An interdisciplinary European group of clinical experts in the field of movement disorders and experienced Botulinum toxin users has updated the consensus for the use of Botulinum toxin in the treatment of children with cerebral palsy (CP). A problem-orientated approach was used focussing on both published and practice-based evidence. In part I of the consensus the authors have tabulated the supporting evidence to produce a concise but comprehensive information base, pooling data and experience from 36 institutions in 9 European countries which involves more than 10,000 patients and over 45,000 treatment sessions during a period of more than 280 treatment years. In part II of the consensus the Gross Motor Function Measure (GMFM) and Gross Motor Function Classification System (GMFCS) based Motor Development Curves have been expanded to provide a graphical framework on how to treat the motor disorders in children with CP. This graph is named "CP(Graph) Treatment Modalities - Gross Motor Function" and is intended to facilitate communication between parents, therapists and medical doctors concerning (1) achievable motor function, (2) realistic goal-setting and (3) treatment perspectives for children with CP. The updated European consensus 2009 summarises the current understanding regarding an integrated, multidisciplinary treatment approach using Botulinum toxin for the treatment of children with CP.
TMS Transcranial magnetic stimulation WMDI White-matter damage of immaturity AIM To investigate relationships between hand function, brain lesions, and corticomotor projections in children with unilateral cerebral palsy (CP).METHOD The study included 17 children (nine males, eight females; mean age 11.4 [SD 2.4] range 7-16y), with unilateral CP at Gross Motor Function Classification System level I and Manual Ability Classification System level I or II. Hand function was assessed with the Box and Blocks test and Assisting Hand Assessment (AHA). Conventional structural magnetic resonance images were assessed visually for type, location, and extent of brain lesions. Single-pulse transcranial magnetic stimulation (TMS) provided information on organization of corticomotor projections. RESULTSThe most favourable hand function was seen in children who had white-matter damage of immaturity with mild white-matter loss and contralateral motor projections. Children with ipsilateral projections had the most impaired function. Nevertheless, in this subgroup a range of ability was seen (AHA 29-59%). Motor-projection patterns appeared to be influenced by lesion extent and location, but not by lesion type. INTERPRETATION Combining information from structural magnetic resonance images and TMScan improve prediction of hand function. A wide variation in hand function was seen within all motor-projection patterns. Although the most impaired hand function was seen in the ipsilateral motor-projection group, some children in this group had fairly good ability. Such information is important for treatment planning.The availability of neuroimaging and neurophysiology techniques, in particular magnetic resonance imaging (MRI) and transcranial magnetic stimulation (TMS), has greatly improved our understanding of the neural correlates of cerebral palsy (CP).1-4 Previous research has mainly been focused on overall motor impairment and the associations with brain abnormalities. Detailed descriptions of hand function have rarely been the focus of existing studies. In the few studies in which hand motor function has been examined specifically, outcome is often classified into broad categories, such as mild, moderate, or severe, which are not sufficiently sensitive to the large variation in hand function that is observed in children with unilateral CP. 5 CP can be caused by a range of brain lesions, 1,6 and there is some evidence that the extent of a lesion is associated with the severity of overall impairment. For example, it has been shown that, in periventricular white-matter lesions, mild white-matter loss is often associated with a mild degree of overall motor impairment, whereas extensive white-matter loss leads to more severely impaired function. 7,8 Lesions that affect grey matter (cortex, thalamus or basal ganglia) have been reported to cause moderate to severe motor impairments.9,10 The few existing studies in which hand function in children with unilateral CP has been investigated also indicate that the extent of a lesion is related t...
ABBREVIATIONSBoNT-A Botulinum toxin type A MAS Modified Ashworth Scale ROM Range of motion SDR Selective dorsal rhizotomy AIM The aim of this study was to evaluate the long-term effects of selective dorsal rhizotomy (SDR) in children with cerebral palsy (CP).METHOD Nineteen children (four females, 15 males; mean age 4y 7mo, SD 1y 7mo) with bilateral spastic CP, were prospectively assessed at baseline and 18 months, 3 years, and 10 years after SDR. Assessments included the Modified Ashworth Scale for spasticity, the Gross Motor Function Measure 88 (GMFM-88) and the Wilson gait scale for ambulation, neurological investigations, and passive joint range of motion assessment. A 10-year retrospective chart review was added for orthopaedic surgery after SDR. RESULTSBaseline muscle tone at the hip, knee, and ankle level displayed a high degree of spasticity that normalized after SDR. After 10 years there was a slight recurrence of spasticity at the knee and ankle. Joint range of motion declined from a maximum at 3 years after SDR to the 10-year follow-up. Median ambulatory status was best 3 years after SDR and then declined. The GMFM-88 score increased from the median baseline value of 51 to 66 (p=0.002) and 76 (p<0.001) at the initial follow-ups. After 10 years there was a decline in gross motor function with a reduction in the GMFM-88 score to 62 (p=0.022). Within 10 years, 16 out of 19 patients had a mean of three orthopaedic surgeries (SD 2.8), soft tissue surgery being the most common. INTERPRETATIONThe spasticity-reducing effect of SDR, although pronounced, did not seem to improve long-term functioning or prevent contractures. This suggests that contracture development in CP is not mediated by spasticity alone.In children with cerebral palsy (CP), spasticity has often been assumed to be the main reason for functional limitations and development of contractures. Accordingly, many treatments are aimed at reducing spasticity. Interventions used to reduce spasticity are injections with botulinum toxin type A (BoNT-A), intrathecal baclofen therapy, oral drugs, orthopaedic surgery, and physiotherapy. 1 Selective dorsal rhizotomy (SDR) is a neurosurgical procedure where afferent excitatory nerve fibres emerging from the proprioceptors in the muscle spindles are cut where they enter the posterior root of the spinal cord, thereby reducing efferent excitation. The aim is to reduce spasticity and improve function. Reduction in spasticity has been shown for up to 5 years after SDR. 2There is conflicting evidence when tone-reducing therapies have been evaluated from a functional perspective, typically using gait or various assessments of gross motor function. 3,4 Thus studies have found moderate functional gains [5][6][7][8][9][10][11] or no positive functional outcomes. [12][13][14][15][16] However, only a subgroup of the studies has analysed in depth the possible correlation between a reduction in spasticity and improved function. Of these studies, only Love et al. 6 investigated this relationship and demonstrated a positive...
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