Measurement of visual ability in children with cerebral palsy: a systematic review

Assessment of Gaze Fixations and Shifts in Children with Cerebral Palsy: A Comparison of Computer- and Object-Based Approaches

Background/Objectives: Gaze behaviours, such as fixation on single objects, and switching gaze between two objects are important for signaling messages, making choices or controlling a computer for children with cerebral palsy (CP) and similar movement disabilities. Observing these behaviours can be challenging for clinicians, with a lack of agreement on how they can be objectively quantified or rated. Methods: This study compares two methods of eliciting and observing gaze behaviours: a computer presentation using an eye tracker and an object presentation scored by two independent observers in order to explore the utility of each to clinicians working in this area. Children with CP (n = 39) attempted single-target fixation (STF) and target-target fixation shift (TTFS) tasks using both presentations and the results were compared. Results: Six children were unable to calibrate the eye tracker to the accuracy level required. Significantly higher scores for both STF (81.3% object presentation and 30.3% computer presentation, p < 0.01) and TTFS (70.1% and 26.9%, p < 0.01) were seen on the object presentation, with children's performance not predicted by developmental age, severity of CP or presence or absence of strabismus. It is not possible to definitively state which method gives the "correct" result; however, the difference in reported success rate merits further discussion. Conclusions: Whilst eye tracking may present an "entry barrier" for some children in terms of its accuracy and calibration requirements, object presentation carries with it the risk of over-interpreting children as having fixated. Conversely, eye tracking may be better at recording fixations in children with strabismus, where object-based paradigms may offer more flexible administration for clinicians. The variability in children's performance on both presentations underlines the risk of assuming these skills to be present and the importance of assessing gaze behaviours in individual children.

Assessing aspects of early social communication in non-speaking children with bilateral cerebral palsy

PURPOSE

Research suggests that rates for autism may be higher in cerebral palsy than in the general population. For those with severe bilateral physical impairment (GMFCS level IV and V) and little or no speech, describing a profile of social communication skills has been difficult because there are currently no assessments for early social communication specifically tailored for these children. Our aim was to explore the assessment of aspects of joint attention and social reciprocity in this group of children with CP.

METHODS

We compared the performance of children with bilateral CP on carefully designed assessments of joint attention and social responsiveness with groups of children with Down syndrome and autism. All three groups were matched for chronological age and mental age.

RESULTS

Approximately 30% of the children with bilateral CP had early social communication scores similar to the autistic children. The remaining 70% of children with CP had a range of early social communication scores similar to the children with Down syndrome.

CONCLUSION

It is possible to assess key early social communication skills in non-speaking children with bilateral motor disability. This could provide insights to help clinicians and caregivers as they discuss abilities and explore potential areas for intervention.

Reliability and Cross-Cultural Validation of the Turkish Version of the Visual Function Classification System (VFCS) for Children with Cerebral Palsy

PURPOSE

This correlational study aimed to determine the reliability and validity of the Turkish version of the Visual Function Classification System (VFCS) for children with CP.

METHOD

Two physiotherapists and caregivers (n = 56) applied the VFCS (n = 120) two times at a 15-day interval. Physiotherapists' classifications were compared for interrater reliability. Same physiotherapists and caregivers' classifications' were compared for intrarater reliability. Expanded & Revised Gross Motor Function Classification System (GMFCS E&R), Manual Ability Classification System (MACS), and Communication Function Classification System (CFCS) were used for assessing validity of the culturally adapted VFCS.

RESULTS

The interrater reliability between physiotherapists was excellent (ICC = 0.974, ICC = 0.988), while interrater reliability between the first physiotherapist and caregivers was good (ICC = 0.866, ICC = 0.893). The intrarater reliability was excellent (ICC = 0.971, ICC = 0.996, ICC = 0.984). A correlation was detected between the VFCS and the GMFCS E&R, MACS, and CFCS levels (r = 0.415, p < .001, r = 0.450, p < .001, r = 0.491, p < .001).

CONCLUSION

The findings of this study demonstrate the utility, compatibility and reliability of the Turkish version of the VFCS.

TRIAL REGISTRATION NUMBER

NCT05102955.

The relation between visual functions, functional vision, and bimanual function in children with unilateral cerebral palsy

BACKGROUND

Accurate visual information is needed to guide and perform efficient movements in daily life.

AIMS

To investigate the relation between visual functions, functional vision, and bimanual function in children with unilateral cerebral palsy (uCP).

METHODS AND PROCEDURES

In 49 children with uCP (7-15 y), we investigated the relation between stereoacuity (Titmus Stereo Fly test), visual perception (Test of Visual Perceptual Skills), visuomotor integration (Beery Buktenica Test of Visual-Motor Integration) and functional vision (Flemish cerebral visual impairment questionnaire) with bimanual dexterity (Tyneside Pegboard Test), bimanual coordination (Kinarm exoskeleton robot, Box opening task), and functional hand use (Children's Hand-use Experience Questionnaire; Assisting Hand Assessment) using correlations (rs) and elastic-net regularized regressions (d).

OUTCOMES AND RESULTS

Visual perception correlated with bimanual coordination (rs=0.407-0.436) and functional hand use (rs=0.380-0.533). Stereoacuity (rs=-0.404), visual perception (rs=-0.391 to -0.620), and visuomotor integration (rs=-0.377) correlated with bimanual dexterity. Functional vision correlated with functional hand use (rs=-0.441 to -0.458). Visual perception predicted bimanual dexterity (d=0.001-0.315), bimanual coordination (d=0.004-0.176), and functional hand use (d=0.001-0.345), whereas functional vision mainly predicted functional hand use (d=0.001-0.201).

