The concept of a toolbox of outcome measures for children with cerebral palsy: why, what, and how to use?

Measuring global activity performance in children with cerebral palsy in West Africa: validation of an adapted version of the ACTIVLIM-CP questionnaire

PURPOSE

To calibrate a West-African version of the ACTIVLIM-CP questionnaire (ACTIVLIM-CP-WA) for children with cerebral palsy (CP).

MATERIALS AND METHODS

We recruited 287 children with CP of various age range: 2-6 years (n = 117, preschoolers), 6-12 years (n = 96, children) and 12-19 years (n = 74, adolescents). Caregivers of children of each age range completed the experimental version of the ACTIVLIM-CP-WA including 76 (preschoolers), 78 (children) and 76 (adolescents) global daily life activities. Responses were analyzed using the Rasch RUMM2030 software.

RESULTS

The final West-African version of ACTIVLIM-CP including 31 items (both common and age-specific items) defined a unidimensional, linear scale with well-discriminated response categories. It presented a high internal consistency (R = 0.94). Moreover, all items were locally independent and the item difficulty hierarchy was invariant regarding caregivers' education, children's age and gender, MACS and GMFCS levels. The ACTIVLIM-CP-WA measures were significantly correlated (p < 0.05) with Gross Motor Function Classification System (ρ = -0.77), Manual Ability Classification System (ρ = -0.75), Box and Block test (dominant hand r = 0.51; non-dominant hand r = 0.49), One-minute walking test (r = 0.28), and Timed up and Go test (r = -0.40).

CONCLUSIONS

The ACTIVLIM-CP-WA questionnaire provides a valid and reliable tool that has the potential to follow children's evolution and quantify changes consecutive to neurorehabilitation in Sub-Saharan Africa.IMPLICATIONS FOR REHABILITATIONThe West-African version of the ACTIVLIM-CP questionnaire (ACTIVLIM-CP-WA) measures global activities requiring a combination of lower and upper extremities in children with cerebral palsy.As a Rasch-built scale, measures are unidimensional and linear to document changes in children with cerebral palsy from 2 to 19 years in Sub-Saharan Africa.Rehabilitation professionals are encouraged to use the ACTIVLIM-CP-WA questionnaire as a psychometrically robust assessment tool measuring the global performance in daily life activities in children with cerebral palsy in Sub-Saharan Africa.

Clinical functional outcome measures for children with cerebral palsy after gait corrective orthopaedic surgery: A scoping review

AIM

To identify the most frequently reported non-instrumented measures of gait, activity, and participation in children with cerebral palsy (CP) after undergoing gait corrective orthopaedic surgery.

METHOD

Four databases were searched from database inception to the 9th December 2021 for studies that evaluated functional outcomes for children with CP under 18 years undergoing gait corrective orthopaedic surgery.

RESULTS

Of 547 citations, 44 publications (n = 3535 participants, n = 1789 males, mean age 10 years 5 months [SD = 3 years 3 months], Gross Motor Function Classification System levels I-III at the time of surgery) were eligible for inclusion. Fourteen different outcome measures were used: one measure of gait, 10 measures of activity, and three measures of participation. Gait was measured with the Edinburgh Visual Gait Scale (EVGS; 4 out of 44). The most common activity and participation measures were the Functional Mobility Scale (FMS; 15 out of 44) and Pediatric Outcomes Data Collection Instrument (11 out of 44) respectively. No studies reported a combination of gait, activity, and participation measures.

INTERPRETATION

The EVGS and FMS should be considered as core outcome measures in gait corrective orthopaedic surgery, while a measure of participation is unclear. Additional considerations for developing a comprehensive suite of outcomes include identifying a combination of clinical measures and performance-reflective questionnaires that are standardized for children with CP undergoing surgery and meaningful to clinicians and families.

Child engagement in daily life measure V2: validation of psychometric properties for children with cerebral palsy

PURPOSE

Measurement development is a reiterative process requiring refinements and revalidation. The purpose of this study was to examine structural validity and reliability of the Child Engagement in Daily Life Measure (Version 2) for parents of children with cerebral palsy (CP) across a broader age span.

METHODS

Participants were 1054 parents of children with CP 1.5-11 years of age. Parents completed the Child Engagement in Daily Life measure that consists of the Participation in Family and Recreational Activities domain (11 items) and the Performance of Self-care Activities domain (18 items) as part of two longitudinal studies related to outcomes for children with CP.

RESULTS

Rasch analysis indicated acceptable fit of items, stable item calibration, and logical ordering of items by difficulty for both frequency of participation in family and recreational activities and performance of self-care activities. Test-retest reliability was good to excellent: ICC = 0.78 for frequency of participation, ICC = 0.68 for enjoyment of participation, and ICC = 0.97 for self-care.

CONCLUSIONS

Evidence supports reliability and validity of the Child Engagement in Daily Life Measure (Version 2) for parent-report of their children's participation in family and recreational activities and performance of self-care activities for children with CP 1.5-12 years of age.IMPLICATIONS FOR REHABILITATIONParticipation in family and recreational activities and performance of self-care activities of children with cerebral palsy can be assessed using the concise parent-report Child Engagement in Daily Life Measure V2.Knowledge of the continuum of difficulty of the frequency of participation in family and recreational activities and performance of self-care activities can assist practitioners in progressing service plans.Practitioners are encouraged to use the measure to guide discussions with parents and children on areas to focus services to support participation in family and recreational activities and performance of self-care activities.

