Validity and reliability of the guidelines of the surveillance of cerebral palsy in Europe for the classification of cerebral palsy

Uncertainties Regarding Cerebral Palsy Diagnosis: Opportunities to Clarify the Consensus Definition

Background and Objectives

We have established that physicians, including neurologists, variably diagnose cerebral palsy (CP) when using the most recent CP definition from 2006. We also know that child neurologists and neurodevelopmentalists view themselves to be optimally suited to diagnose CP based on their training backgrounds. Therefore, to reduce variability in CP diagnosis, our objective was to elucidate uncertainties child neurologists and neurodevelopmentalists may have regarding practical application of the 2006 definition.

Methods

We conducted a cross-sectional survey of child neurologists and neurodevelopmentalists built into a discussion seminar at the 2022 Child Neurology Society (CNS) Annual Meeting, the largest professional meeting of these specialists in North America. Seminar attendees were provided the 2006 definition and asked whether they had any uncertainties about the practical application of the definition across 4 hypothetical clinical vignettes. A group of national and international CP leaders then processed these data through iterative discussions to develop recommendations for clarifying the 2006 definition.

Results

The seminar was attended by 50% of all conference attendees claiming CME (202/401). Of the 164 closing survey respondents, 145 (88%) expressed uncertainty regarding the clinical application of the 2006 definition. These uncertainties focused on 1) age, both regarding the minimum and maximum ages of brain disturbance or motor symptom onset (67/164, 41%), and 2) interpretation of the term "nonprogressive" (48/164, 29%). Almost all respondents (157/164, 96%) felt that we should revise the 2006 consensus definition of CP.

Discussion

To address the most common CP diagnostic uncertainties we identified, we collectively propose 4 points of clarification to the 2006 definition: 1) motor symptoms/signs should be present by 2 years old; 2) CP can and should be diagnosed as early as possible; 3) the clinical motor disability phenotype should be nonprogressive through 5 years old; and 4) a CP diagnosis should be re-evaluated if motor disability is progressive or absent by 5 years old. We anticipate that clarifying the 2006 definition of CP in this manner could address the uncertainties we identified among child neurologists and neurodevelopmentalists and reduce the diagnostic variability that currently exists.

Standardized clinical data capture to describe cerebral palsy

Objective

To describe a standardized methodology for capturing clinically valuable information on young people with cerebral palsy (CP) from caregivers and clinicians during routine clinical care.

Methods

We developed a caregiver-facing intake form and clinician-facing standardized note template and integrated both into routine clinical care at a tertiary care CP center ( https://bit.ly/CP-Intake-Methodology ). We extracted this caregiver and clinician-entered data on people with an ICD10 diagnosis of CP seen between 3/22/23 and 12/28/23. We used this data to describe how CP manifests in this group and which medical features affected the odds of walking, oral feeding, and speech by age 5.

Results

Of 686 visits, 663 (97%) had caregiver- and clinician-entered data and 633 had a clinician-confirmed CP diagnosis (mean age 9.1, 53.4% Male, 78.5% White). It was common to have quadriplegia (288/613, 47.0%), both spasticity and dystonia (257/632, 40.7%), walk independently (368/633, 58.1%), eat all food and drink safely by mouth (288/578, 55.9%), and produce understandable speech (249/584, 42.6%). Cortical grey matter injury and duration of initial critical care unit stay affected the odds of walking, oral feeding, and speech (binary logistic regression, p<0.001).

Conclusions

We comprehensively captured caregiver and clinician-entered data on 97% of people seen in a tertiary care CP Center and used this data to determine medical features affecting the odds of three functional outcomes. By sharing our methodology, we aim to facilitate replication of this dataset at other sites and grow our understanding of how CP manifests in the US.

Article summary

Using caregiver and clinician-entered data on people seen in a tertiary-care CP center, we determined medical features affecting the odds of three functional outcomes.

What’s known on this subject

Detailed CP characterization can be limited if using population-based registries and retrospective chart review alone, including limited data on recently validated functional classification systems for CP.

What this study adds

We comprehensively captured caregiver and clinician-entered data on 97% of people seen in our CP Center to describe how CP manifests and show that cortical injury and initial ICU stay duration affect the odds of walking, oral feeding, and speech.

Contributors Statement

Susie Kim helped design the study, aggregated data, carried out data analyses, and critically reviewed and revised the manuscript.Kelsey Steffen helped conceptualize and design the study and critically reviewed and revised the manuscript.Lauren Gottschalk, Jennifer Miros, Katie Leger, Amy Viehoever, and Karen Taca helped design the study and critically reviewed and revised the manuscript.Bhooma Aravamuthan conceptualized and designed the study, supervised data collection and analysis, drafted the initial manuscript, and critically reviewed and revised the manuscript.

Stimulus zones of Vojta method and trunk control in children with spastic-type cerebral palsy: A quasi-experimental pilot study

BACKGROUND

Vojta method improves motor function by inducing a response by pressing the stimulus zones.

PURPOSE

To determine the effect of the stimulus zones on trunk muscle thickness, trunk control, trunk angle, and gross motor function in children with spastic-type cerebral palsy.

METHODS

A quasi-experimental pilot study was conducted with 19 children with spastic-type cerebral palsy divided into two groups: Vojta method group (n = 10) and general physical therapy group (n = 9). Each group underwent a 6-week intervention, and assessments were conducted to evaluate abdominal muscle thickness, trunk control, trunk angle, and gross motor function.

RESULTS

In the Vojta method group, the change rate in the thickness of the internal oblique and transversus abdominis increased significantly within the group (P < 0.05) and the difference (post-pre) of the transversus abdominis was higher (P < 0.05). The trunk angle increased significantly within the group when thoracic 7 and 11, lumbar 3, and sacrum 1 were supported (P < 0.05). There was a significant difference in trunk angle difference (post-pre) between groups when thoracic 11 and sacrum 1 were supported (P < 0.05). Segmental assessment of trunk control and gross motor function measure-88 scores were significantly increased within the group in all groups (P < 0.05).

CONCLUSION

The stimulus zones of the Vojta method could improve trunk control in children with spastic-type cerebral palsy through intra-abdominal pressure and anti-gravity movement.

The diagnosis of cerebral palsy in two Danish national registries: a validation study

AIMS

To determine the quality of prospectively collected data from the highly specialized Danish Cerebral Palsy Follow-up Program (CPOP), and to establish the validity of a reported cerebral palsy (CP) diagnosis in the Danish National Patient Registry (NPR), regularly used as a proxy for neurodevelopmental disorders in epidemiological research.

METHODS

We compared data from the two registries on children with registered CP, born in Denmark between 2008 and 2009, with information from medical records verified by two experienced physicians specializing in pediatric neurology. Data accuracy was estimated by completeness, correctness, and reliability. Completeness was calculated as the number of cases with correctly registered CP diagnoses divided by the total number of true CP diagnoses (similar to sensitivity). Correctness was calculated as the number of cases with correct registrations divided by the total number of cases (similar to positive predictive value). Reliability was estimated using kappa statistics.

RESULTS

Registered CP diagnoses in the CPOP had high accuracy, with 94% correctness and 91% completeness. Furthermore, most key variables in the CPOP showed excellent reliability, especially variables defining the severity of the condition. In the Danish NPR, only 225 of 348 children with a noted CP diagnosis fulfilled the diagnostic criteria for CP, resulting in 65% correctness.

CONCLUSIONS

Danish CPOP data are a valid source for epidemiological research. Conversely, a noted CP diagnosis in the Danish NPR was, at best, correct in only two out of three patients.

Predictive value of General Movements Assessment for developmental delay at 18 months in children with complex congenital heart disease

BACKGROUND

Infants with complex congenital heart disease are at increased risk of impaired fetal brain growth, brain injury, and developmental impairments. The General Movement Assessment (GMA) is a valid and reliable tool to predict cerebral palsy (CP), especially in preterm infants. Predictive properties of the GMA in infants with complex congenital heart disease (CCHD) are unknown.

AIM

To evaluate predictive properties of the GMA to predict developmental outcomes, including cerebral palsy (CP), at 18-months corrected age (CA) in children with CCHD undergoing heart surgery in the first month of life.

METHODS

A prospective cohort of 56 infants with CCHD (35 males, 21 females) was assessed with GMA at writhing age (0-6 weeks CA) and fidgety age (7-17 weeks CA) and the Bayley Scales of Infant Development at 18 months. GMA focused on markedly reduced GM-variation and complexity (definitely abnormal (DA) GM-complexity) and fidgety movements. Predictive values of GMA for specific cognitive, language and motor delay (composite scores <85th percentile) and general developmental delay (delay in all domains) were calculated at 18 months.

