INCITE: A randomised trial comparing constraint induced movement therapy and bimanual training in children with congenital hemiplegia

Background  

Congenital hemiplegia is the most common form of cerebral palsy (CP) accounting for 1 in 1300 live births. These children have limitations in capacity to use the impaired upper limb and bimanual coordination deficits which impact on daily activities and participation in home, school and community life. There are currently two diverse intensive therapy approaches. Traditional therapy has adopted a bimanual approach (BIM training) and recently, constraint induced movement therapy (CIMT) has emerged as a promising unimanual approach. Uncertainty remains about the efficacy of these interventions and characteristics of best responders. This study aims to compare the efficacy of CIMT to BIM training to improve outcomes across the ICF for school children with congenital hemiplegia.     

Evaluating Functional Outcomes of Botulinum Toxin Type A Injection Combined with Occupational Therapy in the Upper Limbs of Children with Cerebral Palsy: A 9-Month Follow-Up from the Perspectives of Both Child and Caregiver

Objective

To assess the effectiveness of combining botulinum toxin type A (BoNT-A) with functional occupational therapy (OT) at 9-month follow-up in children with cerebral palsy (CP) with bilateral upper limb impairments from the perspectives of both child and caregiver.

Methods

Twelve children with CP and their caregivers were assessed across 5 time points over 9 months based on the ICF after BoNT-A injection and functional OT in this open-label study.

Results

Significant differences were found across the 5 time points (p < .05) for both grasp and visual-motor integration with small effects (effect sizes = 0.12–0.24) and the self-care capability and performance of social function (p < .05). However, based on the effect sizes (0.02–0.14), no significant effects were found at the 4 post-test time points. Small effects were found on the psychological domain (effect sizes = 0.25–0.37) and environmental domains (effect size = 0.27) at follow-ups.

Conclusion

Combining a BoNT-A injection with OT not only reduced the muscle tone and increased ROM but also improved the upper limb function and self-care capability in children with CP. More importantly, these effects persisted for up to 9 months. Functional OT extends the effectiveness of a BoNT-A injection.     

Upper limb children action-observation training (UP-CAT): a randomised controlled trial in Hemiplegic Cerebral Palsy

Background  

Rehabilitation for children with hemiplegic cerebral palsy (HCP) aimed to improve function of the impaired upper limb (UL) uses a wide range of intervention programs. A new rehabilitative approach, called Action-Observation Therapy, based on the recent discovery of mirror neurons, has been used in adult stroke but not in children. The purpose of the present study is to design a randomised controlled trial (RCT) for evaluating the efficacy of Action-Observation Therapy in improving UL activity in children with HCP.     

Muscle Recruitment and Coordination following Constraint-Induced Movement Therapy with Electrical Stimulation on Children with Hemiplegic Cerebral Palsy: A Randomized Controlled Trial

Objective

To investigate changes of muscle recruitment and coordination following constraint-induced movement therapy, constraint-induced movement therapy plus electrical stimulation, and traditional occupational therapy in treating hand dysfunction.

Methods

In a randomized, single-blind, controlled trial, children with hemiplegic cerebral palsy were randomly assigned to receive constraint-induced movement therapy (n = 22), constraint-induced movement therapy plus electrical stimulation (n = 23), or traditional occupational therapy (n = 23). Three groups received a 2-week hospital-based intervention and a 6-month home-based exercise program following hospital-based intervention. Constraint-induced movement therapy involved intensive functional training of the involved hand during which the uninvolved hand was constrained. Electrical stimulation was applied on wrist extensors of the involved hand. Traditional occupational therapy involved functional unimanual and bimanual training. All children underwent clinical assessments and surface electromyography (EMG) at baseline, 2 weeks, 3 and 6 months after treatment. Surface myoelectric signals were integrated EMG, root mean square and cocontraction ratio. Clinical measures were grip strength and upper extremity functional test.

Results

Constraint-induced movement therapy plus electrical stimulation group showed both a greater rate of improvement in integrated EMG of the involved wrist extensors and cocontraction ratio compared to the other two groups at 3 and 6 months, as well as improving in root mean square of the involved wrist extensors than traditional occupational therapy group (p<0.05). Positive correlations were found between both upper extremity functional test scores and integrated EMG of the involved wrist as well as grip strength and integrated EMG of the involved wrist extensors (p<0.05).

