The Gross Motor Performance Measure: validity and responsiveness of a measure of quality of movement

The efficacy of Equine Assisted Therapy intervention in gross motor function, performance, and spasticity in children with Cerebral Palsy

Purpose

To evaluate the efficacy of Equine Assisted Therapy in children with Cerebral Palsy, in terms of gross motor function, performance, and spasticity as well as whether this improvement can be maintained for 2 months after the end of the intervention.

Methods

Children with Cerebral Palsy participated in this prospective cohort study. The study lasted for 28 weeks, of which the equine assisted therapy lasted 12 weeks taking place once a week for 30 min. Repeated measures within the subject design were used for the evaluation of each child's physical performance and mental capacity consisting of six measurements: Gross Motor Function Measure-88 (GMFM-88), Gross Motor Performance Measure (GMPM), Gross Motor Function Classification System (GMFCS), Modified Ashworth Scale (MAS) and Wechsler Intelligence Scale for Children (WISC III).

Results

Statistically significant improvements were achieved for 31 children in Gross Motor Function Measure and all its subcategories (p < 0.005), also in total Gross Motor Performance Measure and all subcategories (p < 0.005). These Gross Motor Function Measure results remained consistent for 2 months after the last session of the intervention. Regarding spasticity, although an improving trend was seen, this was not found to be statistically significant.

Conclusion and implications

Equine Assisted Therapy improves motor ability (qualitatively and quantitatively) in children with Cerebral Palsy, with clinical significance in gross motor function.

Gross motor function profile of children with cerebral palsy in a low-resource setting: A call for reflection on the model of care

PURPOSE

The current study aimed to explore Gross Motor Function Measure (GMFM) profiles among children with cerebral palsy (CP) at various Gross Motor Function Classification System (GMFCS) levels in a low-resource setting. Seventy-one ambulatory children with CP (61% males), were studied after signed informed consent was obtained from parents and assent from children older than 12 years.

METHODS

Ambulatory capacity of children with CP was classified using GMFCS levels. Functional ability of all participants was measured using GMFM-88.

RESULTS

Children with CP in a low-resource setting had 12-44% lower GMFM scores in dimensions of standing, walking, running, and jumping with reference to children from high-resource settings with similar ambulatory capacity reported previously. The most affected components across various GMFCS levels were 'sitting on a large and small bench from floor,' 'arm-free squatting,' 'half-kneeling,' 'kneel-walking,' and 'single-limb hop'.

CONCLUSION

Knowledge of GMFM profiles can guide clinicians and policymakers in low-resource settings for strategic rehabilitation planning and extend the focus of rehabilitation from restoration of body structure and function to the wider domain of social participation in leisure, sport, work, and the community at large. Additionally, providing tailored rehabilitation based on a profile of motor function can ensure an economically, environmentally, and socially sustainable future.

The Early Motor Questionnaire revisited: Starting points, standardized scores, and stability

Motor skills are an important aspect of development during infancy and have been found to predict development in other domains. Therefore, fast and reliable assessments of infant motor skills are needed. The current study revisited a time and cost-effective parent-report measure of infants' motor skills-the Early Motor Questionnaire (EMQ)-and aimed to improve the utility of the EMQ as a tool to examine variability, stability, and individual differences in early motor development. A sample of 446 parents of infants provided a total of 775 EMQ responses for analyses. Using this large sample, regression was used to create age-independent scores for global, gross motor, fine motor, and perception-action scores on the EMQ. Age-adjusted scores were then converted to t-scores to facilitate score interpretation for past and future studies using the EMQ. Finally, starting flags for different age groups were created to decrease the time it takes parents to complete the EMQ. Together, these changes to the EMQ will improve the utility and interpretability of the measure. The EMQ is free to use and available in the supplemental materials or via www.onlinebabylab.com/emq.

Protocol for The Toxin Study: Understanding clinical and patient reported response of children and young people with cerebral palsy to intramuscular lower limb Botulinum neurotoxin-A injections, exploring all domains of the ICF. A pragmatic longitudinal observational study using a prospective one-group repeated measures design

INTRODUCTION

Botulinum neurotoxin-A (BoNT-A) is an accepted treatment modality for the management of hypertonia in children and young people with cerebral palsy (CYPwCP). Nevertheless, there are concerns about the long-term effects of BoNT-A, with a lack of consensus regarding the most meaningful outcome measures to guide its use. Most evidence to date is based on short-term outcomes, related to changes at impairment level (restrictions of body functions and structures), rather than changes in adaptive skills (enabling both activity and participation). The proposed study aims to evaluate clinical and patient reported outcomes in ambulant CYPwCP receiving lower limb BoNT-A injections over a 12-month period within all domains of the WHO's International Classification of Functioning, Disability and Health and health-related quality of life (HRQoL).

METHODS AND ANALYSIS

This pragmatic prospective longitudinal observational study will use a one-group repeated measures design. Sixty CYPwCP, classified as Gross Motor Function Classification System (GMFCS) levels I-III, aged between 4 and 18 years, will be recruited from an established movement disorder service in London, UK. Standardised clinical and patient reported outcome measures within all ICF domains; body structures and function, activity (including quality of movement), goal attainment, participation and HRQoL, will be collected preinjection and at 6 weeks, 6 months and up to 12 months postinjection. A representative subgroup of children and carers will participate in a qualitative component of the study, exploring how their experience of BoNT-A treatment relates to clinical outcome measures.

ETHICS AND DISSEMINATION

Central London Research Ethics Committee has granted ethics approval (#IRAS 211617 #REC 17/LO/0579). Findings will be disseminated in peer-reviewed publications, conferences and via networks to participants and relevant stakeholders using a variety of accessible formats including social media.

