Spastic Forms Of Cerebral Palsy Research Articles

Botulinum toxin type A chemodenervation treatment in spastic forms of cerebral palsy

Cerebral palsy (CP) is one of the most serious outcomes of the perinatal lesion of central nervous system and the most common reason for neurological disability in children. Being the key cause of pathological dynamic stereotypes that frequently result in pathological posture and contractures, spasticity is critically important for CP. The use of botulinum toxin type A (BTA) in complex treatment 2-6 years old CP patients allows significantly to improve motor abilities, help to change the surgical procedure, delay or even avoid some types of surgery. For elder children the use of BTA allows to improve local motor impairment. The treatment of spasticity in CP with BTA is safe (evidence level A) and highly effective (evidence level A). It leads to the positive change of pathological dynamic stereotype, significantly improves gait, decreases muscle tone with Ashworth and Tardeu scales and rises the gross motor function score. Our own experience of onabotulinumtoxinA treatment as a part of complex therapy in 68 patients with spastic forms of CP demonstrates the significant improvement of motor function, most noticeable in younger patients (early pre-school age) with GMFS I-III.

Selection of a dose of the botulinum toxin A in spastic forms of cerebral palsy

To analyze the efficacy and safety of dose ranges of abobotulinum toxin A (BTA) for multilevel injections into upper and lower extremity muscles in children with spastic forms of cerebral palsy (CP). We analyzed retrospectively multilevel BTA injections for 216 patients, aged from 2 to 17 years. Children received 1-6 repeated injections and complex physiotherapy. Patients were classified according to the GMFCS. Treatment results were evaluated with the modified Ashworth and Tardieu scales. Multilevel BTA injections were indicated for the most (89/8%) of the patients with spastic forms of CP, and in most of them the total dosage exceeded 30 U/kg. In the bilateral forms of CP, the total dosage (U and U/kg) was higher compared to the unilateral forms. Doses for each muscle in U/kg were similar in all CP forms. The total doses of BTA and the intervals between the repeated injections were stable for each patient. The dose ranges suggested for CP are effective and safe for the reduction of spasticity in several functional segments of upper and lower extremities in one treatment session.

Characteristics of EMG activity in infants with movement disorders

Neuromuscular characteristics of children without health problems and suffering from movement disorders have been studied by the method of surface electromyography. A total of 76 children aged from 6 months to 3 years have been examined: 61 children with movement disorders (13 of them with the ataxic form of cerebral palsy (CP), 48 with the spastic forms of CP) and 15 without movement disorders. The infant in a recumbent position has had their knee and hip joints passively flexed and extended. The electromyographic (EMG) activity of the basic muscle groups of the hip and shin was recorded. The EMG activity has been assessed using wavelet transform and subsequent analysis of the obtained time dependences. As a result, parameters related to diagnosis of infants with movement disorders have been revealed.

The results of single-event multilevel orthopedic surgeries and the early rehabilitation used in complex with botulinum toxin treatment in patients with spastic forms of cerebral palsy

To evaluate motor possibilities of patients with children spastic palsy (CSP) one year after single-event multilevel orthopedic low extremity surgeries in combination with early rehabilitation treatment including botulinum toxin treatment. Authors studied the results of operative orthopedic treatment in 55 patients with CSP, aged from 5 to 17 years (mean 11.9 ± 2.5 years), who underwent multilevel surgeries with early functional rehabilitation using 1.5 treatment courses with 6-8 week treatment-free periods during 9-12 months in combination with a single injection of disport in the post-operative period. We performed 74 surgeries 140 episodes of botulinum toxin treatment using average doses of Botulinum toxin 10 U per kg of body mass injected into low extremity muscles. In the post-operative period, authors recorded a significant reduction in pain syndrome, assessed with a pain intensity scale, from 8.6 ± 1.2 to 4.3 ± 1.1 scores (p < 0.001). An analysis of gait demonstrated an improvement of gait patterns in all patients able to move independently. An increase in motor abilities, measured with the Gillette Functional Assessment Questionnaire, by 1 level was identified in 28 (50.9%) patients, by 2 levels in 2 (3.6%) patients, no changes were observed in 25 (45.5%) patients. Single-event multilevel orthopedic surgeries in children with CSP reduce a number of repeated surgeries. The effective control over pain syndrome in patients with CSP using multilevel botulinum toxin treatment in the post-operative period promotes the functional rehabilitation, increases rates of loading during training sessions and the motivation of CSP patients to restore the lost activity.

