Quality of life among adolescents with cerebral palsy: what does the literature tell us?

Self-reported Health-related Quality of Life in Adolescents With Cerebral Palsy

BACKGROUND

Happiness, comfort, and motor function contribute to satisfaction with life for individuals with cerebral palsy (CP). Evidence-based medical care can improve motor function and physical health of youth with CP. Less is known about medical care and its relationship to health-related quality of life (HRQOL) in adolescents and young adults with CP. This study aimed to describe HRQOL among adolescents with CP to examine differences between adolescent (self) and parent (proxy) reports of HRQOL and to explore associations of pain, age, and gross motor function with HRQOL.

METHODS

This is a retrospective study including adolescents with CP classified as Gross Motor Function Classification System levels I to V, ages 11 to 20 years, reading ≥ a fourth-grade level, and who completed the self-reported Pediatric Outcomes Data Collection Instrument (PODCI). Parents completed the PODCI concurrently or within 12 months and scores were compared. In addition, self-reported scores were compared between age bands, across Gross Motor Function Classification System levels, with typically developing youth (TDY), and between youth with/without pain.

RESULTS

PODCI scores from 102 adolescents [59 males; 15.0 (SD: 2.6) years old] were examined. Scores from 50 adolescents and parents were matched. Mean self-reported scores were significantly higher than mean parent-reported scores in 4 domains: upper extremity and physical function ( P =0.018), sports and physical function ( P =0.005), happiness ( P =0.023), and global functioning ( P =0.018). All domains, except Happiness, were significantly < TDY ( P <0.01). The presence of pain was associated with lower scores in all domains ( P <0.05).

CONCLUSION

Examining HRQOL with the PODCI revealed significant limitations in physical function and higher pain in adolescents with CP compared with TDY. Self- and parent-reported PODCI results should be considered separately. Adolescents report higher HRQOL compared with parent proxy. Recognizing and validating the perspectives of youth and their parents presents an opportunity for providers to discuss different points of view with families. Such engagement can help promote self-efficacy in youth with CP as they transition to the responsibility of guiding their own care in adulthood.

LEVEL OF EVIDENCE

III, Retrospective comparative study.

Suitability of quality of life outcome measures for children with severe cerebral palsy receiving postural care interventions: a scoping review

Children with Cerebral Palsy (CP) have complex conditions affecting their health which makes it challenging for assistive technology professionals to achieve desired intervention outcomes. Health professions examining quality of life (QOL) changes must use measurement tools capable of capturing intervention-related changes for the specified population. Investigators aimed to complete a scoping review of QOL-related postural care (PC) publications, identify QOL-based assessments and critically analyze their suitability in measuring intervention outcomes for children with non-ambulatory CP. Investigators searched articles published between 1998-2022 relevant to children with CP that addressed QOL-related: meanings/domains, outcome measures and clinical intervention outcomes. Investigators followed standardized published guidelines throughout each step of the scoping review process from search through data analysis. Subsequently, investigators used a published guideline for analyzing the PC outcome measures identified during the review process, examining their suitability for the target population. Results of this review will help care teams understand QOL and choose outcome assessments capable of measuring QOL-related intervention changes. Thus, making it possible for them to better serve children with severe CP.

Validation of a modified Care and Comfort Score and responsiveness to hip surgery in children with cerebral palsy in Gross Motor Function Classification System levels IV and V

AIMS

The purpose of this study was to assess the reliability and responsiveness to hip surgery of a four-point modified Care and Comfort Hypertonicity Questionnaire (mCCHQ) scoring tool in children with cerebral palsy (CP) in Gross Motor Function Classification System (GMFCS) levels IV and V.

METHODS

This was a population-based cohort study in children with CP from a national surveillance programme. Reliability was assessed from 20 caregivers who completed the mCCHQ questionnaire on two occasions three weeks apart. Test-retest reliability of the mCCHQ was calculated, and responsiveness before and after surgery for a displaced hip was evaluated in a cohort of children.

RESULTS

Test-retest reliability for the overall mCCHQ score was good (intraclass correlation coefficient 0.78), and no dimension demonstrated poor reliability. The surgical intervention cohort comprised ten children who had preoperative and postoperative mCCHQ scores at a minimum of six months postoperatively. The mCCHQ tool demonstrated a significant improvement in overall score from preoperative assessment to six-month postoperative follow-up assessment (p < 0.001).

CONCLUSION

The mCCHQ demonstrated responsiveness to intervention and good test-retest reliability. The mCCHQ is proposed as an outcome tool for use within a national surveillance programme for children with CP.

The Lower the Physical Function, the Higher the Quality of Life in Japanese Adolescents with Cerebral Palsy

AIMS

To investigate the factors that contribute to subjective quality of life (QOL) in adolescents with cerebral palsy (CP).

METHODS

We evaluated the subjective QOL in 51 adolescents with CP through interviews using the Japanese version of KIDSCREEN-27 (J-KIDSCREEN-27) and compared the scores with those of 60 typically developing adolescents. Correlations of subjective QOL with age, sex, the levels of functions (gross motor, manipulation, and communication), intelligence, the level of activity of daily living (ADL), and the type of educational support were examined. Thereafter, we investigated the predictors of the subjective QOL by multiple regression analysis.

RESULTS

The total QOL scores and individual J-KIDSCREEN-27 domains were not significantly different from those of typically developing adolescents. Sex, manipulation and communication functions, and intelligence had no relationship with subjective QOL. Gross motor function and ADL level negatively correlated with satisfaction with the school environment. Multiple regression analysis revealed that higher age predicts lower psychological well-being, lower gross motor function predicts higher satisfaction with the school environment, and attending schools or classes for special needs predicts higher physical well-being.

CONCLUSIONS

Seeking adequate support for mildly affected adolescents attending regular classes will be the key to further improving subjective QOL in adolescents with CP.

Trunk Control Measurement Scale (TCMS): Psychometric Properties of Cross-Cultural Adaptation and Validation of the Spanish Version

The aim of this study was to develop a Spanish Version of the Trunk Measurement Scale (TCMS-S) to analyze its validity and reliability and determine the Standard Error of Measurement (SEM) and Minimal Detectable Change (MDC) in children with Cerebral Palsy (CP). Participants were assessed twice 7-15 days apart with the TCMS-S and once with the Gross Motor Function Measurement-88 (GMFM-88), Pediatric Disability Inventory-Computer Adaptive Test (PEDI-CAT), Cerebral Palsy Quality of Life (CPQoL), and Gross Motor Classification System (GMFCS). Internal consistency was evaluated using Cronbach's alpha, and the intraclass correlation (ICC) and kappa coefficients were used to investigate the agreement between the assessments. Finally, 96 participants with CP were included. The TCMS-S showed excellent internal consistency (Cronbach's alpha = 0.95 [0.93 to 0.96]); was highly correlated with the GMFM-88 (rho = 0.816) and the "mobility" subscale of the PEDI-CAT (rho = 0.760); showed a moderate correlation with the "feeling about functioning" CPQoL subscale (rho = 0.576); and differentiated between the GMFCS levels. Excellent test-retest agreement was found for the total and subscale scores (ICC ≥ 0.94 [0.89 to 0.97). For the total TCMS-S score, an SEM of 1.86 and an MDC of 5.15 were found. The TCMS-S is a valid and reliable tool for assessing trunk control in children with CP.

Health-related quality of life in adolescents with cerebral palsy; a cross-sectional and longitudinal population-based study

AIMS

The aims of this population-based cross-sectional and longitudinal study were to investigate different aspects of health-related quality of life (HRQoL) in adolescents with cerebral palsy (CP), to define possible changes in HRQoL from childhood to adolescence and to identify factors associated with low HRQoL in adolescence.

METHODS

Proxy-reports of 64 adolescents, aged 12-17 years, with bilateral CP in GMFCS levels III-V participating in a surveillance programme, included five of the six domains from the HRQoL instrument Caregiver Priorities & Child Health Index of Life with Disabilities (CPCHILD): (1) Activities of Daily Living and Personal Care, (2) Positioning, Transfer and Mobility, (3) Comfort and Emotions, (5) General Health and (6) Overall Quality of Life, and the two questions on pain from the Child Health Questionnaire (CHQ). Fifty-eight participants comprised the longitudinal sample.

RESULTS

From childhood to adolescence, the mean CPCHILD domain scores decreased slightly in General Health and remained unchanged in the other four domains. In the domain General Health, the number of medications increased, which was the reason for the score decrease. Pain severity increased significantly. Severe motor impairment was associated with low scores in domains 1, 2, 3 and 5, and more severe pain with low scores in domains 2, 3, 5 and 6. A low domain score in childhood was associated with a low score in each corresponding domain in adolescence.

