The epidemiology and causes of cerebral palsy

Prevalence and Types of Strabismus in Cerebral Palsy: A Global and Historical Perspective Based on a Systematic Review and Meta-Analysis

PURPOSE

Strabismus is more frequent in cerebral palsy (CP) than in the normal population, but reports differ how much it is increased. We here examined the global prevalence and types of strabismus in CP, whether esotropia or exotropia is more frequent, and whether the prevalence differs between ethnicities and/or country income levels, and between generations.

METHODS

We compiled in a systematic review and meta-analysis the results of 147 CP studies that report the prevalence of strabismus or the ratio of esotropia to exotropia, and we conducted subgroup analyses for region (income level) and ethnicity. We performed a pooled analysis for the CP strabismus prevalence, and estimated the global number of CP cases with strabismus.

RESULTS

The pooled prevalence of strabismus in CP is 49.8% in high-income countries and 39.8% in lower-income countries. We estimate the global number of strabismus cases in CP as 12.2 million, with 7.6 million males and 4.6 million females, based on current estimates of 29.6 million global CP cases. Esotropia is more frequent than exotropia in Caucasians, while exotropia is more frequent than esotropia in Hispanic and in some Asian and African populations. The strabismus prevalence in CP increases with increasing country income levels.

CONCLUSION

Generational changes in strabismus prevalence appear to reflect a transition of CP types and an increase in prevalence as countries attain higher income and more effective maternal health care. The distribution of esotropia and exotropia in CP patients largely reflects the horizontal strabismus type that is predominant in the subject's ethnicity.

Communication challenges and use of communication apps among individuals with cerebral palsy

PURPOSE

Verbal communication is the most immediate way of expressing oneself and the fastest way to make a first impression on others. However, for individuals with cerebral palsy (CP), which is generally accompanied by speech impediments, verbal communication can present a major hurdle to social interactions.

MATERIALS AND METHODS

In this study, 10 individuals with CP (four men and six women) and speech impediments were surveyed using questionnaires and semistructured interviews to explore the following four points: (1) communication difficulties in life, (2) communication methods and related problems, (3) application of existing AAC methods, and (4) predicaments using existing communication technologies.

RESULTS

The study found that individuals with CP and speech impediments speak slowly and generally choose to avoid conversations or engage passively, relying on written words, simplified phrases, and physical gestures to compensate for their language impediments. Family education and educational attainment influence their communication strategies.

CONCLUSION

Following advancements in technology, individuals with CP have become more reliant on text communications via phone apps such as Line and Facebook Messenger, and use text and stickers to express themselves. Despite the many problems with the usability of assistive devices and tech products for individuals with CP, reducing the number of operational steps and time constraints can improve the convenience of these products for individuals with CP.

Needs for rehabilitation in China: Estimates based on the Global Burden of Disease Study 1990-2019

BACKGROUND

As an essential part of health services, rehabilitation is of great significance to improve the health and quality of life of the whole population. Accelerating aging calls for a significant expansion of rehabilitation services in China, but rehabilitation needs remain unclear. We conducted the study to explore the rehabilitation needs in China and project the trend of rehabilitation needs from 2020 to 2034.

METHODS

The data of health conditions that might potentially benefit from rehabilitation were obtained from Global Burden of Disease (GBD) study. Estimated annual percentage changes (EAPCs) were calculated to quantify the trends of the age-standardized rates. Projections of rehabilitation needs were made until 2034 using Bayesian age-period-cohort analysis (BAPC).

RESULTS

Approximately 460 million persons (33.3% of the total population) need rehabilitation in China, contributing to 63 million years lived with disabilities (YLDs) in 2019. The number of prevalent cases that need rehabilitation increased from around 268 (95% uncertainty interval [UI]: 257-282) million in 1990 to almost 460 (95% UI: 443-479) million in 2019, representing an increase of 71.3%. The highest contribution to the need for rehabilitation was musculoskeletal disorders with about 322 (95% UI: 302-343) million persons in seven aggregate disease and injury categories, and hearing loss with over 95 (95% UI: 84-107) million people among 25 health conditions. Based on the projection results, there will be almost 636 million people (45% of the total population) needing rehabilitation services in China by 2034, representing an increase of 38.3%. The rehabilitation needs of neoplasms, cardiovascular diseases, and neurological disorders are expected to increase significantly from 2019 to 2034, with increases of 102.3%, 88.8% and 73.2%, respectively.

CONCLUSIONS

The need for rehabilitation in China substantially increased over the last 30 years. It is predicted that over two in five people will require rehabilitation by 2034, thus suggesting the need to develop rehabilitation services that meet individuals' rehabilitation needs.

Unplanned hospital readmission after cholecystectomy in adults with cerebral palsy

BACKGROUND

Adults with cerebral palsy (CP) are a largely understudied, growing population with unique health care requirements. We sought to establish a deeper understanding of the surgical risk in adults with CP undergoing a common general surgical procedure: cholecystectomy.

METHODS

Data were obtained from the State Inpatient Database developed for the Healthcare Cost and Utilization Project. Inclusion criteria included patients ≥ 18 years with CP and a primary ICD-9 procedure code indicating open or laparoscopic cholecystectomy. Demographics, procedure-related factors, and comorbid conditions were analyzed, and unplanned 30 and 90 day readmission rates calculated for each variable. Reasons for readmission based on ICD-9 diagnosis codes were grouped into relevant categories. Univariate analysis identified factors significantly associated with readmission rates.

RESULTS

A total of 802 patients with CP met the inclusion criteria. Unplanned 30 and 90 day readmission rates after laparoscopic cholecystectomy were 11.4% and 18.1%, respectively. Average length of stay (LOS) after laparoscopic cholecystectomy was 7.1 days. After open cholecystectomy, 30 and 90 day readmission rates were 16.9% and 30.3% with an average LOS of 14.6 days. Infection was the most common cause for 30 and 90 day readmission. Factors associated with 30 day readmission included type of cholecystectomy, LOS, discharge to skilled nursing facility, and comorbid diabetes and malnutrition. Factors associated with 90 day readmission included type of cholecystectomy, LOS, discharge to skilled nursing facility, and comorbid heart failure, renal disease, epilepsy, and malnutrition.

CONCLUSION

Unplanned readmission rates after open and laparoscopic cholecystectomy in adult patients with CP are much higher than previously demonstrated rates in the general population. These patients frequently suffer multiple comorbid conditions that significantly complicate their surgical care. As more and more of these patients live longer into adulthood, further study is warranted to grasp the perioperative risk of simple and complex surgical procedures.

Postoperative outcomes and stimulation responses for sectioned nerve roots during selective dorsal rhizotomy in cerebral palsy

BACKGROUND

Cerebral palsy (CP) is the most cause of motor dysfunction in children. Selective dorsal rhizotomy (SDR) plays a major role in long term spasticity control. However, limited data exists on the effect of SDR on postoperative spasticity treatment requirements and supraspinal effects, and the stimulation responses of dorsal nerve roots in those with CP.

METHODS

The current study included the outcome for 35 individuals undergoing SDR for motor functional outcome, spasticity, baclofen dose changes, botulinum toxin injection frequency, and spasticity related orthopedic procedures. We also report on the stimulation responses in 112 individuals who underwent SDR at our institution.

RESULTS

There was a significant difference in gross motor function measures (GMFM)-66 scores at last follow up that remained present when considering only ambulatory children but not with non-ambulatory children. Ashworth scores were significantly decreased for both upper and lower extremities after SDR at all follow up points. There was a significant decrease in Baclofen dose and botulinum toxin injections requirements after SDR, but no significant difference in the need for orthopedic intervention. A total of 5502 dorsal nerve roots were tested showing a decrease in stimulation intensity and increase in grade on the right side and for descending lumbosacral levels.

CONCLUSIONS

SDR improves gross motor scores during short term follow up but has additional benefits in decreasing baclofen dosing and botulinum toxin injections requirements after surgery. They stimulation responses of sectioned dorsal nerve roots adds to the limited available data and our understanding of the pathological changes that occur in CP.

Magnitude and clinical characteristics of cerebral palsy among children in Africa: A systematic review and meta-analysis

Cerebral palsy (CP) is the most common motor disability in childhood which causes a child's behavioral, feeding, and sleep difficulties. It remains a poorly studied health problem in Africa. The main aim of this study was assessing the pooled prevalence of Cerebral Palsy (CP) and its clinical characteristics in Africa context. Systematic review and meta-analysis were conducted using Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines to search articles from electronic databases (Cochrane library, Ovid platform) (Medline, Embase, and Emcare), Google Scholar, CINAHL, PubMed, Maternity and Infant Care Database (MIDIRS). The last search date was on 12/05/ 2023 G. C. A weighted inverse variance random-effects model was used to estimate the pooled estimates of cerebral palsy and its types. The subgroup analysis, publication bias and sensitivity analysis were done. Studies on prevalence and clinical characteristics of cerebral palsy were included. The primary and secondary outcomes were prevalence and clinical characteristics of cerebral palsy respectively. A total of 15 articles with (n = 498406 patients) were included for the final analysis. The pooled prevalence of cerebral palsy in Africa was found to be 3·34 (2·70, 3·98). The most common type is spastic cerebral palsy accounting 69·30% (66·76, 71·83) of all cases. The second one is quadriplegic cerebral palsy which was found to be 41·49% (33·16, 49·81). Ataxic cerebral palsy accounted 5·36% (3·22, 7·50). On the other hand, dyskinetic cerebral palsy was found to be 10.88% (6·26, 15·49). About 32·10% (19·25, 44.95) of cases were bilateral while 25·17% (16·84, 33·50) were unilateral. The incidence of cerebral palsy in Africa surpasses the reported rates in developed nations. Spastic and quadriplegic subtypes emerge as the most frequently observed. It is recommended to channel initiatives toward the strategic focus on preventive measures, early detection strategies, and comprehensive management protocols.

