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The aim of the present study was to examine the effects of balance training with visual feedback on stance and gait in school-age children with hemiplegic cerebral palsy. Ten participants between 5 and 11 years of age were assigned to either the training or the control group according to an aged-stratified randomization. The training corresponded to three sessions per week during six weeks. Stance and gait parameters, based on force plate data, were assessed three times in both groups: (a) at the beginning of the study (before training); (b) after six weeks; (c) after ten weeks. Spatial and temporal parameters were calculated. The results for stance showed that the training improved the performances on the tasks that were trained. More interesting, the results for gait showed that the walking pattern became more symmetrical after the training. [ABSTRACT FROM AUTHOR]

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Purpose state: Orthotic wearing time may be an important confounder in efficacy studies of treatment in children with spastic cerebral palsy (SCP). Most studies measure parent-reported wearing time (WTparent) with questionnaires, but it is questionable whether this yields valid results. This study aims to compare WTparent with objectively measured wearing time (WTobj) in children with SCP receiving orthotic treatment. Method: Eight children with SCP participated in this observational study. For one year, they received knee-ankle-foot orthosis (KAFO) treatment. WTparent was measured using questionnaires. WTobj was measured using temperature sensor-data-loggers that were attached to the KAFOs. The 2.5th and 97.5th percentiles and median of differences between methods (per participant) were used to calculate limits of agreement and systematic differences. Results: There was no systematic difference between WTparent and WTobj (0.1 h per week), but high inter-individual variation of the difference was found, as reflected by large limits of agreement (lower limit/2.5th percentile: −1.7 h/week; upper limit/97.5th percentile: 11.1 h/week). Conclusions: Parent-reported wearing time (WTparent) of a KAFO differs largely from objectively measured wearing time (WTobj) using temperature sensors. Therefore, parent-reported wearing time (WTparent) of KAFOs should be interpreted with utmost care. Low wearing time of orthoses may be a cause of inefficacy of orthotic treatment and incorrect reported wearing time may bias results of efficacy studies. Results of this study show that parent-reported wearing time is not in agreement with objectively measured wearing time. Parent-reported wearing time of KAFOs should be interpreted with utmost care. Objective methods are recommended for measuring orthotic wearing time. [ABSTRACT FROM AUTHOR]

Purpose: To determine the relationship between isometric leg muscle strength and mobility capacity in children with cerebral palsy (CP) compared to typically developing (TD) peers.Method: Participants were 62 children with CP (6–13 years), able to walk with (n = 10) or without (n = 52) walking aids, and 47 TD children. Isometric muscle strength of five muscle groups of the leg was measured using hand-held dynamometry. Mobility capacity was assessed with the 1-min walk, the 10-m walk, sit-to-stand, lateral-step-up and timed-stair tests.Results: Isometric strength of children with CP was reduced to 36–82% of TD. When adjusted for age and height, the percentage of variance in mobility capacity that was explained by isometric strength of the leg muscles was 21–24% (walking speed), 25% (sit-to-stand), 28% (lateral-step-up) and 35% (timed-stair) in children with CP. Hip abductors and knee flexors had the largest contribution to the explained variance, while knee extensors showed the weakest correlation. Weak or no associations were found between strength and mobility capacity in TD children.Conclusion: Isometric strength, especially hip abductor and knee flexor strength, is moderately related to mobility capacity in children with CP, but not in TD children. To what extent training of these muscle groups will lead to better mobility capacity needs further study.Implications for RehabilitationStrength training in children with cerebral palsy (CP) may be targeted more specifically at hip abductors and knee flexors.The moderate associations imply that large improvements in mobility capacity may not be expected when strength increases. [ABSTRACT FROM PUBLISHER]

