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L Andrew Koman, Beth Paterson Smith, Jeffrey S Shilt Cerebral palsy, a range of non-progressive syndromes of posture and motor impairment, is a common cause of disability in childhood. The disorder results from various insults to different areas within the developing nervous system, which partly explains the variability of clinical findings. Management options include physiotherapy, occupational and speech therapy, orthotics, device-assisted modalities, pharmacological intervention, and orthopaedic and neurosurgical procedures. Since 1980, modification of spasticity by means of orally administered drugs, intramuscular chemodenervation agents (alcohol, phenol, botulinum toxin A), intrathecally administered drugs (baclofen), and surgery (neurectomy, rhizotomy) has become more frequent. Family-directed use of holistic approaches for their children with cerebral palsy includes the widespread adoption of complementary and alternative therapies; however, the prevalence of their use and the cost of these options are unknown. Traditional medical techniques (physiotherapy, bracing, and orthopaedic musculoskeletal surgery) remain the mainstay of treatment strategies at this time. This seminar addresses only the musculoskeletal issues associated with cerebral palsy and only indirectly discusses the cognitive, medical, and social issues associated with this diagnosis. Cerebral palsy is the term for a range of non-progressive syndromes of posture and motor impairment that results from an insult to the developing central nervous system (CNS). The characteristic signs are spasticity, movement disorders, muscle weakness, ataxia, and rigidity. Cerebral palsy is the most common cause of severe physical disability in childhood.1 The worldwide prevalence and incidence of the disorder are not clearly known. The overall reported prevalence in children aged 3–10 years is 2·4 per 1000 children, with variability in the reported rates in girls and boys.2,3 During the past 20 years, there have been increases in the incidence and prevalence of cerebral palsy that may be related to improved documentation of cases by national registries, advances in neonatal care, or other factors.4 Cerebral palsy has substantial effects on function and health-related quality of life of patients and their carers; an estimate of the cost of care of patients in the USA in 2002 was US$8·2 billion.5 This seminar aims to outline the epidemiology, pathophysiology, diagnosis, and management of the musculoskeletal manifestations of cerebral palsy. The cognitive, general medical, and societal issues and implications associated with the disorder are not addressed. quadriparesis secondary to rhesus incompatibility, once a common cause of cerebral palsy, is now very low.7 Improved care in neonatal intensive-care units and higher survival for very-low-birthweight infants increases the risk of cerebral palsy.8 Factors linked to the development of the disorder include multiple birth, chorioamnionitis, maternal infection, antepartum vaginal bleeding, second stage of labour lasting longer than 4 h, untreated hyperbilirubinaemia, fetal anoxic events, and fetal infection (especially meningitis or ventriculitis).8–11 The natural course of cerebral palsy has changed greatly during the past 50 years. If appropriate health care is available, affected children without significant comorbidities have actuarial survival approaching that of the general population.12 However, mortality is higher and lifespan shorter in children with severe quadriparesis, hydrocephalus, lack of basic functional skills, refractory seizures, and profound mental retardation.12,13 Associated disorders of CNS-mediated functions are associated with cerebral palsy.14 More than 50% of patients with the disorder can walk without arm assistance; 25% cannot walk, and 30% are mentally
Search strategy and selection criteria
The information in this paper is based primarily on peerreviewed medical publications from 1900 to 2003, relevant textbooks, and appropriate monographs. From 1968 to the present, the databases of the National Library of Medicine were reviewed for appropriate articles. The search term “cerebral palsy” in combination with “surgery,” “alcohol”, “phenol”, “botulinum toxin,” “rhizotomy”, “baclofen”, “diagnosis”, “physical therapy”, “scoliosis”, and “healthrelated quality of life” were used for the initial search. Articles published during the past 5 years were the target of the search. Several earlier, commonly referenced, key publications have been cited. Relevant references cited in the original source references were also reviewed. Several review articles and book chapters were included because they provided comprehensive overviews beyond the scope of this Seminar. Only papers published in English were reviewed. The reference list was modified during the peer-review process on the basis of reviewers’ comments.
Epidemiology and demographics
Cerebral palsy results from an injury in the developing CNS, which can occur in utero, during delivery, or during the first 2 years of life.6 The peripheral manifestations depend on the magnitude, extent, and location of the insult that causes the irreversible damage to the brain, brainstem, or spinal cord. The severity ranges from subtle motor impairment to involvement of the whole body. In more developed countries, the prevalence of athetoid
Lancet 2004; 363: 1619–31
Department of Orthopaedic Surgery, Wake Forest University School of Medicine, Winston-Salem, NC, USA (L A Koman MD, B P Smith PhD, J S Shilt MD) Correspondence to: Dr L Andrew Koman, Department of Orthopaedic Surgery, Wake Forest University School of Medicine, Medical Center Boulevard, Winston-Salem, NC 27157–1070, USA (e-mail: email@example.com)
THE LANCET • Vol 363 • May 15, 2004 • www.thelancet.com
For personal use. Only reproduce with permission from The Lancet.
