Change in mobility function and its causes in adults with cerebral palsy by Gross Motor Function Classification System level: A cross-sectional questionnaire study

Motor function and gait decline in individuals with cerebral palsy during adulthood: a narrative review of potential physiological determinants

Cerebral palsy (CP) is the most common childhood-onset disability. The evolution of gait according to severity is well known amongst children and thought to peak between 8 and 12 years of age among those walking without assistive devices. However, among adults, clinical experience as well as scientific studies report, through clinical assessments, questionnaires and interviews, increasing walking difficulties leading to an increased dependency of assistive devices in everyday ambulation. For many individuals with CP, this change will occur around 30-40 years, with the risk of losing mobility increasing with age. This narrative review aims to first provide objective evidence of motor function and gait decline in adults with CP when ageing, and then to offer mechanistic hypotheses to explain those alterations. Many studies have compared individuals with CP to the typically developing population, yet the evolution with ageing has largely been understudied. Comorbid diagnoses comprise one of the potential determinants of motor function and gait decline with ageing in people with CP, with the first manifestations happening at an early age and worsening with ageing. Similarly, ageing appears to cause alterations to the neuromuscular and cardiovascular systems at an earlier age than their typically developing (TD) peers. Future studies should, however, try to better understand how the physiological particularities of CP change with ageing that could pave the way for better strategies for maintaining function and quality of life in people with CP.

Adults with cerebral palsy and functional decline: A cross-sectional analysis of patient-reported outcomes from a novel North American registry

BACKGROUND

Adults with cerebral palsy (CP) have unique healthcare needs and risks, including high risk of functional decline. Understanding functional decline is an area of priority for CP research.

OBJECTIVE

Describe factors associated with patient-reported changes in function among adults with CP living in the community.

METHODS

Cross-sectional analysis of adult patient-reported outcomes collected by the CP Research Network (CPRN) Community Registry.

RESULTS

Participants included 263 respondents (76% female (n = 200); mean age 42 years (SD 14); 95% White (n = 249); 92% non-Hispanic (n = 241)). Many reported functional changes, most commonly a decline in gross motor function since childhood (n = 158, 60%). Prevalence of gross motor decline varied significantly by Gross Motor Function Classification System (GMFCS) level (p < 0.001), but neither hand function decline (p = 0.196) nor communication decline (p = 0.994) differed by GMFCS. All types of decline increased with increasing age, with statistically significant differences between age groups (p < 0.001 gross motor; p = 0.003 hand function; p = 0.004 communication). Those with spastic CP (n = 178) most commonly reported gross motor functional decline (n = 108/178, 60.7%). However, the prevalence of gross motor decline did not significantly differ between those with spastic CP and those without spastic CP (p = 0.789).

CONCLUSIONS

Many adults in the CPRN Community Registry reported functional decline, most commonly in gross motor function. Functional decline across domains increased with age. Further research into risk stratification and preventive and rehabilitative measures is needed to address functional decline across the lifespan.

Factors associated with gait efficiency in children with cerebral palsy: association between gait abnormality and balance ability

[Purpose] Children with cerebral palsy require more gait energy than healthy children. The association between gait abnormalities and gait efficiency remains unclear. We investigated the association between gait abnormalities, balance, and maximum step length to determine contributors to gait efficiency in children with cerebral palsy. [Participants and Methods] The study included 33 patients with cerebral palsy, who could walk without the use of walking aids. All participants were instructed to walk for 6 min, and the Total Heart Beat Index was calculated as a measure of walking efficiency. The Edinburgh Visual Gait Score was used to assess gait abnormalities. Additionally, the maximum step length was recorded, and all participants performed the Berg Balance Scale. Correlation analysis and stepwise multiple regression analysis were used to confirm the association between the aforementioned parameters and the Total Heart Beat Index. [Results] The Edinburgh Visual Gait Score was correlated with the heel lift during the stance, knee position during the terminal swing of gait as factors associated with the Total Heartbeat Index. The Berg Balance Scale was correlated with turning 360°, standing with feet together. [Conclusion] Our findings emphasize the need for treatment strategies focused on gait abnormalities and balance.

Effect of an augmented reality active video game for gait training in children with cerebral palsy following single-event multilevel surgery: protocol for a randomised controlled trial

INTRODUCTION

In paediatric rehabilitation, fun and motivation are also critical keys to successful therapy. A variety of interventions have shown positive effects, high level of interest, compliance and engagement with active video game (AVG).This seems to be an interesting approach for the postoperative gait rehabilitation of children with cerebral palsy (CP). In this study, we will investigate if an overground gait training (GT) delivered through an AVG can improve walking capacity and anaerobic performance.

METHODS AND ANALYSIS

This study is a randomised clinical controlled trial. A total of 14 children and adolescents in the age of 10-18 years with CP will be included. The minimum time between surgery and inclusion will be 7 weeks. The test group will participate in the GT programme with Augmented Reality Rehabilitation of Walking-Cerebral Palsy AVG, control group will receive GT on a treadmill. The primary outcome is the 6-Min Walk Test assessing walking capacity; secondary outcomes are the Muscle Power Sprint Test for anaerobic performance and Shuttle Run Test for physical fitness level. Satisfaction is tested with the Physical Activity Enjoyment Scale.