Aim: To validate a detailed intramuscular needle placement protocol using passive muscle stretching and relaxing for botulinum neurotoxin type A (BoNT-A) treatment in the lower extremity of children with spastic cerebral palsy (CP), with verification by electrical stimulation.Method: A prospective observational study was performed in 75 children with spastic CP who received regular BoNT-A treatment under general anaesthesia (52 males, 23 females; mean age 8y 9mo, SD 3y 7mo, range 4-18y; mean body mass index 16.2, SD 3.7, range 7.7-26.7). A total of 1084 intramuscular needle placements using passive muscle stretching and relaxing were verified by electrical stimulation. Primary outcome was the positive predictive value.Results: Intramuscular needle placement in the muscles adductor brevis, adductor longus, gracilis, semimembranosus, semitendinosus, biceps femoris, rectus femoris, and lateral and medial heads of the gastrocnemius and soleus had a positive predictive value ranging from 85.7% to 100% (95% confidence interval ranging from 71.5-89.9% to 91.4-100%).Interpretation: This validated detailed protocol for intramuscular needle placement using passive muscle stretching and relaxing for BoNT-A treatment in the lower extremity of children with spastic CP is reliable and has a high positive predictive value. [ABSTRACT FROM AUTHOR]

Introduction: Rigid Ankle-Foot Orthoses (AFOs) are commonly prescribed to counteract excessive knee flexion during the stance phase of gait in children with cerebral palsy (CP). While rigid AFOs may normalize knee kinematics and kinetics effectively, it has the disadvantage of impeding push-off power. A spring-like AFO may enhance push-off power, which may come at the cost of reducing the knee flexion less effectively. Optimizing this trade-off between enhancing push-off power and normalizing knee flexion in stance is expected to maximize gait efficiency. This study investigated the effects of varying AFO stiffness on gait biomechanics and efficiency in children with CP who walk with excessive knee flexion in stance. Fifteen children with spastic CP (11 boys, 10±2 years) were prescribed with a ventral shell spring-hinged AFO (vAFO). The hinge was set into a rigid, or spring-like setting, using both a stiff and flexible performance. At baseline (i.e. shoes-only) and for each vAFO, a 3D-gait analysis and 6-minute walk test with breath-gas analysis were performed at comfortable speed. Lower limb joint kinematics and kinetics were calculated. From the 6-minute walk test, walking speed and the net energy cost were determined. A generalized estimation equation (p<0.05) was used to analyze the effects of different conditions. Compared to shoes-only, all vAFOs improved the knee angle and net moment similarly. Ankle power generation and work were preserved only by the spring-like vAFOs. All vAFOs decreased the net energy cost compared to shoes-only, but no differences were found between vAFOs, showing that the effects of spring-like vAFOs to promote push-off power did not lead to greater reductions in walking energy cost. These findings suggest that, in this specific group of children with spastic CP, the vAFO stiffness that maximizes gait efficiency is primarily determined by its effect on knee kinematics and kinetics rather than by its effect on push-off power. Trial Registration: Dutch Trial Register [ABSTRACT FROM AUTHOR]

Aim To assess spoken language comprehension in non-speaking children with severe cerebral palsy ( CP) and to explore possible associations with motor type and disability. Method Eighty-seven non-speaking children (44 males, 43 females, mean age 6y 8mo, SD 2y 1mo) with spastic (54%) or dyskinetic (46%) CP (Gross Motor Function Classification System [ GMFCS] levels IV [39%] and V [61%]) underwent spoken language comprehension assessment with the computer-based instrument for low motor language testing (C-Bi LLT), a new and validated diagnostic instrument. A multiple linear regression model was used to investigate which variables explained the variation in C-Bi LLT scores. Associations between spoken language comprehension abilities (expressed in z-score or age-equivalent score) and motor type of CP, GMFCS and Manual Ability Classification System ( MACS) levels, gestational age, and epilepsy were analysed with Fisher's exact test. A p-value <0.05 was considered statistically significant. Results Chronological age, motor type, and GMFCS classification explained 33% ( R=0.577, R2=0.33) of the variance in spoken language comprehension. Of the children aged younger than 6 years 6 months, 52.4% of the children with dyskinetic CP attained comprehension scores within the average range ( z-score ≥−1.6) as opposed to none of the children with spastic CP. Of the children aged older than 6 years 6 months, 32% of the children with dyskinetic CP reached the highest achievable age-equivalent score compared to 4% of the children with spastic CP. No significant difference in disability was found between CP-related variables ( MACS levels, gestational age, epilepsy), with the exception of GMFCS which showed a significant difference in children aged younger than 6 years 6 months ( p=0.043). Interpretation Despite communication disabilities in children with severe CP, particularly in dyskinetic CP, spoken language comprehension may show no or only moderate delay. These findings emphasize the importance of introducing alternative and/or augmentative communication devices from early childhood. [ABSTRACT FROM AUTHOR]

