How do changes in body functions and structures, activity, and participation relate in children with cerebral palsy?

"You gotta try it all": Parents' Experiences with Robotic Gait Training for their Children with Cerebral Palsy

AIMS

Innovative robotic technologies hold strong promise for improving walking abilities of children with cerebral palsy (CP), but may create expectations for parents pursuing the "newest thing" in treatment. The aim of this qualitative study was to explore parents' values about walking in relation to their experiences with robotic gait training for their children.

METHODS

Semi-structured interviews were conducted with parents of five ambulatory children with CP participating in a randomized trial investigating robotic gait training effectiveness.

RESULTS

Parents valued walking, especially "correct" walking, as a key component of their children's present and future well-being. They continually sought the "next best thing" in therapy and viewed the robotic gait trainer as a potentially revolutionary technology despite mixed experiences.

CONCLUSIONS

The results can help inform rehabilitation therapists' knowledge of parents' values and perspectives, and guide effective collaborations toward meeting the therapeutic needs of children with CP.

Effects of hippotherapy on gross motor function and functional performance of children with cerebral palsy

PURPOSE

The purpose of our study was to investigate the effects of hippotherapy on gross motor function and functional performance in children with spastic cerebral palsy (CP).

MATERIALS AND METHODS

We recruited 34 children (M:F=15:19, age: 3-12 years) with spastic CP who underwent hippotherapy for 45 minutes twice a week for 8 weeks. Twenty-one children with spastic CP were recruited for control group. The distribution of gross motor function classification system level and mean age were not significantly different between the two groups. Outcome measures, including the Gross Motor Function Measure (GMFM)-66, GMFM-88 and the Pediatric Evaluation of Disability Inventory: Functional Skills Scale (PEDI-FSS), were assessed before therapy and after the 8-weeks intervention as outcome measures.

RESULTS

There were no significant differences between intervention and control groups in mean baseline total scores of GMFM-66, GMFM-88 or PEDI-FSS. After the 8-weeks intervention, mean GMFM-66 and GMFM-88 scores were significantly improved in both groups. However, the hippotherapy group had significantly greater improvement in dimension E and GMFM-66 total score than the control group. The total PEDI-FSS score and the sub-scores of its 3 domains were significantly improved in the hippotherapy group, but not in the control group.

CONCLUSION

The results of our study demonstrate the beneficial effects of hippotherapy on gross motor function and functional performance in children with CP compared to control group. The significant improvement in PEDI-FSS scores suggests that hippotherapy may be useful to maximize the functional performance of children with CP.

Side-to-side growth discrepancies in children with hemiplegic cerebral palsy: association with function, activity and social participation

OBJECTIVE

Evaluate side-to-side discrepancies in children with hemiplegic cerebral palsy (HCP), and investigate associations of these discrepancies with patients' age at initiation of physical therapy, motor and cognitive function, and degree of activities and social participation.

METHOD

We obtained eight side-to-side measurements from 24 HCP children with mean age 49.3±5.2 months.

RESULTS

Early initiation of physical therapy was associated with lower discrepancy in hand length (p=0.037). Lower foot length discrepancy was associated with lower requirement for caregiver assistance in activities related to mobility. Increased side-to-side discrepancy was associated with reduced wrist extension and increased spasticity. Discrepancy played a larger role in children with hemineglect and in those with right involvement.

CONCLUSION

Increased discrepancy in HCP children was associated with reduced degree of activity/social participation. These results suggest an association between functional use of the extremities and limb growth.

Utility of the International Classification of Functioning, Disability and Health (ICF) for educational psychologists' work

Despite embracing a bio-psycho-social perspective, the World Health Organization's International Classification of Functioning, Disability and Health (ICF) assessment framework has had limited application to date with children who have special educational needs (SEN). This study examines its utility for educational psychologists' work with children who have Autism Spectrum Disorders (ASD). Mothers of 40 children with ASD aged eight to 12 years were interviewed using a structured protocol based on the ICF framework. The Diagnostic Interview for Social and Communication Disorder (DISCO) was completed with a subset of 19 mothers. Internal consistency and inter-rater reliability of the interview assessments were found to be acceptable and there was evidence for concurrent and discriminant validity. Despite some limitations, initial support for the utility of the ICF model suggests its potential value across educational, health and care fields. Further consideration of its relevance to educational psychologists in new areas of multi-agency working is warranted.

Determinants of Developmental Gain in Daily Activities in Young Children with Cerebral Palsy

ABSTRACT The aim of this study was to examine which child and family characteristics at the child's age of 2 years are determinants of development of self-care and mobility activities over a period of 2 years in young children with cerebral palsy (CP). Longitudinal data of 92 children, representing all levels of the Gross Motor Function Classification System (GMFCS), were analyzed. Children's self-care and mobility activities were assessed with the Functional Skills Scale of the Pediatric Evaluation of Disability Inventory. Development of self-care and mobility activities was related to several child determinants but no family determinants. GMFCS, type of CP, intellectual capacity, and epilepsy were related to the development of self-care and mobility activities, while manual ability and spasticity were related to development of mobility activities. Multivariate analysis indicated that GMFCS and intellectual capacity were the strongest determinants of development of self-care activities, and GMFCS was the strongest determinant of development of mobility activities. The change in self-care and mobility activities was less favorable in severely affected children with severe disability. Knowledge of GMFCS level and intellectual capacity is important in anticipating change over time and goal setting in young children with CP.

International Classification of Functioning, Disability and Health (ICF) as a framework for change: revolutionizing rehabilitation

The International Classification of Functioning, Disability and Health (ICF) utilizes domains of body functions and structures, activities and participation, as well as environmental and personal factors to fully encapsulate the concepts of health and disability. The International Classification of Functioning, Disability and Health provides a rich and holistic understanding of functioning that is particularly valuable in the setting of childhood disability and rehabilitation. With applicability that enhances a nuanced understanding of each child within their family, school, and community, the International Classification of Functioning, Disability and Health also ensures facile and meaningful communication between professionals. Use of the International Classification of Functioning, Disability and Health promotes improved treatment plans for individual children and for larger programmatic decisions. This article demonstrates how the International Classification of Functioning, Disability and Health has reinvented the language and understanding of childhood disability and rehabilitation.

