Interventions to improve sensory and motor outcomes for young children with central hypotonia: A systematic review.

OBJECTIVE: To evaluate evidence supporting physical and occupational therapy interventions used to improve sensory and motor outcomes for children 0-6 years with central hypotonia. METHODS: Four electronic databases were searched from 1996 to March 2017. Level of evidence and study conduct was evaluated using American Academy of Cerebral Palsy and Developmental Medicine criteria. Traffic lighting classification identified interventions that were green (proven effective), yellow (possibly effective) or red (proven ineffective or contraindicated). RESULTS: Thirty-seven articles were included. Nine studies measured orthotic interventions while four distinct studies published over nine articles measured treadmill interventions. Remaining studies measured impact of compression garments, massage, motor and sensori-motor interventions, positioning and mobility interventions. CONCLUSIONS: Green light evidence supports treadmill training (to promote ambulation and gait characteristics) and massage (to positively affect muscle tone, motor development and use of vision) for infants with Down syndrome. These interventions are considered Yellow (possibly effective) for other populations. Green light evidence supports impact of orthoses on foot alignment for ambulatory children with hypotonia, while impact on gait characteristics is Yellow light and motor development may be negatively impacted (Red light) in pre-ambulatory children. All other interventions rated Yellow (possibly effective) and therapists should monitor using sensitive outcome measures.

Variability explained by strength, body composition and gait impairment in activity and participation measures for children with cerebral palsy: a multicentre study.

OBJECTIVE: To determine the amount of variability in scores on activity and participation measures used to assess ambulatory individuals with cerebral palsy explained by strength, body composition, gait impairment and participant characteristics. DESIGN: Multicentre prospective cross-sectional study. SETTING: Seven paediatric-orthopaedic specialty hospitals. PARTICIPANTS: Three hundred and seventy-seven ambulatory individuals (241 males, 136 females) with cerebral palsy, Gross Motor Function Classification System (GMFCS) levels I-III (I = 148, II = 153, III = 76), ages 8-18 years (mean 12 years 9 months, SD 2 years 8 months). METHODS: Participants completed assessments of GMFCS level, patient history, lower extremity muscle strength, Gross Motor Function Measure (GMFM-66), Pediatric Outcomes Data Collection Instrument (PODCI), instrumented gait analysis, 1 minute walk test, Timed Up-and-Go and body composition. Multiple linear regression and bootstrap analyses were performed for each outcome measure, stratified by GMFCS level. RESULTS: The amount of variability in outcome measures explained by participant characteristics, strength, and gait impairment ranged from 11% to 50%. Gait impairment was the most common predictor variable and frequently explained the greatest variance across all outcome measures and GMFCS levels. As gait impairment increased, scores on outcome measures decreased. Strength findings were inconsistent and not a primary factor. Body composition contributed minimally (<4%) in explaining variability. Participant characteristics (cerebral palsy type, gestational age and age at walking onset), were significant predictor variables in several models. CONCLUSIONS: Variability in outcome measure scores is multifaceted and only partially explained by strength and gait impairment illustrating the challenges of attempting to explain variation within this heterogeneous population. Clinicians treating individuals with cerebral palsy should consider this when developing treatment paradigms.

One-Minute Walk and modified Timed Up and Go tests in children with cerebral palsy: performance and minimum clinically important differences.

