Nelleke G. Langerak

Gait status 17–26 years after selective dorsal rhizotomy

The purpose of this study was to use three-dimensional gait analysis to describe the gait status of adults with spastic diplegia who underwent selective dorsal rhizotomy (SDR) in childhood. Outcome measures were the gait deviation index (GDI), non-dimensional temporal-distance parameters, and kinematics of the lower limbs. A total of 31 adults with spastic diplegia who had previously undergone SDR were eligible and participated in current study (SDR group). These participants had a median age of 26.8 years (range 21-44 years) with a mean time between surgery and assessment of 21.2±2.9 years (range 17-26 years). For comparison purposes, 43 typically developed adults also participated (CONTROL group), with a median age of 28.3 years (range 21-45 years). More than 17 years after SDR 58% of the SDR group showed improved GMFCS levels, while none of them deteriorated. The participants in the SDR group walked with a mild crouch gait, although there was a loading response, adequate swing-phase knee flexion, adequate swing-phase plantarflexion, reasonable speed and cadence. The gait status of the SDR group more than 17 years after SDR was similar to what has been reported in short-term follow-up studies, as well as our earlier 20 year follow-up study that did not include 3D gait analysis. Appropriate orthopaedic intervention was required in 61% of the study cohort. Whether the types and numbers of orthopaedic interventions are positively affected by SDR remains an open question. Further studies examining this question are warranted. In addition, long-term follow-up studies focused on other interventions would also be of clinical relevance.

Selection criteria for selective dorsal rhizotomy in children with spastic cerebral palsy: a systematic review of the literature

Information regarding the selection procedure for selective dorsal rhizotomy (SDR) in children with spastic cerebral palsy (CP) is scarce. Therefore, the aim of this study was to summarize the selection criteria for SDR in children with spastic CP.

HIV Encephalopathy: pediatric case series description and insights from the clinic coalface

BackgroundThe Human Immune Deficiency Virus (HIV) can manifest neurologically in both adults and children. Early invasion of the central nervous system by the virus, affecting the developing brain, is believed to result in the most common primary HIV-related neurological complication, HIV Encephalopathy (HIVE). In countries such as South Africa where many children have not been initiated on antiretroviral treatment early, HIVE remains a significant clinical problem.MethodsChildren were selected from a clinic for children with neurologic complications of HIV, located at the Red Cross War Memorial Children’s Hospital, South Africa 2008–2012. Eligible subjects fulfilled the following inclusion criteria: aged 6 months-13 years; positive diagnosis of HIV infection, vertically infected and HIVE as defined by CDC criteria. Each participant was prospectively assessed by a Pediatric Neurologist using a standardized proforma which collated relevant details of background, clinical and immunological status.Results The median age of the 87 children was 64 months (interquartile range 27–95 months). All except one child were on antiretroviral treatment, 45% had commenced treatment <12 months of age. Delayed early motor milestones were reported in 80% and delayed early speech in 75% of children in whom we had the information. Twenty percent had a history of one or more seizures and 41% had a history of behavior problems. Forty-eight percent had microcephaly and 63% a spastic diplegia. CD4 percentages followed a normal distribution with mean of 30.3% (SD 8.69). Viral loads were undetectable (<log 1.6) in 70% of the children. Brain imaging was performed on 56% with 71% of those imaged demonstrating at least one abnormality, most commonly white matter volume loss or signal abnormality. ConclusionsAmongst the cohort of children referred to this clinic, the diagnosis of HIVE was unrecognized in the general medical services, even in its most severe form. Developmental delay and school failure were major presenting problems. Co-morbidities are a frequent finding and should be sought actively in order to optimize management and promote best possible outcomes for this vulnerable group of children.

Transition from child- to adult-orientated care for children with long-term health conditions: A process, not an event

Long-term health conditions in childhood include both congenital conditions and acquired diseases. Children with long-term health conditions face issues and potential secondary problems that are different from those of adults with chronic diseases. Transition to adult-orientated care for such children and adolescents is a major challenge. Transition needs to be prepared for and planned. A variety of possible transition models exists, depending on circumstances.

Spastic diplegia in children with HIV encephalopathy: first description of gait and physical status

The aim of this study was to explore the physical status and gait patterns of children with spastic diplegia secondary to human immunodeficiency virus encephalopathy (HIVE).

A Systematic Review of the Effects of Single-Event Multilevel Surgery on Gait Parameters in Children with Spastic Cerebral Palsy

Background Three-dimensional gait analysis (3DGA) is commonly used to assess the effect of orthopedic single-event multilevel surgery (SEMLS) in children with spastic cerebral palsy (CP). Purpose The purpose of this systematic review is to provide an overview of different orthopedic SEMLS interventions and their effects on 3DGA parameters in children with spastic CP. Methods A comprehensive literature search within six databases revealed 648 records, from which 89 articles were selected for the full-text review and 24 articles (50 studies) included for systematic review. The Oxford Centre for Evidence-Based Medicine Scale and the Methodological Index for Non-Randomized Studies (MINORS) were used to appraise and determine the quality of the studies. Results Except for one level II study, all studies were graded as level III according to the Oxford Centre for Evidence-Based Medicine Scale. The MINORS score for comparative studies (n = 6) was on average 15.7/24, while non-comparative studies (n = 18) scored on average 9.8/16. Nineteen kinematic and temporal-distance gait parameters were selected, and a majority of studies reported improvements after SEMLS interventions. The largest improvements were seen in knee range of motion, knee flexion at initial contact and minimal knee flexion in stance phase, ankle dorsiflexion at initial contact, maximum dorsiflexion in stance and in swing phase, hip rotation and foot progression angles. However, changes in 3DGA parameters varied based on the focus of the SEMLS intervention. Discussion The current article provides a novel overview of a variety of SEMLS interventions within different SEMLS focus areas and the post-operative changes in 3DGA parameters. This overview will assist clinicians and researchers as a potential theoretical framework to further improve SEMLS techniques within different SEMLS focus groups. In addition, it can also be used as a tool to enhance communication with parents, although the results of the studies can’t be generalised and a holistic approach is needed when considering SEMLS in a child with spastic CP.

