Correlation between ICIDH handicap code and Gross Motor Function Classification System in children with cerebral palsy

A pilot cohort study of cerebral autoregulation and 2-year neurodevelopmental outcomes in neonates with hypoxic-ischemic encephalopathy who received therapeutic hypothermia

Background

Neurodevelopmental disabilities persist in survivors of neonatal hypoxic-ischemic encephalopathy (HIE) despite treatment with therapeutic hypothermia. Cerebrovascular autoregulation, the mechanism that maintains cerebral perfusion during changes in blood pressure, may influence outcomes. Our objective was to describe the relationship between acute autoregulatory vasoreactivity during treatment and neurodevelopmental outcomes at 2 years of age.

Methods

In a pilot study of 28 neonates with HIE, we measured cerebral autoregulatory vasoreactivity with the hemoglobin volume index (HVx) during therapeutic hypothermia, rewarming, and the first 6 h of normothermia. The HVx, which is derived from near-infrared spectroscopy, was used to identify the individual optimal mean arterial blood pressure (MAP_OPT) at which autoregulatory vasoreactivity is greatest. Cognitive and motor neurodevelopmental evaluations were completed in 19 children at 21–32 months of age. MAP_OPT, blood pressure in relation to MAP_OPT, blood pressure below gestational age + 5 (ga + 5), and regional cerebral oximetry (rSO₂) were compared to the neurodevelopmental outcomes.

Results

Nineteen children who had HIE and were treated with therapeutic hypothermia performed in the average range on cognitive and motor evaluations at 21–32 months of age, although the mean performance was lower than that of published normative samples. Children with impairments at the 2-year evaluation had higher MAP_OPT values, spent more time with blood pressure below MAP_OPT, and had greater blood pressure deviation below MAP_OPT during rewarming in the neonatal period than those without impairments. Greater blood pressure deviation above MAP_OPT during rewarming was associated with less disability and higher cognitive scores. No association was observed between rSO₂ or blood pressure below ga + 5 and neurodevelopmental outcomes.

Conclusion

In this pilot cohort, motor and cognitive impairments at 21–32 months of age were associated with greater blood pressure deviation below MAP_OPT during rewarming following therapeutic hypothermia, but not with rSO₂ or blood pressure below ga + 5. This suggests that identifying individual neonates’ MAP_OPT is superior to using hemodynamic goals based on gestational age or rSO₂ in the acute management of neonatal HIE.

Electronic supplementary material

The online version of this article (doi:10.1186/s12883-015-0464-4) contains supplementary material, which is available to authorized users.

A pilot cohort study of cerebral autoregulation and 2-year neurodevelopmental outcomes in neonates with hypoxic-ischemic encephalopathy who received therapeutic hypothermia

BACKGROUND

Neurodevelopmental disabilities persist in survivors of neonatal hypoxic-ischemic encephalopathy (HIE) despite treatment with therapeutic hypothermia. Cerebrovascular autoregulation, the mechanism that maintains cerebral perfusion during changes in blood pressure, may influence outcomes. Our objective was to describe the relationship between acute autoregulatory vasoreactivity during treatment and neurodevelopmental outcomes at 2 years of age.

METHODS

In a pilot study of 28 neonates with HIE, we measured cerebral autoregulatory vasoreactivity with the hemoglobin volume index (HVx) during therapeutic hypothermia, rewarming, and the first 6 h of normothermia. The HVx, which is derived from near-infrared spectroscopy, was used to identify the individual optimal mean arterial blood pressure (MAPOPT) at which autoregulatory vasoreactivity is greatest. Cognitive and motor neurodevelopmental evaluations were completed in 19 children at 21-32 months of age. MAPOPT, blood pressure in relation to MAPOPT, blood pressure below gestational age + 5 (ga + 5), and regional cerebral oximetry (rSO2) were compared to the neurodevelopmental outcomes.

RESULTS

Nineteen children who had HIE and were treated with therapeutic hypothermia performed in the average range on cognitive and motor evaluations at 21-32 months of age, although the mean performance was lower than that of published normative samples. Children with impairments at the 2-year evaluation had higher MAPOPT values, spent more time with blood pressure below MAPOPT, and had greater blood pressure deviation below MAPOPT during rewarming in the neonatal period than those without impairments. Greater blood pressure deviation above MAPOPT during rewarming was associated with less disability and higher cognitive scores. No association was observed between rSO2 or blood pressure below ga + 5 and neurodevelopmental outcomes.

CONCLUSION

In this pilot cohort, motor and cognitive impairments at 21-32 months of age were associated with greater blood pressure deviation below MAPOPT during rewarming following therapeutic hypothermia, but not with rSO2 or blood pressure below ga + 5. This suggests that identifying individual neonates' MAPOPT is superior to using hemodynamic goals based on gestational age or rSO2 in the acute management of neonatal HIE.

A pilot cohort study of cerebral autoregulation and 2-year neurodevelopmental outcomes in neonates with hypoxic-ischemic encephalopathy who received therapeutic hypothermia

BACKGROUND

Neurodevelopmental disabilities persist in survivors of neonatal hypoxic-ischemic encephalopathy (HIE) despite treatment with therapeutic hypothermia. Cerebrovascular autoregulation, the mechanism that maintains cerebral perfusion during changes in blood pressure, may influence outcomes. Our objective was to describe the relationship between acute autoregulatory vasoreactivity during treatment and neurodevelopmental outcomes at 2 years of age.

