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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: firstname.lastname@example.org)
THE LANCET • Vol 363 • May 15, 2004 • www.thelancet.com
For personal use. Only reproduce with permission from The Lancet.
at.24 The motor impairments result from various neurological deficits. and metatarsal varus with hallux valgus. the clinical manifestations of the neurological injuries depend on the extent and type of CNS damage.20 Urinary incontinence is common (23·5%). and diminished proprioception (46%).com For personal use. knee flexion. Reproduced with permission from Wake Forest University Orthopaedic Press. inappropriate involuntary muscle activity associated with upper-motor-neuron paralysis or syndrome.16 Learning disabilities and activity limitations are associated with the degree of cerebral involvement17 and adversely affect school performance. monoplegia. deep CNS hypoxia. so fetal insults occurring during this period can produce periventricular leucomalacia with spastic diplegia. producing spasticity. diplegia. and thumb-in-palm. the loss of descending inhibitory input through the reticulospinal tract and other systems increases the excitability of gamma and alpha neurons.23 Spasticity associated with cerebral palsy can lead to musculoskeletal complications such as contractures. chorea. 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.24 The motor skills of most children with cerebral palsy improve as they grow.4. The leg shows hip adduction/flexion. or within 2 years of birth. and produces abnormal muscle control and weakness. sensory impairment of the arms (97%). dystonia. Hemiplegia is most common in babies born at term and is associated with single hemisphere injury in most cases. decreases the number of effective motor units.10. . but the rate of improvement is slower in children with cerebral palsy than in unaffected children.23 Even though the lesion itself does not change. especially in children and adults with quadriparesis and mental retardation.19 Hemiplegic patients experience abnormal stereognosis (97%).32 which has been defined as a velocity-dependent resistance of muscle to stretch33 or as excessive. some areas of the brain are more susceptible to damage than others. the location of the irreversible insult. which in turn affects motor control. Injury to extrapyramidal systems results in movement disorders such as athetosis. ataxic.29. Figure 1: Typical posture of a child with left hemiparesis The arm assumes a position of internal rotation of the shoulder.21 Pathophysiology Cerebral palsy results from a permanent static lesion of the cerebral motor cortex that occurs before. or rigidity.23 Primary or secondary abnormalities within the spinal cord can increase spasticity. impairment of visual perception (20–40%). Fetal production of cytokines can damage neurons.15 Neurological problems are common and include seizures (35%). and the ability of the CNS to adapt or reorganise after the insult. and peripheral nociception (pain) can also exacerbate it.31 “Selective vulnerability” of the periventricular white matter occurs between 26 weeks and 34 weeks of gestation.25 Similarly.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.16 hydrocephalus (9%). Classifications of cerebral palsy are based on: deformity or abnormality (spastic. mixed). For example. autonomic dysfunction. 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.35 anatomical distribution of the deformity or abnormality (hemiplegia. preoligodendrocytes. hindfoot valgus. Diplegia is associated with periventricular leucomalacia.SEMINAR impaired. forearm pronation. 1620 THE LANCET • Vol 363 • May 15. whereas movement disorders occur after hyperbilirubinaemia and basal-ganglia injury.11. ankle equines. Ultimately.11 Furthermore. and transient or irreversible ischaemia resulting in cell necrosis secondary to free-radical formation or hypoxia-related metabolic cellular death. diminished two-point discrimination (90%). elbow flexion.34 Quadriplegia is associated with diffuse CNS insults.23 CNS pathology associated with cerebral palsy includes: CNS haemorrhage.28 Injury to upper motor neurons decreases cortical input to the reticulospinal and corticospinal tracts.23 The elimination of spasticity allows many patients with cerebral palsy to use what selective motor control they possess more effectively and functionally. fetal production of cytokines. wrist flexion. and vascular endothelial cells and could contribute to intraventricular haemorrhage. mechanical spinal-cord or brainstem damage. the clinical manifestations of the lesion change as the child grows and develops.10.22. and subluxation.18 and learning disabilities.17. dyskinetic.25–28 or maternal infection or chorioamnionitis. Simultaneously.thelancet. Only reproduce with permission from The Lancet. pain.26. 2004 • www. cerebral cortex hypoxia.