CONCLUSIONS AND IMPLICATIONS

Visual functions and functional vision are related to bimanual function in children with uCP highlighting the importance of performing extensive visual assessment to better understand children's difficulties in performing bimanual tasks.

WHAT THIS PAPER ADDS

Previous findings showed that up to 62 % of children with unilateral cerebral palsy (uCP) present with visual impairment, which can further compromise their motor performance. However, the relation between visual and motor function has hardly been investigated in this population. This study makes a significant contribution to the literature by comprehensively investigating the multi-level relation between the heterogenous spectrum of visual abilities and bimanual function in children with uCP. We found that mainly decreased visual perception was related to decreased bimanual dexterity, bimanual coordination, and functional hand use while impairments in functional vision were only related to decreased functional hand use. Additionally, elastic-net regression models showed that visual assessments can predict bimanual function in children with uCP, however, effect sizes were only tiny to small. With our study, we demonstrated a relation between visual functions and bimanual function in children with uCP. These findings suggest the relevance of thoroughly examining visual functions in children with uCP to identify the presence of visual impairments that may further compromise their bimanual function.

Development and initial validation of a screening tool for visual ability/performance of people with polyhandicap

BACKGROUND

Visual impairments are common in people with polyhandicap although they are poorly assessed. However, evaluation of the visual abilities of these people is critical to determining treatment for impairments.

OBJECTIVES

To develop and validate an easy-to-use visual-behavioural scale for assessing the visual abilities of people with polyhandicap.

METHODS

The development of the Visual Assessment for People with Polyhandicap (VA-PLH) involved 2 steps: i) construction of the scale and ii) field validation. Participant selection criteria were aged > 3 years, age at onset of cerebral lesion < 3 years, a combination of motor impairment and profound intellectual impairment associated with restricted mobility (Gross Motor Function Classification System levels [GMFCS] III, IV or V), and everyday life dependence (Functional Independency Measure [FIM] <55). Vision assessment by both an orthoptist and an ophthalmologist was the reference against which were analysed the items of the scale completed by local health care workers. Acceptability, validity, and reliability were analysed.

RESULTS

Amongst the 232 participants included, 217 had a complete assessment, and 33% were < 18 years of age. Ocular abnormalities were reported in 83% of participants. Visual ability was altered or insufficient in 60% of participants. The final version of the VA-PLH included 3 items related to visual reaction (Area Under Curve Receiver Operating Characteristic = 0.83). Participants were considered at-risk if they had at ≥ 1 of 3 signs present (sensitivity 83% and specificity 73%). The scale's reliability was satisfactory CONCLUSION: The VA-PLH scale provides an easy-to-use, reliable and valid measure of visual status for people with polyhandicap and may be used both in clinical practice and clinical research. In addition, this study provides an overview of the diversity of visual impairments in a large population of people with polyhandicap, showing that most experience visual challenges.

Signs of perceptual disorder during movement were reliably assessed in children with cerebral palsy in Sweden

AIM

The aim of this Swedish study was to evaluate the assessment of clinical signs of perceptual disorder in children with cerebral palsy (CP).

METHODS

Three experienced raters assessed 56 videos of 19 children from 1 to 18 years of age with bilateral spastic CP, which were recorded by colleagues at an Italian hospital. Six signs were evaluated for inter-rater reliability and criterion validity. Clinical applicability was evaluated by assessing inter-rater reliability between 47 Swedish clinicians, who examined 15 of the videos during face-to-face and online education seminars. There were 41 physiotherapists, two occupational therapists and four doctors, with 1-37 years of clinical experience and a median of 10 years.

RESULTS

The experienced raters demonstrated moderate to almost perfect inter-rater reliability (kappa 0.54-0.81) and criterion validity (0.54-0.87) for startle reaction, upper limbs in startle position, averted eye gaze and eye blinking. The clinicians recognised these signs with at least moderate reliability (0.56-0.88). Grimacing and posture freezing were less reliable (0.22-0.35) and valid (0.09-0.50).

CONCLUSION

Four of the six signs of perceptual disorder were reliably recognised by experienced raters and by clinicians after education seminars. Extended education and larger study samples are needed to recognise all the signs.

Reliability and validity of the Japanese version of the Visual Function Classification System for children with cerebral palsy

BACKGROUND

Children with cerebral palsy (CP) often experience visual dysfunction that affects motor function and activities of daily living, but no 'gold standard' classification of visual function has been established. In recent years, however, a valid and reliable Visual Function Classification System (VFCS) for children with CP has been developed.

AIMS

To examine the reliability and validity of the Japanese version of the VFCS in individuals with CP.

METHODS

The translation of the VFCS was performed according to international standards for the translation of measurements. We conducted questionnaires of professionals (three physicians, eight physical therapists, five occupational therapists, six speech-language-hearing therapists and a certified orthoptist) regarding the content validity of the Japanese version of the VFCS. For reliability and concurrent validity, 148 individuals with CP were classified twice by professionals using the Japanese version of the VFCS, Gross Motor Function Classification System (GMFCS), Manual Ability Classification System (MACS), Communication Function Classification System (CFCS) and Eating and Drinking Ability Classification System (EDACS), with several weeks between each evaluation.

