Relationship Between Communication Skills and Gross Motor Function in Preschool-Aged Children With Cerebral Palsy

Objectives

To explore the communication skills of children with cerebral palsy (CP) at 24 months' corrected age with reference to typically developing children, and to determine the relationship between communication ability, gross motor function, and other comorbidities associated with CP.

Design

Prospective, cross-sectional, population-based cohort study.

Setting

General community.

Participants

Children with CP (N=124; mean age, 24mo; functional severity on Gross Motor Function Classification System [GMFCS]: I=47, II=14, III=22, IV=19, V=22).

Interventions

Not applicable.

Main Outcome Measures

Parents reported communication skills on the Communication and Symbolic Behavior Scales Developmental Profile (CSBS-DP) Infant-Toddler Checklist. Two independent physiotherapists classified motor type, distribution, and GMFCS. Data on comorbidities were obtained from parent interviews and medical records.

Results

Children with mild CP (GMFCS I/II) had mean CSBS-DP scores that were 0.5 to 0.6 SD below the mean for typically developing peers, while those with moderate-severe impairment (GMFCS III–V) were 1.4 to 2.6 SD below the mean. GMFCS was significantly associated with performance on the CSBS-DP (F=18.55, P<.001), with gross motor ability accounting for 38% of the variation in communication. Poorer communication was strongly associated with gross motor function and full-term birth.

Conclusions

Preschool-aged children with CP, with more severe gross motor impairment, showed delayed communication, while children with mild motor impairment were less vulnerable. Term-born children had significantly poorer communication than those born prematurely. Because a portion of each gross motor functional severity level is at risk, this study reinforces the need for early monitoring of communication development for all children with CP.     

Children's perceptions of their cerebral palsy and their impact on life satisfaction

Purpose: To assess an individual child's cognitive and emotional perceptions of their cerebral palsy (CP) and how these are associated with their reported life satisfaction and their functional walking ability.Method: Convenience sample of 48 children with cerebral palsy, GMFCS (Gross Motor Function Classification System) I-IV, mean age of 12.2 ± 2.5 years was recruited from tertiary level out-patient clinics. All children completed the Brief Illness Perception Questionnaire-Cerebral Palsy version (BIPQ-CP), Students' Life Satisfaction Scale (SLSS) and 1- and 6-min walk tests.Results: Children with CP reported levels of global life satisfaction (mean score 31.4/42) equivalent to previous studies of typically developing children. Higher total SLSS scores were associated with lower concern about CP (rho = -0.61, p < 0.001), lower emotional impact (rho = -0.58, p < 0.001), fewer perceived consequences (rho = -0.53, p < 0.001) and perceptions of higher levels of personal control (rho = 0.40, p = 0.01). Multiple regression models using BIPQ-CP constructs found that a combination of lower level of concern and fewer perceived consequences predicted 46% of the variance in SLSS score (p < 0.001). GMFCS levels, walk distance and age were not significant predictors of life satisfaction. Conclusions: Life satisfaction in this group of children was strongly associated with a child's perceptions of their CP but was not associated with functional walking ability. Although the cross-sectional nature of the study precludes assumptions of causality, understanding children's cognitive and emotional beliefs about their cerebral palsy would seem to be an important adjunct to clinical management. [Box: see text].     

Daily care activities and hip pain in non-ambulatory children and young adults with cerebral palsy

Hip movement pain was identified in 13 (32.5%) of 40 children and young adults with cerebral palsy who were in residential care. All of the participants were non-ambulatory (Level IV and V of the GMFCS), and their ages ranged from 8 to 26 years (median 16.5 years). Ten of the 13 participants had unilateral hip dislocation and three had bilateral dislocations. Degenerative hip changes were identified on radiographs of the painful dislocated hips. The occurrence of pain during a daily episode of washing, dressing, and transfer was recorded using non-verbal indicators. Washing of the lower body elicited significantly more pain responses than dressing (p=0.008) and transfer (p<0.001). None of the participants had daily pain during all of the care activities. Pain was present in 1/3 of the patients and was intermittent in nature, indicating that conservative management can be considered for persons with cerebral palsy at Levels IV and V of the GMFCS who have established hip dislocations and this type of pain. This management could include medication, attention to seating and positioning, and careful handling during daily care activities.     

