A systematic review of instrumented assessments for upper limb function in cerebral palsy: current limitations and future directions.

INTRODUCTION: Recently, interest in quantifying upper limb function in cerebral palsy has grown. However, the lack of reference tasks and protocols, have hindered the development of quantified movement analysis in clinical practice. This study aimed to evaluate existing instrumented assessments of upper limb function in cerebral palsy, with a focus on their clinical applicability, to identify reasons for the lack of adoption and provide recommendations for improving clinical relevance and utility. METHODS: A systematic review was conducted by a multidisciplinary team of researchers and clinicians (Prospero CRD42023402382). PubMed and Web of Science databases were searched using relevant keywords and inclusion/exclusion criteria. RESULTS: A total of 657 articles were initially identified, and after the selection process, 76 records were included for analysis comprising a total of 1293 patients with cerebral palsy. The quality assessment of the reviewed studies revealed a moderate overall quality, with deficiencies in sample size justification and participant information. Optoelectronic motion capture systems were predominantly used in the studies (N = 57/76). The population mainly consisted of individuals with spastic cerebral palsy (834/1293) with unilateral impairment (N = 1092/1293). Patients with severe functional impairment (MACS IV and V) were underrepresented with 3.4% of the 754 patients for whom the information was provided. Thirty-nine tasks were used across the articles. Most articles focused on unimanual activities (N = 66/76) and reach or reach and grasp (N = 51/76). Bimanual cooperative tasks only represented 3 tasks present in 4 articles. A total of 140 different parameters were identified across articles. Task duration was the most frequently used parameter and 23% of the parameters were used in only one article. CONCLUSION: Further research is necessary before incorporating quantified motion analysis into clinical practice. Existing protocols focus on extensively studied populations and rely on costly equipment, limiting their practicality. Standardized unimanual tasks provide limited insights into everyday arm use. Balancing methodological requirements and performance evaluation flexibility is a challenge. Exploring the correlation between outcome parameters and therapeutic guidance could facilitate the integration of quantified movement assessment into treatment pathways.

Early Intensive Bimanual Stimulation Program (BB-Bim) for Infants at Risk of Unilateral Cerebral Palsy: A Randomized, Multiple-Baseline, Single-Case Study.

IMPORTANCE: Clinical practice guidelines for infants at high risk of cerebral palsy (CP) emphasize the importance of very early and intensive intervention. OBJECTIVE: To determine the feasibility of a new, home-based, early intensive bimanual stimulation program (BB-Bim) and its impact on hand function in infants at risk of unilateral CP. DESIGN: Single case experimental design, multiple baseline across subjects, lasting from 12 to 15 wk, including a 4- to 7-wk randomized baseline, followed by 8 wk of BB-Bim. SETTING: Home. PARTICIPANTS: Infants (ages 3-12 mo) with suspected unilateral CP, whose parents agreed to participate in the stimulation program. INTERVENTION: Parent-provided bimanual stimulation 20 min/day, 6×/wk, with weekly occupational therapist coaching visits. MEASURES: Weekly repeated measures were the Hand Assessment in Infants (HAI) and Goal Attainment Scaling (GAS). Feasibility and relevance were assessed with a logbook and a parental report, including 10 continuous 0-10 scaled questions. RESULTS: Six infants were included (2 with left and 4 with right brain lesions). Parents provided a mean 3.4 to 6.2 stimulation sessions/wk. Feasibility and relevance were highly rated (Ms = 8.2-9.6, SDs = 0.2-1.3). Stimulation significantly improved HAI bimanual and total scores for all infants, with no impact on HAI unilateral scores. GAS scores improved with stimulation (significant for 3 infants). CONCLUSIONS AND RELEVANCE: BB-Bim was feasible and tended to improve bimanual function in infants at risk of unilateral CP. What This Article Adds: Parent-provided daily bimanual stimulation at home is feasible when parents are coached weekly by an occupational therapist. Bimanual stimulation seems to improve functional interactions between the hands among infants at high risk of unilateral CP.

Pain coping strategies in children with cerebral palsy.

