Cerebral Palsy Research- September 2012

miamane — Mon, 03 Dec 2012 17:06:19 +0000

The Cerebral Palsy Alliance has compiled the attached list of the latest cerebral palsy research articles, as indexed in the NCBI PubMed (Medline) and Entrez (GenBank) databases for the week ending September 2012

1. Dev Med Child Neurol. 2012 Sep;54 Suppl 6:1-82. doi: 10.1111/j.1469-8749.2012.04386.x.

Abstracts of the American Academy for Cerebral Palsy and Developmental Medicine 66th Annual Meeting.

September 12-15, 2012. Toronto, Canada.

[No authors listed]

PMID: 22925270 [PubMed - indexed for MEDLINE]

2. Phys Occup Ther Pediatr. 2012 Sep 7. [Epub ahead of print]

Amount and Focus of Physical Therapy and Occupational Therapy for Young Children with Cerebral

Palsy.

Palisano RJ, Begnoche DM, Chiarello LA, Bartlett DJ, McCoy SW, Chang HJ.

Department of Physical Therapy and Rehabilitation Sciences, Drexel University , Philadelphia, Pennsylvania ,

USA.

The aims of this study were to describe physical therapy (PT) and occupational therapy (OT) services for a cohort

of 399 children with cerebral palsy (CP), 2-6 years old, residing in the United States and Canada. Parents

completed a services questionnaire by telephone interview. Therapists classified children’s Gross Motor Function

Classification System (GMFCS) level. Mean minutes per month of PT and OT were greater for children receiving

services in both an educational and clinic setting. Mean minutes per month of PT and OT were greater for children

in levels IV-V than children in level I and greater for children in the United States than children in Canada. Parents

reported that interventions focused a moderate to great extent on primary impairments, secondary impairments,

activity, and structured play activities, a moderate extent on environmental modifications and equipment; and a

moderate to small extent on self-care routines. The results support the importance of coordination of PT and OT

services.

PMID: 22954372 [PubMed - as supplied by publisher]

September 2012

Cerebral Palsy Alliance

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Interventions and Management

Cerebral Palsy Alliance is delighted to bring you this free bulletin of the latest published research into cerebral

palsy. This special issue covers the month of September 2012.

Our organisation is committed to supporting cerebral palsy research worldwide – through information,

education, collaboration and funding. This free weekly bulletin is just one of our activities. Please find out more

at www.cpresearch.org.au

Professor Nadia Badawi

Macquarie Group Foundation Chair of Cerebral Palsy

PO Box 560, Darlinghurst, New South Wales 2010 Australia

Cerebral Palsy Alliance

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3. Disabil Rehabil. 2012 Aug 28. [Epub ahead of print]

Combining strength training and botulinum neurotoxin intervention in children with cerebral palsy: the

impact on muscle morphology and strength.

Williams SA, Elliott C, Valentine J, Gubbay A, Shipman P, Reid S.

School of Sport Science, Exercise & Health.

Purpose: Investigate the combination effects of strength training and Botulinum Toxin Type-A (BoNT-A) on muscle

strength and morphology in children with Cerebral Palsy (CP). Methods: Fifteen children receiving BoNT-A,

classified as Spastic Diplegic CP, GMFCS I-II, and aged 5-12 years were recruited for this study. Randomly

allocated to 10 weeks of strength training either before or after BoNT-A, children were assessed over 6 months.

Eight of the 15 children also completed a control period. The Modified Ashworth Scale measured spasticity. The

Goal Attainment Scale (GAS) assessed achievement of functional goals. Magnetic Resonance Imaging assessed

muscle volume (MV). Instrumented dynamometry assessed strength. Results: Spasticity was significantly reduced

following BoNT-A injection (p = 0.033). Children made significant isokinetic strength gains (mean p = 0.022, ES =

0.57) in the intervention period compared to the control period (mean p = 0.15, ES = 0.56). Irrespective of timing,

significant strength improvements were seen immediately (10 weeks) and over 6 months for all children. This was

also the case for improvements in the GAS (immediately: mean p = 0.007, ES = 4.17, 6 months: mean p = 0.029,

ES = 0.99), and improvements in MV in all assessed muscles. Conclusion: The simultaneous use of BoNT-A and

strength training was successful in spasticity reduction, improving strength and achieving functional goals, over and

above treatment with BoNT-A alone. Muscles targeted for BoNT-A injection should be included in strength training.

PMID: 22928803 [PubMed - as supplied by publisher]

4. J Pediatr Orthop. 2012 Sep;32 Suppl 2:S182-6.

Management of Children With Ambulatory Cerebral Palsy: An Evidence-based Review. Commentary by

Hugh Williamson Gait Laboratory Staff.

Thomason P, Rodda J, Sangeux M, Selber P, Kerr Graham.

* Hugh Williamson Gait Laboratory, The Royal Children’s Hospital † Murdoch Childrens Research Institute,

Parkville ‡ Department of Paediatrics, The University of Melbourne, Carlton, Vic., Australia.

The evaluation of complex interventions, such as Single Event Multilevel Surgery (SEMLS) requires more than

randomized controlled trials. Rehabilitation following SEMLS is prolonged and the outcomes of interest may not be

apparent for 5 years or more after the surgery. We suggest long term, prospective cohort studies with objective

outcome measures be recognized as of equal importance to randomized controlled trials. The evidence in support

of instrumented gait analysis (IGA) is also reviewed. We suggest that clinical levels of evidence are not an

appropriate method to evaluate a measurement tool. Specifically, IGA should be evaluated in terms of validity,

reliability and cost effectiveness. We demonstrate that the use of IGA has improved medium and long term

outcomes in ambulant children with cerebral palsy in a center where IGA has been used routinely both for planning

SEMLS and for monitoring outcomes.

PMID: 22890459 [PubMed - in process]

5. PLoS One. 2012;7(8):e40686. Epub 2012 Aug 16.

Transcriptional abnormalities of hamstring muscle contractures in children with cerebral palsy.

Smith LR, Chambers HG, Subramaniam S, Lieber RL.

Department of Bioengineering, University of California San Diego, La Jolla, California, United States of America.

Cerebral palsy (CP) is an upper motor neuron disease that results in a spectrum of movement disorders.

Secondary to the neurological lesion, muscles from patients with CP are often spastic and form debilitating

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contractures that limit range of motion and joint function. With no genetic component, the pathology of skeletal

muscle in CP is a response to aberrant complex neurological input in ways that are not fully understood. This study

was designed to gain further understanding of the skeletal muscle response in CP using transcriptional profiling

correlated with functional measures to broadly investigate muscle adaptations leading to mechanical deficits.

Biospsies were obtained from both the gracilis and semitendinosus muscles from a cohort of patients with CP (n?=?

10) and typically developing patients (n?=?10) undergoing surgery. Biopsies were obtained to define the unique

expression profile of the contractures and passive mechanical testing was conducted to determine stiffness values

in previously published work. Affymetrix HG-U133A 2.0 chips (n?=?40) generated expression data, which was

validated for selected transcripts using quantitative real-time PCR. Chips were clustered based on their expression

and those from patients with CP clustered separately. Significant genes were determined conservatively based on

the overlap of three summarization algorithms (n?=?1,398). Significantly altered genes were analyzed for overrepresentation

among gene ontologies and muscle specific networks. The majority of altered transcripts were

related to increased extracellular matrix expression in CP and a decrease in metabolism and ubiquitin ligase

activity. The increase in extracellular matrix products was correlated with mechanical measures demonstrating the

importance in disability. These data lay a framework for further studies and development of novel therapies.

PMID: 22956992 [PubMed - in process] PMCID: PMC3431909

6. Int J Pediatr. 2012;2012:976425. Epub 2012 Aug 9.

A systematic review of the clinimetric properties of habitual physical activity measures in young children

with a motor disability.

Oftedal S, Bell KL, Mitchell LE, Davies PS, Ware RS, Boyd RN.

Queensland Cerebral Palsy & Rehabilitation Research Centre, School of Medicine, The University of Queensland,

Brisbane, QLD 4029, Australia.

Aim. To identify and systematically review the clinimetric properties of habitual physical activity (HPA) measures in

young children with a motor disability. Method. Five databases were searched for measures of HPA including:

children aged <6.0 years with a neuromuscular disorder, physical activity defined as “bodily movement produced by

skeletal muscles causing caloric expenditure”, reported HPA as duration, frequency, intensity, mode or energy

expenditure, and evaluated clinimetric properties. The quality of papers was assessed using the COSMIN-checklist.

A targeted search of identified measures found additional studies of typically developing young children (TDC).

Results. Seven papers assessing four activity monitors met inclusion criteria. Four studies were of good

methodological quality. The Minimod had good ability to measure continuous walking but the demonstrated poor

ability to measure steps during free-living activities. The Intelligent Device for Energy Expenditure and Activity and

Ambulatory Monitoring Pod showed poor ability to measure activity during both continuous walking and free-living

activities. The StepWatch showed good ability to measure steps during continuous walking in TDC. Interpretation.

Studies assessing the clinimetric properties of measures of HPA in this population are urgently needed to allow

assessment of the relationship between HPA and health outcomes in this group.

PMID: 22927865 [PubMed] PMCID: PMC3423928

7. Disabil Rehabil. 2012 Sep 20. [Epub ahead of print]

Validity evidence of the Lateral Step Up (LSU) test for adolescents with spastic cerebral palsy.

Chrysagis N, Skordilis EK, Tsiganos G, Koutsouki D.

Department of Physical Education and Sport Sciences, Laboratory of Adapted Physical Activity/Developmental and

Physical Disabilities, National and Kapodistrian University of Athens , Greece.

Purpose: The present study examined the concurrent and construct validity of the Lateral Step Up (LSU) test, for

adolescents with CP. Method: A total of 35 adolescents, classified as GMFCS Levels I, II and III, were examined

using LSU, GMFM – 88 (D & E), other functional mobility measures (TUG, STS, TUDS), body structures and

functions (strength, ROM and spasticity). Results: LSU inter-correlations with: (i) GMFM – 88 (D & E) (r = 0.656), (ii)

functional mobility measures (r = -0.567 to 0.721) and (iii) body structures and functions (r = 0.155 to 0.563) were at

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the appropriate range. The LSU differentiated adolescents with CP (F = 16.185, p = 0.000, η(2) = 0.503), according

to their GMFCS (I > II, II > III, I > III). Finally, 50.27% of the LSU variability was explained by GMFCS differences,

with 65.7% of adolescents classified correctly across the three levels. Conclusions: The LSU may be perceived as

a valid instrument for assessing the functional mobility of adolescents with CP. [Box: see text].

PMID: 22991983 [PubMed - as supplied by publisher]

8. J Biomech. 2012 Sep 4. [Epub ahead of print]

How much muscle strength is required to walk in a crouch gait?

Steele KM, van der Krogt MM, Schwartz MH, Delp SL.

Department of Mechanical Engineering, Stanford University, Stanford, CA, USA.

Muscle weakness is commonly cited as a cause of crouch gait in individuals with cerebral palsy; however,

outcomes after strength training are variable and mechanisms by which muscle weakness may contribute to crouch

gait are unclear. Understanding how much muscle strength is required to walk in a crouch gait compared to an

unimpaired gait may provide insight into how muscle weakness contributes to crouch gait and assist in the design

of strength training programs. The goal of this study was to examine how much muscle groups could be weakened

before crouch gait becomes impossible. To investigate this question, we first created muscle-driven simulations of

gait for three typically developing children and six children with cerebral palsy who walked with varying degrees of

crouch severity. We then simulated muscle weakness by systematically reducing the maximum isometric force of

each muscle group until the simulation could no longer reproduce each subject’s gait. This analysis indicated that

moderate crouch gait required significantly more knee extensor strength than unimpaired gait. In contrast, moderate

crouch gait required significantly less hip abductor strength than unimpaired gait, and mild crouch gait required

significantly less ankle plantarflexor strength than unimpaired gait. The reduced strength required from the hip

abductors and ankle plantarflexors during crouch gait suggests that weakness of these muscle groups may

contribute to crouch gait and that these muscle groups are potential targets for strength training.

PMID: 22959837 [PubMed - as supplied by publisher]

9. Gait Posture. 2012 Aug 29. [Epub ahead of print]

Effect of fine wire electrode insertion on gait patterns in children with hemiplegic cerebral palsy.

Krzak JJ, Corcos DM, Graf A, Smith P, Harris GF.

Shriners Hospitals for Children(®) – Chicago, 2211 North Oak Park Ave., Chicago, IL 60707, United States;

Department of Kinesiology and Nutrition, University of Illinois at Chicago, 1919 West Taylor, 650 AHSB (M/C 994),

Chicago, IL 60612, United States.

BACKGROUND: Fine wire electromyography (EMG) is commonly used for surgical decision making in equinovarus

foot deformity. However, this invasive technique may have the unwanted effect of altering the gait of children with

cerebral palsy (CP). The purpose of this study was to determine if fine wire insertion into the posterior tibialis

muscle affects temporal-spatial parameters and hindfoot kinematics during gait in children with equinovarus

secondary to hemiplegic CP. METHODS: 12 children with hemiplegic CP who presented with an equinovarus foot

(mean age 12.5 yrs, four right-sided, eight left-sided) were recruited. Temporal-spatial parameters and 3-D

segmental foot and ankle kinematic gait data were collected utilizing standard gait analysis and the Milwaukee Foot

Model (MFM). Three representative trials with and without fine wire electrode insertion were compared to determine

the effect of electrode placement in the posterior tibialis on temporal spatial-parameters and hindfoot sagittal,

coronal and transverse plane kinematic peaks, timing of kinematic peaks, and excursions. RESULTS: No significant

differences in any temporal-spatial or kinematic parameters were observed between “with wire” and “without wire”

conditions. Strong correlations were observed among the gait parameters, with the exception of cadence, for the

two conditions. DISCUSSION: Fine wire insertion into the posterior tibialis had no measurable effect on the gait of

individuals with equinovarus secondary to hemiplegic CP. This suggests that the simultaneous collection of

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segmental foot and ankle kinematics and fine wire EMG data of the posterior tibialis is acceptable for surgical

decision making in this patient population.

PMID: 22939752 [PubMed - as supplied by publisher]

10. Gait Posture. 2012 Sep 5. [Epub ahead of print]

Prolonged swing phase rectus femoris activity is not associated with stiff-knee gait in children with

cerebral palsy: A retrospective study of 407 limbs.

Knuppe AE, Bishop NA, Clark AJ, Alderink GJ, Barr KM, Miller AL.

Grand Valley State University, Cook DeVos Center for Health Sciences, 301 Michigan Street NE Suite 200 Grand

Rapids, MI 49503, USA.

Prolonged swing phase rectus femoris (RF) activity has been implicated as a cause of stiff-knee gait (SKG) in

children with cerebral palsy (CP) and continues to be cited as an indicator for RF intervention. The purpose of this

study was to determine what, if any, association exists between abnormal RF activity during preswing, initial swing

and/or midswing and SKG in children with CP. This retrospective analysis involved three examiners independently

reviewing sagittal plane knee kinematic and RF surface electromyographic (EMG) data from 407 affected limbs of

234 pediatric patients with CP. Five kinematic parameters were rated by each examiner as normal or pathologic:

peak knee flexion, knee range of motion during initial swing, total knee range of motion, peak knee flexion timing,

and rate of knee flexion. These ratings were used to classify each limb into one of three groups: SKG, Borderline

SKG, or Non-SKG. From a representative EMG tracing, RF activity was examined during: the first half of preswing,

the latter 2/3 of initial swing, and midswing. Chi-squared tests were used to determine if significant associations

existed between SKG and RF activation during these three subphases. There was no association between SKG

and prolonged RF activity during the latter 2/3 of initial swing or during midswing. However, a significant relationship

between SKG and RF activity during the first half of preswing was found (p<0.001). Neither prolonged RF activity

during initial swing, nor the presence of RF activity during midswing, were associated with SKG, thus refuting these

commonly held associations.

