Limb distribution, motor impairment, and functional classification of cerebral palsy

An association study of IL2RA polymorphisms with cerebral palsy in a Chinese population

Background

Cerebral palsy (CP), the most common physical disability of childhood, is a nonprogressive movement disorder syndrome. Eighty percent of cases are considered idiopathic without a clear cause. Evidence has shown that cytokine abnormalities are widely thought to contribute to CP.

Methods

An association between 6 SNPs (rs12244380, rs2025345, rs12722561, rs4749926, rs2104286 and rs706778) in IL2RA (interleukin 2 receptor subunit alpha) and CP was investigated using a case–control method based on 782 CP cases and 778 controls. The allele, genotype and haplotype frequencies of SNPs were assessed using the SHEsis program. Subgroup analyses based on complications and clinical subtypes were also conducted.

Results

Globally, no differences in genotype or allele frequencies for any SNPs remained significant after Bonferroni correction between patients and controls, except rs706778, which deviated from Hardy–Weinberg equilibrium and was excluded from further analyses. However, subgroup analysis revealed a significant association of rs2025345 with spastic tetraplegia (P genotype = 0.048 after correction) and rs12722561 with CP accompanied by global developmental delay (P allele = 0.045 after correction), even after Bonferroni correction.

Conclusions

These findings indicated that genetic variations in IL2RA are significantly associated with CP susceptibility in the Chinese Han population, suggesting that IL2RA is likely involved in the pathogenesis of CP. Further investigation with a larger sample size in a multiethnic population is needed to confirm the association.

At-Home Orthodontic Treatment for Severe Teeth Arch Malalignment and Severe Obstructive Sleep Apnea Syndrome in a Child with Cerebral Palsy

Children with cerebral palsy typically have severe teeth arch malalignment, causing swallowing and respiration dysfunction. Malalignment in cerebral palsy, especially in children, worsens dysphagia and respiratory disorders; sometimes, it is also noted with obstructive sleep apnea. However, no study has reported on the improvement in obstructive sleep apnea after at-home orthodontic treatment in children with cerebral palsy. We herein present a pediatric case of cerebral palsy wherein obstructive sleep apnea improved with at-home orthodontic treatment for malalignment. We administered at-home orthodontic treatment to a 15-year-old boy with quadriplegia, due to spastic-type cerebral palsy, having no oral intake, obstructive sleep apnea, and teeth arch malalignment. After treatment, a decline in the severity of sleep apnea was observed. Perioral muscle hypertension and oral intake difficulties cause maxillary protrusion, narrowed teeth arch, and tilting of teeth in children with cerebral palsy. We expanded the oral cavity volume by orthodontic treatment to relieve muscle hypertension and correct the tongue position, thereby remarkably improving obstructive sleep apnea. Our findings suggest that at-home orthodontic treatment for malalignment effectively improves perioral muscle hypertension, glossoptosis, and obstructive sleep apnea.

Early detection of Australian Aboriginal and Torres Strait Islander infants at high risk of adverse neurodevelopmental outcomes at 12 months corrected age: LEAP-CP prospective cohort study protocol

INTRODUCTION

Neurodevelopmental disorders (NDD), including cerebral palsy (CP), autism spectrum disorder (ASD) and foetal alcohol spectrum disorder (FASD), are characterised by impaired development of the early central nervous system, impacting cognitive and/or physical function. Early detection of NDD enables infants to be fast-tracked to early intervention services, optimising outcomes. Aboriginal and Torres Strait Islander infants may experience early life factors increasing their risk of neurodevelopmental vulnerability, which persist into later childhood, further compounding the health inequities experienced by First Nations peoples in Australia. The LEAP-CP prospective cohort study will investigate the efficacy of early screening programmes, implemented in Queensland, Australia to earlier identify Aboriginal and Torres Strait Islander infants who are 'at risk' of adverse neurodevelopmental outcomes (NDO) or NDD. Diagnostic accuracy and feasibility of early detection tools for identifying infants 'at risk' of a later diagnosis of adverse NDO or NDD will be determined.

METHODS AND ANALYSIS

Aboriginal and/or Torres Strait Islander infants born in Queensland, Australia (birth years 2020-2022) will be invited to participate. Infants aged <9 months corrected age (CA) will undergo screening using the (1) General Movements Assessment (GMA); (2) Hammersmith Infant Neurological Examination (HINE); (3) Rapid Neurodevelopmental Assessment (RNDA) and (4) Ages and Stages Questionnaire-Aboriginal adaptation (ASQ-TRAK). Developmental outcomes at 12 months CA will be determined for: (1) neurological (HINE); (2) motor (Peabody Developmental Motor Scales 2); (3) cognitive and communication (Bayley Scales of Infant Development III); (4) functional capabilities (Paediatric Evaluation of Disability Inventory-Computer Adaptive Test) and (5) behaviour (Infant Toddler Social and Emotional Assessment). Infants will be classified as typically developing or 'at risk' of an adverse NDO and/or specific NDD based on symptomology using developmental and diagnostic outcomes for (1) CP (2) ASD and (3) FASD. The effects of perinatal, social and environmental factors, caregiver mental health and clinical neuroimaging on NDOs will be investigated.

ETHICS AND DISSEMINATION

Ethics approval has been granted by appropriate Queensland ethics committees; Far North Queensland Health Research Ethics Committee (HREC/2019/QCH/50533 (Sep ver 2)-1370), the Townsville HHS Human Research Ethics Committee (HREC/QTHS/56008), the University of Queensland Medical Research Ethics Committee (2020000185/HREC/2019/QCH/50533) and the Children's Health Queensland HHS Human Research Ethics Committee (HREC/20/QCHQ/63906) with governance and support from local First Nations communities. Findings from this study will be disseminated via peer-reviewed publications and conference presentations.

TRIAL REGISTRATION NUMBER

ACTRN12619000969167.

Parent-Reported PEDI-CAT Mobility and Gross Motor Function in Infants With Cerebral Palsy

PURPOSE

The purpose of this study is to determine the relationship between the Pediatric Evaluation of Disability Index-Computer Adapted Test (PEDI-CAT), a parent-reported outcome measure, and therapist-administered measures of motor function for infants with cerebral palsy (CP) with moderate to severe motor impairments.

METHODS

A prospective, cohort study included 54 infants, ages 6 to 24 months, with CP or high risk of CP, Gross Motor Function Classification System (GMFCS) levels III to V. Measures included the Gross Motor Function Measure (GMFM) and the mobility domain of the PEDI-CAT (PEDI-mob).

RESULTS

A significant correlation was found between PEDI-mob and GMFM scores. Significant differences were found in PEDI-mob scores as a function of GMFCS level.