The Quality Function Measure: reliability and discriminant validity of a new measure of quality of gross motor movement in ambulatory children with cerebral palsy

AIM

Optimizing movement quality is a common rehabilitation goal for children with cerebral palsy (CP). The new Quality Function Measure (QFM)--a revision of the Gross Motor Performance Measure (GMPM)--evaluates five attributes: Alignment, Co-ordination, Dissociated movement, Stability, and Weight-shift, for the Gross Motor Function Measure (GMFM) Stand and Walk/Run/Jump items. This study evaluated the reliability and discriminant validity of the QFM.

METHOD

Thirty-three children with CP (17 females, 16 males; mean age 8y 11mo, SD 3y 1mo; Gross Motor Function Classification System [GMFCS] levels I [n=17], II [n=7], III [n=9]) participated in reliability testing. Each did a GMFM Stand/Walk assessment, repeated 2 weeks later. Both GMFM assessments were videotaped. A physiotherapist assessor pair independently scored the QFM from an assigned child's GMFM video. GMFM data from 112 children. That is, (GMFCS I [n=38], II [n=27], III [n=47]) were used for discriminant validity evaluation.

RESULTS

QFM mean scores varied from 45.0% (SD 27.2; Stability) to 56.2% (SD 27.5; Alignment). Reliability was excellent across all attributes: intraclass correlation coefficients (ICCs) ≥0.97 (95% confidence intervals [CI] 0.95-0.99), interrater ICCs ≥0.89 (95% CI 0.80-0.98), and test-retest ICCs ≥0.90 (95% CI 0.79-0.99). QFM discriminated qualitative attributes of motor function among GMFCS levels (maximum p<0.05).

INTERPRETATION

The QFM is reliable and valid, making it possible to assess how well young people with CP move and what areas of function to target to enhance quality of motor control.

Mothers' experiences with the Pediatric Evaluation of Disability Inventory (PEDI)

Parents of a child with a disability are often asked about their child's functioning in daily activities. One way to gather this information is through parent-report functional questionnaires such as the Pediatric Evaluation of Disability Inventory (PEDI). The purpose of this study was to explore parental experiences associated with completion of the PEDI before and after a functional therapy intervention. Semi-structured interviews were conducted with 12 mothers of children with cerebral palsy (CP) or developmental delay (DD) who had completed the PEDI within a larger study. A content analysis approach was used to code and organize the data into five themes. PEDI completion was associated with increased parental awareness of developmental patterns, and greater insight into levels of assistance they give to their child. Parents described various challenges and concerns with the PEDI that have implications for test administration processes. The findings have potential to enable more sensitive and focused PEDI use.

Effectiveness of functional hand splinting and the cognitive orientation to occupational performance (CO-OP) approach in children with cerebral palsy and brain injury: two randomised controlled trial protocols

BACKGROUND

Cerebral palsy (CP) and brain injury (BI) are common conditions that have devastating effects on a child's ability to use their hands. Hand splinting and task-specific training are two interventions that are often used to address deficits in upper limb skills, both in isolation or concurrently. The aim of this paper is to describe the method to be used to conduct two randomised controlled trials (RCT) investigating (a) the immediate effect of functional hand splints, and (b) the effect of functional hand splints used concurrently with task-specific training compared to functional hand splints alone, and to task-specific training alone in children with CP and BI. The Cognitive Orientation to Occupational Performance (CO-OP) approach will be the task-specific training approach used.

METHODS/DESIGN

Two concurrent trials; a two group, parallel design, RCT with a sample size of 30 participants (15 per group); and a three group, parallel design, assessor blinded, RCT with a sample size of 45 participants (15 per group).

INCLUSION CRITERIA

age 4-15 years; diagnosis of CP or BI; Manual Abilities Classification System (MACS) level I - IV; hand function goals; impaired hand function; the cognitive, language and behavioural ability to participate in CO-OP. Participants will be randomly allocated to one of 3 groups; (1) functional hand splint only (n=15); (2) functional hand splint combined with task-specific training (n=15); (3) task-specific training only (n=15). Allocation concealment will be achieved using sequentially numbered, sealed opaque envelopes opened by an off-site officer after baseline measures. Treatment will be provided for a period of 2 weeks, with outcome measures taken at baseline, 1 hour after randomisation, 2 weeks and 10 weeks. The functional hand splint will be a wrist cock-up splint (+/- thumb support or supination strap). Task-specific training will involve 10 sessions of CO-OP provided in a group of 2-4 children. Primary outcome measures will be the Canadian Occupational Performance Measure (COPM) and the Goal Attainment Scale (GAS). Analysis will be conducted on an intention-to-treat basis.

DISCUSSION

This paper outlines the protocol for two randomised controlled trials investigating functional hand splints and CO-OP for children with CP and BI.

How do changes in motor capacity, motor capability, and motor performance relate in children and adolescents with cerebral palsy?

OBJECTIVE

To investigate the relations between changes in motor capacity (can do, in standardized environment), motor capability (can do, in daily environment), and motor performance (does do, in daily environment) among children with cerebral palsy (CP).

DESIGN

Prospective longitudinal study. After baseline measurements (at the age of 18 mo, 30 mo, 5 y, 7 y, 9 y, 11 y, or 13 y), 2-year follow-up measurements were performed. Change scores were calculated, and Pearson correlations were used for change score relations.

SETTING

Outpatient clinic.

PARTICIPANTS

Toddlers, school-age children, and adolescents with CP (N=321; 200 boys, 121 girls). Levels of severity according to the Gross Motor Function Classification System included level I (42%), level II (15%), level III (17%), level IV (13%), and level V (13%).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Change in motor capacity was assessed with the Gross Motor Function Measure-66. Changes in motor capability and motor performance were assessed with the Pediatric Evaluation of Disability Inventory using the Functional Skills Scale and Caregiver Assistance Scale, respectively.

RESULTS

Within the total group, change score correlations were moderate (.52-.67) and significant (P<.001). For age groups, correlations were significantly higher in toddlers than school-age children and adolescents. For severity levels, correlations were significantly higher in children at level III than level I, IV, and V.

CONCLUSIONS

Results imply that change in motor capacity does not automatically translate to change in motor capability and change in motor capability does not automatically translate to change in motor performance. Results also show different relations for clinically relevant subgroups. These are important insights for clinical practice because they can guide evidence-based interventions with a focus on activities.

