Acupuncture and Allied Methods in the Treatment of People with Cerebral Palsy. A Bibliography from MEDLINE Abstracts (Oct 2, 1997)

Philip AM Rogers MRCVS,
1 Esker Lawns, Lucan, Dublin, Ireland 
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PubMed MEDLINE (http://www.ncbi.nlm.nih.gov/PubMed/medline.html) was searched on Oct 2 1997 for data on acupuncture and allied methods in the treatment of people with cerebral palsy.

 

The search profile was: (("CEREBRAL PALSY"[All Fields] OR "CEREBRAL SPASTICITY"[All Fields]) ) AND (((((((((acup*[All Fields] OR "ELECTRICAL STIMULATION"[All Fields]) OR "ELECTRO-STIMULATION"[All Fields]) OR TENS[All Fields]) OR MASSAGE[All Fields]) OR SHIATSU[All Fields]) OR TUINA[All Fields]) OR MOXA[All Fields]) OR MOXIB*[All Fields]) )

 

The search yielded 62 hits, most of which had abstracts on Medline. The bibliography, sorted by author into two sections. Section A (33 hits) had data directly relevant to the main search. Section B (29 hits) was not directly relevant, but is included as useful background to other ways to help the problem, or because it is relevant to innervation or physiological relationships to AP points.

 

SECTION A: DATA RELEVANT TO AP USE IN CEREBRAL PALSY

 

Antonova LV, Zhukovskii VD, Kovalenko VN, Semenova KA (1995) The clinico-electrophysiological assessment of the efficacy of microwave resonance therapy in the rehabilitative treatment of patients with cerebral palsy in the form of spastic diplegia [Article in Russian]. Vopr Kurortol Fizioter Lech Fiz Kult Jul;4:13-17. As indicated by EEG and EMG data, adjuvant microwave resonance therapy included in the complex of routine aftertreatment of 24 children with spastic diplegia improved therapeutic efficacy and promoted positive trends in the patient's condition of 63% of those treated. The changes in ENMG parameters induced by microwave resonance therapy reflect shifts in the function of peripheral neuromotor system via optimisation of suprasegmental effects.

 

Burygina AD, Drinevskii NP, Sukhinin SI (1994) Multichannel electromyostimulation in patients with infantile cerebral palsy [Article in Russian]. Vopr Kurortol Fizioter Lech Fiz Kult Sep;5:25-28. The paper provides pathogenetic evidence for multichannel electrostimulation used by the author's procedure in patients with infantile cerebral paralysis. It also presents the clinical and functional findings of its use in combination with balneopelotherapy, massage, therapeutical exercises, and orthopedic prophylaxis. The therapeutic efficiency was 82.4 and 84.2% for patients with spastic diplegia and in those with hemiparetic infantile cerebral paralysis, respectively.

 

Burygina AD, Andreev MK, Kukhnina TM, Bogdanova LA (1993) Changes in the clinical electromyographic indices of patients with the hyperkinetic form of infantile cerebral palsy and their dynamics during combined sanatorium-health resort treatment including transcerebral exposure to an ultrahigh-frequency electrical field [Article in Russian]. Vopr Kurortol Fizioter Lech Fiz Kult Sep;5:42-46. Clinical electromyographic studies were made to evaluate the efficacy of transcerebral exposure to UHF electric field which has been used as an adjuvant to therapeutic exercise, massage, climate treatment in 33 patients with hyperkinetic infantile cerebral paralysis (ICP). The effect on the motor disorders reached 70.8%. Specific features of statokinetic function in hyperkinetic ICP children recorded electromyographically dictate combined use of various modalities (therapeutic exercises, preformed physical factors, games, reflex therapy, etc.) to improve therapeutic actions on vestibular apparatus.

 

Carmick J (1995) Managing equinus in children with cerebral palsy: electrical stimulation to strengthen the triceps surae muscle. Dev Med Child Neurol Nov;37(11):965-975. A new therapeutic proposal for the management of equinus in children with cerebral palsy is to strengthen the calf muscles instead of weakening them surgically. Prior research indicates that in children with cerebral palsy the triceps surae muscle is weak and needs strengthening. Neuromuscular electrical stimulation (NMES) was used as an adjunct to physical therapy. A portable NMES unit with a hand-held remote switch stimulated an active muscle gait cycle. Results are discussed for four children, who showed improved gait, balance, posture, active and passive ankle range of motion, and foot alignment. The toe walkers became plantigrade and the equinovalgus posture of the foot decreased. Spasticity did not increase.

 

Carmick J (1997) Use of neuromuscular electrical stimulation and [corrected] dorsal wrist splint to improve the hand function of a child with spastic hemiparesis. Phys Ther Jun;77(6):661-671. [Erratum published in Phys Ther 1997 Aug;77(8):859]. This case report describes a program for a child with spastic hemiparesis who had previously received physical therapy with neuromuscular electrical stimulation (NMES). After a year without physical therapy, he returned to continue to receive NMES to strengthen muscles, increase sensory awareness, and improve hand function. The child quickly regained his previous level of functioning and made additional progress. After 38 sessions, he still lacked adequate wrist stability for independent hand function. A dorsal wrist splint was used to stabilize the wrist while NMES facilitated muscle activity of the hand and wrist. While wearing the splint, the child could use his hand independently without adult interference or "assistance," thus allowing motor learning to occur. After 24 additional sessions (i.e., 9 months of using the splint), the child could use the hand for activities such as tying his shoelaces without the splint. No increase in spasticity was seen in spite of strengthening the spastic finger flexors.

 

Carmick J (1993) Clinical use of neuromuscular electrical stimulation for children with cerebral palsy: Part 1: Lower extremity. Phys Ther Aug;73(8):505-513. This report, part 1 of a two-part case report on the clinical use of neuromuscular electrical stimulation (NMES) for children with cerebral palsy, documents the functional changes that occurred with the application of NMES to the lower extremity of three male children, 1.6, 6.7, and 10 years of age, all with hemiplegia due to cerebral palsy. Neuromuscular electrical stimulation was used in conjunction with a dynamic-systems, task-oriented model of motor learning. The children tolerated NMES well and at times demonstrated carryover after the removal of NMES. The youngest child showed immediate change in the ability to walk and run symmetrically. The two older boys demonstrated significant improvement in locomotor efficiency in a short time, although they were of an age when this improvement was not expected. One boy's Physiological Cost Index (PCI) measurement (a measure of locomotor efficiency) improved fourfold, and the other boy's PCI measurement improved by a factor of two. The results show preliminary evidence for the usefulness of NMES as an adjunct to the physical therapy program for improving function in children with cerebral palsy.

 

Carmick J (1993) Clinical use of neuromuscular electrical stimulation for children with cerebral palsy: Part 2: Upper extremity. Phys Ther Aug;73(8):514-522. This report, part 2 of a two-part case report on the clinical use of neuromuscular electrical stimulation (NMES) for children with cerebral palsy, documents the functional changes that occurred with the application of NMES to the upper extremity of two children, 1.6 and 6.7 years of age, with hemiplegia due to cerebral palsy. The NMES was used as an adjunct to a dynamic-systems, task-oriented physical therapy program. The youngest child showed immediate improvement in the ability to crawl and use both hands together. The older child demonstrated increased sensory awareness and use of the nonfunctional hand. Preliminary findings suggest that NMES may be a useful physical therapy tool for enhancing muscle strength increasing sensory awareness, and assisting motor learning and coordination.