CONCLUSIONS

The PEDI-mob adds value to motor evaluations of infants with CP. Parents can accurately contribute information about daily motor performance for goal setting and treatment planning. The PEDI-mob offers a practical solution when longer assessments cannot be completed.

The Relationship between Parent-reported PEDI-CAT Mobility and Gross Motor Function in Children with Cerebral Palsy: Brief Report

Purpose: The PEDI-CAT mobility domain (PEDI-mob) is a parent-reported measure of mobility for children up to 21 years of age. The purpose of this research is to investigate the relationship between the PEDI-mob and Gross Motor Function Measure (GMFM)-66 and Gross Motor Function Classification Scale (GMFCS) levels.Methods: Fifty-seven children (N = 57), ages 2-8.8 years participated. PEDI-mob and GMFM were administered and GMFCS was confirmed during the same session. A Pearson correlation coefficient was calculated for PEDI-mob and GMFM-66 scores to evaluate the association between these two measures. An ANOVA was used to analyze PEDI-mob across GMFCS levels.Results: Large, statistically significant correlation was found between PEDI-mob and GMFM-66 scores (r = 0.894, p-value<0.001). Differences in PEDI-mob scores were found across GMFCS levels (p-value <0.001), where patients with higher GMFCS levels had lower PEDI-mob scores.Conclusion: These results support a strong relationship between parent-reported and clinically measured motor function.

Associations between impairments and activity limitations components of the international classification of functioning and the gross motor function and subtypes of children with cerebral palsy

[Purpose] Cerebral palsy (CP) encompasses a group of disorders of movement and posture with wide ranges of impairments, activity limitations and participation restrictions. Guiding management of children with CP by the ICF model is important to deliver quality services. This study aimed to explore relationship between CP subtypes and the Gross Motor Function Classification System-Expanded and Revised (GMFCS-E&R) and to examine differences in distribution of impairments and activity limitations across CP subtypes and GMFCS-E&R levels. [Participants and Methods] 70 children with CP (mean age: 6.5 ± 2.9 years) were classified using CP subtypes and GMFCS-E&R. Research assistants examined impairments including: scoliosis, scissoring, and inability to bear weight. Parents described their children’s transfers and functional mobility. [Results] CP subtypes and GMFCS-E&R levels were significantly associated. Scissoring and scoliosis were predominant in children in levels IV and V of the GMFCS-E&R. Only scoliosis was predominant in children with quadriplegia. Transfer activities and functional mobility were more limited in children with quadriplegia and in level V of the GMFCS-E&R. [Conclusion] Impairments and activity limitations components of the ICF can be differentiated by CP subtypes and GMFCS-E&R. Clinicians can use the two classification in providing comprehensive and individualized services for children with CP and their families.

Developmental Trajectories for the Early Clinical Assessment of Balance by Gross Motor Function Classification System Level for Children With Cerebral Palsy

BACKGROUND

Children with cerebral palsy (CP) characteristically present with impairments in balance. Currently, the pattern and timing of the development of balance ability have not been described for children with CP of varying Gross Motor Function Classification System (GMFCS) levels.

OBJECTIVE

The purpose of this study was to document longitudinal developmental trajectories in a measure of balance, the Early Clinical Assessment of Balance (ECAB) scores, along with age-specific reference percentiles and the amount of change typical over a 1-year period for children within different GMFCS levels.

DESIGN

The design was a longitudinal cohort study.

METHODS

Participants included 708 children with CP, aged 18 months through their 12th birthday, and their families. Children participated in 2 to 5 assessments using the GMFCS and ECAB.

RESULTS

Longitudinal trajectories describing the average change in the ECAB score with respect to age were created by fitting separate nonlinear mixed-effect models for children in each GMFCS level. Reference percentiles were constructed using quantile regression of ECAB data from the first visit (baseline) and 12-month and 24-month visits. Using these reference points, the amount of change in percentiles was calculated for all children by subtracting the baseline percentile score from the 12-month percentile score. Children whose percentile changes are within the 80% limits can usually be described as "developing as expected" for their age and GMFCS levels.

LIMITATIONS

Limitations of this study included use of a convenience sample, a ceiling effect of the ECAB for some children in GMFCS levels I and II, and the use of both a 12-month and 24-month study protocol that impacted the number of children available for each assessment session.

CONCLUSIONS

When used appropriately to monitor development and change over time for children with CP, the ECAB longitudinal trajectories, reference percentiles, and the associated change scores presented here should assist therapists and families in collaborative interaction to proactively plan services and interventions relative to balance ability.

An ultrasonographic analysis of the activation patterns of abdominal muscles in children with spastic type cerebral palsy and in typically developing individuals: a comparative study

Background

Abdominal muscles have stiffer appearance in individuals with spastic type cerebral palsy (STCP) than in their typically developing (TD) peers. This apparent stiffness has been implicated in pelvic instability, mal-rotation, poor gait and locomotion. This study was aimed at investigating whether abdominal muscles activation patterns from rest to activity differ in the two groups.

Method

From ultrasound images, abdominal muscles thickness during the resting and active stages was measured in 63 STCP and 82 TD children. The thickness at each stage and the change in thickness from rest to activity were compared between the two groups.

Results

Rectus abdominis (RA) muscle was the thickest muscle at rest as well as in active stage in both groups. At rest, all muscles were significantly thicker in the STCP children (p <  0.001). From rest to active stages muscle thickness significantly increased (p <  0.001) in the TD group and significantly decreased (p <  0.001) in the STCP children, except for RA, which became thicker during activity in both groups. In active stages, no significant differences in the thickness in the four abdominal muscles were found between the STCP and the TD children.

Conclusion

Apart from the RA muscle, the activation pattern of abdominal muscles in individuals with STCP differs from that of TD individuals. Further studies required for understanding the activation patterns of abdominal muscles prior to any physical fitness programmes aimed at improving the quality of life in individuals with STCP.

Trial registration

HREC REF: 490/2011. Human Research Ethics Committee, Faculty of Health Sciences, University of Cape Town, South Africa. November 17, 2011.

Factors affecting social participation of Iranian children with cerebral palsy

The purpose of this study was to identify the factors affecting the social participation of Iranian children with cerebral palsy (CP). Participants were 274 (male = 62%; female = 38%) children with CP, 6- to 12-years old (mean = 1.64) and their parents. Several standardized measures were used to assess social participation, gather environmental factors, and demographic questionnaires. The results of stepwise linear regression analysis indicated that the type of CP, Manual ability level and cognitive level (IQ) appear to be strong predictors of social participation between personal and environmental factors.

How Executive Functions Are Evaluated in Children and Adolescents with Cerebral Palsy? A Systematic Review

Aims: The aim of the present study was to examine how executive functions are assessed in children and adolescents with Cerebral Palsy.

