LEARN2MOVE 0-2 years, a randomized early intervention trial for infants at very high risk of cerebral palsy: neuromotor, cognitive, and behavioral outcome.

Purpose: Evidence for efficacy of early intervention in infants at high risk of cerebral palsy (CP) is limited. We compared outcome of infants at very high risk of CP after receiving the family centered program COPing with and CAring for infants with special needs (COPCA) or typical infant physiotherapy.Materials and methods: Forty-three infants were randomly assigned before the corrected age of 9 months to 1 year of COPCA (n = 23) or typical infant physiotherapy (n = 20). Neuromotor development, cognition, and behavior was assessed until 21 months corrected age. Video-recorded physiotherapy sessions were quantitatively analyzed for further process analyses. Outcome was evaluated with nonparametric tests and linear mixed effect models.Results: During and after the interventions, infant outcome in both intervention groups was similar [primary outcome Infant Motor Profile: COPCA 82 (69-94), typical infant physiotherapy 81 (69-89); Hodges Lehman estimate of the difference 0 (confidence interval -5;4)]. Outcome was not associated with contents of intervention.Conclusions: One year of COPCA and 1 year of typical infant physiotherapy in infants at high risk of CP resulted in similar neurodevelopmental outcomes. It is conceivable that combinations of active ingredients from different approaches are needed for effective early intervention.IMPLICATIONS FOR REHABILITATIONFor infants at very high risk of cerebral palsy, 1 year of intervention with the family-centred programme Coping with and Caring for infants with special needs resulted in similar infant outcome as 1 year of typical infant physiotherapy.Infant's neuromotor, cognitive, and behavioural outcome was not associated with specific interventional elements, implying that the various elements may have a similar effect on developmental outcome.We suggest that a specific mix of ingredients of different approaches may work best, resulting in comprehensive care including both infant and family needs.

LEARN2MOVE 0-2 years, a randomized early intervention trial for infants at very high risk of cerebral palsy: family outcome and infant's functional outcome.

Purpose: To compare family and functional outcome in infants at very high risk of cerebral palsy, after receiving the family centred programme "Coping with and Caring for infants with special needs (COPCA)" or typical infant physiotherapy.Materials and methods: Forty-three infants at very high risk were included before 9 months corrected age and randomly assigned to one year COPCA (n = 23) or typical infant physiotherapy (n = 20). Family and infant outcome were assessed before and during the intervention. Physiotherapy intervention sessions were analysed quantitatively for process analysis. Outcome was evaluated with non-parametric tests and linear mixed-effect models.Results: Between-group comparisons revealed no differences in family and infant outcomes. Within-group analysis showed that family's quality of life improved over time in the COPCA-group. Family empowerment was positively associated with intervention elements, including "caregiver coaching."Conclusions: One year of COPCA or typical infant physiotherapy resulted in similar family and functional outcomes. Yet, specific intervention elements, e.g., coaching, may increase empowerment of families of very high risk infants and may influence quality of life, which emphasizes the importance of family centred services.Implications for rehabilitationOne year of the family centred programme "Coping with and a Caring for infants with special needs" compared with typical infant physiotherapy resulted in similar family outcome and similar functional outcome for the infants at very high risk for cerebral palsy.Specific contents of intervention, such as caregiver coaching, are associated with more family empowerment and increased quality of life.Emphasis on family needs is important in early intervention for infants at very high risk for cerebral palsy.

Effects of forward tilted seating and foot-support on postural adjustments in children with spastic cerebral palsy: An EMG-study.

