Quantifying lower limb muscle stiffness in typically developing children and adolescents using acoustic radiation force impulse shear wave elastography (ARFI/SWE)-a pilot study

OBJECTIVE

To investigate and quantify age-related changes in lower limb muscle stiffness in typically developing children and adolescents using acoustic radiation force impulse shear wave elastography.

MATERIALS AND METHODS

Shear wave velocities of bilateral rectus femoris, tibialis anterior, and medial gastrocnemius muscles at rest were obtained in typically developing children and adolescents aged 3 to 18 years. The participants were classified into three age groups: Group 1 (children), 3 to 7 years old; Group 2, 8 to 12 (pre-adolescent); and Group 3 (adolescent), 13 to 18. The shear wave velocities of muscle were compared across the three age groups, as well as compared between right- and left-side limbs. The correlation between shear wave velocities and body weight or body mass index was assessed.

RESULTS

Of the 47 participants, 21 were in Group 1, 17 in Group 2, and 9 in Group 3. There were no significant differences among the three age groups' shear wave velocities of bilateral lower limb muscles, and no significant differences between right and left sides. There was no correlation between muscle stiffness and body weight or body mass index.

CONCLUSION

The present pilot study applied acoustic radiation force impulse shear wave elastography to quantify lower limb muscle stiffness in typically developing children and adolescents aged 3 to 18 years, suggesting no marked change in muscle stiffness occurs as they develop.

Visual-motor integration in children with unilateral cerebral palsy: application of the computer-aided measure of visual-motor integration

BACKGROUND

Children with unilateral cerebral palsy (UCP) are encouraged to participate in the regular school curriculum. However, even when using the less-affected hand for handwriting, children with UCP still experience handwriting difficulties. Visual-motor integration (VMI) is a predictor of handwriting quality. Investigating VMI in children with UCP is important but still lacking. Conventional paper-based VMI assessments is subjective and use all-or-nothing scoring procedures, which may compromise the fidelity of VMI assessments. Moreover, identifying important shapes that are predictive of VMI performance might benefit clinical decision-making because different geometric shapes represent different developmental stepping stones of VMI. Therefore, a new computer-aided measure of VMI (the CAM-VMI) was developed to investigate VMI performance in children with UCP and to identify shapes important for predicting their VMI performance.

METHODS

Twenty-eight children with UCP and 28 typically-developing (TD) children were recruited. All participants were instructed to complete the CAM-VMI and Beery-Buktenica Developmental Test of Visual-Motor Integration (Beery-VMI). The test items of the CAM-VMI consisted of nine simple geometric shapes related to writing readiness. Two scores of the CAM-VMI, namely, Error and Effort, were obtained by image registration technique. The performances on the Beery-VMI and the CAM-VMI of children with UCP and TD children were compared by independent t-test. A series of stepwise regression analyses were used to identify shapes important for predicting VMI performance in children with UCP.

RESULTS

Significant group differences were found in both the CAM-VMI and the Beery-VMI results. Furthermore, Error was identified as a significant aspect for predicting VMI performance in children with UCP. Specifically, the square item was the only significant predictor of VMI performance in children with UCP.

CONCLUSIONS

This study was a large-scale study that provided direct evidence of impaired VMI in school-aged children with UCP. Even when using the less-affected hand, children with UCP could not copy the geometric shapes as well as TD children did. The copied products of children with UCP demonstrated poor constructional accuracy and inappropriate alignment. Furthermore, the predictive model suggested that the constructional accuracy of a copied square is an important predictor of VMI performance in children with UCP.

Hybrid QUS Radiomics: A Multimodal-Integrated Quantitative Ultrasound Radiomics for Assessing Ambulatory Function in Duchenne Muscular Dystrophy

BACKGROUND

Duchenne muscular dystrophy (DMD) is a neuromuscular disorder that affects ambulatory function. Quantitative ultrasound (QUS) imaging, utilizing envelope statistics, has proven effective in diagnosing DMD. Radiomics enables the extraction of detailed features from QUS images. This study further proposes a hybrid QUS radiomics and explores its value in characterizing DMD.

METHODS

Patients (n = 85) underwent ultrasound examinations of gastrocnemius through Nakagami, homodyned K (HK), and information entropy imaging. The hybrid QUS radiomics extracted, selected, and integrated the retained features derived from each QUS image for classification of ambulatory function using support vector machine. Nested five fold cross-validation of the data was conducted, with the rotational process repeated 50 times. The performance was assessed by averaging the areas under the receiver operating characteristic curve (AUROC).

RESULTS

Radiomics enhanced the average AUROC of B-scan, Nakagami, HK, and entropy imaging to 0.790, 0.911, 0.869, and 0.890, respectively. By contrast, the hybrid QUS radiomics using HK and entropy images for diagnosing ambulatory function in DMD patients achieved a superior average AUROC of 0.971 (p < 0.001 compared with conventional radiomics analysis).

CONCLUSIONS

The proposed hybrid QUS radiomics incorporates microstructure-related backscattering information from various envelope statistics models to effectively enhance the performance of DMD assessment.

Acoustic radiation force impulse shear wave elastography quantifies upper limb muscle in patients with Duchenne muscular dystrophy

We investigated whether the upper limb muscle stiffness quantified by the acoustic radiation force impulse shear wave elastography (ARFI/SWE) is a potential biomarker for age-related muscle alteration and functional decline in patients with Duchenne muscular dystrophy (DMD). 37 patients with DMD and 30 typically developing controls (TDC) were grouped by age (3-8, 9-11, and 12-18 years). ARFI/SWE measured the biceps and deltoid muscle's shear wave velocities (SWVs). Performance of Upper Limb Module (PUL 1.2 module) assessed muscle function in DMD patients. Mann Whitney test compared muscle SWVs between DMD and TDC, stratified by three age groups. We used analysis of variance with Bonferroni correction to compare muscle SWVs between DMD and TDC and correlated muscle SWVs with PUL results in the DMD group. Results showed that the SWVs of biceps differentiated DMD patients from TDC across age groups. Younger DMD patients (3-8 years) exhibited higher SWVs (p = 0.013), but older DMD patients (12-18 years) showed lower SWVS (p = 0.028) than same-aged TDC. DMD patients had decreasing biceps SWVs with age (p < 0.001), with no such age effect in TDC. The SWVs of deltoid and biceps positively correlated with PUL scores (r = 0.527 ∼ 0.897, P < 0.05) and negatively correlated with PUL timed measures (r = -0.425 ∼ -0.542, P < 0.05) in DMD patients. Our findings suggest that ARFI/SWE quantifying the SWVs in upper limb muscle could be a potential biomarker to differentiate DMD from TDC across ages and that DMD patients showed age-related muscle alteration and limb functional decline.

Assessment for Tactile Perception in Children With Cerebral Palsy

IMPORTANCE

Impaired tactile perception frequently accompanies motor deficits in children with cerebral palsy (CP). Assessing tactile perception precisely for children with CP remains challenging because of a lack of assessments with robust psychometric evidence or standard procedures.

OBJECTIVE

To develop a standardized assessment tool, the Tactile Perceptual Test (TPT), for measuring tactile perception in children with CP and to examine its psychometric properties.

DESIGN

Observational study design.

SETTING

University research laboratory and medical center.

PARTICIPANTS

Children with CP (n = 100) and typical development (TD; n = 50).

OUTCOMES AND MEASURES

The TPT includes four subtests measuring stereognosis, roughness, hardness, and heaviness. Three comparator instruments, Semmes-Weinstein monofilaments, Two-Point Discrimination, and the stereognosis subtest of the Revised Nottingham Sensory Assessment, were used for convergent validity.

RESULTS

Good test-retest reliability was confirmed for all of the TPT subtests. The values of minimal detectable change were acceptable. Moderate correlations between the TPT and comparator instruments were found, as expected. For known-groups validity, the significant difference was confirmed between children with CP and those with TD.

CONCLUSIONS AND RELEVANCE

The TPT is a reliable and valid measure for multiple subdomains of tactile perception in children with CP. This tactile assessment may help clarify tactile performance to provide appropriate, precise interventions. What This Article Adds: The TPT measures tactile perception in children with CP. It has four subdomains of tactile perception that could facilitate prioritization of tactile treatment of specific subdomains and thereby aid in the provision of appropriate interventions.

Effects of Intensive Versus Distributed Constraint-Induced Movement Therapy for Children With Unilateral Cerebral Palsy: A Quasi-Randomized Trial

BACKGROUND

Previous studies have compared the effectiveness of constraint-induced movement therapy (CIMT) by different training doses. However, whether the dosing schedule, that is, intensive or distributed, influences the effectiveness of CIMT in children with unilateral cerebral palsy (CP) is unknown.