Abstract: Question: In children with cerebral palsy, does a 6-month physical activity stimulation program improve physical activity, mobility capacity, fitness, fatigue and attitude towards sports more than usual paediatric physiotherapy? Design: Multicentre randomised controlled trial with concealed allocation, blinded assessments and intention-to-treat analysis. Participants: Forty-nine walking children (28 males) aged 7–13 years with spastic cerebral palsy and severity of the disability classified as Gross Motor Function Classification System level I–III. Intervention: The intervention group followed a 6-month physical activity stimulation program involving counselling through motivational interviewing, home-based physiotherapy, and 4 months of fitness training. The control group continued their usual paediatric physiotherapy. Outcome measures: Primary outcomes were walking activity (assessed objectively with an activity monitor) and parent-reported physical activity (Activity Questionnaire for Adults and Adolescents). Secondary outcomes were: mobility capacity, consisting of Gross Motor Function Measure-66 (GMFM-66), walking capacity and functional strength, fitness (aerobic and anaerobic capacity, muscle strength), self-reported fatigue, and attitude towards sport (child and parent). Assessments were performed at baseline, 4 months, 6 months and 12 months. Results: There were no significant intervention effects for physical activity or secondary outcomes at any assessment time. Positive trends were found for parent-reported time at moderate-to-vigorous intensity (between-group change ratio=2.2, 95% CI 1.1 to 4.4) and GMFM-66 (mean between-group difference=2.8 points, 95% CI 0.2 to 5.4) at 6 months, but not at 12 months. There was a trend for a small, but clinically irrelevant, improvement in the children's attitudes towards the disadvantages of sports at 6 months, and towards the advantages of sports at 12 months. Conclusions: This physical activity stimulation program, that combined fitness training, counselling and home-based therapy, was not effective in children with cerebral palsy. Further research should examine the potential of each component of the intervention for improving physical activity in this population. Trial registration: NTR2099. [Van Wely L, Balemans ACJ, Becher JG, Dallmeijer AJ (2014) Physical activity stimulation program for children with cerebral palsy did not improve physical activity: a randomised trial. Journal of Physiotherapy 60: 40–49] [Copyright &y& Elsevier]

Background: Ankle-Foot-Orthoses with a ventral shell, also known as Floor Reaction Orthoses (FROs), are often used to reduce gait-related problems in children with spastic cerebral palsy (SCP), walking with excessive knee flexion. However, current evidence for the effectiveness (e.g. in terms of walking energy cost) of FROs is both limited and inconclusive. Much of this ambiguity may be due to a mismatch between the FRO ankle stiffness and the patient's gait deviations. The primary aim of this study is to evaluate the effect of FROs optimised for ankle stiffness on the walking energy cost in children with SCP, compared to walking with shoes alone. In addition, effects on various secondary outcome measures will be evaluated in order to identify possible working mechanisms and potential predictors of FRO treatment success. Method/Design: A pre-post experimental study design will include 32 children with SCP, walking with excessive knee flexion in midstance, recruited from our university hospital and affiliated rehabilitation centres. All participants will receive a newly designed FRO, allowing ankle stiffness to be varied into three configurations by means of a hinge. Gait biomechanics will be assessed for each FRO configuration. The FRO that results in the greatest reduction in knee flexion during the single stance phase will be selected as the subject's optimal FRO. Subsequently, the effects of wearing this optimal FRO will be evaluated after 12-20 weeks. The primary study parameter will be walking energy cost, with the most important secondary outcomes being intensity of participation, daily activity, walking speed and gait biomechanics. Discussion: The AFO-CP trial will be the first experimental study to evaluate the effect of individually optimised FROs on mobility and participation. The evaluation will include outcome measures at all levels of the International Classification of Functioning, Disability and Health, providing a unique set of data with which to assess relationships between outcome measures. This will give insights into working mechanisms of FROs and will help to identify predictors of treatment success, both of which will contribute to improving FRO treatment in SCP in term. [ABSTRACT FROM AUTHOR]