Figure 1: Typical posture of a child with left hemiparesis The arm assumes a position of internal rotation of the shoulder.19 Hemiplegic patients experience abnormal stereognosis (97%).26. Ultimately.31 “Selective vulnerability” of the periventricular white matter occurs between 26 weeks and 34 weeks of gestation. Simultaneously.23 The elimination of spasticity allows many patients with cerebral palsy to use what selective motor control they possess more effectively and functionally. but the rate of improvement is slower in children with cerebral palsy than in unaffected children. sensory impairment of the arms (97%). ataxic. diplegia.22.34 Quadriplegia is associated with diffuse CNS insults. autonomic dysfunction. Fetal production of cytokines can damage neurons. variations in blood supply and unique metabolic requirements in some brain areas increase the sensitivity to hypoxia in the presence of bacterial or viral infection of the fetus. The leg shows hip adduction/flexion. . deep CNS hypoxia.18 and learning disabilities.16 Learning disabilities and activity limitations are associated with the degree of cerebral involvement17 and adversely affect school performance. especially in children and adults with quadriparesis and mental retardation.24 The motor skills of most children with cerebral palsy improve as they grow.35 anatomical distribution of the deformity or abnormality (hemiplegia. some areas of the brain are more susceptible to damage than others.23 Spasticity associated with cerebral palsy can lead to musculoskeletal complications such as contractures.21 Pathophysiology Cerebral palsy results from a permanent static lesion of the cerebral motor cortex that occurs before. mechanical spinal-cord or brainstem damage. monoplegia. pain.29. or rigidity. diminished two-point discrimination (90%).16 hydrocephalus (9%). and vascular endothelial cells and could contribute to intraventricular haemorrhage.23 Primary or secondary abnormalities within the spinal cord can increase spasticity. dystonia.com For personal use. the location of the irreversible insult. and produces abnormal muscle control and weakness. ankle equines. or within 2 years of birth. knee flexion. Diplegia is associated with periventricular leucomalacia. and the ability of the CNS to adapt or reorganise after the insult.28 Injury to upper motor neurons decreases cortical input to the reticulospinal and corticospinal tracts. mixed). and transient or irreversible ischaemia resulting in cell necrosis secondary to free-radical formation or hypoxia-related metabolic cellular death. cerebral cortex hypoxia. chorea.10.32 which has been defined as a velocity-dependent resistance of muscle to stretch33 or as excessive.20 Urinary incontinence is common (23·5%). and thumb-in-palm.25 Similarly. so fetal insults occurring during this period can produce periventricular leucomalacia with spastic diplegia. whereas movement disorders occur after hyperbilirubinaemia and basal-ganglia injury. and diminished proprioception (46%).4.25–31 A specific hypoxic event associated with immediate and irreversible cell death explains the aetiology of cerebral palsy in less than 50% of cases.24 The motor impairments result from various neurological deficits.11 Furthermore. the clinical manifestations of the neurological injuries depend on the extent and type of CNS damage.thelancet. Classifications of cerebral palsy are based on: deformity or abnormality (spastic. the unique metabolic demands of the basal ganglia in the fetus at 38–40 weeks create “selective” vulnerability that can result in dystonia or movement disorders. fetal production of cytokines. and subluxation. elbow flexion. hindfoot valgus. dyskinetic. Hemiplegia is most common in babies born at term and is associated with single hemisphere injury in most cases.17. wrist flexion. 2004 • www. For example. producing spasticity. Injury to extrapyramidal systems results in movement disorders such as athetosis.23 Even though the lesion itself does not change. impairment of visual perception (20–40%). the clinical manifestations of the lesion change as the child grows and develops. at. 1620 THE LANCET • Vol 363 • May 15. inappropriate involuntary muscle activity associated with upper-motor-neuron paralysis or syndrome.SEMINAR impaired. and peripheral nociception (pain) can also exacerbate it.10.11. the loss of descending inhibitory input through the reticulospinal tract and other systems increases the excitability of gamma and alpha neurons. Reproduced with permission from Wake Forest University Orthopaedic Press. and metatarsal varus with hallux valgus.23 CNS pathology associated with cerebral palsy includes: CNS haemorrhage. preoligodendrocytes.15 Neurological problems are common and include seizures (35%).25–28 or maternal infection or chorioamnionitis. forearm pronation. which in turn affects motor control. Only reproduce with permission from The Lancet. decreases the number of effective motor units.
and other specialised tests are used to assess the extent of the CNS insult. Canada) used ICD9 codes 343. the Canchild Centre for Childhood Disability in Ontario reported the numbers and proportions of patients based on the five levels in the gross motor functional classification system: level I. physical examination. Spinal deformities include scoliosis. motor power. and ancillary investigations.53 For children with cerebral palsy. and quadriplegia (involvement of all four limbs). Similarly.62 Three generic instruments suitable for patients with cerebral palsy are the child health questionnaire. Patterns of spasticity with resultant muscle imbalance across the joints over time can produce shortening of myotendinous units. carers can serve as proxies to provide such information about the child. Global function instruments include the paediatric evaluation of disability index. and presence of limb deformity. spinal alignment. sensibility. 2004 • www.61 For young children with cerebral palsy or those with severe involvement. or forefoot (metatarsus adductus) deformity.57. gait (if applicable). cortical. level IV. diplegia. and 402 (44%) quadriplegia. Pathological gait and static abnormalities include: toe walking (ankle equinus). In addition to a general physical inspection. hemiplegia (involvement of the ipsilateral arm and leg). 210 (23%) hemiplegia. and there can be spasticity.63 the paediatric musculoskeletal functional health questionnaire. and others are associated primarily with joint subluxation or dislocation or bony abnormalities. described for patients in Sweden. Currently. and thumb-in-palm. There are three instruments for assessment of arm function44–46 and three for assessment of leg performance. chorea—are common in cerebral palsy. concentrating on symptoms and dysfunction associated with the specific disorder. finger flexion. 112 (27·5%). Dynamic deformities and movement disorders can be accentuated during ambulation or other activities. level III. windblown pelvis (fixed adduction contracture in one hip associated with contralateral abduction contracture). knee flexion. hypotonia. the gross motor performance measure and the paediatric evaluation of disability index are deemed to be two of the best standard measures because they are complementary and test different features of function. CT. 82 (20·1%). 294 (33%) had diplegia. knee flexion.22 Chronological information about the prevalence and time trends of cerebral palsy has been most thoroughly THE LANCET • Vol 363 • May 15. is difficult to assess because specific diagnoses are not available. In the leg. wrist flexion. forearm pronation. type and extent of movement disorders. and bunion. pyramidal. and hemiplegia 21%. or disease specific.64 and the Peds QL 4. hindfoot valgus. . symptoms. flat foot (hindfoot valgus). MRI. and lordosis. Some deformities are typically related to imbalance of specific muscles. The term double hemiplegia implies bilateral involvement characterised by greater involvement of the arms than the legs. dystonia (eg. these modalities might be valuable for diagnosis and prognosis in the future.36 or location of CNS injury (periventricular. and Australia. Movement disorders—dystonia.65 Classifications Clinical patterns of involvement described in cerebral palsy include: diplegia (significant leg involvement with little effect on the arms). Cranial ultrasonography.0–343.61 Instruments are generic. USA. knee flexion.thelancet. and hemiplegia. and disability.56 and the Tardieu scale.55 the modified Ashworth scale.54 Spasticity and movement disorders Spasticity can be quantified or objectively analysed by the Ashworth spasticity scale. or a mixture of these disorders. Most cases of cerebral palsy included in large databases and national reporting registries are identified by the non-specific code 343. However. joint contracture. level II. intoeing or out-toeing.37–39 However. A study in France identified the distribution of clinical patterns as quadriplegia 40%. Health-related quality of life Measurement of health-related quality of life involves obtaining the patient’s view of his or her health status. 86 (21·1%). functional MRI and transcranial magnetic stimulation are used only for research purposes in children with cerebral palsy. level I indicates few limitations and level V severe impairments. kyphosis. hip flexion. impairment. several functional instruments and health-related quality-of-life measures have been developed or validated for assessment of patients with cerebral palsy. scissoring (hip adduction).SEMINAR quadriplegia).9 to classify 475 children. internal tibial torsion. elbow flexion.41 Function Functional capabilities can be assessed by use of global or function-specific instruments.9 from the International Classification of Diseases ninth revision (ICD9). Some practitioners use this term to suggest asymmetrical involvement or a clearly dominant side. psychological issues. The history should include a detailed account of gestation and perinatal events and documentation of the attainment of developmental milestones. Diagnosis Diagnosis of cerebral palsy requires a complete history. crouched gait (hip flexion. or extrapyramidal).4 The Central West Health Planning Information Network (Ontario. ankle equinus. Intoeing can result from femoral anteversion. social functioning.40 With a sample of 408 children. these features are not a prerequisite for its use. examining all parts of health. ankle equinus). Assessment tools and instruments During the past few years. athetosis. muscle tone (spasticity).42 and the functional independence measure in children43 (panel). Only reproduce with permission from The Lancet. The most common postures observed in the arm are shoulder internal rotation. quadriplegia.14 According to this classification system. the distribution of the most common clinical patterns.58 The Burke-Fahn-Marsden scale of dystonia59 and the Barry-Albright dystonia scale60 are used to rate the severity of movement disorders. Movement disorders can coexist with the clinical patterns of involvement. hip adduction. bony deformity.com 1621 For personal use. They reported that 45·7% of the patients were classified with the non-specific ICD9 code.47–49 Observational gait analysis is done with the physician rating scale50–52 or its modified version (the observational gait scale). ankle calcaneus). jump gait (hip flexion.0. the examination should assess station (pelvic and leg alignment during stance). however. Dynamic deformities and movement disorders are accentuated during ambulation or activity in many cases. the UK. Health-related quality of life includes measures of physical functioning. out-toeing can be secondary to femoral or tibial torsional deformity. In our assessment of 906 children in central and western North Carolina. and joint subluxation or dislocation. and toe flexion are the most common postures (figure 1). and level V. active and passive range of motion of joints. athetosis). 81 (19·9%). brainstem. diplegia 17%. rigidity is rare. 47 (11·5%). rigidity.