ТREATMENT STRATEGY OF FLEXION CONTRACTURE OF THE WRIST JOINT IN CHILDREN WITH CEREBRAL PALSY

Objectives. The objective of study was to assess the effectiveness of transplantation of m. flexor carpi ulnaris tendon on the place of m. extensor carpi radialis brevis / longus (Green operation) to eliminate the deficit of active wrist joint extension in children with cerebral palsy. Materials and methods. The present study is based on a survey of children with cerebral palsy with affected upper limb. The main criterion for selection of patients was the presence of active extension deficit in the wrist joint, both isolated and in combination with other contractures of the upper limb joints. Total 22 patients with spastic forms of cerebral palsy were examined. Results and conclusions. Green operation is a good method of surgical treatment of active extension deficit in the wrist joint in patients with cerebral palsy. In the presence of moderately severe contractures in the wrist joint, serial casting can eliminate them completely. Presence of a fixed pronation contracture of the forearm is a factor that reduces the effectiveness of FCU transplantation. Pronation contracture should be corrected before or during Green surgery. FCU transplantation is effective for children of any age, but its effectiveness is reduced from 12 years old.

SURGICAL TREATMENT OF PRONATION CONTRACTURE OF THE FOREARM IN PATIENTS WITH INFANTILE CEREBRAL PALSY

The objective of the work was to evaluate the efficiency of the existing methods of surgical treatment of pronation contracture of the forearm, the modification of the existing methods of treatment, the development of the indications for each specific method of treatment. Materials and methods. This study is based on a survey of children suffering from infantile cerebral palsy affecting the upper limbs. The main criterion for the patient selection was the presence of a fixed pronation contracture of the forearm, both isolated and combined with other contractures of the joints of the upper limb. Total 42 patients with spastic forms of cerebral palsy were examined. Results and conclusions. With age of the patient, the pronation contracture is usually increased, the contractures of the elbow and wrist joints may develop, which leads to the necessity for more and more radical operative techniques. Therefore, the early surgical treatment allows obtaining optimal results with its minimum scope. The investigation data gave an option to simplify, but to increase the efficiency of surgical treatment methods of pronation contractures in children with infantile cerebral palsy.

Manual ability classification system in assessing hand function in children with cerebral palsy

Manual ability classification system (MACS) describes how children with cerebral palsy handle objects in daily activities. The aim of the research is to identify the opportunities of MACS classification in the assessment of function and evaluation of changes of manual activity in children with cerebral palsy. Patients and methods: The study included 44 children of different ages (4-16 years) and types of cerebral palsy. We conducted a functional assessment and MACS classification for all children. The children were involved in multidisciplinary rehabilitation treatment, while their families were involved in the activities of therapy, intervention and evaluation. Six months after the therapeutic interventions using repeated MACS classification, the changes in manual activities were observed and quantified as: 1.improvement of bimanual hand activity, 2. absence of improvement of bimanual hand activity. Results: Most of the children had the spastic form of cerebral palsy and needed help with the activities of hands. Six months after the therapeutic interventions, hand function was improved in 22 children (p<0.001), in all MACS levels. The biggest change was in the MACS level III (77% of children of this level), in spastic type of cerebral palsy and in schoolchildren (56 % children of that age). Conclusion: Manual Ability Classification System of children with cerebral palsy helps in the assessment of function and evaluation of manual activity changes in children with cerebral palsy.