OBJECTIVE: To evaluate the effect of 15° forward (FW) seat inclination and foot-support in children with cerebral palsy (CP) on postural adjustments during reaching. DESIGN: Observational study repeated-measures design; step two of two-step-project. SETTING: Laboratory unit within University Hospital and two special education schools. PARTICIPANTS: 19 children (ten unilateral spastic CP (US-CP); nine bilateral spastic CP (BS-CP); Gross Motor Function Classification System levels I-III; 6-12 years old). Participants were able to take part for one one-hour session. INTERVENTION: Reaching while sitting in four seating conditions (FW or horizontal seat; with or without foot-support) applied in randomized order. OUTCOME MEASURES: Simultaneously, surface electromyography (EMG) of neck, trunk and arm muscles and kinematics of head and reaching arm (step one of two-step-project) were recorded. Primary outcome parameters were the ability to modulate EMG-amplitudes at baseline and during reaching (phasic muscle activity). Other EMG-parameters were direction-specificity (1st control level), and 2nd level of control parameters: recruitment order, and anticipatory postural activity. Motor behaviour measures: ability to modulate EMG-amplitudes to kinematic characteristics of reaching and head stability. RESULTS: Only foot-support was associated with increased tonic background EMG-amplitudes and decreased phasic EMG-amplitudes of the trunk extensors in children with US-CP and BS-CP (mixed-models analyses; p-values <0.01). The foot-support effect was also associated with better kinematics of reaching (Spearman's Rho; p-values <0.01). CONCLUSION: In terms of postural adjustments during forward reaching, foot-support enhanced the children's capacity to modulate trunk extensor activity, which was associated with improved reaching quality. FW-tilting did not affect postural muscle activity.

Changes in the Content of Pediatric Physical Therapy for Infants: A Quantitative, Observational Study.

AIMS: The aim of our observational longitudinal study is to evaluate changes over time in standard pediatric physical therapy (PPT) for infants at risk of neurodevelopmental disorders. METHODS: Treatment sessions in two time periods (2003-2005 [n = 22] and 2008-2014 [n = 16]) were video recorded and analyzed quantitatively in five categories: neuromotor actions, educational actions, communication, position, and situation of treatment session. Differences in percentages of time spent on therapeutic actions between periods were tested with Mann-Whitney U and Hodges Lehmann's tests. RESULTS: No significant changes appeared in the main categories of neuromotor actions. Time spent on not-specified educational actions toward caregivers (median from 99% to 81%, p = .042) and not-specified communication (median from 72% to 52%, p = .002) decreased. Consequently, time spent on specific educational actions (caregiver training and coaching; median from 1% to 19%, p = .042) and specific communication (information exchange, instruct, provide feedback; median from 21% to 38%, p = .007) increased. Infant position changed only minimally: time spent on transitions-that is, change of position-decreased slightly over time (median from 7% to 6%, p = .042). Situation of treatment session did not change significantly over time. CONCLUSIONS: Neuromotor actions in PPT remained largely stable over time. Specific educational actions and communication increased, indicating larger family involvement during treatment sessions.

Best seating condition in children with spastic cerebral palsy: One type does not fit all.

BACKGROUND: The effect of forward-tilting of the seat surface and foot-support in children with spastic cerebral palsy (CP) is debated. AIM: To assess the effect of forward-tilting of the seat surface and foot-support in children with CP on kinematic head stability and reaching. METHODS: Nineteen children functioning at Gross Motor Function Classification System levels I-III participated [range 6-12y; ten unilateral spastic CP (US-CP) and nine bilateral spastic CP (BS-CP)]. Kinematic data were recorded of head sway and reaching with the dominant arm in four sitting conditions: a horizontal and a 15° forward (FW) tilted seat surface, each with and without foot-support. RESULTS: Seating condition did not affect head stability during reaching, but did affect kinematic reaching quality. The major reaching parameters, i.e., the proportion of reaches with one movement unit (MU) and the size of the transport MU, were not affected by foot-support. Forward-tilting had a positive effect on these parameters in children with US-CP, whereas the horizontal condition had this effect in children with BS-CP. IMPLICATIONS: A 15° forward-tilted seating and foot-support do not affect head stability. Reaching in children with US-CP profits from forward-tilting; in children with BS-CP forward-tilting worsens reaching - effects that are independent of foot-support.

Functional outcome at school age of neonatal post-hemorrhagic ventricular dilatation.