Method: A systematic literature review was conducted using four bibliographic databases (WebScience, Scopus, PubMed, and Psycinfo), and only studies that evaluated at least one executive function were selected. Both the research and reporting of results were based on Cochrane's recommendations and PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) guidelines.

Results: The instrument most frequently used was the D-KEFS. All studies point to the existence of impairments in the executive functions among children and adolescents with Cerebral Palsy with an impact on several cognitive and life domains.

Interpretation: There is a need to further systematize the research protocols to study the executive functions and their assessment in the intervention context. Findings of this review presented a diversity of tests (e.g., D-KEFS) or tasks (e.g., The inhibitory ability task) used with children with Cerebral Palsy. However, no information was given about adaptations performed to the test/task to meet Cerebral Palsy's specificities. Future research could consider including this information, which is key both to researchers and practitioners. The results of this study have important implications and suggestions for future avenues and guidelines for research and practice.

REACH: study protocol of a randomised trial of rehabilitation very early in congenital hemiplegia

OBJECTIVES

Congenital hemiplegia is the most common form of cerebral palsy (CP). Children with unilateral CP show signs of upper limb asymmetry by 8 months corrected age (ca) but are frequently not referred to therapy until after 12 months ca. This study compares the efficacy of infant-friendly modified constraint-induced movement therapy (Baby mCIMT) to infant friendly bimanual therapy (Baby BIM) on upper limb, cognitive and neuroplasticity outcomes in a multisite randomised comparison trial.

METHODS AND ANALYSIS

150 infants (75 in each group), aged between 3 and 6 months ca, with asymmetric brain injury and clinical signs of upper extremity asymmetry will be recruited. Children will be randomised centrally to receive equal doses of either Baby mCIMT or Baby BIM. Baby mCIMT comprises restraint of the unimpaired hand using a simple restraint (eg, glove, sock), combined with intensive parent implemented practice focusing on active use of the impaired hand in a play-based context. In contrast, Baby BIM promotes active play requiring both hands in a play-based context. Both interventions will be delivered by parents at home with monthly home visits and interim telecommunication support by study therapists. Assessments will be conducted at study entry; at 6, 12 months ca immediately postintervention (primary outcome) and 24 months ca (retention). The primary outcome will be the Mini-Assisting Hand Assessment. Secondary outcomes include the Bayley Scale for Infant and Toddler Development (cognitive and motor domains) and the Hand Assessment of Infants. A subset of children will undertake MRI scans at 24 months ca to evaluate brain lesion severity and brain (re)organisation after intervention.

ETHICS AND DISSEMINATION

Full ethical approvals for this study have been obtained from the relevant sites. The findings will be disseminated in peer-reviewed publications.

TRIAL REGISTRATION NUMBER

Australian and New Zealand Clinical Trials Registry: ACTRN12615000180516, Pre results.

Impairments, activity limitations, and participation restrictions of the international classification of functioning, disability, and health model in children with ambulatory cerebral palsy

Objectives:

To examine the impairments, activity limitations, and participation restrictions in children with spastic unilateral and bilateral cerebral palsy (CP). We investigated the relationship between these factors according to the international classification of functioning, disability, and health (ICF) model.

Methods:

This prospective cross sectional study included 60 children aged between 4-18 years with spastic CP (30 unilateral, 30 bilateral involvement) classified as Levels I and II on the gross motor function classification system. Children had been referred to the Pediatric Rehabilitation Unit in the Department of Physiotherapy and Rehabilitation, Hacettepe University, Ankara, Turkey between March 2014 and March 2015. The Physician Rating scale was used to assess body functions and structures. The Gillette Functional Assessment Questionnaire 22-item skill set, Pediatric Functional Independence Measure, and Pediatric Outcomes Data Collection Instrument were used to assess activity and participation levels.

Results:

There was a significant positive correlation between impairments and activity limitations (r=0.558; p=0.000), as well as between activity limitations and participation restrictions (r=0.354, p=0.005).

Conclusion:

These results show that activity limitations in children with unilateral and bilateral ambulatory CP may be related to their impairments and participation restrictions, although the sample size of our study is not large enough for generalizations. Overall, our study highlights the need for up-to-date, practical evaluation methods according to the ICF model.

PREDICT-CP: study protocol of implementation of comprehensive surveillance to predict outcomes for school-aged children with cerebral palsy

OBJECTIVES

Cerebral palsy (CP) remains the world's most common childhood physical disability with total annual costs of care and lost well-being of $A3.87b. The PREDICT-CP (NHMRC 1077257 Partnership Project: Comprehensive surveillance to PREDICT outcomes for school age children with CP) study will investigate the influence of brain structure, body composition, dietary intake, oropharyngeal function, habitual physical activity, musculoskeletal development (hip status, bone health) and muscle performance on motor attainment, cognition, executive function, communication, participation, quality of life and related health resource use costs. The PREDICT-CP cohort provides further follow-up at 8-12 years of two overlapping preschool-age cohorts examined from 1.5 to 5 years (NHMRC 465128 motor and brain development; NHMRC 569605 growth, nutrition and physical activity).

METHODS AND ANALYSES

This population-based cohort study undertakes state-wide surveillance of 245 children with CP born in Queensland (birth years 2006-2009). Children will be classified for Gross Motor Function Classification System; Manual Ability Classification System, Communication Function Classification System and Eating and Drinking Ability Classification System. Outcomes include gross motor function, musculoskeletal development (hip displacement, spasticity, muscle contracture), upper limb function, communication difficulties, oropharyngeal dysphagia, dietary intake and body composition, participation, parent-reported and child-reported quality of life and medical and allied health resource use. These detailed phenotypical data will be compared with brain macrostructure and microstructure using 3 Tesla MRI (3T MRI). Relationships between brain lesion severity and outcomes will be analysed using multilevel mixed-effects models.

ETHICS AND DISSEMINATION

The PREDICT-CP protocol is a prospectively registered and ethically accepted study protocol. The study combines data at 1.5-5 then 8-12 years of direct clinical assessment to enable prediction of outcomes and healthcare needs essential for tailoring interventions (eg, rehabilitation, orthopaedic surgery and nutritional supplements) and the projected healthcare utilisation.

TRIAL REGISTRATION NUMBER

ACTRN: 12616001488493.

Overview of Four Functional Classification Systems Commonly Used in Cerebral Palsy

Cerebral palsy (CP) is the most common physical disability in childhood. CP comprises a heterogeneous group of disorders that can result in spasticity, dystonia, muscle contractures, weakness and coordination difficulty that ultimately affects the ability to control movements. Traditionally, CP has been classified using a combination of the motor type and the topographical distribution, as well as subjective severity level. Imprecise terms such as these tell very little about what a person is able to do functionally and can impair clear communication between providers. More recently, classification systems have been created employing a simple ordinal grading system of functional performance. These systems allow a more precise discussion between providers, as well as better subject stratification for research. The goal of this review is to describe four common functional classification systems for cerebral palsy: the Gross Motor Function Classification System (GMFCS), the Manual Ability Classification System (MACS), the Communication Function Classification System (CFCS), and the Eating and Drinking Ability Classification System (EDACS). These measures are all standardized, reliable, and complementary to one another.