AIM: To describe coping strategies in children and adolescents with cerebral palsy (CP), relative to age. METHOD: Patients were prospectively recruited from two paediatric rehabilitation centres in France. The Pediatric Pain Coping Inventory - French and Structured Pain Questionnaire were completed by an experienced professional for each child. RESULTS: One hundred and forty-two children with CP were included (80 males, 62 females; median age 12y; IQR=8-15y). They generally used fewer coping strategies than typically developing children ('Seeks social support and action': 12.47 vs 12.85, p=0.477; 'Cognitive self-instruction': 9.28 vs 10.90, p<0.001; 'Distraction': 4.89 vs 7.00, p<0.001; 'Problem solving': 4.43 vs 5.19, p<0.001). In the CP group, 'Seeks social support and action' decreased with age (p=0.021) and 'Cognitive self-instruction' increased with age (p<0.001). 'Problem solving' and 'Distraction' did not change with age. Coping strategies were influenced by Gross Motor Function Classification System level (p=0.022) and history of surgery (p=0.002). INTERPRETATION: Children with CP generally used fewer coping strategies than typically developing children and tended to rely on social support. Use of active strategies increased with age; however, they appeared later than in typically developing children and were used to a lesser extent. WHAT THIS PAPER ADDS: Children with cerebral palsy (CP) use fewer pain-coping strategies than typically developing children. Children with CP tend to use social support to cope with pain. Children with CP learn more appropriate strategies from previous painful experiences. Active coping strategies appear later but remain underused in children with CP.

ESTRATEGIAS DE AFRONTAMIENTO DEL DOLOR EN NIÑOS CON PARÁLISIS CEREBRAL: OBJETIVO: Describir estrategias de afrontamiento en niños y adolescentes con parálisis cerebral (PC), en relación con la edad. MÉTODO: Los pacientes fueron reclutados prospectivamente de dos centros de rehabilitación pediátrica en Francia. El Inventario de Afrontamiento del Dolor Pediátrico - Cuestionario de Dolor Francés y Estructurado fue completado por un profesional con experiencia para cada niño. RESULTADOS: Se incluyeron 142 niños con PC (80 varones, 62 mujeres; mediana de edad de 12 años; IQR = 8-15 años). En general, los niños con PC utilizaron menos estrategias de afrontamiento que los niños con desarrollo típico ("Busca apoyo social y acción": 12,47 vs 12,85, p = 0,477; "Autoinstrucción cognitiva": 9,28 vs 10,90, p <0,001; "Distracción": 4,89 vs 7,00, p <0,001; "Resolución de problemas": 4,43 vs 5,19, p <0,001). En el grupo de PC, la búsqueda de apoyo y acción social disminuyó con la edad (p = 0,021) y la autoinstrucción cognitiva aumentó con la edad (p <0,001). La "resolución de problemas" y la "distracción" no cambiaron con la edad. Las estrategias de afrontamiento se vieron influenciadas por el nivel del Sistema de Clasificación de la Función Motora Gruesa (p = 0,022) y los antecedentes quirúrgicos (p = 0,002). INTERPRETACIÓN: Los niños con PC generalmente usaron menos estrategias de afrontamiento que los niños con un desarrollo típico y tendían a confiar en el apoyo social. El uso de estrategias activas aumenta con la edad; sin embargo, aparecieron más tarde que en los niños con un desarrollo típico y se utilizaron en menor medida.

