Rater reliability and scoring duration of the Quality Function Measure in ambulant children with hyperkinetic movement disorders

The novel Next Step test is a reliable measure of anticipatory postural adjustments made by children with cerebral palsy prior to taking a step

BACKGROUND

Children with cerebral palsy (CP) make smaller medio-lateral anticipatory postural adjustments (APAs) than typically developing peers when stepping forward to a medial target. They are also less accurate at reaching the stepping target. The Next Step test involves the biomechanical measurement of APAs and foot placement error. These may be useful outcome measures to evaluate dynamic balance in a clinical trial. The reliability of the measures must be assessed to establish their reliability as research tools.

RESEARCH QUESTION

What is the inter-rater and intra-rater reliability of stepping accuracy and measures of APAs made by children prior to taking a step?

METHODS

Typically developing (TD) (n = 14) or children with CP (n = 16) were recruited from local clinics. Children stepped to electro-luminescent targets placed medially and laterally to each foot. Stepping responses were measured using a force plate and 3D motion analysis of markers placed on the feet and pelvis. The APA was defined as the movement of the centre of pressure (COP) and the centre of mass (COM) estimated via pelvic markers, prior to lifting the lead leg. Stepping accuracy was defined as the absolute distance between the target and end foot position. Participants undertook two data collection sessions separated by at least one week. In session one, the test was measured by rater 1 who repeated this in session two, along with another data collection by a rater 2 or rater 3, after a rest period. Where data were normally distributed, they were assessed for inter-rater and intra-rater reliability using an intra-class correlation coefficient (ICC) and Bland-Altman plots. The standard error of measurement was calculated to determine the minimum difference needed to detect true change.

RESULTS

There was no between-group differences in group characteristics (age, weight, height) or in stepping velocity. We found good to excellent reliability when measuring the amplitude and velocity of medio-lateral APAs (ICC range 0.73-0.89). The reliability of antero-posterior APAs was more variable (ICC range 0.08-0.92). The minimum difference to detect a true change for peak medio-lateral motion of COP ranges from 23.7 mm to 29.6 mm and for peak velocity of medio-lateral COM estimate 41-61.9 mm. Stepping accuracy was not normally distributed.

SIGNIFICANCE

The Next Step test is a reliable measure of dynamic balance. The peak medio-lateral motion of the COP and medio-lateral velocity of the COM estimate are reliable when measured during a constrained stepping task in ambulant children with cerebral palsy.

Reliability and minimal detectable change of the Challenge, an advanced motor skills test for children with cerebral palsy, Danish version

PURPOSE

To translate and cross-culturally adapt the Challenge, and investigate the reliability and minimal detectable change (MDC) of the Danish Challenge in children with cerebral palsy (CP).

MATERIALS AND METHODS

A Danish version of the Challenge was created through a standardized translation process. Four physiotherapists evaluated face validity. Independently ambulatory children with CP were tested. Live performance rating was conducted by assessors independently scoring the Challenge. Video-rating was undertaken for a subset of assessments. Same day assessment test-retest reliability was estimated. The Challenge's Best Score Total was of primary interest.

RESULTS

Forty-five children (5-18 years: mean 10 years 9 months; 19 girls) in Gross Motor Function Classification System levels I and II were tested. Inter-rater reliability was excellent for live assessments (n = 45) ICC = 0.998 (95% CI 0.998-0.999) and video assessments (n = 15) ICC = 0.991 (95% CI 0.963-0.997) and intra-rater reliability was excellent for live versus video-recorded assessments (n = 10) ICC = 0.977 (95% CI 0.895-0.994). Test-retest reliability (n = 22) was excellent with ICC = 0.991 (95% CI 0.979-0.996) and minimal detectable change (MDC₉₀) of 4.7 points.

CONCLUSIONS

The Danish Challenge showed excellent reliability in this testing context when physiotherapists scored from live- or video-recorded assessments. The Challenge's ability to detect 4.7 points change seems a clinically realistic target for progress. Clinical trial registration: This trial has been approved by the Data Protection Agency, Central Region Denmark, Ref nr.: 615216, Case nr.: 1-16-02-46-16. Registration date: 01-01-2016.Implications for rehabilitationThe Challenge remained reliable and maintained a promising minimal detectable change of less than five points after translation and cultural adaptation.The Danish version of the Challenge 20-item version can be used to measure advanced motor skill performance in children with cerebral palsy, GMFCS level I and GMFCS level II.Challenge live scoring is as reliable as the more time-consuming video-recorded scoring, meaning that physiotherapists can choose the method that fits best with their clinical context and preference.