INTERPRETATION

An assessment of HRQoL should be included in CP surveillance programmes because this could identify needs for interventions in individuals with severe CP. This study indicates the importance of improved pain management in both children and adolescents with severe CP.

Validity and Reliability of the Turkish Version of the KIDSCREEN-27 for Individuals With Cerebral Palsy

Our aims in this study were to examine the construct/concurrent validity and internal/test-re-test reliabilities of both the self-report and parent-report questionnaires of a Turkish version of the KIDSCREEN-27 for adolescents with cerebral palsy (CP). We used a convenience sample of 135 children and adolescents with CP aged 8-18 years (65 males, 70 females; M age = 12.39, SD = 3.57) and their parents/caregivers (123 mothers, seven fathers, and five grandmothers). We explored structural construct validity via confirmatory factor analysis (CFA). Concurrent validity was examined via Spearman's correlations between the KIDSCREEN-27 questionnaires and the self-report and primary caregiver report forms of the Cerebral Palsy Quality of Life for Children (CP QOL-Child) and adolescents (CP QOL-Teen). We explored test-retest and internal consistency reliabilities utilizing intraclass correlation coefficients (ICC) and Cronbach's alpha (α), respectively. CFA goodness-of fit indices verified that the predefined model of the KIDSCREEN-27 was a good fit for data from the CP population (X²/df<5, GFI >0.90, AGFI >0.90, RMSEA<0.80). Results showed the subdomains of both KIDSCREEN-27 forms to be significantly correlated with the matched subdomains of the CP QOL-Child and CP QOL-Teen questionnaires (ranges of r = 0.62-0.94). Overall, α and ICC coefficients for all subdomains of both KIDSCREEN-27 versions were acceptable (α and ICC >0.70). Both versions of the KIDSCREEN-27 have satisfactory psychometric properties for use in evaluating health-related quality of life (HRQOL) outcomes in children and adolescents with CP.

The Efficacy of Two Models of Intensive Upper Limb Training on Health-Related Quality of Life in Children with Hemiplegic Cerebral Palsy Mainstreamed in Regular Schools: A Double-Blinded, Randomized Controlled Trial

BACKGROUND

Children with hemiplegic cerebral palsy (CP) are at risk of reduced upper limb function and poorer quality of life than their typically developing peers. Although upper limb impairments have potential negative impact on the health-related quality of life (HRQOL) in children with hemiplegic CP, the efficacy of upper limb rehabilitation approaches aiming to improve upper limb impairments on HRQOL has not been adequately investigated.

OBJECTIVE

This study compares the efficacy of two modes of activity-based upper limb rehabilitation (modified constraint-induced movement therapy [mCIMT] and bimanual training [BIM]) on HRQOL outcomes in children with hemiplegic CP mainstreamed in regular schools.

METHODS

Thirty children with hemiplegic CP aged between 7 and 11 years (mean age 8.53 ± 1.54 years) who had functional ability levels of I-III according to the Manual Ability Classification System (MACS), Gross Motor Classification System (GMFCS), and Communication Function Classification System (CFCS) were randomly assigned to receive mCIMT or BIM training. Result: Both mCIMT and BIM yielded statistically significant improvements in all HRQOL domains immediately after the 10-week interventions (P < .001), which were retained at 16 weeks.

CONCLUSION

While there were some differences in the intervention effects, both of these upper limb rehabilitation approaches based on intensive unimanual or bimanual activity may be beneficial for improving perceived life satisfaction related to physical activity, general mood, family, friends, and school among children with hemiplegic CP mainstreamed in regular schools.

Determinants of Quality of Life of Children and Adolescents with Cerebral Palsy: A Systematic Review

OBJECTIVE

To summarize research findings on the determinants of Quality of Life (QoL) in children with cerebral palsy based on the International Classification of Functioning, Disability, and Health (ICF).

METHODS

The protocol of the review was registered in the International Prospective Register of The Systematic Reviews PROSPERO (CRD42021261966). A PubMed, Web of Science, MEDLINE complete, and CINAHL Plus search was conducted between January 2020 and October 2021 to identify studies that examined determinants of QoL. Inclusion criteria for the studies were children between the ages of birth and 20 years with cerebral palsy. The data extraction and quality evaluation of studies were carried out independently by two reviewers.

RESULTS

A total of 664 studies were identified in the search, of which 23 studies were included in the review. The majority of the studies were conducted in high-income countries. According to the ICF, 48% of the studies examined body function determinants, 52% examined activities determinants, and 26% examined environmental determinants. In contrast, 13% of the studies examined determinants related to participation and 13% examined determinants related to personal factors.

CONCLUSIONS

Based on our findings, most of the determinants identified in the literature are related sequentially to functional activities, body functions and structures, and environmental factors. Researchers should focus on assessing the determinants of QoL related to participation and personal characteristics for children with cerebral palsy in order to improve their QoL.

Thinking About the Future: Perceived Barriers and Supports Among Israeli Young Adults With Physical Disabilities

Young adults with disabilities tend to have lower rates of employment and career indicators as compared with youth without disabilities. Therefore, understanding the factors that may influence such outcomes is crucial. This study examined the future perceptions of 18 young adults with physical disabilities while focusing on the barriers and supports that may impact their transition into adult life. All participants were living in a rehabilitative student community in southern Israel. They participated in an in-depth semi-structured interview. Data analysis, which was conducted according to an adaptation of the Consensual Qualitative Research method, revealed four major domains: emotions, future life roles, barriers, and supports. Findings emphasized that the participants’ disability was extremely dominant in their future perceptions. In general, they expressed caution and concern about their future. They also tended not to express detailed long-term planning. Their perceptions focused on their future work, future intimate relationships, and the need to manage simultaneously different roles. When addressing their possible barriers and supports, they related both to environmental (e.g., social stigma and community support) and to personal (e.g., low self-esteem and high motivation) factors. Implications for research and practice are discussed.

Relationship among four functional classification systems and parent interpredicted intelligence level in children with different clinical types of cerebral palsy

OBJECTIVE

To investigate the relationships between four functional classification systems in children with cerebral palsy (CP) and parent-interpredicted intelligence level, and the functional status in clinical types of CP.

METHODS

Two hundred and twenty-five children with CP ages between 2 and 18 (mean age 6.5 ± 4.4) years included using the Surveillance of CP in Europe (SCPE) database in Turkey. Gross Motor Function Classification System (GMFCS), Manual Ability Classification System (MACS), Communication Function Classification System (CFCS) and Eating and Drinking Classification System (EDACS) levels were classified by clinical observation, and intelligence quotient (IQ) was determined by parent reports.

RESULTS

Correlations were found between all functional levels; the strongest were between GMFCS-MACS (r = 0.784, p < .001), CFCS-EDACS (r = 0.772, p < .001). Strong correlations were found for the IQ-CFCS (r = 0.762, p < .001) and IQ-EDACS (r = 0.634, p < .001). Correlations were stronger in children with bilateral CP and IQ level <70.

CONCLUSIONS

Taken together, these four classification systems and reported IQ levels can adequately describe overall functioning for children with CP. Our results can guide clinicians in the rehabilitation of children with CP.

Rhythm and Reaching: The Influence of Rhythmic Auditory Cueing in a Goal-Directed Reaching Task With Adults Diagnosed With Cerebral Palsy

Improvements in functional reaching directly support improvements in independence. The addition of auditory inputs (e.g., music, rhythmic counting) may improve goal-directed reaching for individuals with cerebral palsy (CP). To effectively integrate auditory stimuli into adapted teaching and rehabilitation protocols, it is necessary to understand how auditory stimuli may enhance limb control. This study considered the influence of auditory stimuli during the planning or execution phases of goal-directed reaches. Adults (with CP = 10, without CP = 10) reached from a home switch to two targets. Three conditions were presented-no sound, sound before, and sound during-and three-dimensional movement trajectories were recorded. Reaction times were shorter for both groups in the sound before condition, while the group with CP also reached peak velocity relatively earlier in the sound before condition. The group with CP executed more consistent movements in both sound conditions. Sound presented before movement initiation improved both the planning and execution of reaching movements for adults with CP.

Does spasticity affect the postural stability and quality of life of children with cerebral palsy?

