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      Best Clinical Practice in Botulinum Toxin Treatment for Children with Cerebral Palsy

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          Abstract

          Botulinum toxin A (BoNT-A) is considered a safe and effective therapy for children with cerebral palsy (CP), especially in the hands of experienced injectors and for the majority of children. Recently, some risks have been noted for children with Gross Motor Classification Scale (GMFCS) of IV and the risks are substantial for level V. Recommendations for treatment with BoNT-A have been published since 1993, with continuous optimisation and development of new treatment concepts. This leads to modifications in the clinical decision making process, indications, injection techniques, assessments, and evaluations. This article summarises the state of the art of BoNT-A treatment in children with CP, based mainly on the literature and expert opinions by an international paediatric orthopaedic user group. BoNT-A is an important part of multimodal management, to support motor development and improve function when the targeted management of spasticity in specific muscle groups is clinically indicated. Individualised assessment and treatment are essential, and should be part of an integrated approach chosen to support the achievement of motor milestones. To this end, goals should be set for both the long term and for each injection cycle. The correct choice of target muscles is also important; not all spastic muscles need to be injected. A more focused approach needs to be established to improve function and motor development, and to prevent adverse compensations and contractures. Furthermore, the timeline of BoNT-A treatment extends from infancy to adulthood, and treatment should take into account the change in indications with age.

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          Central mechanisms of motor skill learning.

          Recent studies have shown that frontoparietal cortices and interconnecting regions in the basal ganglia and the cerebellum are related to motor skill learning. We propose that motor skill learning occurs independently and in different coordinates in two sets of loop circuits: cortex-basal ganglia and cortex-cerebellum. This architecture accounts for the seemingly diverse features of motor learning.
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            Goal attainment scaling (GAS) in rehabilitation: a practical guide.

            Goal attainment scaling is a mathematical technique for quantifying the achievement (or otherwise) of goals set, and it can be used in rehabilitation. Because several different approaches are described in the literature, this article presents a simple practical approach to encourage uniformity in its application. It outlines the process of setting goals appropriately, so that the achievement of each goal can be measured on a 5-point scale ranging from -2 to +2, and then explains a method for quantifying the outcome in a single aggregated goal attainment score. This method gives a numerical T-score which is normally distributed about a mean of 50 (if the goals are achieved precisely) with a standard deviation of around this mean of 10 (if the goals are overachieved or underachieved). If desired, the approach encompasses weighting of goals to reflect the opinion of the patient on the personal importance of the goal and the opinion of the therapist or team on the difficulty of achieving the goal. Some practical tips are offered, as well as a simple spreadsheet (in Microsoft Excel) allowing easy calculation of the T-scores.
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              Clinical and MRI correlates of cerebral palsy: the European Cerebral Palsy Study.

              Magnetic resonance imaging (MRI) findings have been reported for specific clinical cerebral palsy (CP) subgroups or lesion types but not in a large population of children with all CP subtypes. Further information about the causes of CP could help identify preventive strategies. To investigate the correlates of CP in a population sample and compare clinical findings with information available from MRI brain studies. Cross-sectional, population-based investigative study conducted in 8 European study centers (North West London and North East London, England; Edinburgh, Scotland; Lisbon, Portugal; Dublin, Ireland; Stockholm, Sweden; Tübingen, Germany; and Helsinki, Finland). Five hundred eighty-five children with CP were identified who had been born between 1996 and 1999; 431 children were clinically assessed and 351 had a brain MRI scan. Standardized clinical examination results, parental questionnaire responses, MRI results, and obstetric, genetic, and metabolic data from medical records. Important findings include the high rate of infections reported by mothers during pregnancy (n = 158 [39.5%]). In addition, 235 children (54%) were born at term while 47 children (10.9%) were very preterm (<28 weeks). A high rate of twins was found, with 51 children (12%) known to be from a multiple pregnancy. Clinically, 26.2% of children had hemiplegia, 34.4% had diplegia, 18.6% had quadriplegia, 14.4% had dyskinesia, 3.9% had ataxia, and 2.6% had other types of CP. Brain MRI scans showed that white-matter damage of immaturity, including periventricular leukomalacia (PVL), was the most common finding (42.5%), followed by basal ganglia lesions (12.8%), cortical/subcortical lesions (9.4%), malformations (9.1%), focal infarcts (7.4%), and miscellaneous lesions (7.1%). Only 11.7% of these children had normal MRI findings. There were good correlations between the MRI and clinical findings. These MRI findings suggest that obstetric mishaps might have occurred in a small proportion of children with CP. A systematic approach to identifying and treating maternal infections needs to be developed. Multiple pregnancies should be monitored closely, and the causes of infant stroke need to be investigated further so preventive strategies can be formulated. All children with CP should have an MRI scan to provide information on the timing and extent of the lesion.
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                Author and article information

                Contributors
                Role: Academic Editor
                Journal
                Toxins (Basel)
                Toxins (Basel)
                toxins
                Toxins
                MDPI
                2072-6651
                11 May 2015
                May 2015
                : 7
                : 5
                : 1629-1648
                Affiliations
                [1 ]Department of Paediatric- and Neuro-Orthopaedics, Orthopaedic Hospital Rummelsberg, 90592 Schwarzenbruck, Germany and MOTIO, 1080 Vienna, Austria; E-Mail: walter.strobl@ 123456sana.de
                [2 ]Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Nuffield Orthopaedic Centre, Windmill Road Headington, Oxford OX3 7LD, Oxfordshire, UK; E-Mail: timtheologis@ 123456googlemail.com
                [3 ]Department of Paediatric- and Neuro-Orthopaedics, University Children’s Hospital Basel (UKBB), Spitalstrasse 33, 4056 Basel, Switzerland; E-Mail: reinald.brunner@ 123456ukbb.ch
                [4 ]Centre de Réadaptation de COUBERT (Ugecam) 77170, France and ROMATEM, Etiler Istanbul 34337, Turkey; E-Mail: skocer1@ 123456gmail.com
                [5 ]Department of Paediatrics, Hospital Infantil La Paz, Universidad Autonóma de Madrid, Madrid, Spain; E-Mail: sipascual@ 123456telefonica.net
                [6 ]Department of Paediatrics, Hospital Infantil La Paz, Universidad Autonóma de Madrid, Madrid, Spain; E-Mail: sipascual@ 123456telefonica.net
                [7 ]Orthopedic Department, University Hospital Bonn, Sigmund-Freud-Str. 25, 53127 Bonn, Germany
                Author notes
                [†]

                These authors contributed equally to this work.

                [* ]Author to whom correspondence should be addressed; E-Mail: richard.placzek@ 123456ukb.uni-bonn.de ; Tel.: +49-0228-287-14170; Fax: +49-0228-287-14175.
                Article
                toxins-07-01629
                10.3390/toxins7051629
                4448165
                25969944
                © 2015 by the authors; licensee MDPI, Basel, Switzerland.

                This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution license ( http://creativecommons.org/licenses/by/4.0/).

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