Functional classifications for cerebral palsy: correlations between the gross motor function classification system (GMFCS), the manual ability classification system (MACS) and the communication function classification system (CFCS)

Fatigue experienced by people with cerebral palsy: a systematic review of assessment tools and decision tree

PURPOSE

To conduct a systematic review of self- and proxy-report fatigue assessment tools used in studies of people with cerebral palsy (CP) of all ages, and to develop a fatigue assessment tool decision tree for clinicians and researchers.

MATERIALS AND METHODS

Five electronic databases (MEDLINE, PsycInfo, CINAHL, Web of Science and Cochrane) were searched to September 2021 to identify studies assessing self-reported fatigue in people with CP of any age. The assessment tools utilised were extracted and two reviewers appraised the tool characteristics, clinical utility and psychometric properties. A decision tree for selecting fatigue assessment tools was constructed.

RESULTS

Ten assessment tools were identified across thirty-nine studies, three of which are valid and reliable for assessing fatigue severity and impact in people with CP. A four-level fatigue assessment tool decision tree was constructed. No valid and reliable tool for assessing cognitive fatigue was identified; responsiveness has not been evaluated in any tool for people with CP.

CONCLUSIONS

Physical fatigue screening and assessment tools for people with CP are available and are presented in our decision tree, however their utility as outcome measures remains unclear. Cognitive fatigue is understudied and poorly understood, further work is required in this area.

Differential neuropsychological profiles in children and adolescents with motor disability in an inclusive educational setting

The aim of this study was to determine the potential cognitive impairment associated with motor disability in a group of children attending regular schools and to analyze whether there were different cognitive profiles according to the type of motor disability they presented. The study had 87 participants, 31 healthy and 56 with three types of motor disability: Neuromuscular Diseases (NMD Group), Cerebral Palsy-Hemiparesis (CP- HPx Group) and Cerebral Palsy-Diplegia (CP-DP). Ages ranged from 6 to 18 years and they had medium and medium-high socioeconomic and cultural levels. All participants attended regular state-funded and independent schools in an inclusive modality. The neuropsychological assessment included the following cognitive domains: processing speed, working memory, verbal and visual episodic memory, language, visuo-perception and constructive praxis and executive functioning. A second analysis was performed with the groups with CP: one based on the severity of gross motor impairment (GMFCS-E&R scale) and the other based on the levels of manual dexterity (MACS scale). ANCOVAs were performed controlling for age and processing speed in the three analyses. The group with CP-HPx was shown to be the most cognitively impaired of the three groups, with significant deficits in visuo-perception, verbal working memory, and visuo-spatial memory. Subjects with greater gross motor dysfunction (GMFCS-E&R) did not show the greatest cognitive impairment, while those with worse manual dexterity (MACS) exhibited greater cognitive impairment. Children and adolescents with motor disabilities, a priori cognitively normal, present different levels of cognitive impairment. This should be considered when planning educational adaptations for this infant-juvenile population.

Habilidades funcionales de niños, niñas y adolescentes con parálisis cerebral y su relación con el compromiso motor y la discapacidad intelectual en Argentina

Introduction

Motor compromise characterizes cerebral palsy (CP), and is often associated with intellectual disability (ID). Standardized classification systems have been developed to describe the functions of people with CP. The aim was to functionally characterize children and adolescents aged 0 to 18 years with CP in Argentina and to investigate the association between motor compromise (GMFCS), ID and functional classifications.

Methods

Cross-sectional study. Data were collected through family interviews and medical records review. Individuals with CP were included. Data were collected from 19 institutions in different cities of Argentina. Fisher's test and odds ratio [IC95%] were used for data analysis, with significance <0.05.

Results

182 children and adolescents with CP participated. According to GMFCS classification, level V prevailed with 36.3%. Those with more severe motor compromise (GMFCS IV-V) were 72 [25.4;206.0] times and 13 [5.9;28.2] times more likely to present a severe level of MACS and CFCS, respectively. But they were 34 [7.9;146.0] times more likely to have a mild to moderate level of EDACS. Those with DI were 10 [5.1;20.5] times more likely to have severe GMFCS, 6 [3.4;13.2] times more likely to have severe MACS and 4 [2.0;7.8] times more likely to have severe CFCS. On the contrary, they are 4 [1.9;9.5] times more likely to present a mild-moderate EDACS level.

Conclusion

the level of GMFCS and the presence of DI influence general functionality and increase severity in engagement, manual and communication skills.

Exploration of the relationship between functional motor and communication performance levels and amount of use of the more affected upper extremity based on the caregivers' perceptions in children with hemiplegic cerebral palsy: A cross-sectional study

OBJECTIVE

To investigate relationships between amount of use of the more affected upper extremity and functional motor and communication performance classification systems.

MATERIAL AND METHODS

The study comprised 95 children with congenital hemiplegic cerebral palsy (CP) aged 6-15 years (52 males, 43 females; mean age 9.53, SD 3.1) and their parents/caregivers. The amount of use of the more affected upper extremity was assessed using Pediatric Motor Activity Log-Revised-How Often subscale (PMAL-R HO). Functional levels of the enrolled children were defined by the parents/caregivers using Manual Ability Classification System (MACS), Gross Motor Function Classification System-Expanded and Revised (GMFCS-E&R), and Communication Function Classification System (CFCS).

RESULTS

A strong and negative correlation was found between PMAL-R HO subscale score and MACS (r=-0.819), suggesting that children with lower MACS levels are more likely to use their more affected upper extremity spontaneously. Additionally, negative and moderate associations between PMAL-R HO subscale score and GMFCS and CFCS were revealed (r1=-0.549 and r2=-0.567).

CONCLUSION

The amount of use of the more affected upper extremity is more sensitive to MACS than GMFCS-E&R and CFCS. Children with a given MACS level had a wide range of PMAL-R HO subscale score. In addition to MACS, a score on the PMAL-R HO subscale related to the more affected upper extremity should be included as an inclusion criterion in clinical trials to avoid misleading effects of intervention approaches aimed at improving the amount of use of the more affected upper extremity in children with congenital hemiplegic CP.

Asymmetric involvement of hands: Psychometric properties of the Turkish version of the Bimanual Fine Motor Function 2.0 classification in children with cerebral palsy

BACKGROUND

Manual functions affect more than a half of children with Cerebral palsy (CP). Asymmetric involvement of hands may also affect unilateral and bilateral activities of daily life. The Bimanual Fine Motor Function version 2.0 (BFMF-2.0) is a unique functional classification that categorizes the capacity of each hand (what the child can do) during bimanual functions.

PURPOSE

The aim of this study was to investigate the validity and reliability of the Turkish version of the BFMF-2.0 in children with CP.

STUDY DESIGN

Clinical measurement and cross-sectional study.

METHODS

The study included 91 children with CP (56 girls, mean age; 7.41 ± 4.23 years [4-18 years]) and their parents. The Manual Ability Classification System (MACS), the Quality of Upper Extremity Skills Test (QUEST), and the Box and Block Test (BBT) were used for construct and concurrent validity. Experienced/inexperienced therapists and parents classified fine motor capacities of the children via live or video-based observation to assess inter-rater reliability. Three weeks later, the children were reclassified for intra-rater reliability.

RESULTS

The Turkish version of the BFMF-2.0 classification was strongly correlated with the MACS (rho = -0.88, p < 0.001), the QUEST (rho = 0.80, p < 0.001), and the BBT (rho = -0.77, p < 0.001). The inter-rater reliability scores were weak to excellent between the parents and the therapists (via live observation, κw = 0.57) and also between experienced/inexperienced therapists (via live or video-based observation, κw = 0.66-0.79). Intra-rater reliability scores were good to excellent (Intraclass Correlation Coefficient [ICC] = 0.87-0.95).

CONCLUSIONS

The Turkish version of the BFMF-2.0 classification is valid and reliable and could be applied by experienced and inexperienced therapists via live or video-based observation and by parents via live observation.

Psychometric properties of the Viking Speech Scale-Turkish version for children with cerebral palsy aged 4-18 years based on live and video-based observation

BACKGROUND

Speech is the most common method of communication. Video-based clinical communication evaluation is a requirement for children with speech-language impairments living in rural areas, and those who have limited mobility.

AIMS

To determine the validity and reliability of the Turkish version of the Viking Speech Scale (VSS-T) via live and video-based observation for children with cerebral palsy (CP) aged 4-18 years.