AIM This prospective multicenter study assessed performance and changes over time, with and without surgical intervention, in the modified Timed Up and Go (mTUG) and One-Minute Walk tests (1MWT) in children with bilateral cerebral palsy (CP). Minimum clinically important differences (MCIDs) were established for these tools. METHOD Two hundred and nineteen participants with bilateral spastic CP (Gross Motor Function Classification System [GMFCS] levels I­III) were evaluated at baseline and 12 months follow-up. The non-surgical group (n=168; 54 females, 114 males; mean age 12y 11mo, [SD 2y 7mo], range 8y 1mo­19y) had no surgical interventions during the study. The surgical group (n=51; 19 females, 32 males; mean age 12y 10mo [SD 2y 8mo] range 8y 2mo­17y 5mo) underwent soft-tissue and/or bony procedures within 12 months from baseline. The mTUG and 1MWT were collected and MCIDs were established from the change scores of the non-surgical group. RESULTS Dependent walkers (GMFCS level III) required more time to complete the mTUG (p≤0.01) than independent walkers (GMFCS levels I and II). For the 1MWT, distance walked decreased with increasing impairment (p≤0.01). 1MWT and mTUG change scores were not significantly different at any GMFCS level for either the surgical or non-surgical groups (p≤0.01). INTERPRETATION Children with varying levels of function (GMFCS level) perform differently on the 1MWT and mTUG. The data and MCID values can assist clinicians in interpreting changes over time and in assessing interventions.

A prospective cohort study of the effects of lower extremity orthopaedic surgery on outcome measures in ambulatory children with cerebral palsy.

BACKGROUND: Lower-extremity musculotendinous surgery is standard treatment for ambulatory children with deformities such as joint contractures and bony torsions resulting from cerebral palsy (CP). However, evidence of efficacy is limited to retrospective, uncontrolled studies with small sample sizes focusing on gait variables and clinical examination measures. The aim of this study was to prospectively examine whether lower-extremity musculotendinous surgery in ambulatory children with CP improves impairments and function measured by gait and clinical outcome tools beyond changes found in a concurrent matched control group. METHODS: Seventy-five children with spastic CP (Gross Motor Function Classification System levels I to III, age 4 to 18 y) that underwent surgery to improve gait were individually matched on the basis of sex, Gross Motor Function Classification System level, and CP subtype to a nonsurgical cohort, minimizing differences in age and Gross Motor Function Measure Dimension E. At baseline and at least 12 months after baseline or surgery, participants completed gait analysis and Gross Motor Function Measure, and parents completed outcome questionnaires. Mean changes at follow-up were compared using analysis of covariance adjusted for baseline differences. RESULTS: Surgery ranged from single-level soft tissue release to multilevel bony and/or soft tissue procedures. At follow-up, after correcting for baseline differences, Gillette Gait Index, Pediatric Outcomes Data Collection Instrument Expectations, and Pediatric Quality of Life Inventory (PedsQL) Physical Functioning improved significantly for the surgical group compared with the nonsurgical group, which showed minimal change. CONCLUSIONS: On the basis of a matched concurrent data set, there was significant improvement in function after 1 year for a surgical group compared with a nonsurgical group as measured by the Gillette Gait Index, with few significant changes noted in outcome measures. Changes over 1 year are minimal in the nonsurgical group, supporting the possibility of ethically performing a randomized controlled trial using nonsurgical controls. LEVEL OF EVIDENCE: Therapeutic level 2. Prospective comparative study.

Apolipoprotein E and functional motor severity in cerebral palsy.

Cerebral palsy is attributed to non-progressive disturbances in the developing fetal or infant brain. The APOE ε4 allele has been associated with poor outcome after brain injury in adults but may be protective among very young children. We conducted this study to explore the hypothesis that the APOE ε4 is associated with lowered severity of cerebral palsy. 158 individuals with CP and their parents were genotyped for APOE. Mean age was 9.1 years; 54% were males. 61% were preterm at birth; 34% less than 30 weeks gestation. 30% of the CP subjects had at least one ε4 allele. There was a trend towards significance for subjects with at least one ε4 allele assigned to the low severity group (p = 0.11). The greater number of ε4 alleles, the more likely an individual was in the low severity CP group (p = 0.12). Individuals with brain injury in the perinatal period were almost 5 times more likely to be in the low severity group (p < 0.01). Family analysis via the TDT supported a protective effect of APOE ε4. Further study is needed to confirm that, in contrast to adults, the APOE ε4 allele appears to confer protection and/or facilitate recovery after brain injury in the fetus or newborn, particularly when that injury occurs around term.

Cervical spine alignment in the youth football athlete: recommendations for emergency transportation.

