Selective motor control correlates with gross motor ability, functional balance and gait performance in ambulant children with bilateral spastic cerebral palsy

BACKGROUND

Selective motor control (SMC) is a fundamental component of typical human motion. As a result of brain damage, impaired SMC often leads to difficulties with coordination, balance, gait efficiency and symmetry.

RESEARCH QUESTION

What is the association between impaired SMC and lower limb motor ability, functional balance and gait performance in children with bilateral spastic cerebral palsy (CP)?

METHODS

Thirty-six children (aged 5-16 years) with spastic bilateral CP in Gross Motor Function Classification System (GMFCS) level I to II were included in this study. SMC was assessed using Selective Control Assessment of the Lower Extremity (SCALE). Gross motor function was assessed using Gross Motor Function Measure-88 items D and E dimension (GMFM-88 D&E). Functional balance was assessed using Pediatric Balance Scale (PBS) and Timed Up and Go Test (TUG). Gait quality was assessed using Edinburg Visual Gait Score (EVGS) and 10-Meter Walk Test (10MWT). Spearman's rank correlation analyses were used to determine the association between SMC and other factors.

RESULTS

Correlation analyses showed that SCALE was strongly positively correlated with GMFM-88 (D&E) (rs=0.756, p < 0.001), PBS (rs=0.769, p < 0.001), and height-normalized fast walking speed (rs=0.632, p < 0.001), and strongly negatively correlated with TUG (rs=-0.766, p < 0.001) and EVGS (rs=-0.893, p < 0.001).

SIGNIFICANCE

Lower extremity SMC deficits are associated with poor gross motor function and balance control, more severe overall gait deviations and decreased fast walking speed in children with bilateral spastic CP. Physical therapy should include interventions that promote selective motor control in order to improve overall functional ability.

Reliability and validity of the Turkish version of Fullerton Advanced Balance Scale in cerebral palsy

BACKGROUND

The Fullerton Advanced Balance Scale (FAB) is a multi-item balance assessment test designed to measure balance in relatively higher functioning individuals. The aim of this study was to examine the reliability and validity of the Turkish version of the FAB (FAB-T) in children with cerebral palsy (CP).

RESEARCH QUESTION

Is the Turkish version of the Fullerton Advance Balance Scale valid and reliable in determining balance problems in children with cerebral palsy and determining the underlying cause of this condition?

METHODS

Forty-six children with CP participated in this study. Rasch analysis was used to investigate item adherence. Internal consistency of the FAB-T was established using Cronbach's alpha coefficient. Test-retest reliability was also evaluated. In addition, to assess concurrent validity, FAB-T scores were compared with the Pediatric Balance Scale (PBS) using the Spearman correlation coefficient.

RESULTS

The FAB-T showed satisfactory internal consistency (Cronbach's alpha value=0.94) and excellent test-retest reliability (ICC=0.99). The FAB and the PBS exhibited concurrent positive validity (r = 0.913; p < 0.001). All items of the FAB-T were found to fit the Rasch Model (Chi-square 16.01(df=20), p = 0.716).

SIGNIFICANCE

The FAB-T is a reliable and valid tool that can be used to measure balance skills and to identify the source of the problem in children with CP.

Stronger proprioceptive BOLD-responses in the somatosensory cortices reflect worse sensorimotor function in adolescents with and without cerebral palsy

Cerebral palsy (CP) is a motor disorder where the motor defects are partly due to impaired proprioception. We studied cortical proprioceptive responses and sensorimotor performance in adolescents with CP and their typically-developed (TD) peers. Passive joint movements were used to stimulate proprioceptors during functional magnetic resonance imaging (fMRI) session to quantify the proprioceptive responses whose associations to behavioral sensorimotor performance were also examined. Twenty-three TD (15 females, age: mean ± standard deviation 14.2 ± 2.4 years) and 18 CP (12 females, age: mean ± standard deviation, 13.8 ± 2.3 years; 12 hemiplegic, 6 diplegic) participants were included in this study. Participants' index fingers and ankles were separately stimulated at 3 Hz and 1 Hz respectively with pneumatic movement actuators. Regions-of-interest were used to quantify BOLD-responses from the primary sensorimotor (SM1) and secondary (SII) somatosensory cortices and were compared across the groups. Associations between responses strengths and sensorimotor performance measures were also examined. Proprioceptive responses were stronger for the individuals with CP compared to their TD peers in SM1 (p < 0.001) and SII (p < 0.05) cortices contralateral to their more affected index finger. The ankle responses yielded no significant differences between the groups. The CP group had worse sensorimotor performance for hands and feet (p < 0.001). Stronger responses to finger stimulation in the dominant SM1 (p < 0.001) and both dominant and non-dominant SII (p < 0.01, p < 0.001) cortices were associated with the worse hand sensorimotor performance across all participants. Worse hand function was associated with stronger cortical activation to the proprioceptive stimulation. This association was evident both in adolescents with CP and their typically-developed controls, thus it likely reflects both clinical factors and normal variation in the sensorimotor function. The specific mechanisms need to be clarified in future studies.