METHODS & PROCEDURES

A total of 142 children (mean age 8.18 ± 3.98 years; 68 female) with CP were included in this study. Their motor, communication, visual and eating-drinking function levels and comorbidities (dental, swallowing, cognitive impairments and epilepsy) were recorded. The Intelligibility in Context Scale (ICS), the Pediatric Evaluation of Disability Inventory-Social Function (PEDI-SF), and the Functional Independence Measure for Children-Communication (WeeFIM-C) were assessed to examine the concurrent validity of the VSS-T. The interrater reliability of the VSS-T was analysed between parents, physical therapists, and speech and language therapists from live and video-based observation. Intra-rater reliability was calculated from ratings made from live and video-based observations taken 3 weeks apart.

OUTCOMES & RESULTS

The VSS-T was strongly related to the ICS (r = -0.830), PEDI-SF (r = -0.819), WeeFIM-C (r = -0.643), other functional classifications (r > 0.432), and the comorbidities (Cramer's V > 0.284, p < 0.001). Good to excellent interrater reliability (κ_w ≥ 0.838) and intra-rater reliability (intraclass correlation coefficient (ICC) = 0.848-0.995) were found between parents and therapists.

CONCLUSIONS & IMPLICATIONS

Speech and language therapists, physical therapists, and parents can use the VSS-T as a valid and reliable classification system to describe speech intelligibility of 4-18-year-old children with CP. Both live and video-based observations can be used to administer the VSS-T.

WHAT THIS PAPER ADDS

What is already known on the subject The English version of the VSS has been shown to be a valid and reliable tool used to classify the speech of children with CP aged 4-13 years. The scale can be administered by means of live observation of the child or based on clinicians' notes on the case by parents, SLTs, physiotherapists and paediatricians. What this paper adds to existing knowledge The VSS-T is valid and reliable for children with CP aged 4-18 years. Video-based observation is a suitable method for evaluating the VSS-T levels. The VSS-T has a moderate association with the CFCS. What are the potential or actual clinical implications of this work? The VSS-T is a valid and reliable method of categorizing the severity of motor speech impairment for Turkish children with CP in clinical research studies, registry systems or epidemiological studies. Both experienced and inexperienced therapists can use either live or video-based observation methods to administer the VSS-T. This study extended the validity and reliability of the scale in children with CP aged up to 18 years. The VSS-T is also associated with the Visual Functional Classification System (VFCS), which has been recently developed for describing the visual abilities of children with CP in daily life. In addition, the VSS-T is associated with the presence of dental, swallowing, cognitive problems and epilepsy.

Hypoxic-Ischemic Encephalopathy: Changing Outcomes Across the Spectrum

Neonatal hypoxic-ischemic encephalopathy (HIE) is a leading cause of death and neurodevelopmental impairment in neonates. Therapeutic hypothermia (TH) is the only established effective therapy and randomized trials affirm that TH reduces death and disability in moderate-to-severe HIE. Traditionally, infants with mild HIE were excluded from these trials due to the perceived low risk for impairment. Recently, multiple studies suggest that infants with untreated mild HIE may be at significant risk of abnormal neurodevelopmental outcomes. This review will focus on the changing landscape of TH, the spectrum of HIE presentations and their neurodevelopmental outcomes.

Desenvolvimento de crianças, adolescentes e jovens adultos com Paralisia Cerebral de acordo com a CIF? Uma revisão do escopo

Estudos sobre o desenvolvimento de indivíduos com PC ajudam terapeutas e pais a planejarem abordagens de tratamento e prognóstico futuro. Os principais desfechos investigados em indivíduos com PC foram atividade e estruturas e funções corporais. Pouco tem sido explorado em desfechos de participação e de fatores contextuais ao longo do tempo.

Development of children, adolescents, and young adults with cerebral palsy according to the ICF: A scoping review

AIM

To identify and provide a descriptive overview of the development of children, adolescents, and young adults with cerebral palsy (CP) in longitudinal studies; and map areas of focus according to the components of the World Health Organization's International Classification of Functioning, Disability, and Health (ICF).

METHOD

Longitudinal studies of the development of children, adolescents, and/or young adults with CP were included in this scoping review. A search for eligible studies was conducted in the databases MEDLINE, PubMed, LILACS, EMBASE, Cochrane, CINAHL, and Scopus, and was restricted to the years 2002 to 2022. All outcome measures of the studies were classified into ICF components.

RESULTS

In the 56 studies included, there were 19 438 participants, involving mainly children, followed by adolescents, and lastly young adults. All components of the ICF were investigated and many studies reported outcomes in more than one component. Activity was the most investigated (67.9%; n = 38 studies), followed by body functions and structures (42.9%; n = 24 studies). Participation (14.2%; n = 8 studies) and environmental factors (3.6%; n = 2 studies) were the least studied. None of the studies investigated personal factors as an outcome.

INTERPRETATION

This scoping review provides an overview of studies on the development of children, adolescents, and young adults with CP, using the ICF framework, identifying current areas of focus and gaps in the research. Future studies should target participation, contextual factors, and the transition into adulthood.

Reliability and validity of the East Asian children's version of mini-MACS in children with cerebral palsy

Background

Mini-Manual Ability Classification System (Mini-MACS) was developed for children with cerebral palsy aged 1–4 years, but its validity and reliability in different cultures are unavailable yet. This study was to determine the reliability and validity of Mini-MACS in East Asian children with cerebral palsy and investigate the correlation between Mini-MACS and Gross Motor Function Classification System.

Methods

One hundred and four East Asian children with cerebral palsy aged 12–48 months were classified by one of their parents, an occupational therapist, and a physical therapist with Mini-MACS. The results were analyzed for inter-rater reliability by using intraclass correlation coefficient (ICC). The Nine-hole Peg Test was used for the criterion-related validity analysis, and parents retested their children after 2 weeks to evaluate test–retest reliability. Gross Motor Function Classification System levels were also collected to investigate the correlation with Mini-MACS.

Results

Good inter-rater reliability among the occupational therapist, physical therapist, and parents was found [ICC = 0.984 (95% confidence interval, CI, 0.976–0.989), 0.973 (95% CI 0.960–0.982), and 0.966 (95% CI 0.950–0.977), respectively; p &lt; 0.01]. The test–retest reliability in parents was almost perfect [ICC = 0.985 (95% CI 0.977–0.990), p &lt; 0.01]. Mini-MACS had consistency with the Nine-hole Peg Test (r = 0.582, 0.581, and 0.566, respectively; p &lt; 0.01). A correlation was found between Gross Motor Function Classification System and Mini-MACS (r = 0.626, 0.596, and 0.598, respectively; p &lt; 0.01).

Conclusion

The Mini-MACS demonstrates evidence that it is a valid and reliable tool to classify manual ability in East Asian children with cerebral palsy and is also positively related to the Gross Motor Function Classification System.

Relationship among four functional classification systems and parent interpredicted intelligence level in children with different clinical types of cerebral palsy

OBJECTIVE

To investigate the relationships between four functional classification systems in children with cerebral palsy (CP) and parent-interpredicted intelligence level, and the functional status in clinical types of CP.

METHODS

Two hundred and twenty-five children with CP ages between 2 and 18 (mean age 6.5 ± 4.4) years included using the Surveillance of CP in Europe (SCPE) database in Turkey. Gross Motor Function Classification System (GMFCS), Manual Ability Classification System (MACS), Communication Function Classification System (CFCS) and Eating and Drinking Classification System (EDACS) levels were classified by clinical observation, and intelligence quotient (IQ) was determined by parent reports.

RESULTS

Correlations were found between all functional levels; the strongest were between GMFCS-MACS (r = 0.784, p < .001), CFCS-EDACS (r = 0.772, p < .001). Strong correlations were found for the IQ-CFCS (r = 0.762, p < .001) and IQ-EDACS (r = 0.634, p < .001). Correlations were stronger in children with bilateral CP and IQ level <70.

CONCLUSIONS

Taken together, these four classification systems and reported IQ levels can adequately describe overall functioning for children with CP. Our results can guide clinicians in the rehabilitation of children with CP.

