A preliminary study on the spasticity reduction of quadriceps after selective dorsal rhizotomy in pediatric cases of spastic cerebral palsy.

OBJECTIVE: This study aimed to evaluate the potential alleviation of quadriceps spasticity in children diagnosed with spastic cerebral palsy (CP) following selective dorsal rhizotomy (SDR). METHODS: A retrospective study was conducted on children suffering from spastic CP who underwent SDR at the Department of Neurosurgery, Shanghai Children's Hospital, from July 2018 to September 2020. Inclusion criteria comprised children exhibiting quadriceps spasticity exceeding modified Ashworth Scale grade 2. Muscle tone and motor function were assessed before the operation, at short-term follow-up and at the last follow-up after SDR. Additionally, intraoperative neurophysiological monitoring data were reviewed. RESULTS: The study comprised 20 eligible cases, where, prior to surgery, 35 quadriceps muscles exhibited spasticity exceeding modified Ashworth Scale grade 2. Following short-term and mid-term follow-up, specifically an average duration of 11 ± 2 days and 1511 ± 210 days after SDR, it was observed that muscle tension in adductors, hamstrings, gastrocnemius, and soleus decreased significantly. This reduction was accompanied by a decrease in quadriceps muscle tone in 24 out of 35 muscles (68.6%). Furthermore, the study found that intraoperative electrophysiological parameters can predict postoperative spasticity relief in the quadriceps. The triggered electromyographic (EMG) output of the transected sensory root/rootlets after single-pulse stimulation revealed that the higher the EMG amplitudes in quadriceps, the greater the likelihood of postoperative decrease in quadriceps muscle tension. CONCLUSIONS: SDR demonstrates the potential to reduce muscle spasticity in lower extremities in children diagnosed with CP, including a notable impact on quadriceps spasticity even they are not targeted in SDR. The utilization of intraoperative neurophysiological monitoring data enhances the predictability of quadriceps spasticity reduction following SDR.

Detecting Asymmetry of Upper Limb Activity with Accelerometry in Infants at Risk for Unilateral Spastic Cerebral Palsy.

AIMS: To examine whether accelerometry can quantitate asymmetry of upper limb activity in infants aged 3-12 months at risk for developing unilateral spastic cerebral palsy (USCP). METHOD: A prospective study was performed in 50 infants with unilateral perinatal brain injury at high risk of developing USCP. Triaxial accelerometers were worn on the ipsilateral and contralesional upper limb during the Hand Assessment for Infants (HAI). Infants were grouped in three age intervals (3-5 months, 5-7.5 months and 7.5 until 12 months). Each age interval group was divided in a group with and without asymmetrical hand function based on HAI cutoff values suggestive of USCP. RESULTS: In a total of 82 assessments, the asymmetry index for mean upper limb activity was higher in infants with asymmetrical hand function compared to infants with symmetrical hand function in all three age groups (ranging from 41 to 51% versus - 2-6%, p < 0.01), while the total activity of both upper limbs did not differ. CONCLUSIONS: Upper limb accelerometry can identify asymmetrical hand function in the upper limbs in infants with unilateral perinatal brain injury from 3 months onwards and is complementary to the Hand Assessment for Infants.

An increase in relative contribution of compensatory postural adjustments during voluntary movement while standing in adolescents and young adults with bilateral spastic cerebral palsy.

Previous studies have revealed several deficits in anticipatory postural adjustments (APAs) during voluntary movements while standing in individuals with bilateral spastic cerebral palsy (BSCP). However, it remains unclear whether compensatory postural adjustments (CPAs) during movement increase to compensate for APA deficits. We investigated the anticipatory and compensatory activities of postural muscles during voluntary movement while standing in adolescents and young adults with BSCP. The study included seven participants with BSCP with level II on the Gross Motor Function Classification System (GMFCS), seven with BSCP with level III on the GMFCS, and fourteen healthy controls. The participants stood on a force platform and lifted a load under two weight conditions (light and heavy). The electromyographic activities of postural muscles were analyzed at time intervals typical for APAs and CPAs. The percentage of muscle activity in the CPA time epoch against the total muscle activity during the APA and CPA time epochs was higher in the two BSCP groups than in the control group. In the control group, a load-related modulation was observed only in the APA time epoch, whereas in the BSCP-II group, the load-related increase was observed in both the APA and CPA time epochs. No load-related modulations were observed in the BSCP-III group. These findings suggest that adolescents and young adults with BSCP exhibit an increase in the relative contribution of CPAs during voluntary movement and that there exist severity-related differences in the modulation of APAs and CPAs.

