WHAT'S NEW IN CEREBRAL PALSY

Among new researches bearing on cerebral palsy are the growth of brain cells in tissue cultures for experimentation; the use of polysaccharides to prevent the formation of a glial barrier to nerve growth after injury; observation of changes in reactions of neurons at various stages of development; the finding of hypernatremia and hyperchloremia in lesions of the frontal lobe and the thalamus; stimulation of cerebral blood flow by injection of sodium bicarbonate and retardation with ammonium chloride; and studies of serial sections of brains of palsied children who died.Study of development in the early months of life has made possible the detection of significant abnormalities in behavior early in life. Loss of hearing may be tested in very young children by measuring minute variations in electrical resistance of the skin upon auditory stimulation of the sympathetic nervous system.Conditions which have been described as having been confused with cerebral palsy are dislocation of a cervical vertebra, hereditary spastic paraplegia, transverse myelopathy, injury to the spinal cord or cauda equina by anomalous growths of the spine, and also encephalitis and meningitis.Sedation has proved a valuable adjunct to electroencephalographic study of cerebral palsy. Better criteria for abnormality in the young child should be determined and the application of them more clearly standardized.Simple exercises are useful for early training of palsied children to stimulate development. “Crossed laterality”—the dominant eye being contralateral to the preferred hand—has been counteracted by special training with great success in eliminating emotional and behavior problems and accelerating development.Recent studies indicate that only 50 per cent of cerebral palsy patients have normal or better intelligence.Subluxation of the hip joint, a common deformity associated with cerebral palsy, can sometimes be corrected by operation if detected at an early stage. Radical ablation of epileptogenic foci in the cortex is also being done in young patients if drug control of seizures fails. Frontal topectomy, cingulate gyrectomy or prefrontal labotomy may be advisable in cases in which proper response to drug therapy is not obtained.Improvement in behavior as well as control of seizures may follow the use of Benzedrine,® Dexedrine,® Dilantin® sodium, Mebaral® and phenobarbital. Alcohol, paraldehyde and chloral hydrate have been effective as relaxants.     

CARE OF CEREBRAL-PALSIED CHILDREN—The Special Role of Pediatricians

Because the cerebral-palsied child is also a growing person whose development should be encouraged along as normal a course as possible, the pediatrician may well take the lead in coordinating orthopedic, psychiatric, educational and vocational services for such children. In El Centro this policy has been followed in a school for handicapped children serving 30 with cerebral palsy, 15 of them pupils at the school. Those with sufficient intelligence and milder physical handicap attend a regular public school, while others are unable to attend even the special school.Emphasis has been placed on working with children who are less seriously affected. As to children with severe neuromuscular and intellectual handicap, the chief effort is to prevent contractures and maintain function. The pediatrician confers monthly with all workers concerned with the child, and maintains liaison with the family physician who treats acute illnesses, including palsy seizures. Special effort has been made to investigate family circumstances such as foreign background which make it more difficult to evaluate the palsied child''s true capabilities.     

Care of cerebral-palsied children; the special role of pediatricians

Because the cerebral-palsied child is also a growing person whose development should be encouraged along as normal a course as possible, the pediatrician may well take the lead in coordinating orthopedic, psychiatric, educational and vocational services for such children. In El Centro this policy has been followed in a school for handicapped children serving 30 with cerebral palsy, 15 of them pupils at the school. Those with sufficient intelligence and milder physical handicap attend a regular public school, while others are unable to attend even the special school. Emphasis has been placed on working with children who are less seriously affected. As to children with severe neuromuscular and intellectual handicap, the chief effort is to prevent contractures and maintain function. The pediatrician confers monthly with all workers concerned with the child, and maintains liaison with the family physician who treats acute illnesses, including palsy seizures. Special effort has been made to investigate family circumstances such as foreign background which make it more difficult to evaluate the palsied child's true capabilities.     