OBJECTIVES

Cerebral palsy is a unique physical disability that primarily affects children's gross motor functions and postural control. Cerebral palsy has a direct impact on children's daily activities and quality of life. This study aims to determine the relationship between spasticity, motor function, postural stability, and the quality life of children with cerebral palsy.

METHODS

Forty-five children (age range 4-6 years) diagnosed with spasticity from cerebral palsy participated in this study. Spasticity was evaluated by the modified Ashwarth scale; the children's functions were evaluated by gross motor functional measures, postural stability was evaluated by biodex balance system, and quality of life was measured with the pediatric quality of life inventory.

RESULTS

There was a strong positive correlation between the degree of spasticity and quality of life. Additionally, there was a significantly strong association between spasticity and gross motor function. In contrast, there was no correlation between spasticity and postural stability indices. Moreover, there was a strong positive correlation between quality of life and gross motor function. Lastly, there was no association between quality of life and the postural stability index.

CONCLUSION

The findings highlight the impact of spasticity on motor function and the quality of life of a cohort of children with cerebral palsy. These findings may determine therapeutic interventions and priorities to plan physical therapy programs. Such measures may overcome the main cause of disorders that delay and undermine the daily routines of the affected children.

Barriers and facilitators of physical activity participation for young people and adults with childhood-onset physical disability: a mixed methods systematic review

AIM

To understand the attitudes, barriers, and facilitators to physical activity participation for young people and adults with childhood-onset physical disability.

METHOD

Seven electronic databases (Embase, MEDLINE, PsychINFO, AMED, CINAHL, SPORTDiscus, and ERIC) were searched to November 2019. English language studies were included if they investigated attitudes, barriers, or facilitators to physical activity for young people (≥15y) or adults with childhood-onset physical disabilities. Two reviewers applied eligibility criteria and assessed methodological quality. Data were synthesized in three stages: (1) thematic analysis into descriptive themes, (2) thematic synthesis via conceptual framework, and (3) an interpretive synthesis of the thematic results.

RESULTS

Nineteen studies were included. Methodological quality varied, with only four qualitative studies and one quantitative study meeting all quality items. An overarching theme of 'finding the right balance' emerged. Six subthemes relating to capability, opportunity, and motivation contributed to physical activity participation being seen as 'the right fit' or 'all too hard'. The interpretive synthesis found social connections, social environment support, and an appropriate physical environment were essential to 'finding the right balance' to be physically active.

INTERPRETATION

Physical activity participation for young people and adults with childhood-onset physical disabilities is primarily influenced by the social and physical environment. What this paper adds Physical activity participation for young people and adults with childhood-onset physical disabilities is primarily influenced by environmental factors. 'Finding the right balance' between enabling and inhibitory factors was important to physical activity participation being perceived as 'the right fit'. The opportunity for social connection is an important motivator for physical activity participation for young people and adults. The physical environment continues to act as a barrier to physical activity participation for those with physical disabilities.

Health-related quality of life and health literacy among adult primary care patients with subsidized or contributive health insurance in Colombia

CONTEXT

Colombia passed Law 100 in 1993 with the goal of providing universal health care coverage, and by 2013, over 96% of the Colombian population had health insurance coverage. However, little is known about how health-related quality of life (HRQoL) and health literacy are related among those with the two most common types of health insurance coverage: subsidized (those with lower incomes) and contributory (those with higher incomes) coverage.

OBJECTIVES AND METHODS

In the current exploratory investigation, data from adults visiting six primary care clinics in Colombia were analysed to examine the relationship between HRQoL (assessed as problems with mobility, self-care, completing usual activities, pain/discomfort, and anxiety/depression), demographics, the two health insurance types, and health literacy. Analyses also assessed whether, within insurance types, health literacy was related to HRQoL.

RESULTS

Results showed that those with contributory health insurance coverage had greater health literacy than those with subsidized coverage, and this was accounted for by differences in education and socioeconomic status. HRQoL did not differ by insurance type. Although lower health literacy was related to worse HRQoL in the overall sample, in subgroup analyses lower health literacy significantly related to worse HRQoL only among those with subsidized health insurance coverage.

CONCLUSION

Targeting skills which contribute to health literacy, such as interpreting medical information or filling out forms, may improve HRQoL, particularly in those with subsidized insurance coverage.

A pilot study of the impact of the electro-suit Mollii® on body functions, activity, and participation in children with cerebral palsy

Electrical stimulation has been used to treat spasticity in children with cerebral palsy. Building on the benefits of electrical stimulation, a new assistive device, electro-suit Mollii® with imbedded electrodes has been tested. The aim of the study was to evaluate the possible effect of Mollii® on body function, activity and participation in self-selected activities. Six children, five to ten years of age, used the electro-suit for one hour, every other day for three months. The impact was evaluated after four weeks and after three months by measuring passive range of motion (ROM), muscle tone, pain, gross motor function and participation. All participants improved in the total score for Canadian Occupational Performance Measure (COPM), three of them showed significant clinical improvements. Pain was reduced for children who estimated pain when the study started. There were also small changes in Electro-suit Mollii® had a positive impact on activity and participation in self-selected activities among the children in this study. Further studies with more children over a longer time are necessary to evaluate the impact and usefulness over time.

Prolonged Weaning: S2k Guideline Published by the German Respiratory Society

Mechanical ventilation (MV) is an essential part of modern intensive care medicine. MV is performed in patients with severe respiratory failure caused by respiratory muscle insufficiency and/or lung parenchymal disease; that is, when other treatments such as medication, oxygen administration, secretion management, continuous positive airway pressure (CPAP), or nasal high-flow therapy have failed. MV is required for maintaining gas exchange and allows more time to curatively treat the underlying cause of respiratory failure. In the majority of ventilated patients, liberation or "weaning" from MV is routine, without the occurrence of any major problems. However, approximately 20% of patients require ongoing MV, despite amelioration of the conditions that precipitated the need for it in the first place. Approximately 40-50% of the time spent on MV is required to liberate the patient from the ventilator, a process called "weaning". In addition to acute respiratory failure, numerous factors can influence the duration and success rate of the weaning process; these include age, comorbidities, and conditions and complications acquired during the ICU stay. According to international consensus, "prolonged weaning" is defined as the weaning process in patients who have failed at least 3 weaning attempts, or require more than 7 days of weaning after the first spontaneous breathing trial (SBT). Given that prolonged weaning is a complex process, an interdisciplinary approach is essential for it to be successful. In specialised weaning centres, approximately 50% of patients with initial weaning failure can be liberated from MV after prolonged weaning. However, the heterogeneity of patients undergoing prolonged weaning precludes the direct comparison of individual centres. Patients with persistent weaning failure either die during the weaning process, or are discharged back to their home or to a long-term care facility with ongoing MV. Urged by the growing importance of prolonged weaning, this Sk2 Guideline was first published in 2014 as an initiative of the German Respiratory Society (DGP), in conjunction with other scientific societies involved in prolonged weaning. The emergence of new research, clinical study findings and registry data, as well as the accumulation of experience in daily practice, have made the revision of this guideline necessary. The following topics are dealt with in the present guideline: Definitions, epidemiology, weaning categories, underlying pathophysiology, prevention of prolonged weaning, treatment strategies in prolonged weaning, the weaning unit, discharge from hospital on MV, and recommendations for end-of-life decisions. Special emphasis was placed on the following themes: (1) A new classification of patient sub-groups in prolonged weaning. (2) Important aspects of pulmonary rehabilitation and neurorehabilitation in prolonged weaning. (3) Infrastructure and process organisation in the care of patients in prolonged weaning based on a continuous treatment concept. (4) Changes in therapeutic goals and communication with relatives. Aspects of paediatric weaning are addressed separately within individual chapters. The main aim of the revised guideline was to summarize both current evidence and expert-based knowledge on the topic of "prolonged weaning", and to use this information as a foundation for formulating recommendations related to "prolonged weaning", not only in acute medicine but also in the field of chronic intensive care medicine. The following professionals served as important addressees for this guideline: intensivists, pulmonary medicine specialists, anaesthesiologists, internists, cardiologists, surgeons, neurologists, paediatricians, geriatricians, palliative care clinicians, rehabilitation physicians, intensive/chronic care nurses, physiotherapists, respiratory therapists, speech therapists, medical service of health insurance, and associated ventilator manufacturers.

Predictors of participation and quality of life following major traumatic injuries in childhood: a systematic review

OBJECTIVE

Review the literature on predictors of participation and quality of life in children and young people who sustained a traumatic brain injury (TBI), spinal cord injury (SCI), and/or multi-trauma in a motor vehicle or other accident or trauma.