BACKGROUND: Specific knowledge about the functional outcome of preterm born children with post-hemorrhagic ventricular dilatation (PHVD) is lacking. OBJECTIVES: To determine functional outcome at school age in children with post-hemorrhagic ventricular dilatation and to identify whether PHVD characteristics increased the risk for deficits. METHODS: Single-center case-control study. Included were preterm children born between 1996 and 2003 who had PHVD in their neonatal period. The controls were children matched for gestation, gender, and year of birth. At school age, using standardized tests and questionnaires, we assessed intelligence, attention, verbal memory, executive functioning, visual perception, visuomotor integration, motor skills, and behavior. RESULTS: Of 34 children with PHVD 28 survived, three of whom could not be tested at school age (one child's parents declined and two were lost to follow-up). At a mean age of 10years (6-14years) the total and verbal IQs of the remaining 25 children (17 boys, 8 girls) were significantly lower compared to controls (difference in total IQ-14 points, verbal IQ-9 points, P=0.001and P=0.009, respectively). After adjustment for possible confounders, the performance of the PHVD group was poorer on visual perception and attention tests. Selective attention showed a trend toward risk of borderline and abnormal scores (OR 4.03, 95%-CI 0.84-19.2). Within the PHVD group, total IQ was significantly lower (P=0.048) in those who had undergone surgical intervention (n=12). CONCLUSION: At school age, intelligence, attention, and visual perception were more affected in the PHVD group than in the matched controls. Surgical intervention was associated with lower IQ scores.

Therapist-Designed Adaptive Riding in Children With Cerebral Palsy: Results of a Feasibility Study.

BACKGROUND: It is debatable whether adaptive riding (AR) in children with cerebral palsy (CP) improves postural control and gross motor development. OBJECTIVE: The study aim was to explore the feasibility of an extensive assessment protocol for a randomized controlled trial of therapist-designed adaptive riding (TDAR) in children with CP, with the goals of assessing the effect on child outcomes and evaluating working mechanisms of sitting postural control. DESIGN: A pretest-posttest group design with 2 baseline measurements was used. METHODS: Six children (1 girl, 5 boys; age range=6-12 years, median age=8 years 9 months) with bilateral spastic CP (Gross Motor Function Classification System level III) participated. Outcomes were evaluated 3 times (T0, T1, and T2) at 6-week intervals. T0 and T1 were baseline measurements; between T1 and T2, a TDAR intervention including an integrated program of postural challenge exercises (2 times per week for 1 hour) was applied. The complex protocol included the 88-item Gross Motor Function Measure (GMFM-88) and electromyographic (EMG) recording of postural muscle activity during reaching while sitting (EMG recording at T1 and T2 only). RESULTS: The protocol was feasible. Median GMFM-88 scores changed from 64.4 at T0 to 66.7 at T1 and from 66.7 at T1 to 73.2 at T2. The change scores for all children exceeded the minimal clinically important difference of the GMFM-88. Five of 6 children showed a decrease in stereotyped top-down recruitment between T1 and T2. LIMITATIONS: Study limitations included the lack of a control group, small sample size, and potential assessor bias for all but the EMG parameters. CONCLUSIONS: The feasibility of the complex protocol was established. The data suggested that a 6-week TDAR intervention may improve gross motor function and may reduce stereotyped postural adjustments in children with CP. The limited results warrant replication in a well-powered randomized controlled trial.

Adaptive seating systems in children with severe cerebral palsy across International Classification of Functioning, Disability and Health for Children and Youth version domains: a systematic review.

AIM: The aim of this study was to systematically review the effect of adaptive seating systems (AdSSs) in young people less than 19 years of age with severe cerebral palsy (CP), with particular focus on child-related outcomes across all components of the functioning and disability domains of the International Classification of Functioning, Disability, and Health for Children and Youth version (ICF-CY). METHOD: Literature searches of studies published from 1975 to October 2014 were performed. Methodological quality and the risk of bias were analysed using Sackett's level of evidence, the American Academy for Cerebral Palsy and Developmental Medicine guidelines, and Mallen criteria for observational studies. RESULTS: Nine studies fulfilled the selection criteria. All studies had level IV evidence and were of moderate methodological quality. The results focused on the effects of AdSSs on postural control and on upper extremity function and on additional child-related outcomes. The results suggested that AdSSs that include trunk and hip support devices may improve postural control outcomes, and that special-purpose AdSSs may improve self-care and play behaviour at home. INTERPRETATION: Because of a low level of evidence and the moderate methodological quality of the studies available, no robust conclusions can be drawn. Nevertheless, the data suggest that AdSSs may be able to improve activity and participation at home among children with severe CP. More studies of high methodological quality addressing the effect of AdSSs on activity and participation are urgently needed. Suggestions for future research are provided.