PMID: 22959561 [PubMed - as supplied by publisher]

11. Dev Med Child Neurol. 2012 Aug 28. doi: 10.1111/j.1469-8749.2012.04419.x. [Epub ahead of print]

Functional electrical stimulation in children and adolescents with cerebral palsy.

VAN DER Linden M.

Queen Margaret University – Rehabilitation Sciences, Edinburgh, UK.

PMID: 22924527 [PubMed - as supplied by publisher]

12. Orthop Traumatol Surg Res. 2012 Aug 30. [Epub ahead of print]

Neuro-orthopaedic evaluation of children and adolescents: A simplified algorithm.

Cottalorda J, Violas P, Seringe R; the French Society of Pediatric Orthopaedics.

Department of Pediatric Orthopaedics Surgery, University Hospital of Montpellier, Lapeyronie Hospital, 371, avenue

du Doyen-Gaston-Giraud, 34295 Montpellier cedex 05, France.

Orthopaedic surgeons are often the first physicians to evaluate paediatric patients in the event of delayed walking,

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gait abnormalities, or parental concern about motor abilities. Therefore, orthopaedic surgeons must be thoroughly

familiar with the normal neurodevelopmental stages. Neurological disorders are often first recognised during an

orthopaedic evaluation. Minimal neurological abnormalities should be taken as warning signs that require additional

investigations. Consequently, the evaluation must follow a strict protocol, even in children referred for apparently

trivial functional disorders. We have developed an original physical examination protocol in which the largest

possible number of signs is sought in each body position to ensure that the examination is both systematic and

rapid. About ten minutes are required when all findings are normal. This protocol is extremely helpful for identifying

the cause of the problem that motivated the evaluation or for reassuring the child and family. The main causes of

paediatric orthopaedic disorders are cerebral palsy, spinal dysraphism, myopathies, peripheral neuropathies, motor

neuron diseases, and intraspinal tumours. In some instances, no definitive diagnosis can be established clinically.

In this situation, appropriate orthopaedic treatment can be initiated, although considerable caution is in order when

establishing the indications. The cause may be detected only much later, when the clinical manifestations become

more prominent.

PMID: 22939865 [PubMed - as supplied by publisher]

13. Spine (Phila Pa 1976). 2012 Aug 24. [Epub ahead of print]

Growing Rods for the Treatment of Scoliosis in Children With Cerebral Palsy: A Critical Assessment.

McElroy MJ, Sponseller PD, Dattilo JR, Thompson GH, Akbarnia BA, Shah SA, Snyder BD; the Growing Spine

Study Group.

From the * Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, Maryland the † Division

of Pediatric Orthopaedic Surgery, Rainbow Babies and Children’s Hospital, Case Western Reserve University,

Cleveland, Ohio the § Department of Orthopaedic Surgery, University of California, San Diego, California the ¶ San

Diego Center for Spinal Disorders, La Jolla, California the ** Nemours/Alfred I. DuPont Hospital for Children,

Wilmington, Delaware and the ‡ Department of Orthopaedic Surgery, Children’s Hospital Boston, Boston,

Massachusetts.

Study Design. Retrospective analysis.Objective. To evaluate, in children with cerebral palsy (CP), the following

aspects of growing rod (GR) treatment for scoliosis: structural effectiveness, effect of pelvic fixation, hospital stay

duration, and complications. Summary of Background Data. Children with CP frequently develop severe spinal

deformity and pelvic obliquity (PO). Growth-preserving strategies are attractive, but comorbidities raise the risk/

benefit ratio. To our knowledge, no previous studies have focused on growth-preserving spine surgery in these

children. Methods. From our multicenter patient group, we identified 27 children with CP treated with GRs (single

rod in 4; dual rods in 23 [15 extending to the pelvis]). We collected radiographic, surgical, hospital stay, and major

complication data. We compared Cobb angle and PO improvement between patients with and without pelvic

instrumentation via Student’s t test (significance, P = 0.05). No patient required anterior spinal fusion. Results.

Average improvements for all patients (preoperative to latest follow-up) were: Cobb angle, 35° ± 23°; PO, 14° ± 19°;

T1 to S1 length, 7.9 ± 4.4 cm; and space available for lung ratio, 0.17 ± 0.21. For the 8 patients who underwent

fusion, average improvements (preoperative to postfusion) were: Cobb angle, 43° ± 28°; PO, 2° ± 21°; T1 to S1

length, 9.5 ± 6.0 cm; and space available for lung ratio, 0.26 ± 0.28. Pelvic GR fixation produced better PO

correction (P < 0.001) but similar Cobb angle correction (P = 0.556). Hospital stays averaged 8.7 ± 12.1 days after

initial surgery, 1.4 ± 2.5 days after lengthening (45% were outpatient procedures), and 13.4 ± 6.2 days after fusion.

The most common complication was deep wound infection (30%).Conclusion. GRs via a posterior-only approach

are effective. Constructs extending to the pelvis better control PO. However, 30% of patients experienced deep

wound infection.

PMID: 22926278 [PubMed - as supplied by publisher]

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14. J Pediatr Orthop. 2012 Sep;32 Suppl 2:S172-81.

Management of Children With Ambulatory Cerebral Palsy: An Evidence-based Review.

Narayanan UG.

* Divisions of Orthopaedic Surgery & Child Health Evaluative Sciences, The Hospital for Sick Children † Bloorview

Research Institute, Holland Bloorview Kids Rehabilitation Hospital, University of Toronto, Toronto, ON, Canada.

This article reviews the current best evidence for musculoskeletal interventions in children with ambulatory cerebral

palsy (CP). The effectiveness of interventions in CP must first consider what CP and its associated pathophysiology

are and take into account the heterogeneity and natural history of CP to put definitions of “effectiveness” into

perspective. This article reviews the current standards of the definition and classification of CP, discusses the

natural history and specific goals for the management of ambulatory CP, as well as the outcome measures

available to measure these goals. The current best evidence of effectiveness is reviewed for specific interventions

in children with ambulatory CP including spasticity management with botulinum toxin A injections and selective

dorsal rhizotomy; multilevel orthopaedic surgery to address contractures and bony deformity; and the role of gait

analysis for surgical decision-making before orthopaedic surgery.

PMID: 22890458 [PubMed - in process]

15. Acta Med Iran. 2012 Jul;50(7):463-7.

Late sequelae of hip septic arthritis in children.

Baghdadi T, Saberi S, Sobhani Eraghi A, Arabzadeh A, Mardookhpour S.

Department of Orthopedic Surgery, Imam Khomeini Hospital, Tehran University of Medical Sciences, Tehran, Iran.

Septic arthritis of the hip in children has multiple sequelae and may result in severe disability. Significant morbidity

can be prevented by early recognition and treatment. The authors reviewed 13 children with 14 hips with sequelae

of septic arthritis of the hip. All of children had history of hip septic arthritis before age of 4 years. Six were male

subjects, and 7 were female subjects. We evaluated the history, clinical findings and radiographs of all children who

had been treated at the Imam Khomeini hospital between 1986 and 2001 for septic arthritis of the hip. Final results

of operations in patients include range of motion, presence or absence pain, joint stability, limb-length discrepancy

were assessed. Three hips had mild pain in usual daily activities and one patient with cerebral palsy experienced

hip instability. Most of patients (80%) had flexion contracture about 10-15 degrees . Final results showed average

limb length discrepancy was about 2.8 cm. Septic arthritis of the hip in children may result in a spectrum of residual

problems and the significant complications can be averted by early detection and treatment. Treatment in younger

age cause better outcome.

PMID: 22930377 [PubMed - in process]

16. Dev Med Child Neurol. 2012 Aug 27. doi: 10.1111/j.1469-8749.2012.04401.x. [Epub ahead of print]

Acceptability and potential effectiveness of a foot drop stimulator in children and adolescents with cerebral

palsy.

Prosser LA, Curatalo LA, Alter KE, Damiano DL.

Center for Rehabilitation, The Children’s Hospital of Philadelphia, Philadelphia, PA; Functional & Applied

Biomechanics Section, Rehabilitation Medicine Department, National Institutes of Health Clinical Center, Bethesda,

MD; Mount Washington Pediatric Hospital, Baltimore, MD, USA.

Aim: Ankle-foot orthoses are the standard of care for foot drop in cerebral palsy (CP), but may overly constrain

ankle movement and limit function in those with mild CP. Functional electrical stimulation (FES) may be a less

restrictive and more effective alternative, but has rarely been used in CP. The primary objective of this study was to

conduct the first trial in CP examining the acceptability and clinical effectiveness of a novel, commercially available

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device that delivers FES to stimulate ankle dorsiflexion. Method: Twenty-one individuals were enrolled (Gross

Motor Function Classification System [GMFCS] levels I and II, mean age 13y 2mo). Gait analyses in FES and non-

FES conditions were performed at two walking speeds over a 4 month period of device use. Measures included

ankle kinematics and spatiotemporal variables. Differences between conditions were revealed using repeated

measures multivariate analyses of variance. Results: Nineteen individuals (nine females, 10 males; mean age 12y

11mo, range 7y 5mo to 19y 11mo; 11 at GMFCS level I, eight at level II) completed the FES intervention, with all

but one choosing to continue using FES beyond that phase. Average daily use was 5.6 hours (SD 2.3). Improved

dorsiflexion was observed during swing (mean and peak) and at foot-floor contact, with partial preservation of ankle

plantarflexion at toe-off when using the FES at self-selected and fast walking speeds. Gait speed was unchanged.

Interpretation: This FES device was well accepted and effective for foot drop in those with mild gait impairments

from CP.

PMID: 22924431 [PubMed - as supplied by publisher]

17. J Pediatr Orthop B. 2012 Sep 16. [Epub ahead of print]

Percutaneous pelvic osteotomy and intertrochanteric varus shortening osteotomy in nonambulatory

GMFCS level IV and V cerebral palsy patients: preliminary report on 30 operated hips.

Canavese F, Gomez H, Kaelin A, Ceroni D, de Coulon G.

Department of Pediatric Surgery, University Hospital Estaing, Clermont Ferrand, France bDepartment of

Traumatology, Posadas Hospital, Buenos Aires, Argentina cDepartment of Peditiatric Orthopedics, University

Hospitals of Geneva, Geneva, Switzerland.

This study evaluated the outcome of severe cerebral palsy patients (Gross Motor Function Classification System

level IV and V) treated by simultaneous percutaneous pelvic osteotomy and intertrochanteric varus shortening

osteotomy for hip subluxation or dislocation between 2002 and 2011. Twenty-four patients (30 hips) with an

average age of 9.4 years (5-16.5) were reviewed at a mean follow-up of 35.9 months (6-96). Percutaneous pelvic

osteotomy lasted on average 30 min/patient per side (25-40) and was always performed through a skin incision of 2

-3 cm. The migration percentage and acetabular angle were assessed on plain radiographs. The mean Reimers’

migration percentage improved from 67.1% (42-100) preoperatively to 7.7% (0-70) at the last follow-up and the

mean acetabular angle improved from 31.8° (22-48) to 15.7° (5-27). Five patients presented complications: one

redislocation, one bone graft dislodgement, and three with avascular necrosis of the femoral head. This study

should be considered as a pilot study. These results indicate that this combined approach is an effective, reliable,

and minimally invasive alternative method for the treatment of spastic dislocated hips in severe cerebral palsy

patients with an outcome similar to standard techniques reported in the literature.

PMID: 22990440 [PubMed - as supplied by publisher]

18. Pediatr Phys Ther. 2012 Winter;24(4):308-12.

Comparison of articulated and rigid ankle-foot orthoses in children with cerebral palsy: a systematic

review.

Neto HP, Grecco LA, Galli M, Oliveira CS.

Rehabilitation Sciences Department, Universidade Nove de Julho, São Paulo, Brazil (Drs Neto and Santos Oliveira

and Ms Collange Grecco); Bioengineering Department, Politecnico di Milano, Milan, Italy (Dr Galli).

PURPOSE: The aim of this review was to compare the effects of rigid and articulated ankle-foot orthoses on gait in

children with cerebral palsy (CP). METHOD: A systematic review was carried out in 4 databases. The papers

identified were evaluated on the basis of the following inclusion criteria: (1) design-controlled clinical trial; (2)

population-children and adolescents with CP; (3) intervention-rigid or articulated ankle-foot orthoses; and (4)

outcome-improved motor function and gait performance. RESULTS: Seven controlled studies comparing the effects

of different ankle-foot orthoses were found. Studies achieved PEDro scores of 3 and 4 for methodological quality.

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CONCLUSION: There is evidence supporting the use of an articulated ankle-foot orthosis by children with CP,

because of the improved function this type of orthosis provides. However, other studies point out the advantages of

a rigid orthosis for children with greater impairment related to spasticity and contractures.

PMID: 22965199 [PubMed - in process]

19. Pediatr Phys Ther. 2012 Winter;24(4):302-7.

Importance of orthotic subtalar alignment for development and gait of children with cerebral palsy.

Carmick J.

Rocky Mountain University, Provo, Utah. The author is in Private Practice in Alamo, California.

PURPOSE: This case report addresses the assumption that ankle and foot orthoses assist children with cerebral

palsy. KEY POINTS: Outcome research reports are not consistent. Clinical observations and research studies

suggest that inappropriate fit and design of orthoses may contribute to poor outcomes. In particular, problems occur

when the subtalar joint is out of alignment as children often compensate with unwanted movement patterns that

affect progress, development, and function. Four cases are presented to demonstrate problems that can occur

when ankle-foot or supramalleolar orthoses are not cast in subtalar neutral. CONCLUSION: Physical therapists can

use their clinical observation skills to evaluate the proper fit and alignment of orthoses for children with cerebral

palsy.

PMID: 22965198 [PubMed - in process]

20. Dev Neurorehabil. 2012;15(3):202-8.

Validation of the relation between the type and amount of seating support provided and Level of Sitting

Scale (LSS) scores for children with neuromotor disorders.

Field DA, Roxborough LA.

Therapy Department, Sunny Hill Health Centre for Children, Vancouver, BC, Canada. dfield@cw.bc.ca

OBJECTIVES: To assess the construct validity of the Level of Sitting Scale (LSS) by examining the relationship

between LSS scores and the type and amount of seating supports. METHODS: Secondary analysis of the data for

114 children ≤18 years, with neuromotor disorders who participated in a responsiveness study of the Seated

Postural Control Measure. RESULTS: A significant inverse relationship (Spearman rho = -0.42, p < 0.05) was found

between LSS scores and amount of seating support provided. Statistically significant differences were also

revealed between LSS levels of sitting ability (p < 0.004) and pelvic, thigh, trunk and head seating components and

type of seating system, using Kruskal-Wallis test. CONCLUSION: This study provides evidence of construct validity

for the LSS in use as a discriminative measure of sitting ability in children with neuromotor disorders. Further

validation is justified. Clinically intuitive associations between sitting ability and seating interventions were

confirmed.

PMID: 22582851 [PubMed - indexed for MEDLINE]

21. Phys Ther. 2012 Sep 6. [Epub ahead of print]

The Impact of Body-Scaled Information on Reaching.

Huang HH, Fetters L, Ellis TD, Wagenaar RC.