OBJECTIVE

To investigate the effectiveness of intensive and distributed CIMT for children with unilateral CP.

METHODS

Fifty children with unilateral CP were assigned to intensive or distributed CIMT group with a total of 36 training hours. The intensive CIMT was delivered within 1 week, and the distributed CIMT was delivered twice a week for 8 weeks. The outcomes were the Melbourne Assessment 2, Box and Block Test, Pediatric Motor Activity Log-Revised (PMAL-R), Bruininks-Oseretsky test of motor proficiency 2, ABILHAND-Kids and Parenting Stress Index-Short Form. The intensive group was assessed at the initiation of treatment (week 0), at the end of 1 week treatment (week 1), and 8 weeks after the initiation of treatment (week 8). The distributed group was assessed at week 0 and week 8.

RESULTS

The within-group analyses demonstrated significant differences on all motor outcomes. There were no significant between-group differences at post-treatment, while the intensive CIMT demonstrated larger improvements than the distributed CIMT did on quality of use of the more-affected hand, as rated by parents on the PMAL-R at week 8.

CONCLUSIONS

The 2 dosing schedules of CIMT had similar effectiveness for children with unilateral CP. The intensive CIMT yielded additional improvement on parent rated motor quality of the more-affected hand at 8 weeks after the initiation of treatment.

TRIAL REGISTRATION

ClinicalTrials.gov (ID: NCT03128385).

Comparative effects of kinect-based versus therapist-based constraint-induced movement therapy on motor control and daily motor function in children with unilateral cerebral palsy: a randomized control trial

BACKGROUND

Constraint-induced movement therapy (CIMT) is a prominent neurorehabilitation approach for improving affected upper extremity motor function in children with unilateral cerebral palsy (UCP). However, the restraint of the less-affected upper extremity and intensive training protocol during CIMT may decrease children's motivation and increase the therapist's workload and family's burden. A kinect-based CIMT program, aiming to mitigate the concerns of CIMT, has been developed. The preliminary results demonstrated that this program was child-friendly and feasible for improving upper extremity motor function. However, whether the kinect-based CIMT can achieve better or at least comparable effects to that of traditional CIMT (i.e., therapist-based CIMT) should be further investigated. Therefore, this study aimed to compare the effects of kinect-based CIMT with that of therapist-based CIMT on upper extremity and trunk motor control and on daily motor function in children with UCP.

METHODS

Twenty-nine children with UCP were recruited and randomly allocated to kinect-based CIMT (n = 14) or therapist-based CIMT (n = 15). The intervention dosage was 2.25 h a day, 2 days a week for 8 weeks. Outcome measures, namely upper extremity and trunk motor control and daily motor function, were evaluated before and after 36-h interventions. Upper extremity and trunk motor control were assessed with unimanual reach-to-grasp kinematics, and daily motor function was evaluated with the Revised Pediatric Motor Activity Log. Between-group comparisons of effectiveness on all outcome measures were analyzed by analysis of covariance (α = 0.05).

RESULTS

The two groups demonstrated similar improvements in upper extremity motor control and daily motor function. In addition, the kinect-based CIMT group demonstrated greater improvements in trunk motor control than the therapist-based CIMT group did (F(1,28) > 4.862, p < 0.036).

CONCLUSION

Kinect-based CIMT has effects comparable to that of therapist-based CIMT on UE motor control and daily motor function. Moreover, kinect-based CIMT helps decrease trunk compensation during reaching in children with UCP. Therefore, kinect-based CIMT can be used as an alternative approach to therapist-based CIMT.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02808195. Registered on 2016/06/21, https://clinicaltrials.gov/ct2/show/NCT02808195 .

Multidimensional Development and Adaptive Behavioral Functioning in Younger and Older Children With Rett Syndrome

OBJECTIVE

The purpose of this study was to examine clinical severity, multidimensional development, and adaptive behavioral functioning in younger and older children with Rett syndrome (RTT) in the pseudostationary stage (stage III).

METHODS

Fourteen younger (≤10 years of age) and 15 older (11-18 years of age) children with confirmed stage III RTT (assigned to young-RTT and old-RTT groups, respectively) participated in this study. Clinical severity was determined using the Clinical Severity Score (CSS) scale for RTT. The children's cognitive, language, motor, and sociocommunicative development was assessed using the Mullen Scales of Early Learning (MSEL) and the Early Social Communication Scale (ESCS). Their adaptive behavioral and daily functional skills were assessed using the Vineland Adaptive Behavior Scales-Chinese version (VABS-C) and Pediatric Evaluation of Disability Inventory-Chinese version (PEDI-C).

RESULTS

Compared with the young-RTT group, the old-RTT group had higher severity of scoliosis on the CSS scale, poorer fine motor scores on the MSEL, reduced eye contact, reduced alternating eye gaze, and reduced turn-taking during social interaction on the ESCS. However, none of the VABS-C or PEDI-C subscale scores differed significantly between the groups. Higher CSSs were significantly correlated with lower scores in several subscales of MSEL, ESCS, VABS-C, and PEDI-C, especially for gross motor, mobility, and socialization functioning in all children with RTT.

CONCLUSION

Age-related differences in fine motor and sociocommunicative skills were observed between the young-RTT and old-RTT group, as measured using standardized assessments. Greater severity of RTT was correlated with poor motor, sociocommunicative, adaptive behavioral, and daily functional skills in stage III RTT.

IMPACT

Practitioners should be aware of clinical severity and the differences of developmental and adaptive behavioral functioning between younger and older children in the pseudostationary stage of RTT to provide specific age-related treatments.

LAY SUMMARY

With an understanding of severity and differences of developmental and adaptive behavioral functioning between younger and older children, clinical professionals can provide specific age-related treatments.

Psychometric Properties of the Little Developmental Coordination Disorder Questionnaire-Taiwan

IMPORTANCE

Early identification of young children at risk of developmental coordination disorder (DCD) can support early intervention and prevent secondary sequelae.

OBJECTIVE

To examine the psychometric properties of a translated and cross-culturally adapted version of the Little Developmental Coordination Disorder Questionnaire-Taiwan (LDCDQ-TW).

DESIGN

Prospective study.

SETTING

Kindergartens and preschools in north, central, and south Taiwan.

PARTICIPANTS

In Phase 1 the participants were 1,124 parents of typically developing children ages 36-71 mo. Children with confirmed developmental diagnoses were excluded. Participants in Phase 3 were 162 children who had been recruited in Phase 2. Outcomes and Measures: The LDCDQ-TW, a 15-item parent questionnaire for identifying children at risk for DCD, and the Movement Assessment Battery for Children (2nd ed.; MABC-2), were administered.

RESULTS

The findings revealed excellent test-retest reliability (intraclass correlation coefficient [ICC] = .97) and poor interrater reliability (ICC = .47). On the basis of MABC-2 scores, the non-DCD group (≥15th percentile) scored significantly higher than the DCD and suspect-DCD groups on the LDCDQ-TW, but the latter two groups did not differ from one another. Using the 15th percentile as a cutoff for both the MABC-2 and the LDCDQ-TW, sensitivity was .96 and specificity was .68.

CONCLUSIONS AND RELEVANCE

Although standardized performance-based assessments are required to confirm a diagnosis of DCD (typically after age 5 yr), the LDCDQ-TW demonstrated sound reliability and validity and can support the early identification of young children at risk of DCD in Taiwan. What This Article Adds: The LDCDQ-TW can facilitate early intervention for DCD and prevent secondary sequelae, improving outcomes for children with DCD.

Measurement properties of the box and block test in children with unilateral cerebral palsy

This study aimed to examine the reliabilities (test-retest reliability and measurement error), construct validity, and the interpretability (minimal clinically important difference) of the Box and Block Test (BBT) to interpret test scores precisely for children with UCP. A total of 100 children with UCP were recruited and 50 children from the whole sample assessed the BBT twice within 2-week interval. The BBT, the Melbourne Assessment 2, the Bruininks-Oseretsky Test of Motor Proficiency, 2nd Edition, and the Pediatric Motor Activity Log Revised were measured before and immediately after a 36-h intensive neurorehabilitation intervention. Measurement properties of the BBT were performed according to the COnsensus-based Standards for the selection of health Measurement INstruments checklist. The test-retest reliability of the BBT was high (intraclass correlation coefficient = 0.98). The measurement error estimated by the MDC₉₅ value was 5.95. Construct validity was considered good that 4 of 4 (100%) hypotheses were confirmed. The interpretability estimated by the MCID ranged from 5.29 to 6.46. The BBT is a reliable and valid tool for children with UCP. For research and clinical applications, an improvement of seven blocks on the BBT is recommended as an indicator of statistically significant and clinically important change.