Efficacy of Constraint-Induced Movement Therapy Versus Bimanual Intensive Training on Motor and Psychosocial Outcomes in Children With Unilateral Cerebral Palsy: A Randomized Trial

IMPORTANCE

Emerging research has demonstrated that constraint-induced movement therapy (CIMT) and bimanual intensive training (BIT) show promising effectiveness for children with unilateral cerebral palsy (UCP). Considering that neurorehabilitative programs have always been designed with long training periods, psychosocial outcomes have received scarce attention and thus have not been investigated sufficiently.

OBJECTIVE

To compare the efficacy of CIMT and BIT with 36-hr interventional dosages for both motor and psychosocial outcomes.

DESIGN

Randomized trial.

SETTING

Community.

PARTICIPANTS

Forty-eight children with UCP, ages 6 to 12 yr.

INTERVENTION

Both CIMT and BIT delivered via individual intervention for 2.25 hr/day, twice a week, for 8 wk.

OUTCOMES AND MEASURES

The Melbourne Assessment 2, Pediatric Motor Activity Log-Revised, Bruininks-Oseretsky Test of Motor Proficiency, ABILHAND-Kids measure, and Parenting Stress Index-Short Form were administrated at pretreatment, midterm, posttreatment, and 6 mo after intervention. An engagement questionnaire for investigating the child's engagement in the intervention was used to collect the perspectives of the children and the parents weekly.

RESULTS

Children with UCP who received either CIMT or BIT achieved similar motor improvements. The only difference was that CIMT yielded larger improvements in frequency and quality of use of the more affected hand at the 6-mo follow-up. Similar child engagement and parental stress levels were found in the two groups.

CONCLUSIONS AND RELEVANCE

This study comprehensively compared the efficacy of motor and psychosocial outcomes for 36-hr dosages of CIMT and BIT. The promising findings support the clinical efficacy and feasibility of the proposed protocols. What This Article Adds: The core therapeutic principle of CIMT (i.e., remind the child to use the more affected hand) may be more easily duplicated by parents. Parents may have overestimated their child's engagement and given relatively higher scores; therefore, occupational therapists should also consider the opinions of the children themselves.

Psychometric properties of the English language version of the C-BiLLT evaluated in typically developing Canadian children

PURPOSE

This study aimed to 1) investigate the convergent and discriminant validity, internal consistency, and test-retest reliability of the Canadian English version of the Computer-Based instrument for Low motor Language Testing (C-BiLLT-CAN), and 2) explore feasibility of the C-BiLLT assessment for children with cerebral palsy (CP) and complex communication needs in the Canadian health care context.

METHODS

Eighty typically developing children between 1.5 and 8.5 years of age completed the C-BiLLT-CAN, the Peabody Picture Vocabulary Test-IV (PPVT-4), the receptive language sub-test of the New Reynell Developmental Language Scales (NRDLS), and/or the Raven's 2. Correlations between raw scores were calculated for estimates of convergent and discriminant validity. Internal consistency was calculated for all items and separately for items pertaining to vocabulary and grammar. To calculate the standard error of measurement (SEM) and intraclass correlation coefficient (ICC), 33 participants were re-tested with the C-BiLLT within three weeks. Feasibility was explored with nine participants with CP.

RESULTS

C-BiLLT-CAN's convergent validity was good to excellent (Spearman's rho >  0.78) and discriminant validity was higher than hypothesized (Spearman's rho >  0.8). Internal consistency (Cronbach's alpha = 0.96), test-retest reliability (ICC >  0.9), and measurement error (SEM <  5%) were excellent. The feasibility study could not be fully completed due to the COVID-19 pandemic. Preliminary data demonstrated some technical and practical barriers for using the C-BiLLT in children with CP in Canada.

CONCLUSION

The C-BiLLT-CAN demonstrates good to excellent psychometric properties in a sample of typically developing children, indicating that it is an adequate test for measuring language comprehension in English-speaking Canadian children. Further research is needed to investigate the feasibility of the C-BiLLT-CAN in children with CP.

Implementing the language comprehension test C-BiLLT: a qualitative description study using the COM-B model of behaviour change

BACKGROUND

It is challenging to reliably assess the language comprehension of children with severe motor and speech impairments using traditional assessment tools. The Computer Based instrument for Low motor Language Testing (C-BiLLT) aims to reduce barriers to evidence-based assessment for this population by allowing children to access the test using non-traditional methods such as eye gaze so they can independently respond to test items. The purpose of this study is to develop a contextualized understanding of the factors that influenced clinicians' implementation of the C-BILLT in practice in the Netherlands and Norway.

MATERIALS AND METHODS

A qualitative approach including semi-structured individual interviews with 15 clinicians (speech-language pathologists, neuropsychologists, and one teacher, counsellor, and vision specialist) was used. Data analysis was conducted in two rounds. First, a deductive approach including a codebook was used to code data within the COM-B components describing clinicians' capability, opportunity, and motivation for behaviour change. Then, an abductive approach applying thematic analysis was used to identify meaningful patterns within the COM-B components.

