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Hypoxic ischemic encephalopathy (HIE) is the most common cause of neonatal encephalopathy and results in significant morbidity and mortality. Long-term outcomes of the condition encompass impairments across all developmental domains. While therapeutic hypothermia (TH) has improved outcomes for term and late preterm infants with moderate to severe HIE, trials are ongoing to investigate the use of TH for infants with mild or preterm HIE. There is no evidence that adjuvant therapies in combination with TH improve long-term outcomes. Numerous trials of various adjuvant therapies are underway in the quest to further improve outcomes for infants with HIE.

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Objective: This study aims to assess the impact of integrating ATLAS 2030 into the conventional therapy regimen for children with Cerebral Palsy (CP) compared to conventional therapy alone regarding gross motor function, range of motion (ROM) and spasticity. Design: A non-randomized controlled trial conducted in outpatient rehabilitation settings and special education schools, following the recommendations by the Consolidated Standards of Reporting Trials (CONSORT) statement. Participants: Thirty children with CP divided into intervention and control groups. Intervention: The intervention group received three months of therapy (twice per week) with the ATLAS 2030 device in addition to their standard therapy, while the control group underwent standard therapy alone. Main outcome measure: Gross motor function assessed using the Gross Motor Function Measure of 88 items (GMFM-88). Secondary outcomes: Spasticity, measured by the Modified Ashworth Scale (MAS), and ROM of the lower limbs. Results: Statistically significant differences were observed between groups, in favour the intervention group, in both the GMFM-88 total score and dimension A, B and D. Similar findings were noted for spasticity and ROM, demonstrating significant improvements in the intervention group. Conclusion: ATLAS 2030 proves to be a safe and valuable tool for the rehabilitation of children with CP, showing improvements in motor function, spasticity and ROM.

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INTRODUCTION: The pencil grasp and drawing patterns are specific to different age levels. So, if one knows a certain pattern for that particular age, it will guide the intervention plan for children with cerebral palsy (CP). The chances of improvement in diplegic CP are possible with the help of early intervention; therefore, early intervention is only possible if one knows the areas of delay and the age at which the intervention should be started. MATERIAL AND METHODS: It was a cross-sectional, case-control study. A total of 60 children were selected for the study, of which 30 (50%) were normal and 30 (50%) had diplegic cerebral palsy. A convenient sampling method is used for evaluation. RESULTS: The t-value for pencil grasp between the two groups, i.e., normal and CP diplegic, was 3.515 (P=0.001), revealing a significant difference in the grasp pattern of the two groups. Similarly, the t-value for drawing patterns between the two groups, i.e., normal and CP diplegic, was 5.796 (P = 0.001). A significant difference was found in the drawing patterns of both groups. CONCLUSION: Our study found that diplegic CP children performed lower on the Erhardt Developmental Prehension Assessment (EDPA) and showed larger variation in the pencil grasp and drawing than the normal children.

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BACKGROUND: The most common form of movement disorder presented in children with cerebral palsy is spasticity, and dynamic equinus is the most common spastic ankle deformity. Botulinum toxin (BT) injection is now an established first-line treatment for focal spasticity. AIM: To assess the effects of BT injection with casting in the treatment of dynamic equinus in children diagnosed with cerebral palsy with spastic diplegia. SETTING AND DESIGN: A prospective randomized controlled trial was conducted among patients aged 2-12 years with cerebral palsy and spastic diplegia, attending the general outpatient department and admitted to the indoor facility of the Department of Physical Medicine and Rehabilitation and the Department of Pediatric Orthopedics at King George's Medical University, Lucknow. MATERIAL AND METHODS: Two groups of 19 patients each were formed. Group A received BT injection with casting, whereas in group B, only a cast was applied. Outcome measures including spasticity by Modified Ashworth Scale (MAS), Modified Tardieu Scale (MTS), range of motion (ROM), passive ankle dorsiflexion, and Gross Motor Function Measure (GMFM-66) (dimensions D and E) were assessed before and after the intervention. RESULTS: The participants in groups A and B were age-matched. A statistically significant difference was seen within group A and group B for MAS, passive ROM-dorsiflexion (PROM-DF), and passive ROM-plantarflexion (PROM-PF) at various follow-ups. In the 3rd week, MAS in each group was statistically insignificant (p-value> 0.05). CONCLUSION: There was a significant improvement in tone and a significant increase in the passive range of motion in both groups.

