Edward A. Hurvitz

Unipedal stance testing as an indicator of fall risk among older outpatients

OBJECTIVE To test the hypothesis that a decreased unipedal stance time (UST) is associated with a history of falling among older persons. DESIGN Fifty-three subjects underwent a standardized history and physical examination and three trials of timed unipedal stance. SETTING The electroneuromyography laboratories of tertiary care Veterans Administration and university hospitals. SUBJECTS Ambulatory outpatients 50 years and older referred for electrodiagnostic studies. OUTCOME MEASURES UST and fall histories during the previous year. RESULTS Twenty subjects (38%) reported falling. Compared with the subjects who had not fallen, those who fell had a significantly shorter UST (9.6 [SD 11.6] vs 31.3 [SD 16.3] seconds, using the longest of the three trials, p < .00001). An abnormal UST (<30sec) was associated with an increased risk of having fallen on univariate analysis and in a regression model (odds ratio 108; 95% confidence interval 3.8, >100; p < .007). The sensitivity of an abnormal UST in the regression model was 91% and the specificity 75%. When UST was considered age was not a predictor of a history of falls. CONCLUSIONS UST of <30sec in an older ambulatory outpatient population is associated with a history of falling, while a UST of > or = 30sec is associated with a low risk of falling.

The Relationship between Electromyographically Documented Peripheral Neuropatny and Falls

Objective: To determine if the presence of an electromyographically demonstrated peripheral polyneuropathy involving the lower extremities is associated with falls.

Definition and Classification of Negative Motor Signs in Childhood

In this report we describe the outcome of a consensus meeting that occurred at the National Institutes of Health in Bethesda, Maryland, March 12 through 14, 2005. The meeting brought together 39 specialists from multiple clinical and research disciplines including developmental pediatrics, neurology, neurosurgery, orthopedic surgery, physical therapy, occupational therapy, physical medicine and rehabilitation, neurophysiology, muscle physiology, motor control, and biomechanics. The purpose of the meeting was to establish terminology and definitions for 4 aspects of motor disorders that occur in children: weakness, reduced selective motor control, ataxia, and deficits of praxis. The purpose of the definitions is to assist communication between clinicians, select homogeneous groups of children for clinical research trials, facilitate the development of rating scales to assess improvement or deterioration with time, and eventually to better match individual children with specific therapies. “Weakness” is defined as the inability to generate normal voluntary force in a muscle or normal voluntary torque about a joint. “Reduced selective motor control” is defined as the impaired ability to isolate the activation of muscles in a selected pattern in response to demands of a voluntary posture or movement. “Ataxia” is defined as an inability to generate a normal or expected voluntary movement trajectory that cannot be attributed to weakness or involuntary muscle activity about the affected joints. “Apraxia” is defined as an impairment in the ability to accomplish previously learned and performed complex motor actions that is not explained by ataxia, reduced selective motor control, weakness, or involuntary motor activity. “Developmental dyspraxia” is defined as a failure to have ever acquired the ability to perform age-appropriate complex motor actions that is not explained by the presence of inadequate demonstration or practice, ataxia, reduced selective motor control, weakness, or involuntary motor activity.

Complementary and alternative medicine use in families of children with cerebral palsy

In order to assess patterns of usage of complementary and alternative medicine (CAM) in families of children with cerebral palsy (CP), 213 families with a child (0 to 18 years) with CP were recruited at the university medical center in Ann Arbor, MI, USA as part of a descriptive survey. Two hundred and thirty-five surveys were distributed. Mean age of the child was 8 years 6 months (SD 4y : 9mo) and 56% of the sample was male with 35% full-time independent ambulators, while the rest used an assistive device or a wheelchair. Fifty-four percent were in special education classrooms. Families were given a survey on functional status of the child with CP, CAM usage of the child and the parent, factors influencing the decision to use CAM, demographics, and clinical information. Of the families, 56%, used one or more CAM techniques. Massage therapy (25%) and aquatherapy (25%) were the most common. Children of families that used CAM were significantly younger (7y : 9mo, SD 4y : 7mo) than non-users (9y : 6mo, SD 4y : 6mo: t-test p < 0.01 two-tailed). Children with quadriplegic CP, with spasticity, and those who could not walk independently were more commonly exposed to CAM (Pearsons chi2 [P(chi)2] p = 0.01 two-tailed; for mobility, odds ratio [OR] of 2.5 with regression). Mothers with a college degree had a greater tendency to use CAM for their child than those without (P(chi)2 p = 0.01 two-tailed). Fathers of children who used CAM were older than fathers of those who did not (37y : 9mo versus 33y : 2mo, p = 0.04 two-tailed). There was no significant difference between groups for mothers age, fathers education, income, or for population of home town. Parents who used CAM for themselves were more likely to try CAM for their child (70% versus 47%, OR 2.1), and were much more likely to be pleased with the outcome (71% versus 42%, OR 3.5). Childs age (younger), lack of independent mobility, and parental use of CAM were the most significant predictive factors identified via logistic regression.

Body mass index measures in children with cerebral palsy related to gross motor function classification: a clinic-based study.