47–49 Observational gait analysis is done with the physician rating scale50–52 or its modified version (the observational gait scale). hip adduction. and joint subluxation or dislocation. or forefoot (metatarsus adductus) deformity. athetosis. hip flexion. flat foot (hindfoot valgus).14 According to this classification system. and Australia. and lordosis. however. elbow flexion.9 from the International Classification of Diseases ninth revision (ICD9). hindfoot valgus. and bunion. Health-related quality of life Measurement of health-related quality of life involves obtaining the patient’s view of his or her health status. kyphosis. these modalities might be valuable for diagnosis and prognosis in the future. Intoeing can result from femoral anteversion. functional MRI and transcranial magnetic stimulation are used only for research purposes in children with cerebral palsy. and quadriplegia (involvement of all four limbs). spinal alignment. Spinal deformities include scoliosis. internal tibial torsion.thelancet.com 1621 For personal use. scissoring (hip adduction). and hemiplegia. several functional instruments and health-related quality-of-life measures have been developed or validated for assessment of patients with cerebral palsy.57. ankle equinus). carers can serve as proxies to provide such information about the child.42 and the functional independence measure in children43 (panel). Currently. and toe flexion are the most common postures (figure 1).SEMINAR quadriplegia). Patterns of spasticity with resultant muscle imbalance across the joints over time can produce shortening of myotendinous units. Some practitioners use this term to suggest asymmetrical involvement or a clearly dominant side. hypotonia. level IV. intoeing or out-toeing. 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.4 The Central West Health Planning Information Network (Ontario.53 For children with cerebral palsy. Cranial ultrasonography. impairment. hemiplegia (involvement of the ipsilateral arm and leg). motor power. diplegia 17%.40 With a sample of 408 children. Health-related quality of life includes measures of physical functioning. and ancillary investigations. Similarly. muscle tone (spasticity). 2004 • www. physical examination. Assessment tools and instruments During the past few years. Only reproduce with permission from The Lancet. Diagnosis Diagnosis of cerebral palsy requires a complete history.41 Function Functional capabilities can be assessed by use of global or function-specific instruments. and thumb-in-palm. Most cases of cerebral palsy included in large databases and national reporting registries are identified by the non-specific code 343. Global function instruments include the paediatric evaluation of disability index.61 For young children with cerebral palsy or those with severe involvement. 210 (23%) hemiplegia. symptoms. or disease specific. ankle equinus. sensibility. and hemiplegia 21%. Movement disorders can coexist with the clinical patterns of involvement. 82 (20·1%). is difficult to assess because specific diagnoses are not available. gait (if applicable). forearm pronation.58 The Burke-Fahn-Marsden scale of dystonia59 and the Barry-Albright dystonia scale60 are used to rate the severity of movement disorders. concentrating on symptoms and dysfunction associated with the specific disorder. out-toeing can be secondary to femoral or tibial torsional deformity. level II. joint contracture. knee flexion. 112 (27·5%). described for patients in Sweden. psychological issues. The most common postures observed in the arm are shoulder internal rotation. or extrapyramidal). and there can be spasticity. type and extent of movement disorders.61 Instruments are generic. dystonia (eg. They reported that 45·7% of the patients were classified with the non-specific ICD9 code. jump gait (hip flexion. Movement disorders—dystonia. cortical.0–343. A study in France identified the distribution of clinical patterns as quadriplegia 40%. In the leg. knee flexion. bony deformity. the distribution of the most common clinical patterns. However. USA. 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. level I indicates few limitations and level V severe impairments. chorea—are common in cerebral palsy. ankle calcaneus). and 402 (44%) quadriplegia. and presence of limb deformity.54 Spasticity and movement disorders Spasticity can be quantified or objectively analysed by the Ashworth spasticity scale. quadriplegia. crouched gait (hip flexion. and other specialised tests are used to assess the extent of the CNS insult. brainstem.56 and the Tardieu scale. . these features are not a prerequisite for its use. MRI. Dynamic deformities and movement disorders can be accentuated during ambulation or other activities. examining all parts of health.64 and the Peds QL 4.65 Classifications Clinical patterns of involvement described in cerebral palsy include: diplegia (significant leg involvement with little effect on the arms). windblown pelvis (fixed adduction contracture in one hip associated with contralateral abduction contracture). The history should include a detailed account of gestation and perinatal events and documentation of the attainment of developmental milestones.62 Three generic instruments suitable for patients with cerebral palsy are the child health questionnaire. knee flexion. 47 (11·5%). pyramidal. wrist flexion. and others are associated primarily with joint subluxation or dislocation or bony abnormalities.36 or location of CNS injury (periventricular.22 Chronological information about the prevalence and time trends of cerebral palsy has been most thoroughly THE LANCET • Vol 363 • May 15. active and passive range of motion of joints. athetosis). In our assessment of 906 children in central and western North Carolina. CT. and disability. 294 (33%) had diplegia. the UK. level III.37–39 However. The term double hemiplegia implies bilateral involvement characterised by greater involvement of the arms than the legs. 86 (21·1%).63 the paediatric musculoskeletal functional health questionnaire. Pathological gait and static abnormalities include: toe walking (ankle equinus). There are three instruments for assessment of arm function44–46 and three for assessment of leg performance. Canada) used ICD9 codes 343.9 to classify 475 children. Some deformities are typically related to imbalance of specific muscles. rigidity. rigidity is rare. 81 (19·9%). or a mixture of these disorders. In addition to a general physical inspection. Dynamic deformities and movement disorders are accentuated during ambulation or activity in many cases.0. and level V.55 the modified Ashworth scale. finger flexion. the examination should assess station (pelvic and leg alignment during stance). social functioning. diplegia.
