P.E.M. van Schie

Effects of botulinum toxin type A on upper limb function in children with cerebral palsy: a systematic review

Objective: To evaluate whether botulinum toxin type A injections improve upper limb function in children with cerebral palsy. Methods: An extensive search was carried out in PUBMED, CINAHL, PICARTA, EMBASE, PEDRO and the Cochrane Controlled Trials Register. Controlled and uncontrolled studies were included and evaluated on the basis of a best evidence synthesis. Results: Twelve out of 645 identified studies were included: three randomized controlled trials (RCTs) (n = 64) of high methodological quality, and nine uncontrolled studies (n = 107) of sufficient methodological quality. In one of the three RCTs a short-term, significant decrease of spasticity was found in favour of the botulinum toxin type A group, which was supported by five of the seven uncontrolled studies that also measured spasticity. In one RCT significant changes in range of motion were reported for wrist and thumb extension. This finding was supported by two out of seven uncontrolled studies. One RCT reported a significant improvement in activities after one month, according to the Quality of Upper Extremity Skills Test and the Pediatric Evaluation Disability Inventory, whereas five out of the nine uncontrolled studies reported an improvement in functional activities. Conclusion: Insufficient evidence is found for the effects of botulinum toxin type A injections to reduce spasticity or to increase range of motion and upper limb function in children with cerebral palsy. Besides differences in treatment goals, the lack of evidence is mainly due to the use of invalid assessment instruments and insufficient statistical power to demonstrate treatment effects.

Transparency and tuning of rehabilitation care for children with cerebral palsy: A multiple case study in five children with complex needs

Purpose: Generally, there is a lack of knowledge whether and how parent-identified problems, treatment goals and treatment activities are tuned in the treatment of children with cerebral palsy. This study aimed to observe whether parent-identified problems and treatment goals were documented (‘transparency’ of the rehabilitation process), and to examine the relationship (‘tuning’) of parent-identified problems to treatment goals and to treatment activities of children with cerebral palsy in pediatric rehabilitation in the Netherlands. Method: Five school-aged subjects with cerebral palsy were observed in detail during physical, occupational, and speech therapy, and their written reports were studied. Parent-identified problems, treatment goals, and treatment activities were linked to the ICF components, domains and categories and the amount of agreement was determined by code comparison. Results: Only two children with a total of six parent-identified problems could be documented. Forty-five treatment goals were identified and 72 treatment activities were observed. The analyses indicated some tuning of parent-identified problems, goals and activities in all subjects, but only four of the treatment activities were perfectly tuned to treatment goals as well as to parent-identified problems. Conclusions: We conclude that transparency and tuning of the pediatric treatment process described in the present study could be improved substantially. Several suggestions for improving the transparency and tuning of the treatment process are discussed.

Development of non-verbal intellectual capacity in school-age children with cerebral palsy

BACKGROUND Children with cerebral palsy (CP) are at greater risk for a limited intellectual development than typically developing children. Little information is available which children with CP are most at risk. This study aimed to describe the development of non-verbal intellectual capacity of school-age children with CP and to examine the association between the development of non-verbal intellectual capacity and the severity of CP. METHODS A longitudinal analysis in a cohort study was performed with a clinic-based sample of children with CP. Forty-two children were assessed at 5, 6 and 7 years of age, and 49 children were assessed at 7, 8 and 9 years of age. Non-verbal intellectual capacity was assessed by Ravens Coloured Progressive Matrices (RCPM). Severity of CP was classified by the Gross Motor Function Classification System, type of motor impairment and limb distribution. manova for repeated measurements was used to analyse time effects and time × group effects on both RCPM raw scores and RCPM intelligence quotient scores. RESULTS The development of non-verbal intellectual capacity was characterised by a statistically significant increase in RCPM raw scores but no significant change in RCPM intelligence quotient scores. The development of RCPM raw scores was significantly associated with the severity of CP. Children with higher levels of gross motor functioning and children with spastic CP showed greater increase in raw scores than children with lower levels of gross motor functioning and children with dyskinetic CP. CONCLUSIONS Children with CP aged between 5 and 9 years show different developmental trajectories for non-verbal intellectual capacity, which are associated with the severity of CP. The development of non-verbal intellectual capacity in children with less severe CP seems to resemble that of typically developing children, while children with more severe CP show a limited intellectual development compared to typically developing children.

Effect of selective dorsal rhizotomy on gait in children with bilateral spastic paresis: kinematic and EMG-pattern changes.

