Category: Research and Articles

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Fractures in patients with cerebral palsy.

date: 03/01/2007
author: Presedo A, Dabney KW, Miller F.
publication: J Pediatr Orthop. 2007 Mar;27(2):147-53.
pubmed_ID: 17314638

Fractures in children with cerebral palsy (CP) constitute a common clinical problem. The purpose of this retrospective study is to analyze the demographics, identify risk factors, and delineate guidelines for treatment in 156 children with CP who were treated for fractures. To identify changes in demographics, children treated before 1992 (56 patients) were compared with those treated from 1992 to 2000. The latter group of children was compared with an age- and gender-matched group of CP children without fractures. Ambulatory status, the presence of contractures, nutritional status, seizure medication, the type of treatment received, final outcomes, and complications were recorded and statistically analyzed. The mean age at the time of the first fracture was 10 years. Sixty-six percent of patients had spastic quadriplegia, of whom 83% were nonambulatory. Eighty-two percent of fractures occurred in the lower limbs. Forty-eight percent were delayed in diagnosis with no cause determined. Children treated after 1992 had higher incidence of multiple fractures, lower incidence contractures, and a younger age at first fracture. This group showed a statistically significant difference for anticonvulsant therapy (P=0.001), CP pattern (P=0.005), ambulatory status (P=0.001), and osteopenia (P=0.001) when compared with the group of CP patients without fractures. Eighty percent of fractures were treated with a soft bulky dressing. Complications occurred in 17% of patients. The greatest risk factor for fracture is the nonambulatory CP child on anticonvulsant therapy. These risk factors seem to have increased, resulting in a higher prevalence of low energy fractures. Future research must focus on the underlying mechanisms and prevention of this condition.

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Management of hip dislocation with postural management.

date: 03/01/2002
author: Pountney T, Mandy A, Green E, Gard P.
publication: Child Care Health Dev. 2002 Mar;28(2):179-85.
pubmed_ID: 11952654

BACKGROUND: Hip dislocation in children with cerebral palsy has a well-documented history and morbidity. OBJECTIVE: This paper presents a retrospective study of children with bilateral cerebral palsy who had various postural management and its effect on hip deformity. The most widely accepted theoretical model of hip subluxation/dislocation is that an imbalance in muscle length and strength around the hip leads to acetabular dysplasia and consequent hip subluxation. Maintenance of muscle length and strength and loadbearing is therefore a logical prevention. Research on normal infants’ postures has provided biomechanical data to form the theoretical basis of 24 h postural management equipment. METHODS: The notes and X-rays of 59 children with bilateral cerebral palsy from East and West Sussex and Oxfordshire were examined and measured to determine whether a relationship existed between postural management and the level of hip subluxation/dislocation. X-rays were measured using Reimers’ hip migration percentage. Postural management support was divided into three groups for analysis. Category 1: use of a 24-h postural management approach using Chailey Adjustable Postural Support (CAPS) systems in lying, sitting and standing; category 2: two items of CAPS (either lying/sitting or sitting/standing supports); category 3: use of the CAPS seat only and/or any other postural supports. Hip status was recorded for analysis as both hips safe (under 33% migrated), or one/both hips subluxed. RESULTS: Children using ‘All CAPS’ before hip subluxation maintained significantly more hip integrity than other groups (chi2 P < 0.05). CONCLUSIONS: Postural management interventions have an important role in the prevention of hip dysplasia.

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Monitoring standing wheelchair use after spinal cord injury: a case report.

date: 02/04/2005
author: Shields RK, Dudley-Javoroski S.
publication: Disabil Rehabil. 2005 Feb 4;27(3):142-6.
pubmed_ID: 15823996

PURPOSE: An important issue in spinal cord injury (SCI) research is whether standing can yield positive health benefits. However, quantifying dose of standing and establishing subject compliance with a standing protocol is difficult. This case report describes a method to monitor dose of standing outside the laboratory, describes the standing patterns of one subject, and describes this subject’s satisfaction with the standing protocol. METHOD: A man with T-10 complete paraplegia agreed to have his commercially available standing wheelchair instrumented with a custom-designed logging device for a 2-year period. The micro-controller-based logger, under custom software control, was mounted to the standing wheelchair. The logger recorded date, duration, angle of standing, and start/stop times. RESULTS: The client exceeded a suggested minimum dosage of standing per month (130.4% of goal), choosing to stand for short bouts (mean = 11.57 min) at an average angle of 61 degrees, on an average 3.86 days per calendar week. He was generally very satisfied with the standing device and provided subjective reports of improved spasticity and bowel motility. CONCLUSION: This case report describes a standing and surveillance system that allow quantification of standing dose. Future controlled studies are needed to evaluate whether standing can be beneficially affect secondary complications after SCI.