Kinect v2-Assisted Semi-Automated Method to Assess Upper Limb Motor Performance in Children

The interruption of rehabilitation activities caused by the COVID-19 lockdown has significant health negative consequences for the population with physical disabilities. Thus, measuring the range of motion (ROM) using remotely taken photographs, which are then sent to specialists for formal assessment, has been recommended. Currently, low-cost Kinect motion capture sensors with a natural user interface are the most feasible implementations for upper limb motion analysis. An active range of motion (AROM) measuring system based on a Kinect v2 sensor for upper limb motion analysis using Fugl-Meyer Assessment (FMA) scoring is described in this paper. Two test groups of children, each having eighteen participants, were analyzed in the experimental stage, where upper limbs’ AROM and motor performance were assessed using FMA. Participants in the control group (mean age of 7.83 ± 2.54 years) had no cognitive impairment or upper limb musculoskeletal problems. The study test group comprised children aged 8.28 ± 2.32 years with spastic hemiparesis. A total of 30 samples of elbow flexion and 30 samples of shoulder abduction of both limbs for each participant were analyzed using the Kinect v2 sensor at 30 Hz. In both upper limbs, no significant differences (p < 0.05) in the measured angles and FMA assessments were observed between those obtained using the described Kinect v2-based system and those obtained directly using a universal goniometer. The measurement error achieved by the proposed system was less than ±1° compared to the specialist’s measurements. According to the obtained results, the developed measuring system is a good alternative and an effective tool for FMA assessment of AROM and motor performance of upper limbs, while avoiding direct contact in both healthy children and children with spastic hemiparesis.

Deep Brain Stimulation in childhood-onset dystonia due to brain pathology. A long-term study

BACKGROUND

Pallidal Deep Brain Stimulation (DBS) is an established treatment option for isolated, inherited or idiopathic dystonia, however data on its safety and efficacy in other forms of dystonia are more limited.

OBJECTIVES

Retrospective analysis of motor and non-motor outcomes in pediatric onset refractory dystonia due to static or progressive brain disorders in a cohort of patients with a DBS treatment duration ≥12 months.

METHODS

Multidisciplinary assessments including standardised scales/tests of motor function, pain, quality of life, cognition and language were carried out before implantation and longitudinally afterwards.

RESULTS

9 patients were included, 7 had cerebral palsy. Mean age at implantation was 209 months ± 156, mean treatment duration 84 ± 37 months. DBS was well tolerated and positively affected both motor and non-motor functions. In particular, statistically significant improvements were documented in Burke-Fahn-Marsden Scale scores (- 19.9% p 0.01031) at 12 months and in long-term quality of life (+28.6%, p 0.0292).

CONCLUSIONS

DBS may be a useful treatment option in generalized dystonia associated with brain pathology. Even when the motor benefits are limited, improvements in quality of life and non-motor functions, or the possible prevention of serious dystonia-related complications, may have a significant impact on overall clinical status.

Parental Pain Catastrophizing, Communication Ability, and Post-surgical Pain Outcomes Following Intrathecal Baclofen Implant Surgery for Patients With Cerebral Palsy

There is strong evidence that psychosocial variables, including pain catastrophizing, influence parental and child ratings of pain, pain expression, and long-term outcomes among children with chronic pain. The role of these factors among children who have communication deficits due to cerebral palsy (CP) and other intellectual and developmental disabilities is currently unclear. In this study, parental pain catastrophizing was assessed before intrathecal baclofen (ITB) pump implantation for spasticity management in 40 children and adolescents with CP, aged 4 to 24 years. Pain was assessed before and after surgery with two methods: a parent-reported pain interference scale, and behavioral pain signs during a standardized range of motion exam. Linear mixed models with clinical/demographic factors and scores from the Pain Catastrophizing Scale for Parents (PCS-P), and child spoken language ability as predictors and the pain variables as the outcomes were implemented. On average, both pain outcomes improved after surgery. Only child spoken language ability predicted change in behavioral reactivity scores, with children with phrase speech showing an increase in reactivity at follow-up compared to pre-surgery levels, on average. A significant interaction between PCS-P scores and spoken language ability on change in pain interference scores over time showed that dyads with children with phrase speech whose parents reported high PCS-P scores reported the least improvement in pain interference at follow-up. Due to the preliminary nature of the study, future work is needed to investigate the parental behaviors that mediate the relationships between parental catastrophizing and pain outcomes in this population.

The Economic Burden and Determinant Factors of Parents/Caregivers of Children with Cerebral Palsy in Malaysia: A Mixed Methods Study

The economic burden is a major concern for parents/caregivers of children with cerebral palsy (CP). This study used the sequential explanatory mixed-method approach to explorethe economic burden on parents/caregivers with a CP child in Malaysia and the factors associated with the economic burden. The study period spanned April 2020 and December 2020. A total of 106 questionnaire respondents were selected for the quantitative part, and 15 were interviewed to obtain qualitative input. A retrospective costing analysis was conducted based on the cost data obtained from the questionnaire. The majority of the children were GrossMotor Function Classification System (GMFCS) Level 5 (71%), quadriplegic (63%), and aged >4 years (90%). The estimated annual median total economic burden on the parents/caregivers per child in 2020 was RM52,540.00 (~USD12,515.03), with indirect cost being the greatest cost (RM28,800.00, ~USD6860.16), followed by developmental cost (RM16,200.00, ~USD3858.84), direct healthcare cost (RM4540.00, ~USD1081.43) and direct non-healthcare cost (RM3000.00, ~USD714.60). The annual household income was identified as a significant determinant factor (p=0.019, 95% CI: 0.04, 0.40) of the economic burden. The participants’ responses during the in-depth interview in the qualitative part of the study supported the premise that socioeconomic factors play a substantial role in determining the total economic burden. Our findings may aid local policymakers when planning the greater provision of support to the affected families in the future, especially for the parents/caregivers of children with CP, who are facing socioeconomic challenges.

Human Umbilical Cord Mesenchymal Stem Cells for Severe Neurological Sequelae due to Anti-N-Methyl-d-Aspartate Receptor Encephalitis: First Case Report

Anti-N-methyl-d-aspartate (NMDA) receptor encephalitis is caused by altered patient immune reactions. This study reports the first patient with severe neurologic sequelae after NMDA receptor encephalitis treated with allogeneic umbilical cord-derived mesenchymal stem/stromal cells (UC-MSCs). A 5-year-old girl was diagnosed with NMDA receptor encephalitis and treated with immunosuppressive medicaments and intravenous immunoglobulin (IVIG). Despite intensive therapy, the patient's condition worsened so that allogenic UC-MSC therapy was contemplated. The patient received three intrathecal infusions of xeno- and serum-free cultured UC-MSCs at a dose of 10⁶ cells/kg. At baseline and after each UC-MSC administration, the patient was examined by the German Coma Recovery Scale (CRS), the Gross Motor Function Classification System (GMFCS), the Gross Motor Function Measure-88 (GMFM-88), the Manual Ability Classification System (MACS), the Modified Ashworth Scale, and the Denver II test. Before cell therapy, she was in a permanent vegetative state with diffuse cerebral atrophy. Her cognition and motor functions improved progressively after three UC-MSC infusions. At the last visit, she was capable of walking, writing, and counting numbers. Control of urinary and bowel functions was completely recovered. Cerebral atrophy was reduced on brain magnetic resonance imaging (MRI). Overall, the outcomes of this patient suggest a potential cell therapy for autoimmune encephalitis and its neurological consequences.

Functional Communication Abilities in Youth With Cerebral Palsy: Association With Impairment Profiles and School-Based Therapy Goals

PURPOSE

The aim of this study was to examine the relationship between functional communication skills, underlying speech, language, and cognitive impairments and school-based speech pathology services in students with cerebral palsy (CP).

METHOD

Thirty-five participants with CP who had Individualized Education Programs (IEPs) were classified according to the Communication Function Classification System (CFCS). Participants completed laboratory assessments of speech, receptive language, executive functioning, and nonverbal cognition. Each participant's speech and language IEP goals were coded into treatment units and then categorized into seven, mutually exclusive target goal areas. Nonparametric analyses were employed to examine differences among CFCS groups in the number of deficit areas and the number of goal areas from the IEP. Descriptive analyses were used to evaluate the extent to which deficit and goal areas in the IEP co-occurred by CFCS level.