Potentiation of cord blood cell therapy with erythropoietin for children with CP: a 2 × 2 factorial randomized placebo-controlled trial

Background

Concomitant administration of allogeneic umbilical cord blood (UCB) infusion and erythropoietin (EPO) showed therapeutic efficacy in children with cerebral palsy (CP). However, no clinical studies have investigated the effects of UCB and EPO combination therapy using a 2 × 2 four-arm factorial blinded design with four arms. This randomized placebo-controlled trial aimed to identify the synergistic and individual efficacies of UCB cell and EPO for the treatment of CP.

Methods

Children diagnosed with CP were randomly segregated into four groups: (A) UCB+EPO, (B) UCB+placebo EPO, (C) placebo UCB+EPO, and (D) placebo UCB+placebo EPO. Based on the UCB unit selection criteria of matching for ≥ 4/6 of human leukocyte antigen (HLA)-A, -B, and DRB1 and total nucleated cell (TNC) number of ≥ 3 × 10⁷/kg, allogeneic UCB was intravenously infused and 500 IU/kg human recombinant EPO was administered six times. Functional measurements, brain imaging studies, and electroencephalography were performed from baseline until 12 months post-treatment. Furthermore, adverse events were closely monitored.

Results

Eighty-eight of 92 children enrolled (3.05 ± 1.22 years) completed the study. Change in gross motor performance measure (GMPM) was greater in group A than in group D at 1 month (△2.30 vs. △0.71, P = 0.025) and 12 months (△6.85 vs. △2.34, P = 0.018) post-treatment. GMPM change ratios were calculated to adjust motor function at the baseline. Group A showed a larger improvement in the GMPM change ratio at 1 month and 12 months post-treatment than group D. At 12 months post-treatment, the GMPM change ratios were in the order of groups A, B, C, and D. These results indicate synergistic effect of UCB and EPO combination better than each single therapy. In diffusion tensor imaging, the change ratio of fractional anisotropy at spinothalamic radiation was higher in group A than group D in subgroup of age ≥ 3 years. Additionally, higher TNC and more HLA-matched UCB units led to better gross motor outcomes in group A. Adverse events remained unchanged upon UCB or EPO administration.

Conclusions

These results indicate that the efficacy of allogeneic UCB cell could be potentiated by EPO for neurological recovery in children with CP without harmful effects.

Trial registration

ClinicalTrials.gov, NCT01991145, registered 25 November 2013.

Reliability and responsiveness of virtual portion size creation tasks: Influences of context, foods, and a bariatric surgical procedure

Food portion size influences energy intake and sustained high-energy intake often leads to obesity. Virtual portion creation tasks (VPCTs), in which a participant creates portions of food on a computer screen, predict intake in healthy individuals. The objective of this study was to determine whether portions created in VPCTs are stable over time (test-retest reliability) and responsive to factors known to influence food intake, such as eating contexts and food types, and to determine if virtual portions can predict weight loss. Patients with obesity scheduled for bariatric surgery (n = 29), and individuals with a normal BMI (18.5-24.9 kg/m2, controls, n = 29), were instructed to create virtual portions of eight snack foods, which varied in energy density (low and high) and taste (sweet and salty). Portions were created in response to the following eating situations, or "contexts": What they would a) eat to stay healthy (healthy), b) typically eat (typical), c) eat to feel comfortably satisfied (satisfied), d) consider the most that they could tolerate eating (maximum), and e) eat if nothing was limiting them (desired). Tasks were completed before, and 3 months after, surgery in patients, and at two visits, 3 months apart, in controls. Body weight (kg) was recorded at both visits. Virtual portions differed significantly across groups, visits, eating contexts, energy densities (low vs. high), and tastes (sweet vs. salty). Portions created by controls did not change over time, while portions created by patients decreased significantly after surgery, for all contexts except healthy. For patients, desired and healthy portions predicted 3-month weight loss. VPCTs are replicable, responsive to foods and eating contexts, and predict surgical weight loss. These tasks could be useful for individual assessment of expectations of amounts that are eaten in health and disease and for prediction of weight loss.

Reliability of a New Clinical Gait Assessment Scale for Children with Idiopathic Toe Walking Gait - A Pilot Study

AIMS

Children with idiopathic toe walking (ITW) gait are increasingly referred to physical therapists. The purpose of this study was to evaluate the intra-rater and inter-rater reliability of the Clinical Gait Assessment Scale (CGAS), a newly developed observational rating scale.

METHODS

Four raters evaluated videos of four children. Foot, arm and head/trunk movement was scored as children walked over four surfaces. Intra-class correlation coefficients (ICC), model (3,k) were calculated to determine intra-rater and inter-rater reliability of each dependent variable.

RESULTS

The key findings of this study indicate robust intra- and inter-rater reliability, particularly of the foot (Inter-rater reliability, ICC (3,2)=0.9) and head and trunk (Inter-rater reliability, ICC (3,2)=1.0) subsections. Arm movements were more challenging to rate and showed moderate reliability (Inter-rater reliability, ICC (3,2)=0.7). Highest total impairment score; the highest value occurred while walking on the obstacle course (38 ± 29).

CONCLUSIONS

Overall, the CGAS showed adequate/acceptable reliability across different surfaces (linoleum, textured surface, narrow base, obstacle), however the obstacle surface was most challenging surface to the rater.