H. Huang, ScD, OT, Department of Occupational Therapy and Graduate Institute of Behavioral Sciences, Chang

Gung University, Taoyuan, Taiwan; Department of Physical Therapy & Athletic Training, College of Health and

Rehabilitation Sciences: Sargent, Boston University, Boston, Massachusetts; and Division of Biokinesiology &

Physical Therapy, University of Southern California, Los Angeles, California. Mailing address: Department of

Cerebral Palsy Research News ~ September 2012

Cerebral Palsy Alliance

PO Box 184 Brookvale NSW 2100 Australia | T +61 2 9479 7200 | www.cerebralpalsy.org.au

Occupational Therapy and Graduate Institute of Behavioral Sciences, Chang Gung University, 259 Wen-Hwa 1st

Rd, Kwei-Shan Tao-Yuan, Taiwan.

BACKGROUND: Environmental and task modifications are powerful methods used to affect action in rehabilitation

and are frequently used by therapists. OBJECTIVE: The purpose of this study was to examine and quantify the

relationship between hand size (person characteristics) and object size (environmental characteristics) and the

effect of this relationship on the emergent reaching patterns for typically developing children and adults. DESIGN:

This is a cross-sectional prospective study. METHODS: Seventeen children and 20 adults were included and

required to reach and grasp ten pairs of different sizes of cubes. The dimensionless ratios were calculated by

dividing the cube size by the aperture between index finger and thumb to quantify emergent reach and grasp

patterns. A critical ratio was used to establish the shift from a one-handed to an exclusive two-handed reach

pattern. RESULTS: The results demonstrated no significant difference in the mean critical ratios between the two

groups. However, a two-handed reach was used more frequently than a one-handed reach at a significantly smaller

ratio for children in comparison to adults. LIMITATIONS: The relational metrics between the cube and hand is only

one contribution to the emergent reaching and grasping patterns. CONCLUSIONS: Children had more variability of

reaching patterns than adults. A personal constraint such as experience, and a task constraint of accuracy may

account for the variability. The results encourage further research on body-scaled information for individuals with

different personal constraints, e.g., children with cerebral palsy, and the impact of body-scaled information on

emergent actions.

PMID: 22956428 [PubMed - as supplied by publisher]

22. Clin Rehabil. 2012 Sep 5. [Epub ahead of print]

Effect of therapist-based constraint-induced therapy at home on motor control, motor performance and

daily function in children with cerebral palsy: a randomized controlled study.

Chen CL, Kang LJ, Hong WH, Chen FC, Chen HC, Wu CY.

Physical Medicine and Rehabilitation, Chang Gung Memorial Hospital, Tao-Yuan, Taiwan.

Objective: To determine the effect of therapist-based constraint-induced therapy at home on motor performance,

daily function and reaching control for children with cerebral palsy. Design: A single-blinded, randomized controlled

trial. Subjects: Forty-seven children (23 boys; 24 girls) with unilateral cerebral palsy, aged 6-12 years, were

randomized to constraint-induced therapy (n = 24) or traditional rehabilitation (n = 23).Interventions:Constraintinduced

therapy involved intensive functional training of the more affected arm while the less affected arm was

restrained. Traditional rehabilitation involved functional unilateral and bilateral arm training. Both groups received

individualized therapist-based interventions at home for 3.5-4 hours/day, two days a week for four weeks. Main

measures: Motor performance and daily function were measured by the Peabody Developmental Motor Scale,

Second Edition and the Pediatric Motor Activity Log. Reaching control was assessed by the kinematics of reaction

time, movement time, movement unit and peak velocity. Results: There were larger effects in favour of constraintinduced

therapy on motor performance, daily function, and some aspects of reaching control compared with

traditional rehabilitation. Children receiving constraint-induced therapy demonstrated higher scores for Peabody

Developmental Motor Scale, Second Edition – Grasping (pretest mean ± SD, 39.9 ± 3.1; posttest, 44.1 ± 2.8; P <

0.001), Pediatric Motor Activity Log (pretest, 1.8 ± 0.3; posttest, 2.5 ± 0.3; P < 0.001) and shorter reaction time,

normalized movement time (P < 0.001) and higher peak velocity (P = 0.004) of reaching movement. Conclusions:

Constraint-induced therapy induced better grasping performance, daily function, and temporal and spatiotemporal

control of reaching in children with unilateral cerebral palsy than traditional rehabilitation.

PMID: 22952304 [PubMed - as supplied by publisher]

23. Res Dev Disabil. 2012 Aug 30;34(1):183-197. [Epub ahead of print]

How does brain activation differ in children with unilateral cerebral palsy compared to typically developing

children, during active and passive movements, and tactile stimulation? An fMRI study.

Van de Winckel A, Klingels K, Bruyninckx F, Wenderoth N, Peeters R, Sunaert S, Van Hecke W, De Cock P,

Eyssen M, De Weerdt W, Feys H.

Cerebral Palsy Research News ~ September 2012

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PO Box 184 Brookvale NSW 2100 Australia | T +61 2 9479 7200 | www.cerebralpalsy.org.au

Department of Rehabilitation Sciences, Faculty of Kinesiology and Rehabilitation Sciences, KU Leuven, Belgium.

The aim of the functional magnetic resonance imaging (fMRI) study was to investigate brain activation associated

with active and passive movements, and tactile stimulation in 17 children with right-sided unilateral cerebral palsy

(CP), compared to 19 typically developing children (TD). The active movements consisted of repetitive opening and

closing of the hand. For passive movements, an MRI-compatible robot moved the finger up and down. Tactile

stimulation was provided by manually stroking the dorsal surface of the hand with a sponge cotton cloth. In both

groups, contralateral primary sensorimotor cortex activation (SM1) was seen for all tasks, as well as additional

contralateral primary somatosensory cortex (S1) activation for passive movements. Ipsilateral cerebellar activity

was observed in TD children during all tasks, but only during active movements in CP children. Of interest was

additional ipsilateral SM1 recruitment in CP during active movements as well as ipsilateral S1 activation during

passive movements and tactile stimulation. Another interesting new finding was the contralateral cerebellum

activation in both groups during different tasks, also in cerebellar areas not primarily linked to the sensorimotor

network. Active movements elicited significantly more brain activation in CP compared to TD children. In both

groups, active movements displayed significantly more brain activation compared to passive movements and tactile

stimulation.

PMID: 22940170 [PubMed - as supplied by publisher]

24. Disabil Rehabil. 2012 Sep 20. [Epub ahead of print]

Exploration of the relationship between the Manual Ability Classification System and hand-function

measures of capacity and performance.

Ohrvall AM, Krumlinde-Sundholm L, Eliasson AC.

Department of Women’s and Children’s Health , Karolinska Institutet, Stockholm , Sweden.

Purpose: To further investigate the construct of Manual Ability Classification System (MACS) by evaluating the

relationship between children’s designated MACS levels and their outcomes on two different tests of hand function,

measuring capacity and performance, respectively. Another aim was to use the International Classification of

Functioning, Disability and Health-Child and Youth version (ICF-CY) as a framework to explore the uniqueness of

the assessments. Method: Ninety-one children with cerebral palsy in MACS levels I-V, aged 5-17 years (mean 9.8,

SD 3.0) participated. Data were collected using MACS, ABILHAND-Kids and Box and Block Test. Results: A strong

association between MACS and ABILHAND-Kids (r(s) = -0.88, p < 0.05) and MACS and Box and Block Test (r(s) =

-0.81, p < 0.05) was demonstrated. Children’s performance differed significantly between the different MACS levels

(ABILHAND-Kids F (4:86) = 103.86, p < 0.001, Box and Block Test F (4:86) = 59.18, p < 0.001). The content

comparison with ICF-CY, as a frame of reference, showed that these instruments capture fine hand use in the

activity and participation component. The linking of the instruments to various ICF-CY categories demonstrated

conceptual differences between the instruments. MACS had the broadest representation of ICF-CY domains.

Conclusions: This study strengthens the construct, and thereby the validity, of MACS as a classification of children’s

hand function, expressed by the handling of objects in everyday activities in their daily environments. [Box: see

text].

PMID: 22992179 [PubMed - as supplied by publisher]

25. Dev Neurorehabil. 2012 Sep 4. [Epub ahead of print]

Studies comparing the efficacy of constraint-induced movement therapy and bimanual training in children

with unilateral cerebral palsy: A systematic review.

Dong VA, Tung IH, Siu HW, Fong KN.

Department of Rehabilitation Sciences, The Hong Kong Polytechnic University , Hong Kong , PR China.

Objective: To review studies comparing the efficacy of constraint-induced movement therapy (CIMT) and bimanual

training (BIT) in improving the hemiplegic arm functioning and overall functional performance for children with

Cerebral Palsy Research News ~ September 2012

Cerebral Palsy Alliance

PO Box 184 Brookvale NSW 2100 Australia | T +61 2 9479 7200 | www.cerebralpalsy.org.au

unilateral cerebral palsy (CP). Methods: Systematic searches of electronic databases, reference lists and journals

identified seven studies that met pre-determined inclusion criteria. These studies were analysed in terms of

participants, treatment activities and regime, outcome measures and results of intervention. Results: Both CIMT

and BIT produced similar improvements in the bimanual and unimanual capacities of the affected arm and overall

functional performance. Conclusions: CIMT yields more improvements in the unimanual capacity of the impaired

arm compared with BIT. A potential benefit of BIT is that participants may see more improvement in both bimanual

performance and self-determined overall life goals. A combination of CIMT and BIT could be an option on improving

arm function for children with unilateral CP in future.

PMID: 22946588 [PubMed - as supplied by publisher]

26. J Pediatr Rehabil Med. 2012;5(2):117-24.

Modified constraint induced movement therapy enhanced by a neuro-development treatment-based

therapeutic handling protocol: two case studies.

Haynes MP, Phillips D.

NDT Pediatric Therapy, Rockingham, NC 28379, USA. mhaynes@etinternet.net

Modified Constraint Induced Movement Therapy (CIMT) and Neuro-Developmental Treatment (NDT) are both

intervention strategies that focus on active practice to optimize function. CIMT involves constraint of the less

involved upper extremity during function and NDT includes facilitation of optimal postural control and symmetry to

enhance the ability to complete a given motor function. The purpose of this article is to describe an intervention

protocol for children with hemiplegia that integrates key NDT and CIMT principles. Two children participated in a

modified CIMT (mCIMT)/NDT program 2 hours a day for two months. The children wore a constraint on the less

involved arm and participated in guided play with early intervention members and parents. Play was individualized

to developmental level and incorporated principles of NDT. Function was measured pre- and post-intervention

using the PDMS-2, QUEST, ACQUIRE Therapy Motor Patterns, and ACQUIRE Functional Activities. Both children

demonstrated motor skill acquisition, improved quality of functional use, and increased frequency of bilateral hand

use. Parents found the protocol challenging but manageable in their daily routines. The inclusion of NDT principles

within a mCIMT protocol may be an effective intervention to maximize functional motor skill acquisition in children

with hemiplegia. Additional research is warranted to support this intervention.

PMID: 22699102 [PubMed - indexed for MEDLINE]

27. Exp Brain Res. 2012 Sep 14. [Epub ahead of print]

The influence of spatial working memory on ipsilateral remembered proprioceptive matching in adults with

cerebral palsy.

Goble DJ, Aaron MB, Warschausky S, Kaufman JN, Hurvitz EA.

Sensory-Motor and Rehabilitative Technology Laboratory (SMaRTlab), School of Exercise and Nutritional Sciences,

College of Health and Human Services, San Diego State University, 5500 Campanile Drive, San Diego, CA, 92182-

7251, USA, dgoble@mail.sdsu.edu.

Somatosensation is frequently impaired in individuals with Cerebral Palsy (CP). This includes the sense of

proprioception, which is an important contributor to activities of daily living. One means of determining

proprioceptive deficits in CP has been use of an Ipsilateral Remembered (IR) position matching test. The IR test

requires participants to replicate, without vision, memorized joint/limb positions previously experienced by the same

(i.e. ipsilateral) effector. Given the memory component inherent to this task, the present study sought to determine

the extent to which IR proprioceptive matching might be influenced by known spatial working memory deficits.

Eleven adults with CP underwent IR elbow position matching, where blindfolded individuals were given either a

short (2 s) or long (15 s) duration to memorize the target elbow angle. A standard clinical measure of spatial

working memory (i.e. Corsi block-tapping task) was also administered. The results showed that the directional (i.e.

constant) error produced across trials did not differ between the short and long target duration conditions. However,

it was found that participants were significantly more consistent in their matches (i.e. had smaller variable errors)

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PO Box 184 Brookvale NSW 2100 Australia | T +61 2 9479 7200 | www.cerebralpalsy.org.au

when given more time to encode proprioceptive targets in the long duration condition. The benefit of having more

time was greatest for those individuals with the highest variable errors in the short target condition, and a significant

association was seen between improvements in variable error and greater performance on 4/5 spatial working

memory measures. These findings provide the best evidence to date that IR position matching tests are influenced

by spatial working memory.

PMID: 22975865 [PubMed - as supplied by publisher]

28. Otol Neurotol. 2012 Oct;33(8):1347-52.

Pediatric cochlear implants: additional disabilities prevalence, risk factors, and effect on language

outcomes.

Birman CS, Elliott EJ, Gibson WP.

* The Sydney Children’s Network (Westmead); † Sydney Medical School, The University of Sydney, Sydney; and

‡ The Sydney Cochlear Implant Centre, New South Wales, Australia.

OBJECTIVE: To determine the prevalence of additional disabilities in a pediatric cochlear population, to identify

medical and radiologic conditions associated with additional disabilities, and to identify the effect of additional

disabilities on speech perception and language at 12 months postoperatively. STUDY DESIGN: Retrospective case

review. SETTING: Tertiary referral center and cochlear implant program. PATIENTS: Records were reviewed for

children 0 to 16 years old inclusive, who had cochlear implant-related operations over a 12-month period.

INTERVENTIONS: diagnostic and rehabilitative. MAIN OUTCOME MEASURES: Additional disabilities

prevalence; medical history and radiologic abnormalities; and the effect on Categories of Auditory Performance

(CAP) score at 12 months postoperatively. RESULTS: Eighty-eight children having 96 operations were identified.

The overall prevalence of additional disabilities (including developmental delay, cerebral palsy, visual impairment,

autism and attention deficit disorder) was 33%. The main conditions associated with additional disabilities were

syndromes and chromosomal abnormalities (87%), jaundice (86%), prematurity (62%), cytomegalovirus (60%), and

inner ear abnormalities including cochlea nerve hypoplasia or aplasia (75%) and semicircular canal anomalies

(56%). At 12 months postoperatively, almost all (96%) of the children without additional disabilities had a CAP score

of 5 or greater (speech), compared with 52% of children with additional disabilities. Children with developmental

delay had a median CAP score of 4, at 12 months compared with 6 for those without developmental delay.

CONCLUSION: Additional disabilities are prevalent in approximately a third of pediatric cochlear implant patients.

Additional disabilities significantly affect the outcomes of cochlear implants.

PMID: 22975903 [PubMed - in process]

29. NeuroRehabilitation. 2012 Jan 1;31(2):117-29.

Botulinum toxin use in neuro-rehabilitation to treat obstetrical plexus palsy and sialorrhea following

neurological diseases: A review.

Intiso D, Basciani M.

Neuro-Rehabilitation Unit, Scientific Institute, Hospital IRCCS ‘Casa Sollievo della Sofferenza’, San Giovanni

Rotondo, Italy.