electrical stimulation). or deformity.69 The best response to heelcord lengthening of the Achilles tendon is seen in patients older than 6 years. Furthermore. These treatments are used to maintain or improve joint range of motion. the frequency of fixed contractures. chemomodulation of spasticity.065 Health-related quality of life in cerebral palsy: diseasespecific instruments Caregiver questionnaire66 Utility measures Health Utilities Index. The treatment options that are used change with the age and developmental stage of the child. provide support. and surgery for management of spasticity associated with cerebral palsy in North Carolina. deviceassisted modalities (eg. and derotation osteotomy procedures have in the best outcomes in children of 8 years old.68 For example.32 Non-pharmacological treatment Non-pharmacological approaches include occupational therapy. 2–6-year-old children show the best response to injections of botulinum toxin. seating systems).66 The functional health status of patients with cerebral palsy has been assessed by the Health Utilities Index-Mark 3 instrument.68 The use of a combination of physiotherapy and orthotics can increase the beneficial effects associated with intramuscular injections of botulinum toxin.69 Children younger than 3 or 4 years rarely develop fixed deformities.32 For successful management. facilitate or strengthen weak muscles.14 which describes health status and health-related quality of life.70 For children who undergo osseous or soft-tissue procedures before skeletal maturity.67 develop. and the need for surgical intervention increases (figure 2).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. and some reports support the use of these injections. orthotics. neuromuscular blocking agents. torsional deformities. the least invasive and most cost-effective treatment should be chosen and the effect of the intervention monitored by use of outcome instruments. or both might be necessary during rapid periods of growth to maintain the benefits of the surgical procedure. dislocation. or any combination of these methods. and those with severe involvement need more extensive interventions.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. Spasticity management involves the use of a continuum of modalities throughout childhood.thelancet. 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. For example. 2004 • www.32 Most patients with mild involvement receive fewer types of treatments. the consensus is that spasticity associated with cerebral palsy should be treated before children reach the age of 5 or 6 years.com For personal use. and speech therapy. oral pharmacological intervention. casting. In addition. patients’ daily activities can be facilitated by their use of adaptive devices (eg. and surgery. and orthotics in children of this age to modify the natural course of cerebral palsy. improve muscle strength. Treatment of musculoskeletal abnormalities must address one or more of spasticity.69 Treatments should be goal-oriented and produce positive outcomes. muscle stiffness. or bony deformities. As patients grow older. dynamic and static joint deformity. oral pharmacological agents. muscle contracture. physiotherapy. and bony deformity increases. physiotherapy. joint subluxation. 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. However. Only reproduce with permission from The Lancet. the caregiver questionnaire is the only diseasespecific instrument validated for use in patients with cerebral palsy. inhibit or weaken spastic agonist muscles. therefore. and abnormal motor control. chemodenervation. Mark 314. The severity and distribution of spasticity is crucial to identification of appropriate management options. device-assisted modalities. and improve or normalise motor development. many respond to physiotherapy. Available treatment options include observation. and orthotics.32 100 90 80 70 60 50 40 30 20 10 0 0 Non-surgical Chemodenervation Surgery To date. standers. 1622 THE LANCET • Vol 363 • May 15. 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). 1999–2002 Reproduced with permission from Wake Forest University Orthopaedic Press. physiotherapy. joint contractures. the interventions should be adjusted on the basis of efficacy in achieving preintervention goals and the carers’ adherence to the prescribed therapeutic interventions. casting. parenteral medication. .32 most patients are managed with a combination of modalities.67 Management options The spasticity management technique used for children with cerebral palsy is determined primarily by the clinical findings.
Pharmacological options Various orally. placebo-controlled. Braces are used for young cerebral-palsy patients with scoliosis to delay surgical management until the children reach skeletal maturity. to provide joint stability. Therapeutic modalities Various approaches are used to facilitate range of motion. improved muscle strength becomes evident and measurable within 1–2 weeks after the start of treatment. increase stride and step length. orthotics improve ankle kinematics and kinetics. spinal orthotics and chair inserts rarely halt curve progression once the curve has exceeded 40° and are used primarily for positioning. further research is needed to define the long-term effects of this intervention in patients with cerebral palsy. There are several different types including the traditional solid orthosis. pneumothorax. The most common device is the ankle- foot orthosis.75. Functional electrical stimulation combined with dynamic bracing improves arm function. including ear pain.99 Customised wheelchair inserts or orthotics are used for passive correction of scoliosis. 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. to facilitate therapy.103 No significant difference was found between the groups in results of neuropsychological testing. Improved function during brace wear in patients with spastic arms. the latter is licensed for use THE LANCET • Vol 363 • May 15.71–73 However. myopia.24 However. Exceptions include intrathecal baclofen and botulinum toxin A. The former is labelled for children with cerebral palsy in the USA. and intrathecally administered pharmacological options are available to manage spasticity.95 Various features to decrease tone or spasticity are attributed to orthotic use. However.92 In contrast to therapeutic approaches.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. However. the hinged orthosis. there is little evidence-based information supporting or refuting their value in the management of cerebral palsy. and kyphosis are used. and orthotics. controlled study. splinting. critics argue that the placebo treatment in some trials constituted therapeutic amounts of oxygen and that the hyperbaric treatment is beneficial. however. and/or speech).84. leg orthotics or splinting can provide significant functional advantage by stabilising joints during standing or ambulation as well as by maintaining muscle resting length. Preliminary case studies or trials with small numbers of patients suggest that constraint-induced therapy results in improvements in hand function. placebo-controlled trial in 75 children. many internet sites provide information about this therapy.81 paediatric massage. intramuscularly. However.84. and improve function. In patients without ankle or hindfoot contracture. and variable rigidity to address the specific requirements for each patient. quadriparetic involvement.91. and the posterior leaf spring orthosis. Only reproduce with permission from The Lancet. to prevent or delay contractures.83 and constraint-induced movement. Orthotics are made from various materials and incorporate hinges.SEMINAR Therapeutic intervention Most children with cerebral palsy receive therapy of some type (physiotherapy. .94 Arm orthotics are mainly used to maintain myotendinous length. the only group for which bracing may be effective is a small subset of ambulatory patients with spasticity and significant weakness. lordosis.76 patterning. with the exception of ring splints for swan-neck deformity. Neuromuscular electrical stimulation is classified as therapeutic89 or functional. months of this treatment can be needed for efficacy. most reports suggest no effect of brace wearing on the progression of significant spinal deformities. to maintain range of motion.82 Adelphi Polish Suit Program.86–88 However.101. The use of soft spinal orthoses instead of rigid orthoses increases the likelihood that they will be worn. 100% oxygen at 1·75 atmospheres absolute for 40 sessions was compared with air at 1·30 atmospheres absolute for 40 sessions. casting. no improvement in objectively measured function was documented when therapeutic electrical stimulation was compared with placebo treatment.98 Poor adherence to brace wearing may have a role in the failure of spinal orthotics. hyperbaric oxygen therapy should be considered an experimental intervention until further randomised. splinting is used to maintain muscle length. the stimulus used with functional electrical stimulation produces a visible muscle contraction. and fire and explosions associated with the equipment. Although there have been many publications on these therapies. damage to the ear. occupational.102 However. Physiotherapy and occupational therapy interventions include a wide range of techniques and schools including classic neurodevelopmental therapy techniques.80 Vojta techniques. and lumbar curves.90 Therapeutic electrical stimulation uses daily low exposure of spastic muscles. to maximise activity.24 On the basis of the current peer-reviewed scientific data. or to maintain the effects of chemodenervation or surgery. most of the agents routinely used by patients with cerebral palsy are not labelled for paediatric use.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. Serial casting is a non-surgical method to increase musculotendinous length. and to normalise function.74 Strength training has been advocated to promote fitness and increase patients’ participation in various recreational and occupational activities. However. successful medical and surgical interventions generally depend on physiotherapy and occupational therapy for maximum benefit. springs. and orthotics are used to provide stability.78 hippotherapy.thelancet. and Commonwealth nations. western Europe. is rare.77 conductive education. With compliant patients.100 Hyperbaric oxygen Hyperbaric oxygen therapy is used by some patients despite the lack of scientific validation of its efficacy.101 In another double-blind. In a randomised. These include electrical stimulation. but they are less effective in patients with neuromuscular spinal deformity than in patients with idiopathic scoliosis. improve coordination.com 1623 For personal use. and provision of head and neck support. The largest randomised. and some insurance companies will cover its costs. convulsions. parents of children treated with air reported better results than the parents of those treated with hyperbaric oxygen.96 Rigid or soft orthotics designed to maintain or to correct scoliosis. scientific support to validate the use of most orthotics or their effect on the natural course of most deformities in cerebral palsy is lacking.79 aquatics. If functional electrical stimulation is effective. stabilisation of the trunk.73 Muscle strengthening has been associated with improved function in patients with cerebral palsy. double-blind trials are completed. to delay or prevent deformity.97. and to encourage adaptive mechanisms. however. 2004 • www. Hyperbaric oxygen therapy is associated with various risks.