RESULTS

Several meaningful barriers and facilitators were identified across the data. Clinicians used the C-BiLLT with two distinct groups of clients: (1) the population it was originally developed for, and (2) clients that could have also been assessed using a traditional language test. Clinicians working with the first group experienced more, and more complex barriers across all COM-B components, to successful C-BiLLT use than the latter.

CONCLUSION

This study provides timely insights into the capability, opportunity, and motivation factors important for creating and sustaining assessment behaviour change in clinicians who used or attempted to use the C-BiLLT. Potential tailored intervention strategies aimed at improving implementation of novel assessment tools are discussed and may be helpful for others working to improve service delivery for children with complex needs.

What are the relevant categories, modalities, and outcome measures for assessing lower limb somatosensory function in children with upper motor neuron lesions? A Delphi study

PURPOSE

Somatosensory function of the lower limbs is rarely assessed in children with upper motor neuron lesions despite its potential relevance for motor function. We explored consensus regarding somatosensory categories (exteroception, proprioception, interoception, and body awareness), modalities, and outcome measures relevant to lower limb motor function.

METHODS

Fifteen international experts with experience of somatosensory function assessment participated in this Delphi study. Surveys of four rounds, conducted online, included questions on the relevance of somatosensory categories and modalities for motor function and on the use of potential outcome measures in clinical practice.

RESULTS

The experts reached consensus on the relevance of six modalities of the categories exteroception, proprioception, and body awareness. Based on their feedback, we formulated three core criteria for somatosensory outcome measures, namely suitability for clinical practice, child-friendliness, and relevance for motor function. None of the nine available outcome measures fulfilled each criterion. The experts also highlighted the importance of using and interpreting the tests in relation to the child's activity and participation.

CONCLUSION

There was expert consensus on three categories and six modalities of somatosensory function relevant for lower limb motor function. However, existing outcome measures will need to be adapted for use in paediatric clinical practice. IMPLICATION FOR REHABILITATIONConsensus was established for the categories and modalities of somatosensory function relevant for lower limb motor function of children with UMN lesion.Outcome measures should cover tactile function, joint movement and joint position and dynamic position sense, and spatial and structural body representation.None of the nine existing outcome measures fulfilled the core criteria: feasibility for clinical practice, child-friendliness, and relevance to motor function.

Outcome measurement instruments in Rett syndrome: A systematic review

OBJECTIVE

The aim of the study was to identify and characterize outcome measures for objective and subjective assessment in persons with Rett syndrome (RS).

METHODS

A systematic review was conducted consulting the EBSCO, Cochrane, Web of Science, Scielo, MEDLINE and PsycINFO databases for published studies describing the use of patient-reported outcome measures (PROMs) and other outcome measures in persons with RS. Validation studies and observational studies were included. The PROMs were first described, and then the measurement properties were evaluated using predefined criteria according to the COnsensus-based Standards for the selection of health Measurement Instruments (COSMIN). The outcome measures were then grouped according to the International Classification of Functioning, Disability and Health (ICF) to establish a relationship between outcome measures and ICF domains.

RESULTS

Twenty out of 2327 articles were appraised, and seventeen different outcome measures were identified and described. Ten outcome measures corresponded to evaluation questionnaires, while the remaining seven assessed functional outcomes: walking distance, physical activity level and ability to interact visually. A relation between these outcome measures that assess RS and the ICF allows understanding that most of the instruments (fifteen) include the assessment of activity limitations.

CONCLUSIONS

The findings of this study seem to be promising for their use by clinicians and researchers, although they have methodological limitations. The accuracy and quality of these individual outcome measures should continue to be assessed in an attempt to gather a consensus on the best tools used in RS.

Outcomes of importance to children and young adults with cerebral palsy, their parents and health professionals following lower limb orthopaedic surgery: A qualitative study to inform a Core Outcome Set

Introduction

Although several outcomes are commonly measured to assess the effect of surgery for young people with cerebral palsy (CP), these are selected mainly by health professionals and researchers. Including the perspectives of a broader range of stakeholders is an essential step towards determining important outcomes for assessment. This qualitative study involves the development of a core outcome set (COS) for lower limb orthopaedic surgery for ambulant children with CP.

Objective

This study aimed to identify outcomes that matter to children and young people with CP, their parents and healthcare professionals following lower limb orthopaedic surgery.

Methods

Semi‐structured interviews were conducted with 10 healthcare professionals, 10 children and young people with CP and 8 parents. Interview data were analysed by content analysis supported by the International Classification of Functioning, Disability and Health (ICF‐CY) supplemented by thematic analysis.

Findings

Thirty‐one outcomes were identified in total, which were linked to eleven second‐level ICF‐CY categories. There were differences between stakeholder groups in preferences and expectations from surgical outcomes. Healthcare professionals and children with their parents identified 31 and 25 outcomes, respectively. Health outcomes valued by participants were lower limb alignment and symmetry, flexibility and muscle strength, mental health, fatigue, pain, function in life, mobility, participation, being independent, quality of life and adverse events. Compared to previous published trials, 10 new outcomes were revealed by this study.

