Chia-Ying Chung

Pharmacotherapy of Spasticity in Children With Cerebral Palsy

Spasticity is a common disability in children with cerebral palsy. Pharmacological and non-pharmacological treatments, including physical therapy, occupational therapy, orthotics, rhizotomy, and orthopedic surgery, all play important roles in the management of spasticity. The purpose of this article is to provide an overview of available medications for treatment of spasticity in children with cerebral palsy. Common medications include benzodiazepines, dantrolene sodium, baclofen, tizanidine, botulinum toxins, phenol, alcohol and intrathecal baclofen. In general, oral medications and intrathecal baclofen are used for treating generalized spasticity, whilst chemodenervation agents (botulinum toxins, phenol, and alcohol) are used to treat localized spasticity. There is more sufficient evidence for the recommendation of botulinum toxin A as an effective anti-spasticity treatment in children with cerebral palsy. However, more data concerning safety and long-term effects of botulinum toxin A is needed. Further study is needed to determine which kinds of medications can cause substantial improvement in daily activity, participation level, self-competence, or quality of life in children with cerebral palsy.

The Relationship Between Parental Concerns and Final Diagnosis in Children With Developmental Delay

Parental concern is a useful screening approach for early detection of children with developmental delay. We investigated the relationships among parental concerns, functional impairment, and final diagnosis of children (n = 273) with developmental delays. Of these, motor, language, and global delay were most common. Parental concerns, especially in language and motor development, were good predictors of children with language or motor delay, and provided reliable information for detection of children with delays in these domains. Parents were less likely to identify children with cognitive problems, global delay, or associated behavioral problems. Co-occurrence of developmental disorders was also recognized, especially in children with global delay. We conclude that parental concerns are useful information for detection of specific developmental problems in children. Because co-occurrence of developmental disorders is common, their early recognition would be helpful for better care of these children.

Validity, responsiveness, minimal detectable change, and minimal clinically important change of Pediatric Balance Scale in children with cerebral palsy.

This study examined criterion-related validity and clinimetric properties of the pediatric balance scale (PBS) in children with cerebral palsy (CP). Forty-five children with CP (age range: 19-77 months) and their parents participated in this study. At baseline and at follow up, Pearson correlation coefficients were used to determine criterion-related validity by analyzing the correlation between the PBS, including PBS-static, PBS-dynamic, and PBS-total, and criterion measures, including the Gross Motor Function Measure-66 items (GMFM-66) and Functional Independence Measures for Children (WeeFIM). Responsiveness was examined by paired t test and by standardized response mean (SRM). The minimal detectable change (MDC) was analyzed at the 90% confidence level, and the minimal clinically important differences (MCID) was estimated by anchor-based and distribution-based approaches. The PBS with GMFM-66 and WeeFIM showed fair-to-excellent concurrent validity at pretreatment and follow up and predictive validity. The SRM values of all PBS scales were 0.75. For the PBS-static, PBS-dynamic, and PBS-total, the MDC(90) values were 0.79, 0.96, and 1.59, and the MCID ranges were 1.47-2.92, 2.23-2.92, and 3.66-5.83, respectively. Improvement of at least MDC values on the PBS can be considered a true change, not measurement error. A mean change must exceed the MCID range on PBS to be considered clinically important change. Therefore, all PBS scales were moderately responsive to change. Clinicians and researchers can use these clinimetric data for PBS to determine if a change score represents a true or clinically meaningful effect at posttreatment and follow up.

Validity, Responsiveness, and Clinically Important Difference of the ABILHAND Questionnaire in Patients With Stroke

OBJECTIVE To investigate the criterion-related validity, responsiveness, and clinically important differences of the ABILHAND questionnaire in patients with stroke. DESIGN Validation and clinimetric study. SETTING Three medical centers. PARTICIPANTS Patients with stroke (N=51). INTERVENTIONS A total of 51 patients with stroke received 1 of 3 upper extremity rehabilitation programs for 4 weeks. MAIN OUTCOME MEASURES The ABILHAND and the criterion measures, including the Stroke Impact Scale (SIS), FIM, Nottingham Extended Activities of Daily Living (NEADL), and accelerometers, were administered at pretreatment and posttreatment. The score of the ABILHAND, given in logits, was based on the conversion of the ordinal score into a linear measure of ability. RESULTS Correlation coefficients (Pearson r) were moderate to large between the ABILHAND and SIS physical domains (.54-.66), fair to moderate between the ABILHAND and FIM-motor and NEADL (.28-.48), and moderate between the ABILHAND and accelerometer data (.45-.54). The responsiveness of the ABILHAND was large (standardized response mean=1.27). The minimal clinically important difference range for the ABILHAND was .26 to .35, and 51.0% of the patients showed a positive change that exceeded the lower bound of a clinically important difference after intervention. CONCLUSIONS The results support that the ABILHAND is an appropriate outcome measure for assessing upper extremity performance in daily activities in patients with stroke and is sensitive to detect change after rehabilitative interventions. The change score of a patient with stroke on the ABILHAND should reach .26 to .35 logits points to be regarded as a clinically important change.

