Effects of 12-week aquatic exercises on gross motor function, swimming skills and walking ability in children with cerebral palsy.

BACKGROUND: Cerebral palsy (CP) is the most common cause of physical disability in childhood defined as a group of permanent disorders of movement. The aim of this study was to determine the effects of 12-week aquatic exercise program on gross motor function, swimming skills, and walking ability in children with cerebral palsy. METHODS: Eighteen children (Mean ± SD age: 12.3 ± 3 years) with cerebral palsy classified at Levels I, II and III on the Gross Motor Function Classification System were allocated to one group, where the first 12 weeks were a control period while another 12 weeks were an experimental period. The participants underwent the same battery of tests focusing gross motor function, swimming skills, and walking ability on three occasions. RESULTS: Control period was stable with no significant changes in any of measurements. After the 12-week experimental program, a statistically significant improvement was determined in gross motor function (p=0.005), swimming skills (p=0.000), walking endurance and walking (p=0.000). No significant differences (p>0.05) were observed for walking efficiency. CONCLUSIONS: The 12-week aquatic exercise program (3/week, 60 minutes), combining Halliwick method, swimming and walking activities may improve the gross motor function, swimming skills, walking endurance and velocity in ambulatory children with cerebral palsy.

Botulinum toxin type A for spastic cerebral palsy: Is it time to change praxis?

Missing (Letter).

The effectiveness of group Otago exercise program on physical function in nursing home residents older than 65years: A randomized controlled trial.

AIM: To examine whether the 6-months group-based Otago exercise program is more effective than usual care on physical function and functional independence in nursing home residents older than 65 years. METHODS: An observer-blind randomized controlled study included 77 independently walking, cognitively unimpaired residents aged 78.4±7.6years, of which 66.2% were female. Physical function was assessed at baseline, after 3 and 6months of the Otago exercise program by three performance tests: Berg Balance Scale (BBS), Timed Up and Go (TUG) and Chair Rising Test (CRT), and functional independence by the motor Functional Independence Measure (mFIM). RESULTS: Significant within participant effects of time in EG for BBS, TUG and CRT (p<0.001) and for mFIM (p=0.010) were found. Between participant effects of groups on BBS, TUG, CRT and mFIM values were not significant. Changes in values of performed three tests regarding physical function were significantly different in EG and CG (p<0.001), as well as for functional independence test (mFIM) (p=0.019). In EG the values got better, while in CG values worsened. Effect sizes of change in the EG were higher for BBS, TUG and CRT compared to mFIM. CONCLUSION: The Otago exercise program was shown as effective in improving balance, functional mobility, lower limbs muscle strength and functional independence, indicating that it could help in slowing of disability progression.

Are Interferential Electrical Stimulation and Diaphragmatic Breathing Exercises Beneficial in Children With Bladder and Bowel Dysfunction?

OBJECTIVE: To evaluate the effects of interferential current (IC) stimulation and diaphragmatic breathing exercises (DBEs) in children with bladder and bowel dysfunction. PATIENTS AND METHODS: Seventy-nine children with dysfunctional voiding and chronic constipation who were failures of primary care interventions were included in the prospective clinical study. All the children were checked for their medical history regarding lower urinary tract symptoms and bowel habits. Physical examination, including abdominal and anorectal digital examination, was performed. Children kept a bladder and bowel diary, and underwent urinalyses and urine culture, ultrasound examination of bladder and kidneys, and uroflowmetry with pelvic floor electromyography. Eligible children were divided into 3 groups (A, B, and C). All groups were assigned education and behavioral modifications. Additionally, group A underwent DBEs and IC stimulation, whereas group B received only DBEs. The treatment was conducted for 2 weeks in the clinic in all 3 groups,. The behavioral modifications and DBEs were continued at home for 1 month. Clinical manifestations, uroflowmetry parameters, and postvoided residual urine were analyzed before and after 6 weeks of therapy. RESULTS: After the treatment, significant improvement in defecation frequency and fecal incontinence was noticed only in group A (P < .001 and P < .05, respectively). These children demonstrated significant improvement in lower urinary tract symptoms and postvoided residual urine (P < .001 and P < .05, respectively). Bell-shaped uroflowmetry curve was observed in 73.3% of group A patients (P < .001). CONCLUSION: IC stimulation and DBEs are beneficial in chronically constipated dysfunctional voiders. Further trials are needed to define the long-term effects of this program.

