Longitudinal development of gross motor function among Dutch children and young adults with cerebral palsy: an investigation of motor growth curves

Motor development trajectories of children with cerebral palsy in a community-based early intervention program in rural South India

BACKGROUND

Developmental trajectories are crucial for evidence-based prognostication, planning interventions, and monitoring progress in children with cerebral palsy (CP).

AIMS

To describe gross motor development patterns of children with CP in rural South India for the five Gross Motor Function Classification System (GMFCS) levels.

METHODS

Longitudinal cohort study of 302 children (176 males, 126 females) with CP aged 0 to 10 years, followed by a community-based early intervention program. GMFCS levels were 5.4 % level 1, 16.5 % level II, 22.8 % level III, 26.8 % level IV, and 28.5 % level V. Assessments were undertaken using the Gross Motor Function Measure (GMFM-66) at 6-month intervals between April 2017 and August 2020. Longitudinal analyses were performed using mixed-effects linear regression models.

OUTCOMES AND RESULTS

Five distinct motor development curves were created for ages 0 to 10 years by GMFCS levels as a function of age and GMFM-66 with a stable limit model, variation in estimated limits and rates of development.

CONCLUSIONS AND IMPLICATIONS

Motor development trajectories for CP in an LMIC differ from those reported in HICs. Consideration of how social determinants of health, environmental and personal factors impact motor development in low-resource contexts is crucial. Further work is needed to describe developmental trajectories of children for CP in LMICs.

Postoperative outcomes and stimulation responses for sectioned nerve roots during selective dorsal rhizotomy in cerebral palsy

BACKGROUND

Cerebral palsy (CP) is the most cause of motor dysfunction in children. Selective dorsal rhizotomy (SDR) plays a major role in long term spasticity control. However, limited data exists on the effect of SDR on postoperative spasticity treatment requirements and supraspinal effects, and the stimulation responses of dorsal nerve roots in those with CP.

METHODS

The current study included the outcome for 35 individuals undergoing SDR for motor functional outcome, spasticity, baclofen dose changes, botulinum toxin injection frequency, and spasticity related orthopedic procedures. We also report on the stimulation responses in 112 individuals who underwent SDR at our institution.

RESULTS

There was a significant difference in gross motor function measures (GMFM)-66 scores at last follow up that remained present when considering only ambulatory children but not with non-ambulatory children. Ashworth scores were significantly decreased for both upper and lower extremities after SDR at all follow up points. There was a significant decrease in Baclofen dose and botulinum toxin injections requirements after SDR, but no significant difference in the need for orthopedic intervention. A total of 5502 dorsal nerve roots were tested showing a decrease in stimulation intensity and increase in grade on the right side and for descending lumbosacral levels.

CONCLUSIONS

SDR improves gross motor scores during short term follow up but has additional benefits in decreasing baclofen dosing and botulinum toxin injections requirements after surgery. They stimulation responses of sectioned dorsal nerve roots adds to the limited available data and our understanding of the pathological changes that occur in CP.

The Danish child and parent Gait Outcomes Assessment List questionnaires were reliable and valid for cerebral palsy

AIM

We investigated the reliability and validity of the Danish child and parent versions of the Gait Outcomes Assessment List (GOAL) questionnaires for ambulatory children with cerebral palsy (CP).

METHODS

Translation and cultural adaptations were performed and content validity evaluated. Participants were enrolled between 2016 and 2018 from Aarhus University Hospital, Denmark. Children and parents completed the GOAL questionnaires twice for test-retest reliability. Discriminative validity was evaluated by comparing the child and parent GOAL scores between children with Gross Motor Function Classification System (GMFCS) levels I and II. The concurrent validity of the GOAL questionnaires were investigated by comparing them with Challenge-20, which assesses motor skills in children with CP.

RESULTS

We studied 59 children (57% boys) with CP and GMFCS I-II at a mean age of 10.6 years. Test-retest intra-class correlations were excellent for the children (0.91, 95% confidence interval (CI) 0.83-0.96) and good for the parents (0.83, 95% CI 0.67-0.91). GOAL scores decreased with increasing GMFCS (p < 0.05). Both versions correlated well. The mean children's scores were significantly (6.2/100) higher than the parents' (p < 0.001). The GOAL scores correlated positively with Challenge-20.

CONCLUSION

The Danish GOAL child and parent questionnaires demonstrated good reliability and content and discriminative and concurrent validity.

Effects of the EXECP Intervention on Motor Function, Muscle Strength, and Joint Flexibility in Individuals with Cerebral Palsy

PURPOSE

Numerous exercise interventions to enhance motor function in cerebral palsy (CP) have been proposed, with varying degrees of effectiveness. Because motor function requires a combination of muscle strength, joint flexibility, and motor coordination, we designed a supervised multicomponent exercise intervention (EXErcise for Cerebral Palsy, or EXECP) for individuals with CP. Our aim was to evaluate the effects of the EXECP intervention and its retention after it ceased.

METHODS

The EXECP intervention combined strength training for the lower limbs and trunk muscles, passive stretching for the lower limb muscles, and inclined treadmill gait training. Eighteen participants with CP (mean age, 14 yr; 13 were male) were tested twice before the 3-month intervention and twice after the intervention, each test separated by 3 months. Seventeen typically developing age- and sex-matched controls were tested twice. Motor function was assessed with the 6-min walking test (6MWT) and the gross motor function measure dimensions D and E. Passive joint flexibility was measured with goniometry. Isometric and concentric muscle strength were assessed at the knee, ankle, and trunk joints.

RESULTS

The EXECP intervention successfully increased 6MWT ( P < 0.001), gross motor function measure ( P = 0.004), and muscle strength for knee and trunk muscles ( P < 0.05), although no changes were observed for ankle joint muscles. Hip and knee joint flexibility also increased ( P < 0.05). After the retention period, all tested variables except the 6MWT and knee joint flexibility regressed and were not different from the pretests.