Quantifying Lower Limb Muscle Stiffness as Ambulation Function Declines in Duchenne Muscular Dystrophy with Acoustic Radiation Force Impulse Shear Wave Elastography

Duchenne muscular dystrophy (DMD) is a progressive muscular disease, but validated imaging tools to quantify muscle microstructure alteration as mobility declines are lacking. We aimed to determine the feasibility of using acoustic radiation force impulse shear-wave elastography (ARFI/SWE) in the quantitative assessment of lower limb muscle stiffness in DMD patients. Shear wave velocities (SWVs) of lower limbs were measured in 39 DMD patients and 36 healthy controls aged 3-20 y. Mean SWV values of the controls and of the DMD patients at different ambulatory stages were compared using analysis of variance with Bonferroni correction. The DMD group had increased lower limb muscle stiffness compared with controls. Stiffness of the tibialis anterior and medial gastrocnemius muscle decreased from ambulatory to early non-ambulatory stages, whereas stiffness of the rectus femoris muscle increased from ambulatory to late non-ambulatory stages. We describe how SWV changes in lower limb muscles have the potential to predict ambulatory decline in DMD.

Deep Learning of Ultrasound Imaging for Evaluating Ambulatory Function of Individuals with Duchenne Muscular Dystrophy

Duchenne muscular dystrophy (DMD) results in loss of ambulation and premature death. Ultrasound provides real-time, safe, and cost-effective routine examinations. Deep learning allows the automatic generation of useful features for classification. This study utilized deep learning of ultrasound imaging for classifying patients with DMD based on their ambulatory function. A total of 85 individuals (including ambulatory and nonambulatory subjects) underwent ultrasound examinations of the gastrocnemius for deep learning of image data using LeNet, AlexNet, VGG-16, VGG-16_TL, VGG-19, and VGG-19_TL models (the notation TL indicates fine-tuning pretrained models). Gradient-weighted class activation mapping (Grad-CAM) was used to visualize features recognized by the models. The classification performance was evaluated using the confusion matrix and receiver operating characteristic (ROC) curve analysis. The results show that each deep learning model endows muscle ultrasound imaging with the ability to enable DMD evaluations. The Grad-CAMs indicated that boundary visibility, muscular texture clarity, and posterior shadowing are relevant sonographic features recognized by the models for evaluating ambulatory function. Of the proposed models, VGG-19 provided satisfying classification performance (the area under the ROC curve: 0.98; accuracy: 94.18%) and feature recognition in terms of physical characteristics. Deep learning of muscle ultrasound is a potential strategy for DMD characterization.

Bimanual motor performance in everyday life activities of children with hemiplegic cerebral palsy

BACKGROUND

Motor impairments in children with cerebral palsy significantly reduce their ability to learn and adapt bimanual actions into their life roles. The current evidence on bimanual coordination performance in children with hemiplegic cerebral palsy were mostly drawn from kinematic studies. Whether these kinematic findings on bimanual motor performance can be observed when performing daily life activities in a natural environment is not clear. Further, there is no evidence what and how the verbal prompting influences bilateral motor performance. We intend to explore its role on bimanual motor performance as well.

AIM

This study aimed to investigate the bimanual motor performance in everyday life activities of children with hemiplegic cerebral palsy and the role of verbal prompts in facilitating affected hand use.

DESIGN

Observational study.

SETTING

Local medical center and community.

POPULATION

Twenty-five children with hemiplegic cerebral palsy and 25 age-matched typically developing children.

METHODS

The Observation-based Test of Capacity, Performance, and Developmental Disregard and Melbourne Assessment 2 were used to assess the quantitative and qualitative use of hands in everyday activities.

RESULTS

Children with hemiplegic cerebral palsy, demonstrated different motor coordination patterns in daily bimanual activities compared with their counterparts. With verbal prompts, children with hemiplegic cerebral palsy significantly increased the use of their affected hands in bimanual activities. However, the increases were observed only in basic motor components, such as reaching and grasping, and not in complex motor components such as manipulation.

CONCLUSIONS

These findings will assist researchers and clinicians to develop and refine intervention programs that maximize rehabilitation benefits in improving bimanual hand coordination performance for children with hemiplegic cerebral palsy.

CLINICAL REHABILITATION IMPACT

This study increased our understanding of bimanual motor performance of children with hemiplegic cerebral palsy in everyday life activities. The results demonstrated children with cerebral palsy rely more on their less-affected hand to perform bimanual activities with or without verbal prompts. Incorporating bimanual activities and verbal prompts during intervention may only be effective on facilitating basic hand movements but not on improving complex movements of affected hands. Further research is needed to explore other intervention strategies to facilitate complex bilateral hand movements.

Commercial Exergaming in Home-Based Pediatric Constraint-Induced Therapy: A Randomized Trial

Constraint-induced therapy (CIT) is highly effective yet not accessible to many families. Integrating commercial exergaming in home-based CIT may support the availability and attainability of the intervention. The study compared the effects of supplementary use of Nintendo Wii in home-based CIT with dose-equivalent conventional CIT. Eighteen children with cerebral palsy were randomly assigned to 8 weeks of CIT (CIT) or 4 weeks of CIT, followed by 4 weeks of Wii-augmented CIT (CIT-Wii). Outcome measures included the Bruininks-Oseretsky Test of Motor Proficiency (Manual Dexterity), the ABILHAND-Kids, the WeeFIM (Self-Care), the Test of Playfulness, the Engagement Questionnaire, and the Parenting Stress Index-Short Form. Both groups significantly improved motor outcomes and playfulness. The CIT group demonstrated greater improvement in self-care skills, whereas parental stress decreased only in the CIT-Wii group. CIT-Wii yields no significant difference in treatment effects from conventional CIT and may provide psychosocial benefits.

Clinical Evaluation of Duchenne Muscular Dystrophy Severity Using Ultrasound Small-Window Entropy Imaging

Information entropy of ultrasound imaging recently receives much attention in the diagnosis of Duchenne muscular dystrophy (DMD). DMD is the most common muscular disorder; patients lose their ambulation in the later stages of the disease. Ultrasound imaging enables routine examinations and the follow-up of patients with DMD. Conventionally, the probability distribution of the received backscattered echo signals can be described using statistical models for ultrasound parametric imaging to characterize muscle tissue. Small-window entropy imaging is an efficient nonmodel-based approach to analyzing the backscattered statistical properties. This study explored the feasibility of using ultrasound small-window entropy imaging in evaluating the severity of DMD. A total of 85 participants were recruited. For each patient, ultrasound scans of the gastrocnemius were performed to acquire raw image data for B-mode and small-window entropy imaging, which were compared with clinical diagnoses of DMD by using the receiver operating characteristic curve. The results indicated that entropy imaging can visualize changes in the information uncertainty of ultrasound backscattered signals. The median with interquartile range (IQR) of the entropy value was 4.99 (IQR: 4.98–5.00) for the control group, 5.04 (IQR: 5.01–5.05) for stage 1 patients, 5.07 (IQR: 5.06–5.07) for stage 2 patients, and 5.07 (IQR: 5.06–5.07) for stage 3 patients. The diagnostic accuracies were 89.41%, 87.06%, and 72.94% for ≥stage 1, ≥stage 2, and ≥stage 3, respectively. Comparisons with previous studies revealed that the small-window entropy imaging technique exhibits higher diagnostic performance than conventional methods. Its further development is recommended for potential use in clinical evaluations and the follow-up of patients with DMD.

Reliability and Validity of the Chinese Version of the Infant/Toddler Sensory Profile

IMPORTANCE

In Chinese-speaking societies, a reliable and valid measure is needed to enable early identification of young children's challenges in sensory processing.

OBJECTIVE

To examine the psychometric properties of the Chinese version of the Infant/Toddler Sensory Profile (ITSP-C) when used with Taiwanese children.

DESIGN

Prospective study.

SETTING

Multiple settings.

PARTICIPANTS

Participants were 367 typically developing (TD) infants ages 0-6 mo (mean [M] age = 3.44 mo, standard deviation [SD] = 1.82) and 677 toddlers ages 7-36 mo (M age = 22.33 mo, SD = 8.15), along with 42 toddlers with developmental disabilities (DD; M age = 28.4 mo, SD = 6.7).