SEIZURE PROBLEMS IN 250 CEREBRAL PALSIED ADULTS

Seizures occurred at some time in 81 (or 32 per cent) of an unselected, consecutive series of 250 cerebral palsied persons between the ages of 16 and 52 years, an incidence similar to that reported by other investigators in groups of cerebral palsied persons who were mainly children.The incidence of seizures of any kind after 16 years of age in the present series was 10 per cent as compared with 0.5 per cent in the general population. Half of the 10 per cent had more than six convulsions despite drug therapy, and the other half had fewer than six.Of thirty-six who had convulsions in the neonatal period, only four had seizure problems as adults, even though most showed moderate to severe physical handicap after age 16.Data on the small group of paraplegics in the present study, all spastics, were in accord with reports by other investigators with regard to decreased incidence of seizures in cerebral palsied patients with normal upper extremities. Of the thirteen (5 per cent of the 250) whose seizure problems continued to be clinically significant in adult life, ten had had frequent seizures in childhood. Eight were hemiplegic. There appeared to be no relationship between the severity of physical handicap and the incidence of seizures after age 16.     

全身运动质量评估联合颅脑超声对脑损伤高危儿运动发育结局的预测价值

摘要 目的：研究全身运动（GMs）质量评估和颅脑超声（CUS）在脑损伤高危儿运动发育结局中的预测价值。方法：选取2019年10月至2021年6月入住徐州医科大学附属医院新生儿重症监护室（NICU）具有脑损伤高危因素的早产儿605例,建立随访档案。入院24h、3d、7d内各做一次CUS检查,异常者每周复查1次直至出院,记录最异常结果。矫正胎龄36～40周行扭动运动GMs质量评估,矫正3～6月龄行不安运动GMs质量评估。矫正12月龄通过Gesell发育量表和小儿脑瘫诊断分型标准明确运动发育结局,分析GMs质量评估、CUS对不良运动发育结局和脑瘫的预测效度。结果：最终获得完整随访资料的脑损伤高危儿为536例,随访至12月龄的运动发育结局为运动发育正常424例,运动发育迟缓105例,脑瘫7例。扭动运动GMs质量评估对运动发育结局预测的敏感性为56.25%、特异性为82.78%;不安运动GMs质量评估对运动发育结局预测的敏感性为73.21%、特异性为98.82%;CUS对运动发育结局预测的敏感性为54.46%、特异性为94.34%。扭动运动GMs质量评估联合CUS对运动发育结局预测的敏感性为81.25%、特异性为81.13%;不安运动GMs质量评估联合CUS对运动发育结局预测的敏感性为84.82%、特异性为96.46%。GMs质量评估和CUS对脑瘫预测的敏感性和阴性预测值均为100.00%;联合应用GMs质量评估和CUS可明显提高对不良运动结局的敏感性及阳性预测值。结论：CUS对脑损伤高危儿的不良运动发育结局尤其是脑瘫具有良好的预测价值,GMs质量评估联合CUS可明显提升对脑损伤高危儿不良运动发育结局的早期预测价值。     

血清胱抑素C、血肌酐及血尿素氮对窒息新生儿肾功能损害的临床意义

目的:探讨体外反搏联合言语训练治疗脑性瘫痪并语言发育迟缓儿童的临床疗效。方法:选择2015年12月至2017年12月在上海市儿童医院康复科普通门诊确诊的脑瘫并语言发育迟缓患儿52例,按照随机数字表法将其随机分为治疗组和对照组,每组26例。对照组仅给予言语训练治疗,治疗组给予体外反搏联合言语训练治,以4周1个疗程,两组均治疗3个疗程。治疗前后,采用中国康复研究中心汉语版儿童语言发育评定法s-s法、Gesell发育评分法评价和比较患儿言语发育商和认知发育商的变化。结果:治疗后,两组言语发育商和认知发育商均显著高于治疗前,且治疗组言语发育商和认知发育商均显著高于对照组,差异均有统计学意义(均P0.01)。结论:体外反搏联合言语训练较单纯言语训练可更有效改善脑瘫并语言发育迟缓患儿的言语发育和认知发育。     

Effect of Transcranial Direct-Current Stimulation Combined with Treadmill Training on Balance and Functional Performance in Children with Cerebral Palsy: A Double-Blind Randomized Controlled Trial

Background

Cerebral palsy refers to permanent, mutable motor development disorders stemming from a primary brain lesion, causing secondary musculoskeletal problems and limitations in activities of daily living. The aim of the present study was to determine the effects of gait training combined with transcranial direct-current stimulation over the primary motor cortex on balance and functional performance in children with cerebral palsy.

