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Dominant use of the left hand by athetotic cerebral palsied children
SHORT COMMUMCATION
Dominant Use of the Left Hand by Athetotic Cerebral Palsied Children Kenji Yokochi, MD, Satoshi Shimabukuro, MD, Mariko Kodama, MD and Akihiko Hosoe, MD
Hand preference was studied in 57 children with athetotic cerebral palsy. A left-sided preference was seen in 61% of the subjects. In more severely affected children for whom the possible cause was asphyxia, the left-sided preference was especially common. The perinatal brain damage causing athetosis may affect a motor system controlling movement on the right side more severely. Key words: Athetosis, hand preference. Yokochi K, Shimabukuro S, Kodama M, Hosoe A. Dominant use of the left hand by athetotic cerebral palsied children Brain Dev 1990;12:807-8
Athetosis is seen in one type of cerebral palsy and has been shown to be caused by damage to the basal ganglia, mainly due to perinatal asphyxia or severe jaundice [1]. Characteristic symptoms of athetotic cerebral palsied children are various involuntary movements, impairment of postural stability, oral motor dysfunction, and rare mental pro blems [1]. In athetotic children, lateral preference has not been fully studied yet. In this study, hand preference was examined in athetotic cerebral palsied children. MATERIALS & METHODS
Fifty-seven children with athetotic cerebral palsy (33
From the Department of Pediatric Neurology, Seirei-Mikatabara General Hospital, Hamamatsu, Shizuoka (KY); Department of Pediatrics, National Rehabilitation Center for Disabled Children, Tokyo (SS, MK); and Department of Pediatrics, Kagawa Rehabilitation Center, Takamatsu, Kagawa (AH). Received for publication: June 11, 1990. Accepted for publication: August 12, 1990. Correspondence address: Dr. Kenji Yokochi, Department of Pediatric Neurology, Seirei-Mikatabara General Hospital, Mikatabara 3453, Hamamatsu, Shizuoka 433, Japan.
males, 24 females) were studied. Athetosis was defined as an abnormal amount and type of involuntary movement, the absence of pyramidal signs, and uncontrolled, involuntary and incoordinate motions with varying degrees of tension [2]. In all subjects, the deep tendon reflexes were equally elicited in each side. They were aged from 3 to 15 years (mean, 7.6 ± 3.7). Children with severe mental retardation were not included among the subjects, though the intelligence quotient was not evaluated in all children. All children could understand verbal commands relating to daily life. Six children had epilepsy; the electroencephalography demonstrated spike foci in the both hemipheres in three children, in the right one in two, and in the left one in one, respectively. The gestational age of 56 children was 36 weeks and over, that of the remaining one being 32 weeks. The birth weight of 51 children was more than 2,500 g, that of the other 6 children being in the range of 1,650-2,410 g. The brain damage in 35 children was judged to be caused by perinatal asphyxia, because their Apgar scores were three and below, or because they showed poor activity and generalized hypotonia, and had convulsions in the neonatal period. The brain damage in another 8 was judged to be caused by severe neonatal jaundice, because they had severe jaundice and had received exchange transfusions in the neonatal period. The cause of the remaining 14 children's brain damage could not be determined, because they had had no significant pre-, peri-, or postnatal problems that could have caused brain damage. The patients who could not reach and grasp small objects placed in front of them in any way were excluded from the subjects. The upper extremity dysfunction of the subjects was graded as mild, moderate, or severe. The 20 mildly affected children could perform daily activities such as eating or dressing independently, but with some difficulty due to athetotic involuntary movements. They all could hold a pencil and could write letters, but with difficulty. The 23 moderately affected could perform daily activities, but with some limitation, requiring some support. They all could hold a pencil, with difficulty, but could barely write letters. The 14 severely affected children required support in daily activities. None of them could hold a pencil. In the mildly or moderately affected children, hand preference was determined when they used a spoon or a fork, and when they held a pencil. In the severely affected children, it was determined when they reached and grasped a small object placed in front of them. RESULTS.