OUTCOMES AND MEASURES

The ITSP, a caregiver questionnaire that measures how children respond to sensory events in daily life, was translated and cross-culturally adapted into a Chinese version (ITSP-C).

RESULTS

Internal consistency was high for the 0-6 mo subscale (α = .80) and the 7-36 mo subscale (α = .82). Test-retest reliability was excellent for the 7-36 mo subscale (intraclass correlation coefficient = .94). Logistic regression analysis demonstrated that the ITSP-C discriminated between children with DD and TD children.

CONCLUSIONS AND RELEVANCE

The ITSP was successfully adapted to Chinese with similar reliability and validity to the original ITSP. The 7-36 mo subscale had a higher level of reliability than the 0-6 mo subscale, and quadrant scores were more reliable than section scores. Moreover, the ITSP-C discriminated children with DD from TD children on the basis of their sensory processing patterns.

WHAT THIS ARTICLE ADDS

The ITSP-C has sound psychometric properties and support for its use in early identification of sensory processing difficulties in young Chinese-speaking children.

Exploring Sensory Processing Dysfunction, Parenting Stress, and Problem Behaviors in Children With Autism Spectrum Disorder

OBJECTIVE

We examined problem behavior in preschool- and school-age children with autism spectrum disorder and assessed whether sensory processing dysfunction (SPD) and parenting stress were differentially associated with problem behaviors in these groups of children.

METHOD

Participants were 101 preschool- and 61 school-age children. An independent t test was used to examine group differences in problem behaviors. Pearson correlation analysis and multiple linear regression were conducted to identify associations among SPD, parenting stress, and problem behaviors.

RESULTS

Preschool children had more social withdrawal than school-age children. Moderately negative correlations were found between SPD and problem behaviors among preschool children. Parenting stress was a factor associated with problem behaviors in both groups, whereas SPD was a factor specific to preschoolers.

CONCLUSION

Understanding unique problem behaviors and the significant role of SPD and parenting stress in problem behaviors could help occupational therapy clinicians plan interventions accordingly.

Preliminary Efficacy of a Friendly Constraint-Induced Therapy (Friendly-CIT) Program on Motor and Psychosocial Outcomes in Children with Cerebral Palsy

AIMS

Constraint-induced therapy (CIT) is effective, but concerns have been repeatedly raised regarding the generalizability, feasibility, and potentially intrusive nature of restraining a child's unimpaired upper limb. We examined the feasibility and efficacy of friendly-CIT, which uses home-based model, a caregiver-determined schedule, and gentle restraint, in children with cerebral palsy.

METHODS

In a one-group pre-post intervention trial, 15 children (median of age = 8 years, 4 months) participated in 8 weeks of friendly-CIT (36 hours). Motor and psychosocial outcomes were investigated.

RESULTS

Participants showed significant improvement on the manual dexterity subtest of the Bruininks-Oseretsky Test of Motor Proficiency (p = 0.004); the how often (p = 0.01) and how well (p = 0.02) scales of the Revised Pediatric Motor Activity Log; and the functional skills score on the Chinese version of the Pediatric Evaluation of Disability Inventory (p = 0.002). For psychosocial outcomes, children with CP consistently demonstrated high engagement and increased playfulness (p < 0.0001) during the 8-week intervention. Parents showed no change in stress status and high satisfaction with friendly-CIT.

CONCLUSION

Friendly-CIT is feasible and promising for improving a child's motor and psychosocial outcomes without increasing parental stress.

Cross-section and feasibility study on the non-invasive evaluation of muscle hemodynamic responses in Duchenne muscular dystrophy by using a near-infrared diffuse optical technique

Duchenne muscular dystrophy (DMD) is an X-linked debilitating muscular disease that may decrease nitric oxide (NO) production and lead to functional muscular ischemia. Currently, the 6-minute walk test (6-MWT) and the North Star Ambulatory Assessment (NSAA) are the primary outcome measures in clinical trials, but they are severely limited by the subjective consciousness and mood of patients, and can only be used in older and ambulatory boys. This study proposed using functional near-infrared spectroscopy (fNIRS) to evaluate the dynamic changes in muscle hemodynamic responses (gastrocnemius and forearm muscle) during a 6-MWT and a venous occlusion test (VOT), respectively. Muscle oxygenation of the forearm was evaluated non-invasively before, during and after VOT in all participants (included 30 DMD patients and 30 age-matched healthy controls), while dynamic muscle oxygenation of gastrocnemius muscle during 6-MWT was determined in ambulatory participants (n = 18) and healthy controls (n = 30). The results reveal that impaired muscle oxygenation was observed during 6-MWT in DMD patients that may explain why the DMD patients walked shorter distances than healthy controls. Moreover, the results of VOT implied that worsening muscle function was associated with a lower supply of muscle oxygenation and may provide useful information on the relationship between muscular oxygen consumption and supply for the clinical diagnosis of DMD. Therefore, the method of fNIRS with VOT possesses great potential in future evaluations of DMD patients that implies a good feasibility for clinical application such as for monitoring disease severity of DMD.

Evaluation of muscular changes by ultrasound Nakagami imaging in Duchenne muscular dystrophy

Duchenne muscular dystrophy (DMD) is the most common debilitating muscular disorder. Developing a noninvasive measure for monitoring the progression of this disease is critical. The present study tested the effectiveness of using ultrasound Nakagami imaging to evaluate the severity of the dystrophic process. A total of 47 participants (40 with DMD and 7 healthy controls) were recruited. Patients were classified into stage 1 (presymptomatic and ambulatory), stage 2 (early nonambulatory), and stage 3 (late nonambulatory). All participants underwent ultrasound examinations on the rectus femoris, tibialis anterior, and gastrocnemius. The results revealed that the ultrasound Nakagami parameter correlated positively with functional severity in the patients with DMD. The median Nakagami parameter of the gastrocnemius muscle increased from 0.50 to 0.85, corresponding to the largest dynamic range between normal and stage 3. The accuracy, sensitivity, and specificity of diagnosing walking function were 85.52%, 76.31%, and 94.73%, respectively. The Nakagami parameter of the rectus femoris and gastrocnemius muscles correlated negatively with the 6-minute walking distance in the ambulatory patients. Therefore, changes in the Nakagami parameter for the gastrocnemius muscle are suitable for monitoring disease progression in ambulatory patients and for predicting ambulation loss. Ultrasound Nakagami imaging shows potential for evaluating patients with DMD.

Developing the Observatory Test of Capacity, Performance, and Developmental Disregard (OTCPDD) for Children with Cerebral Palsy

PURPOSE

The purpose of this study was to develop a reliable and valid instrument, named the Observatory Test of Capacity, Performance, and Developmental Disregard (OTCPDD), for measuring the amount and quality of use of affected upper limb functions in the daily routines of children with CP.

METHODS

Forty-eight participants (24 children with CP and 24 matched typically developing children) were recruited. The OTCPDD was administered twice (the spontaneous use condition first, followed by the forced use condition) on children with CP. Their parents were asked to complete the Pediatric Motor Activity Log-Revised (PMAL-R). The internal consistency, the intrarater and interrater reliabilities, and the convergent and discriminate validities were measured.

RESULTS

The internal consistency (Cronbach's alpha) and the intrarater and interrater reliabilities were higher than 0.9 for all of the OTCPDD scores. The convergent validity was confirmed by significant correlations between the OTCPDD and the PMAL-R. For the discriminant validity, significant differences (p<0.05) were found between children with CP and typically developing children.

CONCLUSIONS

The results support that the OTCPDD is a reliable and valid observation-based assessment. The OTCPDD, which uses bimanual daily living activities, is able to represent the children's general affected hand functions (including capacity, performance, and developmental disregard) in their daily routines.