and surgery. oral pharmacological agents. and orthotics. device-assisted modalities. chemomodulation of spasticity. The severity and distribution of spasticity is crucial to identification of appropriate management options. or both might be necessary during rapid periods of growth to maintain the benefits of the surgical procedure.67 Management options The spasticity management technique used for children with cerebral palsy is determined primarily by the clinical findings.SEMINAR Functional instruments and health-related quality-of-life measures Global function Paediatric evaluation of disability inventory42 Functional independence measure for children43 Arm functional assessment tests/scales Assessment of quality of movement for unilateral upper-limb function (Melbourne)44 Quality of upper extremity skills45 House classification46 Leg functional assessment instruments Gross motor performance measure47 Gross motor functional measure48 Gross motor functional classification system49 Physician rating scale (lower extremity rating scale)50–53 Spasticity assessment instruments Ashworth scale55 Modified Ashworth scale56 Tardieu scale57. electrical stimulation). orthotics.67 develop. physiotherapy.66 The functional health status of patients with cerebral palsy has been assessed by the Health Utilities Index-Mark 3 instrument. and abnormal motor control. Mark 314. Furthermore. improve muscle strength. and derotation osteotomy procedures have in the best outcomes in children of 8 years old. patients’ daily activities can be facilitated by their use of adaptive devices (eg. Available treatment options include observation. dislocation. many respond to physiotherapy. so that contractures do not have the chance to Frequency of use (%) 2 4 6 8 10 12 14 16 18 Age of patient (years) Figure 2: Use of non-surgical treatments (physiotherapy and occupational therapy). 1622 THE LANCET • Vol 363 • May 15. physiotherapy. the use of intramuscular injections of botulinum toxin to manage focal spasticity might mean that lower doses of orally administered drugs to reduce spasticity are effective. 1999–2002 Reproduced with permission from Wake Forest University Orthopaedic Press.32 Most patients with mild involvement receive fewer types of treatments. provide support. therefore. As patients grow older.thelancet. the interventions should be adjusted on the basis of efficacy in achieving preintervention goals and the carers’ adherence to the prescribed therapeutic interventions. facilitate or strengthen weak muscles. physiotherapy. the frequency of fixed contractures. seating systems). In addition. 2004 • www.69 The best response to heelcord lengthening of the Achilles tendon is seen in patients older than 6 years. and the need for surgical intervention increases (figure 2). and those with severe involvement need more extensive interventions. and surgery for management of spasticity associated with cerebral palsy in North Carolina. casting. Spasticity management involves the use of a continuum of modalities throughout childhood. joint contractures. the caregiver questionnaire is the only diseasespecific instrument validated for use in patients with cerebral palsy.68 The use of a combination of physiotherapy and orthotics can increase the beneficial effects associated with intramuscular injections of botulinum toxin.32 most patients are managed with a combination of modalities. and orthotics in children of this age to modify the natural course of cerebral palsy.68 For example.58 Burke-Rahn-Marsden scale of dystonia59 Barry-Albright dystonia scale60 Health-related quality of life in cerebral palsy: generic instruments Child health questionnaire63 Paediatric musculoskeletal-functional health questionnaire64 Peds QL 4.32 Non-pharmacological treatment Non-pharmacological approaches include occupational therapy. chemodenervation. For example. parenteral medication. deviceassisted modalities (eg. muscle contracture. inhibit or weaken spastic agonist muscles. muscle stiffness.69 Treatments should be goal-oriented and produce positive outcomes. and speech therapy. Treatment of musculoskeletal abnormalities must address one or more of spasticity.69 Children younger than 3 or 4 years rarely develop fixed deformities. The treatment options that are used change with the age and developmental stage of the child. neuromuscular blocking agents. However. casting. torsional deformities.14 which describes health status and health-related quality of life. the consensus is that spasticity associated with cerebral palsy should be treated before children reach the age of 5 or 6 years. 2–6-year-old children show the best response to injections of botulinum toxin.32 For successful management. dynamic and static joint deformity. These treatments are used to maintain or improve joint range of motion. or deformity.70 For children who undergo osseous or soft-tissue procedures before skeletal maturity.com For personal use. Only reproduce with permission from The Lancet.32 100 90 80 70 60 50 40 30 20 10 0 0 Non-surgical Chemodenervation Surgery To date. or any combination of these methods. Skeletally mature children and adults can benefit from chemodenervation (alcohol/phenol) or neuromuscular blockade (botulinum toxin) to manage painful spasticity or to achieve specific functional or positional needs.065 Health-related quality of life in cerebral palsy: diseasespecific instruments Caregiver questionnaire66 Utility measures Health Utilities Index. and some reports support the use of these injections. or bony deformities. standers. the least invasive and most cost-effective treatment should be chosen and the effect of the intervention monitored by use of outcome instruments. . and bony deformity increases. oral pharmacological intervention. joint subluxation. and improve or normalise motor development.