In neuro-rehabilitation, botulinum toxin (BTX) as adjunct to other interventions can result in a useful therapeutic tool

treating disabled people. Other than spasticity, numerous motor and non motor disorders can complicate clinical

course and hamper rehabilitative process of neurological impaired patients. A review of BTX use in treating

muscular imbalance of children with obstetrical brachial plexus palsy and in reducing sialorrhea following

neurological diseases including amyotrophic lateral sclerosis (ASL), Parkinson disease and cerebral palsy (CP) is

provided. Clinicians have to face unique and difficult to treat clinical conditions such as ulcers, sores and abnormal

posture and movement disorders due to neurological affections. BTX effectiveness in treating some of these

conditions is also provided. Since, neurologically disabled subjects can show complex dysfunction, prior to initiating

BTX therapy, specific functional limitations, goals and expected outcomes of treatment should be evaluated and

discussed with family and caregivers.

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PO Box 184 Brookvale NSW 2100 Australia | T +61 2 9479 7200 | www.cerebralpalsy.org.au

PMID: 22951705 [PubMed - in process]

30. Dev Med Child Neurol. 2012 Sep 5. doi: 10.1111/j.1469-8749.2012.04370.x. [Epub ahead of print]

Salivary gland botulinum toxin injections for drooling in children with cerebral palsy and

neurodevelopmental disability: a systematic review.

Rodwell K, Edwards P, Ware RS, Boyd R.

Queensland Paediatric Rehabilitation Service, The Royal Children’s Hospital, Herston, Brisbane; School of

Population Health, The University of Queensland, Brisbane; Queensland Cerebral Palsy and Rehabilitation

Research Centre, School of Medicine, The University of Queensland, Brisbane, Queensland, Australia.

Aim: The aim of this paper was to systematically review the efficacy and safety of botulinum toxin (BoNT) injections

to the salivary glands to treat drooling in children with cerebral palsy and neurodevelopmental disability. Method A

systematic search of The Cochrane Central Register of Controlled Trials, PubMed, CINAHL (Cumulative Index to

Nursing and Allied Health Literature), EMBASE, and the Physiotherapy Evidence Database (PEDro) was conducted

(up to 1 October 2011). Data sources included published randomized controlled trials (RCTs) and prospective

studies. Results Sixteen studies met inclusion criteria. Three outcome measures support the effectiveness of BoNT

for drooling. One RCT found an almost 30% reduction in the impact of drooling on patients’ lives, as measured by

the Drooling Impact Scale (mean difference -27.45; 95% confidence interval [CI] -35.28 to -19.62). There were

sufficient data to pool results on one outcome measure, the Drooling Frequency and Severity Scale, which supports

this result (mean difference -2.71; 95% CI -4.82 to -0.60; p<0.001). There was a significant reduction in the

observed number of bibs required per day. The incidence of adverse events ranged from 2 to 41%, but was

inconsistently reported. One trial was terminated early because of adverse events. Interpretation BoNT is an

effective, temporary treatment for sialorrhoea in children with cerebral palsy. Benefits need to be weighed against

the potential for serious adverse events. More studies are needed to address the safety of BoNT and to compare

BoNT with other treatment options for drooling.

PMID: 22946706 [PubMed - as supplied by publisher]

31. Br J Oral Maxillofac Surg. 2012 Aug 30. [Epub ahead of print]

Ultrasound-guided injection of botulinum toxin A into the submandibular gland in children and young

adults with sialorrhoea.

Gok G, Cox N, Bajwa J, Christodoulou D, Moody A, Howlett DC.

Department of Oral and Maxillofacial Surgery, Eastbourne District General Hospital, Kings Drive, Eastbourne, East

Sussex BN21 2UD, UK.

Hypersalivation is a common and distressing complaint in children with neuromuscular disorders such as cerebral

palsy. Complications associated with severe drooling include daily changes of clothing, perioral dermatitis, dental

problems, dehydration, and aspiration pneumonia, which potentially have a detrimental effect on the quality of life of

the patient and carer. In this paper we update our previous work to show the potential benefits of ultrasound-guided

injection of botulinum toxin A (BTX-A) into the submandibular gland and report on new patients and follow-up data

on the existing group.

reserved.

PMID: 22939893 [PubMed - as supplied by publisher]

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PO Box 184 Brookvale NSW 2100 Australia | T +61 2 9479 7200 | www.cerebralpalsy.org.au

32. J Acoust Soc Am. 2012 Sep;132(3):2089.

Second-formant locus patterns in dysarthric speech.

Kim H, Hasegawa-Johnson M.

Beckman Institute, University of Illinois at Urbana-Champaign, Urbana, IL 61801hkim17@illinois.edu.

Second-formant (F2) locus equations represent a linear relationship between F2 measured at the vowel onset

following stop release and F2 measured at the vowel midpoint in a consonant-vowel (CV) sequence. Prior research

has used the slope and intercept of locus equations as indices to coarticulation degree and the consonant’s place of

articulation. This presentation addresses coarticulation degree and place of articulation contrasts in dysarthric

speech, by comparing locus equation measures for speakers with cerebral palsy and control speakers. Locus

equation data are extracted from the Universal Access Speech (Kim et al. 2008). The data consist of CV sequences

with labial, alveolar, velar stops produced in the context of various vowels that differ in backness and thus in F2.

Results show that for alveolars and labials, slopes are less steep and intercepts are higher in dysarthric speech

compared to normal speech, indicating a reduced degree of coarticulation in CV transitions, while for front and back

velars, the opposite pattern is observed. In addition, a second-order locus equation analysis shows a reduced

separation especially between alveolars and front velars in dysarthric speech. Results will be discussed in relation

to the horizontal tongue body positions in CV transitions in dysarthric speech.

PMID: 22979801 [PubMed - in process]

33. J Pediatr Gastroenterol Nutr. 2012 Sep 13. [Epub ahead of print]

Increased Prevalence of Antibodies Against Dietary Proteins In Children And Young Adults With Cerebral

Palsy.

Stenberg R, Dahle C, Magnuson A, Hellberg D, Tysk C.

* Department of Paediatrics, Centre for Rehabilitation Research, Örebro University Hospital, and School of Health

and Medical Sciences, Örebro University, Örebro, Sweden † Clinical Immunology, Department of Clinical and

Experimental Medicine, Faculty of Health Sciences, Linköping University, and Department of Clinical Immunology

and Transfusion Medicine, County Council of Östergötland, Linköping, Sweden ‡ Clinical Epidemiology and

Biostatistic Unit, Örebro University Hospital, Örebro, Sweden § Centre for Clinical Research, Falun, and

Department of Women’s and Children’s Health, Uppsala University, Uppsala, Sweden || Department of Medicine,

Division of Gastroenterology, Örebro University Hospital, and School of Health and Medical Sciences, Örebro

University, Örebro, Sweden.

OBJECTIVES: Undernourishment is common in children with cerebral palsy (CP) but the reasons are unknown. We

previously reported elevated levels of immunoglobulin (Ig) A and IgG antibodies against gliadin (AGA) and tissue

transglutaminase (tTG) in 99 children and young adults with CP without characteristic findings of gluten enteropathy

in small bowel biopsies. Our aim was to perform a case-control study of IgG-antibodies against other dietary

antigens, AGA, anti-tTG and IgE-antibodies against wheat and gluten. METHODS: Sera from 99 CP-cases and 99

healthy, age- and sex-matched controls were analysed with fluorescence enzyme-linked immunosorbent assay

(FEIA) for detection of IgG-antibodies against beta-lactoglobulin, casein, egg white, IgG- and IgA-AGA, IgA-anti-tTG

and IgE antibodies against gluten and wheat. RESULTS: Compared with controls, the odds ratio (OR) in CP cases

for having elevated levels of IgG antibodies against beta-lactoglobulin was 17.0 (95% CI 2.3-128), against casein

11.0 (95% CI 2.6-46.8) and against egg white 7.0 (95% CI 1.6-30.8). The IgE-responses for wheat/gluten were

generally low. The tetraplegic (TP) and dyskinetic (DK) CP-subtypes had significantly higher frequencies of

elevated levels for all tested antibodies except IgG against egg white, and IgA-anti- tTG. A significantly lower weight

was seen in CP-cases with positive versus negative serology. CONCLUSION: Elevated levels of IgG against

dietary antigens were more frequent in the CP-group compared with controls, and particularly in the TP and DK CPsubtypes

with the most severe neurologic handicap and undernourishment. Hypothetically, malnourishment may

cause increased intestinal permeability and thus immunization against dietary antigens.

PMID: 22983381 [PubMed - as supplied by publisher]

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PO Box 184 Brookvale NSW 2100 Australia | T +61 2 9479 7200 | www.cerebralpalsy.org.au

34. Spec Care Dentist. 2012 Sep;32(5):210-7. doi: 10.1111/j.1754-4505.2012.00267.x.

Integrated approach to outpatient dental treatment of a patient with cerebral palsy: a case report.

Katz CR.

Professor of Pediatric Dentistry, School of Dentistry of Pernambuco State University, Brazil Member of student

team in the Specialization Program on Special Care in Dentistry, Pernambuco State University, Brazil.

The large number of oral manifestations associated with motor disorders in patients with cerebral palsy (CP) makes

the dentist an indispensable member of the multidisciplinary team caring for this population. This case report

presents an 11-year-old girl with spastic CP who had severe motor impairment, and a description of her care

illustrates the importance of integrated care for patients with CP who are receiving outpatient dental treatment. It

was determined that the use of adaptations based on knowledge of CP supported the outpatient dental treatment.

The integrated approach used during dental treatment enabled the application of knowledge from the fields of

dentistry, physical therapy, and speech therapy to provide for a better quality of life for the patient and,

consequently, the caregiver through the improvement in the patient’s oral and general health.

PMID: 22943774 [PubMed - in process]

35. J Adolesc Health. 2012 Sep;51(3):272-8. Epub 2012 Mar 3.

Assessing the health, functional characteristics, and health needs of youth attending a noncategorical

transition support program.

Woodward JF, Swigonski NL, Ciccarelli MR.

Department of Pediatrics, Indiana University School of Medicine, Riley Hospital for Children, Indianapolis, Indiana.

PURPOSE: To assess the health, functional characteristics, and health care service needs of youth and young

adults with special health care needs attending a comprehensive, noncategorical transition program. METHODS: A

self-administered survey was developed from national health surveys and clinical experience to assess concepts

identified as important for successful transition to adulthood. Surveys were mailed to 198 parents of youth and

young adults with special health care needs attending the transition clinic. Parents were asked about the youth’s

health, functional status, and health care services needed. The clinical database provided demographic and patient

health characteristics. Results were compared against the 2005-2006 National Survey of Children with Special

Health Care Needs. RESULTS: Forty-four percent of surveys were returned. Average age of youth was 17.5 (11-

22) years old and diagnoses included cerebral palsy (36%), spina bifida (10%), developmental delay or Down

syndrome (17%), and autism (6%). Most youth needed assistance with personal care (69%) and routine needs

(91%) and used assistive devices (59%). Compared with the 2005-2006 National Survey of Children with Special

Health Care Needs, parents reported higher needs for all services except mental health care and tobacco or

substance use counseling. Forty three percent reported at least one unmet health need. Few parents reported the

need for counseling on substance use (1%), sexual health screening (16%), nutrition (34%), and exercise (41%).

CONCLUSIONS: Youth attending our transition program had more functional limitations, poorer reported health

status, different diagnosis distribution, and higher levels of needed health services. Few parents identified needs for

other recommended adolescent preventive services. Transition programs should assess patient health

characteristics and service needs to design effective patient-centered services.

PMID: 22921138 [PubMed - in process]

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36. J Pediatr Urol. 2012 Aug 21. [Epub ahead of print]

Relationship of bladder dysfunction with upper urinary tract deterioration in cerebral palsy.

Gündogdu G, Kömür M, Avlan D, Sari FB, Delibas A, Tasdelen B, Nayci A, Okuyaz C.

Pediatric Surgery, Bezmialem Vakif University, Medical Faculty, Department of Pediatric Surgery, Division of

Pediatric Urology, Istanbul 34093, Turkey.

Although lower urinary tract dysfunction (LUTD) in patients with cerebral palsy (CP) has been previously

documented by clinical observations and urodynamic tests, its correlation with upper urinary tract deterioration

(UUTD) has not been demonstrated. This paper documents symptoms and urodynamic findings of LUTD and their

relationship with UUTD in 33 children with CP. By sonography, 4 of these children were found to have UUTD. Age

was found to correlate with UUTD, but gender difference and mental or motor functions did not. When comparing

urinary symptoms with UUTD, incontinence (n = 31) did not correlate, but on the other hand symptoms of detrusor

sphincter dyssynergia (interrupted voiding, urinary retention, hesitancy; n = 5) and culture proven febrile urinary

tract infections (n = 4) did. Abnormal urodynamics findings were not diagnostic. We conclude that, apart from

incontinence, dysfunctional voiding symptoms and febrile urinary tract infections are valuable indicators of UUTD.

PMID: 22921013 [PubMed - as supplied by publisher]

37. J Thorac Cardiovasc Surg. 2012 Sep 6. [Epub ahead of print]

Clinical outcome score predicts the need for neurodevelopmental intervention after infant heart surgery.

Mackie AS, Alton GY, Dinu IA, Joffe AR, Roth SJ, Newburger JW, Robertson CM.

Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada; School of Public Health, University of

Alberta, Edmonton, Alberta, Canada; Stollery Children’s Hospital, Edmonton, Alberta, Canada.

OBJECTIVE: Our goal was to determine if a clinical outcome score derived from early postoperative events is

associated with 18- to 24-month Psychomotor Developmental Index (PDI) score among infants undergoing

cardiopulmonary bypass surgery. METHODS: We included infants aged =6 weeks who underwent surgery during

2002-2006, all of whom were referred for neurodevelopmental evaluation at age 18 to 24 months. We excluded

children with chromosomal abnormalities, hearing loss, cerebral palsy, or a Bayley III assessment. The prespecified

clinical outcome score had a range of 0 to 7. Lower scores indicated a more rapid postoperative recovery. Patients

requiring extracorporeal membrane oxygenation were assigned a score of 7. RESULTS: Ninety-nine subjects were

included. Surgical procedures were arterial switch (n = 36), Norwood (n = 26), repair of total anomalous pulmonary

venous connection (n = 16), and other (n = 21). Four subjects had postoperative extracorporeal membrane

oxygenation. Clinical outcome scores were highest in the Norwood group (mean 4.1 ± 1.4) compared with the

arterial switch group (1.9 ± 1.6) (P < .001), total anomalous pulmonary venous connection group (1.6 ± 2.0) (P

< .001), and other group (3.3 ± 1.6, P = not significant). A mean decrease in PDI of 10.9 points (95% confidence

interval, 4.9-16.9; P = .0005) was observed among children who had a clinical outcome score =3, compared with

those with a clinical outcome score <3. Time until lactate =2.0 mmol/L increased with increasing clinical outcome

score (P = .0003), as did highest 24-hour inotrope score (P < .0001). CONCLUSIONS: Clinical outcome scores of

=3 were associated with a significantly lower PDI at age 18 to 24 months. This score may be valuable as an end

point when evaluating novel potential therapies for this high-risk population.

PMID: 22959319 [PubMed - as supplied by publisher]

Cerebral Palsy Research News ~ September 2012

Cerebral Palsy Alliance

PO Box 184 Brookvale NSW 2100 Australia | T +61 2 9479 7200 | www.cerebralpalsy.org.au

38. Scand J Caring Sci. 2012 Aug 24. doi: 10.1111/j.1471-6712.2012.01071.x. [Epub ahead of print]

Psychological distress and perceived support among Jordanian parents living with a child with cerebral

palsy: a cross-sectional study.

Al-Gamal E, Long T.

Faculty of Nursing, The University of Jordan, Amman, Jordan School of Nursing, Midwifery & Social Work,

University of Salford, Salford, UK.