Relationship between gross motor and intellectual function in children with cerebral palsy: a cross-sectional study

Dalvand H, Dehghan L, Hadian MR, Feizy A, Hosseini SA. Relationship between gross motor and intellectual function in children with cerebral palsy: a cross-sectional study.ObjectiveTo explore the relationship between gross motor and intellectual function in children with cerebral palsy (CP).DesignA cross-sectional study.SettingOccupational therapy clinic.ParticipantsChildren with CP (N=662; 281 girls, 381 boys; age range, 3–14y).InterventionsNot applicable.Main Outcome MeasuresIntelligence testing was carried out by means of the Wechsler Preschool and Primary Scale of Intelligence and the Wechsler Intelligence Scale for Children–Revised. Gross motor function level was determined by the Gross Motor Function Classification System Expanded and Revised (GMFCS E&;R).ResultsOf the children, 10.4% were at level I of the GMFCS E&;R, 38% at levels II and III, and 51.5% at levels IV and V. The lowest level of intelligence or profound intellectual disability was found in children with spastic quadriplegia (n=28, 62.2%). Children at the lowest levels (I–IV, GMFCS E&;R) obtained higher ratings in terms of intelligence in comparison with children at level V. Based on the present results, the diagnosis was statistically related to the intellectual level as dependent variable (P<.01); accordingly, hypotonic, quadriplegic, and hemiplegic patients had the highest odds to assign higher ratings in abnormal intelligence, respectively. Sex and age were not statistically related to the dependent variable.ConclusionsThe study results demonstrated a significant association between GMFCS E&;R and intellectual function. Therefore, we suggest that particular attention should be paid to the intellectual level in terms of evaluations of gross motor function. These results, in respect, might be interested for occupational and physical therapists who are involved in rehabilitation programs for these children.     

Validation of a model of gross motor function for children with cerebral palsy

BACKGROUND AND PURPOSE: Development of gross motor function in children with cerebral palsy (CP) has not been documented. The purposes of this study were to examine a model of gross motor function in children with CP and to apply the model to construct gross motor function curves for each of the 5 levels of the Gross Motor Function Classification System (GMFCS). SUBJECTS: A stratified sample of 586 children with CP, 1 to 12 years of age, who reside in Ontario, Canada, and are known to rehabilitation centers participated. METHODS: Subjects were classified using the GMFCS, and gross motor function was measured with the Gross Motor Function Measure (GMFM). Four models were examined to construct curves that described the nonlinear relationship between age and gross motor function. RESULTS: The model in which both the limit parameter (maximum GMFM score) and the rate parameter (rate at which the maximum GMFM score is approached) vary for each GMFCS level explained 83% of the variation in GMFM scores. The predicted maximum GMFM scores differed among the 5 curves (level I=96.8, level II=89.3, level III=61.3, level IV=36.1, and level V=12.9). The rate at which children at level II approached their maximum GMFM score was slower than the rates for levels I and III. The correlation between GMFCS levels and GMFM scores was (.91. Logistic regression, used to estimate the probability that children with CP are able to achieve gross motor milestones based on their GMFM total scores, suggests that distinctions between GMFCS levels are clinically meaningful. CONCLUSION AND DISCUSSION: Classification of children with CP based on functional abilities and limitations is predictive of gross motor function, whereas age alone is a poor predictor. Evaluation of gross motor function of children with CP by comparison with children of the same age and GMFCS level has implications for decision making and interpretation of intervention outcomes.     