Protocol for The Toxin Study: Understanding clinical and patient reported response of children and young people with cerebral palsy to intramuscular lower limb Botulinum neurotoxin-A injections, exploring all domains of the ICF. A pragmatic longitudinal observational study using a prospective one-group repeated measures design

INTRODUCTION

Botulinum neurotoxin-A (BoNT-A) is an accepted treatment modality for the management of hypertonia in children and young people with cerebral palsy (CYPwCP). Nevertheless, there are concerns about the long-term effects of BoNT-A, with a lack of consensus regarding the most meaningful outcome measures to guide its use. Most evidence to date is based on short-term outcomes, related to changes at impairment level (restrictions of body functions and structures), rather than changes in adaptive skills (enabling both activity and participation). The proposed study aims to evaluate clinical and patient reported outcomes in ambulant CYPwCP receiving lower limb BoNT-A injections over a 12-month period within all domains of the WHO's International Classification of Functioning, Disability and Health and health-related quality of life (HRQoL).

METHODS AND ANALYSIS

This pragmatic prospective longitudinal observational study will use a one-group repeated measures design. Sixty CYPwCP, classified as Gross Motor Function Classification System (GMFCS) levels I-III, aged between 4 and 18 years, will be recruited from an established movement disorder service in London, UK. Standardised clinical and patient reported outcome measures within all ICF domains; body structures and function, activity (including quality of movement), goal attainment, participation and HRQoL, will be collected preinjection and at 6 weeks, 6 months and up to 12 months postinjection. A representative subgroup of children and carers will participate in a qualitative component of the study, exploring how their experience of BoNT-A treatment relates to clinical outcome measures.

ETHICS AND DISSEMINATION

Central London Research Ethics Committee has granted ethics approval (#IRAS 211617 #REC 17/LO/0579). Findings will be disseminated in peer-reviewed publications, conferences and via networks to participants and relevant stakeholders using a variety of accessible formats including social media.

The switch access measure: development and evaluation of the reliability and clinical utility of a switching assessment for children with severe and multiple disabilities

PURPOSE

Children with severe, multiple disabilities often need to use switches to control their assistive technology. We developed the Switch Access Measure (SAM) to address the lack of validated functional activity-based measures to evaluate children's success using their prescribed switch(es). This goal-based performance measure evaluates switching ability on 16 skills items (6 motor, 2 visual, and 8 process). This study investigated SAM's reliability and confidence in scoring.

METHODS

Two occupational therapists with switch access intervention experience were trained as SAM study assessors. They independently scored SAM (inter-rater reliability) while viewing 20 study assessment videos where each child undertook at least one goal-based switching activity with their technology, and rated confidence in scoring for each SAM item. The SAM's two developers independently scored these videos as an inter-rater reliability benchmark. Each study assessor re-scored a subset of 10 videos 2-3 weeks later (intra-rater reliability).

RESULTS

SAM Total score inter-rater reliability was excellent for the two study assessors (ICC =0.82) and the two SAM developers (ICC = 0.95). Inter-rater reliability was lowest (moderate) for Motor Subsection for the assessors, but still excellent for the developers. Intra-reliability for both groups of raters was excellent for Total and Subsection scores. Assessors' confidence in scoring was high (mean of 84.7% and 86.8% respectively) across items/participants.

CONCLUSIONS

SAM is sufficiently reliable for clinical use, permitting clinicians, after SAM training and certification, to include it in their assessments and in development of switch access intervention plans for children with severe, multiple disabilities.IMPLICATIONS FOR REHABILITATIONFor practitioners new to the field of switching technology, the SAM will provide a comprehensive understanding of all the components of successful switch use that need consideration when working with those needing switch access technologies.For all practitioners in this area, the SAM offers a consistent language to support clear communication among professionals, families, clients and their support networks. The SAM also gives quantifiable and reliable data to back clinical decision making, particularly important to support the case for funding of these technologies.Use of the SAM will prompt discussions with clients, families and carers and lead to better understanding of strengths and challenges, thus enhancing collaborative working relationships in the pursuit of achieving the best possible outcomes for those needing to use switch access technologies.