Developing and Evaluating Medical Humanities Problem-Based Learning Classes Facilitated by the Teaching Assistants Majored in the Liberal Arts: A Longitudinal Crossover Study

Although medical humanities courses taught by teachers from nonmedical backgrounds are not unusual now, few studies have compared the outcome of medical humanities courses facilitated by physicians to that by teaching assistants majored in the liberal arts. The objectives of this study were to (1) analyze the satisfaction of medical students with medical humanities problem-based learning (PBL) classes facilitated by nonmedical teaching assistants (TAF) majored in the liberal arts, and those facilitated by the attending physicians (APF) and (2) examine the satisfaction of medical students with clinical medicine-related and clinical medicine-unrelated medical humanities PBL classes.A total of 123 medical students, randomly assigned to 16 groups, participated in this study. There were 16 classes in the course: 8 of them were TAF classes; and the others were APF classes. Each week, each group rotated from 1 subject of the 16 subjects of PBL to another subject. All of the 16 groups went through all the 16 subjects in the 2013 spring semester. We examined the medical students' satisfaction with each class, based on a rating score collected after each class was completed, using a scale from 0 (the lowest satisfaction) to 100 (the highest satisfaction). We also conducted multivariate linear regression analysis to examine the association between the independent variables and the students' satisfaction.Medical students were more satisfied with the TAF (91.35 ± 7.75) medical humanities PBL classes than APF (90.40 ± 8.42) medical humanities PBL classes (P = 0.01). Moreover, medical students were more satisfied with the clinical medicine-unrelated topics (92.00 ± 7.10) than the clinical medicine-related topics (90.36 ± 7.99) in the medical humanities PBL course (P = 0.01).This medical humanities PBL course, including nonmedical subjects and topics, and nonmedical teaching assistants from the liberal arts as class facilitators, was satisfactory. This pedagogical approach of student-centered, nonmedical topics, nonmedical facilitators, and small groups, which is associated with a deep approach to learning medical humanities, should be highly encouraged.

Evaluating Functional Outcomes of Botulinum Toxin Type A Injection Combined with Occupational Therapy in the Upper Limbs of Children with Cerebral Palsy: A 9-Month Follow-Up from the Perspectives of Both Child and Caregiver

Objective

To assess the effectiveness of combining botulinum toxin type A (BoNT-A) with functional occupational therapy (OT) at 9-month follow-up in children with cerebral palsy (CP) with bilateral upper limb impairments from the perspectives of both child and caregiver.

Methods

Twelve children with CP and their caregivers were assessed across 5 time points over 9 months based on the ICF after BoNT-A injection and functional OT in this open-label study.

Results

Significant differences were found across the 5 time points (p < .05) for both grasp and visual-motor integration with small effects (effect sizes = 0.12–0.24) and the self-care capability and performance of social function (p < .05). However, based on the effect sizes (0.02–0.14), no significant effects were found at the 4 post-test time points. Small effects were found on the psychological domain (effect sizes = 0.25–0.37) and environmental domains (effect size = 0.27) at follow-ups.

Conclusion

Combining a BoNT-A injection with OT not only reduced the muscle tone and increased ROM but also improved the upper limb function and self-care capability in children with CP. More importantly, these effects persisted for up to 9 months. Functional OT extends the effectiveness of a BoNT-A injection.

Long-term prognosis of patients with infantile-onset Pompe disease diagnosed by newborn screening and treated since birth

OBJECTIVE

To determine the benefit of newborn screening for the long-term prognosis of patients with classic infantile-onset Pompe disease (IOPD).

STUDY DESIGN

A cohort of patients with classic IOPD were diagnosed by newborn screening, treated with recombinant human acid α-glucosidase (rhGAA), and followed prospectively. Outcome measurements included survival, left ventricular mass, serum creatinine kinase, motor function, mental development, and systemic manifestations.

RESULTS

Ten patients who presented with left ventricular hypertrophy at diagnosis received rhGAA infusions starting at a median age of 16 days (6-34 days). All patients were cross-reactive immunologic material-positive. After a median treatment time of 63 months (range 28-90 months), all could walk independently, and none required mechanical ventilation. All patients had motor capability sufficient for participating in daily activities, but muscle weakness over the pelvic girdle appeared gradually after 2 years of age. Ptosis was present in one-half of the patients, and speech disorders were common. Anti-rhGAA antibody titers were low (median maximal titer value 1:1600, range: undetectable ∼ 1:12,800).

CONCLUSION

By studying patients treated since birth who have no significant anti-rhGAA antibody interference, this prospective study demonstrates that the efficacy of rhGAA therapy is high and consistent for the treatment of classic IOPD. This study also exposes limitations of rhGAA treatment. The etiology of the manifestations in these early-treated patients will require further study.

Determinants of quality of life in children with cerebral palsy: a comprehensive biopsychosocial approach

This study investigated the determinants of quality of life (QOL) of children with cerebral palsy (CP) considering possible variables comprehensively from a biopsychosocial perspective by adopting the International Classification of Functioning, Disability and Health (ICF) and using a CP-specific QOL questionnaire. A total of 167 children with CP (mean age 9.06 years, SD 2.61 years) and their caregivers participated in this study. Children's QOL was measured by the Cerebral Palsy Quality of Life for Children (CP QOL-Child) - primary caregiver proxy-report form. The potential determinants of QOL were collected based on all ICF dimensions. Results of seven multiple regression models showed that the determinants of QOL in children with CP were multidimensional and biopsychosocial in nature, i.e., encompassing the domains of health condition, body functions and structures, and contextual factors of the ICF. Children's behavioral and emotional problems as well as caregiver's psychological and family-related factors were important determinants of QOL in children with CP. Knowledge of the determinants of QOL could serve as a guide in a holistic approach to evaluation and intervention targeted at these determinants to improve the QOL of children with CP.

Determinants of school activity performance in children with cerebral palsy: a multidimensional approach using the ICF-CY as a framework

This study aimed to identify the determinants of activity performance in children with cerebral palsy (CP) in school by considering factors from the entire scope of the International Classification of Functioning, Disability, and Health for Child and Youth (ICF-CY). A sample of 167 school-aged children with CP and their caregivers were recruited in the study. Activity performance in school settings was assessed with part 3 of the School Functional Assessment - Chinese version, which divides activity performance into performance of physical activities and cognitive/behavioral activities. Possible determinants were collected according to all dimensions of the ICF-CY. Multiple regression analyses showed that the determinants of performance of physical activities were receiving speech therapy in school, diplegia, having a domestic helper, and severity of gross and fine motor impairments, explaining 83% of the total variance; the determinants of performance of cognitive/behavioral activities were intellectual impairment, prosocial behavior, having an assistant in school, educational placement, severity of fine motor impairment, accounting for 73% of the total variance. Results of the study provide clinicians a holistic understanding of factors influencing school activity performance, and enable clinicians to make appropriate evaluations and interventions targeted at the determinants to enhance children's activity performance in school.

A Home-Based Program Using Patterned Sensory Enhancement Improves Resistance Exercise Effects for Children With Cerebral Palsy

Background. Neurologic music therapy has demonstrated improved walking performance in persons with neurologic disease; however, little evidence supports the use of music with functional resistance exercise to improve motor capacity and daily functions for children with cerebral palsy. Objective. To investigate the effect of additional patterned sensory enhancement (PSE) music combined with exercise for children with spastic diplegia. Methods. An assessor-blind, randomized controlled trial with 6- and 12-week follow-ups was carried out. Thirty-six children with spastic diplegia, aged 5 to 13 years, were assigned to a PSE group (n = 18) or a no-music group (n = 18). Both groups received 6-week, home-based, loaded sit-to-stand exercise, but only the PSE group exercised with prerecorded PSE music. The primary outcome was Gross Motor Function Measure (GMFM). Secondary outcomes included Pediatric Evaluation of Disability Inventory (PEDI) mobility and self-care domains, 1-repetition maximum of sit-to-stand, and walking speeds. Results. Three children did not complete the program. Intention-to-treat analysis showed both groups improved in GMFM D, E, and Goal dimensions; Functional Skills Scales of PEDI mobility domain; and 1-repetition maximum of sit-to-stand at posttest and follow-ups ( P ≤ .005). The PSE group improved significantly greater than the no-music group in the GMFM D and Goal dimensions ( P < .005) after training, and the improvement persisted for at least 6 or 12 weeks ( P ≤ .013). No significant improvements in the rest PEDI scales and walking speeds were found. Conclusions. Adding neurologic music therapy to functional resistance exercise could induce greater improvements in gross motor capacity for children with cerebral palsy.

The Cerebral Palsy Quality of Life for Children (CP QOL-Child): evidence of construct validity

The Cerebral Palsy Quality of Life for Children (CP QOL-Child) is the first health condition-specific questionnaire designed for measuring QOL in children with cerebral palsy (CP). However, its construct validity has not yet been confirmed by confirmatory factor analysis (CFA). Hence, this study assessed the construct validity of the caregiver proxy-report version of the Chinese version of the CP QOL-Child in children with CP using CFA. A total of 312 children with CP (mean age: 8.59 years, SD: 2.52 years) and their caregivers participated in this study. The Chinese version of the CP QOL-Child was completed by the caregivers of children with CP. Then, CFA was applied to evaluate the seven-factor measurement structure of the CP QOL-Child. The seven-factor CFA model had an adequate fit to our data as judged by χ(2) statistic and various goodness-of-fit (GOF) indices, including the root mean square error of approximation (RMSEA). This study provided empirical evidence of the construct validity of the CP QOL-Child to support its use with children with CP in the Chinese speaking society.

