Mild Spastic Diplegia Research Articles

Management of spastic diplegic cerebral palsy and periventricular leukomalacia in a preterm 2-year-old: A case report and review of the literature

Periventricular Leukomalacia (PVL) is the most frequent brain injury to be associated with Cerebral Palsy (CP), especially in preterm infants. Spastic diplegia, a movement disorder commonly seen in CP, is characterized by increased muscle tone and spasticity in the lower extremities. The authors present a case of a 2-year-old child with mild PVL and spastic diplegia CP, with identifying factors including preterm birth history, his present age, and increasing severity of symptoms overtime. Magnetic resonance imaging was significant for an abnormally increased periventricular signal consistent with mild PVL. Due to worsening symptoms of toe-walking, increased gait width, and spasticity of lower extremities, interventions were recommended. This case demonstrates the neurodevelopmental consequences of PVL and ischemic brain injury in a preterm infant, resulting in spastic diplegic CP. A comprehensive and up-to-date review of the literature on PVL and spastic diplegia associated with CP is explored. Keywords: Cerebral palsy; Preterm; Spasticity; Hypoxic-ischemic encephalopathy; Magnetic resonance imaging.

Attenuation of temporal correlations of neuronal oscillations in patients with mild spastic diplegia

The aim of this study was to investigate the temporal correlations of neuronal oscillations in patients with mild spastic diplegia (MSD). Resting-state electroencephalography (EEG) was recorded from 15 male adolescent and young adult patients with MSD and 15 healthy controls. We characterized the temporal correlations of neuronal oscillations, both on long temporal scale (i.e., >1 second) and short-to-intermediate temporal scale (i.e., <≈1 second) using detrended fluctuation analysis (DFA) and an analysis of the life- and waiting-time statistics of oscillation bursts respectively. The DFA exponents at alpha and beta bands, the life-time biomarker of alpha oscillation, and the life- and waiting-time biomarkers of beta oscillation were significantly attenuated in the patients compared with controls. Moreover, altered scalp distributions of some temporal correlation measures were found at alpha and beta bands in these patients. All these findings suggest that MSD is associated with highly volatile neuronal states of alpha and beta oscillations on short-to-intermediate and much longer time scales, which may be related to cognitive dysfunction in patients with MSD.

Altered Resting-State EEG Microstate Parameters and Enhanced Spatial Complexity in Male Adolescent Patients with Mild Spastic Diplegia.

The aim of this study was to investigate the resting-state EEG microstate parameters and spatial complexity in male adolescent patients with mild spastic diplegia (MSD). Resting-state EEG data were collected from male adolescent patients with MSD and healthy controls with eyes closed. EEG microstate and omega complexity analysis were performed. Microstate analysis revealed that the occurrence rate of microstate class A and D were significantly higher and the duration of microstate class B was significantly lower in the patients compared to healthy controls, which indicated that the temporal complexity may be higher and certain cognitive functions may be impaired in these patients. Omega complexity analysis showed that the global omega complexity of alpha-2 band was significantly higher in the patients than the controls. Besides, compared to the anterior regional omega complexities, the posterior regional omega complexities were significantly lower in the delta, theta, alpha-1 and alpha-2 bands, but significantly higher in the beta-2 and gamma-1 bands. And the regional omega complexities in the delta, theta and alpha-1 bands were significantly higher in the patients than controls. The present study reveals that in male adolescent patients with MSD, the temporal and spatial complexities of EEG signal are enhanced, which may be closely associated with the altered brain functions in these patients.

Delayed Finger Tapping and Cognitive Responses in Preterm-Born Male Teenagers With Mild Spastic Diplegia