therapists. physician. the area of effective denervation extends just a few millimetres from the injection site. and phenol.SEMINAR in children with cerebral palsy in 44 countries but not the USA. These agents include botulinum toxins.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. Neuromuscular blockade/chemodenervation Injectable neuromuscular blocking agents balance muscle power across joints by producing selective denervation of muscles and nerves. comfort. and endurance. Parenterally administered agents used to manage spasticity in children with cerebral palsy include baclofen. In fact. Only reproduce with permission from The Lancet. Side-effects of alcohol and phenol injections include pain on Light chain Synaptic vesicle injection. reproduced with permission from Wake Forest University individual muscles depends on the Orthopaedic Press. intrathecal baclofen has produced variable beneficial effects on arm spasticity105 and. joint imbalance secondary to spasticity. formed Compared with phenol injections. and dural leakage). documented spasticity reduction during a trial shows the patient’s responsiveness to the drug.thelancet. and other care providers is essential during the trial process to ensure that everyone sets realistic goals for the treatment. synaptobrevin. 2004 • www.104 Indications for intrathecal baclofen include: impaired gait and leg movement in patients without significant weakness. However. dislodgement. anecdotally. patient. 114 1624 THE LANCET • Vol 363 • May 15. in each patient an intrathecal trial with either a single bolus or short-term infusion of baclofen should be done. and family to meet each individual patient’s needs. Decreased tone interfering with function during the trial of intrathecal baclofen is not a contraindication to pump implantation. and ease of drug administration. the management of spasticity in children is not one of the labelled indications for use. haematoma.108.110 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). and diazepam are examples of the most frequently prescribed medications. 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. erosion. F. tizanidine. rupture. Adapted from Arnon et al. injections of botulinum toxin are associated with fewer complications. 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. however.com For personal use. and pumps must be refilled with drug at a minimum of every 3 months. the pumps are programmed with input from the therapist. generalised spasticity in appropriately selected patients with spasticity and movement disorders. 2001. and seizure medications. The frequency of pump refills is mandated by the fluid capacity of the pump and the limited stability of baclofen in solution. toxin C affects both SNAP-25 and syntaxin. decubitus. and G cleave selective dorsal rhizotomy are used to synaptobrevin. . possible permanent muscle SNARE fibrosis. botulinum toxins. however.110–113 Phenol and alcohol are non-selective proteolytic agents and produce selective denervation when injected into motor nerves or muscles. blockage. intrathecal baclofen and containing vesicle to the cell membrane and release of the neurotransmitter. spastic quadriparesis in non-ambulatory patients that interferes with function. and dysaesthesias lasting for proteins SNARE several weeks. phenol (3–7%). activities of daily living. whereas phenol denervation lasts 4–8 months. Release of acetylcholine produces muscle contraction.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. Toxins A and E cleave SNAP-25. Intrathecal infusion of baclofen is effective in reducing tone. is reported to improve speech. painful or function-limiting dystonia. The duration of denervation associated with alcohol injection is 3–6 months. and syntaxin) are necessary for fusion of the acetylcholinespasticity. In addition to decreasing spasticity in the legs. D. toxins B. non-selective protein denaturation. A successful trial supporting implantation of a baclofen pump is defined as a reduction of at least 1 point on the Ashworth spasticity scale. Replacement of pumps is required every 5–7 years. the short half-life of the drug means that it has to be infused continuously for optimum spasticity management. the pump can be adjusted to deliver one dose of drug during sleep and to lower the dose during the day to facilitate function. Because diffusion of both is limited. Alcohol and phenol injections also are used to assess the effect of spasticity reduction in potential candidates for surgery.104 To test whether intrathecal baclofen is suitable. arm and leg spasticity interfering with function. Orally administered medications used to treat spasticity include GABA agonists. and spasticity interfering with carers’ support activities in nonfunctional children. alcohol. Once a pump is implanted. Complications associated with intrathecal baclofen can be caused by the pump placement (seroma. the criteria to identify the best candidates for this therapy have not been defined completely. infection) or the catheter (migration. Indications for alcohol and phenol injections include spasticity.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. For example. Acetylcholine Syntaxin receptor greater reversibility of effects. 2-adrenergic agonists.104 Intrathecal baclofen is an effective treatment for management of severe. wound breakdown.107–109 and alcohol (45–100%). and decreased function.106 The level of catheter placement within the spinal cord can be adjusted to modulate the effects on arm versus leg control of tone. Failure to produce an effective synaptic manage more widespread spasticity. Baclofen.69 fusion complex prevents vesicle attachment and the release of acetylcholine and produces flaccid The amount of toxin injected into paralysis. muscle relaxants. The participation of parents.