INTRODUCTION Selective dorsal rhizotomy (SDR) is an effective treatment for reducing spasticity and improving gait in children with spastic cerebral palsy. Data concerning muscle activity changes after SDR treatment are limited. PATIENTS AND METHODS In 30 children who underwent SDR a gait analysis was performed before and 12-24 months postoperatively. Subjects walked on a 10-m walkway at comfortable walking speed. Biplanar video was registered and surface EMG was recorded. Sagittal knee angles were measured from video and observational gait assessments were performed using the Edinburgh gait assessment scale (EGAS). RESULTS The EGAS significantly improved after SDR (p<0.001). There were significant improvements of the knee angle kinematics (p<0.001). Only slight changes in EMG activity were observed. The activity of the m. gastrocnemius (GM) decreased and a late peak appeared in stance, the activity of the m. semitendinosus (ST) increased in stance. The activity of the m. rectus femoris (RF) decreased in swing. CONCLUSION SDR improved overall gait performance but EMG changes were only slight. Better timing of the GM in stance and reduced activity of RF in swing may have increased knee flexion in swing. Reduced hamstrings spasticity may have led to postural instability in the hip.

Satisfaction with intrathecal baclofen treatment in paediatric patients with progressive neurological disease

This retrospective report clearly has some limitations. We were dependent on seizure frequency being accurately recorded in notes and aware that some of the changes seen may reflect contemporaneous changes in therapy or circumstances. The trends over 61 switches do suggest a beneficial effect for most children, particularly for tonic seizures and drop attacks, without serious, persistent side effects. In this group of children with medically resistant epilepsies such an approach can be helpful during times of high seizure activity.

PP02.9 – 2853: Neurological follow-up of infants exposed to maternal trauma in pregnancy

Objective Limited knowledge is available about neurodevelopmental outcome after intrauterine mechanical trauma exposure, although 7–8% of pregnancies are complicated by trauma. Guidelines advise hospital admission after trauma in pregnancy, which enabled a prospective evaluation of perinatal and neurological outcome. Examination of fetal motility facilitates assessment of the integrity of the central nervous system. We hypothesize a transient influence on fetal motility after maternal trauma and normal neurological development at one year in case of minor trauma. Methods Pregnant women admitted for trauma after 20 weeks gestational age (GA) between 2011 and 2014 were eligible. Cause of trauma and severity of injuries were analyzed. Three one-hour ultrasonographic observations were performed within 8 hours (T1), 24–72 hours (T2) and > 72 hours (T3) after trauma. Assessment of motility concerned differentiation into specific movement patterns, quality and quantity of general movements (normal values: de Vries et al, Early Hum Dev 1982 and 1988). Neurological examinations were performed at term equivalent age according to Prechtl and at 1 year according to Touwen and Alberta Infant Motor Scale. Results Sixteen women participated at a median GA of 25+6 (range 20–38) weeks. Most traumas were traffic accidents or falls and injuries were mainly minor. Motility assessment showed abnormal differentiation in 2/16; 2/14 and 0/16; abnormal quality in 2/16; 3/14 and 6/16; and abnormal quantity in 6/16, 9/14 and 9/16 at T1, T2 and T3 respectively. Neurological development at 0 and 1 year was normal in 15/16 and 13/13 respectively. Conclusion This preliminary evaluation shows that fetal motility was affected after maternal trauma in majority of the fetuses, however, not transiently in all within four days. The neurological outcome at 0 and 1 year was normal. The changes in motility support the concern that even minor mechanical trauma may have influence on the functional integrity of the central nervous system.

Quality of Life and its Determinants in Preschool Children with Down Syndrome

Objective : Children with Down syndrome (DS) show a delay in cognitive and motor development and have various concomitant health problems. We compared Health-Related Quality of Life (HRQoL) in preschool children with DS with a reference group, and investigated child-related factors (i.e., developmental quotient, adaptive function, health problems, problem behaviour), and maternal level of education on HRQoL. Method : In a cohort of 55 children with DS, HRQoL was measured with the TNO-AZL preschool children Quality of Life Questionnaire (TAPQoL). Data from a reference group were used for comparison. Developmental Quotient (DQ) was assessed with the Bayley Scales of Infant Development II, adaptive function with the Pediatric Evaluation of Disability Inventory, health problems were derived from the medical file, and behavioural problems were measured with the Child Behaviour Checklist. Results : Children with DS (N=55; mean age 41.7 months) scored significantly lower on the TAPQoL domains lung and stomach problems, motor function and communication compared to the reference group. DQ had a significant negative correlation with the domains lung problems and liveliness. Children with DS with respiratory or gastro-intestinal problems showed significant lower scores on lung problems and communication. Problem behavior had a significant negative correlation with the domains sleeping, appetite and social function. A low level of maternal education correlated negatively with positive mood. Adaptive function and congenital heart defect (CHD) did not significantly correlate with HRQoL. Conclusion : Preschool children with DS show a lower HRQoL on particular domains of functioning compared to a normative sample. HRQoL of children with DS is correlated to DQ, respiratory and gastro-intestinal health problems, problem behaviour and maternal education, but not to CHD and adaptive function.