or neonatal brain. More than 80% of cases of CP in term infants originate in the prenatal period; in premature infants, both prenatal or postnatal causes contribute. The most prevalent pathological lesion seen in CP is periventricular white matter injury (PWMI) resulting from vulnerability of the immature oligodendrocytes (pre-OLs) before 32 wk of gestation. PWMI is responsible for the spastic diplegia form of CP and a spectrum of cognitive and behavioral disorders. Oxidative stress and excitotoxicity resulting from excessive stimulation of ionotropic glutamate receptors on preOLs are the most prominent molecular mechanisms for PWMI. Asphyxia around the time of birth in term infants accounts for less than 15% of CP in developed countries but the incidence is higher in underdeveloped areas. Asphyxia causes a different pattern of brain injury and CP than is seen after preterm injuries. This type of CP is associated with the clinical syndrome of hypoxic-ischemic encephalopathy shortly after the insult, and the cortex, basal ganglia, and brainstem are selectively vulnerable to injury. Experimental models indicate that neurons in the neonatal brain are more likely to die by delayed apoptosis extending over days to weeks than those in the adult brain. Neurons die by glutamate-mediated excitotoxicity involving downstream caspase-dependent and caspase-independent cell death pathways. Recent reports indicate that males and females preferentially utilize different pathways. Clinical trials indicate that mild hypothermia reduces death or disability in term infants following asphyxia and basic research suggests that this approach might be combined with pharmacological strategies in the future.

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Gait Posture. 2006 Sep 26; [Epub ahead of print]
The effect of serial casting on gait in children with cerebral palsy: preliminary results from a crossover trial.
McNee AE, Will E, Lin JP, Eve LC, Gough M, Morrissey MC, Shortland AP.
One Small Step Gait Laboratory and Newcomen Centre, Guy's Hospital, London SE1 9RT, United Kingdom.

Serial casting aims to improve an equinus gait pattern in children with spastic cerebral palsy (SCP). We evaluated the effect of short-term stretch casting on gait in children with SCP, compared to the natural history. A crossover trial, consisting of a control phase and a casting phase, was conducted with children randomised into two groups. Both groups were assessed clinically, and using 3D gait analysis, at 0, 5 and 12 weeks. Subjects in one group had the 3 month casting phase first and in the other had the 3 month control period first. Casts were changed weekly and set at maximum available ankle dorsiflexion. The mean changes at 5 weeks and 12 weeks from baseline measurements in the casting phase were compared with the change within the same time interval in the control phase. Significant improvements in passive ankle dorsiflexion (knee flexed) were found at 5 and 12 weeks. Passive ankle dorsiflexion (knee extended), ankle dorsiflexion in single support, ankle dorsiflexion in swing and minimum hip flexion in stance improved significantly at 5 weeks but not at 12 weeks from baseline. Other kinematic parameters, the score on the Gillette Functional Assessment Questionnaire, and maximum reported walking distance were not changed by casting. Casting to improve range appears to improve passive and dynamic ankle dorsiflexion, but the changes are small, short lived and do not appear to affect function.

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Phys Ther. 2006 Sep 26; [Epub ahead of print]
Activity, Activity, Activity: Rethinking Our Physical Therapy Approach to Cerebral Palsy.
Damiano DL.
Research Associate Professor of Neurology, Department of Neurology, and Adjunct Associate Professor, Movement Science Program, Department of Physical Therapy, Washington University, Box 8111, St Louis, MO 63110 (USA).

This perspective outlines the theoretical basis for the presentation with the same name as the second part of this title, which was given at the III STEP conference in July 2005. It elaborates on the take-home message from that talk, which was to promote activity in children and adults with cerebral palsy and other central nervous system disorders. The author proposes that the paradigm for physical therapist management of cerebral palsy needs to shift from traditional or "packaged" approaches to a more focused and proactive approach of promoting activity through more intense active training protocols, lifestyle modifications, and mobility-enhancing devices. Increased motor activity has been shown to lead to better physical and mental health and to augment other aspects of functioning such as cognitive performance, and more recently has been shown to promote neural and functional recovery in people with damaged nervous systems. Although the benefits of fairly intense physical exercise programs such as strength training are becoming increasingly well recognized, few studies on the positive effects of generalized activity programs have been conducted in individuals with cerebral palsy. More research is needed and is currently under way to design and test the efficacy of activity-based strategies in cerebral palsy.

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Phys Occup Ther Pediatr. 2006;26(3):39-53.
The effect of positioning for children with cerebral palsy on upper-extremity function: a review of the evidence.
Stavness C.
Hamilton Health Sciences, Complex Medicine Rehabilitation Unit, Canada. cstavness@cogeco.ca

CONTEXT: Controversy exists about the most appropriate seating position for children with cerebral palsy (CP) to promote energy conservation and maximize upper-extremity function. EVIDENCE ACQUISITION: Sixteen journal articles published after 1980 were identified by searching allied health, medical, and occupational and physical therapy data bases and evidence-based medicine reviews using specific key terms (positioning, wheelchair, postural control, posture, adaptive seating devices, patient positioning, cerebral palsy, movement disorders, upper extremity, reaching, grasping, and occupational therapy) and reviewing bibliographies of retrieved articles. EVIDENCE SYNTHESIS: The majority of the evidence supports the positive effects of a neutral to slightly forward orientation (whole chair tilted) on upper-extremity function. Only one study did not demonstrate such effects. Of the supporting studies, one suggested the addition of an abduction orthrosis (AO), one recommended the entire functional sitting position (FSP) package (this orientation plus a hip-belt, footrests, AO, and cutout tray), and one established the long-term effects of the FSP. One less rigorous study opposed the addition of an AO. With the exception of one study, most of the evidence states that seat angle does not affect functional abilities. However, some of these studies contain faulty methodology and/or their results demonstrate clinical significance. CONCLUSION: Evidence supports that children with CP should be fitted for wheelchairs that place them in a FSP, which includes; orientation in space of 0 degrees -15 degrees, a hip-belt, an AO, footrests, and a cutout tray, with the addition of a sloped forward seat of 0 degrees -15 degrees, to improve upper-extremity function. The exact seat angle and orientation in space within the 0 degrees -15 degrees range should be determined on an individual basis.

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Arch Phys Med Rehabil. 2006 Sep;87(9):1161-9.
Effects of a postoperative resistive exercise program on the knee extension and flexion torque in children with cerebral palsy: a randomized clinical trial.
Patikas D, Wolf SI, Armbrust P, Mund K, Schuster W, Dreher T, Doderlein L.
Department of Orthopaedic Surgery, University of Heidelberg, Germany. Dimitrios.Patikas@ok.uni-hd.de

OBJECTIVE: To investigate the effects of resistive exercise on the knee extension and flexion torque production during the rehabilitation period after multilevel orthopedic surgery. DESIGN: Randomized clinical trial. SETTING: Hospital rehabilitation department. PARTICIPANTS: Thirty-nine children with spastic diplegic cerebral palsy (CP) (age range, 6-16 y), randomly allocated to an exercise group (n=19) and a control group (n=20). All received conventional physiotherapy (PT), and the exercise group also followed a resistive exercise program. INTERVENTION: A 9-month standardized home-based resistive exercise program, which started about 3 months after the surgery. MAIN OUTCOME MEASURES: The Gross Motor Functional Measurement (GMFM) assessed before (E(0)) and 1 year (E(1)) after the surgery. The Modified Ashworth Scale and the isometric and isokinetic torque of the knee extensors and flexors were evaluated at E(0), E(1), and 6 months after the surgery. RESULTS: The knee extension and flexion moments had decreased 6 months after the surgery and recovered to the preoperative level 1 year after surgery. These changes were not group dependent. CONCLUSIONS: Additional long-term, home-based, low-cost resistive exercise that starts soon after the operation of patients with CP was not more beneficial than conventional PT only, in terms of strength and GMFM.

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Neurosurg Focus. 2006 Aug 15;21(2):e4.
Selection of treatment modalities in children with spastic cerebral palsy.
Steinbok P.
Division of Pediatric Neurosurgery, Department of Surgery, British Columbia's Children's Hospital and University of British Columbia, Vancouver, British Columbia, Canada. psteinbok@cw.bc.ca

The purpose of this report was to outline the various options currently used for treatment of spastic cerebral palsy (CP) and to discuss factors involved in selecting the appropriate treatment modalities for the individual child. In a review of the literature and his personal observations, the author presents an outline of treatment options and the criteria for using each. Therapeutic options include the following: physiotherapy; occupational therapy; oral spasmolytic and antidystonic drugs; botulinum toxin injections; orthopedic procedures; continuous infusion of intrathecal baclofen (ITB); selective dorsal rhizotomy (SDR); and selective peripheral neurotomy. The most commonly used neurosurgical procedures are ITB pump placement and SDR, and these are discussed in the most detail. The author's personal schema for assessment of the child to determine the nature of the hypertonia, the impact of the hypertonia, and the appropriate therapeutic intervention is presented. There are factors that help guide the optimal treatment modalities for the child with spastic CP. The treatment of these children is optimized in the setting of a multidisciplinary team.

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Harefuah. 2006 Jul;145(7):510-5, 550.
[Drug treatment for children with cerebral palsy]
[Article in Hebrew]
Ben-Pazi H.
Pediatric Movement Disorders, Department of Child Neurology, Stanford Medical Center, CA 94305-5235, USA. shmaryaho@hotmail.com

Cerebral palsy is the main cause of immobility in children. This motor dysfunction is caused by several motor components such as weakness, lack of motor control and muscle hypertonia. Drug treatment, delineated in this review, mainly addresses the latter. Recently, new definitions for clinical features of hypertonia in children were published, assisting the distinction between the two common motor symptoms in cerebral palsy, spasticity and dystonia. The main functional symptoms disrupt functional daily life, dictating the overall approach and the specific drug treatment. There are an increasing number of treatments for this distressing disorder. For general spasticity, treatments provided include Baclofen. If symptoms are local, either dystonia, or spasticity, Botulinum toxin is the revolutionary drug used with significant success and relatively few side effects. For generalized dystonia, a trial of both Dopamine and Trihexyphenidyl should be considered. Cerebral palsy, like other complex disorders, requires individualized decision-making and a team approach. Drug therapy is only one aspect of treatment, yet sometimes it may serve as a window of opportunity to facilitate better motor control.

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Disabil Rehabil. 2006 May 15;28(9):561-70.
Effectiveness and expectations of intensive training: A comparison between child and youth rehabilitation and conductive education.
Odman PE, Oberg BE.
Department of Health and Society, Physiotherapy, Faculty of Health Sciences, Linkoping University, Linkoping, Sweden.

Objective. To compare the effectiveness of two intensive training-programmes from a professional and parent perspective. To describe and compare the type of expectations of the two intensive training programmes with the self-reported individualized goals.Design. Quasi-experimental with two groups.Setting and intervention. Traditional health care and conductive education.Patients and their parents. Fifty-four children with cerebral palsy, 3-16 years old.Methods. Data included a self-reported individualized goal measure (SRIGM), before and after the ITP. Individualized goals were classified according to the International Classification of Functioning (ICF). Clinical measures (CM) included repeated measures with Gross Motor Function Measure (GMFM) and Pediatric Evaluation of Disability Inventory-Functional Skills (PEDI-FS).Results. Twenty-eight parents out of 54 perceived a clinically significant improvement on the SRIGM with no significant difference between the training programmes. Most individualized goals were formulated in the domain of Mobility (115 out of 248) and Neuromusculoskeletal and movement-related functions (64 out of 248 goals) of ICF in both training programmes. There was no difference in the proportion of improvement measured with SRIGM compared to the CM, if an improvement in any dimension in GMFM or domain in PEDI FS was counted.Conclusion. There were no major differences in outcome and expectations between the training programmes. Parents' expectations were mainly directed towards improvement in prerequisites of motor function and mobility skills. The SRIGM confirmed the outcome on the CM.

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Arch Phys Med Rehabil. 2006 May;87(5):619-26.
Effects of a postoperative strength-training program on the walking ability of children with cerebral palsy: a randomized controlled trial.
Patikas D, Wolf SI, Mund K, Armbrust P, Schuster W, Doderlein L.
Department of Orthopaedic Surgery, University of Heidelberg, Germany. Dimitrios.Patikas@ok.uni-hd.de

OBJECTIVE: To investigate the effect of a postoperative strength-training program on the walking of children with cerebral palsy (CP). DESIGN: Randomized controlled trial. SETTING: Hospital rehabilitation department. PARTICIPANTS: Thirty-nine children with CP (age range, 6-16 y). After orthopedic surgery, the control group (n=20) followed a conventional physiotherapy (PT) program, and the strength-training group (n=19) followed a strength-training program in addition to the conventional PT. Twenty-nine age-matched healthy children were used as references. INTERVENTION: A 9-month strength-training program. MAIN OUTCOME MEASURES: Spatiotemporal, kinematic, and kinetic parameters during gait analysis were analyzed before (E0) and 1 year after (E1) the surgery. For 22 children, a 2-year postoperative gait analysis (E2) took place as well. RESULTS: At E1, several kinematic and kinetic parameters improved, although there was no significant difference between the groups. Spatiotemporal parameters showed a worsening at E1 and a recovery to preoperative values at E2. CONCLUSIONS: The examined parameters may be more substantially influenced by factors such as the surgery outcome and the variability of pathologic characteristics than by the strength-training program per se. However, a more significant effect of the strength-training may appear if more intense and short-term training protocols are used, considering factors such as patients' motivations, ages, and postoperative statuses.

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Dev Med Child Neurol. 2006 May;48(5):325-30.
Comparison of efficacy of Adeli suit and neurodevelopmental treatments in children with cerebral palsy.
Bar-Haim S, Harries N, Belokopytov M, Frank A, Copeliovitch L, Kaplanski J, Lahat E.
Faculty of Health Science, Ben-Gurion University, Beer-Sheva, Israel.

This study compared the efficacy of Adeli suit treatment (AST) with neurodevelopmental treatment (NDT) in children with cerebral palsy (CP). Twenty-four children with CP, Levels II to IV according to the Gross Motor Function Classification System (GMFCS), were matched by age and functional status and randomly assigned to the AST or NDT treatment groups. In the AST group (n=12; eight males, four females; mean age 8.3 y [SD 2.0]), six children had spastic/ataxic diplegia, one triplegia and five spastic/mixed quadriplegia. In the NDT group (n=12; nine males, three females; mean age 8.1 y [SD 2.2]), five children had spastic diplegia and seven had spastic/mixed quadriplegia. Both groups were treated for 4 weeks (2 hours daily, 5 days per week, 20 sessions). To compare treatments, the Gross Motor Function Measure (GMFM-66) and the mechanical efficiency index (EIHB) during stair-climbing were measured at baseline, immediately after 1 month of treatment, and 10 months after baseline. The small but significant time effects for GMFM-66 and EIHB that were noted after 1 month of both intensive physiotherapy courses were greater than expected from natural maturation of children with CP at this age. Improvements in motor skills and their retention 9 months after treatment were not significantly different between the two treatment modes. Post hoc analysis indicated a greater increase in EIHB after 1 month (p=0.16) and 10 months (p=0.004) in AST than that in NDT, predominantly in the children with higher motor function (GMFCS Levels II and III). The results suggest that AST might improve mechanical efficiency without a corresponding gain in gross motor skills, especially in children with higher levels of motor function.

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Cyberpsychol Behav. 2006 Apr;9(2):123-8.
Feasibility, motivation, and selective motor control: virtual reality compared to conventional home exercise in children with cerebral palsy.
Bryanton C, Bosse J, Brien M, McLean J, McCormick A, Sveistrup H.
Rehabilitation Sciences, Health Sciences, University of Ottawa, Ottawa, Ontario, Canada.

Children with cerebral palsy (CP) have difficulty controlling and coordinating voluntary muscle, which results in poor selective control of muscle activity. Children with spastic CP completed ankle selective motor control exercises using a virtual reality (VR) exercise system and conventional (Conv) exercises. Ankle movements were recorded with an electrogoniometer. Children and their parents were asked to comment on their interest in the exercise programs. Greater fun and enjoyment were expressed during the VR exercises. Children completed more repetitions of the Conv exercises, but the range of motion and hold time in the stretched position were greater during VR exercises. These data suggest that using VR to elicit or guide exercise may improve exercise compliance and enhance exercise effectiveness.

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Orthop Clin North Am. 2006 Apr;37(2):185-96, vi.
Evaluation and treatment of hip dysplasia in cerebral palsy.
Spiegel DA, Flynn JM.
Division of Orthopaedic Surgery, Children's Hospital of Philadelphia, 2nd Floor Wood Building, 34th Street and Civic Center Boulevard, Philadelphia, PA 19104, USA. spiegeld@email.chop.edu

Hip problems, including progressive subluxation, dislocation, and pain, are common in patients with cerebral palsy, particularly those who are nonambulatory with a large degree of spasticity. Clinical and radiographic screening facilitates early detection, and surgery is indicated to prevent progressive dysplasia. Although an early soft tissue release may prevent progressive subluxation in a subset of cases, bony reconstructive surgery is indicated for patients with established bony deformity. Salvage procedures are recommended to treat chronic pain caused by established subluxation or dislocation.

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J Pediatr Orthop. 2006 Mar-Apr;26(2):260-4.
Effects of intramuscular psoas lengthening on pelvic and hip motion in patients with spastic diparetic cerebral palsy.
Morais Filho MC, de Godoy W, Santos CA.
Gait Analysis Laboratory, AACD, Sao Paulo, Brazil. mfmorais@terra.com.br

The effects of intramuscular psoas lengthening on gait in cerebral palsy patients have been the subject of debates, and the indications for such procedure are still controversial. The purpose of this study was to evaluate the effects of intramuscular psoas lengthening on sagittal plane pelvic and hip motion in patients with spastic diparetic cerebral palsy and identify the factors linked to the best possible outcome. A retrospective study was performed in 26 independent ambulatory patients. All of them had undergone an intramuscular psoas lengthening over the pelvic brim. The mean age at the time of surgery was 11.10 years, and most cases went through additional simultaneous procedures. A complete gait analysis was performed before and, on average, at 17.69 months (range, 6-39 months) after surgery. The Thomas test values, maximum hip extension in stance, and pelvic tilt were analyzed before and after surgical intervention, and the results were statistically compared. The most significant postoperative effect was the reduction of pelvic range of motion (P < 0.01). Reduction of anterior pelvic tilt was observed only in those patients with no previous need of an external aid (P < 0.01), and the studied group did not show a significant improvement of hip extension at terminal stance. According to the results, intramuscular psoas lengthening was useful in reducing pelvic range of motion at the sagittal plane, but this study also suggests that pelvic and hip disruptions of the same plane (sagittal) seem to have a multifactorial etiology. The use of external assistive devices in patients with balance problems may lead to increased anterior pelvic tilt as well as reduction of hip extension at terminal stance.

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Scand J Occup Ther. 2006 Mar;13(1):13-22.
Effects of constraint-induced movement therapy in adolescents with hemiplegic cerebral palsy: a day camp model.
Bonnier B, Eliasson AC, Krumlinde-Sundholm L.
Department of Habilitation Services, Stockholm, Sweden.

This study examined whether restraining the dominant hand during an intensive training period could provide a means by which to improve adolescents' hemiplegic hand function. Nine adolescents with hemiplegic CP between the ages of 13 and 18 years were enrolled at a two-week day camp, of 7 hours/day. They were restricted in the use of their dominant hand in various daily and recreational activities by wearing a glove-like splint. The basis for intervention was built upon the adolescents' own motivation, and the activities were chosen to be challenging and specifically to provide opportunities for repetition. The treatment approach used was an adapted model of Constraint Induced Movement Therapy. Assessments took place before and after intervention as well as at a 5-month follow-up. The results revealed that hand function did improve and was sustained at follow-up for dexterity, coordination and precision, and manipulative abilities. The performance of tasks that had been trained specifically showed major improvements.

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Dev Med Child Neurol. 2006 Mar;48(3):170-5.
Low-dose/high-concentration localized botulinum toxin A improves upper limb movement and function in children with hemiplegic cerebral palsy.
Lowe K, Novak I, Cusick A.
Department of Paediatric Rehabilitation, Sydney Children's Hospital and University of New South Wales, Randwick, Australia.

The objective was to determine the effects of low-dose, high-concentration, dual localized botulinum toxin A (BTX-A) injections on upper limb movement quality and function. Study design was an evaluator-blinded, randomized, controlled trial. Forty-two children (31 males, 11 females; range 2-8y, mean 4y [SD 1.6]) with hemiplegic cerebral palsy (Gross Motor Function Classification System level I) participated. All received occupational therapy. The treatment group (n=21) received one injection series (mean muscles injected 6 [SD 1.05]; total dose 82-220 units, mean 139 [SD 37.48]; dilution 100 units/0.5ml). Primary outcome of Quality of Upper Extremity Skills Test (QUEST) at 6 months was not significant (p=0.318). Secondary outcomes were average treatment effects at 1, 3, and 6 months, which favoured the treatment group: QUEST (p<0.001); Canadian Occupational Performance Measure (performance, p=0.002; satisfaction p=0.007); parent Goal Attainment Scaling (GAS; p=0.001), therapist GAS (p<0.001); Pediatric Evaluation of Disability Inventory (PEDI) functional skills (p=0.030); Ashworth (p<0.001). PEDI caregiver assistance was not significant (p=0.140). Therapy alone is effective, but at 1 and 3 months movement quality is better where BTX-A is also used. Moreover, function is better at 1, 3, and 6 months, suggesting BTX-A enhances therapy outcomes beyond the pharmacological effect. One- and 3-month Ashworth and QUEST scores suggest precise needle placement accuracy.

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J Pediatr Orthop B. 2006 Mar;15(2):109-112.
Radiographic outcome of soft-tissue surgery for hip subluxation in non-ambulatory children with cerebral palsy.
Bowen RE, Kehl DK.
aShriners Hospitals for Children, Los Angeles, California bWest Yellowstone, Montana Children's Healthcare of Atlanta at Scottish Rite Hospital, Atlanta, Georgia, USA.

This study reviewed radiographs of non-ambulatory spastic tetraparetic cerebral palsy patients who underwent soft tissue hip surgery to address hip subluxation. Patients were under 10 years of age at surgery, had limited hip motion, and radiographic subluxation. At an average 7.4 years postoperatively, hips had a migration percentage in the normal range (0-15%) in 58 of 70 cases (83%). Hips with preoperative subluxation between 30 and 49% had a normal migration percentage in 18 of 21 cases (81%), and those over 50% in three of seven (43%) of cases. Soft tissue surgery alone, even in cases of moderate hip subluxation, can result in long-term radiographic hip stability.

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J Bone Joint Surg Br. 2006 Feb;88-B(2):248-254.
Lengthening and transfer of hamstrings for a flexion deformity of the knee in children with bilateral cerebral palsy: technique and preliminary results.
Ma FY, Selber P, Nattrass GR, Harvey AR, Wolfe R, Graham HK.
1Department of Orthopaedic Surgery, The Royal Children's Hospital, Flemington Road, Parkville, Victoria 3052, Australia.

Between July 2000 and April 2004, 19 patients with bilateral spastic cerebral palsy who required an assistive device to walk had combined lengthening-transfer of the medial hamstrings as part of multilevel surgery. A standardised physical examination, measurement of the Functional Mobility Scale score and video or instrumented gait analysis were performed pre- and post-operatively. Static parameters (popliteal angle, flexion deformity of the knee) and sagittal knee kinematic parameters (knee flexion at initial contact, minimum knee flexion during stance, mean knee flexion during stance) were recorded. The mean length of follow-up was 25 months (14 to 45).Statistically significant improvements in static and dynamic outcome parameters were found, corresponding to improvements in gait and functional mobility as determined by the Functional Mobility Scale. Mild hyperextension of the knee during gait developed in two patients and was controlled by adjustment of their ankle-foot orthosis. Residual flexion deformity > 10 degrees occurred in both knees of one patient and was treated by anterior distal femoral physeal stapling. Two children also showed an improvement of one level in the Gross Motor Function Classification System.

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Ugeskr Laeger. 2006 Feb 20;168(8):785-789.
[Selective dorsal rhizotomy for children with severe spastic cerebral diplegia.]
[Article in Danish]
Illum NO, Torp-Pedersen L, Midholm S, Selmar PE, Simesen K.
Borneneurologisk Afsnit, Borneafdeling H, Odense Universitetshospital, DK-5000 Odense C. niels.illum@ouh.fyns-amt.dk.

INTRODUCTION: Severe spasticity is a limiting factor for motor development in children with spastic cerebral palsy. Botulinum toxin, intrathecal baclofen and peroral baclofen all reduce spasticity but might also limit improvements in functional development over time. In the selective dorsal or posterior rhizotomy (SDR) approach, afferent sensory nerve fibers are cut while efferent motor fibers are preserved. In this way spasticity is reduced and motor functions can improve. SDR is an established treatment method, and the first Danish study is reported. MATERIAL AND METHODS: Twenty Danish children with severe spastic cerebral palsy were evaluated, operated on and trained over a 10-year period from 1992 to 2002. Those on whom operation was performed ranged from 4 to 16 years of age (median 8 years), and training and follow-up took place during the ensuing 60 months. At time of operation, 20-40% of 100-120 dorsal root filaments were cut, corresponding to the II-V lumbar and I-II sacral nerve roots. RESULTS: Spasticity in the lower extremities measured before SDR showed an average Asworth score of 2.0-4.2 (median 3.1). Eighteen months after SDR, scores were 0.8-1.8 (median 1.0), and at 60 months 0.8-1.8 (median 1.0). Both post-operative values were significant (t-test, p < 0.001). Mobility improved over a longer period of time: the Illinois St. Louis scale values before SDR were 1-9 (median 6), while at 18 months post-operative they were 1-9 (median 5) and at 60 months post-operative 1-9 (median 4). At 18 months, scores were non-significant (t test, p > 0.05), but at 60 months they were significant (t < 0.05). According to the Montgomery scale, 4 children had worse post-operative scores and 12 children had better scores. When comparing age at operation with outcome, we observed a certain degree of concordance between relatively younger age and better post-operative muscular function (Pearson's r = 0.8). CONCLUSION: SDR resulted in early and lasting reduction in spasticity in all 20 children operated upon. Improved muscular function, however, required training and time. Not until 60 months after operation were functional measures significantly better than the preoperative values.