RESULTS

The content validity of the Japanese version of the VFCS almost met the criteria set. The percentage of positive and neutral opinions given by the professionals with regard to the four items ranged from 74% to 92%. The intra-rater reliability was 0.86 (95% CI 0.75-0.96) by Cohen's kappa and 0.93 (95% CI 0.88-0.96) by intraclass correlation coefficient. The inter-rater reliability was 0.67 (95% CI 0.56-0.78) by Cohen's kappa and 0.79 (95% CI 0.69-0.86) by intraclass correlation coefficient. The Spearman correlation coefficients between the VFCS and the GMFCS, MACS, CFCS and EDACS were 0.783, 0.764, 0.738, 0.738 and 0.830, respectively. The concurrent validity was confirmed by the correlations observed with other classification systems.

CONCLUSIONS

The results indicated good reliability and validity for the Japanese version of the VFCS.

The Functional Vision for Communication Questionnaire (FVC-Q): Exploring Parental Report of Non-Speaking Children's Fixation Skills Using a Structured History-Taking Approach

This paper explores whether a structured history-taking tool yields useful descriptions of children's looking skills. Parents of 32 children referred to a specialist communication clinic reported their child's looking skills using the Functional Vision for Communication Questionnaire (FVC-Q), providing descriptions of single object fixation, fixation shifts between objects and fixation shifts from object to person. Descriptions were compared with clinical assessment. 24/32 children were reported to have some limitation in fixation. Limitation was subsequently seen in 30/32 children. Parental report and assessment agreed fully in 23/32 (72%). The largest area of discrepancy was object-person fixation shifts, with five children not observed to show this behavior despite its being reported. Findings indicate a structured questionnaire yields description of fixations, which correspond well with clinical assessment. Descriptions supported discussion between parents and clinicians. It is proposed that the FVC-Q is a valuable tool in supporting clinicians in eliciting information about fixation skills.

Interventions for children with cerebral visual impairment: A scoping review

AIM

To examine the nature and scope of the literature on interventions implemented for children with cerebral visual impairment (CVI).

METHOD

Using a scoping review methodology, a systematic search of the literature was conducted using four databases including PubMed, Web of Science, Scopus, and Embase. Titles and abstracts were screened and data were extracted and synthesized from full-text, eligible studies. Twenty-three articles were identified and evaluated using quality criteria.

RESULTS

Twenty-three of the 895 studies were included with children aged between 1 month and 17 years 6 months. Interventions were grouped into six categories including visual stimulation, task/environmental adaptations, vision training, acupuncture, stem cell transplantation, and transcranial electric stimulation. Outcome measures examined changes in visual function, functional vision, and visual processing.

INTERPRETATION

Intervention research for children with CVI is in its infancy. Interventions for children with CVI may be beneficial; however, comparing results is difficult due to inconsistency in outcome measures. Most of the intervention studies had lower-level evidence and included small sample sizes. High-quality studies with larger samples and comparison groups are needed to fully understand which evidence-based interventions are most effective for children with CVI. With the incidence of CVI increasing, further development and validation of intervention methods is imperative.

WHAT THIS PAPER ADDS

Intervention studies for children with cerebral visual impairment (CVI) are sparse. Most intervention studies for children with CVI have low-level evidence with low critical appraisal scores. High-quality, controlled intervention studies are needed to guide families and clinicians toward evidence-based practice.

Validity and reliability of CVI Range assessment for Clinical Research (CVI Range-CR): a longitudinal cohort study

Introduction

Cortical visual impairment (CVI) is the leading cause of paediatric visual impairment in developed countries. Children with CVI exhibit visual behaviours that differ from those with ocular causes of visual impairment. Currently, there is no standard method of assessing these visual characteristics. We have developed a modified version of the CVI Range, a functional vision assessment, suitable for use in clinical research (CVI Range–Clinical Research (CVI Range-CR)). The purpose of this study is to assess the reliability and validity of this instrument in children with CVI.

Methods and analysis

This is a prospective cohort study of 45 children with CVI. A neuro-ophthalmologist will grade visual acuity using the six-level Visual Behaviour Scale (VBS). A neuropsychologist will administer the CVI Range-CR, which will be recorded. The neuropsychologist and two external graders will review and score recorded assessments. These procedures will be performed at baseline and 12 months. We will calculate the intraclass correlation coefficient to assess inter-rater reliability at baseline and follow-up. Additionally, we will correlate CVI Range-CR scores to VBS scores.

Visual Function and Neuropsychological Profile in Children with Cerebral Visual Impairment

Cerebral Visual Impairment (CVI) has become the leading cause of children’s visual impairment in developed countries. Since CVI may negatively affect neuropsychomotor development, an early diagnosis and characterization become fundamental to define effective habilitation approaches. To date, there is a lack of standardized diagnostic methods to assess CVI in children, and the role of visual functions in children’s neuropsychological profiles has been poorly investigated. In the present paper, we aim to describe the clinical and neuropsychological profiles and to investigate the possible effects of visual functions on neuropsychological performance of a cohort of children diagnosed with CVI. Fifty-one children with CVI were included in our retrospective analysis (inclusion criteria: verbal IQ > 70 in Wechsler scales; absence of significant ocular involvement). For each participant, we collected data on neuropsychological assessment (i.e., cognitive, cognitive visual, and learning abilities), basic visual functions (e.g., Best Corrected Visual Acuity—BCVA, contrast sensitivity, and ocular motor abilities) and global development features (e.g., neurological signs and motor development delay) based on standardized tests, according to patients’ ages. The results showed that oculomotor dysfunction involving saccades and smooth pursuit may be a core symptom of CVI and might have a significant impact on cognitive visual and other neuropsychological abilities. Furthermore, visual acuity and contrast sensitivity may influence cognitive, cognitive visual, and academic performances. Our findings suggest the importance of a comprehensive assessment of both visual and neuropsychological functions in children when CVI is suspected, which is needed to provide a more comprehensive functional profile and define the best habilitation strategy to sustain functional vision.

