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

Clinician Knowledge, Confidence, and Practice Patterns Defining, Identifying, and Quantifying Dystonia in Children: A Cross-Sectional Survey Study

A survey was completed by 183 clinicians at a pediatric hospital to investigate knowledge, confidence, and practice patterns defining, identifying, and quantifying dystonia in children. The definition of dystonia was correctly identified by 86% of participants. While 88% reported identifying dystonia, only 42% of physicians and therapists reported quantifying dystonia. A weak, significant correlation, rs =.339, p ≤ .001, was found between years of pediatric experience and confidence identifying dystonia. Clinician reported higher confidence levels identifying and quantifying dystonia if they perform a neurological exam. Clinical training initiatives are needed to improve standardization and build confidence in defining, identifying, and quantifying dystonia.

Declining trends in birth prevalence and severity of singletons with cerebral palsy of prenatal or perinatal origin in Australia: A population-based observational study

AIM

To investigate temporal trends in birth prevalence, disability severity, and motor type for singletons with prenatal or perinatally acquired cerebral palsy (CP).

METHOD

Numerator data, number of children with CP born a singleton between 1995 and 2014, confirmed at 5 years of age, were drawn from three state registers with population-level ascertainment. Birth prevalence estimates and 95% confidence intervals (CI) were calculated per 1000 singleton live births for the three states combined, overall, by gestational age group, by dichotomized disability severity, and spastic laterality. Poisson regression models were used to analyse trends. Using data from all eight registers, trends in the proportional distribution of CP subtypes overall and stratified by gestational age were examined.

RESULTS

Birth prevalence of CP declined from 1.8 (95% CI 1.6-2.0) in 1995 to 1996 to 1.2 (95% CI 1.1-1.4) in 2013 to 2014 (average 5% per 2-year epoch, p < 0.001). Declines in birth prevalence were observed across all gestational age groups with the largest decline in children born at <28 weeks (average 8% per epoch, p < 0.001). Prevalence of moderate-severe disability declined for children born at <28 and ≥37 weeks (average 11% and 7% per epoch respectively, p < 0.001). The proportions of bilateral spastic CP declined (p < 0.001) at <28 weeks (p = 0.014) and ≥37 weeks (p < 0.001). The proportion of children with dyskinesia increased (28-31 weeks: p = 0.021, 32-36 weeks: p = 0.001, and ≥37 weeks: p < 0.001).

INTERPRETATION

Birth prevalence of CP and moderate-severe disability (<28 and ≥37 weeks) declined in Australian singletons between 1995 and 2014, reflecting changes in prenatal and perinatal care over time.

WHAT THIS PAPER ADDS

Declines in birth prevalence of prenatal or perinatally acquired cerebral palsy were observed for singletons born in Australia between 1995 and 2014. These declines were evident across all gestational age groups. Declines in birth prevalence of moderate-severe disability were observed for children born at <28 weeks and ≥37 weeks.

The Dyskinetic Cerebral Palsy Functional Impact Scale: development and validation of a new tool

AIM

To outline the development and examine the content and construct validity of a new tool, the Dyskinetic Cerebral Palsy Functional Impact Scale (D-FIS), which measures the impact of dyskinesia on everyday activities in children with cerebral palsy (CP).

METHOD

D-FIS content was informed by a systematic review of dyskinesia outcome measures, in collaboration with children with dyskinetic CP, parents, caregivers, and expert clinicians. The D-FIS uses parent proxy to rate impact of dyskinesia on everyday activities. Construct validity was determined by examining internal consistency; known groups validity with the Gross Motor Function Classification System (GMFCS), Manual Ability Classification System (MACS), Communication Function Classification System (CFCS), and Eating and Drinking Ability Classification System (EDACS); and convergent validity with the Barry-Albright Dystonia Scale (BADS).