Determinants of gross motor function of young children with cerebral palsy: a prospective cohort study

AIM

The aim of this study was to test a model of determinants of gross motor function of young children with cerebral palsy (CP).

METHOD

Four hundred and twenty-nine children with CP (242 males, 187 females; mean age 3 y 2 mo, SD 11 mo) representing all levels of the Gross Motor Function Classification System (GMFCS) participated. Children in levels I to II and III to V were classified as Groups 1 and 2 respectively. Distribution of CP was quadriplegia, 44%; hemiplegia, 24%; diplegia, 23%; triplegia, 6%; and monoplegia, 2% (data not available for 1%). Impairment and motor function data were collected by reliable assessors; parents completed questionnaires on health conditions and adaptive behavior. Seven months later, parents were interviewed about family life and services received. One year after the study onset, motor function was re-evaluated. Analysis involved structural equation modeling.

RESULTS

The well-fitting model explained 58% and 75% of the variance in motor function at study completion for Groups 1 and 2 respectively. Primary impairments (spasticity, quality of movement, postural stability, and distribution of involvement; β=0.52-0.68) and secondary impairments (strength, range of motion limitations, and reduced endurance; β=0.25-0.26) explained the most variance. Adaptive behavior was a significant determinant only for Group 2 (β=0.21) and participation in community programs was significant only in Group 1 (β=0.13).

INTERPRETATION

Motor function is supported by optimizing body structures and function for all children and enhancing adaptive behavior for children with greater motor challenges.

A path model for evaluating dosing parameters for children with cerebral palsy

Dosing of pediatric rehabilitation services for children with cerebral palsy (CP) has been identified as a national priority. Establishing dosing parameters for pediatric physical therapy interventions is critical for informing clinical decision making, health policy, and guidelines for reimbursement. The purpose of this perspective article is to describe a path model for evaluating dosing parameters of interventions for children with CP. The model is intended for dose-related and effectiveness studies of pediatric physical therapy interventions. The premise of the model is: Intervention type (focus on body structures, activity, or the environment) acts on a child first through the family, then through the dose (frequency, intensity, time), to yield structural and behavioral changes. As a result, these changes are linked to improvements in functional independence. Community factors affect dose as well as functional independence (performance and capacity), influencing the relationships between type of intervention and intervention responses. The constructs of family characteristics; child characteristics (eg, age, level of severity, comorbidities, readiness to change, preferences); plastic changes in bone, muscle, and brain; motor skill acquisition; and community access warrant consideration from researchers who are designing intervention studies. Multiple knowledge gaps are identified, and a framework is provided for conceptualizing dosing parameters for children with CP.

Change in parent-identified goals in young children with cerebral palsy receiving a context-focused intervention: associations with child, goal and intervention factors

The purpose of this study was to examine the relationship between goal achievement measured by the Canadian Occupational Performance Measure (COPM) and child, goal, and intervention factors. Participants were 41 preschool children with cerebral palsy (CP) who were in the context-focused therapy arm of a randomized controlled trial. Factors including child age, Gross Motor Function Classification System (GMFCS) level, type and complexity of goals, and intervention strategies were analyzed. Children made large, positive mean changes on the COPM over 6 months (Performance = 3.8, SD = 1.9; Satisfaction = 4.3, SD 4.3) with younger children showing greater change. The COPM scores had low to moderate correlations with change on the Pediatric Evaluation of Disability Inventory and the Gross Motor Function Measure (GMFM-66). Regression analysis indicated that age, but not GMFCS level influenced COPM change scores. Goal complexity and intervention strategies were not significantly related to COPM change scores. The results provide support for using the COPM as an individualized measure of change in young children with CP receiving intervention.

Effectiveness of hand splints in children with cerebral palsy: a systematic review with meta-analysis

AIM

The aim of this review was to determine the effectiveness of hand splinting for improving hand function in children with cerebral palsy (CP) and brain injury.

METHOD

A systematic review with meta-analyses was conducted. Only randomized and quasi-randomized controlled trials in which all participants were children aged 0 to 18 years with CP or brain injury and a hand splint (cast, brace, or orthosis) were included.

RESULTS

Six studies met the inclusion criteria. No study included participants with a brain injury; therefore, the results relate only to CP. Five studies investigated 'non-functional hand splints' and one investigated a 'functional hand splint'. Moderate-quality evidence indicated a small benefit of non-functional hand splints plus therapy on upper limb skills over therapy alone (standard mean difference [SMD]=0.81, 95% confidence interval [CI]=0.03-1.58), although benefits were diminished 2 to 3 months after splint wearing stopped (SMD=0.35, CI -0.06 to 0.77).

INTERPRETATION

In children with CP, hand splints may have a small benefit for upper limb skills. However, results are diminished after splint wearing stops. Given the costs - potential negative cosmesis and discomfort for the child - clinicians must consider whether hand splinting is clinically worthwhile. Further methodologically sound research regarding hand splinting combined with evidence-based therapy is needed to investigate whether the small clinical effect is meaningful.

Predicting the effects of cerebral palsy severity on self-care, mobility, and social function

In this retrospective, longitudinal cohort study, the Pediatric Evaluation of Disability Inventory was used to predict the effects of cerebral palsy (CP) on self-care, mobility, and social function for 2,768 children, adolescents, and young adults with CP. Multiple linear regression was used to predict functional performance and level of caregiver assistance and found that CP severity, as measured by the Gross Motor Function Classification System and the Manual Ability Classification System, had the strongest effect. More severe levels of gross motor and fine motor dysfunction resulted in lower levels of self-care, mobility, and social function and increased levels of caregiver assistance. This study provides critical evidence regarding the importance of CP severity as a predictor of self-care, mobility, and social function that can be tested in future research to improve therapy treatment planning, caregiver education, and clinical resource utilization.

Relation of stride activity and participation in mobility-based life habits among children with cerebral palsy

OBJECTIVE

To examine the relation between walking performance and participation in mobility-related habits of daily life in children with cerebral palsy (CP). To date, walking outcomes in CP have been capacity-based (what a child does in structured setting). Physical activity performance (what a child really does in daily life) has been documented to affect the relation of capacity-based gross motor measures and participation.