Methods

A double-blind randomized controlled study was carried out with 24 children aged five to 12 years with cerebral palsy randomly allocated to two intervention groups (blocks of six and stratified based on GMFCS level (levels I-II or level III).The experimental group (12 children) was submitted to treadmill training and anodal stimulation of the primary motor cortex. The control group (12 children) was submitted to treadmill training and placebo transcranial direct-current stimulation. Training was performed in five weekly sessions for 2 weeks. Evaluations consisted of stabilometric analysis as well as the administration of the Pediatric Balance Scale and Pediatric Evaluation of Disability Inventory one week before the intervention, one week after the completion of the intervention and one month after the completion of the intervention. All patients and two examiners were blinded to the allocation of the children to the different groups.

Results

The experimental group exhibited better results in comparison to the control group with regard to anteroposterior sway (eyes open and closed; p<0.05), mediolateral sway (eyes closed; p<0.05) and the Pediatric Balance Scale both one week and one month after the completion of the protocol.

Conclusion

Gait training on a treadmill combined with anodal stimulation of the primary motor cortex led to improvements in static balance and functional performance in children with cerebral palsy.

Trial Registration

Ensaiosclinicos.gov.br/RBR-9B5DH7     

Individualized,home-based interactive training of cerebral palsy children delivered through the Internet

Background  

The available health resources limit the amount of therapy that may be offered to children with cerebral palsy and the amount of training in each session may be insufficient to drive the neuroplastic changes, which are necessary for functional improvements to take place. The aim of this pilot study was to provide proof of concept that individualized and supervised interactive home-based training delivered through the internet may provide an efficient way of maintaining intensive training of children with cerebral palsy over prolonged periods.     

神经肌肉关节促进训练对脑性瘫痪患儿智力及肢体功能的影响

摘要 目的：探讨神经肌肉关节促进训练对脑性瘫痪(cerebral palsy,CP,脑瘫)患儿智力及肢体功能的影响。方法：2016年12月到2018年12月选择在本院儿保科门诊就诊的脑瘫患儿134例,根据治疗方法分为观察组与对照组,各67例。对照组给予常规康复训练,观察组在对照组给予神经肌肉关节促进训练,两组康复观察3个月,记录智力及肢体功能变化情况。结果：观察组的总有效率为98.5 %,高于对照组的83.6 %(P<0.05)。两组康复后的粗大运动功能测试量表(gross motor function measure, GMFM)评分都高于康复前(P<0.05),观察组高于对照组(P<0.05)。两组康复后的适应与语言行为评分都高于康复前(P<0.05),观察组也高于对照组(P<0.05)。两组康复后的F波振幅高于康复前(P<0.05),阈值低于康复前(P<0.05),康复后观察组与对照组对比差异也都有统计学意义(P<0.05)。结论：神经肌肉关节促进训练在脑瘫患儿的应用能促进改善智力及肢体功能,重建患儿的肌电功能,从而提高治疗效果。     

Malformations of cortical development in children with congenital cytomegalovirus infection - A study of nine children with proven congenital cytomegalovirus infection

Congenital cytomegalovirus (CMV) infection is the most common vertically transmitted disease with the rate of the infection ranging from 0.2 to 2.4% in newborn infants. Congenital CMV infection causes multiorgan affection, but the most severe and permanent sequelae are those affecting central nervous system such as mental retardation, cerebral palsy, sensorineural hearing loss, chorioretinitis and seizures as a result of direct interference of the virus with neurogenesis. The time of acquiring infection is strongly connected to the level of child's disability. Infection in early pregnancy results in severe neurological sequelae, while later infection has less prominent signs. Radiological findings show connection between onset of infection and brain imaging, from lissencephaly, pachygyria, polymicrogyria, schizencephaly, calcification, cerebellar hypoplasia and/or hypoplasia/agenesis of corpus callosum as a result of an early infection, to white matter abnormalities including disturbed myelination as a result of a late infection. We present nine patients with proven congenital CMV infection and malformations of cortical development and their computed tomography/magnetic resonance (CT/MRI) findings along with clinical assessments. According to CT/MRI results we assume that two of our children with lissencephaly had an early onset of infection. The other seven with less severe cortical dysplasia in form of pachy/polymicrogyria were probably infected later Cerebellar hypoplasia and/or calcifications in our patients also confirm an early onset of infection. Developmental outcome in all of our children was poor: moderate to severe psychomotor retardation has been diagnosed in all children; five of them have developed cerebral palsy (four have bilateral spastic and one dyskinetic) and one is estimated to have minor motor dysfunction. Seven out of nine developed epilepsy, chorioretinitis was found in three of them and sensorineural deafness in two of them. All of our children, except one, were presented by symptomatic infection, yet only four of them were recognized at birth. Therefore, congenital CMV infection should be considered as one of the reasons for childhood disability more often.     