BALANCE CONTROL DURING LEVEL WALKING IN CHILDREN WITH SPASTIC DIPLEGIC CEREBRAL PALSY

Children with cerebral palsy (CP) have been reported to have various levels of deficits in balance control, which can be described using the relationship between the body's centre of mass (COM) and the centre of pressure (COP). This study aimed to investigate the balance control of children with spastic diplegic CP during level walking. The COM-COP inclination angles and angular velocities, as well as temporal-spatial variables from 12 children with spastic diplegic CP (seven girls and five boys, aged 12.4 ± 4.4 years) and 12 normal controls (eight girls and four boys, aged 11.2 ± 4.4 years) were obtained using a motion analysis system and two forceplates. With compromised balance control as a result of neuromusculoskeletal pathologies, the CP group walked with reduced walking speed and stride length (p < 0.05), but increased stride time and step width (p < 0.05), indicating reduced gait efficiency. They also showed significantly reduced anterioposterior COM-COP inclination angles and angular velocities (p < 0.05), but increased mediolateral COM-COP inclination angles and angular velocities (p < 0.05) when compared to the normal controls. The latter phenomenon may be related to an increased risk of falling in these patients. Therefore, it appears that programs and/or devices for preventing falls are needed for children with spastic diplegic CP.

The determinants of daily function in children with cerebral palsy

The aim of this study was to identify determinants of daily function in a population-based sample of children with cerebral palsy (CP). The study took into consideration factors from the entire scope of the International Classification of Functioning, Disability, and Health (ICF). Furthermore, the determinants of daily function were examined from the perspectives of capacity and performance respectively. A total of 216 children with CP (mean age 8.19 years, SD 3.39 years) and their caregivers participated in the study. The potential determinants of daily function from the dimensions of health condition, body functions and structures, environmental and personal factors of the ICF were collected. Stepwise multiple regression models showed that child's age, grade, preferred hand, educational placement, severity of gross and fine motor impairment, and prosocial behavior were important determinants, accounting for 88.29% of the variance of daily capacity. The aforementioned variables together with birth order were determinants of performance of daily function, and accounted for 89.53% of the variance in that performance. Knowledge of determinants of daily function helps clinicians and educators to plan intervention and educational programs targeted at these determinants to improve capacity and performance in daily function for children with CP.

Human chorionic gonadotropin up-regulates expression of myeloid cell leukemia-1 protein in human granulosa-lutein cells: implication of corpus luteum rescue and ovarian hyperstimulation syndrome

CONTEXT

The corpus luteum is a dynamic endocrine structure with periodic development and regression during menstrual cycles. Its lifespan can be prolonged by human chorionic gonadotropin (hCG). However, the signal mechanisms of this phenomenon remain unclear.

OBJECTIVE

Our objective was to investigate the molecular mechanisms of hCG in the maintenance of the viability of granulosa-lutein cells.

DESIGN

Granulosa-lutein cells were obtained from women undergoing in vitro fertilization. We examined the effects of hCG on the survival of cultured granulosa-lutein cells. The signal pathway inducing antiapoptotic protein was investigated.

RESULTS

hCG enhanced viability of granulosa-lutein cells through antiapoptosis but not proliferation, because the apoptotic marker of annexin V was decreased, but the proliferative markers of Ki67 and proliferating cell nuclear antigen were not increased. Myeloid cell leukemia-1 (Mcl-1) protein, but not B-cell lymphoma protein-2 or B-cell lymphoma protein-xL, was significantly induced by hCG and LH. The granulosa-lutein cells secreted vascular endothelial growth factor that induced endothelial permeability. Mcl-1 small interfering RNA increased DNA fragmentation and diminished the antiapoptotic effect of hCG. hCG induced Mcl-1 expression through the LH/hCG receptor, adenylate cyclase, protein kinase A, and cAMP response element-binding protein signal pathway. Flavopiridol inhibited Mcl-1 production, released cytochrome c, and induced apoptosis of granulosa-lutein cells.

CONCLUSIONS

We first demonstrate that hCG prevents apoptosis of granulosa-lutein cells through the induction of Mcl-1 protein via the LH/hCG receptor and a cAMP response element-binding protein-dependent pathway. We may have found the molecular mechanism for luteal rescue during early pregnancy. Mcl-1 prevents apoptosis and increases cell viability but not proliferation as mechanisms for luteal rescue. Mcl-1 is a key molecule of hCG signaling.

Development of walking in preterm and term infants: age of onset, qualitative features and sensitivity to resonance

An increasing number of studies have examined the development of walking in preterm infants; however, the results concerning those who had no major neonatal disease were inconclusive. This study was therefore aimed to examine the age of onset, the quality of early walking movement, and the sensitivity to resonant period of the force-driven harmonic oscillator (FDHO) model in preterm infants who had no major neonatal disease and normal term infants. Twenty-nine preterm infants and 29 term infants were prospectively examined for their age of onset of independent walking and were subsequently assessed the qualitative features of walking at 18 months of corrected age using kinematic analysis. Kinematic variables examined included spatio-temporal organization, inter-joint coordination, and inter-limb coordination. The anthropometric data were used to calculate the resonant period. The results demonstrated that the preterm infants attained independent walking at significantly older ages than the term infants when corrected for prematurity. The preterm infants manifested similar walking characteristics, except for shorter stride lengths, at 18 months of corrected age compared with the term infants. Furthermore, the stride periods of both groups were accurately predicted by the resonant period of the FDHO model. We conclude that preterm birth without accompanied major neonatal disease may affect infants' age of onset and spatial organization but not their sensitivity to resonance during the early stage of walking development.

Role of Sonographic Examination in Traumatic Knee Internal Derangement

OBJECTIVES

To define the accuracy (compared with magnetic resonance imaging [MRI]) of sonographic examination in detecting knee effusion and to determine whether the presence of knee effusions in patients with traumatic knee injury can predict knee internal derangement as assessed by MRI.

DESIGN

Prospective study.

SETTING

Hospital rehabilitation department.

PARTICIPANTS

Thirty patients (19 men, 11 women) with traumatic knee injury were recruited. Subjects received sonographic examination and MRI on the same day.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

The presence or absence of knee effusion was assessed by sonographic examination. MRI was used as criterion standard to evaluate whether the presence of knee effusion and internal derangement, which included tear of anterior and posterior cruciate ligaments, as well as meniscus tear.

RESULTS

The sensitivity of sonographic examination for detecting knee effusion was 79.1%, and specificity was 50%. The positive-predictive value (PPV) was 86.3% and negative-predictive value (NPV) was 37.5%. The PPV of sonographic effusion to internal derangement was 90.9%, and the NPV was 37.5%.

CONCLUSIONS

Sonographic examination can accurately detect effusion of the knee. The detection of knee effusion in patients with traumatic knee injury by sonographic examination is highly indicative of internal knee derangement.

A protocol of electroejaculation and systematic assisted reproductive technology achieved high efficiency and efficacy for pregnancy for anejaculatory men with spinal cord injury

OBJECTIVE

To help anejaculatory men with spinal cord injury (SCI) to procreate.

DESIGN

Prospective, clinical study.

SETTING

A team of physiatrists, urologists, and gynecologists at a university hospital in Taiwan.

PARTICIPANTS

Ten infertile men with SCI seen at our hospital between 1995 and 2001.

INTERVENTIONS

Electroejaculation induced their seminal emission. Depending on semen parameters, the couples were treated with intrauterine insemination (IUI), intracytoplasmic sperm injection (ICSI), surgical retrieval of sperm, cryopreservation of sperm, or donor sperm.

MAIN OUTCOME MEASURES

Fertilization and pregnancy.

RESULTS

Ten couples underwent assisted reproductive technology (ART). One couple achieved pregnancy after the second cycle of electroejaculation and IUI. Seven couples underwent 8 cycles of ICSI, 4 cycles with fresh electroejaculates, 2 with cryopreserved samples, and 2 with cryopreserved samples with addition of pentoxifylline. Seven (88%) clinical pregnancies were achieved, 2 of which ended with spontaneous abortion. One couple accomplished pregnancy by ICSI with cryopreserved sperm from vasal aspiration. The percentages of fertilization and pregnancy of ICSI cycles using sperm from men with SCI were comparable to men without SCI. One couple attained pregnancy by using donor sperm. The cumulative successful pregnancy rate per couple was 80% (8/10).