there is little evidence-based information supporting or refuting their value in the management of cerebral palsy. the latter is licensed for use THE LANCET • Vol 363 • May 15.81 paediatric massage.80 Vojta techniques. and variable rigidity to address the specific requirements for each patient. to delay or prevent deformity. with the exception of ring splints for swan-neck deformity. The largest randomised. Physiotherapy and occupational therapy interventions include a wide range of techniques and schools including classic neurodevelopmental therapy techniques. intramuscularly. many internet sites provide information about this therapy. Therapeutic modalities Various approaches are used to facilitate range of motion. and/or speech). and the posterior leaf spring orthosis. but they are less effective in patients with neuromuscular spinal deformity than in patients with idiopathic scoliosis.74 Strength training has been advocated to promote fitness and increase patients’ participation in various recreational and occupational activities.101. spinal orthotics and chair inserts rarely halt curve progression once the curve has exceeded 40° and are used primarily for positioning. to maintain range of motion. placebo-controlled.98 Poor adherence to brace wearing may have a role in the failure of spinal orthotics. However. scientific support to validate the use of most orthotics or their effect on the natural course of most deformities in cerebral palsy is lacking. Braces are used for young cerebral-palsy patients with scoliosis to delay surgical management until the children reach skeletal maturity. With compliant patients.83 and constraint-induced movement. and intrathecally administered pharmacological options are available to manage spasticity.SEMINAR Therapeutic intervention Most children with cerebral palsy receive therapy of some type (physiotherapy. western Europe.102 However. Improved function during brace wear in patients with spastic arms. Hyperbaric oxygen therapy is associated with various risks. orthotics improve ankle kinematics and kinetics. These include electrical stimulation. to maximise activity. to prevent or delay contractures. Pharmacological options Various orally. pneumothorax. splinting is used to maintain muscle length. the only group for which bracing may be effective is a small subset of ambulatory patients with spasticity and significant weakness.96 Rigid or soft orthotics designed to maintain or to correct scoliosis. damage to the ear. most of the agents routinely used by patients with cerebral palsy are not labelled for paediatric use.84. and improve function.94 Arm orthotics are mainly used to maintain myotendinous length.95 Various features to decrease tone or spasticity are attributed to orthotic use.75. Serial casting is a non-surgical method to increase musculotendinous length. There are several different types including the traditional solid orthosis. splinting. . springs. Neuromuscular electrical stimulation is classified as therapeutic89 or functional.85 Constraint-induced therapy treatment models developed for rehabilitation of the arm in adults with stroke are now under investigation for use in patients with cerebral palsy. lordosis. quadriparetic involvement. and provision of head and neck support.24 On the basis of the current peer-reviewed scientific data. is rare.100 Hyperbaric oxygen Hyperbaric oxygen therapy is used by some patients despite the lack of scientific validation of its efficacy. Preliminary case studies or trials with small numbers of patients suggest that constraint-induced therapy results in improvements in hand function. stabilisation of the trunk. myopia. including ear pain. successful medical and surgical interventions generally depend on physiotherapy and occupational therapy for maximum benefit. However. 100% oxygen at 1·75 atmospheres absolute for 40 sessions was compared with air at 1·30 atmospheres absolute for 40 sessions.91.84. the hinged orthosis.99 Customised wheelchair inserts or orthotics are used for passive correction of scoliosis.93 and functional electrical stimulation of the anterior compartment of the leg combined with injection of botulinum toxin A in the gastrocnemius resulted in improved ambulation and reduced muscle tone in adults with spastic equinus gait.79 aquatics. to provide joint stability. casting. improved muscle strength becomes evident and measurable within 1–2 weeks after the start of treatment. and kyphosis are used. and Commonwealth nations.78 hippotherapy. parents of children treated with air reported better results than the parents of those treated with hyperbaric oxygen. controlled study. Orthotics are made from various materials and incorporate hinges. In patients without ankle or hindfoot contracture.86–88 However. The most common device is the ankle- foot orthosis. In a randomised. months of this treatment can be needed for efficacy. and to normalise function. increase stride and step length. and orthotics.com 1623 For personal use. most reports suggest no effect of brace wearing on the progression of significant spinal deformities. The former is labelled for children with cerebral palsy in the USA.73 Muscle strengthening has been associated with improved function in patients with cerebral palsy. placebo-controlled trial in 75 children. However. no improvement in objectively measured function was documented when therapeutic electrical stimulation was compared with placebo treatment. and orthotics are used to provide stability. double-blind trials are completed. improve coordination. and lumbar curves. Functional electrical stimulation combined with dynamic bracing improves arm function.76 patterning.92 In contrast to therapeutic approaches. Only reproduce with permission from The Lancet. the stimulus used with functional electrical stimulation produces a visible muscle contraction. and fire and explosions associated with the equipment. however. placebo-controlled trial of this therapy found that hyperbaric oxygen did not improve the condition of children with cerebral palsy compared with slightly pressurised air.24 However.thelancet. hyperbaric oxygen therapy should be considered an experimental intervention until further randomised. Exceptions include intrathecal baclofen and botulinum toxin A.77 conductive education.103 No significant difference was found between the groups in results of neuropsychological testing. or to maintain the effects of chemodenervation or surgery. critics argue that the placebo treatment in some trials constituted therapeutic amounts of oxygen and that the hyperbaric treatment is beneficial. The use of soft spinal orthoses instead of rigid orthoses increases the likelihood that they will be worn. and some insurance companies will cover its costs.71–73 However. Although there have been many publications on these therapies. occupational.90 Therapeutic electrical stimulation uses daily low exposure of spastic muscles.97.82 Adelphi Polish Suit Program. convulsions. further research is needed to define the long-term effects of this intervention in patients with cerebral palsy. to facilitate therapy. leg orthotics or splinting can provide significant functional advantage by stabilising joints during standing or ambulation as well as by maintaining muscle resting length. 2004 • www. However.101 In another double-blind. If functional electrical stimulation is effective. however. and to encourage adaptive mechanisms.
104 To test whether intrathecal baclofen is suitable. reproduced with permission from Wake Forest University individual muscles depends on the Orthopaedic Press. the pumps are programmed with input from the therapist. toxins B. within the neuromuscular junctions and the mechanism of action of botulinum toxins Injections of botulinum toxin A are on the synaptic fusion complex used in the management of focal SNARE proteins (SNAP-25. 114 1624 THE LANCET • Vol 363 • May 15. However. These agents include botulinum toxins. dislodgement. Baclofen. injections of botulinum toxin are associated with fewer complications. The participation of parents. tizanidine. Acetylcholine Syntaxin receptor greater reversibility of effects. and family to meet each individual patient’s needs. non-selective protein denaturation. blockage. and endurance. Decreased tone interfering with function during the trial of intrathecal baclofen is not a contraindication to pump implantation. is reported to improve speech.com For personal use. Toxins A and E cleave SNAP-25. synaptobrevin. and pumps must be refilled with drug at a minimum of every 3 months. whereas phenol denervation lasts 4–8 months. Indications for alcohol and phenol injections include spasticity. Only reproduce with permission from The Lancet. F. alcohol. and diazepam are examples of the most frequently prescribed medications. comfort. . and dysaesthesias lasting for proteins SNARE several weeks.68 Botulinum Acetylcholine toxin A has been used clinically in the Muscle cell Synaptic Synaptic does not management of spasticity associated cleft cleft Muscle cell contract with cerebral palsy since 1988. haematoma. and dural leakage). botulinum toxins. infection) or the catheter (migration. Failure to produce an effective synaptic manage more widespread spasticity. The frequency of pump refills is mandated by the fluid capacity of the pump and the limited stability of baclofen in solution. erosion. For example.107–109 and alcohol (45–100%). 2-adrenergic agonists. Orally administered medications used to treat spasticity include GABA agonists. intrathecal baclofen has produced variable beneficial effects on arm spasticity105 and. Once a pump is implanted. painful or function-limiting dystonia. in each patient an intrathecal trial with either a single bolus or short-term infusion of baclofen should be done. documented spasticity reduction during a trial shows the patient’s responsiveness to the drug. patient. and G cleave selective dorsal rhizotomy are used to synaptobrevin. however. muscle relaxants. The duration of denervation associated with alcohol injection is 3–6 months. 