Determinant of Quality of Life in Patients with Chronic Cerebral Infarct

This study investigated how physical and cognitive function and psychological factors affected the health-related quality of life (HRQoL, hereafter HQ) of stroke patients in South Korea. The study enrolled 32 right-handed subjects with chronic cerebral infarction with disability and preserved cognitive function (Mini-Mental State Examination ≥ 20). Physical disability was assessed using the modified Rankin Scale (mRS) and Korean modified Barthel Index (KMBI). Quality of life was measured using the World Health Organization Quality of Life-Abbreviated form (WHOQOL-BREF, hereafter WB) and the 36-Item Short-form Health Survey (SF-36) in face-to-face interviews. Psychological distress was investigated using the Beck Depression Inventory Scale-II. The associations of each domain of WB and SF-36 were investigated using Pearson correlation analyses. Physical disability was negatively correlated with HQ in the SF-36. The physical function and bodily pain scales of the SF-36 were negatively correlated with physical disability. The general health domain of the SF-36 was negatively correlated with psychological scores. Emotional status was associated with physical health, social relationships, and general health in HQ. In summary, the severity of physical disability was associated with the patient's general and physical health and body pain. These findings suggest the importance of psychological, cognitive, and physiological interventions for improving the quality of life of patients after cerebral infarction.

Degeneration of the Inferior Cerebellar Peduncle After Middle Cerebral Artery Stroke: Another Perspective on Crossed Cerebellar Diaschisis

Background and Purpose- Deafferentation of the cortico-ponto-cerebellar pathway has been proposed as a key mechanism of crossed cerebellar diaschisis. Although the cerebellum receives afferent stimuli from both cortico-ponto-cerebellar and spinocerebellar pathways, evidence on whether spinocerebellar deafferentation contributes to a hypofunctional cerebellum is lacking. Therefore, we aimed to determine whether changes in the spinocerebellar pathway occur after middle cerebral artery stroke. Methods- Twenty-three patients admitted to our inpatient rehabilitation facility and 23 age-matched healthy controls were retrospectively enrolled. Patients' functional ambulation category was determined and the Medical Research Council muscle scale test of the lower limb muscles was performed at admission and discharge. The fractional anisotropy (FA) values of the corticospinal tract and the inferior cerebellar peduncle (ICP), as the final route of the dorsal spinocerebellar pathway, were compared between the groups. The FA laterality indices of the ICP and corticospinal tract were calculated as follows: (FA_affected-FA_unaffected)/(FA_affected+FA_unaffected). Pearson correlation analysis and multivariate linear regression models were used to determine the associations between the FA laterality indices and ambulatory function. Results- The FAs of the corticospinal tract and ICP were lower in the patient group than in the control group. The FA laterality index of the corticospinal tract was not correlated with the functional ambulation category or Medical Research Council muscle scale score at admission or discharge. The FA laterality index of the ICP at the pontomedullary junction was positively correlated with the functional ambulation category and Medical Research Council muscle scale scores of all hemiplegic lower limb muscles at admission and discharge. The FA laterality index of the ICP at the pontomedullary junction was independently associated with the functional ambulation category according to the multivariate regression models. Conclusions- ICP degeneration occurs in the subacute and early chronic phase of middle cerebral artery stroke. The lower FA laterality index of the ICP was indicative of poorer ambulatory and lower limb function.

The effect of white matter integrity on functional outcome in central pontine demyelination

[Purpose] Central pontine demyelination is a common osmotic demyelination syndrome. Typically, central pontine demyelination shows high signal intensity with demyelination in the mid-pons. Despite severe imaging findings, patients usually recover. This study investigated the integrity of the corticospinal tract (CST) and corticoreticular pathway (CRP) in patients at 12 months after the onset of central pontine demyelination. [Participants and Methods] This retrospective cross-sectional observational study assessed two patients with central pontine demyelination, who were ultimately able to walk without using an aid or orthosis and to use both hands but with mild residual symptoms. All participants underwent diffusion tensor imaging (DTI) at 12 months after onset. [Results] Both patients had mild ataxia at 12 months after onset. The integrity of the CST was restored in both cases, while the integrity of the CRP recovered partially. [Conclusion] The integrity of the CST and CRP at 12 months after the onset of central pontine demyelination was similar in both cases as well as the recovery status of the hand function and ambulation. These results may be useful in planning therapy for patients with central pontine demyelination.