DESIGN

This systematic review was conducted and reported in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). The protocol was registered on PROSPERO (registration number CRD42020131698). Electronic databases were searched for studies published between January 2000 and August 2020. Prospective and retrospective cohort studies were considered and risk of bias was assessed using the Quality In Prognosis Studies (QUIPS) tool.

RESULTS

The search yielded 5771 articles of which 30 studies met the inclusion criteria. Nineteen studies included patients with TBI and 11 with SCI. No studies of patients with multi-trauma met criteria. Evidence was found for associations with various factors (e.g., injury severity, level of education, mental health problems), although these findings are limited due to the quality of the studies (5 studies moderate and 25 high risk of bias).

CONCLUSION

Research on predictors of participation and quality of life following major traumatic injuries in childhood is lacking. More methodologically sound prospective, longitudinal studies are needed across different injury groups to further elucidate predictors of outcome.IMPLICATIONS FOR REHABILITATIONWhile long-term participation and quality of life is influenced by injury characteristics (i.e., injury severity), a number of potential modifiable factors can be targeted to improve outcomes following traumatic injuries in childhood.Young people should be provided with support to stay in school and pursue further education.Early intervention and prevention of mental health problems may improve long-term outcomes.Better management of ongoing medical problems and greater support for functional independence may improve participation.

Sensory Processing, Functional Performance and Quality of Life in Unilateral Cerebral Palsy Children: A Cross-Sectional Study

Background: The study of children with unilateral cerebral palsy (UCP) has traditionally focused on motor aspects. The extent to which sensory processing disorders can affect their functional performance and quality of life (QoL) is uncertain. This study aimed to explore the differences in sensory processing between UCP and typical development (TD) children and to analyze the relationship of sensory processing with functional performance and QoL. Methods: Fifty-three children aged from 6 to 15 years (TD = 24; UCP = 29) were recruited. The Child Sensory Profile 2, Pediatric Evaluation of Disability Inventory—Computer Adaptive Test and Kidscreen were used to evaluate sensory processing, functional performance and QoL. Results: UCP children showed sensory processing difficulties (avoidance: p = 0.02; registration: p = 0.00; body position: p = 0.00; oral: p = 0.02; social-emotional: p = 0.01), and scored lower in functional performance (daily activities: p = 0.00; mobility: p = 0.00; social/cognitive: p = 0.04) and in physical well-being (p = 0.00). The highest correlations in UCP group were found between proprioceptive processing and daily activities and mobility (r = −0.39); auditory, visual and tactile information and school environment (r = −0.63; r = −0.51; r = −0.46); behavioral and social-emotional responses and psychological well-being (r = −0.64; r = −0.49). Conclusions: UCP children have greater difficulty in sensory processing than TD children. Difficulties in proprioceptive processing contribute to poorer functional performance. Auditory, visual and tactile processing is associated with participation in the school environment and behavioral and social-emotional responses related to sensory processing are associated with the psychological well-being.

Self-perceived gait quality in young adults with cerebral palsy

AIM

To explore how patients with cerebral palsy (CP) perceive their gait and evaluate associations between subjective gait perception and: objective gait parameters, endurance, pain, and fatigue.

METHOD

Sixty-two patients (21 females and 41 males; mean [SD] age 20y [5y 1mo], range 15-29y) performed a clinical gait analysis. Self-selected walking speed, Gait Profile Score, and Gait Variable Score were calculated. Subjective gait perception was assessed with a visual analogue scale using the question: 'On a scale from 0 (worst) to 10 (optimal), how would you describe your walking today?'. A 6-minute walk test (6MWT) measured endurance; the 36-Item Short Form Health Survey (SF-36) evaluated quality of life. T-tests, Pearson correlations, and univariate and multiple linear regression models were used to compare and find associations between the data.

RESULTS

Overall mean (SD) subjective gait perception was 7.5 (1.8) and was significantly higher for patients in Gross Motor Function Classification System (GMFCS) level I (7.9 [1.5]) than for patients in GMFCS levels II and III (5.9 [2.0]). Positive correlations were found between subjective gait perception and gait scores, walking speed, 6MWT distance, and SF-36 score. Only walking speed was a significant predictor of subjective gait perception.

INTERPRETATION

Subjective gait perception was influenced by GMFCS level and linked partially with the walking speed. The gait quality did not explain subjective gait perception. It is important to combine subjective and objective gait scores to develop personalized therapeutic goals.

WHAT THIS PAPER ADDS

Subjective gait perception is influenced by the physical impairment levels of patients with cerebral palsy. Subjective gait perception and objective gait scores are associated. Walking speed is the only predictor of gait perception.

Walking through life with cerebral palsy: reflections on daily walking by adults with cerebral palsy

Purpose: Walking is a major target in childhood physiotherapy for children with cerebral palsy (CP). Little information exists on the importance or value of walking when these children grow up. The aim of this study was to explore personal reflections on daily walking by adults with CP.

Method: Semi-structured individual interviews were conducted and analysed with systematic text condensation, a four-step thematic cross-case analysis.

Results: Eight ambulatory adults (26–60 years, four women and four men) with CP were interviewed. Almost all had experienced deteriorated walking ability in adulthood and reported that walking was restricted and affected by intrinsic features, such as pain, fatigue, reduced balance and fear of falling. Extrinsic features such as being looked at due to walking abnormality and environmental factors, such as seasonal changes affected their free walking and was common. Some had accepted using mobility aids for energy conservation.

Conclusions: Both intrinsic and extrinsic factors influence walking in adults with CP. Reflections by the adults with CP suggest these features may reduce participation in public spaces and potentially increase acceptance and use of mobility aids.

What is the functional mobility and quality of life in patients with cerebral palsy following single-event multilevel surgery?

PURPOSE

To report functional mobility in patients with diplegic cerebral palsy (CP) at long-term follow-up after single-event multilevel surgery (SEMLS). The secondary aim was to assess the relationship between functional mobility and quality of life (QoL) in patients previously treated with SEMLS.

METHODS

A total of 61 patients with diplegic CP, mean age at surgery 11 years, eight months (sd 2 years, 5 months), were included. A mean of eight years (sd 3 years, 10 months) after SEMLS, patients were contacted and asked to complete the Functional Mobility Scale (FMS) questionnaire over the telephone and given a weblink to complete an online version of the CP QOL Teen. FMS was recorded for all patients and CP QOL Teen for 23 patients (38%).

RESULTS

Of patients graded Gross Motor Function Classification System (GMFCS) I and II preoperatively, at long-term follow-up the proportion walking independently at home, school/work and in the community was 71% (20/28), 57% (16/28) and 57% (16/28), respectively. Of patients graded GMFCS III preoperatively, at long-term follow-up 82% (27/33) and 76% (25/33) were walking either independently or with an assistive device at home and school/work, respectively, while over community distances 61% (20/33) required a wheelchair. The only significant association between QoL and functional mobility was better 'feelings about function' in patients with better home FMS scores (r = 0.55; 95% confidence interval 0.15 to 0.79; p = 0.01).

CONCLUSION

The majority of children maintained their preoperative level of functional mobility at long-term follow-up after SEMLS.

LEVEL OF EVIDENCE

IV.

What predicts the proxy-reported health-related quality of life of adolescents with cerebral palsy in Bangladesh?

BACKGROUND

The health-related quality of life (HRQoL) of adolescents with CP in low and middle-income countries is often poor, as is the case in Bangladesh. This exploratory study examined what factors predict the proxy-reported HRQoL of adolescents with CP in rural Bangladesh, a typical low- and middle-income country (LMIC).

METHODS

Adolescents with CP (10 to 18y) were identified using the Bangladesh Cerebral Palsy Register. HRQoL was assessed using the Cerebral Palsy Quality of Life-Teens proxy-report questionnaire (CPQoL-Teens), adolescent mental health using the Strengths and Difficulty Questionnaire (SDQ) and caregiver mental health using the Depression, Anxiety and Stress Scale (DASS-21). Theoretical and statistical interests (i.e. bivariate analysis, p < 0.05) identified potential predictors which were entered into hierarchical multiple linear regression (HMLR) models in order of clinical significance; HMLR related adolescent clinical characteristics, adolescent and caregiver mental health and proxies of socioeconomic status to CPQoL-Teens dimensions.