double-blind dose-ranging studies have examined the effects of various doses of Botox125 or Dysport118. postoperative or post-treatment pain control.32 Common reported sideeffects include muscle soreness. single-blind trial confirmed these findings. 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.thelancet.128 One trial assessed whether toxin injections were more effective when given before or after casting.32.130 The combination of toxin Figure 4: Schematic representation of the technique of selected dorsal rhizotomy A: after laminectomy. hamstring tightness. although functional changes were negligible.120 Patients receiving toxin showed increased range of motion and decreased tone. the facet joints are excluded. if possible. Although there are no standard guidelines on doses in children.116 The doses of these two commercial preparations are not interchangeable.SEMINAR formulation of the toxin.52.5 and drooling reduction. Only reproduce with permission from The Lancet. infection. Botox is used most commonly in concentrations of 50 U/mL or 100 U/mL. and the duration of its effect is speculative. The rootlets are stimulated so that abnormal rootlet activity can be identified.135 Surgical reduction of spasticity The use of selective dorsal rhizotomy for spasticity management was first reported in cerebral palsy in 1981.136 This operation decreases spasticity by balancing spinalcord-mediated facilitory and inhibitory control (figure 4). Botox is approved and licensed for use in cerebral palsy in 44 countries. Doses of 2–6 U/kg bodyweight per muscle with a maximum total dose of 29 U/kg have been reported. as measured by gait analysis. This procedure involves stimulation and transection of selective posterior rootlets or arbitrary transection of a specific proportion of rootlets.5 Botulinum toxin A has an excellent safety profile with a low frequency of side-effects. UK). as a diagnostic trial. One study investigated the effect on arm range of motion and function.116 Overall.126 on gait measures in patients with cerebral palsy. The current practice is to inject several muscles at each injection session. B: a proportion of rootlets are transected.69.127. The procedure requires a laminectomy at L2–L5. Subsequent selective dorsal rhizotomy THE LANCET • Vol 363 • May 15.124 The final randomised. Two prospective. double-blind. double-blind. rash.118. with smaller patients receiving higher doses than reported in the past. influenza-like symptoms.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.94 However.129 Slightly better outcomes. . and the size and weight of the patient. 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. injections and use of a hip orthotic improved gait compared with physiotherapy and “best practice” in a randomised prospective trial. 2004 • www.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.126 Indications for intramuscular botulinum toxin A injections in patients with cerebral palsy include: dynamic deformity interfering with function. easing of the burden on carers. to prevent spinal-column instability and secondary deformity.117 a review of previous publications indicates that the dose that has been used for children with cerebral palsy has increased over time.119 Three randomised. Reproduced with permission from Wake Forest University Orthopaedic Press.120–123 Patients who received toxin injections responded with improved ambulatory status. were observed in patients whose casts were applied after the toxin injections. the size of the muscle. scissoring. excessive weakness. symptomatic focal dystonia. placebo-controlled trials have shown the efficacy and safety of botulinum toxin A in the management of spasticity associated with cerebral palsy. and improved health-related quality of life.52.5 1 U Botox is equivalent to about 3–5 U Dysport. Dysport is not approved for use in the USA. painful spasticity with or without fixed muscle contracture. 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. Two formulations of botulinum toxin A are available for intramuscular injection: Botox (Allergan. muscle imbalance producing or contributing to skeletal deformity. producing pain. both Dysport and Botox have a satisfactory safety profile. The recommended dose of Dysport for children is 30 U/kg bodyweight up to a maximum of 1000 U. although it is not approved for management of spasticity associated with cerebral palsy by the Food and Drug Administration in the USA. In these studies. Irvine. the optimum dose is unknown.121. the dura is opened and the dorsal spinal rootlets are exposed. USA) and Dysport (Ipsen Limited. Maidenhead.5 Seven randomised.68 Type B toxin is a different serotype from type A toxin and is commercially available as Myobloc (USA) or Neurobloc (Europe).118. there are no peer-reviewed publications describing its use.131 Other prospective data support the use of botulinum toxin A in the management of crouched gait. the higher doses of the preparations were more effective in improving gait measures than the lower doses. fatigue. or contributing to progressive deformity. Berkshire. since they are ineffective in this case.68 Although type B toxin has been used for spasticity management in cerebral palsy.132.com 1625 For personal use. CA.118–123 Five of the studies assessed the effect of toxin injections on leg spasticity in ambulatory patients with cerebral palsy. and allergic reaction. A second randomised. pain on injection. the number of neuromuscular junctions in the muscle.
