Long-term course of difficulty in participation of individuals with cerebral palsy aged 16 to 34 years: a prospective cohort study

Cross-cultural adaptation of the Rotterdam Transition Profile to Brazilian Portuguese: measuring autonomy in participation of Brazilian youth with cerebral palsy

BACKGROUND

Autonomy in participation of young adults with cerebral palsy (CP) is not well understood due to the lack of appropriate instruments, especially for the Brazilian population. The Rotterdam Transition Profile (RTP) categorizes autonomy in Participation (education, employment, finances, housing, leisure, intimate relationships, sexuality, transportation) and Health Services (care demands, services and aids, and rehabilitation services) domains.

OBJECTIVES

To cross-culturally adapt the RTP for use in Brazil, and to describe the levels of autonomy in participation and associated factors of Brazilian youth with CP.

METHODS

RTP was translated and content validity was investigated through an expert panel (n = 4 researchers and n = 4 clinicians); 30 adolescents and young adults with CP provided data for construct validity and internal consistency analysis. To analyze influencing factors, 56 youth with CP, mean age 25 years (SD = 6.9 years), with good cognitive level remotely responded to the RTP, sociodemographic information, and functional classifications (gross motor, manual ability).

RESULTS

Following translation, content and construct validity were established, with changes made to improve the clarity of items. Cronbach's alpha (0.82) was considered good and test-reliability was fair to good for most items. High levels of autonomy were found in the areas of Leisure and Rehabilitation, with the lowest proportion of participants with autonomy in Housing, Intimate Relationships, and Finances. Autonomy in participation was associated with age, gross motor and manual ability classifications, and with context-related factors.

CONCLUSION

The Brazilian Portuguese version of the RTP was considered valid and reliable. Findings will support transition planning for young people with CP.

Evaluation of daily and social participation of children with Cerebral Palsy across different age groups with a focus on the 'F'-words: Function, family, fitness, fun, friends and future

BACKGROUND

The impact of disability differs across cultures. This study aimed to determine the predictors of participation in children with cerebral palsy (CP) in Turkey, based on the six F-words.

METHODS

Cross-sectional study exploring participation profiles of 450 children with CP, aged between 2 and 18 years. Pediatric Evaluation of Disability Inventory (PEDI) evaluated functional skills, and Assessment of Life Habits (LIFE-H) version 3.0 assessed daily and social participation. Hierarchical linear regression models were done to determine the predictors of participation in daily activities (PDA) and social roles (PSR) in three age groups (2-4, 5-13 and 14-18 years) based on the 6 F-words (mobility of PEDI for 'fitness'; four classification systems and self-care of PEDI for 'functioning'; social functions of PEDI for 'friends'; demographic information by parents for 'family'; the recreation of LIFE-H for 'fun'; and different stages of development for 'future').

RESULTS

The most important predictors for total PDA by age group were: self-care (p = 0.012) of PEDI in 2-4 y; self-care (p = 0.001) and mobility (p = 0.005) of PEDI in 5-13 y; GMFCS (p = 0.006) and mobility (p = 0.002) of PEDI in 14-18 y. Significant predictors for PSR differed by age group: self-care (p = 0.001) of PEDI in 2-4 y; self-care (p = 0.023) and mobility (p = 0.006) of PEDI in 5-13 y; and GMFCS (p = 0.004) and MACS (p = 0.003) in 14-18 y.

CONCLUSIONS

Six F-words of function and fitness focussed on self-care in younger children with an increasing emphasis on mobility and ability levels according to age. Therefore, rehabilitation for different aspects of the functional levels is needed to improve participation in life across the six F-words framework; plus take into consideration context, age-differences, family's expectations, life requirements, environmental needs, and cultural differences.

Effect of Exercise and Motor Interventions on Physical Activity and Motor Outcomes of Adults with Cerebral Palsy: A Systematic Review

PURPOSE

Systematically review the effect of exercise and motor interventions on physical activity and motor outcomes of adults with cerebral palsy (CP).

METHODS

Eight databases were searched.

RESULTS

Twenty-five studies were included, representing 439 adults with CP. Very low to low quality evidence supports that gait training is more effective than standard care or neurodevelopmental treatment for improving gait velocity, quality of gait, and ankle stiffness; balance training is more effective than seated therapeutic activities for improving walking self-confidence and perceived change in balance; whole-body vibration is no more effective than resistance training for improving strength or gait function; and resistance training is no more effective than a person's typical exercise program for improving strength or gait function of adults with CP. Adverse events were reported for balance training, functional training, resistance training, and whole-body vibration.