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Background Cerebral palsy (CP) is one of the most common neuromuscular disorders in children, and spinal abnormalities are vastly more common in people with CP compared to the general population. Further investigation is needed to improve our understanding of the perioperative factors that place children with CP at greater risk of postoperative complications. This study aims to investigate (1) whether pediatric CP patients have higher rates of postoperative complications after spinal fusion and (2) risk factors for postoperative bleeding, readmission, and reoperation. Methodology The 2019 American College of Surgeons National Surgical Quality Improvement Program Pediatric database was used for this study. Chi-square tests were used to compare patient demographics, frequency of comorbidities, intraoperative factors, and postoperative complications between CP and non-CP patients. Multivariable logistic regression modeling was conducted to determine if CP was an independent risk factor for the composite variable that included postoperative bleeding, readmission, and reoperation. Results A total of 4,445 patients were included in the study, with 606 CP and 3,839 non-CP patients. Several comorbidities were more prevalent in the CP cohort, most notably asthma, gastrointestinal disease, previous cardiac surgery, and hematologic disorders. Multivariable logistic regression modeling revealed that CP, older age, non-Caucasian race, American Society of Anesthesiologists (ASA) class of 3 or higher, posterior surgical approach, previous cardiac surgery, and ostomy were significantly correlated with higher postoperative complications. Conclusions This study demonstrates that CP, older age, non-Caucasian race, ASA class of 3 or higher, posterior approach, previous cardiac surgery, and ostomy are independent risk factors for postoperative complications, including readmission, reoperation, and postoperative bleeding requiring transfusions. Consequently, there is a pressing need for additional research to establish perioperative strategies that reduce postoperative risks for these patients. Spine surgeons should consider the findings of this study when communicating the potential risks of spinal fusion surgery with patients and their families.

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Background and Objective: Cerebral palsy (CP) is the most common motor disability in children. The initial lesion to the developing brain may result in a myriad of neuromuscular comorbidities, including mobility deficiencies. The neuromuscular contributions to disability and rehabilitative frameworks specific to children with CP have been investigated separately. However, few reviews have examined the relationship between neuromuscular pathophysiology and rehabilitative frameworks among children with CP. Therefore, the purpose of this review was to investigate the impact of dynamic stretching orthoses and therapeutic exercise on range of motion (ROM), aerobic capacity, and mobility in relation to the neuromuscular contributions to disability in children with CP. Methods: Reviews of PubMed, Google Scholar, and Web of Science were conducted to identify literature focusing on the neuromuscular pathophysiology contributing to disability in children with CP and rehabilitative frameworks associated with this population. The search used a combination of keywords and subject headings to include 'cerebral palsy', 'musculoskeletal', 'neuromuscular', 'spasticity', 'rehabilitation', 'exercise', 'aerobic', and 'orthosis'. Selected manuscripts featured original cross-sectional and longitudinal research and meta-analyses. Key Content and Findings: A total of 303 manuscripts were initially identified through search terms, with 182 articles excluded based on title and abstract evaluation, leaving 121 manuscripts for full-text analysis. Seven studies meeting the narrative review criteria were included. Evidence supporting the efficacy of dynamic stretching orthoses for improving lower extremity ROM is inconclusive. Aerobic and progressive resistive training may be beneficial for improving aerobic capacity and muscle strength in children with CP, which may result in enhanced mobility. Conclusions: Depending on the individual's clinical presentation, ROM and therapeutic exercise may be implemented to optimize function. Incorporating progressive resistive and aerobic exercises into a rehabilitation plan may improve mobility and aerobic capacity. As such, clinicians should consider resistance and aerobic exercise prescription as part of a long-term treatment plan for children with CP.