ETHICS AND DISSEMINATION

The findings will be disseminated by publications in peer-reviewed journals and conferences. This study received agreement from French ethic committee (Comité de Protection des Personnes Sud-Est VI-Number 2020-A02959-30).

TRIAL REGISTRATION NUMBER

NCT04837105.

Rehabilitation After Single-Event Multilevel Surgery for Children and Young Adults With Cerebral Palsy: A Systematic Review

ABSTRACT

This review sought to describe and analyze published protocols for rehabilitation after single-event multilevel surgery for people with cerebral palsy, to identify their differences and limits, and to introduce a common step-by-step framework for future descriptions and assessments of postoperative rehabilitation protocols.The MEDLINE, Embase, CINAHL, and the Cochrane Library databases were searched. Inclusion criteria were as follows: (1) single-event multilevel surgery, (2) full-text reports published after 1985, and (3) articles with a method section describing the rehabilitation protocol. Interventions were coded using the Oxford Levels of Evidence and the Methodological Index for Non-Randomized Studies Index.Twenty-four articles were included in the review. Studies included patients aged 4-30 yrs with spastic cerebral palsy (hemiplegia, diplegia, and quadriplegia). The mean postoperative rehabilitation duration was 4.5 mos, with 4 sessions per week, and rehabilitation took place in a rehabilitation center. This review provides relevant information about the modalities, contents, limits, and difficulties associated with the post-SEMS rehabilitation protocol reported in the literature. Pain was identified as a major problem.A more precise and comprehensive description of post-SEMS rehabilitation protocols would be useful. The proposed five-step framework could be used by future studies to standardize their protocol description in terms of objective, content, and intensity.

Effectiveness of Botulinum Toxin A Injection in Managing Mobility-Related Outcomes in Adult Patients With Cerebral Palsy: Systematic Review

PURPOSE

Intramuscular botulinum toxin A (BTX-A) is used in the management of focal spasticity in cerebral palsy (CP). The aim was to conduct a systematic review to assess current literature on the use of BTX-A in the management of mobility-related outcomes among adult persons with spastic CP.

METHODS

All studies reporting on the use of BTX-A in the management of spastic CP among adult persons were identified by searching the following electronic databases: PubMed, CINAHL, the Cochrane Library, and EMBASE.

RESULTS

Six studies were included in the review. Most studies were conducted in mixed patient groups comprising patients with movement disorders, traumatic brain injury, CP, and other disorders requiring therapy for spasticity. BTX-A was shown to be effective in improving spasticity-related outcomes among persons with CP, but mixed results were shown for functional outcomes.

CONCLUSIONS

More studies are required on exclusive CP cohorts using recommended and currently used scales, incorporating quality of life and patient satisfaction scales. Results from long-term follow-up studies will be valuable for better evaluation of the effectiveness of BTX-A in the management of spasticity-related outcomes among adult persons with CP.

Perceived Limitations of Walking in Individuals With Cerebral Palsy

OBJECTIVE

Impairments associated with cerebral palsy (CP) can affect gait quality and limit activity and participation. The purpose of this study was to quantify (1) which of 6 factors (pain, weakness, endurance, mental ability, safety concerns, balance) were perceived to limit walking ability the most in individuals with CP and (2) whether age or Gross Motor Function Classification System (GMFCS) level is related to that perception.

METHODS

This cross-sectional study queried data from a gait laboratory database. Perceived walking limitation was quantified using a 5-point Likert scale ("never" to "all of the time"). Included were 1566 children and adults (mean age = 10.9 y [SD = 6.8]; range = 3.0-72.1 y) with CP (GMFCS level I: 502; II: 564; III: 433; IV: 67).

RESULTS

Patients or caregivers perceived balance to limit walking ability to the greatest extent, followed by endurance, weakness, safety, mental ability, and pain. Balance was perceived to always limit walking ability in 8%, 22%, 30%, and 34% of individuals in GMFCS levels I through IV, respectively. Endurance was perceived to always limit walking ability in 5%, 13%, 13%, and 27% of individuals in GMFCS levels I through IV, respectively. There were minor differences in the perceived extent of limitation caused by the factors by GMFCS level. Only weak associations between age and pain, mental ability, safety, and balance were observed (Spearman rho = -0.13 to 0.24).

CONCLUSION

Patients or caregivers perceived decreased balance and endurance to most strongly limit walking ability. Efforts should be made to clinically track how both perceived and objective measures of these limiting factors change with age and intervention.

IMPACT

Following a patient- and family-centered care model, therapy that places greater emphasis on balance and cardiovascular endurance may have the greatest effect on walking ability for individuals with CP. Future research should quantify which therapeutic, surgical, and pharmacologic interventions minimize these impairments and optimize activity and participation.