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Pediatr Neurol. 2006 Feb;34(2):106-9.
Botulinum toxin type a for the treatment of the spastic equinus foot in cerebral palsy.
Cardoso ES, Rodrigues BM, Barroso M, Menezes CJ, Lucena RS, Nora DB, Melo A.
Neurology and Epidemiology Division, Federal University of Bahia, Salvador-Bahia, Brazil.

Muscle overactivity, one of the cardinal features of spasticity, is a common sequel of cerebral palsy. In this group of patients spasticity is responsible for several limitations that interfere with gait, causing variable functional disability. Drugs such as baclofen, tizanidine, or benzodiazepines, or even definitive treatments such as orthopedics or neurosurgeries are generally prescribed with uncertain results. The use of botulinum toxin type A has been frequently suggested for the treatment of spastic equinus foot in cerebral palsy, but few studies with adequate methodology support this idea. The present paper reviews and summarizes the data of published double-blind, randomized clinical trials to assess, with a meta-analysis, if botulinum toxin type A is an adequate treatment for spasticity caused by cerebral palsy. The results reveal a statistical superiority of botulinum toxin type A over placebo on gait improvement, tested using the Physician Rating Scale and Video Gait Analysis (Peto odds ratio = 3.99, 95% confidence interval = 2.20-7.22) in patients with spastic equinus foot. The botulinum toxin group also presented better results in the subjective assessment than the placebo group (Peto odds ratio = 3.49, 95% confidence interval = 1.50-8.12). Adverse events were more frequently observed after the use of botulinum toxin type A, but they were considered mild and self-limited.

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J Pediatr Orthop. 2006 Jan-Feb;26(1):115-8.
Intramedullary nail fixation of femoral and tibial percutaneous rotational osteotomy in skeletally mature adolescents with cerebral palsy.
Ferri-de-Barros F, Inan M, Miller F.
The A. I. duPont Hospital for Children, Wilmington, DE 19899, USA.

Twenty percutaneous rotational osteotomies, stabilized with interlock nails, were performed in the lower limbs of 15 skeletally mature adolescents with cerebral palsy to correct rotational deformities. The medical records and radiographs of those patients were retrospectively reviewed. Nineteen osteotomies (95%) in 15 patients healed without major complications. One patient had one tibia (5%) pseudarthrosis, which was successfully treated with additional fibular osteotomy and exchanging the nail. Excluding this case, the average healing time for the femoral and tibial osteotomies was 8 weeks, ranging from 7 to 9 and from 6 to 10 weeks, respectively. Casting was not required to add stability. Percutaneous rotational osteotomy with intramedullary nail fixation is a reliable and effective treatment option to correct rotational malalignment of the lower limb in skeletally mature patients with cerebral palsy.

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J Pediatr Orthop. 2006 Jan-Feb;26(1):109-14.
Effectiveness of serial stretch casting for resistant or recurrent knee flexion contractures following hamstring lengthening in children with cerebral palsy.
Westberry DE, Davids JR, Jacobs JM, Pugh LI, Tanner SL.
Shriners Hospitals for Children, Greenville Hospital, Greenville, SC, USA. dwestberry@ghs.org

A retrospective review of all cerebral palsy (CP) patients with resistant or recurrent knee flexion contractures treated with serial stretch casting was performed. The protocol consisted of sequential wedging (5 degrees per week) of fiberglass casts until maximum knee extension had been achieved. Measurements were made prior to the initiation of casting, at completion of the casting, and at 1 year after the casting. Forty-six subjects, with 75 involved extremities, met the study inclusion criteria. Mean age at the time of initiation of casting was 12.7 years. Using radiographic measurements, the mean initial degree of knee flexion contracture was -17.6 degrees. At the completion of casting, the mean knee flexion angle was -8.1 degrees. The mean duration of casting was 30 days. At 1 year after completion of the casting, the mean knee flexion angle was -12.2 degrees. Initial correction to within 10 degrees of full extension was achieved in 76% of extremities. Age less than 12 years and initial flexion contracture of less than -15 degrees were statistically significant factors related to maintenance of correction at 1 year. Complications included soft tissue compromise in 13 extremities (17%), transient neurapraxia in 9 extremities (12%), and tibial subluxation in 1 extremity (1%). Serial stretch casting was successful in correcting resistant knee flexion contractures in the majority of cases. Casting was less effective in teenagers and those with larger contractures. Complications were minimized by proper casting technique and controlled rate of correction.

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J Pediatr Orthop. 2006 Jan-Feb;26(1):1-7.
Long-term follow-up after one-stage reconstruction of dislocated hips in patients with cerebral palsy.
Sankar WN, Spiegel DA, Gregg JR, Sennett BJ.
Children's Hospital of Philadelphia, PA, USA. wudbhav.sankar@uphs.upenn.edu

Twelve consecutive patients (average age 10.6 years) with 14 dislocated hips underwent one-stage hip reconstruction between 1973 and 1981. The procedure consisted of (1) adductor myotomy and anterior obturator neurectomy, (2) circumferential capsulotomy, iliopsoas and external rotator tenotomies, and ligamentum teres and pulvinar excision, (3) shortening femoral varus derotational osteotomy, (4) acetabuloplasty, and (5) spica immobilization for 4 weeks. All patients were followed clinically and radiographically at an average of 16.7 (range 12.4-19.5) years. No patients were lost to follow-up. Long-term results revealed complete stability in 13 of 14 hips, with no redislocations or subluxations. The one patient with "instability" had undergone bilateral proximal femoral resections for severe arthritis 12 years after left hip reconstruction; at the time of resection, the left hip was stable and reduced. Pain was absent in 13 of 14 hips. There were no problems with perineal care, decubitus formation, or sitting tolerance. Extension and abduction improved an average of 23 degrees and 10 degrees, respectively. Two patients' ambulatory status improved; none deteriorated. The mean center-edge angle was 35 degrees (range 22-50 degrees), and the mean migration percentage was 10.6% (range 0-31%). Complications included one case of degenerative arthritis, one case of painless coxa vara, and three episodes of supracondylar femur fractures. None of these patients developed radiographic evidence of avascular necrosis. In the authors' experience, one-stage hip reconstruction consisting of soft tissue lengthening, open reduction, femoral osteotomy, and pericapsular acetabuloplasty results in a painless, mobile, and stable hip at long-term follow-up that greatly improves the patient's quality of life.

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Dev Med Child Neurol. 2006 Feb;48(2):103-7.
Drooling in children with cerebral palsy: effect of salivary flow reduction on daily life and care.
Van der Burg JJ, Jongerius PH, Van Hulst K, Van Limbeek J, Rotteveel JJ.
Sint Maartenskliniek, Rehabilitation Centre, Nijmegen, the Netherlands.

The purpose of this study was to investigate the effect of salivary flow reduction on daily life and provision of care in children with cerebral palsy (CP). Parents of children with CP were asked to fill in a questionnaire on the impact of drooling on the daily life of their children and their families and the data were then analyzed. Forty-five children with severe drooling (28 males, 17 females; mean age 9y 5mo [SD 3y 7mo]; range 3 to 16y) were monitored before and after receiving medication (scopolamine and botulinum toxin) to reduce salivary flow. Type of CP included hypotonia (n = 1), spastic paresis (n = 27), and mixed motor disorders with spastic and dyskinetic paresis (n = 17). Eight children were independently ambulant and 37 children were wheelchair users. Thirty-four children had learning disability with a developmental age of below 6 years. Six participants dropped out of the study; data on 39 children were analyzed. Results showed that anticholinergic agents effectively reduced salivary flow. Drooling diminished substantially and this was accompanied by a significant reduction in care needs, making daily care less demanding. The amount of reported damage to communication devices and computers decreased. In addition to the evaluation of primary variables, such as the salivary flow rate, investigation of impact of drooling on daily life provides useful information about the outcome of treatment for reduction in drooling.

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Dev Med Child Neurol. 2005 Dec;47(12):795.
Evidence-based physical therapy for the management of children with cerebral palsy.
Mayston M.

Physical therapy is considered to be an important part of the management of cerebral palsy (CP); but what type of therapy, at what intensity, and for how long? These are questions which are not easily answered. Much valid criticism is directed towards the so-called 'named' therapy approaches because of the lack of a sound scientific basis and proof of efficacy. There is certainly little or no evidence to support the effectiveness of any particular approach, nor is there evidence to demonstrate superiority of one approach over another. Increasingly, therapists are being urged to adopt evidence-based intervention, but is there adequate, robust evidence available to enable them to do this? And how can available evidence be translated into effective practice? Certainly there are pockets of evidence to support the use of various forgotten and emerging modalities, such as muscle strengthening, constraint-induced movement therapy, and task-specific learning. This is encouraging; but such evidence cannot be generalized to all children with CP, particularly those who are classified as level IV and V on the Gross Motor Function Classification System, or to those who reside in disadvantaged environments. How can therapy for children with a multifaceted and complex disorder such as CP reach the stage where it is based on sound evidence?

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Dev Med Child Neurol. 2005 Dec;47(12):838-42.
Aquatic exercise for children with cerebral palsy.
Kelly M, Darrah J.
Calgary Youth Physiotherapy, Calgary, Canada.

Exercise for children with cerebral palsy (CP) is gaining popularity among pediatric physical therapists as an intervention choice. Exercise in water appeals to children with CP because of the unique quality of buoyancy of water that reduces joint loading and impact, and decreases the negative influences of poor balance and poor postural control. In this paper, research of land-based exercise and aquatic exercise for children with CP is reviewed. Clinically relevant considerations for aquatic exercise programming for children with CP are discussed.

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Spine. 2005 Nov 1;30(21):2420-3.
Cervical laminoplasty combined with muscle release in patients with athetoid cerebral palsy.
Ueda Y, Yoshikawa T, Koizumi M, Iida J, Miyazaki K, Nishiyama S, Matsuyama E, Kugai A, Takeshima T, Takakura Y.
Department of Orthopaedic Surgery, Nara Medical University, Nara, Japan. yueda@naramed-u.ac.jp

STUDY DESIGN: A retrospective study comparing cervical laminoplasty with or without muscle release for the treatment of cervical myelopathy resulting from athetoid cerebral palsy. OBJECTIVE: To assess the effectiveness of muscle release in the treatment of athetoid cerebral palsy. SUMMARY OF BACKGROUND DATA: While anterior and/or posterior spinal fusion has been generally accepted as necessary in surgical treatment for cervical myelopathy due to athetoid cerebral palsy, several studies have shown relatively favorable results following laminoplasty. Better results can be obtained by combining muscle release. METHODS.: Study participants were 10 patients who underwent cervical laminoplasty combined with muscle release (mean age, 44.6 years) and 15 patients who underwent cervical laminoplasty alone (mean age, 48.2 years). Therapeutic outcomes 1 year after surgery, as assessed by Kurokawa's methods and JOA scores, were compared between groups. RESULTS: Recovery rate 1 year after surgery was significantly higher for the muscle release group than for the control group. In both groups, recovery rates were significantly better for patients who could walk before surgery. CONCLUSIONS: Cervical laminoplasty combined with muscle release for the treatment of cervical myelopathy due to athetoid cerebral palsy is effective in simplifying postoperative therapy and improving JOA scores.

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J Pediatr Orthop B. 2005 Nov;14(6):389-404.
Management of the upper limb in cerebral palsy.
Chin TY, Duncan JA, Johnstone BR, Kerr Graham H.
Department of Orthopaedics, Royal Children's Hospital, Parkville, Victoria, Australia.

The management of the upper limb in cerebral palsy is often complex and challenging. Effective treatment requires a multidisciplinary approach involving paediatricians, occupational therapists, physiotherapists, orthotists and upper extremity surgeons. Interventions are generally aimed at improving function and cosmesis by spasticity management, preventing contractures and correcting established deformities. Treatment objectives vary according to each child and range from static correction of deformities to ease nursing care, to improvements in dynamic muscle balance to augment hand function. Botulinum toxin A therapy has been shown to relieve spasticity and improve function in the short term. Surgery is also effective but requires careful patient selection, as many children with cerebral palsy are not candidates for surgery. Occupational therapy and physiotherapy have small treatment effects alone but are essential adjuncts to medical and surgical management.

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Zhongguo Zhen Jiu. 2005 Oct;25(10):699-701.
[Clinical observation on children with language disorder of cerebral palsy treated by acupuncture]
[Article in Chinese]
Zhang QM, Jin R.
College of Acupuncture & Massage, Guangzhou TCM University, Guangdong 510405, China.

OBJECTIVE: To observe therapeutic effect of acupuncture on language disorder of cerebral palsy. METHODS: Ninety-eight cases of language disorder of cerebral palsy were randomly divided into an acupuncture group (n = 76) and a control group (n = 22). The acupuncture group were treated by needling main acupoints Sishenzhen, Niesanzhen, Naosanzhen, Zhisanzhen, Shesanzhen, Fengchi (GB 20) and Yamen (GV 15), and the control group by oral administration of pyrithioxine 0.1-0.2 g and gamma-aminobutyric acid, thrice each day, and intramuscular injection of 2 mL nerve growth factor, once daily. They all were treated for 4 months. RESULTS: The total effective rate was 86.8% in the acupuncture group and 59.1% in the control group with very significant difference between the two groups (P < 0.001), and early treatment in the acupuncture group had a better therapeutic effect. CONCLUSION: Acupuncture has obvious improvement action on language disorder in the children of cerebral palsy.

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Indian J Pediatr. 2005 Oct;72(10):869-72.
Pharmacologic interventions for reducing spasticity in cerebral palsy.
Patel DR, Soyode O.
Michigan State University, Kalamazoo Center for Medical Studies, Kalamazoo, Michigan 49008, USA. patel@kcms.msu.edu

Motor function abnormalities are a key feature of cerebral palsy. Spasticity is one of the main motor abnormalities seen in children with cerebral palsy. Spasticity is a velocity dependent increased resistance to movement. While in some children, spasticity may adversely impact the motor abilities, in others, it may help maintain posture and ability to ambulate. Thus, treatment to reduce spasticity requires careful consideration of various factors. Non-pharmacologic interventions used to reduce spasticity include physiotherapy, occupational therapy, use of adaptive equipment, various orthopedic surgical procedures and neurosurgical procedures. Pharmacologic interventions used for reducing spasticity in children with cerebral palsy reviewed in this article include oral administration of baclofen, diazepam, dantrolene and tizanidine, intrathecal baclofen, and local injections of botulinum toxin, phenol, and alcohol.

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Cochrane Database Syst Rev. 2005 Oct 19;(4):CD004093.
Surgical treatment for the thumb-in-palm deformity in patients with cerebral palsy.
Smeulders M, Coester A, Kreulen M, Smeulders M.

BACKGROUND: Thumb-in-palm deformity in patients with spastic cerebral palsy is a deformity that impairs the ability to use the thumb and thus severely limits hand function. From the variety of operative procedures that have been described, it may be clear that there is no consensus on the surgical treatment of thumb-in-palm deformity. OBJECTIVES: To review the efficacy of surgical interventions for the thumb-in-palm deformity in patients with spastic cerebral palsy; to review the selection criteria to surgically treat thumb-in-palm deformity in these patients; and to review the outcome assessment used in these studies. SEARCH STRATEGY: We identified studies for inclusion from searches of several electronic databases: the Cochrane Central Register of Controlled Trials (Issue 4, 2003), MEDLINE (1966 to December 2004), EMBASE (1980 to December 2004) and CINAHL (1982 to December 2004).We also cross-checked the reference lists of these studies to identify additional studies. SELECTION CRITERIA: We considered a trial eligible for inclusion when it met the following criteria. 1) It was described as a randomized clinical trial, clinical controlled trial or prospective study that compared pre-operative- with post-operative outcome assessment. 2) It concerned patients with thumb-in-palm deformity affected by spastic cerebral palsy. There was no restriction in age. 3) It compared or described any surgical intervention to the thumb. 4) It followed subjects for at least six months. 5) Outcomes described included one or more of the following items: rate of success; functional improvement; active and passive range of motion of the thumb; grasp and release; pinch grip; complications and side effects; and quality of life. DATA COLLECTION AND ANALYSIS: Two authors assessed each study using a scoring system. Meta-analysis was not possible because the selected studies were poorly designed, and the results were presented in an incompatible form. Therefore, we compiled a descriptive summary of the results of the individual studies. We did not attempt to acquire the raw data for re-analysis. MAIN RESULTS: We identified 14 prospective studies that compared preoperative and postoperative outcomes as eligible for inclusion in this review. We found no randomized clinical trials or controlled clinical trials. The studies with the best available evidence were prospective studies that compared pre- with post-operative assessment. After assessment, we ultimately included nine studies.Participants In all the included studies the participants were more or less homogeneous regarding the most important prognostic indications. The nine included studies treated 234 patients. Age at operation ranged from 4-48 years (Median approximately 11 years).Interventions Twenty-four different specific interventions were performed, or combined, aiming to 1) stabilize the first metacarpophalangeal joint, 2) weaken the spastic thumb adductors, and 3) augment thumb abduction and extension. Outcome measures All of the included studies assessed whether the thumb had stayed out of the palm at follow-up. Additional outcome measures varied among studies. Selection criteria There was no consensus on the selection criteria for eligibility for surgical treatment. There was also considerable variety in the use of methods of assessment among the studies. There is no standardized method to evaluate the pre- and post-operative data, and most of the assessment methods were not validated. It was impossible to compare the outcomes among studies. Judgement about the effectiveness of one particular surgical intervention was not possible, because different surgical interventions and co-interventions were used within most studies. Nonetheless, generally, the outcome of surgical treatment of thumb-in-palm deformity was considered satisfactory to both patients and to surgeons in all studies. AUTHORS' CONCLUSIONS: Because the methodological quality of the studies is poor, it is impossible to provide a reliable judgement of the role of surgery for thumb-in-palm deformity. This review has demonstrated the need for randomized clinical trials or controlled clinical trials on the surgical treatment of thumb-in-palm deformity. Surgical reconstruction appears to improve hand function, to facilitate hygiene, and to improve the appearance and quality of life. For patient selection, a validated classification system should be developed to determine the type and extent of the cerebral palsied hand. The influence of age, intelligence, and voluntary muscle control still needs to be investigated. Investigators should focus on one particular surgical intervention or a specific group of interventions to find out which procedures produce the best functional improvement.

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Dev Med Child Neurol. 2005 Oct;47(10):709-12.
Botulinum toxin and cerebral palsy: time for reflection?
Gough M, Fairhurst C, Shortland AP.
One Small Step Gait Analysis Laboratory, Guy's Hospital, London, UK. martin.gough@gstt.sthames.nhs.uk

Botulinum toxin A (BTX-A) is increasingly being used in early management of spasticity in ambulant children with cerebral palsy (CP), with the aim of improving function, promoting muscle growth, and delaying the need for surgical intervention. However, there is a lack of evidence about the long-term outcome of BTX-A injections. The focus on spasticity as the predominant problem in younger children with spastic CP may not fully consider the associated muscle weakness. It also raises concern that although BTX-A may improve function in the short term, it has the potential to affect muscle growth and function adversely in the long term. A cautious approach to the early use of BTX-A, with the use of objective outcome measures within a specialized multidisciplinary setting, is recommended, particularly in ambulant children with spastic diplegic CP, until further evidence is available on the long-term outcome of early BTX-A injections in children with CP.

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Dev Med Child Neurol. 2005 Oct;47(10):684-90.
Immediate effect of percutaneous intramuscular stimulation during gait in children with cerebral palsy: a feasibility study.
Orlin MN, Pierce SR, Stackhouse CL, Smith BT, Johnston T, Shewokis PA, McCarthy JJ.
Programs in Rehabilitation Sciences, Drexel University, Philadelphia, PA 19102-1192, USA. margo.n.orlin@drexel.edu

The feasibility of percutaneous intramuscular functional electrical stimulation (P-FES) in children with cerebral palsy (CP) for immediate improvement of ankle kinematics during gait has not previously been reported. Eight children with CP (six with diplegia, two with hemiplegia; mean age 9 years 1 month [SD 1 y 4 mo; range 7 y 11 mo to 11 y 10 mo]) had percutaneous intramuscular electrodes implanted into the gastrocnemius (GA) and tibialis anterior (TA) muscles of their involved limbs. Stimulation was provided during appropriate phases of the gait cycle in three conditions (GA only, TA only, and GA/TA). immediately after a week of practice for each stimulation condition, a gait analysis was performed with and without stimulation. A significant improvement in peak dorsiflexion in swing for the more affected extremity and dorsiflexion at initial contact for the less affected extremity were found in the GA/TA condition. Clinically meaningful trends were evident for improvements in dorsiflexion kinematics for the more and less affected extremities in the TA only and GA/TA conditions. The results suggest that P-FES might immediately improve ankle kinematics in children with CP.

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Eur J Pediatr. 2005 Sep 20; [Epub ahead of print]
Social interaction and self-esteem of children with cerebral palsy after treatment for severe drooling.
van der Burg JJ, Jongerius PH, van Limbeek J, van Hulst K, Rotteveel JJ.
Department of Special Education, Radboud University Nijmegen, PO Box 9104, 6500 HE , Nijmegen, The Netherlands, j.vanderburg@pwo.ru.nl.

The impact of salivary flow reduction following medication (scopolamine and botulinum neurotoxin) on social interaction and emotional development (self-esteem) was evaluated in a group of 45 children with cerebral palsy who suffered from severe drooling. The children ranged in age from 3 to 16 years (median 9.1 years); 28 were male, 17 female. A questionnaire to document the impact of drooling on social interaction and self-esteem for both the children and their parents was developed and administered during the use of scopolamine and up to 24 weeks after intraglandular botulinum neurotoxin in the submandibular glands. The reduction of drooling was related to increased social contacts with peers. In addition, parents perceived that the impact of drooling on the level of the child's satisfaction on physical appearance, relations within the extended family, and life in general increased. Although medication led to (temporary) positive changes, many social and emotional consequences remained unchanged. Conclusion: Interventions to treat drooling should not only be evaluated using measurements of drooling, but the consequences on social interaction and self-esteem should also be assessed.

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J Ir Dent Assoc. 2005 Autumn;51(3):126-31.
Management of drooling by transposition of the submandibular ducts and excision of the sublingual glands.
McAloney N, Kerawala CJ, Stassen LF.
Department of Oral and Facial Surgery, Sunderland Royal Hospital, Kayll Road, Sunderland, Tyne and Wear, SR4 7TP, England.

STATEMENT OF THE PROBLEM: Persistent drooling is common in patients with neurological impairments such as cerebral palsy. Although it may be induced by an excess of saliva, it usually results from incontinence secondary to impaired cerebral control of orofacial function. Various techniques, both medical and surgical, exist to combat the problem. The patient should have a course of conservative management initially (head position, education and training, suction aids, bio-feedback and support). Non-surgical managements and medical treatment should start as early as possible. Surgery has a place, when conservative and medical treatments (drugs/botulinum toxin) have failed. PURPOSE OF THE STUDY: Patients subjected to some of the more radical surgical methods may develop complications of the procedures themselves, it is important therefore that any intervention is based on sound principles. Physiology predicts that the most benefit would be derived from diversion of submandibular rather than parotid salivary flow (Fig. 1). MATERIALS AND METHODS: To assess the effect of bilateral transposition of the submandibular ducts combined with excision of the sublingual glands as a treatment for drooling, a retrospective survey of 21 patients was undertaken by contacting their carers and reviewing the clinical notes. RESULTS: Sixteen out of 21 patients had good to excellent control of their drooling with minimal side-effects and low morbidity. CONCLUSION: Drooling should be managed with a team approach using non-surgical management in the first instance. Surgery has a place and can be beneficial with few long-term side effects. Patients require long-term paedontic/dental follow up to maintain a healthy oral cavity.

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Pediatr Rehabil. 2005 Jul-Sep;8(3):207-13.
GMFM 1 year after continuous intrathecal baclofen infusion.
Krach LE, Kriel RL, Gilmartin RC, Swift DM, Storrs BB, Abbott R, Ward JD, Bloom KK, Brooks WH, Madsen JR, McLaughlin JF, Nadell JM.
Pediatric Rehabilitation Medicine at Gillette Children's Specialty Healthcare, St Paul, MN, USA. lkrach@gillettechildrens.com

The purpose of this study was to assess whether there is an improvement in motor function in persons with cerebral palsy (CP) who have had a reduction of muscle tone by continuous intrathecal baclofen infusion. This was a prospective, open label, non-blinded case series without a control group, conducted at multiple centres. There were 31 subjects, aged 4-29 years. All had a pre-treatment mean lower extremity Ashworth scores of >or= 3 and a significant reduction in tone after a bolus injection of intrathecal baclofen (ITB) and received an implanted pump for continuous delivery of ITB. Motor function was assessed by the Gross Motor Function Measure (GMFM) prior to and 1 year following pump implantation. Significant improvement (p < 0.05) in mean GMFM scores was seen in subjects < 8 years (mean change 4.1) and in those from 8-18 years (mean change 3.7) and in subjects with CP Classes 2 and 5 (mean changes 6.2 and 2.9). There was a statistically significant decrease (p < 0.05) in Ashworth scores in CP classes 2-5. Subjects or their caregivers that completed a survey about perceived changes stated that motor control, positioning and endurance improved.

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Pediatr Neurol. 2005 Aug;33(2):110-113.
Epilepsy and Intrathecal Baclofen Therapy in Children With Cerebral Palsy.
Buonaguro V, Scelsa B, Curci D, Monforte S, Iuorno T, Motta F.
Department of Paediatric Orthopedics, Children's Hospital V. Buzzi, Milan, Italy.