100 Progression of curves beyond 50° is frequent.SEMINAR approaches have used two-level laminectomies. No randomised controlled studies have identified optimum surgical combinations or supported the use of one surgical option over another. overlengthened tendons. or stabilise spinal deformity.141 whereas others believe that it causes accelerated hip subluxation. kyphosis and lordosis are not associated with significant comorbidity. less commonly. tenotomy.139 A meta-analysis of three randomised. comorbidities. restore. In 1995.151 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. many patients require orthotics and long-term physiotherapy to achieve the best outcome.138 Because transient muscle weakness is observed after the procedure. dystonic. with the rate approaching 60–75% in patients with severe involvement and quadriplegia. controversy remains over whether selective dorsal rhizotomy reduces the need for subsequent orthopaedic procedures.142 increases pelvic tilt in ambulatory patients. Other outcomes included muscle strength.146 Therefore. 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. Preoperative discussions with the patients’ parents or carers 1626 THE LANCET • Vol 363 • May 15.144 Furthermore. refractory spinal deformity. diminish painful spasticity.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. ataxia. Some researchers believe that early use of the procedure reduces the need for orthopaedic procedures. The irreversibility of the procedure dictates caution when this therapeutic modality is chosen. and lordosis) are associated with cerebral palsy. fuse unstable joints by arthrodesis. Renshaw and colleagues100 stated that “rhizotomy is not indicated in the presence of athetosis. Neuromuscular blockade of the concave paraspinal musculature has been attempted with varying success (anecdoctal reports). 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.140 In addition.146 Conversely. No randomised prospective trials comparing surgery with observation have been published. good strength. balance joint forces. The natural course of a specific musculoskeletal deformity should be factored into the surgical decision-making process. Spinal deformity Deformities of the spine (scoliosis. muscle weakness. 2004 • www.147. pure spasticity. osteotomy. difficulty in sitting. 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.137.148 The natural course of scoliosis in cerebral palsy differs from that of idiopathic scoliosis and is characterised by curve progression after skeletal maturity. multisegmental spinal fusion. others prefer to operate on children older than 6–8 years. fixed contractures. dystonia. disease severity.139 Therefore. arthrodesis. fractional myotendinous lengthening. Only reproduce with permission from The Lancet. range of motion. with curves beyond 100° a risk factor for complications. 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. no fixed contractures.thelancet. cardiopulmonary compromise. and. diplegia.143 and exaggerates lumbar lordosis and speeds progression of scoliosis. no studies have compared two or more surgical procedures for the management of specific deformities. Furthermore. The primary outcome measure was the total score on the gross motor function measure. ostectomy. early and prompt treatment of hip subluxation at an earlier age is appropriate. and improves outcome in selected patients.149. no prospective trials have documented the effects of intrathecal baclofen on spinal biomechanics.151 Bracing of patients with neuromuscular scoliosis is unsuccessful in many cases. and painful arthritis. the observed improvement in motor function could not be explained by the intensive physiotherapy programme. and severe neurological involvement. untreated hip subluxation can progress to hip dislocation. Both an increase in lumbar lordosis and progression of scoliosis have been reported after rhizotomy144 and implantation of an intrathecal baclofen pump. tendon transfer. decreases the period of postoperative immobilisation and the rate of nonunion.148 Postoperative complications of spine surgery are common in patients with excessive curvature. Most of the indications for orthopaedic surgery in patients with cerebral palsy are based on retrospective reviews that include non-concurrent or historical controls. Patients with normal intelligence. nutritional compromise. 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. The surgical procedures should be individually adjusted according to the patient’s age. transfer motor power. or mixed). and deformity preventing adequate administration of care. Indications for surgery include progressive deformity producing pain or interfering with function. and physiological cost index. and paraspinal muscle-strengthening programmes do not improve outcome. muscle tone. pelvic obliquity. kyphosis. Orthopaedic surgery Long-established orthopaedic surgical procedures are designed to lengthen contracted myotendinous units. rigidity.145 For example. and maintain.70 However. 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. and postural stability have been identified as the best candidates for selective dorsal rhizotomy. and overall well-being.152 However. we have seen extreme hindfoot valgus and midfoot collapse in young children after the procedure. reduce joint subluxation and dislocation to improve joint congruency. . underlying pathology (spastic. Orthopaedic surgical techniques include neurectomy. tendon lengthening. electrical stimulation of the convex paraspinal musculature has not been successful.com For personal use. joint subluxation or dislocation.32 The ideal age and best technique for selective dorsal rhizotomy are unknown. interference with sitting.150 Progression of scoliosis can lead to pain. or severe fixed joint contracture”.148 The use of segmental spinal instrumentation improves correction. or a combination of these procedures. although the exact indications are difficult to define from the existing evidence. Although scoliosis can lead to serious outcomes. correct bony deformity to improve biomechanical alignment. Some surgeons undertake the procedure in children aged 2–4 years.100 The overall frequency of scoliosis in cerebral palsy is 25%.
