Self-care and mobility skills in children with cerebral palsy, related to their manual ability and gross motor function classifications

Self-care and hand function in preschool children with unilateral or bilateral cerebral palsy: A cross-sectional study

AIMS

To describe self-care capabilities among children with cerebral palsy (CP) and explore associations between self-care and hand function for children with unilateral cerebral palsy (UCP) and children with bilateral cerebral palsy (BCP) separately.

METHOD

Cross-sectional data on self-care capabilities (Pediatric Evaluation of Disability Inventory, PEDI), manual abilities (Manual Ability Classification System, MACS) and hand use during bimanual performance (Assisting Hand Assessment, AHA; Both Hands Assessment, BoHA) were retrieved from the Norwegian Quality and Surveillance Registry for Cerebral Palsy (NorCP). Eighty-seven children with CP (UCP, n = 61, mean age 4 years 1 month, SD 1 year 3 months, range 56) or BCP (n = 26, mean age 4 years 4 months, SD 1 year, range 41), classified at MACS level I (n = 26), II (n = 40) or III (n = 21), were included.

RESULTS

No significant differences in self-care capabilities were found between children with UCP and children with BCP. Analysis of variance showed significant differences in self-care between MACS levels for the whole group. No significant differences in self-care between MACS levels were observed for children with UCP (p = 0.36), but significant differences were found for those with BCP (p < 0.001). Whereas a small correlation (r = 0.3) between PEDI and AHA scores was found for children with UCP, a large correlation (r = 0.6) was found for those with BCP. Children with BCP with symmetric hand use during bimanual performance (BoHA) had higher PEDI scores than children with asymmetric hand use.

CONCLUSION

Though children with UCP and children with BCP who were classified at MACS I-III exhibited similar self-care capabilities, the limited hand use seems to contribute differently between the two groups. The two different measures of hand use exhibit different associations with self-care capabilities for young children with UCP and BCP, respectively, and illustrate the need to treat UCP and BCP as two distinct groups, each requiring tailored interventions according to their specific needs.

Can Clinical Assessment of Postural Control Explain Locomotive Body Function, Mobility, Self-Care and Participation in Children with Cerebral Palsy?

Trunk control may influence self-care, mobility, and participation, as well as how children living with cerebral palsy (CP) move around. Mobility and Gross Motor performance are described over environmental factors, while locomotion can be understood as the intrinsic ontogenetic automatic postural function of the central nervous system, and could be the underlying element explaining the relationship between these factors. Our goal is to study the correlation among Trunk Control Measurement Scale (TCMS) and Pediatric Evaluation of Disability Inventory (PEDI) domains, as well as Locomotor Stages (LS).

METHODS

A feasibility observational analysis was designed including 25 children with CP who were assessed with these scales.

RESULTS

The strong correlation confirms higher levels of trunk control in children with better self-care, mobility and participation capacities. Strong correlations indicate also that higher LS show better levels of PEDI and TCMS domains.

CONCLUSIONS

Our results suggest that more mature LS require higher levels of trunk control, benefitting self-care, mobility and social functions.

Assisting hand use and self-care bimanual performance of children with unilateral spastic cerebral palsy

AIM

To examine the relationship between assisting hand use in bimanual activities and children's self-care activities and task performance.

METHOD

We retrospectively analysed daily functioning (Pediatric Evaluation of Disability Inventory [PEDI]) and bimanual performance (Assisting Hand Assessment [AHA]) data from the assessment of 112 children (mean age: 8 years 10 months [SD 2 years 1 month], range 3 years 7 months-17 years 4 months; 66 males, 46 females) with unilateral spastic cerebral palsy (CP). We used Rasch analysis to examine the relationship between individual item scores from the AHA and the self-care items (functional skills, caregiver assistance) from the PEDI.

RESULTS

Most self-care functional skills and caregiver-assisted tasks were located on the middle of the unidimensional continuum. These items showed similar levels of difficulty as the items from the AHA related to the effective coordination of two hands, appropriate pace, and use of the assisting hand to stabilize and release objects, as well as variations in arm movements.

INTERPRETATION

The distribution of the PEDI self-care and AHA items along the unidimensional continuum illustrates the relationship between assisting hand use and self-care bimanual performance. Interpretation of the items' locations on the hierarchical unidimensional continuum may be helpful to therapists' clinical reasoning and suggest intervention goals to improve the hand function and daily functioning of children with unilateral spastic CP. Such an application needs further investigation.

Longitudinal development of hand use in children with unilateral spastic cerebral palsy from 18 months to 18 years

AIM

To describe the development of the use of the affected hand in bimanual tasks in children with unilateral cerebral palsy (CP) from 18 months to 18 years. Specifically, whether early development can be confirmed in a larger cohort and how development progresses during adolescence.

METHOD

In total, 171 participants (95 males, 76 females; mean age 3 years 1 month [SD 3 years 8 months], range 18 months-16 years at inclusion) were classified in Manual Ability Classification System (MACS) levels I (n = 41), II (n = 91), and III (n = 39). Children were assessed repeatedly (median 7, range 2-16 times) with the Assisting Hand Assessment: in total 1197 assessments. Developmental trajectories were estimated using a nonlinear mixed effects model. To further analyse the adolescent period, a linear mixed model was applied.

RESULTS

The developmental trajectories were different between participants in MACS levels (MACS I-II, II-III) in both rate (0.019, 95% confidence interval [CI] 0.006-0.031, p = 0.034; 0.025, 95% CI 0.015-0.037, p < 0.001) and limit (19.9, 95% CI 16.6-23.3, p = 0.001; 7.2, 95% CI 3.3-11.2, p < 0.003). The individual variations were large within each level. The developmental trajectories were stable over time for all MACS levels between 7 and 18 years (p > 0.05).

INTERPRETATION

Children and adolescents with unilateral CP have considerable development at an early age and a stable ability to use their affected hand in bimanual activities from 7 to 18 years in all MACS levels.

The Effect of Bimanual Intensive Functional Training on Somatosensory Hand Function in Children with Unilateral Spastic Cerebral Palsy: An Observational Study

(1) Background: Next to motor impairments, children with unilateral spastic cerebral palsy (CP) often experience sensory impairments. Intensive bimanual training is well known for improving motor abilities, though its effect on sensory impairments is less known. (2) Objective: To investigate whether bimanual intensive functional therapy without using enriched sensory materials improves somatosensory hand function. (3) Methods: A total of twenty-four participants with CP (12-17 years of age) received 80-90 h of intensive functional training aimed at improving bimanual performance in daily life. Somatosensory hand function was measured before training, directly after training, and at six months follow-up. Outcome measures were: proprioception, measured by thumb and wrist position tasks and thumb localization tasks; vibration sensation; tactile perception; and stereognosis. (4) Results: Next to improving on their individual treatment goals, after training, participants also showed significant improvements in the perception of thumb and wrist position, vibration sensation, tactile perception, and stereognosis of the more affected hand. Improvements were retained at six months follow-up. Conversely, proprioception measured by the thumb localization tasks did not improve after training. (5) Conclusions: Intensive functional bimanual training without environmental tactile enrichment may improve the somatosensory function of the more affected hand in children with unilateral spastic CP.