DESIGN

Cross-sectional prospective cohort study.

SETTING

Regional pediatric specialty care centers.

PARTICIPANTS

A cohort of ambulatory children with CP (N=128; age, 2 to 9y; 41% girls; 49% having hemiplegia) participated.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Walking performance was quantified from a 5-day sample of accelerometry data. Stride activity was summarized through the outcomes of the average number of total strides per day (independent of intensity) and the average number of total strides per day at >30 strides/min (marker of intensity). Mobility-based participation was assessed by using the Assessment of Life Habits for Children questionnaire categories of personal care, housing, mobility, and recreation. Regression models were developed controlling for sex, age, cognition, communication, pain, and body composition.

RESULTS

The average number of total strides per day was positively associated with the personal care, housing, mobility, and recreation Assessment of Life Habits for Children questionnaire categories (β=.34-.41, P<.001). The average number of total strides per day at >30 strides/min was associated with all categories (β=.54-.60, P<.001).

CONCLUSIONS

Accelerometry-based walking activity performance is significantly associated with levels of participation in mobility-based life habits for ambulatory children with CP. Evaluation of other factors and the direction of the relation within the International Classification of Functioning, Disability and Health is warranted to inform rehabilitation strategies.

Capacity to participation in cerebral palsy: evidence of an indirect path via performance

OBJECTIVE

To examine the hypothesis that the influence of physical activity capacity on participation is mediated through activity performance.

DESIGN

Secondary analysis of a prospective cross-sectional study sample.

SETTING

Regional pediatric specialty care hospital.

PARTICIPANTS

Children (N=128; 59% boys; age range, 2-9y) with cerebral palsy with Gross Motor Function Classification System levels I to III; 49% had hemiplegia, and 72% had spasticity.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Activity capacity was measured with the Gross Motor Function Measure-66, performance was measured with the Activities Scale for Kids, and participation was measured with the Assessment of Life Habits. Children's Assessment of Participation and Enjoyment and the Assessment of Preschool Children's Participation assessed diversity participation. Regression equations and Sobel z test were used to examine the mediated effect via performance.

RESULTS

Physical activity performance mediates 74.9% (β=.83, P<.001) of the effect of activity capacity on total participation levels and 52.8% (β=.47, P=.001) of the effect of capacity on diversity participation.

CONCLUSIONS

The relation between what an ambulatory child with cerebral palsy is able to perform in a clinical setting and their participation in life is significantly mediated by what they actually do motorically in day-to-day life. Results suggest that interventions focusing on improving what they actually do every day, regardless of their capacity to perform (what they can do when tested), may positively influence participation.

A Home-Based Program Using Patterned Sensory Enhancement Improves Resistance Exercise Effects for Children With Cerebral Palsy

Background. Neurologic music therapy has demonstrated improved walking performance in persons with neurologic disease; however, little evidence supports the use of music with functional resistance exercise to improve motor capacity and daily functions for children with cerebral palsy. Objective. To investigate the effect of additional patterned sensory enhancement (PSE) music combined with exercise for children with spastic diplegia. Methods. An assessor-blind, randomized controlled trial with 6- and 12-week follow-ups was carried out. Thirty-six children with spastic diplegia, aged 5 to 13 years, were assigned to a PSE group (n = 18) or a no-music group (n = 18). Both groups received 6-week, home-based, loaded sit-to-stand exercise, but only the PSE group exercised with prerecorded PSE music. The primary outcome was Gross Motor Function Measure (GMFM). Secondary outcomes included Pediatric Evaluation of Disability Inventory (PEDI) mobility and self-care domains, 1-repetition maximum of sit-to-stand, and walking speeds. Results. Three children did not complete the program. Intention-to-treat analysis showed both groups improved in GMFM D, E, and Goal dimensions; Functional Skills Scales of PEDI mobility domain; and 1-repetition maximum of sit-to-stand at posttest and follow-ups ( P ≤ .005). The PSE group improved significantly greater than the no-music group in the GMFM D and Goal dimensions ( P < .005) after training, and the improvement persisted for at least 6 or 12 weeks ( P ≤ .013). No significant improvements in the rest PEDI scales and walking speeds were found. Conclusions. Adding neurologic music therapy to functional resistance exercise could induce greater improvements in gross motor capacity for children with cerebral palsy.

Sit-to-stand movement in children with hemiplegic cerebral palsy: relationship with knee extensor torque and social participation

This study aimed to investigate the relationship between sit-to-stand (STS) movement, knee extensor torque and social participation in children with cerebral palsy (CP). Seven spastic hemiplegic CP patients (8.0 ± 2.2 years), classified by the Gross Motor Function Classification System as I and II, and 18 typical children (8.4 ± 2.3 years) participated in this study. Trunk, hips, knees, and ankles angles and temporal variables of STS movement were obtained by means of kinematics evaluation. Isokinetic evaluation was performed at 60°/s in the concentric passive mode to measure knee extensors torque. Social participation was assessed by the Assessment of Life Habits for Children (LIFE-H) scale. Results showed that children with spastic hemiplegic CP have lower knee extensor torque in the affected limb and restriction in social participation in dimensions related with fine motor control and language skills when compared to their typical peers. Except for ankle excursion in frontal plane, and ankle excursion and range in transverse plane, patients were similar to typical children regarding the strategies adopted to perform the STS movement, as well as in the participation dimensions related with gross motor function. Moreover, we found a significant non-linear correlation between knee extensors torque and some lower limb and trunk angles for children with CP. Therefore, during evaluation and rehabilitation processes, impairments in body functions and structures should be related with how much they affect a child's ability to perform functional activities, so rehabilitation protocols could be focused on individual needs.

How are actual needs recognized in the content and goals of written rehabilitation plans?

PURPOSE

The primary aim of the study was to investigate the interrelation between needs and functional difficulties and the therapeutic goals in children with cerebral palsy (CP) as documented in individual written rehabilitation plans.

METHOD

The study was a retrospective cross-sectional register study. The data consisted of randomly chosen register documents for 77 children and adolescents with CP in different predetermined age ranges. The International Classification of Functioning, Disability and Health-Child and Youth version (ICF-CY) was used as a reference for analyzing the content of the written statements.