Physician Prescribing and Referral Patterns in Children with Cerebral Visual Impairment

SIGNIFICANCE

Cerebral visual impairment (CVI) is the leading cause of visual impairment in the developed world. Providing children with CVI with the appropriate treatment ensures the best possible visual outcome and potentially improves quality of life.

PURPOSE

The purpose of this study was to determine physician prescribing and visual rehabilitation referral patterns in children with CVI.

METHODS

A retrospective chart review was completed on children with CVI examined at Cincinnati Children's Hospital Medical Center from January 1, 2008, to March 1, 2018. Significant refractive error warranting correction was determined using the American Academy of Ophthalmology Preferred Guidelines and the American Association for Pediatric Ophthalmology and Strabismus Vision Screening Committee Guidelines. The CVI Range was used as a surrogate to categorize CVI severity.

RESULTS

A total of 194 children were included. Sixty-eight (35%) had refractive error warranting correction and were prescribed glasses (group RC), 99 (51%) did not have refractive error warranting correction and were not prescribed glasses (group NRNC), 20 (10%) had refractive error warranting correction but were not prescribed glasses (group RNC), and 7 (4%) did not have refractive error warranting correction but were prescribed glasses (group NRC). There was greater than one-line Snellen equivalent difference between group RC (20/156) and group RNC (20/221). There was greater than six-line Snellen equivalent difference between group NRNC (20/149) and group NRC (20/35). Mean CVI Range score 2 values for each group were 5.9, 4.6, 4.8, and 7.1.

CONCLUSIONS

Children with less severe CVI were less likely to have significant refractive error but given glasses. Despite significant refractive error, children with more severe CVI were not prescribed glasses. Children with very low visual function were not prescribed glasses as frequently, possibly limiting their visual rehabilitation. Providers should ensure that all children with CVI are correctly prescribed glasses to provide the best possible visual outcome.

Multi-Organ Dysfunction in Cerebral Palsy

Cerebral Palsy (CP) describes a heterogenous group of non-progressive disorders of posture or movement, causing activity limitation, due to a lesion in the developing brain. CP is an umbrella term for a heterogenous condition and is, therefore, descriptive rather than a diagnosis. Each case requires detailed consideration of etiology. Our understanding of the underlying cause of CP has developed significantly, with areas such as inflammation, epigenetics and genetic susceptibility to subsequent insults providing new insights. Alongside this, there has been increasing recognition of the multi-organ dysfunction (MOD) associated with CP, in particular in children with higher levels of motor impairment. Therefore, CP should not be seen as an unchanging disorder caused by a solitary insult but rather, as a condition which evolves over time. Assessment of multi-organ function may help to prevent complications in later childhood or adulthood. It may also contribute to an improved understanding of the etiology and thus may have an implication in prevention, interventional methods and therapies. MOD in CP has not yet been quantified and a scoring system may prove useful in allowing advanced clinical planning and follow-up of children with CP. Additionally, several biomarkers hold promise in assisting with long-term monitoring. Clinicians should be aware of the multi-system complications that are associated with CP and which may present significant diagnostic challenges given that many children with CP communicate non-verbally. A step-wise, logical, multi-system approach is required to ensure that the best care is provided to these children. This review summarizes multi-organ dysfunction in children with CP whilst highlighting emerging research and gaps in our knowledge. We identify some potential organ-specific biomarkers which may prove useful in developing guidelines for follow-up and management of these children throughout their lifespan.

Creating a Path for Systematic Investigation of Children With Cortical Visual Impairment Who Use Augmentative and Alternative Communication

Purpose There is limited information about how to support children with cortical visual impairment (CVI) who require augmentative and alternative communication (AAC). An initial review designed to explore the available evidence was used to outline critical needs in moving research and intervention forward for children who use AAC and have CVI. Method Previous systematic reviews, six databases, and theses and dissertations were systematically searched, along with reviews of the resulting works cited. An initial yield of 575 articles was narrowed to 10, which discussed AAC interventions that included children with CVI. Results Three interventions were technology based, and seven were instructional based. The use of textured microswitches was the most frequent form of technology intervention, with the frequency of switch activations being the most frequently coded outcome. Overall, the studies represent explorations in the area rather than systematic lines of inquiry. Conclusions While evidence shows at least some children with CVI have been included in AAC research to date, the inclusion is more incidental than deliberate. Issues such as clear descriptions of the vision capabilities and needs of participants may have impacted study results.

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.

Measure of Early Vision Use: development of a new assessment tool for children with cerebral palsy

PURPOSE

To report the development of an assessment tool to describe "how vision is used" for children with cerebral palsy.