Global and specific behavioral measures of pain in children with cerebral palsy

OBJECTIVES: The aim of this research was to validate global and behavioral observation methods for measuring pain in children with cerebral palsy (CP). MATERIALS AND METHODS: Nineteen children diagnosed with CP (2-21 years of age) and their primary caregivers participated in this study. Children and their caregivers were videotaped in their home before, during, and after a stretching exercise, and tests of cognitive and social development were administered. Children who were able to pass a training task were also asked to rate their experience of pain using a numerical rating scale (self-report NRS), but only 5 children (24%) passed so their self-report scores were not included. Healthcare professionals rated videotaped segments for each of the 3 time periods in a randomized order using an observer NRS and the Non-Communicating Children's Pain Checklist-Postoperative Version (NCCPC-PV). Raters trained in the Child Facial Coding System (CFCS) examined the same videotaped segments. RESULTS: Results showed significantly greater pain behavior (observer NRS, NCCP- PV) during the stretching procedure than during the baseline and recovery segments. There were no significant differences in CFCS scores, across time segments. CONCLUSIONS: These findings support the hypothesis that children with CP express discernible pain behaviors regardless of cognitive or language ability. These results contribute to multidimensional assessment of pain in children with neurologic impairment.     

Pain in children with cerebral palsy: a review.

Children with cerebral palsy (CP) face many challenges including impaired motor control and coordination, functional impairment, sensory disturbances, and, sometimes, communication difficulties and cognitive deficits. Pain also may be a problem for children with CP due in part to the inherent deficits associated with the disease, as well as the invasive medical and surgical procedures and rehabilitative activities children with CP undergo on a regular basis. A review of current literature indicates pain is a common experience for children with CP and has been understudied in this population. Further emphasis and research on appropriate assessment and management strategies sensitive to the unique characteristics and limitations of children with CP are warranted.     

Differences of Respiratory Function According to Level of the Gross Motor Function Classification System in Children with Cerebral Palsy

[Purpose] The current study was designed to investigate the difference in lung capacity and muscle strengthening related to respiration depending on the level of the Gross Motor Function Classification System (GMFCS) in children with cerebral palsy (CP) through tests of respiratory function and respiratory pressure. [Subjects and Methods] A total of 49 children with CP who were classified as below level III of the GMFCS were recruited for this study. They were divided into three groups (i.e., GMFCS level I, GMFCS level II, and GMFCS level III). All children took the pulmonary function test (PFT) and underwent respiratory pressure testing for assessment of respiratory function in terms of lung capacity and respiratory muscle strength. [Results] The GMFCS level III group showed significantly lower scores for all tests of the PFT (i.e., forced vital capacity (FVC), forced expiratory volume at one second (FEV₁), and slow vital capacity (SVC)) and testing for respiratory pressures (maximal inspiratory pressure (MIP) and maximal expiratory pressure (MEP)) compared with the other two groups. The results of post hoc analysis indicated that the GMFCS level III group differed significantly from the other two groups in terms of FVC, FEV₁, MIP, and MEP. In addition, a significant difference in SVC was observed between GMFCS level II and III. [Conclusion] Children with CP who had relatively low motor function showed poor pulmonary capacity and respiratory muscle weakness. Therefore, clinical manifestations regarding lung capacity and respiratory muscle will be required in children with CP who demonstrate poor physical activity.Key words: Cerebral palsy, Gross motor function, Respiratory muscle strength     

A comparison of the Faces Pain Scale and the Facial Affective Scale for children's estimates of the intensity and unpleasantness of needle pain during blood sampling