Children with behavioral problems and motor problems have a worse neurological condition than children with behavioral problems only.

BACKGROUND: Some evidence suggests that children with specific behavioral problems are at risk for motor problems. It is unclear whether neurological condition plays a role in the propensity of children with behavioral problems to develop motor problems. AIMS: To examine the relation between behavioral problems, motor performance and neurological condition in school-aged children. STUDY DESIGN: Cross-sectional study. SUBJECTS: 174 children (95 boys) receiving mainstream education and 106 children (82 boys) receiving special education aged 6 to 13 years (mean 9 y 7 m, SD 1 y 10 m). OUTCOME MEASURES: Behavior was assessed with questionnaires: the parental Child Behavior Checklist (CBCL) and Teacher's Report Form (TRF). Motor performance was assessed with the Movement Assessment Battery for Children (MABC). MABC-scores ≥5th percentile were considered as age-adequate and scores <5th percentile indicated definite motor problems. Neurological condition was assessed in terms of Minor Neurological Dysfunction (MND). RESULTS: The majority of specific behavioral problems were associated with definite motor problems, except somatic complaints and rule breaking behavior. Children with externalizing problems, according to the CBCL or TRF, and motor problems had more often MND than children with externalizing problems only. The same holds true for internalizing problems according to the CBCL. CONCLUSIONS: The present study demonstrated that various forms of behavioral problems were associated with motor problems. Especially children with motor and behavioral problems showed MND.

Functional outcome at school age of preterm-born children treated with high-dose dexamethasone.

BACKGROUND: Postnatal dexamethasone (DXM) treatment is associated with adverse motor outcome. It is largely unknown as to what extent functional outcome at school age is affected. AIMS: Our first aim was to determine motor, cognitive, and behavioural outcome at school age of preterm-born children treated with high-dose DXM for pulmonary problems. Our second aim was to identify DXM-related risk factors for adverse outcome. STUDY DESIGN: In this cohort study, we included 53 very preterm-born children treated with DXM (starting dose 0.5mg/kg/d) after the first week of life. At the median age of 9 years, we performed a detailed neuropsychological assessment. RESULTS: Compared to the norm population, DXM-treated children scored worse on the Movement-ABC (abnormal fine motor, ball skills and balance: 59%, 47% and 30%, respectively). They more often had total (36%), verbal (32%) and performance IQs (55%) below 85 (P<.001, P=.002, P<.001, respectively). On each of the remaining measures, DXM-treated children scored worse than the norm population, except for verbal long-term memory and verbal recognition memory. DXM-related risk factors were associated with poorer performance. CONCLUSIONS: At school age, multiple domains of functional outcome were affected in DXM-treated children. Risk factors related to the use of DXM should be considered as serious potentiaters of adverse outcome in children treated with high-dose DXM.

Neural correlates of developmental coordination disorder.

AIM: To review neuroimaging studies in children with developmental coordination disorder (DCD) systematically. Because only a few studies addressed this, we broadened our search and included neuroimaging studies in children with perinatal adversities and motor impairment without cerebral palsy. METHOD: Two searches were performed in PubMed, PsycINFO, and Web of Science addressing (1) neuroimaging in DCD and (2) neuroimaging in children with perinatal adversities and motor impairment. RESULTS: Five studies in children with DCD were identified. Four functional magnetic resonance imaging (MRI) studies showed that children with DCD activate multiple brain areas differently than controls. One diffusion tensor imaging study indicated that the internal capsule in children with DCD showed differences. The second search identified seven studies: three showed that white matter abnormalities and severe abnormalities on MRI were related to motor impairment; four were unable to demonstrate similar relationships. INTERPRETATION: Data on neuroimaging in DCD are scarce; data available suggest that multiple brain areas are involved in the neuropathophysiology of DCD. Motor impairment in children with perinatal adversities is related especially to white matter abnormalities and severe abnormalities on MRI. We hypothesize that in some children with DCD the neural substrate mimics that of cerebral palsy. More neuroimaging studies are needed to understand the neural correlates of DCD better.