RESULTS

Those in more involved CFCS levels demonstrated more severe speech, receptive language, and cognitive impairments. However, there were no significant differences in the number of deficit areas across CFCS groups. Regardless of CFCS level, there were no differences in the number of treatment goals specified in the IEP. Literacy was the only goal area addressed across all CFCS levels. Those in the most involved CFCS levels had augmentative and alternative communication (AAC) goals, but those with more moderate restrictions in functional communication who also had markedly reduced speech intelligibility did not typically have speech or AAC goals.

INTERPRETATION

Individuals with CP across CFCS levels demonstrate variability in underlying deficit profiles, suggesting that measures of both functional communication and of underlying deficits are necessary to provide a complete picture of communication needs. Literacy goals were common across all CFCS levels, but AAC goals were limited to the most severely involved individuals, suggesting that continuing education may be necessary to support speech-language pathologists in developing treatments involving the integration of AAC and speech to foster functional communication at school. Supplemental Material https://doi.org/10.23641/asha.16968073.

Development of the computerized adaptive test of motor development (MD-CAT) adopting multidimensional Rasch analysis

OBJECTIVE

This study aimed to develop the computerized adaptive test of motor development (MD-CAT) in preschool children based on multidimensional Rasch analysis.

DESIGN

A retrospective study with cross-sectional design SETTING: A medical center PARTICIPANTS: 1,738 children INTERVENTIONS: Not applicable MAIN OUTCOME MEASURES: MD-CAT RESULTS: Multidimensional Rasch analysis was used to develop the item bank of the MD-CAT. The item bank of the MD-CAT contained 74 items, with 44 and 30 items respectively for the subscales of gross and fine motor skills. High correlation existed between the two subscales (r = 0.96). Three stopping rules were set for the MD-CAT: (1) the person reliability achieved 0.95 or the limited reliability increased by < 0.01, (2) at least 3 items were assessed in each dimension, and (3) the number of items used for assessment reached 16. Based on the three stopping rules, the MD-CAT had high correlations with its total test length (r =0.87 to 0.98 for the two dimensions), indicating sufficient construct validity. The MD-CAT also had adequate diagnostic validity (area under the curve = 0.72-0.93) and efficiency (an average of 3 to 6 items used for the assessment).

CONCLUSION

The MD-CAT has high precision and efficiency, good construct validity and high diagnostic validity. The results of our study indicate that the MD-CAT can be useful in clinical practice and in research as a diagnostic measure.

Evidence Based Position Paper on Physical and Rehabilitation Medicine professional practice for persons with cerebral palsy

INTRODUCTION

Cerebral palsy (CP) is a group of the most common developmental disorders affecting movement and posture of the body, causing activity limitations and participation restrictions. The motor disorders of persons with CP are often accompanied by disturbances of sensation, cognition, communication and perception. The symptoms of CP are very diverse and persons with CP are usually presented with a mixed type of symptoms. The non-progressive disturbances can be attributed to disorders that were developed during pregnancy, birth and/or infant stage.

AIM

The aim of this study was to improve Physical and Rehabilitation Medicine physician´s professional practice for persons with cerebral palsy in order to improve their functionality, social and community integration, and to reduce activity limitations and/or participation restrictions.

MATERIAL AND METHODS

A systematic review of the literature including an eighteen-year period and consensus procedure by means of a Delphi process was performed and involved the delegates of all European countries represented in the Union of European Medical Specialists Physical and Rehabilitation Medicine (UEMS PRM) Section.

RESULTS

As the result of a Consensus Delphi procedure process 74 recommendations are presented together with the systematic literature review.

CONCLUSIONS

The PRM physician´s role for persons with cerebral palsy is to lead and coordinate the multiprofessional team, working in an interdisciplinary way. They should propose and manage the complex but individual PRM programme developed in conjunction with other health professionals, medical specialists and importantly in agreement with the patient, their family and care giver. This should be, according to the specific medical diagnosis to improve patients´ health, functioning, social and education status, considering all impairments, comorbidities and complications, activity limitations and participation restrictions.

Caregivers', teachers', and assistants' use and learning of partner strategies in communication using high-tech speech-generating devices with children with severe cerebral palsy

Communication with speech generating devices (SGDs) with children with severe physical, communicative and cognitive impairments, such as children with cerebral palsy (CP), can be difficult. Use of partner strategies facilitates the communication and instructional approaches such as feedback and role play facilitate communication partners' learning in how to use partner strategies. To describe communication partners' use and learning about partner strategies in SGD-mediated communication with children with severe CP. Questionnaires (n = 65) were sent to caregivers (n = 30), teachers (n = 17), and teaching or personal assistants (n = 18) of children with severe CP. Response rate was 80%. To ask open-ended questions was the most frequently used partner strategy and aided augmented input the least frequently used partner strategy. Most commonly, participants learned partner strategies from speech and language pathologists (SLPs) who used verbal instructions when teaching partner strategies but seldom or never feedback, role play or video examples. Communication partners' learning about partner strategies in SGD-mediated communication is inadequate and needs to be improved. SLPs, who are the main prescribers of SGDs and responsible for training and support in using them, should consider using instructional approaches when teaching communication partners about partner strategies in communication with an SGD.

Factors associated with spoken language comprehension in children with cerebral palsy: a systematic review

AIM

To identify factors that are relevant for spoken language comprehension in children with cerebral palsy (CP), following the International Classification of Functioning, Disability and Health - Children and Youth (ICF-CY) framework.

METHOD

A systematic literature search was conducted using the electronic literature databases PubMed, Embase, PsycInfo, and Cochrane Library, from January 1967 to December 2019. Included studies involved children with CP, results regarding spoken language comprehension, and analysis of at least one associated factor. Factors were classified within ICF-CY domains.

RESULTS

Twenty-one studies met inclusion criteria. Factors in the ICF-CY domains of body functions and structure were most frequently reported. White brain matter abnormalities, motor type, functional mobility, and intellectual functioning appear to be relevant factors in spoken language comprehension in CP. Factors in the domain of activities and participation, as well as contextual factors, have rarely been studied in the context of spoken language comprehension in CP.

INTERPRETATION

Most factors known to be important for spoken language comprehension in typically developing children and/or known to be susceptible to change by interventions are understudied in CP.

Nonseizure consequences of Dravet syndrome, KCNQ2-DEE, KCNB1-DEE, Lennox-Gastaut syndrome, ESES: A functional framework

RATIONALE

Developmental epilepsies and encephalopathies (DEEs) are characterized by many severe developmental impairments, which are not well-described. A functional framework could facilitate understanding of their nature and severity and guide the selection instruments to measure improvements in therapeutic trials.

METHODS

An online survey administered through several parent-organized foundations utilized accepted functional classifications and questionnaires derived from common instruments to determine levels of mobility, fine motor, communication, and feeding functions. Statistical analyses focused on overall levels of function and across-group comparisons adjusted for age.

RESULTS

From 6/2018 to 2/2020, 252 parents provided information for one or more functional domains. Median age was 7.2 years (interquartile range (IQR): 3.9 to 11.8), and 128 (51%) were females. DEE groups were Dravet syndrome (N = 72), KCNQ2-DEE (N = 80), KCNB1-DEE, (N = 33), Lennox-Gastaut syndrome (LGS; N = 26), electrographic status epilepticus in sleep (ESES; N = 15), and others (N = 26). Overall, functional hand grasp was absent in 48 (20%). Of children ≥2 years old, 60/214 (28%) could not walk independently, 85 (40%) were dependent on someone else for feeding, and 153 (73%) did not effectively communicate with unfamiliar people. Impairments entailing absence or near absence of independent function (profound impairment) were observed in 0, 1, 2, 3, and 4 domains for 58 (25%), 78 (34%), 40 (17%), 33 (14%), and 22 (10%) children, respectively. After adjustment for age, impairment levels varied substantially across DEE group for mobility (p < 0.0001), feeding (p < 0.0001), communication (p < 0.0001), hand grasp (p < 0.0001), and number of profoundly impaired domains (p < 0.0001). Three or four profoundly affected domains were reported in 44% of KCNQ2-DEE participants, followed by LGS (29%), KCNB1-DEE (27%), ESES (7%), and Dravet syndrome (6%).

CONCLUSIONS

Many children with DEEs experience severe functional impairments, and few children have typical function. As precision therapies will emphasize nonseizures consequences of DEEs, understanding the nature of abilities and impairments will be critical to selecting appropriate outcome measures in therapeutic trials.