Prevalence of Joint Gait Patterns Defined by a Delphi Consensus Study Is Related to Gross Motor Function, Topographical Classification, Weakness, and Spasticity, in Children with Cerebral Palsy

During a Delphi consensus study, a new joint gait classification system was developed for children with cerebral palsy (CP). This system, whose reliability and content validity have previously been established, identified 49 distinct joint patterns. The present study aims to provide a first insight toward the construct validity and clinical relevance of this classification system. The retrospective sample of convenience consisted of 286 patients with spastic CP (3-18 years old, GMFCS levels I-III, 166 with bilateral CP). Kinematic and kinetic trials from three-dimensional gait analysis were classified according to the definitions of the Delphi study, and one classified trial was randomly selected for each included limb (n = 446). Muscle weakness and spasticity were assessed for different muscle groups acting around the hip, knee, and ankle. Subsequently, Pearson Chi square tests, Cramer's V, and adjusted standardized residuals were calculated to explore the strength and direction of the associations between the joint patterns, and the different patient-specific characteristics (i.e., age, GMFCS level, and topographical classification) or clinical symptoms (muscle weakness and spasticity). Patient-specific characteristics showed several significant associations with the patterns of different joints, but the strength of most identified associations was weak. Apart from the knee during stance phase and the pelvis in the sagittal plane, the results systematically showed that the patterns with "minor gait deviations" were the most frequently observed. These minor deviations were found significantly more often in limbs with a lower level of spasticity and good muscle strength. Several other pathological joint patterns were moderately associated with weakness or spasticity, including but not limited to "outtoeing" for weakness and "intoeing" for spasticity. For the joints in the sagittal plane, significantly stronger associations were found with muscle weakness and spasticity, possibly because most of the evaluated muscles in this study mainly perform sagittal plane motions. Remarkably, the hip patterns in the coronal plane did not associate significantly with any of the investigated variables. Although further validation is warranted, this study contributes to the construct validity of the joint patterns of the Delphi consensus study, by demonstrating their ability to distinguish between clinically relevant subgroups in CP.

Perspectives on "Disease" and "Disability" in Child Health: The Case of Childhood Neurodisability

Chronic health conditions are often associated with what is termed disability. Traditional thinking has focused on diagnosis and treatment of chronic diseases and disorders, with less attention to people's functional abilities and their contextual determinants. Understanding all of these factors is integral to addressing the predicaments and needs of persons with chronic conditions. However, these complementary yet distinct "worldviews" reflected in what we call disease and disability perspectives often remain, at best, only vaguely articulated. In this paper, we explore and expand on these perspectives in light of conceptual advances, specifically the framework of the World Health Organization's International Classification of Functioning, Disability and Health, and their epistemic underpinnings with reference to Wilhelm Windelband's notions of nomothetic and idiographic types of knowledge. Our primary focus is the children with neurodisability - life-long conditions that onset early in life and have functional consequences that impact developmental trajectories. We critically review and analyze conceptual material, along with clinical and research evidence relevant to the experiential and clinical realities of this population, to demonstrate the limitations of a biomedically based diagnostic-therapeutic paradigm at the expense of a developmental and disability-oriented perspective. Our main aim in this paper is to argue for an explicit recognition of both disease and disability perspectives, and a more balanced and appropriate deployment of these concepts across the continuum of clinical services, research, policy-making and professional and public education in relation to children with neurodisability; we also provide concrete recommendations to advance this progressive strategy. The relevance of these aims and strategies, however, extends beyond this particular population.

Mental health problems in children with neuromotor disabilities

Mental health in children with neuromotor disorders is part of a dynamic system, including medical and developmental domains, family, school and community. Presentations are often complex and multifactorial, requiring a broad, individualized approach. A narrative overview of mental health symptoms in children with neuromotor disabilities is provided, along with recommendations for their assessment and management using the WHO's International Classification of Functioning framework.

Muscle Recruitment and Coordination following Constraint-Induced Movement Therapy with Electrical Stimulation on Children with Hemiplegic Cerebral Palsy: A Randomized Controlled Trial

Objective

To investigate changes of muscle recruitment and coordination following constraint-induced movement therapy, constraint-induced movement therapy plus electrical stimulation, and traditional occupational therapy in treating hand dysfunction.

Methods

In a randomized, single-blind, controlled trial, children with hemiplegic cerebral palsy were randomly assigned to receive constraint-induced movement therapy (n = 22), constraint-induced movement therapy plus electrical stimulation (n = 23), or traditional occupational therapy (n = 23). Three groups received a 2-week hospital-based intervention and a 6-month home-based exercise program following hospital-based intervention. Constraint-induced movement therapy involved intensive functional training of the involved hand during which the uninvolved hand was constrained. Electrical stimulation was applied on wrist extensors of the involved hand. Traditional occupational therapy involved functional unimanual and bimanual training. All children underwent clinical assessments and surface electromyography (EMG) at baseline, 2 weeks, 3 and 6 months after treatment. Surface myoelectric signals were integrated EMG, root mean square and cocontraction ratio. Clinical measures were grip strength and upper extremity functional test.

Results

Constraint-induced movement therapy plus electrical stimulation group showed both a greater rate of improvement in integrated EMG of the involved wrist extensors and cocontraction ratio compared to the other two groups at 3 and 6 months, as well as improving in root mean square of the involved wrist extensors than traditional occupational therapy group (p<0.05). Positive correlations were found between both upper extremity functional test scores and integrated EMG of the involved wrist as well as grip strength and integrated EMG of the involved wrist extensors (p<0.05).

Conclusions

Constraint-induced movement therapy plus electrical stimulation is likely to produce the best outcome in improving muscle recruitment and coordination in children with hemiplegic cerebral palsy compared to constraint-induced movement therapy alone or traditional occupational therapy.

Trial registration

chictr.org ChiCTR-TRC-13004041

Association between gross motor function and postural control in sitting in children with Cerebral Palsy: a correlational study in Spain

Background

Cerebral palsy (CP) is one of the causes of physical disability in children. Sitting abilities can be described using the Level of Sitting Scale (LSS) and the Gross Motor Function Classification System (GMFCS). There is growing interest in the sitting posture of children with CP owing to a stable sitting position allows for the development of eye-hand coordination, functions of the upper extremities and functional skills. Besides, in recent years researchers have tried to develop a new terminology to classify the CP as performed by the Surveillance of Cerebral Palsy in Europe (SCPE), in order to improve the monitoring of the frequency of the PC, providing a framework for research and service planning. The aim of this study was to analyse the relationship between GMFCS and LSS. The second purpose was to describe how the SCPE relates to sitting abilities with the GMFCS and LSS.