Conclusion

The researchers identified outcomes that are important to all stakeholders following lower limb orthopaedic surgery for ambulant CP. Including these outcomes in future studies would promote patient‐centred care for children and young adults with CP. Findings will be used to inform an international Delphi survey and develop a COS in this field.

Patient and Public Contribution

This study was informed by an advisory group including a young adult with CP and a parent of a child with CP. This group engaged in the design of the study and the information material to support the interview (information sheet and interview topic guide).

Cross-cultural adaptation of the Arabic version of Self-Care Domain of Child Engagement in Daily Life and Ease of Caregiving for Children measures

PURPOSE

To cross-culturally adapt the Self-Care Domain of Child Engagement in Daily Life and the Ease of Caregiving for Children to Arabic language and Saudi culture and to examine the reliability of the Arabic version of both measures.

METHODS

A modified cross-cultural adaptation procedure was employed. A total 36 children with cerebral palsy (aged 1.5-11 years) and their parents participated in the pilot and final testing steps. A committee of 7 stakeholders evaluated cross-cultural equivalence of both measures. Cronbach's alpha, intra-class correlation coefficient, and minimal detectable change were used to establish internal consistency, test-retest reliability, and distribution-based index, respectively.

RESULTS

Minor linguistic, not cultural, adaptations were made in the Arabic version of both measures. Conceptual, item, semantic, and operational types of equivalences were supported. The Arabic version of Self-Care Domain of Child Engagement in Daily Life and Ease of Caregiving for Children demonstrated high internal consistency (0.97 and 0.91, respectively), excellent test-retest reliability (0.99 and 0.96, respectively), and appropriate minimal detectable change values (0.29, 0.43, respectively).

CONCLUSIONS

The Arabic version of Self-Care Domain of Child Engagement in Daily Life and Ease of Caregiving for Children are reliable and culturally appropriate for use with parents of children with cerebral palsy in Saudi Arabia.

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.

Value-Driven Care in Developmental-Behavioral Pediatrics, Part 2: Measuring Quality and Meeting the Challenge

The drive to improve quality and reduce cost of health care is leading to a value-driven transformation of the US health care landscape. This is the second of a 2-part series on value-driven care and its implications for developmental-behavioral pediatrics (DBP). Part 1 addressed costs of care and enhancing value of care, with a particular focus on the value proposition of the field of DBP. This study begins with a discussion of the Donabedian's model of quality, including structure, process, patient satisfaction, and outcomes. The challenges of measuring process and outcomes in DBP are discussed, with a focus on (1) children 0 to 3 years of age identified as having global developmental delay, (2) recent diagnosis of complex attention-deficit hyperactivity disorder (ADHD) (ADHD plus comorbid conditions), and (3) children with autism spectrum disorder (ASD) and disruptive behavior. The study concludes with some of the important next steps for DBP providers, researchers, health care systems, professional societies, and families. With a discussion of national trends and a local example of a DBP program's response to these trends, the series is intended to provoke discussion and action in the field, contribute to the demonstration of value of a DBP approach to care, and help to chart a course toward growth and sustainability of DBP in an era of value-based care.

Development of a core outcome set for lower limb orthopaedic surgical interventions in ambulant children and young people with cerebral palsy: a study protocol

INTRODUCTION

Musculoskeletal deformities and gait deviations are common features in ambulatory cerebral palsy (CP). Deformity correction through lower limb orthopaedic surgery is the standard form of care aimed at improving or preserving motor function. Current research on CP care does not always take into account individual patients' expectations and needs. There is a wide range of outcome domains and outcome measures used to assess outcome from treatment. This can lead to reporting bias and make it difficult to compare and contrast studies. A core outcome set (COS) would enhance the efficiency, relevance and overall quality of CP orthopaedic surgery research. The aim of this study is to establish a standardised COS for use in evaluating lower limb orthopaedic surgery for ambulatory children and young people with CP.

METHODS/ANALYSIS

A set of outcomes domains and outcome measures will be developed as follows: (1) a qualitative evidence synthesis to identify relevant outcomes from children and young people and family perspective; (2) a scoping review to identify relevant outcomes and outcome measures; (3) qualitative research to explore the experience of key stakeholders; (4) prioritisation of outcome domains will be achieved through a two-round Delphi process with key stakeholders; (5) a final COS will be developed at a consensus meeting with representation from key stakeholder groups.

ETHICS AND DISSEMINATION

Ethical approval for this study was granted in the UK by the Oxfordshire Research Ethics Committee B (REC reference 19/SC/0357). Informed consent will be obtained from participants taking part in the qualitative research and Delphi process. Study findings will be published in an open access journal and presented at relevant national and international conferences. Charities and associations will be engaged to promote awareness of the project COS results.

TRIAL REGISTRATION NUMBER

COMET registration: 1236.

PROSPERO REGISTRATION NUMBER

CRD42018089538.

Home programmes based on evidence of best practice for children with unilateral cerebral palsy: Occupational therapists’ perceptions

Introduction

Evidence-based occupational therapy home programmes for children with unilateral cerebral palsy have demonstrated efficacy; however, uptake into routine practice is varied. The aim of this study was to gain a deeper understanding of the therapist-perceived supports and barriers to using occupational therapy home programmes for children with unilateral cerebral palsy, based on evidence of best practice in the United Kingdom.