Outcome measures for children with movement disorders

The huge contribution of advances in the pediatric neurosciences, improvements in clinical practice, and new therapeutic options, has led to the development of new models of treatment and rehabilitation for dystonia in the last decade. It is now generally agreed that a multidimensional therapeutic approach is needed for children with motor disorders, whose motor function-conceived as a complex perceptive, motor and cognitive process - is impaired at a crucial time in their development, with a fall out on how their various adaptive functions evolve. Neurophysiological studies, modern neuroimaging techniques, and advances in cognitive psychology have all contributed to improving our understanding of the potential effects of treatments in early age - not only on the symptoms, but also on plasticity processes and neuronal reorganization. The International Classification of Functioning, Disability and Health (ICF) promoted by the WHO, and the diffusion of family-centered models of healthcare have underscored the importance of the ecological perspective with a view to providing effective therapies and a satisfactory quality of life for dystonic children and their families. The advances made in this area have made it necessary to study and develope more appropriate treatment outcome measures. In the light of these aspects, there is still not enough literature on the generally-accepted, exhaustive dystonia assessment tools. Given these limits, it might be useful to discuss the strengths and weaknesses of the main tools currently used in this setting.

Quality assessment of shoulder plyometric exercises: Examining the relationship to scapular muscle activity

OBJECTIVES

The purpose of the study was to evaluate performance quality of shoulder plyometric exercises, and examine the relationship to scapular muscle activation during an intense exercise bout.

DESIGN

Observational study.

SETTING

University laboratory.

PARTICIPANTS

32 healthy university students (male/female: 14/18) volunteers.

MAIN OUTCOME MEASURES

Subjects performed 10 plyometric exercises. Surface EMG of upper (UT), middle (MT) and lower (LT) trapezius and serratus anterior (SA) was registered. A quality assessment questionnaire was administered at the beginning and end of the exercise bout. Muscle activation at the beginning and end was evaluated by t-test. Mixed repeated measures ANOVA was conducted to test the effects of criterion-quality, time, muscles, exercises, and their interactions.

RESULTS

Increased EMG activation was noted in 34/40 cases, (21/40 significant (p < 0.05) changes). Quality assessment revealed a decline in the ability to maintain initial position (43% of subjects), failure to keep a consistent and symmetrical arc of motion (62% of subjects), and performance with trick movements (48% of subjects). Inability to keep a consistent arc of motion was significant in 4 exercises.

CONCLUSIONS

The novel questionnaire may aid quality assessment during plyometric exercises. Ability to keep a consistent arc of motion was the most sensitive marker of decline of performance quality.

The Stoplight Program: A Proactive Physical Therapy Intervention for Children With Acute Lymphoblastic Leukemia

Chemotherapy may cause neuromuscular impairments that can have life-long effects. The Stoplight Program (SLP) was developed as a proactive physical therapy (PT) intervention directed at impairments in children with acute lymphoblastic leukemia (ALL). In this program evaluation, we assessed the feasibility of the SLP delivered as part of standard care and identified body function and activity patterns in patients who received the intervention. Children ages 1 to 22 years, diagnosed with ALL, received an assessment by a physical therapist as part of usual care. The SLP intervention used 3 levels to categorize the impairment levels and intensity of PT. Of the children (n = 135) screened, 46% completed 5 intervention visits and 32% completed the program and met discharge criteria. At initial assessment, 46% of children ages 1 to 5 years and 67% of children ages 6 to 22 years had abnormal motor function. Those completing the program tested within the healthy norms. Research is needed on variables that influence adherence to a PT program and the range of functional impairment and activity limitations in this population.

Clinical tools designed to assess motor abilities in children with cerebral palsy

OBJECTIVE

This systematic review aimed to list the tools used by rehabilitation professionals to test motor abilities in children with cerebral palsy (CP), to determine if these tools have psychometric properties specifically measured for CP, and to identify the main characteristics of these tools.

METHOD

Web of Science, PEDro, PubMed/MEDLINE, Science Direct, and SciELO databases were searched to identify the tools. PubMed/MEDLINE was then searched to identify the studies assessing those tools' psychometric properties. The agreement-based standards for the selection of health measurement tools and the Terwee criteria were used to assess the quality and the results of each included study, respectively.

RESULTS

Eighteen tools were identified. The psychometric properties of many of the tools used with children with CP have not been evaluated for this population.

CONCLUSION

The psychometric properties evaluated often have a poor methodological quality of measurement. Overall, we suggest the tools with most empirical support to evaluate children with CP.

Clinical Trial of Erythropoietin in Young Children With Cerebral Palsy

This study was conducted to assess the safety and efficacy of recombinant human erythropoietin in young children with cerebral palsy aged between 6 months and 3 years. All participants received subcutaneous recombinant human erythropoietin and 8 weeks of rehabilitation therapy. Adverse events, changes of vital signs, and hematologic tests were monitored up to 8 weeks postinjection. Functional measures of development at 4 and 8 weeks postinjection were compared with baseline values, and improvements were compared with those of an age-matched historical control group. Nine participants completed the trial from June 2012 to February 2015. No adverse events were related to recombinant human erythropoietin. Erythropoiesis was noted, although within normal range. Functional improvements were observed in all participants (P < .05) and increases in motor function were higher in recombinant human erythropoietin group than the control group. Accordingly, recombinant human erythropoietin administration was safe without any significant adverse events and improved the functional outcomes in young children with cerebral palsy.

Description of Primary and Secondary Impairments in Young Children With Cerebral Palsy

PURPOSE

We describe primary and secondary impairments in young children with cerebral palsy (CP); report differences in impairments on the basis of Gross Motor Function Classification System (GMFCS), age, and sex; and examine the extent that individual impairments account for the construct of primary and secondary impairments.

METHODS

Participants included 429 children with CP (242 [56%] male; 1½ to 5 years) representing all GMFCS levels. Reliable assessors collected primary and secondary impairment data using clinical measures. Analyses included descriptive statistics, comparisons among GMFCS, age, and sex, and factor analysis.

RESULTS

Young children with CP present with primary and secondary impairments. Significant differences in impairments occur among some GMFCS levels and age groups but not sex groups. Postural stability contributed most to primary impairments and strength to secondary impairments.

CONCLUSION

Young children with CP across GMFCS levels may have already developed secondary impairments that should be addressed within therapy services.

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.