2001. the criteria to identify the best candidates for this therapy have not been defined completely. anecdotally.SEMINAR in children with cerebral palsy in 44 countries but not the USA.106 The level of catheter placement within the spinal cord can be adjusted to modulate the effects on arm versus leg control of tone. however. delivery of the drug can be modulated according to the degree of spasticity and weakness best suited for each individual patient to avoid interference with functioning. and ease of drug administration. and other care providers is essential during the trial process to ensure that everyone sets realistic goals for the treatment.108. Neuromuscular blockade/chemodenervation Injectable neuromuscular blocking agents balance muscle power across joints by producing selective denervation of muscles and nerves.104 Indications for intrathecal baclofen include: impaired gait and leg movement in patients without significant weakness. and phenol. phenol (3–7%). the management of spasticity in children is not one of the labelled indications for use. toxin C affects both SNAP-25 and syntaxin. joint imbalance secondary to spasticity.thelancet.115 The toxin is injected into spastic muscles Figure 3: Schematic representation of the normal mechanism of acetylcholine release to balance muscle forces across joints. A successful trial supporting implantation of a baclofen pump is defined as a reduction of at least 1 point on the Ashworth spasticity scale. and decreased function. Adapted from Arnon et al. wound breakdown. and syntaxin) are necessary for fusion of the acetylcholinespasticity. activities of daily living. and seizure medications. the short half-life of the drug means that it has to be infused continuously for optimum spasticity management. decubitus.69 fusion complex prevents vesicle attachment and the release of acetylcholine and produces flaccid The amount of toxin injected into paralysis. Intrathecal infusion of baclofen is effective in reducing tone. Complications associated with intrathecal baclofen can be caused by the pump placement (seroma.104 Intrathecal baclofen is an effective treatment for management of severe. rupture. Because diffusion of both is limited. formed Compared with phenol injections.23 The computer software used with the pump can be programmed to deliver different amounts of drug during the day depending on the degree of spasticity reduction that is required for different activities. therapists. Alcohol and phenol injections also are used to assess the effect of spasticity reduction in potential candidates for surgery. Release of acetylcholine produces muscle contraction. arm and leg spasticity interfering with function. the pump can be adjusted to deliver one dose of drug during sleep and to lower the dose during the day to facilitate function.110–113 Phenol and alcohol are non-selective proteolytic agents and produce selective denervation when injected into motor nerves or muscles. and spasticity interfering with carers’ support activities in nonfunctional children. physician. In addition to decreasing spasticity in the legs. intrathecal baclofen and containing vesicle to the cell membrane and release of the neurotransmitter. Side-effects of alcohol and phenol injections include pain on Light chain Synaptic vesicle injection. Replacement of pumps is required every 5–7 years. possible permanent muscle SNARE fibrosis. generalised spasticity in appropriately selected patients with spasticity and movement disorders. 2004 • www.110 complex Synaptobrevin Botulinum toxin A can be injected not intramuscularly to produce selective Heavy formed SNAP 25 Synaptic chain and reversible chemodenervation at fusion complex the neuromuscular junction (figure 3). spastic quadriparesis in non-ambulatory patients that interferes with function. Parenterally administered agents used to manage spasticity in children with cerebral palsy include baclofen. the area of effective denervation extends just a few millimetres from the injection site. In fact. D.
and improved health-related quality of life. Doses of 2–6 U/kg bodyweight per muscle with a maximum total dose of 29 U/kg have been reported. Maidenhead. influenza-like symptoms.94 However. muscle imbalance producing or contributing to skeletal deformity.126 Indications for intramuscular botulinum toxin A injections in patients with cerebral palsy include: dynamic deformity interfering with function. the higher doses of the preparations were more effective in improving gait measures than the lower doses. as a diagnostic trial. CA. rash.52. scissoring.131 Other prospective data support the use of botulinum toxin A in the management of crouched gait.thelancet. with smaller patients receiving higher doses than reported in the past. and allergic reaction. placebo-controlled study showed that patients with cerebral palsy who underwent hip surgery needed less morphine and codeine to manage their postoperative pain if the hip muscles were injected with botulinum toxin A before surgery. since they are ineffective in this case. Dysport is not approved for use in the USA. although functional changes were negligible.133 Adverse events seem to be related to the total dose administered rather than the dose calculated on the basis of the patient’s bodyweight.121. the dura is opened and the dorsal spinal rootlets are exposed.135 Surgical reduction of spasticity The use of selective dorsal rhizotomy for spasticity management was first reported in cerebral palsy in 1981.124 The final randomised.117 a review of previous publications indicates that the dose that has been used for children with cerebral palsy has increased over time. double-blind. if possible. hamstring tightness.118. Two formulations of botulinum toxin A are available for intramuscular injection: Botox (Allergan. symptomatic focal dystonia. the number of neuromuscular junctions in the muscle. Berkshire.128 The use of functional electrical stimulation combined with botulinum toxin A was superior to functional electrical stimulation alone in one short-term study of patients with stroke. In these studies.32 Common reported sideeffects include muscle soreness.118. Botox is used most commonly in concentrations of 50 U/mL or 100 U/mL. Irvine. postoperative or post-treatment pain control. a study of children with cerebral palsy and equinus showed that a combination of injections of botulinum toxin A and functional electrical stimulation did not result in better outcomes than treatment with toxin injections alone. Subsequent selective dorsal rhizotomy THE LANCET • Vol 363 • May 15. double-blind dose-ranging studies have examined the effects of various doses of Botox125 or Dysport118.130 The combination of toxin Figure 4: Schematic representation of the technique of selected dorsal rhizotomy A: after laminectomy. Although there are no standard guidelines on doses in children.116 The doses of these two commercial preparations are not interchangeable.116 Overall. fatigue. double-blind. The rootlets are stimulated so that abnormal rootlet activity can be identified. or contributing to progressive deformity. injections and use of a hip orthotic improved gait compared with physiotherapy and “best practice” in a randomised prospective trial.118–123 Five of the studies assessed the effect of toxin injections on leg spasticity in ambulatory patients with cerebral palsy.SEMINAR formulation of the toxin. to prevent spinal-column instability and secondary deformity. B: a proportion of rootlets are transected.119 Three randomised.136 This operation decreases spasticity by balancing spinalcord-mediated facilitory and inhibitory control (figure 4).68 Although type B toxin has been used for spasticity management in cerebral palsy. One study investigated the effect on arm range of motion and function. A second randomised. randomised trials have shown the efficacy of botulinum toxin A as a substitute for serial casting in equinus deformity.134 A contraindication for these injections is the presence of a fixed contracture.5 and drooling reduction.5 Seven randomised. were observed in patients whose casts were applied after the toxin injections. placebo-controlled trials have shown the efficacy and safety of botulinum toxin A in the management of spasticity associated with cerebral palsy. The current practice is to inject several muscles at each injection session.5 1 U Botox is equivalent to about 3–5 U Dysport. Reproduced with permission from Wake Forest University Orthopaedic Press. there are no peer-reviewed publications describing its use. and the size and weight of the patient. Two prospective.120 Patients receiving toxin showed increased range of motion and decreased tone.68 Type B toxin is a different serotype from type A toxin and is commercially available as Myobloc (USA) or Neurobloc (Europe).129 Slightly better outcomes. The recommended dose of Dysport for children is 30 U/kg bodyweight up to a maximum of 1000 U. The procedure requires a laminectomy at L2–L5. both Dysport and Botox have a satisfactory safety profile.5 Botulinum toxin A has an excellent safety profile with a low frequency of side-effects. pain on injection.127. producing pain. although it is not approved for management of spasticity associated with cerebral palsy by the Food and Drug Administration in the USA. painful spasticity with or without fixed muscle contracture. and the duration of its effect is speculative. as measured by gait analysis.128 One trial assessed whether toxin injections were more effective when given before or after casting.32.69. UK). 2004 • www.52. single-blind trial confirmed these findings.com 1625 For personal use. easing of the burden on carers. excessive weakness. Botox is approved and licensed for use in cerebral palsy in 44 countries. USA) and Dysport (Ipsen Limited.120–123 Patients who received toxin injections responded with improved ambulatory status. infection. Only reproduce with permission from The Lancet. . the size of the muscle. the optimum dose is unknown. This procedure involves stimulation and transection of selective posterior rootlets or arbitrary transection of a specific proportion of rootlets.126 on gait measures in patients with cerebral palsy. the facet joints are excluded.132.