Background In spastic cerebral palsy (SCP), a limited range of motion of the foot (ROM), limits gait and other activities. Assessment of this limitation of ROM and knowledge of active mechanisms is of crucial importance for clinical treatment. Methods For a comparison between spastic cerebral palsy (SCP) children and typically developing children (TD), medial gastrocnemius muscle-tendon complex length was assessed using 3-D ultrasound imaging techniques, while exerting externally standardized moments via a handheld dynamometer. Exemplary X-ray imaging of ankle and foot was used to confirm possible TD-SCP differences in foot deformation. Results SCP and TD did not differ in normalized level of excitation (EMG) of muscles studied. For given moments exerted in SCP, foot plate angles were all more towards plantar flexion than in TD. However, foot plate angle proved to be an invalid estimator of talocrural joint angle, since at equal foot plate angles, GM muscle-tendon complex was shorter in SCP (corresponding to an equivalent of 1 cm). A substantial difference remained even after normalizing for individual differences in tibia length. X-ray imaging of ankle and foot of one SCP child and two typically developed adults, confirmed that in SCP that of total footplate angle changes (0-4 Nm: 15°), the contribution of foot deformation to changes in foot plate angle (8) were as big as the contribution of dorsal flexion at the talocrural joint (7°). In typically developed individuals there were relatively smaller contributions (10 -11%) by foot deformation to changes in foot plate angle, indicating that the contribution of talocrural angle changes was most important. Using a new estimate for position at the talocrural joint (the difference between GM muscle– tendon complex length and tibia length, GM relative length) removed this effect, thus allowing more fair comparison of SCP and TD data. On the basis of analysis of foot plate angle and GM relative length as a function externally applied moments, it is concluded that foot plate angle measurements underestimate angular changes at the talocrural joint when moving in dorsal flexion direction and overestimates them when moving in plantar flexion direction, with concomitant effects on triceps surae lengths. Conclusions In SCP children diagnosed with decreased dorsal ROM of the ankle joint, the commonly used measure (i.e. range of foot plate angle), is not a good estimate of rotation at the talocrural joint. since a sizable part of the movement of the foot (or foot plate) derives from internal deformation of the foot. [ABSTRACT FROM AUTHOR]

Aim To assess ambulatory activity of children with cerebral palsy (CP), aged 7 to 13 years, and identify associated characteristics. Method Sixty-two children with spastic CP (39 males, 23 females; mean age 10y 1mo, SD 1y 8mo; age range 7-13y), classified as Gross Motor Function Classification System (GMFCS) levels I to III, participated. Ambulatory activity was measured during 1 week with a StepWatch activity monitor as steps per day, and time spent at medium and high step rates. Multiple linear regression analyses were performed following a backward selection procedure until only independent variables with p<0.05 remained in the model. Ambulatory activity outcome parameters served as dependent variables, and disease, personal, and environmental characteristics as independent variables. Ambulatory activity was corrected for body height. Results Children took more steps during school days (5169 steps, SD 1641) than during weekend days (4158 steps, SD 2048; p<0.001). Higher GMFCS level, bilateral CP, and higher age were associated with lower ambulatory activity on school days ( R2 ranged from 43-53%), whereas bilateral CP, higher age, and no sport club participation were associated with lower ambulatory activity in the weekend ( R2 ranged from 21-42%). Correcting for body height decreased the association with age. Interpretation Interventions should focus at increasing physical activity at the weekend for children with bilateral spastic CP. [ABSTRACT FROM AUTHOR]