Saccharomyces boulardii improves the behaviour and emotions of spastic cerebral palsy rats through the gut-brain axis pathway.

BACKGROUND: Cerebral palsy (CP) is a kind of disability that influences motion, and children with CP also exhibit depression-like behaviour. Inflammation has been recognized as a contributor to CP and depression, and some studies suggest that the gut-brain axis may be a contributing factor. Our team observed that Saccharomyces boulardii (S. boulardii) could reduce the inflammatory level of rats with hyperbilirubinemia and improve abnormal behaviour. Both CP and depression are related to inflammation, and probiotics can improve depression by reducing inflammation. Therefore, we hypothesize that S. boulardii may improve the behaviour and emotions of spastic CP rats through the gut-brain axis pathway. METHODS: Our new rat model was produced by resecting the cortex and subcortical white matter. Seventeen-day-old CP rats were exposed to S. boulardii or vehicle control by gastric gavage for 9 days, and different behavioural domains and general conditions were tested. Inflammation was assessed by measuring the inflammatory markers IL-6 and TNF-α. Hypothalamic-pituitary-adrenal (HPA) axis activity was assessed by measuring adrenocorticotropic hormone and corticosterone in the serum. Changes in the gut microbiome were detected by 16S rRNA. RESULTS: The hemiplegic spastic CP rats we made with typical spastic paralysis exhibited depression-like behaviour. S. boulardii treatment of hemiplegic spastic CP rats improves behaviour and general conditions and significantly reduces the level of inflammation, decreases HPA axis activity, and increases gut microbiota diversity. CONCLUSIONS: The model developed in this study mimics a hemiplegic spastic cerebral palsy. Damage to the cortex and subcortical white matter of 17-day-old Sprague-Dawley (SD) rats led to spastic CP-like behaviour, and the rats exhibited symptoms of depression-like behaviour. Our results indicate that S. boulardii might have potential in treating hemiplegic spastic CP rat models or as an add-on therapy via the gut-brain axis pathway.

Randomised trial of virtual reality gaming and physiotherapy on balance, gross motor performance and daily functions among children with bilateral spastic cerebral palsy.

BACKGROUND: Balance issues and poor gross motor function affect the daily needs of children with cerebral palsy. PURPOSE: The study objective was to examine the effects of virtual reality gaming and physiotherapy on balance, gross motor performance and daily functioning among children with bilateral spastic cerebral palsy. METHOD: Thirty-eight children with bilateral spastic cerebral palsy aged 6-12 years with GMFCS- level II-III, Manual Ability Classification System level I-III participated in this randomized controlled trial. The experimental group performed virtual reality games and physiotherapy, while the control group underwent physiotherapy alone. The exercise intensity was 60 minutes session a day, 4-days a week for 6-weeks. Paediatric Balance Scale (PBS), Kids-Mini-Balance Evaluation System Test (Kids-Mini-BESTest), Gross Motor Function Measure-88 (GMFM-88), and Wee-Functional Independence Measure (WeeFIM) were the outcome measures collected at baseline, 6-week post-training and 2-months follow-up. RESULTS: The time by group interaction of repeated measures ANOVA revealed no statistical significance for all the outcome measures except Kids-Mini-BESTest (p < 0.05). The PBS and, Kids-Mini-BESTest improved by a mean (standard deviation) score of 5.1(1.7) and 8.7(2.8) points, respectively in the experimental group as compared to control group [3.4(1.6) and 5.8(2.5) points]. These gains remained at follow-up (p < 0.001). CONCLUSION: Combined virtual reality gaming and physiotherapy is not superior over physiotherapy alone in improving the gross motor performance and daily functioning among children with bilateral spastic cerebral palsy. Virtual gaming, along with physiotherapy, appears to be beneficial in their balance capacity, warranting further trials to investigate the same in children with GMFCS level-III.

The effect of combined transcranial pulsed current stimulation and transcutaneous electrical nerve stimulation on lower limb spasticity in children with spastic cerebral palsy: a randomized and controlled clinical study.