 

Dubowitz L, Finnie N, Hyde SA, Scott OM, Vrbova G (1988) Improvement of muscle performance by chronic electrical stimulation in children with cerebral palsy [LETTER]. Lancet Mar 12;1(8585):587-588.

 

Fitzgerald GK, Newsome D (1993) Treatment of a large infected thoracic spine wound using high voltage pulsed monophasic current. Phys Ther Jun;73(6):355-360. Dept of Orthopedic Surgery and Rehabilitation, Hahnemann Univ, Philadelphia, PA 19102. This case report describes the use of electrical stimulation with high voltage pulsed monophasic current for treatment of a large, infected wound of the thoracic spine, following a surgical debridement procedure. The patient was a 21-year-old man with spastic quadriplegic cerebral palsy who was dependent for all self-care and was severely mentally retarded. The initial wound size was as follows: length = 17 cm, top width = 7.5 cm, middle width = 5.5 cm, bottom width = 2 cm, and depth = 5 cm. The wound was infected with Staphylococcus aureus. The initial treatment consisted of 60 minutes of electrical stimulation (20 minutes of negative polarity followed by 40 minutes of positive polarity) once daily. The frequency of treatment was increased to twice daily after 2 weeks. Total treatment duration was 10 weeks. The patient received antibiotic treatment and daily nursing wound care in addition to electrical stimulation treatment. The wound was completely closed after 10 weeks of treatment. The possible role of high voltage pulsed monophasic current in accelerating the wound-healing process is discussed.

 

Gracanin F (1978) Functional electrical stimulation in control of motor output and movements. Electroencephalogr Clin Neurophysiol Suppl 34:355-368. In patient with damaged upper motor neurones we show the therapeutic effect of electrical stimulation (called FES) of peripheral mixed nerves on the restoration of motor activity and movements. The results of neurophysiological, kinesiological and clinical observations are presented. We discuss the possible mechanisms, especially the spinal ones, which are fundamental for such a rhythmic activity as gait. We discuss them also from the point of view of activation of proprioceptive feedback mechanisms and of achieved sensory reinforcement influencing the spinal reflex mechanisms as well as the preserved supraspinal integrated activity which contributes to the long-term FES effect. The stimulation modes, the control of stimuli in relation to the needs of individual patients (hemiplegia in adults, paraparesis, cerebral palsy in children and multiple sclerosis) as well as the motor deficit are discussed. We conclude that the electronic system used for this purpose represents a functionally active orthotic aid with therapeutic effects.

 

Hazlewood ME, Brown JK, Rowe PJ, Salter PM (1994) The use of therapeutic electrical stimulation in the treatment of hemiplegic cerebral palsy. Dev Med Child Neurol Aug;36(8):661-673. Dept of Physiotherapy, Royal Hospital for Sick Children, Edinburgh. The effect of electrical stimulation of the anterior tibial muscles of children with hemiplegic cerebral palsy was studied. 10 children received electrical stimulation, applied by their parents daily for an hour for 35 days; they were compared with 10 matched controls. Active and passive ranges of movement of the ankle, and knee and ankle motion during walking were measured before and after therapy using electrogoniometers. The results showed a significant increase in passive range of movement among children receiving electrical stimulation. Gait analysis of knee and ankle motion showed little change.

 

Illis LS (1982) Rehabilitation following brain damage: some neurophysiological mechanisms: The effects of repetitive stimulation in recovery from damage to the central nervous system. Int Rehabil Med 4(4):178-184. There is a growing body of evidence that the central nervous system (CNS), even in the adult animal, is capable of adaptation and reorganization not only as a result of partial damage to the CNS but also in response to stimulation. Environmental stimulation produces changes including expansion of visual cortex, increases in dendritic branching, glia and cholinesterase. Environmental stimulation also produces behavioural changes. Experimental electrical stimulation produces changes in synapse size, synaptic vesicle change, dendritic branching and changes in synaptic transmission. In man, repetitive electrical stimulation via epidural electrodes increases plasma levels of norepinephrine, epinephrine, and dopamine, and CSF levels of norepinephrine. Repetitive electrical stimulation in man dates back to 1967 and has been used for the control of pain, to improve spasticity, bladder control, motor deficit and the autonomic hyperreflexia of spinal cord injury. In addition, improvement has been reported in epilepsy, cerebral palsy, torticollis and peripheral vascular diseases. The best controlled studies are in multiple sclerosis and peripheral vascular disease, and these results will be presented in more detail.

 

Khakimov AKh, Kozycheva NP (1975) Role and special features of massage in combination therapy of patients with juvenile cerebral palsy [Article in Russian]. Med Sestra Sep;34(9):49.

 

Lang FF, Deletis V, Cohen HW, Velasquez L, Abbott R (1994) Inclusion of the S2 dorsal rootlets in functional posterior rhizotomy for spasticity in children with cerebral palsy. Neurosurgery May;34(5):847-853. Dept of Neurosurgery, New York Univ Med Center, New York. Many neurosurgeons have made a practice of sectioning the S2 dorsal roots during selective posterior rhizotomy for the treatment of spasticity in children with cerebral palsy, but the efficacy of this treatment has not previously been proven. S2 afferents are involved in reflex arcs of the plantar flexors (PFs), so that S2 lesioning should in theory reduce PF spasticity. To test this assumption, we determined the frequency of postoperative residual spasticity in the PFs when S2 lesioning was or was not performed. We assessed 85 children for whom 6-month follow-up was available. Functional rhizotomy from L2-S1 was performed on 13 of them (26 legs with PF spasticity) and from L2-S2 on 72 (141 legs with PF spasticity). Rootlets were lesioned if there was an abnormal response to intraoperative electrical stimulation. In 20 patients, lesioning of the S2 rootlets was assisted by the "pudendal neurogram," a technique previously shown to prevent bladder dysfunction during sectioning of the sacral roots. When S2 roots were excluded from the lesioning process, residual PF spasticity was detected in 35% of the legs that had it preoperatively, leaving 5 (38%) of 13 children with functionally impairing spasticity. When S2 roots were included, 6% of legs that had PF spasticity retained it postoperatively (p<.001), leaving 8 (11%) of 72 patients with functionally limiting spasticity (p<.05). Thus, the addition of the S2 roots to the procedure resulted in an 81% reduction in the number of legs with residual PF spasticity and a 71% reduction in the number of patients with residual PF spasticity.