Impact of sex, race, and social determinants of health on neonatal outcomes

Despite the global improvements in neonatal outcomes, mortality and morbidity rates among preterm infants are still unacceptably high. Therefore, it is crucial to thoroughly analyze the factors that affect these outcomes, including sex, race, and social determinants of health. By comprehending the influence of these factors, we can work towards reducing their impact and enhancing the quality of neonatal care. This review will summarize the available evidence on sex differences, racial differences, and social determinants of health related to neonates. This review will discuss sex differences in neonatal outcomes in part I and racial differences with social determinants of health in part II. Research has shown that sex differences begin to manifest in the early part of the pregnancy. Hence, we will explore this topic under two main categories: (1) Antenatal and (2) Postnatal sex differences. We will also discuss long-term outcome differences wherever the evidence is available. Multiple factors determine health outcomes during pregnancy and the newborn period. Apart from the genetic, biological, and sex-based differences that influence fetal and neonatal outcomes, racial and social factors influence the health and well-being of developing humans. Race categorizes humans based on shared physical or social qualities into groups generally considered distinct within a given society. Social determinants of health (SDOH) are the non-medical factors that influence health outcomes. These factors can include a person's living conditions, access to healthy food, education, employment status, income level, and social support. Understanding these factors is essential in developing strategies to improve overall health outcomes in communities.

Motor imagery ability in children and adolescents with cerebral palsy: a systematic review and evidence map

Background

Cerebral palsy (CP) refers to a group of permanent movement and posture disorders. Motor imagery (MI) therapy is known to provide potential benefits, but data on MI ability in children and adolescents with CP is lacking.

Objective

A systematic review was performed to explore MI abilities in children and adolescents with CP compared to typically developed (TD) subjects.

Methods

We searched on PubMed, Web of Science (WOS), EBSCO, Google Scholar, and PEDro including observational studies. Methodological quality was assessed with the modified Newcastle-Ottawa Scale and evidence map was created to synthesize the evidence qualitatively and quantitatively.

Results

Seven cross-sectional studies were selected, which included 174 patients with CP and 321 TD subjects. Three studies explored explicit MI, two MI-execution synchrony, and four implicit MI domains. Methodological quality ranged from 6 to 8 stars. Moderate evidence supported the absence of differences in vividness between the groups. As there was only limited evidence, establishing a clear direction for the results was not possible, especially for the capacity to generate MI, mental chronometry features, and MI-execution synchrony domains. Moderate evidence supported a lower efficiency in cases for hand recognition, derived from a lower accuracy rate, while reaction time remained similar between the two groups. Moderate evidence indicated that patients with CP and TD controls showed similar features on whole-body recognition.

Conclusion

Moderate evidence suggests that patients with CP present a reduced ability in hand recognition, which is not observed for whole-body recognition compared to healthy controls. Severe limitations concerning sample size calculations and validity of assessment tools clearly limits establishing a direction of results, especially for explicit MI and MI-Execution synchrony domains. Further research is needed to address these limitations to enhance our comprehension of MI abilities in children, which is crucial for prescribing suitable MI-based therapies in this child population.

Prevalence and types of strabismus in cerebral palsy: A global and historical perspective based on a systematic review and meta-analysis

Purpose

Strabismus is more frequent in cerebral palsy (CP) than in the normal population, but reports differ how much it is increased. We here examined the global prevalence and types of strabismus in CP, whether esotropia or exotropia is more frequent, and whether the prevalence differs between ethnicities and/or country income levels, and between generations.

Methods

We compiled in a systematic review and meta-analysis the results of 147 CP studies that report the prevalence of strabismus or the ratio of esotropia to exotropia, and we conducted subgroup analyses for region (income level) and ethnicity. We performed a pooled analysis for the CP strabismus prevalence, and estimated the global number of CP cases with strabismus.

Results

The pooled prevalence of strabismus in CP is 49.8% in high-income countries and 39.8% in lower-income countries. We estimate the global number of strabismus cases in CP as 12.2 million, with 7.6 million males and 4.6 million females, based on current estimates of 29.6 million global CP cases. Esotropia is more frequent than exotropia in Caucasians, while exotropia is more frequent than esotropia in Hispanic and in some Asian and African populations. The strabismus prevalence in CP increases with increasing country income levels.

Conclusion

Generational changes in strabismus prevalence appear to reflect a transition of CP types and an increase in prevalence as countries attain higher income and more effective maternal health care. The distribution of esotropia and exotropia in CP patients largely reflects the horizontal strabismus type that is predominant in the subject's ethnicity.

Altered excitation-inhibition balance in the primary sensorimotor cortex to proprioceptive hand stimulation in cerebral palsy

OBJECTIVE

Our objective was to clarify the primary sensorimotor (SM1) cortex excitatory and inhibitory alterations in hemiplegic (HP) and diplegic (DP) cerebral palsy (CP) by quantifying SM1 cortex beta power suppression and rebound with magnetoencephalography (MEG).

METHODS

MEG was recorded from 16 HP and 12 DP adolescents, and their 32 healthy controls during proprioceptive stimulation of the index fingers evoked by a movement actuator. The related beta power changes were computed with Temporal Spectral Evolution (TSE). Peak strengths of beta suppression and rebound were determined from representative channels over the SM1 cortex.

RESULTS

Beta suppression was stronger contralateral to the stimulus and rebound was weaker ipsilateral to the stimulation in DP compared to controls. Beta modulation strengths did not differ significantly between HP and the control group.

CONCLUSIONS

The emphasized beta suppression in DP suggests less efficient proprioceptive processing in the SM1 contralateral to the stimulation. Their weak rebound further indicates reduced intra- and/or interhemispheric cortical inhibition, which is a potential neuronal mechanism for their bilateral motor impairments.

SIGNIFICANCE

The excitation-inhibition balance of the SM1 cortex related to proprioception is impaired in diplegic CP. Therefore, the cortical and behavioral proprioceptive deficits should be better diagnosed and considered to better target individualized effective rehabilitation in CP.

Pre-pregnancy and pregnancy disorders, pre-term birth and the risk of cerebral palsy: a population-based study

BACKGROUND

Cerebral palsy (CP) is the most common cause of childhood physical disability whose aetiology remains unclear in most cases. Maternal pre-existing and pregnancy complications are recognized risk factors of CP but the extent to which their effects are mediated by pre-term birth is unknown.

METHODS

Population-based cohort study in Sweden including 2 055 378 singleton infants without congenital abnormalities, born between 1999 and 2019. Data on maternal and pregnancy characteristics and diagnoses of CP were obtained by individual record linkages of nationwide Swedish registries. Exposure was defined as maternal pre-pregnancy and pregnancy disorders. Inpatient and outpatient diagnoses were obtained for CP after 27 days of age. Adjusted rate ratios (aRRs) were calculated, along with 95% CIs.

RESULTS

A total of 515 771 (25%) offspring were exposed to maternal pre-existing chronic disorders and 3472 children with CP were identified for a cumulative incidence of 1.7 per 1000 live births. After adjusting for potential confounders, maternal chronic cardiovascular or metabolic disorders, other chronic diseases, mental health disorders and early-pregnancy obesity were associated with 1.89-, 1.24-, 1.26- and 1.35-times higher risk (aRRs) of CP, respectively. Most notably, offspring exposed to maternal antepartum haemorrhage had a 6-fold elevated risk of CP (aRR 5.78, 95% CI, 5.00-6.68). Mediation analysis revealed that ∼50% of the effect of these associations was mediated by pre-term delivery; however, increased risks were also observed among term infants.

CONCLUSIONS

Exposure to pre-existing maternal chronic disorders and pregnancy-related complications increases the risk of CP in offspring. Although most infants with CP were born at term, pre-term delivery explained 50% of the overall effect of pre-pregnancy and pregnancy disorders on CP.