CONCLUSIONS

The improvements in strength, flexibility, and possibly motor coordination brought by the EXECP intervention were transferred to significant functional gains. The regression toward baseline after the intervention highlights that training must be a lifelong decision for individuals with CP.

Motor Development in Children with Cerebral Palsy in Sweden-A Population-Based Longitudinal Register Study

The aim was to explore longitudinal motor development in children with cerebral palsy (CP) in Sweden with respect to the Gross Motor Function Classification System (GMFCS). In this national CP registry-based study, 2138 children aged 0.5-19 years participated (42% girls). The distribution with respect to GMFCS was I: 49%, II: 16%, III: 10%, IV: 14%, and V: 11%. In total, 5538 assessments (mean 2.7, min-max: 1-9) with the Gross Motor Function Measure-66 were included. Data were analysed using non-linear mixed-effects regression models, and the Stable Limit Model was selected to fit data. Five distinct curves of predicted gross motor development with respect to GMFCS levels were obtained. The achieved motor development was maintained over time. The estimated average GMFM-66 limit and the average age when 90% of the expected limits were reached were at GMFCS I: 88 at age 4.5; GMFCS II: 71 at age 4.2; GMFCS III: 54 at age 3.1; GMFCS IV: 38 at age 2.6, and at GMFCS V: 18 at age 0.9. In conclusion, this is the first national population-based study following motor development in CP. Five distinct curves reported in previous controlled research studies were confirmed. Our study adds knowledge about motor development captured in children's everyday context.

Association Between Motor Competence and Percentage of Body Fat in Late Childhood: Comparing Proficiency in Fundamental Motor Skills and Advanced Movement Skills

Background: To solve the problem of a weakening relationship between motor competence and body adiposity from late childhood to adolescence, we defined and utilized advanced movement skills (AMS) characterized by higher biomechanical, physiological, and cognitive processing demands compared with fundamental motor skills (FMS). Methods: As a cross-sectional study, the proficiency in FMS and AMS for participants (43 boys and 45 girls) aged 9-12 years was measured by the Bruininks-Oseretsky Test of Motor Proficiency-Second Edition (BOT-2) and Test of Advanced Movement Skills (TAMS), respectively. Density plots and skewness of scoring distributions between assessments were inspected to examine test scalability. We also compared the incremental validity of BOT-2 and TAMS scores in the multiple linear regression models predicting the percentage of body fat (%BF, measured by Tanita BF-689 body scale). Results: The TAMS outcomes produced a more positively/right-skewed scoring distribution with a skewness of 0.09 compared with -0.49 for the BOT-2 scores, indicating a better test discrimination ability. The TAMS total scores were a significant predictor (B = -0.92, p = 0.03) in the model predicting %BF (R2 = 0.39, p < 0.001) and provided a greater degree of incremental validity (f2 = 0.058) compared with the BOT-2 (f2 = 0.018). Conclusions: This study provides supportive evidence that the proficiency in AMS is more appropriate, compared with FMS, at tracking the increasing motor competence and body adiposity in late childhood, which is helpful for motor skills training, physical activity promotion, and overweight/obesity prevention.

Effect of Active Motor Learning Interventions on Gross Motor Function and Mobility in Children Aged 2 to 6 Years With Bilateral Cerebral Palsy: A Systematic Review and Meta-analysis

PURPOSE

The purpose of this systematic review is to identify evidence-based interventions to promote active motor learning in children aged 2 to 6 years with bilateral cerebral palsy.

SUMMARY OF KEY POINTS

Seven randomized clinical trials of active motor learning interventions targeting gross motor function and mobility were included. Two studies compared context-focused therapy to child-focused therapy. Five studies compared active motor therapy to usual care. Context-focused therapy, child-focused therapy, and active motor therapy were comparable to usual care to improve functional mobility and gross motor function.

CONCLUSIONS AND RECOMMENDATIONS FOR CLINICAL PRACTICE

There are limited active intervention studies targeting gross motor function for young children with bilateral cerebral palsy. The authors recommend consideration of the clinical good practice guidelines, dosage parameters, and improved reporting methods when implementing active motor learning interventions targeting gross motor function and mobility for children with cerebral palsy.

Desenvolvimento de crianças, adolescentes e jovens adultos com Paralisia Cerebral de acordo com a CIF? Uma revisão do escopo

Estudos sobre o desenvolvimento de indivíduos com PC ajudam terapeutas e pais a planejarem abordagens de tratamento e prognóstico futuro. Os principais desfechos investigados em indivíduos com PC foram atividade e estruturas e funções corporais. Pouco tem sido explorado em desfechos de participação e de fatores contextuais ao longo do tempo.

Development of children, adolescents, and young adults with cerebral palsy according to the ICF: A scoping review

AIM

To identify and provide a descriptive overview of the development of children, adolescents, and young adults with cerebral palsy (CP) in longitudinal studies; and map areas of focus according to the components of the World Health Organization's International Classification of Functioning, Disability, and Health (ICF).

METHOD

Longitudinal studies of the development of children, adolescents, and/or young adults with CP were included in this scoping review. A search for eligible studies was conducted in the databases MEDLINE, PubMed, LILACS, EMBASE, Cochrane, CINAHL, and Scopus, and was restricted to the years 2002 to 2022. All outcome measures of the studies were classified into ICF components.

RESULTS

In the 56 studies included, there were 19 438 participants, involving mainly children, followed by adolescents, and lastly young adults. All components of the ICF were investigated and many studies reported outcomes in more than one component. Activity was the most investigated (67.9%; n = 38 studies), followed by body functions and structures (42.9%; n = 24 studies). Participation (14.2%; n = 8 studies) and environmental factors (3.6%; n = 2 studies) were the least studied. None of the studies investigated personal factors as an outcome.

INTERPRETATION

This scoping review provides an overview of studies on the development of children, adolescents, and young adults with CP, using the ICF framework, identifying current areas of focus and gaps in the research. Future studies should target participation, contextual factors, and the transition into adulthood.