Method

Fourteen occupational therapists completed semi-structured telephone interviews. Using a qualitative framework analysis approach, support and barrier factors were indexed against the Theoretical Domains Framework, before being categorised more broadly using the Capability, Opportunity, Motivation and Behaviour Model.

Findings

Common supports included: (a) strong leadership within the team to facilitate the translation of occupational therapy home programmes and evidence-based interventions into service-specific protocols; (b) knowledge exchange within professional networks and (c) mentorship. Common barriers included: (a) lack of resources; (b) restricted opportunities to review occupational therapy home programmes and (c) difficulties keeping up-to-date with the evidence in this area.

Conclusion

To be effective, occupational therapy home programmes need to be based on evidence of best practice; analysis indicated an urgent need to capture outcomes, record parental practice, further integrate ‘occupation’ within goal-setting, and develop use of conceptual models of practice to both enhance family-centred care and articulate the profession’s unique contribution.

A systematic review of upper limb activity measures for 5- to 18-year-old children with bilateral cerebral palsy

AIM

To investigate measurement properties and feasibility of upper limb activity measures in children aged 5-18 years with bilateral cerebral palsy (CP).

METHODS

Five electronic databases were searched to identify measures of upper limb activity with published psychometric data for children with bilateral CP aged 5-18 years. Measures included both Patient-Reported Outcome Measures (PROMs) and observational measures. The COnsensus-based Standards for selection of health Measurement Instruments checklist was used to evaluate methodological quality of studies for each measure.

RESULTS

Forty-eight measures were identified, eight of which met inclusion criteria for reliability and validity. Four PROMs were included: the ABILHAND-Kids and Children's Arm Rehabilitation Measure are parent questionnaires measuring overall manual ability; the ACTIVLIM-CP is a parent questionnaire measuring global activity (upper and lower extremity) performance, and, the Pediatric Upper Limb Measure, Short Form is a child self-report questionnaire. Four observational measures were included: the Both Hands Assessment (BoHA) is an observational measure of bimanual activity performance; the Melbourne Assessment of Unilateral Upper Limb Function and the Melbourne Assessment 2 measure quality of movement of each upper limb separately, and the Peabody Developmental Motor Scales-Second Edition assesses fine motor skill capacity in young children. Based upon available evidence, the most suitable PROM for evaluation of upper limb activity in children with bilateral CP is the ACTIVLIM-CP, and the most suitable observational measure is the BoHA.

CONCLUSION

Selection of upper limb measures depend on clinical information required and available resources. The BoHA is the only observational-based assessment which measures bimanual upper limb activity performance in children with bilateral CP. Recommendation for future measurement studies include familiarisation with the standards required for excellence, which include adequate sample size and content validity studies for PROMs.

Steering towards collaborative assessment: a qualitative study of parents' experiences of evidence-based assessment practices for their child with cerebral palsy

PURPOSE

To understand parents' experiences of evidence-based assessment by health professionals for their child with cerebral palsy.

METHODS

A qualitative interpretive description study was undertaken. Primary carers of children with cerebral palsy (aged 3-18 years) from south-eastern Australia were invited to participate. Face-to-face interviews were held using a semi-structured topic guide and data analyzed inductively. Credibility was ensured through: journal reflections; co-author review; audit trail; and, participant member-checking.

RESULTS

Fourteen parents of children with cerebral palsy, representing Gross Motor Functional Classification System levels I-V, participated. Six themes emerged: (1) Protection; (2) Positively Framed; (3) Bridging the Gap; (4) Involvement; (5) Finding Worth; and (6) Trust. Central to parents' experience was protection of their child's identity and personal self. Assessment can be emotionally confronting, at any stage. Representing the child positively and highlighting possibilities was deemed essential. Parents' involvement ranged from being overlooked spectators to being instigators of assessment. Evidence-based assessment was worthwhile when relevant to parents' direction and family context. The researchers' interpretive description generated a schema and metaphor-the Steering Wheel for Collaborative Assessment.

CONCLUSIONS

A strengths-based approach to diagnosis and assessment is essential. The resulting interpretive description may assist health professionals align evidence-based assessment practices with family-centred care.Implications for rehabilitationParents of children who have cerebral palsy describe having to protect their child's identity and representation, and their own personal well-being, through evidence-based assessment and diagnostic processes.Involving parents in the process of evidence-based assessment and adopting a strengths-based approach is essential.The interpretive description developed-the Steering Wheel for Collaborative Assessment-may assist health professionals to implement evidence-based assessment tools in ways consistent with family-centred care principles.

Use of outcome measures in children with severe cerebral palsy: A survey of U.K. physiotherapists

OBJECTIVES

To investigate the use of outcome measures for children with cerebral palsy (CP) by paediatric physiotherapists (PTs) who are based in the United Kingdom, as limited research exists regarding their use in this population, and to explore therapists' use of measures within different Gross Motor Function Classification System (GMFCS) levels and for different types of CP.