The objective of this study was to analyze the relationship between epilepsy and intrathecal baclofen by investigating a consecutive sample of 150 children with cerebral palsy or spasticity of cerebral origin who underwent intrathecal baclofen. The medical charts of the 150 children were retrospectively reviewed. A series of 100 children with cerebral palsy, operated on other procedures, was reviewed as a control group. Forty percent of the 150 children had epilepsy before intrathecal baclofen pump implantation; 13.3% had a decrease in seizure frequency after intrathecal baclofen, while two children worsened and one child had seizures ex novo. We conclude that in children with spasticity of cerebral origin, intrathecal baclofen does not seem to aggravate or induce seizure activity.

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J Rehabil Med. 2005 Jul;37(4):263-70.
Effectiveness of intensive training for children with cerebral palsy--a comparison between child and youth rehabilitation
and conductive education.
Odman P, Oberg B.
Department of Health and Society, Faculty of Health Sciences, Linkoping University, Linkoping, Sweden. pia.odman@ihs.liu.se

OBJECTIVES: To compare the short-term effectiveness of 1 intensive training period in child and youth rehabilitation with Move&Walk conductive education and describe the effects of 1 intensive training period in terms of changes at 1 year. The amount and influence of additional consumption of training during the 1-year follow-up was also analysed. DESIGN: Quasi-experimental with 2 groups: Lemo (n=23) and Move&Walk (n=29). PATIENTS: A total of 52 children with cerebral palsy, age range 3-16 years. METHODS: Data included repeated measures with Gross Motor Function Measure (GMFM) and Pediatric Evaluation of Disability Inventory-Functional Skills (PEDI-FS). Data on additional consumption of training was collected at the 1-year follow-up. RESULTS: There was no difference in proportion of change on the clinical measures between the training programmes, except for a higher proportion of improvement on the GMFM total score in Lemo. At the group level, small improvements were shown on GMFM and PEDI FS in the short-term and on PEDI FS only at 1 year. A higher proportion of children who participated in repeated intensive training periods showed improved social functioning. CONCLUSION: No major differences were shown between the 2 training programmes. One intensive training period facilitated small improvements in gross motor function. The majority of children had a high consumption of training during the 1-year follow-up and the added value of repeated intensive training periods was limited.

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Ment Retard Dev Disabil Res Rev. 2005;11(2):156-63.
Complementary and alternative therapies for cerebral palsy.
Liptak GS.
University of Rochester Medical Center, NY 14642, USA. Gregory_Liptak@urmc.rochester.edu

The optimal practice of medicine includes integrating individual clinical expertise with the best available clinical evidence from systematic research. This article reviews nine treatment modalities used for children who have cerebral palsy (CP), including hyperbaric oxygen, the Adeli Suit, patterning, electrical stimulation, conductive education, equine-assisted therapy, craniosacral therapy, Feldenkrais therapy, and acupuncture. Unfortunately, these modalities have different degrees of published evidence to support or refute their effectiveness. Uncontrolled and controlled trials of hippotherapy have shown beneficial effects on body structures and functioning. Studies of acupuncture are promising, but more studies are required before specific recommendations can be made. Most studies of patterning have been negative and its use cannot be recommended. However, for the other interventions, such as hyperbaric oxygen, more evidence is required before recommendations can be made. The individual with CP and his or her family have a right to full disclosure of all possible treatment options and whatever knowledge currently is available regarding these therapies. Copyright 2005 Wiley-Liss, Inc.

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Neural Plast. 2005;12(2-3):229-43; discussion 263-72.
Efficacy and effectiveness of physical therapy in enhancing postural control in children with cerebral palsy.
Harris SR, Roxborough L.
School of Rehabilitation Sciences, Faculty of Medicine, University of British Columbia, Vancouver, B.C. V6T 2B5, Canada. shar@interchange.ubc.ca

The purpose of this article was to conduct a systematic review of studies that examined the efficacy and effectiveness of postural control intervention strategies for children with CP. Only physical therapy interventions were included, e.g. adaptive seating devices, ankle foot orthoses, neurodevelopmental treatment. A multifaceted search strategy was employed to identify all potential studies published between 1990 and 2004. The search strategy included electronic databases, reference list scanning, author and citation tracking of relevant studies, and hand searching of pediatric physical therapy journals and conference proceedings. Twelve studies (1991-2004), comprising ten group design studies and two single subject studies, met our inclusion criteria. A variety of age ranges and severity of children with cerebral palsy (n=132) participated in the studies. The study quality scores ranged from 2 to 7 (total possible range of 0 to 7) with a median score of 5.5 and a mode of 6. As was true in an earlier systematic review on adaptive seating, most of the 12 'experimental' studies published since 1990 that were aimed at evaluating the effectiveness of postural control strategies provided lower levels of evidence, i.e. Sackett Levels III to V. Additional studies with stronger designs are needed to establish that postural control interventions for children with CP are effective.

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Neural Plast. 2005;12(2-3):211-9; discussion 263-72.
Postural dysfunction during standing and walking in children with cerebral palsy: what are the underlying problems and what new therapies might improve balance?
Woollacott MH, Shumway-Cook A.
Department of Human Physiology, University of Oregon, Eugene 97403, USA.

In this review we explore studies related to constraints on balance and walking in children with cerebral palsy (CP) and the efficacy of training reactive balance (recovering from a slip induced by a platform displacement) in children with both spastic hemiplegic and diplegic CP. Children with CP show (a) crouched posture, contributing to decreased ability to recover balance (longer time/increased sway); (b) delayed responses in ankle muscles; (c) inappropriate muscle response sequencing; (d) increased coactivation of agonists/antagonists. Constraints on gait include (a) crouched gait; (b) increased co-activation of agonists/antagonists; (c) decreased muscle activation; (d) spasticity. The efficiency of balance recovery can be improved in children with CP, indicated by both a reduction in the total center of pressure path used during balance recovery and in the time to restabilize balance after training. Changes in muscle response characteristics contributing to improved recovery include reductions in time of contraction onset, improved muscle response organization, and reduced co-contraction of agonists/antagonists. Clinical implications include the suggestion that improvement in the ability to recover balance is possible in school age children with CP.

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Early Hum Dev. 2005 Jun;81(6):545-53.
Risk factors for cerebral palsy in preterm infants.
Takahashi R, Yamada M, Takahashi T, Ito T, Nakae S, Kobayashi Y, Onuma A.
Neonatal Intensive Care Unit in Perinatal Center, Japanese Red Cross Sendai Hospital, 2-43-3, Yagiyamahonchou, Sendai 982-8501, Japan. ritsu@sendai.jrc.or.jp

OBJECTIVE: To identify crucial factors that precipitate cerebral palsy by controlling confounding factors in logistic regression analyses. DESIGN AND PATIENTS: We retrospectively investigated a cohort of all 922 infants with gestational ages of less than 34 weeks (22-33 weeks), who were admitted to our neonatal intensive care unit between 1990 and 1998. Thirty (3.7%) were diagnosed to have cerebral palsy. We analyzed the prenatal and postnatal clinical variables of the cerebral palsy cases and compared them with 150 randomly selected controls. RESULTS: Risk factors for cerebral palsy identified in univariate analysis were: twin pregnancy, long-term ritodrine tocolysis, respiratory distress syndrome, air leak, surfactant administration, intermittent mandatory ventilation, high frequency oscillation, lowest PaCO2 levels, prolonged hypocarbia during the first 72 h of life, and postnatal steroid therapy. In a conditional multiple logistic model, long-term ritodrine tocolysis, prolonged hypocarbia and postnatal steroid therapy remained associated with an increased risk of cerebral palsy after adjustment for other antenatal and postnatal variables (OR [Odds Ratio] = 8.62, 95% CI [Confidence Interval], 2.18-33.97; OR = 7.81, 95% CI, 1.42-42.92; OR = 21.37, 95% CI, 2.01-227.29, respectively). CONCLUSIONS: Our results suggest that long-term ritodrine tocolysis underlines the development of cerebral palsy. Further assessments of the effect of ritodrine on fetal circulation and nervous system are required. Moreover, possible alternatives to systemic postnatal steroids are needed, and carbon dioxide levels should be more strictly controlled.

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J Pediatr Orthop. 2005 May-Jun;25(3):286-91.
Accuracy of intramuscular injection of botulinum toxin A in juvenile cerebral palsy: a comparison between manual needle placement and placement guided by electrical stimulation.
Chin TY, Nattrass GR, Selber P, Graham HK.
Department of Orthopaedics, Royal Children's Hospital, Flemington Road, Parkville 3052, Victoria, Australia. kerr.graham@rch.org.au

Most clinicians who perform botulinum toxin A injections for children with cerebral palsy do so using the "free-hand" or manual technique without using radiologic or electrophysiologic guidance to aid needle placement. The objective of this study was to investigate the accuracy of manual needle placement compared with needle placement guided by electrical stimulation. A total of 1,372 separate injections for upper and lower limb spasticity were evaluated in 226 children with cerebral palsy. The accuracy of manual needle placement compared with electrical stimulation was acceptable only for gastroc-soleus (>75%); it was unacceptable for the hip adductors (67%), medial hamstrings (46%), tibialis posterior (11%), biceps brachii (62%), and forearm and hand muscles (13% to 35%). The authors recommend using electrical stimulation or other guidance techniques to aid accurate needle placement in all muscles except the gastroc-soleus. Further study is needed to determine whether more accurate injecting will lead to better functional outcomes and more efficient use of botulinum toxin A.

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J Neurosurg. 2005 May;102(4 Suppl):385-9.
Comparison between botulinum toxin type A injection and selective posterior rhizotomy in improving gait performance in children with cerebral palsy.
Wong AM, Pei YC, Lui TN, Chen CL, Wang CM, Chung CY.
Department of Physical Medicine and Rehabilitation, Chang Gung Memorial Hospital and Chang Gung University, Taipei, Taiwan. walice@adm.cgmh.org.tw

OBJECT: Both botulinum toxin type A (BTA) injection and selective posterior rhizotomy (SPR) are well-recognized treatments for children with spastic cerebral palsy (CP); however, there has been no study in which the long-term effectiveness of these two approaches has been compared. METHODS: The study population comprised 62 ambulatory children with spastic diplegic CP who were participating in the same rehabilitation program and 19 healthy volunteers. The children with CP were divided into the following three groups: BTA (22 cases), SPR (20 cases), and no treatment (20 cases); the healthy volunteers served as the control group. A computer-assisted gait analysis system was used to assess gait performance. Gait was assessed in the three groups of children at 1 week before treatment, and 3, 6, 12, and 20 months after treatment. Based on the analysis of walking velocity, cadence, and step length, the BTA group demonstrated rapid improvement posttreatment but the improvement became insignificant after 12 months even with repeated BTA injections at 4-month intervals. In contrast, the SPR group displayed initial deterioration of gait parameters during the first 3 months posttreatment and then improved continuously from 6 to 20 months. The control group did not display a significant change in gait. CONCLUSIONS: The findings suggest that the effectiveness of BTA injection is more short-lived and SPR initially decreases gait performance but is expected to improve gait performance at between 6 and 20 months after the procedure.

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J Neurosurg. 2005 May;102(4 Suppl):363-73.
Spinal deformities after selective dorsal rhizotomy for spastic cerebral palsy.
Steinbok P, Hicdonmez T, Sawatzky B, Beauchamp R, Wickenheiser D.
Departments of Surgery and Orthopedic Surgery, British Columbia's Children's Hospital, Vancouver, British Columbia, Canada. psteinbok@cw.bc.ca

OBJECT: Spinal deformities are significant problems in children with spastic cerebral palsy. The treatment of their spasticity by selective dorsal rhizotomy (SDR) may worsen or improve these problems. The purpose of this study was to determine the incidence of and change in degree of thoracolumbar scoliosis, thoracic kyphosis, and lumbar lordosis in children who have undergone SDR. METHODS: A retrospective review was conducted of children younger than 18 years of age, who had undergone SDR at British Columbia's Children's Hospital from 1987 to 2001 and in whom preoperative and postoperative spine radiographs have been obtained. Angles for thoracolumbar scoliosis, thoracic kyphosis, and lumbar lordosis were measured. The study group comprised 105 patients. The mean age at surgery was 5.2 years (range 2.7-14.6 years), with a mean time to most recent follow-up radiographs of 4.3 years (1-13.6 years). Sixty-two children had spastic diplegia (59%), 34 spastic quadriplegia (32%), and nine quadriplegia and intellectual delay (9%). A total of 104 children underwent laminoplasty with replacement of the laminae, usually from L-1 to S-1 and 54.8% of children had scoliosis at last follow up, with 25% having worsening of 10 degrees or more. The incidence of abnormal kyphosis at the last follow-up visit was 38.6%, with 31.8% having worsening of 15 degrees or more. The incidence of hyperlordosis at last follow up was 21.3%, with 36% having worsening of 15 degrees or more. The factors in this series impacting development of spinal deformities have been analyzed and are discussed. CONCLUSIONS: The relatively high incidence of spinal deformity in children who have undergone SDR via multi-level lumbosacral laminoplasties should raise some concern.

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J Trop Pediatr. 2005 Apr;51(2):109-13.
The efficacy of diazepam in enhancing motor function in children with spastic cerebral palsy.
Mathew A, Mathew MC, Thomas M, Antonisamy B.
Developmental Paediatrics Unit, Christian Medical College & Hospital, Tamil Nadu, India.

Muscle spasm and hypertonia limit mobility in children with spastic cerebral palsy. This double-blind, placebo-controlled, randomized controlled clinical trial studies the clinical efficacy of a low dose of diazepam in enhancing movement in children with spastic cerebral palsy. One hundred and eighty children fulfilled the criteria and were randomly allocated to receive one of two doses of diazepam or placebo at bedtime; 173 completed the study. There was a significant reduction of hypertonia, improvement in the range of passive movement, and an increase in spontaneous movement in the children who received diazepam. There was no report of daytime drowsiness. In developing countries, where cost factors often determine choice of drug, diazepam is a cheap and effective way of relieving spasm and stiffness, optimizing physical therapy and facilitating movement in children with spasticity.

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Arch Phys Med Rehabil. 2005 Apr;86(4):837-44.
Methods of constraint-induced movement therapy for children with hemiplegic cerebral palsy: development of a child-friendly intervention for improving upper-extremity function.
Gordon AM, Charles J, Wolf SL.
Department of Biobehavioral Sciences, Teachers College, Columbia University, New York, NY 10027, USA. ag275@columbia.edu

We delineate the methodology for constraint-induced movement therapy (CIMT) modified for children with hemiplegic cerebral palsy (CP) and describe important considerations that need to be made when testing this intervention in children. The resulting intervention evolved from piloting and testing it with 38 children with hemiplegic CP who were between the ages of 4 and 14 years. Thirty-seven successfully completed the treatment protocol. The intervention retains the 2 major elements of the adult CIMT (repetitive practice, shaping) and was constructed to be as child-friendly as possible. It involves restraining the noninvolved extremity with a sling and having the child engage in unimanual activities with the involved extremity 6 hours a day for 10 days (60 h). Specific activities are selected by considering joint movements with pronounced deficits and improvement of which interventionists believe have greatest potential. The activities are chosen to elicit repetitive practice and shaping. The intervention is conducted in groups of 2 to 3 children to provide social interaction, modeling, and encouragement. Each child is assigned to an interventionist to maintain at least a 1:1 ratio. CIMT can be modified to be child-friendly while maintaining all practice elements of the adult CIMT. The modified therapy is tolerated by most children. Further modifications will likely be required to hone in on the specific components of the intervention that are most effective before applying them to children who are most likely to benefit.

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Acta Orthop Scand. 2005 Feb;76(1):128-37.
Adductor tenotomy in spastic cerebral palsy. A long-term follow-up study of 78 patients.
Terjesen T, Lie GD, Hyldmo AA, Knaus A.
Department of Orthopedics, Rikshospitalet University Hospital, NO-0027 Oslo, Norway. terje.terjesen@rikshopitalet.no

BACKGROUND: There is a risk of hip dislocation in children with spastic cerebral palsy. We evaluated the prophylactic effect of adductor tenotomy in patients with long-term follow-up. PATIENTS AND METHODS: Our material comprised 78 patients (46 boys) with a mean age of 8 (2-17) years who underwent adductor tenotomy during the period 1986-1991. 40 patients had spastic diplegia and 38 had quadriplegia. For patients who had further hip surgery, follow-up was until the next hip operation. Those who had not undergone further surgery were invited to a follow-up examination. The migration percentage (MP) was measured on the preoperative and follow-up radiographs. The radiographic result was termed good if MP at follow-up was reduced or had increased less than 10%. The follow-up period was 10 (1.6-16) years, with a mean of 6 years for patients with later hip surgery and 13 years without such surgery. RESULTS: The clinical outcome was good in 51 cases, poor in 12, and uncertain in 15. The radiographic result was good in 39 of the 53 patients with radiographs available both preoperatively and at follow-up. The patients with good radiographic results had lower preoperative MP than those with poor results (MP 34% versus 49%) and lower preoperative acetabular index. The mean increase in MP (worst hip in each patient) was 1.9% per year, which is considerably less than that in nonoperated patients. Further hip surgery was necessary in 27 patients, because of increasing MP in 14 cases and for clinical reasons in 13. INTERPRETATION: Adductor tenotomy reduced the trend towards lateral displacement of the hip joints. The operation had a favorable outcome in approximately two-thirds of the patients. The operation should be performed before the MP reaches 50%.

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Childs Nerv Syst. 2005 Feb 10; [Epub ahead of print]
Selective dorsal rhizotomy in cerebral palsy to improve functional abilities: evaluation of criteria for selection.
van Schie PE, Vermeulen RJ, van Ouwerkerk WJ, Kwakkel G, Becher JG.
Department of Rehabilitation Medicine, VU University Medical Center, De Boelelaan 1117, P.O. Box 7057, 1007 MB, Amsterdam, The Netherlands.

OBJECTIVES: The aim of this study is to evaluate the effect of selective dorsal rhizotomy (SDR) on functional abilities in a well-defined group of ambulatory children with spastic diplegia. METHODS: Nine children were selected for SDR (mean age 65 months, range 43-82 months). Gross motor function was measured with the Gross Motor Function Measure (GMFM-88). Self-care was assessed with the Pediatric Evaluation of Disability Inventory (PEDI) and gait pattern was measured with the Edinburgh Visual Gait Score (EGS). There were nine single-case research designs with a 12-month follow-up after surgery. RESULTS: After 12 months the mean improvement in the total GMFM-88 scores was 8.8%. On an individual level, all patients improved significantly in comparison with baseline. Functional skills and care-giver assistance measured with the PEDI showed significant improvement. Improvement in gait was also found; in particular, better initial contact and heel-lift resulted in an increased EGS. CONCLUSION: In this well-defined group of ambulatory children SDR had a small but significant positive effect on gross motor function, self-care and gait pattern.

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J Pediatr Orthop. 2005 Jan-Feb;25(1):84-8.
Results of tibial rotational osteotomy without concomitant fibular osteotomy in children with cerebral palsy.
Ryan DD, Rethlefsen SA, Skaggs DL, Kay RM.
Children's Hospital, Los Angeles, California 90027, USA.

A retrospective review was performed of 46 consecutive ambulatory children with cerebral palsy and tibial torsion who underwent 72 distal tibial derotational osteotomies without concomitant fibular osteotomy. The average amount of derotation measured at surgery was 21 +/- 5 degrees. The average change in thigh-foot angle at follow-up was 21 +/- 9 degrees. There were eight perioperative complications (11%): three delayed unions, three superficial wound dehiscences, one case of osteomyelitis, and one superficial pin tract infection. There were no incidences of malunion or nonunion. Preoperative and postoperative three-dimensional gait analysis data were used to determine the effect of distal tibial osteotomy on foot progression angle in seven subjects (11 limbs). Foot progression improved significantly. This study shows that distal tibial osteotomy alone (without concomitant fibular osteotomy) is an effective and safe procedure for correcting and maintaining correction of tibial torsion in patients with cerebral palsy.

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J Pediatr Orthop. 2005 Jan-Feb;25(1):74-8.
Proximal rectus femoris release surgery is not effective in normalizing hip and pelvic variables during gait in children with cerebral palsy.
McMulkin ML, Baird GO, Barr KM, Caskey PM, Ferguson RL.
Motion Analysis Laboratory, Shriners Hospitals for Children, Spokane, Washington 99204, USA. mmcmulkin@shrinenet.org

The purpose of this study was to determine the efficacy of the proximal rectus femoris release to treat hip flexor contractures and hip and pelvic gait deviations in children with spastic cerebral palsy. This study was a retrospective repeated-measures analysis of data collected on two matched groups of patients, those with and without proximal rectus femoris release surgery, seen in our Motion Analysis Laboratory. Proximal rectus release surgery did not improve hip extension, did not decrease anterior pelvic tilt, and did not improve temporal-distance measures of gait in children with cerebral palsy. A multivariate measure, the Hip Flexor Index, was also unchanged. The group of patients without any hip flexor surgery was not different from the rectus femoris release group on hip or pelvic variables before or after surgery. The findings of this study offer no evidence that the proximal rectus femoris release is successful in achieving desired gait outcomes at the hip and pelvis in children with cerebral palsy.

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Dev Med Child Neurol. 2005 Jan;47(1):46-52.
Effect of functional electrical stimulation, applied during walking, on gait in spastic cerebral palsy.
Postans NJ, Granat MH.
Orthotic Research and Locomotor Assessment Unit, Robert Jones and Agnes Hunt Orthopaedic and District Hospital NHS Trust, Oswestry, Shropshire SY10 7AG, UK. neil.postans@rjah.nhs.uk

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.

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Indian J Pediatr. 2004 Dec;71(12):1087-91.
Botulinum toxin in children with cerebral palsy.
Singhi P, Ray M.
Advanced Pediatric Centre, Postgraduate Institute of Medical Sciences, Chandigarh, India. psinghi@glide.net.in

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

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Schmerz. 2004 Dec;18(6):498-505.
[Botulinum toxin A in orthopedic pain therapy]
[Article in German]
Placzek R, Sohling M, Gessler M, Jerosch J.
Klinik und Poliklinik fur Orthopadie, Universitatsklinikum Hamburg-Eppendorf, Hamburg. placzek@uke.uni-hamburg.de

Botulinum toxin A (BTX A) has been used for more than 20 years as a safe and effective treatment for numerous diseases characterized by pathological muscle hypertension. In patients suffering from dystonia or spasticity, it has been observed that use of BTX A results not only in muscle relaxation but also frequently relieves associated pain. This pain relief is often seen earlier and to a much greater extent than the muscular relaxation itself. This has led to extending the use of BTX A to treat various focal pain syndromes. The results of initial studies in specific musculoskeletal pain therapy suggest that BTX A infiltrations are effective in the treatment of chronic, therapy-resistant pain of the shoulder and back region. Furthermore, BTX A has been found to be a less invasive option for the treatment of chronic epicondylitis and similar tendonitis conditions. The healing process following rupture of tendons or muscle transfer operations may be improved. In adults with increased muscle tone and endoprostheses, the targeted relaxation of spastic muscles might increase the lifetime of the implant and diminish aseptic loosening. In children with cerebral palsy, prophylactic treatment of hip luxation appears possible. The doses used in pain therapy are low; if correctly applied, the tolerance and safety are high and the effect lasts for a number of weeks.

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Am J Health Syst Pharm. 2004 Nov 15;61(22 Suppl 6):S11-23.
Botulinum neurotoxin serotype A: a clinical update on non-cosmetic uses.
Charles PD.
Movement Disorders Clinic, Vanderbilt University, Nashville, TN, USA. david.charles@vanderbilt.edu

PURPOSE: Clinical experience with botulinum toxin type A for non-cosmetic uses that are approved by the Food and Drug Administration (FDA) and various other non-cosmetic uses that are not approved by FDA, including some applications that are widely known and others that currently are emerging, is discussed. SUMMARY: FDA-approved indications for botulinum toxin type A (Botox) include the temporary treatment of cervical dystonia (a neuromuscular disorder involving the head and neck), the oculomotor disorders strabismus (improperly aligned eyes) and blepharospasm (involuntary contraction of the eye muscles), and severe primary axillary hyperhidrosis (excessive sweating). Other uses of botulinum toxin type A that are widely known but not approved by FDA include spastic disorders associated with injury or disease of the central nervous system including trauma, stroke, multiple sclerosis, or cerebral palsy and focal dystonias affecting the limbs, face, jaw, or vocal cords. Treatment and prevention of chronic headache and chronic musculoskeletal pain are emerging uses for botulinum toxin type A. CONCLUSION: Many of the conditions for which botulinum toxin type A has been explored are common and difficult to treat. Temporary improvement in symptoms is associated with botulinum toxin type A injection, and repeat treatment often is required. The drug is well tolerated and has a wide margin of safety.

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Spinal Cord. 2004 Nov 16; [Epub ahead of print]
Intrathecal drug therapy using the Codman Model 3000 Constant Flow Implantable Infusion Pumps: experience with 17 cases.
Ethans KD, Schryvers OI, Nance PW, Casey AR.
1Section of Physical Medicine and Rehabilitation, Department of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada.

OBJECTIVES:: The objective of this study was to evaluate the accuracy, reliability, safety, and efficacy of the Codman Model 3000 Constant Flow Implantable Infusion Pump for intrathecal baclofen delivery as a therapeutic option for the treatment of severe spasticity. The distinctive features of this pump include a raised, easily palpable septum, a safety valve protecting the bolus pathway, no programmer needed, and no battery to fail. DESIGN:: A total of 17 patients with spinal cord injury, multiple sclerosis, or cerebral palsy were implanted with this pump. The accuracy of the pump and drug treatment efficacy was determined at each visit and adjustments to the dosages were made as required. All the intrathecal drug delivery system complications were reviewed. RESULTS:: The expected efficacy was achieved. The accuracy of the implanted pumps ranged from 90-97% (average 94%). There were no complications due to primary pump problems. The complications reported are similar to other implantable infusion devices and include dehiscence of the suture line, pressure ulcer development, formation of seroma, inversion of the pump, baclofen overdose, and catheter failures. CONCLUSION:: The Codman Model 3000 Constant Flow Implantable Infusion Pump is an accurate, reliable, and convenient option for patients needing intrathecal baclofen therapy, with complications similar to other available pumps.Spinal Cord advance online publication, 16 November 2004; doi:10.1038/sj.sc.3101684.