Clinimetric properties of sitting balance measures for children with cerebral palsy: a systematic review

Assessment of sitting balance in children and youth with cerebral palsy (CP) is critical in order to design appropriate interventions to enhance activities and participation. This systematic review synthesized research evidence on the reliability, validity, responsiveness to change, and clinical utility of sitting balance measures for children and youth with CP. A two-tiered search in August 2012 using nine peer-reviewed electronic databases yielded nine articles with relevant information on seven clinical measures. Four of seven clinical measures: the Pediatric Reach Test (PRT), Sitting Assessment for Children with Neuromotor Dysfunction (SACND), Segmental Assessment of Trunk Control (SATCo), and Trunk Control Measurement Scale (TCMS), demonstrate acceptable overall applicability (at least one study supporting clinical utility, reliability, and validity) and are thus recommended for use in practice. Ongoing research on responsiveness to change, however, is warranted to support validity for outcomes measurement.

Umbilical cord blood therapy potentiated with erythropoietin for children with cerebral palsy: a double-blind, randomized, placebo-controlled trial

Allogeneic umbilical cord blood (UCB) has therapeutic potential for cerebral palsy (CP). Concomitant administration of recombinant human erythropoietin (rhEPO) may boost the efficacy of UCB, as it has neurotrophic effects. The objectives of this study were to assess the safety and efficacy of allogeneic UCB potentiated with rhEPO in children with CP. Children with CP were randomly assigned to one of three parallel groups: the pUCB group, which received allogeneic UCB potentiated with rhEPO; the EPO group, which received rhEPO and placebo UCB; and the Control group, which received placebo UCB and placebo rhEPO. All participants received rehabilitation therapy. The main outcomes were changes in scores on the following measures during the 6 months treatment period: the gross motor performance measure (GMPM), gross motor function measure, and Bayley scales of infant development-II (BSID-II) Mental and Motor scales (18). F-fluorodeoxyglucose positron emission tomography (¹⁸F-FDG-PET/CT) and diffusion tensor images (DTI) were acquired at baseline and followed up to detect changes in the brain. In total, 96 subjects completed the study. Compared with the EPO (n = 33) and Control (n = 32) groups, the pUCB (n = 31) group had significantly higher scores on the GMPM and BSID-II Mental and Motor scales at 6 months. DTI revealed significant correlations between the GMPM increment and changes in fractional anisotropy in the pUCB group. ¹⁸F-FDG-PET/CT showed differential activation and deactivation patterns between the three groups. The incidence of serious adverse events did not differ between groups. In conclusion, UCB treatment ameliorated motor and cognitive dysfunction in children with CP undergoing active rehabilitation, accompanied by structural and metabolic changes in the brain. Stem Cells2013;31:581–591

Inter-rater Reliability of the K-GMFM-88 and the GMPM for Children with Cerebral Palsy

Objective

To examine inter-rater reliability of the Korean version Gross Motor Function Measure (K-GMFM-88) and the Gross Motor Performance Measure (GMPM) based on the video clips.

Method

We considered a sample of 39 children (28 boys and 11 girls; the mean age=3.50±1.23 years) with cerebral palsy (CP). Two pediatric physical therapists assessed the children based on video recordings.

Results

For the K-GMFM-88, the intraclass correlation coefficient (ICC_{3, 1}) ranged from .978 to .995, and Spearman's correlation coefficient ranged from .916 to .997. For the GMPM, ICC_{3, 1} ranged from .863 to .929, and Spearman's correlation coefficient ranged from .812 to .885. With the gross motor function classification system classified according to the functional level (GMFCS I-II vs. III-V), the ICCs were .982 and .994 for the K-GMFM-88 total score and .815 and .913 for the GMPM total score. There were good or high correlations between the subscales of the two measures (r=.762-.884).

Conclusion

The K-GMFM-88 and GMPM are reliable tools for assessing the motor function of children with CP. These two methods are highly correlated, which adds more reliability on them. Thus, it is advisable to use K-GMFM-88 and GMPM for children with CP to assess gross motor function.

Functional outcomes following single-event multilevel surgery of the upper extremity for children with hemiplegic cerebral palsy

BACKGROUND

Outcomes following single-event multilevel surgery of the upper extremity for children with cerebral palsy have not been well described in the literature. Since 1996, all children with hemiplegic cerebral palsy at our institution thought to be candidates for upper extremity surgery have had serial Shriners Hospital for Children Upper Extremity Evaluation performed for both clinical decision making and outcome assessment. The goal of the current study was to determine the functional outcomes, as described by the Shriners Hospital for Children Upper Extremity Evaluation, following single-event multilevel surgery of the upper extremity in children with hemiplegic cerebral palsy.

METHODS

The study design was a retrospective, case-control series. The case group consisted of forty children with hemiplegic cerebral palsy who underwent upper-extremity single-event multilevel surgery. The control group consisted of twenty-six children with hemiplegic cerebral palsy who had not received any upper-extremity interventions. The spontaneous functional analysis, dynamic positional analysis, and grasp-release analysis sections of the Shriners Hospital for Children Upper Extremity Evaluation were compared between the two groups.

RESULTS

The operative and nonoperative groups were comparable with respect to age (p = 0.09), sex (p = 0.97), initial spontaneous functional analysis scores (p = 0.37), dynamic positional analysis scores (p = 0.73), and grasp-release analysis scores (p = 0.16). For the single-event multilevel surgery group, significant improvements were noted for the mean spontaneous functional analysis score (p < 0.0001) and the mean dynamic positional analysis score (p < 0.0001), but not the mean grasp-release analysis score (p = 0.75). For the nonoperative control group, no significant changes were noted for the mean spontaneous functional analysis score (p = 0.89), the mean dynamic positional analysis score (p = 0.98), or the mean grasp-release analysis score (p = 0.36). Significant differences were noted between the single-event multilevel surgery and nonoperative control groups for the mean changes in the spontaneous functional analysis score (p = 0.01) and the mean change in the dynamic positional analysis score (p < 0.0001), but not the mean changes in the grasp-release analysis score (p = 0.56).

