Improved Myelination following Camp Leg Power, a Selective Motor Control Intervention for Children with Spastic Bilateral Cerebral Palsy: A Diffusion Tensor MRI Study.

BACKGROUND AND PURPOSE: Children with spastic cerebral palsy have motor deficits associated with periventricular leukomalacia indicating WM damage to the corticospinal tracts. We investigated whether practice of skilled lower extremity selective motor control movements would elicit neuroplasticity. MATERIALS AND METHODS: Twelve children with spastic bilateral cerebral palsy and periventricular leukomalacia born preterm (mean age, 11.5 years; age range, 7.3-16.6 years) participated in a lower extremity selective motor control intervention, Camp Leg Power. Activities promoted isolated joint movement including isokinetic knee exercises, ankle-controlled gaming, gait training, and sensorimotor activities (3 hours/day, 15 sessions, 1 month). DWI scans were collected pre- and postintervention. Tract-Based Spatial Statistics was used to analyze changes in fractional anisotropy, radial diffusivity, axial diffusivity, and mean diffusivity. RESULTS: Significantly reduced radial diffusivity (P < . 05) was found within corticospinal tract ROIs, including 28.4% of the left and 3.6% of the right posterior limb of the internal capsule and 14.1% of the left superior corona radiata. Reduced mean diffusivity was found within the same ROIs (13.3%, 11.6%, and 6.6%, respectively). Additionally, decreased radial diffusivity was observed in the left primary motor cortex. Additional WM tracts had decreased radial diffusivity and mean diffusivity, including the anterior limb of the internal capsule, external capsule, anterior corona radiata, and corpus callosum body and genu. CONCLUSIONS: Myelination of the corticospinal tracts improved following Camp Leg Power. Neighboring WM changes suggest recruitment of additional tracts involved in regulating neuroplasticity of the motor regions. Intensive practice of skilled lower extremity selective motor control movements promotes neuroplasticity in children with spastic bilateral cerebral palsy.

Selective Motor Control is a Clinical Correlate of Brain Motor Tract Impairment in Children with Spastic Bilateral Cerebral Palsy.

BACKGROUND AND PURPOSE: Selective voluntary motor control is an important factor influencing gross motor function, interjoint coordination, and the outcome of hamstring-lengthening surgery in spastic cerebral palsy. Using DTI, we investigated whether selective voluntary motor control would show strong correlations with WM motor tract microstructure and whether selective voluntary motor control is more sensitive to global WM impairment than gross motor function. MATERIALS AND METHODS: Children with spastic bilateral cerebral palsy born preterm and typically developing children were recruited. The Selective Control Assessment of the Lower Extremity (SCALE) and Gross Motor Function Measure (GMFM) were assessed in participants with cerebral palsy. Participants underwent brain MR imaging to collect DWI data. Tract-Based Spatial Statistics was used to analyze the WM for between-group differences and correlations with SCALE and GMFM. ROI analyses compared motor regions. RESULTS: Twelve children with cerebral palsy (mean age, 11.5 years) and 12 typically developing children (mean age, 10.3 years) participated. Altered DTI outcomes were found throughout the whole brain for the cerebral palsy group. SCALE, developed to evaluate selective voluntary motor control in cerebral palsy, showed significant positive correlations with fractional anisotropy in more WM voxels throughout the whole brain and for motor regions, including the corticospinal tract and corpus callosum, compared with GMFM. A significant negative correlation between radial diffusivity and SCALE, but not GMFM, was found within the corpus callosum. CONCLUSIONS: SCALE was a more sensitive clinical correlate of motor and whole-brain WM tract impairment in children with spastic bilateral cerebral palsy, suggesting greater anisotropy and myelination in these regions for those with higher selective voluntary motor control.

Perioperative complications in children undergoing selective posterior rhizotomy: a review of 105 cases.

Medical histories for 105 consecutive children who underwent selective posterior rhizotomy (SPR) were reviewed to determine the incidence and clinical significance of adverse events related to anaesthesia and surgery. No intraoperative or postoperative events with potential for lasting morbidity, nor life threatening events, were identified. Intraoperatively, the most common adverse events were moderate elevation of body temperature (13/105) and transient dysrhythmias (8/105). The most frequent postoperative complications were fever, marginal oxygen saturation in the absence of supplemental oxygen, and postcatheterization cystitis. Early surgical complications, such as wound infection, cerebrospinal fluid leak, haemorrhage, and bowel or bladder disturbance were absent in this series. Surgical technique and anaesthetic management are described.

Intraoperative monitoring during selective posterior rhizotomy: technique and patient outcome.