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Dev Med Child Neurol. 2004 Nov;46(11):740-5.
Effect of intensive neurodevelopmental treatment in gross motor function of children with cerebral palsy.
Tsorlakis N, Evaggelinou C, Grouios G, Tsorbatzoudis C.
Hellenic Society for Care and Rehabilitation of Children with Disabilities, Thessaloniki, Greece. lemamou@in.gr

This study examined the effect of neurodevelopmental treatment (NDT) and differences in its intensity on gross motor function of children with cerebral palsy (CP). Participants were 34 children (12 females, 22 males; mean age 7y 3mo [SD 3y 6mo], age range 3 to 14y) with mild to moderate spasticity and hemiplegia (n=10), diplegia (n=12), and tetraplegia (n=12). Gross Motor Function Classification System levels were: I (n=10), II (n=10), and III (n=14). The paired sample, which was obtained by ratio stratification and matching by sex, age, and distribution of impairment from a total of 114 children with CP, was assigned randomly to two groups: group A underwent NDT twice a week and group B five times a week for 16 weeks. The outcome measure used was the Gross Motor Function Measure, which assessed the performance of the children before and after intervention. The paired-sample t-test revealed that gross motor function of children from both groups improved significantly after intervention (p<0.05). Children in group B performed better and showed significantly greater improvement than those in group A (p<0.05). Results support the effectiveness of NDT and underline the need for intensive application of the treatment.

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J Bone Joint Surg Am. 2004 Nov;86-A(11):2377-84.
Botulinum toxin as an adjunct to serial casting treatment in children with cerebral palsy.
Kay RM, Rethlefsen SA, Fern-Buneo A, Wren TA, Skaggs DL.
Childrens Orthopaedic Center, MS #69 (R.M.K., S.A.R., T.A.L.W., and D.L.S.) and Department of Rehabilitation Services, MS #56, Childrens Hospital Los Angeles, 4650 Sunset Boulevard, Los Angeles, CA 90027. srethlefsen@chla.usc.edu.

BACKGROUND: Although botulinum toxin A is frequently used to augment serial casting in the treatment of soft-tissue contractures in children with cerebral palsy, its effectiveness for this purpose has not been evaluated. The purpose of the present study was to determine whether botulinum toxin A injection increases the efficacy of serial casting. METHODS: A prospective, randomized trial was undertaken to compare serial casting only with serial casting combined with botulinum toxin A (Botox) injection for the treatment of ankle equinus contractures in twenty-three children with cerebral palsy. Range-of-motion testing, spasticity assessment, and computerized gait analysis were performed as long as twelve months after treatment. RESULTS: There was no difference between the groups with regard to the duration of casting required to correct the equinus contracture. Both groups maintained a significant improvement in passive ankle dorsiflexion throughout the follow-up period, although the group managed with casting and Botox had a significant loss of dorsiflexion when the values at six, nine, and twelve months were compared with the value at three months. Peak dorsiflexion during the stance and swing phases was significantly improved in both groups at three months but only in the group managed with casting alone at twelve months. Plantar flexor spasticity was significantly decreased at three months in both groups, but it was significantly decreased at six, nine, and twelve months only in the group managed with casting alone. Spasticity was significantly greater in the group managed with casting and Botox than it was in the group managed with casting only at six, nine, and twelve months. CONCLUSIONS: The present study demonstrates the efficacy of serial casting in the treatment of equinus contractures in children with cerebral palsy who are able to walk. Contrary to our hypothesis, the addition of botulinum toxin A to a serial casting regimen led to earlier recurrence of spasticity, contracture, and equinus during gait. The results of the present study suggest that botulinum toxin combined with serial casting for the treatment of fixed contractures will lead to a recurrence of plantar flexor spasticity and equinus contracture by six months in this patient population. While previous research has indicated that the injection of botulinum toxin A is superior to casting for the treatment of dynamic equinus, the present study suggests that serial casting alone is preferable for the treatment of fixed equinus contractures in children with cerebral palsy. LEVEL OF EVIDENCE: Therapeutic study, Level I-1a (randomized controlled trial [significant difference]). See Instructions to Authors for a complete description of levels of evidence.

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Phys Med Rehabil Clin N Am. 2004 Nov;15(4):843-54, vii.
Hippotherapy.
Meregillano G.
Physical Medicine and Rehabilitation Department, Veterans Affairs Palo Alto Health Care System, Livermore Division Building 62, M/S 117 4951, Arroyo Road, Livermore, CA 94550, USA. gnmotr@aol.com

Hippotherapy refers to the use of the movement of the horse asa treatment tool by physical therapists, occupational therapists,and speech-language therapists to address impairments, functional limitations, and disabilities in clients with neuromusculoskeletal dysfunction, such as cerebral palsy. Hippotherapy is used as part of an integrated treatment program to achieve functional outcomes. Hippotherapy engages the client in activities on the horse that are enjoyable and challenging. In the controlled hippotherapyenvironment, the therapist modifies the horse's movement and carefully grades sensory input, establishing a foundation for improved neurologic function and sensory processing. This foundation can be generalized to a wide range of daily activities,making the horse a valuable therapeutic tool for rehabilitation.

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Neurology. 2004 Oct 26;63(8):1371-5.
Botulinum toxin effect on salivary flow rate in children with cerebral palsy.
Jongerius PH, Rotteveel JJ, van Limbeek J, Gabreels FJ, van Hulst K, van den Hoogen FJ.
Department of Rehabilitation, University Medical Centre St. Radboud, PO Box 9101, 6500HB, Nijmegen (720), The Netherlands. p.jongerius@reval.umcn.nl

OBJECTIVE: To investigate the effectiveness of botulinum neurotoxin (BoNT) type A in reducing salivary flow rate in children with cerebral palsy (CP) with severe drooling. METHODS: During a controlled clinical trial, single-dose BoNT injections into the submandibular salivary glands were compared with scopolamine treatment. Forty-five school-aged children were included. Salivary flow rates from all major glands were obtained at baseline and compared with measurements during the interventions. Basic statistics consisted of analysis of difference scores. RESULTS: Compared with baseline, the mean decrease in submandibular flow was 25% during scopolamine and 42% following BoNT injections. The difference scores were significant with maximum reductions 2, 4, and 8 weeks following BoNT. Of all children, 95% responded during scopolamine. Response rates for BoNT were significantly lower and varied from 69% at 2 weeks to 49% at 24 weeks after injection (the end of the study). Four patients discontinued scopolamine therapy because of side effects. Only incidentally mild side effects were reported from BoNT. CONCLUSIONS: Intraglandular BoNT injections significantly reduce salivary flow rate in the majority of drooling CP children, demonstrating high response rates up to 24 weeks. The procedure is simple to perform, effective, and safe when ultrasound guidance is used. The anticholinergic effect of BoNT exceeds that of scopolamine. As anticholinergic drugs are frequently contraindicated because of side effects, BoNT injections offer an alternative in the treatment of drooling.

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Neurology. 2004 Oct 26;63(8):1357-63.
Oral antispastic drugs in nonprogressive neurologic diseases: a systematic review.
Montane E, Vallano A, Laporte JR.
Unitat d'Assaigs Clinics i Farmacoepidemiologia, Servei de Farmacologia Clinica, Pg Vall d'Hebron, no 119-129, Hospital Universitari Vall d'Hebron, 08035 Barcelona, Spain. eme@icf.uab.es

OBJECTIVE: To assess the efficacy of oral drugs in the treatment of spasticity in patients with nonprogressive neurologic disease (NPND). METHODS: Systematic review of double-blind randomized controlled trials of antispastic oral drugs in the treatment of spasticity in NPND. DATA SOURCES: Electronic MEDLINE, PubMed, Cochrane Library, and hand searches. RESULTS: Twelve studies (469 patients) were included (6 on stroke, 3 on spinal cord diseases, and 3 on cerebral palsy). Tizanidine was assessed in four trials (276 patients, 142 exposed), dantrolene in four (103, 93), baclofen in three (70, 55), diazepam in two (127, 76), and gabapentin in one (28, all exposed). Most trials were of small size, of short duration, and their methodologic quality was inadequate. Ten trials were controlled with placebo and only two were direct comparisons between drugs. Efficacy outcome variables were heterogeneous. Only four reports described the magnitude of the antispastic effect. The incidence of adverse drug effects (drowsiness, sedation, and muscle weakness) was high. CONCLUSION: Evidence on the efficacy of oral antispastic drugs in NPND is weak and does not include evaluation of patients' quality of life. If any, efficacy is marginal. Adverse drug reactions were common. Better methodologic instruments are needed for the evaluation of antispastic treatment.

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Orthopade. 2004 Oct;33(10):1173-82.
[Orthotics and cerebral palsy. Established treatments and trends in orthopaedic devices for patients with cerebral palsy.]
[Article in German]
Fuchs A, Doderlein L.
Abteilung Orthopadie und Rehabilitation, Stiftung Orthopadische Universitatsklinik Heidelberg, Schlierbacher Landstrasse 200a, 69118 Heidelberg, Germany.

The surgical and pharmacological treatment of cerebral palsy patients is, in many cases, complemented by orthopaedic appliances. New knowledge and materials have expanded the possibilities for orthotic treatment in the last years, but have also led to confusion on the correct technology to use in different cases. This paper presents an overview of the current orthotic methods in cerebral palsy patients. Initially, we present the different ideas and show the limitations of the treatment. Next, we consider the problem of spastic hip dislocation and the possibilities of positioning the patients. Beds and splints cut from foam allow safe positioning of severely disabled patients without the risk of pressure sores. This appliance may prevent spastic hip dislocation in the long-term. Results of a patient questionnaire are presented. The third section deals with experiences with full contact braces and differences in their construction compared to conventional corsets. Our own results from a patient questionnaire and clinical cases will be presented. The use of a full contact brace may have a positive influence on the development of the spastic scoliosis.

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Disabil Rehabil. 2004 Oct 7;26(19):1128-34.
Adults with cerebral palsy benefit from participating in a strength training programme at a community gymnasium.
Taylor NF, Dodd KJ, Larkin H.
Musculoskeletal Research Centre, School of Physiotherapy, Faculty of Health Sciences, La Trobe University, Victoria, Australia. N.Taylor@latrobe.edu.au

PURPOSE: This study examined whether a community-based progressive resistance strength training programme could improve muscle strength and functional activity in a group of adults with cerebral palsy with high support needs. METHOD: Using a single group pre-post clinical design, 10 adults (7 males, 3 females; mean age 47.8 SD 5.7 years) with cerebral palsy and high support needs completed 4 weeks of introduction and familiarization, followed by a 10-week progressive resistance strength training programme in a community gymnasium. Participants were measured for muscle strength, locomotion speed and timed sit-to-stand. RESULTS: After establishment of a stable baseline from weeks 2 to 5 with no systematic change and a high degree of association (r>0.86), participants increased leg strength by 22.0% (p=0.02), arm strength by 17.2% (p=0.01) and improved performance of sit-to-stand (p=0.02) during the 10-week strength training intervention. CONCLUSIONS: This study adds to the accumulating evidence that strength training can be beneficial for people with cerebral palsy by demonstrating benefits for adults with cerebral palsy and high support needs who are subject to decline in physical function associated with the ageing process.

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Disabil Rehabil. 2004 Oct 7;26(19):1121-7.
Strength training can be enjoyable and beneficial for adults with cerebral palsy.
Allen J, Dodd KJ, Taylor NF, McBurney H, Larkin H.
Musculoskeletal Research Centre, School of Physiotherapy, Faculty of Health Sciences, La Trobe University, Victoria, Australia.

PURPOSE: To explore the positive and negative perceptions of participating in a strength- training programme for adults with cerebral palsy. METHOD: Ten adults aged over 40 years with cerebral palsy participated in a group-based 10-week progressive resistance strength-training programme in a community gymnasium. After the programme, each participant was interviewed using an in-depth semi-structured format and the results coded thematically. RESULTS: Participants perceived that their strength, and ability to perform everyday activities had improved. However, the main benefit for participants was enjoyment and social interaction. The only negative perceptions related to fatigue, short-term muscle soreness and a feeling that they had not improved as much as they had expected. CONCLUSIONS: Enjoyment, a factor that can promote adherence and sustainability, was a key benefit of this strength-training programme for adults with cerebral palsy that led to perceptions of increased strength and physical functioning. These findings suggest that exercise programmes for adults with cerebral palsy should be conducted in a group in the community, thereby promoting community inclusion. In addition, it is important to provide education to participants about the normal responses and expectations of an exercise programme.

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J Pediatr Orthop. 2004 Sep-Oct;24(5):529-536.
Spinal Deformity After Selective Dorsal Rhizotomy in Ambulatory Patients With Cerebral Palsy.
Johnson MB, Goldstein L, Thomas SS, Piatt J, Aiona M, Sussman M.
*Department of Orthopaedics, Royal Children's Hospital, Parkville, Victoria, Australia; dagger Department of Orthopedics B, Sourasky Medical Centre, Tel Aviv, Israel; double dagger Shriners Hospital for Children, Portland, Oregon; section sign St. Christophers Hospital for Children, Section of Neurosurgery, Philadelphia, Pennsylvania.

Thirty-four patients with ambulatory spastic diplegia (ages 10-19.8 years) who were part of a prospective study of selective dorsal rhizotomy (SDR) had standardized radiographs before and after SDR. Follow-up ranged from 5 to 11.6 years after surgery. Two different surgical approaches were used: laminectomy (14 patients) and laminoplasty (20 patients). Radiographs were measured for coronal and sagittal balance. Thirty patients had a spinal deformity at long-term follow-up compared with 10 patients before surgery. Seventeen patients (50%) developed lumbar hyperlordosis greater than 60 degrees . Six patients (18%) developed grade 1 spondylolisthesis, Scoliosis occurred de novo in eight patients (24%) and progressed by greater than 5 degrees in two patients with preoperative scoliosis. No significant differences were found between laminoplasty and laminectomy patients. None of the patients have undergone any surgical intervention for spinal deformity. There was a higher incidence of spinal deformity after SDR than in normals and an historical control population, which warrants clinical and radiographic long-term follow-up.

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J Pediatr. 2004 Aug;145(2 Suppl):S28-32.
Feeding method and health outcomes of children with cerebral palsy.
Rogers B.
Department of Pediatrics, Division of Developmental Pediatrics, Oregon Health and Science University, Portland, Oregon, USA. rogersbr@ohsu.edu

Disorders of feeding and swallowing are common in children with cerebral palsy. Feeding and swallowing disorders have significant implications for development, growth and nutrition, respiratory health, gastrointestinal function, parent-child interaction, and overall family life. Assessments need to be comprehensive in scope and centered around the medical home. Oral feeding interventions for children with cerebral palsy may be effective in promoting oral motor function, but have not been shown to be effective in promoting feeding efficiency or weight gain. Feeding gastrostomy tubes are a reasonable alternative for children with severe feeding and swallowing problems who have had poor weight gain. Copyright 2004 Elsevier Inc.

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J Bone Joint Surg Br. 2004 Jul;86(5):737-42.
Extra-articular subtalar arthrodesis. A long-term follow-up in patients with cerebral palsy.
Bourelle S, Cottalorda J, Gautheron V, Chavrier Y.
Medical School of Medicine, Saint-Etienne, France.

Of 23 children (35 feet) with cerebral palsy who had undergone a Grice extra-articular subtalar arthrodesis for a valgus hindfoot between 1976 and 1981, we reviewed 17 (26 feet), at a mean of 20 years (17 years 3 months to 22 years 4 months) after operation. Seven were quadriplegic, eight spastic diplegic, and two hemiplegic. They were all able to walk at the time of operation. Thirteen patients (20 feet) were pleased with the Grice procedure, 13 had no pain and 15 (23 feet) were still able to walk. The clinical results were satisfactory for most feet. Radiography showed that the results had been maintained over time but 14 feet developed a mean ankle valgus of 11 degrees (6 to 18) with a compensatory hindfoot varus in 12 feet. No deformity of the talus or arthritis of adjacent joints was noted. The Grice procedure gives good long-term results in children with cerebral palsy.

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Cochrane Database Syst Rev. 2004;(3):CD003469.
Botulinum toxin A as an adjunct to treatment in the management of the upper limb in children with spastic cerebral palsy.
Wasiak J, Hoare B, Wallen M.
Therapeutic Guidelines Limited, 23-47 Villiers Street, North Melbourne, Victoria, AUSTRALIA, 3051.

BACKGROUND: Cerebral palsy (CP) is a central nervous system deficit resulting from a non-progressive lesion in the developing brain. Although the brain lesions are static, the movement disorders that arise are not unchanging and are characterised by atypical muscle tone, posture and movement (Rang 1990). The spastic motor type is the most common form of CP and its conventional therapeutic management may include splinting/casting, passive stretching, facilitation of posture and movement, spasticity-reducing medication and surgery. More recently, health care professionals have begun to use botulinum toxin A (BtA) as an adjunct to interventions in an attempt to reduce muscle tone and spasticity to improve function OBJECTIVES: To assess the effectiveness of intramuscular BtA injections as an adjunct to managing the upper limb in children with spastic CP. SEARCH STRATEGY: We searched the Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 4, 2003), MEDLINE (1966 to March Week 3 2004), EMBASE (1980 to 2003 Week 16) and CINAHL (1982 to Week 3 March 2004). SELECTION CRITERIA: All randomised controlled trials (RCTs) comparing intramuscular BtA injections into any muscle group of the upper limb with placebo, no treatment or other interventions. DATA COLLECTION AND ANALYSIS: Two authors using standardised forms extracted the data independently. Each trial was assessed for internal validity with differences resolved by discussion. Data was extracted and entered into RevMan 4.2.3. MAIN RESULTS: Two trials met the inclusion criteria, each having short-term follow up, a small number of subjects and using a single set of injections.The study by Corry 1997 compared BtA with an injection of normal saline and found promising results in elbow extension, elbow and wrist muscle tone. At three months, encouraging results for wrist muscle tone and grasp and release were noted. The trial reported median change, range of changes and the difference in these measures between groups. The study by Fehlings 2000 compared BtA with no intervention. When data were analysed no treatment effect was found for quality of upper limb function, passive range of motion, muscle tone, grip strength or self-care ability. REVIEWERS' CONCLUSIONS: This systematic review has not found sufficient evidence to support or refute the use of intramuscular injections of BtA as an adjunct to managing the upper limb in children with spastic cerebral palsy. Only one of the two identified RCTs reported some promising results in support of reduced muscle tone following BtA injections. Further research incorporating larger sample sizes, rigorous methodology, measurement of upper limb function and functional outcomes is essential.

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Arch Phys Med Rehabil. 2004 Jul;85(7):1121-4.
Combining botulinum toxin and phenol to manage spasticity in children.
Gooch JL, Patton CP.
Primary Children's Medical Center, 100 N. Medical Drive, Salt Lake City, UT 84112, USA. pcjgooch@ihc.com

OBJECTIVE: To describe the specific techniques and adverse reactions of using concurrent, multiple injections of both botulinum toxin and phenol to manage spasticity in children with cerebral palsy (CP) and other neurologic conditions. DESIGN: A retrospective case series. SETTING: A tertiary care children's hospital. PARTICIPANTS: Consecutive patients (N=68) with spasticity related to CP or other neurologic conditions. INTERVENTION: Ninety injection sessions combining botulinum toxin and phenol to manage spasticity. MAIN OUTCOME MEASURE: Documentation of adverse reactions. RESULTS: The mean phenol dosage was 9.5mL at a mean of 0.6mL/kg per injection dose. The mean botulinum toxin type A (Botox) dose injected was 193U (12U/kg), and the mean of botulinum toxin type B (Myobloc) dose injected was 7750U (530U/kg). The mean number of muscles injected was 14. Adverse reactions are described but were infrequent. Dysesthetic hand pain occurred in 2 patients. One patient developed a systemic reaction to Myobloc. CONCLUSIONS: Using botulinum toxin and phenol injections allowed many muscles to be injected to manage spasticity in children with CP and other neurologic conditions. Using this combination allowed an increased number of injections at the maximal recommended dose.

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Appl Psychophysiol Biofeedback. 2004 Jun;29(2):135-40.
Outcome of biofeedback-assisted relaxation for pain in adults with cerebral palsy: preliminary findings.
Engel JM, Jensen MP, Schwartz L.
University of Washington, Department of Rehabilitation Medicine, Box 356490, Seattle, Washington 98195-6490, USA. knowles@u.washington.edu

Chronic pain is a common secondary problem associated with cerebral palsy (CP). This pain may be due to the musculoskeletal problems that often accompany CP, including spasticity, scoliosis, and bony deformity. The purpose of this study was to determine the effects of biofeedback-assisted relaxation training on self-reported pain and muscle tension in 3 adults with CP using a multiple baseline design across subjects. Two of 3 participants reported decreases in their pain experiences posttreatment. Their subjective reports, however, did not correspond with physiological changes. Complications in the use of progressive relaxation exercises and EMG biofeedback equipment are described and suggestions for future research provided.

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J Am Acad Orthop Surg. 2004 May-Jun;12(3):196-203.
Surgical management of the lower extremity in ambulatory children with cerebral palsy.
Karol LA.
University of Texas Southwestern Medical School, and Staff Orthopaedist, Texas Scottish Rite Hospital for Children, Dallas, TX 75219, USA.

Despite the increasing popularity of nonorthopaedic treatment alternatives for children with cerebral palsy, bony and soft-tissue surgery remains a common component in the management of ambulatory patients. Multisite simultaneous tendon surgery provides improvement in gait by addressing hip, knee, and ankle contractures together. Careful preoperative physical examination is required; computerized gait analysis can be useful in confirming a plan for multiple tendon surgeries. Rotational osteotomies can improve transverse-plane malalignment. Shorter periods of immobilization and aggressive postoperative gait training and strengthening may optimize improvements in gait.

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Lancet. 2004 May 15;363(9421):1619-31.
Cerebral palsy.
Koman LA, Smith BP, Shilt JS.
Department of Orthopaedic Surgery, Wake Forest University School of Medicine, Winston-Salem, NC 27157-1070, USA. lakoman@wfubmc.edu

Cerebral palsy, a range of non-progressive syndromes of posture and motor impairment, is a common cause of disability in childhood. The disorder results from various insults to different areas within the developing nervous system, which partly explains the variability of clinical findings. Management options include physiotherapy, occupational and speech therapy, orthotics, device-assisted modalities, pharmacological intervention, and orthopaedic and neurosurgical procedures. Since 1980, modification of spasticity by means of orally administered drugs, intramuscular chemodenervation agents (alcohol, phenol, botulinum toxin A), intrathecally administered drugs (baclofen), and surgery (neurectomy, rhizotomy) has become more frequent. Family-directed use of holistic approaches for their children with cerebral palsy includes the widespread adoption of complementary and alternative therapies; however, the prevalence of their use and the cost of these options are unknown. Traditional medical techniques (physiotherapy, bracing, and orthopaedic musculoskeletal surgery) remain the mainstay of treatment strategies at this time. This seminar addresses only the musculoskeletal issues associated with cerebral palsy and only indirectly discusses the cognitive, medical, and social issues associated with this diagnosis.

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J Pediatr Orthop B. 2004 Mar;13(2):S1-12.
Treatment of spastic diplegia in patients with cerebral palsy.
Sussman MD, Aiona MD.
Shriners Hospitals for Children, Portland, Oregon 97239, USA. msussman@shrinenet.org

Appropriate treatment, which includes orthopaedic surgery, physical and occupational therapy, recreational therapy, orthotics, and utilization of assistive devices, will improve the functional outcomes of children with cerebral palsy. Medical modalities such as intramuscular injections of botulinum toxin, and constant intrathecal administration of Baclofen via an implanted pump may also be of benefit. There is a defined set of orthopaedic surgical procedures that can enhance function, and the challenge for the surgeon is to identify which combination of procedures is appropriate for each individual patient and at what point during development to implement them. Some surgeons prefer to wait until patients are older (8-10 years) and perform all of their surgical interventions in one sitting. We, however, favor a different approach wherein surgical procedures are done as indicated during childhood development to enhance function and allow further improvement of motor skills. We refer to this approach as 'Staged Multilevel Interventions in the Lower Extremity' or 'SMILE'. This paper will discuss the rationale for this approach and our recommendations regarding the indications and timing of surgical interventions, as well as techniques and outcomes as reported in the literature.

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Arch Phys Med Rehabil. 2004 Mar;85(3):457-65.
Selective dorsal rhizotomy versus orthopedic surgery: a multidimensional assessment of outcome efficacy.
Buckon CE, Thomas SS, Piatt JH Jr, Aiona MD, Sussman MD.
Shriners Hospital for Children, Portland, OR, USA. ceb@shcc.org

OBJECTIVE: To compare the efficacy of selective dorsal rhizotomy (SDR) and orthopedic surgery using multidimensional (National Center for Medical Rehabilitation Research disablement framework) outcome measures. DESIGN: Prospective outcome study. SETTING: Pediatric orthopedic hospital. PARTICIPANTS: Twenty-five children with spastic diplegia. Eighteen participants (mean age, 71.3 mo) chose SDR. Seven participants (mean age, 78.6 mo) chose orthopedic surgery. INTERVENTIONS: Children were evaluated 2 days before surgical intervention and at 6 months, 1 year, and 2 years postsurgically. MAIN OUTCOME MEASURES: The Gross Motor Performance Measure, the Gross Motor Function Measure, and the Pediatric Evaluation of Disability Inventory. RESULTS: The SDR group improved significantly in quality of movement attributes 6 months postsurgically; however, gross motor skills (standing; walking, running, and jumping) gains were seen 2 years postsurgically. The orthopedic group improved significantly in select quality of movement attributes 6 months postsurgically and in standing skills within the first postsurgical year. Self-care skills, mobility, and social function gains were seen earlier and with greater frequency in the SDR group. CONCLUSIONS: Both surgical interventions demonstrated multidimensional benefits for ambulatory children with spastic diplegia. The results suggest that qualitative changes in movement, achieved by spasticity reduction, have a greater effect on the enhancement of functional skill proficiency, thus independence, than recognized.