CONCLUSIONS

Children with hemiplegic cerebral palsy showed significantly improved dynamic segmental alignment and, to a lesser degree, spontaneous use of the upper extremity following single-event multilevel surgery compared with a comparable nonoperative control group. However, the grasp-release ability did not significantly improve in either the operative or nonoperative group.

Development of a challenge assessment tool for high-functioning children with an acquired brain injury

PURPOSE

To develop a performance-based challenge assessment to evaluate gross motor abilities of high-functioning youth with an acquired brain injury (ABI).

METHODS

Potential items were identified from the literature. A panel of 4 expert physical therapists selected items on the basis of 3 criteria: safety to test, feasibility to administer, and importance to perform. Item reduction was completed using ratings from a physical therapist web survey. The Acquired Brain Injury-Challenge Assessment (ABI-CA) was created and pilot tested with youth with an ABI.

RESULTS

Seventy-eight items were identified and reduced to 47 items following expert panel discussion. Web-survey item reduction by 75 pediatric physical therapists yielded a 24-item ABI-CA that was administered to 6 youth with an ABI, aged 8 to 17 years. The ABI-CA mean score was 50.7/81.0 (SD = 17.4).

CONCLUSION

The ABI-CA was feasible to administer and demonstrated gross motor activity challenges beyond the Gross Motor Function Measure. Response option refinement and measure validation are required prior to clinical/research use.

Effects of intensive physiotherapy in infants newly diagnosed with cerebral palsy

PURPOSE

This study was designed to examine effects of blocks of daily physiotherapy in 5 infants with cerebral palsy.

METHODS

A single-subject design was used. Intervention consisted of two 4-week periods of daily physiotherapy, interrupted by 8 weeks of physiotherapy as usual. The children were assessed every 4th week using the Gross Motor Function Measure. Results were visually analyzed, and statistical significance of Gross Motor Function Measure-66 scores was established with the 2 SD band method.

RESULTS

Compliance was high. All infants showed gross motor progress compared with baseline, but separating effect of daily physiotherapy from physiotherapy as usual was inconclusive. Parents preferred the intensive treatment alternative.

CONCLUSION

Blocks of intensive therapy can be an alternative to regular dosage of physiotherapy, but until further studies are conducted, the physiotherapy intervention, intensity, and frequency should be tailored to meet the needs of each individual infant and family.

The exercise redox paradigm in the Down's syndrome: improvements in motor function and increases in blood oxidative status in young adults

Considerable evidence has indicated a pro-oxidant status in the brain of people with Down's syndrome (DS), which may contribute to motor and cognitive impairments verified in this condition. On the other hand, previous studies addressing the role of physical exercise on oxidative stress and antioxidant status in DS have indicated conflicting results. Here, we investigated the effects of a supervised judo training of controlled intensity and monitored on the basis of lactate threshold on the blood oxidative stress status and motor coordination in 21 young adults with DS. The training extended over a period of 16 weeks and consisted of three sessions per week. The exercise improved the motor function and significantly decreased lactate production in the DS subjects. However, blood markers of oxidative damage to lipids (TBARS and lipid peroxides) and proteins (carbonyls) were increased by the judo training. Moreover, superoxide dismutase and catalase activity also increased, while glutathione peroxidase activity remained unaltered after exercise. These results reinforce the notion that physical exercise can improve motor disabilities in people with DS. More importantly, our findings demonstrate that the beneficial effects are accompanied by some degree of oxidative stress, suggesting that young adults with DS may be more susceptible to physical training-induced oxidative stress than adolescents with DS, which should be taken into account in physical training programs for this population.

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

Rehabilitation increasingly addresses the International Classification of Functioning, Disability and Health's (ICF) concepts of activity and participation, but little is known about associations between changes in body functions and structures, activity, and participation. We conducted a before-and-after study of 35 ambulatory children with spastic diplegia or hemiplegic cerebral palsy, mean age 5 years 6 months (SD 2 y 2 mo). Children were in Gross Motor Function Classification System (GMFCS) Levels I (n=11), II (n=12), or III (n=12). We assessed body functions and structures, activity, and participation at baseline and at 2 months and 6 months post-botulinum toxin type A (BoNT-A) injection. Repeated-measures analysis of variance evaluated change, and linear regression assessed relationships. Baseline score relationships were moderate to strong but, despite similar directions of change at 2 months, change score relationships between measures of body functions and structures (spasticity and timed walk), activity (Gross Motor Function Measure and Pediatric Evaluation of Disability Inventory), and participation (Pediatric Outcomes Data Collection Instrument) at 2 months and 6 months were poor to fair (r<0.40). Predictor combinations accounted for <69% of variation in activity and participation change scores. Predictors often pertained to baseline score, GMFCS level, or age. Relationships between changes at different ICF levels are complex, and activity and participation gains post-BoNT-A are likely to be influenced by the child and environment factors.