METHODS

In a pilot study of 28 neonates with HIE, we measured cerebral autoregulatory vasoreactivity with the hemoglobin volume index (HVx) during therapeutic hypothermia, rewarming, and the first 6 h of normothermia. The HVx, which is derived from near-infrared spectroscopy, was used to identify the individual optimal mean arterial blood pressure (MAPOPT) at which autoregulatory vasoreactivity is greatest. Cognitive and motor neurodevelopmental evaluations were completed in 19 children at 21-32 months of age. MAPOPT, blood pressure in relation to MAPOPT, blood pressure below gestational age + 5 (ga + 5), and regional cerebral oximetry (rSO2) were compared to the neurodevelopmental outcomes.

RESULTS

Nineteen children who had HIE and were treated with therapeutic hypothermia performed in the average range on cognitive and motor evaluations at 21-32 months of age, although the mean performance was lower than that of published normative samples. Children with impairments at the 2-year evaluation had higher MAPOPT values, spent more time with blood pressure below MAPOPT, and had greater blood pressure deviation below MAPOPT during rewarming in the neonatal period than those without impairments. Greater blood pressure deviation above MAPOPT during rewarming was associated with less disability and higher cognitive scores. No association was observed between rSO2 or blood pressure below ga + 5 and neurodevelopmental outcomes.

CONCLUSION

In this pilot cohort, motor and cognitive impairments at 21-32 months of age were associated with greater blood pressure deviation below MAPOPT during rewarming following therapeutic hypothermia, but not with rSO2 or blood pressure below ga + 5. This suggests that identifying individual neonates' MAPOPT is superior to using hemodynamic goals based on gestational age or rSO2 in the acute management of neonatal HIE.

Validity of three rating scales for measuring pain intensity in youths with physical disabilities

BACKGROUND

There is growing evidence confirming that youths with physical disabilities are at risk for chronic pain. Although many scales for assessing pain intensity exist, it is unclear whether they are all equally suitable for youths. The aim of this study was to address this knowledge gap by comparing the validity of the Numerical Rating Scale (NRS-11), the Wong Baker FACES Pain Rating Scale (FACES), and a 6-point categorical Verbal Rating Scale (VRS-6) for assessing pain intensity among youths (aged 8-20) with physical disabilities.

METHODS

One hundred and thirteen youths (mean age = 14.19 years; SD = 2.9) were interviewed and asked to rate their current pain intensity and recalled (in the past week) worst, least, and average pain with the NRS-11 and the FACES. Participants were also asked to rate their average pain intensity during the past 4 weeks using a VRS-6, and were administered measures assessing pain interference, disability and psychological functioning.

RESULTS

Analyses showed that all of the pain intensity measures were associated positively with each other. Nevertheless, the NRS-11 appeared to out-perform both the VRS-6 and in particular the FACES scale with respect to: (1) the associations with the validity criterion (i.e. pain interference, disability and psychological functioning) and (2) a lack of any moderating effect of age on the association between the measure and the criterion variables.

CONCLUSIONS

The findings support the validity of the NRS-11 for assessing pain intensity in youths with physical disabilities between the ages of 8 and 20 years.

Correlation between Pediatric Balance Scale and Functional Test in Children with Cerebral Palsy

[Purpose] To investigate the correlation of functional balance with the functional performance of children with cerebral palsy. [Subjects and Methods] This was a cross-sectional study of children with cerebral palsy with mild to moderate impairment. The children were divided into 3 groups based on motor impairment. The evaluation consisted of the administration of the Pediatric Balance Scale (PBS) and the Pediatric Evaluation Disability Inventory. Correlations between the instruments were determined by calculating Pearson’s correlation coefficients. [Results] In Group 1, a strong positive correlation was found between the PBS and the mobility dimension of the Pediatric Evaluation Disability Inventory (r=0.82), and a moderate correlation was found between the PBS and self-care dimension of the Pediatric Evaluation Disability Inventory (r=0.51). In Group 2, moderate correlations were found between the PBS and both the self-care dimension (r=0.57) and mobility dimension (r=0.41) of the Pediatric Evaluation Disability Inventory. In Group 3, the PBS was weakly correlated with the self-care dimension (r=0.11) and moderately correlated with the mobility dimension (r=0.55). [Conclusion] The PBS proved to be a good auxiliary tool for the evaluation of functional performance with regard to mobility, but cannot be considered a predictor of function in children with cerebral palsy.

Proposed guidelines for the management of nodding syndrome

Nodding Syndrome is a poorly understood neurologic disorder of unknown aetiology that affects children and adolescents in Africa. Recent studies have suggested that the head nods are due to atonic seizures and Nodding Syndrome may be classified as probably symptomatic generalised epilepsy. As part of the Ugandan Ministry of Health clinical management response, a multidisciplinary team developed a manual to guide the training of health workers with knowledge and skills to manage the patients. In the absence of a known cause, it was decided to offer symptomatic care. The objective is to relieve symptoms, offer primary and secondary prevention for disability and rehabilitation to improve function. Initial management focuses on the most urgent needs of the patient and the immediate family until 'stability' is achieved. The most important needs were considered as seizure control, management of behavioural and psychiatric difficulties, nursing care, nutritional and subsequently, physical and cognitive rehabilitation. This paper summarises the processes by which the proposed guidelines were developed and provides an outline of the specific treatments currently being provided for the patients.

Children with cerebral palsy: racial disparities in functional limitations

BACKGROUND

Previous studies of the frequency of cerebral palsy in the United States have found excess prevalence in black children relative to other groups. Whether the severity of cerebral palsy differs between black and white children has not previously been investigated.