RESULTS

At fidgety age, all infants had fidgety movements and no child was diagnosed with CP. DA GM-complexity at fidgety age predicted general developmental delay at 18 months (71 % sensitivity, 90 % specificity), but predicted specific developmental delay less robustly. DA GM-complexity at writhing age did not predict developmental delay, nor did it improve prediction based on DA GM-complexity at fidgety age.

CONCLUSIONS

In infants with CCHD and fidgety movements, DA GM-complexity at fidgety age predicted general developmental delay.

Prevalence of cerebral palsy and factors associated with cerebral palsy subtype: A population-based study in Belgium

AIM

To report on the prevalence, neuroimaging patterns, and function of children with cerebral palsy (CP) in Belgium for birth years 2007-2012, and identify distinctive risk indicators and differences in outcome between CP subtypes.

METHODS

Antenatal and perinatal/neonatal factors, motor and speech function, associated impairments, and neuroimaging patterns were extracted from the Belgian Cerebral Palsy Register. Prevalence was estimated per 1000 (overall, ante/perinatal, spastic, dyskinetic CP) or 10,000 (post-neonatal, ataxic CP) live births. Multinomial logistic regression analyses were performed to ascertain the effects of antenatal/perinatal/neonatal factors and neuroimaging patterns on the likelihood of dyskinetic or ataxic CP relative to spastic CP, and test the likelihood of the occurrence of impaired motor and speech function and associated impairments in dyskinetic or ataxic CP relative to spastic CP.

RESULTS

In total, 1127 children with CP were identified in Belgium. The birth prevalence of overall CP was 1.48 per 1000 live births. The likelihood of dyskinetic CP increases if the child was born to a mother aged ≥35 years, mechanically ventilated, and had predominant grey matter injury, while an increased likelihood of ataxic CP is associated with ≥2 previous deliveries. Children with dyskinetic and ataxic CP are more likely to function with impairments in motor, speech, and intellectual abilities.

CONCLUSION

Distinctive risk indicators and differences in outcome between CP subtypes were identified. These factors can be incorporated into clinical practice to facilitate early, accurate, and reliable classification of CP subtype, and may lead to individually tailored neonatal care and other (early) intervention options.

Uncertainties regarding cerebral palsy diagnosis: opportunities to operationalize the consensus definition

Background and Objectives

Cerebral palsy (CP), the most common motor disability of childhood, is variably diagnosed. We hypothesized that child neurologists and neurodevelopmentalists, often on the frontlines of CP diagnosis in North America, harbor uncertainties regarding the practical application of the most recent CP consensus definition from 2006.

Methods

We conducted a cross-sectional survey of child neurologists and neurodevelopmentalists at the 2022 Child Neurology Society Annual Meeting. Attendees were provided the 2006 CP consensus definition and asked whether they had any uncertainties about the practical application of the definition across four hypothetical clinical vignettes.

Results

Of 230 attendees, 164 responded to the closing survey questions (71%). 145/164 (88%) expressed at least one uncertainty regarding the clinical application of the 2006 definition. Overwhelmingly, these areas of uncertainty focused on: 1) Age, both with regards to the minimum age of diagnosis and the maximum age of brain disturbance or motor symptom onset, (67/164, 41%), and 2) Interpretation of the term "non-progressive" (48/164, 29%). The vast majority of respondents (157/164, 96%) answered 'Yes' to the question: Do you think we should revise the 2006 consensus definition of CP?

Discussion

We propose that the uncertainties we identified could be addressed by operationalizing the 2006 consensus definition to support a more uniform CP diagnosis. To address the most common CP diagnostic uncertainties we identified, we propose 3 points of clarification based on the available literature: 1) Motor symptoms/signs should be present by 2 years old; 2) CP can and should be diagnosed as early as possible, even if activity limitation is not yet present, if motor symptoms/signs can be reasonably predicted to yield activity limitation (e.g. by using standardized examination instruments, Brain MRI, and a suggestive clinical history); and 3) The clinical motor disability phenotype should be non-progressive through 5 years old. We anticipate that operationalizing the 2006 definition of CP in this manner could clarify the uncertainties we identified among child neurologists and neurodevelopmentalists and reduce the diagnostic variability that currently exists.

Identifying Postural Instability in Children with Cerebral Palsy Using a Predictive Model: A Longitudinal Multicenter Study

Insufficient postural control and trunk instability are serious concerns in children with cerebral palsy (CP). We implemented a predictive model to identify factors associated with postural impairments such as spastic or hypotonic truncal tone (TT) in children with CP. We conducted a longitudinal, double-blinded, multicenter, descriptive study of 102 teenagers with CP with cognitive impairment and severe motor disorders with and without truncal tone impairments treated in two specialized hospitals (60 inpatients and 42 outpatients; 60 males, mean age 16.5 ± 1.2 years, range 12 to 18 yrs). Clinical and functional data were collected between 2006 and 2021. TT-PredictMed, a multiple logistic regression prediction model, was developed to identify factors associated with hypotonic or spastic TT following the guidelines of "Transparent Reporting of a multivariable prediction model for Individual Prognosis or Diagnosis". Predictors of hypotonic TT were hip dysplasia (p = 0.01), type of etiology (postnatal > perinatal > prenatal causes; p = 0.05), male gender, and poor manual (p = 0.01) and gross motor function (p = 0.05). Predictors of spastic TT were neuromuscular scoliosis (p = 0.03), type of etiology (prenatal > perinatal > postnatal causes; p < 0.001), spasticity (quadri/triplegia > diplegia > hemiplegia; p = 0.05), presence of dystonia (p = 0.001), and epilepsy (refractory > controlled, p = 0.009). The predictive model's average accuracy, sensitivity, and specificity reached 82%. The model's accuracy aligns with recent studies on applying machine learning models in the clinical field.

PredictMed-epilepsy: A multi-agent based system for epilepsy detection and prediction in neuropediatrics

BACKGROUND AND OBJECTIVE

Epileptic seizures are associated with a higher incidence of Developmental Disabilities and Cerebral Palsy. Early evaluation and management of epilepsy is strongly recommended. We propose and discuss an application to predict epilespy (PredictMed-Epilepsy) and seizures via a deep-learning module (PredictMed-Seizures) encompassed within a multi-agent based healthcare system (PredictMed-MHS); this system is meant, in perspective, to be integrated into a clinical decision support system (PredictMed-CDSS). PredictMed-Epilespy, in particular, aims to identify factors associated with epilepsy in children with Developmental Disabilities and Cerebral Palsy by using a prediction-learning model named PredictMed. PredictMed-epilespy methods: We performed a longitudinal, multicenter, double-blinded, descriptive study of one hundred and two children with Developmental Disabilities and Cerebral Palsy (58 males, 44 females; 65 inpatients, 37 outpatients; 72 had epilepsy - 22 of intractable epilepsy, age: 16.6±1.2y, range: 12-18y). Data from 2005 to 2021 on Cerebral Palsy etiology, diagnosis, type of epilepsy and spasticity, clinical history, communication abilities, behaviors, intellectual disability, motor skills, and eating and drinking abilities were collected. The machine-learning model PredictMed was exploited to identify factors associated with epilepsy. The guidelines of the "Transparent Reporting of a multivariable prediction model for Individual Prognosis or Diagnosis" Statement (TRIPOD) were followed. PredictMed-epilepsy results: Cerebral Palsy etiology [(prenatal > perinatal > postnatal causes) p=0.036], scoliosis (p=0.048), communication (p=0.018) and feeding disorders (p=0.002), poor motor function (p<0.001), intellectual disabilities (p=0.007), and type of spasticity [(quadriplegia/triplegia > diplegia > hemiplegia), p=0.002)] were associated with having epilepsy. The prediction model scored an average of 82% of accuracy, sensitivity, and specificity. Thus, PredictMed defined the computational phenotype of children with Developmental Disabilities/Cerebral Palsy at risk of epilepsy. Novel contribution of the work: We have been developing and we have prototypically implemented a Multi-Agent Systems (MAS) that encapsulates the PredictMed-Epilepsy module. More specifically, we have implemented the Patient Observing MAS (PoMAS), which, as a novelty w.r.t. the existing literature, includes a complex event processing module that provides real-time detention of short- and long-term events related to the patient's condition.

Public health indicators for cerebral palsy: A European collaborative study of the Surveillance of Cerebral Palsy in Europe network

BACKGROUND

Public health indicators (PHIs) play an increasingly important role in health policy decision-making. Although cerebral palsy (CP) is the commonest physical disability in children, its impact at population level has not been systematically measured so far.