BACKGROUND: In the current study, we applied a combination of non-invasive neuromodulation modalities concurrently with multiple stimulating electrodes. Specifically, we used transcranial pulsed current stimulation (tPCS) and transcutaneous electrical nerve stimulation (TENS) as a novel strategy for improving lower limb spasticity in children with spastic cerebral palsy (SCP) categorized on levels III-V of the Gross Motor Function Classification System (GMFCS) with minimal side effects. METHODS: Sixty-three SCP children aged 2-12 years, who were classified on levels III-V of the GMFCS were randomly assigned to one of two groups, resulting in 32 children in the experimental group and 31 children in the control group. The experimental group underwent a combination therapy of tPCS (400 Hz, 1 mA cerebello-cerebral stimulation) and TENS (400 Hz, max 10 mA) for 30 min, followed by 30 min of physiotherapy five times per week for 12 weeks. The control group underwent physiotherapy only 30 mins per day five times per week for 12 weeks. In total, all groups underwent 60 treatment sessions. The primary outcome measures were the Modified Ashworth Scale (MAS) and Modified Tardieu Scale (MTS). Evaluations were performed 3 days before and after treatment. RESULTS: We found a significant improvement in MAS and MTS scores of the lower limbs in the experimental group compared to the control group in the hip adductors (Left: p = 0.002; Right: p = 0.002), hamstrings (Left: p = 0.001; Right: p < 0.001, and gastrocnemius (Left: p = 0.001; Right: p = 0.000). Moreover, MTS scores of R1, R2 and R2-R1 in left and right hip adduction, knee joint, and ankle joint all showed significant improvements (p ≤ 0.05). Analysis of MAS and MTS scores compared to baseline scores showed significant improvements in the experimental group but declines in the control group. CONCLUSION: These results are among the first to demonstrate that a combination of tPCS and TENS can significantly improve lower limb spasticity in SCP children classified on GMFCS levels III-V with minimal side effects, presenting a novel strategy for addressing spasticity challenges in children with severe SCP. TRIAL REGISTRATION: ChiCTR.org, ChiCTR1800020283, Registration: 22 December 2018 (URL: http://www.chictr.org.cn/showproj.aspx?proj=33953 ).

Impaired neuromuscular transmission of the tibialis anterior in a rodent model of hypertonia.

Early-onset hypertonia is characteristic of developmental neuromotor disorders, including cerebral palsy (CP). The spa transgenic mouse displays early-onset spasticity, abnormal gait, and motor impairments that are remarkably similar to symptoms of human CP. Previously, we showed that spa mice have fewer motor neurons innervating the tibialis anterior (TA). An expanded innervation ratio may result in increased susceptibility to neuromuscular transmission failure (NMTF). We assessed NMTF in an ex vivo TA muscle nerve preparation from spa and wild-type (WT) mice by comparing forces elicited by nerve versus muscle stimulation. TA muscle innervation ratio was assessed by counting the number of muscle fibers and dividing by the number of TA motor neurons. Muscle fiber cross-sectional areas were also assessed in the TA muscle. We observed that NMTF was immediately present in spa mice, increased with repetitive stimulation, and associated with increased innervation ratio. These changes were concomitant with reduced TA muscle fiber cross-sectional area in spa mice compared with WT. Early-onset hypertonia is associated with increased innervation ratio and impaired neuromuscular transmission. These disturbances may exacerbate the underlying gait abnormalities present in individuals with hypertonia.NEW & NOTEWORTHY Nerve-muscle interaction is poorly understood in the context of early-onset spasticity and hypertonia. In an animal model of early-onset spasticity, spa mice, we found a marked impairment of tibialis anterior neuromuscular transmission. This impairment is associated with an increased innervation ratio (mean number of muscle fibers innervated by a single motor neuron). These disturbances may underlie weakness and gait disturbances observed in individual with developmental hypertonia and spasticity.

Cerebral palsy: Aetiology, pathophysiology and therapeutic interventions.

Cerebral palsy (CP) is the most common non-progressive neurodevelopmental disorder in which the impairment of motor and posture functions occurs. This condition may be present in many different clinical spectra. Various aetiological and risk factors play a crucial role in the causation of CP. In various cases, the causes of CP may not be apparent. Interruption in the supply of oxygen to the fetus or brain asphyxia was considered to be the main causative factor explaining CP. Antenatal, perinatal, and postnatal factors could be involved in the origin of CP. Understanding its pathophysiology is also crucial for developing preventive and protective strategies. A major advancement in the brain stimulation techniques has emerged as a promising status in diagnostic and interventional approaches. This review provides a brief explanation about the various aetiological factors, pathophysiology, and recent therapeutic approaches in the treatment of cerebral palsy.

