Roslyn N. Boyd

Objective measurement of clinical findings in the use of botulinum toxin type A for the management of children with cerebral palsy

Clinicians use a range of clinical and objective measures to quantify the positive and negative features (impairments) of the upper motor neurone syndrome. These measures play an important role in the assessment and selection of suitable candidates for intervention and monitoring of outcome. Intervention strategies often focus on the positive features; however, outcome may be more contingent upon the severity of the negative features. The clinical protocol for patient selection and treatment used by our multidisciplinary team is presented, together with details of the assessment procedure. Measurement tools in routine use are described, including: the Modified Ashworth Scale, the Modified Tardieu Scale (‘R1’), muscle length by joint range of motion ‘R2’, three‐dimensional gait analysis, assessments of strength by the Medical Research Council Scale, Selective Motor Control, the Gross Motor Function Measure and the Observational Gait Scale. Three case studies of children with cerebral palsy who underwent botulinum toxin type A treatment as part of their management of gait disorder are presented, a 2‐year‐old girl with mild hemiplegia (‘true equinus’), a 3‐year‐old boy with moderate hemiplegia (‘apparent equinus’) and a 6‐year‐old girl with diplegia, where a targeted approach was used to treat a distal problem and resulted in correction Of a proximal problem.

Recommendations for the use of botulinum toxin type A in the management of cerebral palsy

Botulinum toxin type A (BTX-A) is increasingly being used for the treatment of childhood spasticity, particularly cerebral palsy. However, until very recently, all such use in this indication has been unapproved with no generally accepted treatment protocols, resulting in considerable uncertainty and variation in its use as a therapeutic agent. In view of the increasing awareness of, and interest in, this approach to the treatment of spasticity, and also the recent licensing in a number of countries of a BTX-A preparation for treating equinus deformity in children, it would seem timely to establish a framework of guidelines for the safe and efficacious use of BTX-A for treating spasticity in children. This paper represents an attempt, by a group of 15 experienced clinicians and scientists from a variety of disciplines, to arrive at a consensus and produce detailed recommendations as to appropriate patient selection and assessment, dosage, injection technique and outcome measurement. The importance of adjunctive physiotherapy, orthoses and casting is also stressed.

Hip displacement in cerebral palsy

BACKGROUND Hip displacement is considered to be common in children with cerebral palsy but the reported incidence and the proposed risk factors vary widely. Knowledge regarding its overall incidence and associated risk factors can facilitate treatment of these children. METHODS An inception cohort was generated from the Victorian Cerebral Palsy Register for the birth years 1990 through 1992, inclusive, and multiple data sources pertaining to the cohort were reviewed during 2004. Gross motor function was assessed for each child and was graded according to the Gross Motor Function Classification System (GMFCS), which is a valid, reliable, five-level ordinal grading system. Hip displacement, defined as a migration percentage of >30%, was measured on an anteroposterior radiograph of the pelvis with use of a reliable technique. RESULTS A full data set was obtained for 323 (86%) of 374 children in the Register for the birth years 1990 through 1992. The mean duration of follow-up was eleven years and eight months. The incidence of hip displacement for the entire birth cohort was 35%, and it showed a linear relationship with the level of gross motor function. The incidence of hip displacement was 0% for children with GMFCS level I and 90% for those with GMFCS level V. Compared with children with GMFCS level II, those with levels III, IV, and V had significantly higher relative risks of hip displacement (2.7, 4.6, and 5.9, respectively). CONCLUSIONS Hip displacement is common in children with cerebral palsy, with an overall incidence of 35% found in this study. The risk of hip displacement is directly related to gross motor function as graded with the Gross Motor Function Classification System. This information may be important when assessing the risk of hip displacement for an individual child who has cerebral palsy, for counseling parents, and in the design of screening programs and resource allocation.

Management of upper limb dysfunction in children with cerebral palsy: a systematic review.