Development of gross motor capacity and mobility performance in children with cerebral palsy: a longitudinal study

AIM

To describe development of gross motor capacity and mobility performance in children with cerebral palsy.

METHOD

This longitudinal cohort study measured gross motor capacity with the Gross Motor Function Measure and mobility performance with the Pediatric Evaluation of Disability Inventory (PEDI) between 18 months and 5 years, and the PEDI - Computer Adaptive Test (PEDI-CAT) between 8 years and 12 years. Longitudinal analyses used mixed-effects regression modelling with interaction between age and Gross Motor Function Classification System (GMFCS). Stability of GMFCS levels over time was measured using agreement.

RESULTS

Two hundred and twenty-two children provided 871 observations (median 4 observations, range 1-7). Children classified in GMFCS level I improved in both capacity and performance until 8 to 12 years. Children classified in GMFCS levels II and III continued to develop mobility performance after gross motor capacity had plateaued at 5 years. Children classified in GMFCS level IV plateaued at 5 years in capacity and performance. Children classified in GMFCS level V showed no changes in capacity or performance between 18 months and 8 to 12 years. Stability of GMFCS levels was 73%.

INTERPRETATION

Change in mobility performance over time somewhat reflected gross motor capacity trajectories. Continued improvement in mobility performance after plateau of gross motor capacity for children classified in GMFCS levels II and III suggests importance of other personal or environmental factors.

Factors for changes in self-care and mobility capabilities in young children with cerebral palsy involved in regular outpatient rehabilitation care

Background

Assessing prognosis of self-care and mobility capabilities in children with cerebral palsy (CP) is important for goal setting, treatment guidance and meaningful professional-caregiver conversations.

Aims

Identifying factors associated with changes in self-care and mobility capabilities in regular outpatient multidisciplinary paediatric CP rehabilitation care.

Methods and procedures

Routinely monitored longitudinal data, assessed with the Paediatric Evaluation of Disability Inventory (PEDI-Functional-Skills-Scale, FSS 0–100) was retrospectively analysed. We determined contributions of age, gross-motor function, bimanual-arm function, intellectual function, education type, epilepsy, visual function, and psychiatric comorbidity to self-care and mobility capability changes (linear-mixed-models).

Outcomes and results

For 90 children (53 boys), in all Gross-Motor-Function-Classification-System (GMFCS) levels, 272 PEDI's were completed. Mean PEDI–FSS–scores at first measurement (median age: 3,2 years) for self-care and mobility were 46.3 and 42.4, and mean final FSS-scores respectively were 55.1 and 53.1 (median age: 6,5 years). Self-care capability change was significantly associated with age (2.81, p < 0.001), GMFCS levels III-V (-9.12 to -46.66, p < 0.01), and intellectual impairment (-6.39, p < 0.01). Mobility capability change was significantly associated with age (3.25, p < 0.001) and GMFCS levels II-V (-6.58 to -47.12, p < 0.01).

Conclusions and implications

Most important prognostic factor for self-care and mobility capabilities is GMFCS level, plus intellectual impairment for self-care. Maximum capability levels are reached at different ages, which is important for individual goal setting and managing expectations.

•

Capabilities of children with CP improve modestly over time in outpatient rehabilitation.

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Children with more severe CP reach maximum mobility and self-care levels at an earlier age.

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After this maintaining capabilities is more realistic than improvement.

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Important prognostic factors are GMFCS level and intellectual impairment.

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Routine monitoring can aid goal setting and expectation management in communication with families.

Hand use development in children with unilateral cerebral palsy

AIM

To describe the development of hand use during bimanual activities among children with unilateral cerebral palsy (CP).

METHOD

A cohort of 166 children (79 females, 87 males; age range 18mo-13y, mean [SD] age at first assessment 37.6mo [20.5mo]) with unilateral CP, registered in the Norwegian CP Follow-up Program with two or more Assisting Hand Assessments (AHAs), were included in this longitudinal study comprising 524 AHAs. Developmental limits and rates were estimated by non-linear mixed effects models and compared between a stable limit model (SLM) and a peak and decline model. Development was described according to Manual Ability Classification System (MACS) levels and AHA performance at 18 months of age (AHA-18).

RESULTS

Children in MACS level I, or in the high AHA-18 group, reached highest limits and had the most rapid development (p<0.001). The developmental trajectories were different between MACS levels I, II, and III and between the high, moderate, and low AHA-18 groups. Seventy-five per cent of the children reached 90% of their estimated limit at 5 years 10 months or earlier. The SLM showed the best model fit (Akaike information criterion: 4008.99).

INTERPRETATION

Most children approached a steady performance limit before 6 years of age. Although children in MACS levels I and II reached 90% of the expected limit at 3 and 4 years respectively, the corresponding age was 8 years for children in MACS level III. The better model fit for the SLM indicates that children with unilateral CP maintain their attained limit of hand use to at least the age of 13 years. What this paper adds Development of hand use between 18 months and 13 years follows a stable-limit pattern. Most children reach a steady limit on the Assisting Hand Assessment before 6 years of age. Manual Ability Classification System levels I, II, and III represent distinct developmental trajectories, level III having a slower rise. Early hand use is an important indicator of future development.

Energetics of walking in individuals with cerebral palsy and typical development, across severity and age: A systematic review and meta-analysis

BACKGROUND

Individuals with cerebral palsy (CP) report physical fatigue as a main cause of limitation, deterioration and eventually cessation of their walking ability. A consequence of higher level of fatigue in individuals with CP leads to a less efficient and long-distance walking ability.

RESEARCH QUESTION

This systematic review investigates the difference in 1) walking energy expenditure between individuals with CP and age-matched typically developing (TD) individuals; and 2) energetics of walking across Gross Motor Function Classification System (GMFCS) levels and age.

METHODS

Five electronic databases (PubMed, Web of Science, CINAHL, ScienceDirect and Scopus) were searched using search terms related to CP and energetics of walking.