A cross-sectional study determining the relationship between eating and drinking skills and functional independence levels of patients with cerebral palsy

Background/Aim: In cerebral palsy (CP), drinking/eating disorders are considered common. To evaluate these disorders, a very detailed and lengthy evaluation is required. Few tools are available to identify children who need to be evaluated. This study determined whether the functional independence level of children with CP is sufficient to predict their drinking/eating skills and to determine the relationship between this functional level and these skills. Methods: A total of 105 children with CP aged 4–8 years participated in a cross-sectional study in our outpatient clinic. Functional classification was assigned using the Gross Motor Function Classification System and Manuel Ability Classification System (GMFCS and MACS, respectively). For a functional assessment of daily life, the Pediatric Evaluation of Disability Inventory (PEDI) was performed by asking a relative of the child. The Eating and Drinking Abilities Classification System (EDACS) level was added to the study after asking the caregivers of the patients for eating/drinking evaluations. Results: According to the current results, we found a negative correlation between EDACS and PEDI scores. As the EDACS grade increased, the PEDI subscale and total scores decreased in a statistically significant manner (P < 0.001), while the GMFCS and MACS scale increased statistically (P < 0.001). As the PEDI subscale and total scores increased, the levels of GMFCS and MACS decreased statistically significantly (P < 0.001). Conclusions: The performances of children with CP in terms of activities of daily living are closely related to their performance in eating/drinking activities. If children are independent in their mobility, social functions, and daily self-care, they are also more independent in terms of eating/drinking.

Validity and test-retest reliability of the Ugandan version of the Pediatric Evaluation of Disability Inventory (PEDI-UG) in children and youth with cerebral palsy

BACKGROUND

Validity of the Ugandan version of the Pediatric Evaluation of Disability Inventory (PEDI-UG) was previously investigated on typically developing children. This study aimed to investigate the validity, test-retest reliability and minimal detectable change (MDC) of the PEDI-UG in children and youth (C&Y) with cerebral palsy (CP).

METHOD

A cross-sectional study design with 118 C&Y with CP (44.7% girls) aged 10 months-22.5 years were included in the study; 37 of them completed the PEDI-UG twice to investigate test-retest reliability, determined by calculating the intraclass correlation coefficient (ICC). Additionally, data from 249 typically developing children were used for differential item functioning (DIF) analysis. The validity of the PEDI-UG was investigated by Rasch analysis. The Kruskal-Wallis test and Spearman's correlation coefficient were calculated to investigate associations between PEDI-UG scores and external classification systems.

RESULTS

The principal component analysis of residuals indicated unidimensionality in all domains. The ICC values were excellent (0.98-0.99), and the MDCs were less than 6 and 13 (on a 0-100 scale) for the functional skills and caregiver assistance parts, respectively. The four-category caregiver assistance rating scale fulfilled the criteria for the analysis of rating scale functioning. In total, 78 of 189 items in the functional skills domain and two items in the caregiver assistance domain demonstrated DIF between C&Y with CP and TD children. The Kruskal-Wallis test (p < 0.05) and Spearman's correlation (coefficients of -0.93 to -0.78) supported the validity of PEDI-UG.

CONCLUSION

The current diagnose-specific version of PEDI-UG demonstrates evidence for validity as a measure of ability in C&Y with CP in Uganda and other similar settings, being a promising tool for use in clinical practice and research. Conversion tables and MDC values are provided to facilitate clinical adoption of the measure.

Assessing IQ in adolescents with mild to moderate cerebral palsy using the WISC-V

Objective: To examine the influence of subtests that require fine motor responses on measures of intellectual ability, and compare three approaches to minimizing motor demands while assessing cognitive abilities in adolescents with cerebral palsy (CP) to the traditional method of the Wechsler Intelligence Scale for Children - Fifth edition (WISC-V). Method: Seventy adolescents with CP (M = 14 years 6 months, SD = 10 months) who were able to provide either a verbal or point response were assessed using the WISC-V administered via Q-interactive. The pencil-to-paper version of Coding was also administered. Performance on Block Design and pencil-to-paper Coding was compared to Visual Puzzles and Coding on Q-interactive, respectively. Full Scale IQ (FSIQ) scores derived according to the Traditional method of the WISC-V were compared to alternative estimates of FSIQ derived according to the Q-interactive, Nonmotor, and Motor-free methods, which minimized motor demands. Results: An additional 7-12% of participants were able to respond to Visual puzzles and Coding on Q-interactive compared to Block Design and pencil-to-paper Coding, respectively, and performance was marginally but significantly better. For 54 adolescents (Gross Motor Function Classification System (GMFCS) Level I-III) who were able to obtain FSIQ scores, the Traditional method underestimated FSIQ by 3-6 points compared to the alternative methods and the difference was most pronounced for those with more severe CP as measured by the GMFCS. Conclusion: Adolescents with CP are at an inherent disadvantage when cognitive ability is assessed using the Traditional method of the WISC-V. Findings suggest clinicians should employ the Nonmotor or Motor-free methods when assessing IQ in adolescents with CP.

External validity of the Both Hands Assessment for evaluating bimanual performance in children with bilateral cerebral palsy

AIM

To investigate the external validity of the Both Hands Assessment (BoHA), a new test evaluating bimanual performance in children with bilateral cerebral palsy (CP), by analysing its relationship to established measurements of hand function and self-care skills.

METHOD

In this cross-sectional study, we recruited children with bilateral CP and manual ability corresponding to Manual Ability Classification System (MACS) levels I to III attending three habilitation units in Norway. All participants completed the BoHA. Unimanual capacity was assessed using the Bimanual Fine Motor Function (BFMF) classification, the Box and Block Test (BBT), and the Melbourne Assessment 2 (MA2). Self-care skills were assessed with the Pediatric Evaluation of Disability Inventory (PEDI).

RESULTS

Thirty-nine children (19 males, 20 females; mean age 8y 2mo, SD 2y 8mo; age range 2y 8mo-12y 6mo) were included. Spearman's correlation coefficient (ρ) suggested high correlation between the BoHA and MACS (p=0.89; 95% confidence interval [CI]  0.79-0.94), BFMF classification (p=0.84; 95% CI  0.71-0.91), and BBT for the non-dominant (p=0.85; 95% CI  0.68-0.95) and dominant hand (p=0.72; 95% CI  0.53-0.85). The Spearman's ρ between the BoHA and the MA2 subscales varied between 0.48 and 0.83, while the PEDI's ρ was 0.51 (95% CI  0.33-0.67).

INTERPRETATION

The BoHA provides valid measures of hand use as suggested by its high correlation with other activity-based measures of hand function.

Determinants of Manual Abilities of Children with Cerebral Palsy: A National Registry-Based Study

PURPOSE

This cross-sectional study aimed to identify determinants of manual abilities of children with cerebral palsy (CP), as measured by the Manual Ability Classification System (MACS), in terms of intrinsic (child-related) and extrinsic (service-related) variables.

METHODS

The participants were 106 children with a confirmed diagnosis of CP (aged 4-16 years). Two ordinal logistic regression models were conducted to identify intrinsic and extrinsic determinants of manual abilities.

RESULTS

Four child-related (intrinsic) variables were found to be significant determinants of manual abilities: bimanual ability, ability to maintain and assume chair sitting, presence of seizures, and gross motor function, and only one service-related (extrinsic) significant variable was identified, which was receiving spasticity medications.

DISCUSSION

The results highlight several determinants that should be considered when assessing and intervening to improve manual abilities of children with CP. The findings are discussed in relation to the intervention approach, contextual modification, and assistive device prescription.