Effectiveness of Hand-Arm Bimanual Intensive Therapy on Hand Function among Children with Unilateral Spastic Cerebral Palsy: A Meta-Analysis.

BACKGROUND: Hand-arm bimanual intensive therapy (HABIT) has been shown to be an effective method for improving upper-extremity function. However, owing to ambiguity within the evidence of HABIT's effects on hand function among children with unilateral spastic cerebral palsy (CP), this meta-analysis sought to elucidate whether the same was true in this patient population. SUMMARY: A computerized database search yielded 468 studies. After meticulous scrutiny and screening of these studies according to the selection criteria, 4 full-text articles were included in the meta-analysis. All 4 studies underwent a methodological quality assessment according to the Physiotherapy Evidence Database Scale (PEDro), with a score of greater than 8. Five comparisons were then made involving the 4 selected randomized controlled trials (RCTs). The effect size was measured using the correlation coefficient (r value). The effect sizes of the individual studies were 0.006, 0.03, 0.04, 0.22, and 0.15. The total effect size was 0.06. Key Message: This meta-analysis determined that there is a trivial benefit using HABIT when compared to constraint-induced movement therapy or structured and unstructured bimanual therapy in pediatric patients with unilateral spastic CP. More RCTs are needed to substantiate our evidence.

The role of intra-operative neuroelectrophysiological monitoring in single-level approach selective dorsal rhizotomy.

OBJECTIVE: Selective dorsal rhizotomy via a single-level approach (SL-SDR) to treat spasticity 100% relies on the interpretation of results from the intra-operative neuroelectrophysiological monitoring. The current study is to investigate the role EMG interpretation plays during SL-SDR procedure with regard to the selection of nerve rootlets for partially sectioning in pediatric cases with spastic cerebral palsy (CP). METHODS: A retrospective study was conducted in pediatric patients with spastic CP undergone our modified rhizotomy protocol-guided SL-SDR from May 2016 to Mar. 2019 in our hospital. Our study focused on intra-operative EMG interpretation and its correlation with pre-op evaluation results, and dorsal rootlet selection difference when data of our intra-operative EMG recordings interpreted using different rhizotomy protocols. RESULTS: Clinical and intra-operative neuroelectrophysiological monitoring data of a total of 318 consecutive cases were reviewed, which include 231 boys and 87 girls with 32 hemiplegias, 161 diplegias, and 125 quadriplegias. Age at the time of SL-SDR in those cases was between 3.0-14.0 (5.9 ± 1.9) years. The number of targeted muscle ranged from 2 to 8 over these cases (the muscle in lower limbs with its pre-op muscle tone ≥ 2 grade, Modified Ashworth scale). Among 21,728 nerve rootlets tested (68.3 ± 8.2/case), 6272 (28.9%) were identified sphincter related by our intra-operative neuromonitoring. In the rest of 15,456 (48.6 ± 7.6/case) nerve rootlets which neuromonitoring suggested associated with lower limbs, 11,009 were taken as the dorsal ones (34.6 ± 7.4/case). A total of 3370 (10.6 ± 4.7/case) rootlets matched our rhizotomy criteria with 3061 (9.6 ± 4.1/case) sectioned 50% and 309 (1.0 ± 1.0/case) cut 75%. The rhizotomy ratio (partially transected nerve rootlets/all dorsal rootlets associated with lower limbs in a particular case) was 15.8%, 22.3%, 33.4%, 41.8%, and 45.7% across cases with their pro-op GMFCS level from I to V, respectively. Rootlets required 75% cut had a tendency to increase as well in our cases with their pro-op GMFCS level from I to V, which comprising 1.5%, 4.8%, 8.5%, 14.1%, and 15.2% of all rootlets transected, respectively. The muscle tone of 2068 targeted muscles in these cases at the time of 3 weeks after the SL-SDR was revealed a significant decrease when compared to pre-op (1.7 ± 0.5 vs. 2.7 ± 0.6). Further investigation to compare our rootlet selection with the one guided by the traditional rhizotomy criteria using our intro-operative EMG recordings in 318 cases, revealed that the overlap ratio had a tendency to increase in cases when their pre-op GMFCS level increased (39.5%, 41.3%, 52.2%, 54.1%, and 62.8% in cases with levels I-V, respectively). While our modified rhizotomy protocol successfully identified 2-23 rootlets for sectioning in all of our 318 cases, the traditional rhizotomy protocol failed to distinguish any for cutting in about 20% of cases with their pre-op GMFCS levels I and II. CONCLUSIONS: The rhizotomy criteria fully rely on the EMG interpretation making intra-operative neuroelectrophysiological monitoring crucial when SDR is performed via a single-level approach. Our modified rhizotomy protocol is feasible, safe, and effective to guide SL-SDR to treat all types of spastic CP cases by decreasing muscle tone in particular spastic muscle groups in their lower limbs. Data of EMG responses during SL-SDR procedure and as well as the clinical outcomes based on their interpretation could help clinicians to further understand how neuronal circuits work in the spinal cord of these patients.