Acceptability of a head-mounted assistive mouse controller for people with upper limb disability: An empirical study using the technology acceptance model

Due to limited motor capabilities, people with upper limb disabilities have trouble utilizing a typical mouse while operating a computer. Different wearable Assistive Mouse Controllers (AMCs) have been developed to overcome their challenges. However, these people may not be able to realize the importance, ease of use, and social approval of these AMCs due to their fear of new technology, lack of confidence, and lack of ingenuity. These may negatively affect their attitude and intention toward accepting AMCs for equitable human-computer interaction. This study presents the development of a sensor-based head-mounted AMC, followed by an empirical analysis of its acceptance using the Technology Acceptance Model (TAM) from the socioeconomic perspective of Bangladesh. In a similar vein, we examined the effects of three additional psychological constructs-technology anxiety, confidence, and innovation, on its acceptance along with the original components of the TAM. A total of 150 individuals with stroke-induced upper limb disability participated in an online survey, and their responses were analyzed using confirmatory factor analysis and structural equation modeling, following the general least square method. Analysis revealed, about 96.44% of the participants had positive attitude towards the AMC, and almost 88.56% of them had positive intentions to accept it. Furthermore, about 68.61% of them expressed signs of anxiety, 96.35% were confident, and 94.16% of them had an innovative mindset in terms of device usage. The findings imply that individuals with an innovative mentality are more capable of comprehending the practical implications of a new technology than those without one. It is also feasible to reduce technological anxiety and boost a user's confidence while using an AMC by combining an innovative mentality with straightforward device interaction techniques. Additionally, peer encouragement and motivation can significantly enhance their positive attitude towards accepting the AMC for facilitating their interaction with a computer.

Adults with Cerebral Palsy: Navigating the Complexities of Aging

The goal of this narrative review is to highlight the healthcare challenges faced by adults with cerebral palsy, including the management of long-term motor deficits, difficulty finding clinicians with expertise in these long-term impairments, and scarcity of rehabilitation options. Additionally, this narrative review seeks to examine potential methods for maintaining functional independence, promoting social integration, and community participation. Although the brain lesion that causes the movement disorder is non-progressive, the neurodevelopmental disorder worsens from secondary complications of existing sensory, motor, and cognitive impairments. Therefore, maintaining the continuum of care across one's lifespan is of utmost importance. Advancements in healthcare services over the past decade have resulted in lower mortality rates and increased the average life expectancy of people with cerebral palsy. However, once they transition from adolescence to adulthood, limited federal and community resources, and health care professionals' lack of expertise present significant obstacles to achieving quality healthcare and long-term benefits. This paper highlights the common impairments seen in adults with cerebral palsy. Additionally, it underscores the critical role of long-term healthcare and management to prevent functional decline and enhance quality of life across physical, cognitive, and social domains.

Gabapentin as Add-on Therapy to Trihexyphenidyl in Children with Dyskinetic Cerebral Palsy: A Randomized, Controlled Trial

OBJECTIVE

To compare the efficacy of gabapentin as add-on therapy to trihexyphenidyl in the treatment of children with dyskinetic cerebral palsy (CP).

METHODS

An open-labelled, randomized, controlled trial was conducted among children aged 3-9 y with dyskinetic CP [Gross Motor Functional Classification System (GMFCS) 4-5]. Participants were assigned into two groups: gabapentin with trihexyphenidyl (n = 30) and trihexyphenidyl alone (n = 30). Dyskinesia Impairment Scale (DIS), Dystonia Severity Assessment Plan (DSAP), and International Classification of Functioning, Disability, and Health-Children and Youth Version (ICF-CY) were measured at baseline, 4 and 12 wk.

RESULTS

There was significant reduction in baseline dystonia in both the groups (DIS: p < 0.001; DSAP: p = 0.007; ICF-CY: p < 0.001) but when data were compared between the groups, there was no significant difference in the severity of dystonia at 4 wk and at 12 wk (DIS: p = 0.09; DSAP: p = 0.49; ICF-CY: p = 0.25). Constipation was the commonest side effect observed in both the groups [3 (11.5%) vs. 4 (14.3%)].

CONCLUSION

Trihexyphenidyl alone is as effective as combination of gabapentin with trihexyphenidyl in decreasing the severity of dystonia at 12 wk. Hence, there is no added benefit of gabapentin as add-on therapy for dystonia among children with dyskinetic CP.

TRIAL REGISTRATION

CTRI/2019/04/018603.

Evaluation of daily and social participation of children with Cerebral Palsy across different age groups with a focus on the 'F'-words: Function, family, fitness, fun, friends and future

BACKGROUND

The impact of disability differs across cultures. This study aimed to determine the predictors of participation in children with cerebral palsy (CP) in Turkey, based on the six F-words.

METHODS

Cross-sectional study exploring participation profiles of 450 children with CP, aged between 2 and 18 years. Pediatric Evaluation of Disability Inventory (PEDI) evaluated functional skills, and Assessment of Life Habits (LIFE-H) version 3.0 assessed daily and social participation. Hierarchical linear regression models were done to determine the predictors of participation in daily activities (PDA) and social roles (PSR) in three age groups (2-4, 5-13 and 14-18 years) based on the 6 F-words (mobility of PEDI for 'fitness'; four classification systems and self-care of PEDI for 'functioning'; social functions of PEDI for 'friends'; demographic information by parents for 'family'; the recreation of LIFE-H for 'fun'; and different stages of development for 'future').

RESULTS

The most important predictors for total PDA by age group were: self-care (p = 0.012) of PEDI in 2-4 y; self-care (p = 0.001) and mobility (p = 0.005) of PEDI in 5-13 y; GMFCS (p = 0.006) and mobility (p = 0.002) of PEDI in 14-18 y. Significant predictors for PSR differed by age group: self-care (p = 0.001) of PEDI in 2-4 y; self-care (p = 0.023) and mobility (p = 0.006) of PEDI in 5-13 y; and GMFCS (p = 0.004) and MACS (p = 0.003) in 14-18 y.

CONCLUSIONS

Six F-words of function and fitness focussed on self-care in younger children with an increasing emphasis on mobility and ability levels according to age. Therefore, rehabilitation for different aspects of the functional levels is needed to improve participation in life across the six F-words framework; plus take into consideration context, age-differences, family's expectations, life requirements, environmental needs, and cultural differences.

Motor deficits are associated with increased glial cell activation in the hypothalamus and cerebellum of young rats subjected to cerebral palsy

Cerebral palsy (CP) is a syndrome characterized by a wide range of sensory and motor damage, associated with behavioral and cognitive deficits. The aim of the present study was to investigate the potential of a model of CP using a combination of perinatal anoxia and sensorimotor restriction of hind paws to replicate motor, behavioral and neural deficits. A total of 30 of male Wistar rats were divided into Control (C, n = 15), and CP (CP, n = 15) groups. The potential of the CP model was assessed by evaluating food intake, the behavioral satiety sequence, performance on the CatWalk and parallel bars, muscle strength, and locomotor activity. The weight of the encephalon, soleus, and extensor digitorum longus (EDL) muscles, and the activation of glial cells (microglia and astrocytes) were also measured. The CP animals showed delayed satiety, impaired locomotion on the CatWalk and open field test, reduced muscle strength, and reduced motor coordination. CP also reduced the weight of the soleus and muscles, brain weight, liver weight, and quantity of fat in various parts of the body. There was also found to be an increase in astrocyte and microglia activation in the cerebellum and hypothalamus (arcuate nucleus, ARC) of animals subjected to CP.

Physical Therapy Interventions in Children With Cerebral Palsy: A Systematic Review

Cerebral palsy is a group of disorders affecting individuals already from birth. It enormously impacts an individual's physical and emotional life and can bring many challenges to the individual, caregivers, and families. Therefore, it is crucial to investigate interventions that could improve various symptoms in children with cerebral palsy. Our systematic review intends to assess the effect of different exercise and physical therapy interventions in children with cerebral palsy. We used three databases for our article search: PubMed, Medical Literature Analysis and Retrieval System Online (MEDLINE), and PubMed Central (PMC). The combined number of papers found in all databases was 65,412. We then applied our inclusion and exclusion criteria, filters, key terms, and Medical Subheadings (MeSH). After applying our quality assessment tools, we included nine papers in our systematic review. The studies included in our review used various interventions to assess for improvement in symptoms in individuals with cerebral palsy. Interventions included stretching and resistance exercises, horse riding, biking, core stability exercises, slackline training, a home exercise program using an online tool, sit-to-stand exercise program, and functional training. Many studies have shown that interventions improved symptoms like balance, coordination, gait, and cardiovascular endurance in cerebral palsy. This review suggests that some of the included interventions have great potential to improve the symptoms of cerebral palsy and, therefore, can be a great addition to existing training and rehabilitation programs. Given that studies included a relatively small number of participants and were conducted over a short time, more research with a more significant number of participants over a longer time is necessary.

Incidence of Cerebral Palsy, Risk Factors, and Neuroimaging in Northeast Mexico

BACKGROUND

Cerebral palsy (CP) comprises a group of lifelong motor and postural development disorders that can cause static motor encephalopathy. The etiology of CP is attributed to nonprogressive lesions of the central nervous system during fetal or infant brain development. A diagnosis of CP is based on a combination of clinical and neurological signs, typically identified between 12 and 24 months. A medical history, several available standardized tools, including the Neoneuro assessment, and the Hammersmith infant neurological examination (HINE) can be used to predict risk. Magnetic resonance imaging (MRI) can contribute to the diagnosis of CP. The incidence of CP is 2 to 3 per 1000 live births, and in Western industrialized nations, it is 2.0-2.5 per 1000 live births; to our knowledge, no epidemiological studies have reported the incidence of CP in Mexico.