RESULTS

Forty-one studies met inclusion criteria. Thirty-one studies compared energy expenditure between CP and age-matched controls. Twelve studies correlated energy expenditure and oxygen cost across GMFCS levels. Three studies investigated the walking efficiency across different ages or over a time period. A significant increase of energy expenditure and oxygen cost was found in individuals with CP compared to TD age-matched individuals, with a strong relationship across GMFCS levels.

SIGNIFICANCE

Despite significant differences between individuals with CP compared to TD peers, variability in methods and testing protocols may play a confounding role. Analysis suggests oxygen cost being the preferred/unbiased physiological parameter to assess walking efficacy in CP. To date, there is a knowledge gap on age-related changes of walking efficiency across GMFCS levels and wider span of age ranges. Further systematic research looking at longitudinal age-related changes of energetics of walking in this population is warranted.

Reliability and minimal detectable change of the Challenge, an advanced motor skills test for children with cerebral palsy, Danish version

PURPOSE

To translate and cross-culturally adapt the Challenge, and investigate the reliability and minimal detectable change (MDC) of the Danish Challenge in children with cerebral palsy (CP).

MATERIALS AND METHODS

A Danish version of the Challenge was created through a standardized translation process. Four physiotherapists evaluated face validity. Independently ambulatory children with CP were tested. Live performance rating was conducted by assessors independently scoring the Challenge. Video-rating was undertaken for a subset of assessments. Same day assessment test-retest reliability was estimated. The Challenge's Best Score Total was of primary interest.

RESULTS

Forty-five children (5-18 years: mean 10 years 9 months; 19 girls) in Gross Motor Function Classification System levels I and II were tested. Inter-rater reliability was excellent for live assessments (n = 45) ICC = 0.998 (95% CI 0.998-0.999) and video assessments (n = 15) ICC = 0.991 (95% CI 0.963-0.997) and intra-rater reliability was excellent for live versus video-recorded assessments (n = 10) ICC = 0.977 (95% CI 0.895-0.994). Test-retest reliability (n = 22) was excellent with ICC = 0.991 (95% CI 0.979-0.996) and minimal detectable change (MDC₉₀) of 4.7 points.

CONCLUSIONS

The Danish Challenge showed excellent reliability in this testing context when physiotherapists scored from live- or video-recorded assessments. The Challenge's ability to detect 4.7 points change seems a clinically realistic target for progress. Clinical trial registration: This trial has been approved by the Data Protection Agency, Central Region Denmark, Ref nr.: 615216, Case nr.: 1-16-02-46-16. Registration date: 01-01-2016.Implications for rehabilitationThe Challenge remained reliable and maintained a promising minimal detectable change of less than five points after translation and cultural adaptation.The Danish version of the Challenge 20-item version can be used to measure advanced motor skill performance in children with cerebral palsy, GMFCS level I and GMFCS level II.Challenge live scoring is as reliable as the more time-consuming video-recorded scoring, meaning that physiotherapists can choose the method that fits best with their clinical context and preference.

Exercise intervention protocol in children and young adults with cerebral palsy: the effects of strength, flexibility and gait training on physical performance, neuromuscular mechanisms and cardiometabolic risk factors (EXECP)

Background

Individuals with cerebral palsy (CP) have problems in everyday tasks such as walking and climbing stairs due to a combination of neuromuscular impairments such as spasticity, muscle weakness, reduced joint flexibility and poor coordination. Development of evidence-based interventions are in pivotal role in the development of better targeted rehabilitation of CP, and thus in maintaining their motor function and wellbeing. Our aim is to investigate the efficacy of an individually tailored, multifaceted exercise intervention (EXECP) in children and young adults with CP. EXECP is composed of strength, flexibility and gait training. Furthermore, this study aims to verify the short-term retention of the adaptations three months after the end of the EXECP intervention.

Methods

Twenty-four children and young adults with spastic CP will be recruited to participate in a 9-month research project with a 3-month training intervention, consisting of two to three 90-min sessions per week. In each session, strength training for the lower limbs and trunk muscles, flexibility training for the lower limbs and inclined treadmill gait training will be performed. We will evaluate muscle strength, joint flexibility, neuromuscular and cardiometabolic parameters. A nonconcurrent multiple baseline design with two pre-tests and two post-tests all interspaced by three months is used. In addition to the CP participants, 24 typically developing age and sex-matched participants will perform the two pre-tests (i.e. no intervention) to provide normative data.

Discussion

This study has a comprehensive approach examining longitudinal effects of wide variety of variables ranging from physical activity and gross motor function to sensorimotor functions of the brain and neuromuscular and cardiometabolic parameters, providing novel information about the adaptation mechanisms in cerebral palsy. To the best of our knowledge, this is the first intervention study providing supervised combined strength, flexibility and gait training for young individuals with CP.

Trial registration number

ISRCTN69044459, prospectively registered (21/04/2017).

Effect of Long-Term Repeated Interval Rehabilitation on the Gross Motor Function Measure in Children with Cerebral Palsy

BACKGROUND

The efficacy of interventions for cerebral palsy (CP) has been frequently investigated with inconclusive results and motor function measured by the Gross Motor Function Measure (GMFM-66) is common.

OBJECTIVE

In this observational analysis, we quantify the GMFM-66 change scores of the second and third year of a multimodal rehabilitation program (interval rehabilitation including home-based, vibration-assisted training) in children with CP.

METHODS

The study was a retrospective analysis of children with CP (2-13 years) participating for a second (n = 262) and third year (n = 86) in the rehabilitation program with GMFM-66 scores at start (M0), after 4 months (M4) of intensive training, and after 8 months of follow-up (M12). A method was previously developed to differentiate between possible treatment effects and expected development under standard of care for GMFM-66 scores using Cohen's d effect size (ES; size of difference).

RESULTS

After the treatment phase of 4 months (M4) in the second year, 125 of 262 children were responder (ES ≥ 0.2) and 137 children nonresponder (ES < 0.2); mean ES for nonresponder was -0.212 (trivial) and for responder 0.836 (large). After M4 in the third year, 43 children of 86 were responder (ES = 0.881 [large]) and 43 nonresponder (ES = -0.124 [trivial]).