Neural correlates of paediatric dysgraphia.

Writing is an important skill that is related both to school performance and to psychosocial outcomes such as the child's self-esteem. Deficits in handwriting performance are frequently encountered in children with developmental coordination disorder. This review focuses on what is known about the neural correlates of atypical handwriting in children. Knowledge of the neural correlates is derived from studies using clinical case designs (e.g. lesion studies), studies using neuroimaging, and assessment of minor neurological dysfunction. The two functional imaging studies suggest a contribution of cortical areas and the cerebellum. The largest study indicated that cortical areas in all regions of the brain are involved (frontal, temporal, parietal, and occipital). The two lesion studies confirmed cerebellar involvement. The findings of the study on minor neurological dysfunction in children with writing problems correspond to the imaging results. The limited data on the neural substrate of paediatric dysgraphia suggest that at least a subset of the children with dysgraphia have dysfunctions in extensive supraspinal networks. In others, dysfunction may be restricted to either the cerebellum or specific cortical sites.

GMFM in infancy: age-specific limitations and adaptations.

PURPOSE: To evaluate longitudinal applicability of the gross motor function measure (GMFM) in infants younger than 2 years. METHODS: Twelve infants at very high risk for cerebral palsy were enrolled between 1 and 9 months corrected age. The children were assessed 4 times during 1 year with the GMFM-66, GMFM-88, and other neuromotor tests. RESULTS: Longitudinal use of the GMFM in infancy was hampered by age and function-specific limitations. The GMFM-66 differentiated less at lower-ability levels than at higher-ability levels. The GMFM-88 demonstrated flattening of the developmental curve when infants had developed more motor abilities. We formulated adaptations for the longitudinal use of GMFM in infancy. CONCLUSIONS: To facilitate use of the GMFM in infancy, an adapted version may be an option. Further research is required to assess reliability and validity, and in particular, the sensitivity to change of the suggested adaptations.

Use and functioning of the affected limb in children with unilateral congenital below-elbow deficiency during infancy and preschool age: a longitudinal observational multiple case study.

BACKGROUND: Children with unilateral congenital below elbow deficiency (UCBED) lack a part of an arm, thereby lacking a part of the typical hand function. Little is known on the performance of daily activities in very young children with UCBED, usage of their affected arm with or without prosthesis during play, and neurological condition. AIM: To explore daily activities, the use of the affected limb with or without prosthesis and neurological condition over time in young children with UCBED. DESIGN: A longitudinal observational multiple case study. METHODS: Four children with UCBED were assessed (first assessment at 3-16months) every 6-8months (follow-up 13-49months) with a video-recorded, standardized play session and a neurological examination. Yearly, functioning in daily activities was evaluated using the Pediatric Evaluation of Disability Inventory - Dutch Version (PEDI-NL). Play behaviour was assessed with and without prosthesis, where applicable (n=2). Video-analysis focused on achievement, exploration, variation and adaptability of the affected limb. Behavioural changes over time were plotted and analysed visually. RESULTS: Over time, children with UCBED showed efficient usage of their affected arm during spontaneous play. Prosthesis use seemed to be associated with reduced manipulation, exploration, variation and adaptation. Three children showed minor neurological dysfunction. Functioning in daily activities was comparable to a norm population. CONCLUSION: The short limb of children with UCBED is used as an exploratory, manipulatory and fixating tool from the beginning of infancy. Its value seems to be reflected in these children's normal functioning in daily life. Prosthetic use may lead to less effective performance.

Health-related physical fitness in Dutch children with developmental coordination disorder.