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Osteomalacia associated with anticonvulsant drug therapy in mentally retarded children.

date: 08/01/1975
author: Tolman KG, Jubiz W, Sannella JJ, Madsen JA, Belsey RE, Goldsmith RS, Freston JW.
publication: Pediatrics. 1975 Jul;56(1):45-50.
pubmed_ID: 1161362

A survey of 289 severely retarded inpatients at a school for retarded children in American Fork; Utah revealed 67 patients with osteomalacia as defined by hypocalcemia, hypophosphatemia, elevated serum alkaline phosphatase levels, and appropriate bone changes. Investigation of the variables which might influence bone mineralization revealed no differences in age, sex, physical activity, sunshine exposure, or dietary intake of vitamin D between the osteomalacia and nonosteomalacia groups. However, all of the patients with osteomalacia were receiving anticonvulsant medications, either phenobarbital, diphenylhydantoin, or both. Duration of anticonvulsant therapy was the most important contributing factor to the development of osteomalacia. Seventy-five percent of patients who had received anticonvulsants for more than ten years had osteomalacia. The single most costly medical problem at the school is the treatment of pathologic bone fractures due to demineralized bone.

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Complications of osteotomies in severe cerebral palsy.

date: 03/01/1999
author: Stasikelis PJ, Lee DD, Sullivan CM.
publication: J Pediatr Orthop. 1999 Mar-Apr;19(2):207-10.
pubmed_ID: 10088690

Seventy-nine consecutive children with cerebral palsy who underwent osteotomies about the hip for subluxation or dislocation were studied retrospectively to determine risk factors that would correlate with postoperative complications of death, fracture, or decubitus ulcer. Except for the three patients who died, all of the children had > or = 1 year of follow-up. Twenty (25%) patients had at least one complication. Three children died; one at 1 week, one at 2 weeks, and one at 5 months after surgery. Sixteen patients sustained 25 fractures. All were managed with cast or splint immobilization in the clinic. Five patients developed decubitus ulcers requiring > or = 2 weeks of local care, but none required skin grafts or flaps. Complications occurred in 13 (68%) of 19 children with gastrostomies or tracheostomies but in only seven (12%) of the remaining 60 children. Only one (8%) of 13 ambulatory patients had a complication compared with 19 (29%) of 66 nonambulatory patients. In conclusion, ambulatory function correlates well with the risk of complications after osteotomies. A nonambulatory patient with a gastrostomy or tracheostomy is at even greater risk. Fortunately the fractures and ulcers observed in this series healed uneventfully with no operative intervention.

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Effect of weight-bearing activities on bone mineral density in spinal cord injured patients during the period of the first two years.

date: 11/01/2008
author: Alekna V, Tamulaitiene M, Sinevicius T, Juocevicius A.
publication: Spinal Cord. 2008 Nov;46(11):727-32. Epub 2008 Apr 29.
pubmed_ID: 18443599

STUDY DESIGN: Prospective study on patients with spinal cord injuries. OBJECTIVES: To evaluate the loss of bone mineral density (BMD) in various body regions of patients with spinal cord injury (SCI) and its dependence on weight bearing activities during 2 years post injury. METHODS: BMD of the whole body was measured in patients with SCI. Baseline measurement was performed in 6-16 weeks after SCI, the second and the third-respectively 12 and 24 months after injury. Fifty-four subjects were selected and divided into two groups: standing and non-standing. From these groups 27 pairs were made according to gender, age and height. RESULTS: There was found to be a well-marked decrease in BMD values for lower extremities, but there was no significant difference between paraplegic and tetraplegic patients 1 and 2 year after injury. Leg BMD reduced by 19.62% (95% CI, 17-22%) in the standing group and by 24% (95% CI, 21-27%) in non-standing group during the first year. Two years after SCI patients in standing group had significantly higher leg BMD-1.018 g/cm(2) (95% CI, 0.971-1.055 g/cm(2)) than in the non-standing group-0.91 g/cm(2) (95% CI, 0.872-0.958 g/cm(2)) (P<or=0.0001). CONCLUSION: SCI patients who performed daily standing >or=1 h and not less than 5 days per week, had significantly higher BMD in the lower extremities after 2 years in comparison to those patients who did not perform standing.

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Measurement of growth in children with developmental disabilities.

date: 09/01/1996
author: Stevenson RD.
publication: Dev Med Child Neurol. 1996 Sep;38(9):855-60.
pubmed_ID: 8810718

The clinical assessment of growth is a challenging, but essential, aspect of managing the health care of children with developmental disabilities. However, with standard equipment, modest training and some patience, almost all children can be measured reliably. Once reliable measurements are obtained, the interpretation or ‘clinical meaning’ of the measurements depends on their comparison with reference data from normal populations or, when available, with condition-specific reference data. More research is needed to improve our understanding of the clinical meaning of obtained measurements. The range of normal growth for some children with disabilities, particularly CP, remains to be defined. Research in the next ten years will, hopefully, lead to the development of growth charts for children with CP, and perhaps children with other conditions, which will facilitate the clinical interpretation of growth data and lead to improved management of health care for children with developmental disabilities.

