Functional classification systems in Brazilian children with cerebral palsy: Reliability and associations between functional levels.

Children with Cerebral palsy (CP) present movement and posture disorders. The Gross Motor Function Classification System (GMFCS), Manual Ability Classification System (MACS), Communication Function Classification System (CFCS), Eating and Drinking Ability Classification System (EDACS), and Visual Function Classification System (VFCS) enhance the understanding of their performance. We verified inter-rater reliability and associations between the classification levels. Physical therapists classified 100 Brazilian children with CP (3-17 years) according to GMFCS, MACS, CFCS, EDACS, and VFCS. To evaluate inter-rater reliability (Intraclass Correlation Coefficient-ICC) two independent examiners concurrently assessed a subset of 60 participants. According to Spearman's correlation coefficients, there were associations between GMFCS/MACS (r = 0.81), GMFCS/CFCS (r = 0.70), MACS/CFCS (r = 0.73), GMFCS/VFCS (r = 0.61), MACS/VFCS (r = 0.61), CFCS/EDACS (r = 0.58), CFCS/VFCS (r = 0.50), and EDACS/VFCS (r = 0.45) (p < .05). The inter-rater reliability ranged from excellent (ICC = 0.93-0.99) to good (ICC = 0.89), p < .05. The classification systems are reliable, and the levels associated with each other in Brazilian children, especially the GMFCS, MACS, and CFCS.

Cerebral Palsy and Motor Impairment After Extreme Prematurity: Prediction of Diagnoses at Ages 2 and 10 Years.

OBJECTIVE: To identify perinatal factors in children born extremely preterm (EP) that were associated with motor impairment (MI) at 2 and 10 years of age and develop a predictive algorithm to estimate the risk of MI during childhood. STUDY DESIGN: Participants of the Extremely Low Gestational Age Newborns Study (ELGANS) were classified as: no MI, MI only at 2 years, MI only at 10 years, and MI at both 2 and 10 years, based on a standardized neurological examination at 2 and the Gross Motor Function Classification System (GMFCS) at 10 years of age. Least Absolute Shrinkage and Selection Operator (LASSO) regression was used to develop the final predictive model. RESULTS: Of the 849 study participants, 64 (7.5%) had a diagnosis of MI at both 2 and 10 years and 63 (7.4%) had a diagnosis of MI at 1 visit but not the other. Of 22 total risk factors queried, 4 variables most reliably and accurately predicted MI: gestational age, weight z-score growth trajectory during neonatal intensive care unit (NICU) stay, ventriculomegaly, and cerebral echolucency on head ultrasound. By selecting probability thresholds of 3.5% and 7.0% at ages 2 and 10, respectively, likelihood of developing MI can be predicted with a sensitivity and specificity of 71.2%/72.1% at age 2 and 70.7%/70.7% at age 10. CONCLUSION: In our cohort, the diagnosis of MI at 2 years did not always predict a diagnosis of MI at 10 years. Specific risk factors are predictive of MI and can estimate an individual infant's risk at NICU discharge of MI at age 10 years.

Variabilidad del ritmo cardiaco en menores de 18 años con parálisis cerebral y su relación con la motricidad gruesa: una revisión sistemática / Hear rate Variability in minors under 18 years with cerebral palsy and its relationship with gross motor function: a systematic Review

INTRODUCTION: Cerebral Palsy (CP) is the main cause of motor deficiency in the child and adolescent population. Its rehabilitation requires non-invasive, cost-effective and easy-to-use measurement systems. Heart rate variability (HRV) meets these requirements, but reference parameters are still lacking in children under 18 years of age with CP. The objective is to write the CRV in children under 18 years of age with CP and its relationship with gross motor skills according to the Gross Motor Function Classification System (GMCFS). MATERIALS (OR PATIENTS) AND METHODS: Systematic review. We searched 11 databases and references from eligible studies that included observational, experimental, and quasi-experimental designs, populations younger than 18 years with CP, and classified with GMFCS. HRV was assessed at rest using time and frequency domain analysis. Risk of bias was assessed using Robins-I. RESULTS: 264 articles were identified. Seven met the inclusion criteria, with a total of 242 patients aged between 4 and 14 years. VRC reporting was done across time (SDNN and rMSSD) and/or frequency (HF, LF, HF, and LF/HF) domains. CONCLUSIONS: There is limited evidence on the analysis of the different domains of the CVR in children under 18 years of age with PC. Findings are conflicting regarding the relationship between VRC and GMFCS. A larger number of studies, larger sample sizes, and better control of confounding variables are still required to generate relationships and reference parameters according to GMFCS.