RESULTS

Fifty-seven parents of children (29 males, 28 females, mean [SD] age 11y 8mo [4y 4mo], range 2y 6mo-18y) completed the D-FIS. Correlation between D-FIS and GMFCS was r=0.86 (95% confidence interval [CI]: 0.77-0.91, p<0.001); MACS r=0.84 (95% CI: 0.73-0.90, p<0.001); CFCS r=0.80 (95% CI: 0.67-0.88, p<0.001); and EDACS r=0.78 (95% CI: 0.66-0.87). Correlation between D-FIS and BADS was r=0.77 (95% CI: 0.64-0.86, p<0.001). Cronbach's alpha was 0.96.

INTERPRETATION

The D-FIS demonstrates good construct validity and high internal consistency. The D-FIS will be useful for identifying priorities for intervention. It adds to the measurement tool kit for children with dyskinetic CP by addressing functional impact of dyskinetic movements and postures. What this paper adds The Dyskinetic Cerebral Palsy Functional Impact Scale (D-FIS) assesses the perceived impact of dyskinesia on daily activities in children with cerebral palsy (CP). The D-FIS demonstrates good construct validity and high internal consistency. The D-FIS is a clinically feasible, family-centred tool that fills a current gap in the dyskinetic CP assessment toolkit.

Dystonia assessment in children with cerebral palsy and periventricular leukomalacia

OBJECTIVE

To describe the frequency, motor phenotype, clinical patterns and functional consequences of dystonia in patients with cerebral palsy (CP) in the setting of periventricular leukomalacia.

METHODS

Retrospective analysis of a cohort of 31 patients with CP and periventricular leukomalacia. Gross Motor Function Classification System (GMFCS) and Manual Ability Classification System (MACS) were used to classify functional ability. Spasticity was rated using the Modified Ashworth Scale. Presence of dystonia was assessed by reviewing video recordings, and its severity by using the Burke-Fahn-Marsden Dystonia Rating Scale.

RESULTS

All patients showed evidence of dystonia involving upper and/or lower limbs, neck, trunk, mouth and eyes in order of frequency. In 29% of patients dystonia involved only the limbs and in 71% it was multifocal. Dystonia severity ranged from slight to severe. Severity and distribution of dystonia did not correlate with gender, age, weeks of gestation or duration of neonatal unit stay. GMFCS and MACS correlated with dystonia but not with spasticity.

CONCLUSIONS

Severity of dystonia, but not spasticity is associated with the severity of motor functional disability in CP patients with periventricular leukomalacia and demonstrates the key role of dystonia in the motor function of these patients.

Test-retest reliability of the Dyskinesia Impairment Scale: measuring dystonia and choreoathetosis in dyskinetic cerebral palsy

AIM

To assess test-retest reliability of the Dyskinesia Impairment Scale (DIS) in children and young adults with dyskinetic cerebral palsy (CP).

METHOD

Dystonia and choreoathetosis were assessed in 15 participants with dyskinetic CP (13 males, 2 females; age range 5-22y, mean 14y, SD 4y) using the DIS in two separate sessions over 7 days. Exclusion criteria were changes in muscle relaxant medication within the previous 3 months, orthopaedic or neurosurgical interventions within the previous year, and spinal fusion. Intraclass correlation coefficient, confidence intervals (CI), standard error of measurement, and the minimal detectable difference (MDD) were determined for test-retest reliability.

RESULT

Intraclass correlation coefficients of the DIS, the dystonia subscale of the DIS, and the choreoathetosis subscale of the DIS were 0.98 (95% CI 0.94-0.99), 0.97 (95% CI 0.92-0.99), and 0.96 (95% CI 0.90-0.99). The standard error of measurement and MDD were 2.6% and 7.2%.

INTERPRETATION

The DIS is a reliable tool to assess dystonia and choreoathetosis; it remains stable over time in children and young adults with dyskinetic CP. These results add to the current evidence for good clinimetric properties of the DIS.

WHAT THIS PAPER ADDS

The Dyskinesia Impairment Scale (DIS) shows stability in scoring dystonia and choreoathetosis. The total DIS score and dystonia and choreoathetosis subscales are clinically useful.