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Mov Disord. 2004 Mar;19 Suppl 8:S162-7.
Use of botulinum toxin in pediatric spasticity (cerebral palsy).
Berweck S, Heinen F.
Children's University Hospital, Munich, Germany.

Local injection of botulinum toxin (BT) is a well-established treatment option for spastic movement disorders in children. BT blocks the release of acetylcholine from the axon terminal into the synaptic cleft of the motor endplate resulting in paresis of the injected musculature. Such localised, temporary chemodenervation of affected muscles can lead to functional gains and may improve the child's daily routine and rehabilitative care. We summarise state-of-the-art treatment of spasticity in children with BT type A, addressing critical issues and introducing recent advances, such as sonography-guided injection of BT and the distal injection of the psoas muscle without the need for general anaesthesia. First-hand experience with BT type B in children is presented. Copyright 2004 Movement Disorder Society.

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Dev Med Child Neurol. 2004 Feb;46(2):91-7.
Short-term outcome of multilevel surgical intervention in spastic diplegic cerebral palsy compared
with the natural history.
Gough M, Eve LC, Robinson RO, Shortland AP.
One Small Step Gait Laboratory, Guy's Hospital, London SE1 9RT, UK. martin.gough@gstt.sthames.nhs.uk

Outcome in 24 ambulant children with spastic diplegic cerebral palsy, in whom multilevel surgical intervention was recommended following gait analysis, is reviewed. Twelve children had surgical intervention (treatment group; eight males, four females; mean age 9 years 10 months, SD 3 years 4 months) while the other 12 did not (control group; five males, seven females; mean age 10 years 1 month, SD 2 years 11 months). All children had interval three-dimensional gait analyses (mean time between analyses: control group, 14.1 months; treatment group, 17.9 months). At follow-up the control group (mean age 11 years 9 months) showed a significant increase in minimum hip and knee flexion in stance which was not related to age, the interval between analyses, changes in the passive joint range of motion, nor changes in anthropometric measurements. The treatment group (mean age at follow-up 11 years 3 months) showed a significant improvement in minimum knee flexion and in ankle dorsiflexion in stance. Parents of nine children said their child's walking distance had increased following intervention. Of five children using posterior walkers preoperatively, two continued to use them postoperatively; two were using crutches or sticks and the remaining child walked independently. Two children who walked independently preoperatively used sticks postoperatively for community ambulation. The deterioration seen in the kinematics of the control group suggests that previous outcome studies comparing postoperative gait with preoperative gait have underestimated the immediate effects of surgery. It also raises concerns about the long-term effects of surgical intervention.

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Dev Med Child Neurol. 2004 Feb;46(2):84-90.
Electrostimulation at sensory level improves function of the upper extremities in children with cerebral palsy: a pilot study.
Maenpaa H, Jaakkola R, Sandstrom M, Airi T, von Wendt L.
Department of Child Neurology, Hospital for Children and Adolescents, Helsinki Central Hospital, Lastenlinnantie 2, SF-00250 Helsinki, Finland. helena.maenpaa@hus.fi

The aim of this study was to evaluate the effect of electrical stimulation (ES) on the function of the upper extremities in children with cerebral palsy (CP). The participants were 12 children (seven females and five males) with spastic hemiplegia (mean age 5 years 7 months, SD 3 years 9 months). Indications were weak wrist dorsiflexion and elbow extension. The ES was given at sensory level (20-40 minutes) on the infraspinatus muscle and on the wrist dorsiflexors during 12 regularly scheduled physical and occupational therapy sessions (during 4-5 weeks). The Goal Attainment Scale, the Zancolli classification of hand function, muscle testing according to Daniels and Worthington, and King hypertonicity scale were used for evaluation. Assessments were made twice before (between 4 weeks) and twice after (between 12 weeks) the stimulation period except the King hypertonicity scale, which was used once before and 3 months after the stimulation period. Active elbow extension, wrist dorsiflexion, and forearm supination with the elbow flexed and extended improved when the results of assessments before ES were compared with those made immediately before (p<0.001) and three months after (p<0.01) this treatment. Results of this pilot uncontrolled study suggest that ES at sensory level can be used as an adjunct to physiotherapy and/or occupational therapy in children with spastic hemiplegia. These results will be used as basis for further research.

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Arch Phys Med Rehabil. 2004 Feb;85(2):192-200.
Functional outcomes of intramuscular botulinum toxin type A in the upper limbs of children with cerebral palsy: a phase II trial.
Wallen MA, O'flaherty SJ, Waugh MC.
Department of Occupational Therapy, The Children's Hospital, Westmead, NSW, Australia. margarew@chw.edu.au

OBJECTIVE: To describe the functional and family-centered assessment protocol and outcomes of a phase II trial evaluating upper-limb function after botulinum toxin injections in children with cerebral palsy (CP). DESIGN: Intervention study, case series, phase II trial, follow-up at 2 weeks and 3 and 6 months. SETTING: Specialist outpatient physical disabilities clinic within a public pediatric teaching hospital. PARTICIPANTS: Convenience sample of 16 children with CP (age range, 2-12y). INTERVENTIONS: Botulinum toxin type A (Botox) injections after electrical stimulation localization of appropriate muscle. MAIN OUTCOME MEASURES: The Canadian Occupational Performance Measure (COPM), Goal Attainment Scale (GAS), Melbourne Assessment of Unilateral Upper Limb Function, Child Health Questionnaire (CHQ), parent questionnaire, Modified Ashworth Scale (MAS), Tardieu scale, and active (AROM) and passive (PROM) range of motion. RESULTS: On the COPM, there was significant improvement at 3 months and 6 months. On the GAS, the T-scores were 42 and 47 at 3 and 6 months, respectively. On the Melbourne Assessment and CHQ, there was no significant change. The parent questionnaire indicated acceptability of injections and positive outcomes. On the MAS, there was a significant reduction in tone at 2 weeks, with a return to baseline by 6 months. On the Tardieu scale, there was a significant increase in angle of first catch at 2 weeks, but only the elbow maintained a significant difference at 3 and 6 months. No significant change was found for AROM or PROM. CONCLUSIONS: Sustained functional outcomes occurred after botulinum toxin injections despite increasing muscle tone after an initial reduction in tone. Randomized controlled trials are required.

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Clin Rehabil. 2004 Feb;18(1):1-14.
Occupational therapy for children with cerebral palsy: a systematic review.
Steultjens EM, Dekker J, Bouter LM, van de Nes JC, Lambregts BL, van den Ende CH.
Netherlands Institute for Health Services Research, PO Box 1568, 3500 BN Utrecht, The Netherlands. e.steultjens@nivel.nl

OBJECTIVE: Occupational therapy (OT) for cerebral palsy focuses on the development of skills necessary for the performance of activities of daily living. The aim of this systematic review was to determine whether OT interventions improve outcome for children with cerebral palsy (CP). METHODS: An extensive search in MEDLINE, CINAHL, EMBASE, AMED and SCISEARCH was performed. Studies with controlled and uncontrolled designs were included. Six intervention categories were distinguished and individually analysed using a best-evidence synthesis. This synthesis is based on the type of design, the methodological quality, the type of outcome measures and the statistical significance of the findings. RESULTS: Seventeen studies were included in this review, seven of which were randomized controlled trials (RCTs). One RCT had a high methodological quality. The analyses resulted in insufficient evidence of the efficacy of occupational therapy in all intervention categories, due to the low methodological quality of studies presenting statistically nonsignificant results. CONCLUSION: Despite the reasonable number of studies identified, the inconclusive findings regarding the efficacy of occupational therapy for children with cerebral palsy may be a reflection of the difficulties in efficacy research in OT for children with CP. Future research should critically reflect on methodological issues.

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Pediatrics. 2004 Feb;113(2):305-12.
Efficacy of constraint-induced movement therapy for children with cerebral palsy with
asymmetric motor impairment.
Taub E, Ramey SL, DeLuca S, Echols K.
Department of Psychology, University of Alabama, Birmingham, Alabama 35294-0018, USA. etaub@uab.edu

OBJECTIVE: Constraint-Induced Movement (CI) therapy has been found to be a promising treatment for substantially increasing the use of extremities affected by such neurologic injuries as stroke and traumatic brain injury in adults. The purpose of this study was to determine the applicability of this intervention to young children with cerebral palsy. METHODS: A randomized, controlled clinical trial of pediatric CI therapy in which 18 children with diagnosed hemiparesis associated with cerebral palsy (7-96 months old) were randomly assigned to receive either pediatric CI therapy or conventional treatment. Pediatric CI therapy involved promoting increased use of the more-affected arm and hand by intensive training (using shaping) of the more-impaired upper extremity for 6 hours/day for 21 consecutive days coupled with bivalved casting of the child's less-affected upper extremity for that period. Children's functional upper-extremity skills were assessed in the laboratory (blinded scoring) and at home (parent ratings) just prior, after, and 3 weeks posttreatment. Treated children were followed for 6 months. RESULTS: Children receiving pediatric CI therapy compared with controls acquired significantly more new classes of motoric skills (9.3 vs 2.2); demonstrated significant gains in the mean amount (2.1 vs 0.1) and quality (1.7 vs 0.3) of more-affected arm use at home; and in a laboratory motor function test displayed substantial improvement including increases in unprompted use of the more-affected upper extremity (52.1% vs 2.1% of items). Benefits were maintained over 6 months, with supplemental evidence of quality-of-life changes for many children. CONCLUSION: Pediatric CI therapy produced major and sustained improvement in motoric function in the young children with hemiparesis in the study.

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Tidsskr Nor Laegeforen. 2004 Jan 22;124(2):156-9.
[Orthopaedic problems in adults with cerebral palsy]
[Article in Norwegian]
Terjesen T, Lofterod B, Myklebust G.
Ortopedisk avdeling, Rikshospitalet, Oslo. terje.terjesen@rikshospitalet.no

BACKGROUND: There is little information about the need for orthopaedic surgery in adults with cerebral palsy; we wanted to assess this problem. MATERIAL AND METHODS: The material included 37 adults with cerebral palsy (19 women and 18 men), mean age 39. The degree of physical disability was mild in 19 cases, moderate or severe in 18. The patients were assessed by clinical examination and radiographs of hips and spine. RESULTS: 15 patients had pain located to the spine or lower extremities but no-one had severe or invalidating pain. Subjects with moderate or severe disability had a markedly reduced range of motion in the hip and knee joints. Subluxation or dislocation of the hip joints was found in six patients but only one of them had hip pain. Orthopaedic surgery had been performed in 23 patients. In 8 patients we found indications for additional orthopaedic surgery aimed at relieving pain, reducing contractures or improving function. The most frequent procedures would be tenotomies in the hip and knee regions, heel cord lengthening, and triple arthrodesis of the foot. INTERPRETATION: Regular follow-up of adults with cerebral palsy is recommended in order to reveal musculoskeletal problems that can be improved by orthopaedic surgery.

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Acta Orthop Scand. 2003 Dec;74(6):749-55.
Botulinum A toxin for treatment of lower limb spasticity in cerebral palsy: gait analysis in 49 patients.
Papadonikolakis AS, Vekris MD, Korompilias AV, Kostas JP, Ristanis SE, Soucacos PN.
Department of Orthopaedic Surgery, University of Athens, School of Medicine, GR-145 61 Athens, Greece.

BACKGROUND: Injection of botulinum type A toxin is a new treatment for spasticity. PATIENTS AND METHODS: We evaluated the effect of botulinum A toxin (BTX-A) in the lower limb muscles of patients having cerebral palsy. We tested 49 patients before and, on average, 4 (2-9) months after giving the toxin. The evaluation included 3-dimensional computerized gait analysis, changes in mobility level, using the Gillette Functional Assessment Questionnaire, and gastrocnemius muscle bulk, using ultrasonographic measurements. RESULTS: The patients were divided into 3 groups, according to the site of BTX-A administration (hamstrings, gastrocnemius and multilevel). Those who were injected in the hamstrings showed a significant improvement in only the maximum knee extension angle during the gait cycle. Those with spastic equinus who were injected in the gastrocnemius muscle responded better than the other groups. The ankle angle on the initial contact, terminal stance and pre-swing, maximum dorsiflexion, ankle range of motion, per cent of single support and gait velocity improved significantly. Overall, the patients showed significant improvements in motor skill performance and functional health. INTERPRETATION: Our findings indicate that botulinum type A toxin can be given as an adjuvant to conservative treatment of patients with cerebral palsy.

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Can J Occup Ther. 2003 Dec;70(5):285-97.
The effects of family-centred functional therapy on the occupational performance of children with cerebral palsy.
Lammi BM, Law M.
Pembroke General Hospital, 705 MacKay, Pembroke, ON K8A 1G8. bren.mcgibbon@sympatico.ca

BACKGROUND: Family-Centred Functional Therapy (FCFT) is a comprehensive approach to paediatric occupational therapy that considers and addresses the skills of the child, the requirements of functional tasks and the elements within the tasks environment, including family goals and preferences. PURPOSE: The purpose of the present study was to determine if interventions based on FCFT, but limited to addressing elements of the task and environment, would improve task performance. METHOD: A single subject, multiple baseline design was applied to three children, for three tasks each. Tasks were selected by parents and measured during baseline and intervention phases. RESULTS: Results indicate that for each child at least one of the two tasks for which intervention was provided demonstrated improved performance. Parents reported a clinically significant improvement in satisfaction with their children's performance in the tasks that were addressed. PRACTICE IMPLICATIONS: This study provides preliminary evidence of the effectiveness of the FCFT approach.

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J Altern Complement Med. 2003 Dec;9(6):817-25.
Improvements in muscle symmetry in children with cerebral palsy after equine-assisted therapy (hippotherapy).
Benda W, McGibbon NH, Grant KL.
Institute for Children, Youth, and Families, University of Arizona, Tucson, AZ, USA. billbenda@earthlink.net

OBJECTIVE: To evaluate the effect of hippotherapy (physical therapy utilizing the movement of a horse) on muscle activity in children with spastic cerebral palsy. DESIGN: Pretest/post-test control group. SETTING/LOCATION: Therapeutic Riding of Tucson (TROT), Tucson, AZ. SUBJECTS: Fifteen (15) children ranging from 4 to 12 years of age diagnosed with spastic cerebral palsy. INTERVENTIONS: Children meeting inclusion criteria were randomized to either 8 minutes of hippotherapy or 8 minutes astride a stationary barrel. OUTCOME MEASURES: Remote surface electromyography (EMG) was used to measure muscle activity of the trunk and upper legs during sitting, standing, and walking tasks before and after each intervention. RESULTS: After hippotherapy, significant improvement in symmetry of muscle activity was noted in those muscle groups displaying the highest asymmetry prior to hippotherapy. No significant change was noted after sitting astride a barrel. CONCLUSIONS: Eight minutes of hippotherapy, but not stationary sitting astride a barrel, resulted in improved symmetry in muscle activity in children with spastic cerebral palsy. These results suggest that the movement of the horse rather than passive stretching accounts for the measured improvements.

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Clin Dermatol. 2003 Nov-Dec;21(6):476-80.
Pharmacology and immunology of botulinum toxin type A.
Aoki KR.
Allergan Inc., 7575 Dupont Drive, Irvine, CA 92612, USA. Aoki_Roger@Allergan.com

The utility of botulinum neurotoxins as therapeutic and esthetic agents depends on their ability to inhibit neurotransmitter release from selected neurons, remain localized at the site of injection, and evade the body's immunologic defenses. The clinical correlates of these actions, respectively, are efficacy, safety, and a low rate of antibody formation. These properties have long formed the basis for the use of botulinum toxin type A (BTX-A) in the treatment of movement disorders such as focal dystonias, spasticity, and cerebral palsy and, more recently, in the treatment of glabellar lines--all of which are characterized by excessive muscle activity.

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Neurol Clin. 2003 Nov;21(4):853-81, vii.
Approach to the rehabilitation of spasticity and neuromuscular disorders in children.
Tilton AH.
Children's Hospital of New Orleans, 200 Henry Clay, New Orleans, LA 70118, USA. atilto@aol.com

The management of children and adults with upper motor neuron disorder is complex and multifaceted. This article reviews new information and potential treatment. As part of the upper motor neuron syndrome (UMNS), spasticity may occur in cerebral palsy, congenital brain malformation, head injury, or other etiologies. Within the UMNS the most recognizable clinical concern is the frequent abnormality of tone, which may have a significant functional impact. Tone reduction is not itself a goal, but is performed for the functional benefits it may allow. New approaches to treatment and management of hypertonia recently have become available. There are many other associated features of the UMNS that affect patient functioning. Ones that frequently occur are abnormalities of speech and other areas of oral motor control. A new area of intervention combines the use of botulinum toxin and ultrasonography to address the common problem of slalorrhea, which is a potential medical issue and a substantial social barrier in affected patients. This article also reviews new information and potential treatment for neuromuscular disorders.

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Phys Med Rehabil Clin N Am. 2003 Nov;14(4):703-25.
The use of botulinum toxin in pediatric disorders.
Gaebler-Spira D, Revivo G.
Pediatric Rehabilitation Program, The Rehabilitation Institute of Chicago, 345 E. Superior Street, Chicago, IL 60611, USA. dgaebler@rehabchicago.org

Botulinum toxins have an exciting and important role in treating the child with hypertonia. The guidelines presented in this article are those that have been published representing the safe use of botulinum toxins in children. Experience and a decade of research have provided the framework for using botulinum toxins in decreasing deformity and promoting function. In children, a window of opportunity exists with botulinum toxin that allows improved motor control and elongation of shortened muscles. Although 3 to 4 months in an adult life is short, for a child it is a relatively greater proportion of their life experience and may be long enough for skill development. The improvement noted in function after botulinum toxin use is facilitated by comprehensive rehabilitation. The pediatric physiatrist has a unique role in the management of children with cerebral palsy and other conditions with hypertonia. Their knowledge and training reflect an understanding of anatomy and development that allows accurate evaluation of specific functional problems in children related to hypertonia. The pediatric physiatrist has experience in localization of muscles by EMG, nerve stimulation, and surface anatomy. Although many other physicians inject botulinum toxins, goal-directed management is the cornerstone to the physiatrist's thinking and treatment plan. Orthopedic surgery ultimately may be the intervention of choice if persistent contracture or progression of contractures occurs. Working in collaboration with an orthopedist identifies the timing of optimal surgical intervention for alignment. For persistent and severe hypertonia, the treatment team includes a neurosurgeon. All options for spasticity, such as selective posterior rhizotomy and intrathecal baclofen, should be considered. Re-evaluation of the child after selective dorsal rhizotomy or intrathecal baclofen is appropriate and should be discussed with therapists for focal intervention. Communication between members of the team and the family is desirable and frequently is one of the major contributions of the pediatric physiatrist. For children with focal hypertonia, botulinum toxins offer a dramatic but temporary repeatable change that affects rehabilitation. Research rapidly has captured the positive effect of the toxins on impairment and functional limitations. Not to be overlooked are outcomes related to quality of life. The long-term use of botulinum toxins and the role the toxins play throughout the life span of the person with a childhood hypertonic disorder are yet to be determined.

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J South Orthop Assoc. 2003 Fall;12(3):125-33, quiz 134.
Recurrence of equinus foot deformity in cerebral palsy patients following surgery: a review.
Koman LA, Smith BP, Barron R.
Department of Orthopaedic Surgery, Wake Forest University School of Medicine, Medical Center Boulevard, Winston-Salem, NC 27157-1070, USA.

Although equinus deformity in children with cerebral palsy is often corrected with surgery, postsurgical recurrence of the deformity is not uncommon. In order to isolate factors that may be related to its recurrence, 31 studies were evaluated. Data from nine articles indicated that children younger than approximately 7 years of age at the time of surgery had a higher risk of recurrence than children who were older at the time of surgery. Recurrence rates may be understated in studies including less than a minimum of 4-5 years of patient follow-up. Lower recurrence rates are documented in diplegic patients compared with hemiplegic patients, and postoperative casting/splinting is stated, but not documented, to reduce recurrence. One study demonstrated that the use of chemodenervation delayed surgery and by inference theoretically would decrease recurrence after surgical release.

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Acta Neurochir Suppl. 2003;87:99-102.
Functional posterior rhizotomy for severely disabled children with mixed type cerebral palsy.
Morota N, Kameyama S, Masuda M, Oishi M, Aguni A, Uehara T, Nagamine K.
Department of Neurosurgery, National Center for Child Health and Development, Tokyo, Japan. morota-n@ncchd.go.jp

The authors evaluated the impact of functional posterior rhizotomy (FPR) for children with severely disabled mixed type cerebral palsy (CP). Three quadriplegic children at the age of 3, 4, and 10 years underwent FPR. They were classified as mixed type CP based on the clinical presentation of marked spasticity with dystonic posture. Preoperative Ashworth score of the lower extremity was 3.5, 4.5, 4.8 respectively. Two children showed prominent opisthotonus and all showed severe subluxation of the hip joint. Advanced scoliosis was associated in two children. FPR was performed from L2 to S1 in one child, L2 to S2 in one and L2 to S1/S2 in one based on the result of pudendal mapping. Rootlet cutting rate ranged from 66 to 75%. Postoperatively, Ashworth score dropped to 1.4, 1.2, 1.3, respectively. Functional improvement of the upper extremity and urination were confirmed in two children. Hip subluxation was reduced in one child and remained stable in two. A one-year follow-up review confirmed no relapse of spasticity among them. FPR achieved highly satisfactory surgical effects in children with severe mixed type CP. Although long-term follow-up is mandatory since there was a report of relapsed spasticity after FPR in this particular population of CP, FPR could be a choice of surgery in severely disabled children with mixed type CP.

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Acta Neurochir Suppl. 2003;87:37-8.
Clinical application of drug pump for spasticity, pain, and restorative neurosurgery: other clinical applications of intrathecal baclofen.
Taira T, Hori T.
Department of Neurosurgery, Neurological Institute, Tokyo Women's Medical University, Tokyo, Japan. ttaira@nij.twmu.ac.jp

Intrathecal baclofen has been successfully used for control of severe spasticity. Baclofen, an agonist of GABA-B receptor, has other potential effects on pain and recovery from coma. Sporadic episodes of dramatic recovery from persistent vegetative state are reported after intrathecal administration of baclofen. There are also reports on the use of baclofen for neuropathic pain including post-stroke central pain syndrome. Baclofen is also used for control of dystonia due to cerebral palsy or reflex sympathetic dystrophy. On the other hand, epidural spinal cord stimulation has been used for pain, spasticity, dystonia, or attempt to improve deteriorated consciousness, though the effects seem variable and modest. Similarity between baclofen and spinal cord stimulation is interesting in that both involves in spinal GABAergic system. The GABAergic system in the spinal cord plays a pivotal role in various clinical effects of these procedures.

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Dev Med Child Neurol. 2003 Oct;45(10):677-82.
Life expectancy in pediatric patients with cerebral palsy and neuromuscular scoliosis who underwent spinal fusion.
Tsirikos AI, Chang WN, Dabney KW, Miller F, Glutting J.
Department of Orthopaedics, University of Athens, KAT Hospital, Athens, Greece.

The aim of this study was to document the rate of survival among 288 severely affected pediatric patients (154 females, 134 males) with spasticity and neuromuscular scoliosis who underwent spinal fusion (mean age at surgery 13 years 11 months, SD 3 years 4 months), and to identify exposure variables that could significantly predict survival times. Kaplan-Meier survival analysis was performed demonstrating a mean predicted survival of 11 years 2 months after spinal surgery for this group of globally involved children with cerebral palsy (CP). Cox's proportional hazards model was used to evaluate predictive efficacy of exposure variables, such as sex, age at surgery, level of ambulation, cognitive ability, degree of coronal and sagittal plane spinal deformity, intraoperative blood loss, surgical time, days in hospital, and days in the intensive care unit. Number of days in intensive care unit after surgery and the presence of severe preoperative thoracic hyperkyphosis were the only factors affecting survival rates. This demonstrated statistically significant predictability for decreased life expectancy after spinal fusion in children with CP.

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Dev Med Child Neurol. 2003 Oct;45(10):658-63.
A qualitative analysis of the benefits of strength training for young people with cerebral palsy.
McBurney H, Taylor NF, Dodd KJ, Graham HK.
School of Physiotherapy, Faculty of Health Sciences, La Trobe University, Victoria, Australia.

This qualitative study investigated the positive and negative outcomes of a home-based strength-training programme for young people with cerebral palsy (CP). Eleven young people with spastic diplegic CP (seven females, four males; mean age 12 years 9 months, SD 2 years 10 months; range 8 to 18 years) and their parents were interviewed. Gross Motor Function Classification System scores ranged from I (walks without limitations) to III (walks with assistive device), with a mode of III. The strength-training program, which was conducted in the participants' homes three times per week for 6 weeks (total of 18 prescribed sessions), comprised three exercises targeting the major support muscles of the lower limbs. Exercises were bilateral half squats, heel raises, and step-ups. The training load was increased by adding free weights to a backpack so that 8 to 10 repetitions of each exercise could be performed. Using thematic coding, three categories of outcome emerged: body function and structure, activity, and participation, which were influenced by environmental and personal contextual factors. The program generated overwhelmingly positive outcomes with only minor negative responses about some equipment and the need for parental involvement. Benefits included perceptions that strength, flexibility, posture, walking, and the ability to negotiate steps had improved. In addition, participants reported psychological benefits such as a feeling of increased well-being and improved participation in school and leisure activities. The contextual factors highlighted the fact that sufficient clinician resources must be allocated to solve individual exercise and equipment problems. As well as providing further evidence that strength training can be beneficial, this study provides useful indicators to guide future quantitative studies of outcomes that are meaningful for people with CP.