AIM

To assess the incidence of CP in children aged up to 18 months in northeast Mexico and analyze the risk factors and neuroimaging findings.

METHODS

This was a multicenter, randomized, prospective, cohort, analytical study of newborn children in three community hospitals and an early intervention and CP center in Nuevo Leon, Mexico, from 2017 to 2021. This study included 3861 newborns randomly selected from a population of 75,951 mothers in the immediate puerperium. According to the Neoneuro tool, high-risk children (n = 432) had abnormal neurological results at birth; they were followed and assessed with the Spanish version of the HINE test by a pediatric neurologist and underwent neuroimaging studies. Neonates with normal results were randomly selected to be in the low-risk group (n= 864). These neonates were followed and assessed with the HINE by a neonatologist.

RESULTS

The incidence of CP was 4.4 of 1000 up to 18 months old, which was higher than that reported in developed countries. Perinatal risk factors were predominantly recognized in the etiology of CP, such as brain hemorrhage, and prematurity, in addition to congenital anomalies. The most frequent neuroimaging findings were ventricular dilation/cortical atrophy and intraventricular/subependymal hemorrhage and periventricular leukomalacia on MRI.

CONCLUSIONS

This study is the first on the incidence/prevalence of CP in Mexico, and there are no formal studies in this field in other Latin American countries either. The incidence of CP in northeast Mexico is higher than that reported in developed countries. The follow-up of high-risk young children must be reinforced in the Mexican population, as children with disabilities have high and sequential health-care needs and may usually be lost to follow-up. Neuroimaging of PVL was the more frequent finding by MRI in this population.

Oral health status and barriers to oral healthcare among children with cerebral palsy attending a health care center in Kampala, Uganda

BACKGROUND

Cerebral palsy (CP) is a non-progressive neuromuscular condition diagnosed in childhood. CP as a form of disability, does not cause any specific oral disease. However, some oral conditions are more commonly associated with people with CP compared to the general population. The overarching aim of the current study was to determine the oral hygiene status, gingival status, and the prevalence of dental caries in children with CP attending a leading hospital institution for children with disabilities in Kampala, Uganda. Additionally, we determined the barriers faced by children with CP in accessing oral healthcare.

METHODS

This cross-sectional study was carried out at the Comprehensive Rehabilitation Services Uganda hospital in Kampala, Uganda. Our study population consisted of a convenient sample of 90 children diagnosed with CP aged 3-17 years and their caregivers. A validated and interviewer administered structured questionnaire was used to collect socio-demographic data of the participants. A modified World Health Organization oral health assessment form for those aged 3-17 years was used to gather data on oral health status (plaque score, gingival bleeding and dental caries.) The data was subjected to statistical tests with critical value set up at 5%.

RESULTS

Only 32.2% of the children evaluated had adequate oral hygiene, while 44.4% of the children experienced gingival bleeding. The prevalence of dental caries for both deciduous and permanent dentition was 63.3%, with DMFT values of 3.8 ± 4.5. The most common barrier reported by the caregivers was the challenge in modality of transportation availability from the children's homes to the health facilities (34.4%).

CONCLUSIONS

Children with CP in the study population have a significant prevalence of oral diseases and face several barriers to oral healthcare. Results from this study aim to provide relevant support to advocate for a nationwide change in policy to improve access to dental care to decrease the burden of oral diseases in children with special healthcare needs.

Lower limb muscle fatigue after uphill walking in children with unilateral spastic cerebral palsy

Fatigue during walking is a common complaint in cerebral palsy (CP). The primary purpose of this study is to investigate muscle fatigue from surface electromyography (sEMG) measurements after a treadmill-based fatigue protocol with increasing incline and speed in children with CP with drop foot. The secondary purpose is to investigate whether changes in sagittal kinematics of hip, knee and ankle occur after fatigue. Eighteen subjects with unilateral spastic CP performed the protocol while wearing their ankle-foot orthosis and scored their fatigue on the OMNI scale of perceived exertion. The median frequency (MF) and root mean square (RMS) were used as sEMG measures for fatigue and linear mixed effects model were applied. The MF was significantly decreased in fatigued condition, especially in the affected leg and in the tibialis anterior and peroneus longus muscle. The RMS did not change significantly in fatigued condition, while the OMNI fatigue score indicated patients felt really fatigued. No changes in sagittal kinematics of hip, knee and ankle were found using statistical non-parametric mapping. In conclusion, the current fatigue protocol seems promising in inducing fatigue in a population with CP with drop foot and it could be used to expand knowledge on muscle fatigue during walking in CP.

Analysis of Joint Power and Work During Gait in Children With and Without Cerebral Palsy

Purpose

To compare joint work in the lower limb joints during different sub-phases of the gait cycle between Cerebral Palsy (CP) and healthy children.

Methods

Eighteen CP and 20 healthy children's gait data were collected. The CP group included orthoses, intra-muscular injection of botulinum toxin and surgery groups. A motion capture system was used to collect gait data. Joint work was calculated as positive and negative components in six subphases during gait and normalised by speed when comparing the groups.

Results

The CP group had a slower walking speed, smaller stride length and longer stance phase than the healthy group. Hip max positive work was 0.12 ± 0.02 Jkg-1/ms-1 for the CP group in pre-mid-stance but 0.07 ± 0.01 Jkg-1/ms-1 for the healthy group during the terminal phase. In terminal stance, ankle positive work was significantly lower in the CP group (0.12 ± 0.01) than in the healthy group (0.18 ± 0.01). The knee showed a similar distribution of positive work in the stance phase for the two groups. In the ankle and hip, the CP group had energy generation mainly in midstance while the healthy group was mainly in terminal stance. In the ankle, the CP group had larger energy absorption in mid-stance than the healthy children group, while the CP group showed lower energy generation in the terminal stance phase than seen in the healthy group.

Conclusion

The qualitative and quantitative analysis of joint work provides useful information for clinicians in the treatment and rehabilitation of CP patients.

A randomized crossover study of functional electrical stimulation during walking in spastic cerebral palsy: the FES on participation (FESPa) trial

Background

Spastic cerebral palsy is the most common cause of motor disability in children. It often leads to foot drop or equinus, interfering with walking. Ankle-foot orthoses (AFOs) are commonly used in these cases. However, AFOs can be too restrictive for mildly impaired patients. Functional electrical stimulation (FES) of the ankle-dorsiflexors is an alternative treatment as it could function as a dynamic functional orthosis. Despite previous research, high level evidence on the effects of FES on activities and participation in daily life is missing. The primary aim of this study is to evaluate whether FES improves the activity and participation level in daily life according to patients, and the secondary aim is to provide evidence of the effect of FES at the level of body functions and activities. Furthermore, we aim to collect relevant information for decisions on its clinical implementation.

Methods

A randomized crossover trial will be performed on 25 children with unilateral spastic cerebral palsy. Patients aged between 4 and 18 years, with Gross Motor Functioning Classification System level I or II and unilateral foot drop of central origin, currently treated with AFO or adapted shoes, will be included. All participants will undergo twelve weeks of conventional treatment (AFO/adapted shoes) and 12 weeks of FES treatment, separated by a six-week washout-phase. FES treatment consists of wearing the WalkAide® device, with surface electrodes stimulating the peroneal nerve during swing phase of gait. For the primary objective, the Goal Attainment Scale is used to test whether FES improves activities and participation in daily life. The secondary objective is to prove whether FES is effective at the level of body functions and structures, and activities, including ankle kinematics and kinetics measured during 3D-gait analysis and questionnaire-based frequency of falling. The tertiary objective is to collect relevant information for clinical implementation, including acceptability using the device log file and side effect registration, cost-effectiveness based on quality adjusted life years (QALYs) and clinical characteristics for patient selection.

Discussion

We anticipate that the results of this study will allow evidence-based use of FES during walking in children with unilateral spastic cerebral palsy.

Trial registration

ClinicalTrials.gov: NCT03440632.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12887-021-03037-9.

Impact of gestational age on risk of cerebral palsy: unravelling the role of neonatal morbidity

BACKGROUND

The contribution of adverse consequences of preterm birth to gestational-age-related risk of cerebral palsy (CP) has rarely been studied. We aimed to assess the potential mediating roles of neonatal morbidity on the association between gestational age and risk of CP.

METHODS

In this Swedish population-based study, 1 402 240 singletons born at 22-40 gestational weeks during 1998-2016 were followed from day 28 after birth for a CP diagnosis until 2017. Potential mediators included asphyxia, respiratory-related, infection-/inflammatory-related and neurological-related diseases within 0-27 days of life. Cox regression was used to estimate hazard ratios (HRs) and 95% confidence intervals (CIs). Causal mediation analysis was performed to estimate the proportion of the association mediated through pathways involving the four sequential mediators.