ESTRATÉGIAS PARA LIDAR COM A DOR EM CRIANÇAS COM PARALISIA CEREBRAL: OBJETIVO: Descrever estratégias para lidar com a dor em crianças e adolescentes com paralisia cerebral (PC), com relação à sua idade. MÉTODO: Pacientes foram prospectivamente recrutados em dois centros de reabilitação pediátrica na França. O Inventário Pediátrico de Manejo da Dor - Francês e o Questionário Estruturado sobre dor foram completados para cada criança por um profissional com experiência. RESULTADOS: Cento e quarenta e duas crianças com PC foram incluídas (80 do sexo masculino, 62 do sexo feminino; idade mediana 12a; IIQ=8-15a). Elas geralmente usaram menos estratégias para lidar com a dor do que crianças com desenvolvimento típico ('Procura suporte e ação social': 12,47 vs 12,85, p=0=,477; 'Auto-instrução cognitiva': 9,28 vs 10,90, p<0,001; 'Distração: 4,89 vs 7,00, p<0,001; 'Resolução do problema': 4,43 vs 5,19, p<0,001). No grupo com PC, 'Procura suporte e ação social' diminuiu com a idade (p=0,021) e Auto-instrução cognitiva' aumentou com a idade (p<0,001). 'Resolução de problemas' e 'Distração' não mudaram com a idade. As estratégias de manejo da dor foram influenciadas pelo nível do Sistema de Classificação da Função Motora Grossa (p=0,022) e histórico de cirurgia (p=0,002). INTERPRETAÇÃO: Crianças com PC geralmente usam menos estratégias para lidar com a dor do que crianças com desenvolvimento típico, e tendem a depender de suporte social. O uso de estratégias efetivas aumentou com a idade; no entanto, elas aparecem mais tarde do que em crianças com desenvolvimento típico, e são utilizadas em menor escala.

Early Botulinum Toxin Injections in Infants With Musculoskeletal Disorders: A Systematic Review of Safety and Effectiveness.

OBJECTIVE: To report current evidence regarding the safety of intramuscular botulinum toxin injection (BTI) in children with orthopedic- and neurologic-related musculoskeletal disorders >2 years of age. DATA SOURCES: PubMed, Cochrane Library, and ScienceDirect, Google Scholar, and Web of Science. STUDY SELECTION: Two reviewers independently selected studies based on predetermined inclusion criteria. DATA EXTRACTION: Data relating to the aim were extracted. Methodologic quality was graded independently by 2 reviewers using the Physiotherapy Evidence Database scale for randomized controlled trials (RCTs) and the Downs and Black evaluation tool for non-RCTs. Level of evidence was determined using the modified Sackett scale. DATA SYNTHESIS: Data of 473 infants were analyzed. Fifty-five infants had cerebral palsy, 112 had obstetric brachial plexus palsy, 257 had clubfoot, and 44 had congenital torticollis. No studies reported any severe adverse event that could be attributed to the BTI. The rate of mild to moderate adverse events reported varied from 5% to 25%. Results regarding efficacy were preliminary, dependent on the pathology, and limited by the small number of studies and their low levels of evidence. CONCLUSIONS: BTI is already widely used as an early treatment for this age group. The safety profile of BTI in infants appears similar to that of older children and risks appear more related to the severity of the pathology and the location of the injections than to the toxin itself. Regarding effectiveness, other studies with higher levels of evidence should be carried out for each specific pathology.

Retrospective study of functional benefits and satisfaction in multisite upper-limb surgery in children with unilateral cerebral palsy.

OBJECTIVES: To evaluate the functional impact of individualised multisite neuro-orthopedic upper-limb surgery in children with unilateral cerebral palsy, and to assess patient satisfaction. PATIENTS AND METHODS: This retrospective study evaluated the impact of surgery on unilateral functional capacity on the Melbourne Assessment (MA2) and Box and Blocks test, on bimanual performance on the Assisting Hand Assessment, and on achievement of individualised goals. Satisfaction was assessed on a Likert scale between 6 and 14 months after surgery. RESULTS: Twenty-three children were included (mean age, 13.2 ± 3 years). They underwent neuro-orthopedic surgery as part of their care pathway, with botulinum toxin, splints and functional training. After surgery, there was a significant 11.7-point improvement in the MA2 dexterity domain (p = 0.003) and 10.6 points in the MA2 range of motion domain (p = 0.005). Satisfaction was high in 81% of patients. CONCLUSION: Neuro-orthopedic upper-limb surgery included in a global care pathway in children with unilateral cerebral palsy improved unilateral upper-limb function and patient satisfaction. The present cohort should be expanded to further explore the impact of surgery on bimanual performance, focusing on more homogeneous functional levels and surgical procedures.

Does accelerometry reflect hand function in infants at risk of unilateral cerebral palsy? A secondary analysis of BB-Bim results.