Hand preference is shown in Table 1. A left-hand preference was found to be common in athetotic cerebral palsied children. In the children for whom the possible cause was perinatal asphyxia, the left-hand preference was
Table 1 Dominant hand use in athetotic cerebral palsied children Dominant hand
Severity
Right
Mild Moderate Severe Mild
Left
Moderate . Severe
Etiological cause
:
Asphyxia
]
6
1~
]
12 (34%)
;I
3 (38%)
23 (66%)
:]
5 (63%)
35
Total
especially common and was most prominent among the moderately and severely affected children {l7 / (7 + 17) = 71 %). In the athetotic children for whom the cause was unknown, the left-hand preference was equal to that of the right.
DISCUSSION In this study, left-hand preference was found to be common in athetotic cerebral palsied children, especially in the more severely affected children for whom the possible cause was asphyxia. Right-handedness has been estimated to be shown by 70-90% of normal controls [3, 4]. Therefore, dominant use of the left hand is seen much more frequently in athetotic children than in healthy children. The left-hand preference occurs in pure athetosis, because spastic hemiparesis mixed with athetosis is excluded in the subjects. This must be considered in planning physical therapy programs for athetosis. The origin of the left-hand preference seen in athetotic children is undetermined. It is possibly understood in two ways. First, the pathological process causing athetosis predominantly involves regions controlling movement on the right side; Le., the left hemisphere may be more severely damaged in athetotic children than the right. Neonatal strokes, a cause of hemiplegic cerebral palsy, have been found to occur more frequently in the left hemisphere, in clinical and pathological studies [5-7]. The predominance of left-sided infarctions coincides with that of left-sided injury in athetotic children. In the fetal circulation, the left common carotid artery is regarded as an end-artery, because the blood in the descending aorta is supplied mainly via the ductus arteriosus [8]. Therefore, circulatory or ischemic insults to the brain are thought to occur in the left hemisphere more severely than in the right one in the perinatal period. Secondly, the motor disturbance seen in athetosis may affect movement on the
808 Brain & Development, Vol 12, No 6, 1990
Jaundice
8
Unknown
:] :]
7 (50%)
7 (50%) 14
Total
I; ]
22 (39%)
35 (61%)
10] 14
11 57
right side predominantly; i.e., athetotic involuntary movement predominantly may disturb use of the right hand, which is the dominant hand in most children. The incidence of left-handedness is higher in patients with various neurological abnormalities, including highlevel cognitive dysfunctions, epilepsy and mental retardation, than in healthy controls [9, 10]. In patients with the syndrome of pathological left-handedness, an early insult to the left side of the brain is postulated. Perinatal anoxic ischemic brain damage is thought to be a cause of pathological left-handedness. It is considered that some perinatal brain damage affects a motor system controlling movement on the right side more severely, as in the case of the brain damage causing athetosis.
REFERENCES
1. Foley J. The athetoid syndrome. A review of a personal series. J Neurol Neurosurg Psychiatry 1983 ;46: 289-98. 2. Minear WL. A classification of cerebral palsy. Pediatrics 1956; 18:841-52. 3. Badian N. Birth order, maternal age, season of birth, and handedness. Cortex 1983; 19:45 Hi3. 4. Schwartz M. Handedness, prenatal stress and pregnancy complications. Neuropsychologia 1988; 26:925-9. 5. Coker SB, Beltran RS, Myer TF, Hmura L. Neonatal stroke: description of patients and investigation into pathogenesis. Pediatr Neural 1988;4:219-23. 6. Sran SK, Baumann RJ. Outcome of neonatal strokes. Am J Dis Child 1988; 142: 1086-8. 7. Barmada MA, Moossy J, Shuman RM. Cerebral infarcts with arterial occlusion in neonates. Ann Neurol 1979;6:495-502. 8. Moore KL. Circulatory system. The developing human. 2nd ed. Philadelphia: WB Saunders, 1977: 282. 9. Satz P. Pathological left-handedness: an explanatory model. Cortex 1973;8:121-35. 10. Orsini DL, Satz P. A syndrome of pathologicalleft-handedness. Correlates of early left hemisphere injury. Arch Neural 1986;43:333-7.