BackgroundInformation on fine motor and basic cognitive functions in spastic diplegia is sparse in the literature. The aim of this study was to investigate index finger's tapping speed and cognitive functions in categorization and old/new recognition of pictures in patients with mild spastic diplegia. MethodsFifteen preterm-born male teenagers with mild spastic diplegia and 15 healthy male teenagers participated in this study. Finger-tapping tests and cognitive tests were performed on all participants. Outcomes were compared between the two groups. ResultsIn the finger-tapping tests, the tapping speed was significantly slower in patients than in controls. In the tests of tapping one key persistently and tapping two keys alternately, the reaction time gaps between the left and right digits were larger in patients than in controls. In the categorization tests, the accuracies and reaction times for animal/plant and girl face pictures, but not for boy face pictures, were significantly worse in patients than in controls. In the recognition tests, the accuracies for old/new, animal/plant, and boy/girl face pictures were significantly lower in patients than in controls. The reaction times for old/new, animal/plant, and new face pictures, but not for old face pictures, were significantly longer in patients compared with controls. ConclusionsOur results demonstrate delayed finger tapping and cognitive responses in preterm-born male teenagers with mild spastic diplegia. Our experimental paradigm is sensitive for the study of fine motor and cognitive functions between patients and healthy controls.

To Determine effectiveness of Closed-Kinetic Chain Exercise on Motor Control and Function as Compared to Open-Kinetic Chain Exercise in Children with Spastic Diplegic CP

Background and purpose : Traditionally, rehabilitation program emphasize strengthening training under close loop exercises. This study is designed to compare the effectiveness of closed-kinetic chain exercise v/s open-kinetic chain on motor function in children with spastic diplegic CP. Method : 30 subjects with mild spastic diplegia (GMFCS level I-II) were selected on the basis of inclusion criteria and randomly assigned in two groups. Group A performed the loaded STS exercises 3 days a week, and 3 sets per day for 6 weeks. Group B performed progressive exercise training for 6 weeks, with three sessions per week, and at least one day's rest between sessions. 10-RM was calculated for the muscle selected. Result : Student's t test while discrete data (Sex and GMFCS level) were analyzed with Fisher's exact est. The pre-test and post-test outcome measures (SCALE score, GMFM dimension D and GMFM dimension E) of two independent groups were compared by repeated measures analysis of variance (RM ANOVA) using general linear models (GLM) and the significance of mean difference within and between the groups was done by Newman-Keuls post hoc test. Conclusion : study revealed that Progressive resisted lower limb strength training was found to be slightly (insignificant) more effective than Loaded sit-to-stand exercise. The SCALE score, GMFM Dimension D and GMFM Dimension E scores improved 1.08, 1.10 and 1.05 times more respectively in children those who received Progressive resisted lower limb strength training than those who received Loaded STS training.

Rootless Century

Rootless Century

Unfavourable outcome of deep brain stimulation in a Tourette patient with severe comorbidity

Unfavourable outcome of deep brain stimulation in a Tourette patient with severe comorbidity

Effect of ankle-foot orthoses on trunk sway and lower limb intersegmental coordination in children with bilateral cerebral palsy

Ankle-foot orthoses may significantly improve lower limb kinematics in the gait of children with cerebral palsy. Here we aimed to analyze the effect of ankle-foot orthoses on trunk postural control and lower limb intersegmental coordination in children with mild spastic diplegia (GMFCS I or II). We recorded tridimensional trunk kinematics and thigh, shank, and foot elevation angles in 20 4-12 year-old children born preterm with spastic diplegia and 20 typically developing children while walking either barefoot or with ankle-foot orthoses. We found significantly greater trunk excursions in children with cerebral palsy compared to typically developing children in both conditions. When wearing ankle-foot orthoses cerebral palsy children showed increased trunk frontal angular velocity. No significant changes in trunk displacement and angular velocity were recorded in the sagittal plane in either group. Typically developing children wearing orthoses showed increased trunk frontal displacement. Wearing orthoses induced significant changes in shank and foot elevation in both groups. Ankle-foot orthoses affect postural control and intersegmental coordination in children with cerebral palsy. This should be taken into account when planning therapeutic management.