Cognitive Orientation to Daily Occupational Performance (CO-OP) in Children with Cerebral Palsy: A Systematic Review with Meta-analysis

Background: Cognitive orientation to daily occupational performance (CO-OP) is a client-centered treatment approach that was developed in the 1990s by occupational therapists. Purpose: Exploring current evidence about the effectiveness of CO-OP on children with cerebral palsy (CP). Method: Major electronic databases were searched. A narrative synthesis of current literature and meta-analyses on randomized control trials (RCTs) were conducted on changes in occupational performance. Findings: Seven studies with 103 participants were included. Four studies were RCTs with moderate levels of evidence, and three studies had single-subject designs. Although beneficial effects of CO-OP on goal achievement and transferring learned skills were reported, meta-analyses showed that CO-OP had no significant effect on the performance (WMD = 1.52, 95% CI = -1.58 to 4.63, P = .33) and satisfaction domains (WMD = 1.71, 95% CI = -1.14 to 4.57, P = .24) of Canadian Occupational Performance Measure scores compared to alternative interventions. Implications: CO-OP improves occupational performance but not more than alternative interventions. Results are inconclusive due to small sample sizes and heterogeneity of alternative interventions and participants. Therefore, research with a larger number of participants with sound RCT methods is needed.

Bimanual performance in children with unilateral perinatal arterial ischaemic stroke or periventricular haemorrhagic infarction

BACKGROUND

Long term outcome data on bimanual performance in children with perinatal arterial ischaemic stroke (PAIS) and periventricular haemorrhagic infarction (PVHI) with and without unilateral spastic cerebral palsy (USCP) is sparse.

AIMS

To assess bimanual performance in children with PAIS or PVHI with and without USCP and to explore the relationship with unilateral hand function and full-scale IQ (FSIQ) in a cross-sectional study.

METHODS

Fifty-two children with PAIS (n = 27) or PVHI (n = 25) participated at a median age of 12 years and 1 month (range 6-20 years). The Bruininks Oseretsky Test of Motor Proficiency-2 (bimanual precision and dexterity subtest), Assisting Hand Assessment, Purdue Pegboard Test and Wechsler Intelligence scale were administered.

RESULTS

Bimanual dexterity was worse in children with USCP (p < 0.02) without a difference for the pathology groups. In children without USCP (n = 21), those with PAIS showed a better bimanual precision compared to children with PVHI (p < 0.04). The AHA score and the Purdue Pegboard score of the dominant hand explained 51% of the variance in bimanual precision and dexterity in children with USCP. In absence of USCP, FSIQ together with AHA scores explained 66% of the variance in bimanual precision and FSIQ together with the Purdue Pegboard Test score of the dominant hand, 71% of the variance in bimanual dexterity.

CONCLUSIONS

Children with PAIS without USCP have a more favourable bimanual hand function compared to children with PVHI. This difference appears to be associated with a preserved FSIQ.

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

Background

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

Aims

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

Methods and procedures

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

Outcomes and results

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

Conclusions and implications

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

•

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

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

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After this maintaining capabilities is more realistic than improvement.

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Important prognostic factors are GMFCS level and intellectual impairment.

•

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

Relationship between the more-affected upper limb function and daily activity performance in children with cerebral palsy: a cross-sectional study

Background

There are differences in roles between the more-affected and less-affected upper limb of children with cerebral palsy (CP). However, there is a lack of studies of the relationship between the more-affected limb function and activities of daily living (ADL) in children with CP. Thus, the aim of this prospective cross-sectional study was to investigate the relationship between more-affected upper limb function and ADL in children with CP.

Methods

Children with spastic CP (unilateral CP n = 28, bilateral CP n = 31; 34 males, 25 females; mean age ± SD, 6.8 ± 3.1y [range, 3-14y]) participated in this study. Function of the more-affected upper limb was measured using the Melbourne Assessment of Unilateral Upper limb Function, version 2 (MA2) and the Upper Limb Physician’s Rating Scale (ULPRS). Performance of daily living activities was measured using the Pediatric Evaluation of Disability Inventory-Computer Adaptive Test (PEDI-CAT).

Results

The range, accuracy and fluency dimension of MA2 and ULPRS total scores were moderately correlated with the daily activity domain (r = 0.47, 0.47, 0.56 for MA2 and r = 0.50 for ULPRS, respectively; P < 0.001) rather than the mobility, social/cognitive, and responsibility domains of the PEDI-CAT. ULPRS scores for elbow extension, supination in extension, supination in flexion, and two-handed function were moderately correlated with the PEDI-CAT daily activity domain (r = 0.44, 0.43, 0.41, and 0.49, respectively; P < 0.01). Finger opening and thumb-in-palm deformity of the ULPRS did not correlate with any PEDI-CAT domain.

Conclusions

The MA2 range, accuracy, and fluency domains (rather than dexterity) had the strongest correlations with the PEDI-CAT daily activity domain. Elbow extension, forearm supination, and two-handed function (rather than wrist and finger movements) of the ULPRS had the strongest correlations with the PEDI-CAT daily activity domain.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12887-021-02927-2.

IncobotulinumtoxinA Efficacy/Safety in Upper-Limb Spasticity in Pediatric Cerebral Palsy: Randomized Controlled Trial

BACKGROUND

This randomized phase 3 study with double-blind main period (MP) and open-label extension (OLEX; NCT02002884) assessed incobotulinumtoxinA safety and efficacy for pediatric upper-limb spasticity treatment in ambulant/nonambulant (Gross Motor Function Classification System [GMFCS] I-V) patients, with the option of combined upper- and lower-limb treatment.

METHODS

Patients were aged two to 17 years with unilateral or bilateral spastic cerebral palsy (CP) and Ashworth Scale (AS) score ≥2 in treatment-selected clinical patterns. In the MP, patients were randomized (2:1:1) to incobotulinumtoxinA 8, 6, or 2 U/kg body weight (maximum 200, 150, 50 U/upper limb), with optional lower-limb injections in one of five topographical distributions (total body dose ≤16 to 20 U/kg, maximum 400 to 500 U, depending on body weight and GMFCS level). In the OLEX, patients received three further treatment cycles, at the highest MP doses (8 U/kg/upper limb group). Outcomes included AS, Global Impression of Change Scale (GICS), and adverse events (AEs).

RESULTS

AS scores improved from baseline to week 4 in all MP dose groups (n = 350); patients in the incobotulinumtoxinA 8 U/kg group had significantly greater spasticity improvements versus the 2 U/kg group (least-squares mean [standard error] for upper-limb main clinical target pattern -1.15 [0.06] versus -0.93 [0.08]; P = 0.017). Investigator's, child/adolescent's, and parent/caregiver's GICS scores showed improvements in all groups. Treatment benefits were sustained over further treatment cycles. AE incidence did not increase with dose or repeated treatment across GMFCS levels.

CONCLUSIONS

Data provide evidence for sustained efficacy and safety of multipattern incobotulinumtoxinA treatment in children and adolescents with upper-limb spasticity.

Impact of Upper Extremity Impairment and Trunk Control on Self-Care Independence in Children With Upper Motor Neuron Lesions

OBJECTIVE

The purpose of this study was to evaluate the relative importance of different approaches to measure upper extremity selective voluntary motor control (SVMC), spasticity, strength, and trunk control for explaining self-care independence in children affected by upper motor neuron lesions.