Study protocol: functioning curves and trajectories for children and adolescents with cerebral palsy in Brazil - PartiCipa Brazil

Background

Gross motor development curves for children with Cerebral Palsy (CP), grouped by Gross Motor Function Classification System (GMFCS) levels, help health care professionals and parents to understand children’s motor function prognosis. Although these curves are widely used in Brazil to guide clinical decision-making, they were developed with Canadian children with CP. Little is known about how these patterns evolve in children and adolescents with CP in low-income countries like Brazil. The PARTICIPA BRAZIL aims to: (i) to identify and draw a profile of functioning and disability of Brazilian children and adolescents with CP by classifying them, for descriptive purposes, with all five valid and reliable functional classifications systems (gross motor function, manual ability, communication function, visual and eating and drinking abilities); (ii) to create longitudinal trajectories capturing the mobility capacity of Brazilian children and adolescents with CP for each level of the GMFCS; (iii) to document longitudinal trajectories in the performance of activities and participation of Brazilian children and adolescents with CP across two functional classification systems: GMFCS and MACS (Manual Abilities Classification System); (iv) to document longitudinal trajectories of neuromusculoskeletal and movement-related functions and exercise tolerance functions of Brazilian children and adolescents with CP for each level of the GMFCS; and (v) to explore interrelationships among all ICF framework components and the five functional classification systems in Brazilian children and adolescents with CP.

Methods

We propose a multi-center, longitudinal, prospective cohort study with 750 Brazilian children and adolescents with CP from across the country. Participants will be classified according to five functional classification systems. Contextual factors, activity and participation, and body functions will be evaluated longitudinally and prospectively for four years. Nonlinear mixed-effects models for each of the five GMFCS and MACS levels will be created using test scores over time to create prognosis curves. To explore the interrelationships among ICF components, a multiple linear regression will be performed.

Discussion

The findings from this study will describe the level and nature of activities and levels of participation of children and youth with CP in Brazil. This will support evidence-based public policies to improve care to this population from childhood to adulthood, based on their prognosis.

Communication ability and communication methods in children with cerebral palsy

AIM

To investigate if communication ability and method were related to each other and to age, sex, gross motor function, or manual ability in children with cerebral palsy.

METHOD

This cross-sectional study used data registered in the Swedish Cerebral Palsy Surveillance Program registry, involving 3000 children aged 0 to 18 years. Pearson's χ² test and Spearman's correlation were used to test associations between variables.

RESULTS

Communication ability and method were related to each other and to age, gross motor function, and manual ability. Aided communication methods were more frequently used among older children. The more functional the communication was, the less use of unaided communication occurred. Different communication methods were used across all Communication Function Classification System (CFCS) levels. Speech was most common in more functional levels, used by 72% of the children. Forty-five per cent were considered effective communicators in all environments. For classification of communication level and method, some recurring registration errors were made by the raters.

INTERPRETATION

Some raters may need clarification on interpretations of CFCS instructions. Results indicate that children should be presented to aided augmentative and alternative communication and manual signs earlier and to a greater extent.

Childhood factors predict participation of young adults with cerebral palsy in domestic life and interpersonal relationships: a prospective cohort study

Purpose: To determine childhood predictors of participation in domestic life and interpersonal relationships of young adults with cerebral palsy (CP).Materials and methods: This 13-year follow-up of an existing cohort (baseline age 9-13 years) included 67 young adults with CP (age 21-27 years). The Vineland adaptive behavior scales (VABS) and Life Habits questionnaire were used to assess attendance and difficulty in participation in domestic life and interpersonal relationships. Baseline factors were categorised according to the international classification of functioning, disability, and health. Stepwise multiple linear regression analyses determined significant predictors (p < 0.05).Results: Lower manual ability, intellectual disability (ID), epilepsy and lower motor capacity predicted decreased future participation in domestic life, and/or interpersonal relationships (explained variance R² = 67-87%), whereas no association was found with environmental and personal factors. Extending models with baseline fine motor skills, communication, and interpersonal relationships increased R² to 79-90%.Conclusions: Childhood factors account for 79-90% of the variation in young adult participation in domestic life and interpersonal relationships of individuals with CP. Children with limited motor capacity, low manual ability, ID, or epilepsy are at risk for restrictions in participation in young adulthood. Addressing fine motor, communication, and social skills in paediatric rehabilitation might promote young adult participation.Implications for rehabilitationChildhood risk factors for limited participation in domestic life and interpersonal relationships as a young adult with CP are ID, epilepsy, low manual ability, low motor capacity, and low activity & participation levels.In line with current practice, this study confirms the importance of addressing gross and fine motor skills in children with CP for their future participation in domestic life.In addition, results suggest that addressing communication and social skills during paediatric rehabilitation may optimise future participation in interpersonal relationships.

Usefulness of Cerebral Palsy Curves in Mexican Patients: A Cross-Sectional Study

Cerebral palsy describes a group of movement and posture disorders that cause activity limitation, and are attributable to nonprogressive disorders that occur in the fetal or infant brain. The growth of these children should not be compared with those of the healthy population. We studied 452 children, 186 female and 266 male. We compared the results in 2 growth charts, Centers for Disease Control and Prevention (CDC) and cerebral palsy, and the results were statistically significant ( P = .00001). With the CDC charts, 40.71% of the patients were below the 5th percentile and only 5.5% of them when we used the charts for cerebral palsy patients. The Mexican cerebral palsy patients were similar to US cerebral palsy patients when we compared height ( P = .4075) and body mass index (BMI) ( P = .4075). Only the weight was found to be different ( P = .00001). All the correlation indexes were negative: Eating and Drinking Ability Classification System (EDACS)-BMI (rho = -0.4798) ( P = .00001), Communication Function Classification System (CFCS)-BMI (rho = -0.4353) ( P = .00001), and Gross Motor Function Classification System (GMFCS)-BMI (rho = -0.3584) ( P = .00001). The growth charts of the healthy pediatric population tend to overestimate the underweight. We propose to use cerebral palsy charts as a reference in our patients. It is possible to determine a functional profile (communication, gross motor function and safety, and feed efficiency) for the cerebral palsy population based on their BMI.

Is there evidence of benefits associated with dancing in children and adults with cerebral palsy? A scoping review

Purpose: Cerebral palsy is a neurological disorder not only affecting motor functions but also cognitive and psychosocial dimension. Multispecialty therapies are needed to address these dimensions. Dance practice provides multidimensional benefits for people with various neurological disorders and may present a real potential for people with cerebral palsy. A scoping review is conducted to evaluate the impact of dance in children and adults with cerebral palsy, based on the Human Development Model-Disability Creation Process 2 and its three key concepts: personal factors, environmental factors and life habits.Materials and methods: Studies were selected based on a systematic search of published literature in the following databases PubMed, Medline, EBM Reviews, EMBASE and CINAHL. Studies addressing any concepts on the impact of dance training on motor, cognitive and psychosocial dimensions in people with cerebral palsy were included.Results: Seven studies representing 45 children and 12 adults with cerebral palsy were selected. They had heterogeneous populations, protocols and outcomes measures, but overall covered the three main concepts of the model. Dance may have both motor and social benefits although the evidence remains weak.Conclusions: Dance appears to be a promising activity for people with cerebral palsy. Recommendations are proposed for future studies.Implications for rehabilitationCerebral palsy affects motor and cognitive functions and has social repercussions.Dance can be a promising activity for people with a cerebral palsy.Dance may have both motor and social benefits although the evidence remains weak.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Reliability of the gross motor function classification system and the manual ability classification system in children with cerebral palsy in Tanzania

OBJECTIVES

Gross Motor Function Classification System (GMFCS) and Manual Ability Classification System (MACS) are broadly studied in high-income countries, but data concerning their functioning are lacking in developing countries. Therefore, we analyzed their reliability and sensitivity to change in children with cerebral palsy in Tanzania.

METHODS

GMFCS and MACS are two ordinal grading systems used to assess motor functions while observing children's performances. Forty-nine children were classified by two independent physiotherapy students at baseline, after one month and after one year. Reliability and sensitivity to change were analyzed using intraclass correlation coefficient (ICC), effect size (ES), standard response mean (SRM), standard error of measurement (SEM), and minimal detectable change (MDC).