Methods

The study involved 139 children with CP (range 3–18 years) from 24 educational centres. Age, gender, CP classification according to SCPE, GMFCS and LSS levels were recorded by an experienced physiotherapist.

Results

A significant inverse relationship between GMFCS and LSS score levels was found (r_s = −0.86, p = 0.00). 45.3 % of the children capable of leaning in any direction and of re-erecting the trunk (level VIII on the LSS) could walk without limitation (level I on the GMFCS). There were differences in the distribution of the GMFCS (χ²(4):50.78) and LSS (χ²(7): 37.15) levels and CP according to the distribution of the spasticity (p <0.01).

Conclusions

There was a negative correlation between both scales and a relation between sitting ability and the capacity to walk with or without technical devices. GMFCS and the LSS are useful tools for describing the functional abilities and limitations of children with CP, specially sitting and mobility. Classification based on the distribution of spasticity and the gross motor function provides clinical information on the prognosis and development of children with CP.

Pathophysiology of muscle contractures in cerebral palsy

Patients with cerebral palsy present with a variety of adaptations to muscle structure and function. These pathophysiologic symptoms include functional deficits such as decreased force production and range of motion, in addition to changes in muscle structure such as decreased muscle belly size, increased sarcomere length, and altered extracellular matrix structure and composition. On a cellular level, patients with cerebral palsy have fewer muscle stem cells, termed satellite cells, and altered gene expression. Understanding the nature of these changes may present opportunities for the development of new muscle treatment therapies.

Caring for a child with Cerebral Palsy: The experience of Zimbabwean mothers

BACKGROUND

The needs of caregivers of children with disability may not be recognized despite evidence to suggest that they experience increased strain because of their care-giving role. This strain may be exacerbated if they live in under-resourced areas.

OBJECTIVES

We set out to establish the well-being of caregivers of children with Cerebral Palsy (CP) living in high-density areas of Harare, Zimbabwe. In addition, we wished to identify factors that might be predictive of caregivers' well-being. Finally, we examined the psychometric properties of the Caregiver Strain Index (CSI) within the context of the study.

METHOD

Caregivers of 46 children with CP were assessed twice, at baseline, and after three months, for perceived burden of care and health-related quality of life (HRQoL) using CSI and EQ-5D respectively. The psychometric properties of the CSI were assessed post hoc.

RESULTS

The caregivers reported considerable caregiver burden with half of the caregivers reporting CSI scores in the 'clinical distress' range. Many of the caregivers experienced some form of pain, depression and expressed that they were overwhelmed by the care-giving role. No variable was found to be associated with clinical distress. The CSI demonstrated good overall internal consistency (Cronbach's Alpha = 0.8), stability over time (Z = 0.87, p = 0.381) and was significantly and negatively correlated with the EQ-5D VAS (Spearman's rho = -0.33, p = 0.027), demonstrating concurrent validity.

CONCLUSION

Caregivers must be monitored routinely for their level of distress and there is an urgent need to provide them with support. The CSI is likely to be a valid measure of distress in this population.

Social Attitudes toward Cerebral Palsy and Potential Uses in Medical Education Based on the Analysis of Motion Pictures

This study presents how motion pictures illustrate a person with cerebral palsy (CP), the social impact from the media, and the possibility of cerebral palsy education by using motion pictures. 937 motion pictures were reviewed in this study. With the criteria of nondocumentary movies, possibility of disability classification, and availability, the total number of motion pictures about CP was reduced to 34. The geographical distribution of movie number ever produced is as follows: North America 12, Europe 11, India 2, East Asia 6, and Australia 3. The CP incidences of different motor types in real world and in movies, respectively, are 78–86%, 65% (Spastic); 1.5–6%, 9% (Dyskinetic); 6.5–9%, 26% (Mixed); 3%, 0% (Ataxic); 3-4%, 0% (Hypotonic). The CP incidences of different Gross Motor Function Classification System (GMFCS) levels in real world and in movies, respectively, are 40–51%, 47% (Level I + II); 14–19%, 12% (Level III); 34–41%, 41% (Level IV + V). Comparisons of incidence between the real world and the movies are surprisingly matching. Motion pictures honestly reflect the general public's point of view to CP patients in our real world. With precise selection and medical professional explanations, motion pictures can play the suitable role making CP understood more clearly.

Clinical profile, predisposing factors, and associated co-morbidities of children with cerebral palsy in South India

INTRODUCTION

Cerebral palsy (CP) is the most common physical disorder of children. Causes like jaundice and birth injury though are decreasing; complications resulting from the survival of low birth weight babies are replacing some of the older etiologies. Hence, this study was planned.

OBJECTIVES

The objective was to study the clinical patterns, predisposing factors, and co-morbidities in children with CP.

MATERIALS AND METHODS

The present study is a hospital based prospective study conducted from January 2012 to January 2013 in children presenting to neurodevelopmental clinic at a tertiary care teaching hospital in India. Hundred cases with clinical features suggestive of CP were included in the study. Cases were evaluated by history, clinical examination, and necessary investigations.

RESULTS

Results of the study showed 81% of spastic, 12% of hypotonic, 5% of dystonic, and 2% of mixed CP cases. The mean age of presentation was 2 year, 2 month, and male to female ratio of 1:2. Pregnancy-induced hypertension (PIH) was the most common antenatal complication observed in 6%. Four percent had neonatal sepsis and 19% were born premature. Associated co-morbidities were mental retardation (55%), seizure disorder (46%), visual problems (26%), hearing problems (19%), and failure to thrive (47%).

DISCUSSION

Sex distribution observed in our study was male to female ratio of 1.2, which was comparable with a multicenter study in Europe. PIH was observed in 6% of cases, which was comparable with prior studies. Birth asphyxia was observed in 43% of cases. Eighty-one percent of the cases constituted a spastic variety of CP which was comparable to other studies.

CONCLUSION

Perinatal asphyxia was the important etiological factor. We found preventable intranatal causes (60%) and antenatal causes (20%) forming a significant proportion. Co-morbidities were significantly observed in our study.

The impact of hospital-based and community based models of cerebral palsy rehabilitation: a quasi-experimental study

BACKGROUND

Cerebral palsy requires appropriate on-going rehabilitation intervention which should effectively meet the needs of both children and parents/care-givers. The provision of effective support is a challenge, particularly in resource constrained settings. A quasi-experimental pragmatic research design was used to compare the impact of two models of rehabilitation service delivery currently offered in Harare, Zimbabwe, an outreach-based programme and the other institution-based.