LAY SUMMARY

Balance and endurance are perceived to be the greatest factors limiting walking in people with CP. If you have CP, your physical therapist might emphasize balance and cardiovascular endurance to improve your walking ability.

Adults with Cerebral Palsy Require Ongoing Neurologic Care: A Systematic Review

Cerebral palsy (CP) neurologic care and research efforts typically focus on children. However, most people with CP are adults. Adults with CP are at increased risk of new neurologic conditions, such as stroke and myelopathy, that require ongoing neurologic surveillance to distinguish them from baseline motor impairments. Neurologic factors could also contribute to the motor function decline, chronic pain, and chronic fatigue that are commonly experienced by adults with CP. Based on a systematic literature review, we suggest (1) guidelines for neurologic surveillance and neurologist referral and (2) clinical research questions regarding the evolving neurologic risks for adults with CP. ANN NEUROL 2021;89:860-871.

Is sensory-level electrical stimulation effective in cerebral palsy children with dysphagia? A randomized controlled clinical trial

Dysphagia is one of the common findings in children with cerebral palsy (CP). Electrical stimulation (ES) has been demonstrated to positively contribute to swallowing functions, particularly in adult patients with various neurological disorders. Therefore, the objective of this study was to assess the effects of sensory-level ES treatment combined with conventional dysphagia rehabilitation in pediatric age group CP patients who had any oropharyngeal dysphagia symptoms and/or findings. Participants were randomly assigned to either the experimental group (Group 1, n = 52) who underwent intermittent galvanic stimulation to bilateral masseter muscles for 5 days/week, for 4 weeks combined with conventional dysphagia rehabilitation or the control group (Group 2, n = 50) who received sham stimulation with conventional dysphagia rehabilitation. The experimental group achieved significantly more improvement in swallowing functions including drooling, tongue movements, chewing, eating large food ability, feeding duration, as well as dysphagia screen test and dysphagia level, compared to control group. This study suggested that sensory-level ES might be a useful and safe therapeutic modality to improve oropharyngeal symptoms, symptom severity and dysphagia level in children with CP and dysphagia. Further research is needed to determine the long-term effects of ES on dysphagia, especially in different neurological disorders such as CP.

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

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

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

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

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

An Observational Tool to Assess Activity Limitation in Ambulatory People with Cerebral Palsy When Performing Motor Skills

Ratios of physical activity and sports participation in people with cerebral palsy (CP) are still low compared with people without a disability. For an adequate and useful practice, physical activity professionals should understand how different types of CP profiles constrain the performance of motor skills that are required during sports practice. This study aims to develop an observation-based assessment tool to evaluate activity limitations in individuals with a moderate level of CP when performing skills requiring jumping, sprinting, change of direction, coordination, and balance. Nineteen observers with different backgrounds from five world regions were recruited for this study, with accredited experience classifying/observing para-athletes with CP. All observers watched videos of 20 international para-athletes with different CP profiles (bilateral spasticity, athetosis/ataxia, unilateral spasticity; all Gross Motor Function Classification System level I) performing 16 motor tasks, and their observations were recorded throughout an ad-hoc data collection instrument. A total of 6080 units of qualitative information were recorded for data analysis. An observation-based tool with qualitative descriptors is derived from data analyses, describing how coordination and balance affected mainly in those with dyskinesia/ataxia, range of movement in those with diplegia, and asymmetries in those with hemiplegia. This tool would help sports practitioners and physical educators to better understand how different CP profiles constrain the performance of motor skills.

Cross-Cultural Validation Study of the Japanese Version of the ABILOCO-Kids in Ambulatory Children With Cerebral Palsy Using Rasch Analysis

Aims: To determine the structural validity, construct validity, cross-cultural validity, internal consistency and test-retest reliability of the Japanese version of the ABILOCO-Kids in children with cerebral palsy. Methods: One-hundred sixteen parents of children with cerebral palsy (Gross Motor Function Classification System level I [n = 66], II [n = 32], and III [n = 18]) reported on walking ability using the Japanese version of the ABILOCO-Kids. For test-retest reliability, 23 participants were evaluated. Results: The mean ABILOCO-Kids logit score was 2.48 (range -7.44 to 5.83). Rasch analysis and principal component analysis were used to determine the structural validity. The construct validity was confirmed on the basis of differences in the ABILOCO-Kids scores among the Gross Motor Function Classification System levels. Cronbach's α and the item-to-total correlation coefficient supported the internal consistency. The intra-class correlation coefficient was 0.96, standard error of measurement 0.56 and minimal detectable change 1.55. The cross-cultural validity analyses showed differential item functioning according to the analyses of the invariance of item difficulty and person's ability estimates. Conclusions: The ABILOCO-Kids is a reliable and valid measure of walking ability in children with cerebral palsy in Japan. The lack of evidence on cross-cultural validity indicates we should interpret results cautiously in cases of international comparison.