Whether the newly modified rhizotomy protocol is applicable to guide single-level approach SDR to treat spastic quadriplegia and diplegia in pediatric patients with cerebral palsy?

PURPOSE: Our aim was to test whether the newly modified rhizotomy protocol which could be effectively used to guide single-level approach selective dorsal rhizotomy (SL-SDR) to treat spastic hemiplegic cases by mainly releasing those spastic muscles (target muscles) marked pre-operatively in their lower limbs was still applicable in spastic quadriplegic or diplegic cerebral palsy (CP) cases in pediatric population. METHODS: In the current study, we retrospectively conducted a cohort review of cases younger than 14 years of age diagnosed with spastic quadriplegic or diplegic CP who undergone our modified protocol-guided SL-SDR in the Department of Neurosurgery, Children's Hospital of Shanghai since July 2016 to November 2017 with at least 12 months post-op intensive rehabilitation program (pre-op GMFCS level-based). Clinical data including demographics, intra-operative EMG responses interpretation, and relevant assessment of included cases were taken from the database. Inclusion and exclusion criteria were set for the selection of patients in the current study. Muscle tone (modified Ashworth scale) and strength of those spastic muscles (muscle strength grading scale), range of motion (ROM) of those joints involved, the level of Gross Motor Function Classification System (GMFCS), and Gross Motor Function Measure 66 items (GMFM-66) score of those cases were our focus. RESULTS: A total of 86 eligible cases were included in our study (62 boys). Among these patients, 61.6% were quadriplegic. Pre-operatively, almost 2/3 of our cases were with GMFCS levels II and III. Mean age at the time of surgery in these cases was 6.2 (3.5-12) years. Pre-op assessment marked 582 target muscles in these patients. Numbers of nerve rootlets tested during SDR procedure were between 52 and 84 across our cases, with a mean of 66.5 ± 6.7/case. Among those tested (5721 in 86 cases), 47.9% (2740) were identified as lower limb-related sensory rootlets. Our protocol successfully differentiated sensory rootlets which were considered to be associated with spasticity of target muscles across all our 86 cases (ranged from 3 to 21). Based on our protocol, 871 dorsal nerve rootlets were sectioned 50%, and 78 were cut 75%. Muscle tone of those target muscles reduced significantly right after SL-SDR procedure (3 weeks post- vs. pre-op, 1.7 ± 0.5 vs. 2.6 ± 0.7). After an intensive rehabilitation program for 19.9 ± 6.0 months, muscle tone continued to decrease to 1.4 ± 0.5. With the reduction of muscle tone, strength of those target muscles in our cases improved dramatically with statistical significance achieved (3.9 ± 1.0 at the time of last follow-up vs. 3.3 ± 0.8 pre-op), and as well as ROM. Increase in GMFCS level and GMFM-66 score was observed at the time of last follow-up with a mean of 0.4 ± 0.6 and 6.1 ± 3.2, respectively, when compared with that at pre-op. In 81 cases with their pre-op GMFCS levels II to V, 27 (33.3%) presented improvement with regard to GMFCS level upgrade, among which 4 (4.9%) even upgraded over 2 levels. Better results with regard to upgrading in level of GMFCS were observed in cases with pre-op levels II and III when compared with those with levels IV and V (24/57 vs. 3/24). Upgrading percentage in cases younger than 6 years at surgery was significantly greater than in those older (23/56 vs. 4/25). Cases with their pre-op GMFM-66 score ≥ 50 had greater score increase of GMFM-66 when compared with those less (7.1 ± 3.4 vs. 5.1 ± 2.8). In the meanwhile, better score improvement was revealed in cases when SDR performed at younger age (6.9 ± 3.3 in case ≤ 6 years vs. 4.7 ± 2.7 in case > 6 years). No permanent surgery-related complications were recorded in the current study. CONCLUSION: SL-SDR when guided by our newly modified rhizotomy protocol was still feasible to treat pediatric CP cases with spastic quadriplegia and diplegia. Cases in this condition could benefit from such a procedure when followed by our intensive rehabilitation program with regard to their motor function.