RESULTS

One hundred fifty-four adolescents with CP (mean age 15y 1mo, SD 1y 8mo, female 31.2%) participated in this study. Twenty-four factors were identified to explore for relationship to adolescent proxy-reported HRQoL. Fifteen of the factors correlated to one or more CPQoL-Teens dimension; strongest correlation was between 'feelings about functioning' and motor impairment (r = 0.545). Nine were predictive of CPQoL-Teens dimensions; adolescent sex, school attendance, severity of motor impairment, hearing and speech impairment, mother's education, primary caregiver depression and stress, and having a sanitary latrine at home resulting in score changes of between 0.79 (95% CI 0.24 to 1.35) to 35.1 (95% CI 6.03 to 64.22).

CONCLUSIONS

Many of the factors predicting the proxy-reported HRQoL of adolescents with CP are amenable to intervention, and have the potential to improve adolescent wellbeing. Several determinants are priorities of the sustainable development goals (SDGs); these findings should inform resource prioritization to improve the wellbeing of adolescents with CP in Bangladesh and other LMICs.

A quality of life questionnaire for adolescents with cerebral palsy: psychometric properties of the Bengali CPQoL-teens

BACKGROUND

Quality of life (QoL) and health-related quality of life (HRQoL) measurement in low and middle-income countries of people with cerebral palsy (CP), the major cause of childhood physical disability, is essential to assess the impact of interventions and inform policies that best improve people's lives. The purpose of this study was to cross-culturally translate and psychometrically validate the Cerebral Palsy Quality of Life-Teens (CPQoL-Teens) self- and proxy-report questionnaires for application with adolescents with CP in Bangladesh.

METHOD

The CPQoL-Teens questionnaires were translated to Bengali using forward and backwards cross-cultural translation protocols. The questionnaires were interviewer administered to adolescents and their primary caregivers, identified through the Bangladesh Cerebral Palsy Register. Feasibility, sensitivity, internal consistency, content, concurrent and construct validity were assessed.

RESULTS

One hundred fifty four adolescents with CP (10 to 18y; mean 15y 1mo SD 1y 8mo; 31.2% female) participated. Feasibility, sensitivity and internal consistency of both self- and proxy-report questionnaires was excellent; nil missing scores except 'school wellbeing' which was associated with non-school attendance (48.4 to 74.7%); floor and ceiling effect ≤13.6%; Cronbach's alpha 0.77 to 0.94. Instrument validity was good; confirmatory factor analysis reflected five of the seven original instrument dimensions. CPQoL-Teens correlated to Kidscreen-27 on most dimensions (r = 0.176 to 0.693, p < 0.05); minimal difference in known groups was observed by mental health status (p < 0.05) although could be accounted for by homogeneity of mental health problems in the sample.

CONCLUSION

The CPQoL-Teens self- and proxy report questionnaires successfully translated to Bengali and showed excellent feasibility and strong psychometric properties confirming suitability to assess indicators of HRQoL among adolescents with CP in Bangladesh.

The Quality of Life of Polish Children with Cerebral Palsy and the Impact of the Disease on the Family Functioning

PURPOSE

Care and upbringing of a child with cerebral palsy (CP) may affect the functioning of parents and the whole family. This study aimed to evaluate the quality of life (QOL) of children with CP in parents' opinion and the impact of disease on family functioning.

DESIGN AND METHODS

This cross-sectional study was conducted among 100 parents of children with CP. Survey instruments used included an Authors-Designed Questionnaire (ADQ) to collect sociodemographic and educational background data as well as four standardized questionnaires for pediatric QOL (PedsQL-GC, PedsQL-CPM, PedsQL-FIM) and for life satisfaction (SWLS).

RESULTS

Teenagers were characterised by a higher QOL compared to other age groups. The lowest scores were observed in the PedsQL-CPM domain of daily and school activities and in the physical functioning domain of the PedsQL. It was shown that family functioning is affected by the children's age and place of residence as well as the level of parental education. It was also shown that men, parents in a relationship, those living in the city and those with vocational education were characterised by a higher level of satisfaction with life than other groups.

CONCLUSIONS

The QOL of children with CP is reduced compared to the QOL of healthy children and their condition has a significant impact on family functioning. Therefore, learning about the factors that influence QOL will allow health care providers to properly plan actions aimed at minimising the negative impact of CP on children's QOL and improving the functioning of their families.

Health-related quality of life and mental health of adolescents with cerebral palsy in rural Bangladesh

AIM

To assess the health-related quality of life (HRQoL) and mental health of adolescents with cerebral palsy (CP) in rural Bangladesh.

METHODS

Case-control study of adolescents with CP (10 to ≤18-years) and age and sex matched controls without disability. Primary caregivers were included for proxy report. HRQoL was measured with Bengali versions CP Quality of Life-Teens (CPQoL-Teens) and KIDSCREEN-27. Mental health was measured with Strengths and Difficulties Questionnaire (SDQ).

RESULTS

154 cases and 173 controls matched on age and sex participated (mean age 15.1 (1.6) and 14.9 (1.6) respectively; female n = 48, n = 55 respectively, p>0.05). CPQoL-Teens was administered to adolescents with CP only; mean outcomes ranged from 38.5 (27.4) to 71.5 (16.1) and 'feelings about functioning' was poorest domain for both self- and proxy-report groups. KIDSCREEN-27 was administered to adolescents with CP and controls; adolescents with CP mean outcomes ranged from 25.9 (12.2) to 48.7 (10.56) and were significantly poorer than controls, mean difference 4.3 (95% CI 0.7 to 7.8) to 16.7 (95% CI 14.5 to 18.5), p<0.05. 'Peers and social support' was poorest domain for all groups. In regards to mental health, adolescents with CP reported significantly poorer mean SDQ than peers without disability, mean difference 0.7 (95% CI 0.3 to 1.1) to 7.8 (95% CI 6.7 to 8.9), p<0.05; and were for self-report 7.8 (95% CI 2.6 to 23.0) and proxy-report 12.0 (95% CI 6.9 to 20.9) times more likely to report 'probable' range 'total difficulties' score. Individual item analysis of CPQoL-Teens and KIDSCREEN-27 identified unique areas of concern for adolescents with CP related to pain, friendships, physical activity and energy, what may happen later in life, and feelings about having CP. Financial resources were of concern for both cases and controls.

INTERPRETATION

Adolescents with CP in rural Bangladesh are at high risk of poor HRQoL and mental health problems. Effort to reduce the disparity between adolescents with CP and those without disability should consider wellbeing holistically and target dimensions including physical, psychological and social wellbeing. Specific interventions to alleviate modifiable aspects of HRQoL including pain, social isolation, and physical in-activity are recommended.

Health-related quality of life in adults with cerebral palsy living in Sweden and relation to demographic and disability-specific factors

BACKGROUND

The knowledge base on health-related quality of life (HRQoL) in adults with cerebral palsy (CP) is small and inconsistent.

OBJECTIVE

The aim was to study HRQoL in adults with CP stratified on demographic and disability-specific factors using both experience- and hypothetical-based value-sets.

METHODS

Cross-sectional study based on registry data from the Swedish follow-up program CPUP. The EQ-5D-3L (5 domains; self-care, usual activities, mobility, pain/discomfort, anxiety/depression) was used to measure HRQoL. The Swedish experience-based and the United Kingdom hypothetical-based value-sets were used to calculate the quality-adjusted life-years (QALY), and associations to demographic and disability-specific factors were studied in univariate and multivariate analyses.

RESULTS

The sample consisted of 408 adults with CP (189 women, 219 men), 18-73 years (mean age = 27, SD = 10). Approximately half reported no problems on self-care, usual activities, anxiety/depression, and some problems on mobility and pain/discomfort. Using the value-set based on experienced health states resulted in substantially higher HRQoL scores (0.77) compared to the hypothetical-based values (0.54) (when the health state is described to someone not personally experiencing it). Level of functioning and pain were strongly related to HRQoL, with gross motor functioning being a dominating factor. Sex and CP-subtype were not associated with HRQoL in the multivariate analysis.

CONCLUSIONS

HRQoL was found to be high in this Swedish population of adults with CP although severe pain and reduced functioning was associated with lower HRQoL. The choice of value-set have strong influence on the HRQoL estimations, especially for lower levels of functioning.

A systematic review of utility values in children with cerebral palsy

PURPOSE

Project aims include the following: (i) to identify reported utility values associated with CP in children aged ≤ 18 years; (ii) to explore utility value elicitation techniques in published studies; and (iii) to examine performance of the measures and/or elicitation approaches.

METHODS

Peer-reviewed studies published prior to March 2017 were identified from six electronic databases. Construct validity, convergent validity, responsiveness, and reliability of instruments were assessed.