OBJECTIVES

We aimed to propose six PHIs for CP designed to annually document the extent of CP and effectiveness of perinatal organisation, the burden of this condition, access to health services and preventive health strategies in the post-neonatal period and to report on the latest updated estimations using population-based data routinely collected by European CP registries.

METHODS

The study included children with CP born between 2002 and 2011. Harmonised data (number of cases, functional profile, imaging) were extracted from the Surveillance of Cerebral Palsy in Europe (SCPE) database. Eligibility criteria for analyses were applied separately for each indicator by selecting registries, birth years and CP cases. Current estimates were based on the last 3 birth years, while trends were reported over a 10-year period. All analyses were descriptive. Sensitivity analyses were carried out to examine the stability of the results using various thresholds of percentages of missing values.

RESULTS

Analyses were performed on a total of 8621 children with CP from 12 to 17 SCPE registries. A decreasing prevalence of pre/perinatal CP overall, as well as in preterm and full-term-born children, was observed. The burden of the condition was strongly dependent on CP subtype and the presence of associated impairments. Access to brain imaging ranged from 80% to 100% depending on registries. The overall prevalence of post-neonatally acquired CP was approximately 0.8 per 10,000 live births over the study period.

CONCLUSIONS

Population-based CP registries can provide data that are relevant for generating key outcomes of interest at the population level, thus potentially contributing to improving public health policies for children with disabilities.

Prediction Model for Identifying Factors Associated with Epilepsy in Children with Cerebral Palsy

(1) Background: Cerebral palsy (CP) is associated with a higher incidence of epileptic seizures. This study uses a prediction model to identify the factors associated with epilepsy in children with CP. (2) Methods: This is a retrospective longitudinal study of the clinical characteristics of 102 children with CP. In the study, there were 58 males and 44 females, 65 inpatients and 37 outpatients, 72 had epilepsy, and 22 had intractable epilepsy. The mean age was 16.6 ± 1.2 years, and the age range for this study was 12−18 years. Data were collected on the CP etiology, diagnosis, type of epilepsy and spasticity, clinical history, communication abilities, behaviors, intellectual disability, motor function, and feeding abilities from 2005 to 2020. A prediction model, Epi-PredictMed, was implemented to forecast the factors associated with epilepsy. We used the guidelines of “Transparent Reporting of a multivariable prediction model for Individual Prognosis or Diagnosis” (TRIPOD). (3) Results: CP etiology [(prenatal > perinatal > postnatal causes) p = 0.036], scoliosis (p = 0.048), communication (p = 0.018), feeding disorders (p = 0.002), poor motor function (p < 0.001), intellectual disabilities (p = 0.007), and the type of spasticity [(quadriplegia/triplegia > diplegia > hemiplegia), p = 0.002)] were associated with having epilepsy. The model scored an average of 82% for accuracy, sensitivity, and specificity. (4) Conclusion: Prenatal CP etiology, spasticity, scoliosis, severe intellectual disabilities, poor motor skills, and communication and feeding disorders were associated with epilepsy in children with CP. To implement preventive and/or management measures, caregivers and families of children with CP and epilepsy should be aware of the likelihood that these children will develop these conditions.

Prevalence of the need for adaptive seating systems among children with cerebral palsy in Egypt

BACKGROUND

An adaptive seating system is a basic rehabilitation need for children and youth with cerebral palsy (CP) as it supports the structure and function of the musculoskeletal system and can positively affect their activities and participation. Despite the importance of adaptive seating systems, there is limited access to such systems in low-income countries.

OBJECTIVES

To determine the percentage of children and youth between 4 and 18 years of age with CP in Egypt whose activity level and sitting ability suggest the need for an adaptive seating system.

STUDY DESIGN

Observational cross-sectional study.

METHODS

One hundred ninety-three participants were included after fulfilling the criteria of the Surveillance of Cerebral Palsy of Europe. Their level of activity was assessed by a physical therapist using the Gross Motor Function Classification System (GMFCS), and their sitting ability was evaluated using the Level of Sitting Scale (LSS). Participants were considered to require an adaptive seating system if they scored GMFCS level IV or V and LSS level 1-5 concurrently.

RESULTS

Approximately 44% of the study participants were classified as GMFCS level IV or V and LSS level 1-5, suggesting that they were in need of an adaptive seating system.

CONCLUSIONS

There is a large percentage of children and youth with CP in Egypt who need an adaptive seating system to be integrated into their rehabilitation.

PredictMed: A Machine Learning Model for Identifying Risk Factors of Neuromuscular Hip Dysplasia: A Multicenter Descriptive Study

Neuromuscular hip dysplasia (NHD) is a common and severe problem in patients with cerebral palsy (CP). Previous studies have so far identified only spasticity (SP) and high levels of Gross Motor Function Classification System as factors associated with NHD. The aim of this study is to develop a machine learning model to identify additional risk factors of NHD. This was a cross-sectional multicenter descriptive study of 102 teenagers with CP (60 males, 42 females; 60 inpatients, 42 outpatients; mean age 16.5 ± 1.2 years, range 12-18 years). Data on etiology, diagnosis, SP, epilepsy (E), clinical history, and functional assessments were collected between 2007 and 2017. Hip dysplasia was defined as femoral head lateral migration percentage > 33% on pelvic radiogram. A logistic regression-prediction model named PredictMed was developed to identify risk factors of NHD. Twenty-eight (27%) teenagers with CP had NHD, of which 18 (67%) had dislocated hips. Logistic regression model identified poor walking abilities (p < 0.001; odds ratio [OR] infinity; 95% confidence interval [CI] infinity), scoliosis (p = 0.01; OR 3.22; 95% CI 1.30-7.92), trunk muscles' tone disorder (p = 0.002; OR 4.81; 95% CI 1.75-13.25), SP (p = 0.006; OR 6.6; 95% CI 1.46-30.23), poor motor function (p = 0.02; OR 5.5; 95% CI 1.2-25.2), and E (p = 0.03; OR 2.6; standard error 0.44) as risk factors of NHD. The accuracy of the model was 77%. PredictMed identified trunk muscles' tone disorder, severe scoliosis, E, and SP as risk factors of NHD in teenagers with CP.

Trends in Prevalence and Severity of Pre/Perinatal Cerebral Palsy Among Children Born Preterm From 2004 to 2010: A SCPE Collaboration Study

Aim: To report on prevalence of cerebral palsy (CP), severity rates, and types of brain lesions in children born preterm 2004 to 2010 by gestational age groups.

Methods: Data from 12 population-based registries of the Surveillance of Cerebral Palsy in Europe network were used. Children with CP were eligible if they were born preterm (<37 weeks of gestational age) between 2004 and 2010, and were at least 4 years at time of registration. Severity was assessed using the impairment index. The findings of postnatal brain imaging were classified according to the predominant pathogenic pattern. Prevalences were estimated per 1,000 live births with exact 95% confidence intervals within each stratum of gestational age: ≤27, 28–31, 32–36 weeks. Time trends of both overall prevalence and prevalence of severe CP were investigated using multilevel negative binomial regression models.

Results: The sample comprised 2,273 children. 25.8% were born from multiple pregnancies. About 2-thirds had a bilateral spastic CP. 43.5% of children born ≤27 weeks had a high impairment index compared to 37.0 and 38.5% in the two other groups. Overall prevalence significantly decreased (incidence rate ratio per year: 0.96 [0.92–1.00[) in children born 32–36 weeks. We showed a decrease until 2009 for children born 28–31 weeks but an increase in 2010 again, and a steady prevalence (incidence rate ratio per year = 0.97 [0.92–1.02] for those born ≤27 weeks. The prevalence of the most severely affected children with CP revealed a similar but not significant trend to the overall prevalence in the corresponding GA groups. Predominant white matter injuries were more frequent in children born <32 weeks: 81.5% (≤27 weeks) and 86.4% (28–31 weeks), compared to 63.6% for children born 32–36 weeks.

Conclusion: Prevalence of CP in preterm born children continues to decrease in Europe excepting the extremely immature children, with the most severely affected children showing a similar trend.

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

INTRODUCTION

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

METHODS AND ANALYSIS

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

ETHICS AND DISSEMINATION

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

Motor outcome after perinatal stroke and early prediction of unilateral spastic cerebral palsy

BACKGROUND

Unilateral spastic cerebral palsy (USCP) occurs in 30%-68% of infants with perinatal stroke. Early detection of USCP is essential for referring infants to early intervention. The aims of this study were to report motor outcomes after perinatal stroke, and to determine the predictive value of the General Movements Assessment (GMA) and Hand Assessment for Infants (HAI) for detection of USCP.