METHODS

A six-item online survey was advertised through two paediatric therapy special interest groups inviting physiotherapists to participate. Descriptive statistics (range, frequencies, and percentages) were used to analyse survey data.

RESULTS

Two hundred and seven physiotherapists returned completed survey questionnaires. One hundred and seventy-six (85%) therapists reported using a wide variety of outcome measures (57). Eighty-one per cent of therapists' responses for having "most difficulty" in identifying responsive outcome measures were for children with impaired mobility at GMFCS Levels IV-V and children with more significant body involvement (76%), for example, spastic quadriplegia or dyskinesia. Eighty-six per cent of therapists' responses for having "greatest ease" of identifying responsive outcome measures were for children within GMFCS Levels I-III and for children with less significant body involvement (72%), for example, hemiplegia. The variety of outcome measures used by therapists with children within GMFCS IV-V was less (16).

CONCLUSIONS

The majority (85%) of the PTs surveyed used outcome measures with children with CP, but 81% perceived a difficulty in identifying responsive measures for children with more severe impairments who are classified as GMFCS IV-V. The reasons for this perceived difficulty warrant investigation and may suggest a need for training regarding relevant measures and/or a need to develop new measures for this group of children.

Functional Gains in Children With Spastic Hemiplegia Following a Tendon Achilles Lengthening Using Computerized Adaptive Testing-A Pilot Study

Purpose:

This pilot study evaluated the outcomes of tendon Achilles lengthening in 12 children (mean age: 11.2 years) with spastic hemiplegia.

Methods:

Cerebral Palsy Computer Adaptive Tests, the timed up-and-go, the Gross Motor Function Measure, the Gillette Functional Assessment Questionnaire, and the Pediatric Outcomes Data Collection Instrument were administered at baseline and at 6, 12, and 24 months postsurgery.

Results:

Significant improvement at the latest follow-up (12-24 months following surgery) was seen in all domains of the Cerebral Palsy Computer Adaptive Test: activity (P = .017), lower extremity (P = .005), global (P = .005), pain (P = .005), and fatigue (P = .028), as well as in the Gross Motor Function Measure-standing domain (P = .02) and the mobility domain of the Pediatric Outcomes Data Collection Instrument (P = .04).

Conclusion:

These findings indicate that the tendon Achilles lengthening improved functional outcome in these children as measured by tests of physical function, walking speed, and activity performance.

Biofeedback interventions for individuals with cerebral palsy: a systematic review

Purpose: The purpose of this study is to evaluate the quality of evidence of biofeedback interventions aimed at improving motor activities in people with Cerebral Palsy (CP). Second, to describe the relationship between intervention outcomes and biofeedback characteristics. Methods: Eight databases were searched for rehabilitation interventions that provided external feedback and addressed motor activities. Two reviewers independently assessed and extracted data. The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework was used to evaluate quality of evidence for outcome measures related to two International Classification of Functioning, Disability and Health (ICF) chapters. Results: Fifty-seven studies were included. There were 53 measures related Activities and Participation and 39 measures related to Body Functions. Strength of evidence was "Positive, Very-Low" due to the high proportion of non-controlled studies and heterogeneity of measures. Overall, 79% of studies and 63% of measures showed improvement post-intervention. Counter to motor learning theory recommendations, most studies provided feedback consistently and concurrently throughout the intervention regardless of the individual's desire or progress. Conclusion: Heterogeneous interventions and poor study design limit the strength of biofeedback evidence. A thoughtful biofeedback paradigm and standardized outcome toolbox can strengthen the confidence in the effect of biofeedback interventions for improving motor rehabilitation for people with CP. Implications for Rehabilitation Biofeedback can improve motor outcomes for people with Cerebral Palsy. If given too frequently, biofeedback may prevent the client from learning autonomously. Use consistent and concurrent feedback to improve simple/specific motor activities. Use terminal feedback and client-directed feedback to improve more complex/general motor activities.

Goal setting in paediatric rehabilitation for children with motor disabilities: a scoping review

Objectives:

The three objectives of this scoping review were to (1) identify key conceptual/theoretical frameworks and the extent to which they are used to inform goal setting related to rehabilitation goal setting with children with motor disabilities, (2) describe research that has evaluated goal setting processes and outcomes, and (3) summarize the purposes of goal setting described in paediatric rehabilitation literature.

Methods:

The scoping review process described by Arksey and O’Malley was used to guide article selection and data extraction.

Results:

A total of 62 articles were included in the final review. While the concept of family-centered care was well represented, theoretical frameworks specific to goal setting (i.e. goal setting theory described by Locke and Latham, mastery motivation, social cognitive, personal construct, and self-determination theories) were rarely addressed. No articles reviewed addressed prominent behavior change theory. With the exception of the description of tools specifically designed for use with children, the role of the child in the goal setting process was generally absent or not well described. Few studies ( n = 6) discussed the linkage between goals and intervention strategies explicitly. Only two studies in the review evaluated outcomes associated with goal setting. The primary purpose for goal setting identified in the literature was to develop goals that are meaningful to families ( n = 49).

Conclusion:

The results highlight significant gaps in the literature explicating a sound theoretical basis for goal setting in paediatric rehabilitation and research evaluating the effects of goal qualities and goal setting processes on the achievement of meaningful outcomes.