Influence of 3-month therapy using the neuro-orthopaedic suit Atlant on gait characteristics in preschool children with spastic cerebral palsy

Different kinds of physical therapy are used in medical rehabilitation of neurological patients with motor deficiency: partial body weight-supported treadmill training, driven gait orthosis, neuromuscular electrical stimulation and neuro-orthopaedic suit therapies. Neuro-orthopaedic pneumosuit (NOPS) Atlant (Dynaforce, Russia) creates a muscle framework by dynamic proprioceptive stimulation, stabilizing the trunk and the extremities, reducing pathological synergies and normalizing patient’s motor activity. The aim of the present study was to investigate the influence of 3-month therapy using the NOPS Atlant on gait characteristics in preschool children with spastic form of cerebral palsy (CP). Six CP children with spasticity of lower extremities with (mean±SE) age of 5.2±0.8 years participated in the present study. Children had NOPS Atlant therapy sessions during three months, supervised by an experienced physiotherapist. The kinematic and kinetic characteristics of gait were measured using 3-D movement analysis system Elite Clinic (BTS S.p.A., Italy). After 3-month therapy using the NOPS Atlant, significant increase (7.9%) of the stride length of gait was found as compared with the initial data. Children with spastic CP demonstrated significant improvement of range of motion of hip joint abduction, decrease of knee joint external rotation, as well as positive changes in foot progression angle during gait. In conclusion, motor function re-activation during gait in preschool children with spasticity caused by cerebral palsy was noted after 3-month therapy using the NOPS Atlant. However, future research is needed to elucidate mechanisms of neurodynamic therapy effect on motor ability in children with CP.

DEVELOPMENT OF MOTOR FUNCTIONS AND MANUAL ABILITIES IN PEDIATRIC PATIENTS WITH SPASTIC CEREBRAL PALSY AFTER BOTULINUM TOXIN TREATMENT AND COMPLEX REHABILITATION

To investigate the dynamic of general motor function and manual abilities in children with spastic forms of cerebral palsy (CP) after complex rehabilitation combined with single and repeated injections of botulinum toxin A (BTA). The article presents 18 month followup of 52 patients with mono- and bilateral spastic forms of CP after single and multiple injections of botulinum toxin A and complex rehabilitation/ Patients received totally 74 injection sessions: 17 (32.7%) children--twice, 5 (9.6%) children--three times. Motor development assessment was done according to the GMFCS and GMFMS-88 scales and centile curves of normal motor development connected with these scales, hand function was classified according to the MACS scale. For the first time results of botulinum toxin therapy and rehabilitation were compared with the natural motor development of patients with different levels of motor disturbances according to centile tables. Patients with bilateral cerebral palsy improved slowly than hemiparetic and changes lasted for longer period. Level according to the MACS scale didn't depend on the gestational age of the patients, was higher in children with hemiparesis and changed for 1 level in 4 (7.7%) patients after the first botulinum toxin A injections.

Planning of surgical treatment of upper extremity in patients with cerebral palsy

The purpose - to devise the algorithm of patient examination with spastic hand to determine what the variant of surgical treatment is indicated. The variant of surgical treatment and it's results are depend on the cause of upper extremity deformation. Materials and methods. This study is based on a survey of children with cerebral palsy with lesions of the upper extremity. The main criterion for the selection of patients was the presence of the combined lesion of the upper extremity, where the cause of dysfunction hands are not only fixed contractures, but primary tonic. Was to survey 47 patients with spastic forms of cerebral palsy with the defeat of the upper limb, but the study group included only 26 of them in the ages of 7 to 18 years (average 12,1), as having the clinical picture both types of contractures. We have developed and applied a system of examinations, modeling expected outcome of selective neurotomy motor nerves of the upper limb, which allows to estimate the possible result of such treatment, and clearly differentiate tonic and fixed contracture. Results and conclusions. Based on the results of study we supposed that, using diagnostic blockade motor nerve at the period of planning surgical treatment help us to create temporary reversible model of selective neurotomy motor nerve branches and identify the type of contracture, degree of manifestation and functional perspective.

BOTULINUM TOXIN A INJECTION PRECISION CONTROL AT SPASTIC FORMS OF CEREBRAL PALSY: METHODOLOGY CHOICE

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Influence of botulinum toxin therapy on postural control and lower limb intersegmental coordination in children with spastic cerebral palsy.