RESULTS

We found an inverse dose-response relationship between gestational age and risk of CP, where the strongest association was observed for 22-24 weeks (HR 47.26, 95% CI 34.09-65.53) vs 39-40 weeks. Compared with non-diseased peers, children with neonatal morbidity, particularly those with neurological-related diseases (HR 31.34, 95% CI 26.39-37.21), had a higher risk of CP. The increased risk of CP was, at 24 weeks, almost entirely explained by neonatal morbidity (91.7%); this proportion decreased to 46.1% and 16.4% at 32 and 36 weeks, respectively. Asphyxia was the main mediating pathway from 22 to 34 weeks, and neurological-related neonatal diseases led the mediating pathways from 34 weeks onwards.

CONCLUSION

Neonatal morbidity mediates a large proportion of the effect of preterm birth on CP, but the magnitude declines as gestational age increases.

Saccharomyces boulardii improves the behaviour and emotions of spastic cerebral palsy rats through the gut-brain axis pathway

BACKGROUND

Cerebral palsy (CP) is a kind of disability that influences motion, and children with CP also exhibit depression-like behaviour. Inflammation has been recognized as a contributor to CP and depression, and some studies suggest that the gut-brain axis may be a contributing factor. Our team observed that Saccharomyces boulardii (S. boulardii) could reduce the inflammatory level of rats with hyperbilirubinemia and improve abnormal behaviour. Both CP and depression are related to inflammation, and probiotics can improve depression by reducing inflammation. Therefore, we hypothesize that S. boulardii may improve the behaviour and emotions of spastic CP rats through the gut-brain axis pathway.

METHODS

Our new rat model was produced by resecting the cortex and subcortical white matter. Seventeen-day-old CP rats were exposed to S. boulardii or vehicle control by gastric gavage for 9 days, and different behavioural domains and general conditions were tested. Inflammation was assessed by measuring the inflammatory markers IL-6 and TNF-α. Hypothalamic-pituitary-adrenal (HPA) axis activity was assessed by measuring adrenocorticotropic hormone and corticosterone in the serum. Changes in the gut microbiome were detected by 16S rRNA.

RESULTS

The hemiplegic spastic CP rats we made with typical spastic paralysis exhibited depression-like behaviour. S. boulardii treatment of hemiplegic spastic CP rats improves behaviour and general conditions and significantly reduces the level of inflammation, decreases HPA axis activity, and increases gut microbiota diversity.

CONCLUSIONS

The model developed in this study mimics a hemiplegic spastic cerebral palsy. Damage to the cortex and subcortical white matter of 17-day-old Sprague-Dawley (SD) rats led to spastic CP-like behaviour, and the rats exhibited symptoms of depression-like behaviour. Our results indicate that S. boulardii might have potential in treating hemiplegic spastic CP rat models or as an add-on therapy via the gut-brain axis pathway.

Effects of Dynamic Suit Orthoses on the Spatio-Temporal Gait Parameters in Children with Cerebral Palsy: A Systematic Review

Dynamic suit orthoses (DSO) are currently used as a complementary treatment method in children with Cerebral Palsy (cwCP). The aim of this review was to assess the effects of interventions with DSO on the altered spatio-temporal gait parameters (STGPs) in cwCP. An electronic search was conducted in the Web of Science, Scopus, PEDro, Cochrane Library, MEDLINE/PubMed, and CINAHL databases up to July 2021. We included a total of 12 studies, which showed great heterogeneity in terms of design type, sample size, and intervention performed (two employed a Therasuit, three employed the Adeli suit, three employed Theratogs, one employed elastomeric tissue dynamic orthosis, one employed a full-body suit, one employed external belt orthosis, and one employed dynamic orthosis composed of trousers and T-shirt). The Cochrane collaboration's tool and the Checklist for Measuring Study Quality were used to assess the risk of bias and the methodological quality of the studies. It was variable according to the Checklist for Measuring Study Quality, and it oscillated between eight and 23. The studies of higher methodological quality showed significant post-intervention changes in walking speed (which is the most widely evaluated parameter), cadence, stride length, and step length symmetry. Although the evidence is limited, the intervention with DSO combined with a programme of training/physical therapy seems to have positive effects on the STGPs in cwCP, with the functional improvements that it entails. Despite the immediate effect after one session, a number of sessions between 18 and 60 is recommended to obtain optimum results. Future studies should measure all STGPs, and not only the main ones, such as gait speed, in order to draw more accurate conclusions on the functional improvement of gait after the use of this type of intervention.

Analysis of Selected Risk Factors Depending on the Type of Cerebral Palsy

Background: Cerebral palsy (CP) is not a defined, separate disease classification, but a set of etiologically diverse symptoms that change with the child's age. According to the up-to-date definition, CP is a group of permanent but not unchanging disorders of movement and/or posture and motor function, which are due to a nonprogressive interference, lesion, or abnormality of the developing/immature brain. CP is one of the most frequent causes of motor disability in children. The aim of the present study was to analyze whether selected risk factors may vary depending on particular types of CP. Methods: 181 children with CP (aged 4-17 years), hospitalized at the Department of Pediatrics and Developmental Age Neurology in Katowice in the years 2008-2016 were retrospectively analyzed in the present study. The assumed risk factors of CP were divided into two groups: 1-pre-conception and prenatal (mother's age, family history of epilepsy, burdened obstetric history, mother's systemic diseases, pregnancy order, multiple pregnancy, duration of pregnancy, bleedings from the genital tract during gestation, arterial hypertension during pregnancy, infections during pregnancy, preterm contractions, maintained pregnancy, premature rupture of membranes, abruptio placentae, and others), 2-perinatal and postnatal (mode of delivery, birth weight, Apgar score at the first and fifth minute, neonatal convulsions, respiratory failure, infections in neonatal and infant period, and intraventricular bleeding). The division into particular CP types was based on Ingram's classification. Results: The following risk factors were the most frequent in the total group: respiratory failure, infections, intraventricular bleeding, and prematurity. Among the analyzed preconception and prenatal factors, the duration of pregnancy and preterm contractions during pregnancy significantly differentiated the subgroups of patients depending on the type of CP. The prevalence of almost all analyzed perinatal, neonatal, and infant-related risk factors (i.e., birth weight, Apgar score at the first and fifth minute, neonatal convulsions, respiratory failure, infections in neonatal and infant period, and intraventricular bleeding) significantly differed between CP types, apart from the mode of delivery. However, in multivariate regression, only intraventricular bleeding was an independent predictor for tetraplegic CP type when compared to joined extrapyramidal and ataxic types (OR = 2.801, p = 0.028). Conclusions: As CP is a syndrome of multifactorial etiology, the identification of CP risk factors entails the need for careful observation and comprehensive care of children in the risk group. The presence of certain risk factors may be a prognostic indicator for particular types of CP. The knowledge about the association between the risk factor(s) and the CP type could be a very useful tool for pediatricians looking after the child at risk of developmental disorders.

Reliability and construct validity of the Activities Scale for Kids in Italian children with cerebral palsy

PURPOSE

To investigate internal consistency and construct validity of the of the Activities Scale for Kids performance (ASKp) in Italian children with cerebral palsy (CP).

METHODS

This cross-sectional study was conducted from 2014 up to 2019 and consisted in the single self-administration of the Italian ASKp to 206 children aged 5-15, with unilateral or bilateral CP, classified on the basis of the Gross Motor Function Classification System (GMFCS).

RESULTS

The ASKp showed good internal consistency (Chronbach's α 0.91, 95% CI 0.89-0.93). It distinguished between children and adolescents (70.3 ± 16.6 versus 83.0 ± 18.0, respectively; p < 0.001), unilateral and bilateral CP clinical manifestations (82.5 ± 13.6 versus 72.4 ± 19.0, respectively; p = 0.002), children with and without intellectual disability (60.3 ± 18.3 versus 77.2 ± 17.3, respectively; p < 0.001). It also distinguished children using assistive devices for indoor mobility from children who did not use devices or those who use devices only for outdoor mobility (66.1 ± 18.3 versus 83.6 ± 12.8 and versus 80.4 ± 17.4, respectively; both p < 0.001).

CONCLUSIONS

The ASKp could help integrate the perspective of children with CP in their rehabilitation process. Trial registration: ClinicalTrials.gov Identifier: NCT03325842IMPLICATIONS FOR REHABILITATIONThe ASKp is a valid and widely used measure for several ICF domains of activities and participation in pediatrics.It has never been formally validated in children with CP, although this disorder causes restrictions in everyday activities.Recently, the culturally adapted Italian version of the ASKp has been tested in typically developing Italian children, confirming its high acceptability and providing evidence of construct validity.This study confirms the internal consistency reliability and the construct validity of the Italian ASKp when applied to the population with CP.The ASKp can support rehabilitation professionals in planning therapeutic intervention targeted to relevant goals.