Conclusions

Constraint-induced movement therapy plus electrical stimulation is likely to produce the best outcome in improving muscle recruitment and coordination in children with hemiplegic cerebral palsy compared to constraint-induced movement therapy alone or traditional occupational therapy.

Trial registration

chictr.org ChiCTR-TRC-13004041     

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.     

Presence of Cleaved Synaptosomal-Associated Protein-25 and Decrease of Purinergic Receptors P2X3 in the Bladder Urothelium Influence Efficacy of Botulinum Toxin Treatment for Overactive Bladder Syndrome

Objectives

To evaluate whether botulinum toxin A (BoNT-A) injection and Lipotoxin (liposomes with 200 U of BoNT-A) instillation target different proteins, including P2X3, synaptic vesicle glycoprotein 2A, and SNAP-25, in the bladder mucosa, leading to different treatment outcomes.

Materials and Methods

This was a retrospective study performed in a tertiary teaching hospital. We evaluated the clinical results of 27 OAB patients treated with intravesical BoNT-A injection (n = 16) or Lipotoxin instillation (n = 11). Seven controls were treated with saline. Patients were injected with 100 U of BoNT-A or Lipotoxinin a single intravesical instillation. The patients enrolled in this study all had bladder biopsies performed at baseline and one month after BoNT-A therapy. Treatment outcome was measured by the decreases in urgency and frequency episodes at 1 month. The functional protein expressions in the urothelium were measured at baseline and after 1 month. The Wilcoxon signed-rank test and ordinal logistic regression were used to compare the treatment outcomes.

Results

Both BoNT-A injection and Lipotoxin instillation treatments effectively decreased the frequency of urgency episodes in OAB patients. Lipotoxin instillation did not increase post-void residual volume. BoNT-A injection effectively cleaved SNAP-25 (p < 0.01). Liposome encapsulated BoNT-A decreased urothelial P2X3 expression in the five responders (p = 0.04), while SNAP-25 was not significantly cleaved.

Conclusions

The results of this study provide a possible mechanism for the therapeutic effects of BoNT-A for the treatment of OAB via different treatment forms. BoNT-A and Lipotoxin treatments effectively decreased the frequency of urgency episodes in patients with OAB.     

Diagnostic accuracy of the neurological upper limb examination II: Relation to symptoms of patterns of findings

Background  

In a sample of patients in clinical occupational medicine we have demonstrated that an upper limb neurological examination can reliably identify patterns of findings suggesting upper limb focal neuropathies. This further study aimed at approaching the diagnostic accuracy of the examination.     

The relationship between lower limb muscle volume and body mass in ambulant individuals with bilateral cerebral palsy

Background

Individuals with cerebral palsy have smaller muscle volumes normalised to body mass than their typically developing peers. The aim of this study is to investigate the relationship between lower limb muscle volume and body mass in young people with bilateral cerebral palsy and their typically developing peers.

Methods

Twenty-five participants with bilateral cerebral palsy (aged 14.7±3.0 years, GMFCS level I-III) and 25 of their typically developing peers (aged 16.8±3.3 years) took part in this study. None of the participants had undergone orthopaedic surgery, botulinum toxin injections, or serial casting in the previous year. All participants underwent magnetic resonance imaging of both lower limbs. Nine major muscles of each lower limb were individually manually segmented and the muscle volumes calculated.

Results

Body mass and total lower limb muscle volume were significantly linearly related in both the cerebral palsy (R² = 0.75, p<0.001) and typically developing (R² = 0.77, p<0.001) groups. The slope of the relationship between muscle volume and body mass was significantly shallower in the cerebral palsy group compared to the typically developing group (p=0.007).

Conclusions

This cross-sectional study suggests that the increase in size of lower limb muscles relative to body mass is reduced in adolescents and young adults with cerebral palsy. Longitudinal studies are required to further investigate altered muscle growth trajectories in this group and their impact on long-term mobility.

