A review of the effectiveness of lower limb orthoses used in cerebral palsy

To produce this review, a systematic literature search was conducted for relevant articles published in the period between the date of the previous ISPO consensus conference report on cerebral palsy (1994) and April 2008. The search terms were 'cerebral and pals* (palsy, palsies), 'hemiplegia', 'diplegia', 'orthos*' (orthoses, orthosis) orthot* (orthotic, orthotics), brace or AFO

Effectiveness of Functional Electrical Stimulation - Cycling Treatment in Children with Cerebral Palsy

AimThe purpose of this study was to evaluate the effects of functional electrical stimulation (FES) bicycle therapy system on motor function, gait pattern, spasticity, daily living activities, and aerobic capacity in children with cerebral palsy (CP) and to compare the results with sham stimulation and standard treatment.MethodsPatients with cerebral palsy who received botulinum toxin type-A injections to lower extremities and those with Gross Motor Function Measure Classification System (GMFCS) levels I – III, were included in the study. Twenty-five patients were randomly assigned into three treatment groups for 4-weeks: Group 1, FES-cycling and standard treatment; Group 2, Sham stimulus FES-cycling and standard treatment; Group 3, Standard treatment. Clinical assessment tools included the Modified Ashworth Scale (MAS), Modified Tardieu Scale (MTS), Pediatric Functional Independence Measure (WeeFIM), GMFCS, Gross Motor Function Measure-88 (GMFM-88), selective motor control tests, 6-minute walk test, and Visual Gait Analysis (VGA).ResultsIn all groups, there were significant improvements in MAS, MTS, WeeFIM, GMFM-88, 6-minute walk test, and VGA scores. No changes in GMFCS levels were observed in any group. At the end of the study, there was no significant difference among the groups in terms of any clinical assessment parameter.ConclusionsAll groups showed statistically significant improvements in motor function, walking pattern, spasticity, daily living activities, and aerobic capacity in patients with CP following the rehabilitation period. Although FES-cycling demonstrated no superiority over the other approaches and provided no additional benefit to the results, FES appears to be safe and well-tolerated in children with CP, at least as much as standard exercise treatment

Gait parameters in children with bilateral spastic cerebral palsy: a systematic review of randomized controlled trials

To identify the gait parameters used to assess gait disorders in children with bilateral spastic cerebral palsy ( BSCP) and evaluate their responsiveness to treatments : A systematic search within Pubmed, Web of Science and Scopus ( English, 2000 - 2016) for randomized controlled trials of children with BSCP who were assessed by i nstrumented gait analysis ( IGA ) was done . Data r elated to participants and study characteristics, risk of bias and outcome measures w ere collected . A list of gait parameters responsive to clinical interventions was obtained. Results : Twenty - one articles met the inclusion criteria. Eighty - nine gait parameters were identified and fifty - six of them showed responsiveness to treatments . Spatiotemporal and kinematic parameters were widely used compared to kinetic and surface electromyography data . The majority of responsive gait parameters were joint angles at the sagittal plane (flexion - extension) . The IGA yields responsive outcome measure s for the gait assessment of children with BSCP . Spatiotemporal and kinematic parameters are the gait parameters used most frequently . Further research is needed to establish the relevant gait parameters for each clinical problem.Peer ReviewedPostprint (author's final draft

An Investigation Into the Effect of Functional Electrical Stimulation to Assist the Gait of Children with Cerebral Palsy.

