Limb In Cerebral Palsy Research Articles

The “Exo hand-2” complex in the rehabilitation of the upper limb in cerebral palsy using the non-invasive interface “brain-computer”

Improving the function of the upper limb in cerebral palsy is one of the main tasks of rehabilitation treatment and socialization of the patient.The purpose of the study was to evaluate the effectiveness of the “Exo hand-2” complex with the non-invasive interface “brain-computer” for correcting the motor function of the upper limb in cerebral palsy.The study involved 50 male and female with cerebral palsy (main group n = 30, control group n = 20) aged 12–18 years old. The level of motor activity according to the criteria of classification of large motor functions (GMFCS) was not more than III. All patients received a standard course of spa rehabilitation for 21 days. Patients of the main group were additionally rehabilitated using the “Exo hand-2” complex with the non-invasive interface “brain-computer”. As a result of treatment in the main group, spasticity in the paretic hand on the Modified Ashworth Scale decreased from 3 (2; 3) to 2 (1; 2) points (p <0.002); according to Tardieu, spasticity decreased from the level of 3 (2; 3) to 2 (1; 2) (p <0.002). Half of the patients had paretic arm muscle strength in the Medical Research Counsil Weakness Scale sums core from 2.3 (2; 3) to 3 (2; 3) points after treatment (p = 0.002); assessment of household skills on the Modified Franchay Scale showed an improvement from 37 (22.75; 63.75) to 45 (30; 72.75) points after therapy.

Effect of botulinum toxin type-A in spasticity and functional outcome of upper limbs in cerebral palsy

IntroductionSpasticity has been considered to be a main contributor to both the impairment of function as well as posture in children with cerebral palsy (CP). Patterns of upper limb motor involvement in CP vary with resultant limitations in daily independence, participation, and quality of life. Botulinum Toxin-A (BTX-A) is a potent neurotoxin which acts by preventing the release of acetylcholine (Ach) from presynaptic axon at motor end plate reducing focal spasticity. With literature established role of BTX-A available for lower limb spasticity in CP, the purpose of this study was to present an objective analysis of the effect of a single i.m. injection of BTX-A in reduction of spasticity in the upper limb as well as functional outcome in children (4–12yrs) with spastic CP. MethodsA total of 28 patients (30 upper limbs) of spastic CP with minimum follow up of 6months were included in the study. Modified Ashworth Scale (MAS) and Modified Tardieu Scale (MTS) were used to measure the spasticity. Surface landmarks were used to give I.m. Botox in selected spastic muscles followed by targeted rehabilitation. Functional outcomes were measured by MACS (Manual Ability Classification System) and Canadian Occupational Performance Measure (COPM) before treatment, at 3 and 6 months follow up. ResultsPronator teres was the most frequently injected muscle followed by FCU and Adductor pollicis. MAS scores at all joints and MTS scores at forearm deteriorated between 3 and 6 months. However, MACS and COPM showed sustained improvement at 3months and 6months with statistically significant change. ConclusionI.m. BTX-A injected using anatomical landmarks had significant improvement in both clinical and functional outcome measures. We noticed significant improvement in MACS and COPM at 6 months despite return of local spasticity. It is safe and effective for spasticity of upper limbs in cerebral palsy and capable of improving function without major side effects. MACS & COPM are easy to use, less time consuming & easily adjusted to local needs. Randomized control trials with long follow up are required in future with special focus on dosing and timing, scoring system for functional outcome as per regional needs and issue for antibody formation for repeat injections of BTX-A.

Does fascial manipulation and myofascial surgery reduce spasticity and improve function of upper limb in cerebral palsy?

Does fascial manipulation and myofascial surgery reduce spasticity and improve function of upper limb in cerebral palsy?

Contracture formation in the upper limb in cerebral palsy starts early.

This commentary is on the original article by Hedberg‐Graff et al. on pages 204–211 of this issue.