Toolbox of multiple-item measures aligning with the ICF Core Sets for children and youth with cerebral palsy

Selecting appropriate measure(s) for clinical and/or research applications for children and youth with Cerebral Palsy (CP) poses many challenges. The newly developed International Classification of Functioning, Disability and Health (ICF) Core Sets for children and youth with CP serve as universal guidelines for assessment, intervention and follow-up. The aims of this study were: 1) to identify valid and reliable measures used in studies with children and youth with CP, 2) to characterize the content of each measure using the ICF Core Sets for children and youth with CP as a framework, and finally 3) to create a toolbox of psychometrically sound measures covering the content of each ICF Core Set for children and youth with CP. All clearly defined multiple-item measures used in studies with CP between 1998 and 2015 were identified. Psychometric properties were extracted when available. Construct of the measures were linked to the ICF Core Sets. Overall, 83 multiple-item measures were identified. Of these, 68 measures (80%) included reliability and validity testing. The majority of the measures were discriminative, generic and designed for school-aged children. The degree to which measures with proven psychometric properties represented the ICF Core Sets for children and youth with CP varied considerably. Finally, 25 valid and reliable measures aligned highly with the content of the ICF Core Sets, and as such, these measures are proposed as a novel ICF Core Sets-based toolbox of measures for CP. Our results will guide professionals seeking appropriate measures to meet their research and clinical needs worldwide.

Orthopedic surgery in cerebral palsy: Instructional course lecture

Orthopedic surgery (OS) plays an important role in the management of cerebral palsy (CP). The objectives of OS are to optimize functions and prevent deformity. Newer developments in OS for CP include emphasis on hip surveillance, minimally invasive procedures, use of external fixators instead of plates and screws, better understanding of lever arm dysfunctions (that can only be corrected by bony OS), orthopedic selective spasticity-control surgery, and single-event multilevel lever arm restoration and anti spasticity surgery, which have led to significant improvements in gross motor function and ambulation, especially in spastic quadriplegia, athetosis, and dystonia. The results of OS can be dramatic and life altering for the person with CP and their caregivers if it is performed meticulously by a specialized surgical team, at the appropriate age, for the correct indications, employing sound biomechanical principles and is followed by physician-led, protocol based, intensive, multidisciplinary, institutional rehabilitation, and long term followup. However, OS can be a double-edged sword, and if performed less than optimally, and without the supporting multidisciplinary medical and rehabilitation team, expertise and infrastructure, it often leads to significant functional worsening of the person with CP, including irretrievable loss of previous ambulatory capacity. OS must be integrated into the long term management of the person with CP and should be anticipated and planned at the optimal time and not viewed as a "last resort" intervention or failure of rehabilitation. This instructional course lecture reviews the relevant contemporary principles and techniques of OS in CP.

Exploring suitable participation tools for children who need or use power mobility: A modified Delphi survey

OBJECTIVES

To identify suitable tools for measuring important elements of participation for children, aged 18 months to 12 years, who need or use power mobility, and to indicate which tools should be considered for inclusion in a measurement toolkit.

METHODS

Parents, therapists and researchers with expertise in paediatric power mobility and participation (n = 70) completed an online modified Delphi survey, with consensus set a priori >80% agreement. Existing tools were matched against participation elements ranked most important for those in early childhood (18 months-5 years) and of school-age (6-12 years) by the panel.

RESULTS

Six out of 13 tools demonstrated potential, meeting at least three elements each, although none addressed all elements deemed important to measure by the panel. Only the Participation and Environment Measure for Children and Youth (PEM-CY) reached consensus for inclusion in a participation measure toolkit.

CONCLUSION

Further evaluation of these tools with this population is warranted.

A systematic review of evidence-based assessment practices by allied health practitioners for children with cerebral palsy

AIM

The routine use of psychometrically robust assessment tools is integral to best practice. This systematic review aims to determine the extent to which evidence-based assessment tools were used by allied health practitioners for children with cerebral palsy (CP).

METHOD

The Preferred Reporting Items for Systematic Reviews and Meta-Analysis protocols 2015 was employed. A search strategy applied the free text terms: 'allied health practitioner', 'assessment', and 'cerebral palsy', and related subject headings to seven databases. Included articles reported assessment practices of occupational therapists, physiotherapists, or speech pathologists working with children with CP aged 0 to 18 years, published from the year 2000.

RESULTS

Fourteen articles met the inclusion criteria. Eighty-eight assessment tools were reported, of which 23 were in high use. Of these, three tools focused on gross motor function and had acceptable validity for use with children with CP: Gross Motor Function Measure, Gross Motor Function Classification System, and goniometry. Validated tools to assess other activity components, participation, quality of life, and pain were used infrequently or not at all.

INTERPRETATION

Allied health practitioners used only a few of the available evidence-based assessment tools. Assessment findings in many areas considered important by children and families were rarely documented using validated assessment tools.

Chronic Pain Assessment Tools for Cerebral Palsy: A Systematic Review

BACKGROUND AND OBJECTIVE

Chronic pain in children with cerebral palsy (CP) is underrecognized, leading to detriments in their physical, social, and mental well-being. Our objective was to identify, describe, and critique pediatric chronic pain assessment tools and make recommendations for clinical use for children with CP. Secondly, develop an evidence-informed toolbox to support clinicians in the assessment of chronic pain in children with disabilities.