Association of Lesion Location With Long-Term Recovery in Post-stroke Aphasia and Language Deficits

Background: Recovery from post-stroke aphasia is important for performing the activities of daily life, returning to work, and quality of life. We investigated the association between specific brain lesions and the long-term outcome of four dimensions of aphasia: fluency, comprehension, naming, and repetition 12 months after onset in patients with stroke. Methods: Our retrospective cross-sectional observational study investigated the relationship between the Korean version of the Western Aphasia Battery scores in 31 stroke patients 1 year after the onset of stroke and stroke lesion location. Brain lesions were assessed using voxel-based lesion symptom mapping (VLSM) in conjunction with magnetic resonance imaging. Results: Damage to the Rolandic cortex, Heschl's gyrus, the posterior corona radiata, supramarginal cortex, superior longitudinal fasciculus, superior temporal gyrus, and insula was associated with a low total AQ score. Lesions in the inferior triangularis and inferior operculum of the frontal cortex, supramarginal cortex, and insula were associated with a poor fluency outcome. Damage to the parietal cortex, angular cortex, temporal middle cortex, sagittal stratum, and temporal superior cortex was associated with poor recovery of comprehension skills. Lesions in the angular cortex, supramarginal cortex, posterior corona radiata, superior longitudinal fasciculus, internal capsule, temporal superior cortex, and temporal middle cortex were associated with poor recovery of naming in patients with stroke. Damage to the superior temporal cortex, posterior corona radiata, and superior longitudinal fasciculus was associated with poor recovery of repetition component. Conclusions: We identified specific brain lesions associated with long-term outcomes in four dimensions of aphasia, in patients with post-stroke aphasia. Our findings may be useful for advancing understanding for the pathophysiology of aphasia in stroke patients.

The Role of Regular Physical Therapy on Spasticity in Children With Cerebral Palsy

OBJECTIVE

To investigate the effect of physical therapy (PT) intervention on spasticity in patients with cerebral palsy (CP), and to assess the degree of deterioration of spasticity when regular PT is interrupted in those patients.

METHODS

We recruited 35 children with spastic CP who visited our hospital for PT, and whose Modified Tardieu Scale (MTS) scores were serially recorded including before and after a 10-day public holiday time frame period. The outcome measures were the angle of range of motion (ROM) of dorsiflexion of the ankle joint (R1 and R2) in the knee flexion and extension positions as assessed using the MTS.

RESULTS

The range of dorsiflexion of the ankle joint (R1 and R2) after the holiday period was significantly decreased as compared with that measured ROM noted before the holiday period, regardless of the knee position, age, or gross motor function. The dynamic component of the MTS (R2-R1) showed a slight decrease in the knee flexion position.

CONCLUSION

Interruption of regular PT aggravated spasticity and decreased ankle joint ROM in children with spastic CP. Our findings suggest that regular PT in the care continuum for children with CP is crucial for the maintenance of ROM in the spastic ankle joints.

Chromosomal Microarray Analysis as a First-Tier Clinical Diagnostic Test in Patients With Developmental Delay/Intellectual Disability, Autism Spectrum Disorders, and Multiple Congenital Anomalies: A Prospective Multicenter Study in Korea

Background

To validate the clinical application of chromosomal microarray analysis (CMA) as a first-tier clinical diagnostic test and to determine the impact of CMA results on patient clinical management, we conducted a multicenter prospective study in Korean patients diagnosed as having developmental delay/intellectual disability (DD/ID), autism spectrum disorders (ASD), and multiple congenital anomalies (MCA).

Methods

We performed both CMA and G-banding cytogenetics as the first-tier tests in 617 patients. To determine whether the CMA results directly influenced treatment recommendations, the referring clinicians were asked to complete a 39-item questionnaire for each patient separately after receiving the CMA results.

Results

A total of 122 patients (19.8%) had abnormal CMA results, with either pathogenic variants (N=65) or variants of possible significance (VPS, N=57). Thirty-five well-known diseases were detected: 16p11.2 microdeletion syndrome was the most common, followed by Prader-Willi syndrome, 15q11-q13 duplication, Down syndrome, and Duchenne muscular dystrophy. Variants of unknown significance (VUS) were discovered in 51 patients (8.3%). VUS of genes putatively associated with developmental disorders were found in five patients: IMMP2L deletion, PTCH1 duplication, and ATRNL1 deletion. CMA results influenced clinical management, such as imaging studies, specialist referral, and laboratory testing in 71.4% of patients overall, and in 86.0%, 83.3%, 75.0%, and 67.3% of patients with VPS, pathogenic variants, VUS, and benign variants, respectively.