BACKGROUND: Infants at high-risk of unilateral Cerebral Palsy (UCP) may have asymmetry in upper extremity movement and function, which should be identified as soon as possible for management. AIMS: To explore the feasibility of using two AX3 Axivity monitors in wrist-worn bracelets to quantify movements, and to identify whether accelerometry parameters are consistent with hand function. METHODS AND PROCEDURES: 6 infants at high risk of UCP (aged 3 to -12 months) were included in a Single-Case Experimental Design to explore the impact of an 8-week bimanual stimulation home program. OUTCOMES: Each week of the baseline (randomized duration 4-7 weeks) and 8-week program, the Hand Assessment for Infants (HAI) was performed and accelerometry parameters were collected during HAI and also during spontaneous activity, several times a week. RESULTS: Actimetry was analyzed during HAI and 238 spontaneous activity sessions (mean 42 ± 21 min). Actimetry ratios distribution and evolution show a high variability, especially for spontaneous activity. No strong correlation was found between HAI scores and accelerometry parameters, either collected during HAI, or during spontaneous activity times. CONCLUSION AND IMPLICATIONS: Despite its feasibility, using accelerometry bracelets looks unreliable for detecting and monitoring hand function in infants under one year.

The PRESLO study: evaluation of a global secondary low back pain prevention program for health care personnel in a hospital setting. Multicenter, randomized intervention trial.

BACKGROUND: Common low back pain represents a major public health problem in terms of its direct cost to health care and its socio-economic repercussions. Ten percent of individuals who suffer from low back pain evolve toward a chronic case and as such are responsible for 75 to 80% of the direct cost of low back pain. It is therefore imperative to highlight the predictive factors of low back pain chronification in order to lighten the economic burden of low back pain-related invalidity. Despite being particularly affected by low back pain, Hospices Civils de Lyon (HCL) personnel have never been offered a specific, tailor-made treatment plan. The PRESLO study (with PRESLO referring to Secondary Low Back Pain Prevention, or in French, PREvention Secondaire de la LOmbalgie), proposed by HCL occupational health services and the Centre Médico-Chirurgical et de Réadaptation des Massues - Croix Rouge Française, is a randomized trial that aims to evaluate the feasibility and efficiency of a global secondary low back pain prevention program for the low back pain sufferers among HCL hospital personnel, a population at risk for recurrence and chronification. This program, which is based on the concept of physical retraining, employs a multidisciplinary approach uniting physical activity, cognitive education about low back pain and lumbopelvic morphotype analysis. No study targeting populations at risk for low back pain chronification has as yet evaluated the efficiency of lighter secondary prevention programs. METHODS/DESIGN: This study is a two-arm parallel randomized controlled trial proposed to all low back pain sufferers among HCL workers, included between October 2008 and July 2011 and followed over two years. The personnel following their usual treatment (control group) and those following the global prevention program in addition to their usual treatment (intervention group) are compared in terms of low back pain recurrence and the impairments measured at the beginning and the end of the study. The global prevention program is composed of a two-hour information session about low back pain and pain pathways, followed by five weekly 90-min exercise sessions with one physiotherapist per group of eight to ten personnel. A booklet for home use with patient-managed exercise instructions and information (The Back Book) is given to each participant at the end of the program.An X-ray assessment of the entire spinal column of each participant (in both the control and intervention groups) is performed at the onset of the study in order to analyze sagittal spinopelvic balance as well as lombopelvic morphotype. DISCUSSION: The results of this study, which is innovative and unique in France, will be available in 2014 and will make it possible to draw conclusions regarding the program's impact on the risk of recurrence and chronification of low back pain. TRIAL REGISTRATION: http://www.clinicaltrials.gov # NCT00782925.

VETCOSED study: efficacy of compressive garments for patients with hypermobile Ehlers-Danlos syndrome on shoulder stability and muscles strength.