disease severity. The primary outcome measure was the total score on the gross motor function measure. range of motion. Patients with normal intelligence. with the rate approaching 60–75% in patients with severe involvement and quadriplegia.152 However. no studies have compared two or more surgical procedures for the management of specific deformities. In 1995. restore. nutritional compromise. dystonic.151 A progressive spinal curve deformity between 40° and 50° in a growing child and documented progression of a curve beyond 50° after skeletal maturity are indications for surgery in patients with favourable risk/benefit ratios. underlying pathology (spastic.140 In addition. pelvic obliquity. pure spasticity. others prefer to operate on children older than 6–8 years. and postural stability have been identified as the best candidates for selective dorsal rhizotomy.com For personal use. and. ostectomy. or severe fixed joint contracture”.148 Anterior and posterior spinal instrumentation and fusion might be necessary for adequate correction of spinal alignment to be achieved and the risk of non-union kept to a minimum. Indications for surgery include progressive deformity producing pain or interfering with function.139 Therefore. No randomised prospective trials comparing surgery with observation have been published. The irreversibility of the procedure dictates caution when this therapeutic modality is chosen. and paraspinal muscle-strengthening programmes do not improve outcome. no prospective trials have documented the effects of intrathecal baclofen on spinal biomechanics.142 increases pelvic tilt in ambulatory patients. electrical stimulation of the convex paraspinal musculature has not been successful. Orthopaedic surgical techniques include neurectomy. fractional myotendinous lengthening. heelcord surgery done in children over the age of 6·5 years results in improved function and is associated with little recurrence of the equinus deformity.147. muscle tone. good strength. early and prompt treatment of hip subluxation at an earlier age is appropriate.thelancet. Orthopaedic surgery Long-established orthopaedic surgical procedures are designed to lengthen contracted myotendinous units.70 However.145 For example. Spinal deformity Deformities of the spine (scoliosis. diminish painful spasticity. kyphosis and lordosis are not associated with significant comorbidity.151 Bracing of patients with neuromuscular scoliosis is unsuccessful in many cases. Some surgeons undertake the procedure in children aged 2–4 years. the observed improvement in motor function could not be explained by the intensive physiotherapy programme. and severe neurological involvement. many patients require orthotics and long-term physiotherapy to achieve the best outcome. and deformity preventing adequate administration of care. No randomised controlled studies have identified optimum surgical combinations or supported the use of one surgical option over another.150 Progression of scoliosis can lead to pain. we have seen extreme hindfoot valgus and midfoot collapse in young children after the procedure. tendon lengthening. and improves outcome in selected patients. untreated hip subluxation can progress to hip dislocation. Other outcomes included muscle strength. The natural course of a specific musculoskeletal deformity should be factored into the surgical decision-making process. Preoperative discussions with the patients’ parents or carers 1626 THE LANCET • Vol 363 • May 15. Although scoliosis can lead to serious outcomes. controlled trials concluded that selective dorsal rhizotomy and physiotherapy provided a small but significant increase in scores on the gross motor function measure compared with physiotherapy alone. with curves beyond 100° a risk factor for complications. rigidity.148 The natural course of scoliosis in cerebral palsy differs from that of idiopathic scoliosis and is characterised by curve progression after skeletal maturity. overlengthened tendons. Our own experience suggests a need for careful documentation of existing spinal deformity before pump placement and careful radiographic monitoring of the patient’s spine twice a year after pump implantation. Renshaw and colleagues100 stated that “rhizotomy is not indicated in the presence of athetosis. Both an increase in lumbar lordosis and progression of scoliosis have been reported after rhizotomy144 and implantation of an intrathecal baclofen pump. kyphosis. interference with sitting. . adductor tenotomy and iliopsoas recession in a child with 50% subluxation of the femoral head will prevent dislocation and will improve hip stability and coverage in over 80% of children. Furthermore. Some researchers believe that early use of the procedure reduces the need for orthopaedic procedures. refractory spinal deformity. dystonia. fixed contractures.148 Postoperative complications of spine surgery are common in patients with excessive curvature. difficulty in sitting. or stabilise spinal deformity. joint subluxation or dislocation. controversy remains over whether selective dorsal rhizotomy reduces the need for subsequent orthopaedic procedures. cardiopulmonary compromise. reduce joint subluxation and dislocation to improve joint congruency. and overall well-being. Most of the indications for orthopaedic surgery in patients with cerebral palsy are based on retrospective reviews that include non-concurrent or historical controls. and lordosis) are associated with cerebral palsy. The surgical procedures should be individually adjusted according to the patient’s age.144 Furthermore. arthrodesis.146 Conversely. decreases the period of postoperative immobilisation and the rate of nonunion. 2004 • www.149. and painful arthritis.146 Therefore. muscle weakness. diplegia.139 A meta-analysis of three randomised.137.148 The use of segmental spinal instrumentation improves correction.138 Because transient muscle weakness is observed after the procedure. tendon transfer. and maintain. balance joint forces.32 The ideal age and best technique for selective dorsal rhizotomy are unknown. although the exact indications are difficult to define from the existing evidence.143 and exaggerates lumbar lordosis and speeds progression of scoliosis. less commonly. ataxia. A randomised single-blind trial of 30 patients showed that patients assigned rhizotomy and intensive outpatient physiotherapy for 9 months experienced better outcomes than those assigned intensive physiotherapy alone.100 Progression of curves beyond 50° is frequent.SEMINAR approaches have used two-level laminectomies. Only reproduce with permission from The Lancet. transfer motor power. no fixed contractures. or mixed).141 whereas others believe that it causes accelerated hip subluxation. or a combination of these procedures. comorbidities. Delays in surgery that do not compromise function and health-related quality of life are recommended to avoid recurrence of the deformity and the unpredictable results common in younger children related to their growth potential. multisegmental spinal fusion. Neuromuscular blockade of the concave paraspinal musculature has been attempted with varying success (anecdoctal reports). tenotomy. osteotomy. and physiological cost index. correct bony deformity to improve biomechanical alignment.100 The overall frequency of scoliosis in cerebral palsy is 25%. fuse unstable joints by arthrodesis.
