Jean-Claude Bernard

A French observational study of botulinum toxin use in the management of children with cerebral palsy: BOTULOSCOPE

BACKGROUND Dystonia and spasticity are common symptoms in children with Cerebral Palsy (CP), whose management is a challenge to overcome in order to enable the harmonized development of motor function during growth. AIM To describe botulinum toxin A (BTX-A) use and efficacy as a treatment of focal spasticity in CP children in France. METHODS This prospective observational study included 282 CP children mostly administered according to French standards with BTX-A in lower limbs. Realistic therapeutic objectives were set with parents and children together before treatment initiation and assessed using the Visual Analogue Scale (VAS). Child management was recorded and the efficacy of injections was assessed during a 12-month follow-up period by physicians (Modified Ashworth Scale, joint range of motion, Physician Rating Scale, Gillette Functional Assessment Questionnaire and Gross Motor Function Measure-66) and by patients/parents (Visual Analogue Scale). RESULTS BTX-A treatment was administered in different muscle localizations at once and at doses higher than those recommended by the French Health Authorities. Children were treated in parallel by physiotherapy, casts and ortheses. Injections reduced spasticity and improved joint range of motion, gait pattern and movement capacity. Pain was reduced after injections. BTX-A administration was safe: no botulism-like case was reported. The log of injected children who were not included in the study suggested that a large population could benefit from BTX-A management. CONCLUSIONS We showed here the major input of BTX-A injections in the management of spasticity in CP children. The results are in favor of the use of BTX-A as conservative safe and efficient treatment of spasticity in children, which enables functional improvement as well as pain relief.

Upper limb assessment in children with cerebral palsy: translation and reliability of the French version for the Melbourne unilateral upper limb assessment (test de Melbourne).

INTRODUCTION The Melbourne unilateral upper limb assessment evaluates upper limb function in children with neurologic impairment aged from 5 to 15 years old. Its validity and reliability have been well demonstrated for the English version, which supports this tool as a reference tool. OBJECTIVES To present the French version of the Melbourne, its validity and reliability in order to offer French-speaking clinicians a relevant tool. PATIENTS AND METHODS The criterion validity was studied in a group of 46 children (mean age 10.6 years, gross motor function classification system in cerebral palsy [GMFCS] 1 to 4) in comparison with Box and Block test; the intra-rater and inter-rater reliability was studied in a group of 11 hemiplegic children (mean age 9.8 years, GMFCS 1 or 2). RESULTS The French version of the Melbourne test has a good criterion validity, with a good correlation between the score of Melbourne and the score of Box and Block test; the intra-rater reliability is very high or excellent, the inter-rater reliability is good on the whole, from moderate to excellent depending on the items. CONCLUSION The Melbourne test is a tool which has good psychometric properties. The French version is usable and reliable.

Use of videographic examination for analysis of efficacy of botulinum toxin in the lower limbs in children with cerebral palsy.

The objective of this study was to test the interobserver and intraobserver reproducibility of videographic gait analysis in paediatric cerebral palsy patients following botulinum toxin type-A injections. Standardized videos according to gait-specific functional criteria were assessed for 1 h. For intraobserver reproducibility, 13 of 17 items showed good/moderate correlation, one mediocre and three poor correlation. For interobserver reproducibility, 12 of 17 items showed excellent, good or moderate agreement, five items showed poor agreement. Overall, 9 of 17 items showed good intraobserver or interobserver reproducibility. Mean interobserver scores for sagittal plane items were slightly lower than mean intraobserver scores (κ=0.509 and 0.536, respectively). In conclusion, video analysis of children with cerebral palsy based on functional criteria is useful.

Vital capacity evolution in patients treated with the CMCR brace: statistical analysis of 90 scoliotic patients treated with the CMCR brace

SummaryObjectiveTo study the evolution of pulmonary capacity during orthopaedic treatment of scoliosis with the CMCR brace.BackgroundInvestigating the impact of moderate scoliosis on respiratory capacity and its evolution during CMCR brace treatment with mobile pads.ContextSeveral studies demonstrate the impact of scoliosis on respiratory capacity but few of them focus on the impact of bracing treatment. We studied the evolution of the pulmonary capacity of a cohort of 90 scoliotic patients.MethodsThis retrospective study included 90 scoliotic patients treated since 1999 with a brace with mobile pads called CMCR (n = 90; mean age: 13 years; 10-16). These patients were diagnosed with an idiopathic scoliosis (mean angulation 20.6°). All patients underwent a radiographic and respiratory evaluation at the beginning, the middle and the end of treatment.ResultsMean age at treatment start was 13. Before treatment, our patients did not have a normal pulmonary capacity: Forced Vital Capacity (FVC) was only 75% of the theoretical value. All curvature types (thoracic, thoraco-lumbar and combined scoliosis) involved this reduced pulmonary capacity, with moderate-angulated scoliosis having a negative impact. At the beginning of brace treatment, the loss of real vital capacity with brace (0.3 litres) was 10% lower than without brace.At CMCR removal, the FVC had increased by 0.4 litre (21% +/- 4.2% compared to the initial value). The theoretical value had increased by 3%. This positive evolution was most important in girls at a low Risser stage (0,1,2), and before 11 years of age.ConclusionThese results supported our approach of orthesis conception for adolescent idiopathic scoliosis which uses braces with mobile pads to preserve thorax and spine mobility.