PURPOSE: to assess the effect of wearing a compressive short-sleeve jacket on shoulder stability and rotator muscles in adult patients with a hypermobile subtype of Ehlers-Danlos syndrome. MATERIALS AND METHODS: a quasi-experimental study with "Pre/Post" design (4 weeks with versus 4 weeks without), open, conducted on a national cohort. Shoulder rotators were assessed with an isokinetic device at 180°/s and 90°/s; frequency of shoulder stability defects, pain (Visual Analogical Scale), and satisfaction (Quebec User Evaluation of Satisfaction with Assistive Technology) were reported. RESULTS: 36 patients (35 women), mean age 37.9 years, wore jackets for a meanly 7.8 h/day. >70% were satisfied with the effect on arthralgia, instability, or function. QUEST results were high (m = 4.1, SD = 0.7). After jacket wear, the power of external rotators at 180°/s was significantly increased (+1.29 W, CI95%: 0.31; 2.28; p = 0.0318). At 90°/s, no significant difference was found, either on power or strength. The on-off effect highlights a significant difference in external and internal rotators power, whatever the speed. The occurrence of subluxation (p = 0.0140) and dislocations (p = 0.0163) decreased. Pain decreased from 3.5/10 to 2.5/10, without significance (p = 0.0964). CONCLUSION: compressive CICATREX SED® jackets are well supported by patients, impact the power of external rotators at high speed (180°/s), and improve joint stability.IMPLICATIONS FOR REHABILITATIONCompressive garments made to measure are beneficial to patients with hypermobile Ehlers-Danlos syndrome.Compressive CICATREX SED® jackets clearly improve shoulder stability and help to promote muscle power in shoulder external rotators during high-speed movements.One month of jacket wearing seems to bring no lasting effect on shoulder-rotator power, so the jacket needs to be kept on for the benefits to be maintained.

Validity, reliability and responsiveness to change of the French version of the drooling impact scale.

BACKGROUND: work still needs to be done to measure the impact of sialorrhea on quality of life and define the efficacy of different therapies. The Drooling Impact Scale showed good validity and sensitivity to change, especially after botulinum toxin injection. The aim of this study is to present its French translation and to explore its validity, reliability and responsiveness to change in a group of children with Cerebral Palsy. METHODS: multicentre study at six rehabilitation centres in France. Children with Cerebral Palsy aged 4-18 years with sialorrhea problems were included (n = 55), either in a control group (n = 33) or in the intervention group (n = 22, with 3 drug treatment and 19 botulinum toxin injections). The French Drooling Impact Scale was administered twice, 1 month apart. RESULTS: The French Drooling Impact Scale total score at inclusion was meanly 53.9 (Standard Deviation 11.9) in the stable control group and 66.0 (16.1) in the intervention group (p = 0.0058). The validity of the scale was established, as well as an adequate internal consistency (Cronbach's α = 0.71); correlations between each item and the total score were found between 0.5 and 0.71 except for item 5 (r = 0.38) and item 7 (0.41). The test-retest reliability in stable children was good (Lin coefficient = 0.83, bias correction factor = 0.92 and Pearson correlation coefficient = 0.89). There was a high responsiveness to change, mean change was -40.0 in the intervention group and -3.6 in the stable group (p < 0.0001), with Standard Error of Measurement = 2.6. CONCLUSION: the French Drooling Impact Scale has shown sufficient clinometric properties to be used now by clinicians or researchers.IMPLICATIONS FOR REHABILITATIONThe Drooling Impact scale has now its French version.The French version of the Drooling Impact Scale has shown its validity and a good test-retest reliability.The responsiveness to change was explored in a group of children undergoing saliva-control interventions and the scale was able to show a big change.The authors recommend to use this questionnaire in a semi-directed interview conducted by a health professional.

Sagittal spino-pelvic alignment in chronic low back pain.

INTRODUCTION: The differences in sagittal spino-pelvic alignment between adults with chronic low back pain (LBP) and the normal population are still poorly understood. In particular, it is still unknown if particular patterns of sagittal spino-pelvic alignment are more prevalent in chronic LBP. The current study helps to better understand the relationship between sagittal alignment and low back pain. MATERIALS AND METHODS: To compare the sagittal spino-pelvic alignment of patients with chronic LBP with a cohort of asymptomatic adults. Sagittal spino-pelvic alignment was evaluated in prospective cohorts of 198 patients with chronic LBP and 709 normal subjects. The two cohorts were compared with respect to the sacral slope (SS), pelvic tilt (PT), pelvic incidence (PI), lumbar lordosis (LL), lumbar tilt (LT), lordotic levels, thoracic kyphosis (TK), thoracic tilt (TT), kyphotic levels, and lumbosacral joint angle (LSA). Correlations between parameters were also assessed. RESULTS: Sagittal spino-pelvic alignment is significantly different in chronic LBP with respect to SS, PI, LT, lordotic levels, TK, TT and LSA, but not PT, LL, and kyphotic levels. Correlations between parameters were similar for the two cohorts. As compared to normal adults, a greater proportion of patients with LBP presented low SS and LL associated with a small PI, while a greater proportion of normal subjects presented normal or high SS associated with normal or high PI. CONCLUSION: Sagittal spino-pelvic alignment was different between patients with chronic LBP and controls. In particular, there was a greater proportion of chronic LBP patients with low SS, low LL and small PI, suggesting the relationship between this specific pattern and the presence of chronic LBP.