 

Leyendecker C (1975) Electrical stimulation therapy and its effects on the general activity of motor impaired cerebral palsied children; a comparative study of the Bobath physiotherapy and its combination with the Hufschmidt electrical stimulation therapy [Article in German]. Rehabilitation (Stuttg) Aug;14(3):150-159. The purpose of this study was to answer the following questions: (1) Is it more effective to treat spastic cerebral palsy with the Hufschmidt electrical stimulation therapy combined with the Bobath neuro-development treatment or only with the Bobath therapy? (2) Can a general increase in activity be obtained by the electrotherapeutic muscle stimulation? A test group (combined Hufschmidt/Bobath therapy) and a control group (Bobath), both consisting of 10 subjects, were observed for four months. The duration of observation was divided into two four months treatment periods with a rest interval of two months in between. At the start of therapeutic measures, motor activity and psychic condition were tested with corresponding motormetric and psychodiagnostic techniques; three check-up examinations were carried out at the end of the first, and at the beginning and end of the second period of treatment. The motor-metric control examination showed that at the end of the first period the test group had achieved by far the better results, but at the end of the second therapeutic period, both groups were equally successful. The combined electrophysiotherapy hence reached in a relatively shorter time - as it were by leaps and bounds - the optimal obtainable state of functional improvements which, with the Bobath therapy alone, can be effected more slowly but with more continuity. The psychodiagnostic controls clearly indicate that the electrical stimulation produced an unspecified increase in activity, especially after the first phase of treatment, whereas in the second phase this could only be proven in a graded form. The report closes with an examination of the results and their consequences for the implementation of the treatment for cerebral palsied children.

 

Lu W (1994) Prompt pressure applied to peculiar points in the treatment of spasmodic infantile cerebral palsy: a report of 318 cases. J Tradit Chin Med Sep;14(3):180-184. Institute of Orthopedics and Traumatology, China Academy of TCM, Beijing. Infantile cerebral palsy is a nonprogressive central motor disturbance of varied etiology. The spasmodic type is its main form, accounting for 50-60% of the infants afflicted with the disease. The causal factors include multifarious conditions arising during parturition and in the pre- and postnatal periods. As yet there is no specific treatment for the disease. We have used a method of applying prompt pressure to peculiar points in treating it and received satisfactory results. The present group comprised 318 patients treated for the disease by the method of prompt pressure applied to peculiar points combined with appropriate orthopedic manipulations, resulting in a 73.27% rate of good to excellent therapeutic effect. Follow-up exam was done in 52 cases, among which the efficacy was assessed as stable in 21 cases, and the remaining 31 cases as being in an improved condition. Infantile peculiar points are points peculiar to infants, mostly located in the head and extremities, and constitute an important component part of the treasure-house of TCM. The method recommended here is simple and convenient, causing little pain in the invalid yet showing a marked therapeutic effect, and therefore can be regarded as a new way for treating infantile cerebral palsy.

 

Maslova OI (1990) Organization of the rehabilitation treatment of children with organic lesions of the nervous system [Article in Russian]. Zh Nevropatol Psikhiatr Im S S Korsakova 90(8):27-29. A scheme for rehabilitation treatment of children with organic CNS lesions is offered. The rehabilitation scheme includes the following measures: remedial gymnastics, massage, therapeutic physical training, reconstruction and formation of the most important motor skills, mastering exercises to correct postural activity, speech correction with manual training, psychological rehabilitation, social adaptation, occupational therapy, acupuncture, electroneurostimulation, therapeutic drug blockades, orthopedic correction, the use of the biological feedback, conductive training, restorative cosmetic surgery, sanatorium treatment, drug therapy, the use of physical factors, correction of somatic disturbances, recommendations of the specialists of the medico-genetic++ consultations, determination of possibilities of placing into kindergartens, schools, and sexual education. The rehabilitation scheme turned out effective in almost half of the patients.

 

Metherall P, Dymond EA, Gravill N (1996) Posture control using electrical stimulation biofeedback: a pilot study. J Med Eng Technol Mar;20(2):53-59. Lincoln Med Physics and Computing Services, County Hospital, Lincoln, UK. The investigation studied the effects of biofeedback on the sitting posture of a 14 year old girl with cerebral palsy. The subject's posture was quantified using a video analysis technique which established the threshold of poor posture at 30 degrees from the vertical plane. A stimulator system was designed using an adapted drop foot stimulator and a custom made controller with a mercury tilt switch as the posture angle transducer. If posture became greater than 30 degrees tactile electrical stimulation was administered to the subject's lower back. Repetitive stimuli occurred on non-correction of posture, with a maximum of 4 consecutive stimuli, upon which an alarm was activated. 10 training sessions of 20 min duration were completed over a 4 week period, monitored using a data logger. Following initial improvement the daily results show a gradual deterioration in posture, whilst post-trial video analysis indicates a significant improvement in posture. An improved response to the alarm stimulus is observed. Reasons for these conflicting findings are discussed.

 

Migita K, Uozumi T, Arita K, Monden S (1995) Transcranial magnetic coil stimulation of motor cortex in patients with central pain. Neurosurgery May;36(5):1037-1039. Dept of Neurosurgery, Hiroshima Univ School of Med, Japan. We report two patients with deafferentation pain secondary to central nervous system lesions who were evaluated by noninvasive magnetic coil stimulation of the motor cortex followed by electrical motor cortex stimulation with epidural electrode array implantation. Magnetic coil stimulation was very useful to estimate the effect of electrical stimulation. Our first patient was a 52-year-old man who experienced a left putamenal hemorrhage at the age of 48. Two years later, he had paresthesias and intractable pain in the extremities and face on the right side. Pain was resistant to barbiturates but responded to magnetic coil stimulation of the motor cortex. Electrical motor cortex stimulation provided excellent relief from the pain. The second patient was a 43-year-old man who was suffering from congenital cerebral palsy for which left thalamotomy was performed two times, at the ages of 9 and 13. He began to experience intractable pain on the right side 20 years later. Although barbiturate administration was effective for pain relief, neither magnetic coil stimulation nor electrical stimulation of the motor cortex gave relief from pain.

 

Miyazaki MH, Lourencao MI, Ribeiro Sobrinho JB, Battistella LR (1992) Functional electric stimulation (FES) in cerebral palsy [Article in Portugese]. Rev Hosp Clin Fac Med Sao Paulo Jan;47(1):28-30. Divisao de Reabilitacao Profissional de Vergueiro do HCFMUSP. Our study concerns a patient with cerebral palsy, submitted to conventional occupational therapy and functional electrical stimulation. The results as to manual ability, spasticity, sensibility and synkinesis were satisfactory.

 

Mukhamedzhanov NZ, Kurbanova DU, Tashkhodzhaeva ShI (1992) The principles of the combined rehabilitation of patients with perinatal encephalopathy and its sequelae [Article in Russian]. Vopr Kurortol Fizioter Lech Fiz Kult Jan;1:24-28. A comprehensive examination was made of 548 patients suffering from perinatal encephalopathy or from its aftereffects. The analysis covers aftercare measures: reflex therapy, physiobalneotherapy, exercise, massage, logopedic aid, auriculotherapy with introduction of cerebrolysin or lidase into the lobule of the ear. The efficacy of the treatment was assessed at echoencephaloscopy and other procedures.

 

Pape KE, Kirsch SE, Galil A, Boulton JE, White MA, Chipman M (1993)Neuromuscular approach to the motor deficits of cerebral palsy: a pilot study. J Pediatr Orthop Sep;13(5):628-633. Magee Clinic, North York, Ontario, Canada. Six children with mild cerebral palsy (CP) entered a study of overnight low-intensity transcutaneous electrical stimulation (ES) to the leg muscles. After 6 months, statistically significant improvement was noted on the Peabody Developmental Motor Scales scores in gross motor, locomotor, and receipt/propulsion skills. When ES was withdrawn for 6 months, there was uniform loss in scores. Reinstitution of ES resulted in further significant improvements in total gross motor, balance, locomotor, and receipt/propulsion skills. In selected cases, overnight ES may be a useful addition to standard rehabilitation services.