Conclusions

Clinical application of CMA as a first-tier test improves diagnostic yields and the quality of clinical management in patients with DD/ID, ASD, and MCA.

Corticospinal Tract Integrity and Long-Term Hand Function Prognosis in Patients With Stroke

Background: The restoration of hand function is an important goal for patients with stroke. This study investigated the relationship between corticospinal tract (CST) integrity and the functional status of the hand in patients with stroke 6 months after onset and evaluated which of the following values would be useful for predicting hand function: fiber number (FN), fractional anisotropy (FA) at the mid-pons, and FA at the pontomedullary junction.

Methods: The present retrospective cross-sectional observational study assessed 44 patients with stroke who were able to walk without using a walking aid or orthosis. The final hand function results were classified into three groups: no recovery (unable to grasp), partial recovery (able to grasp, unable to oppose), and full recovery (able to grasp and oppose). All subjects underwent diffusion tensor imaging (DTI) at 6 months after stroke onset. Values for FA at the mid-pons and pontomedullary junction and CST FN were measured. The normalization ratio for FN and FA was calculated using the following formula: data for affected hand/data for non-affected hand.

Results: The normalized FN, FA (mid-pons), and FA (pontomedullary junction) DTI values differed significantly. The FA (mid-pons) value for the full recovery group was higher than those for the other groups. The FA (mid-pons) value for the partial recovery group was higher than that for the no recovery group. The normalized FA (mid-pons) value differed significantly among all three groups.

Conclusions: The present study showed that CST integrity (at 6 months after onset) in patients with chronic stroke was related to functional hand status. In addition, the mid-pons FA value was more predictive of functional restoration of the hand than the FN or FA value at the pontomedullary junction. These results may be useful in predicting the functional restoration of the hand and understanding the functional prognosis of stroke.

Sinking Skin Flap Syndrome or Syndrome of the Trephined: A Report of Two Cases

Decompressive craniectomy (DC) is commonly performed in patients with intracranial hypertension or brain edema due to traumatic brain injury. Infrequently, neurologic deteriorations accompanied by sunken scalp may occur after DC. We report two patients with traumatic subdural hemorrhage who had neurologic deteriorations accompanied by sunken scalp after DC. Neurologic function improved dramatically in both patients after cranioplasty. Monitoring for neurologic deterioration after craniectomy is advised. For patients showing neurologic deficit with a sunken scalp, early cranioplasty should be considered.

Physical Activity of Workers in a Hospital

Purpose: This study aims to evaluate the physical activity of healthcare personnel and the affecting factors of physical activity (PA) in a hospital using an accelerometer device (Actigraph wGT3X-BT). Method: A total of 63 subjects (22 physicians, 19 nurses, and 23 supporting staff) participated and wore an accelerometer for seven days. Among the outputs, the mean counts for a minute, time spent for light, moderate, and vigorous intensity PA, and step count were extracted. As a secondary study, 16 subjects continued for one more week after feedback on their PA of the previous week and counseling to encourage PA. Result: Most of (62/63) the participants fulfilled the recommended amount of PA, which is more than 300 min of moderate to vigorous physical activity (MVPA). Physicians showed significantly less PA than nurses or supporting staffs: Mean counts per minute (210.4 vs. 476.0 and 441.8 respectively), time in MVPA per week (904.7 min vs. 1471.3 min and 1451.0 min), and step counts per week (69,029 vs. 87,119 and 84,700) (p < 0.001). Nurses and supporting staff were not statistically different. There was no significant difference in the PA of workers in the hospital regarding gender and marital status. However, the average calorie expenditure of the child raising group was significantly higher. There was no statistically significant difference in PA before and after counseling. No participants reported a vigorous degree of exercise intensity over the study period. Conclusion: Most of the healthcare personnel met the recommended PA, however, only 57% (36/63) recalled having engaged in MVPA during the study period. The group of physicians showed less PA compared to nurses or supporting staff. Single check-up and counseling were not found to increase PA.