METHODS

Ovid Medline, Cumulative Index to Nursing and Allied Health Literature, and Embase databases were systematically searched by using key terms "chronic pain" and "clinical assessment tool" between January 2012 and July 2014. Tools from multiple pediatric health conditions were explored contingent on inclusion criteria: (1) children 1 to 18 years; (2) assessment focus on chronic pain; (3) psychometric properties reported; (4) written in English between 1980 and 2014. Pediatric chronic pain assessment tools were extracted and corresponding validation articles were sought for review. Detailed tool descriptions were composed and each tool underwent a formal critique of psychometric properties and clinical utility.

RESULTS

Of the retrieved 2652 articles, 250 articles met eligibility, from which 52 chronic pain assessment tools were retrieved. A consensus among interprofessional working group members determined 7 chronic pain interference tools to be of importance. Not all tools have been validated with children with CP nor is there 1 tool to meet the needs of all children experiencing chronic pain.

CONCLUSIONS

This study has systematically reviewed and recommended, through expert consensus, valid and reliable chronic pain interference assessment tools for children with disabilities.

Computerized Adaptive Tests Detect Change Following Orthopaedic Surgery in Youth with Cerebral Palsy

BACKGROUND

The Cerebral Palsy Computerized Adaptive Test (CP-CAT) is a parent-reported outcomes instrument for measuring lower and upper-extremity function, activity, and global health across impairment levels and a broad age range of children with cerebral palsy (CP). This study was performed to examine whether the Lower Extremity/Mobility (LE) CP-CAT detects change in mobility following orthopaedic surgery in children with CP.

METHODS

This multicenter, longitudinal study involved administration of the LE CP-CAT, the Pediatric Outcomes Data Collection Instrument (PODCI) Transfer/Mobility and Sports/Physical Functioning domains, and the Timed "Up & Go" test (TUG) before and after elective orthopaedic surgery in a convenience sample of 255 children, four to twenty years of age, who had CP and a Gross Motor Function Classification System (GMFCS) level of I, II, or III. Standardized response means (SRMs) and 95% confidence intervals (CIs) were calculated for all measures at six, twelve, and twenty-four months following surgery.

RESULTS

SRM estimates for the LE CP-CAT were significantly greater than the SRM estimates for the PODCI Transfer/Mobility domain at twelve months, the PODCI Sports/Physical Functioning domain at twelve months, and the TUG at twelve and twenty-four months. When the results for the children at GMFCS levels I, II, and III were grouped together, the improvements in function detected by the LE CP-CAT at twelve and twenty-four months were found to be greater than the changes detected by the PODCI Transfer/Mobility and Sports/Physical Functioning scales. The LE CP-CAT outperformed the PODCI scales for GMFCS levels I and III at both of these follow-up intervals; none of the scales performed well for patients with GMFCS level II.

CONCLUSIONS

The results of this study showed that the LE CP-CAT displayed superior sensitivity to change than the PODCI and TUG scales after musculoskeletal surgery in children with CP.

The development of the Pediatric Motivation Scale for rehabilitation

Background.

Clinicians recognize that client motivation is key to optimizing rehabilitation; however, they are limited in its assessment by a paucity of motivation measures.

Purpose.

This paper presents the preliminary psychometrics of the Pediatric Motivation Scale (PMOT) designed to measure motivation from a child’s perspective.

Method.

Content validity of the PMOT was measured through expert feedback ( n = 12), and field testing ocurred with 41 children, 21 in rehabilitation and 20 healthy. Pearson product-moment correlations were used to analyze subscale correlations, test-retest reliability, and convergent validity with the Pediatric Volitional Questionnaire (PVQ). Internal consistency was measured using Cronbach’s alpha.

Findings.

Preliminary psychometric evaluation indicates strong internal consistency for PMOT total (α = .96) and subscales (α = .79–.91). The PMOT and PVQ moderately correlated in the rehabilitation subsample ( r = .71, p < .01); no correlation was found in the healthy subsample ( p > .05). Test-retest reliability was excellent ( r = .97).

Implications.

This study provides preliminary psychometric evidence of the PMOT for children undergoing rehabilitation. These pilot findings warrant ongoing scale development.

International Classification of Functioning, Disability and Health (ICF) as a framework for change: revolutionizing rehabilitation

The International Classification of Functioning, Disability and Health (ICF) utilizes domains of body functions and structures, activities and participation, as well as environmental and personal factors to fully encapsulate the concepts of health and disability. The International Classification of Functioning, Disability and Health provides a rich and holistic understanding of functioning that is particularly valuable in the setting of childhood disability and rehabilitation. With applicability that enhances a nuanced understanding of each child within their family, school, and community, the International Classification of Functioning, Disability and Health also ensures facile and meaningful communication between professionals. Use of the International Classification of Functioning, Disability and Health promotes improved treatment plans for individual children and for larger programmatic decisions. This article demonstrates how the International Classification of Functioning, Disability and Health has reinvented the language and understanding of childhood disability and rehabilitation.