Abstract: Selective motor control (SMC) is an important determinant of functioning in cerebral palsy (CP). Currently its assessment is based on subjective clinical tests with a low sensitivity. Electromyography (EMG) profiles during gait represent muscle coordination and might be used to assess SMC. EMG measurements during gait were processed into a measure of extensor synergy and thigh synergy. This was obtained in two groups of children with CP, and 30 typically developing children. Extensor synergy in CP was higher (0.95) than in healthy children (0.77), thigh synergy was almost equal in both groups. GMFM scores in the first group of 39 children with CP did not correlate to EMG based synergy measures. In a second group of 38 children with CP, a clear relation of clinical SMC score with extensor synergy was found, but only a weak relation with thigh synergy. Although an extensor synergy was validated at group level, our results present no convincing evidence for the use of EMG during gait to assess SMC in individual subjects with CP. Since gait involves both synergistic and selective contractions, the inherent motor control properties of this task will not allow for an assessment of selectivity comparable to the ability to perform isolated movements. Nevertheless, our results support the sensitive nature of EMG to represent an aberrant motor control in CP. [Copyright &y& Elsevier]

Abstract: The objective of the study was to evaluate the effectiveness of functional progressive resistance exercise (PRE) training on walking ability in children with cerebral palsy (CP). Fifty-one ambulant children with spastic CP (mean age 10 years 5 months, 29 boys) were randomized to an intervention (n =26) or control group (n =25, receiving usual care). The intervention consisted of 12 weeks functional PRE circuit training, for 3 times a week. Main outcome measures were walking ability and participation. Secondary outcomes were muscle strength and anaerobic muscle power. Possible adverse outcomes were spasticity and passive range of motion (ROM). Muscle strength increased significantly in the training group compared to the control group, but walking ability, participation and anaerobic muscle power did not change. Spasticity and ROM remained unchanged, except for a significant decrease in rectus femoris length in the intervention group. It is concluded that twelve weeks of functional PRE-training does not improve walking ability, despite improved muscle strength. [Copyright &y& Elsevier]

Abstract: Aim: Treatment options for dystonic cerebral palsy (CP) are limited. Our aims were to determine whether intrathecal baclofen (ITB) improves daily care, decreases dystonia and decreases pain in patients with dystonic CP. Methods: Patients received randomized blinded treatment with ITB or placebo. Scores on problems of daily care were recorded and dystonia, pain and comfort were assessed. Results: Four patients (three males, average age 12 years 6 months) were included (all Gross Motor Function Classification System level V). During the trial period problem scores and dystonia scores decreased in all four patients. Conclusion: In this pilot study we report positive functional effects of ITB trial treatment in four patients with dystonic CP. A randomized trial with a larger cohort is needed to verify these results. [Copyright &y& Elsevier]

To assess the long-term outcome and adverse events of selective dorsal rhizotomy (SDR) in children with spastic cerebral palsy (CP). Studies were selected based on the following inclusion criteria: children with CP that underwent SDR with a follow-up period of at least 5 years. The following databases were searched: MEDLINE, Web of Science, Embase, PEDro, and the Cochrane library. Studies meeting the inclusion criteria were scored by two reviewers, who graded the level of evidence and the quality/conduct of the studies. Outcomes were classified according to the International Classification of Functioning, Disability and Health (ICF). Only three of the 21 studies who met the inclusion criteria allowed a tentative conclusion on outcome. There is moderate evidence that SDR has a positive long-term influence on the ICF body structure and body function domains but there is no evidence that SDR has an influence on the ICF activity and participation domains. Spinal abnormalities seem to be common, but no conclusion can be drawn about their relation to SDR. There is lack of evidence concerning the long-term outcomes after SDR. Future studies need to clarify the long-term influence of SDR - especially in the ICF domains of activity and participation. [ABSTRACT FROM AUTHOR]