Which brain lesions produce spasticity? An observational study on 45 stroke patients

Spasticity is an important barrier that can hinder the restoration of function in stroke patients. Although several studies have attempted to elucidate the relationship between brain lesions and spasticity, the effects of specific brain lesions on the development of spasticity remain unclear. Thus, the present study investigated the effects of stroke lesions on spasticity in stroke patients. The present retrospective longitudinal observational study assessed 45 stroke patients using the modified Ashworth Scale to measure muscle spasticity. Each patient was assessed four times: initially (within 2 weeks of stroke) and at 1, 3, and 6 months after the onset of stroke. Brain lesions were analyzed using voxel-based lesion symptom mapping (VLSM) with magnetic resonance imaging images. Spasticity developed to a certain degree within 3 months in most stroke patients with spasticity. The VLSM method with non-parametric mapping revealed that lesions in the superior corona radiata, posterior limb of the internal capsule, posterior corona radiata, thalamus, putamen, premotor cortex, and insula were associated with the development of upper-limb spasticity. Additionally, lesions of the superior corona radiata, posterior limb of the internal capsule, caudate nucleus, posterior corona radiata, thalamus, putamen, and external capsule were associated with the development of lower-limb spasticity. The present study identified several brain lesions that contributed to post-stroke spasticity. Specifically, the involvement of white matter tracts and the striatum influenced the development of spasticity in the upper and lower limbs of stroke patients. These results may be useful for planning rehabilitation strategies and for understanding the pathophysiology of spasticity in stroke patients.

Cervical Spine Malformations Associated With a 5q34-5q35.2 Micro-interstitial Deletion: A Case Report

We report a female proband carrying a de novo 5q34-q35.2 deletion breakpoint, and review the unique skeletal phenotype and possible genotype related to this mutation. The patient presented with a persistent head tilt and limited head rotation. Non-contrast-enhanced three-dimensional computed tomography of the cervical spine revealed several malformations including a bone cleft in the right pars interarticularis, a bone defect in both C5 lamina and the transverse foramen at C2-C3, agenesis of the right articular process of C5, bony fusion of C4-C5, and subluxation of the craniocervical joints. Several deformities of the cervical spine seen in this patient have not been associated with the 5q deletion. A review of 5q-related mutations suggests that abnormalities associated with MSX2 gene might cause cervical spine abnormalities.

Modification of Cerebellar Afferent Pathway in the Subacute Phase of Stroke

BACKGROUND

This study aims to identify the relationship between corticopontocerebellar tract (CPCT) and corticospinal tract (CST) integrity as well as motor function after stroke.

MATERIALS AND METHODS

A total of 33 patients with stroke (18 left, 15 right hemispheric lesions) who underwent diffusion tensor imaging within 2 months of stroke onset and 17 age- and sex-matched healthy controls were retrospectively enrolled. Tract volume and the asymmetry index based on tract volume (AI_TV) of the CST and CPCT were used to identify structural changes in individual tracts and the correlation between those tracts. Motor function was assessed using the Medical Research Council (MRC) muscle scale, manual function test (MFT), functional ambulation category, and modified Barthel index.

RESULTS

The volume of the affected CPCT was lower, and that of the unaffected CPCT was higher than the volumes in the control group (P < .001, P = .001, respectively). The CPCT AI_TV showed a strong positive correlation with the CST AI_TV in patients with either left or right hemispheric lesions (r_s = .779, P < .001; r_s = .732, P = .003, respectively). The CPCT AI_TV negatively correlated with the MRC muscle scale of the shoulder, wrist, and ankle muscles (r = -.490, -.490, -.416; P = .004, .004, .016, respectively). A higher unaffected CPCT volume was indicative of less affected upper extremity function, as assessed by MFT (r_s= -.546, P = .029).

CONCLUSIONS

Modification of the CPCT depended on CST integrity and was associated with the severity of hemiplegia and hemiplegic upper extremity function. The CPCT may complement the role of the CST and help to predict the motor function.

Botulinum Toxin Type A Injection for Neuropathic Pain in a Patient With a Brain Tumor: A Case Report

Neuropathic pain is usually managed pharmacologically, rather than with botulinum toxin type A (BTX-A). However, medications commonly fail to relieve pain effectively or have intolerable side effects. We present the case of a 62-year-old man diagnosed with an intracranial chondrosarcoma, which was removed surgically and treated with radiation therapy. He suffered from neuropathic pain despite combined pharmacological therapy with gabapentin, amitriptyline, tramadol, diazepam, and duloxetine because of adverse effects. BTX-A (100 units) was injected subcutaneously in the most painful area in the posterior left thigh. Immediately after the injection, his pain decreased significantly from 6/10 to 2/10 on a visual analogue scale. Pain relief lasted for 12 weeks. This case report describes intractable neuropathic pain caused by a brain tumor that was treated with subcutaneous BTX-A, which is a useful addition for the management of neuropathic pain related to a brain tumor.

