GRIN: "GRoup versus INdividual physiotherapy following lower limb intra-muscular Botulinum Toxin-A injections for ambulant children with cerebral palsy: an assessor-masked randomised comparison trial": study protocol

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

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

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.

SPORTS STARS study protocol: a randomised, controlled trial of the effectiveness of a physiotherapist-led modified sport intervention for ambulant school-aged children with cerebral palsy

BACKGROUND

Modified sport interventions run by physiotherapists have shown potential as cost-effective, engaging, and effective interventions to improve gross motor skills and support transition to real-world sports participation for children with cerebral palsy. At present, this population demonstrates decreased participation in physical activities and sport compared to peers due to barriers ranging from body function to accessibility challenges. Sport provides culturally relevant opportunities for social integration, community participation and physical activity and has been shown to improve the fitness, self-esteem, confidence and quality of life of children with disabilities. The Sports Stars physiotherapy group has been designed to support the development of a range of fundamental movement and sports skills through activity skill practice and participation in modified popular Australian sports.

METHODS

This randomised, waitlist controlled, assessor blinded, superiority trial with two parallel groups will aim to compare the effectiveness of Sports Stars to standard care across all ICF domains. Children in the Sports Stars group are expected to demonstrate greater improvement in their individually-selected, sports related goals measured by the Canadian Occupational Performance Measure. This study will aim to assess sixty ambulant children aged six to 12 years with a diagnosis of cerebral palsy. Children will be excluded if they have had recent Botox or neurological/orthopaedic surgery. The Sports Stars intervention includes eight, one-hour, weekly physiotherapy group sessions with four to six participants and one lead physiotherapist. Outcome measures will be collected pre, post and 12 weeks post the immediate Sports Stars group to assess change immediately after, and at follow up time points.

DISCUSSION

This will be the first study of its kind to investigate a culturally relevant sports-focussed fundamental movement skills physiotherapy group for ambulant children with cerebral palsy. The findings will add to a growing pool of evidence supporting group physiotherapy for children with cerebral palsy and the Sports Stars group will provide an avenue for children to transition from individual physiotherapy to mainstream and modified recreational and competitive sports.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry: ACTRN12617000313336 Registered 28, February 2017. WHO Universal Trial Number: U1111-1189-3355 Registered 1, November 2016.

The Edinburgh visual gait score - The minimal clinically important difference

OBJECTIVE

The primary aim was to define the minimal clinically important difference (MCID) of the Edinburgh Visual Gait Score (EVGS) using correlations with the Gross Motor Function Classification System (GMFCS) and the Functional Assessment Questionnaire (FAQ). The secondary aim was to confirm the numerical value of the MCID in the Gait Profile Score (GPS).

METHOD

The EVGS and GPS scores for 151 patients with diplegic cerebral palsy (GMFCS Levels I-III) were retrospectively identified from a database held at the study centre. One-hundred and forty-one patients had FAQ data available.

RESULTS

The EVGS and GPS correlated with increasing GMFCS level (p<0.001) and FAQ score (p<0.001). A gradient of 3.8 (2.9-4.7) for the EVGS and 2.9 (2.1-3.7) for the GPS corresponded to a one-level change in GMFCS level. A gradient of 1.9 (1.3-2.4) for EVGS and 1.5 (1.1-2.0) for GPS corresponded to a one-point change in FAQ.

CONCLUSIONS

The authors propose an MCID value of 2.4 for the EVGS; representing the improvement in gait score after surgery that is likely to reflect a clinical improvement in function. This MCID is closely related to other studies defining post-operative improvements in kinematic data (GPS) and may offer guidance to post-surgical changes that might reasonably be expected to either improve or prevent deteriorating function.