Motor Recovery of Lower Limbs in Cerebral Palsy with Botulinum Toxin and Physioteraphy

The gait is a central function in the neuropsychological development of the normal child and in neuromotor diseases such as PCI. Spasticity is a major problem that prevents the development of motor functions remaining in these patients, thus producing a limited participation in recreational and sports activities and social activities. The synergistic action of the FET and the BTX-A can be a valuable aid, as the transient inhibition of muscle spasticity, can allow the subject to learn to reorganize through the rehabilitation intervention movement in a different way, in order to reduce the functional limitations in the lower limbs allowing a greater motor skills and thus a better quality of life.

One stage correction of forearm pronation, wrist flexion and thumb in palm deformity in spastic cerebral palsy

Thirty eight patients, with spastic cerebral palsy hemiplegic aged from 4to16 years with mean of 10 years had surgical procedures for the upper limb to increase functional status of hand. All the patients underwent various surgical procedures depending upon the necessity. IQ of all the patients were more than seventy. 36 patients felt an improvement in function, range of movement in the fore arm and wrist were also increased 74.7% the patients, thumb in palm deformity was completely corrected and resting position towards neutral and stability of hand were also some of the achievements of surgery. There was improvement in different functional grasps. The management of upper limb in cerebral palsy is a challenge, but in properly selected patients there is some improvement in functional status.

Treatment of spasticity of lower limbs in cerebral palsy with the selective lumbosacral posterior rhizotomy: an accompanying long-term efficacy

Objective To investigate the treatment of spasticity of lower limbs in cerebral palsy with the selective lumbosacral posterior rhizotomy (SPR). Methods The clinical data of 1 455 patients with spastic cerebral palsy with lower limbs pasticity treated by SPR were analyzed retrospectively. In addition to relieving the lower limb spasticity after procedure, the long-term follow-up of other accompanying effects were performed. Results All 1 455 patients were followed up for 21.8 (mean, 12-44) months. While adding up the efficacy of relieving lower limb spasticity with operation (the total spasm remission rate was 94.8% and the gait function improvement rate was 85.6%) during the follow-up period, the improvement of other concomitant symptoms of patients was observed: the improvement rates of salivation, oral dyskinesia and dysarthria, spasticity of upper limbs, and strabismus were 64.5% (300/465), 39.1% (135/345), 33.3% (240/720), and 33.3% (225/675), respectively. Conclusions While in the treatment of spasticity of lower limbs in cerebral palsy, SPR improves the concomitant symptoms, such as salivation, oral dyskinesia and dysarthria, spasticity of upper limbs, and strabismus in different degrees in 33.3-64.5% patients. Its specific mechanism needs to be further studied. Key words: Spastic cerebral palsy; Selective lumbosacral posterior rhizotomy; Efficacy

SHUEE on the evaluation of upper limb in cerebral palsy.

OBJECTIVE: To demonstrate the use of the tool for evaluation of spastic upper limb SHUEE (Shriners Hospital Upper Extremity Evaluation) in the evaluation of upper limb in cerebral palsy (CP) and its ability to detect changes after surgical treatment of identified deformities. METHODS: 19 patients with spastic hemiplegic CP had their upper limb evaluated by SHUEE. Five patients underwent surgical treatment of deformities detected and performed the test at one year postoperatively. RESULTS: The mean age was 9.02 years old; 18 patients were classified as level I GMFCS and one patient as level II. At baseline, the mean spontaneous functional analysis was 59.01; dynamic positional analysis was 58.05 and grasp-and-release function, was 91.21. In the postoperative period the scores were, respectively, 65.73, 69.62 and 100, showing an improvement of 3.5% in the spontaneous functional analysis and of 44.8% in dynamic positional analysis. CONCLUSIONS: SHUEE is a tool for evaluation of spastic upper limb in cerebral palsy that helps in the specific diagnosis of deformities, indication of treatment and objective detection of results after surgical treatment. Level of Evidence IV, Case Series.