Bisphosphonate use in children with cerebral palsy

BACKGROUND

Cerebral palsy (CP) is a heterogeneous group of non-progressive disorders of posture or movement, caused by a lesion of the developing brain. Osteoporosis is common in children with cerebral palsy, particularly in children with reduced gross motor function, and leads to an increased risk of fractures. Gross motor function in children with CP can be categorised using a tool called the Gross Motor Function Classification System (GMFCS). Bisphosphonate increases bone mineral density (BMD) and reduces fracture rates. Bisphosphonate is used widely in the treatment of adult osteoporosis. However, the use of bisphosphonate in children with CP remains controversial, due to a paucity of evidence and a lack of recent trials examining the efficacy and safety of bisphosphonate use in this population.

OBJECTIVES

To examine the efficacy and safety of bisphosphonate therapy in the treatment of low BMD or secondary osteoporosis (or both) in children with cerebral palsy (GMFCS Levels III to V) who are under 18 years of age.

SEARCH METHODS

In September 2020, we searched CENTRAL, MEDLINE, Embase, six other databases, and two trial registers for relevant studies. We also searched the reference lists of relevant systematic reviews, trials, and case studies identified by the search, and contacted the authors of relevant studies in an attempt to identify unpublished literature.

SELECTION CRITERIA

All relevant randomised controlled trials (RCTs), and quasi-RCTs, comparing at least one bisphosphonate (given at any dose, orally or intravenously) with placebo or no drug, for the treatment of low BMD or osteoporosis in children up to 18 years old, with cerebral palsy (GMFCS Levels III to V).

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. We were unable to conduct any meta-analyses due to insufficient data, and therefore provide a narrative assessment of the results.

MAIN RESULTS

We found two relevant RCTs (34 participants). Both studies included participants with non-ambulatory CP or CP and osteoporosis. Participants in both studies were similar in severity of CP, age distribution, and sex distribution. The two trials used different bisphosphonate medications and different intervention durations, but further comparison of the interventions was not possible due to a lack of published data from one trial. One trial received funding and support from research, academic, and hospital foundations, with pharmaceutical companies providing components of the calcium and vitamin supplement; the other trial did not report sources of funding. We judged one study at an overall high risk of bias; the other as overall unclear risk of bias.

PRIMARY OUTCOME

Compared to placebo or no treatment, both studies provided very low certainty evidence of improved BMD at least four months post-intervention in children treated with bisphosphonate. Only one study (12 participants) provided sufficient detail to assess a measure of the effect, and reported an improvement at six months post-intervention in lumbar spine z-score (mean difference (MD) 18%, 95% confidence interval (CI) 6.57 to 29.43; very low certainty evidence).

SECONDARY OUTCOMES

Very low certainty evidence from one study found that bisphosphonate reduced serum N-telopeptides (NTX) more than placebo; the other study reported that both bisphosphonate plus alfacalcidol and alfacalcidol alone reduced NTX, but did not compare groups. One study reported inconclusive results between groups for serum bone-specific alkaline phosphatase (BAP). The other study reported that both bisphosphonate plus alfacalcidol and alfacalcidol alone reduced BAP, but did not compare groups. Neither study reported data for the effect of bisphosphonate treatment on changes in volumetric BMD in the distal radius or tibia, changes in fracture frequency, bone pain, or quality of life. One study reported that two participants had febrile events noted during their first dosing schedule, but no further adverse events were reported in either relevant study.

AUTHORS' CONCLUSIONS

Based on the available evidence, there is very low certainty evidence that bisphosphonate treatment may improve bone health in children with cerebral palsy. We could only include one study with 14 participants in the assessment of the effect size; therefore, the precision of the effect estimate is low. We could only evaluate one planned primary outcome, as there was insufficient detail reported in the relevant studies. Further research from RCTs on the effect and safety of bisphosphonate to improve bone health in children with cerebral palsy is required. These studies should clarify the optimal standard treatment regarding weight-bearing exercises, vitamin D and calcium supplementation, and should include fracture frequency as a primary outcome.

Trends in Prevalence and Severity of Pre/Perinatal Cerebral Palsy Among Children Born Preterm From 2004 to 2010: A SCPE Collaboration Study

Aim: To report on prevalence of cerebral palsy (CP), severity rates, and types of brain lesions in children born preterm 2004 to 2010 by gestational age groups.

Methods: Data from 12 population-based registries of the Surveillance of Cerebral Palsy in Europe network were used. Children with CP were eligible if they were born preterm (<37 weeks of gestational age) between 2004 and 2010, and were at least 4 years at time of registration. Severity was assessed using the impairment index. The findings of postnatal brain imaging were classified according to the predominant pathogenic pattern. Prevalences were estimated per 1,000 live births with exact 95% confidence intervals within each stratum of gestational age: ≤27, 28–31, 32–36 weeks. Time trends of both overall prevalence and prevalence of severe CP were investigated using multilevel negative binomial regression models.

Results: The sample comprised 2,273 children. 25.8% were born from multiple pregnancies. About 2-thirds had a bilateral spastic CP. 43.5% of children born ≤27 weeks had a high impairment index compared to 37.0 and 38.5% in the two other groups. Overall prevalence significantly decreased (incidence rate ratio per year: 0.96 [0.92–1.00[) in children born 32–36 weeks. We showed a decrease until 2009 for children born 28–31 weeks but an increase in 2010 again, and a steady prevalence (incidence rate ratio per year = 0.97 [0.92–1.02] for those born ≤27 weeks. The prevalence of the most severely affected children with CP revealed a similar but not significant trend to the overall prevalence in the corresponding GA groups. Predominant white matter injuries were more frequent in children born <32 weeks: 81.5% (≤27 weeks) and 86.4% (28–31 weeks), compared to 63.6% for children born 32–36 weeks.

Conclusion: Prevalence of CP in preterm born children continues to decrease in Europe excepting the extremely immature children, with the most severely affected children showing a similar trend.

Cytokine dysregulation in children with cerebral palsy

AIM

To examine pro- and anti-inflammatory cytokines in children with cerebral palsy (CP) at baseline and in response to endotoxin (lipopolysaccharide), and correlate outcomes compared with age-matched comparisons, to evaluate their ability to mount an immune response.

METHOD

Serum cytokines were assessed in 12 children (eight males, four females; mean age 10y 1mo [SD 1y 8mo], 6-16y) with CP against 12 age-matched comparisons (eight males, four females; mean age 9y 1mo [SD 1y 1mo]). Pro- and anti-inflammatory cytokines (interleukin-1β, interleukin-2, interleukin-6, interleukin-8, interleukin-10, interleukin-18, tumour necrosis factor [TNF]-α, TNF-β, interferon-γ, granulocyte-macrophage colony-stimulating factor [GM-CSF], vascular endothelial growth factor [VEGF], erythropoietin, and interleukin-1 receptor antagonist) were measured at baseline and in response to in vitro simulation with lipopolysaccharide by multiplex enzyme-linked immunosorbent assay.

RESULTS

Significantly higher erythropoietin was found at baseline in children with CP compared with the comparison group. There was a strong response to lipopolysaccharide for interleukin-8, VEGF, TNF-α, and GM-CSF in both children with CP and the comparison group; however, there was significant lipopolysaccharide hyporesponsiveness in children with CP compared with the comparison group for interleukin-1α, interleukin-1β, interleukin-2, and interleukin-6.

INTERPRETATION

Altered cytokine responses in children with CP compared with the comparison group demonstrate an altered inflammatory state that may contribute to ongoing sequelae and could be a target for therapy.

WHAT THIS PAPER ADDS

Altered inflammatory responses persist in children with cerebral palsy (CP). Erythropoietin is elevated in children with CP compared with the comparison group. Children with CP have reduced interleukin-1α, interleukin-1β, interleukin-2, and interleukin-6 inflammatory responses to lipopolysaccharide.

The influence of neonatal infections on the development of cerebral palsy

One of the most significant biological factors predisposing to cerebral palsy (CP) are infections. The paper aims to analyze neonatal infections’ influence in the risk of CP development with consideration of all significant risk factors including single, twin, full-term and pre-term pregnancies.

278 children with CP attending the chosen school-educational centers in Poland were included in the questionnaire. The control group included data obtained from the medical documentation of 435 children born in Limanowa County Hospital, Poland. Socio-economic factors, factors connected with pregnancy, and the coexisting disorders and diseases in children were taken into consideration. Constructed models of logistic regression were applied in the statistical analysis.

Neonatal infections increase the risk of CP development in all children (odds ratio (OR) 5.1, 95% confidence interval (CI) 2.6–9.8), children from single pregnancies (OR 5.8, 95% CI: 3.0–11.29), full-term (OR 6.2, 95% CI: 3.2–12.3), and single full-term pregnancies (OR 6.0, 95% CI: 3.0–12.0). The influence of neonatal infections in the risk of CP development in children from pre-term and single premature pregnancies was not indicated.

Neonatal infections are an independent risk factor for CP development in newborns from full-term pregnancy (>37 weeks of pregnancy). The patho-mechanism of CP is different in children from full-term and premature pregnancy and results from interrelating factors are discussed in this paper.

Association of Gestational Age at Birth With Brain Morphometry

IMPORTANCE

Preterm and postterm births are associated with adverse neuropsychiatric outcomes. However, it remains unclear whether variation of gestational age within the 37- to 42-week range of term deliveries is associated with neurodevelopment.