Effects of vibrotactile stimulation on the control of muscle tone and movement facilitation in children with cerebral injury

Afferent signals from the muscle's proprioceptors play important role in the control of muscle tone and in the facilitation of movements. Peripheral afferent pathway enables the restoration of connections with supraspinal structures and so includes mechanism of synaptic inhibition in the performance of normal movement. Different sensory stimuli, as vibrotactile stimulation, excite muscle's proprioceptors which then send sensorimotor information via spinal cord. In this way afferent signals promote cortical control and modulation of movements. The goal of this study is to evaluate the effects of vibrotactile stimulation on the spasticity and motor performance in children with cerebral injury. Subjects included in this study were 13 children who were developing the classification of spastic cerebral palsy. For all children perinatal brain damage was documented by medical reports and neonatal brain ultrasound scan. At the mean age of 3 years and 6 months subject underwent the assessment of motor development by Gross Motor Function Measurement (GMFM-88). Gross Motor Classification System (GMFCS) has been used to classify functions of lower extremities. Therapeutic intervention was conducted once a week during 3 months. All subjects were stimulated with vibrotactile stimuli of 40Hz in duration of 20 minutes in order to reduce spasticity. After the ending of the treatment subjects underwent second assessment of motor performance and the classification of lower extremities functions. The results have shown that there was a significant improvement in motor performance, what has been seen in the facilitation of rotations, better postural trunk stability and head control and in greater selectivity of movements. Further randomized, control trial investigations with bigger sample and included spasm scale are needed to gain better insight in the role of vibrotactile stimulation in the facilitation of normal movements.     

小儿脑瘫数字化社区康复系统在拇内收畸形中的应用研究

目的:探讨数字化康复系统对于小儿脑瘫拇内收畸形的康复效果。方法:选择普陀区残联系统下脑瘫患儿21例及上海市儿童医院康复门诊家庭康复每月随访的脑瘫患儿21例,将其分成两组,每组21例。对照组由家长行常规OT训练后佩戴为患儿定制的拇外展支具进行治疗,治疗组除以上治疗外加用数字化康复系统随访治疗。三个月后,对疗效进行评估和比较。结果:经3个月治疗后,两组拇指内收肌肌张力改善总有效率(显效率与有效率之和)分别为90.5%和81%,治疗组显著高于对照组(P0.05)。两组患儿治疗后PROM均较治疗前有所改善(P0.01),且治疗组治疗后PROM显著高于对照组(P0.05)。两组FMFM比较两组治疗后FMFM均较治疗前显著升高(P0.01),且治疗组治疗后FMFM显著高于(P0.01)。结论:家庭(社区)数字化康复系统干预可有效提高小儿脑瘫拇内收畸形的康复效果。     