Botuloscope: 1-year follow-up of upper limb post-stroke spasticity treated with botulinum toxin.

BACKGROUND: Botuloscope is a cohort study supported by a French public grant and aiming to evaluate a 1-year treatment of the post-stroke spastic upper limb with botulinum toxin type A (BoNT-A) in terms of individual satisfaction with respect to personalized goals and quality of life. METHODS: This was an open-label prospective, multicentric study (11 French centres) that followed 330 adults [mean (SD) age 53.7 (13.7) years] over 1 year; participants had ranked 5 therapeutic goals at inclusion [mean (SD) 5.1 (7.3) years post-stroke], had severe hemiparesis [median motricity index (MI) 40 (Q1-Q3 24 to 60)], and were assessed at inclusion (M0) and at month 3 (M3) and M12. Outcome criteria were: spasticity, range of motion, pain [visual analog scale (VAS)], motor function [Modified Ashworth Scale (MAS)] and activities (MI; Frenchay Arm Test), and overall satisfaction with the achievement of each goal (VAS) and quality of life (Reintegration to Normal Life Index). Criteria at M0 and M12 were compared. Adverse effects were also collected, as were medication changes. RESULTS: The primary goal was comfort and activities for 63% of participants and motor function for 36%. Participants underwent a mean of 2.4 injection sessions, 19% causing adverse effects. The greatest spasticity attenuation occurred with wrist flexors (median decrease in MAS -2 [Q1-Q3; -2 to -1], P<10-3). Fewer individuals took oral anti-spastic drugs (56% at M12 vs 50% at M0; P<10-2). Range of motion increased by 16°, on average (13 to 19; P<10-3) for wrist extension. Pain prevalence decreases at rest (29% at M0 vs. 19% at M12; P<10-4) and during mobilization (64% vs. 43%; P<10-4), and fewer participants took analgesics (25% vs. 17%; P<10-3). Satisfaction was high for the goals "hand hygiene" and "pain release" and moderate for "improvement in upper limb function". However, function was more improved for participants who selected this goal as the first priority than others (P<10-2). Overall, 22% had the goal "improving gait and balance", which was reasonably achieved at M12. Quality of life improved markedly [median 8 (4 to 11) vs. 6 (3 to 10); P<10-4]. Prevalence of complete dissatisfaction with the first objective was 10% to 15%. CONCLUSION: This is the first long-term follow-up of BoNT-A treatment for upper limb spasticity involving a large cohort independent of industry. Quality of life was improved by treating upper limb spasticity with BoNT-A, even at 5 years post-stroke. Personalizing objectives of the treatment amplified its efficacy. BoNT-A was a powerful analgesic when pain was spasticity-related. Treating the spastic upper limb also improved balance and gait abilities.

Impact of an ergonomic seat on the stand-to-sit strategy in healthy subjects: Spinal and lower limbs kinematics.