To what degree can facial expression scales help children differentiate between the sensory and emotional aspects of the pain experience? This study examined the relationship between children's ratings on the Faces Pain Scale (an intensity measure), the Facial Affective Scale (an affective measure), and a paired mechanical visual analogue (MVAS) method for measuring the intensity and unpleasantness of pain. It was predicted that ratings on the Faces Pain Scale should correlate best with the MVAS measure of pain intensity rather than unpleasantness. Likewise, ratings on the Facial Affective Scale should correlate best with the MVAS measure of pain unpleasantness (assumed to reflect an emotional dimension) rather than intensity. Eighty children scheduled for blood sampling were selected in two age groups: 4 to 6, and 7 to 10 years. Children rated needle pain using each pain scale. As hypothesized, ratings on the Faces Pain Scale correlated more highly with the MVAS ratings for intensity (r = 0.77) than for unpleasantness (r = 0.52). A smaller reverse finding was confirmed for the Facial Affective Scale which correlated more highly with the MVAS for unpleasantness (r = 0.64) than for intensity (r = 0.51). Factor analysis indicated that ‘pain dimension’ (intensity vs affect) was a relatively weak factor as compared with shared instrument variance (two MVAS vs two face scales). No systematic age effects were observed. In conclusion, the Faces Pain Scale and the Facial Affective Scale may partly measure different aspects of the pain experience in children, although it remains to be determined to what degree the obtained differences are clinically meaningful.     

Impact of Threat Level,Task Instruction,and Individual Characteristics on Cold Pressor Pain and Fear among Children and Their Parents

The cold pressor task (CPT) is increasingly used to induce experimental pain in children, but the specific methodology of the CPT is quite variable across pediatric studies. This study examined how subtle variations in CPT methodology (eg. provision of low‐ or high‐threat information regarding the task; provision or omission of maximum immersion time) may influence children's and parents' perceptions of the pain experience. Forty‐eight children (8 to 14 years) and their parents were randomly assigned to receive information about the CPT that varied on 2 dimensions, prior to completing the task: (i) threat level: high‐threat (task described as very painful, high pain expressions depicted) or low‐threat (standard CPT instructions provided, low pain expressions depicted); (ii) ceiling: informed (provided maximum immersion time) or uninformed (information about maximum immersion time omitted). Parents and children in the high‐threat condition expected greater child pain, and these children reported higher perceived threat of pain and state pain catastrophizing. For children in the low‐threat condition, an informed ceiling was associated with less state pain catastrophizing during the CPT. Pain intensity, tolerance, and fear during the CPT did not differ by experimental group, but were predicted by child characteristics. Findings suggest that provision of threatening information may impact anticipatory outcomes, but experienced pain was better explained by individual child variables.     

Children’s perceptions of their cerebral palsy and their impact on life satisfaction

Purpose: To assess an individual child’s cognitive and emotional perceptions of their cerebral palsy (CP) and how these are associated with their reported life satisfaction and their functional walking ability.Method: Convenience sample of 48 children with cerebral palsy, GMFCS (Gross Motor Function Classification System) I-IV, mean age of 12.2 ± 2.5 years was recruited from tertiary level out-patient clinics. All children completed the Brief Illness Perception Questionnaire-Cerebral Palsy version (BIPQ–CP), Students’ Life Satisfaction Scale (SLSS) and 1- and 6-min walk tests.Results: Children with CP reported levels of global life satisfaction (mean score 31.4/42) equivalent to previous studies of typically developing children. Higher total SLSS scores were associated with lower concern about CP (rho = ?0.61, p < 0.001), lower emotional impact (rho = ?0.58, p < 0.001), fewer perceived consequences (rho = ?0.53, p < 0.001) and perceptions of higher levels of personal control (rho = 0.40, p = 0.01). Multiple regression models using BIPQ-CP constructs found that a combination of lower level of concern and fewer perceived consequences predicted 46% of the variance in SLSS score (p < 0.001). GMFCS levels, walk distance and age were not significant predictors of life satisfaction. Conclusions: Life satisfaction in this group of children was strongly associated with a child’s perceptions of their CP but was not associated with functional walking ability. Although the cross-sectional nature of the study precludes assumptions of causality, understanding children’s cognitive and emotional beliefs about their cerebral palsy would seem to be an important adjunct to clinical management.