DISCUSSION

Further research is needed that is adequately powered and uses well-controlled study designs.

Social participation in adults with cerebral palsy: a systematic review of the evidence-base

PURPOSE

To identify and synthesise the current evidence on social participation in adults with cerebral palsy (CP).

METHODS

Four databases (PubMed, CINAHL Plus, PsycINFO, Web of Science) were systematically searched between December 2021 and February 2022. Pre-specified eligibility criteria were applied to all identified studies resulting in the inclusion of 16 articles. Data extraction was performed using a standardised tool and quality appraisal was assessed using the Mixed Methods Appraisal Tool. A narrative synthesis approach was taken for data analysis.

RESULTS

The 16 included studies were rated as high (n = 11) and medium quality (n = 5). Numbers of participants included in the studies ranged from 7 to 335. Definitions of social participation were discussed. Common themes were identified: the impact of home and work environments on social participation, the importance of age-appropriate support and interventions, and the impact of limited autonomy on social participation.

CONCLUSIONS

Adults with CP experience limited social participation due to lack of appropriate support in childhood, issues across the lifespan including physical limitations when ageing, and factors such as societal expectations and inaccessible environments which limit opportunities for autonomy. Social participation may be improved by supporting families to provide opportunities in childhood, providing timely interventions, and by enhancing autonomy.

Development and content validity of the youth and young-adult participation and environment measure (Y-PEM)

PURPOSE

To develop and evaluate the content of a self-reported measure of participation and environment, named Youth, Young-adult Participation and Environment Measure (Y-PEM), capturing participation at home, school, community, and the workplace among individuals with physical disabilities aged 12-30.

MATERIALS AND METHODS

A multi-phase sequential design based on elements of COnsensus for Standard Measurements INstrument was employed. Five consecutive rounds of cognitive interviews with 24 participants aged 12-33 years (X̅ = 20.9; n = 19 with a physical disability) and consultation with experts (n = 15) were conducted for item development and validation. Relevancy and clarity of items in each setting were assessed using the 10-cm Visual Analogue Scales (VASs).

RESULTS

Participants recommended adding activities specific to this age group (i.e., dating, caregiving, preparing meals, employment). On a 4-point Likert scale, work-related items were perceived important by experts (X̅ = 3.4) and young adults (X̅ = 3.1) with average clarity of 8.8 and relevancy of 8.4 out of 10, on the VASs. Similarly, the average clarity of items across settings (home, school, community) ranged from 6.9 to 8.7 and relevancy from 7.4 to 8.1. No modifications were required in environmental items.

CONCLUSIONS

Results suggest that Y-PEM is clear, relevant, comprehensive, and can be completed by individuals aged 12-30 with physical disabilities.IMPLICATIONS FOR REHABILITATIONThe Y-PEM can provide a standardized and systematic method to assess the first-hand subjective experience of youth and young adults with disabilities aged 12-30 in their participation at home, school, community, and the workplace.The Y-PEM can provide information regarding participation in activities that prepare youth or young adults for the job market as well as their perspective on the environmental barriers or supports that they may face in their employment.Clinicians can use the Y-PEM to identify environmental barriers and facilitators that impact participation across different settings and address them to further promote participation in meaningful and age-related activities.

Is Mobility Sufficient to Understand Community Participation of Adolescents and Young Adults With Cerebral Palsy? The Mediating and Moderating Roles of Contextual Factors

OBJECTIVE

To explore whether self-determination and family socioeconomic status (SES) mediate and/or moderate the relationship between mobility and community participation of adolescents and young adults with cerebral palsy (CP).

DESIGN

Survey.

SETTING

Online platform.

PARTICIPANTS

Of 55 eligible adolescents/young adults with CP, 50 agreed to participate and 2 were excluded. The final convenience sample included 48 individuals (N=48), aged 15-32 years, levels I-IV of the Gross Motor Function Classification System and I-II of the Communication Function Classification System.

MAIN OUTCOME MEASURES

The Temple University Community Participation Measure documented the amount, breadth, and insufficiency/sufficiency ratios of participation across 26 community settings. The ARC Self-determination Scale and the Mobility Scale of the Pediatric Evaluation of Disability Inventory-Computer Adaptive Test (PEDI-CAT) measured individuals' self-determination (ie, autonomy, psychological empowerment, self-realization) and mobility skills, respectively. The Brazilian Economic Classification Criteria-2021 assessed family SES.