METHOD

Measurement development consisted of three steps: (i) an online survey to explore the relevance and comprehensiveness of visual behaviours identified in a previous conceptualisation study; (ii) construction of items and a rating scale for the new measure; and (iii) cognitive interviews to explore comprehensibility and refine the measure in preparation for field testing. Survey respondents were 130 parents of children with cerebral palsy, eight adults with cerebral palsy, and 108 clinicians (n = 246). Nine parents participated in the interviews.

RESULTS

The new tool, the Measure of Early Vision Use, is a 14-item descriptive measure of typical performance of visual behaviours observable in everyday activities, as rated by parent/caregiver observation. Each item is rated on a 4-point ordinal scale.

CONCLUSIONS

This new measure is conceptually grounded within the Activity level domain of the International Classification of Functioning, Disability and Health as a measure of a single visual ability construct. The target population is children with cerebral palsy, and using parent report the Measure of Early Vision Use describes both strengths and limitations in using vision. This study addressed the selection of items and response options for the new scale, and provides evidence to support content relevance, comprehensiveness and comprehensibility from key stakeholders. Further research will explore psychometric properties and clinical utility.Implications for rehabilitationThe ability to use vision in daily activities is relevant to the development and learning of all children, so the availability of a method for describing visual abilities has potential for diverse research and clinical purposes.The Measure of Early Vision Use is a parent-report tool that provides a criterion-referenced method for quantifying and describing how children use vision in typical daily activities to support intervention planning.Clinicians and parents wishing to measure vision use in children with cerebral palsy can be confident about the rigorous methods used to develop this tool, including consultation with key stakeholders.

Measure of early vision use: initial validation with parents of children with cerebral palsy

PURPOSE

To report initial psychometric evidence on the Measure of Early Vision Use.

METHOD

Data on performance of the Measure of Early Vision Use scale were collected from 100 parents of children with cerebral palsy aged 0-12 years via online survey. Psychometric evaluation included assessment of scale dimensionality using Classical Test Theory and hypothesis testing for evidence of construct validity.

RESULTS

Principal components analysis of the 14-item parent-rated Measure of Early Vision Use revealed one component with an eigenvalue of 9.343, explaining 66.7% of variance; internal consistency was high (Cronbach's α = 0.96). Total scores ranged from 15-56 (Mean 42.8, standard deviation = 10.6). The results support seven pre-defined hypotheses including statistically significant differences in MEVU-total scores between children with and without parent-reported cerebral visual impairment.

CONCLUSIONS

Measure of Early Vision Use is the first assessment tool to describe 'how vision is used' in children with cerebral palsy. Results provide preliminary evidence that the measure comprises a unidimensional construct, sufficient construct validity, and feasibility as a parent-completed online assessment. Findings on internal structure provide foundational evidence and require further testing with Confirmatory Factor Analysis or Rasch Analysis.IMPLICATIONS FOR REHABILITATIONThe Measure of Early Vision Use is a new instrument to describe the use of basic visual abilities and is feasible to use as a parent-completed online questionnaire.The Measure of Early Vision Use is a unidimensional scale with sufficient construct validity to supports its use as a measure of 'how vision is used' without confounding visual ability with the reason why it might be impaired (e.g., cerebral vision impairment, motor limitations, or cognition).There is potential for the Measure of Early Vision Use to support early intervention planning for children with (or at high risk of) cerebral palsy.

Stakeholder consensus for decision making in eye-gaze control technology for children, adolescents and adults with cerebral palsy service provision: findings from a Delphi study

BACKGROUND

Limited research exists to guide clinical decisions about trialling, selecting, implementing and evaluating eye-gaze control technology. This paper reports on the outcomes of a Delphi study that was conducted to build international stakeholder consensus to inform decision making about trialling and implementing eye-gaze control technology with people with cerebral palsy.

METHODS

A three-round online Delphi survey was conducted. In Round 1, 126 stakeholders responded to questions identified through an international stakeholder Advisory Panel and systematic reviews. In Round 2, 63 respondents rated the importance of 200 statements generated by in Round 1. In Round 3, 41 respondents rated the importance of the 105 highest ranked statements retained from Round 2.

RESULTS

Stakeholders achieved consensus on 94 of the original 200 statements. These statements related to person factors, support networks, the environment, and technical aspects to consider during assessment, trial, implementation and follow-up. Findings reinforced the importance of an individualised approach and that information gathered from the user, their support network and professionals are central when measuring outcomes. Information required to support an application for funding was obtained.

CONCLUSION

This Delphi study has identified issues which are unique to eye-gaze control technology and will enhance its implementation with people with cerebral palsy.

Motor beta cortical oscillations are related with the gait kinematics of youth with cerebral palsy

OBJECTIVE

It is widely believed that the perinatal brain injuries seen in youth with cerebral palsy (CP) impact neuronal processing of sensory information and the production of leg motor actions during gait. However, very limited efforts have been made to evaluate the connection between neural activity within sensorimotor networks and the altered spatiotemportal gait biomechanics seen in youth with CP. The objective of this investigation was to use magnetoencephalographic (MEG) brain imaging and biomechanical analysis to probe this connection.

METHODS

We examined the cortical beta oscillations serving motor control of the legs in a cohort of youth with CP (N = 20; Age = 15.5 ± 3 years; GMFCS levels I-III) and healthy controls (N = 15; Age = 14.1 ± 3 years) using MEG brain imaging and a goal-directed isometric knee target-matching task. Outside the scanner, a digital mat was used to quantify the spatiotemporal gait biomechanics.