Delayed Recognition of Profound Hearing Loss in a 7-Year-Old Girl With a Neurological Condition

Kelly is a 7-year-old girl with a complex medical history including asthma, mild spastic diplegia, and seizure disorder that is controlled with carbamazepine. She had a significant receptive and expressive language impairment and milder delays in gross and fine motor skills. Kelly is currently repeating first grade in a self-contained classroom; she receives speech, occupational, and physical therapy. At the 7-year-old well child visit, her mother is worried about Kelly's poor progress in school, and she expresses concern about her daughter's hearing. Her pediatrician observes that Kelly is withdrawn, uses minimal language, and is fearful of the examination. Kelly was born full-term by Cesarean section because of placental abruption. She was in the neonatal intensive care nursery for 2 weeks with metabolic acidosis because of acute tubular necrosis. One day after arriving home, she had a cardiopulmonary arrest followed by emergency open-heart surgery for critical pulmonary hypertension. Her postoperative course was significant for renal failure, extracorporal membrane oxygenation, ventilator dependency, tracheostomy, and gastrostomy. By 3 years of age her medical condition stabilized, and the tracheostomy and gastrostomy tubes were removed. A review of Kelly's previous audiological tests revealed a failed otoacoustic emission test at 5 months. An auditory brain stem response test at 8 months recorded normal hearing in the right ear. At 4 years, behavioral audiometry was attempted but not completed because Kelly cried throughout the session. At 5 years, testing with ear inserts showed normal hearing bilaterally. Because of the concerns raised by Kelly's mother at the pediatric visit, she was referred to audiology for a reevaluation. Testing at this time revealed moderate to profound sensorineural hearing loss in both the ears, which was confirmed on subsequent examinations. Kelly was promptly fitted for hearing aids. Her individual education plan was changed to reflect the diagnosis of hearing impairment, and hearing services were implemented in the classroom. On a recent follow-up visit, Kelly was talkative, engaging, and cheerful.

Delayed Recognition of Profound Hearing Loss in a 7-Year-Old Girl With a Neurological Condition

Kelly is a 7-year-old girl with a complex medical history including asthma, mild spastic diplegia, and seizure disorder that is controlled with carbamazepine. She had a significant receptive and expressive language impairment and milder delays in gross and fine motor skills. Kelly is currently repeating first grade in a self-contained classroom; she receives speech, occupational, and physical therapy. At the 7-year-old well child visit, her mother is worried about Kelly's poor progress in school, and she expresses concern about her daughter's hearing. Her pediatrician observes that Kelly is withdrawn, uses minimal language, and is fearful of the examination.Kelly was born full-term by Cesarean section because of placental abruption. She was in the neonatal intensive care nursery for 2 weeks with metabolic acidosis because of acute tubular necrosis. One day after arriving home, she had a cardiopulmonary arrest followed by emergency open-heart surgery for critical pulmonary hypertension. Her postoperative course was significant for renal failure, extracorporal membrane oxygenation, ventilator dependency, tracheostomy, and gastrostomy. By 3 years of age her medical condition stabilized, and the tracheostomy and gastrostomy tubes were removed.A review of Kelly's previous audiological tests revealed a failed otoacoustic emission test at 5 months. An auditory brain stem response test at 8 months recorded normal hearing in the right ear. At 4 years, behavioral audiometry was attempted but not completed because Kelly cried throughout the session. At 5 years, testing with ear inserts showed normal hearing bilaterally.Because of the concerns raised by Kelly's mother at the pediatric visit, she was referred to audiology for a reevaluation. Testing at this time revealed moderate to profound sensorineural hearing loss in both the ears, which was confirmed on subsequent examinations. Kelly was promptly fitted for hearing aids. Her individual education plan was changed to reflect the diagnosis of hearing impairment, and hearing services were implemented in the classroom. On a recent follow-up visit, Kelly was talkative, engaging, and cheerful.

MR Spectroscopy and Serial Magnetic Resonance Imaging in a Patient with Mitochondrial Cystic Leukoencephalopathy due to Complex I Deficiency andNDUFV1Mutations and Mild Clinical Course

We present clinical, magnetic resonance imaging and MR spectroscopic findings of a female patient, first admitted at the age of 9 months for regression of motor milestones and signs of mild spastic diplegia. Magnetic resonance imaging (MRI) demonstrated periventricular white matter abnormalities with sparing of the subcortical white matter. Subsequent MRIs, performed at the ages of 13 and 16 months, demonstrated progression of the white matter changes, progressive white matter rarefaction and cystic degeneration, and additional involvement of the corpus callosum; only the subcortical white matter remained spared. Proton MR spectroscopy revealed lactate elevation in the white matter. Blood lactate and lactate/pyruvate ratio were mildly elevated. Subsequent analysis of mitochondrial function in muscle tissue showed decreases in substrate oxidation and in ATP and CrP production rates. Complex I activity was seriously decreased, whereas mild decreases of complex II and IV activities were also noted. Analysis of the NDUFV1 gene revealed compound heterozygosity for two point mutations, each of them carried by one parent. The further clinical course of the patient was uphill; she slowly regained all previously lost motor milestones. In conclusion, diffuse white matter changes on MRI are compatible with mitochondrial encephalopathy and not necessarily associated with a severe clinical course.