OBJECTIVE

To investigate the association of gestational age at birth (GAB) with structural brain morphometry in children aged 10 years.

DESIGN, SETTING, AND PARTICIPANTS

This population-based cohort study included pregnant women living in Rotterdam, the Netherlands, with an expected delivery date between April 1, 2002, and January 31, 2006. The study evaluated 3079 singleton children with GAB ranging from 26.3 to 43.3 weeks and structural neuroimaging at 10 years of age from the Generation R Study, a longitudinal, population-based prospective birth cohort from early pregnancy onward in Rotterdam. Data analysis was performed from March 1, 2019, to February 28, 2020, and at the time of the revision based on reviewer suggestions.

EXPOSURES

The GAB was calculated based on ultrasonographic assessment of crown-rump length (<12 weeks 5 days) or biparietal diameter (≥12 weeks 5 days) in dedicated research centers.

MAIN OUTCOMES AND MEASURES

Brain structure, including global and regional brain volumes and surface-based cortical measures (thickness, surface area, and gyrification), was quantified by magnetic resonance imaging.

RESULTS

In the 3079 children (1546 [50.2%] female) evaluated at 10 years of age, GAB was linearly associated with global and regional brain volumes. Longer gestational duration was associated with larger brain volumes; for example, every 1-week-longer gestational duration corresponded to an additional 4.5 cm3/wk (95% CI, 2.7-6.3 cm3/wk) larger total brain volume. These associations persisted when the sample was restricted to children born at term (GAB of 37-42 weeks: 4.8 cm3/wk; 95% CI, 1.8-7.7 cm3/wk). No evidence of nonlinear associations between GA and brain morphometry was observed.

CONCLUSIONS AND RELEVANCE

In this cohort study, gestational duration was linearly associated with brain morphometry during childhood, including within the window of term delivery. These findings may have marked clinical importance, particularly given the prevalence of elective cesarean deliveries.

Construct Validity of the Activities Scale for Kids Performance in Children with Cerebral Palsy: Brief Report

Aims: This study collects evidence of construct convergent validity of the Activity Scale for Kids performance (ASKp), comparing its results with the 66-item Gross Motor Function Measure (GMFM-66) and with the Gross Motor Function Classification System (GMFCS) and testing the ASKp's ability to discriminate between individuals with different functional capabilities. Methods: This cross-sectional study involved 60 children with spastic cerebral palsy (CP) assessed with the GMFM-66 who self-administered the Italian version of the ASKp. Results: Children were 10.9 (±3) years old with GMFCS Level I-III. Moderate correlations were found between GMFM and ASKp scores (r = 0.577; p < .001), and between GMFCS levels and ASKp score (r_s = -0.541, p < .001). The ASKp discriminated between children with different functional capabilities, determined by the GMFCS (F = 18.2, p < .001). Conclusions: ASKp is valid to assess physical functioning, a crucial domain in rehabilitation of children with spastic CP. Trial registration: ClinicalTrials.gov Identifier: NCT03325842.

Weekend and off-hour effects on the incidence of cerebral palsy: contribution of consolidated perinatal care

Objective

This study estimated the effects of weekend and off-hour childbirth and the size of perinatal medical care center on the incidence of cerebral palsy.

Methods

The cases were all children with severe cerebral palsy born in Japan from 2009 to 2012 whose data were stored at the Japan Obstetric Compensation System for Cerebral Palsy database, a nationally representative database. The inclusion criteria were the following: neonates born between January 2009 and December 2012 who had a birth weight of at least 2000 g and gestational age of at least 33 weeks and who had severe disability resulting from cerebral palsy independent of congenital causes or factors during the neonatal period or thereafter. Study participants were restricted to singletons and controls without report of death, scheduled cesarean section, or ambulance transportation. The controls were newborns, randomly selected by year and type of delivery (normal spontaneous delivery without cesarean section and emergency cesarean section) using a 1:10 case to control ratio sampled from the nationwide Japan Society of Obstetrics and Gynecology database.

Results

A total of 90 cerebral palsy cases and 900 controls having normal spontaneous delivery without cesarean section were selected, as were 92 cerebral palsy cases and 920 controls with emergent cesarean section. A significantly higher risk for cerebral palsy was found among cases that underwent emergent cesarean section on weekends (odds ratio [OR] 1.72, 95% confidence interval [CI] 1.06–2.81) and during the night shift (OR 2.29, 95% CI 1.30–4.02). No significant risk was found among normal spontaneous deliveries on weekends (OR 1.63, 95% CI 0.97–2.73) or during the quasi-night shift (OR 1.26, 95% CI 0.70–2.27). Regional perinatal care centers showed significantly higher risk for cerebral palsy in both emergent cesarean section (OR 2.35, 95% CI 1.47–3.77) and normal spontaneous delivery (OR 2.92, 95% CI 1.76–4.84).

Conclusion

Labor on weekends, during the night shift, and at regional perinatal medical care centers was associated with significantly elevated risk for cerebral palsy in emergency cesarean section.

Long-term follow-up after patellar tendon shortening for flexed knee gait in bilateral spastic cerebral palsy

BACKGROUND

Flexed knee gait is a common gait dysfunction in individuals with bilateral spastic cerebral palsy (BSCP) and is often addressed with single event multilevel surgery (SEMLS). SEMLS has been shown to have positive short-term effects especially on sagittal knee joint kinematics with less knee flexion during stance phase. However, mid- and long-term observations are rare, and results are reported in discrete parameters or summary statistics where temporal aspects are not considered.

RESEARCH QUESTION

Does the improved knee joint kinematics after patellar tendon shortening (PTS) as part of SEMLS persist in the long-term in individuals with BSCP?

METHODS

Data of instrumented gait analysis of twelve participants (females/males: 5/7, mean age: 15.3 ± 3.4 years) with BSCP treated with PTS as part of SEMLS were retrospectively analyzed. Participants had had follow-up gait analysis 1, 5 and 7 years or more after surgery. Three-dimensional lower extremity kinematics of walking at a self-selected speed were collected using a 12-camera motion capture system and 4 embedded force plates. One-dimensional statistical parametric mapping (SPM) was used for data analysis, permitting time point comparisons of continuous data.

RESULTS

Time point comparison revealed no significant differences in the sagittal plane for knee joint kinematics (p > 0.05) over the tree measurement time points. Hip and ankle joint kinematics as well as normalised walking speed remained stable over the observation period.

SIGNIFICANCE

This is the first study investigating lower extremity kinematics in patients with BSCP and flexed knee gait after SEMLS with SPM. Results demonstrate that positive effects on sagittal knee joint kinematics of PTS as part of SEMLS persist up to 9 years after surgery and progressivity does not reoccur. Thus, if clinical examination indicates an operation in individuals with BSCP, improved kinematics through SEMLS persist into adulthood. With the relatively new statistical procedure SPM gait can be displayed and analysed in established joint angle curves making them easier to understand (e.g. physiotherapists, movement scientists, physicians).

Evaluation of Risk Factors for Epilepsy in Pediatric Patients with Cerebral Palsy

Cerebral palsy (CP) is a set of etiologically diverse symptoms that change with the child's age. It is one of the most frequent causes of motor disability in children. CP occurs at a frequency of 1.5 to 3.0 per 1000 live-born children. CP often coexists with epilepsy, which is drug-resistant in a high number of cases. The aim of the present study was to analyze the associations between preconception, prenatal, perinatal, neonatal, and infancy risk factors for epilepsy in a group of pediatric patients with CP. We retrospectively analyzed 181 children with CP (aged 4-17 years at diagnosis), hospitalized at the Department of Pediatrics and Developmental Age Neurology in Katowice in the years 2008-2016. Division into particular types of CP was based on Ingram's classification. Data were analyzed using STATISTICA 13.0 (STATSOFT; Statistica, Tulsa, OK, USA). Epilepsy was diagnosed in 102 children (56.35%), of whom 44 (43%) had drug-resistant epilepsy; only in 15 cases (14.71%) was epilepsy susceptible to treatment. The incidence of epilepsy varied between the types of CP. It occurred significantly more often in children with tetraplegia (75%), ataxic form (83%), and mixed form (80%) in comparison to diplegia (32%) and hemiplegia (38%). Maternal hypertension was found to be a risk factor for epilepsy in CP patients (OR = 12.46, p < 0.001) as well as for drug-resistant epilepsy (the odds ratio (OR) = 9.86, p = 0.040). Delivery by cesarean section increased the risk of epilepsy in the CP patients over two-fold (OR = 2.17, p = 0.012). We observed also that neonatal convulsions significantly increased the risk for epilepsy (OR = 3.04, p = 0.011) as well as drug-resistant epilepsy (OR = 4.02, p = 0.002). In conclusion, maternal hypertension, neonatal convulsions, and delivery by cesarean section were the most important factors increasing the risk of epilepsy as well as drug-resistant epilepsy in the analyzed group of patients with CP.

