Journal of Pediatric Rehabilitation Medicine - Volume 16, issue 1
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The Journal of Pediatric Rehabilitation Medicine (JPRM): An Interdisciplinary Approach Throughout the Lifespan is designed to parallel the multidisciplinary teams caring for children, adolescents and adults with childhood-onset physical disabilities and complex care needs worldwide. Published quarterly, topics include, and are not limited to, cerebral palsy, traumatic brain injury, spinal cord injury, spina bifida, limb deficiency, muscular dystrophy, stroke, cancer, developmental delays, and rare disorders. Furthermore, the journal welcomes papers dedicated to pediatric rehabilitation from a global health perspective.
The aim of JPRM is to engage a diverse group of international experts with the goal of providing readers with comprehensive information regarding children and adolescents requiring rehabilitation. JPRM brings together specialists from medicine, nursing, psychology, social work, nutrition, child life, family centered care, and occupational, physical, and speech therapy. For manuscript submissions, authorship involving at least two different specialties is encouraged, although not required, to facilitate a transdisciplinary and collaborative approach. Manuscripts are blinded and peer reviewed including biostatistical analysis. Authors are invited to submit original research, systematic and scoping reviews, guidelines, protocols, care pathways, case reports, book reviews, commentaries, editorials, and dates for future conferences.
Abstract: PURPOSE: The goal of this retrospective chart review study was to explore factors that contributed to consideration of or actual pump explantation in pediatric patients with intrathecal baclofen (ITB) pumps. METHODS: Medical records of 30 patients with ITB pumps were reviewed. Quantitative data, including demographic, clinical, psychosocial, and service utilization variables were culled from the records. Qualitative data were collected from clinic visit notes, pump-related follow-up phone calls, and any pump-related emergency room visits. RESULTS: Of those reviewed, six underwent ITB pump explantation, and two considered explantation. Factors contributing to pump explantation or consideration of explantation…included the following: postoperative infection, pump malfunction, non-adherence, anxiety/behavioral factors impacting the patient’s tolerance of the pump, distance to the medical provider, frequency of required pump refill appointments, lack or perceived lack of intrathecal baclofen effect, and difficulty transitioning to adult care providers. CONCLUSION: Due to the complex care regimen associated with ITB pumps and various psychosocial and logistical factors that impact treatment success, a standardized multidisciplinary pre-implantation education, screening, and assessment process should be developed. Such a process would ensure that patients/families receive appropriate education, including proactively identifying treatment barriers and potential complications, possibly minimizing dissatisfaction with treatment and the need for explantation.
Abstract: PURPOSE: The purpose of this study was to evaluate the effectiveness of intrathecal morphine following selective dorsal rhizotomy in pediatric patients previously diagnosed with cerebral palsy. METHODS: This was a retrospective, cohort analysis over the course of four years. The analysis consisted of a treatment group which received intrathecal morphine (5 mcg/kg) injection and a control group that did not receive the injection prior to dural closure. All patients underwent multilevel laminectomies for selective dorsal rhizotomy at Akron Children’s Hospital. The effectiveness of the treatment was measured by total dose of hydromorphone administered on patient-controlled analgesia (PCA), number…of days on oral narcotics, and cumulative dose of oral narcotic. RESULTS: Of the analyzed 15 pediatric patients, seven patients received intrathecal morphine injection while the other eight did not receive the treatment prior to dural closure. There was a difference of 1135 mcg in total PCA dose between the study group (3243 mcg) and the control group (4378 mcg). The total PCA dose based on weight was lower in the study group (163 mcg/kg) than in the control group (171 mcg/kg). CONCLUSION: Based on these findings, the administration of intrathecal morphine clinically reduces the opiate need in the first 96 hours post-operatively.
Abstract: PURPOSE: The incidence of dystonic cerebral palsy causing significant morbidity is on the rise. There is a paucity of evidence for the management of dystonia in children. METHODS: Forty-one children aged 6 months-5 years with predominantly dystonic cerebral palsy were started on a predetermined protocol of trihexyphenidyl (0.25–0.52 mg/kg) and followed up at 3, 6 and 12 weeks. Dystonia severity, motor function and developmental age at baseline and 12 weeks were compared using the Global Dystonia Scale (GDS), the Gross Motor Function Measure (GMFM), and Fine Motor/Perceptual Subscale of the Early Developmental Profile-2. Thirty-four children completed the entire 12…weeks of intervention. RESULTS: The mean age of participants was 25±11 months. A significant decrease in median total dystonia scores on the GDS was observed post-intervention (74.5 to 59, p < 0.0001), and 64% of participants gained motor milestones. GMFM scores increased significantly from a median of 19.8% pre-intervention to 26.5% post-intervention (p < 0.0001). There was improvement in the fine motor domain as compared to the baseline (p < 0.0001). The number of children classified at Gross Motor Function Classification System levels 1 and 2 increased to 47.05% from 5.88% in the pre-intervention group. CONCLUSION: Trihexyphenidyl significantly improved dystonia, motor function and development in children with dystonic cerebral palsy in this study. Additional studies are needed to clarify its role in larger numbers of children with this condition.