A common feature of cerebral palsy is persistent toe walking on the most affected side, which may result in an unstable gait and frequent falls. Results from current interventions, such as AFOs, plaster boots, botulinum, or surgery are mixed, with some being poorly tolerated and/or with only temporary results. An alternative intervention may be functional electrical stimulation (FES) in which (for this application) electrical pulses are applied to motor points through surface electrodes by a small, lightweight, external battery unit. The dynamic nature of FES may promote a more normal gait pattern and strengthen and re-educate the affected muscles. There are two apparently opposing approaches, with some studies reporting positive results from stimulating the anterior tibial muscles and studies reporting positive results from stimulating the calf muscles. Whilst both approaches have shown some encouraging results they fail to produce conclusive evidence as to which should be the treatment of choice or provide prescription guidelines for appropriate selection. The aim of this pilot study was to establish whether FES applied to the anterior tibial muscles can be used successfully to control toe walking in children with CP, building on the widely accepted model used in adults. In addition it was aimed at establishing any preconditions that need to be met. An ABA approach was used (A - non intervention; B - intervention) with each phase lasting three months, which allowed the treatment to continue for a greater period than previous studies. In terms of daily exposure, children used the device throughout their daily activities. Sufficient subjects were recruited for a statistical analysis. To control for the effects of other treatments existing therapeutic inputs continued, whilst making kinematic, kinetic, energy consumption, and clinical measurements to quantify changes. Data for over 2000 steps from ten children at six measurement sessions were recorded. Results suggest immediate orthotic and longer term therapeutic effects, as measured by the heel-toe interval, knee angle at foot contact, step and stride length, cycle time, speed, and energy consumption. Significance at the 0.05 level was reached for step and stride lengths, and speed. The effectiveness of the stimulation from the users’ point of view was assessed through a questionnaire, completed by the child and their parent or carer. A major weakness identified in the course of the study was a lack of sufficient subject numbers to allow greater statistical significance to be achieved. In addition, the lack of sufficient subjects did not allow the unambiguous identification of any sub-groups who may benefit more or less than others. Improved equipment may also have made possible a better estimate of heel-toe intervals, which appears to be potentially useful outcome measure. Future work planned includes a similar study of calf muscle stimulation and improvements to the stimulator equipment

Use of Botulinum Toxin A in Cerebral Palsy

Botulinum toxin A (BTX-A) is widely used worldwide to overcome the significant problem in spastic cerebral palsy (CP). In the past three decades, botulinum toxin serotype A (BTX-A) has been introduced as a selective treatment option for spasticity in children with cerebral palsy. BTX-A is an acetylcholine-blocking agent that causes presynaptic neuromuscular blocking when injected into the muscle. Its action of decreasing or normalization of tone prevent the development of contractures and deformities and avoid or postponed surgical intervention particularly when combined with other treatment modalities such as physiotherapy, casting, orthosis, etc. Equinus deformity, scissoring and crouch gait in the lower limbs, and different spastic deformities like pronation of forearm, elbow flexion, wrist flexion, fisting, or abnormal dystonic posture of upper limb deformities were the main indications wherein botulinum toxin injection is needed in spastic cerebral palsy; moreover, its benefit of relieving pain that are associated with muscular hypertonia and palpation of the muscle, particularly the large one, remains the cornerstone for injection of BTX in CP patient for most experts worldwide, but it needs a well of knowledge in anatomy and its landmark. Invasive procedure like electromyography (EMG) is more difficult to be applied successfully in children than in adults. Spasticity is considered a positive phase of muscle function. Therefore, when relaxing the muscle, the patient’s condition might get worse functionally in some instance. So, the first question clinician put in his account before injecting BTX is whether hypertonia is impeding or improving function; therefore, injection is tailored individually by an expert physician. Generally, the adverse side effects of BTX-A are seldom to occur providing that the physician strictly adheres to the dose ranges and reinjection period. The inter-injection period must be at least 12 weeks to avoid antibodies ands. So far, BTX-A is considered to be safe to some extent if used professionally; however, long-term adverse effect particularly with multilevel therapy are still not clear

Influence of 3-month therapy using the neuro-orthopaedic suit Atlant on gait characteristics in preschool children with spastic cerebral palsy

Different kinds of physical therapy are used in medical rehabilitation of neurological patients with motor deficiency: partial body weight-supported treadmill training, driven gait orthosis, neuromuscular electrical stimulation and neuro-orthopaedic suit therapies. Neuro-orthopaedic pneumosuit (NOPS) Atlant (Dynaforce, Russia) creates a muscle framework by dynamic proprioceptive stimulation, stabilizing the trunk and the extremities, reducing pathological synergies and normalizing patient’s motor activity. The aim of the present study was to investigate the influence of 3-month therapy using the NOPS Atlant on gait characteristics in preschool children with spastic form of cerebral palsy (CP). Six CP children with spasticity of lower extremities with (mean±SE) age of 5.2±0.8 years participated in the present study. Children had NOPS Atlant therapy sessions during three months, supervised by an experienced physiotherapist. The kinematic and kinetic characteristics of gait were measured using 3-D movement analysis system Elite Clinic (BTS S.p.A., Italy). After 3-month therapy using the NOPS Atlant, significant increase (7.9%) of the stride length of gait was found as compared with the initial data. Children with spastic CP demonstrated significant improvement of range of motion of hip joint abduction, decrease of knee joint external rotation, as well as positive changes in foot progression angle during gait. In conclusion, motor function re-activation during gait in preschool children with spasticity caused by cerebral palsy was noted after 3-month therapy using the NOPS Atlant. However, future research is needed to elucidate mechanisms of neurodynamic therapy effect on motor ability in children with CP