METHODS

A population-based surveillance system in 4 regions of the United States identified 476 children with cerebral palsy among 142,338 8-year-old children in 2006. Motor function was rated by the Gross Motor Function Classification System and grouped into 3 categories of severity. We used multiple imputation to account for missing information on motor function and calculated the race-specific prevalence of each cerebral palsy severity level.

RESULTS

The prevalence of cerebral palsy was 3.7 per 1000 black children and 3.2 per 1000 white children (prevalence odds ratio [OR] = 1.2 [95% confidence interval = 1.0-1.4]). When stratified by severity of functional limitation, the racial disparity was present only for severe cerebral palsy (black vs. white prevalence OR=1.7 [1.1-2.4]). The excess prevalence of severe cerebral palsy in black children was evident in term and very preterm birth strata.

CONCLUSION

Black children in the United States appear to have a higher prevalence of cerebral palsy overall than white children, although the excess prevalence of cerebral palsy in black children is seen only among those with the most severe limitations. Further research is needed to explore reasons for this disparity in functional limitations; potential mechanisms include racial differences in risk factors, access to interventions, and under-identification of mild cerebral palsy in black children.

A robust Kalman algorithm to facilitate human-computer interaction for people with cerebral palsy, using a new interface based on inertial sensors

This work aims to create an advanced human-computer interface called ENLAZA for people with cerebral palsy (CP). Although there are computer-access solutions for disabled people in general, there are few evidences from motor disabled community (e.g., CP) using these alternative interfaces. The proposed interface is based on inertial sensors in order to characterize involuntary motion in terms of time, frequency and range of motion. This characterization is used to design a filtering technique that reduces the effect of involuntary motion on person-computer interaction. This paper presents a robust Kalman filter (RKF) design to facilitate fine motor control based on the previous characterization. The filter increases mouse pointer directivity and the target acquisition time is reduced by a factor of ten. The interface is validated with CP users who were unable to control the computer using other interfaces. The interface ENLAZA and the RKF enabled them to use the computer.

Arithmetic performance of children with cerebral palsy: the influence of cognitive and motor factors

Children diagnosed with cerebral palsy (CP) often show difficulties in arithmetic compared to their typically developing peers. The present study explores whether cognitive and motor variables are related to arithmetic performance of a large group of primary school children with CP. More specifically, the relative influence of non-verbal intelligence, working memory, word decoding capacities, gross- and fine motor skills on arithmetic performance is examined using structural equation modeling. One-hundred sixteen primary school children with a formal diagnosis of CP participated (76 males, M = 7; 3 years, SD = 3 months). In agreement with previous studies our results showed that the cognitive and motor predictors were all positively correlated to each other. Furthermore, in the cognitive model, non-verbal intelligence and word decoding were related to arithmetic in primary school. Our combined model (that included both motor and cognitive variables) showed that word decoding and fine motor skills were the strongest predictors of arithmetic performance. To conclude, this study was the first to show the influence of word decoding and fine motor skills on arithmetic performance of children with CP.

Development of non-verbal intellectual capacity in school-age children with cerebral palsy

BACKGROUND

Children with cerebral palsy (CP) are at greater risk for a limited intellectual development than typically developing children. Little information is available which children with CP are most at risk. This study aimed to describe the development of non-verbal intellectual capacity of school-age children with CP and to examine the association between the development of non-verbal intellectual capacity and the severity of CP.

METHODS

A longitudinal analysis in a cohort study was performed with a clinic-based sample of children with CP. Forty-two children were assessed at 5, 6 and 7 years of age, and 49 children were assessed at 7, 8 and 9 years of age. Non-verbal intellectual capacity was assessed by Raven's Coloured Progressive Matrices (RCPM). Severity of CP was classified by the Gross Motor Function Classification System, type of motor impairment and limb distribution. manova for repeated measurements was used to analyse time effects and time × group effects on both RCPM raw scores and RCPM intelligence quotient scores.

RESULTS

The development of non-verbal intellectual capacity was characterised by a statistically significant increase in RCPM raw scores but no significant change in RCPM intelligence quotient scores. The development of RCPM raw scores was significantly associated with the severity of CP. Children with higher levels of gross motor functioning and children with spastic CP showed greater increase in raw scores than children with lower levels of gross motor functioning and children with dyskinetic CP.

CONCLUSIONS

Children with CP aged between 5 and 9 years show different developmental trajectories for non-verbal intellectual capacity, which are associated with the severity of CP. The development of non-verbal intellectual capacity in children with less severe CP seems to resemble that of typically developing children, while children with more severe CP show a limited intellectual development compared to typically developing children.

Validity and reliability of Ability for Basic Movement Scale for Children (ABMS-C) in disabled pediatric patients

The objective of this pilot study was to test the validity and reliability of a new scale, the Ability for Basic Movement Scale for Children (ABMS-C). A total of 45 pediatric patients with disabilities (aged 0.1-8.8 years; 29 males, 16 females) participated in this prospective study. To prove the validity and reliability of the ABMS-C, subjects were administered the ABMS-C at a 2-week interval. In addition to the ABMS-C score, data on age, diagnosis, and results of the Gross Motor Function Classification System (GMFCS) were recorded. Spearman's rank correlation coefficient analysis showed that the ability to perform basic movements according to the scores for each item and the total scores of the ABMS-C correlated significantly with the levels of the GMFCS (r=-0.628-0.784, p<0.001). The five items on the ABMS-C had appropriate internal consistency (Cronbach's α=0.944). Test-retest reliability analysis indicated that the "head control", "sitting", "locomotion on flat surface", "standing" and "walking" items on the ABMS-C had almost perfect reliability (κ=0.865-1.000). This study provides evidence for the validity and reliability of the ABMS-C with regard to assessment of functional ability in disabled pediatric patients.