Observer reliability of the Gross Motor Performance Measure and the Quality of Upper Extremity Skills Test, based on video recordings

The aim of this study was to examine observer reliability of the Gross Motor Performance Measure (GMPM) and the Quality of Upper Extremity Skills Test (QUEST) based on video clips. The tests were administered to 26 children with cerebral palsy (CP; 14 males, 12 females; range 2-13y, mean 7y 6mo), 24 with spastic CP, and two with dyskinesia. Respectively, five, six, five, four, and six children were classified in Gross Motor Function Classification System Levels I to V; and four, nine, five, five, and three children were classified in Manual Ability Classification System levels I to V. The children's performances were recorded and edited. Two experienced paediatric physical therapists assessed the children from watching the video clips. Intraobserver and interobserver reliability values of the total scores were mostly high, intraclass correlation coefficient (ICC)(1,1) varying from 0.69 to 0.97 with only one coefficient below 0.89. The ICCs of subscores varied from 0.36 to 0.95, finding'Alignment'and'Weight shift'in GMPM and'Protective extension'in QUEST highly reliable. The subscores'Dissociated movements'in GMPM and QUEST, and'Grasp'in QUEST were the least reliable, and recommendations are made to increase reliability of these subscores. Video scoring was time consuming, but was found to offer many advantages; the possibility to review performance, to use special trained observers for scoring and less demanding assessment for the children.

An evaluation of the responsiveness of a comprehensive set of outcome measures for children and adolescents with traumatic brain injuries

The relative responsiveness of nine outcome measure scales was evaluated with 33 children and adolescents (aged 4-18 years) who had sustained traumatic brain injuries. Scales were selected to evaluate outcomes from each of the World Health Organization (WHO) International Classification of Functioning, Disability and Health domains. The outcome measures were administered to all participants during their inpatient rehabilitation stay and again at a follow-up clinic visit. No single outcome measure captured the diversity of improvement in this sample. The measures agreed that improvement had occurred, but did not agree about which children were improving. This result suggests that the scales were measuring different skills and outcomes. Three of the measures used in combination, either the Child Health Questionnaire or the Functional Independence Measure for Children, the American Speech-Language-Hearing Association National Outcome Measures System (Birth to Kindergarten NOMS/School-aged Health Care) and the Gross Motor Function Measure, are sufficient to detect change in each of the children where change occurred. The Pediatric Evaluation of Disability Inventory and the MultiAttribute Health Status Classification were the least responsive of the nine measures used.

Adaptive downhill skiing in children with cerebral palsy: effect on gross motor function

PURPOSE

The study was designed to examine the effect of adaptive downhill skiing (ADS) on gross motor function in children with spastic cerebral palsy.

METHODS

One girl and four boys participated (mean age = eight years, five months). All were ambulatory. Participants' Gross Motor Function Measure (GMFM) classifications were: Level I (n = 2); Level II (n = 2); Level III (n = 1). ADS was conducted for a 10-week period at one ski resort. Each participant had the same ski instructor. GMFM was obtained every five weeks: beginning five weeks before ADS instruction and continuing to 10 weeks after ADS instruction.

RESULTS

After 10 weeks of ADS GMFM-D, and GMFM-Total Score increased 5.4% (p = 0.022) and 3.2% (p = 0.035), respectively, and remained increased 10 weeks after ADS.

CONCLUSION

ADS could be recommended by clinicians as a recreational activity for the gross motor rehabilitation of ambulatory children with spastic cerebral palsy.

Relation Between Cognitive and Motor Performance in 5- to 6-Year-Old Children: Results From a Large-Scale Cross-Sectional Study

The relation between cognitive and motor performance was studied in a sample of 378 children aged 5-6. Half of these children had no behavior problems; the others were selected for externalizing (38%) or internalizing problems (12%). Quantitative and qualitative aspects of motor performance were related to several aspects of cognition, after controlling for the influence of attention. No relation between global aspects of cognitive and motor performance was found. Specific positive relations were found between both aspects of motor performance, visual motor integration and working memory, and between quantitative aspects of motor performance and fluency. These findings reveal interesting parallels between normal cognitive and motor development in 5- to 6-year-old children that cannot be ascribed to attention processes.

Exploring the comparative responsiveness of a core set of outcome measures in a school-based conductive education programme

BACKGROUND

Conductive education (CE) is a holistic educational system that uses an active cognitive approach to teach individuals with motor disorders to become more functional participants in daily activities. While CE's popularity continues to grow in North America and Europe, its effectiveness has not been established. The lack of definition of responsive outcome measures for evaluation of CE programmes has limited the interpretability of conclusions from earlier studies evaluating effectiveness.

OBJECTIVE

To determine which measures from a core set were most responsive to physical, functional and psychosocial changes associated with a school-based CE programme.

METHODS

This was a one-group before and after data collection design using an 8-month follow-up period. We enrolled a referral sample of nine children with cerebral palsy in Kindergarten or Grade 1 (Gross Motor Function Classification System levels 3, 4 or 5). The study took place within a school-based CE programme at a Canadian children's rehabilitation centre. Children participated in a CE full-day class for an entire school year. Physical, functional, psychosocial and participation measures included: Gross Motor Function Measure (GMFM), Quality of Upper Extremity Skills Test (QUEST), Peabody Developmental Motor Scales, Paediatric Evaluation of Disability Inventory (PEDI), Pictorial Scale of Perceived Competence and Social Acceptance for Young Children, Individualized Educational Plan, and Goal Attainment Scaling (GAS). Four children from the study's second year were also evaluated on the Impact on Family Scale (IFS), GAS and School Function Assessment.

RESULTS

The Gross Motor Function Measure, QUEST, PEDI (Caregiver Assistance) and IFS were most responsive to change. GAS was useful in documenting and quantifying goals. Problems were encountered in evaluating self-esteem and school participation.

CONCLUSIONS

Several strong measures of outcome were identified. Further work is needed to find valid and sensitive psychosocial and school participation measures for these young children.

Assessment of motor development and function in preschool children

The process of identification of children with delays or disorders in motor development includes developmental screening, examination, and reexamination. Throughout this process, various types of measures are used, including discriminative and evaluative measures. Discriminative and evaluative measures of motor development and function that are commonly used for preschool-aged children include the Bayley Scales of Infant Development II, Peabody Developmental Motor Scales, 2nd edition, Toddler and Infant Motor Evaluation, Pediatric Evaluation of Disability Inventory, and Gross Motor Function Measure. Selecting an appropriate measure is a crucial part of the examination process and should be geared toward the purpose of testing and characteristics of the child. Evidence of reliability and validity are important considerations for selection of a measure.