     

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。     

A new child-friendly 3D bimanual protocol to assess upper limb movement in children with unilateral cerebral palsy: Development and validation

Unilateral cerebral palsy (uCP) causes upper limb movement disorders that impact on daily activities, especially in bimanual condition. However, a few studies have proposed bimanual tasks for 3D motion analysis. The aim of this study was to validate the new version of a child-friendly, 3D, bimanual protocol for the measurement of joint angles and movement quality variables. Twenty children with uCP and 20 typically developing children (TDC) performed the five-task protocol integrated into a game scenario. Each task specifically targeted one or two upper limb degrees of freedom. Joint angles, smoothness and trajectory straightness were calculated. Elbow extension, supination, wrist extension and adduction amplitudes were reduced; hand trajectories were less smooth and straight in children with uCP compared to TDC. Correlations between the performance-based score and kinematic variables were strong. High within and between-session reliability was found for most joint angle variables and lower reliability was found for smoothness and straightness in most tasks. The results therefore demonstrated the validity and reliability of the new protocol for the objective assessment of bimanual function in children with uCP. The evaluation of both joint angles and movement quality variables should increase understanding of pathological movement patterns and help clinicians to optimize treatment.ClinicalTrials.gov identifier: NCT03888443.     

Association between Antibiotic Prescribing in Pregnancy and Cerebral Palsy or Epilepsy in Children Born at Term: A Cohort Study Using The Health Improvement Network

Background

Between 19%-44% pregnant women are prescribed antibiotics during pregnancy. A single, large randomised-controlled-trial (ORACLE Childhood Study II) found an increased risk of childhood cerebral palsy and possibly epilepsy following prophylactic antibiotic use in pregnant women with spontaneous preterm labour. We ascertained whether this outcome could be reproduced across the population of babies delivered at term and prospectively followed in primary-care using data from The Health Improvement Network.

Methods

We determined the risk of cerebral palsy or epilepsy in children whose mothers were prescribed antibiotics during pregnancy using a cohort of 195,909 women linked to their live, term-born, singleton children. We compared the effect of antibiotic class, number of courses and timing of prescribing in pregnancy. Analyses were adjusted for maternal risk factors (e.g. recorded infection, age, chronic conditions, social deprivation, smoking status). Children were followed until age seven years or cessation of registration with the primary-care practitioner.

Results

In total, 64,623 (33.0%) women were prescribed antibiotics in pregnancy and 1,170 (0.60%) children had records indicating cerebral palsy or epilepsy. Adjusted analyses showed no association between prescribing of any antibiotic and cerebral palsy or epilepsy (adj.HR 1.04, 95%CI 0.91–1.19). However, compared with penicillins, macrolides were associated with an increased risk of cerebral palsy or epilepsy (adj.HR 1.78, 95%CI 1.18–2.69; number needed to harm 153, 95%CI 71–671).

Conclusions

We found no overall association between antibiotic prescribing in pregnancy and cerebral palsy and/or epilepsy in childhood. However, our finding of an increased risk of cerebral palsy or epilepsy associated with macrolide prescribing in pregnancy adds to evidence that macrolide use is associated with serious harm.     

Mental practice-based rehabilitation training to improve arm function and daily activity performance in stroke patients: a randomized clinical trial

Background  

Over 50% of patients with upper limb paresis resulting from stroke face long-term impaired arm function and ensuing disability in daily life. Unfortunately, the number of effective treatments aimed at improving arm function due to stroke is still low. This study aims to evaluate a new therapy for improving arm function in sub-acute stroke patients based on mental practice theories and functional task-oriented training, and to study the predictors for a positive treatment result. It is hypothesized that a six-week, mental practice-based training program (additional to regular therapy) targeting the specific upper extremity skills important to the individual patient will significantly improve both arm function and daily activity performance, as well as being cost effective.     

The effects of whole body vibration on mobility and balance in children with cerebral palsy: a systematic review with meta-analysis

Objective:

We performed a meta-analysis to evaluate the effects of whole-body vibration on physiologic and functional measurements in children with cerebral palsy.