Predicting equipment needs of children with cerebral palsy using the Gross Motor Function Classification System: a cross-sectional study

BACKGROUND

Children with cerebral palsy (CP) routinely use assistive equipment to improve their independence. Specialist equipment is expensive and therefore not always available to the child when needed.

AIM

The aim of this study was to determine whether the assistive equipment needs of children with CP and the associated costs could be predicted.

METHOD

A cross-sectional study using a chart audit was completed. Two hundred forty-two children met eligibility criteria and were included in the study. Data abstracted from files pertained to the child's CP, associated impairments and assistive equipment prescribed. The findings were generated using linear regression modelling.

RESULTS

Gross Motor Function Classification System (GMFCS) level [B = 3.01 (95% CI, 2.36-3.57), p = 0.000] and the presence of epilepsy [B = 2.35 (95% CI, 0.64-4.06), p = 0.008] predicted the prescription of assistive equipment. The more severely affected the gross motor function impairment, the more equipment that was required and the more the equipment cost.

INTERPRETATION

The equipment needs of children with CP can be predicted for the duration of childhood. This information may be useful for families and for budget and service planning.

Alzheimer's disease-associated disability: An ICF approach

PURPOSE

The aim of the study is to provide a description of dementia-associated disability in Alzheimer's disease (AD) patients through the International Classification of Functioning, Disability and Health (ICF).

METHOD

Twenty-six AD patients at different stages of disease participated in the study. Mini Mental State Examination (MMSE) and Global Deterioration Scale (GDS) were used to stage the degree of cognitive impairment and the stage of disease, respectively. All subjects were classified using the ICF categories in the more detailed four-level version. Correlation between compromised ICF items and both MMSE and GDS scores were calculated through Spearman Rho test.

RESULTS

Mental functions were impaired in all the subjects examined. Data on activity and participation showed that not only domestic life, self care, and mobility but also communication and interaction and social relationships are compromised in AD patients. Three main areas appeared as the most relevant facilitators: products and technology, support and relationship and services, systems and policies. ICF codes were generally correlated with both MMSE and GDS: subjects who appeared more compromised on MMSE and GDS showed higher impairment of functions, activity limitation, and participation restriction.Conclusion. ICF is a useful tool to describe health status in AD patients in that it underlines important aspects of daily living generally not considered by activity of daily living scales such as communication, social relationships, and recreation and leisure.

Cerebral palsy update

A common language on CP has been developed for the European registers by the SCPE (Surveillance of Cerebral Palsy in Europe) working group and the common database allows prevalence analyses on a larger basis. CP prevalence increases with lower birthweight and higher immaturity. Increase of survival after preterm birth has first also increased CP rates. But already in the 80s this trend was reversed for LBW infants, and in the 90 s also for VLBW or very immature infants. The outcome with respect to CP in the group of extremely LBW or immature infants remains a matter of specific concern, as prevalence seems to be rather stable on a high level. CP is caused in more than 80% by brain lesions or maldevelopments which can be attributed to different timing periods of the developing brain. Extent and topography determine the clinical subtype of CP and are related also to the presence and severity of associated disabilities. CP, thus, offers a model to study plasticity of the developing brain. Reorganisation following unilateral lesions is mainly interhemispheric and homotopic. In the motor system, it involves the recruitment of ipsilateral tracts; functionality seems to be limited and decreases already towards the end of gestation. There is no clear evidence for substantial reorganisation in the sensory system. The best compensatory potential is described concerning language function following left hemispheric lesions. Language function reorganized to the right hemisphere eventually seems not to be impaired, this occurs, however, on the expense of primary right hemispheric functions.

Stability of neuromotor outcomes at 18 and 30 months of age after extremely low birth weight status

BACKGROUND

Extremely low birth weight (< or =1000 g) children have increased rates of cerebral palsy and other abnormal neurologic findings.

OBJECTIVE

To investigate the stability of neuromotor findings between 18 and 30 months' adjusted age in extremely low birth weight infants. METHODS. Seven hundred nineteen extremely low birth weight infants with assessments at 18 and 30 months' adjusted age were included in this analysis. At each visit a neurologic examination, the modified gross motor function classification system, and the Bayley Scales of Infant Development II were administered. Logistic regression models were constructed to assess neonatal factors and neuromotor function at 18 months of age associated with stability in neuromotor function.

RESULTS

Eighty-four percent of the children had agreement in neurologic/motor function at both visits. However, classification changed from normal to abnormal in 6% and from abnormal to normal in 10%. Diagnosis of cerebral palsy was consistent for 91% of the children, and the gross motor function classification system score was consistent for 83%. In multivariate models, factors associated with decreased severity or absence of cerebral palsy diagnosis at 30 months of age were higher gestational age, no periventricular leukomalacia or severe intraventricular hemorrhage, and a gross motor function classification system score of 0 (normal) at the 18-month visit, whereas factors associated with a new cerebral palsy diagnosis at 30 months of age were postnatal steroid use, periventricular leukomalacia or severe intraventricular hemorrhage, a gross motor function classification system score of > or =1 at 18 months of age, and asymmetrical limb movement at 18 months of age.

CONCLUSIONS

Stability of neurologic diagnosis in 84% and cerebral palsy in 91% of the children is reassuring. However, for a significant percentage of children, the neurologic diagnosis changes between 18 and 30 months of age. The diagnosis of cerebral palsy may be delayed in some infants until an older adjusted age.