INTRODUCCIÓN: La Parálisis Cerebral (PC) es la principal causa de deficiencia motriz en la población infanto-juvenil. Su rehabilitación requiere de sistemas de medición no invasivos, costo-efectivos y de fácil aplicación. La variabilidad del ritmo cardiaco (VRC) cumple estos requisitos, pero aún faltan parámetros de referencia en menores de 18 años con PC. El objetivo es escribir la VRC en menores de 18 años con PC y su relación con la motricidad gruesa, según el Gross Motor Function Classification System (GMCFS). MATERIALES (O PACIENTES) Y MÉTODOS: Revisión sistemática. Se buscó en 11 bases de datos y referencias de estudios elegibles que incluyeron diseños observacionales, experimentales y cuasi-experimentales, población menor de 18 años con PC y clasificados con GMFCS. La VRC se evaluó en reposo utilizando análisis de dominio de tiempo y frecuencia. El riesgo de sesgo se evaluó con Robins-I. RESULTADOS: Se identificaron 264 artículos. Siete cumplieron con los criterios de inclusión, con un total de 242 pacientes con edades entre 4 y 14 años. Los informes de VRC se realizaron a través de los dominios de tiempo (SDNN y rMSSD) y/o frecuencia (HF, LF, HF y LF/HF). CONCLUSIONES: Existe evidencia limitada sobre el análisis de los diferentes dominios de la VRC en menores de 18 años con CP. Los hallazgos son contradictorios con respecto a la relación entre VRC y GMFCS. Aún se requiere un mayor número de estudios, mayores tamaños muestrales y un mejor control de las variables de confusión para generar relaciones y parámetros de referencia según GMFCS.

Analysis of orthopedic surgical procedures in children with cerebral palsy.

BACKGROUND: Orthopedic surgery in children with cerebral palsy (CP) aims to improve function and prevent deformities. Each child's condition in CP is unique and many co-variables influence surgical decision-making including a patient's age and their functional level. Little is known about the frequency of different types of orthopedic surgery in children with CP who have varied functional levels, particularly in countries from Latin America. AIM: To assess the type of orthopedic surgical procedures in relation to age and gross motor function in children with CP. METHODS: This retrospective study included all children with CP (n = 245) treated with elective orthopedic surgery at a Uruguayan university hospital between October 2010 and May 2016 identified from a surgical database. Eighteen children (7%) were lost to follow-up due to missing medical charts. Demographics, gross motor function classification (GMFCS), and orthopedic surgeries were obtained from the medical records of 227 children. Chi-squared tests and analysis of variance were used to assess the frequency of surgery, accounting for GMFCS levels. Mean age for soft tissue vs bone surgery was compared with the independent samples t-test. RESULTS: A total of 711 surgical procedures were performed between 1998 and 2016. On average, children had 3.1 surgical procedures and the mean age at first surgery was 8.0 years. There were no significant differences in age at first surgery among GMFCS levels (P = 0.47). The most common procedures were lower leg soft tissue surgery (n = 189, 27%), hip tenotomy (n = 135, 19%), and hamstring tenotomy (n = 104, 14%). For children with GMFCS level I, the mean number of surgeries per child [1.8 (range 1-9)] differed significantly at P < 0.05 in children with GMFCS levels II [3.2 (1-12)], III [3.2 (1-8)], IV [3.3 (1-13)], and V [3.6 (1-11)]. Within II, III, IV, and V, there was no significant difference in mean number of surgeries per child when comparing across the groups. The proportion of soft tissue surgery vs bone surgery was higher in GMFCS levels I-III (80%-85%) compared to levels IV (68%) and V (55%) (P < 0.05). CONCLUSION: The frequency of surgical procedures per child did not increase with higher GMFCS level after level I. However, the proportion of bone surgery was higher in GMFCS levels IV-V compared to I-III.

Clinical, biochemical, and neuroimaging findings predict long-term neurodevelopmental outcome in symptomatic congenital cytomegalovirus infection.

OBJECTIVE: To evaluate clinical, biochemical, and neuroimaging findings as predictors of neurodevelopmental outcome in patients with symptomatic congenital cytomegalovirus (CMV). STUDY DESIGN: The study cohort comprised 26 patients with symptomatic congenital CMV born between 1993 and 2009 in a single center. Absolute and weight deficit-adjusted head circumference were considered. Cerebrospinal fluid (CSF) investigations included standard cytochemical analysis, determination of beta2-microglobulin (ß2-m), neuron-specific enolase, and CMV DNA detection. Neuroimaging was classified according to a validated scoring system comprising calcifications, ventriculomegaly, and atrophy, with findings graded from 0 to 3. Systematic long-term neurodevelopmental assessment included motor function, cognition, behavior, hearing, vision, and epilepsy. Sequelae were graded as mild/absent, moderate, or severe; adverse outcome was defined as death or moderate to severe disability. RESULTS: Three children died. The mean age at follow-up of the survivors was 8.7 ± 5.3 years (range, 19 months to 18.0 years). Neonatal findings showing a significant association with adverse outcome were relative microcephaly, CSF ß2-m concentrations, and grade 2-3 neuroimaging abnormalities (P < .05). Receiver operator characteristic curve analysis indicated that the most accurate single factor for predicting unfavorable outcome was CSF ß2-m >7.9 mg/L (area under the curve, 0.84 ± 0.08; sensitivity, 69%; specificity, 100%). The combination of CSF ß2-m >7.9 mg/L and moderate-severe neuroimaging alterations improved predictive ability (area under the curve, 0.92 ± 0.06; sensitivity, 87%; specificity, 100%). CONCLUSION: Adjusted head circumference, CSF ß2-m level, and neuroimaging studies have prognostic significance for neurodevelopmental outcome in newborns with congenital CMV. A combination of early findings improves the predictive value.