RESULTS

Five studies met the inclusion criteria. Utility values of hypothetical general CP states obtained from a general population of parents ranged from 0.55 to 0.88 using time trade off (TTO) and 0.60-0.87 using standard gamble (SG) techniques. Utility values reported by clinicians of three hypothetical spastic quadriplegic CP states, using the Health Utility Index Mark 2 (HUI-2), ranged from 0.40 to 0.13. Other sources of utilities identified were based on both proxy and child ratings using Health Utility Index Mark 3 (HUI-3) (values ranged from - 0.013 to 0.84 depending on the valuation source) and the Assessment of Quality of Life 4 Dimension instrument, with values ranging from 0.01 to 0.58. Construct validity of the HUI-3 varied from moderate to strong, whereas mixed results were found for convergent validity. Responsiveness and reliability were not reported.

CONCLUSION

There was substantial variation in reported utilities. Indirect techniques (i.e. via multi-attribute utility instruments) were more frequently used than direct techniques (e.g. TTO, SG). Further research is required to improve the robustness of utility valuation of health-related quality of life in children with CP for use in economic evaluation.

Health-related quality of life of children and adolescents with cerebral palsy in low- and middle-income countries: a systematic review

AIM

To systematically review literature on health-related quality of life (HRQoL) of children and adolescents (≤18yo) with cerebral palsy (CP) from low- and middle-income countries (LMICs) to identify trends in HRQoL and areas for future research.

METHOD

We systematically reviewed six key bibliographic databases and two reviewers independently screened results. Peer-reviewed original articles examining HRQoL of children from LMICs were eligible.

RESULTS

A total of 22 524 papers were identified, of which 16, from eight LMICs, were included. Four measures of HRQoL were used; Child Health Questionnaire Parent Form 50 (n=5); Paediatric Quality of Life Inventory 3.0 and 4.0 (n=4); CP Quality of Life Questionnaire for Children (n=4); Lifestyle Assessment Questionnaire CP (n=3). Children with CP from LMICs (n=1579; 2-18y) had significantly poorer HRQoL on all instrument dimensions when compared to age-matched controls (p<0.003) and on all except two dimensions when compared to peers in high-income countries (p<0.001). Physical well-being dimensions of HRQoL were poorest overall and associated with impaired motor function.

INTERPRETATION

Research to improve HRQoL in LMICs is required and should address all aspects of HRQoL. Future research is recommended to incorporate multi-respondent assessment, utilize both general and CP-specific measures of HRQoL, and delineate adolescents as a unique cohort. What this paper adds Children with cerebral palsy from low- and middle-income countries are at high risk of poor health-related quality of life (HRQoL). Physical well-being was poorest dimension of HRQoL and associated with impaired motor function.

Longitudinal study showed that the quality of life of Finnish adolescents with cerebral palsy continued to be relatively good

AIM

This longitudinal study examined what perceptions paediatric patients with cerebral palsy (CP) and their caregivers had of the patient's quality of life (QoL). It examined changing trends as children with CP became adolescents and examined the feasibility of the Finnish version of the CP QOL-Teen questionnaire.

METHODS

Carried out in autumn 2015, this study formed part of the multi-centre Finnish national CP project and aimed to validate the CP QOL-Teen questionnaire, which was posted to 54 adolescents and their caregivers. They included 24 who had responded to CP QOL-Child questionnaire in 2013.

RESULTS

The questionnaires were returned by 27 pairs of adolescents and caregivers and one extra caregiver also responded. Of these, 24 pairs had taken part in the 2013 survey. The internal consistencies of the sum variables were found to be acceptable in all cases. Overall QoL showed an average score of 81.8 on a scale from 0 to 100. Adolescents reported significantly higher QoL than their caregivers. There were no significant differences between the responses of the children and adolescents.

CONCLUSION

We showed that QoL was relatively good in childhood and adolescence. The Finnish version of the CP QOL-Teen questionnaire was an appropriate clinical tool for assessing QoL.

Protocol for a systematic review of instruments for the assessment of quality of life and well-being in children and adolescents with cerebral palsy

INTRODUCTION

Cerebral palsy is the most common cause of physical disability in children and adolescents and is associated with impairments that may reduce the quality of life (QOL) of this population. Patient-reported outcome measures (PROMs) can facilitate the assessment of the effect of disease and treatment on QOL, from a patient viewpoint. The purpose of this systematic review is to identify PROMs that are used to measure QOL and subjective well-being (SWB) outcomes in young people with cerebral palsy and to evaluate the suitability of these PROMs for application in economic evaluations within this population.

METHODS AND ANALYSIS

MEDLINE, Scopus, the Cochrane Library, Web of Science Core Collection, EconLit, PsycINFO, CINAHL, EMBASE and Informit will be systematically searched from inception to date of search. Published peer-reviewed, English-language articles reporting PROMs measuring QOL or SWB outcomes in children and adolescents with cerebral palsy will be included. One reviewer will conduct the initial search and screen titles and abstracts for potentially eligible studies. The search will be performed in November 2017. To reduce the likelihood of reviewer selection bias, two other reviewers will independently screen a randomly selected subsample (10%) of the citations. Two reviewers will then retrieve full texts of potentially eligible studies and assess them against predefined inclusion criteria. The suitability of selected PROMs for use in economic evaluations of young people with cerebral palsy will be assessed using the International Society of Quality of Life Research recommended Minimum Standards and the Patient-Centered Outcomes and Comparative Effectiveness Research checklist. A narrative synthesis of extracted data will be presented including study descriptive data, PROMs measurement properties, settings in which they were applied and the valuation methods. Recommendations for practice on the selection of PROMs for use in economic evaluations of children and adolescents with cerebral palsy will be presented.

ETHICS AND DISSEMINATION

Ethical approval is not required as the proposed systematic review will not use primary data. The results of this study will be widely disseminated through publication in a peer-reviewed journal and conference presentation(s).

SYSTEMATIC REVIEW REGISTRATION NUMBER

International Prospective Register of Systematic Reviews number: CRD42016049746.

Measuring the health-related quality of life of children with impaired mobility: examining correlation and agreement between children and parent proxies

Objective

The objective of this research project was to evaluate the validity of proxy health-related quality of life measures in the context of paediatric mobility impairment. Accurate health-related quality of life data is essential for quality-adjusted life year calculation; a key outcome in economic evaluation. Thirteen child-parent dyads (13 children with mobility impairments, 13 parent proxies) were asked to complete a range of outcome measures (EQ-5D-Y, VAS and HUI2/3) relating to the child’s health. The relationship between respondent outcomes was examined using tests of respondent type effect (Wilcoxon signed-rank), correlation (Spearman’s rank-order) and agreement (Bland–Altman plots).

Results

Parent proxies significantly undervalued the health-related quality of life of their mobility-impaired children: children rated their health-related quality of life higher than their parents by proxy on all measures. The VAS had the highest overall mean score for children and proxies (79.50 [SD = 15.01] and 75.77 [SD = 14.70] respectively). Child and proxy results were significantly different (p < 0.05) for all measures besides the VAS (p = 0.138). Strong correlation and acceptable agreement were observed for equivalent child/proxy VAS and HUI measures. The EQ-5D-Y exhibited the least agreement between children and proxies. Sufficient association between child/proxy VAS and HUI measures indicated a degree of interchangeability.

An exploratory study investigating the multidimensional factors impacting the health and well-being of young adults with cerebral palsy

BACKGROUND

For young adults with cerebral palsy, changes in psychological and social development, in conjunction with the progression of musculoskeletal deformities and the onset of secondary conditions, make the transition to adulthood a difficult developmental phase. Preliminary evidence shows that many of the physical impairments reported in adults with cerebral palsy begin during late adolescence; however, there is little information about prevalence of impairments and the combined role impairments, psychological and social factors have on the health and well-being of young adults with cerebral palsy.

METHODS

A cross-sectional, multidimensional survey approach was used to examine the ambulatory decline, pain, pain interference, depression, fatigue, locus of control, emotional support, overall health status and satisfaction with life of young adults with cerebral palsy, age 18-30 years.

RESULTS

Ninety-seven surveys (57 self-report and 40 proxy report) were completed across all gross motor function classification system levels. No significant differences were found amongst functional levels for pain, pain interference, fatigue or depression. Only pain interference significantly contributed to the variance in health status, while emotional support significantly contributed to the variance in satisfaction with life.