 

Ray CD (1978) Electrical stimulation: new methods for therapy and rehabilitation. Scand J Rehabil Med 10(2):65-74. Electrical stimulation is emerging as a new therapeutic and rehabilitative agent. Reviewed are pain control, restoration of lost functions and alteration of abnormal movement and other functions using electrical stimulation. Reported for acute and chronic pain control use are transcutaneous, dorsal column, spinal cord, peripheral nerve, and direct brain stimulation methods and results. Overall success ranges up to 50% for chronic pain problems and up to 80% for acute pain; e.g., postoperative incisional pain, sports medicine, and trauma. Restoration of lost function has broad implications for the future. These include phrenic nerve pacing for respiration, foot drop control, restoration of bladder function, and grasp control in the spinal cord-injured patient. Amelioration of abnormal function includes stimulation for epilepsy and cerebral palsy, certain symptoms of multiple sclerosis and scoliosis. The effects of electrostimulation are completely reversible and nondestructive. Technical details of devices and stimulus waveforms are also briefly considered.

 

Sanner C, Sundequist U (1981) Acupuncture for the relief of painful muscle spasms in dystonic cerebral palsy [LETTER]. Dev Med Child Neurol Aug;23(4):544-545.

 

Semenova KA (1990) Problem of rehabilitation in perinatal lesions of the central nervous system [Article in Russian]. Vestn Akad Med Nauk SSSR 8:21-26. Studies into the central nervous system (CNS) of fetuses, newborns, and infants with a history of intrauterine infection or intoxication suggest a possibility for development of viral, bacterial, and fungal encephalitis and encephalomyelitis in utero. These conditions may resolve antenatally or persist for a number of years after birth, and may give rise to autoimmune nonspecific inflammation which is self-sustained and thus of long duration. A complex rehabilitation therapy for these conditions employs immunomodulators, which significantly increases its efficacy. New techniques of massage and exercise were elaborated. A new method of local hypothermia has found wide application in various types of dysarthrosis in children with cerebral palsy.

 

Semenova KA, Dotsenko VI (1988) Vestibulometry and its importance in elucidating the pathogenesis and prognosis of the course of nervous system diseases in children [Article in Russian]. Zh Nevropatol Psikhiatr 88(8):32-37. A retrospective analysis of electronystagmograms recorded over 2 years from 90 children aged 1 to 3 with spastic diplegia due to the infantile cerebral paralysis was performed and its results correlated with the clinical course of the disease. The vestibulometric criteria were derived in order to predict the course of motor functions in the patients' postnatal ontogenesis. The causes of inefficacy of rehabilitation therapy were analyzed in children which had suffered from meningoencephalitis in their infancy. Specific features of the neurodynamic processes in these patients were displayed in their vestibulometric indices. Mesencephalic-cortical control mechanisms of the vestibular nystagmus were shown to normalize under effect of acupuncture. This accounts for its greater clinical efficacy as compared to the passive vestibular therapy which exerted beneficial influence over the bulbar-pontine nystagmogenic mechanisms.

 

Semenova KA, Zhukovskaia ED, Pol'skoi VV (1985) Clinico-biochemical indicators of the effectiveness of acupuncture in children with cerebral palsy (spastic diplegia) during the first 2 years of life [Article in Russian]. Pediatriia Oct;10:58-60.

 

Shaitor IN, Bogdanov OV, Shaitor VM (1990) The combined use of functional biocontrol and acupuncture reflexotherapy in children with the spastic forms of infantile cerebral palsy [Article in Russian]. Vopr Kurortol Fizioter Lech Fiz Kult Nov;6:38-42. An optimal method of rehabilitation is outlined for children with movement disorders due to spastic cerebral paralysis. It implies combined use of functional biocontrol and acupuncture. In drug intolerance the treatment acquires special significance. The effectiveness of these two modalities comes from mutual potentiation effect on central regulation of motor functions as shown by electrophysiological findings. Marked positive shifts in clinical and electrophysiological patterns develop within 15 training procedures with the external feedback in addition to 11 sessions of acupuncture.

 

Shi B, Bu H, Lin L (1992) A clinical study on acupuncture treatment of pediatric cerebral palsy. J Tradit Chin Med Mar;12(1):45-51. Children's Hospital, Shanghai Med Univ.

 

Steinbok P, Langill L, Cochrane DD, Keyes R (1992) Observations on electrical stimulation of lumbosacral nerve roots in children with and without lower limb spasticity. Childs Nerv Syst Oct;8(7):376-382. Dept of Surgery, Fac of Med, Univ of British Columbia, Vancouver, Canada. Selective functional posterior rhizotomy (SFPR) is a popular operation for the treatment of spasticity in children with cerebral palsy, but the physiologic basis of the procedure is poorly understood. As part of SFPR operations in 60 consecutive children, the responses to electrical stimulation of posterior lumbosacral roots and rootlets, and the corresponding anterior roots were studied. In addition, similar electrical stimulation of posterior roots was performed in four nonspastic "control" children. Sustained responses to 50 Hz stimulation, one of the criteria used to signify abnormality in the spastic children, was found frequently in the "control" children. Contralateral spread to the lower limb muscles and suprasegmental spread to the upper limbs, face, and neck were determined to be the most valid criteria which differentiated abnormal from normal responses. Stimulation of anterior nerve roots at 50 Hz caused sustained responses and ipsilateral lower limb spread, at a low threshold compared to that of corresponding posterior roots. The results of this study bring into question the validity of some of the criteria that are used to select abnormal posterior rootlets in the SFPR procedure, and suggest criteria that may be more valid based on findings in nonspastic children.

 

Steinbok P, Reiner A, Kestle JR (1997) Therapeutic electrical stimulation following selective posterior rhizotomy in children with spastic diplegic cerebral palsy: a randomized clinical trial. Dev Med Child Neurol Aug;39(8):515-520. Dept of Surgery, Univ of British Columbia, Vancouver, Canada. A randomized controlled trial was carried out to determine the effectiveness of therapeutic electrical stimulation (TES) in improving the function of children with spastic cerebral palsy (CP), who had undergone selective posterior lumbosacral rhizotomy more than a year previously. Children were randomly assigned to groups to receive TES for 1 year, or to have no TES. The primary outcome was the change in the Gross Motor Function Measure (GMFM), a quantitative and validated measure for use in children with spastic CP. There was a statistically significant and clinically important improvement in outcome for the treated children, with the mean change in the GMFM score at one year being 5.5% compared with 1.9% in the untreated group (p=.001). TES was simple to use, had no significant complications, and was well accepted by the children and their caregivers, as indicated by an average compliance of 93% for the application of TES on a nightly basis over the course of the study. It was concluded that TES may be beneficial in children with spastic CP who have undergone a selective posterior rhizotomy procedure more than 1 year previously.

 

Tsypurskii BG (1986) Therapeutic massage in infantile cerebral palsy [Article in Russian]. Med Sestra Mar;45(3):38-40.