METHOD

Questionnaires were distributed to 46 caregivers of children with cerebral palsy at baseline and after three months. Twenty children received rehabilitation services in a community setting and 26 received services as outpatients at a central hospital. The Gross Motor Function Measurement was used to assess functional change. The burden of care was measured using the Caregiver Strain Index, satisfaction with physiotherapy was assessed using the modified Medrisk satisfaction with physiotherapy services questionnaire and compliance was measured as the proportion met of the scheduled appointments.

RESULTS

Children receiving outreach-based treatment were significantly older than children in the institution-based group. Regression analysis revealed that, once age and level of severity were controlled for, children in the outreach-based treatment group improved their motor function 6% more than children receiving institution-based services. There were no differences detected between the groups with regard to caregiver well-being and 51% of the caregivers reported signs consistent with clinical distress/depression. Most caregivers (83%) expressed that they were overwhelmed by the caregiving role and this increased with the chronicity of care. The financial burden of caregiver was predictive of caregiver strain. Caregivers in the outreach-based group reported greater satisfaction with services and were more compliant (p < .001) as compared to recipients of institution-based services.

CONCLUSION

Long term caregiving leads to strain in caregivers and there is a need to design interventions to alleviate the burden. The study was a pragmatic, quasi-experimental study thus causality cannot be inferred. However findings from this study suggest that the provision of care within a community setting as part of a well-structured outreach programme may be preferable method of service delivery within a resource-constrained context. It was associated with a greater improvement in functioning, greater satisfaction with services and better compliance.

Australian Cerebral Palsy Child Study: protocol of a prospective population based study of motor and brain development of preschool aged children with cerebral palsy

BACKGROUND

Cerebral palsy (CP) results from a static brain lesion during pregnancy or early life and remains the most common cause of physical disability in children (1 in 500). While the brain lesion is static, the physical manifestations and medical issues may progress resulting in altered motor patterns. To date, there are no prospective longitudinal studies of CP that follow a birth cohort to track early gross and fine motor development and use Magnetic Resonance Imaging (MRI) to determine the anatomical pattern and likely timing of the brain lesion. Existing studies do not consider treatment costs and outcomes. This study aims to determine the pathway(s) to motor outcome from diagnosis at 18 months corrected age (c.a.) to outcome at 5 years in relation to the nature of the brain lesion (using structural MRI).

METHODS

This prospective cohort study aims to recruit a total of 240 children diagnosed with CP born in Victoria (birth years 2004 and 2005) and Queensland (birth years 2006-2009). Children can enter the study at any time between 18 months to 5 years of age and will be assessed at 18, 24, 30, 36, 48 and 60 months c.a. Outcomes include gross motor function (GMFM-66 & GMFM-88), Gross Motor Function Classification System (GMFCS); musculoskeletal development (hip displacement, spasticity, muscle contracture), upper limb function (Manual Ability Classification System), communication difficulties using Communication and Symbolic Behaviour Scales-Developmental Profile (CSBS-DP), participation using the Paediatric Evaluation of Disability Inventory (PEDI), parent reported quality of life and classification of medical and allied health resource use and determination of the aetiology of CP using clinical evaluation combined with MRI. The relationship between the pathways to motor outcome and the nature of the brain lesion will be analysed using multiple methods including non-linear modelling, multilevel mixed-effects models and generalised estimating equations.

DISCUSSION

This protocol describes a large population-based study of early motor development and brain structure in a representative sample of preschool aged children with CP, using direct clinical assessment. The results of this study will be published in peer reviewed journals and presented at relevant international conferences.

TRIAL REGISTRATION

Australia and New Zealand Clinical Trials Register (ACTRN1261200169820).

Assessment of social function in four-year-old children with cerebral palsy

OBJECTIVE

To determine whether scores from the social function domain of the Paediatric Evaluation of Disability Inventory (PEDI) would reflect differences among speech-language profile groups for children with cerebral palsy (CP).

METHODS

Thirty-four children with CP participated (mean age = 54.4 months). PEDI social function raw scores, developmentally stratified skill levels, and types of skills mastered at a 75% criterion level were examined.

RESULTS

Significant differences were observed in social function scores overall and within early and age-appropriate skills among all profile groups with one exception. Skill mastery varied based on profile group and on developmental age category of each skill.

CONCLUSIONS

The PEDI appears to capture language delay in children with CP, but it may not be sensitive to the impact of speech intelligibility deficits on social function. Findings call for the development of a new tool that more accurately assesses communicative activities and participation in children with CP.

Inter-relationships of functional status in cerebral palsy: analyzing gross motor function, manual ability, and communication function classification systems in children

AIM

To investigate the relationships among the Gross Motor Function Classification System (GMFCS), Manual Ability Classification System (MACS), and Communication Function Classification System (CFCS) in children with cerebral palsy (CP).

METHOD

Using questionnaires describing each scale, mothers reported GMFCS, MACS, and CFCS levels in 222 children with CP aged from 2 to 17 years (94 females, 128 males; mean age 8 y, SD 4). Children were referred from pediatric developmental/behavioral, physiatry, and child neurology clinics, in the USA, for a case-control study of the etiology of CP. Pairwise relationships among the three systems were assessed using Spearman's correlation coefficients (r(s) ), stratifying by age and CP topographical classifications.

RESULTS

Correlations among the three functional assessments were strong or moderate. GMFCS levels were highly correlated with MACS levels (r(s) = 0.69) and somewhat less so with CFCS levels (r(s) = 0.47). MACS and CFCS were also moderately correlated (r(s) = 0.54). However, many combinations of functionality were found. Of the 125 possible combinations of the three five-point systems, 62 were found in these data.

INTERPRETATION

Use of all three classification systems provides a more comprehensive picture of the child's function in daily life than use of any one alone. This resulting functional profile can inform both clinical and research purposes.

Multilevel surgery improves gait in spastic hemiplegia but does not resolve hip dysplasia

BACKGROUND

Multilevel orthopaedic surgery may improve gait in Type IV hemiplegia, but it is not known if proximal femoral osteotomy combined with adductor release as part of multilevel surgery in patients with hip dysplasia improves hip development.

QUESTIONS/PURPOSES

We asked whether varus derotational osteotomy of the proximal femur, combined with adductor release, influenced hip development in patients with Type IV hemiplegia having multilevel surgery.

PATIENTS AND METHODS

We retrospectively reviewed 11 children and adolescents with Type IV hemiplegia who had a proximal femoral osteotomy due to unilateral hip displacement to correct gait dysfunction between 1999 and 2006. The mean age at the time of surgery was 11.1 years (range, 7 to 16 years). We obtained the Movement Analysis Profile and Gait Profile Score before and after surgery. We also measured the Migration Percentage of Reimers and applied the Melbourne Cerebral Palsy Hip Classification System (MCPHCS). The minimum followup was 2 years 3 months (mean, 6 years 6 months; range, 2 years 3 months to 10 years 8 months).