BACKGROUND: Substantial literature exists regarding recommendations for the on-field treatment and subsequent transportation of adult collision-sport athletes with a suspected injury to the cervical spine. PURPOSE: To develop an evidence-based recommendation for transportation of suspected spine-injured youth football players. STUDY DESIGN: Descriptive laboratory study. METHODS: Three lateral radiographs were obtained in supine to include the occiput to the cervical thoracic junction from 31 youth football players (8-14 years). Each child was imaged while wearing helmet and shoulder pads, without equipment, and with shoulder pads only. Two independent observers measured cervical spine angulation as Cobb angle from C1 to C7 and subaxial angulation from C2 to C7. We calculated intraclass correlation coefficients for intraobserver reliability analysis and compared Cobb and C2 to C7 angles between equipment conditions with t tests. RESULTS: Interobserver analysis showed excellent reliability among measurements. Cobb and subaxial angle measurements indicated significantly greater cervical lordosis while children wore shoulder pads only, compared with the other 2 conditions (no equipment and helmet and shoulder pads) (P .05). CONCLUSIONS: Equipment removal for the youth football athlete with suspected cervical spine injury should abide by the "all or none" policy that has been widely accepted for adult athletes. Helmet and shoulder pads should be left in place during emergency transport of the suspected spine-injured youth athlete. CLINICAL RELEVANCE: Despite differences in head to torso size ratios between youth and adult players, helmet removal alone is not recommended for either during emergency transportation.

Pediatric outcomes data collection instrument scores in ambulatory children with cerebral palsy: an analysis by age groups and severity level.

BACKGROUND: The Pediatric Outcomes Data Collection Instrument (PODCI) was developed in 1994 as a patient-based tool for use across a broad age range and wide array of musculoskeletal disorders, including children with cerebral palsy (CP). The purpose of this study was to establish means and SDs of the Parent PODCI measures by age groups and Gross Motor Function Classification System (GMFCS) levels for ambulatory children with CP. METHODS: This instrument was one of several studied in a prospective, multicenter project of ambulatory patients with CP between the aged 4 and 18 years and GMFCS levels I through III. Participants included 338 boys and 221 girls at a mean age of 11.1 years, with 370 diplegic, 162 hemiplegic, and 27 quadriplegic. Both baseline and follow-up data sets of the completed Parent PODCI responses were statistically analyzed. RESULTS: Age was identified as a significant predictor of the PODCI measures of Upper Extremity Function, Transfers and Basic Mobility, Global Function, and Happiness With Physical Condition. Gross Motor Function Classification System levels was a significant predictor of Transfers and Basic Mobility, Sports and Physical Function, and Global Function. Pattern of involvement, sex, and prior orthopaedic surgery were not statistically significant predictors for any of the Parent PODCI measures. Mean and SD scores were calculated for age groups stratified by GMFCS levels. Analysis of the follow-up data set validated the findings derived from the baseline data. Linear regression equations were derived, with age as a continuous variable and GMFCS levels as a categorical variable, to be used for Parent PODCI predicted scores. CONCLUSIONS: The results of this study provide clinicians and researchers with a set of Parent PODCI values for comparison to age- and severity-matched populations of ambulatory patients with CP.

Comparing functional profiles of children with hemiplegic and diplegic cerebral palsy in GMFCS Levels I and II: Are separate classifications needed?

The goal was to compare children with hemiplegia with those with diplegia within Gross Motor Functional Classification System (GMFCS) levels using multiple validated outcome tools. Specifically, we proposed that children with hemiplegia would have better gait and gross motor function within levels while upper extremity function would be poorer. Data were collected on 422 ambulatory children with cerebral palsy: 261 with diplegia and 161 with hemiplegia, across seven centers. Those with hemiplegia in each level performed significantly and consistently better on gait or lower extremity function and poorer on upper extremity and school function than those with diplegia. In GMFCS Level II, the group with hemiplegia walked faster (p = 0.017), scored 6.6 points higher on Dimension E of the Gross Motor Function Measure (p = 0.017), 6.7 points lower on Upper Extremity subscale of the Pediatric Outcomes Data Collection Instrument, and 9.1 points lower on WeeFIM self-care (p = 0.002). Basing motor prognosis on GMFCS level alone may underestimate lower extremity skills of children with hemiplegia, and overestimate those of children with diplegia.