 

Zhou XJ, Chen T, Chen JT (1993) 75 infantile palsy children treated with acupuncture, acupressure and functional training [Article in Chinese]. Chung Kuo Chung Hsi I Chieh Ho Tsa Chih Apr;13(4):220-222. Children's Hospital, Zhejiang Med Univ, Hangzhou. In treating infantile cerebral palsy (CP), 75 CP children were treated with a comprehensive meridian therapy including scalp and body acupuncture, acu-point injection and auriculo-point stimulation, supplemented with acu-pressure and massage, and functional training. A minimum of 10 times of treatment within twenty days, and a maximum of 120 times within a year was performed. The effect of the treatment was evaluated by appraising the children's performance of physical exercise and their social adaptability. The intelligence quotient (IQ) of 30 sick children that had been treated for 60 times (6 courses) was compared prior to and after treatment. It indicates that the treatment yielded a very positive improvement in the children's physical capability and an increase of their intelligence.

 

SECTION B: BACKGROUND DATA ON CEREBRAL PALSY AND OTHER METHODS OF TREATMENT

 

Albright AL (1992) Neurosurgical treatment of spasticity: selective posterior rhizotomy and intrathecal baclofen. Stereotact Funct Neurosurg 58(1-4):3-13. Dept of Neurosurgery, Children's Hospital, Univ of Pittsburgh School of Med, Pa. The pathophysiology of spasticity and the history of posterior rhizotomies are reviewed. The rationale for selective posterior rhizotomies is that electrical stimulation identifies afferent posterior rootlets that terminate on relatively uninhibited alpha motoneurons; if these uninhibited rootlets are divided, spasticity can be alleviated without loss of other posterior root functions. Indications, technique, and results of selective posterior rhizotomies are presented. The use of continuous intrathecal baclofen (CITB) is summarized. CITB at doses of approximately 300 micrograms/day consistently reduces lower extremity spasticity and diminishes or alleviates muscle spasms in adults with spasticity of spinal origin. Single doses of intrathecal baclofen significantly decrease lower extremity muscle tone in children with cerebral palsy, and the effects can be maintained in these patients by CITB infusions which diminish muscle tone not only in the lower extremities, but in the upper extremities as well. CITB is best accomplished via an externally programmable pump that allows titration of the daily dose to attain the desired reduction in spasticity. Factors influencing the decision for rhizotomy or CITB are presented.

 

Aurich H (1978) Physiotherapy of cerebral movement disorders in childhood[Article in German]. Kinderarztl Prax Dec;46(12):617-627.

 

Babina LM, Tsvetkov VA, Kotliarov VV, Borisenko ND (1996) Laser therapy in the combined health-resort treatment of children with the sequelae of a perinatal brain lesion [Article in Russian]. Vopr Kurortol Fizioter Lech Fiz Kult Jul;4:11-13.

 

Babina LM (1979) Health resort treatment of preschool children with cerebral palsy [Article in Russian]. Zh Nevropatol Psikhiatr 79(10):1359-1363. In the Pyatigorsk resort, 226 children from 3-7 years of age with different forms of cerebral paralysis were studied. For therapeutic purposes, besides general health improvement measures, remedial gymnastic and massage, such resort factors as carbon dioxide and sulfurated hydrogen and radon baths of different concentrations and mud procedures were used. As a result of such studies, some indications for referrals of preschool children with cerebral paralysis to balneomud resorts were outlined. Differentiated complexes of resort treatment, depending upon the form and severity of clinical sings were elaborated, as well as the possibility of resort therapy in children with cerebral paralysis, complicated by the intracranial hypertensive syndrome.

 

Barry MJ (1996) Physical therapy interventions for patients with movement disorders due to cerebral palsy. J Child Neurol Nov;11 Suppl 1:S51-S60. Dept of Neurosurgery, Children's Hospital of Pittsburgh, PA 15213-2583, USA. The purpose of this paper is to present evidence of the efficacy of physical therapy interventions for patients with cerebral palsy and identify goals for these patients. Studies suggest that neurodevelopmental treatment and Vojta techniques improve postural control. Little evidence supports the efficacy of early intervention, but researchers have not yet studied effects on the family. Strengthening, electrical stimulation, the use of orthoses, and seating show positive effects in studies of small numbers of subjects. For severely involved children, ease of care and comfort are important goals, as well as prevention of deformity, which is important for all children. To the extent possible, therapy should prepare a child for independent adult life. In early intervention through school age, therapy focuses on promoting communication, self-care, and mobility. Independence is a key issue for adolescents transitioning into adulthood. The rehabilitation and health needs of adults with cerebral palsy need to be addressed. Research needs to determine the effects of physical therapy not only on impairment but also on function and disability.

 

Bensman AS, Szegho M (1977) Ban proposed on cerebellar electrical stimulation [LETTER]. Neurology Oct;27(10):996-999.

 

Bensman AS, Szegho M (1978) Cerebellar electrical stimulation: a critique.Arch Phys Med Rehabil Oct;59(10):485-487. Cerebellar electrical stimulation has been advocated as a beneficial treatment device for improving function in cerebral palsy, but a review of the literature raises questions as to its efficacy and safety. Evaluation of one reported study showed that only 32% of people with implanted cerebellar stimulators had significant improvement in function. This is in contrast to 68% to 92% improvement levels claimed by advocates of the procedure. There is evidence of potential long-term damage to the cerebellum from the device. Further studies are indicated, following the criteria established by the 1976 Med Device Amendment to the Drug and Cosmetic Act dealing with medical device regulation and control.

 

Bergstrom MR, Johansson GG, Laitinen LV, Sipponen P (1966) Electrical stimulation of the thalamic and subthalamic area in cerebral palsy. Acta Physiol Scand Jun;67(2):208-213.

 

Brandell BR (1982) Development of a universal control unit for functional electrical stimulation (FES). Am J Phys Med Dec;61(6):279-301. In collaboration with the College of Engineering the author has developed a laboratory, or clinic, based, battery operated "universal" control system, designed to improve disabled gait in upper motor neuron disabilities, especially stroke, hemiplegia, and cerebral palsy, by applying several channels of FES (Functional Electrical Stimulation) to the lower limb muscles while the patient is walking. The timing of the FES pulses, which can be applied to as many as six of the patient's muscles, is determined by potentiometer controlled one-shot timers, which are triggered by any of three switches in the sole of either shoe. Combinations of inverters, flip flops, AND gates and OR gates in the externally connected logic circuits determine the sequence of delays and pulses applied to the patient's muscles. This paper describes and diagrams some of the logic circuits and as an example of the possible application of the concept of a "universal" control unit reports the modifications of gait induced in a hemiplegic, four year post-stroke, patient. The characteristics of this patient's gait with FES in comparison to its characteristics without FES are demonstrated with motion picture frames, EMG recordings and graphic tracings of her right knee and ankle joint positions. They include more symmetrical timing of her right and left stance and swing phases, increased dorsiflexion of her right ankle in the swing phase, followed by a more distinct heel strike, and improved flexion--extension sequences of the knee and ankle joints and an increased heel rise in the stance phase. The author concludes that the gait characteristics of some hemiplegic patients will improve as they become adapted over a period of weeks or months to a control logic, which lessens their functional limitations by the use of a properly timed and amplified sequence of FES pulses. He suggests that the FES control requirements for individual patients should be determined experimentally with a control system "universally" adaptable to a wide range of disabilities, and that these control parameters could then determine the design of portable units, which may be used on a long term basis. These units would include only the operational options needed to duplicate the gait corrections found to be practicable for each individual patient, by the testing procedure, through a universal logic unit as described in this paper.