Dominant Use of the Left Hand by Athetotic Cerebral Palsied Children Kenji Yokochi, MD, Satoshi Shimabukuro, MD, Mariko Kodama, MD and Akihiko Hosoe, MD
Hand preference was studied in 57 children with athetotic cerebral palsy. A left-sided preference was seen in 61% of the subjects. In more severely affected children for whom the possible cause was asphyxia, the left-sided preference was especially common. The perinatal brain damage causing athetosis may affect a motor system controlling movement on the right side more severely. Key words: Athetosis, hand preference. Yokochi K, Shimabukuro S, Kodama M, Hosoe A. Dominant use of the left hand by athetotic cerebral palsied children Brain Dev 1990;12:807-8
Athetosis is seen in one type of cerebral palsy and has been shown to be caused by damage to the basal ganglia, mainly due to perinatal asphyxia or severe jaundice [1]. Characteristic symptoms of athetotic cerebral palsied children are various involuntary movements, impairment of postural stability, oral motor dysfunction, and rare mental pro blems [1]. In athetotic children, lateral preference has not been fully studied yet. In this study, hand preference was examined in athetotic cerebral palsied children. MATERIALS & METHODS
Fifty-seven children with athetotic cerebral palsy (33
From the Department of Pediatric Neurology, Seirei-Mikatabara General Hospital, Hamamatsu, Shizuoka (KY); Department of Pediatrics, National Rehabilitation Center for Disabled Children, Tokyo (SS, MK); and Department of Pediatrics, Kagawa Rehabilitation Center, Takamatsu, Kagawa (AH). Received for publication: June 11, 1990. Accepted for publication: August 12, 1990. Correspondence address: Dr. Kenji Yokochi, Department of Pediatric Neurology, Seirei-Mikatabara General Hospital, Mikatabara 3453, Hamamatsu, Shizuoka 433, Japan.
males, 24 females) were studied. Athetosis was defined as an abnormal amount and type of involuntary movement, the absence of pyramidal signs, and uncontrolled, involuntary and incoordinate motions with varying degrees of tension [2]. In all subjects, the deep tendon reflexes were equally elicited in each side. They were aged from 3 to 15 years (mean, 7.6 ± 3.7). Children with severe mental retardation were not included among the subjects, though the intelligence quotient was not evaluated in all children. All children could understand verbal commands relating to daily life. Six children had epilepsy; the electroencephalography demonstrated spike foci in the both hemipheres in three children, in the right one in two, and in the left one in one, respectively. The gestational age of 56 children was 36 weeks and over, that of the remaining one being 32 weeks. The birth weight of 51 children was more than 2,500 g, that of the other 6 children being in the range of 1,650-2,410 g. The brain damage in 35 children was judged to be caused by perinatal asphyxia, because their Apgar scores were three and below, or because they showed poor activity and generalized hypotonia, and had convulsions in the neonatal period. The brain damage in another 8 was judged to be caused by severe neonatal jaundice, because they had severe jaundice and had received exchange transfusions in the neonatal period. The cause of the remaining 14 children's brain damage could not be determined, because they had had no significant pre-, peri-, or postnatal problems that could have caused brain damage. The patients who could not reach and grasp small objects placed in front of them in any way were excluded from the subjects. The upper extremity dysfunction of the subjects was graded as mild, moderate, or severe. The 20 mildly affected children could perform daily activities such as eating or dressing independently, but with some difficulty due to athetotic involuntary movements. They all could hold a pencil and could write letters, but with difficulty. The 23 moderately affected could perform daily activities, but with some limitation, requiring some support. They all could hold a pencil, with difficulty, but could barely write letters. The 14 severely affected children required support in daily activities. None of them could hold a pencil. In the mildly or moderately affected children, hand preference was determined when they used a spoon or a fork, and when they held a pencil. In the severely affected children, it was determined when they reached and grasped a small object placed in front of them. RESULTS.