RESULTS

The majority of gait parameters improved but hip development was not normalized. According to the MCPHCS at last followup, no hips were classified as Grade I, two hips were classified as Grade II, and the remainder were Grade III and IV.

CONCLUSIONS

Unilateral surgery including a proximal femoral osteotomy improved gait and walking ability in individuals with spastic hemiplegic cerebral palsy. However, hip dysplasia persists.

LEVEL OF EVIDENCE

Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Longitudinal cohort protocol study of oropharyngeal dysphagia: relationships to gross motor attainment, growth and nutritional status in preschool children with cerebral palsy

INTRODUCTION

The prevalence of oropharyngeal dysphagia (OPD) in children with cerebral palsy (CP) is estimated to be between 19% and 99%. OPD can impact on children's growth, nutrition and overall health. Despite the growing recognition of the extent and significance of health issues relating to OPD in children with CP, lack of knowledge of its profile in this subpopulation remains. This study aims to investigate the relationship between OPD, attainment of gross motor skills, growth and nutritional status in young children with CP at and between two crucial age points, 18-24 and 36 months, corrected age.

METHODS AND ANALYSIS

This prospective longitudinal population-based study aims to recruit a total of 200 children with CP born in Queensland, Australia between 1 September 2006 and 31 December 2009 (60 per birth-year). Outcomes include clinically assessed OPD (Schedule for Oral Motor Assessment, Dysphagia Disorders Survey, Pre-Speech Assessment Scale, signs suggestive of pharyngeal phase impairment, Thomas-Stonell and Greenberg Saliva Severity Scale), parent-reported OPD on a feeding questionnaire, gross motor skills (Gross Motor Function Measure, Gross Motor Function Classification System and motor type), growth and nutritional status (linear growth and body composition) and dietary intake (3 day food record). The strength of relationship between outcome and exposure variables will be analysed using regression modelling with ORs and relative risk ratios.

ETHICS AND DISSEMINATION

This protocol describes a study that provides the first large population-based study of OPD in a representative sample of preschool children with CP, using direct clinical assessment. Ethics has been obtained through the University of Queensland Medical Research Ethics Committee, the Children's Health Services District Ethics Committee, and at other regional and organisational ethics committees. Results are planned to be disseminated in six papers submitted to peer reviewed journals, and presentations at relevant international conferences.

Aquatic exercise programs for children and adolescents with cerebral palsy: what do we know and where do we go?

Aquatic exercise programs may be a beneficial form of therapy for children and adolescents with cerebral palsy (CP), particularly for those with significant movement limitations where land-based physical activity is difficult. The most recently published systematic review (2005) on aquatic interventions in children with CP found supportive but insufficient evidence on its effectiveness. The aim of this paper is to review recently published literature since 2005 with a focus on aquatic exercise for children with CP. In total, six new studies were published with a main focus on aerobic aquatic interventions in higher functioning children and adolescents with CP. Swimming is one of the most frequently reported physical activities in children and adolescents with CP. Therefore, information on its safety and benefits is highly needed, for those with more severe CP in particular. Research design issues are discussed to help guide future research and practice.

Functional connectivity for somatosensory and motor cortex in spastic diplegia

Functional connectivity (fcMRI) was analyzed in individuals with spastic diplegia and age-matched controls. Pearson correlations (r-values) were computed between resting state spontaneous activity in selected seed regions (sROI) and each voxel throughout the brain. Seed ROI were centered on foci activated by tactile stimulation of the second fingertip in somatosensory and parietal dorsal attention regions. The group with diplegia showed significantly expanded networks for the somatomotor but not dorsal attention areas. These expanded networks overran nearly all topological representations in somatosensory and motor areas despite a sROI in a fingertip focus. A possible underlying cause for altered fcMRI in the group with dipegia, and generally sensorimotor deficits in spastic diplegia, is that prenatal third trimester white-matter injury leads to localized damage to subplate neurons. We hypothesize that intracortical connections become dominant in spastic diplegia through successful competition with diminished or absent thalamocortical inputs. Similar to the effects of subplate ablations on ocular dominance columns (Kanold and Shatz, Neuron 2006;51:627-638), a spike timing-dependent plasticity model is proposed to explain a shift towards intracortical inputs.

Perinatal Hypoxic-Ischemic Encephalopathy: epileptic and paretic outcome at one year of age

Background

The issue concerning neurologic outcome in patients with perinatal Hypoxic-Ischemic Encephalopathy (H.I.E) has inspired many studies which tried to identify adequate prognostic factors. Our work aims to find among neonatal parameters:

- factors which help to predict the risk to develop both Cerebral Palsy (CP) and secondary Epilepsy at one year of age in subjects affected by perinatal Hypoxic-Ischemic Encephalopathy,

- correlations between the neonatal parameters and the variable severity of above mentioned sequelae.

Methods

We have recruited 32 subjects, whose history and neuroimages suggested a perinatal H.I.E and we have retrospectively analysed clinical-instrumental parameters at birth and at one year of age.

Results

At one year cut-off, 9 patients developed both secondary epilepsy and CP (28%), whereas the other subjects showed only motor delay (31%), only secondary epilepsy (3%) or only CP (38%). Patients with both the severest sequelae were essentially term infants (only 2/9 were pre-term infants), with normal weight (only 3 LBW) and 7 of them with early pathologic EEG and neuroimages pointing out cortex injuries (typical of term infants). A statistic analysis showed the following correlations: birth weight and global prognosis (χ² = 14,03; p = 0,04); neonatal clinical pattern and CP's severity (χ² = 14,03; p = 0,0009); early EEG and CP's severity (χ² = 4,32; p = 0,04); epileptic onset age and CP and Epilepsy's severity (F = 16,01; p = 0,005).

Birth weight represented a predictive factor of early neurological outcome (<1,5 kg birth weight neonates are not at risk of both epilepsy and CP); neonatal clinical pattern and early EEG were correlated with variable severity of CP; an epileptic exordium in the first 6 months led up to a more severe epileptic and paretic outcome.

Conclusion

From a clinical point of view it is of crucial importance to have some parameters which enable to discriminate patients at risk of more severe sequelae from those at risk of moderate severity outcome.

Measuring global physical health in children with cerebral palsy: illustration of a multidimensional bi-factor model and computerized adaptive testing

PURPOSE

The purposes of this study were to apply a bi-factor model for the determination of test dimensionality and a multidimensional CAT using computer simulations of real data for the assessment of a new global physical health measure for children with cerebral palsy (CP).