Hip Displacement in Cerebral Palsy: The Role of Surveillance

INTRODUCTION

Hip displacement is common in cerebral palsy (CP) and is related to the severity of neurological and functional impairment. It is a silent, but progressive disease, and can result in significant morbidity and decreased quality of life, if left untreated. The pathophysiology of hip displacement in CP is a combination of hip flexor-adductor muscle spasticity, abductor muscle weakness, and delayed weight-bearing, resulting in proximal femoral deformities and progressive acetabular dysplasia. Due to a lack of symptoms in the early stages of hip displacement, the diagnosis is easily missed. Awareness of this condition and regular surveillance by clinical examination and serial radiographs of the hips are the key to early diagnosis and treatment.

HIP SURVEILLANCE PROGRAMMES

Several population-based studies from around the world have demonstrated that universal hip surveillance in children with CP allows early detection of hip displacement and appropriate early intervention, with a resultant decrease in painful dislocations. Global hip surveillance models are based upon the patients' age, functional level determined by the Gross Motor Function Classification system (GMFCS), gait classification, standardized clinical exam, and radiographic indices such as the migration percentage (MP), as critical indicators of progressive hip displacement.

CONCLUSION

Despite 25 years of evidence showing the efficacy of established hip surveillance programmes, there is poor awareness among healthcare professionals in India about the importance of regular hip surveillance in children with CP. There is a need for professional organizations to develop evidence-based guidelines for hip surveillance which are relevant to the Indian context.

Suit therapy versus whole-body vibration on bone mineral density in children with spastic diplegia

OBJECTIVES

Osteoporosis because of physical inactivity is one of the major complications associated with neuromuscular disorders. The study aimed to compare using Suit therapy and whole-body vibration in addition to selected physical therapy program to improve Bone Mineral Density in children with cerebral palsy of spastic diplegia.

METHODS

Forty-six patients were classified randomly into two equal groups. Patients in the group (A) engaged in a selected physical therapy program, also besides, suit therapy training program while those in the group (B) received the same selected physical therapy program received by group (A) in addition to the whole-body vibration training program. The treatment programs were conducted three times per week for twelve successive weeks. Measurements obtained included bone mineral density at the lumbar spine as well as at the femoral neck. These measures were recorded pre- and post-treatment.

RESULTS

There was a significant improvement in favor of the whole-body Vibration group. Bone mineral density improved significantly at both the lumbar spine (P=.038) and the femoral neck (P=.005) in the WBV group as compared to the Suit therapy group.

CONCLUSIONS

Whole-body vibration is effective in improving Bone Mineral Density rather than Suit therapy in children with cerebral palsy of spastic diplegia.

Effect of whole-body vibration on abdominal thickness and sitting ability in children with spastic diplegia

Objective

Reduced muscle and bone mass, improper muscle function, and varying degrees of mobility dysfunctions are the main complications of cerebral palsy (CP). Many children with CP also present with poor abdominal muscle activation. Whole-body vibration (WBV) is a unique approach for enhancing strength and motor abilities in several clinical conditions. This study aimed to determine the influence of a 12-week WBV intervention on the thickness of the abdominal muscles and the sitting ability of children with diplegia.

Methods

A total of 30 children with spastic diplegic CP (aged 4–6 years) were randomly divided into two groups (control and experimental). The control group received a selected physical therapy program for 1 h, and the study group received WBV training for 10 min in addition to the same selected program for the control group for 3 times/week over a period of 12 weeks. Thereafter, abdominal muscle thickness and sitting ability were measured using ultrasonography and the Gross Motor Function Measure-88 (GMFM-88, sitting domain).