DISCUSSION AND CONCLUSION

Repeated rehabilitation shows a large additional treatment effect to standard of care in 50% of children which is likely due to the intervention, because in the follow-up period (standard of care), no additional treatment effect was observed and the children followed their expected development.

Postural deformity in children with cerebral palsy: Why it occurs and how is it managed

Despite the fact that children with cerebral palsy may not have any deformities at the time of birth, postural deformities, such as scoliosis, pelvic obliquity, and windswept hip deformity, can appear with increasing age. This may lead to respiratory function deterioration and, in more severe cases, affects survival. To date, postural care is believed to help improve the health and quality of life of children with cerebral palsy. This review provides an overview of the cause and clinical management of postural deformity that is seen in children with cerebral palsy.

Danish translation, adaptation and validation of the ABILHAND-Kids questionnaire for children with cerebral palsy

Purpose: To translate and cross-culturally adapt the ABILHAND-Kids questionnaire into Danish and assess its psychometric properties in children with cerebral palsy (CP).Materials and methods: A Danish version of the parent-reported ABILHAND-Kids questionnaire was created through a standardized translation process. Dimensionality (confirmatory factor analysis), reliability, smallest detectable change, floor and ceiling effects, and Rasch analysis were carried out.Results: One-hundred-and-fifty children diagnosed with CP were included. No parent had difficulty completing the ABILHAND-Kids (DK). Psychometric testing demonstrated a unidimensional scale, excellent test-retest reliability (ICC2.1A = 0.97) and internal consistency (α = 0.96). A smallest detectable change of 5.15 points was considered acceptable. One item showed Differential Item Functioning, four pairs of items showed signs of local dependence and one item had disordered thresholds. Nevertheless, analyses did not lead to the removal of any items. Item thresholds covered most levels of person abilities. Lastly, 24.7% scored within measurement error at the ceiling of the scale, indicating that it was not possible to measure further improvement.Conclusion: ABILHAND-Kids (DK) seems to be a valid, reliable and comprehensive measurement scale to assess manual ability in children with CP. It can be used in goal setting and to inform future interventions and rehabilitation evaluation.IMPLICATIONS FOR REHABILITATIONImpaired hand function leads to limited participation in activities of everyday life in children with cerebral palsy.Adequate outcome measures of hand function are crucial for the planning and evaluation of interventions.The Danish version of ABILHAND-Kids is a valid and reliable measure of manual ability in children with cerebral palsy, and it can be used in clinical practice and for research purposes.

Anteroposterior balance reactions in children with spastic cerebral palsy

AIM

To compare anterior and posterior standing balance reactions, as measured by single-stepping thresholds, in children with and without spastic cerebral palsy (CP).

METHOD

Seventeen ambulatory children with spastic CP (eight males, nine females) and 28 typically developing children (13 males, 15 females; age range 5-12y, mean [SD] 9y 2mo [2y 3mo]), were included in this cross-sectional, observational study. Balance reaction skill was quantified as anterior and posterior single-stepping thresholds, or the treadmill-induced perturbations that consistently elicited a step in that direction. In order to understand the underlying mechanisms of between-group differences in stepping thresholds, dynamic stability was quantified using the minimum margin of stability. Ankle muscle activation latency, magnitude, and co-contraction were assessed with surface electromyography.

RESULTS

We observed an age and group interaction for anterior thresholds (p=0.001, partial η² =0.24). At older (≈11y; p<0.001, partial η² =0.48), but not younger (≈7y; p=0.33, partial η² =0.02) ages, typically developing children had larger anterior thresholds than those with CP. In response to near-threshold anterior perturbations, older typically developing children recovered from more instability than their peers with CP (p=0.004, partial η² =0.18). Older children had no between-group differences in ankle muscle activity. No between-group differences were observed in posterior thresholds.

INTERPRETATION

The effects of CP on balance reactions are age- and direction-specific. Older typically developing children are more able or willing to withhold a step when unstable.

WHAT THIS PAPER ADDS

Children with spastic cerebral palsy have age- and direction-specific balance-reaction impairments. Lower anterior stepping thresholds were observed in older, but not younger children. Older typically developing children withheld a forward step at higher levels of instability. No between-group differences were seen in posterior stepping thresholds.

Lessons learned from conducting a pragmatic, randomized, crossover trial on robot-assisted gait training in children with cerebral palsy (PeLoGAIT)

PURPOSE

To investigate the effectiveness of outpatient robot-assisted gait training (RAGT) in ambulatory children with spastic cerebral palsy.

METHODS

Children were randomized to two different intervention sequences within a pragmatic crossover design. They performed five weeks of RAGT (3 sessions per week) and five weeks of usual care (UC). Dimension E of the Gross Motor Function Measure-88 (GMFM E) as the primary outcome as well as Dimension D (GMFM D), and timed walking tests were assessed before and after each treatment sequence and after a 5-week follow-up.

RESULTS

The trial was stopped early because of recruitment problems. We included 16 children with a mean age of 11.3 years (6.0-15.3 years). GMFM E median (IQR) change scores were -0.7 (-2.8 to 3.5) after RAGT and 0 (-2.4 to 2.4) after UC. Neither GMFM E nor any secondary outcome measure changed significantly after RAGT or UC, nor were any period, follow-up, or carry-over effects observable.

CONCLUSIONS

RAGT as a single intervention was not effective in improving walking abilities in the included children. It should be embedded in a holistic treatment approach, as it cannot cover all aspects relevant to gait. Furthermore, children's personalized rehabilitation goals should be carefully monitored with individualized measurement instruments.

Development curves of communication and social interaction in individuals with cerebral palsy

AIM

To determine development curves of communication and social interaction from childhood into adulthood for individuals with cerebral palsy (CP).

