Test-Retest Reliability and Construct Validity of the German Translation of the Gait Outcome Assessment List (GOAL) Questionnaire for Children with Ambulatory Cerebral Palsy

Feasibility of the Challenge Assessment, the Gait Outcomes Assessment List and 'Moving Together' ('Sammen I Bevægelse'), a Group-Based Motor Skills Intervention for Independent School-Aged Children with Cerebral Palsy

This single group pre and posttest study evaluated the feasibility of a new 10-week group-based motor skills enhancement intervention: "Moving Together," and associated use of the Challenge assessment and Gait Outcomes Assessment List (GOAL). Participant attendance/completion and satisfaction with the assessments and intervention were evaluated, and a first estimate of associated motor skill-related changes obtained. Ten ambulatory children with cerebral palsy (7-14 years) and their parents participated. Ninety percent of Challenge sessions were attended and 82.5% of GOAL questionnaires completed. Program attendance was 83% overall. Satisfaction with assessments was high for the Challenge and moderate for the GOAL, and intervention satisfaction was high. Mean change scores (95% CI) post-intervention for the Challenge and GOAL were 4.2 (-11.4 to 3.1) and 3.6 (-14.4 to 4.0) points (/100) respectively. Challenge and GOAL use was feasible and appropriate for "MovingTogether" and associated with gains in motor skill performance and functional abilities.

The Danish child and parent Gait Outcomes Assessment List questionnaires were reliable and valid for cerebral palsy

AIM

We investigated the reliability and validity of the Danish child and parent versions of the Gait Outcomes Assessment List (GOAL) questionnaires for ambulatory children with cerebral palsy (CP).

METHODS

Translation and cultural adaptations were performed and content validity evaluated. Participants were enrolled between 2016 and 2018 from Aarhus University Hospital, Denmark. Children and parents completed the GOAL questionnaires twice for test-retest reliability. Discriminative validity was evaluated by comparing the child and parent GOAL scores between children with Gross Motor Function Classification System (GMFCS) levels I and II. The concurrent validity of the GOAL questionnaires were investigated by comparing them with Challenge-20, which assesses motor skills in children with CP.

RESULTS

We studied 59 children (57% boys) with CP and GMFCS I-II at a mean age of 10.6 years. Test-retest intra-class correlations were excellent for the children (0.91, 95% confidence interval (CI) 0.83-0.96) and good for the parents (0.83, 95% CI 0.67-0.91). GOAL scores decreased with increasing GMFCS (p < 0.05). Both versions correlated well. The mean children's scores were significantly (6.2/100) higher than the parents' (p < 0.001). The GOAL scores correlated positively with Challenge-20.

CONCLUSION

The Danish GOAL child and parent questionnaires demonstrated good reliability and content and discriminative and concurrent validity.

Reliability of the Gait Outcomes Assessment List questionnaire

AIM

To report the test-retest reliability of the parent version of the Gait Outcomes Assessment List (GOAL) questionnaire for item, domain, total score, and goal importance in children with cerebral palsy (CP) functioning in Gross Motor Function Classification System (GMFCS) levels I to III.

METHOD

The GOAL questionnaire was completed twice, 3 to 31 days apart, in a prospective cohort study of 112 caregivers of children aged 4 to 17 years with CP (40% unilateral; GMFCS level I = 53; II = 35; III = 24; 76 males). All had an outpatient visit over a 1-year period. The standard error of measurement (SEM), minimum detectable change, and agreement were calculated for all responses, including goal importance.

RESULTS

The SEM for the total score was 3.1 points for the cohort (GMFCS level I = 2.3, GMFCS level II = 3.8, GMFCS level III = 3.6). The standardized domain and item scores were less reliable than the total score and varied according to GMFCS level. The gait function and mobility domain exhibited the best reliability for the cohort (SEM = 4.4), whereas the use of braces and mobility aids domain exhibited the lowest (SEM = 11.9). Goal importance was reliable (cohort average agreement 73%).

INTERPRETATION

The parent version of GOAL has acceptable levels of test-retest reliability for most domains and items. Caution is advised when interpreting the least reliable scores. Essential information necessary for accurate interpretation is provided.

WHAT THIS PAPER ADDS

The standard error of measurement (SEM) of the Gait Outcomes Assessment List (GOAL) total score was approximately 3 points. The SEM of the GOAL domain score ranged from 4 to 12 points. The use of braces and mobility aids domain had the lowest reliability score. Item-level reliability varied according to domain and Gross Motor Function Classification System level. Caregivers reliably identified item importance with approximately 73% agreement.

Factor analysis of the Gait Outcomes Assessment List's goal questions: A new method to measure goal prioritization in ambulatory individuals with cerebral palsy

AIM

To evaluate the factor structure of the 49 goal prioritization questions of the Gait Outcome Assessment List (GOAL).