Abstract: PURPOSE: This study aimed to explore the feasibility of using time-matched uniaxial accelerometers for measuring movement in daily life in children with cerebral palsy (CP) before and after botulinum toxin injections. METHODS: This observational study of clinical care with a pre-post design was set in the home and school environment. Participants included eleven children (4–13 years of age) with CP (GMFCS I-III). The children wore uniaxial accelerometers (ActiGraph, model GT1M) for 4 days on both wrists, the right ankle and around the waist before, 3 weeks and 3 months after BoNT-A injections in the legs. Five children also…got BoNT-A in the most affected arm. All injections were given according to clinical indications and routine. The accelerometers were all time-matched to define ambulation, arm swing, voluntary activity of arms, and bimanual activity. The feasibility of wearing accelerometers with this setup was evaluated. A linear mixed model was used for analysis of the percentage time and at which intensity the different activities were performed. The confidence interval demonstrated any difference between the dominant and non-dominant arm. RESULTS: Time-matching of accelerometers placed on both wrists, the waist, and one ankle is a feasible method of registering ambulation, arm swing during gait, and arm movements while not ambulating. Before injections, the children spent 5.6% of their time ambulating. This value declined to 3.9% at 3 months. Contrary to clinical goals, arm movement did not increase after injecting the most affected arm with BoNT-A, however, injections may have decreased mirror movements, which are often bothersome for the child. CONCLUSION: A time-matched 4-accelerometer set-up is feasible in children with cerebral palsy. A future study including time-matched multi-axial accelerometers on all four limbs, could provide important information on the effect of BoNT-A in daily life.
Keywords: Accelerometry, adolescent, botulinum toxins, Type A, cerebral palsy, child, extremities
Abstract: PURPOSE: This study aimed to examine outpatient hospital utilization (number of specialties seen and number of visits to each specialty) in the year after single event multi-level surgery (SEMLS) in children with cerebral palsy (CP), and to determine if utilization differs across the medical center in the year after compared to the year before SEMLS. METHODS: This retrospective cross-sectional study used electronic medical record data of outpatient hospital utilization in children with CP who underwent SEMLS. RESULTS: Thirty children with CP (Gross Motor Function Classification System Levels I–V, mean age of 9.9 years) were included. In…the year after surgery, a significant difference (p = 0.001) was found for the number of specialties seen, with non-ambulatory children seeing more specialties than ambulatory children. No statistically significant difference was found between the number of outpatient visits to each specialty in the year after SEMLS. Compared to the year before SEMLS, fewer therapy visits occurred in the year after SEMLS (p < 0.001) but significantly more visits to orthopaedics (p = 0.001) and radiology (p = 0.001). CONCLUSION: Children with CP had fewer therapy visits but more orthopaedic and radiology visits the year after SEMLS. Nearly half of the children were non-ambulatory. Examination of care needs in children with CP undergoing SEMLS is justified with consideration of ambulatory status, surgical burden, and post-operative immobilization.
Keywords: Cerebral palsy, single event multi-level surgery, surgical burden
Abstract: PURPOSE: This study evaluated the effects of an instrumented balance board on the balance parameters in children with spastic cerebral palsy by carrying out a pilot single-group pre-post clinical trial. METHODS: Five children aged 5 to 15 years with spastic diplegia and a Gross Motor Function Classification System level of I or II were included. All participants attended 20 sessions with an instrumented balance board, 45 minutes per session, 3 times a week for 7 weeks. The main outcome measures included the center of pressure excursion, velocity, and overshoot during quiet standing with open and closed eyes. The…assessments were performed in the mediolateral and anteroposterior directions at pre- and one week post-intervention. RESULTS: Non-parametric tests showed that the excursion did not change significantly except in the mediolateral direction with eyes closed (p < 0.05). The velocity of the center of pressure improved in both directions and eye conditions (p < 0.05). Also, the maximum velocity decreased with eyes open (mediolateral, anteroposterior, and total) (p < 0.05), while the change was not significant with the eyes closed. The overshoot measurements did not change significantly. CONCLUSION: It is recommended to consider balance board training for improving balance parameters in children with cerebral palsy.
Keywords: Cerebral palsy, spastic, balance board, balance, center of pressure, rehabilitation
Abstract: PURPOSE: In children with cerebral palsy (CP), gastrocnemius muscle spasticity may lead to pes equinus posture which causes insufficient ankle joint dorsiflexion for normal gait. The aim of this study was to analyze the stiffness of gastrocnemius and tibialis anterior muscles by shear wave elastography (SWE) in children with pes equinus deformity due to spastic CP. METHODS: 24 legs of 12 children (6 females and 6 males, mean age 45.8 months) with CP were prospectively included in the study. Tissue stiffness quantification with shear-wave velocity (SWV) was analyzed. RESULTS: The mean SWVs of the gastrocnemius and…tibialis anterior muscles were 3.91±0.26 m/s and 2.67±0.18 m/s, respectively. The stiffness of the gastrocnemius muscle was significantly higher than the stiffness of the tibialis anterior muscle (p < 0.0001). There was no correlation between the stiffness of these muscles (r = 0.129, p > 0.05). CONCLUSION: Gastrocnemius muscles were stiffer than tibialis anterior muscles in patients with spastic CP. But stiffness between these muscles was not correlated with each other. Pes equinus may be related to stiff gastrocnemius in these patients. This study demonstrates the clinical potential for SWE as a non-invasive tool for analyzing calf muscle stiffness.