Efficacy of home-based virtual cycling training on bone mineral density in ambulatory children with cerebral palsy

SummaryThe 12-week home-based virtual cycling training (hVCT) improved lower limb muscle strength and areal bone mineral density (aBMD) than the control program in children with cerebral palsy (CP). A muscle strengthening program, rather than general physical activity, is more specific in enhancing aBMD for these children. A novel hVCT is an effective and efficient strategy that enhances lower limb bone density in these children.IntroductionThis is the first study to assess the efficacy of a novel hVCT program on bone density for children with spastic CP using a well-designed randomized controlled trial.MethodsTwenty-seven ambulatory children with spastic CP, aged 6–12 years, were randomly assigned to the hVCT group (n = 13) or control group (n = 14). Outcome measures—motor function [Gross Motor Function Measure-66 (GMFM-66)], muscle strength (curl up scores and isokinetic torque of knee extensor and flexor muscle) and aBMD of the lumbar and distal femur—were administered before and immediately after the 12-week intervention.ResultsAnalysis of covariance results show that the hVCT group had greater distal femur aBMD and isokinetic torques of knee extensor and flexor muscles than the control group at posttreatment (p < 0.05). However, curl up scores, GMFM-66, and lumbar aBMD at posttreatment did not differ between the two groups.ConclusionsAnalytical findings suggest that the muscle strengthening program is more specific in enhancing bone density for children with CP than general physical activity. Thus, the proposed 12-week hVCT protocol is an effective and efficient strategy for improving lower limb aBMD in these children.

Neonatal lupus complicated by hemorrhagic stroke

Neonatal lupus is a passively acquired autoimmune syndrome resulting from the transplacental passage of maternal anti-Ro/SSA and/or anti-La/SSB antibodies to the fetus. Few past studies have reported central nervous system involvement in neonatal lupus, and most cases had a good neurological outcome. We report here a preterm case of neonatal lupus with thrombocytopenia and comorbid hemorrhagic stroke. In the follow-up, the infant developed spastic quadriplegia and showed delayed milestones. We believe that this is the first reported case of neonatal lupus accompanied by perinatal hemorrhagic stroke. We present this case to remind clinicians to conduct regular central nervous system surveys in cases of neonatal lupus.

Knee Muscle Strength at Varying Angular Velocities and Associations with Gross Motor Function in Ambulatory Children with Cerebral Palsy.

The aim of this study was to evaluate the relationships of muscle strength at different angular velocities and gross motor functions in ambulatory children with cerebral palsy (CP). This study included 33 ambulatory children with spastic CP aged 6-15 years and 15 children with normal development. Children with CP were categorized into level I (n=17) or level II (n=16) according to Gross Motor Function Classification System (GMFCS) levels. All children underwent curl-up test and isokinetic tests of the knee extensor and flexor muscle. Children with CP underwent the gross motor function assessments, including the Gross Motor Function Measure (GMFM-66) and the gross motor subtests of Bruininks-Oseretsky Test of Motor Proficiency (BOTMP). The hamstring-quadriceps ratio (HQ ratio) was calculated as 100%×(isokinetic peak torque of hamstring (knee flexor)/isokinetic peak torque of quadriceps (knee extensor)). Children with GMFCS level II had lower BOTMP and GMFM-66 scores, curl-up scores, HQ ratio, and knee muscle strength, especially knee flexor, compared to those with GMFCS level I. The regression analysis showed that knee flexor torques at 60 and 90°/s are mainly related to balance (r(2)=0.167, p=0.011) and strength (r(2)=0.243, p=0.002) while knee flexor torques at 120°/s mainly contribute to running speed and agility (r(2)=0.372, p<0.001). These findings suggest that children with CP had knee strength deficits, especially knee flexor. Postural muscle (knee flexor) strength dominated gross motor function than antigravity muscle strength (knee extensor). The knee flexor strength at different angular velocities was associated with various gross motor tasks. The HQ ratio may be used as a potential biomarker to probe the therapeutic effectiveness for muscle strengthening in these children. These data may allow clinician for formulating effective muscle strengthening strategies for these children.