运动疗法联合作业疗法用于脑瘫患儿的疗效及对肢体运动功能作用

摘要 目的：探讨运动疗法联合作业疗法用于脑瘫患儿的疗效对肢体运动功能的作用。方法：选择2020年3月~2022年6月我院康复科收治的80例脑瘫患儿作为研究对象,采用随机数字表法分为两组各40例,对照组予以运动疗法干预,包括Bobath技术和核心稳定性训练,试验组在对照组基础上进行作业疗法干预,包括手功能、手眼协调能力、进食、如厕、更衣及游戏训练。干预前后采用粗大运动功能测量（GMFM）、精细运动功能评估表（FMFM）及Gesell发育量表对患儿进行评估,评价临床疗效,并采用SF-36健康调查简表（SF-36）对患者进行评估。结果：两组患儿干预后的GMFM评分、FMFM评分均明显提高,而试验组明显高于对照组（P<0.05）。两组患儿干预后的DQ评分均明显提高,而试验组明显高于对照组,试验组DQ评分增幅明显大于对照组（P<0.05）。试验组的总有效率（95.0%）明显高于对照组（77.5%）（P<0.05）。两组患儿干预后SF-36评分均明显提高,试验组在活力、社会功能和精神健康维度明显高于对照组（P<0.05）。结论：运动疗法联合作业疗法可有效促进脑瘫患儿的上肢与下肢运动功能改善,提高康复效果,改善患儿生存质量,应充分重视脑瘫的综合康复疗法。     

CEREBRAL PALSY—An Approach to the Problem

A program for the cerebral palsied child has been developed in California which has been made possible through the cooperation of the state and local departments of education, the state and local departments of health, the Children''s Hospital and Orthopedic Hospital at Los Angeles and the University of California School of Medicine in San Francisco. An attempt is being made to deal with not only the medical and educational needs of the cerebral palsied but also the social and emotional aspects.     

从"补脾强肾"小儿推拿手法论治小儿脑瘫

目的:从中医的角度,探究"补脾强肾"小儿推拿手法论治小儿脑瘫的作用机制。方法:采用回顾性的分析,收集中西医治疗小儿脑瘫的相关文章,分析小儿脑瘫的原因、治疗方法及作用机制。结果:在中医中脑瘫病位在脑、脾、肾,脑瘫患儿普遍存在脾肾亏虚,表现为肌肉瘦削,筋骨痿软,故属于"五迟"、"五软"范畴。这与现代医学所观察到的脑瘫患儿肢体运动障碍和营养吸收障碍相符。因此该病除了应用现代康复技术手段外,还应从补益脾肾的角度开展相应的中医治疗。临床中不能接受内服药物治疗的患儿,可以采用小儿推拿治疗,治疗效果显著。结论:在脑瘫康复训练中配合补脾强肾小儿推拿手法,同补先后天之本,可提高营养生长水平,缩短康复疗程,提升康复疗效,最终达到全面促进脑瘫患儿康复的目的。     

重复经颅磁刺激对痉挛型脑瘫患儿语言发育能力及运动功能的影响

目的:分析重复经颅磁刺激(rTMS)对痉挛型脑瘫患儿语言发育能力及运动功能的影响。方法:采用随机数字表法将54例我院于2015年8月至2016年8月收治的痉挛型脑瘫患儿分为观察组与对照组,每组27例,观察组患儿给予rTMS治疗,对照组给予常规的康复治疗。采用儿童语言发育迟缓检查法(S-S法)评价治疗前后患儿的语言发育能力,采用踝关节活动度及GMFM-88粗大运动功能测试表评估治疗前后患儿的运动功能。结果:治疗后两组患儿语言理解商与表达商较治疗前均增加,且观察组高于对照组,差异有统计学意义(P0.05);观察组患儿总有效率为77.8%,高于对照组的51.9%,差异有统计学意义(P0.05);治疗后两组患儿踝关节活动度均增加,且治疗后观察组患儿踝关节活动度高于对照组(P0.05);治疗后两组患儿GMFM-88评分均增加,且治疗后观察组患儿GMFM-88评分高于对照组(P0.05)。结论:rTMS康复方法可以促进痉挛型脑瘫患儿的语言发育能力及运动功能,值得临床推广。     

Endogenous heme oxygenase prevents impairment of cerebral vascular functions caused by seizures

