ABSTRACT:

BACKGROUND: Long waiting times and large caseloads are a challenge to children’s therapy services internationally. Research in hospital-based healthcare indicates that waiting times are a function of throughput, and that length of care episode is related to clinicians’ caseload management behaviour (i.e. actions at assessment, treatment, post-treatment, and discharge). There have been few attempts to study this in community health services. The present study investigated whether community occupational therapists’ behaviour predicts children’s length of time (LoT) on caseloads.

METHODS: Retrospective survey of case notes of children recently discharged from occupational therapy services. Using cluster random sampling, case notes were drawn from therapy records in six NHSScotland Health Boards. Data about therapists’ behaviours of assessing, treating, reviewing and discharging, together with child characteristics, were used to construct regression models of factors related to LoT.

RESULTS: Twenty-six therapists [median(IQR) time in paediatrics 8(6-13) years] and 154 of their cases [mean(SD) age 7(3) years; median(IQR) LoT 10(3-21)] were included. A multi-level model, adjusting for clustering, for therapists’ actions of communicating assessment outcomes to parents, providing treatment, and placing the child on review, and for a diagnosis of cerebral palsy, explained 44% of variation in LoT.

CONCLUSIONS: Occupational therapists’ caseload management behaviours are associated with children’s LoT on caseloads. Further research is required to investigate the direction of relationships between therapists’ behaviours and LoT; and the relationships between contextual factors, therapists’ caseload management behaviours and LoT. Further exploration of therapists’ beliefs about caseload management could also be useful in identifying possible factors contributing to variation between therapists.

This work was undertaken to assess the usefulness of magnetic resonance imaging (MRI) of the brain for early prognosis of cerebral palsy. The study group included 47 neonates (24 term and 23 preterm) with symptoms of perinatal asphyxia. MRI examinations in term neonates were performed during the first month of life but not before the second week of life, while in preterm neonates MRI data were acquired between 38 and 40 weeks from conception. MRI of the brain demonstrated hypoxic-ischemic findings in all neonates born with perinatal asphyxia who later progressed to cerebral palsy. These results support the hypothesis that MRI performed in the neonatal period plays an essential role in predicting cerebral palsy in both term and preterm neonates, regardless of their gestational age.

Objective Poor condition at birth may impact on IQ, although its effect on other measures of neurodevelopment is unclear. The authors’ aim was to determine whether infants receiving resuscitation after birth have reduced scores in measures of attention, memory and language skills or the need for educational support at school even in the absence of clinical encephalopathy. Methods Three groups of term infants were identified from the Avon longitudinal study of parents and children: infants resuscitated at birth but asymptomatic for encephalopathy (n=612), infants resuscitated who developed symptoms of encephalopathy (n=40) and the reference infants who were not resuscitated and had no further neonatal care (n=8080). Measures of attention, language, memory and the need for educational support were obtained for children between 8 years and 11 years. Test results (standardised to a mean of 100 and SD of 15) were adjusted for clinical and social covariates. Missing covariate data were imputed using chained equations. Results Infants asymptomatic after resuscitation had similar scores to those not requiring resuscitation for all measures while infants who developed encephalopathy had lower working memory (-6.65 (-12.34 to -0.96)), reading accuracy (-7.95 (-13.28 to -2.63)) and comprehension (-9.32 (-14.47 to -4.17) scores and increased risk of receiving educational support (OR 6.24 (1.52 to 26.43)) than infants thought to be well at birth, although there was little evidence for an association after excluding infants who developed cerebral palsy. Conclusions The authors found no evidence that infants who were resuscitated but remained well afterwards differed from those not requiring resuscitation in the aspects of neuropsychological functioning assessed in this study. Infants who developed neonatal encephalopathy had evidence of worse functioning, particularly in language skills and were more likely to receive educational support at school.

PURPOSE: We sought to identify measures of variability from sitting postural sway that are significantly different among infants who were developing typically, those who were developmentally delayed or hypotonic, and those who later on had a diagnosis of spastic or athetoid cerebral palsy.