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Background Hip instability is a concern in pediatric cerebral palsy (CP) patients, with approximately one-third developing hip displacement. This may lead to pain, functional limitations, and decreased quality of life. Due to the progressive nature of hip displacement in CP, earlier surgical interventions may be beneficial. However, any shifts in practice to earlier surgical intervention, on a national scale, is not well described. The purpose of this study was to determine the recent trends in the surgical timing of hip interventions in children with CP. Methods A retrospective study was conducted using the PearlDiver Mariner all-payer claims database (PearlDiver Technologies, Colorado Springs, Colorado, United States). CP patients aged 10 years and younger were identified between 2010 and 2021. Hip surgeries including open reduction, adductor tenotomy, and pelvic osteotomy were identified. Patients were stratified by their age on the date of surgery and the year of the procedure. Linear regression analysis was conducted for temporal trends. Further, the compounded annual growth rate (CAGR) was calculated. Results A total of 309,677 CP patients were identified. For those aged one to four years old, the percentage undergoing hip surgery increased from 10.2% in 2010 to 19.4% in 2021. In the five- to 10-year-old age group, the surgery rate peaked at 14.9% in 2016 and steadily declined to 11.5% in 2021. The overall CAGR from 2010 to 2021 was +6.03% for the one- to four-year-old group and +0.88% for the five- to 10-year-old group. Linear regression demonstrated a significant association between year and the percentage of operations for patients ages one to four (R2=0.792, p<0.001), but not ages five-10 (R2=0.019, p=0.704). Conclusions Rates of surgical hip procedures in one- to four-year-old CP patients have been increasing since 2010, whereas the rate in five- to 10-year-old CP patients has been decreasing since 2016. Recently, CP patients may be undergoing hip surgery at younger ages.

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This longitudinal study investigated the impact of the first independent steps on harmonic gait development in unilateral cerebral palsy (CP) and typically developing (TD) children. We analysed the gait ratio values (GR) by comparing the duration of stride/stance, stance/swing and swing/double support phases. Our investigation focused on identifying a potential trend towards the golden ratio value of 1.618, which has been observed in the locomotion of healthy adults as a characteristic of harmonic walking. Locomotor ability was assessed in both groups at different developmental stages: before and after the emergence of independent walking. Results revealed that an exponential fit was observed only after the first unsupported steps were taken. TD children achieved harmonic walking within a relatively short period (approximately one month) compared to children with CP, who took about seven months to develop harmonic walking. Converging values for stride/stance and stance/swing gait ratios, averaged on the two legs, closely approached the golden ratio in TD children (R2 = 0.9) with no difference in the analysis of the left vs right leg separately. In contrast, children with CP exhibited a trend for stride/stance and stance/swing (R2 = 0.7), with distinct trends observed for the most affected leg which did not reach the golden ratio value for the stride/stance ratio (GR = 1.5), while the least affected leg exceeded it (GR = 1.7). On the contrary, the opposite trend was observed for the stance/swing ratio. These findings indicate an overall harmonic walking in children with CP despite the presence of asymmetry between the two legs. These results underscore the crucial role of the first independent steps in the progressive development of harmonic gait over time.

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The prevalence of cerebral palsy (CP) varies globally, with higher rates and burden of disease in low- and middle-income countries. CP is a lifelong condition with no cure, presenting diverse challenges such as motor impairment, epilepsy, and mental health disorders. Research progress has been made but more is needed, especially given consumer demands for faster advancements and improvements in the scientific evidence base for interventions. This paper explores three strategies to accelerate CP research: consumer engagement, global clinical trial networks, and adaptive designs. Consumer engagement involving individuals with lived experience enhances research outcomes. Global clinical trial networks provide efficiency through larger and more diverse participant pools. Adaptive designs, unlike traditional randomized controlled trials, allow real-time modifications based on interim analyses, potentially answering complex questions more efficiently. The establishment of a CP Global Clinical Trials Network, integrating consumer engagement, global collaboration, and adaptive designs, marks a paradigm shift. The Network aims to address consumer-set research priorities. While challenges like ethical considerations and capacity building exist, the potential benefits for consumers, clinicians, researchers, and funding bodies are substantial. This paper underscores the urgency of transforming CP research methodologies for quicker translation of novel treatments into clinical practice to improve quality of life for those with CP.