RESULTS

Analyses of mediating/moderating effects revealed that the influence of individuals' mobility skills on their breadth of community participation was mediated by autonomy. Family SES moderated the indirect effect of mobility on community participation breadth through autonomy. When the model was adjusted for participants' age, individuals with higher SES reported greater breadth in community participation than those from moderate and lower SES for all mobility levels. However, the magnitude of the differences among individuals of different SES levels diminished as mobility increased.

CONCLUSIONS

The mobility skills of youths with CP influence their community participation through autonomy. To foster greater engagement of these individuals in the community, rehabilitation professionals should focus not only on improvement of mobility skills but also on the promotion of self-determined behaviors, especially autonomy.

Assessing Participation in Adolescents With Cerebral Palsy: Comparison of Life-Habits and USER-Participation

Objective

To explore and compare the contents and scores of the Assessment of Life Habits (Life-H) with the Utrecht Scale for Evaluation of Rehabilitation-Participation (USER-Participation) in adolescents with cerebral palsy.

Design

Youth versions of both instruments were used for (1) content comparison and (2) analyses of relations between both instruments, based on cross-sectional data.

Setting

Clinic.

Participants

Participants were adolescents with cerebral palsy, aged 12-18 years; Gross Motor Function Classification System I-V; N=45.

Interventions

Not applicable.

Main outcome measures

Assessment of Life Habits (Life-H) with USER-Participation.

Results

Both instruments measure independence in participation, called accomplishment (Life-H) and restrictions (USER-Participation), and satisfaction with participation. Life-H provides a profile of 6 domain scores and the USER-Participation a total score per dimension. Compared with the USER-Participation, the Life-H contains more specific items, more items not-applicable to many participants and more ceiling effects. Total scores on the accomplishment/restrictions and satisfaction scales between both instruments showed strong correlation coefficients (0.87 and 0.67, respectively). Correlations between domain scores were stronger within the accomplishment/restrictions scales (range 0.37-0.88) compared with the satisfaction scales (range 0.22-0.68).

Conclusions

Compared with the USER-Participation, the Life-H takes more effort to complete but provides a more comprehensive assessment of participation. Participation accomplishment/restrictions scores were more similar between the instruments compared with satisfaction scores. Researchers and clinicians should carefully compare participation instruments in selecting one that matches their purpose.

ICF Core Sets for the assessment of functioning of adults with cerebral palsy

AIM

To report on the results of the online international consensus process to develop the comprehensive and brief International Classification of Functioning, Disability and Health (ICF) Core Sets for adults with cerebral palsy (CP).

METHOD

An online iterative decision-making and consensus process involved 25 experts, including clinicians and researchers working with adults with CP, an adult with CP, and the parents of adults with CP from all six regions of the World Health Organization. The most relevant categories were selected from a list of 154 unique second-level candidate categories to develop the ICF Core Sets for adults with CP. This list resulted from evidence gathered during four preparatory studies, that is, a systematic literature review, a qualitative study, an expert survey, and an empirical study.

RESULTS

The consensus process resulted in the comprehensive ICF Core Set containing 120 second-level ICF categories: 33 body functions; eight body structures; 50 activities and participation; and 29 environmental factors, from which the most essential categories, 33 in total, were selected for the brief ICF Core Set. For body functions, most of the categories were mental functions and neuromusculoskeletal and movement-related functions. Body structures were mostly related to movement. All the chapters of the activities and participation component were represented, with mobility and self-care as the most frequently covered chapters. For environmental factors, most of the categories addressed products and technology and services, systems, and policies.

INTERPRETATION

The comprehensive and brief ICF Core Sets for adults with CP were created using a new online version of an established ICF Core Set consensus process. These Core Sets complement the age-specific ICF Core Sets for children and young people with CP and will promote standardized data collection worldwide.

Factors for changes in self-care and mobility capabilities in young children with cerebral palsy involved in regular outpatient rehabilitation care

Background

Assessing prognosis of self-care and mobility capabilities in children with cerebral palsy (CP) is important for goal setting, treatment guidance and meaningful professional-caregiver conversations.

Aims

Identifying factors associated with changes in self-care and mobility capabilities in regular outpatient multidisciplinary paediatric CP rehabilitation care.