Abstract: PURPOSE: The aim of this study was to assess serum vitamin D levels and related factors in children with cerebral palsy (CP). METHODS: One hundred and nineteen children with CP between the ages of 1 year to 10 years 9 months who were admitted to the children’s inpatient rehabilitation unit of a tertiary rehabilitation hospital between January 1, 2017, and December 31, 2018, were included in this study. Demographic and clinical characteristics were obtained from the patient files. CP types and serum 25 hydroxyvitamin D (25OHD) levels were recorded. Gross Motor Function Classification System (GMFCS) was used to…assess the functional level. RESULTS: Mean age was 5.1±2.9 years. Forty-two (35.3%) were girls, 105 (88.3%) were spastic, and 14 (11.7%) were ataxic and mixed type CP. Mean GMFCS level was 4 (IQR:2). Thirty-one (26.1%) were getting extra liquid feed while the rest were eating a normal diet. Mean serum 25OHD level was 27.4±15.7 (3–79) ng/mL. Vitamin D levels were normal in 68 children (57.1%), whereas 36 (30.3%) had vitamin D insufficiency and 15 (12.6%) showed vitamin D deficiency. Those whose serum vitamin D levels were within a normal range had a median age of 3.8 (IQR:4.2) years. On the other hand, mean age was 6.4 (4.3) years for those with low vitamin D level (p < 0.0001). Vitamin D level was 19.8 (21.4) ng/mL in those (n = 88) who had regular diets, whereas it was 31.0 [16 ] ng/mL in those (n = 31) who were getting extra liquid feed (p = 0.015). There was no statistically significant correlation between vitamin D level and gender, GMFCS, CP type, season or antiepileptic drug treatment. A binary logistic regression model showed that older age and having only regular meals were significant risk factors for low vitamin D. CONCLUSION: In this study, 42.9% of the children with CP had low vitamin D. Older children with CP or those who had regular diets were higher risk groups in terms of low vitamin D.
Abstract: PURPOSE: Cerebral palsy is a common pediatric neurological problem that has multiple comorbidities, including nutritional issues. Hematological and biochemical parameters significantly affect the health status of patients with cerebral palsy, and till now very few studies have analyzed these parameters. This study aimed to describe the hematological and biochemical parameters of children diagnosed with cerebral palsy. METHODS: This four-year observational study included children with cerebral palsy who were admitted to the Department of Pediatrics of a medical college teaching hospital. Hemoglobin, platelet count, white blood count (WBC), red blood cells (RBCs), packed cell volume, RBC indices, and biochemical…parameters (urea, creatinine, total bilirubin, total protein, albumin, globulin, aspartate transaminase, alanine transaminase, electrolytes, calcium and alkaline phosphatase) were noted and values (mean, standard deviation, and interquartile range) presented. Age and gender-based analyses were performed. RESULTS: The average hemoglobin level was 11.48 mg/dl, platelet count was 301.24×109 /L, and WBC count was 11.13 109 /L. Anemia was observed more commonly in males younger than nine years of age. Of 282 patients, 14 (4.96%) had a platelet count of less than 150×109/L. Abnormal alkaline phosphatase levels were observed more commonly in patients who were younger than nine years of age and in females more than males, and the difference was statistically significant. Protein levels and calcium levels were similar between both age groups. CONCLUSION: Anemia was more common in younger patients and males with cerebral palsy. Abnormal bone turnover markers (alkaline phosphatase) were more common in young patients and females with cerebral palsy. Understanding the differential effect of age and gender on various investigational parameters will help improve care of children with cerebral palsy by initiating appropriate and timely clinical interventions, thereby providing a better quality of life.
Abstract: Music is an art form that strongly affects people and can elicit many different emotions at the same time, including happiness, anxiety, sadness, and even ecstasy. What is it about music that causes such a strong reaction from each of us? Music engages many senses, which in turn can produce a multiplicity of responses and help create more extensive neuronal connections, as well as influence behaviour through structural and functional changes in the brain. Music-based interventions as a therapeutic tool in rehabilitation are becoming more common. It is said that the impact of music on the human body is positive.…However, what impact does music have on the young nervous system, especially the affected one? This review presents the advantages and disadvantages of the use of music in paediatric neurology to treat dyslexia, cerebral palsy, and stroke, among others. Potential negative impacts such as musicogenic epilepsy and hallucinations will be discussed.
Keywords: Music, music therapy, brain, neuroplasticity, children and adolescents, neurological disorders