Results

Post treatment values revealed significant improvement in the measured variables in favour of the experimental group (p < 0.05), as there was improvement in the thickness of the four abdominal muscles compared to the control group (external oblique: F = 38.783; internal oblique: F = 99.547; transverse abdominis: F = 111.557, and rectus abdominis: F = 129.940, p < 0.05). Additionally, the study group showed a significantly greater improvement in GMFM-88 values compared to the control group (F = 129.940, p < 0.05).

Conclusion

WBV can be a viable strategy for improving sitting ability and abdominal muscle thickness among children with spastic diplegia.

Percutaneous Versus Open Hamstring Lengthening in Spastic Diplegic Cerebral Palsy

BACKGROUND

Open hamstring lengthening (oHSL) is commonly performed to decrease knee contracture and improve gait and posture for children with spastic diplegia. Furthermore, percutaneous hamstring lengthening (pHSL) is also gaining popularity as an alternative to the open approach. This study aimed to compare the results of pHSL versus oHSL and to determine the efficacy and safety of the percutaneous approach.

METHODS

This retrospective included 54 patients (108 knees) with spastic diplegia operated for flexed knee gait with either open or percutaneous HSL. The mean age of the participants at the time of surgery was 10.3±1.7 years (age range: 5-25 years) for the open and 8.5±1.5 years (age range: 7-23 years) for the percutaneous group. Overall, 29 and 25 children were subjected to oHSL and pHSL, respectively.

RESULTS

The mean durations of follow-up were 19.1 months (range: 12-49 months) and 18.3 months (range: 14-45 months) for oHSL and pHSL groups, respectively. In the open group, the mean of preoperative popliteal angle decreased from 64.3±3.6 to 28.4±4.3 (P<0.001), and in the percutaneous group from 63.8±2.7 to 29.5±2.3 (P<0.001). The obtained results revealed no significant differences between the two approaches leading to a similar improvement among the investigated patients (P=0.83). Although the Gross Motor Function Class Score improved significantly within each group (P<0.001); this improvement was insignificant between the groups (P=0.88). The mean of hospital stay for the percutaneous group was 1.6 days (range:1-3 days) compared to 3.6 days (range: 2-6 days) for the open group, which indicated a significant difference (P=0.001). The mean values of total cost were $333 and $473 in the percutaneous group and open group (P=0.001), respectively. There was no significant difference between the groups regarding the complication rate (P=0.85).

CONCLUSION

Percutaneous HSL is a safe, easy, rapid, and brief procedure that is as effective as the open technique for children with spastic diplegia in a short period of time. However, it is essential to examine the effects of this approach during longer follow-ups to generalize the findings of the current study.

Is hiragana decoding impaired in children with periventricular leukomalacia?

BACKGROUND

There are few studies on hiragana reading skill and phonological awareness in Japanese schoolchildren with periventricular leukomalacia (PVL).

METHODS

Three seven-year-old children with PVL who had no intellectual disabilities or dysarthria were recruited. Their perinatal information, brain magnetic resonance image (MRI) at term equivalent age, accompanying neurodevelopmental disorders, ophthalmologic features, Kaufman Assessment Battery for Children (K-ABC), a hiragana reading test (four tasks), and a phonological awareness task (mora reversal tasks) were analyzed.

RESULTS

Patient (Pt) 1 and pt2 were male. Pt2 and pt3 were siblings of triplets. Their gestational age was 28 or 32 weeks, and their birth weights were 1196, 1554, and 1848 g, respectively. Their brain MRI revealed cystic or non-cystic periventricular white matter injury involving the deep white matter at the trigone of both lateral ventricles. Pt1 had attention-deficit/hyperactivity disorder and pt3 had pervasive developmental disorder not otherwise specified. All patients had strabismus with spared best-corrected visual acuity. Scores of Reading/Decoding in K-ABC ranged from 89 to 99. As for the single mora reading task or the non-word reading task in the kana reading test, Z scores of their reading time ranged from 2.3 to 5.9 compared to control children. Pt1 and pt3 made significant errors in the mora reversal task of three-mora words, whereas all patients could answer all words correctly in the mora reversal task of two-mora words.

CONCLUSION

All children showed significantly prolonged reading time despite their adequate letter recognition. Two patients showed delayed phonological awareness. It was suggested that hiragana decoding impairment due to subcortical and/or cortical injury related to PVL affected their reading ability.