PURPOSE: To assess differences in spinal, pelvic and lower limb parameters in healthy individuals during a stand-to-sit task using three different seating conditions. METHODS: Ten healthy adults carried out three stand-to-sit movements on different stools: a high ergonomic stool with the seat tilted 10° forward; a standard stool (adjusted to the same height as the ergonomic stool) and a standard stool at a lower level (so their thighs were horizontal). Movements were recorded by an optoelectronic Vicon system. RESULTS: Hip flexion was altered by the height of the seat (significantly greater for the low standard stool in comparison to either the ergonomic stool or the high standard stool (p < 0.0001)). There was also significantly less knee flexion with the ergonomic stool in comparison to the low standard stool (p < 0.0001) and to the high standard stool (p = 0.0017). Lumbar lordosis was not significantly altered by seat height, although it was less pronounced with the ergonomic stool, with a significantly higher range of motion for the pelvis (p = 0.015). At the thoracic level, no differences were observed, except that the stand-to-sit movement on the lower stool produced greater flexion. CONCLUSION: Lumbar lordosis was not increased by the ergonomic stool and the range of lower limb motion was reduced by the high seat. These findings contrast with current opinion that ergonomic seats promote lumbar lordosis.

European consensus table 2006 on botulinum toxin for children with cerebral palsy.

An interdisciplinary group of experienced botulinum toxin users and experts in the field of movement disorders was assembled, to develop a consensus on best practice for the treatment of cerebral palsy using a problem-orientated approach to integrate theories and methods. The authors tabulated the supporting evidence to produce a condensed but comprehensive information base, pooling data and experience from nine European countries, 13 institutions and more than 5500 patients. The consensus table summarises the current understanding regarding botulinum toxin treatment options in children with CP.

Use of videographic examination for analysis of efficacy of botulinum toxin in the lower limbs in children with cerebral palsy.

The objective of this study was to test the interobserver and intraobserver reproducibility of videographic gait analysis in paediatric cerebral palsy patients following botulinum toxin type-A injections. Standardized videos according to gait-specific functional criteria were assessed for 1 h. For intraobserver reproducibility, 13 of 17 items showed good/moderate correlation, one mediocre and three poor correlation. For interobserver reproducibility, 12 of 17 items showed excellent, good or moderate agreement, five items showed poor agreement. Overall, 9 of 17 items showed good intraobserver or interobserver reproducibility. Mean interobserver scores for sagittal plane items were slightly lower than mean intraobserver scores (kappa=0.509 and 0.536, respectively). In conclusion, video analysis of children with cerebral palsy based on functional criteria is useful.

Pelvic-Spinal Analysis and the Impact of Onabotulinum toxin A Injections on Spinal Balance in one Child With Cerebral Palsy.

BACKGROUND: In children with cerebral palsy, primary (eg, abnormal muscle tone and weakness) and secondary impairments (eg, contractures) can modify pelvic-spinal alignment. The main aim of this article was to establish a new approach to pelvic-spinal analysis in children with cerebral palsy, taking into account the whole pelvis-spine complex, illustrated by a case study. METHODS: This is a case study of an ambulatory child with cerebral palsy (spastic diplegia) who underwent analysis of the pelvic-spine complex from X-ray images taken in standing position from C2 to the proximal femur. Pelvic shape was characterized by the pelvic incidence angle, which is the sum of sacral slope and pelvic tilt, before and after the treatment by regular onabotulinumtoxinA injections into the hip flexors, and the use of soft lumbar brace over 5 years. RESULTS: The sagittal balance of the spine was improved following the treatment, with a reduction in lumbar lordosis and sacral slope. The reduction in lumbar hyperextension likely reduced the risk of spondylolysis, low back pain, and degenerative spondylolisthesis in adulthood. CONCLUSION: A biomechanical approach to the evaluation of the pelvic-spinal complex offers new perspectives to increase the understanding of spinal balance in children with cerebral palsy, providing more options for treatment, such as onabotulinumtoxinA.

Long-term effectiveness of an educational and physical intervention for preventing low-back pain recurrence: a randomized controlled trial.