Acute hip pain in the nonambulatory infant: Salter-Harris type I fracture in the capital femoral epiphysis without a traumatic history.

An otherwise healthy 11-month-old girl was brought to the hospital after her parents noted the acute onset of right hip pain and refusal to bear weight. No abnormalities were seen in the initial radiographs, laboratory values were within reference range, and noninvasive workup was negative for septic arthritis. The parents reported a recent minor fall from a standing position, but stated that the child seemed to return to normal without pain after a few minutes of crying. A hemarthrosis without purulence was found upon joint aspiration, and the patient improved significantly after administration of anti-inflammatory medication. Follow-up radiographs 13 days after initial presentation showed an extremely rare Salter-Harris type I proximal physeal fracture well into the healing process.

Natural progression of gait in children with cerebral palsy.

Twenty-eight children with cerebral palsy had two gait analyses an average of 4.4 years apart with no surgical intervention between the tests. The effects of growth and age were examined using three-dimensional kinematics, temporal and stride parameters, and clinical examination measures. Kinematic changes showed decreases in hip, knee, and ankle sagittal plane ranges of motion (ROM), peak hip flexion in swing, and peak knee flexion over time. Temporal and stride parameters showed declines in timing of toe off, cadence, and walking velocity. Clinical measures showed declines in hip abduction ROM (knees flexed and extended), popliteal angle, and sagittal plane ankle ROM (knees flexed and extended). Overall results showed that gait function in these individuals with cerebral palsy decreased longitudinally with respect to temporal/stride measures, passive ROM, and kinematic parameters compared with a group of individuals who had had orthopaedic intervention.

Long-term effects of femoral derotation osteotomies: an evaluation using three-dimensional gait analysis.

The purpose of this study was to evaluate the long-term effects of the femoral derotation osteotomy (FDO) in the ambulatory patient with cerebral palsy (CP). The effectiveness of the FDOs were evaluated using three-dimensional gait analysis just before surgery (P0), 1 year after surgery (P1), and 5 years after surgery (P2). A total of 20 patients (27 sides) with CP were evaluated. Related physical examination and motion measures showed significant improvements at P1 that were maintained at P2. Mean maximum internal hip rotation at P0 of 77 degrees +/- 9 degrees decreased to 53 degrees +/- 8 degrees at P1 and was maintained at 58 degrees +/- 11 degrees at P2. Mean maximum external hip rotation at P0 of 21 degrees +/- 11 degrees increased to 35 degrees +/- 15 degrees at P1 and was maintained at 32 degrees +/- 13 degrees at P2. Mean femoral anteversion at P0 of 63 degrees +/- 9 degrees was reduced to 26 degrees +/- 15 degrees and was maintained at 31 degrees +/- 13 degrees at P2. During gait, mean hip rotation in stance at P0 of 20 degrees +/- 8 degrees was decreased to 2 degrees +/- 10 degrees at P1 and was maintained at 4 degrees +/- 5 degrees at P2. There were associated significant foot progression changes from an internal progression mean of 5 degrees +/- 17 degrees at P0 to -11 degrees +/- 17 degrees at P1 that were maintained at -12 degrees +/- 5 degrees at P2. The findings suggest that the FDO is a viable and lasting treatment option for the correction of anteversion and associated internal hip rotation during gait in children with CP.

Streptococcus pyogenes pyomyositis.

Group A beta-hemolytic Streptococcus pyomyositis continues to be an uncommon disease. We present a case of a 7-year-old boy with an M protein type 1, streptococcal pyrogenic exotoxin A and B, Streptococcus pyogenes pyomyositis and streptococcal toxic shock syndrome.