The relationship between medical impairments and arithmetic development in children with cerebral palsy

Arithmetic ability was tested in children with cerebral palsy without severe intellectual impairment (verbal IQ >or= 70) attending special (n = 41) or mainstream education (n = 16) as well as control children in mainstream education (n = 16) throughout first and second grade. Children with cerebral palsy in special education did not appear to have fully automatized arithmetic facts by the end of second grade. Their lower accuracy and consistently slower (verbal) response times raise important concerns for their future arithmetic development. Differences in arithmetic performance between children with cerebral palsy in special or mainstream education were not related to localization of cerebral palsy or to gross motor impairment. Rather, lower accuracy and slower verbal responses were related to differences in nonverbal intelligence and the presence of epilepsy. Left-hand impairment was related to slower verbal responses but not to lower accuracy.

An algorithm for identifying and classifying cerebral palsy in young children

OBJECTIVE

To develop an algorithm on the basis of data obtained with a reliable, standardized neurological examination and report the prevalence of cerebral palsy (CP) subtypes (diparesis, hemiparesis, and quadriparesis) in a cohort of 2-year-old children born before 28 weeks gestation.

STUDY DESIGN

We compared children with CP subtypes on extent of handicap and frequency of microcephaly, cognitive impairment, and screening positive for autism.

RESULTS

Of the 1056 children examined, 11.4% (120) were given an algorithm-based classification of CP. Of these children, 31% had diparesis, 17% had hemiparesis, and 52% had quadriparesis. Children with quadriparesis were 9 times more likely than children with diparesis (76% versus 8%) to be more highly impaired and 5 times more likely than children with diparesis to be microcephalic (43% versus 8%). They were more than twice as likely as children with diparesis to have a score <70 on the mental scale of the BSID-II (75% versus 34%) and had the highest rate of the Modified Checklist for Autism in Toddlers positivity (76%) compared with children with diparesis (30%) and children without CP (18%).

CONCLUSION

We developed an algorithm that classifies CP subtypes, which should permit comparison among studies. Extent of gross motor dysfunction and rates of co-morbidities are highest in children with quadriparesis and lowest in children with diparesis.

Reliability and validity of the Child Health QuestionnairePF-50 for European children with cerebral palsy

OBJECTIVE

To evaluate the psychometric performance of the Child Health Questionnaire (CHQ) in children with cerebral palsy (CP).

METHOD

818 parents of children with CP, aged 8-12 from nine regions of Europe completed the CHQ (parent form 50 items). Functional abilities were classified using the five-level Gross Motor Function Classification Scheme (Levels I-III as ambulant; Level IV-V as nonambulant CP).

RESULTS

Ceiling effects were observed for a number of subscales and summary scores across all Gross Motor Function Classification System levels, whilst floor effects occurred only in the physical functioning scale (Level V CP). Reliability was satisfactory overall. Confirmatory factor analysis (CFA) revealed a seven-factor structure for the total sample of children with CP but with different factor structures for ambulant and nonambulant children.

CONCLUSION

The CHQ has limited applicability in children with CP, although with judicious use of certain domains for ambulant and nonambulant children can provide useful and comparable data about child health status for descriptive purposes.

Comorbidities and clinical determinants of outcome in children with spastic quadriplegic cerebral palsy

The objective of this study was to determine the major comorbidities in patients with spastic quadriplegic (SQ) cerebral palsy (CP) and their possible clinical associations. Medical records of patients with SQ CP from a pediatric neurology practice over a 14-year period were retrospectively and systematically reviewed. Variables examined included demographics, prenatal, perinatal, and postnatal risk factors. Comorbidities documented included those involving hearing, vision, feeding status, and epilepsy. Binomial logistic regression analyses were applied to identify clinical associations of the comorbidities. Ninety-two children were included in this study of whom 39 were born preterm. Mean age of presentation was 2 months (SD 3.5) and males comprised 60% of the group. A total of 57% had a Gross Motor Function Classification Score (GMFCS) of Level IV or V. The four documented comorbidities occurred at a high frequency: 66 out of 83 children (80%) had a visual impairment with 13 (21%) having a substantial impairment; 37 out of 86 children (40%) had a hearing deficit; 43 out of 92 children (47%) had epilepsy; and 29 (33%) required assisted feeding. A GMFCS Level of IV or V and documented microcephaly was associated with the need for assisted feeding (odds ratio [OR] 8.1; 95% confidence interval [CI] 2.1-29.8, p=0.002 and OR 4.9, 95% CI 1.7-14.8, p=0.004 respectively). Epilepsy was associated with the occurrence of neonatal encephalopathy (OR 2.3, 95% CI 1.0-55; p=0.05), microcephaly (OR 4.9, 95% CI 1.6-14.8; p=0.004), periventricular leukomalacia (OR 7.4, 95% CI 1.6-35.0; p=0.012), and perinatal asphyxia (OR 3.6, 95% CI 1.5-8.9; p=0.005). There is a high frequency of comorbidity in the setting of SQ CP which can impact on quality of life and burdens of care. Few clinical associations of this burden appear, thus necessitating systematic programmatic follow-up of these children to facilitate early identification and intervention.

Energy efficiency in gait, activity, participation, and health status in children with cerebral palsy

The aim of the study was to establish if a relationship exists between the energy efficiency of gait, and measures of activity limitation, participation restriction, and health status in a representative sample of children with cerebral palsy (CP). Secondary aims were to investigate potential differences between clinical subtypes and gross motor classification, and to explore other relationships between the measures under investigation. A longitudinal study of a representative sample of 184 children with ambulant CP was conducted (112 males, 72 females; 94 had unilateral spastic C P, 84 had bilateral spastic C P, and six had non-spastic forms; age range 4-17 y; Gross Motor Function Classification System Level I, n=57; Level II, n=91; Level III, n=22; and Level IV, n=14); energy efficiency (oxygen cost) during gait, activity limitation, participation restriction, and health status were recorded. Energy efficiency during gait was shown to correlate significantly with activity limitations; no relationship between energy efficiency during gait was found with either participation restriction or health status. With the exception of psychosocial health, all other measures showed significant differences by clinical subtype and gross motor classification. The energy efficiency of walking is not reflective of participation restriction or health status. Thus, therapies leading to improved energy efficiency may not necessarily lead to improved participation or general health.