knee flexion. and abductor pollicis longus.23 Intrathecal baclofen and rhizotomy can decrease arm spasticity and positively affect function. if present: joint stability (capsulodesis170 or arthrodesis158). anterior elbow release in selected patients reduces flexion posture angle without increasing maximum flexion. improve function.16 Furthermore. although contractures of 30–60° might benefit from surgical intervention. THE LANCET • Vol 363 • May 15. or rerouting of the pronator teres. However. to improve joint alignment or congruency. humeral osteotomy. wrist arthrodesis.171 dorsal release of the adductor and first dorsal interosseous from the first and second metacarpals. and volitional control. flexor tendon transfers to the wrist or digit extensors.157 However.158 Reduced sensitivity is common in patients with spastic arms as shown by deficits in stereognosis (97%). and joint reduction with capsulodesis. Leg surgery Surgical procedures for the legs are designed to improve ambulation.162 or plication. 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. and some sensibility.105. internal rotation of the hip.SEMINAR about the possible effect of pump placement on the progression of spinal deformity are imperative. Concomitant pump implantation and spinal fusion have been done in patients with pre-existing spine deformities.157. arthrodesis.158. Thumb-in-palm deformity is multifactorial. and humeral osteotomy. ankle equinus. to prevent or delay arthritis or progressive deformity. A deformity of less than 30° rarely justifies surgery. metacarpal phalangeal hyperextension or global instability. continuous electromyographic activity of the flexor carpi ulnaris supports the transfer of this muscle to the finger extensors rather than a wrist extensor. The procedure used depends on the patient’s age.164–167 Wrist extension can be improved by: transfer of a wrist flexor to a wrist extensor or finger extensor. joint congruency.169 Figure 5: Thumb-in-palm deformity The deformity is complex and can include: soft-tissue contracture of the thumb–index web. 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. hip adduction.thelancet. and to improve activities of daily living.157 Electromyography of the forearm muscles can facilitate the selection of the appropriate surgical option. Reproduced with permission from Wake Forest University Orthopaedic Press. 2004 • www. or both. skin contracture (four-flap Z plasty or skin graft158. to improve self-care and self-esteem. two-point discrimination (90%). decrease pain. movement disorders.168. splinting. and planovalgus foot deformity.159 Functional deficits are observed in 80% of limbs in children with hemiplegia and quadriplegia.153. tendon lengthening. or joint incongruity are candidates for soft-tissue procedures. neurectomy.16. to facilitate or decrease orthotic use. extrinsic motor imbalance with overlengthening and/or weakness of the extension pollicis longus. extensor pollicis brevis.162 Surgical procedures for thumb and finger deformities provide predictable beneficial results for children and adults who have spasticity. hip flexion.158. improves function. proximal row carpectomy. In general.162 lengthening or reinforcement of the flexor pollicis longus. The goals of these procedures are: to improve ambulation by improving quality of gait. some voluntary motor control. first dorsal interosseous. finger flexion deformity. tendon transfer.157. and proprioception (46%).96 Surgical options include tenotomy. and contracture of the first web space represent the most common thumb and finger deformities in patients with cerebral palsy (figure 5). or both (release of the origin of the adductor). capsulodesis.157 In general. decrease spasticity. For example. intrinsic motor contracture and spasticity. and surgical management of this deformity must therefore address the following.163 Osseous procedures are rarely indicated to manage elbow flexion. osteotomy. and improves appearance and selfesteem. lengthening.163 Forearm pronation deformity can be decreased by tenotomy. Postoperative care.com 1627 For personal use. is important for optimum surgical outcomes. and improve health-related quality of life. including hand therapy.153–156 Soft-tissue procedures are rarely successful in patients with movement disorders. or shoulder fusion. swan-neck deformity. others may need bony options. Arms Surgical management of the arms in patients with cerebral palsy is designed to correct muscle contracture. sensory reeducation.162 transfer of the adductor insertion to the metacarpal. and pronator flexor slide. patients with movement disorders who lack voluntary motor control and sensibility experience inconsistent postoperative results. to facilitate care. extent of motor involvement.158. to decrease pain by reducing spasticity. Z plasty of the biceps brachii. reduce deformity. Thumb-in-palm deformity. transfer of the extensor carpi ulnaris to the fourth metacarpal. and strengthening programmes. Shoulder fusion is rarely indicated. Patients with elbow flexion contractures of greater than 60° are candidates for surgery if the goals of patient and physician are reasonable. only 10–15% of these patients are candidates for corrective musculoskeletal surgery.158. increases active extension. intrinsic-muscle overactivity. transfer of the latissimus dorsi and teres major tendons to the lateral humerus. arthrodesis can improve outcomes in these patients. Weakening biceps function may exacerbate pronation deformities and must be factored into any surgical decision.158.158 By contrast. contracture of the adductor pollicis. Significant elbow flexion contracture can be decreased by any permutation of the following: brachialis fractional lengthening.162). neurectomy procedures are avoided.162 Deformities of the fingers can be managed by arthrodesis. and contracture and/or weakness of the flexor pollicis longus. Only reproduce with permission from The Lancet. bony architecture. rerouting. joint instability.160 A preliminary report of C8 root division documented reduced muscle tone in wrist and finger flexors.168 or a combination of these options.161 Shoulder internal rotation can be managed by: lengthening of the pectoralis major or subscapularis tendons.157. .156. or reinforcement of the extrinsic thumb extensors and abductors. flexor-pronator slide. release of the elbow capsule.162 Younger patients without arthritis. the extent of sensory loss does not correlate directly with the severity of the motor deficit. or intrinsic/extrinsic rebalancing.157. or facilitate care activities.