joint instability. decrease pain. bony architecture. patients with movement disorders who lack voluntary motor control and sensibility experience inconsistent postoperative results.157. hip adduction. to facilitate or decrease orthotic use. anterior elbow release in selected patients reduces flexion posture angle without increasing maximum flexion.158. and planovalgus foot deformity. release of the elbow capsule.162).163 Forearm pronation deformity can be decreased by tenotomy. and improve health-related quality of life. and humeral osteotomy. rerouting.157. splinting. hip flexion. or rerouting of the pronator teres. Leg surgery Surgical procedures for the legs are designed to improve ambulation.158 By contrast. ankle equinus. or both. osteotomy. proximal row carpectomy.162 transfer of the adductor insertion to the metacarpal. wrist arthrodesis. arthrodesis can improve outcomes in these patients. intrinsic motor contracture and spasticity.162 Younger patients without arthritis. Thumb-in-palm deformity is multifactorial. some voluntary motor control. Postoperative care. Weakening biceps function may exacerbate pronation deformities and must be factored into any surgical decision. arthrodesis. the extent of sensory loss does not correlate directly with the severity of the motor deficit. or facilitate care activities. reduce deformity. metacarpal phalangeal hyperextension or global instability. Arms Surgical management of the arms in patients with cerebral palsy is designed to correct muscle contracture.158.96 Surgical options include tenotomy. THE LANCET • Vol 363 • May 18.104.22.168 Osseous procedures are rarely indicated to manage elbow flexion. sensory reeducation. improve function. neurectomy. The role of surgery is not as prominent for arm deformities as for the legs because of sensory impairments associated with spasticity of the arms and the limited functional gains after surgery.168. and pronator flexor slide.157 Electromyography of the forearm muscles can facilitate the selection of the appropriate surgical option. The goals of these procedures are: to improve ambulation by improving quality of gait.153.com 1627 For personal use. The procedure used depends on the patient’s age. contracture of the adductor pollicis.169 Figure 5: Thumb-in-palm deformity The deformity is complex and can include: soft-tissue contracture of the thumb–index web. . internal rotation of the hip.162 or plication.162 Deformities of the fingers can be managed by arthrodesis. joint congruency. or both (release of the origin of the adductor). Only reproduce with permission from The Lancet.157 In general.16 Furthermore. two-point discrimination (90%).162 Surgical procedures for thumb and finger deformities provide predictable beneficial results for children and adults who have spasticity.159 Functional deficits are observed in 80% of limbs in children with hemiplegia and quadriplegia. swan-neck deformity. and volitional control. However. and proprioception (46%).157. tendon transfer. Patients with elbow flexion contractures of greater than 60° are candidates for surgery if the goals of patient and physician are reasonable. to prevent or delay arthritis or progressive deformity. movement disorders. or reinforcement of the extrinsic thumb extensors and abductors. or joint incongruity are candidates for soft-tissue procedures. or shoulder fusion. although contractures of 30–60° might benefit from surgical intervention.157. Significant elbow flexion contracture can be decreased by any permutation of the following: brachialis fractional lengthening.158 Reduced sensitivity is common in patients with spastic arms as shown by deficits in stereognosis (97%). extent of motor involvement.162 lengthening or reinforcement of the flexor pollicis longus. others may need bony options. increases active extension.158. transfer of the latissimus dorsi and teres major tendons to the lateral humerus. finger flexion deformity. flexor-pronator slide. and abductor pollicis longus. first dorsal interosseous. skin contracture (four-flap Z plasty or skin graft158. if present: joint stability (capsulodesis170 or arthrodesis158). neurectomy procedures are avoided. and some sensibility.168 or a combination of these options. decrease spasticity. knee flexion. Shoulder fusion is rarely indicated.164–167 Wrist extension can be improved by: transfer of a wrist flexor to a wrist extensor or finger extensor. or intrinsic/extrinsic rebalancing. extrinsic motor imbalance with overlengthening and/or weakness of the extension pollicis longus. is important for optimum surgical outcomes. including hand therapy.156. continuous electromyographic activity of the flexor carpi ulnaris supports the transfer of this muscle to the finger extensors rather than a wrist extensor. and contracture and/or weakness of the flexor pollicis longus.158. and improves appearance and selfesteem.161 Shoulder internal rotation can be managed by: lengthening of the pectoralis major or subscapularis tendons. For example.thelancet. transfer of the extensor carpi ulnaris to the fourth metacarpal. A deformity of less than 30° rarely justifies surgery.SEMINAR about the possible effect of pump placement on the progression of spinal deformity are imperative.23 Intrathecal baclofen and rhizotomy can decrease arm spasticity and positively affect function. to facilitate care. humeral osteotomy. to improve joint alignment or congruency. Reproduced with permission from Wake Forest University Orthopaedic Press. flexor tendon transfers to the wrist or digit extensors.153–156 Soft-tissue procedures are rarely successful in patients with movement disorders.157 However. Thumb-in-palm deformity. extensor pollicis brevis. to improve self-care and self-esteem.105. 2004 • www.171 dorsal release of the adductor and first dorsal interosseous from the first and second metacarpals. In general. Z plasty of the biceps brachii. The walking pattern of patients with cerebral palsy is inefficient and abnormal as a result of increased muscle tone in the legs associated with increased pelvic tilt.160 A preliminary report of C8 root division documented reduced muscle tone in wrist and finger flexors. intrinsic-muscle overactivity. and to improve activities of daily living. and joint reduction with capsulodesis. to decrease pain by reducing spasticity. Concomitant pump implantation and spinal fusion have been done in patients with pre-existing spine deformities. lengthening. tendon lengthening. and contracture of the first web space represent the most common thumb and finger deformities in patients with cerebral palsy (figure 5). and strengthening programmes. improves function. capsulodesis. only 10–15% of these patients are candidates for corrective musculoskeletal surgery. and surgical management of this deformity must therefore address the following.