RESULTS

Inter- (ICC = 0.97/0.95 for GMFCS/MACS) and intra-rater reliability (ICC = 0.98/0.96 GMFCS/MACS) were excellent. Sensitivity to change was small (ES = -0.14/0.11, SRM = -0.24;/0.24 GMFCS/MACS). SEM was 0.2 points, resulting in MDC = 0.5/0.7 for GMFCS/MACS, respectively.

CONCLUSIONS

GMFCS and MACS demonstrated excellent reliability, but not sensitivity to change.

A systematic review of comorbidity between cerebral palsy, autism spectrum disorders and Attention Deficit Hyperactivity Disorder

OBJECTIVES

The aim of this systematic review was to examine the incidence and prevalence of comorbidity between Cerebral Palsy (CP), Autism spectrum disorders (ASDs) and Attention-Deficit/Hyperactivity Disorder (ADHD).

METHODS

We searched for articles indexed in PubMed, EBSCOhost, Scopus, Web of Science and other potentially relevant internet sources using a combination of expressions including "cerebral palsy" AND "autism" OR "ASD" OR "pervasive development disorder" AND "Attention Deficit Hyperactivity Disorder" OR "ADHD".

RESULTS

We identified 2542 studies on CP and ASD and 998 studies on CP and ADHD. After screening titles and abstracts and removing duplicated studies, 47 full papers (CP and ASD n = 28; CP and ADHD n = 19) were downloaded and screened for eligibility. Twenty-eight (CP and ASD n = 16; CP and ADHD n = 12) studies were identified in the peer-review literature. Based on this systematic review, ASD and ADHD seem to be more common in people with CP than in the general population, yet the gold standard methods for diagnosing ASD or ADHD are not suitable for children with motor problems.

CONCLUSIONS

Assessing the occurrence of ASD and ADHD would improve the significant cost of healthcare, therapies, and overall daily living for families with children affected by CP. However, psychometric studies are needed in the future to promote development of measures suitable for individuals with CP. In addition, this review highlights the paucity of peer-reviewed studies investigating the occurrence of ASD and ADHD in children with different CP subtypes or functional abilities, and there are still some open questions about pathogenic mechanisms common to CP, ASD and ADHD.

Functional Communication Profiles in Children with Cerebral Palsy in Relation to Gross Motor Function and Manual and Intellectual Ability

PURPOSE

The aim of the present study was to investigate communication function using classification systems and its association with other functional profiles, including gross motor function, manual ability, intellectual functioning, and brain magnetic resonance imaging (MRI) characteristics in children with cerebral palsy (CP).

MATERIALS AND METHODS

This study recruited 117 individuals with CP aged from 4 to 16 years. The Communication Function Classification System (CFCS), Viking Speech Scale (VSS), Speech Language Profile Groups (SLPG), Gross Motor Function Classification System (GMFCS), Manual Ability Classification System (MACS), and intellectual functioning were assessed in the children along with brain MRI categorization.

RESULTS

Very strong relationships were noted among the VSS, CFCS, and SLPG, although these three communication systems provide complementary information, especially for children with mid-range communication impairment. These three communication classification systems were strongly related with the MACS, but moderately related with the GMFCS. Multiple logistic regression analysis indicated that manual ability and intellectual functioning were significantly related with VSS and CFCS function, whereas only intellectual functioning was significantly related with SLPG functioning in children with CP. Communication function in children with a periventricular white matter lesion (PVWL) varied widely. In the cases with a PVWL, poor functioning was more common on the SLPG, compared to the VSS and CFCS.

CONCLUSION

Very strong relationships were noted among three communication classification systems that are closely related with intellectual ability. Compared to gross motor function, manual ability seemed more closely related with communication function in these children.

Reliability and validity of the Korean-language version of the Communication Function Classification System in children with cerebral palsy

PURPOSE

The Communication Function Classification System (CFCS) and Viking Speech Scale (VSS) are useful systems for describing the broad communication function and speech intelligibility, respectively, of children with cerebral palsy (CP). The aims of this study were to determine the reliability and validity of the Korean version of the CFCS and also to investigate the association between the CFCS and the VSS and other functional classifications for children with CP.

MATERIALS AND METHODS

Participants were 50 children with CP (33 males, 17 females; mean age 7.2 years, range 4-16 years) recruited from a rehabilitation hospital. We analysed the interrater and intrarater reliabilities of the Korean version of the CFCS and VSS between parents, a physiatrist, and a speech-language pathologist (SLP). The social function domain of the Paediatric Evaluation of Disability Inventory was assessed to examine the concurrent validity of the CFCS and VSS.

RESULTS

The intrarater reliabilities of the CFCS and VSS were excellent in a physiatrist (ƙ = 0.92, ƙ = 0.94, respectively) and an SLP (ƙ = 0.98, ƙ = 0.98) and very good in parents (ƙ = 0.87, ƙ = 0.89). The interrater reliability of the CFCS and VSS was very good between the physiatrist and SLP (ƙ = 0.87, ƙ = 0.89) and good between parents and the SLP (ƙ = 0.63, ƙ = 0.78) and between parents and the physiatrist (ƙ = 0.61, ƙ = 0.76). The CFCS and VSS were strongly related with the social function domain of Paediatric Evaluation of Disability Inventory. In addition, we found very strong associations between the VSS and CFCS.

CONCLUSIONS

The Korean version of the CFCS is a valid and reliable tool to classify communication ability and is strongly associated with the VSS, a reliable tool to classify speech intelligibility.

Comparisons of severity classification systems for oropharyngeal dysfunction in children with cerebral palsy: Relations with other functional profiles

This study aimed to investigate the relationships between various classification systems assessing the severity of oropharyngeal dysphagia and communication function and other functional profiles in children with cerebral palsy (CP). This is a prospective, cross-sectional, study in a university-affiliated, tertiary-care hospital. We recruited 151 children with CP (mean age 6.11 years, SD 3.42, range 3-18yr). The Eating and Drinking Ability Classification System (EDACS) and the dysphagia scales of Functional Oral Intake Scale (FOIS), Swallow Function Scales (SFS), and Food Intake Level Scale (FILS) were used. The Communication Function Classification System (CFCS) and Viking Speech Scale (VSS) were employed to classify communication function and speech intelligibility, respectively. The Pediatric Evaluation of Disability Inventory (PEDI) with the Gross Motor Function Classification System (GFMCS) and the Manual Ability Classification System (MACS) level were also assessed. Spearman correlation analysis to investigate the associations between measures and univariate and multivariate logistic regression models to identify significant factors were used. Median GMFCS level of participants was III (interquartile range II-IV). Significant dysphagia based on EDACS level III-V was noted in 23 children (15.2%). There were strong to very strong relationships between the EDACS level with the dysphagia scales. The EDACS presented strong associations with MACS, CFCS, and VSS, a moderate association with GMFCS level, and a moderate to strong association with each domain of the PEDI. In multivariate analysis, poor functioning in EDACS were associated with poor functioning in gross motor and communication functions.

Participation in physical activities for children with cerebral palsy: feasibility and effectiveness of physical activity on prescription

Background

Children with cerebral palsy (CP) are less physically active and more sedentary than other children which implies risk factors for their physical and mental health. Physical activity on prescription (PAP) is an effective intervention to promote a lifestyle change towards increased physical activity in adults in general. Knowledge is lacking about the use of PAP in children with CP. Therefore, the aim of this study was to evaluate the feasibility of PAP for children with CP and its effectiveness on participation in physical activity and sedentary behaviour.

Methods

Eleven children with CP, aged 7-11 years, participated in PAP, consisting of a written agreement between each child, their parents and the physiotherapist and based on Motivational Interviewing (MI), Canadian Occupational Performance Measure (COPM) and Goal Attainment Scaling (GAS). Individual goals, gross motor function and physical activity were assessed at baseline, at 8 and/or 11 months using COPM, GAS, logbooks, Gross Motor Function Measure (GMFM-66), physical activity questionnaires, physical activity and heart rate monitors and time-use diaries. At 8 and 11 months the feasibility of the intervention and costs and time spent for the families and the physiotherapist were evaluated by questionnaires.

Results

The intervention was feasible according to the feasibility questionnaire. Each child participated in 1-3 self-selected physical activities during 3-6 months with support from the physiotherapist, and clinically meaningful increases from baseline of COPM and GAS scores were recorded. Being physically active at moderate-vigorous levels varied between less than 30 and more than 240 minutes/day, and the median for the whole group was 84 minutes/day at baseline and 106 minutes/day at 8 months.