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Dev Med Child Neurol. 2003 Oct;45(10):652-7.
A randomized clinical trial of strength training in young people with cerebral palsy.
Dodd KJ, Taylor NF, Graham HK.
Musculoskeletal Research Centre, School of Physiotherapy, Faculty of Health Sciences, La Trobe University, Victoria, Australia. K.Dodd@latrobe.edu.au

This randomized clinical trial evaluated the effects of a home-based, six-week strength-training programme on lower limb strength and physical activity of 21 young people (11 females, 10 males; mean age 13 years 1 month, SD 3 years 1 month; range 8 to 18 years) with spastic diplegic cerebral palsy (CP) with independent ambulation, with or without gait aids; (Gross Motor Function Classification System levels I to III). Compared with the 10 controls, the 11 participants in the strength-training programme increased their lower limb strength (combined ankle plantarflexor and knee extensor strength as measured by a hand-held dynamometer) at 6 weeks (F(1,19)=4.58, p=0.046) and at a follow-up 12 weeks later (F(1,18)=6.25, p=0.041). At 6 weeks, trends were also evident for improved scores in Gross Motor Function Measure dimensions D and E for standing, running and jumping, and faster stair climbing. A relatively short clinically feasible home-based training programme can lead to lasting changes in the strength of key lower-limb muscles that may impact on the daily function of young people with CP.

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J Child Neurol. 2003 Sep;18 Suppl 1:S89-94.
Controversial treatment of spasticity: exploring alternative therapies for motor function in children
with cerebral palsy.
Rosenbaum P.
CanChild Centre for Childhood Disability Research, McMaster University, Hamilton, ON. rosenbau@mcmaster.ca

The treatment and management of children with cerebral palsy is an ever-evolving story. In the past 20 years, a number of exciting innovations in treatment have expanded the opportunities to help children. At the same time, the field has experienced a remarkable proliferation of "alternative" therapies-approaches based on ideas about the biologic basis of neurodevelopmental disabilities and their management that differ considerably from conventional thinking in Western medicine. Professionals working with children with cerebral palsy and their families are frequently asked for an opinion about or even endorsement of these new and "promising" approaches to therapy. These can be very difficult to provide when the evidence is limited, peer-reviewed reports are scarce, and the primary source of information is the World Wide Web. The purposes of this article are to discuss briefly why it can be difficult to ascertain whether any treatment--conventional or alternative--does more harm than good, and to consider what rules of evidence can be applied to make a sound judgment about a new treatment. The article then discusses several current controversial alternative therapies, reviewing the available literature and offering a critical appraisal of each. Topics addressed include hyperbaric oxygen therapy, conductive education, the Adeli suit, and therapeutic (subthreshold) electrical stimulation because these approaches have been applied to children with cerebral palsy.

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J Child Neurol. 2003 Sep;18 Suppl 1:S50-66.
Injectable neuromuscular blockade in the treatment of spasticity and movement disorders.
Tilton AH.
Department of Neurology, Section of Child Neurology, Louisiana State University Health Science Center, New Orleans, LA, USA. atilto@aol.com

Neuromuscular blockade via injection of alcohol, phenol, or botulinum toxin reduces the tone of overactive muscles in order to restore the appropriate balance between agonists and antagonists. Such a restoration allows improved stretch and increased resting length and can reduce the likelihood of contracture. Alcohol or phenol, injected onto the motor nerve, denatures proteins and promotes axonal degeneration. The onset of action is within hours, whereas the duration of action is variable, ranging from 2 weeks to 6 months and beyond. The advantages of alcohol or phenol chemodenervation lie in their low cost and lack of antigenicity. The disadvantages include the technical difficulty of the injections and significant risk for pain as a result of treatment. Botulinum toxins, purified forms of Clostridium botulinum exotoxins, are injected directly into muscle, where they cleave one or more vesicle fusion proteins, thus blocking release of acetylcholine at the neuromuscular junction. Three commercial products--two of serotype A and one of B--are available. Each differs in its unit potency, side effects, and duration of action. On average, botulinum toxin has a clinical onset of action approximately 12 to 72 hours after injection, with a peak effect at 1 to 3 weeks. Effects then plateau for 1 to 2 months, with patients often requiring reinjection approximately every 3 months. Side effects may include local discomfort at the site of the injection and excessive weakness of the injected or nearby muscles, although more distant effects may occur. Antibody formation is a significant clinical concern and eventually obviates treatment benefit in approximately 5% of patients. Switching serotypes may be effective, at least temporarily. Consensus dosing guidelines have been developed and are presented within. Numerous studies have suggested that botulinum toxin has a role in the care of children with spasticity or dystonia related to cerebral palsy, and may improve equinus, gait, upper extremity use, comfort, and care. Evidence of functional improvement remains equivocal in the severely impaired child; however, there is evidence for improvement in less impaired children. The optimal candidate for injectable neuromuscular blockade is one who has a limited number of muscles that need treatment, who does not have fixed contracture, and who retains selective motor control. The ultimate goal of treatment for the hypertonic child is to maximize function, comfort, and independence. Hypertonia is only one aspect of the upper motoneuron syndrome, which includes both positive and negative symptoms. The treatment program, in which chemodenervation is only one tool, requires a multidisciplinary evaluation and individualized plan to address the whole patient.

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J Pediatr Orthop B. 2003 Sep;12(5):311-4.
Rehabilitation after femoral osteotomy in cerebral palsy.
Stasikelis PJ, Davids JR, Johnson BH, Jacobs JM.
The Shriners Hospitals for Children, Greenville, South Carolina 29605, USA. pstasikelis@shrinenet.org

This is a study of the time required to return to preoperative functional levels after proximal femoral osteotomy in children with cerebral palsy. Seventy-one consecutive children who underwent proximal femoral osteotomy to treat an unstable hip secondary to cerebral palsy are retrospectively reviewed. All children returned to their preoperative ambulatory function within 30 months of the procedure. Children who were community or household ambulators returned to their preoperative function at a mean of 7 months after osteotomy, while wheelchair and therapeutic ambulators required a mean of 10 months. Children who had regular visits with a licensed therapist tended to return to function more quickly than those who had exercises preformed by their parents or care-takers after instruction by a therapist. The authors conclude that families should be advised that rehabilitation after osteotomy requires on average 7-10 months, but times up to 30 months are possible.

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Phys Occup Ther Pediatr. 2003;23(2):19-44.
Feeding management of children with severe cerebral palsy and eating impairment: an exploratory study.
Gisel EG, Tessier MJ, Lapierre G, Seidman E, Drouin E, Filion G.
School of Physical & Occupational Therapy, McGill University, 3630 Promenade Sir-William-Osler, Montreal, Quebec, H3G 1Y5, Canada. erika.gisel@mcgill.ca

Some children with cerebral palsy and severe feeding impairment experience pulmonary complications from aspiration and gastroesophageal reflux. This exploratory study examined whether pulmonary function would improve following one year of intervention with optimal positioning for feeding, control of gastroesophageal reflux and use of food textures that would minimize aspiration from swallowing. Two children showed a 28% and 45% improvement, respectively, in functional residual capacity. One child experienced a 37% improvement in total respiratory resistance and a 284% improvement in respiratory compliance. All children gained sufficient weight to maintain their growth trajectories but only one who was changed from oral to tube feeding due to aspiration showed catch-up growth in length. One child showed pathological gastroesophageal reflux that was controlled medically throughout the study period. Although all children experienced pulmonary illnesses during the one year of follow up, control of aspiration permitted a clinically significant improvement of their pulmonary obstructive syndrome Further study is needed to more fully determine the effect of this treatment approach on pulmonary function.

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Rev Neurol. 2003 Sep 1-15;37(5):454-8.
[Palliative surgical treatment of spastic paralysis in the upper extremity]
[Article in Spanish]
Suso Vergara S, Lopez Prats F, Fores Vi eta J, Ferreres Claramunt A, Gutierrez Carbonell P.
Hospital Clinic de Barcelona, Barcelona, Espa a.

AIMS. In this paper we review the main studies conducted on therapy applied to the bony and soft parts in spastic paralysis of the upper extremity. DEVELOPMENT. Spasticity presents muscular hypertonia and hyperexcitability of the stretch reflex, which are typical of upper motoneuron syndrome. Physiopathologically, spasticity is due to the medullar and supramedullar alteration of the afferent and efferent pathways. Treatment is multidisciplinary and involves the collaboration of rehabilitators, neurophysiologists, neurologists, paediatricians, orthopaedic surgeons and psychologists, who all contribute with their different therapeutic aspects and characteristics (which can be pharmacological, peripheral neurological blockages, surgical, etc.). The characteristic posture of the upper extremities in spastic cerebral palsy is the inward rotation of the shoulder, flexion of the elbow and pronated forearm, and the deformity of the fingers (swan neck and thumbs in palm). The primary objectives in these patients will be to improve communication with their surroundings, perform activities of daily living, increase mobility and walking. CONCLUSIONS. The surgical treatment applied by orthopaedic surgeons in the upper extremities are aimed at achieving an enhanced adaptive functionality rather than morphological normality. Factors to be taken into account include age, voluntary control over muscles and joints, level of severity of the spasticity (Ashworth scale) and stereognostic sensitivity. In general, on soft parts we will use procedures such as dehiscence or lengthening of the flexor muscles of the shoulder and elbow or of the adductor of the thumb; transfer of the pronators in order to adopt the supinating function or of the flexors so as to reinforce the extensors of the forearm, and capsulodesis or tenodesis in the hand. The bony procedures will consist in derotational osteotomies of the humerus and radius and arthrodesis in the wrist or in the metacarpophalangeal joints of the thumb, depending on whether there is greater rigidity or age in the former cases or instability in the latter.

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Isr Med Assoc J. 2003 Aug;5(8):543-6.
Surgical treatment of spasticity by selective posterior rhizotomy: 30 years experience.
Salame K, Ouaknine GE, Rochkind S, Constantini S, Razon N.
Department of Neurosurgery, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.

BACKGROUND: Spasticity is a common neurologic disorder with adverse effects on the patient's function. Conservative management is unsuccessful in a significant proportion of patients and neurosurgical intervention should be considered. The mainstay of surgical treatment of spasticity is selective posterior rhizotomy, i.e., section of sensory nerve roots of the cauda equina. OBJECTIVE: To report our experience with selective posterior rhizotomy in the treatment of spasticity. METHODS: We retrospectively reviewed our experience in 154 patients who underwent SPR during 30 years. The indication for surgery was spasticity that significantly hindered the patient's function or care and was resistant to conservative treatment. All patients were evaluated for spasticity in the lower and upper limbs, the presence or absence of painful spasms, and sphincter disturbances. The decision as to which roots to be sectioned, and to what extent, was based mainly on clinical muscle testing. RESULTS: Reduction of spasticity in the lower limbs was obtained in every case, with improvement in movements in 86% of cases. Painful spasms were alleviated in 80% of cases. Amelioration of neurogenic bladder was observed in 42%. A minority of the patients also showed improvement in speech and cognitive performance. There was no perioperative mortality or major complications. CONCLUSION: SPR is a safe and effective method for the treatment of spasticity with long-lasting beneficial effects. We suggest that this method be considered more frequently for patients with spasticity that interferes with their quality of life.

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Rev Neurol. 2003 Aug 16-31;37(4):359-64.
[Hyperbaric oxygen treatment for children with cerebral palsy]
[Article in Spanish]
Papazian O, Alfonso I.
Departamento de Neurologia, Centro de Espasticidad y Movimientos Involuntarios, Miami Children's Hospital, Florida 33155, USA. oscar.papazian@mch.com

AIMS: Demand from parents has made hyperbaric oxygenation (HO) inhalation the most popular and rapid growing therapy for children with cerebral palsy (CP). To review peer reviewed articles of HO in children with CP to determine its efficacy and risks, literature was searched on-line using PubMed indexed for MEDLINE (1996-2003) for articles under CP and HO headings. METHOD: We found 16 references: 5 articles (1 uncontrolled pilot study, 2 from a single controlled study, 1 case report of complications and 1 revision) and 11 letters to the editor. The control study showed significant improvements in the middle, at the end and 3 months after 40 treatments with OH (O2=100%/1.75 AA) and placebo (O2=21%/1.3 AA) in the gross motor function measure, (2.9% vs 3%), self-control, auditory attention and visual working memory. There were no significant differences between the groups. Side effects included barometric otitis media (48.2% and 22.2% in the OH and placebo groups). The authors and the Advisory Scientific Committee of the American Academy of Cerebral Palsy and Developmental Medicine agreed that the positive results in both groups were due to a participation effect. The Southern Africa Undersea and Hyperbaric Association discouraged the ongoing, widespread, and informal use of HO for children with CP in South Africa based on the results of this randomized controlled study. CONCLUSION: There are no scientific evidences for the use of HO in children with CP. Risks include barometric otitis media.

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Eur J Neurol. 2003 Jul;10(4):415-9.
Botulinum toxin in the management of childhood muscle spasticity: comparison of clinical practice of 17 treatment centres.
Bakheit AM.
Peninsula Medical School & Plymouth Primary Care Trust, Plymouth, UK. magid.bakheit@pcs-tr.swest.nhs.uk

At least two randomized controlled trials (RCTs) have shown botulinum toxin type A (BtxA) to be efficacious and safe when used in the management of muscle spasticity in children. However, the need to use standard treatment protocols in these studies obscures some aspects of routine clinical practice that may have important effect on clinical outcomes. The purpose of this study was to seek additional information on the use of BtxA that is not usually captured by RCTs. This was performed by reviewing the clinical practice of practitioners in 17 treatment centres in Europe. The details of treatment with BtxA, including the dose, site and frequency of injections and the use of anaesthesia or sedation, were abstracted from the patient's records. Information was also obtained on the response to treatment and the occurrence and severity of adverse events. The data on 758 children who received a total of 1,594 treatments in 17 different clinics in Europe were analysed. Ninety-four per cent of patients had cerebral palsy. There was a general agreement on the indications for treatment but the average dose of BtxA used varied between centres. One treatment centre used general anaesthesia (GA) prior to injections in most patients. The reported efficacy and adverse events profile was similar for all centres. The evidence from routine clinical practice for the efficacy and safety of BtxA in the management of muscle spasticity in children, as described in this study, is in agreement with that of most of the open-label and RCTs published to date. The present study also demonstrates the disagreement between clinicians on the optimal dose of BtxA for individual muscles and confirms that the injections can be carried out without GA in almost all cases.

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Ann Readapt Med Phys. 2003 Jul;46(6):346-52.
[Botulinum toxin type A in children: evaluation of indications with a review of the literature]
[Article in French]
Bertrand H, Forin V.
Service de chirurgie orthopedique, hopital d'enfants Armand-Trousseau, 26, avenue du Docteur-A.-Netter, 75012 Paris, France.

INTRODUCTION: The aim of this study is to review the literature to indications of botulinum toxin type A in children. METHOD: We review the international literature from 1990 to 2002 by querying the Pubmed database with the keywords "children" and "botulinum toxin". RESULTS: Two hundred and forty-eight articles are retrieved. We selected the most relevant 64 articles among them. Several questions remain pending: which optimal dose, which periodicity for injections, which optimal age to prolong efficiency? The main criteria to estimate efficiency is functional ability improvement. No significant side effects are noted. The main use of botulinum toxin is the management of the spastic lower limb in cerebral palsy. DISCUSSION: This review of the literature makes it possible to specify the interests and the operational limits of botulinum toxin in the child. Its effectiveness with the upper limb is not proven. The other indications remain to be studied in a more precise way. CONCLUSION: This review shows many studies give the indications of botulinum toxin in children. The main indication is the lower limb spaticity in cerebral palsy. New prospective and double-blind studies should be performed with larger samples.

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Dev Med Child Neurol. 2003 Jun;45(6):385-90.
Electrical stimulation of gluteus maximus in children with cerebral palsy: effects on gait characteristics and muscle strength.
van der Linden ML, Hazlewood ME, Aitchison AM, Hillman SJ, Robb JE.
Royal Hospital for Sick Children, Edinburgh, UK. mlinden@lhb.scot.nhs.uk

The purpose of this study was to determine whether electrical stimulation of the gluteus maximus would improve hip extensor strength, decrease excessive passive and dynamic internal hip rotation, and improve gross motor function in children with cerebral palsy (CP). Twenty-two ambulant children (15 females, 7 males, mean age 8 years 6 months, SD 2 years 9 months, aged 5 to 14 years) with diplegic (n = 14), hemiplegic (n = 7), and quadriplegic (n = 1) CP participated in this study. All were randomly assigned to either the stimulation or control group. The stimulation group (n = 11) received electrical stimulation of the gluteus maximus of the most affected legs for 1 hour a day, 6 days a week for a period of 8 weeks. Electrodes were applied proximally and distally over the gluteus maximus, with the active electrode initially positioned over the motor points. The control group (n = 11) did not receive any extra treatment. Measurements of hip extensor strength, gait analysis, passive limits of hip rotation, and section E of the Gross Motor Function Measure were made before and after treatment for both groups. Subjectively, 7 of the 11 parents thought that the treatment made a difference to their child. However, no statistically or clinically significant improvement was found in the stimulation group when compared with the control group.

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Bull Hosp Jt Dis. 2002-2003;61(1-2):63-7.
Effect of exercise at the AT point for children with cerebral palsy.
Shinohara TA, Suzuki N, Oba M, Kawasumi M, Kimizuka M, Mita K.
Izu Iryo-Fukushi Center for Children's Rehabilitation, Shizuoka, Japan.

Eleven children with spastic cerebral palsy (CP) who could walk underwent exercise at the anaerobic threshold (AT) point. The subjects exercised for 20 minutes per session, twice a week for a period ranging from 6 to 20 weeks. The subjects were divided into two groups. The leg exercise group contained six CP children who exercised on a cycle ergometer with average attendance of 1.8 days a week. The other five CP children constituted the arm exercise group and exercised using an arm cranking ergometer with average attendance of 1.5 days per week. After the exercise period, the oxygen uptake (VO2) at the AT point increased significantly in the children in the leg exercise group. On the other hand, the VO2 at the AT point did not change in children in the arm exercise group. These results demonstrate that cycle ergometer exercise at the AT point is effective in improving the physical endurance of children with CP. In contrast, arm exercises for children with CP seem to have little effect on increasing physical endurance.

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NeuroRehabilitation. 2003;18(3):261-70.
Life expectancy for children with cerebral palsy and mental retardation: implications for life care planning.
Katz RT.
Department of Physical Medicine and Rehabilitation, Washington University School of Medicine, 4660 Maryland Avenue, St. Louis, MO 63108, USA. pianodoctor@pol.net

OBJECTIVES: Physicians may be asked by attorneys or other patient advocates to help plan for the long-term needs of children with cerebral palsy (CP) and developmental disability (DD). The first step in such planning is to thoroughly examine the literature dealing with life expectancy in these populations. This review paper comprehensively reviews the literature relating to survival in children with cerebral palsy and developmental disability. STUDY SELECTION: A Medline data search was completed using the terms cerebral palsy, life expectancy, survival, as well as other pertinent terms. Further articles were gleaned from bibliographies of pertinent literature. DATA SYNTHESIS: Certain key disabilities can be used to accurately predict life expectancy in children with cerebral palsy and mental retardation. These include: (1) presence and severity of mental retardation, (2) inability to speak intelligible words, (3) inability to recognize voices, (4) inability to interact with peers, (4) severity of physical disability, (5) use of tube feeding, (6) incontinence, and (7) presence and severity of seizures. CONCLUSIONS: Literature review definitively shows that children with CP and DD have a diminished life expectancy, which can be assessed based on simple clinical examination findings.

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Neurochirurgie 2003 May;49(2-3 Pt 2):408-12
[Neurosurgical treatment of spasticity: indications in children]
[Article in French]
Hodgkinson I, Sindou M.
Service de Medecine Physique et Readaptation Pediatrique, L'Escale, Centre Hospitalier Lyon-Sud, Pierre-Benite.

Today, we have several efficient neurosurgical treatments of spasticity in children with cerebral palsy. A good indication is possible only if a consensus about the goal of the surgery is found between the surgeon, the child and his/her family, and the reeducation team. This goal is not always functional. Clinical examination is not limited to the analytical assessment of spasticity, but must take into account the general and orthopedic state of the child, and his/her functional evolution, cognitive abilities, habits and general envionment. The struggle against spasticity is part of a therapeutical programme which extends over several years. It must be considered before muscular contractures. On lower limbs, in the cases of general spasticity, we propose posterior rhizotomy or intrathecal baclofen administration. Posterior rhizotomy is proposed when a more aggressive intervention is preferred for some muscular groups or when the child's general environment does not allow for the medical care imposed by intrathecal administration. In the case of localized spasticity, botulinum toxin injection permits delaying until the child reaches the age for selective neurotomy. On upper limbs, in children with quadriplegia the indication is essentially physical and occupational therapy. We cannot count on the positive side effects of rhizotomy or intrathecal administration of baclofen on the upper limbs. In children with hemiplegia, with localized or global spasticity of the upper limb, botulinum toxin is proposed as the first form of treatment. Neurotomy or rhizotomy can follow toxin, according to the efficacy of the toxin.

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Am J Phys Med Rehabil 2003 Apr;82(4):284-9
Effect of botulinum toxin type A on cerebral palsy with upper limb spasticity.
Yang TF, Fu CP, Kao NT, Chan RC, Chen SJ.
Department of Physical Therapy, School of Medicine, National Yang-Ming University, Taipei, Taiwan.

OBJECTIVE: The objective of this study was to investigate the effects of botulinum toxin type A injections in reducing upper limb muscular spasticity and in improving motor function in children with cerebral palsy. DESIGN: Fifteen children with spastic cerebral palsy who were undergoing regular physical and occupational therapy were enrolled. Botulinum toxin type A injections in clinically indicated target muscle groups were administered after the children had received 3 mo of therapy. A follow-up study was carried out at 6 wk and 12 wk, respectively, after the botulinum toxin type A injections. The main outcome measurements included the Modified Ashworth Scale, the upper limb Physician's Rating Scale, the Bruininks-Oseretsky Test of Motor Proficiency, and the self-care domain of the Pediatric Evaluation of Disability Inventory. RESULTS: The reduction of spasticity in the treated muscle groups differed significantly between the control period and both study periods. Improvements on the Physician's Rating Scale score during the study period also differed significantly as compared with improvements during the control period. There was a significant difference in the improvement of fine motor skills, as measured with Bruininks-Oseretsky Test of Motor Proficiency, between the control period and both study periods. Improvements in self-care capability differed significantly between the control period and 12 wk after botulinum toxin type A treatment, but not between the control period and at 6 wk after treatment. Muscle strength of grasp and pinch did not differ significantly between the control and the study period. Distribution of body parts involvement, disease severity, and function in daily living activities had no significant correlation with functional improvement after the treatment. CONCLUSIONS: Our findings support the premise that botulinum toxin type A injections are effective in reducing upper limb spasticity and in improving movement pattern and fine motor function of patients with spastic cerebral palsy. A reduction in caregivers' burden and improved quality of life were demonstrated through the study period.

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Clin Rehabil 2003 Feb;17(1):48-57
Functional strength training in cerebral palsy: a pilot study of a group circuit training class for
children aged 4-8 years.
Blundell SW, Shepherd RB, Dean CM, Adams RD, Cahill BM.
Faculty of Health Sciences, University of Sydney, New South Wales, Australia.

OBJECTIVE: To determine the effects of intensive task-specific strength training on lower limb strength and functional performance in children with cerebral palsy. DESIGN: A nonrandomized ABA trial. SETTING: Sydney school. SUBJECTS: Eight children with cerebral palsy, aged 4-8 years, seven with diagnosis of spastic diplegia, one of spastic/ataxic quadriplegia. INTERVENTION: Four weeks of after-school exercise class, conducted for one hour twice weekly as group circuit training. Each work station was set up for intensive repetitive practice of an exercise. Children moved between stations, practising functionally based exercises including treadmill walking, step-ups, sit-to-stands and leg presses. MAIN OUTCOME MEASURES: Baseline test obtained two weeks before training, a pre-test immediately before and a post-test following training, with follow-up eight weeks later. Lower limb muscle strength was tested by dynamometry and Lateral Step-up Test; functional performance by Motor Assessment Scale (Sit-to-Stand), minimum chair height test, timed 10-m test, and 2-minute walk test. RESULTS: Isometric strength improved pre- to post-training by a mean of 47% (SD 16) and functional strength, on Lateral Step-up Test, by 150% (SD 15). Children walked faster over 10 m, with longer strides, improvements of 22% and 38% respectively. Sit-to-stand performance had improved, with a reduction of seat height from 27 (SD 15) to 17 (SD 11) cm. Eight weeks following cessation of training all improvements had been maintained. CONCLUSIONS: A short programme of task-specific strengthening exercise and training for children with cerebral palsy, run as a group circuit class, resulted in improved strength and functional performance that was maintained over time.

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Neuropediatrics 2003 Apr;34(2):67-71
Follow-up of children with cerebral palsy after selective posterior rhizotomy with intensive physiotherapy or physiotherapy alone.
Maenpaa H, Salokorpi T, Jaakkola R, Blomstedt G, Sainio K, Merikanto J, Von Wendt L.
Paediatric Neurology, The Hospital for Children and Adolescents, Helsinki, Finland. helena.maenpaa@hus.fi

In all 21 children with spastic cerebral palsy (CP) underwent surgery involving selective posterior rhizotomy (SPR), followed by six months intensive physiotherapy (PT). Neurological and physiotherapeutic assessments were made one, three and five years after the operation. The children undergoing surgery were compared to 21 comparison children who took part in a regular physiotherapy programme during the same time period. At the preoperative assessment, the children undergoing surgery were similar to the comparative children in terms of age, sex, type of CP, spasticity of the legs and mean functional scores. The children were selected for SPR on the basis of more than half a year's arrest of motor development, which was the only significant difference to the comparative group. Motor function was measured using two different methods, the Illinois-St Louis Scale and the Gross Motor Functional Classification System (GMFC). Both groups experienced steady development during the five-year follow-up period and no significant differences were observed in the mean functional scores between the groups. We conclude that this comparative study, like most controlled studies, failed to demonstrate any additional effect of SPR on motor development of children with spastic CP. Nevertheless, SPR may contribute to a resumption of motor development in children with arrested motor development despite vigorous conservative therapy. SPR is therefore justified as treatment in selected cases.