Predictors for changes in various developmental outcomes of children with cerebral palsy—A longitudinal study

We aimed to identify predictors for the changes of various developmental outcomes in preschool children with cerebral palsy (CP). Participants were 78 children (49 boys, 29 girls) with CP (mean age: 3 years, 8 months; SD: 1 year, 7 months; range: 1 year to 5 years, 6 months). We examined eight potential predictors: age, sex, CP subtype, Gross Motor Function Classification System (GMFCS) level, selective motor control, Modified Ashworth Scale, and the spinal alignment (SA) and range of motion subscales of the Spinal Alignment and Range of Motion Measure (SAROMM). Developmental outcomes for cognition, language, self-help, and social and motor functions were measured at baseline and a 6-month follow-up with the Comprehensive Developmental Inventory for Infants and Toddlers. Regression model showed GMFCS level was a negative predictor for change of language (adjusted r(2)=0.30, p<.001), motor function (adjusted r(2)=0.26, p<.001), social function (adjusted r(2)=0.07, p=0.014), and self-help (adjusted r(2)=0.26, p<.001). Age was a negative predictor for change of cognition (adjusted r(2)=0.21, p<.001) and language functions (adjusted r(2)=0.26, p<.001). SAROMM-SA was a negative predictor for cognitive change (adjusted r(2)=0.30, p<.001). The GMFCS levels and age are robust negative predictors for change of most developmental domains in these children.

Linguistic and gait disturbance in a child with Laurence-Moon-Biedl syndrome: left temporal and parietal lobe hypoplasia.

Chen CL, Chung CY, Cheng PT, Chen CH, Chen MH: Linguistic and gait disturbance in a child with Laurence-Moon-Biedl syndrome: Left temporal and parietal lobe hypoplasia. Am J Phys Med Rehabil 2004;83:69–74.Laurence-Moon-Biedl syndrome is an autosomal recessive disorder characterized by retinitis pigmentosa, obesity, polydactyly, hypogenitalism, mental retardation, and renal abnormalities. We report the linguistic and gait disorders in a child with Laurence-Moon-Biedl syndrome associated with left temporal and parietal hypoplasia as determined by magnetic resonance imaging. Our patient was mildly mentally retarded, scoring better on the performance subtest than on the verbal subtest. He received serial assessments for developmental, language, speech, and gait functions, before and after rehabilitation, at age 4.5 and 6 yr, respectively. After comprehensive rehabilitation, the boy achieved improvement in speech, language, fine motor, and gait functions. Early comprehensive rehabilitation programs seem beneficial for improving functional development for children with Laurence-Moon-Biedl syndrome.

Symptomatic Pulmonary Embolism Among Stroke Patients in Taiwan: A Retrospective Cohort Study

Abstract Background: Stroke patients are at particular risk for developing pulmonary embolism (PE), which is a cardiovascular emergency associated with a high mortality rate. Little information is available on symptomatic PE in Asian stroke patients. Objective: To determine the frequency of symptomatic PE in ischemic and hemorrhagic stroke patients; to identify common characteristics and risk factors of symptomatic PE in Taiwanese stroke patients; and to compare the difference between fatal PE and nonfatal PE among these stroke patients. Methods: This is a retrospective cohort study of stroke patients admitted between January 2002 and December 2009 to a tertiary referral center in Northern Taiwan. We used the International Classification of Diseases, Ninth Revision, Clinical Modification codes to identify eligible patients. We determined annual frequency and risk factors of symptomatic PE. We also compared the difference between ischemic stroke patients with fatal and nonfatal PE. Results: Among the admitted stroke patients, 21,129 (78.87%) had ischemic strokes and 5,662 (21.13 %) had hemorrhagic strokes. There were 14 (0.066%) ischemic and 1 hemorrhagic stroke (0.018%) patients included in this study. Of the recruited stroke patients, 64.29% had past heart disease history, especially atrial fibrillation (42.86%). Patients with fatal PE showed a significantly lower poststroke Glasgow Coma Scale (GCS) motor component than patients with nonfatal PE. Conclusions: Symptomatic PE is not common in stroke patients in Taiwan. Clinicians need to keep this fatal disease in mind, especially for persons with heart disease like atrial fibrillation. Stroke patients with impaired poststroke GCS motor components seemed to have a greater mortality risk if they have symptomatic PE.