RESULTS

Our MEG imaging results revealed that the participants with CP exhibited stronger sensorimotor beta oscillations during the motor planning and execution stages compared to the controls. Interestingly, we also found that those with the strongest sensorimotor beta oscillations during motor execution also tended to walk slower and have a reduced cadence.

INTERPRETATION

These results fuel the impression that the beta sensorimotor cortical oscillations that underlie leg musculature control may play a central role in the altered mobility seen in youth with CP.

Oculomotor deficits in children adopted from Eastern Europe

AIM

We aim to assess oculomotor behaviour in children adopted from Eastern Europe, who are at high risk of maternal alcohol consumption.

METHODS

This cross-sectional study included 29 adoptees and 29 age-matched controls. All of them underwent a complete ophthalmological examination. Oculomotor control, including fixation and saccadic performance, was assessed using a DIVE device, with eye tracking technology. Anthropometric and facial measurements were obtained from all the adopted children, to identify features of foetal alcohol spectrum disorders (FASD). Fixational and saccadic outcomes were compared between groups, and the effect of adoption and FASD features quantified.

RESULTS

Oculomotor performance was poorer in adopted children. They presented shorter (0.53 vs 1.43 milliseconds in the long task and 0.43 vs 0.82 in the short task) and more unstable fixations (with a bivariate contour ellipse area of 27.9 vs 11.6 degree² during the long task and 6.9 vs 1.3 degree² during the short task) and slower saccadic reactions (278 vs 197 milliseconds). Children with sentinel finding for FASD showed the worst oculomotor outcomes.

CONCLUSION

Children adopted from Eastern Europe present oculomotor deficits, affecting both fixation and saccadic skills. We highlight prenatal exposure to alcohol as the main cause for these deficits.

Beyond the eye: Cortical differences in primary visual processing in children with cerebral palsy

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Visual processing deficits are common in children with CP.

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MEG was used to image multispectral cortical oscillations during visual processing.

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Compared with controls, children with CP had weaker occipital oscillations.

•

Aberrant cortical oscillations likely impact early visual processing abilities.

Despite the growing clinical recognition of visual impairments among people with cerebral palsy (CP), very few studies have evaluated the neurophysiology of the visual circuitry. To this end, the primary aim of this investigation was to use magnetoencephalography and beamforming methods to image the relative change in the alpha–beta and gamma occipital cortical oscillations induced by a spatial grating stimulus (e.g., visual contrast) that was viewed by a cohort of children with CP and typically-developing (TD) children. Our results showed that the high-contrast, visual gratings stimuli induced a decrease in alpha–beta (10 – 20 Hz) activity, and an increase in both low (40 – 56 Hz) and high (60 – 72 Hz) gamma oscillations in the occipital cortices. Compared with the TD children, the strength of the frequency specific cortical oscillations were significantly weaker in the children with CP, suggesting that they had deficient processing of the contrast stimulus. Although CP is largely perceived as a musculoskeletal centric disorder, our results fuel the growing impression that there may also be prominent visual processing deficiencies. These visual processing deficits likely impact the ability to perceive visual changes in the environment.

Visual Function Classification System for children with cerebral palsy: development and validation

AIM

To develop and validate the Visual Function Classification System (VFCS), which was created to classify how children with cerebral palsy (CP) use visual abilities in daily life.

METHOD

The process of development and validation of the VFCS involved four phases: (1) drafting of the five levels from the analysis of literature and clinical experience; (2) validation of constructs and revision of the levels for concept meaningfulness, using nominal group process; (3) refinement by international Delphi survey; and(4) assessment of interrater reliability among professionals and with caregivers, and of test-retest reliability.

RESULTS

Five nominal groups involved 29 participants; 65 people completed the first round and 51 the second round of the Delphi survey. Construct validity was demonstrated within an expert group and external validation through several stakeholders, with the involvement of patients and families to ensure meaningfulness of the concept. Discussions continued until consensus was reached about the construct and content of the five levels. Participants in the reliability study included 29 professionals, 39 parents, and a total sample of 160 children with CP (mean age [SD] 6y 6mo [3y 4mo]; median 5y 7mo, range 1-19y). Absolute interrater agreement among professionals was 86% (weighted κ=0.88; 95% confidence interval [CI] 0.83-0.93). Test-retest reliability was high (weighted κ=0.97; 95% CI 0.95-0.99). Parent-professional interrater reliability on 39 children was moderate (weighted κ=0.51; 95% CI 0.39-0.63).

INTERPRETATION

The VFCS has been appropriately constructed and provides a reliable system to classify visual abilities of children with CP both in clinical and in research settings.

WHAT THIS PAPER ADDS

The Visual Function Classification System is a valid and reliable system. It classifies visual abilities of children with cerebral palsy in clinical and research settings. At a clinical level, it can be used to harmonize communication among professionals and identify patients' strengths and weaknesses. In research settings, it can be used to stratify patients, define natural history evolution, and interpret intervention studies.

A Questionnaire Assessing What Teachers of the Visually Impaired Know About Cortical/Cerebral Vision Impairment

Cortical/cerebral visual impairment (CVI) is now the main cause of visual impairment in developed countries, yet it remains poorly understood. Four hundred and ninteen teachers of the visually impaired (TVIs) from across the United States responded to a questionnaire targeted at evaluating the preparedness of TVIs to serve their students with CVI. The TVIs were asked about their background knowledge, their abilities to assess a student with CVI, and their abilities to apply what they know to best help their students. The primary finding was that there is a perceived unmet need for TVIs to receive formal training in CVI during their certification. The results of this survey provide a foundation for future research on CVI knowledge and education among TVIs.