OBJECTIVE: To compare components of health-related physical fitness between Dutch children with clinically diagnosed developmental coordination disorder (DCD) and typically developing children (TDC), and to examine associations between motor performance problems and components of health-related fitness in children with DCD. METHODS: A multicenter case-control study was used to compare health-related physical fitness in children with DCD (N = 38; age, 7-12 years; 10 girls and 28 boys) with that in age- and gender-matched TDC. Motor coordination problems (manual dexterity, ball and balance skills) were assessed using the movement assessment battery for children. Health-related physical fitness was indicated by (1) cardiorespiratory fitness, (2) muscle strength, and (3) body mass index. RESULTS: Significantly lower values of cardiorespiratory fitness (6.7% lower maximal cardiorespiratory fitness) were found in children with DCD compared with TDC. Extension and flexion of the elbow and flexion of the knee were also significantly lower (by 15.3%, 16.7%, and 18.4%, respectively) in DCD children compared with TDC. A significant negative and large association was found between cardiorespiratory fitness and balance performance. CONCLUSION: Lower cardiorespiratory fitness and muscle strength in children with clinically diagnosed DCD compared with TDC support the importance of examining and training cardiorespiratory fitness and muscle strength, besides the regular attention for motor coordination problems.

A systematic evaluation of the effect of thumb opponens splints on hand function in children with unilateral spastic cerebral palsy.

OBJECTIVE: To examine the effects of a neoprene thumb opponens splint on hand function during a self-selected activities of daily living task in children with unilateral spastic cerebral palsy with thumb-in-palm position of the affected hand. DESIGN: Systematic evaluation of seven cases using a multiple baseline design across individuals. SETTING: Outpatient clinic. SUBJECTS: Seven children with unilateral cerebral palsy (2-7 years old), Manual Ability Classification System level 2-3 participated in the study. INTERVENTIONS: Neoprene thumb opponens splints (McKie splint) were used. Children were followed for about four months. Baseline period ranged from 4 to 9 weeks, intervention period was two months and duration of follow-up one month. MAIN MEASURES: Hand function was assessed using goal attainment scaling and visual analogue scales. Data was assessed visually. RESULTS: In four children goal attainment scaling and/or visual analogue scale scores increased after introducing the splint. These effects remained when splints were not worn. Two children only benefited from the splint when it was worn. Thumb opponens splints were tolerated well by all children who participated in this study. CONCLUSIONS: Thumb opponens splints may have a positive effect on hand function in children with unilateral spastic cerebral palsy.

Limited motor performance and minor neurological dysfunction at school age.

AIM: To investigate the relationship between motor performance and minor neurological dysfunction (MND) at school age. METHODS: Two hundred and fifty-three children (158 boys, 95 girls; mean age 8 years and 7 months) of whom 167 children received mainstream education and 86 children special education were neurologically examined according to Touwen. Special attention was paid to the severity of MND (simple or complex form) and type of dysfunction. Motor performance was assessed with the Movement Assessment Battery for Children (MABC), a parental questionnaire (Developmental Coordination Disorder Questionnaire; DCD-Q) and a teacher's questionnaire (Motor Observation Questionnaire for Teachers; MOQ-T). RESULTS: Total scores of MABC, DCD-Q and MOQ-T were strongly related to the severity of MND and to dysfunctional coordination and fine manipulation. Mild dysfunction in posture and muscle tone was only weakly related to limited motor performance. Children with a MABC score < 5th percentile showed significantly more often complex MND than children with scores between the 5th and 15th percentile or >15th percentile (54% vs 17% and 10%). CONCLUSION: Limited motor performance is related to the severity and type of MND. Coordination problems and fine manipulative disability are strongly related to poor motor performance, mild dysfunctions of posture and muscle tone to a lesser extent.

LEARN 2 MOVE 0-2 years: effects of a new intervention program in infants at very high risk for cerebral palsy; a randomized controlled trial.