Brain lesions affecting gait recovery in stroke patients

OBJECTIVES

Gait recovery is an important goal in stroke patients. Several studies have sought to uncover relationships between specific brain lesions and the recovery of gait, but the effects of specific brain lesions on gait remain unclear. Thus, we investigated the effects of stroke lesions on gait recovery in stroke patients.

MATERIALS AND METHODS

In total, 30 subjects with stroke were assessed in a retrograde longitudinal observational study. To assess gait function, the functional ambulation category (FAC) was tested four times: initially (within 2 weeks) and 1, 3, and 6 months after the onset of the stroke. Brain lesions were analyzed via overlap, subtraction, and voxel-based lesion symptom mapping (VLSM).

RESULTS

Ambulation with FAC improved significantly with time. Subtraction analysis showed that involvement of the corona radiata, internal capsule, globus pallidus, and putamen were associated with poor recovery of gait throughout 6 months after onset. The caudate nucleus did influence poor recovery of gait at 6 months after onset. VLSM revealed that corona radiata, internal capsule, globus pallidus, putamen and cingulum were related with poor recovery of gait at 3 months after onset. Corona radiata, internal capsule, globus pallidus, putamen, primary motor cortex, and caudate nucleus were related with poor recovery of gait at 6 months after onset.

CONCLUSION

Results identified several important brain lesions for gait recovery in patients with stroke. These results may be useful for planning rehabilitation strategies for gait and understanding the prognosis of gait in stroke patients.

Long-term effect of repetitive transcranial magnetic stimulation on disability in patients with stroke

High-frequency repetitive transcranial magnetic stimulation (rTMS) is widely used to improve motor function in stroke patients. However, the long-term effects of rTMS on disability and motor function are not clear. We investigated the effects of high-frequency rTMS administered within 1 month of stroke on disability and motor function 6 months after stroke onset. The study was conducted by an open-label longitudinal study, and were included 76 (38 rTMS and 38 control) subacute stroke patients. The rTMS group received 10 Hz stimulation over the primary motor cortex of the affected hemisphere for 10 days with a daily dose of 1000 pulses. The Korean version of the Modified Barthel Index (K-MBI), the Medical Research Council (MRC) scale for motor deficits in the affected arm, the Manual Function Test (MFT), and the Functional Ambulation Classification (FAC) were administered at baseline (within 1 month of stroke onset) and at 3 and 6 months after onset. The K-MBI, MRC scale, MFT, and FAC scores of both groups changed significantly over time (p < 0.001); however, the motor strength, hand function, FAC classification, and K-MBI scores of the rTMS and control groups did not differ. Our findings indicate that rTMS did not have a long-lasting effect (6 months after onset) on disability and motor function in patients with stroke.

Efficacy and Safety of Letibotulinum Toxin A for the Treatment of Dynamic Equinus Foot Deformity in Children with Cerebral Palsy: A Randomized Controlled Trial

The objective of this clinical trial was to compare the efficacy and safety of letibotulinum toxin A and onabotulinum toxin A for improving dynamic equinus foot deformity in children with cerebral palsy (CP). In total, 144 children with spastic CP who had dynamic equinus foot deformity were assigned randomly to the Botulax group (injection of letibotulinum toxin A) or the Botox group (injection of onabotulinum toxin A). The Physician’s Rating Scale (PRS), ankle plantar flexor spasticity using the Modified Tardieu Scale, the Gross Motor Function Measure (GMFM)-88, and the GMFM-66 were completed before injection and at 6, 12, and 24 weeks after injection. The PRS responder rate was 60.27% in the Botulax group and 61.43% in the Botox group at 12 weeks after treatment, and the lower limit of the 95% confidence interval for the between-group difference in responder rates was −17.16%, higher than the non-inferiority margin of −24.00%. The clinical efficacy and the safety profiles of the groups did not significantly differ. The results suggest that injection of letibotulinum toxin A is as effective and safe as that of onabotulinum toxin A for the treatment of dynamic equinus foot deformity in children with spastic CP.