Analysis of long-term effect of selective posterior rhizotomy for treatment of spasticity of lower limbs in cerebral palsy patients

Objective Selective posterior rhizotomy (SPR) of lumbosacral region was a well-recognized treatment for spasticity of lower limbs in spastic cerebral palsy (CP).However,there was still no agreement on long-term outcome of SPR.The purpose of this study was to assess the long-term outcome in a large amount of patients by using quantitative,standardized assessment tools.Methods 141 patients who had undergone SPR from Jan.2001 to Dec.2006 were followed-up with integrated clinical data for at least 9 years averagely.The outcomes were assessed at the time points of 1 year,5 years and final trace after operation respectively with quantitative,standardized assessment tools,including Modified Ashworth Scale (MAS),Gross Motor Function Classification System (GMFCS) and performance of Activities of Daily Living Scale(ADL).Combined with the subsequent treatment which was required by those patients,statistical analysis was performed to evaluate the long term effects of SPR.Results MAS scores in hip adductors,knee flexors and ankle plantar flexors were reduced persistently until the final follow-up visit and the differences were statistically significant (P ＜ 0.01).The overall improvement rate of muscle tone during follow-up was 90.7％.The distribution of GMFCS was statistically different compared with preoperative levels(P ＜ 0.01).The overall improvement rate of gross motor function compared with preoperative was 80.1％.ADL scores were statistically different when compared with preoperative group(P ＜0.01).The overall improvement rate of quality of life was 88.9％.When stratified by the preoperative GMFCS,the ADL Scores of GMFCS Group Ⅱ and Ⅲ continued to increase after SPR.The proportion of patients who received subsequent procedures including selective peripheral neurotomy (SPN),Achilles tendon lengthening,orthopedic surgery and botulinum toxin treatment was 27.7％ at final follow-up.The independent-samples T test showed that the necessary subsequent surgical treatments after operation significantly increased the last follow-up ADL score improvement(P ＜ 0.01).Conclusions The benefits of SPR were persistent in the majority of patients.These benefits were mainly improved muscle tone,gross motor function,and performance of ADL.Patients in preoperative GMFCS Groups Ⅱ and Ⅲ were most likely to display these long-term benefits.Postoperative necessary subsequent surgical treatments contributed to maintaining and improving motor function,and eventually improved the performance of activities of daily living. Key words: Rhizotomy; Cerebral palsy; Muscle spasticity; Lower extremity ; Long-term effect

Neuromuscular taping for the upper limb in Cerebral Palsy: A case study in a patient with hemiplegia

Objective: To assess quantitatively the effects of Neuromuscular Taping (NMT) on the upper limb in a female child with left hemiplegia, due to Cerebral Palsy (CP).Methods: The patient underwent NMT on cervical level, shoulder and hand only of the plegic upper limb, followed by physical therapy. Kinematic data of upper limbs during reaching task were collected before (PRE) and after 2 weeks of treatment (POST).Results: After the intervention, the affected limb improved in terms of movement duration, Average Jerk and Number of Unit Movements indices, indicating a faster, smoother and less segmented movement. Improvements appeared at the ranges of motion of the upper limb joints, both at shoulder and elbow joints. No significant changes were globally displayed for the unaffected arm.Conclusion: NMT seems to be a promising intervention for improving upper limb movement in patients with CP. Further investigations are certainly needed to assess effectively the effects of the intervention in this pathological state.

Upper Extremity Surgery in Spastic Cerebral Palsy

Involvement of the upper extremity in cerebral palsy often results in a typical pattern of spasticity, with elbow flexion, forearm pronation, ulnar deviation and flexion of the wrist, and adduction-flexion posture of the thumb. Although only a relatively small subset of cerebral palsy patients are candidates for surgery, properly selected patients and procedures yield a reasonable improvement. Nonsurgical treatment modalities include physical therapy, orthoses, and medications aimed at decreasing spasticity. Surgical options for the management of the spastic upper extremity vary with the specific parts, however they are focused around three basic principles: weakening the overactive muscle/tendons, strengthening the underactive muscle/tendons, and stabilizing non-stable joints. Surgical management of the spastic upper limb in cerebral palsy requires meticulous evaluation and planning. It is important to know that upper extremity deformities are secondary manifestations of the cerebral injury. Therefore, in addition to evaluation of upper extremity function, consideration should be given to the intelligence and motivation of the patient, and voluntary use of the upper extremity. Prior to surgery, the overall level of function needs to be considered. These are also important details for the patients and their families, who should know that surgery is aimed at improving the upper extremity deformity, and not the primary disorder. Appropriately indicated surgery can significantly contribute to upper extremity function. (JAREM 2012; 2: 43-54)