[Benefits of robotics in gait rehabilitation in cerebral palsy: A systematic review]

BACKGROUND AND AIM

Cerebral palsy is the most common motor disability in childhood, with an estimated incidence of two out of every 1,000 live births. The impairment mostly affects gait. The aim of rehabilitation programmes is to enhance independence in affected individuals, especially mobility. To do this, robot-assisted gait rehabilitation programmes have been developed. Therefore, this study aimed to identify the benefits of robotics in gait rehabilitation in cerebral palsy.

MATERIAL AND METHODS

We performed a literature search using the MeSH terms «cerebral palsy», «robotics» and «gait».

RESULTS

After applying the selection criteria, we obtained 10 research studies and three protocols analysing the benefits of robotics in cerebral palsy and demonstrating that their use provides major advantages.

Cerebral Palsy: Current Opinions on Definition, Epidemiology, Risk Factors, Classification and Treatment Options

Cerebral palsy (CP) is one of the most frequent causes of motor disability in children. According to the up-to-date definition, CP is a group of permanent disorders of the development of movement and posture, causing activity limitations that are attributed to non-progressive disturbances that occurred in the developing foetal or infant brain. The CP definition has evolved over time; the problem is aetiologically and clinically very heterogeneous. According to European data, the average frequency of CP is 2.08 per 1000 live births, but in the group of children born with a body weight below 1500 g, the frequency is 70 times higher when compared with the group of children with a body weight over 2500 g at birth. The risk factors for CP can be divided into pre-conception, prenatal, perinatal and postnatal ones. CP commonly co-exists with epilepsy, in particular drug-resistant epilepsy, but also with mental retardation, visual and hearing impairment, as well as feeding and behavioral disorders. The degree of motor problem varies from mild to very severe making the child totally dependent on caregivers. Cerebral palsy is divided into forms depending on the type of motor disorders which dominate the clinical presentation; the traditional classifications by Ingram and Hagberg have now been replaced by the Surveillance of Cerebral Palsy in Europe classification which divides CP into spastic, dyskinetic and ataxic forms. Although cerebral palsy is a clinical diagnosis, modern diagnostic imaging provides information that allows the division of the results of magnetic resonance imaging in children with cerebral palsy into five groups according to the magnetic resonance imaging classification system. Just as the clinical presentation and the factors predisposing for CP are very diverse, treatment is also a very complex problem. Modern treatment of spasticity includes both botulinum toxin therapies and surgical techniques, eg, rhizotomy. The authors present current views on definitions, risk factors, diagnostics and treatment of CP as well as comorbid problems, eg, drug-resistant epilepsy.

Animal models of developmental motor disorders: parallels to human motor dysfunction in cerebral palsy

Cerebral palsy (CP) is the most common motor disability in children. Much of the previous research on CP has focused on reducing the severity of brain injuries, whereas very few researchers have investigated the cause and amelioration of motor symptoms. This research focus has had an impact on the choice of animal models. Many of the commonly used animal models do not display a prominent CP-like motor phenotype. In general, rodent models show anatomically severe injuries in the central nervous system (CNS) in response to insults associated with CP, including hypoxia, ischemia, and neuroinflammation. Unfortunately, most rodent models do not display a prominent motor phenotype that includes the hallmarks of spasticity (muscle stiffness and hyperreflexia) and weakness. To study motor dysfunction related to developmental injuries, a larger animal model is needed, such as rabbit, pig, or nonhuman primate. In this work, we describe and compare various animal models of CP and their potential for translation to the human condition.

Longitudinal Change in Speech Rate and Intelligibility Between 5 and 7 Years in Children With Cerebral Palsy

Purpose We examined growth between 5 and 7 years in speech intelligibility, speech rate, and intelligible words per minute (IWPM) in 3 groups of children: those who were typically developing (TD), those with cerebral palsy (CP) and clinical speech motor impairment (SMI), and those with CP and no SMI (NSMI). Method Twenty-six children with CP, 16 with SMI, and 10 with NSMI were each seen at 5, 6, and 7 years of age. A cross-sectional group of 30 age-matched TD children, 10 in each age group, were included as controls. All children produced a corpus of utterances of 2-7 words. Results All groups of children showed increases in intelligibility and IWPM between 5 and 7 years. Only children with SMI showed increases in speech rate over time. Patterns of change were similar for children in the TD and NSMI groups but different for children in the SMI group. Conclusions The window of time between 5 and 7 years is an important period of growth for the production of connected speech where nearly all children, regardless of group, made significant changes in speech intelligibility and IWPM. Interventions focusing specifically on enhancing intelligibility in this age range may help facilitate even further growth in children with SMI, who still had marked intelligibility reductions at 7 years of age.

Magnesium Sulfate and Novel Therapies to Promote Neuroprotection

Cerebral palsy occurs more often in preterm than in term deliveries and is one of the major neurologic injuries seen in preterm infants. Magnesium sulfate has been found to reduce the risk of cerebral palsy in patients at risk of delivery before 32 weeks' gestational age. Multiple large clinical trials have shown this effect. The authors recommend magnesium sulfate bolus followed by continuous dosing of magnesium sulfate in those at risk of delivery before 32 weeks' gestation until delivery occurs or is no longer imminent. This article also discusses novel and emerging therapies for the prevention of cerebral palsy.

A Critical Evaluation of Current Concepts in Cerebral Palsy

Spastic cerebral palsy (CP), despite the name, is not consistently identifiable by specific brain lesions. CP animal models focus on risk factors for development of CP, yet few reproduce the diagnostic symptoms. Animal models of CP must advance beyond risk factors to etiologies, including both the brain and spinal cord.

The Perception of Disability Among Mothers Living With a Child With Cerebral Palsy in Saudi Arabia

The purpose of this study was to explore the perceptions of disability among Saudi mothers and to understand the implication of the meaning for the mothers of children with disability. A critical ethnographic approach was employed using focus groups and follow-up interviews with the mothers. Three primary themes were identified that specifically influenced and affected the mothers’ experiences: (a) culture and religion, (b) motherhood and disability, and (c) community stigma and discrimination. The study reveals much-needed knowledge and sheds light on a topic, the details of which are rarely available in research literature from the Middle East. The findings further endorse the need for clinicians to listen to the mothers to consider their beliefs and the impact of these beliefs on their experiences. This, in turn, may provide a valuable conceptual lens for health care practitioners to use the family-centered model when working with cerebral palsy children.

Are perceptual disorder signs in diplegic cerebral palsied children stable over time? A retrospective cohort analysis

BACKGROUND

A group of diplegic cerebral palsied (CP) children presents six precise signs that can be easily observed during clinical examinations, physiotherapy sessions and everyday activities. These signs are: startle reaction, upper limbs in startle position, averted-eye gaze, grimaces, eye blinking and posture freezing.

METHODS

In a population of 32 diplegic CP children (aged 1-8 years) perceptual signs were retrospectively identified through videos to verify their stability in the same child over time.

RESULTS

Startle reaction, upper limb in startle position and posture freezing were the most frequently observed signs and the easiest to recognize with the highest agreement in both observations (P<0.001). Eye signs (eye blinking and averted-eye gaze) were more difficult to detect in our recordings.

CONCLUSIONS

Signs of perceptual disorders were present in our sample of diplegic CP children from the second year of age and could still be observed after 1- to 3-year intervals, demonstrating they remain unaltered over time. Furthermore, if absent in the first observation, they did not appear later on. CP children with these perceptual signs could represent a new clinical entity, which we are currently describing and defining.

Cicloergômetro na melhora da função motora grossa de crianças comparalisia cerebral: uma revisão sistemática com meta-anális

RESUMO A paralisia cerebral é um grupo de desordens neurológicas causadora de inúmeros déficits, principalmente relacionados à função motora, comprometendo os movimentos e o seu controle seletivo. Dentre as diversas terapias disponíveis para tentar amenizar esse processo, o cicloergômetro aparece como um aparato estacionário que tem por finalidade facilitar a movimentação dos membros inferiores. Portanto, o objetivo deste estudo foi analisar os efeitos do cicloergômetro na função motora grossa de crianças com paralisia cerebral através da escala Gross Motor Function Measure (GMFM-66). Trata-se de uma revisão sistemática, com inclusão de ensaios clínicos randomizados publicados até julho de 2017. A busca foi realizada nas bases de dados: MEDLINE (PubMed), Physiotherapy Evidence Database (PEDro), SciELO e Embase. Para a avaliação da qualidade metodológica das investigações foi utilizada a escala da Cochrane Handbook. Foram selecionados artigos que aplicaram o cicloergômetro em crianças com paralisia cerebral, comparadas a crianças com paralisia cerebral no grupo-controle ou em outra intervenção, e que avaliaram a função motora grossa com a GMFM. A revisão incluiu três artigos e um total de 127 pacientes. Os resultados mostraram um aumento nos valores da GMFM-66, porém não significativo estatisticamente nem relevantes para uma melhora clínica. Por meio desta revisão sistemática, verificou-se uma grande heterogeneidade nos estudos que abordam esta área e que, apesar do incremento de valores no grupo que realizou o cicloergômetro, não houve diferença estatística quando comparado ao grupo-controle, demonstrando não beneficiar a função motora grossa dessa população quando avaliada pela GMFM66.