Idiopathic Toe Walking

The differential diagnosis in children who walk on their toes includes mild spastic diplegia and idiopathic toe walking (ITW). A diagnosis of ITW is often one of exclusion. To better characterize the diagnosis of ITW, quantitative gait analysis was utilized in a series of patients with an established diagnosis of ITW.Patients with an established diagnosis of ITW were analyzed by quantitative gait analysis. Data were recorded as each subject walked in a self-selected toe-walking pattern. The subject was then asked to ambulate making every effort to walk in a normal heel-toe reciprocating fashion. Data were collected to determine if this group of idiopathic toe walkers was able to normalize their gait. Datasets were compared with each other and with historical normal controls.Fifty-one neurologically normal children (102 extremities) with ITW were studied in the Motion Analysis Laboratory at a mean age of 9.3 years. In the self-selected trials, significant deviations in both kinematics and kinetics at the level of the ankle were identified. Disruption of all 3 ankle rockers and a plantar flexion bias of the ankle throughout the gait cycle were most commonly seen. When asked to attempt a normal heel-toe gait, 17% of the children were able to normalize both stance and swing variables. In addition, 70% were able to normalize some but not all of the stance and swing variables.Quantitative gait analysis is an effective tool for differentiating mild cerebral palsy from ITW. Kinematic and kinetic distinctions between the diagnoses are evident at the knee and ankle. The ability to normalize on demand at least some of the kinematic and kinetic variables associated with toe walking is seen in most children with ITW.

Percutaneous transluminal angioplasty in recurrent necrotizing enterocolitis—a case report

A 35-week gestation male neonate had 3 episodes of necrotizing enterocolitis (NEC), the first of which was managed surgically. Two further episodes of NEC were treated by medical management. Angiography then identified a stricture at the origin of the superior mesenteric artery. Percutaneous transluminal angioplasty successfully dilated the stenosis, and no further episodes of NEC occurred. Eight years later, the child exhibits a mild spastic diplegia and is thriving with no gastrointestinal disturbances. Angioplasty is technically feasible in the neonate and may be a treatment option in recurrent NEC associated with visceral arterial stenosis.

Effectiveness of Loaded Sit-to-Stand Resistance Exercise for Children With Mild Spastic Diplegia: A Randomized Clinical Trial

Liao H-F, Liu Y-C, Liu W-Y, Lin Y-T. Effectiveness of loaded sit-to-stand resistance exercise for children with mild spastic diplegia: a randomized clinical trial. Objective To investigate effectiveness of a functional strengthening program, the loaded sit-to-stand (STS) resistance exercise, for children with cerebral palsy (CP). Design A single-blind, randomized block design. Setting STS exercises were carried out at the children’s homes. Participants Twenty children (12 boys, 8 girls; age range, 5−12y) with spastic diplegia CP and classified by the Gross Motor Function Classification System as level I or II were stratified by their severity and age and randomly allocated into either the experimental or control group. Intervention Both groups received their regular physical therapy. The experimental group underwent loaded STS exercise 3 times a week for 6 weeks. Main Outcome Measures Goal dimension scores of the Gross Motor Function Measure (GMFM), gait speed, 1 repetition maximum (1-RM) of the loaded STS, isometric strength of knee extensor, and Physiological Cost Index (PCI). The outcome measures were conducted at the beginning and end of the 6-week study. Results After loaded STS exercise, the experimental group showed statistically significant differences in GMFM goal dimension scores, 1-RM STS, and PCI from the control group. The changes in gait speed and isometric strength of the knee extensor did not differ significantly between the 2 groups. Conclusions After the loaded STS exercise, children with mild spastic diplegia improved their basic motor abilities, functional muscle strength, and walking efficiency.