RESULTS

The rehabilitation plans for 70 children, 1-16 years of age, representing all GMFCS levels were analyzed. Goals were not well reflected in the children's needs and functional difficulties. The needs, functional difficulties and goals mainly encompassed the components of body functions and activity/participation. In half of the plans the presence of the parents was mentioned, and the plans were made in multidisciplinary collaboration.

CONCLUSIONS

The results of this study indicate deficiencies in the content and goals of the written rehabilitation plans. The ICF-CY could serve as a framework to help professionals and parents identify the child's needs and those areas where the goals should be targeted. Implications for Rehabilitation Documenting the child's and family's needs in relation to activity and participation preferences is critical to rehabilitation and intervention planning. Goals, based on the child's needs, should be identified in collaboration with all parties involved, and focus on the child's functioning in meaningful everyday activities. The ICF-CY could serve as a framework for the family and professionals to identify needs and to communicate rehabilitation goals.

Structural equation modeling of motor impairment, gross motor function, and the functional outcome in children with cerebral palsy

Physical therapy intervention for children with cerebral palsy (CP) is focused on reducing neurological impairments, improving strength, and preventing the development of secondary impairments in order to improve functional outcomes. However, relationship between motor impairments and functional outcome has not been proved definitely. This study confirmed the construct of motor impairment and performed structural equation modeling (SEM) between motor impairment, gross motor function, and functional outcomes of regarding activities of daily living in children with CP. 98 children (59 boys, 39 girls) with CP participated in this cross-sectional study. Mean age was 11 y 5 mo (SD 1 y 9 mo). The Manual Muscle Test (MMT), the Modified Ashworth Scale (MAS), range of motion (ROM) measurement, and the selective motor control (SMC) scale were used to assess motor impairments. Gross motor function and functional outcomes were measured using the Gross Motor Function Measure (GMFM) and the Functional Skills domain of the Pediatric Evaluation of Disability Inventory (PEDI) respectively. Measurement of motor impairment was consisted of strength, spasticity, ROM, and SMC. The construct of motor impairment was confirmed though an examination of a measurement model. The proposed SEM model showed good fit indices. Motor impairment effected gross motor function (β=-.0869). Gross motor function and motor impairment affected functional outcomes directly (β=0.890) and indirectly (β=-0.773) respectively. We confirmed that the construct of motor impairment consist of strength, spasticity, ROM, and SMC and it was identified through measurement model analysis. Functional outcomes are best predicted by gross motor function and motor impairments have indirect effects on functional outcomes.

Using the International Classification of Functioning, Disability and Health (ICF) to describe children referred to special care or paediatric dental services

Children in dentistry are traditionally described in terms of medical diagnosis and prevalence of oral disease. This approach gives little information regarding a child’s capacity to maintain oral health or regarding the social determinants of oral health. The biopsychosocial approach, embodied in the International Classification of Functioning, Disability and Health - Child and Youth version (ICF-CY) (WHO), provides a wider picture of a child’s real-life experience, but practical tools for the application of this model are lacking. This article describes the preliminary empirical study necessary for development of such a tool - an ICF-CY Core Set for Oral Health. An ICF-CY questionnaire was used to identify the medical, functional, social and environmental context of 218 children and adolescents referred to special care or paediatric dental services in France, Sweden, Argentina and Ireland (mean age 8 years ±3.6yrs). International Classification of Disease (ICD-10) diagnoses included disorders of the nervous system (26.1%), Down syndrome (22.0%), mental retardation (17.0%), autistic disorders (16.1%), and dental anxiety alone (11.0%). The most frequently impaired items in the ICF Body functions domain were ‘Intellectual functions’, ‘High-level cognitive functions’, and ‘Attention functions’. In the Activities and Participation domain, participation restriction was frequently reported for 25 items including ‘Handling stress’, ‘Caring for body parts’, ‘Looking after one’s health’ and ‘Speaking’. In the Environment domain, facilitating items included ‘Support of friends’, ‘Attitude of friends’ and ‘Support of immediate family’. One item was reported as an environmental barrier – ‘Societal attitudes’. The ICF-CY can be used to highlight common profiles of functioning, activities, participation and environment shared by children in relation to oral health, despite widely differing medical, social and geographical contexts. The results of this empirical study might be used to develop an ICF-CY Core Set for Oral Health - a holistic but practical tool for clinical and epidemiological use.

Functional priorities in daily life for children and young people with dystonic movement disorders and their families

PURPOSE

This study aims to describe the most prevalent functional concerns of a group of young people with dystonia and their primary carers, and to explore the relationship between concerns, aetiology, severity of motor disability and manual ability.

METHOD

The Canadian Occupational Performance Measure (COPM) was completed with 57 children with dystonic movement disorders (65% males/35% females, mean 11.2 years (3.5-18.1)): 25% had primary dystonia, 75% secondary dystonia. Gross motor and manual function were classified using the Gross Motor Function Classification System (GMFCS) and the Manual Ability Classification System (MACS). COPM concerns were analysed with respect to aetiology and severity of motor disability.

RESULTS

Almost three quarters of the respondents were GMFCS/MACS IV-V. All respondents had at least one concern around self-care. Other concerns included access to assistive technology, pain, dressing activities, use of tools and social participation. The nature and presence of concerns did not statistically differ according to the severity of gross motor or manual function impairment, though qualitative differences were noted. No statistical difference was found in relation to aetiology.

INTERPRETATION

Children and young people with dystonia have common functional concerns and priorities independent of the cause of dystonia, gross motor severity or manual function ability.

Predicting mental health among mothers of school-aged children with developmental disabilities: the relative contribution of child, maternal and environmental factors

AIM

Many mothers of children with developmental disabilities are known to experience high levels of stress, and compromised mental health. Research is crucial to better understand and assist mothers with compromised mental health, and ultimately better service families raising and supporting a child with a disability.

METHOD

Data were collected using cross sectional mail-out survey with follow up phone call. Instruments included the Short Form 36 version 2 (SF-36v2) and instruments that measured maternal, child and environmental factors. Descriptive statistics examined characteristics of participants. Correlation, t-tests, and multiple regression analyses were used to identify factors associated with mothers' mental health.