Inhibitory control and temporal perception in cerebral palsy

Prepotent response inhibition and temporal perception abilities were explored in a sample of individuals with cerebral palsy relative to typically developing peers. The extent to which inhibitory control difficulties might affect temporal processing was also investigated. For this purpose, two inhibitory control tasks and two duration estimation tasks were given to the groups of cerebral palsy and typically developing children. Results showed inhibition and temporal perception problems in the group with cerebral palsy. A relationship was found between inhibition and temporal estimation performances, which indicates that inhibitory control contributes, at least partially, to acquisition of the temporal processing ability.

The effect of visual support strategies on the quality of life of children with cerebral palsy and cerebral visual impairment/perceptual visual dysfunction in Nigeria: study protocol for a randomized controlled trial

BACKGROUND

Cerebral visual impairment (CVI), including perceptual visual dysfunction (PVD), is common in children with cerebral palsy (CP). Inventories of questions relating to practical aspects of visual perception in everyday life, in particular the closed-ended Insight Questions Inventory (IQI), can be used to assess CVI/PVD. Studies linking responses to the inventory with specific visual support strategies, aimed at modifying the child's environment and/or behaviour to minimize the impact of the CVI/PVD, have been piloted. The IQI and tailored strategies have not been used in an African population, nor have they been tested in a controlled trial. This trial will compare the effectiveness of the IQI and linked visual support strategies versus general supportive treatments on the quality of life of children with CVI/PVD and CP through a randomized controlled trial.

METHODS/DESIGN

This is a prospective, double-blind, parallel-arm, randomized controlled trial. The primary outcome is change in quality of life scores between the two arms of the trial at 6 weeks, assessed using the Paediatric Quality of Life Inventory (PedsQL) generic 4.0 and CP 3.0 module. All children will undergo baseline assessment including the Open Questions Inventory, IQI, PedsQL 3.0, PedsQL 4.0 generic, and the Strengths and Difficulties Questionnaire (SDQ). Eligible children with CP aged 4 years to < 16 years will be stratified and blocked by the age groups 4-9 and 10 to < 16 years and by Gross Motor Function Classification System (GMFCS) levels 1-3 and 4-5. Families in the intervention arm will receive tailored insight visual support strategies and telephone calls during the 6-week trial period. The control arm will receive standard treatment and the intervention after the 6-week trial period. Follow-up interviews will be performed in both arms at 6 weeks with a repeat administration of the PedsQL CP 4.0 and 3.0, the IQI and the SDQ. Secondary outcomes include a change in functional vision.

DISCUSSION

This randomized controlled trial will provide evidence of the effectiveness of this intervention for children with CP in a resource-poor setting.

TRIAL REGISTRATION

Pan African Clinical Trials Registration, PACTR201612001886396 . Registered on 3 December 2016.

Towards population screening for Cerebral Visual Impairment: Validity of the Five Questions and the CVI Questionnaire

INTRODUCTION

Cerebral Visual Impairment (CVI) is the most common cause of visual impairment in children in the developed world and appears to be more prevalent in children with additional support needs (ASN). There is an urgent need for routine screening for CVI, particularly in children with ASN, however, current screening questionnaires for CVI have limited validation. The aim of this study was to evaluate two screening tools: the Five Questions and the CVI Questionnaire. Additionally, the distribution of CVI across neurodevelopmental disorders is unknown. This too was investigated.

METHODS

An online survey was completed by 535 parents. The survey was advertised via social media, CVI websites and parent email systems of four schools. The survey comprised of the Five Questions, the CVI Questionnaire and additional questions regarding the child's diagnoses. Whether or not a child had a diagnosis of CVI and/or additional neurodevelopmental disorders was based on parental report.

RESULTS

Based on parent reports, both the screening tools accurately screened for CVI diagnoses in children. The Five Questions and the CVI Questionnaire have construct validity (as determined through factor analysis), high internal consistency (as determined by Cronbach's alpha) and convergent validity (as determined by correlation analysis of the raw scores of each questionnaire). This study also highlights that among children with neurodevelopmental disorders, a large proportion have parent-reported CVI (23%-39%) and potential CVI (6.59-22.53%; as identified by the questionnaires).

CONCLUSION

The current study demonstrates that the Five Questions and CVI Questionnaire have good convergent validity, internal consistency and a reliable factor structure and may therefore be suitable as screening tools. The study also highlights that reported or potential CVI is evident in a large proportion of children with neurodevelopmental disorders.

Impairments of Visuospatial Attention in Children with Unilateral Spastic Cerebral Palsy

Aim

This observational study aimed at assessing the prevalence of visuospatial attention deficits in children with unilateral spastic cerebral palsy (USCP), taking into consideration the affected hemibody and the localization of the brain lesion.

Method

Seventy-five children with USCP were assessed with four visuospatial attention tests: star cancellation, Ogden figure copy, line bisection, and proprioceptive pointing.

Results

A majority (64%) of children with USCP presented a deficit in at least one test compared to the reference values. The alterations observed in children with left or right USCP were related to egocentric or allocentric neglect, respectively. Children with cortico/subcortical lesion presented more often visuospatial attention deficits than children with periventricular lesion. Visuospatial attention deficits were not associated with brain lesion locations.