HIV encephalopathy with bilateral lower limb spasticity: upper limb motor function and level of activity and participation

To describe upper limb motor function and level of activity and participation in children with HIV encephalopathy (HIVE) and bilateral lower limb (BLL) spasticity.

Submaximal Markers of Fatigue and Overreaching; Implications for Monitoring Athletes

The regular monitoring of athletes is important to fine-tune training and detect early symptoms of overreaching. Therefore the aim of this study was to determine if a noninvasive submaximal running test could reflect a state of overreaching. 14 trained runners completed a noninvasive Lamberts Submaximal Running Test, one week before and 2 days after finishing an ultramarathon, and delayed onset of muscle soreness and the daily analysis of life demands for athletes questionnaire were also captured. After the ultramarathon, submaximal heart rate was lower at 70% (-3 beats) and 85% of peak treadmill running speed (P<0.01). Ratings of perceived exertion were higher at 60% (2 units) and 85% (one unit) of peak treadmill running speed, while 60-second heart rate recovery was significantly faster (7 beats, P<0.001). Delayed Onset of Muscle Soreness scores and the number of symptoms of stress (Daily Analysis of Life Demands for Athletes) were also higher after the ultramarathon (P<0.01). The current study shows that the Lamberts Submaximal Running Test is able to reflect early symptoms of overreaching. Responses to acute fatigue and overreaching were characterized by counterintuitive responses, such as lower submaximal heart rates and faster heart rate recovery, while ratings of perceived exertion were higher.

HIV encephalopathy with bilateral lower limb spasticity: gross motor function and antiretroviral therapy

To describe gross motor function in children with bilateral lower limb (BLL) spasticity due to human immunodeficiency virus encephalopathy (HIVE), and to investigate the association between age, CD4 percentage, and viral load at initiation of antiretroviral therapy (ART) and current gross motor function.

Evaluating treatment options for spasticity

While prospective randomized controlled trials (RCTs) have long been considered the criterion standard of evidence for a medical therapy or intervention, the limitations to this approach are increasingly recognized, especially with respect to surgical interventions. For the past three decades, the surgical procedure of selective dorsal rhizotomy (SDR) has been performed worldwide for spasticity due to cerebral palsy and has been shown by many groups to be effective in reducing spasticity in the long term. A persistent criticism however has been the lack of sufficient evidence of efficacy from RCTs. The study by Munger et al. presents a novel approach to providing a higher level of evidence to guide practitioners in selecting the best treatment option for these children. Munger et al. retrospectively matched patients who had not undergone SDR to a very well-characterized cohort of those who underwent SDR 10 to 17 years earlier. The authors utilized a ‘propensity model’ which enabled them to identify 96 eligible patients, of whom 35 ultimately participated in the study and of these, 24 had undergone SDR and 11 had not. Given the retrospective nature of the study, the groups were not equally matched, with the non-SDR group being quite heterogenous, having more orthopaedic interventions and three patients also having received intrathecal baclofen. Furthermore, the reasons why these patients had not undergone SDR were unknown and might explain the differences in the groups, as acknowledged by the authors. Munger et al. adopted a holistic approach to determining outcome using a range of measures including physical exam, functional outcome measures, quality of life, pain, and gait. All the patients had baseline gait analysis (including physical examination, metabolic energy cost, and barefoot kinematics) and all completed six survey-based outcome measures. Notably, only 13 out of 24 (54%) of the SDR group and 8 out of 11 (72%) of the non-SDR group underwent follow-up gait analysis, which is regrettable as gait quality (as reflected in Gait Deviation Index) was one of the important long-term outcomes of this study. An interesting question raised by this study is what constitutes the best measure of outcome. If it is gait quality, the non-SDR group did better; while outcome in terms of level of spasticity and number of orthopaedic interventions and anti-spasticity injections was better in the SDR group. In this study, there was no difference between the groups with respect to pain, functional level and quality of life, and energy expenditure. An important consideration in evaluating treatment options is what is possible in different environments, for example botulinum toxin, intrathecal baclofen, and singleevent multilevel surgery are not standard of care in developing countries like South Africa. Available treatments for spasticity in children with cerebral palsy clearly differ between countries (or even within countries) and this plays an important role in determining individual treatment decisions. Finally, before evidence for the efficacy of a surgical procedure can be adopted, there should be consensus about the procedure itself. With regards to SDR, besides differences in preand post-operative care and neurosurgical techniques, there is wide variation in SDR selection criteria, which indisputably impacts on the outcome of the procedure. Munger et al. conclude that ‘differing treatment courses provide similar outcomes into early adulthood’. It might also be said that similar treatment courses may provide different outcomes. The present study is a valuable contribution, but further prospective longitudinal follow-up studies, with well-matched non-SDR study cohorts and a holistic approach assessing outcome, are needed to evaluate the efficacy of interventions for spasticity in different environments.