Range of Motion in Children with Spastic Diplegia, GMFCS I-II Compared to Age and Gender Matched Controls

Measurements of passive range of motion are often used to define the degree of muscle shortening in children with spastic diplegic cerebral palsy. However, little is known about the expected values of passive range of motion measurements in children with spastic diplegia and how these might differ from age and gender matched norms taken from the same population. Therefore, the purpose of this study was to compare eight lower limb measurements of sagittal plane passive range of motion in 22 children with spastic diplegia, GMFCS I to II, with 22 matched controls. Children with spastic diplegia had minimal hip extension loss, but reduced hamstring length, with popliteal angle averaging -59.2+/-10.6 degrees (control -38.8+/-13.4 degrees, p < 0.001) and SLR averaging 52.7+/-10.2 degrees (control 75.8+/-11.1 degrees, p < 0.001). Ankle dorsiflexion with knee extension averaged -2.5+/-8.4 degrees in children with spastic diplegia (control 8.6+/-6.8 degrees, p < 0.001). These data confirmed that children with mild spastic diplegia had some restriction in passive range of motion compared to controls but that there was considerable variability between individuals.

Range of Motion in Children with Spastic Diplegia, GMFCS I-II Compared to Age and Gender Matched Controls

Measurements of passive range of motion are often used to define the degree of muscle shortening in children with spastic diplegic cerebral palsy. However, little is known about the expected values of passive range of motion measurements in children with spastic diplegia and how these might differ from age and gender matched norms taken from the same population. Therefore, the purpose of this study was to compare eight lower limb measurements of sagittal plane passive range of motion in 22 children with spastic diplegia, GMFCS I to II, with 22 matched controls. Children with spastic diplegia had minimal hip extension loss, but reduced hamstring length, with popliteal angle averaging −59.2 ± 10.6 degrees (control −38.8 ± 13.4 degrees, p < 0.001) and SLR averaging 52.7 ± 10.2 degrees (control 75.8 ± 11.1 degrees, p < 0.001). Ankle dorsiflexion with knee extension averaged −2.5 ± 8.4 degrees in children with spastic diplegia (control 8.6 ± 6.8 degrees, p < 0.001). These data confirmed that children with mild spastic diplegia had some restriction in passive range of motion compared to controls but that there was considerable variability between individuals.

Botulinum toxin with and without casting in ambulant children with spastic diplegia: a clinical and functional assessment

This study compared clinical and functional outcomes after treatment with botulinum toxin A (BTX‐A) and BTX‐A with casting in children with dynamic equinus foot. Ten children (seven males, three females; mean age 6 years 4 months, SD 2 years 7 months; range 4 to 11 years) with mild spastic diplegia and independent walking were divided into two groups: group 1, BTX‐A and group 2, BTX‐A plus casting. BTX‐A was injected in the triceps surae bilaterally at multiple sites while the children were sedated with mask anaesthesia. Dysport® toxin was used, 15 to 20 IU/kg in each muscle. Immediately after injection an ankle‐foot orthosis was applied to children in group 1 and a cast to children in group 2. Clinical assessment using the Ash worth scale, Gross Motor Function Measure (GMFM), range of movement measurement, and gait analysis was performed before treatment and 1, 4, and 12 months after treatment. Spasticity decreased significantly at 1‐month examination in both groups (p=0.002), at 4–month examinations (Wilcoxon test p=0.003), and 12 month (p=0.052) examinations in group 2. GMFM highlighted a significant improvement in group 2 at the 4–month examination (p=0.052 for standing, p=0.007 for walking). Gait analysis showed a significant increase in the walking speed in group 2 (p=0.04). No change was detected in ankle kinematics and kinetics or in muscular activity during the gait cycle. We confirmed that BTX‐A reduces spasticity and improves functional performance in standing and walking; association with casting provides more marked and enduring results.

Is nCPAP of value in extreme preterms with no access to neonatal intensive care?

