Else Odding

The epidemiology of cerebral palsy: Incidence, impairments and risk factors

Purpose. Describing the epidemiology of cerebral palsy (CP), its impairments and risk factors. Method. Literature review 1965 – 2004. Search terms: Cerebral palsy, incidence, prevalence, impairments, risk factors. Results. In the last 40 years the prevalence of CP has risen to well above 2.0 per 1000 life births. In this time span the proportion of low-birthweight infants rose, the proportion of diplegia decreased, while the proportion of hemiplegia increased. CP is more prevalent in more deprived socio-economic populations. The majority of people with CP have the spastic syndrome of which the diplegic group is the smallest. Dependent on the subgroup of CP, 25 – 80% have additional impairments. A large proportion has some kind of cognitive impairment; the prevalence varies with the type of CP and especially increases when epilepsy is present. Epilepsy is present in 20 – 40%; it is most common among the hemi- and tetraplegics. Sensibility of the hands is impaired in about half. Chronic pain is reported by more than a quarter of the adults. Up to 80% have at least some impairment of speech. Low visual acuity is reported in almost three-quarters of all children. Half of all children have gastrointestinal and feeding problems. Stunted growth occurs in a quarter, while under- or overweight problems are present in half of the children. Almost 70% of people with spastic CP have abnormal brain CT findings; abnormal cranial ultrasounds is most strongly associated with hemiplegia, normal cranial ultrasounds with diplegia. The most important risk factors for CP are low birthweight, intrauterine infections and multiple gestation.

Associations of radiological osteoarthritis of the hip and knee with locomotor disability in the Rotterdam Study

OBJECTIVE To assess the contribution of radiological osteoarthritis of the hips and knees to disabilities in the activities of daily living related to lower limb function. METHODS During a home interview 1156 men and 1739 women, randomly chosen from the source population of all independently living residents aged 55 years and over living in a district of Rotterdam (the Rotterdam Study) were asked about locomotor disability by six questions of the Health Assessment Questionnaire (HAQ) and about pain in the hips and knees in the past month. Radiographs of hips and knees were scored according to the Kellgren grading system for osteoarthritis. RESULTS The prevalence of locomotor disability, defined as at least some difficulty with three or more out of six lower limb functions, was 20.2% for men and 31.9% for women; hip pain was present in 8.3% of the men and 16.6% of the women; knee pain in 12.6% of the men and 22.3% of the women. The prevalence of radiological osteoarthritis grade 2+ of the hip was 14.1% for men and 15.9% for women, and of the knee 16.3% and 29.1% respectively. The odds ratio (OR) (95% confidence intervals) of hip radiological osteoarthritis for locomotor disability adjusted for age and all other variables was for men: 1.4 (0.9, 2.1) and for women: 2.2 (1.6, 2.9). The ORs of knee radiological osteoarthritis adjusted for age and all other variables were 1.1 (0.9, 2.1) and 1.4 (1.1, 1.8) respectively. Severe radiological osteoarthritis (grade 3+) was stronger associated. The ORs of pain in the hips or knees and morning stiffness were much higher (between 2.7 and 5.5 for men and between 2.1 and 5.1 for women). CONCLUSIONS Radiological osteoarthritis of the hip and knee are only weak independent predictors of locomotor disability in women, and not at all independently associated with locomotor disability in men. Age, pain of the hips and knees, and morning stiffness seem to be the most important independent determinants of locomotor disability.