RESULTS

Mothers (N=152) cared for a school-aged child (aged 5-18 years) with high care needs and developmental disabilities including autism spectrum disorder (n=94); cerebral palsy (n=29); attention deficit hyperactivity disorder (n=19). Factors associated with maternal mental health included the child's psychosocial health (r=.36) and challenging behaviour (r=-.33); maternal empowerment (r=.40); maternal participation in health promoting activities (r=.43); and the child's unmet service needs (r=-.29). The strongest predictors of maternal mental health in this cross sectional study were maternal participation in healthy activity and empowerment, the child's emotional functioning and unmet service needs.

CONCLUSION

This study identified maternal factors as the most important influence on self reported mental health among this sample of mothers. Findings suggest that service changes that provide mothers with information about their own health and need for health enhancing activities, as well as education that empowers mothers to manage and master their child's disability and needs, may contribute to maternal mental health and well being.

Beyond the Burke-Fahn-Marsden Dystonia Rating Scale: deep brain stimulation in childhood secondary dystonia

PURPOSE

Deep brain stimulation is now widely accepted as an effective treatment for children with primary generalized dystonia. More variable results are reported in secondary dystonias and its efficacy in this heterogeneous group has not been fully elucidated. Deep brain stimulation outcomes are typically reported using impairment-focused measures, such as the Burke-Fahn-Marsden Dystonia Rating Scale, which provide little information about function and participation outcomes or changes in non-motor areas. The aim is to demonstrate that in some cases of secondary dystonia, the sole use of impairment level measures, such as the Burke-Fahn-Marsden Dystonia Rating Scale, may be insufficient to fully evaluate outcome following deep brain stimulation.

METHODS

Six paediatric cases who underwent deep brain stimulation surgery with a minimum of one year follow up were selected on the basis of apparent non-response to deep brain stimulation, defined as a clinically insignificant change in the Burke-Fahn-Marsden Dystonia Movement Scale (<20%), but where other evaluation measures demonstrated clinical efficacy across several domains.

RESULTS

Despite no significant change in Burke-Fahn-Marsden Dystonia Rating Scale scores following deep brain stimulation, parallel outcome measures demonstrated significant benefit in a range of child and family-centred goal areas including: pain and comfort, school attendance, seating tolerance, access to assistive technology and in some cases carer burden.

CONCLUSIONS

Sole use of impairment-focused measures, are limited in scope to evaluate outcome following deep brain stimulation, particularly in secondary dystonias. Systematic study of effects across multiple dimensions of disability is needed to determine what deep brain stimulation offers patients in terms of function, participation, care, comfort and quality of life. Deep brain stimulation may offer meaningful change across multiple domains of functioning, disability and health even in the absence of significant change in dystonia rating scales.

The 'F-words' in childhood disability: I swear this is how we should think!

The 21st century is witnessing a sea change in our thinking about 'disability'. Nowhere are these developments more apparent than in the field of childhood disability, where traditional biomedical concepts are being incorporated into--but expanded considerably by--new ways of formulating ideas about children, child development, social-ecological forces in the lives of children with chronic conditions and their families, and 'points of entry' for professionals to be helpful. In this paper, we have tried to package a set of ideas, grounded in the World Health Organization's International Classification of Functioning, Disability and Health (the ICF), into a series of what we have called 'F-words' in child neurodisability--function, family, fitness, fun, friends and future. We hope this will be an appealing way for people to incorporate these concepts into every aspect of clinical service, research and advocacy regarding disabled children and their families.

International Classification of Functioning, Disability and Health in children with cerebral palsy

PURPOSE

We intended to describe how concepts from recent models of disability have been studied for evaluation of children with cerebral palsy (CP) and their clinical implications.

METHOD

We revised studies that focused on the components of the International Classification of Functioning, Disability and Health (ICF) in children with CP.

RESULTS

Researchers have reported that children with CP exhibit impairments in various body functions/structures, limitations in functional activities performance and experience poorer participation outcomes than their typical peers. Moreover, it has been showed that participation of children with CP was affected by environmental factors.

CONCLUSION

Therefore, evaluation and rehabilitation processes should be focused on the quality of life improvement by emphasizing what a child can and wants to execute within the environment. Also, environmental factors should be recognized so that barriers could be minimized and adaptations to the environment achieved. However, few studies have verified the interrelationship between contextual factors and the functioning and disability domains in children with CP. This would allow us to know about approaches specifically designed for these children's needs.

Perfil cognitivo, déficits motores e influência dos facilitadores para reabilitação de crianças com disfunções neurológicas

OBJETIVO: Investigar se crianças e adolescentes saudáveis e com doenças neurológicas podem ser reunidas em grupos distintos e homogêneos, usando como critérios o desempenho cognitivo, o funcionamento motor e as percepções dos pais quanto aos facilitadores para a reabilitação. MÉTODOS: Participaram deste estudo 15 crianças saudáveis (C) e 43 pacientes (28 com paralisia cerebral e 15 com acidente vascular cerebral), entre cinco e 18 anos. Foi aplicado aos pais o instrumento denominado Avaliação dos Fatores Ambientais relacionados à Reabilitação Neurológica Infantil (AFARNI). O comprometimento cognitivo foi avaliado por meio do Mini-Exame do Estado Mental, adaptado para essa faixa etária, e o comprometimento motor foi investigado por avaliação clínica. Para comparar os resultados, foi realizada uma análise de conglomerados e ANOVA. RESULTADOS: A análise de conglomerados identificou quatro grupos de pacientes com características clínicas e sociodemográficas distintas, confirmados pela ANOVA (p<0,001). Houve dissociação entre os grupos com relação ao comprometimento cognitivo e motor. Os pais de crianças com maior comprometimento avaliaram de forma mais positiva os facilitadores para a reabilitação. CONCLUSÕES: A qualificação dos facilitadores para a reabilitação por meio da AFARNI e a avaliação cognitiva com auxílio do Mini-Exame do Estado Mental podem contribuir para identificar as necessidades de suporte para crianças com deficiências neurológicas que apresentam comprometimento cognitivo e motor.