 

Brouwer B, Smits E (1996) Corticospinal input onto motor neurons projecting to ankle muscles in individuals with cerebral palsy. Dev Med Child Neurol Sep;38(9):787-796. School of Rehabilitation Therapy, Queen's Univ, Kingston, Ontario, Canada. Cross-correlograms between voluntarily active soleus (SOL) and tibialis anterior (TA) motor units were generated from seven control subjects and six subjects with spastic cerebral palsy (CP). Short-duration central peaks were observed in three subjects with spastic diplegia only. All subjects demonstrated reciprocal inhibition in TA following electrical stimulation of group I afferents to SOL, and all subjects with CP demonstrated strong activation of both TA and SOL in response to transcranial magnetic stimulation. Responses in SOL were stronger than those observed from controls. These data support the existence of abnormal corticospinal projections to soleus motor neurons in individuals with spastic CP. In spastic diplegia, short-term discharge synchrony between SOL and TA motor units may reflect abnormal interneuronal modulation at the spinal level. Abnormal corticospinal projections and/or modulation of spinal interneurons may contribute to the disordered movement patterns and co-activation observed in this population.

 

Cooper IS, Upton AR, Amin I (1980) Reversibility of chronic neurologic deficits: Some effects of electrical stimulation of the thalamus and internal capsule in man. Appl Neurophysiol 43(3-5):244-258. Stimulation of the thalamus and internal capsule with Medtronic deep brain stimulation electrodes produced improvement in pain, hemiparesis, dystonia, torticollis, tremor. speech impairment and epilepsy. Stimulation at voltages above or below clinically effective levels (e.g., 6 V, 0.3 ms, 74 Hz) resulted in a loss of clinical efficacy. Somatosensory evoked responses (short and long latency) and depth electrode recordings were helpful in localisation and 'biocalibration' of electrical stimulation.

 

Deletis V, Vodusek DB, Abbott R, Epstein FJ, Turndorf H (1992) Intraoperative monitoring of the dorsal sacral roots: minimizing the risk of iatrogenic micturition disorders. Neurosurgery Jan;30(1):72-75. Dept of Anesthesiology, New York Univ, Med Center, New York. In 31 children (age, 2-17 years) and 1 adult, individual dorsal root action potentials (DRAPs) from the S1-S3 roots were recorded intraoperatively after electrical stimulation of the dorsal penile or clitoral nerves, in preparation for surgery within the cauda equina. In most patients, pudendal afferent activity was present in S2 and S3 bilaterally; in some, the afferent activity was confined to a single root bilaterally, and in one, to a single root on one side. Dorsal root action potentials of small amplitude were recorded from S1 in 15 patients, although in no patient was S1 the primary carrier of these afferents. No lesion of the roots or rootlets carrying significant afferent activity was created during the rhizotomy, and no dysfunction in micturition resulted. We propose that the neurophysiological identification of roots and rootlets carrying afferent activity from the penile or clitoral nerves allows for rhizotomy of the S2 roots with the least possible risk of postoperative micturition and sexual dysfunction.

 

Emly M (1993) Abdominal massage. Nurs Times Jan 20;89(3):34-36.

 

Fasano VA, Broggi G, Zeme S (1988) Intraoperative electrical stimulation for functional posterior rhizotomy. Scand J Rehabil Med Suppl 17:149-154. Institute of Neurosurgery, Univ of Torino, Italy. Intraoperative electrical stimulation of dorsal spinal roots from L1 to S1 bilaterally was performed in 80 patients affected by cerebral palsy, in whom spasticity was the main symptom. Clinical examination and EMG recordings showed three main features of reflex responses. We know that they indicate respectively a normal presence, a defect or an excess of inhibitory activity within the spinal circuits examined. Only those roots or rootlets involved in circuits where normal inhibitory processes are reduced or absent are surgically sectioned. Therefore these circuits are interrupted. The theoretical bases and long-term results indicate that this method is a useful and correct approach to the neurosurgical therapy of spasticity. It allows us to utilize a new important criterion to identify the roots or rootlets to be sectioned, based not on the anatomic, but on the functional selection.

 

Galanda M, Zoltan O (1987) Motor and psychological responses to deep cerebellar stimulation in cerebral palsy (correlation with organization of cerebellum into zones). Acta Neurochir Suppl (Wien) 39:129-131. VULB Bratislava, KUNZ Banska Bystrica, Czechoslovakia. The study includes 68 cases of cerebral palsy stereotaxically operated on from 1977. Deep cerebellar stimulation treatment was performed. The motor and psychological responses to electrical stimulation of 305 points of subcortical regions of cerebellum, mostly lobus anterior were analysed. The characteristic response--slight motor jerk immediately--followed by relaxation and feeling of pleasure, even laughing, to the electrical stimulation from selected points was always found. The level of stimulating current must be adjusted individually. The higher current increased pathological posture, muscular tonus and was conducted with the state of fear. The lower current was without detectable influence on the patient. On the trajectory of electrode, nearly perpendicular to the sagittal plane were narrow areas, which recurred as the strips, from where it was possible or not to elicit characteristic response. The most convenient target is in the region of brachia conjunctiva cerebelli. Localization of the point of stimulation in respect to organization of cerebellum into sagittally oriented zones and the parameters of stimulation seem to contribute to the diversity of responses to cerebellar stimulation.

 

Gokaslan ZL, Samudrala S, Deletis V, Wildrick DM, Cooper PR (1997) Intraoperative monitoring of spinal cord function using motor evoked potentials via transcutaneous epidural electrode during anterior cervical spinal surgery.J Spinal Disord Aug;10(4):299-303. Dept of Neurosurgery, Univ of Texas, M.D. Anderson Cancer Center, Houston 77030, USA. Because false-positive results are not infrequent when monitoring somatosensory evoked potentials during surgery, monitoring of motor evoked potentials (MEPs) has been proposed and successfully used during the removal of spinal cord tumors. However, this often requires direct visual placement of an epidural electrode after a laminectomy. We evaluated the use of MEPs, recorded via a transcutaneously placed epidural electrode, to monitor motor pathway functional integrity during surgery on the anterior cervical spine. Sixteen patients underwent anterior cervical vertebral decompression and fusion for cervical myelopathy and/or radiculopathy. Before surgery, an epidural monitoring electrode was placed transcutaneously at the midthoracic level and was used to record MEPs after transcranial cortical electrical stimulation. Electrode placement was successful in all patients but one, and satisfactory baseline spinal MEPs were obtained except for one patient who had cerebral palsy with significant motor dysfunction. Patients showed no significant changes in spinal MEPs during surgery, and all had baseline or better motor function postoperatively. None had complications from epidural electrode placement or electrical stimulation. We conclude that motor pathways can be monitored safely during anterior cervical spinal surgery surgery using spinal MEPs recorded via a transcutaneously placed epidural electrode, that MEP preservation during surgery correlates with good postoperative motor function, and that cerebral palsy patients may possess too few functional motor fibers to allow MEP recording.