Evaluation of group versus individual physiotherapy following lower limb intra-muscular Botulinum Toxin-Type A injections for ambulant children with cerebral palsy: A single-blind randomized comparison trial

This study aimed to evaluate efficacy of group (GRP) versus individual (IND) physiotherapy rehabilitation following lower limb intramuscular injections of Botulinum Toxin-Type A (BoNT-A) for ambulant children with cerebral palsy (CP). Following lower limb BoNT-A injections, 34 children were randomly allocated to GRP (n=17; mean age 7y8m SD 2.0; 13 males; Gross Motor Function Classification System (GMFCS) I=5, II=8, III=4) or IND physiotherapy (n=17; mean age 8y7m SD 2.0; 11 males; GMFCS I=9, II=5, III=3). Primary outcomes were the Canadian Occupational Performance Measure (COPM) and Edinburgh Visual Gait Score (EVGS) assessed at baseline, 10 and 26 weeks post intervention. There were no baseline differences between groups. GRP intervention had greater, but not clinically meaningful, improvement in COPM satisfaction (estimated mean difference EMD 1.7, 95% CI 0.4-3.1; p<0.01) at 26 weeks. Both groups demonstrated clinically significant improvements in COPM performance and satisfaction, but minimal change in quality of gait (EVGS). Six hours of direct physiotherapy (either GRP or IND) with an additional indirect dose (median 16 episodes) of individualized home programme activities following lower limb BoNT-A injections, however, was inadequate to drive clinically meaningful changes in lower limb motor outcomes.

[Effect of botulinum toxin A injection in the treatment of gastrocnemius spasticity in children aged 9-36 months with cerebral palsy: a prospective study]

OBJECTIVE

To investigate the long-term clinical efficacy and adverse effects of botulinum toxin-A (BTX-A) injection in the treatment of gastrocnemius spasticity in children aged 9-36 months with cerebral palsy.

METHODS

Eighty children aged 9-36 months with cerebral palsy and gastrocnemius spasticity were selected and randomly divided into a BTX-A injection group and a conventional treatment group (n=40 each). The children in the BTX-A injection group received injections of BTX-A guided by color Doppler ultrasound and 4 courses of rehabilitation training after injection. Those in the conventional treatment group received 4 courses of the same rehabilitation training alone. Before treatment and at 1, 2, 3, and 6 months after treatment, the modified Tardieu scale (MTS) was applied to assess the degree of gastrocnemius spasticity, the values in the passive state measured by surface electromyography (sEMG) were applied to evaluate muscle tension, and the Gross Motor Function Measure (GMFM) was used to evaluate gross motor function.

RESULTS

Compared with the conventional treatment group, the BTX-A injection group had significantly greater reductions in MTS score and the values in the passive state measured by sEMG (P<0.05), as well as significantly greater increases in joint angles R1 and R2 in MTS and gross motor score in GMFM (P<0.05). No serious adverse reactions related to BTX-A injection were found.

CONCLUSIONS

BTX-A injection is effective and safe in the treatment of gastrocnemius spasticity in children aged 9-36 months with cerebral palsy.

[Effect of botulinum toxin A injection in the treatment of gastrocnemius spasticity in children aged 9-36 months with cerebral palsy: a prospective study]

OBJECTIVE

To investigate the long-term clinical efficacy and adverse effects of botulinum toxin-A (BTX-A) injection in the treatment of gastrocnemius spasticity in children aged 9-36 months with cerebral palsy.

METHODS

Eighty children aged 9-36 months with cerebral palsy and gastrocnemius spasticity were selected and randomly divided into a BTX-A injection group and a conventional treatment group (n=40 each). The children in the BTX-A injection group received injections of BTX-A guided by color Doppler ultrasound and 4 courses of rehabilitation training after injection. Those in the conventional treatment group received 4 courses of the same rehabilitation training alone. Before treatment and at 1, 2, 3, and 6 months after treatment, the modified Tardieu scale (MTS) was applied to assess the degree of gastrocnemius spasticity, the values in the passive state measured by surface electromyography (sEMG) were applied to evaluate muscle tension, and the Gross Motor Function Measure (GMFM) was used to evaluate gross motor function.

RESULTS

Compared with the conventional treatment group, the BTX-A injection group had significantly greater reductions in MTS score and the values in the passive state measured by sEMG (P<0.05), as well as significantly greater increases in joint angles R1 and R2 in MTS and gross motor score in GMFM (P<0.05). No serious adverse reactions related to BTX-A injection were found.

CONCLUSIONS

BTX-A injection is effective and safe in the treatment of gastrocnemius spasticity in children aged 9-36 months with cerebral palsy.