Interpretation

Visuospatial attention deficits are prevalent in children with USCP and should be taken into account during their rehabilitation process. The present results shed new light on the interpretation of motor impairments in children with USCP as they may be influenced by the frequent presence of visuospatial deficits.

Vision Assessments and Interventions for Infants 0-2 Years at High Risk for Cerebral Palsy: A Systematic Review

We performed a systematic review and evaluated the level of evidence of vision interventions and assessments for infants at high risk for or with a diagnosis of cerebral palsy from zero to two years of age. Articles were evaluated based on the level of methodologic quality, evidence, and clinical utilization. Thirty publications with vision assessments and five with vision interventions met criteria for inclusion. Assessments included standard care neuroimaging, electrophysiology, and neuro-ophthalmologic examination techniques that are utilized clinically with any preverbal or nonverbal pediatric patient. The overall level of evidence of interventions was strong for neuroprotective interventions such as caffeine and hypothermia but weak for surgery, visual training, or developmental programs. There are few evidence-based interventions and assessments that address cerebral/cortical visual impairment-related needs of infants and toddlers at high risk for or with cerebral palsy. Recommendation guidelines include the use of three types of standard care methodologies and two types of protective interventions.

Children with cerebral palsy have altered oscillatory activity in the motor and visual cortices during a knee motor task

The neuroimaging literature on cerebral palsy (CP) has predominantly focused on identifying structural aberrations within the white matter (e.g., fiber track integrity), with very few studies examining neural activity within the key networks that serve the production of motor actions. The current investigation used high-density magnetoencephalography to begin to fill this knowledge gap by quantifying the temporal dynamics of the alpha and beta cortical oscillations in children with CP (age = 15.5 ± 3 years; GMFCS levels II–III) and typically developing (TD) children (age = 14.1 ± 3 years) during a goal-directed isometric target-matching task using the knee joint. Advanced beamforming methods were used to image the cortical oscillations during the movement planning and execution stages. Compared with the TD children, our results showed that the children with CP had stronger alpha and beta event-related desynchronization (ERD) within the primary motor cortices, premotor area, inferior parietal lobule, and inferior frontal gyrus during the motor planning stage. Differences in beta ERD amplitude extended through the motor execution stage within the supplementary motor area and premotor cortices, and a stronger alpha ERD was detected in the anterior cingulate. Interestingly, our results also indicated that alpha and beta oscillations were weaker in the children with CP within the occipital cortices and visual MT area during movement execution. These altered alpha and beta oscillations were accompanied by slower reaction times and substantial target matching errors in the children with CP. We also identified that the strength of the alpha and beta ERDs during the motor planning and execution stages were correlated with the motor performance. Lastly, our regression analyses suggested that the beta ERD within visual areas during motor execution primarily predicted the amount of motor errors. Overall, these data suggest that uncharacteristic alpha and beta oscillations within visuomotor cortical networks play a prominent role in the atypical motor actions exhibited by children with CP.

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Children with CP performed an isometric task with the knee joint.

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Children with CP had stronger alpha and beta ERD during motor planning.

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These ERD differences extended through the motor execution period.

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Occipital cortices and visual MT area alpha and beta ERD were weaker.

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Altered alpha and beta ERD were accompanied by impaired motor actions.

Methods for conceptualising 'visual ability' as a measurable construct in children with cerebral palsy

Background

Vision influences functioning and disability of children with cerebral palsy, so there is a growing need for psychometrically robust tools to advance assessment of children’s vision abilities in clinical practice and research. Vision is a complex construct, and in the absence of clarity about this construct it is challenging to know whether valid, reliable measures exist. This study reports a method for conceptualising ‘visual ability’ as a measurable construct.

Methods

Using the items from 19 assessment tools previously identified in a systematic review, this study used a two-phase process: first, deductive content analysis linked items to the International Classification of Functioning, Disability and Health - Child and Youth version (ICF-CY), and second, vision-specific ‘Activity’-level items were explored using inductive thematic analysis.

Results

The linking and content analysis identified that existing assessment tools are measuring vision across the ICF-CY domains of Body Functions, Activities and Participation, and Environmental and Personal Factors. Items specifically coded to vision at the Activity level were defined as measuring ‘how vision is used’, and these items form the basis of the conceptualisation that ‘visual ability’ is measurable as a single construct.

The thematic analysis led to the identification of 3 categories containing 13 themes that reflect a child’s observable visual behaviours. Seven abilities reflect how a child uses vision: responds or reacts, initiates, maintains or sustains looking, changes or shifts looking, searches, locates or finds, and follows. Four interactions reflect the contexts in which a child uses their vision to purposefully interact: watches and visually interacts with people and faces, objects, over distance, and with hands. Finally, two themes reflect a child’s overall use of vision in daily activities: frequency of use, and efficiency of use.

Conclusions

This study demonstrates an approach to exploring and explaining a complex topic utilising World Health Organization language and building on existing research. Despite the complexity of vision, the concept of ‘how vision is used’ can be clearly defined as a measurable construct at the Activity level of the ICF-CY. This study has identified observable visual behaviours that may be developed into items assessing how vision is used in daily activities.

Electronic supplementary material

The online version of this article (doi:10.1186/s12874-017-0316-6) contains supplementary material, which is available to authorized users.