Background: Cerebral palsy, with a prevalence in Europe of 2-2.5 per 1000 live births, is the most common severe

physical disability affecting children. While many parents have positive perceptions of their disabled children, caring

for a child with disability can be exhausting and stressful, and social support is an important coping resource. There

is little evidence about how having a child with cerebral palsy affects Jordanian parents. Aim: The purpose of this

study was to provide insight into the psychological distress and perceived support among Jordanian parents living

with a child with cerebral palsy. Method: In 2010, a cross-sectional, descriptive, correlational design was used with

a nonprobability sample of 204 Jordanian parents. Both mothers and fathers, interviewed individually rather than in

pairs, were recruited from health care centres that provided comprehensive care for children with cerebral palsy in

Jordan and from designated schools for special education. The Gross Motor Function Classification System, the

Perceived Stress Scale (PSS), the Beck Depression Inventory, the Strengths and Difficulties Questionnaire and the

Multidimensional Scale of Perceived Social Support (MSPSS) were administered to parents. Descriptive statistical

analysis was applied. Bivariate correlation analysis was undertaken to examine the relationship between variables.

Results: More than 60% of parents often felt nervous and stressed. The mean score on the PSS was 27.0 (SD =

9.33), and the mean score on the MSPSS was 58.9 (SD = 15.1). Severe disability in the child was associated with

high mental distress in the parent and linked to low support from friends. There was a significant negative

correlation between parental stress, depression and social support. Parents with the most psychological distress

were the least well supported. Conclusion: This study has implications for health professionals in terms of

developing strategies for reducing parental stress. There are implications for policy to provide support for parents

and to develop family-centred services. The findings will inform an intervention study to investigate multiprofessional

support.

PMID: 22924549 [PubMed - as supplied by publisher]

39. Res Dev Disabil. 2012 Sep 15;34(1):344-352. doi: 10.1016/j.ridd.2012.08.018. [Epub ahead of print]

Description and psychometric properties of the CP QOL-Teen: A quality of life questionnaire for

adolescents with cerebral palsy.

Davis E, Mackinnon A, Davern M, Boyd R, Bohanna I, Waters E, Graham HK, Reid S, Reddihough D.

Jack Brockhoff Child Health and Wellbeing Program, McCaughey Centre, University of Melbourne, Melbourne,

Victoria, Australia. Electronic address: eda@unimelb.edu.au.

To assess the measurement properties of a new QOL instrument, the Cerebral Palsy Quality of Life Questionnaire-

Teen (CP QOL-Teen), in adolescents with cerebral palsy (CP) aged 13-18 years, examining domain structure,

reliability, validity and adolescent-caregiver concordance. Based on age, 695 eligible families were invited to

participate by mail. Questionnaires were returned by 112 primary caregivers (71.8% of questionnaires sent). 87

adolescents aged 12-18 years also completed the questionnaires. CP QOL-Teen, generic QOL instruments

(KIDSCREEN, Pediatric Quality of Life Inventory), functioning (Gross Motor Function Classification System) and a

condition-specific instrument (PedsQL-CP) were used. Principal components analysis produced seven scales:

wellbeing and participation; communication and physical health; school wellbeing; social wellbeing; access to

services; family health; feelings about functioning. Cronbach’s alphas for the derived scales ranged from 0.81 to

0.96 (primary caregiver report) and 0.78 to 0.95 (adolescent report). Test-retest reliability (4 weeks) ranged from

0.57 to 0.88 for adolescent self-report and 0.29 to 0.83 for primary caregiver report. Moderate correlations were

observed with other generic and condition specific measures of QOL, indicating adequate construct validity.

Moderate correlations were observed between adolescent self-report and primary caregiver proxy report. This study

demonstrates acceptable psychometric properties of both the adolescent self-report and the primary caregiver

Cerebral Palsy Research News ~ September 2012

Cerebral Palsy Alliance

PO Box 184 Brookvale NSW 2100 Australia | T +61 2 9479 7200 | www.cerebralpalsy.org.au

proxy report versions of the CP QOL-Teen.

PMID: 22989577 [PubMed - as supplied by publisher]

40. Res Dev Disabil. 2012 Sep 15;34(1):266-275. doi: 10.1016/j.ridd.2012.08.017. [Epub ahead of print]

Patterns and predictors of participation in leisure activities outside of school in children and adolescents

with Cerebral Palsy.

Longo E, Badia M, Orgaz BM.

INICO, Faculty of Psychology, University of Salamanca, Spanish Agency of International Cooperation – MAEC -

AECID, Avda. de la Merced, 109-131, 37005 Salamanca, Spain.

This study analyzed the patterns and predictors of participation in leisure activities outside of school of Spanish

children and adolescents with Cerebral Palsy (CP). Children and adolescents with CP (n=199; 113 males and 86

females) participated in this cross-sectional study. Their mean age was 12.11 years (SD=3.02; range 8-18 years),

and they were evaluated using the Spanish version of the Children’s Assessment of Participation and Enjoyment

(CAPE). Means, standard deviations and percentages were used to characterize the profile of participation, and

linear regression analyses were employed to assess associations between the variables (child, family and

environmental factors) and the diversity, intensity and enjoyment of participation. Children and adolescents with CP

reported low diversity and intensity of participation and high levels of enjoyment. Participation in leisure activities

outside of school was determined more by child and environmental factors than by family ones.

PMID: 22989575 [PubMed - as supplied by publisher]

41. Res Dev Disabil. 2012 Aug 29;34(1):157-167. [Epub ahead of print]

Physical activity in a total population of children and adolescents with cerebral palsy.

Lauruschkus K, Westbom L, Hallström I, Wagner P, Nordmark E.

Department of Health Sciences, Faculty of Medicine, Lund University, Sweden.

The aims of this study were to describe the participation in physical activity of children with cerebral palsy (CP) at

school and during leisure time and to identify characteristics associated with physical activity. The frequency of

receiving physiotherapeutic interventions were described as a variable of interest. A total population of 364 children

with verified CP aged 7-17 years living in the Skåne region in Sweden was studied using cross-sectional data from

the CP follow-up programme (CPUP). Proportional odds ratios showed the most severe gross motor limitations

Gross Motor Function Classification System Expanded and Revised (GMFCS-E&R) to be a characteristic for low

participation in physical education at school (PE) and GMFCS-E&R level III to be a characteristic for low

participation in regular physical leisure activity. The age group of 7-11 years and obesity were characteristics

associated with high participation in PE, whereas thinness was associated with low participation in regular physical

leisure time activities. The highest proportion of children receiving physiotherapeutic interventions was found in

GMFCS-E&R level III, while mental retardation, especially if moderate or severe, proved to be an independent

characteristic associated with low frequency of physiotherapeutic interventions. Gender and epilepsy did not

influence the odds for participation in physical activities. Special considerations are needed when planning

interventions for increased physical activity in children with CP, as the individual prerequisites differ, even among

children with the same gross motor function level according to the GMFCS-E&R.

PMID: 22940169 [PubMed - as supplied by publisher]

Cerebral Palsy Research News ~ September 2012

Cerebral Palsy Alliance

PO Box 184 Brookvale NSW 2100 Australia | T +61 2 9479 7200 | www.cerebralpalsy.org.au

42. Epilepsia. 2012 Sep 7. doi: 10.1111/j.1528-1167.2012.03639.x. [Epub ahead of print]

Bone mineral density in a population of children and adolescents with cerebral palsy and mental

retardation with or without epilepsy.

Coppola G, Fortunato D, Mainolfi C, Porcaro F, Roccaro D, Signoriello G, Operto FF, Verrotti A.

Clinic of Child Neuropsychiatry, University of Salerno, Salerno, Italy Clinic of Child Neuropsychiatry, Second

University of Naples, Naples, Italy Department of Radiology, Federico II University, Naples, Italy Department of

Public Health, Second University of Naples, Naples, Italy Department of Pediatrics, University of Chieti, Chieti, Italy.

Purpose: The present study aimed to assess bone mineral density (BMD) in a population of children and

adolescents with cerebral palsy and mental retardation with or without epilepsy. Methods: One hundred thirteen

patients (63 male and 50 female) were recruited for evaluation. Patients were divided in three groups: 40 patients

(group 1) were affected by cerebral palsy and mental retardation; 47 (group 2) by cerebral palsy, mental

retardation, and epilepsy; and 26 (group 3) by epilepsy. The control group consisted of 63 healthy children and

adolescents. Patients underwent a dual-energy x-ray absorptiometry (DEXA) scan of the lumbar spine (L1-L4), and

z-score was calculated for each patient; t-score was considered for patients 18 years of age and older. Key

Findings: Abnormal BMD by DEXA was found in 17 patients (42.5%) in group 1, in 33 (70.2%) in group 2, and in 3

(11.5%) in group 3. In groups 1 and 2, tetraparesis and severe/profound mental retardation were related to a

significantly abnormal BMD (p = 0.003). The multivariate analysis of independent factors on BMD (z-score)

revealed a significant correlation between BMD (z-score) and age (p = 0.04), body mass index (BMI; p = 0.002),

severe/profound mental retardation (p = 0.03), and epilepsy (p = 0.05). Significance: A significantly lower BMD zscore

value was found in patients with cerebral palsy, mental retardation, and epilepsy compared with those without

epilepsy. The epileptic disorder appears to be an aggravating factor on bone health when comorbid with cerebral

palsy and mental retardation.

PMID: 22958083 [PubMed - as supplied by publisher]

43. Fiziol Zh. 2012;58(3):77-84.

Effects of intermittent normobaric hypoxia on the state of the CNS and cerebral circulation in children with

cerebral palsy.

Yatsenko KV, Berezovskii VA, Deyeva JV.

Bogomoletz Institute of Physiology, National Academy of Sciences of Ukraine, Kyiv.

We studied the effects of intermittent normobaric hypoxia (INH) on the processes of CNS functions and cerebral

circulation recovery in children with cerebral palsy (CP). Altogether, 87 patients (from 8.5 months to 12 years) with

CP were examined and received the course of treatment. Clinico-neurophysiological examination was performed

before the treatment and immediately after termination of the therapeutic course. Patients were divided into two

groups; age and sex distributions and clinical manifestations of CP were randomized. The comparison group was

formed from 34 children who received the course of the generally accepted complex therapy (medicamental

treatment, massage, Bobat-therapy, Vojta-therapy at al). The main group included 53 patients who, in addition to

the same therapy, were exposed to INH using an individual apparatus for artificial mountain air, Borey-M, made in

the Scientific Medico-Engineering Center NORT (Ukrainian National Academy of Sciences, Kyiv). Children of the

main group were exposed to the dosed normobaric sanogenetic level hypoxia intermittently once per day. For this

purpose, we used a normobaric gas hypoxic mixture (12% O2 + 88% N2). Each cycle included a 15-min-long

episode of breathing with the gas mixture alternated by a 5-min-long episode of breathing an ambient atmospheric

air. The number of hypoxic cycles was gradually increased (from one to three). The entire course of treatment

included, on average, 10 sessions. After complex therapy the stable positive effects on the motor status were

observed in 94% of patients of the main group (exposed to INH) and in 74% of patients of the comparison group

(unexposed to INH). EEG examination showed that positive dynamics of spectral EEG components were in 70% of

patients of the main group and in 56% of children of the comparison group. Doppler examination showed that brain

hemodynamics was normalized in 85% of patients of the main group and in 59% of children of the comparison

group. In the course of ophthalmoscopic examination, we found that the dynamics of indices of the state of the eye

Cerebral Palsy Research News ~ September 2012

Cerebral Palsy Alliance

PO Box 184 Brookvale NSW 2100 Australia | T +61 2 9479 7200 | www.cerebralpalsy.org.au

fundus were expressed more clearly in children of the main group than in patients of the comparison group (in 32

and 12% of patients, respectively).

PMID: 22946316 [PubMed - in process]

44. Med Wieku Rozwoj. 2012;16(2):81-88.

Assessment of somatic development and body composition in the 7th year of life in children born as

extremely low birth weight infants (=1000g); a multi-centre cross-sectional study of a cohort born between

2002 and 2004 in the Malopolska voivodship [Article in Polish]

Kwinta P, Klimek M, Grudzien A, Piatkowska E, Kralisz A, Nitecka M, Profus K, Gasinska M, Pawlik D, Lauterbach

R, Olechowski W, Drozdz D, Pietrzyk JJ.

Klinika Chorób Dzieci Katedry Pediatrii, UM UJ, ul. Wielicka 265, 30-663 Kraków, tel./fax (12) 658 44 46,

kwintap@mp.pl.

Children born with extremely low birth weight often present delayed growth in the first years of their lives: they

remain shorter and weigh less than their peers. Current reports published worldwide state that later in life these

children are at an increased risk of cardiac and vascular diseases, diabetes and obesity. Abnormal distribution and

the excess of fat tissue predispose them to develop the metabolic syndrome. The aim of the study was to evaluate

the somatic development of seven-year-old children born with birth-weight =1000 g (ELBW) in the Malopolska

voivodship and to estimate the content and distribution of fat tissue. Moreover, the risk factors of disturbed somatic

development were evaluated. Materials and methods: Two hundred and four live newborns with birth weight =1000

g were born in the Malopolska voivodship between 1.09.2002 and 31.08.2004. One hundred and fifteen of these

children (56%) died in early infancy. The study included 81 children in the 7th year of life out of the 89 surviving

ones. Their mean gestational age at birth was 27.3 weeks. (SD: 2.1 weeks) and their mean birth-weight was 840 g

(SD: 130 g). All the children underwent anthropometric measurements and the thickness of the skin fold over the

triceps was measured. Body mass index (BMI) was calculated and the body composition was assessed by

multifrequency bioimpedance. The control group consisted of 39 children born at term chosen randomly from the

general population and matched with regard to age and sex. Results: The ELBW children in the 7th year of life were

shorter (z-score: -1.06±1.4 p<0.001), had lower body mass (z-score: -0.57±0.9; p=0.01), smaller head

circumference (z-score: -1.2±1.3; p<0.001), lower BMI (z-score: -0.99±1.6; p<0.001) as compared to their peers.

Fat tissue mass was lower in the ELBW group than in the control group (11% vs 16%; p<0.01). The most retarded

somatic development was observed in the group of children suffering from cerebral palsy. Conclusions: 1. Children

born with ELBW, at 7 years of life, present significantly retarded somatic development as compared with their fullterm

peers. 2. The most important risk factor of somatic development disturbances is cerebral palsy. 3. Children

born with low birth weight and ELBW, need long term follow up.

PMID: 22971650 [PubMed - as supplied by publisher]

45. Int J Integr Care. 2012 Jan;12:e9. Epub 2012 Mar 6.

A web-based communication system for integrated care in cerebral palsy: experienced contribution to

parent-professional communication.

Gulmans J, Vollenbroek-Hutten M, van Gemert-Pijnen L, van Harten W.

Roessingh Research and Development, Institute for Research in Rehabilitation Medicine and Technology,

Enschede, The Netherlands.

INTRODUCTION: To improve communication in the integrated care setting of children with cerebral palsy, we

developed a web-based system for parent-professional and inter-professional communication. The present study

aimed to evaluate parents’ experiences regarding the system’s contribution to their communication with

professionals during a six-months pilot in three Dutch care regions. In addition, factors associated with parents’

system use and non-use were analyzed. THEORY AND METHODS: The system’s functional specifications were

based on key elements of the Chronic Care Model and quality dimensions formulated by the Institute of Medicine.