METHODS: Sixty-five infants were evaluated when they were just developing the ability to sit upright by assessing center of pressure (COP) data, using measures of both amount and temporal organization of COP variability.

RESULTS: The results indicated that measures of variability of COP could discriminate between infants with developmental delay and infants with cerebral palsy and add to the description of sitting postural behavior.

CONCLUSIONS: Our method of evaluating sitting postural control could be an objective tool to help describe distinctive features of motor delay in an individual infant and could lead in the design of selective therapeutic interventions for improving postural control of infants with motor delays.

A diagnosis of ‘cerebral palsy’ in childhood is relatively common. Abnormalities of the upper cervical spine causing spinal cord compression are rare, but can be a cause of symptoms and signs that may otherwise be attributed to brain injury acquired during development. We present an interesting case of a congenital abnormality of the atlas causing severe cervical spinal cord compression in a 9-year-old child, together with a discussion of the relevant aspects of spinal development and a review of the literature.

OBJECTIVE: To investigate the validity of MTI accelerometer as a physical activity (PA) measurement instrument for children with cerebral palsy (CP).

DESIGN: Participants were classified within Gross Motor Function Classification System I to III and took part in 2 activity sessions: (1) a structured activity protocol with increasing intensities and (2) a free play session. Concurrent measurements of activity counts, heart rate, and observed physical activity were performed.

SETTING: Data were collected on normal school days in special schools within the participants’ 30-minute break period.

PARTICIPANTS: Convenience sample of children with CP (N=31; 17 girls, 14 boys) age between 6 and 14 years (mean +/- SD, 9.71+/-2.52 y).

INTERVENTIONS: Not applicable.

MAIN OUTCOME MEASURES: MTI measured activity counts, a monitoring device measured heart rate, and the System for Observing Fitness Instruction Time (SOFIT) was used for direct PA observation.

RESULTS: There were strong relationships between MTI and SOFIT (r=.75; R(2)=.56; P<.001) and heart rate monitor (HRM) and SOFIT (r=.65; R(2)=.43; P<.001) data in structured activities, but the difference between these 2 correlation coefficients was not significant (P=.46). In free play activities, the association between MTI and SOFIT data (r=.67; R(2)=.45; P<.001) was significantly stronger (P=.01) than that between heart rate and SOFIT data (r=.14; R(2)=.02; P<.001) . Bland-Altman plots showed better agreement between observed SOFIT and MTI-predicted SOFIT data than observed SOFIT and HRM-predicted SOFIT data from the linear regression analysis.

CONCLUSIONS: The findings suggest that the MTI appears to be a valid instrument for measuring raw activity volume among children with CP and is suitable for use in studies attempting to characterize the PA of this population.

OBJECTIVES: To develop a questionnaire that specifically and comprehensively measures mobility limitations in children with cerebral palsy (CP) and to investigate certain psychometric properties (scalability, unidimensionality, internal consistency) of this questionnaire.

DESIGN: Cross-sectional study.

SETTING: Private physical therapy practices and outpatient departments of hospitals and rehabilitation centers.

PARTICIPANTS: Children with CP undergoing physical therapy or rehabilitation. The Mobility Questionnaire, 47-item (MobQues47), was completed by the mothers of these children (N=323; mean age +/- SD, 7.1+/-2.9y; 57% boys; Gross Motor Function Classification levels: I [48%], II [26%], III [19%], IV [7%]).

INTERVENTIONS: Not applicable.

MAIN OUTCOME MEASURES: Mokken scale analysis was used to investigate (1) scalability, indicating that the items form a scale; (2) unidimensionality, indicating that the items measure only 1 concept; and (3) internal consistency, indicating the degree of interrelatedness of the items.

RESULTS: The MobQues47, made up of 47 items, was developed on the basis of 3 pilot studies and careful operationalization of the concept (or construct) of mobility limitations. The scalability (coefficient H=.70), unidimensionality, and internal consistency (coefficient rho=.99) of the MobQues47 were found to be very good.