CONCLUSION

Electroejaculation and systematic ART are highly efficient for achieving pregnancy with the spouses of men with SCI. The neurologic deficit and electroejaculation did not affect the outcome of ICSI. Using cryopreserved sperm for ICSI may reduce risk from electroejaculation or surgery.

Axotomy along with hypoxia enhances the neuronal NADPH-d/NOS expression in lower brain stem motor neurons of adult rats

This study was aimed to determine whether axotomy coupled with hypoxia would exert a more profound effect on injury-induced neuronal nitric oxide synthase (NOS) expression. In this connection, the vagus and the hypoglossal nerves of adult rats were transected unilaterally in the same animal, and half of the operated animals were subjected to hypoxia treatment. Both the neuronal NOS immunohistochemistry and the nicotinamide adenine dinucleotide phosphate-diaphorase (NADPH-d) histochemistry were used to assess the neuronal NOS expression. The present results have shown that the number of NADPH-d/NOS-positive [NADPH-d/NOS(1)] neurons in the hypoglossal nucleus (HN) peaked at 14 days after axotomy, while that in dorsal motor nucleus of vagus (DMN) and nucleus ambiguus (NA) was progressively increased up to 60 days. The up-regulation of NADPH-d/NOS in HN and DMN was more pronounced in hypoxic than in normoxic animals, a feature that was not evident in the NA. Quantitative analysis showed that the number of surviving motoneurons in normoxic animals was significantly higher than those subjected to hypoxia at 14 days postaxotomy in HN and at all postaxotomy time points in DMN. The difference may be attributed to their different functional components. Since O2 deprivation leads to poor cellular function, the stronger expression of NADPH-d/NOS and the more drastic neuronal loss following nerve transection in the hypoxic animals compared with the controls suggest that hypoxia plays an important role in peripheral neuropathies in which NO is implicated.

The distribution and characterization of NADPH-d/NOS-IR neurons in the rat cuneate nucleus

Nicotinamide adenine dinucleotide phosphate-diaphorase (NADPH-d) histochemistry and nitric oxide synthase (NOS) immunohistochemistry have been used to characterize the nitric oxide (NO)-containing neurons in the rat cuneate nucleus. The present results showed that NADPH-d-positive/NOS-immunoreactive (-IR) neurons were distributed in the entire rostrocaudal extent of the nucleus. In the caudal region (approximately 1-2 mm caudal to the obex), NADPH-d/NOS-IR neurons were aggregated along the dorsal area of the nucleus notably in the lateral aspect. When traced rostrally, labeled neurons were progressively reduced and the cells were randomly distributed. The labeled neurons varied from round, ovoid to spindle-shaped with a mean profile area of about 140.1+/-1.7 microm(2) (n=720). They made up 7-10% of the neuronal population in the cuneate nucleus. By immunoelectron microscopy, the immunoreaction product was deposited throughout the cytoplasm extending from the soma to the proximal and distal dendrites. Results of NADPH-d staining paralleled that of NOS immunohistochemistry. Furthermore, NADPH-d reactivity and NOS-IR were colocalized in the same neurons following double labeling. Using NADPH-d histochemistry along with anti-gamma-aminobutyric acid (GABA) and -glycine postembedding immunolabeling for identification of GABA- and glycine-IR neurons, respectively, about 33% of the NADPH-d-positive neurons contained both GABA and glycine, 26% of them contained only glycine, while 41% of them showed neither GABA nor glycine labeling. Cuneothalamic neurons (CTNs) were identified by injecting the retrograde tracer Fluorogold (FG) into the ventrobasal complex of the thalamus. Numerous FG-labeled neurons were present in the contralateral cuneate nucleus, but none were reactive for NADPH-d. The present results suggest that approximately 60% of the NADPH-d/NOS-IR neurons in the cuneate nucleus are interneurons containing GABA and/or glycine.

Afferent synaptic contacts on glycine-immunoreactive neurons in the rat cuneate nucleus

This study was aimed to clarify whether the primary afferent terminals (PATs), GABAergic terminals, and glutamatergic terminals made direct synaptic contacts with glycine-IR neurons in the cuneate nucleus of rats. In this connection, injection of the anterograde tracer WGA-HRP into brachial plexus, antiglycine preembedding immunoperoxidase, and anti-GABA, along with antiglutamate postembedding immunogold labeling, were used to identify the PATs, glycine-IR neurons, GABA-IR terminals, and glutamate-IR terminals, respectively. The present results showed that HRP-labeled PATs, immunoperoxidase-labeled glycine-IR terminals, immunogold-labeled GABA-IR, and glutamate-IR terminals made axodendritic synaptic contacts with immunoperoxidase-labeled glycine-IR neurons. The latter three presynaptic elements also formed axosomatic synapses with glycine-IR neurons. Statistical analysis has shown that the minimum diameter of the glycine-IR dendrites postsynaptic to the above-mentioned four presynaptic elements did not differ significantly. In addition, the synaptic ratio of the glutamate-IR terminals on the glycine-IR dendrites was higher than that of GABA-IR terminals. The synaptic ratio of the GABA-IR terminals on glycine-IR dendrite was in turn higher than that of the PATs and glycine-IR terminals. It is suggested that the PATs and glutamate-IR terminals on the glycine-IR neurons may be involved in subsequent postsynaptic inhibition for spatial precision of lateral inhibition. On the other hand, the GABA-IR and glycine-IR terminals which make synaptic contacts with the dendrites of glycine-IR neurons may provide a putative means for disinhibition or facilitation to maintain the baseline neuronal activity in the rat cuneate nucleus. The results of quantitative analysis suggest that glutamate act as the primary excitatory neurotransmitter, while GABA, when compared with glycine, may serve as a more powerful inhibitory neurotransmitter on glycine-IR neurons in the rat cuneate nucleus.

Somatic noxious mechanical stimulation induces Fos expression in the postsynaptic dorsal column neurons in laminae III and IV of the rat spinal dorsal horn

This study was conducted to ascertain the possible expression of Fos-like immunoreactivity (Fos-LI) in the postsynaptic dorsal column (PSDC) neurons in response to noxious mechanical stimulation of the forepaw glabrous area of normal rats. For this purpose, Fos immunohistochemistry along with Fluoro-Gold (FG) retrograde tracing was utilized. After repeated noxious pinching of the forepaw glabrous area, there was a marked increase in number of Fos-LI neurons in the dorsal horn, including Rexed's laminae III and IV, at C5-T1 spinal cord segments ipsilateral to the stimulation. Between segments C5 and T1, about 40% of the Fos-LI neurons in laminae III and IV were distributed at segment C7. In the rats subjected to the noxious pinch coupled with FG injection into the right cuneate nucleus, PSDC neurons double labeled with Fos and FG were localized in the ipsilateral laminae III and IV extending from segment C5 to T1, with about 70% of them distributed at segments C6 and C7. At segment C6 or C7, double-labeled neurons made up about 10% of the PSDC neurons that projected their axons to the cuneate nucleus. Most of the double-labeled neurons appeared fusiform with their primary dendrites projected dorso-ventrally. The present results suggest that the morphologically distinct, subclasses of PSDC neurons in spinal laminae III and IV may contribute to the central transmission of mechanical nociceptive information through the dorsal column into the cuneate nucleus.

A beta-fiber intensity stimulation of chronically constricted median nerve induces c-fos expression in thalamic projection neurons of the cuneate nucleus in rats with behavioral signs of neuropathic pain

This study was aimed to investigate the possible involvement of neurons in the cuneate nucleus (CN) in the processing of A beta afferent inputs evoked by electrical stimulation of constricted median nerve in rats with behavioral signs of neuropathic pain. Immunohistochemical localization of Fos protein was used to examine the neuronal activation, and the combination of Fos immunohistochemistry with the retrograde labeling of Fluoro-Gold (FG) injected into the ventrobasal complex of the thalamus was used to characterize the activated neurons. Two weeks after unilateral median nerve constriction injury, the rats exhibited behavioral signs of neuropathic pain in the affected forepaws. In rats after nerve injury but without electrical stimulation, some Fos-like immunoreactive (Fos-LI) neurons were detected in the dorsal horn of the seventh cervical segment (C7) but none was found in the CN. Similar features were also noted when the stimulation of the intact median nerve served as an additional control. After A beta-fiber intensity stimulation of the previously constricted median nerve, an increase in number of Fos-LI neurons occurred in the medial half of the ipsilateral C7 dorsal horn as well as in the ipsilateral CN. In the latter, the Fos-LI neurons were located in the median nerve projection territory throughout the nucleus. Most of the Fos-LI neurons were distributed in the middle region of the CN, with about 78% of them emitting FG fluorescence indicating that they were cuneothalamic projection neurons. The results of this study suggest that the dorsal column-medial lemniscal system may contribute to the transmission and modulation of A beta-fiber mediated neuropathic pain signals.