This prospective study was undertaken to investigate the efficacy of nasal continuous positive airway pressure (nCPAP) in a group of extremely small infants denied access to a neonatal intensive care unit (NICU) in South Africa. Consecutive infants weighing less than 1200 g and/or of a gestational age below 28 weeks admitted to the neonatal ward with respiratory distress syndrome (RDS), and who were refused admission to the NICU, received either nCPAP (Infant Flow System E.M.E., UK) of headbox oxygen. Of 22 infants, 11 infants were included in the treatment group (nCPAP) and 10 in the control group. Within the first 24 h, two infants (18 per cent) in the nCPAP group and eight infants (80 per cent) in the control group died (p = 0.007) (survival OR = 18; RR = 4.09). A statistically significant improvement in the arterial-alveolar (a/A) oxygen ratio occurred in the nCPAP group between postnatal day 1 and day 3 of life (0.17 vs. 0.36; p < 0.005). Neonatal complications occurred in six (55 per cent) infants who survived the first 24 h of life. Eighty per cent of the infants with intraventricular haemorrhage (IVH) died, as well as all the infants who were born before arrival at the hospital. At the time of discharge from hospital, 45 per cent (five infants) in the nCPAP group survived vs. 20 per cent (two infants) in the control group. The neurodevelopmental outcome of six of the surviving seven infants were evaluated at 1 year of corrected age. The neurodevelopmental outcome as assessed by the Griffith Score was within normal limits in all infants. One infant has sensorineural deafness and one is deaf and has a possible mild spastic diplegia (both in the treatment group). We conclude that nCPAP significantly improves the short-term survival of very low birth-weight (VLBW) infants with moderate to severe respiratory distress syndrome who could not be admitted to intensive care. nCPAP significantly improves the a/A oxygen ratio between day 1 and day 3 of life.

Electromyographic Test to Differentiate Mild Diplegic Cerebral Palsy and Idiopathic Toe-Walking

The purpose of this study was to determine whether children with mild spastic diplegic cerebral palsy (CP) could be differentiated from those with idiopathic toe-walking (ITW) based on an obligatory coactivation during voluntary contraction of the quadriceps or gastrocnemius. Twenty-four subjects participated in this study, eight children with mild spastic diplegia CP, eight with ITW, and eight age-matched controls. Measurements included passive range of motion and surface electromyographic recordings of the lateral quadriceps and lateral gastrocnemius. Electromyographic recordings were obtained during resisted knee extension with knee flexed 30 degrees, isometric quadriceps contraction with knee extended (quad set), active plantarflexion, and during gait. The range-of-motion values were not different between the CP and ITW subjects, with the exception of the popliteal angle, which was greater in subjects with CP, with an overlap in values. Gait electromyography showed premature firing of gastrocnemius in swing in both groups of subjects compared with controls. During resisted knee extension and quad set, the mean duration of gastrocnemius coactivation in subjects with CP was high: 86% and 86% compared with 20% and 35% for the subjects with ITW and 0.4% and 3% for controls, respectively. Voluntary plantarflexion did not consistently elicit coactivation of the quadriceps. The results suggest that electromyographic testing of resisted knee extension and quad set to identify gastrocnemius coactivation can help differentiate patients with mild CP from those with ITW.

Neurophysiology and MRI in late-infantile metachromatic leukodystrophy

We present serial clinical, radiologic, and neurophysiologic findings of a patient with late-infantile metachromatic leukodystrophy who was first admitted at 30 months of age because of gait disturbance. The neurologic findings were consistent with mild spastic diplegia (occasionally with toe walking). Magnetic resonance imaging disclosed diffuse high intensity in the cerebral white matter on T 2-weighted images. Nerve conduction velocity studies and evoked-potential studies were markedly abnormal. Assay of arylsulfatase A activity in leukocyte culture disclosed a marked deficiency of the enzyme, confirming the diagnosis of late-infantile metachromatic leukodystrophy. Serial neurophysiologic studies demonstrated a marked decrease of nerve conduction velocities, both motor and sensory, as well as prolongation or disappearance of brainstem auditory-, visual-, and somatosensory–evoked potential latencies. Magnetic resonance imaging studies revealed initially diffuse increased signal intensity of periventricular and subcortical white matter on T 2-weighted images, progressing to cortical atrophy with involvement of the arcuate fibers and the cerebellar white matter, correlating with the clinical deterioration (severe spastic tetraplegia with optic atrophy and epilepsy).