To identify the use and utility of language comprehension tests for unintelligible or non-speaking children with severe cerebral palsy (CP). Severe CP was defined as severe dysarthria (unintelligible speech) or anarthria (absence of speech) combined with severe limited mobility, corresponding to Gross Motor Function Classification System levels IV to V. An electronic search in the databases of PubMed, PsychInfo, Embase, and CINAHL was made of studies published between January 1965 and December 2008. Indexing terms and free-text terms for 'cerebral palsy', 'language', and 'instrumentation' were used. Studies were included when (1) the focus was to investigate comprehension of spoken language of children (0-18y) with severe CP, and (2) language tests were described. Twelve standardized tests and five experimental instruments were identified. All standardized tests were developed for children without limited mobility. Only the Peabody Picture Vocabulary Test - Revised was frequently used and feasible for older children with severe CP (>9y). The other tests were used occasionally. To establish utility, adaptations of standardized test procedures were necessary. Language comprehension tests for children with severe CP are scarce. A language comprehension test specifically designed for these children is warranted. [ABSTRACT FROM AUTHOR]

Aim To evaluate the effectiveness of functional progressive resistance exercise (PRE) strength training on muscle strength and mobility in children with cerebral palsy (CP). Method Fifty-one children with spastic uni- and bilateral CP; (29 males, 22 females; mean age 10y 5mo, SD 1y 10mo, range 6y 0mo–13y 10mo; Gross Motor Function Classification System levels I–III) were randomized to the intervention group ( n=26) or the control group ( n=25, receiving usual care). The intervention group trained for 12 weeks, three times a week, on a five-exercise circuit, which included a leg-press and functional exercises. The training load progressively increased based on the child’s maximum level of strength, determined by the eight-repetition maximum. Muscle strength (measured with hand-held dynamometry and a six-repetition maximum leg-press test), mobility (measured with the Gross Motor Function Measure, two functional tests, and a mobility questionnaire), and spasticity (measured by the appearance of a catch) were evaluated before, during, directly after, and 6 weeks after the end of training by two blinded research assistants. Results Directly after training, there was a statistically significant effect ( p<0.05) on muscle strength (knee extensors +12% [0.56N/kg; 95% confidence interval {CI} 0.13–0.99]; hip abductors +11% [0.27N/kg; 95% CI 0.00–0.54]; total +8% [1.30N/kg; 95% CI 0.56–2.54]; six-repetition maximum +14% [14%; 95% CI 1.99–26.35]), but not on mobility or spasticity. A detraining effect was seen after 6 weeks. Interpretation Twelve weeks of functional PRE strength training increases muscle strength up to 14%. This strength gain did not lead to improved mobility. [ABSTRACT FROM AUTHOR]

Aim The objective of this longitudinal study was to describe the course of social functioning and communication in children with cerebral palsy (CP) over a 3-year period, its difference with the normative course, and its relationship with disease characteristics and personal and environmental factors. Method Participants in this study were 110 children with CP (70 males, 40 females) with a mean age of 11 years and 3 months (SD 1y 8mo). Social functioning and communication were measured with the Vineland Adaptive Behavior Scales. Comparisons were made with normative data; data were analysed with generalized estimating equations. According to the Gross Motor Function Classification System (GMFCS), 50 of the 110 children were categorized as GMFCS level I, 16 as level II, 13 as level III, 13 as level IV, and 18 as level V. Results The course of social functioning over a 3-year period showed an increase in restrictions in children with CP ( p<0.001). Restrictions in communication increased more in children with the most severe forms of CP ( p<0.001). In addition to disease characteristics (GMFCS category, presence of epilepsy, and speech problems), personal factors (externalizing behaviour problems) and environmental factors (having no siblings, low parental level of education, and parental stress) were associated with greater restrictions in social functioning and communication. Interpretation The results indicate that it is important to focus not only on the medical treatment of children with CP, but also on their behavioural problems and social circumstances, and to support the parents so that social functioning and communication in these children may be improved. [ABSTRACT FROM AUTHOR]