Conclusions

The intervention PAP seems to be feasible and effective for children with CP, involving both every day and organised physical activities to promote an active lifestyle through increased participation, motivation, and engagement in physical activities. Further research of PAP is needed, preferably in a long term randomised controlled trial and including health economic analysis to show costs and benefits.

Trial Registration

ISRCTN76366356, retrospectively registered.

Antenatal and intrapartum interventions for preventing cerebral palsy: an overview of Cochrane systematic reviews

BACKGROUND

Cerebral palsy is an umbrella term encompassing disorders of movement and posture, attributed to non-progressive disturbances occurring in the developing fetal or infant brain. As there are diverse risk factors and causes, no one strategy will prevent all cerebral palsy. Therefore, there is a need to systematically consider all potentially relevant interventions for their contribution to prevention.

OBJECTIVES

To summarise the evidence from Cochrane reviews regarding the effects of antenatal and intrapartum interventions for preventing cerebral palsy.

METHODS

We searched the Cochrane Database of Systematic Reviews on 7 August 2016, for reviews of antenatal or intrapartum interventions reporting on cerebral palsy. Two authors assessed reviews for inclusion, extracted data, assessed review quality, using AMSTAR and ROBIS, and quality of the evidence, using the GRADE approach. We organised reviews by topic, and summarised findings in text and tables. We categorised interventions as effective (high-quality evidence of effectiveness); possibly effective (moderate-quality evidence of effectiveness); ineffective (high-quality evidence of harm or of lack of effectiveness); probably ineffective (moderate-quality evidence of harm or of lack of effectiveness); and no conclusions possible (low- to very low-quality evidence).

MAIN RESULTS

We included 15 Cochrane reviews. A further 62 reviews pre-specified the outcome cerebral palsy in their methods, but none of the included randomised controlled trials (RCTs) reported this outcome. The included reviews were high quality and at low risk of bias. They included 279 RCTs; data for cerebral palsy were available from 27 (10%) RCTs, involving 32,490 children. They considered interventions for: treating mild to moderate hypertension (two) and pre-eclampsia (two); diagnosing and preventing fetal compromise in labour (one); preventing preterm birth (four); preterm fetal maturation or neuroprotection (five); and managing preterm fetal compromise (one). Quality of evidence ranged from very low to high. Effective interventions: high-quality evidence of effectiveness There was a reduction in cerebral palsy in children born to women at risk of preterm birth who received magnesium sulphate for neuroprotection of the fetus compared with placebo (risk ratio (RR) 0.68, 95% confidence interval (CI) 0.54 to 0.87; five RCTs; 6145 children). Probably ineffective interventions: moderate-quality evidence of harm There was an increase in cerebral palsy in children born to mothers in preterm labour with intact membranes who received any prophylactic antibiotics versus no antibiotics (RR 1.82, 95% CI 0.99 to 3.34; one RCT; 3173 children). There was an increase in cerebral palsy in children, who as preterm babies with suspected fetal compromise, were born immediately compared with those for whom birth was deferred (RR 5.88, 95% CI 1.33 to 26.02; one RCT; 507 children). Probably ineffective interventions: moderate-quality evidence of lack of effectiveness There was no clear difference in the presence of cerebral palsy in children born to women at risk of preterm birth who received repeat doses of corticosteroids compared with a single course (RR 1.03, 95% CI 0.71 to 1.50; four RCTs; 3800 children). No conclusions possible: low- to very low-quality evidence Low-quality evidence found there was a possible reduction in cerebral palsy for children born to women at risk of preterm birth who received antenatal corticosteroids for accelerating fetal lung maturation compared with placebo (RR 0.60, 95% CI 0.34 to 1.03; five RCTs; 904 children). There was no clear difference in the presence of cerebral palsy with interventionist care for severe pre-eclampsia versus expectant care (RR 6.01, 95% CI 0.75 to 48.14; one RCT; 262 children); magnesium sulphate for pre-eclampsia versus placebo (RR 0.34, 95% CI 0.09 to 1.26; one RCT; 2895 children); continuous cardiotocography for fetal assessment during labour versus intermittent auscultation (average RR 1.75, 95% CI 0.84 to 3.63; two RCTs; 13,252 children); prenatal progesterone for prevention of preterm birth versus placebo (RR 0.14, 95% CI 0.01 to 3.48; one RCT; 274 children); and betamimetics for inhibiting preterm labour versus placebo (RR 0.19, 95% CI 0.02 to 1.63; one RCT; 246 children).Very low-quality found no clear difference for the presence of cerebral palsy with any antihypertensive drug (oral beta-blockers) for treatment of mild to moderate hypertension versus placebo (RR 0.33, 95% CI 0.01 to 8.01; one RCT; 110 children); magnesium sulphate for prevention of preterm birth versus other tocolytic agents (RR 0.13, 95% CI 0.01 to 2.51; one RCT; 106 children); and vitamin K and phenobarbital prior to preterm birth for prevention of neonatal periventricular haemorrhage versus placebo (RR 0.77, 95% CI 0.33 to 1.76; one RCT; 299 children).

AUTHORS' CONCLUSIONS

This overview summarises evidence from Cochrane reviews on the effects of antenatal and intrapartum interventions on cerebral palsy, and can be used by researchers, funding bodies, policy makers, clinicians and consumers to aid decision-making and evidence translation. We recommend that readers consult the included Cochrane reviews to formally assess other benefits or harms of included interventions, including impacts on risk factors for cerebral palsy (such as the reduction in intraventricular haemorrhage for preterm babies following exposure to antenatal corticosteroids).Magnesium sulphate for women at risk of preterm birth for fetal neuroprotection can prevent cerebral palsy. Prophylactic antibiotics for women in preterm labour with intact membranes, and immediate rather than deferred birth of preterm babies with suspected fetal compromise, may increase the risk of cerebral palsy. Repeat doses compared with a single course of antenatal corticosteroids for women at risk of preterm birth do not clearly impact the risk of cerebral palsy.Cerebral palsy is rarely diagnosed at birth, has diverse risk factors and causes, and is diagnosed in approximately one in 500 children. To date, only a small proportion of Cochrane reviews assessing antenatal and intrapartum interventions have been able to report on this outcome. There is an urgent need for long-term follow-up of RCTs of interventions addressing risk factors for cerebral palsy, and consideration of the use of relatively new interim assessments (including the General Movements Assessment). Such RCTs must be rigorous in their design, and aim for consistency in cerebral palsy outcome measurement and reporting to facilitate pooling of data, to focus research efforts on prevention.

Risk Factors for Developing Scoliosis in Cerebral Palsy: A Cross-Sectional Descriptive Study

This study aims to identify the risk factors leading to the development of severe scoliosis among children with cerebral palsy. A cross-sectional descriptive study of 70 children (aged 12-18 years) with severe spastic and/or dystonic cerebral palsy treated in a single specialist unit is described. Statistical analysis included Fisher exact test and logistic regression analysis to identify risk factors. Severe scoliosis is more likely to occur in patients with intractable epilepsy ( P = .008), poor gross motor functional assessment scores ( P = .018), limb spasticity ( P = .045), a history of previous hip surgery ( P = .048), and nonambulatory patients ( P = .013). Logistic regression model confirms the major risk factors are previous hip surgery ( P = .001), moderate to severe epilepsy ( P = .007), and female gender ( P = .03). History of previous hip surgery, intractable epilepsy, and female gender are predictors of developing severe scoliosis in children with cerebral palsy. This knowledge should aid in the early diagnosis of scoliosis and timely referral to specialist services.

Evaluating the Discriminant Validity of the Pediatric Evaluation of Disability Inventory: Computer Adaptive Test in Children With Cerebral Palsy

BACKGROUND

The Pediatric Evaluation of Disability Inventory-Computer Adaptive Test (PEDI-CAT) is a new clinical assessment for children and youth from birth through 20 years of age.

OBJECTIVE

To determine the discriminant validity of the PEDI-CAT according to the Gross Motor Function Classification System (GMFCS) and Manual Ability Classification System (MACS) in children with cerebral palsy (CP).

DESIGN

A prospective convenience cross-sectional sample of 101 school-age children with CP was stratified by GMFCS level.