Methods and procedures

Routinely monitored longitudinal data, assessed with the Paediatric Evaluation of Disability Inventory (PEDI-Functional-Skills-Scale, FSS 0–100) was retrospectively analysed. We determined contributions of age, gross-motor function, bimanual-arm function, intellectual function, education type, epilepsy, visual function, and psychiatric comorbidity to self-care and mobility capability changes (linear-mixed-models).

Outcomes and results

For 90 children (53 boys), in all Gross-Motor-Function-Classification-System (GMFCS) levels, 272 PEDI's were completed. Mean PEDI–FSS–scores at first measurement (median age: 3,2 years) for self-care and mobility were 46.3 and 42.4, and mean final FSS-scores respectively were 55.1 and 53.1 (median age: 6,5 years). Self-care capability change was significantly associated with age (2.81, p < 0.001), GMFCS levels III-V (-9.12 to -46.66, p < 0.01), and intellectual impairment (-6.39, p < 0.01). Mobility capability change was significantly associated with age (3.25, p < 0.001) and GMFCS levels II-V (-6.58 to -47.12, p < 0.01).

Conclusions and implications

Most important prognostic factor for self-care and mobility capabilities is GMFCS level, plus intellectual impairment for self-care. Maximum capability levels are reached at different ages, which is important for individual goal setting and managing expectations.

•

Capabilities of children with CP improve modestly over time in outpatient rehabilitation.

•

Children with more severe CP reach maximum mobility and self-care levels at an earlier age.

•

After this maintaining capabilities is more realistic than improvement.

•

Important prognostic factors are GMFCS level and intellectual impairment.

•

Routine monitoring can aid goal setting and expectation management in communication with families.

Social Outcomes of School Leavers With Cerebral Palsy Living in Victoria

Objective: In Australia, the National Disability Strategy provides a framework to guide actions and investment to achieve equity in social inclusion and economic participation for people with disability. We investigated the social outcomes of school leavers with cerebral palsy (CP) in Victoria, Australia and explored the determinants of desirable outcomes. Methods: We used the Victorian CP Register to invite all adults with CP aged 18-25 years (n = 649). On-line and/or paper-based surveys explored participation in education, employment, community activities, living situation, relationships and life satisfaction. Functional and health status data were collected. Social outcomes were summarized descriptively and compared between individuals with CP and non-disabled peers aged 18-25 years from the Household Income and Labor Dynamics in Australia dataset. Within the CP cohort we explored whether physical and mental health and level of functioning were associated with social outcomes. In addition, a descriptive comparison was undertaken between the social outcomes of the current CP cohort with that of a previously reported 2007 cohort. Results: Ninety participants (57% male; mean age 22.4 years (SD: 2.2) in 2020; 61.1% self-reported) provided data for analyses; response rate 16.9%. CP characteristics were similar between respondents and non-respondents. In comparison to similar aged peers, 79.8% had completed secondary school (compared to 83.2%); 32.6% (compared to 75.8%) were in paid work; 87.5% (compared to 48.2%) were living in their parental home; and 3.4% (compared to 31.6%) were married or partnered. Individuals with CP and higher levels of functional capacity and better physical health were more likely to undertake post-secondary education. Higher levels of functional capacity and physical health, as well as lower mental health status were associated with being employed. Conclusions: While foundational education completion rates were similar to non-disabled peers, significant gaps in social outcomes remain, including residence in the parental home and single status. While addressing these issues is challenging, substantial efforts are needed to reduce these disparities-work that needs to be done in collaboration with people with CP and their families.

Development of an ICF Core Set for adults with cerebral palsy: capturing their perspective on functioning

AIM

To examine the most relevant aspects of functioning of adults with cerebral palsy (CP) from their perspective, in order to develop an International Classification of Functioning, Disability and Health (ICF) Core Set for adults with CP.

METHOD

We conducted six focus group discussions with adults with CP without intellectual disability and seven interviews with adults with CP with intellectual disability and caregivers, addressing all ICF components. Meaningful concepts were identified from verbatim transcripts and linked to ICF categories by two independent researchers.