METHOD

This was a retrospective review of 622 consecutive individuals diagnosed with cerebral palsy (median = 11 years 2 months, SD = 6 years 0 months, 370 male), who underwent a routine clinical gait analysis at a specialty center and completed the validated GOAL. To assess dimensionality, we performed exploratory and confirmatory factor analyses on the goal ratings of its 49 gait-related items. For internal consistency, we calculated Cronbach's alpha. We created standardized goal scores for each factor and determined floor and ceiling effects according to the Gross Motor Function Classification System (GMFCS).

RESULTS

Factor analyses suggested that the GOAL's 49 goal prioritization items represented eight factors, one more than the original GOAL validation because pain and fatigue were separated into distinct factors. Cronbach alphas were acceptably high (≥0.80) across factors except for use of braces and mobility aids (α = 0.68). Goal importance varied across domains and GMFCS levels.

INTERPRETATION

The GOAL can be expanded as a tool to better understand goal priorities in ambulatory individuals with cerebral palsy. These scores can be used to guide clinical conversations and provide more focus than previously available when faced with 49 individual goals. Scores can also be aggregated across relevant populations for larger-scale studies.

WHAT THIS PAPER ADDS

The goal items of the Gait Outcomes Assessment List (GOAL) can be reduced into eight goal domains. Pain and fatigue represent distinct goal domains. The level of goal importance varies across GOAL domains and Gross Motor Function Classification System levels.

Functional Repetitive Neuromuscular Magnetic Stimulation (frNMS) Targeting the Tibialis Anterior Muscle in Children with Upper Motor Neuron Syndrome: A Feasibility Study

Non-invasive neurostimulation as an adjunctive intervention to task-specific motor training is an approach to foster motor performance in patients affected by upper motor neuron syndrome (UMNS). Here, we present first-line data of repetitive neuromuscular magnetic stimulation (rNMS) in combination with personalized task-specific physical exercises targeting the tibialis anterior muscle to improve ankle dorsiflexion (functional rNMS (frNMS)). The main objective of this pilot study was to assess the feasibility in terms of adherence to frNMS, safety and practicability of frNMS, and satisfaction with frNMS. First, during 10 training sessions, only physical exercises were performed (study period (SP) A). After a 1 week break, frNMS was delivered during 10 sessions (SPC). Twelve children affected by UMNS (mean age 8.9 ± 1.6 years) adhered to 93% (SPA) and 94% (SPC) of the sessions, and omittance was not related to the intervention itself in any case. frNMS was safe (no AEs reported in 88% of sessions, no AE-related discontinuation). The practicability of and satisfaction with frNMS were high. Patient/caregiver-reported outcomes revealed meaningful benefits on the individual level. The strength of the ankle dorsiflexors (MRC score) clinically meaningfully increased in four participants as spasticity of ankle plantar flexors (Tardieu scores) decreased in four participants after SPC. frNMS was experienced as a feasible intervention for children affected by UMNS. Together with the beneficial effects achieved on the individual level in some participants, this first study supports further real-world, large-scale, sham-controlled investigations to investigate the specific effects and distinct mechanisms of action of frNMS.

Addressing gross motor function by functional repetitive neuromuscular magnetic stimulation targeting to the gluteal muscles in children with bilateral spastic cerebral palsy: benefits of functional repetitive neuromuscular magnetic stimulation targeting the gluteal muscles

Background

Impaired selective motor control, weakness and spasticity represent the key characteristics of motor disability in the context of bilateral spastic cerebral palsy. Independent walking ability is an important goal and training of the gluteal muscles can improve endurance and gait stability. Combining conventional physical excercises with a neuromodulatory, non-invasive technique like repetitive neuromuscular magnetic stimulation probably enhances effects of the treatment. This prospective study aimed to assess the clinical effects of repetitive neuromuscular magnetic stimulation in combination with a personalized functional physical training offered to children and adolescents with bilateral spastic cerebral palsy.

Methods

Eight participants Gross Motor Function Classification System level II and III (10.4 ± 2y5m; 50% Gross Motor Function Classification System level II) received a personalized intervention applying functional repetitive neuromuscular magnetic stimulation (12 sessions within 3 weeks; 12,600 total stimuli during each session). At baseline and follow up the following assessments were performed: 10-m-walking-test, 6-min-walking-test, GMFM-66. Six weeks after the end of treatment the patient-reported outcome measure Gait Outcome Assessment List was completed.

Results

GMFM-66 total score improved by 1.4% (p = 0.002), as did scoring in domain D for standing (1.9%, p = 0.109) and domain E for walking, jumping and running (2.6%, p = 0.021). Gait speed or distance walked during 6 min did not improve from baseline to follow up. Patient-reported outcome showed improvement in 4 patients in altogether 14 ratings. Caregiver-reported outcome reported benefits in 3 participants in altogether 10 ratings.

Conclusion

Repetitive neuromuscular magnetic stimulation promises to be a meaningful, non-invasive treatment approach for children and adolescents with bilateral spastic cerebral palsy that could be offered in a resource-efficient manner to a broad number of patients. To further investigate the promising effects of repetitive neuromuscular magnetic stimulation and its mechanisms of action, larger-scaled, controlled trials are needed as well as comprehensive neurophysiological investigations.