BACKGROUND: It is widely accepted that infants at risk for cerebral palsy need paediatric physiotherapy. However, there is little evidence for the efficacy of physiotherapeutic intervention. Recently, a new intervention program, COPCA (Coping with and Caring for infants with special needs - a family centered program), was developed. COPCA has educational and motor goals. A previous study indicated that the COPCA-approach is associated with better developmental outcomes for infants at high risk for developmental disorders. LEARN 2 MOVE 0-2 years evaluates the efficacy and the working mechanisms of the COPCA program in infants at very high risk for cerebral palsy in comparison to the efficacy of traditional infant physiotherapy in a randomized controlled trial. The objective is to evaluate the effects of both intervention programs on motor, cognitive and daily functioning of the child and the family and to get insight in the working elements of early intervention methods. METHODS/DESIGN: Infants are included at the corrected age of 1 to 9 months and randomized into a group receiving COPCA and a group receiving traditional infant physiotherapy. Both interventions are given once a week during one year. Measurements are performed at baseline, during and after the intervention period and at the corrected age of 21 months. Primary outcome of the study is the Infant Motor Profile, a qualitative evaluation instrument of motor behaviour in infancy. Secondary measurements focus on activities and participation, body functions and structures, family functioning, quality of life and working mechanisms. To cope with the heterogeneity in physiotherapy, physiotherapeutic sessions are video-recorded three times (baseline, after 6 months and at the end of the intervention period). Physiotherapeutic actions will be quantified and related to outcome. DISCUSSION: LEARN 2 MOVE 0-2 years evaluates and explores the effects of COPCA and TIP. Whatever the outcome of the project, it will improve our understanding of early intervention in children with cerebral palsy. Such knowledge is a prerequisite for tailor-made guidance of children with CP and their families. TRIAL REGISTRATION: The trial is registered under NTR1428.

Handwriting, visuomotor integration, and neurological condition at school age.

AIM: the study investigated the relationships between handwriting, visuomotor integration, and neurological condition. We paid particular attention to the presence of minor neurological dysfunction (MND). METHOD: participants were 200 children (131 males, 69 females; age range 8-13y) of whom 118 received mainstream education (mean age 10y 5mo, SD 1y 4mo) and 82 special education (mean age 10y 8mo, SD 1y 2mo). Each child had four assessments: a neurological examination, which paid attention to the type and severity of MND, a test to measure motor performance, a handwriting test, and the Developmental Test of Visual Motor Integration. RESULTS: dysgraphic handwriting and slow writing speed were closely related to the severity of neurological dysfunction (both p<0.001); impaired visuomotor integration was related to the presence of MND (p<0.001) but somewhat less to its severity. Impaired handwriting and visuomotor integration were strongly related to two specific dysfunctions: fine manipulative disability and coordination problems (both p<0.001). Impaired visuomotor integration was weakly related to dysfunctional muscle tone regulation (p=0.009) and sensory dysfunction (p=0.042). INTERPRETATION: poor handwriting and impaired visuomotor integration are related to MND, but in a differential way. Poor handwriting is related to the severity of neurological dysfunction and to dysfunctions of complex supraspinal circuitries. Impaired visuomotor integration is associated with the presence of any of the most common types of MND.

Risk factors for emergence and progression of scoliosis in children with severe cerebral palsy: a systematic review.

AIM: Scoliosis is a frequently occurring and serious complication of severe cerebral palsy (CP). This systematic review aims to the assess the risk factors associated with the emergence and progression of scoliosis in children with CP functioning at level IV or V of the Gross Motor Function Classification System (GMFCS). METHOD: Relevant studies conducted from 1966 to March 2009 were identified in Embase, Medline, and Scopus. The methodological quality of the studies was assessed and relations between risk factors and scoliosis were documented systematically. RESULTS: Ten studies were included. They had a low level of evidence and heterogeneous methodological quality. No systematic associations were found between type of CP and scoliosis or between age, type, and location of scoliotic curve and progression of scoliosis. Weak evidence was present for an association between the severity of CP, hip dislocation, and pelvic obliquity and scoliosis. INTERPRETATION: The low level of evidence precludes the drawing of firm conclusions on risk factors for the emergence and progression of scoliosis in children with severe CP. However, given the high prevalence of the disorder and its serious consequences for daily life, more research in this area is urgently needed.