44: 352–55. Holmgreen P. or total joint replacement if nonoperative management (anti-inflammatory dugs. Evans P. Decoufle P. or to restore hip joint congruency. Yeargin-Allsopp M. Infection. Yeargin-Allsopp M. Prevalence of selected developmental disabilities in children 3-10 years of age: the Metropolitan Atlanta Developmental Disabilities Surveillance Program. or rarely neurectomy. or calcaneal osteotomy. The most common combined deformity is hindfoot equinovalgus and midfoot pronation. the development of techniques to strengthen and improve motor power. Surveillance of cerebral palsy in Europe: a collaboration of cerebral palsy surveys and registers.174. 42: 816–24. Visual-perceptual impairment in a random sample of children with cerebral palsy. 21: 359–66. Nelson KB. Surgical procedures of the hip are designed to improve abduction (decrease scissoring). The availability of validated and reliable outcome 22 1628 THE LANCET • Vol 363 • May 15. Causes of cerebral palsy. hindfoot valgus. 44: 240–47. Dabney KW. positively affect health-related quality of life. Only reproduce with permission from The Lancet. Soft-tissue procedures—adductor tenotomy.188 or less commonly. Willoughby RE. Surgical options to treat painful dislocated hips include resection of the femoral head. 197–201. du MC. or femur to correct foot progression angle. Curr Opin Pediatr 1997. 44: 309–16. Dillard RG. Paediatr Drugs 2003. and participation restrictions in children with cerebral palsy. improve function. fibula. control of movement disorders and deformity. Prevalence and health impact of developmental disabilities in US children. Dev Med Child Neurol 2002. Rosenbaum P. Preisser JS. hip subluxation with scissoring is initially managed by: adductor tenotomy alone. Hutton JL. Int J Epidemiol 1992. lengthening of the gastrocnemius aponeurosis alone. Beckung E. Elliott M. Int J Epidemiol 1997. N Engl J Med 1994. hip dislocation or significant subluxation is managed with varus derotation osteotomy alone or combined with pelvic osteotomy and open reduction capsular plication and adductor release. Murphy CC.190 The Reimer’s migration index describes the amount of the femoral head that is subluxated out of the acetabulum expressed as a percentage. Roijen LE. Health status of school-aged children with cerebral palsy: information from a population-based sample. recurrence of this deformity is possible in children who undergo surgery before they are 10 years old. and utility. motor. 9: 81–88. Dev Med Child Neurol 1998. Kennes J. Refractory valgus deformity can be corrected by: medial displacement osteotomy of the calcaneus. metatarsus primus varus. Hanna SE. 45: 1–14.189 In older children. will facilitate the appropriate evaluation of the interventions currently used to manage children and adults with cerebral palsy. and improve self-esteem in these patients. Motor disability in children in three birth cohorts.177 articular or extra-articular subtalar fusion.thelancet. 43: 103–07. Grandjean H. Mlika A. tendon transfer. Koman LA. 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 Conclusion The management of patients with cerebral palsy continues to evolve. 18: 278–81. Dev Med Child Neurol 2002. Arch Dis Child 1985. Prevalence and time trends of disabilities in school-age children. Pediatrics 1998.187 combined adductor tenotomy and iliopsoas lengthening.172–174 Equinus ankle deformity can be complicated by coexisting deformities including hindfoot varus.176. Coene S. Stanley E. Dequae L. 60: 940–45. De Rammelaere M.179 or triple arthrodesis. Klinepeter KL. Pediatrics 1994. 2000: 22–39. Evans S. health-related quality of life. Trends in mortality and cerebral palsy in a geographically based cohort of very low birth weight neonates born between 1982 to 1994. the ability to alter spasticity with surgical procedures. O’Shea TM.185 Medial and lateral hamstring lengthening combined with psoas lengthening decreases pelvic tilt. adductor transfer. Pharoah PO. anti-spasticity drugs) is unsuccessful.181 Knee joint contractures require capsulotomy182 and associated. Curr Opin Neurol 2000. Cans C. Nelson KB. and reduction of discomfort. abduction osteotomy of the proximal femur. Development of bladder control in children and adolescents with cerebral palsy. Paneth N. Verrier A. Femoral osteotomy can improve hip coverage during stance. Cans C. Dev Med Child Neurol 2000. Boyle CA. 13: 133–39. Prevalence and disabilities in 4 to 8 year olds with cerebral palsy. Miller F. functional status. or antispasticity medications). How common are the cerebral palsies? In: Cerebral palsies: epidemiology and causal pathways. anti-inflammatory drugs. Grether JK.186 Many non-ambulatory patients with cerebral palsy are characterised by hip instability that is associated with hip pain and difficulties with walking and sitting. Boyle CA. Lipton GE. Sensibility deficiencies in the hands of children with spastic hemiplegia. Cerebral palsy in multifoetal pregnancies. and anterior branch obturator neurectomy—are most effective in patients with stable hips without bony deformity. and supination or pronation of the midfoot-forefoot complex. Blickstein I. Doernberg NS. Effects of cognitive. . Blair E. transfer of the Achilles tendon.70. References 1 2 Kuban KC.175 calcaneal lengthening.22 Management of hip deformity is dictated by the extent of deformity and the time it has been present. Stiers P. Cerebral palsy. London: MacKeith Press. 330: 188–95.190 Onestage comprehensive hip reconstruction is an effective treatment for children aged 4 years or older who have a migration index greater than 60%. Dev Med Child Neurol 2002. inappropriate coexisting contraction of the rectus femoris might require release or transfer of the rectus femoris to the iliotibial band or a medial hamstring. and the identification of surgical procedures to correct deformities will provide resources that can be used to modify untoward natural histories. 2004 • www. Etiologic factors in cerebral palsy. House J. A painful dislocated hip is commonly treated by non-operative management (analgesics. including the technical success of surgical procedures.174. 93: 399–403. Dev Med Child Neurol 2001. Pediatr Ann 1986.183. 44: 370–82. Current management models are patient-centred and are focused on modification of spasticity. Spasticity associated with cerebral palsy in children: guidelines for the use of botulinum A toxin. Shavelle R. Dev Med Child Neurol 2002. Vandenbussche E. Van Heest AE. Alberman E. Vanneste G. Neuroimpairments. Cerebral palsy. Balkrishnan R. 15: 191.com For personal use. however. activity limitations. instruments that can be used to assess multiple outcomes of various therapeutic options.SEMINAR The most commonly reported procedures used to correct equinus ankle and foot deformity include lengthening of the Achilles tendon. 101: 642–47. 194–95. lengthening of both the aponeurosis of the gastrocnemius and soleus. Alberman E. J Hand Surg [Am] 1993. Kuppevelt VH. Smith BP. Schendel DE. iliopsoas release or recession. 40: 369–75. In patients under the age of 7 years. Morb Mortal Wkly Rep CDC Surveill Summ 1996. 26: 137–45. Arch Dis Child 2002. 5: 11–23.184 Proximal hamstring lengthening is effective in the treatment of knee deformities in nonambulatory children. and sensory disabilities on survival in cerebral palsy. Rumeau-Rouquette C. inflammation and the risk of cerebral palsy. to prevent hip subluxation. Vanderkelen R. The availability of oral and parenteral drugs. et al. 11: 487–91. Limbeek VJ. Varus deformity can be managed by tendon lengthening. analgesics. Life expectancy of adults with cerebral palsy. 1991. Leviton A. Crouched gait and knee flexion deformities are corrected by medial or combined medial and lateral hamstring lengthening procedures. Curr Opin Pediatr 1999.178. 86: 84–89. Strauss D.180 Rotational or torsional deformities can be managed by rotational osteotomy of the tibia. hallux valgus. du MC. Putnam M. Postema K. Hagberg G. Rumeau-Rouquette C.
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