Cerebral palsy

Extreme prematurity confers about a 100-fold increase in the risk of cerebral palsy (CP), relative to birth at term gestation. Although CP is primarily a disorder of movement, many children with this disorder have other impairments which may affect their quality of life and life expectancy. Epidemiologic and clinical studies of cerebral palsy have benefited from recent efforts to develop greater uniformity of definition and classification. Particularly noteworthy is the development of the Gross Motor Function Classification System, which is a reliable and valid measure used with increasing frequency in observational and experimental studies. Also of great importance are efforts to quantify reliably the quality of life for children with cerebral palsy, thereby providing a target for medical and community interventions that aim to increase participation and well-being among affected children. During the late 1970s and early 1980s, the rate of CP actually rose, presumably as a result of increased survival of especially vulnerable infants who otherwise would have died. In developed countries over the past two decades (late 1980s to present), CP rates have been either stable or decreasing. Although considerable effort is being directed at prevention, the only perinatal interventions for which there is strong evidence of a beneficial effect on both mortality and the risk of CP is antenatal treatment of the mother with glucocorticoid.

Cerebral palsy in a total population of 4-11 year olds in southern Sweden. Prevalence and distribution according to different CP classification systems

BACKGROUND

The aim of this study was to investigate the prevalence of cerebral palsy (CP) as well as to characterize the CP population, its participation in a secondary prevention programme (CPUP) and to validate the CPUP database.

METHODS

The study population was born 1990-1997 and resident in Skåne/Blekinge on Jan 1st 2002. Multiple sources were used. Irrespective of earlier diagnoses, neuropaediatrician and other professional medical records were evaluated for all children at the child habilitation units. The CPUP database and diagnosis registers at hospital departments were searched for children with CP or psychomotor retardation, whose records were then evaluated. To enhance early prevention, CP/probable CP was searched for also in children below four years of age born 1998-2001.

RESULTS

The prevalence of CP was 2.4/1,000 (95% CI 2.1-2.6) in children 4-11 years of age born in Sweden, excluding post-neonatally acquired CP. Children born abroad had a higher prevalence of CP with more severe functional limitations. In the total population, the prevalence of CP was 2.7/1,000 (95% CI 2.4-3.0) and 48% were GMFCS-level I (the mildest limitation of gross motor function). One third of the children with CP, who were born or had moved into the area after a previous study in 1998, were not in the CPUP database. The subtype classification in the CPUP database was adjusted in the case of every fifth child aged 4-7 years not previously reviewed.

CONCLUSION

The prevalence of CP and the subtype distribution did not differ from that reported in other studies, although the proportion of mild CP tended to be higher. The availability of a second opinion about the classification of CP/CP subtypes is necessary in order to keep a CP register valid, as well as an active search for undiagnosed CP among children with other impairments.

Association between gross motor function (GMFCS) and manual ability (MACS) in children with cerebral palsy. A population-based study of 359 children

Background

The Gross Motor Function Classification System (GMFCS) has become an important tool to describe motor function in children with Cerebral Palsy (CP). The Manual Ability Classification System (MACS) was developed recently as a corresponding classification of manual ability. The aim of this study was to describe the association between gross motor function and manual ability in a total population of children with cerebral palsy.

Methods

365 children, born 1992 to 2001, who were registered in a population-based health care programme (CPUP) for children with CP living in the south of Sweden were included in the study. GMFCS was evaluated by the child's physiotherapist and MACS by the occupational therapist. CP diagnosis and subtype were determined by the neuropaediatrician at or after the age of four.

Results

GMFCS levels were available in all 365 children, MACS levels in 359 (98%). There was a poor overall correlation between gross motor function and manual ability. However, different associations between gross motor function and manual ability were found in the different diagnostic subtypes. Children with spastic hemiplegia generally had a lower level of manual ability than gross motor function (p < 0.001). The reverse association was generally found in children with spastic diplegia (p < 0.001). Children with dyskinetic CP had large limitations in both gross motor function and manual ability, with no significant discrepancy between GMFCS and MACS levels.

Conclusion

Gross motor function and manual ability are often discrepant in children with CP, and the patterns seem to vary across the different subgroups based on the predominant neurological findings. To give a complete clinical picture when evaluating these children, both aspects have to be described. The GMFCS and the MACS seem to work well in this context and seem very useful in population-based studies, in health care registers for children with CP, and in clinical practice.