CONCLUSIONS

The large percentage of young adults in this study reporting pain, fatigue and depression indicates that the onset of these impairments may begin at an earlier age. This study found that emotional support from family facilitates improved health status and enhanced satisfaction with life in young adults with cerebral palsy. Similar to physical impairments, social and psychological factors also contribute to the health and well-being of young adults with cerebral palsy, a holistic approach to care that includes preventative strategies to address both mental and physical health outcomes should begin well in advance to their transition into young adulthood in order to mitigate the impact these factors have on health and well-being during this critical developmental time. Implications for Rehabilitation Pain, fatigue and depression were reported for all levels of GMFCS and should be assessed and addressed with appropriate treatment early in order to determine whether there are surgical, pharmacological, rehabilitative or counseling services that could be implemented at a younger age to improve outcomes in young adulthood. For young adults with CP, emotional support plays a significant role in the health status and satisfaction with life and strategies to enhancing support beyond the family could enhance health status and satisfaction with life.

Proxy-reported quality of life in adolescents and adults with dyskinetic cerebral palsy is associated with executive functions and cortical thickness

PURPOSE

Quality of life (QOL) is a key outcome for people with cerebral palsy (CP), and executive functioning is an important predictor of QOL in other health-related conditions. Little is known about this association in CP or about its neural substrate. We aim to analyze the influence of executive functioning (including cognitive flexibility) as well as that of other psychological, motor, communication and socioeconomic variables on QOL and to identify neuroanatomical areas related to QOL in adolescents and adults with CP.

METHODS

Fifty subjects diagnosed with dyskinetic CP (mean age 25.96 years) were recruited. Their caregivers completed the primary caregiver proxy report version of the CP QOL-Teen questionnaire. Motor status, communication, IQ, four executive function domains, anxiety/depression and socioeconomic status were evaluated. Correlations and multiple linear regression models were used to relate CP QOL domains and total score to these variables. Thirty-six participants underwent an MRI assessment. Correlations were examined between cortical thickness and CP QOL total score and between cortical thickness and variables that might predict the CP QOL total score.

RESULTS

Executive functions predict scores in four domains of CP QOL (General well-being and participation, Communication and physical health, Family health and Feelings about functioning) in the regression model. Among the cognitive domains that comprise executive function, only cognitive flexibility measured in terms of performance on the Wisconsin card sorting test (WCST) predicts the CP QOL total score. Monthly income, fine motor functioning and communication ability predict scores on the domains Access to services and Family Health, Feelings about functioning and School well-being, respectively. The clusters resulting from the correlation between cortical thickness and both CP QOL total score and WCST performance overlapped in the posterior cingulate and precuneus cortices.

CONCLUSIONS

Cognitive flexibility predicts proxy report CP QOL-Teen total score in dyskinetic CP. This relationship has its anatomical correlate in the posterior cingulate and precuneus cortices.

A Qualitative Study of Physician Perspectives on Prognostication in Neonatal Hypoxic Ischemic Encephalopathy

Hypoxic ischemic encephalopathy is the most frequent cause of neonatal encephalopathy and yields a great degree of morbidity and mortality. From an ethical and clinical standpoint, neurological prognosis is fundamental in the care of neonates with hypoxic ischemic encephalopathy. This qualitative study explores physician perspectives about neurological prognosis in neonatal hypoxic ischemic encephalopathy. This study aimed, through semistructured interviews with neonatologists and pediatric neurologists, to understand the practice of prognostication. Qualitative thematic content analysis was used for data analysis. The authors report 2 main findings: (1) neurological prognosis remains fundamental to quality-of-life predictions and considerations of best interest, and (2) magnetic resonance imaging is presented to parents with a greater degree of certainty than actually exists. Further research is needed to explore both the parental perspective and, prospectively, the impact of different clinical approaches and styles to prognostication for neonatal hypoxic ischemic encephalopathy.

Single-level selective dorsal rhizotomy for spastic cerebral palsy

The management of cerebral palsy (CP) is complex and requires a multidisciplinary approach. Selective dorsal rhizotomy (SDR) is a neurosurgical technique that aims to reduce spasticity in the lower limbs. A minimally invasive approach to SDR involves a single level laminectomy at the conus and utilises intraoperative electromyography (EMG). When combined with physiotherapy, SDR is effective in selected children and has minimal complications. This review discusses the epidemiology of CP and the management using SDR within an integrated multidisciplinary centre. Particular attention is given to the single-level laminectomy technique of SDR and its rationale, and the patient workup, recovery and outcomes of SDR.

Physical Activity Among Adolescents with Cerebral Palsy: An Integrative Review

PROBLEM

Physical activity is necessary for optimum physical and psychosocial health in the general population. It is even more important for adolescents who struggle with impairments that limit motor function. Recommendations for best practice are needed as adolescents transition into adulthood.

PURPOSE

An integrative review was performed to determine the state of the science regarding 1) what factors impact physical activity in adolescents with cerebral palsy, and 2) how the needs of this population have been addressed regarding physical activity.

SEARCH STRATEGY

A literature search of MEDLINE, CINAHL, and PubMed was conducted using the terms cerebral palsy, mobility or activity, and adolescents. Exclusion criteria were surgical or pharmacological interventions.

RESULTS OF THE LITERATURE SEARCH

Descriptive and intervention studies were included and evaluated for purpose, design, and key findings.

SYNTHESIS OF EVIDENCE

Correcting the decline of physical activity in adolescents with CP may carry benefits over into adulthood. There are few studies that adapt physical activity to age and level of impairment. Several studies support approaching physical activity from a social model, focusing on participation of the person in the context of environment. There is a lack of research incorporating family-centered care. Many study designs are shallow and lack the proper instruments for assessing outcomes.

IMPLICATIONS FOR PRACTICE

Home and community based interventions need to be developed that are individualized. More studies are needed with stronger research designs and better instruments in order to generalize results for practice.

Socialization and nonverbal communication in atypically developing infants and toddlers

Emphasis on early identification of atypical development has increased as evidence supporting the efficacy of intervention has grown. These increases have also directly affected the availability of funding and providers of early intervention services. A majority of research has focused on interventions specific to an individual's primary diagnoses. For example, interventions for those with cerebral palsy (CP) have traditionally focused on physiological symptoms, while intervention for individuals with Autism Spectrum Disorder (ASD) focus on socialization, communication, and restricted interests and repetitive behaviors. However deficits in areas other than those related to their primary diagnoses (e.g., communication, adaptive behaviors, and social skills) are prevalent in atypically developing populations and are significant predictors of quality of life. Therefore, the purpose of the current study was to examine impairments in socialization and nonverbal communication in individuals with Down's syndrome (DS), CP, and those with CP and comorbid ASD. Individuals with comorbid CP and ASD exhibited significantly greater impairments than any diagnostic group alone. However, individuals with CP also exhibited significantly greater impairments than those with DS. The implications of these results are discussed.

A lifestyle intervention improves fatigue, mental health and social support among adolescents and young adults with cerebral palsy: focus on mediating effects

Objective:

To evaluate the effect of a lifestyle intervention on fatigue, participation, quality of life, gross motor functioning, motivation, self-efficacy and social support, and to explore mediating effects of physical behavior and physical fitness.

Design:

A randomized controlled trial with intention to treat analysis.

Setting:

Rehabilitation centers in university hospitals in the Netherlands.

Subjects:

Adolescents and young adults with spastic cerebral palsy.

Interventions:

A six-month lifestyle intervention that consisted of physical fitness training combined with counseling sessions focused on physical behavior and sports participation.

Main measures:

Fatigue, social participation, quality of life and gross motor functioning.

Results:

The lifestyle intervention was effective in decreasing fatigue severity during the intervention (difference = –6.72, p = 0.02) and in increasing health-related quality of life with respect to bodily pain (difference = 15.14, p = 0.01) and mental health (difference = 8.80, p = 0.03) during follow-up. Furthermore, the domain participation and involvement of the social support increased during both the intervention (difference = 5.38, p = 0.04) and follow-up (difference = 4.52, p = 0.03) period. Physical behavior or physical fitness explained the observed effects for 22.6%, 9.7% and 28.1% of improvements on fatigue, bodily pain and mental health, but had little effect on social support (2.6%).

Interpretation:

Fatigue, bodily pain, mental health and social support can be improved using a lifestyle intervention among adolescents and young adults with cerebral palsy. Furthermore, substantial mediating effects were found for physical behavior and physical fitness on fatigue, bodily pain and mental health.

Validation of the activPAL activity monitor in children with hemiplegic gait patterns resultant from cerebral palsy

BACKGROUND

Current investigation of treatment outcomes by clinicians is currently hampered by a lack of clinically viable tools. The use of activity monitors specifically validated for a population could help resolve this situation.