 

Gottlieb GL, Myklebust BM, Stefoski D, Groth K, Kroin J, Penn RD (1985) Evaluation of cervical stimulation for chronic treatment of spasticity. Neurology May;35(5):699-704. Electrical stimulation of the spinal cord (SCS) to reduce spasticity was evaluated in seven patients who, along with their physicians, perceived significant and prompt benefit from stimulation. In two 24-hour test periods, on or off stimulation, we used two independent methods of evaluation: quantitative measures of joint compliance and stretch reflexes, and a standardized neurologic examination. Neither method did better than chance in determining whether SCS was actually being received. Problems with the experimental protocol are discussed, but the results cannot be interpreted as supporting the efficacy of SCS as a treatment for spasticity.

 

Gracanin F (1977) Use of electrical stimulation in external control of motor activity and movements of human extremities: Actual situation and problems. Med Prog Technol Apr 25;4(4):149-156. Functional electrical stimulation (FES) is used in control of motor activity and movements in patients suffering movement handicaps due to central nervous system damage. The method is analyzed from the viewpoint of physical medicine, biocybernetics and technological development. Systems developed to date are presented and a critical survey of the method in light of indications is provided. Special attention is devoted to the present applicability of the systems of FES and to their potential use.

 

Lazareff JA, Valencia Mayoral PF (1990) Histological differences between rootlets sectioned during selective posterior rhizotomy by two surgical techniques. Acta Neurochir (Wien) 105(1-2):35-38. Departamento de Cirugia Experimental, Hospital Infantil de Mexico. During selective posterior rhizotomy, for the treatment of spasticity in infantile cerebral palsy, the rootlets to be divided are chosen by the type of electromyographic response elicited by intraoperative electrical stimulation. Two different surgical techniques were used for exposing the lumbar roots. The first approach was to expose the conus medullaris through a T 12-L 1 laminectomy, while the other approach to the dorsal roots was distally in the cauda equina through a L 2-L 3 to S1 laminectomy. Although the clinical results obtained with either of them are not very different, there is anatomical evidence that suggests that the histological structure of the divided rootlets may be different in the two techniques. We designed our study to determine of a significant difference in the number of large myelinated fibers was found between rootlets divided close to the conus medullaris and those divided distally in the cauda equina. Two groups of five children with spasticity secondary to cerebral palsy where randomly designed to be operated upon by one of the techniques. The divided rootlets were processed with standard histological techniques and the large myelinated fibers were counted on enlarged (40 x) photomicrograph of the rootlet. A significantly (p less than 0.001) larger number of large myelinated axons was found in the rootlets dissected and divided close to the conus medullaris.

 

Lazareff JA, Mata-Acosta AM, Garcia-Mendez MA, Escanero-Salazar A (1990)Selective limited posterior rhizotomy at 3 dorsal levels: A variant for the neurosurgical treatment of spasticity [Article in Spanish]. Bol Med Hosp Infant Mex Feb;47(2):72-77. Departamento de Cirugia Experimental, Hospital Infantil de Mexico Federico Gomez, D.F. INTRODUCTION. Selective posterior rhizotomy (SPR) is effective for reducing spasticity associated to infantile cerebral palsy (ICP). To avoid excessive muscular hypotone a different surgical technique is proposed. PATIENTS AND METHODS. Sixteen children with spasticity secondary to ICP were evaluated before and after rhizotomy. The degree of spasticity was compared in the lower an in the upper limbs. Dorsal roots of levels L4, L5, and S1 were analyzed and sectioned according to the results yielded by intraoperative electrical stimulation. RESULTS. Spasticity was reduced in all the muscular groups analyzed. One of the patients had bladder incontinence. CONCLUSIONS. The limited surgical procedure is sufficient for reducing spasticity.

 

Le Floch-Prigent P, Khouri N (1982) The nerve of the posterior muscle of the leg [Article in French]. Bull Assoc Anat (Nancy) Jun;66(193):241-248. The nerve of the musculus tibialis posterior was dissected to prepare its elective neuroclasia in a girl with cerebral palsy. Numerous variations relative to the other branches in the neighbourhood were proved, but one may conclude that the origin of this branch from the nervus tibialis at the level of the arcus tendineus musculi solei, as the apparent termination on the muscle's surface are the most proximal of the branches for the deep muscles of the leg. The surgical approach prohibits a complete dissection and it was only the electrical stimulation which identified the nerve with certainty.

 

Ojemann JG, Park TS, Komanetsky R, Day RA, Kaufman BA (1997) Lack of specificity in electrophysiological identification of lower sacral roots during selective dorsal rhizotomy. J Neurosurg Jan;86(1):28-33. Dept of Neurosurgery, St Louis Children's Hospital, Washington Univ School of Med, Missouri, USA. The authors investigated the efficacy of anal sphincter electromyography (EMG) in identifying the lower sacral roots during selective dorsal rhizotomy. In nine children undergoing selective dorsal rhizotomy for cerebral palsy (CP) spasticity, direct electrical stimulation of the L1-S5 dorsal and ventral roots was performed while monitoring EMG responses from the anal sphincter and lower-extremity muscles. Anal sphincter activation was seen with stimulation of lumbosacral roots at many levels. Stimulation of dorsal and ventral roots gave anal sphincter EMG responses in 100% of the dorsal and ventral roots from L-4 and caudally. Only at the L-1 level did a minority of nerve roots have anal sphincter response to stimulation. Patterns of extremity muscle and sphincter activation specific to the S3-5 roots, namely anal sphincter activation without activation of other muscle groups, were found in only five (22%) of 23 roots stimulated. The pattern of stimulation responses in the majority of S3-5 roots indicated that the pathophysiology of lower-extremity spasticity in CP may involve the anal sphincter and does not spare the lower sacral roots. Thus, this study indicates that electrophysiological mapping alone, without anatomical identification, cannot be used to identify the lower sacral roots during selective dorsal rhizotomy for CP spasticity, and it proposes a model for investigation of associated bowel and bladder symptoms.

 

Penn RD, Myklebust BM, Gottlieb GL, Agarwal GC, Etzel ME (1980) Chronic cerebellar stimulation for cerebral palsy: Prospective and double-blind studies. J Neurosurg Aug;53(2):160-165. The effects of chronic electrical stimulation of the cerebellum in patients with cerebral palsy have been studied using objective tests of joint compliance, and standardized assessments of developmental reflexes and motor skills. Of 14 patients studied prospectively for 1 to 44 months, 11 showed improvement in motor function. A double-blind test of 10 patients off and on stimulation for an average 8-week period showed no significant changes. Thus, we have no proof that the functional improvements seen with long-term stimulation are the result of cerebellar stimulation.