MATERIALS AND METHODS

This was a prospective observational study involving infants with perinatal stroke. GMA was conducted between 10 and 15 weeks post term-age (PTA). The HAI was performed between 3 and 5 months PTA. Motor outcome was collected between 12 and 36 months PTA.

RESULTS

The sample consisted of 46 infants. Fifteen children (32.6%) were diagnosed with CP, two children with bilateral CP and 13 with USCP. Abnormal GMA had a sensitivity of 85% (95% confidence interval [CI] 55-98%) and a specificity of 52% (95% CI 33-71%) to predict USCP. When asymmetrically presented FMs were also considered as abnormal, sensitivity increased to 100%, hence the specificity declined to 43%. A HAI asymmetry index cut-off of 23, had both a sensitivity and a specificity of 100% to detect USCP.

CONCLUSION

Using GMA and HAI can enable prediction of USCP before the age of 5 months in infants with perinatal stroke. Nevertheless, GMA must be interpreted with caution in this particular population. The HAI was found to be a very accurate screening tool for early detection of asymmetry and prediction of USCP.

PredictMed: A logistic regression-based model to predict health conditions in cerebral palsy

Logistic regression-based predictive models are widely used in the healthcare field but just recently are used to predict comorbidities in children with cerebral palsy. This article presents a logistic regression approach to predict health conditions in children with cerebral palsy and a few examples from recent research. The model named PredictMed was trained, tested, and validated for predicting the development of scoliosis, intellectual disabilities, autistic features, and in the present study, feeding disorders needing gastrostomy. This was a multinational, cross-sectional descriptive study. Data of 130 children (aged 12-18 years) with cerebral palsy were collected between June 2005 and June 2015. The logistic regression-based model uses an algorithm implemented in R programming language. After splitting the patients in training and testing sets, logistic regressions are performed on every possible subset (tuple) of independent variables. The tuple that shows the best predictive performance in terms of accuracy, sensitivity, and specificity is chosen as a set of independent variables in another logistic regression to calculate the probability to develop the specific health condition (e.g. the need for gastrostomy). The average of accuracy, sensitivity, and specificity score was 90%. Our model represents a novelty in the field of some cerebral palsy-related health outcomes treatment, and it should significantly help doctors' decision-making process regarding patient prognosis.

Implementing accurate identification and measurement of dyskinesia in cerebral palsy into clinical practice: A knowledge translation study

AIM

The application of current, best evidence into clinical practice is problematic. This article describes a knowledge translation (KT) project aimed at improving clinician identification, classification and measurement of dyskinesia in children with cerebral palsy (CP).

METHOD

A 2-year KT fellowship investigated clinicians' understanding of dyskinetic CP, identified knowledge gaps, determined educational needs and implemented a multifaceted KT strategy and dissemination framework to address those needs.

RESULTS

Australian and New Zealand medical and allied health clinicians identified significant gaps in their clinical knowledge regarding dyskinetic CP, particularly confidence in identifying and measuring dyskinesia and poor knowledge of available identification and measurement tools. Following a targeted implementation strategy, there was a definite shift towards increased awareness of dyskinetic CP, a significant improvement in identification and measurement confidence (mean change from 47 to 66% confidence, P < 0.0001), and the embedding of the knowledge and skills into everyday clinical practice.

CONCLUSIONS

This targeted and well-resourced KT project in dyskinetic CP improved clinician knowledge and led to meaningful change in clinical practice. The strategy utilised would be appropriate across a range of health-care settings.

Functional strength measurement in cerebral palsy: feasibility, test-retest reliability, and construct validity

Purpose: No instrument exists that measures functional strength in both lower and upper extremities in children with cerebral palsy (CP). Therefore, the functional strength measurement (FSM) was tested for feasibility, test-retest reliability and validity in CP. Methods: Thirty-seven children with CP (aged 4-10 years, Gross Motor Function Classification System I and II) participated. The most common compensations for CP were described; new item descriptions were standardized, and one item was removed. Test-retest reliability was examined. To measure convergent validity, correlations between the FSM-CP and isometric muscle strength measured with the handheld dynamometer (HHD) were determined. Results: Test-retest reliability was considered high for all items (intra-class correlation coefficient 0.79-0.95). Significant correlations between the HHD and FSM-CP ranged from r = 0.36 to 0.75. Conclusion: The FSM-CP is feasible, reliable, and valid to use in children with CP. The FSM-CP can be considered as a helpful tool in clinical practice of physical examination of children with CP.

Identifying Factors Associated With Severe Intellectual Disabilities in Teenagers With Cerebral Palsy Using a Predictive Learning Model

BACKGROUND

Intellectual disability and impaired adaptive functioning are common in children with cerebral palsy, but there is a lack of studies assessing these issues in teenagers with cerebral palsy. Therefore, the aim of this study was to develop and test a predictive machine learning model to identify factors associated with intellectual disability in teenagers with cerebral palsy.

METHODS

This was a multicenter controlled cohort study of 91 teenagers with cerebral palsy (53 males, 38 females; mean age ± SD = 17 ± 1 y; range: 12-18 y). Data on etiology, diagnosis, spasticity, epilepsy, clinical history, communication abilities, behaviors, motor skills, eating, and drinking abilities were collected between 2005 and 2015. Intellectual disability was classified as "mild," "moderate," "severe," or "profound" based on adaptive functioning, and according to the DSM-5 after 2013 and DSM-IV before 2013, the Wechsler Intelligence Scale for Children for patients up to ages 16 years, 11 months, and the Wechsler Adult Intelligence Scale for patients ages 17-18. Statistical analysis included Fisher's exact test and multiple logistic regressions to identify factors associated with intellectual disability. A predictive machine learning model was developed to identify factors associated with having profound intellectual disability. The guidelines of the "Transparent Reporting of a Multivariable Prediction Model for Individual Prognosis or Diagnosis Statement" were followed.

RESULTS

Poor manual abilities (P ≤ .001), gross motor function (P ≤ .001), and type of epilepsy (intractable: P = .04; well controlled: P = .01) were significantly associated with profound intellectual disability. The average model accuracy, specificity, and sensitivity was 78%.

CONCLUSION

Poor motor skills and epilepsy were associated with profound intellectual disability. The machine learning prediction model was able to adequately identify high likelihood of severe intellectual disability in teenagers with cerebral palsy.

Trunk control and functionality in children with spastic cerebral palsy

PURPOSE

To investigate the relationship between trunk control in sitting and functionality in children with spastic cerebral palsy (CP).

METHODS

Fifty-eight children with spastic CP were included in the study. Functional abilities were evaluated with the Gross Motor Function Measurement-88 (GMFM-88) and the Pediatric Evaluation of Disability Inventory Functional Skills domain (PEDI-FSD). Trunk control in sitting was tested with the Trunk Control Measurement Scale (TCMS) and the Trunk Impairment Scale (TIS). The scores of the TCMS and TIS were compared with GMFM-88 and PEDI-FSD with Spearman correlation analysis.

RESULTS

The total score of GMFM-88 was significantly correlated with the total score of TCMS (r_ho = 0.90, p < 0.01) and TIS (r_ho = 0.78, p < 0.01). The total score of PEDI-FSD was also significantly correlated with the total score of TCMS (r_ho = 0.76, p < 0.01) and TIS (r_ho = 0.72, p < 0.01).

CONCLUSIONS

The evaluation of trunk control can provide valuable information for functional abilities of children with spastic CP.

Protocol for N-of-1 trials proof of concept for rehabilitation of childhood-onset dystonia: Study 1: Protocole des essais de validation à effectif unique pour la réadaptation de la dystonie débutant dans l'enfance : Étude 1

BACKGROUND

Hyperkinetic movement disorders (HMD) are a heterogeneous group of neurological conditions among which dystonia is the predominant disorder and dyskinetic cerebral palsy the largest secondary dystonia group. Currently, there are no evidence-based, non-medical management options for childhood HMD. The Cognitive Orientation to daily Occupational Performance (CO-OP) Approach is a task-oriented, performance-based intervention that focuses on participation.

PURPOSE

This paper reports the protocol for a proof-of-concept study to assess feasibility and preliminary evidence regarding efficacy of CO-OP for HMD following deep brain stimulation (DBS).

METHOD

A series of N-of-1 trials with replications will be conducted with children, ages 6 and 21 years with HMD and DBS as indicated by the Manual Ability Classification System. Ten individualized CO-OP sessions, with multiple baselines before, during, and after, will be completed. The primary outcome measures are the Performance Quality Rating Scale and the Assessment of Motor and Process Skills. Outcome data will be plotted over time for each participant and supplemented with graph statistical analysis and effect size estimates.