METHODS

Parent respondents of 306 children with cerebral palsy were recruited from four pediatric rehabilitation hospitals and outpatient clinics. We compared confirmatory factor analysis results across four models: (1) one-factor unidimensional; (2) two-factor multidimensional (MIRT); (3) bi-factor MIRT with fixed slopes; and (4) bi-factor MIRT with varied slopes. We tested whether the general and content (fatigue and pain) person score estimates could discriminate across severity and types of CP, and whether score estimates from a simulated CAT were similar to estimates based on the total item bank, and whether they correlated as expected with external measures.

RESULTS

Confirmatory factor analysis suggested separate pain and fatigue sub-factors; all 37 items were retained in the analyses. From the bi-factor MIRT model with fixed slopes, the full item bank scores discriminated across levels of severity and types of CP, and compared favorably to external instruments. CAT scores based on 10- and 15-item versions accurately captured the global physical health scores.

CONCLUSIONS

The bi-factor MIRT CAT application, especially the 10- and 15-item versions, yielded accurate global physical health scores that discriminated across known severity groups and types of CP, and correlated as expected with concurrent measures. The CATs have potential for collecting complex data on the physical health of children with CP in an efficient manner.

An algorithm for identifying and classifying cerebral palsy in young children

OBJECTIVE

To develop an algorithm on the basis of data obtained with a reliable, standardized neurological examination and report the prevalence of cerebral palsy (CP) subtypes (diparesis, hemiparesis, and quadriparesis) in a cohort of 2-year-old children born before 28 weeks gestation.

STUDY DESIGN

We compared children with CP subtypes on extent of handicap and frequency of microcephaly, cognitive impairment, and screening positive for autism.

RESULTS

Of the 1056 children examined, 11.4% (120) were given an algorithm-based classification of CP. Of these children, 31% had diparesis, 17% had hemiparesis, and 52% had quadriparesis. Children with quadriparesis were 9 times more likely than children with diparesis (76% versus 8%) to be more highly impaired and 5 times more likely than children with diparesis to be microcephalic (43% versus 8%). They were more than twice as likely as children with diparesis to have a score <70 on the mental scale of the BSID-II (75% versus 34%) and had the highest rate of the Modified Checklist for Autism in Toddlers positivity (76%) compared with children with diparesis (30%) and children without CP (18%).

CONCLUSION

We developed an algorithm that classifies CP subtypes, which should permit comparison among studies. Extent of gross motor dysfunction and rates of co-morbidities are highest in children with quadriparesis and lowest in children with diparesis.

Cerebral palsy in a total population of 4-11 year olds in southern Sweden. Prevalence and distribution according to different CP classification systems

BACKGROUND

The aim of this study was to investigate the prevalence of cerebral palsy (CP) as well as to characterize the CP population, its participation in a secondary prevention programme (CPUP) and to validate the CPUP database.

METHODS

The study population was born 1990-1997 and resident in Skåne/Blekinge on Jan 1st 2002. Multiple sources were used. Irrespective of earlier diagnoses, neuropaediatrician and other professional medical records were evaluated for all children at the child habilitation units. The CPUP database and diagnosis registers at hospital departments were searched for children with CP or psychomotor retardation, whose records were then evaluated. To enhance early prevention, CP/probable CP was searched for also in children below four years of age born 1998-2001.

RESULTS

The prevalence of CP was 2.4/1,000 (95% CI 2.1-2.6) in children 4-11 years of age born in Sweden, excluding post-neonatally acquired CP. Children born abroad had a higher prevalence of CP with more severe functional limitations. In the total population, the prevalence of CP was 2.7/1,000 (95% CI 2.4-3.0) and 48% were GMFCS-level I (the mildest limitation of gross motor function). One third of the children with CP, who were born or had moved into the area after a previous study in 1998, were not in the CPUP database. The subtype classification in the CPUP database was adjusted in the case of every fifth child aged 4-7 years not previously reviewed.

CONCLUSION

The prevalence of CP and the subtype distribution did not differ from that reported in other studies, although the proportion of mild CP tended to be higher. The availability of a second opinion about the classification of CP/CP subtypes is necessary in order to keep a CP register valid, as well as an active search for undiagnosed CP among children with other impairments.

Association between gross motor function (GMFCS) and manual ability (MACS) in children with cerebral palsy. A population-based study of 359 children

Background

The Gross Motor Function Classification System (GMFCS) has become an important tool to describe motor function in children with Cerebral Palsy (CP). The Manual Ability Classification System (MACS) was developed recently as a corresponding classification of manual ability. The aim of this study was to describe the association between gross motor function and manual ability in a total population of children with cerebral palsy.

Methods

365 children, born 1992 to 2001, who were registered in a population-based health care programme (CPUP) for children with CP living in the south of Sweden were included in the study. GMFCS was evaluated by the child's physiotherapist and MACS by the occupational therapist. CP diagnosis and subtype were determined by the neuropaediatrician at or after the age of four.

Results

GMFCS levels were available in all 365 children, MACS levels in 359 (98%). There was a poor overall correlation between gross motor function and manual ability. However, different associations between gross motor function and manual ability were found in the different diagnostic subtypes. Children with spastic hemiplegia generally had a lower level of manual ability than gross motor function (p < 0.001). The reverse association was generally found in children with spastic diplegia (p < 0.001). Children with dyskinetic CP had large limitations in both gross motor function and manual ability, with no significant discrepancy between GMFCS and MACS levels.

Conclusion

Gross motor function and manual ability are often discrepant in children with CP, and the patterns seem to vary across the different subgroups based on the predominant neurological findings. To give a complete clinical picture when evaluating these children, both aspects have to be described. The GMFCS and the MACS seem to work well in this context and seem very useful in population-based studies, in health care registers for children with CP, and in clinical practice.

Cerebral palsy in Victoria: motor types, topography and gross motor function

OBJECTIVES

To study the relationships between motor type, topographical distribution and gross motor function in a large, population-based cohort of children with cerebral palsy (CP), from the State of Victoria, and compare this cohort to similar cohorts from other countries.

METHODS

An inception cohort was generated from the Victorian Cerebral Palsy Register (VCPR) for the birth years 1990-1992. Demographic information, motor types and topographical distribution were obtained from the register and supplemented by grading gross motor function according to the Gross Motor Function Classification System (GMFCS).

RESULTS

Complete data were obtained on 323 (86%) of 374 children in the cohort. Gross motor function varied from GMFCS level I (35%) to GMFCS level V (18%) and was similar in distribution to a contemporaneous Swedish cohort. There was a fairly even distribution across the topographical distributions of hemiplegia (35%), diplegia (28%) and quadriplegia (37%) with a large majority of young people having the spastic motor type (86%).

CONCLUSIONS

The VCPR is ideal for population-based studies of gross motor function in children with CP. Gross motor function is similar in populations of children with CP in developed countries but the comparison of motor types and topographical distribution is difficult because of lack of consensus with classification systems. Use of the GMFCS provides a valid and reproducible method for clinicians to describe gross motor function in children with CP using a universal language.