Assessment of the upper limb in cerebral palsy: validity and reliability of the revised VOAA‐DDD

This paper is on the original article by Houwink et al. on pages 76–82 of this issue

The terms diplegia, quadriplegia, and hemiplegia should be phased out

SIR–In the June 2010 issue of Developmental Medicine and Child Neurology, Michael Shevell presents a thoughtful argument in favor of maintaining the terms diplegia and quadriplegia as descriptions of cerebral palsy (CP). He does not really address the term hemiplegia, and I assume this suggests he feels that term is now safely ensconced in the CP lexicon. I would like to make the argument that all three terms be phased out, particularly in research. They should be replaced by the Gross Motor Function Classification System (GMFCS) and the Manual Ability Classification System which have shown great utility for describing individuals with CP. First of all, Shevell’s definition of diplegia (spasticity of the lower limbs far in excess of any perceptible upper limb involvement) is at odds with the various definitions that have been used historically, as noted in Colver and Sethumadhavan’s 2003 article. The fact that there are various definitions argues strongly for abandoning the use of the term in research. Furthermore, Colver and Sethumadhavan make the point that it is not clear what is meant by ‘more involved’ and ‘less involved.’ Is this tone, function, or some other factor? Tone and function can change based on time of day, age, intervention, and other factors, making borderline cases unclassifiable. Second, there really is no such thing as an uninvolved limb in CP. Studies of individuals with hemiplegia demonstrate marked impairment of movement kinematics in the more affected side. However, the uninvolved side is generally impaired as well, not really matching the performance of normal controls. Because of this, we use the terms ‘less affected’ arm and ‘more affected’ arm for an asymmetric patient. Patients with diplegia who truly lack perceptible upper limb involvement are few and far between. In essence, the great majority of patients, if not all, have quadriplegia to some degree. Finally, Shevell suggests that there is strong correlation between quadriplegia and GMFCS levels IV and V, with diplegia having higher levels. He talks about comorbidities and radiological differences between the two. Based on the several fine articles that have shown the ability of the GMFCS to distinguish children with CP for many characteristics, I would suspect that the GMFCS by itself would also show differences for radiological findings and comorbidities, with much less question as to classification of the participants. The topological descriptive terms for CP are not completely useless, owing to their familiarity. They are still helpful for clinical communication and for a quick description of a population, perhaps even in the title of a research paper. However, they should be phased out of clinical research and replaced with the more robust classification systems, perhaps with some modifiers to describe limbs involved. Indeed, since in many cases the borderline nature of the involvement brings to mind Lewis Carroll’s Humpty Dumpty (‘When I use a word ... it means just what I choose it to mean ...’), we should consider coming out of our comfort zones and changing our clinical descriptions as well.

Management of the upper limb in cerebral palsy

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.

Toxine botulinique type A chez l’enfant : évaluation des indications à partir d’une revue de la littérature

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.

Functional outcome of botulinum toxin A injections to the lower limbs in cerebral palsy,

Functional outcome of botulinum toxin A injections to the lower limbs in cerebral palsy,

Functional outcome of botulinum toxin A injections to the lower limbs in cerebral palsy

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.

Current evidence for the use of botulinum toxin type A in the management of children with cerebral palsy: a systematic review.

Management of children with cerebral palsy (CP) is the focus of considerable resources in many countries, so that evaluation of the efficacy for new and established treatments is imperative. Botulinum toxin type A (BTX-A) is a relatively new method of spasticity management in children with cerebral palsy. It has been the focus of extensive research since its application to cerebral palsy 10 years ago. In a systematic review relating to the management of the lower limb in cerebral palsy 156 papers were identified. These were categorized according to Sackett and the World Health Organisation International Classification of Impairments, Disabilities and Handicaps model. We identified 10 randomized trials evaluating the use of BTX-A in the lower limb in children with cerebral palsy in a systematic review. A meta-analysis showed the pooled risk difference between BTX-A and placebo in three trials was 0.25 (95% CI 0.13, 0.37) and 0.23 (95% CI -0.06, 0.53) for two trials of BTX-A and casting using the physicians rating scale. These represent moderate treatment effects that are dosage-dependent. Outcomes were also compared for function in five studies. The type of evidence for BTX-A was graded by each treatment indication and directions for future research were then drawn from the available evidence.