French validation of brace questionnaire

Material and methods The BrQ is made of 34 items on Likert Scale, divided in 8 domains. The questionnaire was developed in order that the child could fill in it alone and is adapted for 9 to 18 years old. The lowest scale is 20 and the best 100. The highest scales show a better QoL. The process of cultural adaptation of the questionnaire was in accordance with the International Quality of Life Assessment (IQOLA) Guidelines.

Sagittal X-ray parameters in walking or ambulating children with cerebral palsy.

Adolescents with cerebral palsy (CP) who walk or ambulate often have an abnormal clinical and radiological spinal profile during pubertal growth compared with adolescents of the same age without neuromotor impairments. Therefore, in the following study, we aimed to conduct a radiological assessment of static data on the lumbar-pelvic-femoral complex in ambulatory children with CP to compare these data with those of an asymptomatic population. The CP population was comprised of 119 children and the asymptomatic population was comprised of 652 children. The large format (30×90cm) sagittal X-rays were taken while subjects were in a comfortable position in which knees and hips were in maximal extension. Analyses were performed using Optispine(®) software to measure the parameters of an X-ray of the profile of the spine, pelvis and femurs. Comparing, the two populations, we found no difference in the shape parameter (pelvic incidence) but we did find significant differences in the positional parameters (pelvic tilt and sacral slope) of the pelvis. We found a difference in the curvature and orientation of lumbar lordosis as well as in the number of vertebrae involved in the kyphosis and its orientation. There was also a significant difference in the C7 plumb line. We can say that the CP population is not structurally different from the control population, but that parameters become disturbed during growth. These disturbances should be identified and monitored so that changes can be detected early and progression can be prevented.

French validation of the Brace Questionnaire (BrQ)

BackgroundQuality of Life (QoL) scales have to be introduced in the treatment evaluation of our patients with adolescent idiopathic scoliosis.Vasiliadis et. al. created the Brace Questionnaire (BrQ), which is specific for brace-treated adolescents. This tool was developed and validated in Greek.The aim of our study was to undertake the process of cultural adaptation of the Brace Questionnaire (BrQ) into French.MethodsThe BrQ is made of 34 items on Likert scale, divided in eight domains. The questionnaire was developed for self-completion by the children and is adapted for 9 to 18-year-old patients.The process of cultural adaptation of the questionnaire was in accordance with the International Quality of Life Assessment (IQOLA) guidelines.In the first place, descriptive statistics were used to calculate mean scores and standard deviations for a given question and a domain. The second level was comparative, concerning reliability and validity.ResultsThe internal consistency was satisfactory; Cronbach’s alpha coefficient was 0.85. There were no floor or ceiling effects.ConclusionsThe French version of the BrQ (F-BrQ) is reliable and reproducible, and can therefore be used to evaluate the quality of life of children and adolescents treated with a brace for idiopathic scoliosis.

Analysis of pelvic motion during gait with bivalve brace

Materials and methods 2 asymptomatic adults, with similar physical feature. They wear a thoracolumbar bivalve brace, made with the same protocol (using CAD CAM) for reproducibility. We design the braces according to the principles of the brace immobilization: a good grip on the waist and overall tightening supports on the abdomen, thorax and lumbar. We use the gait analysis system Vicon. To use this system, we make holes in the brace at the location of the markers. Each person walks 6-8 trials in the gait analysis system with and without the brace.

Pelvic-Spinal Analysis and the Impact of Onabotulinum toxin A Injections on Spinal Balance in one Child With Cerebral Palsy

Background: In children with cerebral palsy, primary (eg, abnormal muscle tone and weakness) and secondary impairments (eg, contractures) can modify pelvic-spinal alignment. The main aim of this article was to establish a new approach to pelvic-spinal analysis in children with cerebral palsy, taking into account the whole pelvis-spine complex, illustrated by a case study. Methods: This is a case study of an ambulatory child with cerebral palsy (spastic diplegia) who underwent analysis of the pelvic-spine complex from X-ray images taken in standing position from C2 to the proximal femur. Pelvic shape was characterized by the pelvic incidence angle, which is the sum of sacral slope and pelvic tilt, before and after the treatment by regular onabotulinumtoxinA injections into the hip flexors, and the use of soft lumbar brace over 5 years. Results: The sagittal balance of the spine was improved following the treatment, with a reduction in lumbar lordosis and sacral slope. The reduction in lumbar hyperextension likely reduced the risk of spondylolysis, low back pain, and degenerative spondylolisthesis in adulthood. Conclusion: A biomechanical approach to the evaluation of the pelvic-spinal complex offers new perspectives to increase the understanding of spinal balance in children with cerebral palsy, providing more options for treatment, such as onabotulinumtoxinA.

Effects of orthopaedic treatments upon 3D radiologic morphologies and equilibrated postures in adolescent idiopathic scoliosis

In case of scoliosis, spinal deformations are measured upon frontal radiographs. However, these deformations are developed in 3D space. Recent studies have been proposed to access to 3D features of spine and pelvis in upstanding patients.