Cadaveric study of blood supply to the lower intraorbital fat: etiologic relevance to the complication of anaerobic cellulitis in orbital floor fracture

BACKGROUND AND PURPOSE

Although orbital fractures are common, orbital cellulitis rarely develops following orbital fracture. We hypothesized that compromise of the blood supply to the intraorbital fat during orbital floor fracture is responsible for this condition. The purpose of this study was to determine whether or not the lower intraorbital fat is supplied by a branch of the infraorbital artery along the orbital groove or canal on the orbital floor.

MATERIALS AND METHODS

We dissected 14 orbits from seven fixed human cadavers and 12 orbits from six fresh cadaver heads following dye injection into the maxillary artery. The sites of dye-filled vessels branching from the infraorbital artery supplying the lower intraorbital fat were measured and plotted on a two-dimensional orbital floor graph.

RESULTS

A main branch of the infraorbital artery rose through the medial orbital floor to supply the lower intraorbital fat in all of the cadaver orbits. The sites of the branching point of the vessel ranged from 0 to 5 mm (mean, 2.2 mm; n = 14) medial to the line connecting the infraorbital foramen and the infraorbital groove. The shortest distance measured from the branching point to the orbital rim ranged from 3 to 20 mm (mean, 14.1 mm; n = 14). This suggests that if orbital fracture were to occur around the infraorbital groove or canal, this vascular pedicle would be in danger of being incarcerated by bone fragments.

CONCLUSION

Our cadaveric investigation revealed that the lower intraorbital fat is supplied by a branch of the infraorbital artery along the infraorbital groove or canal on the orbital floor. This finding suggests that compromised blood supply to the intraorbital fat may cause anaerobic cellulitis or enophthalmos.

Somatostatin-IR neurons are a major subpopulation of the cuneothalamic neurons in the rat cuneate nucleus

This study was aimed to localize and characterize the somatostatin-immunoreactive (SOM-IR) neurons in the rat cuneate nucleus (CN). By immuno-histochemistry, the SOM-IR neurons, which were widely distributed in the nucleus, were round, spindle or multiangular in shape (mean area = 226.1 +/ -3.1 microm(2), n = 1016). By electron microscopy, the neurons shared all the ultrastructural features of the cuneothalamic neurons (CTNs) which showed a slightly indented nucleus and a fairly rich cytoplasm containing well-developed Golgi apparatuses and rough endoplasmic reticulum (rER). The SOM immunoreaction product filled the cytoplasm of the neurons extending from the soma to the proximal and distal dendrites, which were postsynaptic to unlabeled boutons. In addition to soma and dendrites, SOM-IR boutons were also identified which made axodendritic synaptic contacts with SOM-IR dendrites. The SOM-IR neurons were characterized by using anti-SOM pre-embedding immunolabeling coupled with horseradish peroxidase (HRP) retrograde method, or SOM immunolabeling along with anti-glutamate, gamma-aminobutyric acid (GABA) or glycine post-embedding immunolabeling for identification of CTNs, glutamate-IR, GABA-IR and glycine-IR neurons, respectively. It was shown that more then 80% of the CTNs contained SOM and, furthermore, they contained glutamate but not GABA or glycine. On the basis of present findings, it is suggested the majority of the SOM-IR neurons in the rat CN are CTNs and that they may be involved in modulation of somatosensory synaptic transmission.

Cuneothalamic relay neurons are postsynaptic to glycine-immunoreactive terminals in the rat cuneate nucleus

This study was aimed to clarify whether the cuneothalamic relay neurons (CTNs) in the rat cuneate nucleus contained glycine or whether the neurons were modulated directly by presynaptic glycine-IR terminals. For this purpose, retrograde transport of wheat germ agglutinin conjugated with horseradish peroxidase (WGA-HRP) and immunoperoxidase labelling for glycine have been used to ascertain if the CTNs in the rat are glycine-immunoreactive (glycine-IR). Our results have shown that the WGA-HRP-labelled CTNs (mean area = 318 +/- 6.5 microm(2)) were not reactive for glycine. Glycine immunoreactivity, however, was localized in some small-sized neurons (mean area = 210 +/- 6.2 microm(2)) and axon terminals associated with the CTNs. The synaptic organization between the glycine-IR terminals and CTNs was further analyzed using anti-glycine postembedding immunogold labelling. By electron microscopy, the immunogold-labelled glycine-IR terminals containing pleomorphic synaptic vesicles formed symmetrical synaptic contacts with the dendrites, dendritic spines, and somata of CTNs. Quantitative estimation showed that the mean ratios of glycine-IR terminals to total terminals associated with the soma, proximal dendrites and distal dendrites of the CTN were 49.5, 45.2, and 45.8%, respectively. The higher incidence of glycine-IR terminals on the soma, however, was not significantly different from that of the proximal and distal dendrites. Notwithstanding the above, this study has shown a large number of glycine-IR terminals making direct synaptic contacts with CTNs, suggesting that glycine is one of the important neurotransmitters involved in postsynaptic inhibition on the cuneothalamic relay neurons to modulate incoming somatosensory information from forelimb areas in the rat.

Melatonin attenuates neuronal NADPH-d/NOS expression in the hypoglossal nucleus of adult rats following peripheral nerve injury

Oxidative stress and massive production of nitric oxide (NO) have been implicated in the neuropathogenesis following peripheral nerve injury. This study was aimed to ascertain whether melatonin would exert its neuroprotective effect on the lesioned hypoglossal neurons after peripheral axotomy, since it is known to reduce the oxidative damage in a variety of experimental neuropathologies in which NO is involved. Right-sided hypoglossal nerve transection was performed in adult rats following which the animals were given two different doses of melatonin administered intraperitoneally for 3, 7, 14, 21 and 30 successive days. Nicotinamide adenine dinucleotide phosphate-diaphorase (NADPH-d) histochemistry and neuronal nitric oxide synthase (nNOS) immunohistochemistry were carried out to detect the neuronal NADPH-d/NOS expression in the hypoglossal nucleus (HN). At various time intervals following axotomy, the neurons in the affected HN were induced to express NADPH-d/NOS reactivity on the lesioned side peaking at 14 days. However, the enzyme expression was markedly depressed by melatonin treatment in a dose-dependent manner in terms of frequency of labelled neurons and staining intensity. It is suggested that the suppressive effect of melatonin on NADPH-d/NOS expression may be attributed to its antioxidant properties. Hence, in consideration of therapeutic strategies for reducing the oxidative stress following peripheral nerve injury, melatonin may prove to be beneficial.

Noninvasive assessment of the viscoelasticity of peripheral arteries

Currently used methods of examining the mechanical properties of blood vessel walls are either indirect or invasive, or measure vessel diameter and pressure waveforms at different sites. We developed a noninvasive technique to assess the mechanical properties and viscoelasticity of peripheral arteries. The pressure-strain elastic modulus (Ep) and the viscoelastic properties (energy dissipation ratio, EDR) of the common carotid artery (CCA), brachial artery (BA), radial artery (RA) and dorsalis pedis artery (DPA) were determined by means of palpating pressure and diameter distension waveforms extracted from high-resolution ultrasonography. The methodology was validated in vitro using an elastic tube phantom, as well as in vivo. In vivo study in 10 healthy volunteers (mean age 22 y) showed that the pressure-diameter curves were nonlinear, with an inflection at about 85-90 mmHg, and routed clockwise with slight hysteresis. The CCA (n = 5) had a mean diameter of 6.74 mm and the pulsatile diameter distension was 12.2%. The Ep calculated at the CCA was 0.44 x 10(6) dyne/cm2 with an EDR of 7.18%. The BA, RA and DPA (n = 10) had mean diameters of 3.91 mm, 2.21 mm and 2.12 mm; arterial strains of 4.60%, 4.25% and 8.91%; mean Ep of 1.39, 1.45, 0.90 x 10(6 )dyne/cm2; and mean EDRs of 6.34%, 6.15% and 5.60%, respectively. The method presented is relatively simple to implement clinically and has potential as a new diagnostic tool for detecting local vascular changes.