 

Pinder RM, Brogden RN, Speight TM, Avery GS (1977) Dantrolene sodium: a review of its pharmacological properties and therapeutic efficacy in spasticity. Drugs Jan;13(1):3-23. Dantrolene sodium or dantrolene1 is 1([5-(nitrophenyl)furfurylidend] amino) hydantoin sodium hydrate. It is indicated for use in chronic disorders characterised by skeletal muscle spasticity, such as spinal cord injury, stroke, cerebral palsy and multiple sclerosis. Dantrolene is believed to act directly on the contractile mechanism of skeletal muscle to decrease the force of contraction in the absence of any demonstrated effects on neural pathways, on the neuromuscular junction, or on the excitable properties of the muscle fibre membranes. Controlled trials have demonstrated that dantrolene is superior to placebo in adults or children with spasticity from various causes, as evidenced by clinical assessments of disability and daily activities, and by muscle and reflex responses to mechanical and electrical stimulation. It is somewhat less effective in patients with multiple sclerosis than in those with spasticity from other causes. There has been a general clinical impression in controlled trials that dantrolene caused less sedation than would have been expected from therapeutically comparable doses of diazepam. In 2 controlled trials, there was no significant difference between dantrolene and diazepam in terms of reductions in spasticity, clonus, and hyperreflexia, but side-effects such as drowsiness and inco-ordination occurred significantly more frequently on diazepam. Long-term studies have indicated continuing benefit for patients taking dantrolene, though the incidence of side-effects has often been high and there has been a suggestion of exacerbation of seizures in children with cerebral palsy. Dantrolene may be of value in the medical treatment of spasm of the external urethral sphincter due to neurological and non-neurological disease, and animal studies suggest a potential use in the management of malignant hyperpyrexia. Chemical evidence of liver dysfunction may occur in 0.7 to 1% of patients on long-term treatment with dantrolene, with symptomatic hepatitis in 0.35 to 0.5% and fatal hepatitis in 0.1 to 0.2%. The drug commonly causes transient drowsiness, dizziness, weakness, general malaise, fatigue and diarrhoea at the start of therapy. Muscle weakness may be the principal limiting side-effect in ambulant patients, particularly in those with multiple sclerosis, and therapy could be hazardous in patients with pre-existing bulbar or respiratory weakness. The dosage of dantrolene has been fixed in most controlled trials, though long-term studies have indicated the need for individualisation of dosage. The initial dose is usually 25mg once daily, increasing to 25mg two, three or four times daily, and then by increments of 25mg up to as high as 100mg two, three or four times daily. The lowest dose compatible with optimal response is recommended.

 

Robertson LT, Smith WL (1980) Physiological and behavioral changes produced by cerebellar stimulation in the monkey. J Neurosurg Oct;53(4):533-540. Small surface electrodes were placed bilaterally over the intermediate or lateral cerebellar cortex of cynomolgus monkeys to determine how electrical stimulation of different areas of the cerebellar cortex affected average evoked responses and a sequential forelimb movement. Biphase electrical stimulation was applied between various electrode combinations, and various intensities and frequencies were established for each combination. Transcortical stimulation between the right and left intermediate cerebellar cortex required the lowest intensity (1.5 microC/sq cm/ph) to elicit an average evoked response in the sensorimotor cortex; stimulation between the electrodes over the contralateral intermediate or lateral cortex required slightly higher levels (2.0 microC/sq cm/ph). No response could be elicited from stimulating the ipsilateral cortex. Likewise, 1 minute of transcortical stimulation was more effective than comparable stimulation of the contralateral intermediate or lateral cortex in altering the waveforms of a somatosensory evoked response. Transcortical stimulation also modified the forelimb movement, whereas contralateral stimulation of the intermediate or lateral cortex had little or no effect. Transcortical stimulation at 2.0 microC/sq cm/ph, with frequencies of 150 Hz or higher, increased the time required to execute the forelimb movement but did not affect the accuracy of the movement. High-speed motion pictures indicated that transcortical stimulation decreased the velocity of forelimb movement and in some cases also affected the limb trajectory. These results indicate that consideration should be given to the area of the cerebellum stimulated and to the mode of stimulation, in the hope of achieving optimum clinical benefit.

 

Speelman JD (1990) Cervical epidural spinal cord stimulation in infantile encephalopathy [Article in Dutch]. Ned Tijdschr Geneeskd Sep 8;134(36):1732-1735. Academisch Medisch Centrum, afd. Neurologie, Amsterdam. The effect of Cervical Epidural Spinal cord Electrical Stimulation (ESES) was studied in 15 patients with cerebral palsy. Spasticity and dyskinesia, daily functioning and the emotional and physical burden of this therapy for the patients were examined. Twelve patients did not continue the treatment after completing the study, because of lack of symptomatic or functional improvement and many complications due to broken or migrated electrodes. Two patients still continue ESES and a third is awaiting replacement of a broken electrode. None of these three patients showed a clear improvement of the ADL scale or the disability score. ESES cannot be recommended as a symptomatic treatment for cerebral palsy patients.

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 Xu L, Hong Y, Wang AQ, Wang ZX, Tang T (1993) Hyperselective posterior rhizotomy in treatment of spasticity of paralytic limbs. Chin Med J (Engl) Sep;106(9):671-673. Dept of Orthopaedic Surgery, China Rehabilitation Research Center, Beijing. One hundred and eight patients with spasticity of the paralytic limbs were treated successfully with hyperselective posterior rhizotomy (SPR). Of the 108 patients, 100 had cerebral palsy, 2 hemiplegia, 3 sequelae of cerebral injury, 2 paraplegia and 1 multiple sclerosis. Twelve patients received cervical SPR and 96 lumbosacral SPR. Laminectomy is performed to open the dura and to separate the posterior spinal root into several rootlets. The lower threshold rootlets were divided after electrical stimulation. Follow-up for 6 to 30 months showed that the effective rate of reducing spasticity was over 95% and functional improvement rate over 80%.

 

Xu L (1993) Hyperselective posterior rhizotomy in the treatment of spasticity of paralytic limbs [Article in Chinese]. Chung Hua I Hsueh Tsa Chih May;73(5):292-294. Dept of Orthopedics, China Rehabilitation Research Center, Beijing. 108 cases of spasticity of paralytic limbs were treated successfully with hyperselective posterior rhizotomy (SPR). Among them, 100 had cerebral palsy, 2 hemiplegia, 2 paraplegia, 3 sequelae of cerebral injury, and 1 multiple sclerosis. Cervical SPR was performed in 12 cases and lumbosacral SPR in 96 cases. After laminectomy, the posterior nerve roots were split into some rootlets, and the lower threshold rootlets were divided after electrical stimulation. Follow up for 6-30 months showed an effective rate of 95% and an improvement rate of 81%.

 

Zhukovskaia ED, Semenova KA, Devchenkova VD, Morozova TP (1991) Zinc sulfate in the complex treatment of children with cerebral palsy [Article in Russian]. Zh Nevropatol Psikhiatr Im S S Korsakova 91(8):15-17. Ninety-six children aged 3 to 14 years with cerebral paralysis in the form of spastic diplegia of medium and grave intensity were examined. The majority of the children showed disorders of zinc metabolism and of other types of metabolism. To correct metabolic abnormalities, 20 children received zinc sulfate in biological doses per os in addition to the main complex of treatment measures. 38 children suffering from cerebral paralysis made up the control group and were given a complex of routine rehabilitation treatment measures. It has been established that introduction of the biotic doses of zinc sulfate into the complex of therapeutic measures for children with cerebral paralysis in the form of spastic diplegia favoured the improvement of metabolic processes, the clinical health status of the children, and enhancement of the body defence properties.