Does combining physiotherapy with Botulinum toxin type A injections improve the management of children with spastic cerebral palsy?

Cerebral palsy (CP) affects around every one in 500 children born. It isn’t a particular illness or disease, but an umbrella term used to describe a physical condition that affects movement as a result of injury to the brain. There are several types of CP, the main ones being spastic, athetoid and ataxic. Despite medical advances, there is no cure for CP but there are ranges of treatments from drugs to Botulinum toxin type A injections, massage therapy to surgery. The aim of this study is to look at two of these treatments, namely Botulinum toxin type A injections and physiotherapy to treat spastic CP. Botulinum toxin is widely used to reduce muscle tone in the treatment of spasticity in children with cerebral palsy. The aim of the study is to compare the effects treatment with Botulinum toxin type A and Botulinum toxin type A with additional physical therapy in the management of a group of children with cerebral palsy. Experiments were done at The Prince Sultan Hospital and Al-Hada Armed Forces Hospital in Saudi Arabia. The local Ethics Committee approved the protocol. 47 children were recruited. All had cerebral palsy, diplegia, spasticity of the ankle planter flexors and significant gait abnormalities due to dynamic equinus foot deformity. They were divided into two groups. Both groups had their Gross Motor Function assessed one week before injection and at 4 and 6 weeks after injection. Additional measurements of range of movement and stiffness at the ankle and soleus electromyograms were recorded The soleus EMG was silent during ankle dorsiflexion in 20 children four weeks after injection of Botox. The EMG had returned six weeks after injection in every child. The Gross Motor Function Measurements were not significantly different in the two groups before the injection (p=0.23). The measurements improved significantly over the next six weeks in both groups (p<0.001). The magnitude of the improvement was greater in the group, which received Botulinum toxin type A and physical therapy (means 57.2 + 8.90 before, 64.9 + 9.78 after. Mean + SD) than in the group which received Botulinum toxin type A alone (59.5 + 11.0 before, 62.4 + 11.3 after Mean + SD). Conclusions 1. . The Treatment allocation provided groups, which were comparable pre-treatment in terms of baseline GMFM. 2. . Both treatments showed evidence of improvement in GMFM over the period of the study and particularly at 52 weeks. 3. . Treatment 2 showed a significant average advantage in GMFM over Treatment 1 at all times in the study. 4. . This advantage in average GMFM increased from 4 through to 52 weeks with a clear and significant difference between 4 and 52 weeks. 5. . This average advantage appeared to increase the higher the child’s baseline GMFM

Neuromusculoskeletal Rehabilitation of Severe Cerebral Palsy

Persons with Gross Motor Function Classification System (GMFCS) levels IV and V are considered as severe cerebral palsy (CP) and are non-ambulatory. These persons are at a higher risk of complications such as hip displacement (sub-luxation or dislocation), spinopelvic deformities, musculoskeletal pain, low bone mineral density and low energy fracture. The recommended management strategy at present for this group is wheelchair-aided mobility, with which none of these complications can be prevented. There is a strong need to evaluate alternative methods of treatment that can allow assisted ambulation in persons with severe CP. The role of Single Event Multilevel Lever Arm Restoration and AntiSpasticity Surgery (SEMLARASS) and protocol-based active rehabilitation on gross motor function and ambulation of non-ambulatory persons with CP at GMFCS levels IV and V is examined. Active rehabilitation involves making the person with severe CP active through most of the waking hours and participating actively in the rehabilitation. A well-planned and executed SEMLARASS, followed by intensive, protocol-based, sequenced multidisciplinary active rehabilitation, provides the persons with GMFCS levels IV and V a significant functional improvement in gross motor function and mobility