IMPLICATIONS

A written protocol will be developed based on evidence and feedback incorporating any changes to the CO-OP intervention for children and young people with HMD, as per the Medical Research Council's Framework for Complex Interventions.

SPORTS STARS study protocol: a randomised, controlled trial of the effectiveness of a physiotherapist-led modified sport intervention for ambulant school-aged children with cerebral palsy

BACKGROUND

Modified sport interventions run by physiotherapists have shown potential as cost-effective, engaging, and effective interventions to improve gross motor skills and support transition to real-world sports participation for children with cerebral palsy. At present, this population demonstrates decreased participation in physical activities and sport compared to peers due to barriers ranging from body function to accessibility challenges. Sport provides culturally relevant opportunities for social integration, community participation and physical activity and has been shown to improve the fitness, self-esteem, confidence and quality of life of children with disabilities. The Sports Stars physiotherapy group has been designed to support the development of a range of fundamental movement and sports skills through activity skill practice and participation in modified popular Australian sports.

METHODS

This randomised, waitlist controlled, assessor blinded, superiority trial with two parallel groups will aim to compare the effectiveness of Sports Stars to standard care across all ICF domains. Children in the Sports Stars group are expected to demonstrate greater improvement in their individually-selected, sports related goals measured by the Canadian Occupational Performance Measure. This study will aim to assess sixty ambulant children aged six to 12 years with a diagnosis of cerebral palsy. Children will be excluded if they have had recent Botox or neurological/orthopaedic surgery. The Sports Stars intervention includes eight, one-hour, weekly physiotherapy group sessions with four to six participants and one lead physiotherapist. Outcome measures will be collected pre, post and 12 weeks post the immediate Sports Stars group to assess change immediately after, and at follow up time points.

DISCUSSION

This will be the first study of its kind to investigate a culturally relevant sports-focussed fundamental movement skills physiotherapy group for ambulant children with cerebral palsy. The findings will add to a growing pool of evidence supporting group physiotherapy for children with cerebral palsy and the Sports Stars group will provide an avenue for children to transition from individual physiotherapy to mainstream and modified recreational and competitive sports.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry: ACTRN12617000313336 Registered 28, February 2017. WHO Universal Trial Number: U1111-1189-3355 Registered 1, November 2016.

Identification, classification and assessment of dyskinesia in children with cerebral palsy: A survey of clinicians

AIM

The aims of this study were to investigate clinicians' knowledge, and barriers they perceive exist, relating to the identification and measurement of dyskinesia (dystonia/choreoathetosis) in children with cerebral palsy (CP) and to explore educational needs regarding improving identification and assessment of dyskinesia.

METHODS

This was a cross-sectional online survey of clinicians working with children with CP. Data analysis was descriptive, with qualitative analysis of unstructured questions.

RESULTS

In total, 163 completed surveys from Australian clinicians were analysed. Respondents were allied health (n = 140) followed by medical doctors (n = 18) working mainly in tertiary hospitals and not-for-profit organisations. Hypertonia subtypes and movement disorders seen in children with CP appear to be identified by clinicians, although limited knowledge about dyskinesia and access to training were reported as significant barriers to accurate identification. Despite knowledge of available measurement scales, only a small percentage were used clinically and reported to be only somewhat useful or not useful at all. Barriers identified for use of scales included limited training opportunities and knowledge of scales and lack of confidence in their use.

CONCLUSION

A lack of confidence in identifying and measuring movement disorders in children with CP was reported by Australian clinicians. It was identified that a greater understanding of dyskinetic CP and the tools available to identify and measure it would be valuable in clinical practice. The results of this survey will inform the development of a 'Toolbox' to help identify, classify and measure dyskinetic CP and its impact on activity and participation using the framework of the International Classification of Functioning, Disability and Health.

Identification and measurement of dystonia in cerebral palsy

AIM

To establish the prevalence and severity of dystonia in a population of children with cerebral palsy (CP) with hypertonia assessment and measurement tools.

METHOD

A cross-sectional study of 151 children (84 males, 67 females) with CP who were assessed with the Hypertonia Assessment Tool (HAT) and Barry-Albright Dystonia scale (BAD) for identification and measurement of severity of dystonia. HAT dystonia items were assessed for construct and convergent validity.

RESULTS

Distribution by predominant motor type (PMT) was: 85% spastic, 14% dyskinetic, and 1% ataxic. Spastic and dyskinetic groups showed widespread evidence of dystonia according to HAT profiles and BAD scores. The dyskinetic PMT group had a higher mean BAD score than the spastic group (difference of 13 units, 95% CI 9.1-16.4). Dystonia severity (BAD score) increased linearly across gross motor (p<0.001), manual ability (p<0.001) and communication functional levels (p<0.001). Divergence was noted in how HAT item six identified dystonia compared to items one and two.

INTERPRETATION

The HAT provided an estimate of the prevalence of both spasticity and dystonia in a large CP population, beyond predominant motor type. Dystonia is a common finding in the spastic PMT group, and its severity increases as motor function worsens.

WHAT THIS PAPER ADDS

Dystonia is readily identified in cerebral palsy (CP) using the Hypertonia Assessment Tool, regardless of the predominant motor type. Spasticity and dystonia frequently coexist in the CP population. Severity of dystonia is inversely related to motor function.

Efficacy of oral pharmacological treatments in dyskinetic cerebral palsy: a systematic review

AIM

To evaluate the actual evidence of efficacy of oral pharmacological treatments in the management of dyskinetic cerebral palsy (CP).

METHOD

A systematic review was performed according to the American Academy for Cerebral Palsy and Developmental Medicine (AACPDM) and Preferred Reporting Items for Systematic Reviews and Meta-Analyses methodology. Articles were searched for in PubMed/MEDLINE, Scopus, Web of Science, Cochrane Library, Database of Reviews of Effectiveness, OTSeeker, Physiotherapy Evidence Database, REHABDATA, and ClinicalTrials.gov.

RESULTS

Sixteen articles met the eligibility criteria. Eight studies on trihexyphenidyl and two on levodopa showed contradictory results. Low efficacy was reported for diazepam, dantrolene sodium, perphenazine, and etybenzatropine. Tetrabenazine, gabapentin and levetiracetam should be studied in more detail. The updated available evidence does not support any therapeutic algorithm for the management of dyskinetic CP.

INTERPRETATION

This lack of evidence is partially owing to the inconsistency of classifications of patients and of outcome measures used in the reviewed studies. Further randomized, double-blind, placebo-controlled pharmacological trials, optimized for different age groups, based on valid, reliable, and disease-specific rating scales are strongly needed. Outcome measures should be selected within the framework of the International Classification of Functioning, Disability and Health.

WHAT THIS PAPER ADDS

Evidence to prove (or disprove) the efficacy of oral drugs in dyskinetic cerebral palsy is low. The most investigated drugs, trihexyphenidyl and levodopa, show contradictory results. Tetrabenazine, levetiracetam, and gabapentin efficacy should be studied in more detail. Lack of evidence is partially due to the inconsistency of classifications and outcome measures used. Outcome measures should be selected within the framework of the International Classification of Functioning, Disability and Health in next clinical trials.

Advances in pharmacotherapies for movement disorders in children: current limitations and future progress

PURPOSE OF REVIEW

In childhood, movement disorders are generated by a very large number of disorders of the nervous system, and the very different developmental ages at which these occur make studies of pharmacotherapy efficacy extremely difficult. In most clinical practices, medication used in management is by trial and error, and limited by lack of efficacy and/or adverse drug reactions leading to drug intolerance. Nevertheless, symptom reduction using polypharmacy must be balanced against any accompanying comorbidities such as poor attention and concentration, constipation, ileus, urinary retention, blurred vision sedation and respiratory depression.

RECENT FINDINGS

A 'personalised medicine' approach may lead to specific management breakthroughs that are beneficial to a wider number of children. At present, neuromodulation with implantable devices offers greater proven efficacy for dystonia, myoclonus and dystonic-choreoathetosis, but enteral, intravenous and, more recently, transdermal medication strategies with clonidine patches and enteral gabapentin may provide important relief for both home management and critical care settings.

SUMMARY

The current review brings the clinician up-to-date with the latest, albeit limited, thinking on the pharmacological management of movement disorders in children by focussing on goal-directed outcome measures to improve clinical decision-making in an evidence-light clinical setting.

Perspectives on classification of selected childhood neurodisabilities based on a review of literature

PURPOSE

Classifying children with heterogeneous health conditions is challenging. The purposes of this perspective are to explore the prevailing classifications in children with the three selected neurodisabilities using the underlying framework of ICF/ICF-CY, explore the utility of the identified classifications, and make recommendations aimed at improving classifications.