METHODS

Participants were excluded if they underwent recent surgery (<6 months). Receiver operating characteristics curve analysis was used to quantify the discriminant validity of the PEDI-CAT domains to distinguish the level of independence in fine and gross motor function. General linear modeling was used to assess discriminant ability across all GMFCS and MACS levels.

RESULTS

Mean age was 11 years, 11 months (SD 3.7). Mobility and Daily Activities domains exhibited excellent discriminant validity distinguishing between ambulatory and nonambulatory participants [area under the curve (AUC) = 0.98 and 0.97, respectively] and the Daily Activities domain exhibited excellent discriminant validity distinguishing between independent and dependent hand function (AUC = 0.93). All PEDI-CAT domains were able to discriminate between ambulatory (GMFCS levels I-III) or nonambulatory (GMFCS levels IV-V) as well as manually independent (MACS levels I-II) or manually dependent functional levels (MACS levels III-V) ( P < .001).

LIMITATIONS

Our convenience cross-sectional sample included school-age children with primarily Caucasian, middle-income parents and may not be representative of other cultural, socioeconomic backgrounds. Not all participants had a MACS level assigned, however, no differences were found in PEDI-CAT scores between those with and without MACS scores.

CONCLUSIONS

These results demonstrate that the PEDI-CAT is a valid outcome instrument for measuring functional abilities in children with CP, able to differentiate across fine and gross motor functional levels.

Language Development and Brain Magnetic Resonance Imaging Characteristics in Preschool Children With Cerebral Palsy

PURPOSE

The purpose of this study was to investigate characteristics of language development in relation to brain magnetic resonance imaging (MRI) characteristics and the other contributing factors to language development in children with cerebral palsy (CP).

METHOD

The study included 172 children with CP who underwent brain MRI and language assessments between 3 and 7 years of age. The MRI characteristics were categorized as normal, malformation, periventricular white matter lesion (PVWL), deep gray matter lesion, focal infarct, cortical/subcortical lesion, and others. Neurodevelopmental outcomes such as ambulatory status, manual ability, cognitive function, and accompanying impairments were assessed.

RESULTS

Both receptive and expressive language development quotients (DQs) were significantly related to PVWL or deep gray matter lesion severity. In multivariable analysis, only cognitive function was significantly related to receptive language development, whereas ambulatory status and cognitive function were significantly associated with expressive language development. More than one third of the children had a language developmental discrepancy between receptive and expressive DQs. Children with cortical/subcortical lesions were at high risk for this discrepancy.

CONCLUSIONS

Cognitive function is a key factor for both receptive and expressive language development. In children with PVWL or deep gray matter lesion, lesion severity seems to be useful to predict language development.

Motor learning paradigm and contextual interference in manual computer tasks in individuals with cerebral palsy

BACKGROUND

Cerebral palsy (CP) is a group of disorders of movement and posture that cause activity limitations. Due to the different motor problems these individuals encounter there is a need to offer rehabilitation programs that promote motor learning. Additionally, the understanding of the learning patterns of these individuals can help us attend to their learning needs to maximize their learning efficiency.

AIMS

The present study aimed to add to the knowledge base in regards to motor learning and the contextual interference (CI) effect.

METHODS AND PROCEDURES

The study included 40 individuals with CP and 40 typically developing (TD) participants matched for age and gender with the CP group. Both groups were divided into 2 subgroups regarding the practice schedule (random or constant practice) of a manual maze test on the computer. The participants who performed in the constant practice schedule performed the same standard maze 30 times, while participants in the random practice schedule performed a total of 30 trials on 5 mazes with a different spatial layout including the standard maze. After 5min of rest, retention was studied with a task in which all participants performed the standard maze. To examine the transfer effect, all participants also performed a maze with a new layout. Time of completion was registered in seconds for each trial.

OUTCOMES AND RESULTS

The results showed that the performance was lower in individuals with CP compared to typically developing individuals. In addition, only the participants with CP showed a contextual interference effect, with performance after the random practice schedule being superior compared to participants who practiced with a constant practice schedule.

CONCLUSIONS AND IMPLICATIONS

Overall performance was lower in individuals with CP compared to individuals with TD. Additionally, both TD individuals and individuals with CP showed the contextual interference effect in the transfer phase, with the execution of random practice leading to better performance than constant practice. These findings provide important information to assist clinicians in developing rehabilitation programs for children with CP.

What do the relationships between functional classification systems of children with cerebral palsy tell us?

[Purpose] To examine the distribution of and relationship between the Gross Motor Function, Manual Ability, and Communication Function Classification Systems in different limbs of children with spastic cerebral palsy. We also investigated whether the four predicting variables of gender, age, manual ability, and gross motor classifications could significantly predict effective and non-effective communicator groups in communication function. [Subjects and Methods] This retrospective cross-sectional study included 327 children with a mean age of 10.13 ± 4.09 years. Classifications were performed by an experienced pediatric physiotherapist. [Results] Gross motor function levels showed a strong correlation with manual ability levels (r_s=0.78). Manual ability level was strongly correlated with communication function levels (r_s=0.73), particularly in quadriplegic children (r_s=0.78). Gross motor function levels were moderately correlated with communication function levels (r_s=0.71). Effective communicators in communication function showed more functional levels of manual ability and were determined by Gross Motor Function classifications. The variables were better at predicting ineffective communicators (91% correct) compared with effective communicators (85% correct). [Conclusion] Further studies are needed to relate these functional performance systems to the activity and participation levels as well as the quality of life, desires, and participation of the subjects.

Multidisciplinary rehabilitation for patients with cerebral palsy: improving long-term care

Cerebral palsy (CP) is one of the most frequent causes of child disability in developed countries. Children with CP need lifelong assistance and care. The current prevalence of CP in industrialized countries ranges from 1.5 to 2.5 per 1,000 live births, with one new case every 500 live births. Children with CP have an almost normal life expectancy and mortality is very low. Despite the low mortality rate, 5%-10% of them die during childhood, especially when the severe motor disability is comorbid with epilepsy and severe intellectual disability. Given this life expectancy, children with CP present with a lifelong disability of varying severity and complexity, which requires individualized pathways of care. There are no specific treatments that can remediate the brain damage responsible for the complex clinical-functional dysfunctions typical of CP. There are, however, a number of interventions (eg, neurorehabilitation, functional orthopedic surgery, medication, etc) aimed at limiting the damage secondary to the brain insult and improving these patients' activity level and participation and, therefore, their quality of life. The extreme variability of clinical aspects and the complexity of affected functions determine a multifaceted skill development in children with CP. There is a need to provide them with long-term care, taking into account medical and social aspects as well as rehabilitation, education, and assistance. This long-term care must be suited according to children's developmental stage and their physical, psychological, and social development within their life contexts. This impacts heavily on the national health systems which must set up a network of services for children with CP, and it also impacts heavily on the family as a whole, due to the resulting distress, adjustment efforts, and changes in quality of life. This contribution is a narrative review of the current literature on long-term care for children with CP, aiming at suggesting reflections to improve these children's care.

Management of the spastic wrist and hand in cerebral palsy

Research from the last 5 years on the pathophysiology and treatment of upper extremity sequelae of cerebral palsy (CP) is presented. The development of new treatments of CP-affected limbs, utilizing the brain's inherent neuroplasticity, remains an area of promising and active research. Functional magnetic resonance imaging scans have evaluated the role of neuroplasticity in adapting to the initial central nervous system insult. Children with CP appear to have greater recruitment of the ipsilateral brain for motor and sensory functions of the affected upper limb. Studies have also shown that constraint-induced movement therapy results in localized increase in gray matter volume of the sensorimotor cortex contralateral to the affected arm targeted during rehabilitation. Recent therapy interventions have emphasized the role of home therapy programs, the transient effects of splinting, and the promise of constraint-induced movement therapy and bimanual hand training. The use of motion laboratory analysis to characterize the movement pattern disturbances in children with CP continues to expand. Classification systems for CP upper limb continue to expand and improve their reliability, including use of the House Classification, the Manual Ability Classification System, and the Shriner's Hospital Upper Extremity Evaluation. Surgical outcomes have greater patients' satisfaction when they address functional limitations, also in addition to aesthetics, which may improve patients' self-esteem. Surgical techniques for elbow, wrist, fingers, and thumb continue to be refined. Research into each of these areas continues to expand our understanding of the nervous system insults that cause CP, how they may be modified, and how hand surgeons can continue to serve patients by improving their upper limb function and aesthetics.