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Background: Cerebral palsy (CP) is a unique neurological disorder which adversely affects motion. Cytokines and gut microbial composition contribute to CP and other diseases, such as reproductive tract inflammation and bone loss. Importantly, Saccharomyces boulardii (S. boulardii) reduces the degree of inflammation and improves overall health status. As our previous study showed that Lactobacillus rhamnosus (L. rhamnosus) OF44, a selected strain of gut bacteria originally used to treat reproductive tract inflammation and bone loss, has effects similar to that of S. boulardii, we decided to use L. rhamnosus OF44 on CP rats. Validation of the effects of L. rhamnosus OF44 on CP adds to its confirmed effects in treating osteoporosis and reproductive tract microbiota disorders, increasing its potential as a probiotic. The purpose of this was to ascertain whether L. rhamnosus OF44 can alleviate the symptoms of CP. Methods: CP rat models were created through left carotid artery ligation. Following this, 100-day old CP rats were exposed to L. rhamnosus OF44, S. boulardii, or normal saline gastric gavage daily for 28 days. Grouping of the rats is determined randomly. Before and after the gavage, behavioral experiments were conducted and the inflammation levels assessed via measurements of interleukin (IL)-1ß, IL-6, IL-8, and tumor necrosis factor alpha (TNF-α) inflammatory markers. The efficacy of the outcome is measured by performing statistical analysis like the t-test on the data to see its significance. Additionally, variations inside gut microbiome were evaluated via 16S ribosomal RNA sequencing. Results: Before intervention, CP rats failed to exhibit depression-like behavior (P=0.6). L. rhamnosus OF44 treatment significantly reduced the level of IL-6 (P=4.8e-05), S. boulardii treatment significantly reduced the level of TNF-α (P=0.04). In addition, both treatments altered the composition and complexity of the gut microbiome. Conclusions: Our results indicated that L. rhamnosus OF44 has potential in alleviating inflammation and altering the gut microbial composition in CP, and that it has the potential to clinically treat CP. There are some limitations of this study. For example, dietary differences and their effects on gastrointestinal dysfunction are not considered in this study, and only two behavioral experiments were used.

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PURPOSE: We aim to determine whether preoperatively initiated gabapentin for pain control impacts the percentage of rootlets cut during monitored, limited laminectomy selective dorsal rhizotomy (SDR) procedure. METHODS: This retrospective cohort study includes participants with cerebral palsy who had SDR for treatment of spasticity between 2010 and 2019 at a single-institution tertiary care center. One-level laminectomy SDR aimed to evaluate the cauda equina roots from levels L2-S1 with EMG monitoring. Gabapentin titration began 3 weeks prior to SDR. Data was analyzed using simple linear regression. Thirty-one individuals met inclusion criteria. Mean age was 7 years, 4 months. Eighteen participants (58%) identified as male, 12 (39%) female, and one (3%) non-binary. Thirty (97%) had bilateral CP. Sixteen (52%) were GMFCS II, four (13%) GMFCS III, five (16%) GMFCS IV, and six (19%) GMFCS V. RESULTS: Mean percentage of rootlets transected was 50.75% (SD 6.00, range 36.36-60.87). There was no relationship between the dose of gabapentin at time of SDR and percentage of rootlets cut with a linear regression slope of - 0.090 and an R2 of 0.012 (P = 0.56). CONCLUSION: Results indicate that preoperative initiation of gabapentin did not impact the percentage of rootlets transected. Thus, gabapentin can be initiated prior to SDR at moderate dosages without impacting SDR surgical outcomes.

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Background The unprecedented situation due to the coronavirus disease 2019 (COVID-19) lockdown necessitated the need for teleconsultations with caregivers of children with disabilities. The objective of this study was to explore the acceptability, satisfaction, perceived relevance, and barriers to teleconsultation from a caregiver's perspective. Methodology This was a descriptive qualitative study (telephonic interviews) involving in-depth interviews (IDIs) with the caregivers of children with developmental disabilities who received teleconsultations. Manual content analysis of transcripts of IDIs was done. Results Eight IDIs were conducted with the caregivers of children with cerebral palsy, autism, and developmental delay. The respondents expressed increased challenges in managing their children during the pandemic and the need for professional consultation. They also expressed difficulty in accessing professional help during the pandemic due to poor healthcare access and fear of getting COVID-19. The following responses were noted: "For almost a year we couldn't take her for the therapy," "We were unable to take him to therapy which resulted in an increase in tightness of his limbs, and he became more irritable." All respondents preferred video teleconsultations during lockdown due to flexible timings, ease of communication, and no travel restrictions; "I can benefit from teleconsultation because she does not have any physical problem." However, caregivers of children with physical ailments preferred face-to-face consultation. Conclusions Teleconsultation was found to effectively support the treatment and rehabilitation of children with disabilities during the COVID-19 lockdown, although direct face-to-face consultation was preferred by caregivers of children with physical ailments. The use of modern mobile/digital technologies creates new opportunities to improve the quality and accessibility of such services.