Assessment of general movements and heart rate variability in prediction of neurodevelopmental outcome in preterm infants.

BACKGROUND: Adverse neurologic outcome in preterm infants could be associated with abnormal heart rate (HR) characteristics as well as with abnormal general movements (GMs) in the 1st month of life. AIMS: To demonstrate to what extent GMs assessment can predict neurological outcome in preterm infants in our clinical setting; and to assess the clinical usefulness of time-domain indices of heart rate variability (HRV) in improving predictive value of poor repertoire (PR) GMs in writhing period. STUDY DESIGN: Qualitative assessment of GMs at 1 and 3 months corrected age; 24h electrocardiography (ECG) recordings and analyzing HRV at 1 month corrected age. SUBJECTS: Seventy nine premature infants at risk of neurodevelopmental impairments were included prospectively. OUTCOME MEASURES: Neurodevelopmental outcome was assessed at the age of 2 years corrected. Children were classified as having normal neurodevelopmental status, minor neurologic dysfunction (MND), or cerebral palsy (CP). RESULTS: We found that GMs in writhing period (1 month corrected age) predicted CP at 2 years with sensitivity of 100%, and specificity of 72.1%. Our results demonstrated the excellent predictive value of cramped synchronized (CS) GMs, but not of PR pattern. Analyzing separately a group of infants with PR GMs we found significantly lower values of HRV parameters in infants who later developed CP or MND vs. infants with PR GMs who had normal outcome. CONCLUSIONS: The quality of GMs was predictive for neurodevelopmental outcome at 2 years. Prediction of PR GMs was significantly enhanced with analyzing HRV parameters.

Influence of fear of movement on total knee arthroplasty outcome.

UNLABELLED: arthroplasty (TKA) patients and to determine the association of fear of movement with established outcome measures. METHODS: A prospective study included 78 patients with primary TKA for osteorthritis. The occurence of fear of movement was assessed by Tampa Scale of Kinesiophobia (TSK). The patients were assessed at three time points: 2 weeks, 4 weeks and 6 months after the surgery. Pain and flexion were measured at all the three time points while function according to the Oxford knee score 1 was evaluated only at 6 month after surgery. RESULTS: Fear of movement occurred in 17 patients (21.8%). Patients with a high degree of fear of movement showed significantly poorer results compared to those with a low degree in terms of pain, flexion and function. Improvement in pain and flexion over time was achieved in both groups but it was significantly greater in the low degree fear of movement group. DISCUSSION: Our study showed that postoperative fear of movement was significantly associated with pain, flexion and function. Other authors found that preoperative level of fear of movement was a predictor of postoperative functional limitations. CONCLUSIONS: Fear of movement occurred in a substantial proportion of patients after TKA and it was associated with knee pain, flexion and function. According to our results fear of movement may represent a risk for poor TKA outcome.

The effects of botulinum toxin type A on improvement and dynamic spastic equinus correction in children with cerebral palsy - preliminary results.

INTRODUCTION: We evaluated the effects of botulinum toxin type A (BTA) with physical therapy on dynamic foot equinus correction and higher motor functional outcome in children with spastic type of cerebral palsy (CP). MATERIAL AND METHODS: Ankle joint active and passive movement, gastrocnemial muscle spasticity levels (Modified Ashworth Scale (MAS)), and higher motor functional status (Gross Motor Function Classification System (GMFCS) and Gross Motor Function Measure (GMFM) (GMFM-D - standing and GMFM-E - walking) were assessed before treatment and 3, 8, 16 weeks and 6 months after BTA administration in 12 children. RESULTS: There was a significant improvement of active (initial - (-)13.07 ±5.78; 6 months - (-)10.64 ±4.77; p < 0.001) and passive (initial - 4.21 ±2.29; 6 months - 4.71 ±2.16; p < 0.05) ankle joint foot dorsiflexion. GMFM-D and GMFM-E were significantly higher after 3, 8, 16 weeks (p < 0.001) and GMFM-D after 6 months (p < 0.001). CONCLUSIONS: Botulinum toxin type A administration and physical therapy in patients with spastic CP improves the motion range of dynamic foot equinus after 3 weeks and higher motor functional outcome (standing and walking).