Hurvitz EA, Green LB, Hornyak JE, Khurana SR, Koch LG: Body mass index measures in children with cerebral palsy related to gross motor function classification: a clinic-based study. Am J Phys Med Rehabil 2008;87:395–403. Objective:To investigate the prevalence of overweight in a clinic-based population of children with cerebral palsy (CP) and its association with gross motor function status. Design:Retrospective chart review. We calculated body mass index (BMI; kg/m2) from charted height and weight and recorded Gross Motor Function Classification Scale (GMFCS levels I–V) on the basis of clinical descriptions in clinic notes for 137 children (2–18 yrs old) with CP seen in a pediatric rehabilitation clinic at an academic medical center. BMI percentiles were reported according to sex-specific age group standards for growth set by the U.S. Centers for Disease Control and Prevention (CDC). Associations were modeled by Pearson’s &khgr;2 distribution. Results:Out of the total CP subject group, 29.1% were considered overweight (>95th percentile) or at risk for overweight (85th to 95th percentile). Ambulatory children (GMFCS levels I and II) showed a trend (Pearson’s &khgr;2, P = 0.06) toward higher prevalence of overweight (22.7%) compared with nonambulatory children (levels IV and V, 9.6%). Underweight was more prevalent in nonambulatory children (P < 0.01). Logistic regression analysis did not identify any significant predictors for overweight. Conclusions:In our patient population, analysis of BMI suggests that children with CP have a high rate of overweight and are at risk of overweight, particularly among ambulatory children. More study is needed, using measures more accurate than BMI, to clarify risk.

Chronic disease risk among adults with cerebral palsy: the role of premature sarcopoenia, obesity and sedentary behaviour

Premature declines in function among adults with cerebral palsy (CP) are generally attributed to weakness, spasticity and orthopaedic abnormalities, as well as chronic pain and fatigue. Very little research or clinical attention has been devoted to the confluence and consequences of early muscle wasting and obesity as mediators of secondary comorbidity in this population, and perhaps more importantly, to the role of lifestyle to potentiate these outcomes. At present, there are no national surveillance programmes that monitor chronic health in adults with CP; however, mortality records have demonstrated a greater prevalence of coronary heart disease as compared with the general population. Although by definition, CP is a ‘non‐progressive’ condition, secondary factors such as habitual sedentary behaviour, obesity, and premature sarcoepenia may increase the severity of functional impairment throughout adulthood, and lead to cardiometabolic disease, fragility and/or early mortality. Herein we describe the heightened health risk represented in adults with CP, and discuss the hallmark phenotypic features that coincide with ageing, obesity and cardiometabolic disorders. Moreover, we provide discussion regarding the protective role of habitual physical activity to stimulate anti‐inflammatory pathways and to ameliorate global risk. Although physical therapeutic modalities are already widely acknowledged as a vital component to improve movement quality in CP, the purpose of this review was to present a compelling case for the value of lifelong physical activity participation for both function and cardiometabolic health preservation.

Inter-Relationships of Functional Status in Cerebral Palsy: Analyzing Gross Motor Function, Manual Ability, and Communication Function Classification Systems in Children.

Aim  To investigate the relationships among the Gross Motor Function Classification System (GMFCS), Manual Ability Classification System (MACS), and Communication Function Classification System (CFCS) in children with cerebral palsy (CP).

Deficits in the Ability to Use Proprioceptive Feedback in Children with Hemiplegic Cerebral Palsy.

Compared with motor impairment in children with hemiplegic cerebral palsy (CP), less attention has been paid to sensory feedback processing deficits. This includes, especially, proprioceptive information regarding arm position. This study examined the ability of children with hemiplegic CP to use proprioceptive feedback during a goal-directed target-matching task. Eight children with hemiplegic CP and eight typically developing children performed proprioceptively guided matching of elbow position with either arm. Between groups, it was found that matching errors were significantly greater for the affected arm of children with hemiplegic CP. With respect to the side of brain injury, deficits were only seen for children with right hemisphere damage. These results provide valuable information that may assist in the development of more effective sensorimotor rehabilitation and training paradigms.

Functional outcome of paediatric stroke survivors

OBJECTIVE To examine the medical and functional outcome of paediatric stroke survivors. PATIENTS Patients aged 1 month to 18 years diagnosed with stroke over a 10 year period. MAIN OUTCOME MEASURES Discharge functional outcome data were collected by reviewing therapy, nursing, and other chart notes relating to specific functional tasks. Current functional information, living situation, school placement, and medical outcome data were obtained in the telephone survey. RESULTS Fifty patients responded. The mean age at event was 8.0 years (range: 7 months to 17 years, 7 months). The mean follow-up time was 70 months. Diagnoses included: haemorrhagic (30%), thrombotic/embolic (46%), and undiagnosed (24%). At follow-up, 76% of the patients were independent in all activities of daily living (ADL), compared to 64% at hospital discharge. Younger age at onset, female gender, history of cardiac disease, and presentation with hemiparesis were significant risk factors for dependence in ADL (p < 0.05), while thrombotic/embolic aetiology demonstrated a trend (p = 0.06). Eighty-four per cent were independent in mobility, compared to 74% at discharge. Forty per cent of the patients had speech and language deficits. Of the school age children, only 50% were in a regular classroom. CONCLUSIONS Children and adolescents who survive stroke have good outcome for mobility and ADL skills, but more difficulty with language and cognitive recovery. Functional recovery is maintained after discharge, and functional gains occur over time with very little evidence of functional regression. Comorbidities are relatively low. All children in the group returned to a home setting.

Exercise and physical activity recommendations for people with cerebral palsy

Physical activity and its promotion, as well as the avoidance of sedentary behaviour, play important roles in health promotion and prevention of lifestyle‐related diseases. Guidelines for young people and adults with typical development are available from the World Health Organisation and American College of Sports Medicine. However, detailed recommendations for physical activity and sedentary behaviour have not been established for children, adolescents, and adults with cerebral palsy (CP). This paper presents the first CP‐specific physical activity and exercise recommendations. The recommendations are based on (1) a comprehensive review and analysis of the literature, (2) expert opinion, and (3) extensive clinical experience. The evidence supporting these recommendations is based on randomized controlled trials and observational studies involving children, adolescents, and adults with CP, and buttressed by the previous guidelines for the general population. These recommendations may be used to guide healthcare providers on exercise and daily physical activity prescription for individuals with CP.