RESULTS

In total, 31 adults with CP without intellectual disability (mean [SD] age 46y 1mo [14y 1mo]; 20 females, 11 males; Gross Motor Function Classification System [GMFCS] levels I-IV) and seven adults with CP and intellectual disability (mean [SD] age 25y 8mo [6y 8mo]; four females, three males; GMFCS levels III-V) participated. We identified 132 unique second-level categories: 47 body functions, seven body structures, 43 activities and participation, and 35 environmental factors. The most frequently mentioned categories were emotional function, pain, muscle tone function, support of family, products and technology, and health services.

INTERPRETATION

Adults with CP experienced problems in a broad range of body functions and activities and indicated the importance of environmental factors for functioning. The identified categories will be added to the list of candidate items to reach consensus on an ICF Core Set for adults with CP. What this paper adds Including the lived experience is crucial for fully understanding functioning of adults with cerebral palsy (CP). Adults with CP perceive environmental factors as essential elements for everyday functioning. Adults with intellectual disability should be considered as a group with specific problems.

Adults with spastic diplegic cerebral palsy living in a low-to-middle income Country: A six-year follow-up study on pain, functional mobility, activity and participation

BACKGROUND

Insight into the day-to-day challenges faced by adults living with Cerebral Palsy (CP) in low-to-middle income countries (LMICs) will enable support towards healthy ageing in this population.

OBJECTIVES

To determine changes in level of pain, functional mobility and accomplishment as well as satisfaction in daily life of ambulant adults with CP living in a LMIC over a six-year period, compared to typically developed (TD) adults. In addition, to determine associations with individual characteristics.

METHODS

Twenty-eight adults with CP and spastic diplegia (median [interquartile ranges] age = 39.0 [34.0-45.7] years; Gross Motor Function Classification System level I/II/III: n = 11/12/5) participated in this study, together with 28 matched TD adults. Levels of accomplishment and satisfaction were assessed with the Life-Habits questionnaire, functional mobility was determined with the Functional Mobility Scale and (back, lower and upper limb) pain frequency was gauged with a standardized questionnaire.

RESULTS

Life-Habits accomplishment and satisfaction scores of adults with CP remained unchanged during the six-year follow-up, with 79% being independent and 100% satisfied. Functional mobility decreased and related to the total accomplishment score. No change in pain frequency was observed, but adults with CP experienced more pain than their peers. Back pain was significantly associated with the total satisfaction score.

CONCLUSIONS

Relative high levels of accomplishment and satisfaction and no change in pain frequency were noted during a six-year follow-up study of adults with CP living in a LMIC. The importance of exercise/rehabilitation programs to reduce pain and maintain functional mobility in persons ageing with CP was highlighted.

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.

Short-term longitudinal participation trajectories related to domestic life and peer relations for adolescents with and without self-reported neurodevelopmental impairments

Background

With maturity and development, complexity in demands and roles change. As participation is often restricted in children with disabilities, this process might be delayed in adolescents. Investigating profiles of participation for adolescents with and without neurodevelopmental impairments could provide an understanding of which factors relate to high level of participation. The aim is to investigate trajectories of participation in everyday activities across clusters based on self-rated participation patterns in frequency of participation and perceived importance of activities related to domestic life and peer-related activities for adolescents with and without self-reported neurodevelopmental impairments.

Methods and procedures

A prospective person-based cohort study design.

Outcomes and results

Five typical trajectories were identified. Trajectories between clusters with high perceived involvement in peer relations were associated with sibling support and family communication. Self-reported neurodevelopmental impairments did not predict participation profiles at certain time points, nor movements between clusters when measuring self-reported attendance and importance in domestic life and in peer-related activities.

Conclusion and implications

Perceived sibling support and family communication are important for predicting typical trajectories across clusters in frequency of attendance and the perceived importance of domestic life and peer relations. Type of impairment was less important in predicting typical trajectories.

The level of accomplishment and satisfaction in activity and participation of adults with cerebral palsy and spastic diplegia

BACKGROUND

Orthopaedic surgery is commonly performed in children with cerebral palsy (CP) and spastic diplegia to improve functional mobility. However, no research has quantified levels of accomplishment and satisfaction in daily activities and participation long-term after surgery. Therefore, this study aimed to investigate 1) the level of accomplishment and satisfaction of life habits in adults with CP, 2) whether there were differences between Gross Motor Function Classification System (GMFCS) levels, and 3) associations with contextual factors, functional level and frequency of pain.