Selective dorsal rhizotomy at the lumbar level is a neurosurgical procedure, which reduces spasticity in the legs. Its effect has mainly been studied in children with spastic cerebral palsy. Little is known about the outcome of selective dorsal rhizotomy in patients with neurodegenerative disorders. We report the clinical course after selective dorsal rhizotomy in 2 patients with progressive spasticity. Leg spasticity was effectively and persistently reduced in both patients, facilitating care and improving sitting comfort. However, spasticity of the arms and other motor disturbances, such as spontaneous extension spasms and the ataxia, increased gradually in time. Selective dorsal rhizotomy leads to a disappearance of leg spasticity in patients with a neurodegenerative disease. Other motor signs are not influenced and may increase due to the progressive nature of the underlying disease. [ABSTRACT FROM AUTHOR]

The objective of this study was to describe skeletal maturation in relation to chronological age in children with cerebral palsy (CP) aged 9 to 16 years, and to analyze the relationship between skeletal maturation and motor functioning. The skeletal age of 100 children with CP (37 females, 63 males; age 9, 11, or 13y; 73 ambulant, 27 non-ambulant) was determined over a period of 3 years based on X-rays of the hand (Greulich and Pyle technique). Motor functioning was measured with the Gross Motor Function Measure-66. The skeletal age of females with CP was significantly higher than their chronological age, but this did not apply to males. Longitudinal analysis showed no difference in the course of skeletal age in relation to chronological age over a 3-year period for sex or for level of ambulation. No association was found between changes in skeletal age and changes in gross motor function over the 3-year period. Skeletal age during (pre-)puberty in females with CP is advanced in relation to chronological age. No evidence was found that children with CP are at risk for deterioration in gross motor function as a result of skeletal maturation during puberty. [ABSTRACT FROM AUTHOR]

Objective: To measure the effect of botulinum toxin type A (BTX-A) treatment in children with cerebral palsy with regard to individual goals concerning functional abilities, using goal attainment scaling. Design: A single-blind randomized multiple baseline/treatment phase design across subjects. Setting: The paediatric department of a rehabilitation centre. Subjects: Eleven children with cerebral palsy participated. Intervention: BTX-A treatment of the lower extremity. Main measures: A six-point goal attainment scaling of three individual treatment goals at the level of functional abilities. Standardized video-tapes of each goal were recorded weekly for a period of 14 weeks. Rating on the predetermined goal attainment scaling was blinded. Results: Nine of the 11 subjects showed significant improvement in 18 out of 33 goals. Seven subjects showed clinically relevant improvement (at least 2 points on the goal attainment scaling) in 11 goals. Testing the difference between all medians of baseline measurements (after correction for improvement during baseline) and the medians of the treatment phase measurements for all goal attainment scaling scores (n = 33) resulted in significant improvement (p < 0.001). Tested at subject level (medians of the three goal attainment scaling scores per assessment, n = 11), a significant improvement was also found (p = 0.005). The change in goal attainment scaling score was related to the moment of treatment with BTX-A. Conclusion: Clinically relevant improvement in individual rehabilitation goals at ability level, achieved with the treatment of BTX-A in children with cerebral palsy, were demonstrated using the goal attainment scaling method. [ABSTRACT FROM AUTHOR]