Hand preference is shown in Table 1. A left-hand preference was found to be common in athetotic cerebral palsied children. In the children for whom the possible cause was perinatal asphyxia, the left-hand preference was
Table 1 Dominant hand use in athetotic cerebral palsied children Dominant hand
Severity
Right
Mild Moderate Severe Mild
Left
Moderate . Severe
Etiological cause
:
Asphyxia
]
6
1~
]
12 (34%)
;I
3 (38%)
23 (66%)
:]
5 (63%)
35
Total
especially common and was most prominent among the moderately and severely affected children {l7 / (7 + 17) = 71 %). In the athetotic children for whom the cause was unknown, the left-hand preference was equal to that of the right.
DISCUSSION In this study, left-hand preference was found to be common in athetotic cerebral palsied children, especially in the more severely affected children for whom the possible cause was asphyxia. Right-handedness has been estimated to be shown by 70-90% of normal controls [3, 4]. Therefore, dominant use of the left hand is seen much more frequently in athetotic children than in healthy children. The left-hand preference occurs in pure athetosis, because spastic hemiparesis mixed with athetosis is excluded in the subjects. This must be considered in planning physical therapy programs for athetosis. The origin of the left-hand preference seen in athetotic children is undetermined. It is possibly understood in two ways. First, the pathological process causing athetosis predominantly involves regions controlling movement on the right side; Le., the left hemisphere may be more severely damaged in athetotic children than the right. Neonatal strokes, a cause of hemiplegic cerebral palsy, have been found to occur more frequently in the left hemisphere, in clinical and pathological studies [5-7]. The predominance of left-sided infarctions coincides with that of left-sided injury in athetotic children. In the fetal circulation, the left common carotid artery is regarded as an end-artery, because the blood in the descending aorta is supplied mainly via the ductus arteriosus [8]. Therefore, circulatory or ischemic insults to the brain are thought to occur in the left hemisphere more severely than in the right one in the perinatal period. Secondly, the motor disturbance seen in athetosis may affect movement on the
808 Brain & Development, Vol 12, No 6, 1990
Jaundice
8
Unknown
:] :]
7 (50%)
7 (50%) 14
Total
I; ]
22 (39%)
35 (61%)
10] 14
11 57
right side predominantly; i.e., athetotic involuntary movement predominantly may disturb use of the right hand, which is the dominant hand in most children. The incidence of left-handedness is higher in patients with various neurological abnormalities, including highlevel cognitive dysfunctions, epilepsy and mental retardation, than in healthy controls [9, 10]. In patients with the syndrome of pathological left-handedness, an early insult to the left side of the brain is postulated. Perinatal anoxic ischemic brain damage is thought to be a cause of pathological left-handedness. It is considered that some perinatal brain damage affects a motor system controlling movement on the right side more severely, as in the case of the brain damage causing athetosis.
REFERENCES
1. Foley J. The athetoid syndrome. A review of a personal series. J Neurol Neurosurg Psychiatry 1983 ;46: 289-98. 2. Minear WL. A classification of cerebral palsy. Pediatrics 1956; 18:841-52. 3. Badian N. Birth order, maternal age, season of birth, and handedness. Cortex 1983; 19:45 Hi3. 4. Schwartz M. Handedness, prenatal stress and pregnancy complications. Neuropsychologia 1988; 26:925-9. 5. Coker SB, Beltran RS, Myer TF, Hmura L. Neonatal stroke: description of patients and investigation into pathogenesis. Pediatr Neural 1988;4:219-23. 6. Sran SK, Baumann RJ. Outcome of neonatal strokes. Am J Dis Child 1988; 142: 1086-8. 7. Barmada MA, Moossy J, Shuman RM. Cerebral infarcts with arterial occlusion in neonates. Ann Neurol 1979;6:495-502. 8. Moore KL. Circulatory system. The developing human. 2nd ed. Philadelphia: WB Saunders, 1977: 282. 9. Satz P. Pathological left-handedness: an explanatory model. Cortex 1973;8:121-35. 10. Orsini DL, Satz P. A syndrome of pathologicalleft-handedness. Correlates of early left hemisphere injury. Arch Neural 1986;43:333-7.