METHOD

This Pediatric Rehabilitation Research in the Netherlands (PERRIN)-DECADE study longitudinally assessed 421 individuals with CP, aged from 1 to 20 years at baseline, after 13 years (n=121 at follow-up). Communication and social interactions were assessed using the Vineland Adaptive Behavior Scales. We estimated the average maximum performance limit (level) and age at which 90% of the limit was reached (age₉₀ ) using nonlinear mixed-effects modeling.

RESULTS

One-hundred individuals without intellectual disability were aged 21 to 34 years at follow-up (39 females, 61 males) (mean age [SD] 28y 5mo [3y 11mo]). Limits of individuals without intellectual disability, regardless of Gross Motor Function Classification System (GMFCS) level, approached the maximum score and were significantly higher than those of individuals with intellectual disability. Ages₉₀ ranged between 3 and 4 years for receptive communication, 6 and 7 years for expressive communication and interrelationships, 12 and 16 years for written communication, 13 and 16 years for play and leisure, and 14 and 16 years for coping. Twenty-one individuals with intellectual disability were between 21 and 27 years at follow-up (8 females, 13 males) (mean age [SD] 24y 7mo [1y 8mo]). Individuals with intellectual disability in GMFCS level V showed the least favourable development, but variation between individuals with intellectual disability was large.

INTERPRETATION

Individuals with CP and without intellectual disability show developmental curves of communication and social interactions similar to typically developing individuals, regardless of their level of motor function. Those with intellectual disability reach lower performance levels and vary largely in individual development.

WHAT THIS PAPER ADDS

Communication and social interactions in individuals with cerebral palsy without intellectual disability develop similarly to typically developing individuals. Communication and social interactions of individuals with intellectual disability develop less favourably and show large variation.

Reference centiles for the gross motor function measure and identification of therapeutic effects in children with cerebral palsy

RATIONALE, AIMS, AND OBJECTIVES

Children with cerebral palsy (CP) can show an increase in gross motor function until the age of 9 to 10 years under the standard of care. Additionally, the motor development can have large individual fluctuations. Therefore, in clinical setting, it is not trivial to estimate the effect of an additional therapeutic intervention at this age interval. The study aim was to develop a method which allows quantification of the gross motor function changes over 6 months of the individual child with CP.

METHOD

The present study was a single center retrospective analysis. Data were collected in children with CP who participated in a rehabilitation program between 2006 and 2016. The gross motor function of the children was measured with the Gross Motor Function Measurement (GMFM-66). Reference centiles for the GMFM-66 were created with data before starting the rehabilitation program. The variability of the evolution of the GMFM-66 was assessed with data at the start and the end of a 6-month observational phase of standard of care.

RESULTS

In total, the GMFM-66 data of 919 children before starting the rehabilitation program were available (age 6.49 ± 2.49 years, GMFCS-level I-V). For 515 study participants (6.76 ± 2.30 years, GMFCS-level I-V), data were also available at the start and the end of a 6-month observational phase.

CONCLUSIONS

The presented method helps to guide the clinician to track the individual patient's gross motor development and assess the additional effect of an additionally applied intervention while taking into account the expected progression of gross motor function under standard of care.

Socioeconomic Status Influences Functional Severity of Untreated Cerebral Palsy in Nepal: A Prospective Analysis and Systematic Review

BACKGROUND

Cerebral palsy (CP) comprises a heterogeneous group of disorders whose clinical manifestations and epidemiologic characteristics vary across socioeconomic and geographic contexts. The functional severity of untreated CP in low-income countries has been insufficiently studied; a better understanding of how these children present for care in resource-constrained environments is important because it will better characterize the natural history of CP, guide clinical decision-making, and aid in the prognostication of children with untreated CP.

QUESTIONS/PURPOSES

The purposes of this study were (1) to determine the etiologies, motor subtypes, topographic distributions, and functional classifications of a large cohort of Nepali children with untreated CP presenting to a large pediatric rehabilitation center in Nepal; and (2) to compare the Gross Motor Function Classification System (GMFCS), the Manual Ability Classification System (MACS), and the Communication Function Classification System (CFCS) scores of a subset of patients with spastic CP in the Nepali cohort with control subjects from high-income countries.

METHODS

A cross-sectional study was conducted at the Hospital and Rehabilitation Centre for Disabled Children in Nepal. Two hundred six consecutive Nepali children (76 girls; median age 4.0 years [interquartile range {IQR}, 2.5-9.0 years]) were evaluated to determine the demographic, clinical, and functional characteristics of a cohort of Nepali children with untreated CP. A systematic review of the Medline and Cochrane databases was then performed to obtain reference classification scores from high-income countries. Cross-sectional, noninterventional studies reporting at least one functional classification system with a sample size of at least 50 participants were included. Only studies of patients with spastic CP were included to allow for compatible comparisons with a subset of our study sample with spastic CP. A random-effects analysis was used to pool functional scores from participants in the included studies. Among the 206 children in our sample, 102 had spastic CP (35 girls; median age 5.5 years [IQR, 3.5-9.0 years]). Functional scores from these children were compared with pooled scores obtained from the systematic review by assessing the proportions of children in each sample with GMFCS, MACS, and CFCS score categories of I or II versus III to V.

RESULTS

Children with spastic hemiplegia from high-income countries were more likely to have a GMFCS score of I or II (96% [95% confidence interval {CI}, 92%-99%] versus 78% [95% CI, 62%-89%]) and a MACS score of I or II (83% [95% CI, 77%-88%] versus 50% [95% CI, 32%-68%]) relative to those from Nepal, but they were less likely to have a CFCS score of I or II (67% [95% CI, 51%-80%] versus 97% [95% CI, 87%-99%]). No differences were seen in children with spastic diplegia or quadriplegia.

CONCLUSIONS

Children in Nepal with hemiplegic CP display less difficulty in communicating and social engagement (CFCS) despite more-severe upper- and lower-extremity impairments in gross motor function (GMFCS) and manual ability (MACS) than do children with hemiplegic CP from high-income countries. Targeted interventions, including perhaps simple orthopaedic interventions to treat soft-tissue contractures, may therefore provide more-substantial improvements in function and quality of life to Nepali children than could be achieved for the same deployment of resources in more-affluent settings.