METHODS

Levels of accomplishment and satisfaction in activity and participation were assessed using the Life-Habits 3.1 questionnaire in 30 adults with CP and spastic diplegia who received the first orthopaedic intervention more than 15 years ago (age: median [interquartile range (IQR)] = 27:8 [21:7-33:8] y:mo; GMFCS level I/II/III: n = 15/11/4). GMFCS and Functional Mobility Scale (FMS) assessed mobility over 5 m, 50 m and 500 m. Participants reported frequency of back pain and pain in the lower and upper limb.

RESULTS

On average 63% of the participants were independent and faced no difficulties in the accomplishment of all life habits. Difficulties were mostly experienced for 'mobility', 'housing' and 'recreation' (all 61%). Participants were overall satisfied, with lowest scores for 'employment' (13% dissatisfied). Between the GMFCS levels, accomplishment scores of participants with level I were significantly higher than level II. In addition, negative associations were found between accomplishment of life habits and GMFCS level, FMS, and pain on spinal level.

CONCLUSION

Levels of accomplishment and satisfaction were relatively high among adults with CP who underwent orthopaedic interventions during childhood. However, negative associations between accomplishment levels and level of functioning and back pain argue for rehabilitation programs specialized on these factors. This information is imperative for physicians and allied health care professionals to guide adults with CP during ageing.

Environmental Factors that Impact the Workplace Participation of Transition-Aged Young Adults with Brain-Based Disabilities: A Scoping Review

Workplace participation of individuals with disabilities continues to be a challenge. The International Classification of Functioning, Disability and Health (ICF) places importance on the environment in explaining participation in different life domains, including work. A scoping review was conducted to investigate environmental facilitators and barriers relevant to workplace participation for transition-aged young adults aged 18-35 with brain-based disabilities. Studies published between 1995 and 2018 were screened by two reviewers. Findings were categorized into the ICF's environmental domains: Products and technology/Natural environment and human-made changes to environment, Support and relationships, Attitudes, and Services, systems and policies. Out of 11,515 articles screened, 31 were retained. All environmental domains of the ICF influenced workplace participation. The majority of the studies (77%) highlighted factors in the Services, systems and policies domain such as inclusive and flexible systems, and well-defined policies exercised at the organizational level. Social support mainly from family, friends, employers and colleagues was reported as a facilitator (68%), followed by physical accessibility and finally, the availability of assistive technology (55%). Attitudes of colleagues and employers were mostly seen as a barrier to workplace participation (48%). Findings can inform the development of guidelines and processes for implementing and reinforcing policies, regulations and support at the organization level.

Epidemiology of Cerebral Palsy in Adulthood: A Systematic Review and Meta-analysis of the Most Frequently Studied Outcomes

OBJECTIVE

To describe the epidemiology of health status, impairments, activities and participation in adults with cerebral palsy (CP).

DATA SOURCES

Embase, MEDLINE, Web of Science, PsycINFO, Cumulative Index to Nursing and Allied Health, Cochrane, and Google Scholar were searched for 3 themes ("cerebral palsy," "adult," and "outcome assessment") in literature published between January 2000 and December 2018.

STUDY SELECTION

Full-article peer-reviewed English journal articles on descriptive, observational, or experimental studies describing the most studied outcomes in adults with CP (n≥25, age≥18y) were included. Studies were included in the analyses if frequently studied outcomes were described in at least 3 studies using similar methods of assessment.

DATA EXTRACTION

Data were extracted independently by 2 authors from 65 articles (total N=28,429) using a standardized score sheet.

DATA SYNTHESIS

Meta-analyses revealed that overall, on average 65.1% (95% confidence interval [CI], 55.1-74.5) of adults with CP experienced pain, 57.9% (95% CI, 51.1-64.6) were ambulant, 65.5% (95% CI, 61.2-69.7) had little or no limitation in manual ability, 18.2% (95% CI, 10.6-27.2) had tertiary education, 39.2% (95% CI, 31.5;47.1) were employed, and 29.3% (95% CI, 9.0-55.3) lived independently. In adults without intellectual disability, proportions of individuals who were ambulant (72.6% [95% CI, 58.8-84.5]) and lived independently (90.0% [95% CI, 83.8-94.9]) were higher (P=.014 and P<.01, respectively). The Fatigue Severity Scale score was 4.1 (95% CI, 3.8-4.4). Epilepsy (28.8% [95% CI, 20.1-38.4]) and asthma (28.3% [95% CI, 18.7-38.9]) were especially prevalent comorbidities.

