Amichai Brezner

Visual assessment in children with cerebral palsy: implementation of a functional questionnaire

Aim  The aim of this study was to evaluate an interdisciplinary visual assessment for multiply challenged children diagnosed with cerebral palsy (CP).

Spinal cord ultrasonography in children with myelomeningocele

Secondary tethering of the spinal cord in people with myelomeningocele (MMC) is almost universal but there is a relatively low incidence of the secondary tethered cord syndrome (S‐TCS). In view of this, we wish to explore the notion that cord pulsation, as demonstrated by ultrasound of the spinal cord, can become an independent measure for increased tension of the spinal cord in patients with MMC. One‐hundred and six patients with MMC underwent ultrasonographic examination of their back, a thorough physical examination, and a careful review of their clinical history. Of these patients, 53 had MRI of their back. Cord pulsation was graded and the statistical relation between pulsation and various clinical and MRI findings was analysed. Age and arm span were not correlated with grades of cord pulsation. The absence of cord pulsation correlated with the presence of symptoms but this relation may be explained by MRI findings of certain structural cord malformations and not by tethering per se. Assuming that cord pulsation is a reliable marker for the tension within the spinal cord, the results of our study suggest that overstretching of the cord is not the main cause for the development of the S‐TCS.

Serum Biochemical Markers for Brain Damage in Children with Emphasis on Mild Head Injury

Despite the high incidence of mild pediatric head injuries, only within the past few years has there been increased interest and research in this area. This interest began when the findings from research done in adult patients showed that the effects of mild closed head injuries could interfere significantly with higher cognitive functioning, which impacted daily activities and employment. Traumatic brain injury (TBI) often involves a combination of mechanical trauma and local hypoxemia, on which serum biomarker concentrations may provide critical therapeutic data to time the brain injury. Biochemical serum markers after TBI may be used as a source for the identification of the injury, the extent of the injury and the time of its occurrence, and even for identifying its most likely outcome. This article discusses current research and theories regarding biochemical serum markers in brain injury with an emphasis on their impact on and utility in mild head injury in children.

Deficit in implicit motor sequence learning among children and adolescents with spastic cerebral palsy.

Skill learning (SL) is learning as a result of repeated exposure and practice, which encompasses independent explicit (response to instructions) and implicit (response to hidden regularities) processes. Little is known about the effects of developmental disorders, such as Cerebral Palsy (CP), on the ability to acquire new skills. We compared performance of CP and typically developing (TD) children and adolescents in completing the serial reaction time (SRT) task, which is a motor sequence learning task, and examined the impact of various factors on this performance as indicative of the ability to acquire motor skills. While both groups improved in performance, participants with CP were significantly slower than TD controls and did not learn the implicit sequence. Our results indicate that SL in children and adolescents with CP is qualitatively and quantitatively different than that of their peers. Understanding the unique aspects of SL in children and adolescents with CP might help plan appropriate and efficient interventions.

Parents and teachers reporting on a child’s emotional and behavioural problems following severe traumatic brain injury (TBI): The moderating effect of time

Abstract Background: Gathering information from parents and teachers following paediatric traumatic brain injury (TBI) has substantial clinical value for diagnostic decisions. Yet, a multi-informant approach has rarely been addressed when evaluating children at the chronic stage post-injury. In the current study, the goals were to examine (1) differences between parents’ and teachers’ reports on a child’s emotional and behavioural problems and (2) the effect of time elapsed since injury on each rater’s report. Methods: A sample of 42 parents and 42 teachers of children following severe TBI completed two standard rating scales. Receiver Operating Characteristic (ROC) curves were used to determine whether time elapsed since injury reliably distinguished children falling above and below clinical levels. Results: Emotional–behavioural scores of children following severe TBI fell within normal range, according to both teachers and parents. Significant differences were found between parents’ reports relatively close to the time of injury and 2 years post-injury. However, no such differences were observed in teachers’ ratings. Conclusions: Parents and teachers of children following severe TBI differ in their reports on a child’s emotional and behavioural problems. The present study not only underscores the importance of multiple informants, but also highlights, for the first time, the possibility that informants’ perceptions may vary across time.

Cognitive procedural learning among children and adolescents with or without spastic cerebral palsy: the differential effect of age.

INTRODUCTION Children learn to engage their surroundings skillfully, adopting implicit knowledge of complex regularities and associations. Probabilistic classification learning (PCL) is a type of cognitive procedural learning in which different cues are probabilistically associated with specific outcomes. Little is known about the effects of developmental disorders on cognitive skill acquisition. METHODS Twenty-four children and adolescents with cerebral palsy (CP) were compared to 24 typically developing (TD) youth in their ability to learn probabilistic associations. Performance was examined in relation to general cognitive abilities, level of motor impairment and age. RESULTS Improvement in PCL was observed for all participants, with no relation to IQ. An age effect was found only among TD children. CONCLUSIONS Learning curves of children with CP on a cognitive procedural learning task differ from those of TD peers and do not appear to be age sensitive.