Cerebral palsy

Cerebral palsy, a range of non-progressive syndromes of posture and motor impairment, is a common cause of disability in childhood. The disorder results from various insults to different areas within the developing nervous system, which partly explains the variability of clinical findings. Management options include physiotherapy, occupational and speech therapy, orthotics, device-assisted modalities, pharmacological intervention, and orthopaedic and neurosurgical procedures. Since 1980, modification of spasticity by means of orally administered drugs, intramuscular chemodenervation agents (alcohol, phenol, botulinum toxin A), intrathecally administered drugs (baclofen), and surgery (neurectomy, rhizotomy) has become more frequent. Family-directed use of holistic approaches for their children with cerebral palsy includes the widespread adoption of complementary and alternative therapies; however, the prevalence of their use and the cost of these options are unknown. Traditional medical techniques (physiotherapy, bracing, and orthopaedic musculoskeletal surgery) remain the mainstay of treatment strategies at this time. This seminar addresses only the musculoskeletal issues associated with cerebral palsy and only indirectly discusses the cognitive, medical, and social issues associated with this diagnosis.

Selective dorsal rhizotomy versus orthopedic surgery: a multidimensional assessment of outcome efficacy

OBJECTIVE

To compare the efficacy of selective dorsal rhizotomy (SDR) and orthopedic surgery using multidimensional (National Center for Medical Rehabilitation Research disablement framework) outcome measures.

DESIGN

Prospective outcome study.

SETTING

Pediatric orthopedic hospital.

PARTICIPANTS

Twenty-five children with spastic diplegia. Eighteen participants (mean age, 71.3 mo) chose SDR. Seven participants (mean age, 78.6 mo) chose orthopedic surgery.

INTERVENTIONS

Children were evaluated 2 days before surgical intervention and at 6 months, 1 year, and 2 years postsurgically.

MAIN OUTCOME MEASURES

The Gross Motor Performance Measure, the Gross Motor Function Measure, and the Pediatric Evaluation of Disability Inventory.

RESULTS

The SDR group improved significantly in quality of movement attributes 6 months postsurgically; however, gross motor skills (standing; walking, running, and jumping) gains were seen 2 years postsurgically. The orthopedic group improved significantly in select quality of movement attributes 6 months postsurgically and in standing skills within the first postsurgical year. Self-care skills, mobility, and social function gains were seen earlier and with greater frequency in the SDR group.

CONCLUSIONS

Both surgical interventions demonstrated multidimensional benefits for ambulatory children with spastic diplegia. The results suggest that qualitative changes in movement, achieved by spasticity reduction, have a greater effect on the enhancement of functional skill proficiency, thus independence, than recognized.

Controversial treatment of spasticity: exploring alternative therapies for motor function in children with cerebral palsy

The treatment and management of children with cerebral palsy is an ever-evolving story. In the past 20 years, a number of exciting innovations in treatment have expanded the opportunities to help children. At the same time, the field has experienced a remarkable proliferation of "alternative" therapies-approaches based on ideas about the biologic basis of neurodevelopmental disabilities and their management that differ considerably from conventional thinking in Western medicine. Professionals working with children with cerebral palsy and their families are frequently asked for an opinion about or even endorsement of these new and "promising" approaches to therapy. These can be very difficult to provide when the evidence is limited, peer-reviewed reports are scarce, and the primary source of information is the World Wide Web. The purposes of this article are to discuss briefly why it can be difficult to ascertain whether any treatment--conventional or alternative--does more harm than good, and to consider what rules of evidence can be applied to make a sound judgment about a new treatment. The article then discusses several current controversial alternative therapies, reviewing the available literature and offering a critical appraisal of each. Topics addressed include hyperbaric oxygen therapy, conductive education, the Adeli suit, and therapeutic (subthreshold) electrical stimulation because these approaches have been applied to children with cerebral palsy.

Agreement between physiotherapists on quality of movement rated via videotape

BACKGROUND

Although achieving quality of movement after stroke is an important aim of physiotherapy it is rarely measured objectively or described explicitly.

OBJECTIVE

To test whether physiotherapists agree on a composite measure of quality of movement. SETTING; A movement analysis laboratory

SUBJECTS

Ten stroke patients and 10 healthy age-matched volunteers.

DESIGN

Prospective correlational.

PROCEDURE

All subjects were videofilmed performing three trials of six standardized functional tasks. Two videotapes were made, each with a different randomized order of appearance of the trials. Ten senior physiotherapists independently rated the videotapes twice using a 100-mm visual analogue scale.

ANALYSIS

Analysis of variance models were fitted to transformed data. Estimates of components of variance were calculated and presented as a percentage of the total variance for differences, within subjects (intra-subject), between raters (inter-rater) and within raters (intra-rater). An acceptable percentage was set at less than 10%.

RESULTS

The percentage of intra-subject variance ranged from 1% (pick up box and walking) to 9% (step on block). The percentage of inter-rater variance ranged from 18% (pick up pencil) to 38% (sit to stand). The percentage of intra-rater variance was less than 1% for all tasks.

CONCLUSIONS

Although physiotherapists disagreed with each other on quality of movement they were more consistent in their own scoring.

Biomechanical consequences of impairment: a taxonomically valid basis for classification in a unified disability athletics system

Developing a unified classfication system to replace four of the systems currently used in disability athletics (i.e., track and field) has been widely advocated. The diverse impairments to be included in a unified system require several assessment methods, results of which cannot be meaningfully compared. Therefore, the taxonomic basis of current classification systems is invalid in a unified system. Biomechanical analysis establishes that force, a vector described in terms of magnitude and direction, is a key determinant of success in all athletic disciplines. It is posited that all impairments to be included in a unified system may be classified as either force magnitude impairments (FMI) or force control impairments (FCI). This framework would provide a valid taxonomic basis for a unified system, creating the opportunity to decrease the number of classes and enhance the viability of disability athletics.