In newborn pigs, the mechanism of seizure-induced cerebral hyperemia involves carbon monoxide (CO), the vasodilator product of heme catabolism by heme oxygenase (HO). We hypothesized that seizures cause cerebral vascular dysfunction when HO activity is inhibited. With the use of cranial window techniques, we examined cerebral vascular responses to endothelium-dependent (hypercapnia and bradykinin) and endothelium-independent (isoproterenol and sodium nitroprusside) dilators during the recovery from bicuculline-induced seizures in saline controls and in animals pretreated with a HO inhibitor, tin protoporphyrin (SnPP). SnPP (3 mg/kg iv) blocked dilation to heme and reduced the CO level in cortical periarachnoid cerebrospinal fluid, indicating HO inhibition in the cerebral microcirculation. In saline control piglets, seizures increased the CO level, which correlated with the time-dependent cerebral vasodilation; during the recovery (2 h after seizure induction), responses to all vasodilators were preserved. In SnPP-treated animals, cerebral vasodilation and the CO responses to seizures were greatly reduced, and cerebral vascular reactivity was severely impaired during the recovery. These findings suggest that HO in the cerebral microcirculation is rapidly activated during seizures and provides endogenous protection against seizure-induced vascular injury.     

Febrile seizures: traffic slows in the heat

Febrile seizures, which occur in young children, have long been known to have a major inherited component. Mutations in some genes that encode sodium channel and GABA(A) receptor subunits have been found in a few families affected by febrile seizures. These mutations account only for a minority of cases, and much remains to be learnt about the molecular architecture of febrile seizures. A rare inherited cause--a mutation in the GABA(A) receptor subunit GABRG2 gene--has been recently shown to cause a temperature-dependent intracellular trafficking defect. This is an important step in unravelling the molecular pathogenesis of this common childhood disorder.     

Case-control study of intrapartum care,cerebral palsy,and perinatal death.

OBJECTIVE--To investigate the relation between suboptimal intrapartum obstetric care and cerebral palsy or death. DESIGN--Case-control study. SETTING--Oxford Regional Health Authority. SUBJECTS--141 babies who subsequently developed cerebral palsy and 62 who died intrapartum or neonatally, 1984-7. All subjects were born at term of singleton pregnancies and had no congenital anomaly. Two controls, matched for place and time of birth, were selected for each index case. MAIN OUTCOME MEASURES--Adverse antenatal factors and suboptimal intrapartum care (by using predefined criteria). RESULTS--Failure to respond to signs of severe fetal distress was more common in cases of cerebral palsy (odds ratio 4.5; 95% confidence interval 2.4 to 8.4) and in cases of death (26.1; 6.2 to 109.7) than among controls. This association persisted even after adjustment for increased incidence of a complicated obstetric history in cases of cerebral palsy. Neonatal encephalopathy is regarded as the best clinical indicator of birth asphyxia; only two thirds (23/33) of the children with cerebral palsy in whom there had been a suboptimal response to fetal distress, however, had evidence of neonatal encephalopathy; these 23 formed 6.8% of all children with cerebral palsy born to residents of the region in the four years studied. CONCLUSION--There is an association between quality of intrapartum care and death. The findings also suggest an association between suboptimal care and cerebral palsy, but this seems to have a role in only a small proportion of all cases of cerebral palsy. The contribution of adverse antenatal factors in the origin of cerebral palsy needs further study.     

生物标记物对脑损伤患儿早期诊断及监测价值的研究进展

脑损伤是新生儿期危害严重的疾病之一,可导致脑瘫、运动发育迟缓、认知功能障碍及学习困难等后遗症,严重影响了新生儿的健康发育及生活质量的提高。新生儿脑损伤(NBI)是一种由多种原因导致的范围很广的疾病,其临床表现缺乏特异性,临床上在判断其损伤严重程度、持续时间及产前损伤时间等存在较大的困难,受到广大科研者及临床医师的重视。目前,影像学方法是NBI确诊的主要手段,但影像学检查通常存在滞后性和一定的局限性。体液生物标记物水平在脑损伤后会较早发生变化,通过检测其水平变化可早期预测脑损伤情况。近年来,新生儿各种体液中已检测出多种具有敏感性的脑损伤生物标记物,主要包括神经元特异性烯醇化酶(NSE)、泛素羟基末端水解酶L-1(UCH-L1)、S100B蛋白、Tau蛋白、髓鞘碱性蛋白(MBP)、胶质纤维酸性蛋白(GFAP)、激活素A等,本研究对上述常用生物标记物在NBI中的应用情况以及研究进展进行综述,探讨其临床应用前景。