Determinants of locomotor disability in people aged 55 years and over: The Rotterdam study

Locomotor disability, as defined by difficulties in activities of daily living related to lower limb function, can be the consequence of diseases and impairments of the cardiovascular, pulmonary, nervous, sensory and musculoskeletal system. We estimated the associations between specific diseases and impairments and locomotor disability, and the proportion of disability attributable to each condition, controlling for age and comorbidity. The Rotterdam Study is a prospective follow-up study among people aged 55 years and over in the general population. Locomotor disability in 1219 men and 1856 women was assessed with the Stanford Health Assessment Questionnaire. Diseases and impairments were radiological osteoarthritis, pain of the hips and knees, morning stiffness, fractures, hypertension, vascular disease, ischemic heart disease, stroke, heart failure, chronic obstructive pulmonary disease (COPD), depression, Parkinsons disease, osteoporosis, diabetes mellitus, overweight, and low vision. Adjusted odds ratios, etiologic and attributable fractions were calculated for locomotor disability. The occurrence of locomotor disability can partly be ascribed to joint pain, COPD, morning stiffness, diabetes and heart failure in both men and women. In addition in women osteoarthritis, osteoporosis, low vision, fractures, stroke and Parkinsons disease are significant etiologic fractions. In men with morning stiffness, joint pain, heart failure, diabetes mellitus, and COPD a significant proportion of their disability is attributable to this impairment. In women this was the case for Parkinsons disease, morning stiffness, low vision, heart failure, joint pain, diabetes, radiological osteoarthritis, stroke, COPD, osteoporosis, and fractures of the lower limbs, in that order. We conclude that locomotor complaints, heart failure, COPD and diabetes mellitus contribute considerably to locomotor disability in non-institutionalized elderly people.

Traumatic brain injury: classification of initial severity and determination of functional outcome

Purpose : The aim of the present manuscript is to review current methods for classifying initial severity and final outcome in traumatic brain injury (TBI) and to suggest a direction and form of further research. Method : The literature on valid and reliable measurements used in TBI-research for classifying initial severity and final outcome was reviewed. Results : Classifying initial severity in patients with head injury according to clinical condition or CT-parameters is valid. Classifying outcome according to measurement tools of disability showed adequate validity and reliability. Conclusions : Future research in TBI outcome, particularly in rehabilitation medicine, should focus on determinants of outcome, identifying those patients who will have the greatest chance of benefiting from intensive rehabilitation programmes. More research is needed to determine the long-term functional outcome in TBI, the long-term socio-economic costs, and the influence of behavioural problems on family cohesion. Finally, validation of outcome measures is required in the TBI-population; the relative value of various outcome measures needs to be determined, and the usefulness and applicability of measures for health related quality of life in TBI should be established.

Clinical presentation, associated disorders and aetiological moments in Cerebral Palsy: A Dutch population-based study

Purpose. Cerebral Palsy (CP) contains varying clinical presentations, associated disorders and aetiological moments. Quantitative data and trends on these aspects were lacking in The Netherlands. Method. Within a population-based study on prevalence, presentation and functioning of Dutch children with CP born in the years 1977 – 1988, individual history taking, examination and medical file checking was done by experienced clinicians. Clinical subtypes, motor disability, important co-morbidity (mental retardation, visual disability and epilepsy) were recorded, aetiological moments identified if possible. By comparing the four most recent years with the earlier years possible trends were studied. Results. A quarter of children beforehand recorded as CP did not meet inclusion criteria after individual examination. Spastic subtypes accounted for over 90% of all CP cases: bilateral spastic cerebral palsy as a group are the majority although spastic hemiplegia is percentage-wise the largest individual clinical subtype. Epilepsy and mental retardation are common. Clinical patterns and associated disorders remained rather constant comparing earlier to more recent birth years. Conclusions. An early diagnosis of CP may be challenged. General clinical patterns remained rather constant in following years, as did most studied items. Even if this study revealed a prevalence rise, no aspect stood out as a possible explanation for this prevalence rise. Comparable studies performed elsewhere showed similar findings.

Association of locomotor complaints and disability in the Rotterdam study.