Phototherapy for Vitiligo: A Systematic Review and Meta-analysis

Importance

References to the expected treatment response to phototherapy would be helpful in the management of vitiligo because phototherapy requires long treatment durations over several months.

Objective

To estimate the treatment response of vitiligo to phototherapy.

Data Sources

A comprehensive database search of MEDLINE, EMBASE, and the Cochrane library from inception to January 26, 2016, was performed for all prospective studies. The main keywords used were vitiligo, phototherapy, psoralen, PUVA, ultraviolet, NBUVB, and narrowband.

Study Selection

All prospective studies reporting phototherapy outcome for at least 10 participants with generalized vitiligo were included. Of 319 studies initially identified, the full texts of 141 studies were assessed for eligibility, and 35 were finally included in the analysis. Of these, 29 studies included 1201 patients undergoing narrowband UV-B (NBUVB) phototherapy, and 9 included 227 patients undergoing psoralen-UV-A (PUVA) phototherapy.

Data Extraction and Synthesis

Two reviewers independently extracted the following data: study design, number and characteristics of the participants, phototherapy protocol, and rate of repigmentation based on the quartile scale. Single-arm meta-analyses were performed for the NBUVB and PUVA groups. Sample size-weighted means were calculated using a random-effects model for the repigmentation rates of the included studies.

Main Outcomes and Measures

The primary outcomes were at least mild (≥25%), at least moderate (≥50%), and marked (≥75%) responses on a quartile scale. Response rates were calculated as the number of participants who showed the corresponding repigmentation divided by the number of all participants enrolled in the individual studies.

Results

The meta-analysis included 35 unique studies (1428 unique patients). For NBUVB phototherapy, an at least mild response occurred in 62.1% (95% CI, 46.9%-77.3%) of 130 patients in 3 studies at 3 months, 74.2% (95% CI, 68.5%-79.8%) of 232 patients in 11 studies at 6 months, and 75.0% (95% CI, 60.9%-89.2%) of 512 patients in 8 studies at 12 months. A marked response was achieved in 13.0% (95% CI, 2.1%-23.9%) of 106 patients in 2 studies at 3 months, 19.2% (95% CI, 11.4%-27.0%) of 266 patients in 13 studies at 6 months, and 35.7% (95% CI, 21.5%-49.9%) of 540 patients in 9 studies at 12 months. For PUVA phototherapy, an at least mild response occurred in 51.4% (95% CI, 28.1%-74.7%) of 103 patients in 4 studies at 6 months and 61.6% (95% CI, 20.2%-100%) of 72 patients in 3 studies at 12 months. In the subgroup analyses, marked responses were achieved on the face and neck in 44.2% (95% CI, 24.2%-64.2%), on the trunk in 26.1% (95% CI, 8.7%-43.5%), on the extremities in 17.3% (95% CI, 8.2%-26.5%), and on the hands and feet in none after at least 6 months of NBUVB phototherapy.

Conclusions and Relevance

Long-duration phototherapy should be encouraged to enhance the treatment response in vitiligo. The greatest response is anticipated on the face and neck.

Factors Influencing the Gross Motor Outcome of Intensive Therapy in Children with Cerebral Palsy and Developmental Delay

The study was designed to identify factors influencing the short term effect of intensive therapy on gross motor function in children with cerebral palsy or developmental delay. Retrospectively, total Gross Motor Function Measure-88 (GMFM-88) scores measured during the first and last weeks of intensive therapy were analyzed (n = 103). Good and poor responder groups were defined as those in the top and bottom 25% in terms of score difference, respectively. The GMFM-88 score increased to 4.67 ± 3.93 after 8 weeks of intensive therapy (P < 0.001). Gross Motor Function Classification System (GMFCS) level (I-II vs. IV-V; odds ratio [OR] = 7.763, 95% confidence interval [CI] = 2.177-27.682, P = 0.002) was a significant factor in a good response to therapy. Age (≥ 36 months; OR = 2.737, 95% CI = 1.003-7.471, P = 0.049) and GMFCS level (I-II vs. IV-V; OR = 0.189, 95% CI = 0.057-0.630, P = 0.007; and III vs. IV-V; OR = 0.095, 95% CI = 0.011-0.785, P = 0.029) were significantly associated with a poor response. GMFCS level is the most important prognostic factor for the effect of intensive therapy on gross motor function. In addition, age ≥ 36 months, is associated with a poor outcome.