CONCLUSIONS

The present systematic review and meta-analysis on the epidemiology of adults with CP provided state-of-the-art knowledge on the most frequently studied outcomes. On average, adults with CP are fatigued, and a majority experience pain, are ambulant, and have little or no difficulty with manual ability. On average, 40% are employed and 30% live independently. More uniformity in assessment and reports is advised to improve knowledge on epidemiology and gain insight in more outcomes.

Teenage predictors of participation of adults with cerebral palsy in domestic life and interpersonal relationships: A 13-year follow-up study

BACKGROUND

Adults with cerebral palsy (CP) may experience problems with participation in domestic life and interpersonal relationships.

AIMS

To identify teenage predictors of adult participation in domestic life and interpersonal relationships.

METHODS AND PROCEDURES

This 13-year follow-up of the PERRIN 16-24 cohort included 53 adults with CP without intellectual disability [current age 31.7 (SD = 1.4) years]. Participation performance was assessed as attendance (Vineland Adaptive Behavior Scales), and difficulty/assistance with participation (Life Habits questionnaire). 56 teenage factors were categorized in ICF components. Stepwise multiple linear regression analyses explored predictors of participation.

OUTCOMES AND RESULTS

Lower gross motor capacity, following special education, having protective parents and a rigid personality predicted less participation in domestic life. Having rejective parents, receiving little daily support, having a socially avoidant personality or coping style and the male gender predicted less participation in interpersonal relationships. Lower activity and participation levels as a teenager predicted less participation in both domestic life and interpersonal relationships of adults with CP.

CONCLUSIONS AND IMPLICATIONS

Environmental and personal factors, gross motor capacity and teenage participation were predictors of participation of adults with CP. These factors help identify subgroups at risk for suboptimal adult participation and provide targets for rehabilitation.

Development curves of communication and social interaction in individuals with cerebral palsy

AIM

To determine development curves of communication and social interaction from childhood into adulthood for individuals with cerebral palsy (CP).

METHOD

This Pediatric Rehabilitation Research in the Netherlands (PERRIN)-DECADE study longitudinally assessed 421 individuals with CP, aged from 1 to 20 years at baseline, after 13 years (n=121 at follow-up). Communication and social interactions were assessed using the Vineland Adaptive Behavior Scales. We estimated the average maximum performance limit (level) and age at which 90% of the limit was reached (age₉₀ ) using nonlinear mixed-effects modeling.

RESULTS

One-hundred individuals without intellectual disability were aged 21 to 34 years at follow-up (39 females, 61 males) (mean age [SD] 28y 5mo [3y 11mo]). Limits of individuals without intellectual disability, regardless of Gross Motor Function Classification System (GMFCS) level, approached the maximum score and were significantly higher than those of individuals with intellectual disability. Ages₉₀ ranged between 3 and 4 years for receptive communication, 6 and 7 years for expressive communication and interrelationships, 12 and 16 years for written communication, 13 and 16 years for play and leisure, and 14 and 16 years for coping. Twenty-one individuals with intellectual disability were between 21 and 27 years at follow-up (8 females, 13 males) (mean age [SD] 24y 7mo [1y 8mo]). Individuals with intellectual disability in GMFCS level V showed the least favourable development, but variation between individuals with intellectual disability was large.

INTERPRETATION

Individuals with CP and without intellectual disability show developmental curves of communication and social interactions similar to typically developing individuals, regardless of their level of motor function. Those with intellectual disability reach lower performance levels and vary largely in individual development.

WHAT THIS PAPER ADDS

Communication and social interactions in individuals with cerebral palsy without intellectual disability develop similarly to typically developing individuals. Communication and social interactions of individuals with intellectual disability develop less favourably and show large variation.

Pain, fatigue, depressive symptoms and sleep disturbance in young adults with cerebral palsy

PURPOSE

Investigate pain, fatigue, depressive symptoms and sleep disturbance in young adults with cerebral palsy compared to references.

MATERIALS AND METHODS

Young adults with cerebral palsy (n = 97, aged 21-34 years) and age-matched references from the general population (n = 190) rated pain using a numeric rating scale and fatigue, depressive symptoms, sleep disturbance and global health using Patient-Reported Outcomes Measurement Information System® short forms. Scores were compared between cerebral palsy subgroups and the reference population. Correlation coefficients and linear regression analyses assessed interrelationships of health issues and associations with global health.