OBJECTIVES

The purpose of the study was to validate an activity monitor for monitoring children with cerebral palsy. The study was designed to validate the duration of time spent sitting, standing and walking and the number of steps taken when being measured by the activPAL activity monitor.

STUDY DESIGN

A validation study was undertaken.

METHODS

Observations of participants were carried out while completing a specifically designed activity course using video footage, which were then compared to the output from the activity monitor.

RESULTS

The activity monitor was found to be valid for the time spent standing and walking, the number of steps taken and the number of transitions.

CONCLUSIONS

The results demonstrated that the monitor may prove useful to clinicians as a measurement outcome device for children with hemiplegic gait patterns resultant from cerebral palsy. However, the sensitivity of the device is variable, and further investigations are necessary to confirm it would also be able to detect minor changes after interventions.

CLINICAL RELEVANCE

The monitor may provide clinicians with a simplistic tool that is easily utilised, to enable audit exercises of current and future treatments.

Health-related quality of life of ambulant adults with cerebral palsy and its association with falls and mobility decline: a preliminary cross sectional study

Background

Despite an increasing number of studies examining the profile of falls and mobility decline in adults with cerebral palsy (CP), little is known about its impact on an individual’s life quality. The aim of this preliminary study was to assess the wellbeing and health status aspects of health-related quality of life (HRQOL) in ambulant adults with CP and explore the relationship of falls and mobility decline with HRQOL.

Method

Ambulant adults with CP completed postal surveys which sought demographic data, mobility (Gross Motor Function Classification System; GMFCS-E&R), presence of mobility decline, falls history, and HRQOL (Personal Wellbeing Index (PWI), Short Form-36 Health Survey (SF-36)).

Results

Thirty-four community-dwelling ambulant adults with CP with a mean age of 44.2 years (SD; 8.6; range 26–65) participated. Twenty-eight (82%) participants reported mobility decline since reaching adulthood, and a similar proportion of individuals (82%) reported having had more than two falls in the previous year. The health status and wellbeing of this sample of ambulant adults with CP were generally lower compared with the Australian normative population. Mobility decline was found by univariate regression analysis to be associated with mental health status (β = 0.52; p = 0.002), but not when other predictor variables were included in the multivariate model (β = 0.27; p = 0.072). In contrast, self-reported history of falls was found to be a significant contributing factor for both physical health status (β = −0.55; p = 0.002) and personal wellbeing (β = −0.43; p = 0.006).

Conclusions

This sample of ambulant adults with CP perceived their HRQOL to be poor, with some health status and wellbeing domains below that of population wide comparisons. A majority of these individuals also experienced a fall in the last year and a decline in their mobility since reaching adulthood. While further research is required, this preliminary study has highlighted the potential implications of falls and mobility decline on HRQOL in adults with CP.

Quality of life in children with cerebral palsy: implications for practice

The ability to assess the quality of life of children with cerebral palsy to inform and evaluate individual care plans, service planning, interventions, and policies is crucial. In this article, the recent evidence on quality of life in children with cerebral palsy is reviewed, with attention to the determinants of quality of life and role of this construct as a practical outcome indicator in clinical trials. Quality of life measurement advances for children with cerebral palsy are discussed with a focus on condition-specific quality of life measures, particularly, the Cerebral Palsy Quality of Life-Child, which is the first condition-specific quality of life measure for children with cerebral palsy. The article presents an overview for clinicians and researchers intending to use quality of life measures on children with cerebral palsy and provides recommendations for future research that will better inform practice in the field.

Exploring young patients’ perspectives on rehabilitation care: methods and challenges of organizing focus groups for children and adolescents

BACKGROUND

In research on quality of care, the experiences of children and (pre)adolescents are usually assessed by asking their parents. However, these young patients may have preferences of their own, and their experiences do not necessarily concur with those of their parents. Therefore, our research aimed to give young patients an opportunity to speak up for themselves.

METHODS

Focus group meetings and online focus groups were organized for two age groups (8–11 and 12–15 years) of young patients from two Dutch rehabilitation centres, with the use of a tailored interview technique. The feasibility and applicability of both types of focus groups were assessed.

RESULTS

For both types of focus groups, recruitment proved a major problem. The focus group meetings with (pre)adolescents proved both feasible and applicable in obtaining information regarding the preferences and experiences towards rehabilitation care. Regarding children's meetings, there were mixed results. The setting suited most of them, but some were more anxious. In general, online focus groups were less successful than expected for both age groups.

CONCLUSIONS

Possibilities for enhancing the recruitment rate should be considered, as the low participation rates limited generalizability of focus group results. The tailored design proved useful for obtaining relevant input from (pre)adolescents through meetings, but, especially for children, repeated meetings or other locations (e.g. at home) could be considered. This may make participants more at ease. For both age groups, the online focus groups proved far less useful, in terms of participation.

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.

Adolescents with cerebral palsy: transitioning to adult health care services

Data from the 2009-2010 US National Survey of Children with Special Health Care Needs were examined to determine the health, developmental and behavioral status of adolescents with cerebral palsy (CP) and to assess how well pediatric health care providers were preparing them for transition to adult health care services. Adolescents with CP had no higher rates of attention deficit hyperactivity disorder, depression, anxiety, oppositional or conduct disorders, or autism spectrum than a comparison group. However, those with CP participated less in sports, clubs, or other organized activities (P < .001). Neither group reported much help in coordinating health services or preparing for transition to adult health care services. Inadequate adult health care services have a direct and unsatisfactory impact on the adult life span. Physicians and other health care providers who include adolescents with CP in their practices should begin discussion and planning for transition to adult health care early in adolescence.

ICF-based functional components and contextual factors as correlates of perceived quality of life for youth with chronic conditions

PURPOSE

To explore International Classification of Functioning, Disability and Health (ICF)-based functional components and contextual factors associated with perceived quality of life (QOL) for youth with chronic conditions from the perspective of youth and parents.

METHOD

Baseline data were obtained from a longitudinal study examining predictors of changes in perceived QOL for youth with chronic conditions. 439 youth aged 11-17 (and one of their parents) completed a questionnaire. Standardized tools were used to measure youth functioning, contextual factors and perceived QOL. Multivariate linear regression analyses, controlling for socio-demographic and health information, were conducted to explore correlations among youth functioning/contextual factors and youth and parent perceptions of youth QOL.

RESULTS

Significant (p ≤ 0.05) negative correlates with both youth and parent perceptions of youth QOL included pain/other physical symptoms and emotional symptoms. Significant factors positively correlated with youth and parent perceptions of youth QOL included school productivity and spirituality. Other significant positive correlates of youth perspectives were family social support and school belongingness/safety. Family functioning was positively correlated, and youth social anxiety and environmental barriers were negatively correlated, with parent perceptions of youth QOL.

CONCLUSIONS

This study provides preliminary evidence of factors upon which services aimed at improving perceived QOL of youth with chronic conditions could be based.

IMPLICATIONS FOR REHABILITATION

This study supports the utility of clinicians assessing the QOL of youth with chronic conditions in terms of youths' and their families' perspectives. This is the first study to identify key factors that impact perceived QOL at one point in time across a group of youth with chronic conditions, offering clinicians a main starting-point for considering youths' strengths and needs and the supportiveness of the environment. Findings suggest youth and families would benefit from the availability of services that encompass the full scope of the ICF.

A physical fitness follow-up in children with cerebral palsy receiving 12-week individualized exercise training

Physical fitness in children with cerebral palsy (CP) is lower than in their peers. A 12-week individualized home-based exercise program completed by 11 children with CP 10 years earlier showed a favorable effect on physical fitness performance. We follow-up the physical fitness of those 11 children with CP, and compare their physical fitness and health-related quality of life (HRQoL) to children with CP without exercise training matched with age and motor levels. Eleven children with CP in the 2003 program as a follow-up group (FUG) and 12 volunteers recruited as a control group (CG) participated in this study. Physical fitness measures, including cardiopulmonary endurance, muscle strength, body mass index (BMI), flexibility, agility, balance, and the SF-36 Taiwan version, were assessed in both groups. After 10 years, the FUG showed better physical fitness in cardiopulmonary endurance and muscle strength (p<.05). Compared to the CG, the FUG demonstrated better muscle strength, agility, and balance (p<.05). However, the HRQoL did not show a significant difference between the FUG and the CG. Individualized home-based exercise training is beneficial for children with CP. Over 10 years, the FUG was more devoted to physical activity than was the CG. Physical exercise may not directly affect the HRQoL in this study.