Scintigraphy evaluation of the types of functional constipation in children with bowel bladder dysfunction.

PURPOSE: To evaluate the types of constipation according to colonic transit time in chronically constipated children with dysfunctional voiding (bowel bladder dysfunction, BBD group) and to compare the results with transit type in children with chronic functional constipation without urinary symptoms (constipation group) and children with normal bowel habits, but with lower urinary tract symptoms (control group). PATIENTS AND METHODS: One-hundred and one children were included and their medical histories were obtained. The BBD group kept a voiding diary, and underwent urinalyses and urine culture, ultrasound examination of bladder and kidneys and uroflowmetry with pelvic floor electromyography. Radionuclear transit scintigraphy was performed in all children according to a standardized protocol. Patients were categorized as having either slow-transit (ST), functional fecal retention (FFR) or normal transit. RESULTS: FFR was diagnosed in 31 out of 38 children with BBD, and 34 out of 43 children in the constipation group. ST was found in seven children with BBD, compared with nine children in the constipation group. The control group children demonstrated normal colonic transit. Urgency, daily urinary incontinence and nocturnal enuresis were noted only in children with FFR. Both children with ST constipation and FFR complained of difficulties during voiding, voiding postponement and urinary tract infections. CONCLUSIONS: FFR is the most common form of constipation in children with dysfunctional voiding. However, some children might suffer from ST constipation. Differentiation between these two types of constipation is clinically significant because they require different treatment. Future studies with larger numbers of patients are needed to confirm the noted differences in urological symptoms in these two groups of constipated children..

Hypertensive encephalopathy as a late complication of autonomic dysreflexia in a 12-year-old boy with a previous spinal cord injury.

UNLABELLED: The scope of paediatric autonomic disorders is not well recognised, and paediatricians seem to be generally unaware of the complexity and diversity of their clinical manifestations. We report a 12-year-old boy presenting with hypertensive encephalopathy caused by autonomic dysreflexia. CONCLUSION: This observation emphasises the importance of the recognition of this rare autonomic disorder, which can have potentially life-threatening neurological complications.

Estimation of botulinum toxin type A efficacy on spasticity and functional outcome in children with spastic cerebral palsy.

AIM: We evaluated the effects of botulinum toxin type A (BTA) - abobotulinumtoxinA on passive motion resistance (PMR) values of lower limbs affected muscles and on the functional motor status in children with spastic cerebral palsy (CP). METHODS: In Group I (28 lower limbs with spastic muscles), and in Group II (14 lower limbs with dynamic spastic equinus) BTA was administered. Physical therapy was prescribed for 16 weeks. We estimated PMR using the Modified Ashworth Scale. Achieved functional motor level was evaluated by Gross Motor Function Classification System (GMFCS) and Gross Motor Function Measure (GMFM). Parameters were assessed before treatment and after 3,8,16 weeks and 6 months respectively. RESULTS: In Group I, PMR was significantly lower for hip adductors and knee extensors over 3-16 weeks, and for ankle joint extensors in both groups. There were significant differences for both groups in frequencies of GMFCS values after 16 weeks from BTA application. There was a significant increase in GMFM scores after 8 and 16 weeks from BTA application in both groups of patients. CONCLUSIONS: BTA treatment in CP children is followed by reduction in PMR values and improvement in functional motor status.

Artificial neural networks based prediction of cerebral palsy in infants with central coordination disturbance.