LEVEL OF EVIDENCE

Level II, prognostic study.

Activity Performance Curves of Individuals With Cerebral Palsy

: media-1vid110.1542/5804911840001PEDS-VA_2017-3723Video Abstract OBJECTIVES: Describe development curves of motor and daily activity performance in individuals with cerebral palsy (CP).

METHODS

Participants with CP aged 1 to 20 years at baseline (n = 421) and Gross Motor Functioning Classification System (GMFCS) levels I to V (27% of participants with intellectual disability [ID]) were longitudinally assessed up to a 13-year follow-up period. Motor and daily activity performance were assessed using the relevant subdomains of the Vineland Adaptive Behavior Scales survey. Nonlinear mixed effects analyses were used, estimating the limit (average maximal performance level) and the age by which individuals reached 90% of the limit (age₉₀).

RESULTS

Limits of motor performance decreased with each lower functional level. Age₉₀ for motor performance was reached at ∼6 to 8 years of age in children with GMFCS levels I to III, and at younger ages in those with lower functional levels. Limits of daily activity performance did not differ between individuals without ID with GMFCS levels I to III. The age₉₀s of daily activities were reached between 11 and 14 (personal), 26 and 32 (domestic), and 22 and 26 years of age (community). Individuals with ID reached lower daily activity performance limits earlier.

CONCLUSIONS

Individuals with CP continue to develop motor performance after gross motor capacity limits are reached. For those without ID, daily activities continue to develop into their 20s. Individuals who are severely affected functionally have the least favorable development of motor performance, and those with ID have the least favorable development of daily activity performance.

Relationship Between Mobility and Self-Care Activity in Children With Cerebral Palsy

Objective

To investigate the factors influencing the development of self-care activity, and the association between mobility and self-care activity in children with cerebral palsy (CP).

Methods

A total of 63 CP children aged ≥4 years, were studied retrospectively. Children with severe intellectual disability or behavioral problems were excluded. The relationship between the Gross Motor Function Classification System (GMFCS), the Manual Ability Classification System (MACS), and the Pediatric Evaluation of Disability Inventory (PEDI) was analyzed. Simple and multiple linear regression analyses were conducted for continuous variables, such as verbal intelligence quotient (IQ) and PEDI subscales.

Results

Final evaluation was done for 25 children, ranging from 4 to 11 years of age. According to GMFCS levels, the differences in PEDI-self-care scores, showed statistically borderline significance (p=0.051). Conversely, differences in PEDI-self-care scores according to CP types and MACS levels were not statistically significant. Simple linear regression analysis showed that PEDI mobility and PEDI social function significantly influence the PEDI self-care. Multiple linear regression analysis showed that PEDI mobility was the only factor significantly influencing PEDI self-care in children aged ≥7 years (R²=0.875, p=0.03).

Conclusion

Mobility is important for the acquisition of self-care abilities in children with CP aged ≥7 years.

Longitudinal development of hand function in children with unilateral spastic cerebral palsy aged 18 months to 12 years

AIM

The aim of the study was to describe the development of hand function, particularly the use of the affected hand in bimanual tasks, among children with unilateral cerebral palsy aged 18 months to 12 years.

METHOD

A convenience sample of 96 children (53 males, 43 females) was assessed with the Assisting Hand Assessment (AHA) at regular intervals from the ages of 18 months to 12 years. The children ranged from 17 to 127 months (median age 24mo) at recruitment. Subgroups were created to identify differences in development using the child's AHA at 18 months and the Manual Ability Classification System (MACS). A nonlinear mixed effects model was used to analyze data according to a 'stable limit' development model.

RESULTS

The results were based on 702 AHA sessions. The children showed a rapid development at a young age and reached 90% of their stable limit between 30 months and 8 years. The subgroups, based on the 18-month AHA and the MACS levels respectively, had distinctly different patterns of development.

INTERPRETATION

The AHA at 18 months may be used to make a crude prediction of future development.

Longitudinal Association Between Gross Motor Capacity and Neuromusculoskeletal Function in Children and Youth With Cerebral Palsy

OBJECTIVE

To examine associations over longitudinal measurements between neuromusculoskeletal function and gross motor capacity in children and youth with cerebral palsy (CP).

DESIGN

A prospective cohort study.

SETTING

Rehabilitation departments of university medical centers and rehabilitations centers.

PARTICIPANTS

A sample (N=327) consisting of 148 children (aged 5-9y) and 179 youth (aged 11-20y) with CP, Gross Motor Function Classification System level I (n=180), level II (n=44), level III (n=36), level IV (n=34), and level V (n=33).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Gross motor capacity was assessed with the Gross Motor Function Measure-66 over a period of 2 to 4 years in different age cohorts. Neuromusculoskeletal function included selective motor control (SMC), muscle strength, spasticity, and range of motion (ROM) of the lower extremities.

RESULTS

Multilevel analyses showed that SMC was significantly associated with gross motor capacity in children and youth with CP, showing higher values and a more favorable course of gross motor capacity in those with better SMC. Strength was only associated with gross motor capacity in youth. Reduced ROM of hip (children) and knee extension (youth) and spasticity of the hip adductors (youth) were additionally-but more weakly-associated with lower values and a less favorable course of gross motor capacity.

CONCLUSIONS

Results indicate that children and youth with more severely impaired SMC and youth with reduced muscle strength have a less favorable course of gross motor capacity, while spasticity and reduced ROM are less determinative.

Application of the Gross Motor Function Measure-66 (GMFM-66) in Dutch clinical practice: a survey study

Background

The Gross Motor Function Measure-66 (GMFM-66) is an observational clinical measure designed to evaluate gross motor function in children with Cerebral Palsy (CP). It is a shortened version of the GMFM-88. A free computer program, the Gross Motor Ability Estimator (GMAE), is required to calculate the interval level total score of the GMFM-66. The aim of this study was to explore pediatric physiotherapists’ experiences with the GMFM-66 and application of the measure in Dutch clinical practice.