Movement Disorders - Childhood Rating Scale 4-18 revised in children with dyskinetic cerebral palsy

BACKGROUND

Movement Disorders - Childhood Rating Scale for age 4-18 (MD-CRS 4-18) is a tool aimed to evaluate movement disorders in developmental age, validated since 2008 and applied in the literature. Psychometric properties, including inter- and intra-reliability and construct validity have been evaluated over time on children and adolescents with different types of movement disorders.

AIM

The aim of the study is to revise the Movement Disorders - Childhood Rating Scale 4-18 (MD-CRS 4-18 R) and evaluate its psychometric properties, compared to previous version of the scale, in dyskinetic cerebral palsy.

DESIGN

This is a measurement-focused study of video recorder sessions.

SETTING

Video session carried out inpatient and outpatient.

POPULATION

This measurement-focused study was carried out on a cohort of 57 participants with DCP (37 males; mean age 9 years and 6 months ±3 years and 8 months) evaluated through video-recorded sessions by experienced scorers using MD-CRS 4-18 and MR-CRS 4-18 R.

METHODS

Inter-rater reliability, intra-rater reliability of MD-CRS 4-18 and MD-CRS 4-18 R were performed.

RESULTS

This study supports the relevant contribution of MD-CRS 4-18 R to identify the severity of movement disorders in dyskinetic cerebral palsy, as indicated by the higher ICC values on Index II compared to previous MD-CRS 4-18 results. Standard Error Measurement (SEM) and Minimally Detectable Difference (MDD) of MD-CRS 4-18 R in DCP were all very low, with SEMs ranging from 0.01 to 0.02 and MDD from 0.03 to 0.06.

CONCLUSIONS

Data obtained with MD-CRS 4-18 R are in accordance with previous scale on individuals with movement disorders due to different etiologies, tested with MD-CRS 4-18.

CLINICAL REHABILITATION IMPACT

MD-CRS 4-18 R is able to verify natural history of the disease and represents a standardized clinical outcome measure in the evaluation and follow-up of children with DCP. Also MD-CRS 4-18 Revised form is a feasible tool, now easier to understand than the previous one, more available for incoming clinical trials.

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.

Getting inTOUCH: outcomes of a knowledge translation intervention for tactile assessment knowledge, barriers, and practice in paediatric therapists working with children with cerebral palsy

Background: Tactile impairments are common in children with cerebral palsy (CP), however assessment is not routinely carried out by therapists. We investigated a multi-faceted Knowledge Translation intervention to improve Knowledge, remove Barriers and enhance Practice of tactile assessments by paediatric therapists. Method: Twelve therapists from a state-wide service for children with CP (seven physiotherapists, five occupational therapists; 12 female) received: written information, demonstration videos, a face-to-face workshop, equipment provision, and on-call mentoring. Therapists completed pre-post-intervention questionnaires reporting their perceived tactile assessment Knowledge, current Practices and implementation Barriers. Results: Following intervention, therapists improved Knowledge of correct (1) tactile impairment prevalence in children with CP (pre 3/12; post 9/12), (2) tactile assessment items (e.g. Registration - pre 1/12; post 9/12; Localisation - pre 2/12; post 10/12), and (3) equipment choice (e.g. Monofilaments - pre 1/12; post 10/12). Tactile assessment Practice improved slightly. All major clinician-level implementation Barriers were resolved and less obvious organisational-level Barriers were identified for follow-up. Conclusion: A 12-month multi-faceted Knowledge Translation intervention can improve tactile assessment Knowledge, resolve major clinician-level implementation Barriers, and identify less obvious organisational-level Barriers to be addressed to achieve maximum Practice improvement. Ongoing multi-faceted knowledge translation processes are essential for high-performing organisations. Implications for rehabilitation A multi-faceted knowledge translation intervention significantly improved paediatric therapists' knowledge of the items and equipment necessary for tactile assessment. A 12-month intervention can address clinician-level barriers of knowledge, confidence, and access to equipment and assist in the identification of less obvious organisational-level barriers. Consideration of motivational readiness for change, intervention timelines, monitoring of emergent barriers, and fitting tactile assessment into a broader assessment framework are critical for improving uptake of tactile assessment in practice.