OBJECTIVE: Low-back pain (LBP) is a common and recurrent condition, but the evidence is scarce about effective strategies to prevent recurrence and disability in the longer term. This study investigated the effect of a light exercise program, initiated in the workplace and continued at home, in reducing recurrence of LBP episodes among healthcare workers. METHODS: A total of 353 healthcare workers from ten hospitals were enrolled in a randomized controlled trial (RCT) and were randomized to the intervention or control groups, the latter of which received usual care. The intervention comprised three steps: (i) a 2-hour education session, (ii) five weekly 90-minutes exercise training sessions in the workplace, and (iii) a home-based self-managed exercise program. The main outcome was recurrence of LBP with sick-leave at 24-months follow-up. RESULTS: At two-year follow-up, 35 workers (24%) in the intervention group and 31 workers (21%) in the control group had at least one LBP recurrence with sick leave. No effect was observed between groups [odds ratio (OR) 1.22, 95% confidence interval (95% CI) 0.67-2.23, P=0.516]. The intervention was effective in reducing fear avoidance with a mean reduction of -3.6 (95% CI -4.8- -2.4) points on the fear-avoidance beliefs questionnaire score for physical activity (FABQ-P) in the intervention group compared with -1.3 (95% CI -2.2- -0.3) points in the control group (P<0.05). It was also effective in improving muscle endurance with a mean increase of 13.9 (95% CI 3.3-24.5) minutes on the Sorensen test in the intervention group compared with -8.3 (95% CI-17.5-0.9) minutes in the control group (P<0.05). Healthcare utilization was reduced in the intervention group for painkillers, medical visits, imaging and outpatient physiotherapy. CONCLUSION: It was not possible to conclude about the effectiveness of a light exercise program to reduce LBP recurrence episodes in the long-term in healthcare workers. However, it was effective to improve muscle endurance, and to reduce fear-avoidance beliefs and healthcare utilization. Further studies are necessary in order to identify effective interventions to reduce LBP recurrence and related sick-leaves.

Relevance of intraglandular injections of Botulinum toxin for the treatment of sialorrhea in children with cerebral palsy: a review.

BACKGROUND: After the age of 4 years, drooling becomes pathological and impacts the quality of life of children with cerebral palsy. Intraglandular injection of Botulinum toxin is one of the treatments available to limit this phenomenon. AIMS: The objectives of this review were to validate the efficacy of Botulinum toxin injections for drooling in children with cerebral palsy, determine recommendations and identify potential side effects. METHODS: We conducted a literature review from 2001 in the following databases: Embase, Pubmed and Cochrane using the keywords: sialorrhea, drooling, hypersalivation, Botulinum toxin, cerebral palsy and children. Only the articles evaluating the efficacy of Botulinum toxin in children with cerebral palsy over the age of 4 were researched. RESULTS: Eight studies were found: 2 case studies, 3 open and non-controlled studies and 3 randomized controlled trials. Efficacy results in this indication are quite encouraging and the use of BTX injections is safe but the overall level of evidence of these studies was quite low. CONCLUSION: However, intraglandular injection of Botulinum toxin has a place among the therapeutic array available for the management of sialorrhea in this population even if no standardized protocol is available yet.

A French observational study of botulinum toxin use in the management of children with cerebral palsy: BOTULOSCOPE.

BACKGROUND: Dystonia and spasticity are common symptoms in children with Cerebral Palsy (CP), whose management is a challenge to overcome in order to enable the harmonized development of motor function during growth. AIM: To describe botulinum toxin A (BTX-A) use and efficacy as a treatment of focal spasticity in CP children in France. METHODS: This prospective observational study included 282 CP children mostly administered according to French standards with BTX-A in lower limbs. Realistic therapeutic objectives were set with parents and children together before treatment initiation and assessed using the Visual Analogue Scale (VAS). Child management was recorded and the efficacy of injections was assessed during a 12-month follow-up period by physicians (Modified Ashworth Scale, joint range of motion, Physician Rating Scale, Gillette Functional Assessment Questionnaire and Gross Motor Function Measure-66) and by patients/parents (Visual Analogue Scale). RESULTS: BTX-A treatment was administered in different muscle localizations at once and at doses higher than those recommended by the French Health Authorities. Children were treated in parallel by physiotherapy, casts and ortheses. Injections reduced spasticity and improved joint range of motion, gait pattern and movement capacity. Pain was reduced after injections. BTX-A administration was safe: no botulism-like case was reported. The log of injected children who were not included in the study suggested that a large population could benefit from BTX-A management. CONCLUSIONS: We showed here the major input of BTX-A injections in the management of spasticity in CP children. The results are in favor of the use of BTX-A as conservative safe and efficient treatment of spasticity in children, which enables functional improvement as well as pain relief.