METHODS

Thirty-one patients (mean [SD] age = 12.5 [3.2] years) with mild to moderate arm function impairments participated in this observational study. Self-care independence was evaluated with the Functional Independence Measure for children (WeeFIM). Upper extremity SVMC was quantified with the Selective Control of the Upper Extremity Scale (SCUES), a similarity index (SISCUES) calculated from simultaneously recorded surface electromyography muscle activity patterns, and an accuracy and involuntary movement score derived from an inertial-measurement-unit-based assessgame. The Trunk Control Measurement Scale was applied and upper extremity spasticity (Modified Ashworth Scale) and strength (dynamometry) were assessed. To determine the relative importance of these factors for self-care independence, 3 regression models were created: 1 included only upper extremity SVMC measures, 1 included upper extremity and trunk SVMC measures (overall SVMC model), and 1 included all measures (final self-care model).

RESULTS

In the upper extremity SVMC model (total variance explained 52.5%), the assessgame (30.7%) and SCUES (16.5%) were more important than the SISCUES (4.5%). In the overall SVMC model (75.0%), trunk SVMC (39.0%) was followed by the assessgame (21.1%), SCUES (11.0%), and SISCUES (4.5%). In the final self-care model (82.1%), trunk control explained 43.2%, upper extremity SVMC explained 23.1%, spasticity explained 12.3%, and strength explained 2.3%.

CONCLUSION

Although upper extremity SVMC explains a substantial portion of self-care independence, overall trunk control was even more important. Whether training trunk control and SVMC can translate to improved self-care independence should be the subject of future research.

IMPACT

This study highlights the importance of trunk control and selective voluntary motor control for self-care independence in children with upper motor neuron lesions.

Relevant factors of self-care in children and adolescents with spastic cerebral palsy

Objective

Manual ability is considered one of the factors that can predict functional independence in activities of daily living. For evaluating personal tasks such as self-care, the Pediatric Evaluation of Disability Inventory (PEDI) comprises/introduces/offers a set of useful measures that assist in enhancing the capability for self-care among children and adolescents with cerebral palsy (CP). The aim of this study was to investigate the relevant factors of self-care capability and performance in children and adolescents with spastic CP.

Methods

This was a cross-sectional study. Seventy-six children and adolescents with spastic CP (between 5 and 18 years of age), representing levels I to IV of the Gross Motor Function Classification System-Expanded & Revised version (GMFCS), were analyzed. Multiple linear regression analysis with forward stepwise selection was conducted to examine which determinants were related to self-care capability and performance. Independent variables were age, CP type, GMFCS, Manual Ability Classification System, Box and Block Test, and grip strength in the dominant and non-dominant hands. Dependent variables were scores for the PEDI Functional Skills Scale and the PEDI Caregiver Assistance Scale.

Results

Results of the multiple regression analysis showed that the PEDI Functional Skills scale scores were correlated with the Box and Block Test in the dominant hand and GMFCS (Adjusted R² = 0.69). The PEDI Caregiver Assistance Scale scores were correlated with the Box and Block Test in the dominant hand, GMFCS, and age (adjusted R² = 0.71).

Conclusion

When considering self-care of children and adolescents with spastic CP, it is necessary to consider the evaluation of upper limb dysfunction in addition to GMFCS.

Rehabilitation in childhood-onset hyperkinetic movement disorders including dystonia: Treatment change in outcomes across the ICF and feasibility of outcomes for full trial evaluation

BACKGROUND

Childhood-onset hyperkinetic movement disorders (HMD), including dystonia are notoriously difficult to treat and there are limited studies showing successful medical, surgical or non-pharmacological interventions.

METHODS

This prospective study used grouped data (n = 22) from two studies of the Cognitive Orientation to daily Occupational Performance (CO-OP) Approach for patient-selected goals. Eligibility included aged 6-21 years, deep brain stimulation in place, with manual ability classification system level I-IV. Outcome was assessed on a range of patient-reported and clinician-rated measures across the International Classification of Function at end-treatment (10 weekly sessions) (series 1 and 2) and 3-month follow-up (series 1). Feasibility of outcomes to be used in a full trial were explored.

FINDINGS

Nineteen participants completed the intervention and were included in the analysis. Of the primary outcome measures, the self-reported Canadian Occupational Performance Measure showed improvement in goal performance (mean change 4.08, 95% CI [3.37,4.79] post-; 4.18 [5.10,5.26] follow-up), and satisfaction (4.03 [3.04,5.03) post-; 4.44 [3.07,5.82] follow-up]. The Assessment of Motor and Process Skills showed improved motor score (0.52 [0.01,1.03] at follow-up only, while the process score did not change. Objective blind-rated pooled data using the Performance Quality Rating Scale-individualized indicated significant change for trained goals (3.79 [3.37,4.21] post-; (4.01,5.10) follow-up] and untrained goals (1.90 [1.24,2.55] post 1.91 [0.23,3.60] follow-up]. Motor impairment assessed by the Burke-Fahn Motor Disability Rating Scale was unchanged (-3.26 [-6.62,0.09] post-; -1.11 [-8.05,5.82] follow-up). Improvement was also observed in self-efficacy (0.97 [0.47,1.47] post-; 1.37 [1.91-0.83] follow-up) and Quality of Life (0.12 [0.03-0.22] follow-up). Goal improvement; self-efficacy and quality of life captured significant change post-intervention. This improvement was shown despite no change on impairment-related measures and were shown to be feasible measures to use in a larger study of CO-OP for this population.

FUNCTIONAL CLASSIFICATION OF CHILDREN WITH CEREBRAL PALSY IN KRAPINA-ZAGORJE COUNTY

The aim was to study functional abilities and to create functional classification of children with cerebral palsy (CP) in Krapina-Zagorje County, based on the classification of gross and fine motor skills and associated impairments. Classification was performed according to the SCPE (Surveillance of Cerebral Palsy in Europe) criteria. We used standardized and complementary functional classification systems for cerebral palsy to create a functional profile. Research included 44 children with CP in the age range of 4 to 18 years. The results showed that the majority of children had bilateral spastic CP (63.6%), followed by unilateral spastic (22.7%) while the representation of dyskinetic CP was 9.09% and ataxic CP 4.55%. Based on the classification of gross and fine motor skills, 43.2% of children had the ability to walk, 11% of children could walk with assistive mobility devices, while 45.4% of children had a low functional level. The study also analyzed the associated impairments where higher classification score of motor impairment correlated with the severity of impairment. The results showed that children with dyskinetic CP and severe motor impairment could have mild cognitive impairment. We systematically present the neuropsychological and functional profile according to the CP type.

Hand function and self-care in children with cerebral palsy

AIM

To examine the relationship between self-care and bimanual performance in children aged 8 to 12 years with cerebral palsy (CP).

METHOD

This was a cross-sectional study of 74 children with CP (unilateral n=30, bilateral n=44; 48 males, 26 females; median age 9y 8mo [25th, 75th centiles 9y 1mo, 10y 8mo], Manual Abilities Classification System level I=30, II=28, III=16). Self-care was measured using the Pediatric Evaluation of Disability Inventory-Computer Adaptive Test (PEDI-CAT), and bimanual performance using the Assisting Hand Assessment (AHA) and Both Hands Assessment (BoHA). Measures of cognition, behavioural regulation, inattention, and gross motor function were included. Analyses used a directed acyclic graph to select variables for linear regression modelling.