RESULTS

Individuals with Gross Motor Function Classification System level I had less pain, fatigue and depressive symptoms, while individuals with levels II and III-V had more pain (53% and 56%, p < 0.001) and those with levels III-V more fatigue (39%, p = 0.035) than references (pain: 26%, fatigue: 14%). Pain and fatigue were more interrelated (correlation coefficients: 0.71 vs. 0.41) and stronger associated with global mental health in individuals with cerebral palsy.

CONCLUSIONS

Young adults with Gross Motor Function Classification System levels II-V report more pain and those with levels III-V report more fatigue than references. Pain and fatigue are highly interrelated and specifically relate to mental health in individuals with cerebral palsy.Implications for rehabilitationExcept for those in the highest level of motor function, young adults with cerebral palsy report higher levels of pain and fatigue compared to the general population of the same age.Pain and fatigue are strongly interrelated and associated with mental health in young adults with cerebral palsy.The present study recommends to monitor pain and fatigue in young adults with cerebral palsy with low levels of gross motor function.We advise rehabilitation professionals to consider combined treatment for both pain and fatigue.

Outcomes in adults with cerebral palsy: systematic review using the International Classification of Functioning, Disability and Health

AIM

In the context of the development of an International Classification of Functioning, Disability and Health (ICF) Core Set for adults with cerebral palsy (CP), this systematic review sought to identify the outcome measures used in studies on adults with CP, to examine their content using the ICF as a reference, and to demonstrate the most studied areas in this population.

METHOD

Embase, MEDLINE, Web of Science, PsycINFO, CINAHL, Cochrane, and Google Scholar were searched for studies on adults with CP published between 2000 and 2017. Meaningful concepts of commonly used outcome measures were linked to the ICF, and frequencies of resultant ICF categories were explored.

RESULTS

In 274 included articles, 332 outcome measures were identified of which 155 were commonly used. In total, 4409 meaningful concepts were linked to the ICF. The component 'Activities and participation' included the most frequent categories, followed by 'Body functions'. The most frequent categories were b280 'Sensation of pain' (37.6%), d450 'Walking' (33.3%), and d850 'Remunerative employment' (27.5%).

INTERPRETATION

The broad range of ICF categories identified in this systematic review emphasizes the heterogeneity of functioning and disability in adults with CP. The current results specifically reflect the researchers' perspective and will serve as candidate categories to consider in the development of an ICF Core Set for adults with CP.

WHAT THIS PAPER ADDS

Outcomes studied in adults with cerebral palsy are captured in varying International Classification of Functioning, Disability and Health (ICF) categories. Activities and participation were studied more frequently than body functions and structures. Mobility, employment, and self-care were most frequent within ICF's 'Activities and participation' component. Pain and neuromusculoskeletal and movement-related functions were most frequent within 'Body functions'.

Participation in Social Roles of Adolescents With Cerebral Palsy: Exploring Accomplishment and Satisfaction

Objective

To explore participation in social roles of adolescents (aged 12-18y) with cerebral palsy (CP), in terms of satisfaction compared with accomplishment.

Design

Cohort study as part of a prospective longitudinal research program.

Setting

Clinic.

Participants

Participants were adolescents (N=45; 58% male, mean age 15y 6mo) with CP at levels I-II (88%) and III-IV-V (12%) of the Gross Motor Function Classification System.

Interventions

Not applicable.

Main Outcome Measures

Accomplishment (0-9 scale; with score <8 “having difficulties”) and satisfaction (1-5 scale; with score 3 “neutral”) were assessed using the Life-Habits questionnaire, on 6 domains (Responsibilities, Interpersonal relationships, Community life, Education, Employment, Recreation). Per domain, we analyzed scatterplots of accomplishment vs satisfaction. Additionally, we compared determinant-models (including factors of CP, activity, person, and environment) using regression analysis.

Results

For accomplishment, mean scores were <8.00 except for Interpersonal relationships. For satisfaction, mean scores varied between 3.85 and 4.34. Overall, individuals with similar levels of accomplishment showed large ranges in their levels of satisfaction, which was expressed by low explained variances, especially on Education (6%). Furthermore, different sets of determinants were found for accomplishment (predominantly CP factors) compared with satisfaction (predominantly environment factors).

Conclusions

This study revealed a dissociation between participation accomplishment and satisfaction with participation among adolescents with CP. For practice and research, we recommend not only to focus on accomplishment but also, if not mainly, on satisfaction.

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

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