METHODS

A literature search on six databases and Google was conducted. Articles published between the years 2000 and 2013 were included if they provided information on classification of cerebral palsy (CP), and/or developmental coordination disorder (DCD) and/or autism spectrum disorders (ASD).

RESULTS

Children with DCD and ASD are classified using combinations of multiple measures. The classifications in CP meet more of the proposed criteria for utility than those in DCD and ASD.

CONCLUSION

None of the existing classifications addressed all the criteria. The heterogeneity associated with the selected neurodisabilities poses major challenges. Further work is required to establish improved classifications.

Theory of mind, emotional and social functioning, and motor severity in children and adolescents with dystonic cerebral palsy

AIMS

This cross-sectional study aimed to investigate whether children and adolescents with dystonic cerebral palsy (CP) present with emotional and social difficulties along side motor limitations.

PARTICIPANTS/MEASURES

Twenty-two verbal and nonverbal children and adolescents with dystonic CP were compared with a normative sample of twenty children and adolescents on measures of theory of mind (ToM), emotion regulation (ER), and social difficulties (SD).

RESULTS

Higher social and emotional difficulties were found in the dystonic CP group compared to the control group. Nonverbal participants with dystonic CP were found to present with greater social impairment and lower ToM ability than their verbal counterparts. Emotional regulation and hyperactivity and attentional difficulties (HAD) significantly predicted ToM ability and social difficulties. Lower Gross Motor Function Classification System (GMFCS) level and IQ also contributed to differences in ToM ability.

INTERPRETATION

Findings support the need for greater attention to the emotional health and social development of children/adolescents with dystonic CP, along with assessments of motor difficulties in the planning and implementation of interventions and individual care plans. Further research is needed to explore links between motor disorder and mental state understanding in this clinical group.

The International Classification of Functioning (ICF) to evaluate deep brain stimulation neuromodulation in childhood dystonia-hyperkinesia informs future clinical & research priorities in a multidisciplinary model of care

The multidisciplinary team (MDT) approach illustrates how motor classification systems, assessments and outcome measures currently available have been applied to a national cohort of children and young people with dystonia and other hyperkinetic movement disorders (HMD) particularly with a focus on dyskinetic cerebral palsy (CP). The paper is divided in 3 sections. Firstly, we describe the service model adopted by the Complex Motor Disorders Service (CMDS) at Evelina London Children's Hospital and King's College Hospital (ELCH-KCH) for deep brain stimulation. We describe lessons learnt from available dystonia studies and discuss/propose ways to measure DBS and other dystonia-related intervention outcomes. We aim to report on current available functional outcome measures as well as some impairment-based assessments that can encourage and generate discussion among movement disorders specialists of different backgrounds regarding choice of the most important areas to be measured after DBS and other interventions for dystonia management. Finally, some recommendations for multi-centre collaboration in regards to functional clinical outcomes and research methodologies for dystonia-related interventions are proposed.

Burke-Fahn-Marsden dystonia severity, Gross Motor, Manual Ability, and Communication Function Classification scales in childhood hyperkinetic movement disorders including cerebral palsy: a 'Rosetta Stone' study

AIM

Hyperkinetic movement disorders (HMDs) can be assessed using impairment-based scales or functional classifications. The Burke-Fahn-Marsden Dystonia Rating Scale-movement (BFM-M) evaluates dystonia impairment, but may not reflect functional ability. The Gross Motor Function Classification System (GMFCS), Manual Ability Classification System (MACS), and Communication Function Classification System (CFCS) are widely used in the literature on cerebral palsy to classify functional ability, but not in childhood movement disorders. We explore the concordance of these three functional scales in a large sample of paediatric HMDs and the impact of dystonia severity on these scales.

METHOD

Children with HMDs (n=161; median age 10y 3mo, range 2y 6mo-21y) were assessed using the BFM-M, GMFCS, MACS, and CFCS from 2007 to 2013. This cross-sectional study contrasts the information provided by these scales.

RESULTS

All four scales were strongly associated (all Spearman's rank correlation coefficient rs >0.72, p<0.001), with worse dystonia severity implying worse function. Secondary dystonias had worse dystonia and less function than primary dystonias (p<0.001). A longer proportion of life lived with dystonia is associated with more severe dystonia (rs =0.42, p<0.001).

INTERPRETATION

The BFM-M is strongly linked with the GMFCS, MACS, and CFCS, irrespective of aetiology. Each scale offers interrelated but complementary information and is applicable to all aetiologies. Movement disorders including cerebral palsy can be effectively evaluated using these scales.

Cerebral palsy

Cerebral palsy is the most common cause of childhood-onset, lifelong physical disability in most countries, affecting about 1 in 500 neonates with an estimated prevalence of 17 million people worldwide. Cerebral palsy is not a disease entity in the traditional sense but a clinical description of children who share features of a non-progressive brain injury or lesion acquired during the antenatal, perinatal or early postnatal period. The clinical manifestations of cerebral palsy vary greatly in the type of movement disorder, the degree of functional ability and limitation and the affected parts of the body. There is currently no cure, but progress is being made in both the prevention and the amelioration of the brain injury. For example, administration of magnesium sulfate during premature labour and cooling of high-risk infants can reduce the rate and severity of cerebral palsy. Although the disorder affects individuals throughout their lifetime, most cerebral palsy research efforts and management strategies currently focus on the needs of children. Clinical management of children with cerebral palsy is directed towards maximizing function and participation in activities and minimizing the effects of the factors that can make the condition worse, such as epilepsy, feeding challenges, hip dislocation and scoliosis. These management strategies include enhancing neurological function during early development; managing medical co-morbidities, weakness and hypertonia; using rehabilitation technologies to enhance motor function; and preventing secondary musculoskeletal problems. Meeting the needs of people with cerebral palsy in resource-poor settings is particularly challenging.

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

Background

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

Methods

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

Results

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

Conclusions

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

PPREMO: a prospective cohort study of preterm infant brain structure and function to predict neurodevelopmental outcome

BACKGROUND

More than 50 percent of all infants born very preterm will experience significant motor and cognitive impairment. Provision of early intervention is dependent upon accurate, early identification of infants at risk of adverse outcomes. Magnetic resonance imaging at term equivalent age combined with General Movements assessment at 12 weeks corrected age is currently the most accurate method for early prediction of cerebral palsy at 12 months corrected age. To date no studies have compared the use of earlier magnetic resonance imaging combined with neuromotor and neurobehavioural assessments (at 30 weeks postmenstrual age) to predict later motor and neurodevelopmental outcomes including cerebral palsy (at 12-24 months corrected age). This study aims to investigate i) the relationship between earlier brain imaging and neuromotor/neurobehavioural assessments at 30 and 40 weeks postmenstrual age, and ii) their ability to predict motor and neurodevelopmental outcomes at 3 and 12 months corrected age.

METHODS/DESIGN

This prospective cohort study will recruit 80 preterm infants born ≤ 30 week's gestation and a reference group of 20 healthy term born infants from the Royal Brisbane & Women's Hospital in Brisbane, Australia. Infants will undergo brain magnetic resonance imaging at approximately 30 and 40 weeks postmenstrual age to develop our understanding of very early brain structure at 30 weeks and maturation that occurs between 30 and 40 weeks postmenstrual age. A combination of neurological (Hammersmith Neonatal Neurologic Examination), neuromotor (General Movements, Test of Infant Motor Performance), neurobehavioural (NICU Network Neurobehavioural Scale, Premie-Neuro) and visual assessments will be performed at 30 and 40 weeks postmenstrual age to improve our understanding of the relationship between brain structure and function. These data will be compared to motor assessments at 12 weeks corrected age and motor and neurodevelopmental outcomes at 12 months corrected age (neurological assessment by paediatrician, Bayley scales of Infant and Toddler Development, Alberta Infant Motor Scale, Neurosensory Motor Developmental Assessment) to differentiate atypical development (including cerebral palsy and/or motor delay).

DISCUSSION

Earlier identification of those very preterm infants at risk of adverse neurodevelopmental and motor outcomes provides an additional period for intervention to optimise outcomes.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry ACTRN12613000280707. Registered 8 March 2013.

Spoken language comprehension of phrases, simple and compound-active sentences in non-speaking children with severe cerebral palsy

BACKGROUND

Children with severe cerebral palsy (CP) (i.e. 'non-speaking children with severely limited mobility') are restricted in many domains that are important to the acquisition of language.

AIMS

To investigate comprehension of spoken language on sentence type level in non-speaking children with severe CP.