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Family-centered care is widely considered as best practice in pediatric rehabilitation. We aimed to investigate parents' perception of the family-centeredness of health care services for their children with cerebral palsy (CP) using the Arabic Measure of Processes of Care-20 (AR-MPOC-20). We also explored factors related to the child (sex, secondary impairments, and gross motor classification system level) and environment (family and residential region) that may influence the family-centeredness of services in Saudi Arabia. This was a cross-sectional study of 223 children with CP (age 6 months-18.2 years, M = 6.2 + 3.7 years) and their parents. Generally, parents perceived services as less family-centered. The lowest average score was for 'Providing General Information' (M = 2.9 ± 1.5), while 'Respectful and Supportive Care' had the highest average (M = 4.6 ± 1.8). Factors influencing the provision of family-centered care included being a female child and a mother's educational level. In addition, all subscales of AR-MPOC-20 differed by region, p < 0.001, except for 'Providing Specific Information' which did not significantly differ by region p = 0.163. Clinicians should consider the families' need for information regarding their children's condition and available services, with special attention to the mothers of female children and mothers with low levels of education.

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Cerebral palsy, one of the most common reasons for infirmity in children and young people in developed countries, refers to several neurological diseases that impact movement and coordination. Central nervous system damage received during the first stages of brain development can cause cerebral palsy, a non-progressive condition that manifests as impairments of movement and posture. Two cases per 1000 are reported, and the causes include those mentioned for high-risk infants. Mental retardation, sensory deficiencies, failure to thrive, seizures, and behavioral or emotional issues are some of the associated difficulties. To enable interdisciplinary intervention, early identification is crucial. The result varies depending on the topography, severity, and presence of concomitant abnormalities in cerebral palsy. Cerebral palsy is caused by a static injury to the cerebral motor cortex that happens before, during, or within five years after birth. Various circumstances can influence the disease, including cerebral anoxia, cerebral hemorrhage, infection, and hereditary disorders. Interventions for children are typically provided as part of multidisciplinary rehabilitation programs. Musculoskeletal complaints are common, and pain is a significant underreported symptom.

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The recent emergence of research on cerebral palsy (CP) in developing countries aims to improve knowledge on affected children and the utilization of the available services. This study seeks to describe children with CP in Saudi Arabia and service utilization as per Gross Motor Function Classification System (GMFCS) levels and geographic regions. A cross-sectional survey of 227 children with CP (Mean age 6.3, SD 3.9 years) was conducted. Parents reported on children's demographics, impairments, and service utilization. Half of the children (n = 113, 49.8%) had ≥3 impairments with speech, visual and learning impairments being the most frequent. The total number of impairments differed significantly by GMFCS, F (4, 218) = 8.87, p < 0.001. Most of the children (n = 86, 83.4%) used 2-5 services. Moreover, 139 (62.3%) did not attend school, 147 (65.9%) did not receive occupational therapy, and only 32 (14.3%) received speech therapy. More children in GMFCS level I did not receive neurologist services. Profiles of children and services were described by GMFCS and by regions. This was the first study to describe children with CP and service utilization in Saudi Arabia. Although many impairments affected the children, there was low utilization of related services. Data on service utilization and on unmet needs support a comprehensive approach to rehabilitation and the proper service allocation.