Botulinum toxin injections may significantly improve lower limb kinematics in gait of children with spastic forms of cerebral palsy. Here we aimed to analyze the effect of lower limb botulinum toxin injections on trunk postural control and lower limb intralimb (intersegmental) coordination in children with spastic diplegia or spastic hemiplegia (GMFCS I or II). We recorded tridimensional trunk kinematics and thigh, shank and foot elevation angles in fourteen 3–12 year-old children with spastic diplegia and 14 with spastic hemiplegia while walking either barefoot or with ankle-foot orthoses (AFO) before and after botulinum toxin infiltration according to a management protocol. We found significantly greater trunk excursions in the transverse plane (barefoot condition) and in the frontal plane (AFO condition). Intralimb coordination showed significant differences only in the barefoot condition, suggesting that reducing the degrees of freedom may limit the emergence of selective coordination. Minimal relative phase analysis showed differences between the groups (diplegia and hemiplegia) but there were no significant alterations unless the children wore AFO. We conclude that botulinum toxin injection in lower limb spastic muscles leads to changes in motor planning, including through interference with trunk stability, but a combination of therapies (orthoses and physical therapy) is needed in order to learn new motor strategies.

Dental management of early childhood caries in spastic quadriparesis: A case report and clinical guidelines

Cerebral palsy (CP) describes a group of permanent disorders of the development of movement and posture, causing activity limitation, that are attributed to non-progressive disturbances that occurred in the developing fetal or infant brain. The motor disorders of CP are often accompanied by epilepsy, secondary musculoskeletal problems, and disturbances of sensation, perception, cognition, communication, and behavior. Spastic quadriparesis is the most severe form of spastic cerebral palsy. The present report describes the management of a 5-year-old patient with early childhood caries and spastic quadriparesis. The oral manifestations and clinical guidelines are discussed considering the special health care needs in these patients so as to provide comprehensive dental care.

Anwendung von Botulinumtoxin A in der Behandlung der spastischen infantilen Zerebralparese: Retrospektive klinische Beobachtungsstudie

Botulinum toxin therapy now has a firm place in the treatment of spastic forms of cerebral palsy in children. This paper considers the subjective and practical results and the degrees of satisfaction from the point of view of the patients and their families. It also documents the data of infiltrations carried out under anaesthesia. 57 patients with an average age of 11 (± 6.7; 2-30) and with infantile spastic cerebral palsy underwent altogether 118 botulinum toxin A infiltrations. The patients were divided into two groups: those with spastic hemiparesis or diparesis, and those with tetraparesis, and then compared with each other. The results of the treatment were evaluated from the point of view of the patients and their families with the help of a specially developed questionnaire. The study shows that, broadly-speaking, patients less affected with spastic hemiparesis or diparesis felt they profited more from the treatment than patients more severely affected with tetraparesis. The statistics also show that the first group's expectations were significantly more often fulfilled and that they more frequently perceived greater success after each infiltration than the group with tetraparesis. Most patients and their families from both groups were satisfied with the treatment. Patients and their families feel that the use of botulinum toxin in the management of spastic cerebral palsy in children is an effective and accepted form of treatment. The aims of the therapy should be defined accurately and realistically before starting treatment, especially for those severely affected with tetraparesis, and discussed in detail with both the patient and his/her family.

Treatment of the Spasticity in Children with Cerebral Palsy

Botulinum toxin is a natural purified protein and one of the strongest biological poisons--neurotoxin. It is produced by the bacterium Clostridium botulinum. Its medical usage started in USA in 1981 and in Europe in 1992. There are seven different immune types of the toxin: A, B, C1, D, E, F and G. Toxin types A and B are used to decrease muscular spasticity. Botulinum toxin prevents the formation of acetylcholine from cholinergic nerve tissues in muscles, which in the end irreversibly destroys neuromuscular synapses. It is called temporary local chemodenervation. It does not affect the synthesis of acetylcholine. As it affects neuromuscular bond it also affects one of the symptoms of cerebral palsy--spasticity. Decreasing the spasticity of children with cerebral palsy leads to the improvement of conscious movements, muscles are less toned, passive mobility is improved, orthosis tolerance is also improved, and the child is enabled to perform easier and better motor functions such as crawling, standing and walking. Since the action of Botulinum toxin is limited to 2-6 months, new neural collaterals are formed and neuromuscular conductivity is reestablished which in the end once again develops a muscular spasm. This leads to a conclusion that botulinum toxin should again be applied into spastic muscles. It is very important for good effect of Botulinum toxin to set the goals of the therapy in advance. The goals include improvement of a function, prevention of contractions and deformities, ease of care and decrease of pain for children with cerebral palsy. After application of botulinum toxin, it is necessary to perform adequate and intensive physical treatment with regular monitoring of effects. This work shows a case of a boy with spastic form of cerebral palsy. After being rehabilitated using Vojta therapy and Bobath concept and the conduct of certain physical procedures, botulinum toxin is administered into his lower limbs' muscles and kinesiotherapy is intensified. After the administration of botulinum toxin significant functional improvement is noted.