Ankle-Foot Orthoses (AFOs) are commonly prescribed to promote gait in children with cerebral palsy (CP). The AFO prescription process is however largely dependent on clinical experience, resulting in confusing results regarding treatment efficacy. To maximize efficacy, the AFO's mechanical properties should be tuned to the patient's underlying impairments. This study aimed to investigate whether the efficacy of a ventral shell AFO (vAFO) to reduce knee flexion and walking energy cost could be improved by individually optimizing AFO stiffness in children with CP walking with excessive knee flexion. Secondarily, the effect of the optimized vAFO on daily walking activity was investigated. Fifteen children with spastic CP were prescribed with a hinged vAFO with adjustable stiffness. Effects of a rigid, stiff, and flexible setting on knee angle and the net energy cost (EC) [Jkg(-1)m(-1)] were assessed to individually select the optimal stiffness. After three months, net EC, daily walking activity [stridesmin(-1)] and knee angle [deg] while walking with the optimized vAFO were compared to walking with shoes-only. A near significant 9% (p=0.077) decrease in net EC (-0.5Jkg(-1)m(-1)) was found for walking with the optimized vAFO compared to shoes-only. Daily activity remained unchanged. Knee flexion in stance was reduced by 2.4° (p=0.006). These results show that children with CP who walk with excessive knee flexion show a small, but significant reduction of knee flexion in stance as a result of wearing individually optimized vAFOs. Data suggest that this also improves gait efficiency for which an individual approach to AFO prescription is emphasized. [ABSTRACT FROM AUTHOR]

Children diagnosed with cerebral palsy (CP) often show difficulties in arithmetic compared to their typically developing peers. The present study explores whether cognitive and motor variables are related to arithmetic performance of a large group of primary school children with CP. More specifically, the relative influence of non-verbal intelligence, working memory, word decoding capacities, gross- and fine motor skills on arithmetic performance is examined using structural equation modeling. One-hundred sixteen primary school children with a formal diagnosis of CP participated (76 males, M =7; 3 years, SD=3 months). In agreement with previous studies our results showed that the cognitive and motor predictors were all positively correlated to each other. Furthermore, in the cognitive model, non-verbal intelligence and word decoding were related to arithmetic in primary school. Our combined model (that included both motor and cognitive variables) showed that word decoding and fine motor skills were the strongest predictors of arithmetic performance. To conclude, this study was the first to show the influence of word decoding and fine motor skills on arithmetic performance of children with CP. [Copyright &y& Elsevier]

Abstract: Purpose: To determine the reproducibility and validity of video screen measurement (VSM) of sagittal plane joint angles during gait. Methods: 17 children with spastic cerebral palsy walked on a 10m walkway. Videos were recorded and 3d-instrumented gait analysis was performed. Two investigators measured six sagittal joint/segment angles (shank, ankle, knee, hip, pelvis, and trunk) using a custom-made software package. The intra- and interrater reproducibility were expressed by the intraclass correlation coefficient (ICC), standard error of measurements (SEM) and smallest detectable difference (SDD). The agreement between VSM and 3d joint angles was illustrated by Bland–Altman plots and limits of agreement (LoA). Results: Regarding the intrarater reproducibility of VSM, the ICC ranged from 0.99 (shank) to 0.58 (trunk), the SEM from 0.81° (shank) to 5.97° (trunk) and the SDD from 1.80° (shank) to 16.55° (trunk). Regarding the interrater reproducibility, the ICC ranged from 0.99 (shank) to 0.48 (trunk), the SEM from 0.70° (shank) to 6.78° (trunk) and the SDD from 1.95° (shank) to 18.8° (trunk). The LoA between VSM and 3d data ranged from 0.4±13.4° (knee extension stance) to 12.0±14.6° (ankle dorsiflexion swing). Conclusion: When performed by the same observer, VSM mostly allows the detection of relevant changes after an intervention. However, VSM angles differ from 3d-IGA and do not reflect the real sagittal joint position, probably due to the additional movements in the other planes. [Copyright &y& Elsevier]