OBJECTIVE--To determine the association between joint complaints and locomotor disability. METHODS--During a home interview survey 1901 men and 3135 women aged 55 years and over (the Rotterdam Study) were asked about joint pain and morning stiffness in the past month, and locomotor disability was assessed by six questions from the Health Assessment Questionnaire (HAQ). RESULTS--The prevalence of locomotor disability was 24.5% for men and 40.5% for women. The prevalence of joint pain in men was 0.7% for pain in the hips, knees, and feet simultaneously, 3.7% for pain at two joint sites, 16.0% for pain at one joint site, and 20.4% for pain in the hips and/or knees and/or feet (any joint site); the corresponding estimates for women were 1.9%, 9.0%, 23.7%, and 34.5%, respectively. The prevalence of generalised morning stiffness was 4.9% for men and 10.4% for women. The age adjusted odds ratios for locomotor disability in men ranged from 2.4 of pain at one joint site to 8.8 of pain at all three joint sites; for women these odds ratios varied between 2.5 and 5.7, respectively. The age adjusted odds ratios of generalised morning stiffness were 8.0 for men and 7.3 for women. CONCLUSION--There is a strong and independent association between locomotor disability and age, joint pain, and generalised morning stiffness in people aged 55 years and over. The odds for locomotor disability increase onefold for every year increase in age, while the presence of generalised morning stiffness is of greater influence than the presence of joint pain.

Being restricted in participation after a traumatic brain injury is negatively associated by passive coping style of the caregiver

Purpose: To examine whether the caregivers’ coping style is associated with the functional outcome of the traumatic brain injury (TBI) patient 1 year post-injury. Method: A cross-sectional study among patients with a TBI, including their primary caregivers. The study included 51 patients aged 17–64 years with a moderate-to-severe TBI and 51 caregivers (23 parents and 28 partners) aged 23–67 years. The coping preferences of the caregivers were assessed at minimum 6 and maximum 12 months post-injury, by filling out the Utrecht Coping List (UCL) and were related to limitations in activity, as measured with the Frenchay Activities Index and with restrictions in participation as measured with the Sickness Impact Profile-68 of TBI patients 1 year post-injury. The patients were interviewed at their homes; the caregivers received and returned the UCL by mail. Results: The patients’ age and the caregivers’ coping style are independently associated with restrictions in participation 1 year post-injury. Conclusions: A passive coping style of the primary caregiver is negatively associated with the patients functional outcome in terms of participation in society.

Cognitive status at discharge from the hospital determines discharge destination in traumatic brain injury patients

Purpose: To determine which basic and functional status characteristics of patients with a moderate or severe traumatic brain injury (TBI) are associated with discharge destination. Method: Cross-sectional study among TBI patients. The study included 111 patients aged 16–67 years with a moderate-to-severe TBI (Glasgow Coma Scale (GCS) score 3–14). Functional outcome was assessed with Barthel Index (BI), Functional Independence Measurement (FIM), Level of Cognitive Functioning Scale (LCFS), Functional Assessment Measurement (FAM), Supervision Rating Scale (SRS) and Neurobehavioural Rating Scale (NRS). Patients were interviewed at the time of being discharged from hospital. Outcome variable was discharge destination; (1) home vs. institution and (2) rehabilitation centre vs. nursing home. Results: Gender, age and length of stay were not associated with discharge destination. TBI severity, physical status, level of arousal and cognitive status were univariately associated. Multivariate analyses, however, showed that the risk of being admitted to an institution was significantly higher for those with severe TBI (adjusted OR = 14) and/or lowered cognitive status at the time of discharge from hospital (adjusted OR = 12). Conclusions: Discharge destination is associated with TBI-severity at admittance to the hospital and cognitive status at discharge from the hospital.

Traumatic Brain Injury: Severity and Outcome

Traumatic brain injury (TBI) has been termed a silent epidemic [1]. In the USA, approximately 95 per 100 000 inhabitants sustain a fatal, or severe enough injury to require hospital admission, each year [2]. In the Federal Republic of Germany, the annual incidence of severe TBI is estimated at 10000 [3]. In the Netherlands, the incidence is 79 per 100 000 inhabitants [4]. Whilst this incidence is lower, compared to other causes of brain injury, such as stroke, the long-term effects and socio-economic costs are equal or even higher, as TBI primarily affects younger age groups.