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Eur J Neurol 2003 May;10(3):313-7
Functional improvement in cerebral palsy patients treated with botulinum toxin A injections—preliminary results.
Slawek J, Klimont L.
Department of Neurosurgery, Subdivision of Movement Disorders and Functional Neurosurgery, Medical University, Early Intervention Center*, Gdansk, Poland.

Authors report the preliminary results of an open-label, prospective study to evaluate a functional benefit of botulinum toxin type A injections in diparetic cerebral palsy patients, using gross motor function measure (GMFM) score. In a group of 14 children (mean age 3.9 years, range 2-6) treated with Dysport 30 IU/kg, a statistically significant improvement (P < 0.05) was noticed in both simple measurements (Modified Ashworth Scale, Selective Motor Control, Passive Range of Movements, Physician Rating Scale and parental Clinical Global Impression) and complex functions (GMFM dimensions D and E) after 1 and 3 months. However, the simple measurement scores decreased (but not to the baseline) after 3 months; surprisingly, GMFM scores were still increasing (7.7% change after 3 months and 11.3% change after 6 months in nine patients). These results are in concordance with a few other data published to date. The study may support the concept of persistent functional gain in long-term treatment of spasticity caused by cerebral palsy with botulinum toxin type A.

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Neurochirurgie 2003 May;49(2-3 Pt 2):276-88
[Intrathecal baclofen. Literature review of the results and complications]
[Article in French]
Emery E.
Service de Neurochirurgie (Pr J.-M. Derlon), CHU, Caen.

Intrathecally delivered baclofen has been used as a treatment for severe spasticity since 1984. A systematic literature review was conducted from 1984 to December 2002 to analyze the results of this treatment and to collect data on complications. Studies were included if the following criteria were met: clear selection of patients suffering from spasticity of spinal or cerebral origin, clear measurements of outcome (Ashworth score, Spasm score and/or reflex score and/or functional scales), average follow-up of at least 6 months. Almost all the studies had open follow-up with no control groups (controls were used to examine the effect of test doses of baclofen rather than to assess long-term results). Studies often included heterogeneous patients groups with different causes of spasticity (spinal and/or cerebral etiology) and functional outcome was measured using different scales from one study to another. This literature review shows evidence that intrathecally administered baclofen is effective in reducing the positive signs of spasticity (tone, spasms, reflex activity). Significant reductions in spasm-related pain were noted. The reduction in spasticity led to improvement in ability to transfer and ease of nursing care in the majority of patients. Significant improvements were noted in terms of mobility. Benefits were most notable in bedridden patients who became able to sit in a wheelchair. Many benefited from improved wheelchair mobility, ability to sit down comfortably, and improvement in their ability to transfer. Such benefits were approved by all the patients as an improvement of their quality of life. Ambulatory patients could also benefit from an improved gait but were less often treated because they usually relied upon their spasticity for support during ambulation. Complications were rather rare and mainly were not life-threatening, although there was a high rate of catheter dysfunction (10 to 45%) leading to reoperation. Wound complications were the leading cause of explantation in children with cerebral palsy. Despite the risks, patient satisfaction was high and was related to the improvement of the quality of life.

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Neurochirurgie 2003 May;49(2-3 Pt 2):306-11
[Percutaneous sacral thermorhizotomy to treat equinism of spastic cerebral palsy children]
[Article in French]
Frerebeau P, Rejou F, Trouillas J, El Fertit H, Segnarbieux F, Coubes P.
Service de Neurochirurgie B.

We propose to evaluate the effect of sacral percutaneous thermorhizotomy on cerebral palsy children. A prospective study including 29 children followed by a multidisciplinary team was conducted from 1990 to 2000. A thermal radiofrequency lesion of the first sacral root was obtained by percutaneous puncture of the posterior intervertebral foramen with evaluation by stimulation of the best motor response for the minimal threshold (<0.5 volts). The efficacy of the lesion was evaluated by testing and modification of the stimulation threshold obtained (x 2). The results on spasticity was evaluated using the Held score and the functional effect on walking, and classified as "good" (9 cases), "efficacy" (6 cases) and "nil" (4 cases). Indications of the procedure are discussed during the walking acquisition period and growing period of the cerebral palsy child.

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Zh Nevrol Psikhiatr Im S S Korsakova 2003;103(2):25-7
[Advantages of ride therapy in different forms of infantile cerebral palsy (therapeutic riding)]
[Article in Russian]
Ionatamishvili NI, Tsverava DM, Loriia MSh, Avaliani LA.

One hundred children with cerebral palsy, aged 3-14 years, were divided into two equal groups, the first one including 50 children assigned to ride therapy and the second one--to Bobath therapeutic gymnastics. All the patients underwent a functional examination, which was rated using score system worked out by the authors, thus enabling a quantitative evaluation of treatment efficacy. In all the cases, physical rehabilitation resulted in a positive but not the same effect, with ride therapy being significantly (p < 0.001) more beneficial treatment compared to therapeutic gymnastics. Ride therapy provides an acquisition of new movement skills, spastics and hyperkinesis reduction and an extreme mobilization of compensatory abilities of developing children brain.

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Neurochirurgie 2003 May;49(2-3 Pt 2):256-62
[Alcohol neurolytic blocks for pain and muscle spasticity]
[Article in French]
Viel E, Pelissier J, Pellas F, Boulay C, Eledjam JJ.
Departement d'Anesthesie et Centre de la Douleur.

Peripheral nerve blockade is one of the therapeutic options for spasticity of various muscles. Percutaneous nerve stimulation allows accurate location of nerves and neurolysis can be performed using intraneural injection of 65% ethanol or 5 to 12% phenol. Spastic contraction of various muscle groups is a common source of pain and disability which prevents efficient rehabilitation. Neurolytic blocks are possible in most of motor nerves of the upper and lower limbs and main indications are spastic sequelae of stroke and spinal trauma but also of multiple sclerosis, cerebral palsy and chronic coma. The use of percutaneous nerve stimulation allows accurate location and four nerves are more frequently treated: pectoral nerve loop, median, obturator and tibial nerves. In patients with spasticity of the adductor thigh muscles, nerve blocks are performed via a combined approach using fluoroscopy and nerve stimulation to identify the obturator nerve. No complications occur and minor side effects are transient painful phenomena during injection. These approaches have proved to be accurate, fast, simple, highly successful and reproducible. Percutaneous neurolytic procedures, should be performed as early as possible, as soon as spasticity becomes painful and disabling in patients with neurological sequelae of stroke, head trauma or any lesion of the motor neurons.

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Neurochirurgie 2003 May;49(2-3 Pt 2):226-38
[Interest of anesthetic blocks for assessment of the spastic patient. A series of 815 motor blocks]
[Article in French]
Filipetti P, Decq P.
Groupe d'Evaluation et de Traitement de la Spasticite et de la Dystonie, Service de Neurochirurgie (Pr Y. Keravel), Hopital Henri-Mondor, Creteil.

BACKGROUND: The purpose of the study was to emphasize the value of anesthetic blocks in the approach to the spastic patient. The report relates our experience concerning 566 patients (ranging in age from 4 to 72 years, mean 48 years) tested by 815 motor blocks performed within a "spasticity and dystonia evaluation" unit. The spasticity was mainly due to stroke (56%), cerebral palsy (21%) and traumatic brain injury (14%).METHODS: Motor blocks were performed with standardized procedure (specific needle, neurostimulator, localization technique), analytic and functional assessment.RESULTS: The anesthetic was mostly 1% non-adrenalized etidocaine, chosen for its onset and duration of action. Re-injections were few and side effects exeptional. Quality and motor blocks results were technique-dependent and required patient cooperation. The spasticity disappeared in blocked muscles. Tardieu and Ashworth modified scale showed constantly decreased spasticity (2 to 3 points) with better sensitivity for the Tardieu modified score. Local anesthetic blocks determined the relative contributions of overactivity and of muscle shortening in the generation of the pathologic posture, the muscle or muscles responsable for the spastic pattern and the level of active performance of the antagonistic muscle. New stability was evaluated by functional assessment of gait posture and prehension.CONCLUSION: At the present time, anesthetic motor blocks represent a necessary and decisive stage procedure as regards spastic patient assessment. This method is particularly useful to anticipate a new functional balance and simulate treatment. Motor blocks provide acute knowledge of the pathological pattern and a better adjustment of therapeutic directions.

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Acta Orthop Traumatol Turc 2002;36(5):397-400
[Treatment of stiff-knee gait by distal rectus femoris transfer]
[Article in Turkish]
Ucar DH, Isiklar ZU, Tumer Y.
Ankara Ortopedi ve Travmatoloji Tedavi Merkezi, Turkey. h.ucar@superonline.com

OBJECTIVES: We evaluated the preliminary results of distal rectus femoris transfer in patients with stiff-knee gait due to cerebral palsy. METHODS: Eight knees of four patients who had stiff-knee gait due to cerebral palsy were treated by distal rectus femoris transfer. All the patients were females with a mean age of 11 years (range 9.5 to 12 years). Preoperatively and postoperatively, lower extremity examinations, the Ely test, and clinical gait analyses were performed. Satisfaction levels of the patients and their families were questioned. The mean follow-up was 17.5 months (range 3 to 23 months). RESULTS: None of the patients manifested flexion contracture of their hips and knees postoperatively. The Ely test was negative in all patients. There were no clinical signs of stiff-knee gait. All the patients and their families but one expressed their satisfaction with clinical and functional results. CONCLUSION: Our clinical results suggest that distal rectus femoris transfer is effective in the treatment of stiff-knee gait due to cerebral palsy.

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Clin J Pain 2002 Nov-Dec;18(6 Suppl):S182-90
Treatment of spasticity with botulinum toxin.
O'Brien CF.
Elan Pharmaceuticals, San Diego, California 92121, USA. Christopher.Obrien@elan.com

Spasticity is an abnormal increase in muscle contraction often caused by damage to central motor pathways that control voluntary movement. During clinical examination, spasticity manifests as an increase in stretch reflexes, producing tendon jerks and resistance appearing as muscle tone. There are many causes of spasticity, including demyelination from multiple sclerosis, congenital damage from diseases such as cerebral palsy, trauma to the brain or spinal cord, hemorrhage or infarction, and other pathologic conditions that interrupt neural pathways. Effects of spasticity range from mild muscle stiffness to severe, painful muscle contractures and repetitive spasms that reduce mobility and substantially impede normal activities of daily living. Botulinum toxin therapy reduces spasticity and pain associated with several disorders. Local treatment with botulinum toxins can be used as adjunctive therapy, along with oral antispasticity medications, or alone to provide localized decrease in symptoms of spasticity and pain. Botulinum toxin therapy may be particularly useful for patients with spasticity due to stroke, whose treatment can be tailored based on recovery of function over time. In addition, botulinum toxin therapy is safe for pediatric patients, including children with cerebral palsy, who may not be able to tolerate the cognitive side effects of oral medications. Results of studies evaluating botulinum toxin for the treatment of spasticity due to various causes are presented here.

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Child Care Health Dev 2002 Nov;28(6):469-77
Use of physiotherapy and alternatives by children with cerebral palsy: a population study.
Parkes J, Donnelly M, Dolk H, Hill N.
Health & Social Care Research Unit, The Queen's University of Belfast, Belfast, UK. j.parkes@qub.ac.uk

OBJECTIVES: To describe the use of physiotherapy services and alternative therapies by a population of children with moderate to severe cerebral palsy (CP). DESIGN: Descriptive cross-sectional survey. SUBJECTS: A total of 212 parents of children aged 4-14 years with moderate to severe CP were identified from the Northern Ireland Cerebral Palsy Register (NICPR) and a random subsample of their paediatric physiotherapists. MAIN MEASURES: A standardized description of motor impairment or assessment form; a postal questionnaire to parents and paediatric physiotherapists (to validate parents' reports of service use). RESPONSE RATES: In total, 85% of parent questionnaires were returned and 100% of paediatric physiotherapists responded. RESULTS: Service use among families was high; on average the families had contact with approximately seven services in a 6-month time interval. The overwhelming majority of children (96%) received physiotherapy during the school term and most (59%) received treatment at least twice a week for 30 min; 43% of children had their physiotherapy discontinued over the summer holidays. Over one-quarter (28%) of families had opted out of the NHS and bought alternatives like conductive education (21%) or private forms of conventional physiotherapy (16%). Children with more severe forms of CP, in special education, particularly at schools for physical disability, were high-intensity users of the physiotherapy service. Despite this, 74% of parents wanted more physiotherapy for their child. CONCLUSIONS AND IMPLICATIONS: The demand for physiotherapy services is likely to continue given the relatively stable prevalence rate of CP, the proportion of children with disabling CP and the level of parent interest in the service. A number of quality aspects and gaps in the service have been identified.

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Arch Phys Med Rehabil 2002 Dec;83(12):1721-5
Intrathecal baclofen therapy in children with cerebral palsy: efficacy and complications.
Murphy NA, Irwin MC, Hoff C.
Department of Pediatrics, University of Utah, Salt Lake City, UT 84132, USA. Nancy.Murphy@hsc.utah.edu

OBJECTIVES: To describe the efficacy of intrathecal baclofen (ITB) therapy in the management of spasticity in young children with cerebral palsy (CP) and to identify risk factors for complications. DESIGN: Consecutive case series of 25 implanted ITB delivery systems during a 48-month period. SETTING: Pediatric specialty hospital and outpatient department. PARTICIPANTS: Twenty-three children (age range, 4.5-17.4y) with CP (spastic diplegia in 22%; spastic quadriplegia in 61%; mixed-type diplegia in 4%; mixed-type quadriplegia in 13%). INTERVENTION: Intrathecal baclofen therapy in children with cerebral palsy. MAIN OUTCOME MEASURES: Ashworth Scale scores before treatment and at 6 and 12 months after ITB therapy; frequency and nature of complications; and relation between patient characteristics and outcomes. RESULTS: Average Ashworth scores +/- standard deviation decreased from 3.26+/-.73 to 2.34+/-.83 (P<or=.01) in the lower extremities and from 2.69+/-.79 to 2.00+/-.55 (P<or=.05) in the upper extremities 6 months after ITB therapy and remained comparably decreased at 12 months. Explantation was required in 44% (11/25), with wound complications as the leading cause in 73% (8/11). Complications were associated with the diagnosis of mixed-type CP, as compared with pure spastic types (P<or=.01). Trends suggest that children of smaller size and younger age, as well as those with gastrostomy tubes and nonambulatory status, were more likely to encounter complications necessitating explantation. CONCLUSION: ITB therapy effectively reduced spasticity in children with CP. However, complications necessitating explantation can occur. Further research is needed to identify criteria describing the ideal pediatric candidate for ITB. Copyright 2002 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation

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Dev Med Child Neurol 2002 Dec;44(12):820-7
Functional outcome of botulinum toxin A injections to the lower limbs in cerebral palsy.
Reddihough DS, King JA, Coleman GJ, Fosang A, McCoy AT, Thomason P, Graham HK.
Murdoch Childrens Research Institute, Melbourne, Victoria, Australia. reddihod@cryptic.rch.unimelb.edu.au

We evaluated gross motor function following botulinum toxin A (BTX-A) injections in the lower limbs of children with spastic cerebral palsy in a randomized clinical trial, using a cross-over design. Forty-nine children (24 males, 25 females, age range 22 to 80 months) were randomly allocated to two groups: group 1 received BTX-A and physiotherapy, and group 2 received physiotherapy alone for 6 months. At the end of this period, group 2 received BTX-A and physiotherapy and group 1 continued with physiotherapy alone. Assessment measures were the Gross Motor Function Measure (GMFM), the Vulpe Assessment Battery (VAB), joint range of movement, the Modified Ashworth Scale, and a parental questionnaire. Sustained gains in gross motor function were found in both groups of children but the only additional benefit found in group 1 was a significant increase in fine motor rating on the VAB. By contrast, parents rated the benefit of treatment highly. It is likely that assessment at 3 and 6 months post injection was too late to demonstrate peak gross motor function response and that changes in GMFM are not sustained over 6 months with a single dose. Further studies should investigate changes over shorter time periods and consider covariables such as BTX-A dosage, number of injection sites, and the role of repeated injections combined with other interventions such as casting.

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Zh Nevrol Psikhiatr Im S S Korsakova 2002;102(10):42-5
[Hippotherapy as a method for complex rehabilitation of patients with late residual stage of infantile cerebral palsy]
[Article in Russian]
Sokolov PL, Dremova GV, Samsonova SV.

Influence and therapeutic efficacy of horseback riding (hippotherapy) as a method for complex rehabilitation of patients with late residual stage of infantile cerebral palsy were studied. Significant increase of a range of active and passive mosements in large joints of lower extremities, higher, indices of hand dynamometry on the left, of vital lung capacity as well as a relief of relief of reactive and personality anxiety and depression, higher motivation for rehabilitation treatment, etc., were registered. Neurophysiological study revealed significant changes of afferentation at stem and thalamus cortical levels and of spectral components of cortical rhythmics. The data obtained allow to consider hippotherapy as an effective method of complex rehabilitation of patients with late residual stage of infantile cerebral palsy. A combination of sensory stimulation and motor rehabilitation components may be a key mechanism of positive effect.

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Dev Med Child Neurol 2002 Oct;44(10):666-75
Botulinum toxin treatment of spasticity in diplegic cerebral palsy: a randomized, double-blind, placebo-controlled, dose-ranging study.
Baker R, Jasinski M, Maciag-Tymecka I, Michalowska-Mrozek J, Bonikowski M, Carr L, MacLean J, Lin JP, Lynch B, Theologis T, Wendorff J, Eunson P, Cosgrove A.
Musgrave Park Hospital, Belfast, Northern Ireland. bakerr@cryptic.rch.unimelb.edu.au

This study evaluated the efficacy and safety of three doses of botulinum toxin A (BTX-A; Dysport) in 125 patients (mean age 5.2 years, SD 2; 54% male)with dynamic equinus spasticity during walking. Participants were randomized to receive Dysport (10, 20, or 30 units/kg) or placebo to the gastrocnemius muscle of both legs. Muscle length was calculated from electrogoniometric measurements and the change in the dynamic component of gastrocnemius shortening at four weeks was prospectively identified as the primary outcome measure. All treatment groups showed statistically significant decreases in dynamic component compared with placebo at 4 weeks. Mean improvement in dynamic component was most pronounced in the 20 units/kg group, being equivalent to an increase in dorsiflexion with the knee extended at 19 degrees, and was still present at 16 weeks. The safety profile of the toxin appears satisfactory.

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Pediatr Neurosurg 2002 Nov;37(5):225-30
The effect of intrathecal baclofen on muscle co-contraction in children with spasticity of cerebral origin.
Sgouros S, Seri S.
Department of Neurosurgery, Birmingham Children's Hospital, Birmingham, UK. S.Sgouros@bham.ac.uk

AIM: Investigation of the effect of intrathecal baclofen administration on the time course of electrical patterns of muscle activation in patients with spasticity due to upper motor neuron syndrome. METHODS: Six children with clinical signs of upper motor neuron syndrome resulting from an acquired cerebral hypoxic injury were tested. Simultaneous multichannel acquisition of surface EMG activity from flexor/extensor muscle groups of the upper and lower limbs was recorded. Investigated muscle group pairs included biceps/triceps brachii, wrist flexors/extensors, rectus/biceps femoris and tibialis anterioris/gastrocnemius. Time-frequency analysis of EMG activity at rest and while eliciting a stretch reflex was performed. The non-linear cross-correlation coefficient and time lag estimation were computed between paired channel groups both for baseline and post-intrathecal baclofen injection conditions for epochs consisting of 2 s prior to and 2 s after voluntary contraction. The effect of baclofen was assessed 3 h following single-bolus intrathecal injections of 25 or 50 microg during the baclofen trial and 6 months after baclofen pump implantation. RESULTS: In the baseline condition, the stretch reflex resulted in a synchronous increase in spectral EMG power in both the agonist and the antagonist muscles. The mean correlation coefficient between agonist and antagonist muscles was 0.948 (SD = 0.034), and the mean time lag was 4.64 ms (SD = 1.84 ms). After intrathecal administration of baclofen, a dramatic decrease in the correlation coefficient between agonist and antagonists (mean value = 0.342) during voluntary contraction was observed. This corresponded to a significant reduction of tone and spasticity in all four limbs, and reduction of the Ashworth score by 2 points on average. CONCLUSION: After intrathecal baclofen administration, we observed a significant decrease in the co-contraction pattern typically associated with upper motor neuron spasticity. This was evident clinically and was quantitatively expressed by the significantly decreased degree of coupling in EMG activity of agonist/antagonist muscles. Although a relatively small sample was investigated in this study, we were able to demonstrate the efficacy of this procedure in restoring selective activation of agonists during voluntary contraction. This is one of the prerequisites of an improvement of motor function in patients with spasticity. Copyright 2002 S. Karger AG, Basel

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J Neurosurg 2002 Sep;97(3):510-8
Functional performance following selective posterior rhizotomy: long-term results determined using a validated evaluative measure.
Mittal S, Farmer JP, Al-Atassi B, Montpetit K, Gervais N, Poulin C, Benaroch TE, Cantin MA.
Division of Neurosurgery, Montreal Children's Hospital, McGill University Health Centre, Quebec, Canada.

OBJECT: Selective posterior rhizotomy (SPR) may result in considerable benefit for children with spastic cerebral palsy. To date, however, there have been few studies in which validated functional outcome measures have been used to report surgical results beyond 3 years. The authors analyzed data obtained from the McGill Rhizotomy Database to determine long-term functional performance outcomes in patients who underwent lumbosacral dorsal rhizotomy performed using intraoperative electrophysiological monitoring. METHODS: The study population was composed of children with debilitating spasticity who underwent SPR and were evaluated by a multidisciplinary team preoperatively and at 6 months and 1 year postoperatively. Quantitative standardized assessments of activities of daily living (ADL) were obtained using the Pediatric Evaluation of Disability Inventory (PEDI). Of 57 patients who met the entry criteria for the study, 41 completed the 3-year assessments and 30 completed the 5-year assessments. Statistical analysis demonstrated significant improvement in the mobility and self-care domains of the functional skills dimension at 1 year after SPR. The preoperative and 1-, 3-, and 5-year postoperative scaled scores for the mobility domain were 56, 64, 77.2, and 77.8, respectively. The scaled score for the self-care domain increased from 59 presurgery to 67.9, 81.6, and 82.4 at the 1-, 3-, and 5-year postoperative assessments, respectively. CONCLUSIONS: The results of this study support the presence of significant improvements in functional performance, based on PEDI scores obtained 1 year after SPR. The improvements persisted at the 3- and 5-year follow-up examinations. The authors conclude that SPR performed using intraoperative stimulation is valuable in the augmentation of motor function and self-care skills essential to the performance of ADL.

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Dev Med Child Neurol 2002 Jul;44(7):436-46
Neuropsychological effects of hyperbaric oxygen therapy in cerebral palsy.
Hardy P, Collet JP, Goldberg J, Ducruet T, Vanasse M, Lambert J, Marois P, Amar M, Montgomery DL, Lecomte JM, Johnston KM, Lassonde M.
Groupe de Recherche en Neuropsychologie Experimentale, Universite de Montreal, Quebec, Canada.

We conducted a double-blind placebo study to investigate the claim that hyperbaric oxygen treatment (HBO2) improves the cognitive status of children with cerebral palsy (CP). Of 111 children diagnosed with CP (aged 4 to 12 years), only 75 were suitable for neuropsychological testing, assessing attention, working memory, processing speed, and psychosocial functioning. The children received 40 sessions of HBO2 or sham treatment over a 2-month period. Children in the active treatment group were exposed for 1 hour to 100% oxygen at 1.75 atmospheres absolute (ATA), whereas those in the sham group received only air at 1.3 ATA. Children in both groups showed better self-control and significant improvements in auditory attention and visual working memory compared with the baseline. However, no statistical difference was found between the two treatments. Furthermore, the sham group improved significantly on eight dimensions of the Conners' Parent Rating Scale, whereas the active treatment group improved only on one dimension. Most of these positive changes persisted for 3 months. No improvements were observed in either group for verbal span, visual attention, or processing speed.

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Dev Med Child Neurol 2002 Jul;44(7):447-60
Evaluation of the functional effects of a course of Bobath therapy in children with cerebral palsy: a preliminary study.
Knox V, Evans AL.
Bobath Centre, London, UK. info@bobathlondon.co.uk

This study aimed to evaluate functional effects of Bobath therapy in children with cerebral palsy (CP). Fifteen children with a diagnosis of CP were recruited (9 males, 6 females; mean age 7 years 4 months, SD 2 years 8 months; age range 2 to 12 years). Types of motor disorder were as follows: spastic quadriplegia (n=9); spastic diplegia (n=4); athetoid quadriplegia (n=1), and ataxia (n=1). Participants were distributed across the following Gross Motor Function Classification levels: level I, n=1; level II, n=4; level III, n=5; level IV, n=4; and level V, n=1. Children awaiting orthopaedic intervention were excluded. A repeated measures design was used with participants tested with the Gross Motor Function Measure (GMFM) and Pediatric Evaluation of Disability Inventory (PEDI) at 6-weekly intervals (baseline, before and after Bobath therapy, and follow-up). As the data were of ordinal type, non-parametric statistics were used, i.e. Wilcoxon's test. Participants showed a significant improvement in scores in the following areas following Bobath therapy compared with the periods before and after Bobath therapy: GMFM total score (p=0.009); GMFM goal total (p=0.001); PEDI self care skills (p=0.036); and PEDI caregiver assistance total score (p=0.012). This demonstrates that in this population, gains were made in motor function and self care following a course of Bobath therapy.