[Effect of Biofeedback Combined with Task-oriented Training on Hand Function, Gesell Scale Score and Balance Ability in Children with Spastic Cerebral Palsy].

OBJECTIVE: To analyze the effects of biofeedback combined with task-oriented training on hand function, Gesell's infant development scale score (Gesell) and balance ability in children with spastic cerebral palsy (SCP). METHODS: 66 children with SCP admitted to our hospital from January 2016 to June 2018 were randomly divided into the control group and the observation group. The control group ( n=33) received conventional rehabilitation treatment, and the observation group ( n=33) received biofeedback combined with task-oriented training based on the treatment of control group. After 6-month treatment, Modified Ashworth scale (MAS) score, Berg balance scale (BBS) score, standing and walking function score in gross motor function scale (GMFM), assisting hand assessment scales (AHA) score, Gesell scale score and satisfaction of the children's parents were compared between the two groups. RESULTS: The MAS score after treatment was lower than that before treatment in both two groups ( P<0.05), and the BBS score after treatment was higher than that before treatment in both two groups ( P<0.05). After treatment, the MAS score in the observation group was lower than the control group, and the BBS score in the observation group was higher than the control group ( P<0.05). The scores of standing and walking function after treatment were higher than that before treatment in both two groups ( P<0.05). After treatment, the scores of standing and walking function in the observation group were higher than the control group ( P<0.05). The AHA score and Gesell developmental quotient (DQ) score after treatment were higher than that before treatment in both two groups ( P<0.05). After the treatment, the AHA score and Gesell DQ score in the observation group were higher than the control group ( P<0.05). The satisfaction rate of rehabilitation treatment in the observation group was higher than the control group (90.91% vs. 60.61%, P<0.05). CONCLUSION: Biofeedback combined with task-oriented training can improve balance ability, spasm relieve, hand function, development level, standing and walking function in the children with spastic cerebral palsy and increase the treatment satisfaction degree of children's guardians.

Utilization of electromyography during selective obturator neurotomy to treat spastic cerebral palsy accompanied by scissors gait.

Selective obturator neurotomy is a commonly used neurosurgical intervention for spastic cerebral palsy with scissors gait. Here we report the use of surface electromyography to assess the accuracy and effect of selective obturator neurotomy procedures. Selective obturator neurotomy was carried out on 18 patients while using intraoperative electromyography. Contractions of adductor muscles were recorded by electromyography before and after neurotomy and assessed using root mean square and integrated electromyography tests. Passive and voluntary movements were recorded for all patients. Our results show that adductor spasms and adductive deformity of hip were improved in all patients with spastic cerebral palsy. Adductor muscle spatiality was improved significantly, confirmed by a significant decrease in the values of root mean square and integrated electromyography in both passive and voluntary movements after surgery. We show that electromyography is an effective tool for accurately and safely targeting nerve tracts during selective obturator neurotomy. Thus, we demonstrate a valuable noninvasive method to objectively evaluate the effect of treatment in spastic cerebral palsy patients.

Muscle morphology of the lower leg in ambulant children with spastic cerebral palsy.