RESULTS

Higher AHA and BoHA scores were associated with higher PEDI-CAT scores. An increase of 1 AHA unit was associated with an increase of 0.12 PEDI-CAT scores, and a 1 BoHA unit increase was associated with an increase of 0.17 PEDI-CAT scores. The BoHA accounted for 57% of variance in PEDI-CAT scores for children with bilateral CP, while BoHA and cognition accounted for 68% of variance. The AHA accounted for 40% of variance in PEDI-CAT scores for unilateral CP with no effect of cognition on self-care.

INTERPRETATION

Self-care was strongly and positively associated with bimanual performance. Associations between self-care and bimanual performance differed for those with unilateral and bilateral CP.

WHAT THIS PAPER ADDS

There is a strong positive relationship between self-care and bimanual performance for unilateral and bilateral cerebral palsy (CP). Both Hands Assessment (BoHA) scores have a stronger association with self-care than Assisting Hand Assessment scores. BoHA scores also account for more variation in self-care. There is a strong positive relationship between self-care and cognition overall. The effect of cognition on self-care performance differed for bilateral and unilateral CP.

IncobotulinumtoxinA for the treatment of lower-limb spasticity in children and adolescents with cerebral palsy: A phase 3 study

PURPOSE

Investigate the efficacy and safety of multipattern incobotulinumtoxinA injections in children/adolescents with lower-limb cerebral palsy (CP)-related spasticity.

METHODS

Phase 3 double-blind study in children/adolescents (Gross Motor Function Classification System - Expanded and Revised I-V) with unilateral or bilateral spastic CP and Ashworth Scale (AS) plantar flexor (PF) scores ⩾ 2 randomized (1:1:2) to incobotulinumtoxinA (4, 12, 16 U/kg, maximum 100, 300, 400 U, respectively) for two 12- to 36-week injection cycles. Two clinical patterns were treated. Pes equinus (bilateral or unilateral) was mandatory; if unilateral, treatment included flexed knee or adducted thigh.

ENDPOINTS

Primary: AS-PF change from baseline to 4 weeks; Coprimary: investigator-rated Global Impression of Change Scale (GICS)-PF at 4 weeks; Secondary: investigator's, patient's, and parent's/caregiver's GICS, Gross Motor Function Measure-66 (GMFM-66).

RESULTS

Among 311 patients, AS-PF and AS scores in all treated clinical patterns improved from baseline to 4-weeks post-injection and cumulatively across injection cycles. GICS-PF and GICS scores confirmed global spasticity improvements. GMFM-66 scores indicated better motor function. No significant differences between doses were evident. Treatment was well-tolerated, with no unexpected treatment-related adverse events or neutralising antibody development.

CONCLUSION

Children/adolescents with lower-limb spasticity experienced multipattern benefits from incobotulinumtoxinA, which was safe and well-tolerated in doses up to 16 U/kg, maximum 400 U.

Clinical Relevance of State-of-the-Art Analysis of Surface Electromyography in Cerebral Palsy

Surface electromyography (sEMG) can be used to assess the integrity of the neuromuscular system and its impairment in neurological disorders. Here we will consider several issues related to the current clinical applications, difficulties and limited usage of sEMG for the assessment and rehabilitation of children with cerebral palsy. The uniqueness of this methodology is that it can determine hyperactivity or inactivity of selected muscles, which cannot be assessed by other methods. In addition, it can assist for intervention or muscle/tendon surgery acts, and it can evaluate integrated functioning of the nervous system based on multi-muscle sEMG recordings and assess motor pool activation. The latter aspect is especially important for understanding impairments of the mechanisms of neural controllers rather than malfunction of individual muscles. Although sEMG study is an important tool in both clinical research and neurorehabilitation, the results of a survey on the clinical relevance of sEMG in a typical department of pediatric rehabilitation highlighted its limited clinical usage. We believe that this is due to limited knowledge of the sEMG and its neuromuscular underpinnings by many physiotherapists, as a result of lack of emphasis on this important methodology in the courses taught in physical therapy schools. The lack of reference databases or benchmarking software for sEMG analysis may also contribute to the limited clinical usage. Despite the existence of educational and technical barriers to a widespread use of, sEMG does provide important tools for planning and assessment of rehabilitation treatments for children with cerebral palsy.

Functioning of young patients with cerebral palsy: Rasch analysis of the pediatric evaluation of disability inventory computer adaptive test daily activity and mobility

BACKGROUND

People with cerebral palsy experience limitations in performing activities of daily living. Rehabilitation practitioners seek valid instruments to measure changes in the performance of those activities. The Pediatric Evaluation of Disability Inventory Computer Adaptive Test (PEDI-CAT) is a new tool to assess functioning in children and youth with various health conditions. Its validity needs to be evaluated in a way that is consistent with the theoretical model on which it was based. We aimed to evaluate the fit of daily activity and mobility items and children with CP to the Rasch model and to compare the performance in daily activities and mobility of older children, adolescents, and young adults with CP based on manual function and gross motor function limitations.

METHODS

Eighty-three parents of children and youth of 8-20 years old (mean age: 11.6) with different severity levels of cerebral palsy participated in this study. Ninety-one items of the PEDI-CAT Daily Activities and Mobility domains were analyzed through Rasch analysis to evaluate relative item difficulty and participant ability. Participants were described according to the Manual Ability (MACS) (level I: 21.7%; II: 32.5%; III: 24.1%; IV: 7.2% and V: 3.6%) and the Gross Motor Function (GMFCS) (level I: 37.3%; II: 26.5%; III: 6%; IV: 18.1%; and V: 7.2%) classification systems levels.

RESULTS

Our data fit the Rasch Model. Parents had difficulty distinguishing some PEDI-CAT response categories. Participants from MACS and GMFCS levels IV and V showed lower ability to perform relatively more difficult items. There was a floor effect in both domains. Only 7.7% of the items presented differential item functioning when individuals with mild MACS and GMFCS levels (I, II) and moderate level (III) and individuals with moderate (III) and severe levels (IV, V) were compared.

CONCLUSIONS

PEDI-CAT daily activities and mobility domains are valid to evaluate children, adolescents and youth with CP of different severities, but the addition of items to these domains is recommended in order to address their floor effect.

Hand-arm bimanual intensive therapy and daily functioning of children with bilateral cerebral palsy: a randomized controlled trial

AIM

To examine the efficacy of Hand-Arm Bimanual Intensive Therapy (HABIT) on daily functioning, unimanual dexterity, and bimanual performance of children with bilateral cerebral palsy (CP) compared with customary care.

METHOD

Forty-one children with bilateral CP, aged 4 to 16 years, classified in levels I to III of the Manual Ability Classification System, were randomly assigned to HABIT (90h) (n=21) or to customary care (4.5h) (n=20). Participants' daily functioning (Pediatric Evaluation of Disability Inventory [PEDI], Canadian Occupational Performance Measure [COPM]), unimanual dexterity (Jebsen-Taylor Test of Hand Function, Box and Blocks Test [BBT]), and bimanual performance (Both Hands Assessment) were assessed pre-, post-, and 6 months after the intervention. Linear mixed-effects models were used for inferential analysis.

RESULTS

Children participating in HABIT showed greater improvements in daily functioning (COPM_performance : χ 1 2 =9.50, p<0.01; COPM_satisfaction : χ 1 2 =5.07, p<0.05; PEDI_{functional skills} : χ 1 2 =6.81, p<0.01; PEDI_{caregiver assistance} : χ 1 2 =6.23, p<0.05) and in the dexterity of the dominant hand (BBT: χ 1 2 =3.99, p<0.05) compared with children maintaining customary care. Group or time effects did not explain any variance in bimanual performance or in the dexterity of the non-dominant hand.