At baseline, parents completed a T0-questionnaire on their experiences regarding sufficiency of contact,

Cerebral Palsy Research News ~ September 2012

Cerebral Palsy Alliance

PO Box 184 Brookvale NSW 2100 Australia | T +61 2 9479 7200 | www.cerebralpalsy.org.au

accessibility of professionals, timeliness of information exchange, consistency of information and parents’ role as

messenger of information and/or care coordinator. After the pilot, parents completed a T1-questionnaire on their

experiences regarding the system’s contribution to each of these aspects. RESULTS: Of the 30 participating

parents 21 had used the system, of which 20 completed the T1-questionnaire. All these parents indicated that they

had experienced a contribution of the system to parent-professional communication, especially with respect to

accessibility of professionals, sufficiency of contact and timeliness of information exchange, and to a lesser extent

consistency of information and parents’ messenger/coordinator role. In comparison with non-users, users had less

positive baseline experiences with accessibility and a higher number of professionals in the child’s care network.

CONCLUSIONS: All users indicated a contribution of the system to parent-professional communication, although

the extent of the experienced contribution varied considerably. Based on the differences found between users and

non-users, further research might focus on the system’s value for complex care networks and problematic access to

professionals.

PMID: 22977435 [PubMed - in process]

46. BMC Res Notes. 2012 Sep 11;5(1):498. [Epub ahead of print]

Paediatric palliative home care in areas of Germany with low population density and long distances: a

questionnaire survey with general paediatricians.

Kremeike K, Eulitz NK, Jünger S, Sander A, Geraedts M, Reinhardt D.

BACKGROUND: In 2007, the patient’s right to specialised palliative home care became law in Germany. However,

childhood palliative care in territorial states with low patient numbers and long distances requires adapted models to

ensure an area-wide maintenance. Actually, general paediatricians are the basic care providers for children and

adolescents. They also provide home care. The aim of this study was to improve the knowledge about general

paediatrician’s involvement in and contribution to palliative care in children. FINDINGS: To evaluate the current

status of palliative home care provided by general paediatricians and their cooperation with other paediatric

palliative care providers, a questionnaire survey was disseminated to general paediatricians in Lower Saxony, a

German federal state with nearly eight million inhabitants and a predominantly rural infrastructure. Data analysis

was descriptive. One hundred forty one of 157 included general paediatricians completed the questionnaire

(response rate: 89.8%). A total of 792 children and adolescents suffering from life-limiting conditions were cared for

by these general paediatricians in 2008. Severe cerebral palsy was the most prevalent diagnosis. Eighty-nine per

cent of the general paediatricians stated that they had professional experience with paediatric palliative care.

Collaboration of general paediatricians and other palliative care providers was stated as not well developed. The

support by a specialised team including 24-hour on-call duty and the intensification of educational programs were

emphasised. CONCLUSIONS: The current regional infrastructure of palliative home care in Lower Saxony can

benefit from the establishment of a coordinated network of palliative home care providers.

PMID: 22967691 [PubMed - as supplied by publisher]

47. Int J Palliat Nurs. 2012 Jul;18(7):355-9.

Application of the M technique to two severely disabled children in Belarus.

Breen Rickerby K, Cordell B. kbreenrickerby@gmail.com

Following the early-morning explosion of reactor four at the Chernobyl nuclear plant on 26 April 1986, radioactive

fallout fell over 80% of Belarus. More than 2.2 million people were affected, including thousands of children. As a

result, there are now over 50,000 children in 600 orphanages in Belarus. Many of the orphanages are without basic

amenities and are operating in dire circumstances. This article outlines two case studies of orphaned children with

profound disabilities in one of these orphanages. The first author, a nurse volunteer from Ireland, used a method of

touch called the ‘M technique’ to calm and soothe the children. The M technique is a gentle repetitive method of

touch that can be learnt in a few hours. The results suggest that even when the situation appears very challenging,

simple touch can have a beneficial effect.

PMID: 22885968 [PubMed - indexed for MEDLINE]

Cerebral Palsy Research News ~ September 2012

Cerebral Palsy Alliance

PO Box 184 Brookvale NSW 2100 Australia | T +61 2 9479 7200 | www.cerebralpalsy.org.au

48. J Matern Fetal Neonatal Med. 2012 Oct;25 Suppl 4:21-3.

Chorioamnionitis and prematurity: a critical review.

Martinelli P, Sarno L, Maruotti GM, Paludetto R.

Department of Obstetrics & Gynaecology, High-Risk Pregnancy Unit, University Federico II of Naples, Naples, Italy.

Chorioamnionitis is the inflammatory response to an acute inflammation of the membranes and chorion of the

placenta. We provide a critical review of the relationship between chorioamnionitis and the risk of prematurity and

adverse maternal-fetal outcome. Chorioamnionitis results as a major risk factor for preterm birth and its incidence is

strictly related to gestational age. It is associated with a significant maternal, perinatal and long-term adverse

outcomes. The principal neonatal complications are neonatal sepsis, pneumonia, bronchopulmonary dysplasia,

perinatal death, cerebral palsy and intraventricular hemorrhage. The role in neonatal outcome is still controversial

and more conclusive studies could clarify the relationship between chorioamnionitis and adverse neonatal outcome.

Maternal complications include abnormal progression of labour, caesarean section, postpartum hemorrhage,

abnormal response after use of oxytocin and placenta abruption. Prompt administration of antibiotics and steroids

could improve neonatal outcomes.

PMID: 22958008 [PubMed - in process]

49. J Inflamm Res. 2012;5:67-75. Epub 2012 Jul 30.

Placental-mediated increased cytokine response to lipopolysaccharides: a potential mechanism for

enhanced inflammation susceptibility of the preterm fetus.

Boles JL, Ross MG, Beloosesky R, Desai M, Belkacemi L.

Department of Obstetrics and Gynecology, Harbor-UCLA Medical Center, Los Angeles Biomedical Research

Institute at Harbor-UCLA, David Geffen School of Medicine at UCLA, University of California, Los Angeles,

Torrance, CA, USA;

BACKGROUND: Cerebral palsy is a nonprogressive motor impairment syndrome that has no effective cure. The

etiology of most cases of cerebral palsy remains unknown; however, recent epidemiologic data have demonstrated

an association between fetal neurologic injury and infection/inflammation. Maternal infection/inflammation may be

associated with the induction of placental cytokines that could result in increased fetal proinflammatory cytokine

exposure, and development of neonatal neurologic injury. Therefore, we sought to explore the mechanism by which

maternal infection may produce a placental inflammatory response. We specifically examined rat placental cytokine

production and activation of the Toll-like receptor 4 (TLR4) pathway in response to lipopolysaccharide exposure at

preterm and near-term gestational ages. METHODS: Preterm (e16) or near-term (e20) placental explants from

pregnant rats were treated with 0, 1, or 10 μg/mL lipopolysaccharide. Explant integrity was assessed by lactate

dehydrogenase assay. Interleukin-6 and tumor necrosis alpha levels were determined using enzyme-linked

immunosorbent assay kits. TLR4 and phosphorylated nuclear factor kappa light chain enhancer of activated B cells

(NF?B) protein expression levels were determined by Western blot analysis. RESULTS: At both e16 and e20,

lactate dehydrogenase levels were unchanged by treatment with lipopolysaccharide. After exposure to

lipopolysaccharide, the release of interleukin-6 and tumor necrosis alpha from e16 placental explants increased by

4-fold and 8-9-fold, respectively (P < 0.05 versus vehicle). Conversely, interleukin-6 release from e20 explants was

not significantly different compared with vehicle, and tumor necrosis alpha release was only 2-fold higher (P < 0.05

versus vehicle) following exposure to lipopolysaccharide. Phosphorylated NF?B protein expression was significantly

increased in the nuclear fraction from placental explants exposed to lipopolysaccharide at both e16 and e20,

although TLR4 protein expression was unaffected. CONCLUSION:

Lipopolysaccharide induces higher interleukin-6 and tumor necrosis alpha expression at e16 versus e20,

suggesting that preterm placentas may have a greater placental cytokine response to lipopolysaccharide infection.

Furthermore, increased phosphorylated NF?B indicates that placental cytokine induction may occur by activation of

the TLR4 pathway.

Cerebral Palsy Research News ~ September 2012

Prevention and Cure

Cerebral Palsy Alliance

PO Box 184 Brookvale NSW 2100 Australia | T +61 2 9479 7200 | www.cerebralpalsy.org.au

PMID: 22924006 [PubMed - in process] PMCID: PMC3422858

50. Epilepsy Res Treat. 2012;2012:747565. Epub 2012 Jul 12.

Epileptic encephalopathy in children with risk factors for brain damage.

Ricardo-Garcell J, Harmony T, Porras-Kattz E, Colmenero-Batallán MJ, Barrera-Reséndiz JE, Fernández-Bouzas

A, Cruz-Rivero E.

Unidad de Investigación en Neurodesarrollo, Departamento de Neurobiología Conductual y Cognitiva, Instituto de

Neurobiología, Universidad Nacional Autónoma de México, Campus Juriquilla, 76230 Querétaro, ORO, Mexico.

In the study of 887 new born infants with prenatal and perinatal risk factors for brain damage, 11 children with West

syndrome that progressed into Lennox-Gastaut syndrome and another 4 children with Lennox-Gastaut syndrome

that had not been preceded by West syndrome were found. In this study we present the main findings of these 15

subjects. In all infants multifactor antecedents were detected. The most frequent risk factors were prematurity and

severe asphyxia; however placenta disorders, sepsis, and hyperbilirubinemia were also frequent. In all infants MRI

direct or secondary features of periventricular leukomalacia were observed. Followup of all infants showed

moderate to severe neurodevelopmental delay as well as cerebral palsy. It is concluded that prenatal and perinatal

risk factors for brain damage are very important antecedents that should be taken into account to follow up those

infants from an early age in order to detect and treat as early as possible an epileptic encephalopathy.

PMID: 22957240 [PubMed] PMCID: PMC3420497

51. Congenit Anom (Kyoto). 2012 Sep;52(3):147-54. doi: 10.1111/j.1741-4520.2012.00375.x.

Pluripotent stem cells are protected from cytomegalovirus infection at multiple points: Implications of a

new pathogenesis for congenital anomaly caused by cytomegalovirus.

Kawasaki H.

Department of Regenerative & Infectious Pathology, Hamamatsu University School of Medicine, Hamamatsu,

Japan.

In humans, the cytomegalovirus (CMV) is the most significant cause of intrauterine infections that cause congenital

anomalies. Intrauterine infection with human CMV is thought to be responsible for a variety of abnormalities,

including mental retardation, microcephaly, developmental delay, seizure disorders, and cerebral palsy, depending

on the timing of the fetal infection, the infectious route, and the virulence of the virus. In addition to the adaptive

immune system, the embryo has potential resistance to CMV during early embryogenesis. Embryonic stem (ES)

cells are more resistant to CMV than most other cell types, although the mechanism responsible for this resistance

is not well understood. ES cells allow approximately 20-fold less murine CMV (MCMV) DNA to enter the nucleus

than mouse embryonic fibroblasts (MEFs), and this inhibition occurs in a multistep manner. In situ hybridization

showed that ES cell nuclei had significantly less MCMV DNA than MEF nuclei. This finding appears to be supported

by the fact that ES cells express less heparan sulfate, ß1-integrin, and vimentin and have fewer nuclear pores than

differentiated cells such as MEF. This may reduce the ability of MCMV to attach to and enter the cellular

membrane, translocate to the nucleus, and cross the nuclear membrane in pluripotent stem cells (ES-induced

pluripotent stem cells). This finding may indicate a new pathogenesis for the congenital anomaly caused by CMV.

PMID: 22925215 [PubMed - in process]

Cerebral Palsy Research News ~ September 2012

Cerebral Palsy Alliance

PO Box 184 Brookvale NSW 2100 Australia | T +61 2 9479 7200 | www.cerebralpalsy.org.au

52. Neuropediatrics. 2012 Aug 29. [Epub ahead of print]

Head Circumference Growth Function as a Marker of Neurological Impairment in a Cohort of Microcephalic

Infants and Children.

Coronado R, Giraldo J, Macaya A, Roig M.

Secció de Neurologia Infantil, Hospital Vall d’Hebron, Universitat Autònoma de Barcelona and Unitat de Neurologia

Pediàtrica, Consorci Sanitari de Terrassa, Spain.

Our aim was to investigate the correlations between head circumference (HC) growth and neurological impairment

in microcephalic patients.HC charts of 3,269 patients from a tertiary pediatric neurology section were reviewed and

136 microcephalic participants were selected. Standardized HC Minimum, HC Drop, and HC Catch-up variables

were defined. Children with evidence of significant learning disability and/or significant cerebral palsy were

classified within the neurologically impaired group and the rest of participants within the normal group.Using

discriminant analysis, we found that HC Minimum and HC Drop were relevant markers of neurological impairment.

A positive HC Catch-up was significantly linked to a better outcome although this variable did not add significant

information to HC Minimum and HC Drop. A Fisher linear discrimination cutoff function (C-function) was obtained as

C = HC Minimum + HC Drop with a cutoff level of C = -4.28 standard deviations (SD).In our cohort, the addition of

the lowest HC z-score to the preceding HC z-score drop was below -4.28 SD in 6 out of 10 neurologically impaired

patients , whereas in the normal group, the result was over -4.28 SD in 9 out of 10 participants.

Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

PMID: 22932949 [PubMed - as supplied by publisher]

53. Pediatrics. 2012 Sep;130(3):390-6. Epub 2012 Aug 29.

Neurologic disorders among pediatric deaths associated with the 2009 pandemic influenza.

Blanton L, Peacock G, Cox C, Jhung M, Finelli L, Moore C.

Centers for Disease Control and Prevention, 1600 Clifton Rd, NE, Mailstop A-32, Atlanta, GA 30333.

lblanton@cdc.gov.

OBJECTIVE: The goal of this study was to describe reported influenza A (H1N1)pdm09 virus (pH1N1)-associated

deaths in children with underlying neurologic disorders. METHODS: The study compared demographic

characteristics, clinical course, and location of death of pH1N1-associated deaths among children with and without

underlying neurologic disorders reported to the Centers for Disease Control and Prevention. RESULTS: Of 336

pH1N1-associated pediatric deaths with information on underlying conditions, 227 (68%) children had at least 1

underlying condition that conferred an increased risk of complications of influenza. Neurologic disorders were most

frequently reported (146 of 227 [64%]), and, of those disorders, neurodevelopmental disorders such as cerebral

palsy and intellectual disability were most common. Children with neurologic disorders were older (P = .02), had a

significantly longer duration of illness from onset to death (P < .01), and were more likely to die in the hospital

versus at home or in the emergency department (P < .01) compared with children without underlying medical

conditions. Many children with neurologic disorders had additional risk factors for influenza-related complications,

especially pulmonary disorders (48%). Children without underlying conditions were significantly more likely to have

a positive result from a sterile-site bacterial culture than were those with an underlying neurologic disorder (P < .01).

CONCLUSIONS: Neurologic disorders were reported in nearly two-thirds of pH1N1-associated pediatric deaths

with an underlying medical condition. Because of the potential for severe outcomes, children with underlying

neurologic disorders should receive influenza vaccine and be treated early and aggressively if they develop

influenza-like illness.

PMID: 22931899 [PubMed - in process]

Cerebral Palsy Research News ~ September 2012

Cerebral Palsy Alliance

PO Box 184 Brookvale NSW 2100 Australia | T +61 2 9479 7200 | www.cerebralpalsy.org.au

54. Eur J Obstet Gynecol Reprod Biol. 2012 Sep 1. [Epub ahead of print]

Independent effects of pregnancy induced hypertension on childhood development: a retrospective cohort

study.

Love ER, Crum J, Bhattacharya S.

University of Aberdeen, United Kingdom.