Comparison of the GMFM-66 and the PEDI Functional Skills Mobility domain in a group of Chinese children with cerebral palsy

BACKGROUND

Previous research has suggested there is a high level of comparability between the Gross Motor Function Measure-66 (GMFM-66) and the Pediatric Evaluation of Disability Inventory (PEDI) Functional Skills Mobility domain. However, there are only a few studies that have examined the correlations between these instruments. The purpose of this study was to determine the correlation between the GMFM-66 and the PEDI Functional Skills Mobility domain scaled scores in a group of Chinese children with spastic cerebral palsy, at the ages of 12-70 months, in order to explore the feasibility of using them interchangeably.

METHODS

Secondary data analysis was conducted of data collected during a prospective international collaborative study that used the GMFM-66 and the PEDI to examine the impact of treatment. This study examined the Pearson correlations between the GMFM-66 and the PEDI Functional Skills Mobility domain at six time points over the course of 28 consecutive weeks for 115 Chinese children who participated at baseline.

RESULTS

Pearson correlations between the GMFM-66 and the PEDI Functional Skills Mobility domain ranged from 0.83 to 0.90 for the six time points of data collection, with statistically significant P-values <0.0001 for each correlation.

CONCLUSIONS

These results support previous research that the GMFM-66 and the PEDI Functional Skills Mobility domain are complementary assessments that may be used interchangeably when it is not possible to administer both.

A multivariate model of determinants of change in gross-motor abilities and engagement in self-care and play of young children with cerebral palsy

A multivariate model of determinants of change in gross-motor ability and engagement in self-care and play provides physical and occupational therapists a framework for decisions on interventions and supports for young children with cerebral palsy and their families. Aspects of the child, family ecology, and rehabilitation and community services may influence children's activity and participation. Aspects of the child include primary and secondary impairments, associated and comorbid health conditions, and adaptive behaviors. Literature support for the model is reviewed. A clinical scenario illustrates the use of the model as a framework for practice. The model encourages therapists to broaden the focus of rehabilitation services for young children with CP to include not only development of motor abilities but also comprehensive interventions and supports to enhance participation in daily activities and routines. Therapists are encouraged to consider how child, family, and service factors interact when planning interventions and evaluating outcomes.

Development of daily activities in school-age children with cerebral palsy

The purpose of this study was to describe the course of capabilities in self-care, mobility, and social function in school-age children with cerebral palsy (CP) and to investigate associations with CP-, child-, and family-characteristics. A clinic-based sample of children with CP (n = 116; 76 males, 40 females; mean age 6 y 3 mo, SD 12 mo) was followed longitudinally in three yearly measurements. Children's capabilities were assessed with the Pediatric Evaluation of Disability Inventory Functional Skills Scale (PEDI-FSS). Averaged for the total group, significant increases over time were shown in PEDI-FSS scores in all three domains. For self-care, the course was best predicted by a model including level of gross motor function (measured by the Gross Motor Function Classification System) and intellectual capacity (measured by Raven's Coloured Progressive Matrices). For mobility, the course was best predicted by a model containing only level of gross motor function. For social function, the course was best predicted by a model comprising level of bimanual function (measured by the Manual Ability Classification System) and paternal educational level. Generally, the increase in capabilities was greater if level of functioning was higher, except for level of paternal education. The findings indicate that there are different sets of determinants for the course of different domains of daily activities. Such different sets of determinants may help to set realistic expectations and to create appropriate treatment plans for different domains of daily activities in school-age children with CP.

Self-care and mobility skills in children with cerebral palsy, related to their manual ability and gross motor function classifications

AIM

The aim of this study was to investigate the acquisition of self-care and mobility skills in children with cerebral palsy (CP) in relation to their manual ability and gross motor function.

METHOD

Data from the Pediatric Evaluation of Disability Inventory (PEDI) self-care and mobility functional skill scales, the Manual Ability Classification System (MACS), and the Gross Motor Function Classification System (GMFCS) were collected from 195 children with CP (73 females, 122 males; mean age 8 y 1 mo; SD 3 y 11 mo; range 3-15 y); 51% had spastic bilateral CP, 36% spastic unilateral CP, 8% dyskinetic CP, and 3% ataxic CP. The percentage of children classified as MACS levels I to V was 28%, 34%, 17%, 7%, and 14% respectively, and classified as GMFCS levels I to V was 46%, 16%, 15%, 11%, and 12% respectively.

RESULTS

Children classified as MACS and GMFCS levels I or II scored higher than children in MACS and GMFCS levels III to V on both the self-care and mobility domains of the PEDI, with significant differences between all classification levels (p<0.001). The stepwise multiple regression analysis verified that MACS was the strongest predictor of self-care skills (66%) and that GMFCS was the strongest predictor of mobility skills (76%). A strong correlation between age and self-care ability was found among children classified as MACS level I or II and between age and mobility among children classified as GMFCS level I. Many of these children achieved independence, but at a later age than typically developing children. Children at other MACS and GMFCS levels demonstrated minimal progress with age.

INTERPRETATION

Knowledge of a child's MACS and GMFCS level can be useful when discussing expectations of, and goals for, the development of functional skills.

Applying the ICF framework to study changes in quality-of-life for youth with chronic conditions

OBJECTIVE

The objective of this paper is to describe how the ICF framework was applied as the foundation for a longitudinal study of changes in quality-of-life (QoL) for youth with chronic conditions.

METHOD

This article will describe the study's aims, methods, measures and data analysis techniques. It will point out how the ICF framework was used--and expanded upon--to provide a model for studying the impact of factors on changes in QoL for youth with chronic conditions. Further, it will describe the instruments that were chosen to measure the components of the ICF framework and the data analysis techniques that will be used to examine the impact of factors on changes in youths' QoL.

CONCLUSIONS

Qualitative and longitudinal designs for studying QoL based on the ICF framework can be useful for unraveling the complex ongoing inter-relationships among functioning, contextual factors and individuals' perceptions of their QoL.

The ICF model of functioning and disability: incorporating quality of life and human development

OBJECTIVE

Since its 2001 publication, a number of issues have been raised about the ICF. The World Health Organization anticipated the ICF would undergo a continuous process of revision. This paper adds to this process.

METHOD

This article describes how the ICF framework shares a number of tenets with a systems perspective. An argument is built for why the ICF model of functioning and disability should be expanded to include the concepts of quality of life and human development. A modified model is presented that depicts a person's life quality and his/her potential for development as the outcomes and processes that arise from the interconnected, ever-changing influences of health, functioning and contextual factors.