Methods

An explorative cross-sectional survey study was performed. Dutch pediatric physiotherapists were invited to complete an online survey. Data-analysis merely consisted of frequency tables, cross-tabulations and data-driven qualitative analysis.

Results

Fifty-six respondents were included in the analysis. In general, the therapists expressed a positive opinion on the GMFM-66, in particular regarding its user-friendly administration and benefits of the GMAE. The majority of questions revealed that therapists deviate from the guidelines provided by the manual to a greater or lesser extent though. The most worrisome finding was that 28.8 % (15/52) of the therapists calculate the total score of the GMFM-66 using the score form of the GMFM-88 instead of the GMAE.

Discussion

The consequences of the high number of therapists who stated that they calculate the total score of the GMFM-66 with the GMFM-88 score form are far-reaching; it has a misleading impact on the opinion of rehabilitation teams and parents on the development of the child, on decision-making in rehabilitation, and ultimately on the development of the child.

Conclusions

Information currently available on psychometric properties, motor growth curves and percentiles cannot be generalized to clinical practice in the Netherlands, as they were generated in highly controlled testing conditions, which do not hold in clinical practice.

Electronic supplementary material

The online version of this article (doi:10.1186/s12887-015-0459-8) contains supplementary material, which is available to authorized users.

Long-term trajectories of health-related quality of life in individuals with cerebral palsy: a multicenter longitudinal study

OBJECTIVES

To (1) determine the long-term trajectory of health-related quality of life (HRQOL) for the dimensions of physical complaints and motor, psychological, and social functioning for groups of individuals with cerebral palsy (CP) aged 1 to 24 years; (2) assess the variability in HRQOL within individuals with CP over time; (3) assess the variability in HRQOL between individuals with CP; and (4) compare the HRQOL in individuals with CP to reference data of typically developing individuals.

DESIGN

Multicenter prospective longitudinal study.

SETTING

Rehabilitation departments of 3 university medical centers and various rehabilitation centers in The Netherlands.

PARTICIPANTS

Dutch individuals with CP (N=424; age, 1-24y).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

The HRQOL dimensions of physical complaints and motor, psychological, and social functioning. Each individual visited the rehabilitation department for 3 or 4 measurements. The time between measurements was 1 or 2 years.

RESULTS

Individuals with CP experience an HRQOL that, on average, remains fairly stable over time. Variability in HRQOL within individuals with CP was similar to that within typically developing individuals. Variability between individuals with CP could be explained by type of CP (motor functioning), Gross Motor Function Classification System level (physical complaints and motor and social functioning), and intellectual disability (physical complaints and social functioning). Finally, individuals with CP experienced a lower HRQOL than did typically developing individuals, especially for the dimensions of motor and social functioning.

CONCLUSIONS

Many changes take place in the psychosocial development of the individual with CP, which accordingly change their expectations and those of their caregivers, peers, and professionals. As a result, perceived physical complaints and motor, psychological, and social functioning remain fairly stable over many years.

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

OBJECTIVE

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

DESIGN

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

SETTING

Outpatient clinic.

PARTICIPANTS

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

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

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

RESULTS

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

CONCLUSIONS

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

Developmental trajectories of social participation in individuals with cerebral palsy: a multicentre longitudinal study

AIM

This study aimed to determine the developmental trajectories of social participation, by level of gross motor function and intellectual disability, in a Dutch population of individuals with cerebral palsy (CP) aged 1 to 24 years.

METHOD

As part of the Pediatric Rehabilitation Research in the Netherlands (PERRIN+), 424 individuals with CP (261 males, 163 females; mean age [SD] 9y 6mo [6y 2mo]; Gross Motor Function Classification [GMFCS] levels I-V [50% level I]; 87% with spastic CP; 26% with intellectual disability) were longitudinally followed for up to 4 years between 2002 and 2007. Social participation was assessed with the Vineland Adaptive Behavior Scales survey. Effects of age, GMFCS level and intellectual disability were analysed using multilevel modelling.

RESULTS

The developmental trajectories for individuals in GMFCS levels I to IV did not significantly differ from each other. For individuals without intellectual disability, the degree of social participation increased with age and stabilized at about 18 years. These individuals reached social participation levels similar to typically developing individuals. The trajectories were significantly less favourable for individuals in GMFCS level V and individuals with intellectual disability.

INTERPRETATION

Intellectual disability is more distinctive for the development of social participation than GMFCS level. The developmental trajectories will support individuals with CP and their families in setting realistic goals and professionals in optimizing the choice of interventions at an early age.

Developmental trajectories of daily activities in children and adolescents with cerebral palsy

OBJECTIVES

To describe the developmental trajectories of mobility performance and daily activities in children and young adults with cerebral palsy (CP). To explore the influence of gross motor function and intellectual disability on these trajectories.

METHODS

Four hundred and twenty-four Dutch participants with CP (aged 1-20 years at study onset) were followed yearly over a period of 2 to 4 years. Developmental trajectories (from ages 1-16 years) were described for mobility performance and performance of daily activities, assessed by using the Vineland Adaptive Behavior Scale for gross motor function (classified by the Gross Motor Function Classification System) and intellectual disability (by IQ or school type). A subanalysis was done for performance of daily activities in a subgroup of participants without intellectual disability (aged 1-24 years).

RESULTS

The developmental trajectories of mobility performance differed according to levels of gross motor function but not levels of intellectual disability. Intellectual disability affected the performance of daily activities, with lower overall trajectory levels for participants with intellectual disabilities. For participants without intellectual disability, high-level developmental trajectories were found, with values similar to those of typically developing children despite differences in gross motor function level.

CONCLUSIONS

Mobility performance is determined mainly by levels of gross motor function. For performance of daily activities, intellectual disability was a more important determinant. Participants without intellectual disability showed developmental trajectories approaching values for typically developing participants. These estimated trajectories can guide rehabilitation interventions and future expectations for children and young adults with CP.