METHODS & PROCEDURES

From an original sample of 87 non-speaking children with severe CP, 68 passed the pre-test (i.e. they matched at least five spoken words to the corresponding objects) of a specifically developed computer-based instrument for low motor language testing (C-BiLLT), admitting them to the actual C-BiLLT computer test. As a result, the present study included 68 children with severe CP (35 boys, 33 girls; mean age 6;11 years, SD 3;0 years; age range 1;9-11;11 years) who were investigated with the C-BiLLT for comprehension of different sentence types: phrases, simple active sentences (with one or two arguments) and compound sentences. The C-BiLLT provides norm data of typically developing (TD) children (1;6-6;6 years). Binomial logistic regression analyses were used to compare the percentage correct of each sentence type in children with severe CP with that in TD children (subdivided into age groups) and to compare percentage correct within the CP subtypes.

OUTCOMES & RESULTS

Sentence comprehension in non-speaking children with severe CP followed the developmental trajectory of TD children, but at a much slower rate; nevertheless, they were still developing up to at least age 12 years. Delays in sentence type comprehension increased with sentence complexity and showed a large variability between individual children and between subtypes of CP. Comprehension of simple and syntactically more complex sentences were significantly better in children with dyskinetic CP than in children with spastic CP. Of the children with dyskinetic CP, 10-13% showed comprehension of simple and compound sentences within the percentage correct of TD children, as opposed to none of the children with spastic CP.

CONCLUSION & IMPLICATIONS

In non-speaking children with severe CP sentence comprehension is delayed rather than deviant. Results indicate the importance of following comprehension skills across all age groups, even beyond age 12 years. Moreover, the subtype of CP should be considered when establishing an educational programme for sentence comprehension, and augmentative and alternative communication support. In addition, educational programmes for children with severe CP should take into account the linguistic hierarchy of sentence comprehension when focusing on the input and understanding of spoken language comprehension.

Denervation of the infraspinatus and release of the posterior deltoid muscles in the management of dyskinetic external shoulder rotation in cerebral palsy

OBJECT

The dyskinetic subtype of cerebral palsy is difficult to manage, and there is no established gold standard for treatment. External rotation of the shoulder(s) is often managed nonsurgically using injections of botulinum toxin A into the external rotator muscles. This article reports a new surgical technique for managing external rotation when botulinum toxin A treatment is not sufficient or possible.

METHODS

Six patients with dyskinetic cerebral palsy underwent denervation of the infraspinatus muscle and release of the posterior part of the deltoid muscle. Postoperative questionnaires were given to the patients/caregivers, and video recordings were made both pre- and postoperatively. Preoperative and postoperative Assisting Hand Assessment was possible in only 1 case.

RESULTS

Five patients were very satisfied with their outcome. Four patients' video recordings showed improvement in their condition. One patient developed postoperative complications.

CONCLUSIONS

The results indicate that denervation of the infraspinatus muscle and posterior deltoid release can be an option for patients with dyskinetic cerebral palsy to manage external rotation of the shoulder when other treatment alternatives are insufficient.

Systematic Review of Cerebral Palsy Registries/Surveillance Groups: Relationships between Registry Characteristics and Knowledge Dissemination

The aims of this study were to provide a comprehensive summary of the body of research disseminated by Cerebral Palsy (CP) registries and surveillance programs from January 2009 through May 2014 in order to describe the influence their results have on our overall understanding of CP. Secondly, registries/surveillance programs and the work they produced were evaluated and grouped using standardized definitions and classification systems.

METHOD

A systematic review search in PubMed, CINAH and Embase for original articles published from 1 January 2009 to 20 May 2014 originating from or supported by population based CP registries and surveillance programs or population based national registries including CP were included. Articles were grouped by 2009 World CP Registry Congress aim, registry/surveillance program classification, geographical region, and the International Classification of Function, Disability and Health (ICF) domain. Registry variables were assessed using the ICF-CY classification.

RESULTS

Literature searches returned 177 articles meeting inclusion criteria. The majority (69%) of registry/surveillance program productivity was related to contributions as a Resource for CP Research. Prevention (23%) and Surveillance (22%) articles were other areas of achievement, but fewer articles were published in the areas of Planning (17%) and Raising the Profile of CP (2%). There was a range of registry/surveillance program classifications contributing to this productivity, and representation from multiple areas of the globe, although most of the articles originated in Europe, Australia, and Canada. The domains of the ICF that were primarily covered included body structures and function at the early stages of life. Encouragingly, a variety of CP registry/surveillance program initiatives included additional ICF domains of participation and environmental and personal factors.

INTERPRETATION

CP registries and surveillance programs, including novel non-traditional ones, have significantly contributed to the understanding of how CP affects individuals, families and society. Moving forward, the global CP registry/surveillance program community should continue to strive for uniformity in CP definitions, variables collected and consistency with international initiatives like the ICF so that databases can be consolidated for research use. Adaptation to new technologies can improve access, reduce cost and facilitate information transfer between registrants, researchers and registries/surveillance programs. Finally, increased efforts in documenting variables of individuals with CP into adulthood should be made in order to expand our understanding of CP across the lifespan.

The impact and prognosis for dystonia in childhood including dystonic cerebral palsy: a clinical and demographic tertiary cohort study

INTRODUCTION AND METHODS

The impact of dystonia in childhood is poorly understood. We report our experience of referrals between 2005 and 2012.

RESULTS

Of 294/315 assessable children, 15/294 had pure spasticity, leaving 279/294 with dystonia classified as primary (30/279:10.7%); primary-plus (19/279:6.8%) and secondary (230/279:82.4%) dystonia, including heredodegenerative dystonia (29/279:10.3%); 150/279 (53.7%) with cerebral palsy and 51/279 (18.2%) acquired brain injury. Definitive diagnoses were available in 222/294 (79.6%), but lower in primary/primary-plus compared with secondary groups (11/49 vs 211/230: Fisher's exact test p<0.0001). Spasticity comorbidity was present in 79/230 (34.3%) children. Median age (interquartile years) at referral was 9.75 (6.58-13), not significantly differing by aetiology (Kruskal-Wallis test p>0.05); dystonia-onset age was 3 (0.5-7.0) for primary/primary-plus and 0.25 (0.08-0.8) in the secondary/CP groups. Dystonia duration at referral was 4.75 years (3.0-10.33) for primary/primary-plus groups and 7.83 (5.4-11) in the secondary group. The mean (interquartile range) proportion of life lived with dystonia, derived as dystonia duration normalised to age was 0.68 (0.31-0.96); 0.59 (0.35-0.8); 0.75 (0.62-0.95)and 0.9 (0.92-0.99) for primary, primary-plus, heredodegenerative and secondary-static dystonias respectively. Only 91/279 (32.6%) experienced a period of normal motor development. Carers perceived dystonia deterioration in 168/279 (60.2%), stabilisation in 88/279 (31.5%) and improvement in 23/279 (8.2%). Dystonia occurred in 26/225 (11.6%) siblings: 14/26 secondary and 5/26 heredodegenerative dystonia. Comorbidities were identified in 176/279 (63.1%) cases. Gross Motor Function Classification System (GMFCS) levels I-III were commoner in primary/primary-plus (37/49: 75%) compared with secondary/CP (29/230:13%) cases, χ(2) p<0.0001).

DISCUSSION

In this selective cohort, childhood dystonia is severe, presenting early before worsening without remission. Secondary dystonias spend a higher proportion of life living with dystonia and lower functional capacity. Despite referral bias, services offering neurosurgical interventions and health service planning agencies should understand the context and predicament of life with childhood dystonia.

Everyday psychological functioning in children with unilateral cerebral palsy: does executive functioning play a role?

AIM

To identify whether executive functioning mediates the effect of having unilateral cerebral palsy (CP) on executive functioning in everyday life, psychological functioning, and social functioning.

METHOD

A cross-sectional cohort of 46 children with unilateral CP (25 males, 21 females; mean age 11y 1mo, SD 2y 5mo; 24 right-sided, 22 left-sided) and 20 children with typical development (nine males, 11 females; mean age 10y 10mo, SD 2y 4mo). Cognitive executive functioning was tested using a neuropsychological battery. Executive functioning in everyday life was measured with the Behavior Rating Inventory of Executive Function (BRIEF; teacher and parent reports) and psychological and social functioning by the Strengths and Difficulties Questionnaire (SDQ). Analysis included analysis of covariance and bootstrapping.

RESULTS

Children with unilateral CP were found to have significantly decreased functioning, compared with children with typical development, on the BRIEF Behavioral Regulation Index, the BRIEF Metacognition Index, and on the SDQ emotion, conduct, hyperactivity, and peer problems subscales. Group differences were mediated by cognitive executive functioning for the BRIEF Metacognition Index (teacher and parent report), the BRIEF Behavioral Regulation Index (parent report only), the SDQ conduct subscale, and the SDQ hyperactivity subscale.