Blair E. Beckung E. lengthening of both the aponeurosis of the gastrocnemius and soleus. Rumeau-Rouquette C. Curr Opin Pediatr 1997. Alberman E.175 calcaneal lengthening. 44: 240–47. and reduction of discomfort. The most common combined deformity is hindfoot equinovalgus and midfoot pronation.178. Verrier A.22 Management of hip deformity is dictated by the extent of deformity and the time it has been present. 18: 278–81. Dev Med Child Neurol 2002. metatarsus primus varus. Prevalence and disabilities in 4 to 8 year olds with cerebral palsy. or rarely neurectomy. Prevalence and health impact of developmental disabilities in US children. Cerebral palsy. Rumeau-Rouquette C. In patients under the age of 7 years. 194–95. Curr Opin Neurol 2000. A painful dislocated hip is commonly treated by non-operative management (analgesics. and supination or pronation of the midfoot-forefoot complex. Vandenbussche E. du MC. Pediatrics 1998. Murphy CC. 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. 40: 369–75. Balkrishnan R. 42: 816–24. Health status of school-aged children with cerebral palsy: information from a population-based sample.172–174 Equinus ankle deformity can be complicated by coexisting deformities including hindfoot varus. Grandjean H. and sensory disabilities on survival in cerebral palsy. Grether JK.183. Cans C. tendon transfer. anti-spasticity drugs) is unsuccessful. Int J Epidemiol 1997. Dabney KW. Morb Mortal Wkly Rep CDC Surveill Summ 1996. analgesics.177 articular or extra-articular subtalar fusion. Smith BP. Yeargin-Allsopp M. Etiologic factors in cerebral palsy. lengthening of the gastrocnemius aponeurosis alone. Willoughby RE. et al. du MC. Nelson KB. Trends in mortality and cerebral palsy in a geographically based cohort of very low birth weight neonates born between 1982 to 1994. 5: 11–23. Dev Med Child Neurol 1998. Sensibility deficiencies in the hands of children with spastic hemiplegia. 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. including the technical success of surgical procedures. Holmgreen P. 9: 81–88. improve function. Elliott M. Development of bladder control in children and adolescents with cerebral palsy.180 Rotational or torsional deformities can be managed by rotational osteotomy of the tibia. recurrence of this deformity is possible in children who undergo surgery before they are 10 years old. Van Heest AE. Cerebral palsy.185 Medial and lateral hamstring lengthening combined with psoas lengthening decreases pelvic tilt. Dev Med Child Neurol 2001. Evans P. Arch Dis Child 2002. Doernberg NS. fibula. hallux valgus.190 Onestage comprehensive hip reconstruction is an effective treatment for children aged 4 years or older who have a migration index greater than 60%. O’Shea TM. Hagberg G. Life expectancy of adults with cerebral palsy. hip subluxation with scissoring is initially managed by: adductor tenotomy alone. Coene S. Dillard RG. control of movement disorders and deformity. Pediatr Ann 1986. Pharoah PO. and anterior branch obturator neurectomy—are most effective in patients with stable hips without bony deformity. Only reproduce with permission from The Lancet. Preisser JS. 13: 133–39. Boyle CA. or femur to correct foot progression angle. Rosenbaum P. Kennes J. Stanley E.com For personal use. Int J Epidemiol 1992. De Rammelaere M. inflammation and the risk of cerebral palsy. Surgical procedures of the hip are designed to improve abduction (decrease scissoring). Vanderkelen R. functional status. or total joint replacement if nonoperative management (anti-inflammatory dugs. Roijen LE. 15: 191. Nelson KB. Hutton JL. 44: 370–82.187 combined adductor tenotomy and iliopsoas lengthening. and improve self-esteem in these patients.174.181 Knee joint contractures require capsulotomy182 and associated.189 In older children. 26: 137–45. Neuroimpairments. Decoufle P. inappropriate coexisting contraction of the rectus femoris might require release or transfer of the rectus femoris to the iliotibial band or a medial hamstring. Prevalence and time trends of disabilities in school-age children. the development of techniques to strengthen and improve motor power. Surveillance of cerebral palsy in Europe: a collaboration of cerebral palsy surveys and registers. hindfoot valgus. Vanneste G. activity limitations. 21: 359–66. N Engl J Med 1994. Paediatr Drugs 2003.SEMINAR The most commonly reported procedures used to correct equinus ankle and foot deformity include lengthening of the Achilles tendon. How common are the cerebral palsies? In: Cerebral palsies: epidemiology and causal pathways.190 The Reimer’s migration index describes the amount of the femoral head that is subluxated out of the acetabulum expressed as a percentage. Postema K. Paneth N. 43: 103–07. Lipton GE. Spasticity associated with cerebral palsy in children: guidelines for the use of botulinum A toxin. positively affect health-related quality of life. Limbeek VJ. Dev Med Child Neurol 2002. Mlika A. J Hand Surg [Am] 1993.186 Many non-ambulatory patients with cerebral palsy are characterised by hip instability that is associated with hip pain and difficulties with walking and sitting. Hanna SE. Motor disability in children in three birth cohorts. instruments that can be used to assess multiple outcomes of various therapeutic options. 2000: 22–39. Pediatrics 1994. The availability of validated and reliable outcome 22 1628 THE LANCET • Vol 363 • May 15. and the identification of surgical procedures to correct deformities will provide resources that can be used to modify untoward natural histories. to prevent hip subluxation. Causes of cerebral palsy. Alberman E. 1991. Schendel DE. Dev Med Child Neurol 2000.70. Effects of cognitive. Koman LA.thelancet. 11: 487–91. Dequae L. House J. transfer of the Achilles tendon. 60: 940–45. Prevalence of selected developmental disabilities in children 3-10 years of age: the Metropolitan Atlanta Developmental Disabilities Surveillance Program. 2004 • www. will facilitate the appropriate evaluation of the interventions currently used to manage children and adults with cerebral palsy. Refractory valgus deformity can be corrected by: medial displacement osteotomy of the calcaneus. Curr Opin Pediatr 1999. Cerebral palsy in multifoetal pregnancies. Varus deformity can be managed by tendon lengthening. and participation restrictions in children with cerebral palsy.174. Surgical options to treat painful dislocated hips include resection of the femoral head. Arch Dis Child 1985. or to restore hip joint congruency. adductor transfer. Crouched gait and knee flexion deformities are corrected by medial or combined medial and lateral hamstring lengthening procedures. Dev Med Child Neurol 2002. 330: 188–95. Boyle CA. anti-inflammatory drugs. References 1 2 Kuban KC. Current management models are patient-centred and are focused on modification of spasticity. 45: 1–14. or calcaneal osteotomy. Evans S. London: MacKeith Press. Kuppevelt VH. 197–201. iliopsoas release or recession. The availability of oral and parenteral drugs. Blickstein I.188 or less commonly. 101: 642–47. Putnam M. abduction osteotomy of the proximal femur. Stiers P. Cans C. the ability to alter spasticity with surgical procedures.179 or triple arthrodesis. Infection. 44: 352–55. Klinepeter KL.176. however.184 Proximal hamstring lengthening is effective in the treatment of knee deformities in nonambulatory children. . Dev Med Child Neurol 2002. motor. health-related quality of life. 44: 309–16. Strauss D. Yeargin-Allsopp M. Visual-perceptual impairment in a random sample of children with cerebral palsy. or antispasticity medications). Leviton A. Femoral osteotomy can improve hip coverage during stance. Soft-tissue procedures—adductor tenotomy. Shavelle R. 93: 399–403. and utility. 86: 84–89. Miller F.
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