INTRODUCTION: In this study we aimed to determine the lower limb morphological characteristics of skeletal muscle of ambulant children with spastic cerebral palsy (CP) and typically developing (TD) children. METHODS: Seventeen children with spastic diplegic CP (10 boys and 7 girls, 5-12 years of age, Gross Motor Function Classification System [GMFCS] level I or II) and 19 TD children (8 boys and 11 girls, 5-11 years of age) underwent lower limb T1-weighted MRI. Morphological characteristics of the triceps surae, including muscle volume, anatomical cross-sectional area, muscle length, and subcutaneous adipose tissue, were digitally quantified, and the proportional distribution calculated. RESULTS: Children with GMFCS II had significantly reduced muscle volume, cross-sectional area, and muscle length, and increased subcutaneous fat compared with TD children. Children classified as GMFCS II consistently exhibited the greatest deficits in all morphology variables. DISCUSSION: Morphological variables were significantly different between the groups. These alterations have the potential to influence the functional capabilities of the triceps surae muscle group. Muscle Nerve 58:818-823, 2018.

Effects of an underwear-type hip abduction orthosis on sitting balance and sit-to-stand activities in children with spastic cerebral palsy.

[Purpose] Hip dislocation and subluxation are common in patients with cerebral palsy (CP). Hip abduction orthoses are used to prevent and treat these problems. This study investigated the effects of an underwear-type hip abduction orthosis on sitting balance and sit-to-stand (STS) activity in children with spastic CP. [Participants and Methods] This trial had a cross-over design. Eight children aged 6 to 18 years old with spastic CP and Gross Motor Function Classification level III and IV were randomly allocated to groups with or without use of the underwear-type hip orthosis. The trunk impairment scale (TIS) score was evaluated and the 5-times sit-to-stand test (FTSST) was conducted with and without the underwear. [Results] The dynamic sitting balance scores in the TIS and FTSST showed significant improvement with use of the orthotic underwear. [Conclusion] The dynamic sitting balance scores of the TIS and FTSST were higher, thus indicating better stability, when wearing the orthosis underwear. Thus, it was suggested that underwear-type hip abduction orthoses are effective for promoting sitting balance and STS activities in children with spastic CP.

Comparative analysis of curative effect of bone marrow mesenchymal stem cell and bone marrow mononuclear cell transplantation for spastic cerebral palsy.

BACKGROUND: Bone marrow mesenchymal stem cells (BMMSCs) and bone marrow mononuclear cells (BMMNCs) are both used to treat spastic cerebral palsy. However, the differences in therapeutic effect remain unknown. METHODS: A total of 105 patients with spastic cerebral palsy were enrolled and randomly assigned to three groups: the BMMSC group, the BMMNC group and the control group. Patients in both transplantation groups received four intrathecal cell injections. Patients in the control group received Bobath therapy. The gross motor function measure (GMFM) and the fine motor function measure (FMFM) were used to evaluate the therapeutic efficacy before transplantation and 3, 6, and 12 months after transplantation. RESULTS: Three months after cell transplantation, scores in the A dimension of GMFM and the A and C dimensions of FMFM scores in the BMMSC group are all higher than those of the BMMNC and the control groups (P < 0.05). Six months after cell transplantation, scores in the A, B dimensions of GMFM and the A, B, C, D, and E dimensions of FMFM scores in the BMMSC group are higher than those of the BMMNC and the control groups (P < 0.05). Twelve months after cell transplantation, scores in the A, B, and C dimensions of GMFM and the A, B, C, D, and E dimensions of FMFM scores in the BMMSC group are all higher than those of the BMMNC and the control groups (P < 0.05). No obvious adverse effects were investigated during follow-up. CONCLUSIONS: BMMSC transplantation for the treatment of cerebral palsy is safe and feasible, and can improve gross motor and fine motor function significantly. In addition, compared with BMMNC, the motor function of children improved significantly in terms of gross motor and fine motor functions.

Brain Lesions in Children with Unilateral Spastic Cerebral Palsy.

INTRODUCTION: Unilateral spastic cerebral palsy (US CP) is the second most common subtype of cerebral palsy. AIM: The aim of the study was to analyze neuroimaging findings in children with unilateral spastic cerebral palsy. MATERIAL AND METHODS: The study was hospital based, which has included 106 patients with US CP (boys 72/girls 34, term 82/preterm 24). Neuroimaging findings were classified into 5 groups: Brain maldevelopment, predominant white matter injury, predominant gray matter injury, non specific findings and normal neuroimaging findings. RESULTS: Predominant white matter lesions where the most frequent (48/106,45.28%; term 35/preterm 13), without statistically significant difference between term and preterm born children (x2=0.4357; p=0.490517). Predominant gray matter lesions had 32/106 children, 30.19%; (term 25/preterm 7, without statistically significant difference between term and preterm born children (x2=0.902; p=0.9862). Brain malformations had 10/106 children, 9.43%, and all of them were term born. Other finding had 2/106 children, 1.89%, both of them were term born. Normal neuroimaging findings were present in14/106 patients (13.21%). CONCLUSION: Neuroimaging may help to understand morphological background of motor impairment in children with US CP. Periventricular white matter lesions were the most frequent, then gray matter lesions.