THE EFFECT OF SURGICAL INTERVENTION ON BIOMECHANICAL ALIGNMENT IN THE TRANSVERSE PLANE DURING WALKING IN CHILDREN WITH CEREBRAL PALSY.

Objective The study evaluated the effectiveness of orthopedic surgical intervention in correcting transverse plane gait abnormalities for patients with the spastic form of cerebral palsy (CP). Background Quantitative gait analysis is useful in identifying causes of walking abnormalities in patients with CP. One significant problem in spastic CP patients is “in-toeing,” resulting in inadequate foot clearance and tripping. Causes of “in-toeing” include femoral anteversion, internal rotation of the tibia relative to the femur, and subtalar joint inversion. With the advent of clinical gait analysis laboratories, objective kinematic and kinetic data are now used in designing an optimal course of treatment for patients. Subjects Data were collected at the UCLA Center for Cerebral Palsy. Subjects were five patients with the spastic form of CP who had undergone orthopedic surgery to correct abnormalities of gait in the transverse plane (age range = 8-21, mean = 12.4, median = 10.8 years). All subjects and guardians provided informed consent. Methods A retrospective records search was used to identify all pediatric patients with cerebral palsy who were recommended for orthopedic surgery to correct in-toeing. Patients who proceeded with the surgery were then identified. Gait analysis was performed at the Kameron Gait and Motion Analysis Laboratory. Eight cameras were used to capture movement after 15 reflective markers were placed on specific bony landmarks on the patients9 pelvis and lower extremities. Kinematic data were calculated using OrthoTrak 6.29 (Motion Analysis Corporation, Santa Rosa, CA). Of the five subjects, two subjects underwent operations on the femur, two on the tibia, and one on the foot; three of the subjects had bilateral surgery. Postoperational gait analysis was performed an average of 16 months after surgery. The study was IRB approved. Results/Conclusions Normalization of foot angle progression in the transverse plane during gait was the primary outcome measured. Between the five patients, a total of 8 feet was assessed. The average improvement in foot progression angle was 22.51° of external rotation, placing the foot into a more normal progression angle. Secondary improvements in knee rotation and hip rotation were also observed. Gait analysis is an established method to assess the success of orthopedic surgical interventions in patients with cerebral palsy. Following orthopedic interventions, kinematic data demonstrated an improved foot progression angle with less in-toeing and a more stable, normalized gait pattern.

An autosomal recessive form of spastic cerebral palsy (CP) with microcephaly and mental retardation

Cerebral palsy (CP) is defined as any nonprogressive motor deficits resulting from cerebral abnormalities that occur in the prenatal or perinatal period. Symptoms become apparent during the first year of life. Genetic forms of CP account for about 2% in European populations but are thought to cause a substantial proportion in consanguineous families. We have identified a large consanguineous family from Oman with spastic diplegia, microcephaly, and mental retardation. Additional manifestations include hyperreflexia, clumsiness, unstable gait, drooling, and dysarthria. There was phenotypic variability among different individuals, but spastic diplegia, microcephaly, and mental retardation were three constant traits present in all affected individuals.