INTERPRETATION

This study suggests that the increased risk of children with unilateral CP experiencing executive functioning difficulties in everyday life, conduct problems, and hyperactivity can be partly explained by decreased cognitive executive functioning abilities relative to children with typical development.

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.

GRIN: "GRoup versus INdividual physiotherapy following lower limb intra-muscular Botulinum Toxin-A injections for ambulant children with cerebral palsy: an assessor-masked randomised comparison trial": study protocol

BACKGROUND

Cerebral palsy is the most common cause of physical disability in childhood. Spasticity is a significant contributor to the secondary impairments impacting functional performance and participation. The most common lower limb spasticity management is focal intramuscular injections of Botulinum Toxin-Type A accompanied by individually-delivered (one on one) physiotherapy rehabilitation. With increasing emphasis on improving goal-directed functional activity and participation within a family-centred framework, it is timely to explore whether physiotherapy provided in a group could achieve comparable outcomes, encouraging providers to offer flexible models of physiotherapy delivery. This study aims to compare individual to group-based physiotherapy following intramuscular Botulinum Toxin-A injections to the lower limbs for ambulant children with cerebral palsy aged four to fourteen years.

METHODS/DESIGN

An assessor-masked, block randomised comparison trial will be conducted with random allocation to either group-based or individual physiotherapy. A sample size of 30 (15 in each study arm) will be recruited. Both groups will receive six hours of direct therapy following Botulinum Toxin-A injections in either an individual or group format with additional home programme activities (three exercises to be performed three times a week). Study groups will be compared at baseline (T1), then at 10 weeks (T2, efficacy) and 26 weeks (T3, retention) post Botulinum Toxin-A injections. Primary outcomes will be caregiver/s perception of and satisfaction with their child's occupational performance goals (Canadian Occupational Performance Measure) and quality of gait (Edinburgh Visual Gait Score) with a range of secondary outcomes across domains of the International Classification of Disability, Functioning and Health.

DISCUSSION

This paper outlines the study protocol including theoretical basis, study hypotheses and outcome measures for this assessor-masked, randomised comparison trial comparing group versus individual models of physiotherapy following intramuscular injections of Botulinum Toxin-A to the lower limbs for ambulant children with cerebral palsy.

TRIAL REGISTRATION

ACTRN12611000454976.

Children with cerebral palsy and periventricular white matter injury: does gestational age affect functional outcome?

This study aimed to determine differences in functional profiles and movement disorder patterns in children aged 4-12 years with cerebral palsy (CP) and periventricular white matter injury (PWMI) born >34 weeks gestation compared with those born earlier. Eligible children born between 1999 and 2006 were recruited through the Victorian CP register. Functional profiles were determined using the Gross Motor Function Classification System (GMFCS), Manual Abilities Classification System (MACS), Communication Function Classification System (CFCS), Functional Mobility Scale (FMS) and Bimanual Fine Motor Function (BFMF). Movement disorder and topography were classified using the Surveillance of Cerebral Palsy in Europe (SCPE) classification. 49 children born >34 weeks (65% males, mean age 8 y 9 mo [standard deviation (SD) 2 y 2 mo]) and 60 children born ≤ 34 weeks (62% males, mean age 8 y 2 mo [SD 2 y 2 mo]) were recruited. There was evidence of differences between the groups for the GMFCS (p=0.003), FMS 5, 50 and 500 (p=0.003, 0.002 and 0.012), MACS (p=0.04) and CFCS (p=0.035), with a greater number of children born ≤ 34 weeks more severely impaired compared with children born later. Children with CP and PWMI born >34 weeks gestation had milder limitations in gross motor function, mobility, manual ability and communication compared with those born earlier.

Reliable classification of functional profiles and movement disorders of children with cerebral palsy

OBJECTIVE

To examine the inter-rater reliability of the Communication Function Classification System (CFCS), Bimanual Fine Motor Function (BFMF), Surveillance of Cerebral Palsy in Europe (SCPE) classification tree, and Gross Motor Function Classification System (GMFCS) in children with cerebral palsy (CP) and periventricular white matter injury (PWMI) aged 4-11 years.

METHOD

Twenty children were assessed by two raters using the four tools, in addition parents undertook ratings on the Manual Ability Classification System (MACS). Kappa statistics were used to calculate the level of agreement between raters' classifications.

RESULTS

Participants comprised 12 males and 8 females with CP and PWMI, mean age 8 years 1 month (standard deviation 2 years 3 months). Inter-rater reliability across the four tools was 0.98 (CFCS, BFMF, and GMFCS) and 0.84 (SCPE).

IMPLICATIONS

These findings suggest that these four tools are reasonably robust to inter-rater variability supporting their routine use along with the MACS in clinical and research applications.

Trends in prevalence and characteristics of post-neonatal cerebral palsy cases: a European registry-based study

The present paper aims to analyze trends over time in prevalence of cerebral palsy of post-neonatal origin, to investigate whether changes are similar according to severity and to describe the disability profile by etiology. Post-neonatal cases, birth years 1976 to 1998, were identified from the Surveillance of Cerebral Palsy in Europe collaboration (19 population-based registries). A recognized causal event occurring between 28 days and 24 months of age was considered to define the cases. Trends in prevalence were explored using graphical methods (Lowess and Cusum control chart) and modeled with negative binomial regressions. Over the study period, 404 cases were identified as post-neonatal cases (5.5% of the total). Mean prevalence rate was 1.20 per 10,000 live births (95% CI [1.08-1.31]). A significant downward trend was observed (p=0.001), with an accentuated decrease in the 1990 s. The prevalence of severe cases which account for around one third of the total also significantly decreased over time (p<0.001). In 46% of cases, an infectious aetiology was reported; the corresponding prevalence significantly decreased since 1989. No significant decrease was observed for the rate of cases due to a vascular episode or of traumatic origin. Our results emphasize the need of large population-based surveillance systems to reliably monitor trends in prevalence in rare subgroups of children like those with acquired cerebral palsy. The decrease of the overall prevalence as well as those of the most severe cases may be partly due to public health actions targeted to prevent such events.

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

PURPOSE

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

METHOD

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

RESULTS

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

INTERPRETATION

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

Interventions for drooling in children with cerebral palsy

BACKGROUND

Drooling is a common problem for children with cerebral palsy (CP). This can be distressing for these children as well as for their parents and caregivers. The consequences of drooling include risk of social rejection, damp and soiled clothing, unpleasant odour, irritated chapped skin, mouth infections, dehydration, interference with speech, damage to books, communication aids, computers, and the risk of social isolation (Blasco 1992; Van der Burg 2006). A range of interventions exist that aim to reduce or eliminate drooling. There is a lack of consensus regarding which interventions are most effective for children with CP.

OBJECTIVES

(1) To evaluate the effectiveness and safety of interventions aimed at reducing or eliminating drooling in children with cerebral palsy. (2) To provide the best available evidence to inform clinical practice. (3) To assist with future research planning.

SEARCH METHODS

We searched the following databases from inception to December 2010 : Cochrane Central Register of Controlled Trials (CENTRAL); Medline via Ovid; EMBASE; CINAHL; ERIC; Psych INFO; Web of Science; Web of Knowledge; AMED; SCOPUS; Dissertation Abstracts.We searched for ongoing clinical trials in the Clinical Trials web site (http://clinicaltrials.gov.) and in the Current Controlled Trials web site (http://www.controlled-trials.com/). We hand searched a range of relevant journals and conference proceeding abstracts.

SELECTION CRITERIA

Only randomised controlled trials (RCTs) and controlled clinical trials (CCTs) were included.

DATA COLLECTION AND ANALYSIS

Data were extracted independently by MW, MS and LP and differences resolved through discussion.

MAIN RESULTS

Six studies were eligible for inclusion in the review. Four of these studies were trials using botulinum toxin-A (BoNT-A) and two were trials on the pharmacological interventions, benztropine and glycopyrrolate. No RCTs or CCTs were retrieved on surgery, physical, oro-motor and oro-sensory therapies, behavioural interventions, intra-oral appliances or acupuncture. In the studies eligible for review, there was considerable heterogeneity within and across interventions and a meta-analysis was not possible. A descriptive summary of each study is provided. All studies showed some statistically significant change for treatment groups up to 1 month post intervention. However, there were methodological flaws associated with all six studies.

AUTHORS' CONCLUSIONS

It was not possible to reach a conclusion on the effectiveness and safety of either BoNT-A or the pharmaceutical interventions, benztropine and glycopyrrolate. There is insufficient evidence to inform clinical practice on interventions for drooling in children with CP. Directions for future research are provided.