Relationship between gross motor function and the function, activity and participation components of the International Classification of Functioning in children with spastic cerebral palsy.

[Purpose] This study aimed to evaluate the relationship between gross motor function, measured using the Gross Motor Function Measure (GMFM), Gross Motor Function Classification System (GMFCS), Manual Ability Classification System (MACS), and Functional Independence Measure for Children (WeeFIM), and Function, and Activity and Participation components of the International Classification of Functioning, Disability, and Health-Child and Youth Check List (ICF-CY) in children with spastic cerebral palsy (CP). [Subjects and Methods] Seventy-seven children with spastic CP participated in the study. The GMFM, GMFCS, MACS, and WeeFIM were administered in their entirety to patients without orthoses or mobility aids. The ICF-CY was used to evaluate the degree of disability and health. [Results] The score of the ICF component of Activity and Participation had a significantly strong correlation with the scores of GMFM, GMFCS, MACS, WeeFIM, and ICF component of Function. [Conclusion] When establishing a treatment plan for children with spastic CP, the children's physical abilities, and their limitation in activity, performance, and participation, which would be measured using the ICF-CY, should be taken into consideration.

Effects of combined Adeli suit and neurodevelopmental treatment in children with spastic cerebral palsy with gross motor function classification system levels I and II.

BACKGROUND: Children with cerebral palsy (CP) exhibit diverse gait patterns depending on their neurological deficits and musculoskeletal problems. The Adeli suit treatment (AST) has been proposed as an intensive exercise protocol in the management of CP. OBJECTIVES: The aim of this study was to compare the effects of a 6-week programme of combined AST and neurodevelopment treatment (NDT) with those of NDT alone on Gross Motor Function Measure (GMFM), balance, and gait in children with CP. METHODS: Twenty children with CP of Gross Motor Function Classification System levels I and II were randomly assigned to one of the following two groups: (1) NDT or (2) AST/NDT. The participants were assessed using the GMFM, Pediatric Balance Scale (PBS), Timed Up and Go (TUG) test, and spatiotemporal gait parameters. RESULTS: The GMFM, PBS, and TUG test for both groups showed a statistically significant increase (p < 0.05). Three children were excluded. Compared to the NDT group (n = 9), the AST/NDT group (n = 8) demonstrated a significant increase in spatiotemporal gait parameters (p < 0.05). CONCLUSION: These results provide evidence for the greater effectiveness of combined AST/NDT than NDT alone in improving spatiotemporal gait parameters but not GMFM, PBS, and TUG test.

Clinical usefulness of brain-computer interface-controlled functional electrical stimulation for improving brain activity in children with spastic cerebral palsy: a pilot randomized controlled trial.

[Purpose] Evaluating the effect of brain-computer interface (BCI)-based functional electrical stimulation (FES) training on brain activity in children with spastic cerebral palsy (CP) was the aim of this study. [Subjects and Methods] Subjects were randomized into a BCI-FES group (n=9) and a functional electrical stimulation (FES) control group (n=9). Subjects in the BCI-FES group received wrist and hand extension training with FES for 30 minutes per day, 5 times per week for 6 weeks under the BCI-based program. The FES group received wrist and hand extension training with FES for the same amount of time. Sensorimotor rhythms (SMR) and middle beta waves (M-beta) were measured in frontopolar regions 1 and 2 (Fp1, Fp2) to determine the effects of BCI-FES training. [Results] Significant improvements in the SMR and M-beta of Fp1 and Fp2 were seen in the BCI-FES group. In contrast, significant improvement was only seen in the SMR and M-beta of Fp2 in the control group. [Conclusion] The results of the present study suggest that BCI-controlled FES training may be helpful in improving brain activity in patients with cerebral palsy and may be applied as effectively as traditional FES training.