Reliability of Greek version Gross Motor Function Classification System

The Gross Motor Function Classification System for Cerebral Palsy (GMFCS), a reliable and valid system, has been widely utilized for objective classification of the patterns of motor disability in children with cerebral palsy. The objective of this study was to produce a Greek version of the instrument, with the same construct as the original one and to investigate the reliability of application of the Greek version GMFCS. Translation and back translation was made by two of the authors, one of whom did not know the original English text. The final translation was fixed by consensus. Two physicians were trained and given practice in the use of the GMFCS and its application to clinical documentation. The raters classified children with cerebral palsy according to GMFCS - Greek version. The reliability was assessed with the weighted kappa statistic. The sample consisted of 47 boys and 47 girls, mean age 5.4 years. The overall weighted Kappa was 0.80 (95% CI=0.67-0.94). Weighted Kappa for level I was 0.91 (95% CI=0.74-1.09), for level II, 0.78 (95% CI=0.62-0.95), for level III, 0.85 (95% CI=0.68-1.02), for level IV, 0.85 (95% CI=0.67-1.03) and for level V, 0.84 (95% CI=0.66-1.03). The inter-rater reliability was lowest at level II. Percent agreement was 75%. Results of this study suggest that GMFCS - Greek version can be used reliably to classify patients with CP from clinical documentation. These results further support use of the GMFCS in clinical settings and for research. Investigation is needed to further assess the reliability and to determine the validity of the Greek version of the GMFCS.

The relationship between gross motor function and participation restriction in children with cerebral palsy: an exploratory analysis

BACKGROUND

Children with cerebral palsy (CP) experience a variety of functional limitations depending on the severity of their condition that impact on their participation in day-to-day activities.

METHODS

The gross motor function and participation restrictions experienced by 60 ambulant children with CP (mean age 11.04 years) were assessed using the Gross Motor Function Measure (GMFM-88) and the Lifestyle Assessment Questionnaire - Cerebral Palsy (LAQ-CP).

RESULTS

A significant negative correlation existed between the GMFM-88 and the LAQ-CP (r = -0.52, P < 0.001). Significant relationships were also identified between the GMFM-88 and the physical independence, mobility, economic burden and social integration domains of the LAQ-CP.

CONCLUSION

In ambulatory children with CP, better physical function is associated with a lesser impact of disability; however, the relationship between function and participation is complex. Measures of participation restriction may assist with goal setting appropriate to the specific needs of the child and family.

A comparison of spastic diplegic and tetraplegic cerebral palsy

The aim of this study was to compare spastic diplegic and tetraplegic cerebral palsy. Thirty-eight children had spastic diplegic cerebral palsy and 48 spastic tetraplegic cerebral palsy. Risk factors of cerebral palsy, seizures, severity of cerebral palsy, electroencephalogram, and magnetic resonance imaging findings were analyzed. Gestational history, low birth weight, and perinatal pathologies were present in similar percentages in both groups. Lower values of the Apgar score were recorded more often in the tetraplegic cerebral palsy group than the diplegic group. The children with spastic diplegia were classified more frequently into levels I and II of the Gross Motor Function Classification System, but patients with spastic tetraplegia were classified more frequently into levels IV and V. Similarly, mental retardation was observed more frequently in the patients with spastic tetraplegia. In magnetic resonance imaging, periventricular leukomalacia was detected in a higher proportion of children with spastic diplegia than in patients with tetraplegia. Cerebral atrophy occurred more frequently in the tetraplegic group compared with diplegic patients. Twenty-four (50.0%) children with spastic tetraplegia had epilepsy compared with six children with spastic diplegia. The incidence of intractable epilepsy was higher in the tetraplegic patients than in the children with spastic diplegia.

Cerebral palsy: correlation of risk factors and functional performance using the Functional Independence Measure for Children (WeeFIM)

We studied the risk factors affecting the functional status of cerebral palsy. A cross-sectional study of 73 children with cerebral palsy was conducted with the Functional Independence Measure for Children (WeeFIM), which assesses functional skills in the domains of self-care, mobility, and cognition. The mean total Functional Independence Measure for Children quotient was 67.5%. The mean subquotients for self-care, mobility, and cognition were 68.3%, 62.7%, and 69.4%, respectively. The risk factors related to the degree of functional dependency were (1) mental retardation (P = .030), (2) epilepsy (P = .005), (3) type of cerebral palsy (P < .001), and (4) severity of cerebral palsy using the Gross Motor Function Classification System (P < .001) (using univariate analysis). However, when using multivariate analysis, only epilepsy (P = .02) and severity status according to the Gross Motor Function Classification System (P < .001) were significantly related. When the etiology was analyzed, only prematurity was significantly associated with better Functional Independence Measure for Children scores using both univariate (P = .022) and multivariate (P = .007) analyses. The functional status of children with cerebral palsy depends on the severity and the presence of epilepsy. Despite impairment, we found that most children with cerebral palsy could achieve functional independence.

ABILHAND-Kids

OBJECTIVE

To develop a clinical tool for measuring manual ability (ABILHAND-Kids) in children with cerebral palsy (CP) using the Rasch measurement model.

METHODS

The authors developed a 74-item questionnaire based on existing scales and experts' advice. The questionnaire was submitted to 113 children with CP (59% boys; mean age, 10 years) without major intellectual deficits (IQ > 60) and to their parents, and resubmitted to both groups after 1 month. The children's and parents' responses were analyzed separately with the WINSTEPS Rasch software to select items presenting an ordered rating scale, sharing the same discrimination, and fitting a unidimensional scale.

RESULTS

The final ABILHAND-Kids scale consisted of 21 mostly bimanual items rated by the parents. The parents reported a finer perception of their children's ability than the children themselves, leading to a wider range of measurement, a higher reliability (R = 0.94), and a good reproducibility over time (R = 0.91). The item difficulty hierarchy was consistent between the parents and the experts. The ABILHAND-kids measures are significantly related to school education, type of CP, and gross motor function.

CONCLUSIONS

ABILHAND-Kids is a functional scale specifically developed to measure manual ability in children with CP providing guidelines for goal setting in treatment planning. Its range and measurement precision are appropriate for clinical practice.

