1. Incidence of Seizure Activity in Cerebral Palsy – A Proposed Study
Tatiana N. Oliveira, MD, Patricia C. Heyn, PhDa,b, Zhaoxing Pan, PhDa,b, David M. Robertson, BSa, James J. Carollo, PhD, PEa,b
aCenter for Gait and Movement Analysis (CGMA), Children’s Hospital Colorado, Aurora, CO
bDepartment of Physical Medicine and Rehabilitation, University of Colorado Denver Anschutz Medical Campus
Introduction
Overall Aim
Impact
To study the incidence and prevalence of epilepsy activity in a population of adults with CP, retrospectively studying their health status since childhood. According to the worldwide trends of pediatric research the percentage of children with CP presenting with epilepsy is 15-40%; we expect to see a higher percentage in the CP population as a whole as they age, considering the patients who developed epilepsy in or after the transition to adulthood. To our knowledge, no previous studies have addressed the needs to identify and treat epilepsy in adults with CP as it is being proposed here. Through a dedicated epilepsy status clinical evaluation with individuals with CP and their caregivers (if applicable) the following data will be obtained:
1) Identify if there is a history of seizures;
2) Classify the type (s) of seizures;
3) Age of onset of seizures;
4) Treatment responsiveness;
5) Disease course until adulthood;
6) Physical and cognitive disabilities degree;
7) Cardiovascular and metabolic status in the individuals with CP and epilepsy.
Cerebral Palsy (CP) is one of the most common chronic childhood disorders, with new cases occurring in of every 1000 live births. CP is generally defined as a persistent disorder of movement and posture caused by nonprogressive defects or lesions of the immature brain. Since the original injury can affect any portion of the growing brain at any stage of development, the combination and severity of symptoms are highly variable. Epilepsy is an important problem in children with CP, with past studies showing an average incidence of epilepsy in about one-third in cases of CP, at a rate of combined epilepsy and CP of 0.8 per 1,000 live births. Epilepsy is characterized by an enduring predisposition to generate seizures, common in patients who have other factors that are associated with a very high likelihood of a persistently lowered seizure threshold and therefore a high recurrence risk.
A few studies were conducted in the past analyzing the correlation of severity of CP and epilepsy in children, and its subtypes; however, no longitudinal study has been conducted yet evaluating the evolution of CP and aging, specifically in the transition from childhood to adulthood, and how the incidence, prevalence and clinical course of epilepsy and its associations with the other clinical features of CP behave in such a time lapse. Furthermore, no studies demonstrate an analysis of the types of seizures and their correlations to CP and its variants, causing epidemiological data to be lacking in that regard.
Our goal is to perform this study to fill this gap, in collaboration with the parent NIDRR funded grant study: “Health and Functional Outcomes in Cerebral Palsy”, currently in its initial phase. Dr. Carollo and colleagues are conducting a longitudinal study of former patients with CP treated at the Children’s Hospital Colorado as children, who now are adults between years of age. We are proposing to investigate epilepsy outbreak and its associations in adults with CP as they age from the parent study referenced above.
This ancillary study will be the largest and most comprehensive longitudinal investigation of objectively measured health outcomes in adults with CP and epilepsy. Our proposed study will supplement and add knowledge to the parent study findings by generating novel clinical knowledge that could contribute to impairment-specific CP transition to adulthood recommendations, aimed to supply current evidence addressing the needs for treatment for persons with CP associated to epilepsy as they age.
Upon completion concomitantly with the parent NIDRR grant study, this will be the largest and most comprehensive longitudinal investigation of objectively measured health outcomes in adults with CP and epilepsy. It will also support the development of new impairment-specific transition to adulthood interventions and treatments, aiming to provide evidence to support health-care policy changes for persons with CP and epilepsy as they age.
Methods
Our subjects are from a cohort of 400 patients with CP who were evaluated and treated at Children’s Hospital Colorado as children, and now are between the ages of
Through an initial phone interview, as part of the parent NIDRR study, subjects who consent will be asked specific health questions. If a positive answer is obtained for the existence of seizure(s) in any period of life, those subjects will be contacted for inclusion in this ancillary study and further investigation. A subset of 40 patients will be drawn from the original pool, and then evaluated for past medical history (by chart review and interviews) and current health history. Cognitive evaluation and perceived quality of life assessment will also be performed. In a second visit, patients will be physically examined and have blood samples drawn.
Specific Aims
Primary Aim and Hypothesis: This research project has one primary aim and two secondary aims:
Aim #1: To determine correlation between CP and epilepsy, and its incidence and prevalence as this
specific population ages. Based on participant’s medical records and current medical history, there probably will be a higher percentage of persons with CP and epilepsy due to the adults who will develop associated epilepsy after transition to adulthood.
Secondary Aim and Hypothesis:
Aim #2: To prospectively evaluate the associations between epilepsy status in this group with CP with their physical and mental health status, impact in daily life and quality of life.
Aim #3: To prospectively evaluate the associations between epilepsy in this group with CP with their
cardiovascular and metabolic status (blood pressure, lipid panel, insulin, glucose, BMI), and associated diets (for example, ketogenic diet).
Rationale and Conclusion
Healthcare for individuals with CP must pay attention to transition to adulthood services to ensure that as adults they receive age appropriate care such as routine comprehensive health assessments and health promotion.
A few studies over the last three decades were conducted studying the epidemiological features of CP and epilepsy; however, as cerebral palsy is generally seen as a childhood disorder, no studies have been done on the CP population who reach adulthood, analyzing the segment of the previously non-affected CP individuals who might have presented epilepsy in adulthood, and how the disorder evolves and behaves in this older population.
We have reason to believe that, as it is with other childhood chronic ailments, the transition to adulthood in CP may bring significant changes in clinical features and associated impairments and conditions such as epilepsy, cardiovascular/metabolic changes, and shifts in severity and disease course that require adaptations in preventative and palliative treatments targeted to this population. Epilepsy, one of the many secondary disabilities that are associated with cerebral palsy, can pose severe limitations to the patient who already has a physical challenge in integrating in society and the work force.
We hope that novel data drawn from this proposed study will aid clinical practitioners to better promote health in a comprehensive fashion for individuals with CP and epilepsy, and with associated secondary ailments such as metabolic and cardiovascular disease, improving the overall quality of life of this specific population.