BACKGROUND: In a previous study we demonstrated that heart variability parameters (HRV) could be helpful clinically as well as a prognostic tool in infants with central coordination disturbance (CCD). In recent years, outcome predictions using artificial neural networks (ANN) have been developed in many areas of health care research, but there are no published studies considered ANN models for prediction of cerebral palsy (CP) development. OBJECTIVE: To compare the results of an ANN analysis with results of regression analysis, using the same data set and the same clinical and HRV parameters. METHODS: The study included 35 infants with CCD and 37 healthy age and sex-matched controls. Time-domain HRV indices were analyzed from 24h electrocardiography recordings. Clinical parameters and selected time domain HRV parameters are used to predict CP by logistic regression, and then an ANN analysis was applied to the same data set. Input variables were age, gender, postural responses, heart rate parameters (minimum, maximum and average), and time domain parameters of HRV (SDNN, SDANN and RMSSD). For each of one the pairs of ANN and clinical predictors, the area under the receiver operating characteristic (ROC) curves with test accuracy parameters were calculated and compared. RESULTS: In the observed dataset, ANN model overall correctly classified all infants, compared with 86.11% correct classification for the logistic regression model, and compared with 67.65% and 77.14% for SDANN and SDNN respectively. CONCLUSIONS: ANN model, based on clinical and HRV data can predict development of CP in patients with CCD with accuracy greater than 90%. Our results strongly indicate that a well-validated ANN may have a role in the clinical prediction of CP in infants with CCD.

Pulsed electromagnetic field during cast immobilization in postmenopausal women with Colles' fracture.

INTRODUCTION: Although Colles' fracture i.e. a dorsally displaced distal radius fracture (DRF) is one of the most common fractures, there is no enough evidence to determine the best form of rehabilitation. OBJECTIVE: To assess whether the use of pulsed electromagnetic field (PEMF) therapy during cast immobilization of DRF provides beneficial effects on pain, edema, wrist range of motion and function, as well as on the frequency of complications immediately after cast removal. METHODS: The prospective randomized controlled study included 60 women over the age of 55 years with extra-articular displaced DRF treated with reduction and cast immobilization. The patients were alternately allocated to either a PEMF group (n = 30, received 10 days of PEMF therapy during immobilization), or a control group (n = 30, without PEMF therapy). Pain, function, hand circumference, wrist and forearm range of motion and frequency of complications for each patient was evaluated within two to three days of cast removal. RESULTS: Better mean values for the majority of examined parameters were recorded in the PEMF group than in the control group, but the difference was statistically significant just for edema (p < 0.001), flexion, extension and supination range (p < 0.01). CONCLUSION: During immobilization PEMF therapy in DRF patients gave better results immediately after cast removal in terms of edema and wrist range of motion (ROM).

[Aquatic exercise in the treatment of children with cerebral palsy].

INTRODUCTION: Aquatic exercise is one of the most popular supplementary treatments for children with neuro-motor impairment, especially for cerebral palsy (CP). As water reduces gravity force which increases postural stability, a child with CP exercises more easily in water than on land. OBJECTIVE: The aim of the study was to examine aquatic exercise effects on gross motor functioning, muscle tone and cardiorespiratory endurance in children with spastic CP. METHODS: The study included 19 children of both sexes, aged 6 to 12 years, with spastic CP. They were included in a 12-week aquatic exercise program, twice a week. Measurements of GMFM (gross motor function measurement), spasticity (MAS-Modified Ashworth Scale), heart rate (HR) and maximal oxygen consumption (VO2max) were carried out before and after treatment. The measurement results were compared before and after treatment. RESULTS: GMFM mean value before therapy was 80.2% and statistically it was significantly lower in comparison to the same value after therapy, which was 86.2% (p < 0.05). The level of spasticity was considerably decreased after therapy; the mean value before treatment was 3.21 according to MAS, and after treatment it was 1.95 (p < 0.001). After treatment there was a statistically significant improvement of cardiorespiratory indurance, i.e., there was a significant decrease in the mean value of HR and a significant increase of VO2max (p < 0.001). CONCLUSION: Aquatic exercise program can be useful in improving gross motor functioning, reducing spasticity and increasing cardiorespiratory endurance in children with spastic CP.