Challenge of conducting trials of neuroprotection in the asphyxiated term infant

There has been much progress in understanding the pathogenesis of hypoxic-ischemic brain injury in the near-term and term infant. Although gaps in our knowledge base persist, advances over the past two decades have led to the development of specific brain oriented therapies directed at critical events contributing to tissue damage. The primary goal of these interventions is to prevent or attenuate neurologic and developmental sequelae of brain injury. Examples of current potential treatments include modest reductions in brain temperature, receptor antagonists of excitatory neurotransmitters, reductions in O2 free radicals, blockade of inflammatory mediators, and inhibition of apoptotic pathways. At present, some of these treatments have sufficient animal data that demonstrate benefit, to justify moving experiments from the laboratory to the clinical arena. Modest hypothermia represents the neuroprotective intervention that has been investigated in the most complete fashion for the newborn, and there are multiple ongoing clinical trials testing its efficacy. This review will address specific challenges that are pertinent to the evaluation of any neuroprotective therapy implemented shortly after birth. Specific issues to be covered include the therapeutic window, establishing a diagnosis of hypoxic-ischemic encephalopathy, patient selection, characteristics of an effective therapy, safety considerations, appropriate outcome variables, and sample size considerations. Since clinical trials of brain hypothermia are in progress, many of these issues will be addressed from the perspective of this specific intervention.

Follow-up data their use in evidence-based decision-making

Experience with certain perinatal interventions, such as supplemental oxygen and dexamethasone, leads to the conclusion that follow-up data are needed to be well informed about the safety of certain perinatal interventions. Experience with indomethacin suggests that follow-up data also are regarded by some clinicians as a necessary aspect of evidence about effectiveness. Ideally, clinical trials of perinatal interventions might involve collection of data about neonatal predictors of outcome (such as a neuroimaging study and a standardized neurologic assessment); several developmental and neurologic assessments before school entry; a comprehensive evaluation of the child's cognitive function, behavioral competencies, and academic performance at 7 to 8 years of age; serial detailed assessments of the family psychosocial functioning; and an inventory of resources available for the child. Many clinical trials have not included follow-up after the neonatal period, and in such cases information about the effect of the intervention on participants' HRQL is incomplete. The approach taken in several recent trials, in which the outcome of interest is neurodevelopmental outcome at 18 months, attempts to strike a balance between a theoretical ideal (a comprehensive, longitudinal follow-up through school age) and a follow-up regimen that is not prohibitively expensive. Such trials include follow-up during the first 1 to 3 years of life, when major disabilities can be identified reliably, thereby providing moderately informative data about participants' eventual quality of life, related to the presence or absence of major disability. If, however, there is reason to suspect that the intervention has effects on the developing brain, follow-up after school entry may provide additional evidence pertinent to the risks and benefits of the intervention.

Reliability and validity of the gross motor function classification system for cerebral palsy

PURPOSE

The purposes of this study were to evaluate interrater reliability using videotapes and criterion-related and construct validity of the Gross Motor Function Classification System (GMFCS), aspects of reliability and validity not previously published.

METHODS

Two experienced pediatric physical therapists rated 30 videotapes of children with cerebral palsy (CP) or Down syndrome (DS) to test interrater reliability. Criterion-related validity was evaluated by comparing GMFCS levels with tests of motor and nonmotor development. Construct validity was assessed by comparing GMFCS trends over time in children with CP and DS.

RESULTS

Interrater reliability was 0.84. Correlation was higher between GMFCS level and tests of motor development than GMFCS level and tests of nonmotor development. The GMFCS level remained relatively stable in children with CP but tended to improve in children with DS.

CONCLUSIONS

This study extends reliability and validity of the GMFCS, supporting its use in clinical practice and research.

Using the berg balance scale to distinguish balance abilities in children with cerebral palsy

PURPOSE

This study was designed to evaluate the use of the Berg Balance Scale (BBS) to assess the balance abilities of children with cerebral palsy.

METHODS

Thirty-six ambulatory children with cerebral palsy and 14 children with no motor impairment (ages eight to 12 years) were assessed on the BBS and the Gross Motor Function Measure (GMFM). Participants with cerebral palsy comprised three groups based on diagnosis (spastic hemiplegia, spastic diplegia who ambulated without aids, and spastic diplegia who ambulated with aids). A fourth group consisted of control subjects with no motor impairment. It was hypothesized that these four groups demonstrated a hierarchy of balance abilities. A one-way ANOVA was used to detect significant differences in test scores among the four groups. The analysis was repeated categorizing children on the Gross Motor Function Classification System (GMFCS) instead of diagnosis.

RESULTS

The ability to use scores on the GMFM was slightly better than using BBS scores to distinguish among the groups when children were classified using diagnosis. Significant pair-wise differences among the groups were present on both the BBS and the GMFM when the children were grouped on the GMFCS.

CONCLUSIONS

The results suggest that the BBS can be considered as a clinical measure of balance for children with cerebral palsy, and a functional classification system can be used to group children more homogeneously than traditional classification by diagnosis.

Outcome measurement of effectiveness of botulinum toxin type A in children with cerebral palsy: an ICIDH-2 approach

The ICIDH-2 serves as a useful framework for differentiating measurement by dimensions of the disabling process. Such differentiation is important to achieve more valid measurement of health related outcomes. We have attempted to examine one intervention, treatment with botulinum toxin type A, for one patient population, children with cerebral palsy, and to describe the outcome measures used in the evaluation of that intervention using this evolving classification system. This process supports the concept that measurement of health outcomes should focus on the nature and extent of functional limitations in physical, social and psychological domains. The selection of measurement outcomes must be determined not only by the requirements of the scientific process but also by the needs of the patients who are the intended beneficiaries of the intervention.