Design and methods:

We searched MEDLINE, Cochrane Controlled Trials Register, EMBASE, Scielo, CINAHL (from the earliest date available to November 2014) for randomized controlled trials, that aimed to investigate the effects of whole-body vibration versus exercise and/or versus control on physiologic and functional measurements in children with cerebral palsy. Two reviewers independently selected the studies. Weighted mean differences (WMDs) and 95% confidence intervals (CIs) were calculated.

Results:

Six studies with 176 patients comparing whole-body vibration to exercise and/or control were included. Whole-body vibration resulted in improvement in: gait speed WMDs (0.13 95% CI:0.05 to 0.20); gross motor function dimension E WMDs (2.97 95% CI:0.07 to 5.86) and femur bone density (1.32 95% CI:0.28 to 2.36). The meta-analysis also showed a nonsignificant difference in muscle strength and gross motor function dimension D for participants in the whole-body vibration compared with control group. No serious adverse events were reported.

Conclusions:

Whole-body vibration may improve gait speed and standing function in children with cerebral palsy and could be considered for inclusion in rehabilitation programs.     

A New Non-Human Primate Model of Photochemically Induced Cerebral Infarction

Background and Purpose

Rat models of photochemically induced cerebral infarction have been readily studied, but to date there are no reports of transcranial photochemically induced infarctions in the marmoset. In this report, we used this non-human primate as a model of cerebral thrombosis and observed the recovery process.

Methods

Five common marmosets were used. Cerebral ischemia was produced via intravascular thrombosis induced by an intravenous injection of Rose Bengal and irradiation with green light. After inducing cerebral infarction, we observed the behavior of marmosets via a continuous video recording. We evaluated maximum speed, mean speed, and distance traveled in 1 min. In addition, we evaluated scores for feeding behavior, upper limb grip, and lower limb grip. We confirmed the infarct area after cerebral infarction using 2,3,5-triphenyltetrazolium chloride staining in a separate marmoset.

Results

We found functional decreases 2 days after creating the cerebral infarction in all measurements. Total distance traveled, average speed, upper limb score, and feeding behavior score did not recover to pre-infarction levels within 28 days. Maximum speed in 1 min and lower limb score recovered 28 days after infarction as compared to pre-infarction levels. We confirmed the infarct area of 11.4 mm×6.8 mm as stained with 2,3,5-triphenyltetrazolium chloride.

Conclusion

We were able to create a primate photothrombosis-induced cerebral infarction model using marmosets and observe functional recovery. We suggest that this is a useful model for basic research of cerebral infarction.     

Comparing unilateral and bilateral upper limb training: The ULTRA-stroke program design

Background  

About 80% of all stroke survivors have an upper limb paresis immediately after stroke, only about a third of whom (30 to 40%) regain some dexterity within six months following conventional treatment programs. Of late, however, two recently developed interventions - constraint-induced movement therapy (CIMT) and bilateral arm training with rhythmic auditory cueing (BATRAC) - have shown promising results in the treatment of upper limb paresis in chronic stroke patients. The ULTRA-stroke (acronym for Upper Limb TRaining After stroke) program was conceived to assess the effectiveness of these interventions in subacute stroke patients and to examine how the observed changes in sensori-motor functioning relate to changes in stroke recovery mechanisms associated with peripheral stiffness, interlimb interactions, and cortical inter- and intrahemispheric networks. The present paper describes the design of this single-blinded randomized clinical trial (RCT), which has recently started and will take several years to complete.     

Corticosteroid and antiviral therapy for Bell's palsy: A network meta-analysis

Background  

Previous meta-analyses of treatments for Bell's palsy are still inconclusive due to different comparators, insufficient data, and lack of power. We therefore conducted a network meta-analysis combining direct and indirect comparisons for assessing efficacy of steroids and antiviral treatment (AVT) at 3 and 6 months.     

Pulseless electrical activity during electroconvulsive therapy: a case report

Background

Arrhythmias resulting in cardiac arrest during electroconvulsive therapy have been reported. Most reported cases of cardiac arrest had asystole as the initial rhythm. Pulseless electrical activity as an initial rhythm of cardiac arrest during electroconvulsive therapy has never been reported. Also, thromboembolism after inflation of pneumatic tourniquet during lower limb surgery has been reported but never following tourniquet inflation during an electroconvulsive therapy.