Effective use of the upper limb can impact on educational outcomes, participation in activities of daily living and vocational options for many children with cerebral palsy (CP). This article presents the results of a systematic review of the literature on the management of upper limb dysfunction in children with CP. The range of management options includes therapies such as physiotherapy, occupational therapy, neurodevelopmental therapy and conductive education; peripheral splinting and casting; focal or generalized pharmacotherapy; and surgery to improve upper limb function or correct deformity. A literature search identified 60 papers, of which four were randomized controlled trials and 44 were prospective studies with objective outcome measures. Principal studies undertaken for each type of treatment and the efficacy of the different types of treatment were critically evaluated. In addition, the current level of evidence for each study was evaluated according to Sackett’s (1989) model and ICIDH‐2 classification. A close examination of two relatively new treatments for upper limb spasticity, constraint induced movement therapy and botulinum toxin type A (BTX‐A) was conducted with reference to more extensive data on the efficacy of BTX‐A in the lower limb.

A systematic review of the clinimetric properties of neuromotor assessments for preterm infants during the first year of life

This systematic review evaluates assessments used to discriminate, predict, or evaluate the motor development of preterm infants during the first year of life. Eighteen assessments were identified; nine met the inclusion criteria. The Alberta Infant Motor Scale (AIMS), Bayley Scale of Infant and Toddler Development ‐ Version III, Peabody Developmental Motor Scales ‐ Version 2, Test of Infant Motor Performance (TIMP), and Toddler and Infant Motor Examination have good discriminative validity when examined in large populations. The AIMS, Prechtls Assessment of General Movements (GMs), Neuro Sensory Motor Development Assessment (NSMDA), and TIMP were designed for preterm infants and are able to detect more subtle changes in movement quality. The best predictive assessment tools are age dependent: GMs, the Movement Assessment of Infants, and TIMP are strongest in early infancy (age 4mo or less) and the AIMS and NSMDA are better at older ages (8‐12mo). The TIMP is the only tool that has demonstrated a difference between groups in response to intervention in two randomized controlled trials. The AIMS, TIMP, and GMs demonstrated the highest levels of overall reliability (interrater and intrarater intraclass correlation coefficient or κ>0.85). Selection of motor assessment tools during the first year of life for infants born preterm will depend on the intended purpose of their use for discrimination, prediction, and/or evaluation.

Paediatric quality of life instruments: a review of the impact of the conceptual framework on outcomes.

With an increasing number of paediatric quality of life (QOL) instruments being developed, it is becoming difficult for researchers and clinicians to select the most appropriate instrument. Reviews of QOL instruments tend to report only basic properties of the instruments such as domains and psychometric properties. This paper seeks to appraise critically the conceptual underpinnings of paediatric QOL instruments. A systematic review was conducted to identify QOL instruments for children aged 0 to 12 years, and to examine and compare their conceptual frameworks, definitions employed, and structure. Both generic and condition‐specific measures were reviewed. Fourteen generic and 25 condition‐specific QOL instruments were identified. Eleven types of definition of QOL and health‐related QOL and three theories of QOL were identified. QOL was measured by a variety of domains including emotional, social and physical health, and well‐being. Items commonly assessed difficulties, or intensity/frequency of feelings/symptoms, in contrast to positive aspects of life and happiness. The findings highlight the diversity that is apparent in the conceptualization of paediatric QOL and draw attention to the lack of empirical evidence for many of the fundamental assumptions. The impact of the conceptual underpinnings of the instruments on the resulting QOL scores is discussed.