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The pieces fall into place: the views of three Swedish habilitation teams on conductive education and support of disabled children.

date: 03/01/2003
author: Lind L.
publication: Int J Rehabil Res. 2003 Mar;26(1):11-20.
pubmed_ID: 12601263
Outside_URL: http://www.ncbi.nlm.nih.gov/pubmed/12601263
A survey concerning how Swedish habilitation staff view the support of disabled children and their families was conducted in 2001. It focused on what support the staff knew about, offered and considered good for the children and parents, and on how they viewed conductive education. Interviews were conducted with 25 team members in three habilitation teams in the south of Sweden. The results show that the support habilitation staff most feel children need is the opportunity to investigate their surroundings, play with other children, meet other children in the same situation and try out different activities. The support that parents are felt to need is mainly aid and housing adaptation, relief, financial help, information, medical knowledge, emotional support and to meet others in the same situation. The staff gave information pertaining to different methods of treatment only if the parents specifically asked for it. What the habilitation teams recommended were contracture prophylaxis, motor skills exercises, riding, swimming, splints, standing shells, surgery, injections and medicines. The habilitation staff were of the opinion that conductive education is focused purely on intensive mobility training.

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Prevention of severe contractures might replace multilevel surgery in cerebral palsy: results of a population-based health care programme and new techniques to reduce spasticity.

date: 07/01/2005
author: Hägglund G, Andersson S, Düppe H, Lauge-Pedersen H, Nordmark E, Westbom L
publication: J Pediatr Orthop B. 2005 Jul;14(4):269-73.
pubmed_ID: 15931031

During the 1990s three new techniques to reduce spasticity and dystonia in children with cerebral palsy (CP) were introduced in southern Sweden: selective dorsal rhizotomy, continuous intrathecal baclofen infusion and botulinum toxin treatment. In 1994 a CP register and a health care programme, aimed to prevent hip dislocation and severe contractures, were initiated in the area. The total population of children with CP born 1990-1991, 1992-1993 and 1994-1995 was evaluated and compared at 8 years of age. In non-ambulant children the passive range of motion in hip, knee and ankle improved significantly from the first to the later age groups. Ambulant children had similar range of motion in the three age groups, with almost no severe contractures. The proportion of children treated with orthopaedic surgery for contracture or skeletal torsion deformity decreased from 40 to 15% (P = 0.0019). One-fifth of the children with spastic diplegia had been treated with selective dorsal rhizotomy. One-third of the children born 1994-1995 had been treated with botulinum toxin before 8 years of age. With early treatment of spasticity, early non-operative treatment of contracture and prevention of hip dislocation, the need for orthopaedic surgery for contracture or torsion deformity is reduced, and the need for multilevel procedures seems to be eliminated.

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Randomised trial of the effects of four weeks of daily stretch on extensibility of hamstring muscles in people with spinal cord injuries.

date: 01/01/2003
author: Harvey LA, Byak AJ, Ostrovskaya M, Glinsky J, Katte L, Herbert RD.
publication: Aust J Physiother. 2003;49(3):176-81.
pubmed_ID: 12952517

The aim of this assessor-blind randomised controlled trial was to determine the effect of four weeks of 30 minute stretches each weekday on extensibility of the hamstring muscles in people with recent spinal cord injuries. A consecutive sample of 16 spinal cord-injured patients with no or minimal voluntary motor power in the lower limbs and insufficient hamstring muscle extensibility to enable optimal long sitting were recruited. Subjects’ legs were randomly allocated to experimental and control conditions. The hamstring muscles of the experimental leg of each subject were stretched with a 30 Nm torque at the hip for 30 minutes each weekday for four weeks. The hamstring muscles of the contralateral leg were not stretched during this period. Extensibility of the hamstring muscles (hip flexion range of motion with knee extended, measured with a 48 Nm torque at the hip) of both legs was measured by a blinded assessor at the commencement of the study and one day after the completion of the four-week stretch period. Changes in hamstring muscle extensibility from initial to final measurements were calculated. The effect of stretching was expressed as the mean difference in these changes between stretched and non-stretched legs. The mean effect of stretching was 1 degree (95% CI -2 to 5 degrees). Four weeks of 30 minute stretches each weekday does not affect the extensibility of the hamstring muscle in people with spinal cord injuries.