The effect of aquatic intervention on the gross motor function and aquatic skills in children with cerebral palsy.

The objective of this study was to investigate the effect of an aquatic intervention on the gross motor function and aquatic skills of children with cerebral palsy (CP). Twenty-nine children with CP, aged 5 to 14, were recruited. Fourteen children completed an aquatic intervention (EG), and 13 children served as controls (CG). Two participants dropped out due to events (illness) unrelated to the intervention. The aquatic intervention lasted 6 weeks (2 sessions per week at 55 minutes per session) with a follow-up period of 3 weeks. The outcome measures were the Gross Motor Function Measure (GMFM) for motor function and the Water Orientation Test Alyn 2 (WOTA 2) for aquatic skills assessment. A significant improvement was observed in the secondary assessment of GMFM and WOTA 2. In contrast to the aquatic skills improvement, the GMFM change was not maintained at follow-up. Our results indicate that children with CP can improve gross motor function on dry land and aquatic skills with a 6-week water intervention. The intervention period was too short for sustainable improvement in dry-land motor skills after intervention (follow-up), but time was sufficient to achieve sustainable improvements in aquatic skills.

Heart rate variability in infants with central coordination disturbance.

Despite a remarkable medical progress in the field of Developmental Medicine and Child Neurology, early identification of infants at risk for permanent motor disabilities still presents challenge for both clinicians and researchers. As an indicator of cardiac autonomic control, it was shown that heart rate variability (HRV) might reflect not only sympathetic or parasympathetic activity but also functional integrity of the central nervous system (CNS). Furthermore a pattern of HRV was demonstrated to correlate with motor developmental outcome in high risk infants. The purpose of this study was to analyze the clinical usefulness as well as predictive value of time-domain HRV parameters in infants with central coordination disturbance. The study included 35 infants with central coordination disturbance and 37 healthy age and sex-matched controls. Time-domain HRV indices were analyzed from 24-h electrocardiography recordings. We found significantly lower values of SDNN, SDANN and RMSSD parameters in infants with central coordination disturbance compared to controls. Additionally, logistic regression analyses demonstrated independent predictive value of parameters SDNN and SDANN in infants who subsequently developed cerebral palsy (CP). By performing receiver operating characteristic (ROC) analyses, the optimal cut-off value of SDNN<=48ms predicted CP with a sensitivity of 68.7% (95% CI 41.4-88.9) and specificity of 84.2% (95 CI 60.4-96.4) while the optimal cut-off value of SDANN<=41ms predicted CP with a sensitivity of 87.5% (95% CI 61.6-98.1) and specificity of 57.9% (95 CI 33.5-79.7). We are in opinion that time domain HRV analysis could be helpful clinically as well as a prognostic tool in infants with central coordination disturbance.

The value of modified DASH questionnaire for evaluation of elbow function after supracondylar fractures in children.

BACKGROUND/AIM: The Disabilities of the Arm, Shoulder and Hand (DASH) Outcome Questionnaire represents a region-specific instrument for functional outcome measurement of hand function. The aim of the study was to analyse the correlation between the values of modified DASH questionnaire and change of elbow function after supracondylar fracture (SCF) of humerus and to analyse the effects of early rehabilitation. METHODS: The study included 35 schoolaged children with flexion of SCF of humerus without lesion of nerves. The patients were divided into two groups: group A in which rehabilitation started up to 14 days after the removal of fixation (20 children), and group B in which rehabilitation started after 15 days and more (15 children). The effects of the applied rehabilitation procedures were analyzed by measuring the range of motion of elbow and using modified DASH questionnaire. Testing was performed during the first examination, on the first day of rehabilitation (retest) and after the rehabilitation. Pearson's coefficient of liner correlation was applied. RESULTS: Statistically significant negative correlation of DASH score and extension was verified in all three measurements. The values for the first test and for the final test were highly significant (p < 0.001), as well as negative correlation of DASH score and flexion on the first test and retest (p < 0.01), and at the end of rehabilitation (p < 0.001) in the group B. For all three tests in the group A negative correlation without significant differences for DASH score and flexion was found. CONCLUSION: A modified DASH questionnaire correlates with objective parameters of final status of elbow after SCF in children and it is applicable to small series of patients. A positive effect of early rehabilitation of children with SCF was found.