Incoming President's Address

I thank you for the confidence that you have shown in electing me your President. It is a great honour to be following in the footsteps of Knud Jansen, our Founding President, and the other Presidents who came after him, all whom have made a significant contribution to the Society. I have had the good fortune to have worked for ISPO in one capacity or another under all the Presidents. I hope that some of their dedication, wisdom and good humour has passed on to me to allow me to carry out this task in a positive and productive manner. The Society has achieved a great deal since its foundation in 1970. It has created a truly international and multidisciplinary forum of all those professionals working in the fields of prosthetics, orthotics and rehabilitation engineering through its Congresses, conferences, and regional and national meetings. It has run workshops and seminars on such topics as the deformed foot, CAD CAM in prosthetics and orthotics and trans-femoral sockets. It has organised consensus conferences on amputation surgery, the orthotic treatment of the lower limb in cerebral palsy, appropriate prosthetic technology for low-income countries and, most recently, the treatment of poliomyelitis. It has disseminated information worldwide through its publications, Prosthetics and Orthotics International and the reports of its workshops and consensus conferences, and also by offering courses in different regions of the world. As a result of a series of meetings the Society has laid down standards for education and training of prosthetics and orthotics personnel in low-income countries. These standards have now been accepted by all the major international and national agencies working in this important area. This work has culminated in the publication of a package for education and training of the Category I1 professional that provides detailed information to those who wish to establish a course in low-income countries. We could continue to look back at other activities and congratulate ourselves for all that the Society has achieved. However the truth of the matter is that we have only just scratched the surface and much remains to be done. The World Health Organisation has estimated that there is a need for 20,000 trained prosthetics and orthotics personnel to meet the needs in low-income countries. Altogether there are only about 2,000, a shortfall of 18,000. The overall needs in low-income countries are immense. They have few resources and many problems. It is our duty to ensure that all efforts that are made are part of a strategy to ensure the establishment of long-term prosthetics and orthotics and other rehabilitation services in these countries. It is necessary to examine the components and technologies used in these countries with regard to function and costs as well as the sustainability and effectiveness of the services established. Many low-income countries require aid as a direct result of present or past conflict. The Society must support, as far as it can, those National and International agencies that are providing prosthetics and orthotics services in these situations. In the industrial world the standards of education and training of prosthetists and orthotists are extremely varied, from university level in some countries to little or none in others. The challenge in this regard is to produce adequate numbers of well-educated prosthetics and orthotics personnel to an acceptable standard and it is the Society’s intention to pursue the implementation of its information package for the education and training of Category I professionals. There continues to be a great proliferation of components and techniques, many of which have reached the market place without any proper independent evaluation of their effectiveness, function or outcome. Much work needs to be done in this direction.

Quantitative analysis and classification of gait patterns in cerebral palsy using a three-dimensional motion analyzer.

Gait disorders in cerebral palsy can be accurately analyzed using the CODA-3 system presenting quantitative data representing movement of the hip, knee, and ankle in the sagittal plane. We describe a technique that classifies abnormal gait automatically on the basis of sagittal kinematic data. Fifty-five hemiplegic and 91 diplegic patients were analyzed using an opto-electronic scanner (CODA-3). The sagittal kinematics of the affected limb in hemiplegics correlated with those of both affected limbs in diplegics. We introduce the concept of the "plegic limb." Sagittal kinematics of 237 affected limbs were studied using cluster statistical analysis. Eight clear groups emerged. The predominant clinical features, typical of each group, were identified and described (eg, stiff leg gait, genu recurvatum, or crouch gait). We propose this classification system as a new technique to use gait analysis data to automatically classify abnormal movements of the lower limb in cerebral palsy.