The effect of age-at-testing on verbal memory among children following severe traumatic brain injury

Memory deficits are a common sequelae following childhood traumatic brain injury (TBI), which often have serious implications on age-related academic skills. The current study examined verbal memory performance using the Rey Auditory Verbal Learning Test (RAVLT) in a pediatric TBI sample. Verbal memory abilities as well as the effect of age at-testing on performance were examined. A sample of 67 children following severe TBI (age average = 12.3 ± 2.74) and 67 matched controls were evaluated using the RAVLT. Age effect at assessment was examined using two age groups: above and below 12 years of age during evaluation. Differences between groups were examined via the 9 RAVLT learning trials and the 7 composite scores conducted out of them. Children following TBI recalled significantly less words than controls on all RAVLT trials and had significantly lower scores on all composite scores. However, all of these scores fell within the low average range. Further analysis revealed significantly lower than average performance among the older children (above 12 years), while scores of the younger children following TBI fell within average limits. To conclude, verbal memory deficits among children following severe TBI demonstrate an age-at-testing effect with more prominent problems occurring above 12 years at the time of evaluation. Yet, age-appropriate performance among children below 12 years of age may not accurately describe memory abilities at younger ages following TBI. It is therefore recommended that clinicians address child’s age at testing and avoid using a single test as an indicator of verbal memory functioning post TBI.

Sense of autonomy and daily and scholastic functioning among children with cerebral palsy

BACKGROUND There is growing evidence that childrens sense of autonomy is an important psychological need closely linked with the development of self-esteem and motivation. Among children with physical disabilities, motor or cognitive limitations may negatively affect childs sense of autonomy (CSA) and competency. PURPOSE To examine how sense of autonomy among children with cerebral palsy (CP) directly and indirectly relates to their activity of daily living (ADL) and scholastic performance. METHODS Seventy-three children with CP and their mothers participated in this study. Childs ADL skills and scholastic performance were assessed using the Pediatric Evaluation Disability Inventory (PEDI) and the Scholastic Skills Rating Scale (SSRS), respectively. Level of impairment was assessed using the Gross Motor Function Measure-66 (GMFM-66). CSA was established via videotaped mother-child interactions. Regression analyses were conducted to examine factors predicting childs functional level (ADL and scholastic). The overall model was tested for goodness-of-fit and test of mediation. RESULTS GMFM and CSA significantly predicted childs ADL and scholastic functioning. GMFM explained 15% of the variance for CSA, 84% for PEDI, and 24% for scholastic functioning. CSA positively mediated the association between GMFM and childs ADL skills. GMFM was positively associated with CSA. CONCLUSION Motor impairment has a substantial impact on childs level of functioning. However, childs functioning is a complex construct that is also affected by her or his sense of autonomy. Therefore, sense of autonomy can serve as a potential point of intervention to improve functioning among children with CP.

Ultrasound Measurement of Urine Volume

SIR-In the April issue of this journal ( p p . 3 14-3 18), Massagli and colleagues report on ‘Ultrasound measurement of urine volume of children with neurogenic bladder’. They conclude that it is an appropriate method for determining post-voiding residual urine volume in pediatric patients, and that its accuracy and precision ‘are clinically acceptable for small bladder volumes and over a wide range of patients, from infant to teenager’. Based on our own experience and reviewing those authors’ results, we must question the validity of this conclusion. Using the same ultrasound equipment (bladder scan, B VI 2000), we measured bladder volumes in a comparable population. We found that the magnitude of positive or negative measurement errors is unacceptably high when the bladder volume is small, and that this problem limits the clinical usefulness of the method for infants and young children. Data published in the article illustrate the same fact. The average magnitude of measurement errors was 111 per cent (range 8 to 400 per cent) at true bladder volumes of 1 to 29mL, 37per cent (range I to 160 per cent) at 30 to 99mL, and 26 per cent (range 7 to 77per cent) at 100 to 199mL. When bladder volumes exceeded 200mL, the magnitude of measurement errors decreased to an average of 12 per cent (range I to 22 per cent), customarily an acceptable limit for most medical laboratory measurements. A n essential consideration for clinical usefulness is the magnitude of measurement error in relation to normal bladder capacity at different ages and acceptable post-voiding residual volume. Estimated normal bladder capacity in infancy is 20 to 90mL’. ’. The generally accepted limit of post-voiding residual urine is 10 to 15 per cent of bladder capacity. Thus a I0 to 20mL error has greater significance in infancy than after the age of four years, when the estimated normal bladder capacity is 200mL or more. This relationship remains important even if one considers that the capacity of the neurogenic bladder may be higher or lower than that predicted for age.