[Botulinum toxin type A for the treatment of spasticity in children with cerebral palsy].

BACKGROUND/AIM: Cerebral palsy (CP) is the most common physical disability in childhood. Children have problems with motor functions as a result of limbs spasticity, which leads to severe contractures and limbs deformity. There is a growing interest in the therapeutic role of botulinum toxin type A (BTA) in CP. The aim of this study was to examine the effects of BTA on spasticity, active range of motion and functional motor outcomes in children with CP. METHODS: This study included 42 children of both sexes, aged 2-6 years, with spastic CP, divided into two groups: group I (21 child) treated with BTA and physical therapy, and group II (21 child) treated with physical therapy only. The following parameters were analyzed: spasticity; active range of motion of the hip, knee and ankle, and functional motor outcome. These parameters measurements were carried out four times in both groups: before the treatment, three, eight and 16 weeks after the beginning of the treatment. The obtained results were statistically processed and compared. RESULTS: There was no evidence of any significant difference between the groups before the treatment. After eight weeks there was a remarkable difference concerning spasticity reducing on behalf of the group I (group I -- 0.76 +/- 0.51 vs. II group -- 2.17 +/- 0.64; p < 0.0001). There was statistically significant difference concerning active range of motion increasing on behalf of the group I (hip abduction: group I --44.37 +/- 1.13(0) vs. group II -- 32.61 +/- 8.07(0),p < 0,01; knee extension: group I -- 0.77 +/- 1.82(0) vs. II group -- 14.99 +/- 7.61(0), p < 0.01; dorsiflexion of the foot: group I -- 11.50 +/- 6.08(0) vs. group II -- 8.98 +/- 7.85(0), p < 0.01). A statistically significant difference was found after 16 weeks in functional motor outcome as well, on behalf of the group I: functional motor abilities level in the group I was 1.86 vs. 2.71 in the group II, p < 0.05. CONCLUSION: Botulinum toxin type A application leads to an important spasticity decreasing, active range of motion increasing, as well as to functional abilities in children with CP.

Heart rate variability in children with idiopathic ventricular tachycardia.

Idiopathic ventricular tachycardia (IVT) is a rare arrhythmia in children. A great deal of uncertainty and numerous questions still remain regarding the extent of investigation, therapy, and long-term prognosis for children with IVT. The existence of subclinical cardiac disease, as well as of autonomic dysfunction in patients with ventricular arrhythmias, has been well documented. A number of experimental and clinical studies have suggested that imbalances within the cardiac autonomic system's activity may be crucial in the generation of ventricular tachycardia, irrespective of the presence of cardiovascular pathological substrate. Heart rate variability (HRV) analysis provides a useful method for measuring the autonomic activity. This study evaluates HRV in children with IVT. The study included 31 children with ventricular arrhythmia who were divided into two groups: (1) patients with frequent ventricular extrasystoles (VES) and (2) patients with IVT. The control group comprised 23 healthy children without pathological findings on 24-h ECG Holter. Twenty-four-hour ambulatory electrocardiography recordings were obtained, and the time-domain variables were calculated. HRV was compared to age-related normal values. It was observed that the overall heart rate variability is diminished in children with IVT. We recommend HRV analysis of any child with IVT. Quantification of the autonomic nervous system activity using time domain analyses may be a helpful diagnostic tool in the clinical assessment and initial evaluation of these children.

[Functional voiding disorders: rehabilitation of children with urge syndrome].

Urge syndrome is a condition associated with functional voiding disorders. Urological symptoms (urgency, frequency and incontinence) are manifestations of uninhibited detrusor contractions. The goal of rehabilitation programs is to develop voluntary bladder control, to improve urologic symptoms and to increase bladder capacity. Bladder training, strategies to suppress urgency, electrical stimulations such are anogenital, transcutaneous and percutaneous electrical nerve stimulations have been used in the treatment.