INTERPRETATION

HABIT may be beneficial for children with bilateral CP, with benefits evidenced for daily functioning outcomes.

WHAT THIS PAPER ADDS

Hand-Arm Bimanual Intensive Therapy (HABIT) improved daily functioning of children with bilateral cerebral palsy (CP). Bimanual performance, measured by the Both Hands Assessment, did not change after HABIT in children with bilateral CP. Children with asymmetric and symmetric hand use exhibited similar improvements after HABIT.

Impairments, functional limitations, and access to services and education for children with cerebral palsy in Uganda: a population-based study

AIM

To describe the functional limitations and associated impairments of children with cerebral palsy (CP) in rural Uganda, and care-seeking behaviour and access to assistive devices and education.

METHOD

Ninety-seven children with CP (42 females, 55 males; age range 2-17y) were identified in a three-stage population-based screening with subsequent medical examinations and functional assessments. Information on school and access to care was collected using questionnaires. The data were compared with Swedish and Australian cohorts of children with CP. We used the χ² test and linear regression models to analyse differences between groups.

RESULTS

Younger children were more severely impaired than older children. Two-fifths of the children had severe impairments in communication, about half had intellectual disability, and one third had seizures. Of 37 non-walking children, three had wheelchairs and none had walkers. No children had assistive devices for hearing, seeing, or communication. Care-seeking was low relating to lack of knowledge, insufficient finances, and 'lost hope'. One-third of the children attended school. Ugandan children exhibited lower developmental trajectories of mobility and self-care than a Swedish cohort.

INTERPRETATION

The needs for children with CP in rural Uganda are not met, illustrated by low care-seeking, low access to assistive devices, and low school attendance. A lack of rehabilitation and stimulation probably contribute to the poor development of mobility and self-care skills. There is a need to develop and enhance locally available and affordable interventions for children with CP in Uganda.

WHAT THIS PAPER ADDS

Development of mobility and self-care skills is lower in Ugandan than Swedish children with cerebral palsy (CP). Older children in Uganda with CP are less impaired than younger children. Untreated seizures and impairments of communication and intellect are common. Access to health services, assistive devices, and education is low. Caregivers lack knowledge and finances to seek care and often lose hope of their child improving.

Novel insights into cerebral palsy

Cerebral palsy (CP) is a neurodevelopmental disorder characterized by abnormalities of muscle tone, movement and motor skills, and is attributed to injury to the developing brain. CP affects about 1 in 500 neonates. CP shows clinical features which evolve with age, and these may over time lead to deterioration of motor function although the lesion to the developing brain is non-progressive. The underlying causes for CP remain unclear. Based on recent research we are able to give a physiological explanation on the appearance and development of the condition. The damage to the central nervous system causes a change in collagen structure, with a higher level of deposition of collagen around the muscles, increasing throughout life. Assuming this premise is correct, the question is, will it by any treatment be possible to delay or prevent this collagen accumulation in the CP muscles, thereby giving CP patients a better prognosis in the future.

Changes in Activity Participation After Multiple Sclerosis Diagnosis

BACKGROUND

Multiple sclerosis (MS) results in impairments in cognitive and motor skills, which may reduce the level of activity participation in people with MS. This study compares past and current levels of activity participation in adults with MS and controls. The relationship between retained activity participation (since diagnosis) and cognitive, motor, functional status, and depression symptoms of persons with MS was examined.

METHODS

Twenty-seven individuals with MS living in the community and 21 controls completed cognitive and motor tests and rated their activity participation (using the Activity Card Sort), depression symptoms, and functional status.

RESULTS

The MS group reported significantly lower current activity participation than the control group. Percentage of retained activity participation (from prediagnosis to current) in the MS group correlated with time since diagnosis, executive function and motor skill ability, depression symptoms, and current functional status.

CONCLUSIONS

Persons with MS report negative changes in activity participation in most aspects of life after diagnosis. These findings call attention to changes in activity participation in people with MS that are directly related to disease symptoms. Therefore, using a quantitative measure of activity participation-the Activity Card Sort-can provide important information to aid the clinician in developing individualized treatment goals for people with MS.

Cross-cultural adaptation and measurement properties of the Arabic version of the ABILHAND-Kids scale

Purpose: To cross-culturally adapt the ABILHAND-Kids into Arabic and to examine its measurement properties in children with cerebral palsy.Materials and methods: The Cross-cultural adaption of the ABILHAND-Kids into Arabic language included forward translation, backward translation, expert committee followed by preliminary testing. Structural validity using Rasch analysis, internal consistency, test-retest reliability, measurement error, and construct validity of the Arabic ABILHAND-Kids were examined in children with cerebral palsy (N = 154; 54% male, mean age 7.4 years).Results: Rasch analysis did not support the structural validity of the Arabic ABILHAND-Kids mainly due to response dependency. Removal of two items addressed the issue of the response dependency and resulted in a unidimensional scale meeting the requirement of the Rasch model. The scale had excellent internal consistency (Person Separation Index = 0.93) and excellent test-retest reliability (intraclass correlation coefficient = 0.98). The results supported 86% of the predefined hypotheses regarding correlation of the Arabic ABILHAND-Kids with the manual ability classification system, gross motor function classification system and the functional independence measure for children.Conclusion: The Arabic ABILHAND-Kids demonstrated adequate evidence supporting its structural validity as a unidimensional measure along with evidence supporting its internal consistency, test-retest reliability and construct validity as a measure of manual ability in children with cerebral palsy.Implications for rehabilitationThe Arabic ABILHAND-Kids is a reliable and valid measure of manual ability in children with cerebral palsy.The Arabic ABILHAND-Kids can be used to quantify manual ability in children with cerebral palsy in clinical practice and for research purposes.

Self-care and manual ability in preschool children with cerebral palsy: a longitudinal study

AIM

To describe longitudinal development of self-care and its relationship to manual ability in children with cerebral palsy (CP) aged 18 months to 5 years across all functional abilities.

METHOD

This was a prospective longitudinal population-based study of 290 children with CP (178 [61%] males, 112 [39%] females). Self-care was assessed using the Pediatric Evaluation of Disability Inventory (PEDI). At 60 months (n=242), children were classified using the Manual Ability Classification System (MACS); 113 in level I (47%), 61 in MACS level II (25%), 24 in MACS level III (10%), 14 in MACS level IV (6%), and 30 in MACS level V (12%). Measures were taken at 18 months, 24 months, 30 months, 36 months, 48 months, and 60 months of age. Longitudinal analyses were performed using mixed-effects linear regression models.

RESULTS

Self-care development achieved by 60 months was negatively associated with the severity of manual ability impairment. Distinct self-care developmental trajectories were found with estimated changes in PEDI self-care scaled scores per month: 0.61 for MACS level I, 0.46 for MACS levels II, 0.31 for MACS level III, 0.16 for MACS level IV, and 0.03 for MACS level V. Children classified in MACS level V had the lowest level of self-care skills at 18 months and showed no progress in self-care development.

INTERPRETATION

This study reports rate of self-care development in preschool children with CP. Self-care performance was highest in children with greatest manual ability. Clinicians may use rates of change to predict or monitor self-care performance. PEDI trajectories inform goal setting in discussions with families regarding expected levels of independence in self-care.