Implications for Rehabilitation

• Children with cerebral palsy as young as eight years can self-report cognitive and emotional beliefs about their condition.

• The reported degree of concern about cerebral palsy is the strongest predictor of the child’s reported level of life satisfaction.

• Those children with cerebral palsy who do report high levels of concern about their condition also report that they have feelings of reduced personal control and are more affected emotionally, suggesting possible targets for intervention.

     

Functional priorities reported by parents of children with cerebral palsy: contribution to the pediatric rehabilitation process

Background:

Collaborative actions between family and therapist are essential to the rehabilitation process, and they can be a catalyst mechanism to the positive outcomes in children with cerebral palsy (CP).

Objectives:

To describe functional priorities established by caregivers of CP children by level of severity and age, and to assess changes on performance and satisfaction on functional priorities reported by caregivers, in 6-month interval.

Method:

75 CP children, weekly assisted at Associação Mineira de Reabilitação, on physical and occupational therapy services. The following information was collected: gross motor function (Gross Motor Function Classification System-GMFCS) and functional priorities established by caregivers (Canadian Occupational Performance Measure-COPM). Data were collected in two moments, with a 6-month interval.

Results:

The main functional demands presented by caregivers were related to self-care activities (48.2%). Parents of children with severe motor impairment (GMFCS V) pointed higher number of demands related to play (p=0.0036), compared to the other severity levels. Parents of younger children reported higher number of demands in mobility (p=0.025) and play (p=0.007), compared to other age groups. After 6 months, there were significant increase on COPM performance (p=0.0001) and satisfaction scores (p=0.0001).

Conclusions:

Parents of CP children identified functional priorities in similar performance domains, by level of severity and age. Orienting the pediatric rehabilitation process to promote changes in functional priorities indentified by caregivers can contribute to the reinforcement of the parent-therapist collaboration.     

Validation of the numerical rating scale for pain intensity and unpleasantness in pediatric acute postoperative pain: sensitivity to change over time

This study evaluates the construct validity (including sensitivity to change) of the numerical rating scale (NRS) for pain intensity (I) and unpleasantness (U) and participant pain scale preferences in children/adolescents with acute postoperative pain. Eighty-three children aged 8 to 18 years (mean = 13.8, SD = 2.4) completed 3 pain scales including NRS, Verbal Rating Scale (VRS), and faces scales (Faces Pain Scale-Revised [FPS-R] and Facial Affective Scale [FAS], respectively) for pain intensity (I) and unpleasantness (U) 48 to 72 hours after major surgery, and the NRS, VRS and Functional Disability Index (FDI) 2 weeks after surgery. As predicted, the NRSI correlated highly with the VRSI and FPS-R and the NRSU correlated highly with the VRSU and FAS 48 to 72 hours after surgery. The FDI correlated moderately with the NRS at both time points. Scores on the NRSI and NRSU at 48 to 72 hours were significantly higher than at 2 weeks after surgery. Children found the faces scales the easiest to use while the VRS was liked the least and was the hardest to use. The NRS has adequate evidence of construct validity including sensitivity for both pain intensity and unpleasantness. This study further supports the validity of the NRS as a tool to measure both intensity and unpleasantness of acute pain in children. PERSPECTIVE: This article evaluates the construct validity including sensitivity of the Numerical Rating Scale for pain intensity and pain unpleasantness over time in children after major surgery. The NRS could be used by clinicians to assess these 2 different dimensions of children's pain experience in acute pain settings.     

Painful pricks and prickle pains: is there a relation between children's ratings of venipuncture pain and parental assessments of usual reaction to other pains?