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Introduction: Cerebral palsy (CP) is the most common motor disability in childhood, but its causes are only partly known. Early-life exposure to toxic metals and inadequate or excess amounts of essential elements can adversely affect brain and nervous system development. However, little is still known about these as perinatal risk factors for CP. This study aims to investigate the associations between second trimester maternal blood levels of toxic metals, essential elements, and mixtures thereof, with CP diagnoses in children. Methods: In a large, population-based prospective birth cohort (The Norwegian Mother, Father, and Child Cohort Study), children with CP diagnoses were identified through The Norwegian Patient Registry and Cerebral Palsy Registry of Norway. One hundred forty-four children with CP and 1,082 controls were included. The relationship between maternal blood concentrations of five toxic metals and six essential elements and CP diagnoses were investigated using mixture approaches: elastic net with stability selection to identify important metals/elements in the mixture in relation to CP; then logistic regressions of the selected metals/elements to estimate odds ratio (OR) of CP and two-way interactions among metals/elements and with child sex and maternal education. Finally, the joint effects of the mixtures on CP diagnoses were estimated using quantile-based g-computation analyses. Results: The essential elements manganese and copper, as well as the toxic metal Hg, were the most important in relation to CP. Elevated maternal levels of copper (OR = 1.40) and manganese (OR = 1.20) were associated with increased risk of CP, while Hg levels were, counterintuitively, inversely related to CP. Metal/element interactions that were associated with CP were observed, and that sex and maternal education influenced the relationships between metals/elements and CP. In the joint mixture approach no significant association between the mixture of metals/elements and CP (OR = 1.00, 95% CI = [0.67, 1.50]) was identified. Conclusion: Using mixture approaches, elevated levels of copper and manganese measured in maternal blood during the second trimester could be related to increased risk of CP in children. The inverse associations between maternal Hg and CP could reflect Hg as a marker of maternal fish intake and thus nutrients beneficial for foetal brain development.

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BACKGROUND: The family represents the most essential and supportive environment for children with cerebral palsy (CP). To improve children's outcomes, it is crucial to consider the needs of families in order to offer family-centered care, which tailors services to these needs. OBJECTIVE: We conducted a needs assessment to identify the family needs of patients with CP attending two hospitals in Accra. METHODS: The study was a cross-sectional study involving primary caregivers of children with CP attending neurodevelopmental clinics. Structured questionnaires were used to collect data spanning an 8-month period. The data were summarized, and statistical inference was made. RESULTS: Service needs identified were childcare, counseling, support groups, financial assistance, and recreational facilities. Information needs included adult education, job training/employment opportunities, education, health and social programs, knowledge about child development, and management of behavioral and feeding/nutrition problems. Reducing extensive travel time was desirable to improve access to healthcare. With the increasing severity of symptoms came the need for improved accessibility in the home to reduce the child's hardship, as well as assistive devices, recreational facilities, and respite for the caregiver(s). CONCLUSION: Families of children with CP have information, service, and access needs related to their disease severity and family context.

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BACKGROUND: Surgical treatment of hip subluxation in cerebral palsy typically involves proximal femoral osteotomy with or without concurrent supra-acetabular pelvic osteotomy. The literature lacks data on isolated pelvic osteotomy for this condition. We present superior lateral outcropping bone as a novel procedure for augmenting pelvic osteotomies for additional femoral coverage. METHODS: In this retrospective case series, all patients were included for whom a single surgeon at a single institution performed pelvic osteotomy with adjunctive superior lateral outcropping bone for the treatment of hip subluxation in cerebral palsy over a 12-year period. Patients with less than two years of X-ray follow-up were excluded, as were patients with frank dislocation preoperatively. Regarding each case, multiple variables were collected, including X-ray measurements of migration percentage and acetabular index preoperatively, immediately postoperatively, and at last available X-ray. Paired t tests were performed to confirm a significant difference between preoperative and postoperative measurements. Surgical failure was defined as either any subsequent hip or pelvic procedure other than myotendinous lengthening or alcohol nerve blocks, or final migration percentage of greater than 50%. RESULTS: Thirty-three hips (23 patients, 13 males) were included. Mean age at surgery was seven years. Mean time to follow-up was 49 months. Migration percentage of the hips improved from an average 44% preoperatively to 25% at first postoperative measurement and 22% at final follow-up (p < 0.001). Acetabular index improved from an average 27 degrees preoperatively to 15 degrees at first postoperative measurement and 17 degrees at final follow-up (p < 0.001). No hips met failure criteria of repeat surgery other than myotendinous lengthening or nerve blocks, but two presented with a migration percentage of greater than 50% at final follow-up, giving us a failure rate of 6%. CONCLUSIONS: We present a novel procedure that appears to provide safe and successful outcomes for hip subluxation in cerebral palsy. Our clinical results compare favorably to those in the literature for isolated proximal femoral osteotomy for similar patient populations, yet there is no need for implanted hardware.