OBJECTIVE: To assess whether maternal hypertension in pregnancy was independently associated with additional

support needs in children. STUDY DESIGN: Retrospective cohort study using linkage of birth records of all

singleton deliveries occurring in primigravidae between 1995 and 2008 in Aberdeen Maternity and Neonatal

Databank with the Support Needs System (SNS) dataset in Grampian. Crude and adjusted odds ratios with 95%

confidence intervals of having a record in SNS in the presence of maternal pregnancy induced hypertension were

calculated using logistic regression taking account of confounders such as preterm birth and low birth weight.

RESULTS: After adjusting for confounding factors, neither pre-eclampsia {Adj OR 0.80 (95% CI 0.60, 1.07)} nor

gestational hypertension {Adj OR 1.16 (95% CI 0.99, 1.36)} showed statistically significant associations with

additional support needs. An association of pre-eclampsia with cerebral palsy seen on univariate analysis also

disappeared on adjusting for confounders {Adj OR 1.26 (95% CI 0.43, 3.68)}. Birth before 32 weeks gestation and

birthweight below 1500g were independently associated with additional support needs in children. CONCLUSIONS:

While maternal hypertension was not found to be independently associated with special needs in children, very

preterm birth and very low birthweight showed an association.

PMID: 22948131 [PubMed - as supplied by publisher]

55. Acta Med Iran. 2012 Jul;50(7):473-6.

Intraventricular hemorrhage in premature infants and its association with pneumothorax.

Pishva N, Parsa G, Saki F, Saki M, Saki MR.

Neonatology Research Center, Namazi Hospital, Shiraz University of Medical Science, Shiraz, Iran.

Intraventricular hemorrhage (IVH) is one of the major causes of the cerebral palsy and mental retardation.

Prevention and early management of these neurologic developmental problems will require determining the

perinatal risk factors associated with this clinical entity. Pneumothorax increase the risk of IVH, and cause of

pneumothorax has an important effect in severity of IVH. This is a prospective cross sectional study in 2010. This

study includes 150 preterm neonates. Cranial ultrasound was performed in all neonates in age 3, 7, 30, 60, just

after pneumothorax and every 2 week until chest tube discontinuation. Then prevalence of IVH and pneumothorax

was calculated in preterm infant and severity of IVH was investigated before and after development of

pneumothorax, and this comparison was divided by different causes of pneumothorax with SPSS version 11.5.

Prevalence of IVH and pneumothorax in preterm infants were 30% and 10% respectively. Pneumothorax was not a

risk factor of IVH (P>0.05), but prevalence of pneumothorax caused by RDS was a risk factor of development of

IVH (P=0.01). Also pneumothorax in patients with birth weight less than 1000 g and gestational age less than 28

week was a risk factor of IVH pneumothorax (P=0.008, P=0.01 respectively). Our study discusses the differences in

previous studies about association of pneumothorax and IVH. Also we suggest the hypothesis that lack of cerebral

autoregulation in neonates with gestational age less than 28 week can cause IVH development after hypotension

induces by pneumothorax.

PMID: 22930379 [PubMed - in process]

Cerebral Palsy Research News ~ September 2012

Cerebral Palsy Alliance

PO Box 184 Brookvale NSW 2100 Australia | T +61 2 9479 7200 | www.cerebralpalsy.org.au

56. Pediatrics. 2012 Sep 3. [Epub ahead of print]

EEG for Predicting Early Neurodevelopment in Preterm Infants: An Observational Cohort Study.

Hayashi-Kurahashi N, Kidokoro H, Kubota T, Maruyama K, Kato Y, Kato T, Natsume J, Hayakawa F, Watanabe K,

Okumura A.

Department of Pediatric Neurology, Central Hospital of Aichi Welfare Center for Persons with Developmental

Disabilities, Kasugai, Japan;

OBJECTIVE: To clarify the prognostic value of conventional EEG for the identification of preterm infants at risk for

subsequent adverse neurodevelopment in the current perinatal care and medicine setting. METHODS: We studied

780 EEG records of 333 preterm infants born <34 weeks’ gestation between 2002 and 2008. Serial EEG recordings

were conducted during 3 time periods; at least once each within days 6 (first period), during days 7 to 19 (second

period), and days 20 to 36 (third period). The presence and the grade of EEG background abnormalities were

assessed according to an established classification system. Neurodevelopmental outcomes were assessed at a

corrected age of 12 to 18 months. RESULTS: Of the 333 infants, 33 (10%) had developmental delay and 34 (10%)

had cerebral palsy. The presence of EEG abnormalities was significantly predictive of developmental delay and

cerebral palsy at all 3 time periods: the first period (n = 265; odds ratio [OR], 4.5; 95% confidence interval [CI], 2.2-

9.4), the second period (n = 278; OR, 7.6; 95% CI, 3.6-16), and the third period (n = 237; OR, 5.9; 95% CI, 2.8-13).

The grade of EEG abnormalities correlated with the incidence of developmental delay or cerebral palsy in all

periods (P < .001). After controlling for other clinical variables, including severe brain injury, EEG abnormality in the

second period was an independent predictor of developmental delay (OR, 3.2; 95% CI, 1.1-9.7) and cerebral palsy

(OR, 6.8; 95% CI 2.0-23). CONCLUSIONS: EEG abnormalities within the first month of life significantly predict

adverse neurodevelopment at a corrected age of 12 to 18 months in the current preterm survivor.

PMID: 22945413 [PubMed - as supplied by publisher]

57. Pediatrics. 2012 Sep 10. [Epub ahead of print]

Incidence of Chronic Bilirubin Encephalopathy in Canada, 2007-2008.

Sgro M, Campbell DM, Kandasamy S, Shah V.

Keenan Research Centre, Li Ka Shing Knowledge Institute, and.

BACKGROUND AND OBJECTIVES: Despite the implementation of screening guidelines to identify infants at risk

for hyperbilirubinemia, chronic bilirubin encephalopathy (CBE) continues to be reported worldwide in otherwise

healthy infants. The incidence of CBE in Canada is unknown. The objectives of this study were to establish the

incidence of CBE in Canada and identify epidemiological and medical risk factors associated with its occurrence.

METHODS: Data on infants were collected prospectively through the Canadian Pediatric Surveillance Program.

Infants born between January 1, 2007 and December 31, 2008 were included if they either had symptoms of CBE

and a history of hyperbilirubinemia, or if they presented in the newborn period with severe hyperbilirubinemia and

an abnormal MRI finding as per the reporting physician. RESULTS: During the study period, 20 cases were

identified; follow-up data were available for 14 of these. The causes for the hyperbilirubinemia included glucose-6-

phosphate dehydrogenase deficiency (n = 5), sepsis (n = 2), ABO incompatibility and other red blood cell antibodies

(n = 7). Fifteen infants had abnormal brain MRI findings during the neonatal period. At follow-up, 5 infants

developed classic choreoathetoid cerebral palsy, 6 had spectrum of neurologic dysfunction and developmental

delay (as described by the reporting physician), and 3 were healthy. CONCLUSIONS: CBE continues to occur in

Canada at an incidence that appears to be higher than previously reported.

PMID: 22966025 [PubMed - as supplied by publisher]

Cerebral Palsy Research News ~ September 2012

Cerebral Palsy Alliance

PO Box 184 Brookvale NSW 2100 Australia | T +61 2 9479 7200 | www.cerebralpalsy.org.au

58. J Pediatr. 2012 Aug 31. [Epub ahead of print]

Normal Imaging in Patients with Cerebral Palsy: What Does It Tell Us?

Benini R, Dagenais L, Shevell MI; Registre de la Paralysie Cérébrale au Québec (Quebec Cerebral Palsy Registry)

Consortium.

Division of Pediatric Neurology, McGill University, Montreal, Canada and Montreal Children’s Hospital-McGill

University Health Center, Montreal, Quebec, Canada.

OBJECTIVE: To identify distinctive clinical features characterizing children with cerebral palsy (CP) and normalappearing

magnetic resonance imaging (MRI) findings. STUDY DESIGN: Using a population-based CP registry, the

Registre de la Paralysie Cérébrale au Québec (Quebec Cerebral Palsy Registry), various antenatal, perinatal, and

postnatal predictor variables, as well as current phenotype, were compared in patients with normal-appearing MRI

findings and those with abnormal MRI findings. RESULTS: Of the 213 patients evaluated, 126 (60%) had MRI

imaging results available and were included in our analysis. Of these 126 patients, 90 (71%; 51 males, 39 females)

had abnormal findings and 36 (29%; 17 males and 19 females) had normal-appearing findings. Compared with

other CP variants, normal-appearing MRI was more prevalent (P = .001) in dyskinetic CP (72.7%; 8 of 11) and less

prevalent (P = .002) in spastic hemiplegic CP (10%; 4 of 40). There were no significant differences between the 2

groups (P > .05) in terms of the prevalence of perinatal or postnatal clinical features or clinical outcomes.

Furthermore, 42% (15 of 36) of the children with normal-appearing MRI exhibited a high degree of functional

disability (Gross Motor Functional Classification System IV-V), compared with 33% (30 of 90) with abnormal MRI.

CONCLUSION: No clinical features, except a higher prevalence of dyskinetic CP, was identified in the children with

normal-appearing MRI. More refined imaging techniques may be needed to evaluate patients with normalappearing

MRI findings. Furthermore, genetic or functional, rather than gross structural lesions, may underlie the

pathophysiology of CP in this cohort. Finally, the high proportion of substantial functional disability underscores the

importance of continuous follow-up even in the absence of early structural abnormalities on imaging.

PMID: 22944004 [PubMed - as supplied by publisher]

59. AJNR Am J Neuroradiol. 2012 Sep 13. [Epub ahead of print]

Diffusion Tensor Imaging-Demonstrated Differences between Hemiplegic and Diplegic Cerebral Palsy with

Symmetric Periventricular Leukomalacia.

Cho HK, Jang SH, Lee E, Kim SY, Kim S, Kwon YH, Son SM.

Departments of Physical Medicine and Rehabilitation, Pediatrics, and Physical Therapy, College of Science and

Technology, College of Medicine, Yeungnam University, Taegu, Republic of Korea; and Department of Pediatrics,

College of Medicine, Eulji University, Daejeon, Republic of Korea.

BACKGROUND AND PURPOSE: Patients with cerebral palsy have variable clinical presentations such as

hemiplegic, diplegic, or quadriplegic patterns though they have PVL on conventional MR images. The authors

investigated whether DTT can differentiate between hemiplegic and diplegic CP in patients presenting with

symmetric PVL on conventional MR images. MATERIALS AND METHODS: One hundred thirteen consecutive

pediatric patients with definite hemiplegic (59 patients; 30 boys, 29 girls; mean age, 34.19 months; range, 24-52

months) or diplegic (54 patients; 27 boys, 27 girls; mean age, 31.07 months; range, 24-48 months) symptoms and

bilateral symmetric PVL on conventional brain MR imaging were recruited. The states of CSTs were examined by

using DTT, and the asymmetries of right and left CSTs in the hemiplegic and diplegic groups were compared by

using asymmetric anisotropy indexes and asymmetric mean diffusivity indexes. RESULTS: All patients in the

hemiplegic group with asymmetric results exhibited disrupted integrities of more affected CSTs and sparing of less

affected CSTs. However, diplegic patients revealed symmetric disrupted findings of the right and left CSTs at the

upper periventricular level. Asymmetric anisotropy index and asymmetric mean diffusivity index values were

significantly higher in the hemiplegic group than in the diplegic group (P < .05), and these results of DTT

significantly corresponded with their typical clinical manifestation. CONCLUSIONS: DTT may be very useful for the

detailed estimation of the CST state in patients with bilateral symmetric PVL.

Cerebral Palsy Research News ~ September 2012

Cerebral Palsy Alliance

PO Box 184 Brookvale NSW 2100 Australia | T +61 2 9479 7200 | www.cerebralpalsy.org.au

PMID: 22976239 [PubMed - as supplied by publisher]

60. Am J Obstet Gynecol. 2012 Sep;207(3):192.e1-9. Epub 2012 Jul 7.

Brain damage in preterm newborns and maternal medication: the ELGAN Study.

Tyler CP, Paneth N, Allred EN, Hirtz D, Kuban K, McElrath T, O’Shea TM, Miller C, Leviton A; ELGAN Study

Investigators.

Department of Epidemiology, College of Human Medicine, Michigan State University, East Lansing, MI.

OBJECTIVE: We sought to evaluate the association between maternal medication use during pregnancy and

cerebral white matter damage and cerebral palsy (CP) among very preterm infants. STUDY DESIGN: This analysis

of data from the Extremely Low Gestational Age Newborns (ELGAN) Study included 877 infants born <28 weeks’

gestation. Mothers were interviewed, charts were reviewed, placentas were cultured and assessed histologically,

and children were evaluated at 24 months corrected age. A diagnostic algorithm classified neurologic findings as

quadriparetic CP, diparetic CP, hemiparetic CP, or no CP. RESULTS: After adjustment for the potential

confounding of disorders for which medications might have been indicated, the risk of quadriparetic CP remained

elevated among the infants of mothers who consumed aspirin (odds ratio [OR], 3.0; 95% confidence interval [CI],

1.3-6.9) and nonsteroidal antiinflammatory drugs (NSAIDs) (OR, 2.4; 95% CI, 1.04-5.8). The risk of diparetic CP

was also associated with maternal consumption of an NSAID, but only if the consumption was not approved by a

physician (OR, 3.5; 95% CI 1.1-11.0). CONCLUSION:

The possibility that aspirin and NSAID use in pregnancy could lead to perinatal brain damage cannot be excluded.

PMID: 22939723 [PubMed - in process] PMCID: PMC3432943 [Available on 2013/9/1]

61. J Physiol. 2012 Sep 10. [Epub ahead of print]

Reduced Corticomotor Excitability and Motor Skills Development in Children Borm Preterm.

Pitcher JB, Schneider LA, Burns NR, Drysdale JL, Higgins RD, Ridding MC, Nettelbeck TJ, Haslam RR, Robinson

JS.

University of Adelaide

The mechanisms underlying the altered neurodevelopment commonly experienced by children born preterm, but

without brain lesions, remain unknown. While individuals born the earliest are at most risk, late preterm children

also experience significant motor, cognitive and behavioural dysfunction from school age, and reduced income and

educational attainment in adulthood. We used transcranial magnetic stimulation and functional assessments to

examine corticomotor development in 151 non-cerebral palsy children aged 10-13 years and born after gestations

of 25 – 41 completed weeks. We hypothesised that motor cortex and corticospinal development are altered in

preterm children and underpins at least some of their motor dysfunction. We report for the first time that every week

of reduced gestation is associated with a reduction in corticomotor excitability that remains evident in late

childhood. This reduced excitability was associated with poorer motor skill development, particularly manual

dexterity. However, child adiposity, sex and socio-economic factors regarding the child’s home environment soon

after birth were also powerful influences on motor skills development. Preterm birth was also associated with

reduced left hemisphere lateralisation, but without increasing the likelihood of being left-handed per se. These

corticomotor findings have implications for normal motor development, but also raise questions regarding possible

longer-term consequences of preterm birth on motor function.

PMID: 22966161 [PubMed - as supplied by publisher]

Cerebral Palsy Research News ~ September 2012

Cerebral Palsy Alliance

PO Box 184 Brookvale NSW 2100 Australia | T +61 2 9479 7200 | www.cerebralpalsy.org.au

62. Bone Marrow Transplant. 2012 Sep 10. doi: 10.1038/bmt.2012.169. [Epub ahead of print]

Rescuing the neonatal brain from hypoxic injury with autologous cord blood.

Liao Y, Cotten M, Tan S, Kurtzberg J, Cairo MS.

Department of Pediatrics, New York Medical College, Valhalla, NY, USA.