WHAT THIS PAPER ADDS

Distinct self-care developmental trajectories in children with cerebral palsy were found according to Manual Ability Classification System (MACS) levels. Children in MACS levels IV and V with epilepsy did not show any significant change in self-care. Children in MACS levels IV and V without epilepsy demonstrated small yet significant gains in self-care performance.

Normative values and discriminative ability across functional levels of ACTIVLIM-CP, a measure of global activity performance for children with cerebral palsy

Purpose: This study aims to provide normative values of a global activity performance questionnaire (ACTIVLIM-CP) and investigate its ability to discriminate children with cerebral palsy of various functional levels.Methods: Parents of 503 typically developing children aged 2-18 years old (mean age ± standard deviation (SD): 9.56 ± 4.62 years) and 285 children with cerebral palsy aged 2-18 years old (mean age ± SD: 10.08 ± 4.09 years) answered ACTIVLIM-CP. To provide normative values, influence of typically developing children's characteristics on ACTIVLIM-CP measures was investigated with a multiple linear regression. A Kruskal-Wallis test and Dunn's post-hoc tests were performed to investigate age differences in ACTIVLIM-CP measures. Discriminative ability of ACTIVLIM-CP was investigated using a one-way analysis of variance and post-hoc tests between children with cerebral palsy who differed in manual and gross motor functional levels.Results: In typically developing children, age was the strongest predictor, explaining 74% of the variance of ACTIVLIM-CP measures (β = 0.86, t = 38.21, p < 0.001). ACTIVLIM-CP measure increased with age until 17-18 years old where all children reached the maximal value, although 50% of the children at 12 years old already reached the maximal measure. Normative values were developed for each age bracket. In addition, ACTIVLIM-CP was able to discriminate children with CP's performance measures across most manual ability and gross motor functional levels.Conclusions: Normative values developed in this study with a representative sample of typically developing children allow clinicians to appraise the functional delay of children with cerebral palsy from the normal development of global activity performance. The good discriminative ability of ACTIVLIM-CP support its precision, construct validity, and clinical relevance to describe global activity limitations in children with cerebral palsy with manual ability levels and gross motor function levels II-V.Implications for rehabilitationNormative data of ACTIVLIM-CP developed with a representative sample of typically developing children can be used with children with CP to differentiate the age effect from the disruption caused by cerebral palsy.ACTIVLIM-CP showed the ability to discriminate across children with cerebral palsy having different manual and gross motor function, highlighting its precision, construct validity, and its clinical relevance to describe limitations in children with manual ability levels and gross motor function levels II-V.ACTIVLIM-CP covers a wide age range, is a cost-effective, easy and freely-available assessment of global activity performance in activities of daily living for clinicians.

Activity Performance Curves of Individuals With Cerebral Palsy

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Sense of autonomy and daily and scholastic functioning among children with cerebral palsy

BACKGROUND

There is growing evidence that children's sense of autonomy is an important psychological need closely linked with the development of self-esteem and motivation. Among children with physical disabilities, motor or cognitive limitations may negatively affect child's sense of autonomy (CSA) and competency.

PURPOSE

To examine how sense of autonomy among children with cerebral palsy (CP) directly and indirectly relates to their activity of daily living (ADL) and scholastic performance.

METHODS

Seventy-three children with CP and their mothers participated in this study. Child's ADL skills and scholastic performance were assessed using the Pediatric Evaluation Disability Inventory (PEDI) and the Scholastic Skills Rating Scale (SSRS), respectively. Level of impairment was assessed using the Gross Motor Function Measure-66 (GMFM-66). CSA was established via videotaped mother-child interactions. Regression analyses were conducted to examine factors predicting child's functional level (ADL and scholastic). The overall model was tested for goodness-of-fit and test of mediation.

RESULTS

GMFM and CSA significantly predicted child's ADL and scholastic functioning. GMFM explained 15% of the variance for CSA, 84% for PEDI, and 24% for scholastic functioning. CSA positively mediated the association between GMFM and child's ADL skills. GMFM was positively associated with CSA.

CONCLUSION

Motor impairment has a substantial impact on child's level of functioning. However, child's functioning is a complex construct that is also affected by her or his sense of autonomy. Therefore, sense of autonomy can serve as a potential point of intervention to improve functioning among children with CP.

Effects of Transcutaneous Electrical Acupoint Stimulation on Motor Functions and Self-Care Ability in Children with Cerebral Palsy

OBJECTIVES

To observe the effects of transcutaneous electrical acupoint stimulation (TEAS) in improving motor functions and self-care abilities in children with cerebral palsy in their early childhood.

DESIGN

A preliminary, prospective, cohort study.

SETTINGS/LOCATION

Multicenter.

SUBJECTS

Children aged 2-6 years old.

INTERVENTIONS

Twenty-three children were included in the study and randomly assigned to a control group ([CG] N = 11) or a therapeutic group ([TG] N = 12). In the TG, children were treated with TEAS (Shousanli [LI10] and Waiguan [SJ5]) plus the exercise therapy, while in the control group, they were treated with sham TEAS plus exercise therapy. Therapies were performed five days per week for eight weeks.

OUTCOME MEASURES

The Gross Motor Function Measure (GMFM) and the Functional Independent Measurement for children (WeeFIM) were used to evaluate motor functions and self-care abilities before and after the therapies.

RESULTS

Greater improvements were observed in the TG concerning all the measurements, although without statistical differences. The increments of the GMFM score and the WeeFIM motor, self-care and total scores were 36.08 ± 18.34 (26%), 16.17 ± 8.21 (33%), 7.67 ± 3.42 (40%) and 20.33 ± 10.08 (28%) in the TG, while 22.73 ± 16.54 (17%), 9.09 ± 9.43 (19%), 5.64 ± 6.73 (29%) and 12.82 ± 11.77 (18%) in the CG, respectively. No statistically significant correlations were shown between functional improvements and the demographics in the TG or the CG. The GMFM improvement was not statistically correlated with the improvements of the WeeFIM motor, self-care or total scores. However, the WeeFIM motor, self-care and total score were significantly positively correlated with one another in both groups (P < 0.01). No adverse effect was recorded during the study.

CONCLUSION

TEAS may be effective in improving motor functions and self-care abilities in children with cerebral palsy, in addition to conventional exercise therapy. Larger samples are required to confirm the efficacies.

Bimanual Capacity of Children With Cerebral Palsy: Intra- and Interrater Reliability of a Revised Edition of the Bimanual Fine Motor Function Classification

AIMS

To develop a revised edition of the Bimanual Fine Motor Function (BFMF 2), as a classification of fine motor capacity in children with cerebral palsy (CP), and establish intra- and interrater reliability of this edition.

METHODS

The content of the original BFMF was discussed by an expert panel, resulting in a revised edition comprising the original description of the classification levels, but in addition including figures with specific explanatory text. Four professionals classified fine motor function of 79 children (3-17 years; 45 boys) who represented all subtypes of CP and Manual Ability Classification levels (I-V). Intra- and inter-rater reliability was assessed using overall intra-class correlation coefficient (ICC), and Cohen's quadratic weighted kappa.

RESULTS

The overall ICC was 0.86. Cohen's weighted kappa indicated high intra-rater (к_w: >0.90) and inter-rater (к_w: >0.85) reliability.