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Arch Phys Med Rehabil 2002 Aug;83(8):1157-64
A systematic review of the effectiveness of strength-training programs for people with cerebral palsy.
Dodd KJ, Taylor NF, Damiano DL.
School of Physiotherapy, La Trobe University, Bundoora, Victoria, Australia. k.dodd@latrobe.edu.au

OBJECTIVE: To determine whether strength training is beneficial for people with cerebral palsy (CP). DATA SOURCES: We used electronic databases to find trials conducted from 1966 though 2000; key words used in our search were cerebral palsy combined with exercise, strength, and physical training. We supplemented this search with citation tracking. STUDY SELECTION: To be selected for detailed review, reports found in the initial search were assessed by 2 independent reviewers and had to meet the following criteria: (1) population (people with CP), (2) intervention (strength training or a progressive resistance exercise program), and (3) outcomes (changes in strength, activity, or participation). Of 989 articles initially identified, 23 were selected for detailed review. DATA EXTRACTION: Empirical studies were rated for methodologic rigor with the PEDro Scale, and studies with a PEDro score of less than 3 were excluded. Review articles were evaluated for quality with the National Health Service Centre for Reviews and Dissemination form. DATA SYNTHESIS: Of the 23 selected articles, 11 studies (10 empirical, 1 review) met the criteria for quality and were included. Only 1 randomized controlled trial was identified. With respect to impairment, 8 of the 10 empirical studies reported strength increases as a result of a strength-training program, with effect sizes ranging from d equal to 1.16 (95% confidence interval,.11-2.21) to d equal to 5.27 (95% CI, 4.69-5.05). Two studies reported improvements in activity, and 1 study reported improvement in self-perception. No negative effects, such as reduced range of motion or spasticity, were reported. There was insufficient evidence from which to draw conclusions about the effects of environmental and personal contextual factors. CONCLUSIONS: The trials suggest that training can increase strength and may improve motor activity in people with CP without adverse effects. More rigorous studies are needed that have a greater focus on changes in activity and participation and that consider contextual factors. Copyright 2002 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation

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Dev Med Child Neurol 2002 Jun;44(6):364-9
Threshold electrical stimulation (TES) in ambulant children with CP: a randomized double-blind placebo-controlled clinical trial.
Dali C, Hansen FJ, Pedersen SA, Skov L, Hilden J, Bjornskov I, Strandberg C, Jette C, Ulla H, Herbst G, Ulla L.
Department of Paediatrics, Hvidovre Hospital, Denmark.

A randomized double-blind placebo-controlled clinical trial was carried out to determine whether a group of stable children with cerebral palsy (36 males, 21 females; mean age 10 years 11 months, range 5 to 18 years) would improve their motor skills after 12 months of threshold electrical stimulation (TES). Two thirds received active and one third received inactive stimulators. For the primary outcome we constructed a set of plausible motor function tests and studied the change in summary indices of the performance measurements. Tests were videotaped and assessed blindly to record qualitative changes that might not be reflected in performance measurements. We also judged range of motion, degree of spasticity, and muscle growth measured by CT. Fifty seven of 82 outpatients who were able to walk at least with a walker, completed all 12 months of treatment (hemiplegia n=25, diplegia n=32). There was no significant difference between active and placebo treatment in any of the tested groups, nor combined. Visual and subjective assessments favoured TES (ns), whereas objective indices showed the opposite trend. We conclude that TES in these patients did not have any significant clinical effect during the test period.

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Dev Med Child Neurol 2002 May;44(5):301-8
Horseback riding in children with cerebral palsy: effect on gross motor function.
Sterba JA, Rogers BT, France AP, Vokes DA.
Center for Sports Therapy Research, East Aurora, NY 14052-2233, USA. sportstherapy@earthlink.net

The effects of recreational horseback riding therapy (HBRT) on gross motor function in children with cerebral palsy (CP: spastic diplegia, spastic quadriplegia, and spastic hemiplegia) were determined in a blinded study using the Gross Motor Function Measure (GMFM). Seventeen participants (nine females, eight males; mean age 9 years 10 months, SE 10 months) served as their own control. Their mean Gross Motor Function Classification System score was 2.7 (SD 0.4; range 1 to 5). HBRT was 1 hour per week for three riding sessions of 6 weeks per session (18 weeks). GMFM was determined every 6 weeks: pre-riding control period, onset of HBRT, every 6 weeks during HBRT for 18 weeks, and 6 weeks following HBRT. GMFM did not change during pre-riding control period. GMFM Total Score (Dimensions A-E) increased 7.6% (p<0.04) after 18 weeks, returning to control level 6 weeks following HBRT. GMFM Dimension E (Walking, Running, and Jumping) increased 8.7% after 12 weeks (p<0.02), 8.5% after 18 weeks (p<0.03), and remained elevated at 1.8% 6 weeks following HBRT (p<0.03). This suggests that HBRT may improve gross motor function in children with CP, which may reduce the degree of motor disability. Larger studies are needed to investigate this further, especially in children. with more severe disabilities. Horseback riding should be considered for sports therapy in children with CP.

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J Child Neurol 2002 Mar;17(3):169-72
Use of modafinil in spastic cerebral palsy.
Hurst DL, Lajara-Nanson W.
Department of Neuropsychiatry and Behavioral Science, Texas Tech University Health Sciences Center, Lubbock 79430, USA. daniel.hurst@ttmc.ttuhsc.edu

After an initial patient with cerebral palsy had an apparent dramatic reduction in spasticity when placed on modafinil, a pilot study was undertaken in 10 pediatric patients to confirm or refute the benefit of modafinil in cerebral palsy. Nine of 10 patients completed the 1-month treatment period. The study patients were treated with 50 or 100 mg of modafinil once daily in the morning. An assessment was made at baseline and at 1 month on treatment. All patients had a clinical examination, Modified Ashworth Scale scores (spasticity) determined by a physical therapist, and videotaping of ambulation. In comparing visit 1 (baseline) and visit 2 (on treatment), statistically significant improvement in the modified Ashworth Scale scores was noted in seven of the nine patients completing the study (P = .0080). A blinded review of the videotapes did not show statistically significant differences in ambulation, but the speed (ft/sec) of gait improved in six of the nine patients (P = .0192). In this study, modafinil, a newly released central stimulant for narcolepsy, showed benefit in treating spasticity in patients with cerebral palsy. A second larger, placebo-controlled, double-blinded trial is planned to confirm these initial results and observations. Modafinil appears to benefit spastic cerebral palsy by a yet to be determined mechanism; however, a primary effect of modafinil on brainstem structures is hypothesized to reduce spasticity of central origin.

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Disabil Rehabil 2002 May 10;24(7):345-7
Ankle-foot orthoses: effect on gait in children with cerebral palsy.
Dursun E, Dursun N, Alican D.
Kocaeli University Faculty of Medicine, Department of Physical Medicine and Rehabilitation, Turkey. erbild@atlas.net.tr

PURPOSE: In this study our aim was to evaluate the effectiveness of Ankle-Foot Orthoses (AFOs) on gait function in patients with spastic cerebral palsy for whom orthoses were indicated to control dynamic equines deformity. METHOD: Twenty-four spastic cerebral palsied patients with dynamic equines deformity were included in the study. Videotape recordings were performed to each patient on the same day with barefoot and AFOs. Temporal distance factors including velocity, cadence, stride length, stride width and Clinical Gait Assessment Score (CGAS) were compared across two conditions. RESULTS: The use of AFOs during gait, produced a statistically significant increase in velocity (p=0.011) and stride length (p<0.001), no significant difference in cadence (p=0.501), and stride width (p=0.796), and a significant decrease in CGAS (p<0.001), compared to barefoot condition. CONCLUSIONS: Cerebral palsied children with dynamic equines deformities can benefit from AFOs for ambulation.

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Dev Med Child Neurol 2002 Apr;44(4):233-9
Intermittent intensive physiotherapy in children with cerebral palsy: a pilot study.
Trahan J, Malouin F.
Physiotherapist Institut de readaptation en deficience physique de Quebec, Quebec City, Canada.

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.

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Orthopedics 2002 Apr;25(4):411-5
A comparison of the effects of solid, articulated, and posterior leaf-spring ankle-foot orthoses and shoes alone on gait and energy expenditure in children with spastic diplegic cerebral palsy.
Smiley SJ, Jacobsen FS, Mielke C, Johnston R, Park C, Ovaska GJ.
Department of Orthopedics and Marshfield Clinic, WI 54449, USA.

Fourteen children with spastic diplegic cerebral palsy were evaluated wearing threedifferent ankle-foot orthoses and shoes alone. The ankle-foot orthoses included solid, articulated ankle, and posterior leaf-spring types. Evaluation measures included computerized gait analysis, Energy Efficiency Index data, and individual preference. Highly significant kinematic differences were found at the ankle with shoes alone approaching normative data and braces showing abnormal dorsiflexion. No significant differences, were found in velocity, cadence, stride length, or in the Energy Efficiency Index. Eight children preferred articulated braces, six chose posterior leaf-spring, and none chose the solid brace.

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Dev Med Child Neurol 2002 Apr;44(4):227-32
Clinically prescribed orthoses demonstrate an increase in velocity of gait in children with cerebral palsy: a retrospective study.
White H, Jenkins J, Neace WP, Tylkowski C, Walker J.
Motion Analysis Laboratory, Shriners Hospital for Children, 1 Lexington, KY 40502, USA.

The purpose of this study was to determine the effect clinically prescribed ankle-foot orthoses (AFOs) have on the temporal-spatial parameters of gait, as compared with barefoot walking in children with cerebral palsy. A retrospective chart review of data collected between 1995 and 1999 in our motion analysis laboratory was performed. A retrospective chart review of 700 patients revealed 115 patients (mean age 9 years) who had a primary diagnosis of CP (diplegia n=97, hemiplegia n=18). All were wearing clinically prescribed hinged or solid AFOs at the time of undergoing a three dimensional gait analysis. In line with our standard clinical practice, data for both conditions (braced and barefoot walking) were collected the same day by the same examiner. Statistical analyses indicated the temporal and spatial gait parameters of velocity, stride length, step length, and single limb stance were significantly increased (p<0.001) with the use of AFOs versus barefoot walking. Cadence was the only parameter found to not be statistically different.

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Dev Med Child Neurol 2002 Apr;44(4):220-6
Changes in hip spasticity and strength following selective dorsal rhizotomy and physical therapy for spastic cerebral palsy.
Engsberg JR, Ross SA, Wagner JM, Park TS.
Human Performance Laboratory, Barnes-Jewish Hospital, St. Louis, MO 63108, USA. jre6264@bjc.org

Hip adductor spasticity and strength in participants with cerebral palsy (CP) were quantified before and after selective dorsal rhizotomy (SDR) and intensive physical therapy. Twenty-four participants with cerebral palsy (CP group) and 35 non-disabled participants (ND controls) were tested with a dynamometer (OP group: mean age 8 years 5 months, 13 males, 11 females; ND group: mean age 8 years 6 months, 19 males, 16 females). According to the Gross Motor Function Classification System (GMFCS), of the 24 participants with CP, eight were at level I, six were at level II, and 10 participants were at level III. For the spasticity measure, the dynamometer quantified the resistive torque of the hip adductors during passive abduction at 4 speeds. The adductor strength test recorded a maximum concentric contraction. CP group spasticity was significantly reduced following SDR and adductor strength was significantly increased after surgery. Both pre- and postoperative values remained significantly less than the ND controls. Spasticity results agreed with previous studies indicating a reduction. Strength results conflicted with previous literature subjectively reporting a decrease following SDR. However, results agreed with previous objective investigations examining knee and ankle strength, suggesting strength did not decrease following SDR.

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Rev Neurol 2002 Jan 1-15;34(1):52-9
[Treatment of spasticity in cerebral palsy with botulinum toxin]
[Article in Spanish]
Calderon-Gonzalez R, Calderon-Sepulveda RF.
Centro Neurologico para Ninos y Adolescentes. Hospital San Jose Tec de Monterrey, Monterrey, 64710, Mexico. racacena@neuroped.com.mx

OBJECTIVE: A review of the pathophysiological and developmental basis, measurement scales and the usefulness of botulinum toxin A injections in selected muscles for the treatment of spasticity in children with cerebral palsy. DEVELOPMENT: Cerebral palsy is the most common cause of spasticity in children. The increase in muscle length is achieved through the addition of sarcomeres in series at the level of the muscle tendinous junction. The regulation of the number of sarcomeres seems to be determined by the lengthening of the muscle. The muscle contracture is a shortening of the length of a muscle as a result of a decrease in the number of sarcomeres. Spasticity and motor function assessment scales used in children with cerebral palsy: a) Modified Ashworth scale for the assessment of spasticity; b) modified Tardieu scale for the assessment of dynamic muscle length; c) muscle spasms frequency scale; d) modified Medical Research Council scale for muscle strength; e) hip adductor muscle tone scale; f) global pain scale with affective facial expression represented in a drawing; g) goniometric measurement of the joint range of movement; h) Palisano gross motor function measure; i) observational video gait analysis scale. Recommended guidelines for dosing the botulinum toxin A: 1. Total maximum dose administered per visit up to 15 U/kg or a total of 400 U; 2. Dose range of large muscles 3 to 6 U/kg per visit; 3. Dose range of small muscles 1 to 3 U/kg per visit; 4. Maximum dose per injection site: 50 U dividing the total planned unit dose/muscle into equal amounts/injection site; 5. Frequency: no more than one injection every 3 months, frequently once every 6 or more months. CONCLUSION: Botulinum toxin A injection is a well tolerated, safe and effective procedure in the treatment of children with spastic cerebral palsy.

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Rev Neurol 2002 Jan 1-15;34(1):1-6
[Clinical treatment (non surgical) of spasticity in cerebral palsy]
[Article in Spanish]
Calderon-Gonzalez R, Calderon-Sepulveda RF.
Centro Neurologico para Ninos y Adolescentes. Hospital San Jose Tec de Monterrey, Monterrey, 64710, Mexico. racacena@neuroped.com.mx

OBJECTIVE: A review about the procedures used in the non surgical management of spasticity in children with cerebral palsy. DEVELOPMENT: Therapeutic modalities for the management of spasticity in cerebral palsy include: (1) elimination of factors aggravating spasticity: pain, fatigue, stress, excitement, cold, illness, sleep disturbance, immobility, and hormonal changes; (2) rehabilitative therapies, there are four major groups: (a) biomechanical approach, (b) neurophysiologic approach, (c) developmental approach and (d) sensory approach; (3) orthosis; (4) oral pharmacotherapy: baclofen, tizanidine, diacepam and dantroleno; (5) chemical denervation: phenol injections and botulinum toxin injections. The medical management of spasticity in cerebral palsy is based on: 1. Oral pharmacotherapy: (a) baclofen, binds GABAB receptors of spinal interneurons presynaptically, inhibits release of excitatory neurotransmitters in the spinal cord; (b) tizanidine, binds alfa 2 adrenergic receptors presinaptically, inhibits release of excitatory neurotransmitters in the spinal cord; (c) diacepam, augments GABA mediated inhibition in the spinal cord and supraspinally;(d) dantrolene, inhibits release of calcium from sarcoplasmic reticulum in muscle, weakens muscle contraction in response to myofiber excitation. 2. Chemical denervation: (a) phenol injection perineurally or into the motor point disrupts efferent signals from hyperexcitable anterior horn cells causing necrosis of axons or muscle; (b) botulinum toxin injection in selected muscles blocks the release of acetylcholine presynaptically and weakens the force of muscle contraction produced by hyperexcitable motoneurons. CONCLUSIONS: At the present time, there is not irrefutable evidence of a sustain benefit of physical rehabilitation in the management of spasticity. There are few studies with oral pharmacological agents involving children with cerebral palsy to define its role. On the other hand, botulinum toxin A is effective, well tolerated, and safe in the treatment of spasticity in children with cerebral palsy.

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Am J Phys Med Rehabil 2002 Apr;81(4):291-6
Pain treatment in persons with cerebral palsy: frequency and helpfulness.
Engel JM, Kartin D, Jensen MP.
Department of Rehabilitation Medicine, School of Medicine, University of Washington, Seattle, Washington 98195-6490, USA.

OBJECTIVES: To identify the interventions currently being used by adults with cerebral palsy (CP) for pain management, examine the perceived helpfulness of these interventions, and determine the extent to which these individuals with cerebral palsy-related pain were accessing the services of healthcare providers for the explicit purpose of addressing pain. DESIGN: Retrospective, descriptive study of 64 adults with cerebral palsy-related chronic pain. Subjects ranged in age from 18 to 76 yr and included 35 women and 29 men. Subjects were evaluated by using a protocol-based interview. RESULTS: The study sample sought and used a variety of pain treatments and healthcare providers and rated many of the interventions as being at least moderately helpful. Despite the reported helpfulness of the pain interventions, however, most are only being used by a small subset of the sample. CONCLUSION: The majority of the sample with chronic pain did not access healthcare providers for help in managing their pain. Cerebral palsy-related pain is undertreated in the adult population with cerebral palsy.

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J Pediatr Orthop B 2002 Apr;11(2):159-66
Effect of derotation osteotomy of the femur on hip and pelvis rotations in hemiplegic and diplegic children.
Saraph V, Zwick EB, Zwick G, Dreier M, Steinwender G, Linhart W.
Paediatric Orthopaedic Unit, Department of Paediatric Surgery, Karl Franzens University, Graz, Austria.

The purpose of this study was to evaluate hip and pelvis rotations in groups of hemiplegic and diplegic children before and after surgical correction of fixed internal rotation deformity of the hip. Twenty-two children with cerebral palsy (eight diplegia, 14 hemiplegia) having fixed internal rotation deformity at the hip were treated by multilevel surgery which included derotation osteotomy of the femur. Evaluation was done before and at a mean of 3.1 years after surgery using three-dimensional computerized gait analysis. Preoperatively, the patients in the hemiplegia group had a significantly greater compensatory external rotation of the pelvis than those in the diplegic group. Post-operatively there were no significant differences between the two groups. In the hemiplegia group the external rotation of the pelvis was corrected after correction of hip rotation by derotation osteotomy. Patients in the diplegia group showed significant improvements in the hip rotation with no significant change in the pelvis rotation after multilevel surgery.

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Arch Phys Med Rehabil 2002 Apr;83(4):454-60
Objective measurement of muscle strength in children with spastic diplegia after selective dorsal rhizotomy.
Buckon CE, Thomas SS, Harris GE, Piatt JH Jr, Aiona MD, Sussman MD.
Clinical Research Department, Shriners Hospital for Children, 3101 SW Sam Jackson Park Rd., Portland, OR 97201, USA. CEB@SHCC.org

OBJECTIVES: To examine changes in isometric muscle strength at the elbow, knee, and ankle at 6 months and 1 year after selective dorsal rhizotomy (SDR) and to determine if SDR altered the frequency of muscle cocontraction. DESIGN: Prospective outcome study of a consecutive sample. SETTING: Children's hospital. PATIENTS: Ten children with spastic diplegia (7 independent and 3 dependent ambulators who used assistive devices) and 8 age-matched controls. INTERVENTIONS: SDR; physical and occupational therapy; elbow, knee, and ankle measured for flexion and extension strength during three 10-second isometric contractions for each muscle group; and monitored cocontraction measured via muscle electrodes. MAIN OUTCOME MEASURES: Absolute and normalized values of isometric strength; and alterations in the frequency of cocontraction at 6 months and 1 year postoperatively. RESULTS: Children with spastic diplegia showed significantly weaker knee extensors, ankle dorsiflexors, and ankle plantarflexors than age-matched controls. There were no significant differences in strength between the 2 groups in the elbow flexors, elbow extensors, and knee flexors. Isometric strength did not increase or decrease significantly after SDR. Cocontraction during knee extension was normalized after SDR, whereas cocontraction during ankle plantarflexion was unchanged by SDR in the majority of children. CONCLUSION: SDR did not result in a significant decrease in muscle strength in ambulatory children with spastic diplegia. The normalization of the electromyographic patterns at the knee and not the ankle after SDR lends support to the premise that in children with cerebral palsy cocontraction is multifaceted, representing a volitional strategy to enhance control, as well as a disorder of the mechanisms that govern patterns of muscle activity. Copyright 2002 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation

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Pediatr Neurosurg 2002 Mar;36(3):142-7
Comparison of motor outcomes after selective dorsal rhizotomy with and without preoperative intensified physiotherapy in children with spastic diplegic cerebral palsy.
Steinbok P, McLeod K.
Division of Pediatric Neurosurgery, Department of Surgery, University of British Columbia, Vancouver, B.C., Canada. psteinbok@cw.bc.ca

A previous randomized clinical trial compared selective dorsal rhizotomy (SDR) plus postoperative intensified physiotherapy (group 1) with intensified physiotherapy alone (group 2) for children with spastic diplegic cerebral palsy. At the end of this trial, all patients in group 2 had an SDR, followed by further intensified physiotherapy. This study was performed to determine if the additional intensified physiotherapy before SDR, as occurred in group 2, improved long-term motor outcome. Outcomes were compared in the two groups, i.e. group 1 without intensified physiotherapy before SDR and group 2 with intensified physiotherapy before SDR. The primary outcome measure was the Gross Motor Function Measure (GMFM). Lower-limb spasticity, range and strength were secondary outcome measures. Baseline assessments had been done for the prior clinical trial. For this study, patients were reassessed by physiotherapists blinded to the treatment group. Thirteen children in each group were studied at a mean follow-up of 53 months. The mean improvement in GMFM was 10.0 in group 1 and 10.4 in group 2 (p = 0.9). Improvements in spasticity and range were similar in the two groups. There was no significant change in muscle strength in either group. It was concluded that in this relatively small series of patients, additional intensified physiotherapy before SDR did not improve motor outcomes. Copyright 2002 S. Karger AG, Basel

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Pediatr Neurosurg 2002 Mar;36(3):133-41
Impact of selective posterior rhizotomy on fine motor skills. Long-term results using a validated
evaluative measure.
Mittal S, Farmer JP, Al-Atassi B, Montpetit K, Gervais N, Poulin C, Cantin MA, Benaroch TE.
Division of Neurosurgery, Montreal Children's Hospital, McGill University Health Centre, Montreal, P.Q., Canada.

Suprasegmental effects following selective posterior rhizotomy have been frequently reported. However, few studies have used validated functional outcome measures to report the surgical results beyond 3 years. The authors analyzed data obtained from the McGill Rhizotomy Database to determine the long-term impact of lumbosacral dorsal rhizotomy on fine motor skills. The study population comprised children with debilitating spasticity who underwent SPR and were evaluated by a multidisciplinary team preoperatively, at 6 months and 1 year postoperatively. Quantitative standardized assessments of upper extremity function were obtained using the fine motor skills section of the Peabody Developmental Motor Scales (PDMS) test. Of 70 patients who met the entry criteria for the study, 45 and 25 completed the 3- and 5-year assessments, respectively. Statistical analysis demonstrated significant improvements in grasping, hand use, eye-hand coordination, and manual dexterity at 1 year after SPR. More importantly, all improvements were maintained at 3 and 5 years following SPR. This study supports that significant improvements in upper extremity fine motor function using the PDMS evaluative measure are present after SPR and that these suprasegmental benefits are durable. Copyright 2002 S. Karger AG, Basel

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J Pediatr Orthop 2002 Mar-Apr;22(2):169-72
Outcome of medial versus combined medial and lateral hamstring lengthening surgery in cerebral palsy.
Kay RM, Rethlefsen SA, Skaggs D, Leet A.
Pediatric Orthopaedics, Childrens Hospital Los Angeles, Los Angeles, California 90027, USA. rkay@chla.usc.edu

Pre- and postoperative gait analysis and static measurements from 37 children with cerebral palsy who underwent hamstring lengthening were evaluated. Significant improvements in static and kinematic measures were noted after surgery in both groups. Although the differences were not statistically significant, there was a suggestion that combined medial/lateral hamstring lengthening may provide greater improvement in popliteal angle and maximum knee extension in stance. However, there also appears to be a greater risk of knee hyperextension during gait after combined medial and lateral hamstring lengthening than after medial hamstring lengthening alone. Postoperative calf spasticity also appears to be a risk factor for postoperative knee hyperextension. Assessment of calf spasticity may be important in patients undergoing medial and lateral hamstring lengthening. Additional treatments such as bracing and/or botulinum toxin injections to the calf to control equinus and knee hyperextension may be beneficial.

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J Pediatr Orthop 2002 Mar-Apr;22(2):139-45
Long-term effects of femoral derotation osteotomies: an evaluation using three-dimensional gait analysis.
Ounpuu S, DeLuca P, Davis R, Romness M.
Connecticut Children's Medical Center, Hartford, Connecticut, USA. sounpuu@ccmckids.org

The purpose of this study was to evaluate the long-term effects of the femoral derotation osteotomy (FDO) in the ambulatory patient with cerebral palsy (CP). The effectiveness of the FDOs were evaluated using three-dimensional gait analysis just before surgery (P0), 1 year after surgery (P1), and 5 years after surgery (P2). A total of 20 patients (27 sides) with CP were evaluated. Related physical examination and motion measures showed significant improvements at P1 that were maintained at P2. Mean maximum internal hip rotation at P0 of 77 degrees +/- 9 degrees decreased to 53 degrees +/- 8 degrees at P1 and was maintained at 58 degrees +/- 11 degrees at P2. Mean maximum external hip rotation at P0 of 21 degrees +/- 11 degrees increased to 35 degrees +/- 15 degrees at P1 and was maintained at 32 degrees +/- 13 degrees at P2. Mean femoral anteversion at P0 of 63 degrees +/- 9 degrees was reduced to 26 degrees +/- 15 degrees and was maintained at 31 degrees +/- 13 degrees at P2. During gait, mean hip rotation in stance at P0 of 20 degrees +/- 8 degrees was decreased to 2 degrees +/- 10 degrees at P1 and was maintained at 4 degrees +/- 5 degrees at P2. There were associated significant foot progression changes from an internal progression mean of 5 degrees +/- 17 degrees at P0 to -11 degrees +/- 17 degrees at P1 that were maintained at -12 degrees +/- 5 degrees at P2. The findings suggest that the FDO is a viable and lasting treatment option for the correction of anteversion and associated internal hip rotation during gait in children with CP.

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