Gross motor function outcomes following deep brain stimulation for childhood-onset dystonia: A descriptive report

AIM

To examine the impact of deep brain stimulation (DBS) on gross motor function in children with dystonic movement disorders.

METHOD

Prospective audit involving children implanted 2007-2015, followed for up to two years. Outcomes were evaluated across aetiological sub-groups (inherited, acquired, idiopathic) using the GMFM-88 and BFMDRS movement scale (BFM-M). The predictive value of proportion of life lived with dystonia (PLD) and baseline motor capacity were evaluated.

RESULTS

Data was available for 60 children (median surgery age 10y11mo). Inherited monogenetic dystonias demonstrated a median increase in GMFM-88 scores of 6.9% (p = 0.021) and 14.5% (p = 0.116) at one and two years. Heredodegenerative and idiopathic dystonias showed disparate responses, with non-significant changes seen in GMFM-88 and BFM-M scores, with the exception of improved one-year BFM-M scores in the idiopathic group [median change 5.5, p = 0.021]. Median GMFM-88 and BFM-M change scores were near zero for acquired dystonias, though improvement was noted in 9/18 CP cases with one-year GMFM-88 data. No significant relationship was found between PLD, or baseline GMFM-88, and GMFM-88 change following DBS.

CONCLUSION

Gross motor response to DBS is similar in profile to literature reporting results using impairment-based dystonia rating scales. Relatively consistent improvements were seen in inherited monogenetic ("primary") dystonias, while highly variable, often disappointing, gross motor responses were found in acquired, heredodegenerative, and idiopathic dystonias. In view of such response variability, alternatives to mean group studies, such as single case experimental designs with multiple replications, are needed to determine the efficacy of DBS in childhood-onset dystonias. Ongoing research is needed to identify factors that predict treatment response.

Should the Gross Motor Function Classification System be used for children who do not have cerebral palsy?

This literature review addressed four questions. (1) In which populations other than cerebral palsy (CP) has the Gross Motor Function Classification System (GMFCS) been applied? (2) In what types of study, and why was it used? (3) How was it modified to facilitate these applications? (4) What justifications and evidence of psychometric adequacy were used to support its application? A search of PubMed, MEDLINE, and Embase databases (January 1997 to April 2017) using the terms: 'GMFCS' OR 'Gross Motor Function Classification System' yielded 2499 articles. 118 met inclusion criteria and reported children/adults with 133 health conditions/clinical descriptions other than CP. Three broad GMFCS applications were observed: as a categorization tool, independent variable, or outcome measure. While the GMFCS is widely used for children with health conditions/clinical description other than CP, researchers rarely provided adequate justification for these uses. We offer recommendations for development/validation of other condition-specific classification systems and discuss the potential need for a generic gross motor function classification system.

WHAT THIS PAPER ADDS

The Gross Motor Function Classification System should not be used outside cerebral palsy or as an outcome measure. The authors provide recommendations for development and validation of condition-specific or generic classification systems.

The International Classification of Functioning (ICF) to evaluate deep brain stimulation neuromodulation in childhood dystonia-hyperkinesia informs future clinical & research priorities in a multidisciplinary model of care

The multidisciplinary team (MDT) approach illustrates how motor classification systems, assessments and outcome measures currently available have been applied to a national cohort of children and young people with dystonia and other hyperkinetic movement disorders (HMD) particularly with a focus on dyskinetic cerebral palsy (CP). The paper is divided in 3 sections. Firstly, we describe the service model adopted by the Complex Motor Disorders Service (CMDS) at Evelina London Children's Hospital and King's College Hospital (ELCH-KCH) for deep brain stimulation. We describe lessons learnt from available dystonia studies and discuss/propose ways to measure DBS and other dystonia-related intervention outcomes. We aim to report on current available functional outcome measures as well as some impairment-based assessments that can encourage and generate discussion among movement disorders specialists of different backgrounds regarding choice of the most important areas to be measured after DBS and other interventions for dystonia management. Finally, some recommendations for multi-centre collaboration in regards to functional clinical outcomes and research methodologies for dystonia-related interventions are proposed.