CONCLUSIONS

The revised BFMF 2 had high intra- and interrater reliability. The classification levels could be determined from short video recordings (<5 minutes), using the figures and precise descriptions of the fine motor function levels included in the BFMF 2. Thus, the BFMF 2 may be a feasible and useful classification of fine motor capacity both in research and in clinical practice.

Evaluation of speed-accuracy trade-off in a computer task in individuals with cerebral palsy: a cross-sectional study

BACKGROUND

Individuals with Cerebral Palsy (CP) present with sensorimotor dysfunction which make the control and execution of movements difficult. This study aimed to verify the speed-accuracy trade-off in individuals with CP.

METHODS

Forty eight individuals with CP and 48 with typical development (TD) were evaluated (32 females and 64 males with a mean age of 15.02 ± 6.37 years: minimum 7 and maximum 30 years). Participants performed the "Fitts' Reciprocal Aiming Task v.1.0 (Horizontal)" on a computer with different sizes and distance targets, composed by progressive indices of difficulty (IDs): ID2, ID4a and ID4b.

RESULTS

There were no statistical differences between the groups in relation to the slope of the curve (b1) and dispersion of the movement time (r²). However, the intercept (b0) values presented significant differences (F(1.95) = 11.3; p = .001]), with greater movement time in the CP group compared to the TD group. It means that for individuals with CP, regardless of index difficulty, found the task more difficult than for TD participants. Considering CP and TD groups, speed-accuracy trade-off was found when using different indices of difficulty (ID2 and ID4). However, when the same index of difficulty was used with a larger target and longer distance (ID4a) or with a narrow target and shorter distance (ID4b), only individuals with CP had more difficulty performing the tasks involving smaller targets. Marginally significant inverse correlations were identified between the values of b1 and age (r = -0.119, p = .052) and between r² and Gross Motor Function Classification System (r = -0.280, p = .054), which did not occur with the Manual Ability Classification System.

CONCLUSION

We conclude that the individuals with CP presented greater difficulty when the target was smaller and demanded more accuracy, and less difficulty when the task demanded speed. It is suggested that treatments should target tasks with accuracy demands, that could help in daily life tasks, since it is an element that is generally not considered by professionals during therapy.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT03002285 , retrospectively registered on 20 Dec 2016.

Hand Function in Young Children with Cerebral Palsy: Current Practice and Parent-Reported Benefits

AIMS

To (1) describe characteristics of current interventions to improve hand function in young children with Cerebral Palsy (CP), and explore factors associated with (2) increased likelihood of hand and ADL training and (3) child benefits of training.

METHODS

A cross-sectional design was used with parent-reported data and data from the Norwegian CP Follow-up Program (CPOP). A total of 102 children (53% of the cohort of newly recruited children in the CPOP, mean age: 30.3 months, SD: 12.1) were included. Hand function was classified according to the Mini-Manual Ability Classification System (Mini-MACS). Data were analyzed with descriptive statistics, cross-tables and direct multiple logistic regressions.

RESULTS

The majority of the children performed training of hand skills and ADL. Parents reported high amounts of training, and training was commonly integrated in everyday activities. Both parents (OR = 5.6, p < .011) and OTs (OR = 6.2, p < .002) reported more hand training for children at Mini-MACS levels II-III compared to level I. Parents reported larger child benefits when training was organized as a combination of training sessions and practice within everyday activities (OR = 7.090, p = .011).

CONCLUSIONS

Parents reported that the children's everyday activities were utilized as opportunities for training, hence describing the intensity of therapy merely by counting minutes or number of sessions seems insufficient.

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

Objective

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

Methods

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

Results

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

Conclusion

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

The relationship of dystonia and choreoathetosis with activity, participation and quality of life in children and youth with dyskinetic cerebral palsy

AIM

To relate dystonia and choreoathetosis with activity, participation and quality of life (QOL) in children and youth with dyskinetic Cerebral Palsy (CP).

METHODS

Fifty-four participants with dyskinetic CP (mean age 14y6m, SD 4y2m, range 6-22y) were included. The Dyskinesia Impairment Scale (DIS) was used to evaluate dystonia and choreoathetosis. Activity, participation and quality of life (QOL) were assessed with the Gross Motor Function Measure (GMFM), the Functional Mobility Scale (FMS), the Jebsen-Taylor Hand Function Test (JTT), the ABILHAND-Kids Questionnaire (ABIL-K), the Life Habits Kids (LIFE-H) and the Quality of Life Questionnaire for children with CP (CP-QOL). Spearman's rank correlation coefficient (r_s) was used to assess the relationship between the movement disorders and activity, participation and QOL measures.

RESULTS

Significant negative correlations were found between dystonia and the activity scales with Spearman's rank correlation coefficient (r_s) varying between -0.65 (95% CI = -0.78 to -0.46) and -0.71 (95% CI = -0,82 to -0.55). Correlations were also found with the LIFE-H (r_s = -0.43; 95%CI = -0.64 to -0.17) and the CP-QOL (r_s = -0.32; 95%CI = -0.56 to -0.03). As far as choreoathetosis is concerned, no or only weak relationships were found with the activity, participation and quality of life scales.

INTERPRETATION

This cross-sectional study is the first to examine the relationship of dystonia and choreoathetosis in dyskinetic CP with the level of activity, participation and QOL. The results revealed dystonia has a higher impact on activity, participation and quality of life than choreoathetosis. These findings seem to suggest it is necessary to first focus on dystonia reducing intervention strategies and secondly on choreoathetosis.

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.

Instrumentos que avaliam a independência funcional em crianças com paralisia cerebral: uma revisão sistemática de estudos observacionais

RESUMO Este artigo teve como objetivo fazer uma revisão sistemática de instrumentos que avaliam a independência funcional de crianças com paralisia cerebral. As bases eletrônicas da MEDLINE/PubMed, Scopus e Web of Science foram usadas para as buscas. Estudos observacionais dos últimos cinco anos, com texto completo disponível e sem restrição de idioma foram incluídos nesta revisão. Foram encontrados 222 artigos, dos quais, 63 foram analisados e 24 foram incluídos no estudo. Os principais instrumentos encontrados foram: PEDI, WeeFIM, ASK, PODCI, VABS-II, LIFE-H e CAPE/PAC.

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.

Bimanual Fine Motor Function (BFMF) Classification in Children with Cerebral Palsy: Aspects of Construct and Content Validity

The Bimanual Fine Motor Function (BFMF) is currently the principal classification of hand function recorded by the Surveillance of Cerebral Palsy in Europe (SCPE) register. The BFMF is used in a number of epidemiological studies, but has not yet been validated.

AIMS

To examine aspects of construct and content validity of the BFMF.

METHODS AND RESULTS

Construct validity of the BFMF was assessed by comparison with the Manual Ability Classification System (MACS) using register-based data from 539 children born 1999-2003 (304 boys; 4-12 years). The high correlation with the MACS (Spearman's rho = 0.89, CI: 0.86-0.91, p<.001) supports construct validity of the BFMF. The content of the BFMF was appraised through literature review, and by using the ICF-CY as a framework to compare the BFMF and MACS. The items hold, grasp and manipulate were found to be relevant to describe increasingly advanced fine motor abilities in children with CP, but the description of the BFMF does not state whether it is a classification of fine motor capacity or performance.

CONCLUSION

Our results suggest that the BFMF may provide complementary information to the MACS regarding fine motor function and actual use of the hands, particularly if used as a classification of fine motor capacity.