An examination of the relationship between dynamic knee joint stiffness and gait pattern of children with cerebral palsy

Dynamic joint stiffness represents the resistance that a joint opposes to an applied moment. Stiffness arises in conditions of joint laxity, instability and increased co-contraction and is commonly utilized as a means to stabilize the joint. The knee joint seems to be crucial for determining the walking pattern. The aim of this study was to investigate the association between the gait pattern, globally quantified by the Gait Profile Score (GPS), which indicates the 'quality' of a particular walking strategy, and knee dynamic joint stiffness (Kk) in children with diplegia. Kk is expressed by plotting the values of the knee flexion-extension moment versus the knee flexion-extension angle during weight acceptance. In this interval, the linear regression was fitted. The angular coefficient of the linear regression corresponded to the joint stiffness index. Sixty-one children with diplegia and 18 healthy individuals took part in this study. From their gait analysis data, the GPS (with its Gait Variable Scores-GVSs) and the Kk were calculated. Data showed that GPS (p = 2.73 × 10^-21) and GVSs values for the patients with diplegia were higher in comparison to healthy controls. The Kk values for patients were not statistically different from those of controls. The correlation between Kk and GPS did not show the presence of any significant relationship (r = -0.04; p > 0.05). Thus, the functional limitation in diplegic children does not seems to be strictly related to Kk.

Trunk movements during gait in cerebral palsy

BACKGROUND

Lower limb deficits have been widely studied during gait in cerebral palsy, deficits in upper body have received little attention. The purpose of this research was to describe the characteristics of trunk movement of cerebral palsy children in terms of type of deficits (diplegia/hemiplegia) and gross motor function classification system (1, 2 or 3).

METHODS

Data from 92 cerebral palsy children, which corresponds to 141 clinical gait analysis, were retrospectively selected. Kinematic parameters of trunk were extracted from thorax and spine angles in the sagittal, transverse and coronal planes. The range of motion and the mean positions over the gait cycle were analysed. Intra-group differences between the children with diplegia or hemiplegia, gross motor function classification systems 1 to 3 and typically developing participants were analysed with Kruskal-Wallis tests and post hoc tests. Pearson correlation coefficients between the gait profile score normalised walking speed and kinematic parameters of the thorax were assessed.

FINDINGS

The results revealed: 1) the range of motion of the thorax and spine exhibited more significant differences between groups than the mean positions; 2) greater levels of impairment were associated with higher thorax range of motion, and 3) the children with diplegia and gross motor function classification system 3 exhibited a greater range of motion for all planes with the exception of spine rotation.

INTERPRETATION

This study confirmed that greater levels of impairment in cerebral palsy are associated with greater thorax range of motion during gait. The thorax plays an important role during gait in cerebral palsy.

Kinematic analysis of upper limb during walking in diplegic children with Cerebral Palsy

Movements of the lower limbs during walking have been widely investigated in literature, while quantification of arm movement during gait is scanty. The aim of the present study was to assess quantitatively the upper limb motion during gait in children with Cerebral Palsy (CP). Sixteen children with diplegic CP were evaluated using a full-body marker set, which allows assessing both the lower and upper limb kinematics. Our results demonstrated that movement of the arms was characterized by an abducted shoulder and a more flexed elbow position at the initial contact of the gait cycle with a quite physiological range of motion if compared to controls. These data showed that gait of children with diplegic CP is generally characterized by abnormal upper limb position which could be considered a strategy to keep balance and posture control during walking.

Sjogren-Larsson syndrome: A case report of a rare disease

We report a case of Sjogren-Larsson syndrome with clinical profile (spastic diplegia, icthyosis, mental retardation) and imaging findings on magnetic resonance imaging.

Tension pneumocephalus with diplegia and deterioration of consciousness

Tension pneumocephalus results from intracranial air under pressure as a rare complication after head injury or craniofacial surgery. A 58-year-old man underwent ethmoid sinus surgery and subsequently developed rapidly progressive global headache, restlessness, diplegia with sensory loss, and deterioration of the conscious level. A head CT demonstrated extensive pneumocephalus with gross compression of the brain. The frontal retention of air caused widening of the interhemispheric fissure leading to a peaked appearance of the frontal poles, referred to as the ‘Mount Fuji sign’. Surgical revision of a dural air leak resulted in rapid improvement and full clinical resolution. Early diagnosis of tension pneumocephalus and emergent surgical treatment are crucial to prevent life-threatening deterioration.