Brain injury resulting from perinatal hypoxic-ischemic encephalopathy (HIE) is a major cause of acute mortality in

infants and chronic neurologic disability in surviving children. Recent multicenter clinical trials demonstrated the

effectiveness of hypothermia initiated within the first 6 postnatal hours to reduce the risk of death or major

neurological disabilities among neonates with HIE. However, in these trials, approximately 40% of cooled infants

died or survived with significant impairments. Therefore, adjunct therapies are required to improve the outcome in

neonates with HIE. Cord blood (CB) is a rich source of stem cells. Administration of human CB cells in animal

models of HIE has generally resulted in improved outcomes and multiple mechanisms have been suggested

including anti-inflammation, release of neurotrophic factors and stimulation of endogenous neurogenesis.

Investigators at Duke are conducting studies of autologous CB infusion in neonates with HIE and in children with

cerebral palsy. These pilot studies indicate no added risk from the regimens used, but results of ongoing placebocontrolled

trials are needed to assess efficacy. Meanwhile, further investigations are warranted to determine the

best strategies, that is, timing, dosing, route of delivery, choice of stem cells and ex vivo modulations, to attain longterm

benefits of CB stem cell therapy.

PMID: 22964590 [PubMed - as supplied by publisher]

63. Brain. 2012 Sep 10. [Epub ahead of print]

Genotype-phenotype correlations in spastic paraplegia type 7: a study in a large Dutch cohort.

van Gassen KL, van der Heijden CD, de Bot ST, den Dunnen WF, van den Berg LH, Verschuuren-Bemelmans CC,

Kremer HP, Veldink JH, Kamsteeg EJ, Scheffer H, van de Warrenburg BP.

Department of Human Genetics, Institute for Genetic and Metabolic Disease, Radboud University Nijmegen

Medical Centre, Nijmegen, 6500 HB, The Netherlands.

Spastic paraplegia type 7 is an autosomal recessive neurodegenerative disorder mainly characterized by

progressive bilateral lower limb spasticity and referred to as a form of hereditary spastic paraplegia. Additional

disease features may also be observed as part of a more complex phenotype. Many different mutations have

already been identified, but no genotype-phenotype correlations have been found so far. From a total of almost 800

patients referred for testing, we identified 60 patients with mutations in the SPG7 gene. We identified 14 previously

unreported mutations and detected a high recurrence rate of several earlier reported mutations. We were able to

collect detailed clinical data for 49 patients, who were ranked based on a pure versus complex phenotype, ataxia

versus no ataxia and missense versus null mutations. A generally complex phenotype occurred in 69% of all

patients and was associated with a younger age at onset (trend with P = 0.07). Ataxia was observed in 57% of all

patients. We found that null mutations were associated with the co-occurrence of cerebellar ataxia (trend with P =

0.06). The c.1409 G > A (p.Arg470Gln) mutation, which was found homozygously in two sibs, was associated with

a specific complex phenotype that included predominant visual loss due to optical nerve atrophy. Neuropathology in

one of these cases showed severe degeneration of the optic system, with less severe degeneration of the

ascending tracts of the spinal cord and cerebellum. Other disease features encountered in this cohort included

cervical dystonia, vertical gaze palsy, ptosis and severe intellectual disability. In this large Dutch cohort, we seem to

have identified the first genotype-phenotype correlation in spastic paraplegia type 7 by observing an association

between the cerebellar phenotype of spastic paraplegia type 7 and SPG7 null alleles. An overlapping phenotypic

presentation with its biological counterpart AFG3L2, which when mutated causes spinocerebellar ataxia type 28, is

apparent and possibly suggests that abnormal levels of the SPG7 protein impact the function of the mitochondrial

ATPases associated with diverse cellular activities-protease complex (formed by SPG7 and AFG3L2) in the

cerebellum. In addition, a missense mutation in exon 10 resulted in predominant optical nerve atrophy, which might

suggest deleterious interactions of this SPG7 variant with its substrate OPA1, the mutated gene product in optic

atrophy type 1. Functional studies are required to further investigate these interactions.

PMID: 22964162 [PubMed - as supplied by publisher]

Cerebral Palsy Research News ~ September 2012

Cerebral Palsy Alliance

PO Box 184 Brookvale NSW 2100 Australia | T +61 2 9479 7200 | www.cerebralpalsy.org.au

64. Gynecol Obstet Fertil. 2012 Sep 17. pii: S1297-9589(12)00232-9. doi: 10.1016/j.gyobfe.2012.08.005. [Epub

ahead of print]

Use of magnesium sulfate in obstetrics [Article in French]

Kayem G, Mandelbrot L, Haddad B.

Service de gynécologie-obstétrique, hôpital Louis-Mourier, AP-HP, HUPNVS, université Paris Diderot, 178, rue des

Renouillers, 92700 Colombes, France. Electronic address: gkayem@gmail.com.

Magnesium sulfate (MgSO(4)) is the best treatment of eclampsia, reduces the risk of recurrence better than other

anticonvulsants and is recommended as first line in cases of eclampsia. In cases of severe pre-eclampsia and

especially when prodromes are present, MgSO(4) reduces better than conventional anticonvulsants the risk of

eclampsia. More recently, MgSO(4) was used in cases of preterm delivery to reduce the risk of cerebral palsy in

premature infants. Three large randomized trials have obtained convergent results which all tended to show a

neuroprotective effect of MgSO(4). These trials were included in three meta-analyzes that showed a 30% reduction

in the incidence of cerebral palsy before 32weeks gestation suggesting that this drug should be used in cases of

preterm birth. A protocol using low doses associated with a well-conducted maternal surveillance reduces of

maternal hypermagnesemia and the risk of maternal toxicity.

PMID: 22995056 [PubMed - as supplied by publisher]

65. Z Geburtshilfe Neonatol. 2012 Aug;216(4):173-6. Epub 2012 Aug 27.

Intrauterine inflammation and its sequelae: does chorioamnionitis really matter for outcome of very low

birth weight infants? [Article in German]

Thomas W, Speer CP.

Universitäts-Kinderklinik, Würzburg.

Infections in utero and chorioamnionitis are major risk factors for spontaneous, very early premature birth. Thus

chorioamnionitis contributes significantly to prematurity-associated morbidity and mortality. Evidence for a gestation

-independent effect of chorioamnionitis on the outcome of very low birth weight infants is much more difficult to

obtain as most of the studies addressing this issue lack a normal “control group”, as prematurity is mostly

associated with some kind of prenatal pathology with a potential influence on neonatal outcome. Moreover, major

advances in perinatal and neonatal care for this high-risk group have mitigated the impact of chorioamnionitis on

morbidity and mortality of very low birth weight infants. Histological chorioamnionitis is associated with a lower

incidence and severity of respiratory distress syndrome. However, short-term maturational effects on the lung are

associated with a higher susceptibility for postnatal noxious events, such as mechanical ventilation, thus

contributing to the risk of bronchopulmonary dysplasia. Data regarding the importance of chorioamnionitis for brain

damage of the very premature infant are inconsistent although meta-analyses have shown an increased risk of

cystic periventricular leukomalacia and cerebral palsy after exposure to inflammation in utero. Very recent

epidemiological studies suggest a role of chorioamnionitis in the aetiology and pathogenesis of retinopathy of

prematurity.

PMID: 22926817 [PubMed - in process]

66. Arch Med Res. 2012 Sep 6. [Epub ahead of print]

Hearing Loss, Auditory Neuropathy, and Neurological Comorbidity in Children with Birthweight <750 g.

Martínez-Cruz CF, Alonso-Themann PG, Poblano A, Ochoa-López JM.

Cerebral Palsy Research News ~ September 2012

Cerebral Palsy Alliance

PO Box 184 Brookvale NSW 2100 Australia | T +61 2 9479 7200 | www.cerebralpalsy.org.au

Instituto Nacional de Perinatología Dr. Isidro Espinosa de los Reyes (INPer), Mexico, D.F., Mexico.

BACKGROUND AND AIMS: The current literature considers a birthweight <1,500 g as a risk factor for

sensorineural hearing loss (SNHL, hearing threshold >25 decibels), auditory neuropathy (AN), and several

neurological sequelae. The aim of the study was to determine the frequency and risk factors associated with SNHL,

AN, and neurological morbidity in a group of children with birthweights of <750 g treated at a neonatal care unit and

recruited into a long-term follow-up study. METHODS: A case-control study was carried out. Inclusion criteria were

birthweight <750 g and born between the years 2000 and 2010. We performed brainstem auditory-evoked

potentials (BAEP), evoked otoacoustic emissions (EOAE) and free-field audiometry (FFA) in this population.

eonatal variables and procedures were compared between children with SNHL and children with normal bilateral

hearing (NBH). RESULTS: A total of 93 children with a mean age of 4 years were included in the follow-up. Six

children (6.4%) had SNHL and 87 had NBH. We were unable to identify AN in the sample. Mean weight for this

sample was 673 ± 68 g and gestational age 27.5 ± 2 weeks. Variables reflecting differences between groups

included days under mechanical ventilation, furosemide treatment, and bronchopulmonary dysplasia. In the SNHL

group, three patients had periventricular leukomalacia, two had hydrocephalus, and one patient had cerebral palsy.

CONCLUSIONS: Frequency of SNHL in children with birthweights <750 g was higher than in other premature

infants and was related with mechanical ventilation, furosemide application, and bronchopulmonary dysplasia.

Association with other neurological morbidities was frequent. Early diagnosis and intervention are required.

PMID: 22960856 [PubMed - as supplied by publisher]

67. J Matern Fetal Neonatal Med. 2012 Oct;25 Suppl 4:86-8.

Therapeutic hypothermia in the prevention of hypoxic-ischaemic encephalopathy: new categories to be

enrolled.

Gancia P, Pomero G.

Neonatal Intensive Care – Neonatology , ASO S. Croce e Carle, Cuneo , Italy.

Therapeutic hypothermia is now the standard of care for brain injury control in term infants with perinatal hypoxic

ischemic encephalopathy (HIE). Accumulated evidence shows a reduction in mortality and long-term

neurodevelopmental disability at 12-24 months of age, with more favourable effects in the less severe forms of HIE.

Only few trials recruited newborns <36 weeks gestational age, or mild-to-moderate encephalopathy with base

deficit (BD) <16. The new categories of patients to be enrolled should include (late) preterm infants, neonates with

unexpected postnatal collapse, and newborns with stroke. Preterm HIE: Therapeutic hypothermia shows a good

safety profile in clinical studies, and no adverse effects were noted in the preterm fetal animal model. Recently, it

has been shown that mild hypothermia in preterm newborns with necrotizing enterocolitis (NEC) and multiple organ

dysfunction syndrome (MODS) does not increase mortality, bleeding, infection, or need for inotropes in cooled

newborns. A pilot study (NCT00620711) is currently recruiting newborns of > 32 but < 36 weeks gestation with

standard criteria for HIE. Postnatal Collapse: The postnatal collapse (PNC) is a rare (0.03-0.5/1000 live births) but

life-threatening hypoxic-ischemic event. No clinical trials of therapeutic hypothermia have specifically addressed to

PNC. Nevertheless, a beneficial effect of brain cooling is expectable, and it has been proposed to include in brain

hypothermia trials the infants with PNC fulfilling the entry criteria for HIE. Stroke: Perinatal arterial ischemic stroke is

the most common cause of cerebral palsy (CP) in term and near-term newborn. In a systematic review and metaanalysis

of animal studies of focal cerebral ischemia, hypothermia reduced the infarct size by 44%. No specific

neuroprotective interventions are available for the management of acute perinatal stroke. Hypothermia may

decrease seizures in newborns with encephalopathy and a focal infarct, potentially improving the long-term

outcome for these infants. Concluding remarks: Future studies of therapeutic hypothermia should include the

categories of newborns excluded from the published clinical trials, that is infants <36 weeks gestation, PNC or

stroke, or admitted outside of the established 6-hour window, and with encephalopathy not imputable to HIE. New

entry criteria will allow significant number of newborns to benefit from the treatment.

PMID: 22958032 [PubMed - in process]

Cerebral Palsy Research News ~ September 2012

Cerebral Palsy Alliance

PO Box 184 Brookvale NSW 2100 Australia | T +61 2 9479 7200 | www.cerebralpalsy.org.au

68. J Community Health. 2012 Aug 29. [Epub ahead of print]

Cerebral Palsy Among Children Seen in the Neurology Clinic of Federal Medical Centre (FMC), Asaba.

Okike CO, Onyire BN, Ezeonu CT, Agumadu HU, Adeniran KA, Manyike PC.

Federal Medical Centre, Asaba, Nigeria, cliffordokike@yahoo.com.

Cerebral palsy (CP) is a non-progressive disorder of motor function caused by irreversible damage to the immature

brain. The disorder may be associated with seizure, mental retardation, visual and hearing defects. This study was

designed to determine the types of CP, the risk factors and the co-morbidities associated with the disorder. Records

of patients who were seen in the neurology clinic were kept for two years (June 2009-July 2011). Medical history

and examination were essentially used to determine risk factors, antenatal care and co-morbidities. Data was

analyzed using SPSS soft-ware. CP made up 45 % of 60 neurological cases and 0.006 % of 4,873 patients seen in

the clinic with a male to female ratio of 1.1:1. Birth asphyxia was the commonest risk factor for the development of

the disorder while seizure disorder among others was the commonest co-morbid state.

PMID: 22926682 [PubMed - as supplied by publisher]

69. Semin Reprod Med. 2012 Apr;30(2):84-91. Epub 2012 Apr 27.

Adverse perinatal events associated with ART.

Skora D, Frankfurter D.

The George Washington University, Medical Faculty Associates, Washington, DC 20037, USA.

Since the advent of ART, much research has focused on the potential adverse for resultant harm. Prematurity, low

birth-weight, PIH, congenital malformations, and CP are closely tied to multiple gestation. With the increase in

elective single embryo transfer, there will be a reduction in adversity related to multiple birth. It is understood that

underlying causes of infertility, including advanced maternal age, PCOS, thyroid disease, and uterine fibroids,

predispose to adverse outcomes. However, imprinting abnormalities do not appear to stem from multiple births, and

thus the need to consider the association between fertility treatment and methylation disorders remains essential.

These, as well as risks of multi-fetal gestation, must be discussed with patients when considering using assisted

reproduction.

Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

PMID: 22549708 [PubMed - indexed for MEDLINE]

70. J Genet Couns. 2012 Sep 8. [Epub ahead of print]

On the Precarious Cusp of Genetic Medicine.

Powell AM.

Center for Prevention & Early Intervention Policy, Florida State University, Tallahassee, FL, USA,

apowell@mindspring.com.

This is the story of two brothers at the dawn of genetic medicine, the first severely disabled by cerebral palsy, the

other an MD scientist who happens to uncover the genetic cause of his brother’s condition. A test confirms their

mother’s carrier status. But what about their only sister-is she a carrier as well? The question would send the author

down a path she never dreamed she would take.

PMID: 22961238 [PubMed - as supplied by publisher]

Cerebral Palsy Research News ~ September 2012

71. No To Hattatsu. 2012 May;44(3):221-4.

The present status and problems of compensation system for birth troubles [Article in Japanese]

Sugai K, Aso K.

sugaik@ncnp.go.jp

PMID: 22712223 [PubMed - indexed for MEDLINE]

72. Nurs Law Regan Rep. 2012 Jul;53(2):4.

Mom smoked while pregnant: sued for cerebral palsy & injury to fetus. Case on point: Armagost v.

Gunderson Clinic, Inc., 2011 AP522 (5/31/2012) -WI.

[No authors listed]

PMID: 22919780 [PubMed - in process]

BRIGHT's Cerebral Palsy Cure Project » Ambulatory cerebral palsy

Cerebral Palsy Research- September 2012