CONCLUSIONS: The MobQues47 is a unidimensional scale with excellent internal consistency that can be used to measure caregiver-reported mobility limitations in children with CP.

BACKGROUND AND OBJECTIVES: Patients with cerebral palsy (CP) frequently receive drugs for the treatment of concomitant diseases, such as seizures. Midazolam is a benzodiazepine with hypnotic action most often used as pre-anesthetic medication and its drug interactions in patients with CP are unknown. The objective of the present study was to evaluate the effect of midazolam as pre-anesthetic drug on the BIS of patients with CP undergoing chronic treatment with anticonvulsant agents.

METHOD: Three groups of patients were assessed: CP without anticonvulsant treatment, CP undergoing treatment with anticonvulsant and a group with no disease and no medication use (control group). On the day before the surgery, with the patients conscious and in dorsal decubitus, the BIS monitor was placed and the basal BIS values were recorded. On the following day, 40 minutes before the surgery, the patients received 0.6 mg*kg(-1) of midazolam orally. Before the start of the anesthetic procedure, the same procedure for BIS recording was carried out after midazolam administration.

RESULTS: A total of 107 patients were studied – 39 patients from the Control Group (CG) and 68 with a diagnosis of CP. Among these, 17 used anticonvulsant drugs. Regarding the mean BIS value after the midazolam administration, there was no difference between patients from the CG and those in the CP group that did not take anticonvulsant drugs, whereas the ones who took anticonvulsants exhibited a difference (p = 0.003). The possibility of decrease in the BIS after midazolam use increases according to the number of anticonvulsant drugs used by the patient.

CONCLUSIONS: The chronic use of anticonvulsants associated to oral midazolam as pre-anesthetic medication can lead to the decrease in the BIS values, which configures deep level of hypnosis.

Crigler Najjar syndrome type II is related to a defect of bilirubin conjugation due to partial deficiency of the enzyme uridine diphosphate-glucuronyl transferase. Usually has a benign course, unlike Crigler Najjar type I, where the enzyme deficiency is total and the affected patients usually die at early ages. We present the case of a teenager with indirect hyperbilirubinemia, seizures and cerebral palsy. A good clinical history with pedigree and appropriate functional tests allowed us to determine the definitive diagnosis. This is an autosomal recessive disorder, has a very low prevalence worldwide, and is a diagnostic challenge for physicians in general.

Sätilä H, Huhtala H: Botulinum toxin type A injections for treatment of spastic equinus in cerebral palsy: A secondary analysis of factors predictive of favorable response.

OBJECTIVE: To investigate markers predicting favorable botulinum toxin injection outcomes in treating spastic equinus gait in children with cerebral palsy.

DESIGN: Thirty-six children (21 boys and 15 girls, aged 1.5-9.6 yrs; 20 with unilateral and 16 with bilateral cerebral palsy levels I to IV with the Gross Motor Function Classification System) with 49 treated lower limbs were included. Passive range of movement, selective dorsiflexion, dynamic muscle length (modified Tardieu Scale), calf tone (modified Ashworth Scale), attainment of anticipated gait pattern (Goal Attainment Scale), and video gait analysis (Observational Gait Scale) were assessed before and 1, 2, and 4 mos after intervention. Participants were classified as poor or good responders, according to the Goal Attainment Scale response at 2 mos.

RESULTS: Good response was noted in 23 (64%) children and 29 (59%) legs, whereas 13 (36%) children and 20 (41%) legs were defined as poor responders. In a multivariate regression analysis, the best predictors of good response per child were higher initial Observational Gait Scale total scores, one-level treatment, and normal cognition; and the best predictors per leg were good initial selective motor control in the ankle and capability of occasional flatfoot contact at pretreatment.

CONCLUSIONS: These results suggest that children with less severe functional deficit, fair to good selective motor control in the ankle, and mild equinus gait respond best to focal botulinum toxin type A treatment, with an eye to flatfoot or heel strike contact. Likewise, children with higher cognitive level seem to derive functional benefit from the treatment.