Botulinum toxin type A in the treatment of lower limb spasticity in cerebral palsy

OBJECTIVES

To determine whether botulinum toxin (BtA) is an effective and safe treatment for lower limb spasticity in children with cerebral palsy. Functional outcomes are of particular interest.

SEARCH STRATEGY

Studies for inclusion in the review were identified using the Movement Disorders Review Group trials register, the Cochrane Controlled Trials Register, MEDLINE, pharmaceutical company databases, communication with other researchers in the field and reference lists of papers found using above search strategies.

SELECTION CRITERIA

Studies were considered eligible for inclusion in the review if they evaluated the efficacy of BtA for the treatment of leg spasticity in children with cerebral palsy. They must have been randomised and include a concurrent control group receiving another intervention.

DATA COLLECTION AND ANALYSIS

A paper pro forma was used to collect data from the included studies using double extraction by two independent reviewers. Each trial was assessed for internal validity by each of the two reviewers. Meta-analysis was not possible because results were presented in an incompatable form. A Peto odds ratio was calculated where this was appropriate, otherwise a descriptive summary of the results of the individual studies was compiled.

MAIN RESULTS

Three eligible studies were found each with small numbers of subjects. They were short term, used single injection sessions with follow-up of between 4 and 26 weeks. One study (Koman), of twelve ambulant children, compared BtA with injection of a placebo and found non-significant improvements in gait in the BtA group compared to the placebo group. Two studies (Corry, Flett) compared BtA with the use of casts. Each included 20 ambulant children and found improvements in gait, range of ankle movement and muscle tone in both the BtA and cast groups. However there were no significant differences between the groups in either trial. One of these trials (Flett) also assessed motor function using the gross motor function measure (GMFM) (Russell, 1989) and found significant improvements in each group compared to baseline but no significant differences between the groups. The other trial (Corry) performed 3D gait analysis on those children able to co-operate. Maximal plantar flexion and maximal dorsiflexion during walking were both found to be significantly greater in the BtA group compared to the cast group. In all other dimensions there were no significant differences between the groups.

REVIEWER'S CONCLUSIONS

This systematic review has not revealed strong controlled evidence to support or refute the use of BtA for the treatment of leg spasticity in cerebral palsy. Ongoing randomised controlled trials are likely to provide useful data on the short term effects of BtA for leg spasticity. Future research should also assess the longer term use of BtA. Ideally studies should be pragmatic in their approach to dose and distribution of toxin to reflect practise. Outcome measures assessing function and disability would give the most useful information.

Functional motor abilities of children with cerebral palsy: a systematic literature review of assessment measures

OBJECTIVE

To provide an overview of functional assessment measures for children with cerebral palsy, supporting the selection of measures and the interpretation of results from measures.

METHODS

Instruments were selected on the basis of a literature search of the Medline, Sportdisk and PsychLIT databases. ISSUES REVIEWED: Instruments were reviewed with respect to target group, purpose, nature, type and psychometric properties.

RESULTS

In the literature 17 instruments that are used in paediatric rehabilitation and paediatric physical therapy to assess the functional motor abilities of children with cerebral palsy were found. While there is an urgent need for measures that can evaluate change in functional abilities, it was found that most measures are developed and validated for discriminative purposes.

CONCLUSIONS

Although instruments developed within the last decade meet psychometric criteria more adequately than those developed previously, it is concluded that only two evaluative assessment measures, the Gross Motor Function Measure (GMFM) and the Pediatric Evaluation of Disability Inventory (PEDI), fulfil the criteria of reliability and validity with respect to responsiveness to change.

A comparison of intensive neurodevelopmental therapy plus casting and a regular occupational therapy program for children with cerebral palsy

The purpose of this research was to evaluate the combined effect of intensive neurodevelopmental therapy (NDT) and casting in improving hand function, quality of upper-extremity movement and range of motion in children aged between 18 months and 4 years with cerebral palsy (CP). A randomized crossover design was used to evaluate the difference between intensive NDT plus casting and a less intensive regular occupational therapy (OT) program. Blinded assessments of hand function, quality of upper-extremity movement, and parents' perception of hand-function performance were carried out at baseline, 4 months (end of first intervention period), 6 months (after a 2-month 'washout' period), and 10 months (end of second intervention period). Analysis of the outcomes revealed no significant differences in hand function, quality of upper-extremity movement, or parents' perception of hand-function performance between the two treatment groups-intensive NDT plus casting or regular OT programs. There does not appear to be any beneficial effect of an increased amount of therapy for the children in this study.

Development and reliability of a system to classify gross motor function in children with cerebral palsy

To address the need for a standardized system to classify the gross motor function of children with cerebral palsy, the authors developed a five-level classification system analogous to the staging and grading systems used in medicine. Nominal group process and Delphi survey consensus methods were used to examine content validity and revise the classification system until consensus among 48 experts (physical therapists, occupational therapists, and developmental pediatricians with expertise in cerebral palsy) was achieved. Interrater reliability (kappa) was 0.55 for children less than 2 years of age and 0.75 for children 2 to 12 years of age. The classification system has application for clinical practice, research, teaching, and administration.

Quantifying the effects of interventions for movement disorders resulting from cerebral palsy

The purpose of this article is to review a variety of tests and measures that are useful in documenting and quantifying the outcomes of intervention for persons with cerebral palsy. The topics included are (1) a discussion of the need for meaningful outcome measures, (2) a model of the disabling process for classifying measures used to assess several different dimensions of disablement, and (3) a review of selected tests and measures categorized according to the model described.