Case presentation

We report a case involving an 81- year- old female who presented to us for an electroconvulsive therapy for severe depression and developed pulseless electrical activity immediately after electroconvulsive therapy. She was successfully resuscitated and was later found to have bilateral pulmonary emboli with a complete occlusion of the right lower lobe pulmonary artery. The source of embolus was from her left lower extremity deep venous thrombus, which we believe, got dislodged intraoperatively after inflation of pneumatic tourniquet. Our patient not only survived the massive pulmonary embolus, but also showed significant improvement in her mental status compared to her pre-admission level at the time of discharge to a sub-acute rehabilitation centre.

Conclusion

We recommend that patients who are elderly and at high risk of thromboembolism should selectively undergo a preoperative doppler ultrasound for deep venous thrombosis. Also, selective application of tourniquet in the upper limb, to monitor for seizure activity, would reduce the incidence of pulmonary thrombo-embolism as embolic events are significantly less from deep venous thromboses of upper extremities when compared to lower extremities.     

Literature Review and Comparison of Two Statistical Methods to Evaluate the Effect of Botulinum Toxin Treatment on Gait in Children with Cerebral Palsy

Aim

This study aimed at comparing two statistical approaches to analyze the effect of Botulinum Toxin A (BTX-A) treatment on gait in children with a diagnosis of spastic cerebral palsy (CP), based on three-dimensional gait analysis (3DGA) data. Through a literature review, the available expert knowledge on gait changes after BTX-A treatment in children with CP is summarized.

Methods

Part 1—Intervention studies on BTX-A treatment in children with CP between 4–18 years that used 3DGA data as an outcome measure and were written in English, were identified through a broad systematic literature search. Reported kinematic and kinetic gait features were extracted from the identified studies. Part 2—A retrospective sample of 53 children with CP (6.1 ± 2.3years, GMFCS I-III) received 3DGA before and after multilevel BTX-A injections. The effect of BTX-A on gait was interpreted by comparing the results of paired samples t-tests on the kinematic gait features that were identified from literature to the results of statistical parametric mapping analysis on the kinematic waveforms of the lower limb joints.

Results

Part 1–53 kinematic and 33 kinetic features were described in literature. Overall, there is no consensus on which features should be evaluated after BTX-A treatment as 49 features were reported only once or twice. Part 2—Post-BTX-A, both statistical approaches found increased ankle dorsiflexion throughout the gait cycle. Statistical parametric mapping analyses additionally found increased knee extension during terminal stance. In turn, feature analyses found increased outtoeing during stance after BTX-A.

Conclusion

This study confirms that BTX-A injections are a valuable treatment option to improve gait function in children with CP. However, different statistical approaches may lead to different interpretations of treatment outcome. We suggest that a clear, definite hypothesis should be stated a priori and a commensurate statistical approach should accompany this hypothesis.     

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     

矫形鞋垫联合踝关节持续被动运动用于偏瘫型脑瘫患儿步态稳定性控制的临床研究

目的:探讨矫形鞋垫联合踝关节持续被动运动(CPM)用于偏瘫型脑瘫患儿姿势控制的临床价值。方法:选择2016年6月~2017年6月在我院康复科就诊的56例偏瘫型脑瘫患儿,随机均分成两组。对照组患儿每日行物理治疗(PT)训练,每次共30分钟,每日一次,每周五次。治疗组患儿常规物理治疗训练同对照组,并同时运用足部生物力学矫形技术及踝关节CPM治疗,每次15分钟,角度恒定为-45-45度,每天一次。两组治疗疗程为三个月。治疗结束后,比较两组患儿的儿平衡能力总有效率、GMFM(E功能区评分)、肢体运动功能、踝关节张力及踝关节活动范围的改善情况。结果:两组患儿平衡能力总有效率(显效率与有效率之和)分别为92.9%和67.9%,治疗组明显优于对照组(P0.05)。治疗组治疗后GMFM(E功能区评分比较)明显高于对照组(P0.01),患侧肢体运动功能改善、踝关节张力、踝关节活动范围改善情况均明显优于对照组(P0.05)。结论:矫形鞋垫联合踝关节CPM明显有助于偏瘫型脑瘫患儿姿势控制的治疗。