OBJECTIVE: The objective of this study was to examine whether parental assessment of a child's usual behavioral reaction to common painful events predicts the child's ratings of needle pain intensity from routine venipuncture. DESIGN: Children aged 3 to 12 years (n = 88) used the Faces Pain Scale to rate how much venipuncture hurt and also indicated whether the pain was more, less, or the same as expected. The child's parent (mother) used the same scale to predict how much the needle would hurt the child as well as to rate the child's pain as observed at the time of venipuncture. Parents also estimated their child's usual reaction to six common painful events. An independent observer used a behavioral checklist to rate the child's pain response at the time of venipuncture as well as to assign a global pain rating on the Faces Pain Scale. OUTCOME MEASURES: The Faces Pain Scale and a behavioral checklist (scoring facial, vocal, motor, and verbal reactions) were used in this study. RESULTS AND CONCLUSIONS: Those children who reported venipuncture as hurting more than expected also gave the highest mean needle pain ratings and tended to have their pain underpredicted by their parents before venipuncture. For these children, parental estimates of reactions to other painful events proved to be a useful predictor of self-reported needle pain. Parent and child ratings of pain agreed more closely for those parents who indicated having relied on what their child "did" rather than "said." Additionally, and consistent with previous studies, independent observation of children's facial responses was the most useful indicator of needle pain severity. Preparation of children for venipuncture may be enhanced by asking a parent beforehand how the child usually responds to everyday pain. Specifically, reaction to other sharp time-limited pains (e.g., finger pinch, stepping on a prickle) may provide a useful guide to identifying which children will report experiencing greater pain than expected from venipuncture.     

Pain,Fatigue, Family Functioning,and Attitude Toward Illness in Children with Juvenile Rheumatic Diseases

Pain and fatigue adversely affect the physical and psychosocial functioning of children with Juvenile Rheumatic Diseases (JRDs). Research investigating relations among disease severity and family functioning has produced mixed results. There is scant research examining the relations among illness attitudes and disease severity. Children (50 girls and 32 boys) with a JRD and their parents participated in this study. Parents completed a scale assessing family functioning and children completed information about their experience of pain and fatigue and attitude toward their illness. Regression analyses indicated that children experiencing more pain and fatigue were apt to hold negative attitudes toward their illness, and that parents reported lower family functioning when children were experiencing higher levels of fatigue. Research examining relations among child and reports of family functioning and children’s attitudes toward their illness will provide information for health care teams serving these children and their families.     

Reframe the Pain: A Randomized Controlled Trial of a Parent-Led Memory-Reframing Intervention

Negatively-biased pain memories (ie, recalling more pain as compared to earlier reports) are a robust predictor of future pain experiences. This randomized controlled trial examined the efficacy of a memory-reframing intervention to reframe children's pain memories. Sixty-five children (54% girls, M_age=5.35 years) underwent a tonsillectomy and reported their levels of post-surgical pain intensity and pain-related fear. 2 weeks post-surgery, children and 1 of their parents were randomized to the memory-reframing intervention or control group. Following control/intervention instructions, parents and children reminisced about the past surgery as they normally would (control) or using the memory-reframing strategies (intervention). Children recalled their post-surgical pain intensity and pain-related fear one week later. Parents reported the intervention's acceptability. Recruitment statistics were used to assess feasibility. Controlling for initial pain intensity ratings and using the Faces Pain Scale Revised, children in the intervention group reported more accurate/positively-biased memories for day 1 post-surgery pain intensity (M = 2.60/10; 95% CI, 1.62 to 3.68), compared to children in the control group (M = 4.11/10; 95% CI, 3.12 to 5.03), η_p² = .07, p = .040. The intervention was acceptable and feasible. Optimal parent-child reminiscing about a past pain experience resulted in children remembering their pain more accurately/positively. Clinicaltrials.gov:NCT03538730.PerspectiveThis article presents results of the first randomized controlled trial examining the efficacy of parent-led memory-reframing intervention to change children's memories for pain. Children of parents who were taught and engaged in optimal reminiscing about a past surgery experience remembered their pain intensity more accurately/positively.