Paraliticka dislokacija kuka kod cerebralne paralize - hirursko lecenje mekotkivnim postupcima

Results of a combination of soft tissue procedures performed for the first time in treating paralytic dislocation of the hip in cerebral palsy are presented. All hip flexors and adductors release, along with possible transposition or elongation of knee flexors on the side of the dislocation (if knee contracture exceeded 20) were peformed. 75 hips in 57 patients were operated on. 54 patients were analyzed. The average age of the patients was 6.6 years, the average follow-up was 7 years. Excellent result was achieved in 33patients (61%), good in 10 (18,6%), fair in 4 (7,4%) poor in 7 patients (13%). Poor results were registered in patients over 10 years of age and in patients with athetosis. Results were assessed according to clinical finding, radiological finding (migrational percentage) and the ability of patients to walk. When based on radiological findings only, excellent results were achieved in 63 hips (84%). This combination of soft-tissue procedures which includes all muscles that take part in the dislocation proved to be very successful in achieving reposition. It can be recommended to patients suffering from the spastic form of cerebral palsy up to 10 years of age.

Medial rotation deformity of the hip in cerebral palsy: Surgical treatment by transposition of gluteal muscles

Medial rotation deformity of the hip is a problem to patients who are handicapped by cerebral palsy but able to walk, because the knees point inward during gait ("kissing patellae") and cause falls and frequent injuries. Knees and ankles are subject to stress and, therefore, they assume compensating positions. Lower legs assume position of valgus and external rotation, whereas feet rotate either inwards or outwards. Secondary deformities make gait more difficult and cause rapid tear of footwear. The purpose of the paper was to retrospectively analyze the effects of transposition of the gluteus medius and minimus muscles, a procedure introduced for the first time in our country in order to correct the deformity. A new method of binding the muscles by wire was described. There had been no previous experience with this method. This operation was indicated in patients with spastic form of cerebral palsy, who were able to walk, who had difficulties in gait and whose lateral rotation was less than 10 degrees along with the medial rotation of over 70 degrees of the hip on the side of the deformity. Additional prerequisite for the operation was the absence of flexion contracture of more than 15 degrees of either the hip or the knee on the side of deformity, as there is possibility of aggravation of the flexion hip deformity due to transposed gluteal muscles (now in front of the hip joint). Fifteen hips of 10 patients were operated on. Five patients were operated on bilaterally at one time. The average age was 8 (6-12) years. The majority of patients, 8 (80%) were aged between 6 and 8. The average follow-up was 5 years (3-8). The assessment of the results was based on the comparison of rotational abilities of both hips before and after the operation (in unilateral and bilateral deformities), as well as on individual complaints before and after the operation. In patients with unilateral deformity, their "healthy" hips were the control hips. The analysis of the femoral neck anteversion before and after operation was performed. Average values of medial and lateral rotation of the deformed hips before operation exhibited significant statistical difference when compared to control hips. The difference of average values of rotatory movements of control and operated hips was not statistically significant after operation. The difference of average preoperative values of the femoral neck anteversion in hips with deformity was statistically significant (49.40+/-4.63 degrees compared to 32.8+/-3.11 degrees ). Postoperative average values of anteversion in operated and control hips were not statistically significant. The difference between average preoperative (49.40+/-4.63 degrees ) and postoperative (35.80+/-7.66 degrees ) values of the femoral neck anteversion was statistically significant. Excellent results were achieved in 5 (50%) patients, i.e. 8 (53.3%) hips; good results were achieved in 3 (30%) patients, i.e. 5 (33.3%) hips; poor result in 2 (20%) patients, i.e. 2 (13.3%) hips. All 5 patients who had undergone surgery of both hips had symmetric outcome. Three patients had excellent results, while two had good results. Patients with excellent and good results (80% of patients, 86.6% of hips) showed neither weakening of the operated hip abduction nor pelvic instability (positive Trendelenburgh hip test). No complications were recorded postoperatively. Transposition of gluteal muscles can be recommended in patients under 10 years of age as there is still a chance for their femoral neck to change orientation, to decrease the anteversion and thus to achieve long-lasting effect. Fixation of transposed muscles by wire proved to be effective.

Hearing function and auditory evoked potentials in children with spastic forms of cerebral palsy

Hearing function and auditory evoked potentials in children with spastic forms of cerebral palsy