CONCLUSIONS

A modified ICF model based on a systems perspective depicts a holistic view that acknowledges health, functioning, life quality and development are intertwined and are essential concepts to consider in the lives of all people.

Change in basic motor abilities, quality of movement and everyday activities following intensive, goal-directed, activity-focused physiotherapy in a group setting for children with cerebral palsy

BACKGROUND

The effects of intensive training for children with cerebral palsy (CP) remain uncertain. The aim of the study was to investigate the impact on motor function, quality of movements and everyday activities of three hours of goal-directed activity-focused physiotherapy in a group setting, five days a week for a period of three weeks.

METHODS

A repeated measures design was applied with three baseline and two follow up assessments; immediately and three weeks after intervention. Twenty-two children with hemiplegia (n = 7), diplegia (n = 11), quadriplegia (n = 2) and ataxia (n = 2) participated, age ranging 3-9 y. All levels of Gross Motor Function Classification System (GMFCS) and Manual Ability Classification System (MACS) were represented. Parents and professionals participated in goal setting and training. ANOVA was used to analyse change over repeated measures.

RESULTS

A main effect of time was shown in the primary outcome measure; Gross Motor Function Measure-66 (GMFM-66), mean change being 4.5 (p < 0.01) from last baseline to last follow up assessment. An interaction between time and GMFCS-levels was found, implying that children classified to GMFCS-levels I-II improved more than children classified to levels III-V. There were no main or interaction effects of age or anti-spastic medication. Change scores in the Pediatric Evaluation of Disability Inventory (PEDI) ranged 2.0-6.7, p < 0.01 in the Self-care domain of the Functional Skills dimension, and the Self-care and Mobility domains of the Caregiver Assistance dimension. The children's individual goals were on average attained, Mean Goal Attainment Scaling (GAS) T-score being 51.3. Non-significant improved scores on the Gross Motor Performance Measure (GMPM) and the Quality of Upper Extremities Skills Test (QUEST) were demonstrated. Significant improvement in GMPM scores were found in improved items of the GMFM, not in items that maintained the same score.

CONCLUSIONS

Basic motor abilities and self-care improved in young children with CP after goal-directed activity-focused physiotherapy with involvement of their local environment, and their need for caregiver assistance in self-care and mobility decreased. The individualized training within a group context during a limited period of time was feasible and well-tolerated. The coherence between acquisition of basic motor abilities and quality of movement should be further examined.

The updated European Consensus 2009 on the use of Botulinum toxin for children with cerebral palsy

An interdisciplinary European group of clinical experts in the field of movement disorders and experienced Botulinum toxin users has updated the consensus for the use of Botulinum toxin in the treatment of children with cerebral palsy (CP). A problem-orientated approach was used focussing on both published and practice-based evidence. In part I of the consensus the authors have tabulated the supporting evidence to produce a concise but comprehensive information base, pooling data and experience from 36 institutions in 9 European countries which involves more than 10,000 patients and over 45,000 treatment sessions during a period of more than 280 treatment years. In part II of the consensus the Gross Motor Function Measure (GMFM) and Gross Motor Function Classification System (GMFCS) based Motor Development Curves have been expanded to provide a graphical framework on how to treat the motor disorders in children with CP. This graph is named "CP(Graph) Treatment Modalities - Gross Motor Function" and is intended to facilitate communication between parents, therapists and medical doctors concerning (1) achievable motor function, (2) realistic goal-setting and (3) treatment perspectives for children with CP. The updated European consensus 2009 summarises the current understanding regarding an integrated, multidisciplinary treatment approach using Botulinum toxin for the treatment of children with CP.

The relationship between spasticity in young children (18 months of age) with cerebral palsy and their gross motor function development

Background

It is thought that spasticity has an influence on the development of functional motor abilities among children with cerebral palsy (CP). The extent to which spasticity is associated with the change in motor abilities in young children with CP has not been established. The objective of this study is to evaluate the relationship of initial spasticity in young children with CP and their gross motor function development over one year.

Methods

Fifty children with CP aged 18 months, GMFCS-levels I-V participated in a longitudinal observational study. Change in gross motor functioning (GMFM-66) was measured over one year. The level of spasticity measured at the first assessment was determined with the Modified Tardieu Scale in three muscle groups of the lower extremity (adductor muscles, the hamstrings and the m. gastrocnemius). The Spasticity Total Score per child was calculated with a maximum score of 12 points.

Results

Spearman's Rho Correlation (-0.28) revealed a statistically significant relationship (p < 0.05) of small strength between the Spasticity Total Score and the change score of the GMFM-66.

Conclusion

Our findings indicate that when measured over one year, spasticity is marginally related to gross motor function development in infants with CP. The initial level of spasticity is only one of the many child, environmental and family factors that determines gross motor development of a young child with CP.

Development of the Assistance to Participate Scale (APS) for children's play and leisure activities

AIM

This paper describes the development and psychometric evaluation of the Assistance to Participate Scale (APS). The APS measures the assistance that a school-aged child with a disability requires to participate in play and leisure activities from the primary carer's perspective.

METHOD

Mixed methodology using an instrument design model was used to complete two studies. First, a qualitative research design was used to generate items and scoring criteria for the APS. Second, a quantitative study evaluated the instrument using data collected from 152 mothers with children aged 5-18 years. Statistical analysis assessed the underlying structure, internal consistency and construct validity of the APS.

RESULTS

Exploratory factor analysis revealed two correlated components, reflecting home-based and community-based play activities. Both subscales and the total APS scale showed good internal consistency. The APS correlated as predicted with individual domains and overall scores for other validated measures (Pediatric Evaluation of Disability Inventory caregiver scales and Pediatric Quality of Life Inventory) with correlations ranging from rho = 0.42 to rho = 0.77. The APS was able to discriminate between groups of children based on type of schooling (regular or segregated), need for equipment/assistive devices, frequency of lifting and disability.

CONCLUSIONS

The APS provides professionals with a brief psychometrically sound tool that measures the amount of caregiver assistance provided to a child with a disability to participate in play and recreation. The APS may be used as an outcome measure and to evaluate and predict the amount and type of additional assistance families need to facilitate their child's participation in an important aspect of the child's daily life and development: play and recreation.