We evaluated intraoperative electromyographic (EMG) results among 110 pediatric patients with spastic cerebral palsy who underwent selective posterior rhizotomy. We analyzed surgical outcomes for 60 of these patients who returned for follow-up assessment between 4 and 17 months postoperatively. Reduction in muscle tone (resistance to passive movement), increased range of motion and improvements in functional skills were seen at follow-up. To control for possible changes due to development, participation in therapy, or instability of measurements, 30 rhizotomy patients were evaluated twice during a baseline period of several months prior to surgery. No significant changes were found between these two measurement sessions during the baseline control period suggesting that the rhizotomy surgery itself caused the postoperative improvements. These intraoperative EMG monitoring techniques have been adopted at many other centers but variations in specific methods and EMG criteria have developed subsequently among major hospitals where selective posterior rhizotomy is performed. These variations in neurophysiologic methods and recent controversy about the usefulness of such intraoperative EMG monitoring created a need for us to publish our standard EMG selection technique. We describe here, in detail, methods for nerve rootlet testing and selection.

Functional outcomes following selective posterior rhizotomy in children with cerebral palsy.

The recent increase in popularity of selective posterior rhizotomy demands objective documentation of surgical outcome. For this reason, the authors have analyzed the status of 25 children with spastic cerebral palsy before and after rhizotomy to determine the effects of this therapy on muscle tone, range of movement, and motor function. Postoperative tests showed a reduction in muscle tone compared with preoperative assessments. Range of motion in the lower extremities was significantly increased and improvements in functional gross motor skills were noted. An increase in range of motion in the knees and thighs during gait was detected in 18 ambulatory patients studied with computerized two-dimensional motion analysis. Preliminary findings indicate that selective posterior rhizotomy reduced spasticity, thereby increasing range of motion and contributing to improvements in active functional mobility.

Selective posterior rhizotomy: evolution of theory and practice.

The spastic type of cerebral palsy has become more prevalent due to improved survival rates of premature infants. Selective posterior rhizotomy is a neurosurgical procedure which is designed to reduce spasticity and has been successfully used for children with spastic cerebral palsy. Although the procedure of posterior rhizotomy is nearly 100 years old, a revised technique was introduced in 1981. Since that time, the procedure has been further refined and its use has altered the theory and practice of cerebral palsy management. This paper reviews the neurophysiological and anatomical facts that have influenced the development of the technique. The current practice of selective posterior rhizotomy is an evolving process which has stimulated scientific interest in spasticity, cerebral palsy and its management.

Spasticity in cerebral palsy and the selective posterior rhizotomy procedure.

A review of the selective posterior rhizotomy procedure for reduction of spasticity in cerebral palsy is presented. The history of the procedure, selection of patients, operative technique, and results are described. The neurophysiologic basis for spasticity is considered, as well as the role of spasticity in the complex motor disorder of cerebral palsy. Cerebral palsy is a multifaceted disorder of which spasticity is only one aspect. Reduction of spasticity can be effectively achieved using the current technique of selective posterior rhizotomy, but careful patient selection and establishment of realistic goals are vital to successful outcome. Postoperative physical and occupational therapy are felt to be essential for regaining strength and improving motor function following the rhizotomy procedure. Further study in the areas of spasticity, cerebral palsy, and the effects of rhizotomy is expected to advance our treatment of spastic children.

Gait analysis of cerebral palsy children before and after rhizotomy.

Over the past decade, selective posterior rhizotomy has been used successfully to reduce spasticity in patients with cerebral palsy. Although clinical evaluation of these patients revealed functional improvement following surgery, more objective analysis of the outcome of this surgery was sought. Kinematic gait analysis of 14 patients with spastic cerebral palsy was performed before and after selective posterior rhizotomy. Measurements of stride length, thigh range of motion, knee range of motion, average speed of walking, and cadence were made. Statistically significant increases in stride length, thigh range and knee range were found. Average speed was increased and cadence was virtually unchanged. These results corroborate clinical findings of improvement in gait of spastic patients with cerebral palsy following selective posterior rhizotomy.

Monitoring Road Racing in the Heat.

In brief: The guidelines that have been published to prevent runners from collapsing with heat injury have been based on laboratory studies with different conditions from those experienced in actual road races. A new portable heat stress monitor was used to test whether high levels of solar radiation raised rectal temperature more than no-sun conditions. The authors propose guidelines using color codes to alert runners to the degree of danger during races. They say that below 18 C (64 F) there is a low risk of heat injury, and races should not be started at temperatures above 28 C (82 F).