Systematic Review and Meta-analysis of Therapeutic Management of Upper-Limb Dysfunction in Children With Congenital Hemiplegia

CONTEXT. Rehabilitation for children with congenital hemiplegia to improve function in the impaired upper limb and enhance participation may be time-consuming and costly. OBJECTIVES. To systematically review the efficacy of nonsurgical upper-limb therapeutic interventions for children with congenital hemiplegia. METHODS. The Cochrane Central Register of Controlled Trials, Medline, CINAHL (Cumulative Index to Nursing and Allied Health Literature), AMED (Allied and Complementary Medicine), Embase, PsycINFO, and Web of Science were searched up to July 2008. Data sources were randomized or quasi-randomized trials and systematic reviews. RESULTS. Twelve studies and 7 systematic reviews met our criteria. Trials had strong methodologic quality (Physiotherapy Evidence Database [PEDro] scale ≥ 5), and systematic reviews rated strongly (AMSTAR [Assessment of Multiple Systematic Reviews] score ≥ 6). Four interventions were identified: intramuscular botulinum toxin A combined with upper-limb training; constraint-induced movement therapy; hand-arm bimanual intensive training; and neurodevelopmental therapy. Data were pooled for upper-limb, self-care, and individualized outcomes. There were small-to-medium treatment effects favoring intramuscular botulinum toxin A and occupational therapy, neurodevelopmental therapy and casting, constraint-induced movement therapy, and hand-arm bimanual intensive training on upper-limb outcomes. There were large treatment effects favoring intramuscular botulinum toxin A and upper-limb training for individualized outcomes. No studies reported participation outcomes. CONCLUSIONS. No one treatment approach seems to be superior; however, injections of botulinum toxin A provide a supplementary benefit to a variety of upper-limb–training approaches. Additional research is needed to justify more-intensive approaches such as constraint-induced movement therapy and hand-arm bimanual intensive training.

Do early intervention programmes improve cognitive and motor outcomes for preterm infants after discharge? A systematic review

Aim  The aim of this study was to review the effects of early developmental intervention after discharge from hospital on motor and cognitive development in preterm infants.

Analgesic effects of botulinum toxin A: a randomized, placebo-controlled clinical trial.

Postoperative pain in children with spastic cerebral palsy (CP) is often attributed to muscle spasm and is difficult to manage using opiates and benzodiazepines. Adductor‐release surgery to treat or prevent hip dislocation in children with spastic CP is frequently performed and is often accompanied by severe postoperative pain and spasm. A double‐blinded, randomized, placebo‐controlled clinical trial of 16 patients (mean age 4.7 years) with a mainly spastic type of CP (either diplegic or quadriplegic in distribution) was used to test the hypothesis that a significant proportion of postoperative pain is secondary to muscle spasm and, therefore, might be reduced by a preoperative chemodenervation of the target surgical muscle by intramuscular injection of botulinum toxin A (BTX/A). Compared with the placebo, BTX/A was found to be associated with a reduction in mean pain scores of 74% (P<0.003), a reduction in mean analgesic requirements of approximately 50% (P<0.005), and a reduction in mean length of hospital admission of 33% (P<0.003). It was concluded that an important component of postoperative pain in the patient population is due to muscle spasm and this can be managed effectively by preoperative injection with BTX/A. These findings may have implications for the management of pain secondary to muscle spasm in other clinical settings.

Clinimetric properties of participation measures for 5- to 13-year-old children with cerebral palsy: a systematic review

This study systematically reviewed the validity, reliability, sensitivity to change, and clinical utility of measurements of participation for children with cerebral palsy. Sixteen measures were identified and seven met the inclusion criteria of having 30% content measuring participation, for use with children aged 5 to 13 years with physical disability, and were condition specific. The Childrens Assessment of Participation and Enjoyment (CAPE) assessed participation in leisure and recreation, while the School Function Assessment (SFA) and School Outcome Measure addressed participation in the school environment. The Assessment of Life Habits for Children (LIFE‐H) measured participation in home, school, and community life, and the Children Helping Out: Responsibilities and Expectations assessed childrens participation in household duties. The Canadian Occupational Performance Measure (COPM) and Goal Attainment Scaling (GAS) were individualized tools used to evaluate goal achievement. Results showed most instruments had adequate reliability and validity. The COPM and GAS were the only measures that reported adequate responsiveness to detect clinically significant change. Limited data are currently available to determine the responsiveness of the CAPE, LIFE‐H, and SFA. A combination of assessments is required to capture participation of children in home, school, and community environments.