Effectiveness of selective muscle-release surgery for children with cerebral palsy: longitudinal and stratified analysis

The purpose of this study was to determine the effectiveness of muscle-release surgery for children with cerebral palsy (CP) using longitudinal and stratified analysis. Twenty-five children with CP (15 females, 10 males; age range 4 to 16 years; mean age 8 years 2 months, SD 3 years 2 months) were selected from five treatment centres in Japan. Twenty-two children had spastic diplegia, two had spastic quadriplegia, and one had athetospastic quadriplegia. Motor function for each child was assessed using the Gross Motor Function Measure (GMFM). Assessment was conducted on eight separate occasions: 1 month and 1 week before surgery, and 1, 2, 4, 6, 9, and 12 months after surgery. Participants' motor function before surgery was classified using the Gross Motor Function Classification System (GMFCS). Six children were classified at level I, three at level II, six at level III, and 10 at level IV. A significant difference was found after surgery in the GMFCS levels III and IV groups (p<0.05). Improvement in GMFM scores between 1 week before surgery and 12 months after surgery were 1, 5, 8.5, and 8.5 for GMFCS levels I to IV respectively. Results indicate that this treatment is advantageous for improving motor function in children within GMFCS levels III and IV.     

Gross and fine motor function and accompanying impairments in cerebral palsy

The aim of this study was to describe and analyze gross and fine motor function and accompanying neurological impairments in children with cerebral palsy (CP) born between 1991 and 1998 in western Sweden. A population-based study comprised 411 children with a diagnosis of CP ascertained at 4 to 8 years of age. Gross Motor Function Classification System (GMFCS) levels were documented in 367 children (205 males, 162 females). Bimanual Fine Motor Function (BFMF) classification levels of 345 of the children and information on learning disability, epilepsy, visual and hearing impairments, and hydrocephalus from 353 children were obtained. For spastic CP, a new classification according to the Surveillance of Cerebral Palsy in Europe of uni- and bilateral spastic CP was applied. GMFCS was distributed at Level I in 32%, Level II in 29%, Level III in 8%, Level IV in 15%, and Level V in 16%. The corresponding percentages for BFMF were 30.7%, 31.6%, 12.2%, 11.9%, and 13.6% respectively. Learning disability was present in 40%, epilepsy in 33%, and severe visual impairment in 19% of the children. Motor function differed between CP types. More severe GMFCS levels correlated with larger proportions of accompanying impairments and, in children born at term, to the presence of adverse peri/neonatal events in the form of intracranial haemorrhage/stroke, cerebral infection, and hypoxic-ischaemic encephalopathy. GMFCS Level I correlated positively to increasing gestational age. We conclude that the classification of CP should be based on CP type and motor function, as the two combine to produce an indicator of total impairment load.     

Testing of the spinal alignment and range of motion measure: a discriminative measure of posture and flexibility for children with cerebral palsy

In this study we describe the development and preliminary psychometric testing of the Spinal Alignment and Range of Motion Measure (SAROMM). Through consultation with pediatric physiotherapists, the items were refined. Subsequently 25 children and adolescents with cerebral palsy (CP; 17 males, 8 females) with a mean age of 9 years 8 months (SD 4y 4mo), stratified by the Gross Motor Function Classification System (GMFCS, n=5 in each group), were recruited. Twenty-two children had spastic CP, and one each was also diagnosed with hypotonic, athetoid, and mixed CP. Three children had hemiplegia, 12 had diplegia, and 10 had quadriplegia. These participants were examined by two physiotherapists on one occasion and by the primary physiotherapist again two weeks later. The intraclass correlation coefficients reflecting interrater and test-retest reliabilities for the spine and range of motion subscales and the total scores were all above 0.80. Validity was supported by a significant contribution of GMFCS level and age to the SAROMM score (r2=0.44). The SAROMM has sufficient reliability and validity for use with children with CP in clinical and research settings by rehabilitation therapists.     

Horseback riding in children with cerebral palsy: effect on gross motor function

The effects of recreational horseback riding therapy (HBRT) on gross motor function in children with cerebral palsy (CP: spastic diplegia, spastic quadriplegia, and spastic hemiplegia) were determined in a blinded study using the Gross Motor Function Measure (GMFM). Seventeen participants (nine females, eight males; mean age 9 years 10 months, SE 10 months) served as their own control. Their mean Gross Motor Function Classification System score was 2.7 (SD 0.4; range 1 to 5). HBRT was 1 hour per week for three riding sessions of 6 weeks per session (18 weeks). GMFM was determined every 6 weeks: pre-riding control period, onset of HBRT, every 6 weeks during HBRT for 18 weeks, and 6 weeks following HBRT. GMFM did not change during pre-riding control period. GMFM Total Score (Dimensions A-E) increased 7.6% (p<0.04) after 18 weeks, returning to control level 6 weeks following HBRT. GMFM Dimension E (Walking, Running, and Jumping) increased 8.7% after 12 weeks (p<0.02), 8.5% after 18 weeks (p<0.03), and remained elevated at 1.8% 6 weeks following HBRT (p<0.03). This suggests that HBRT may improve gross motor function in children with CP, which may reduce the degree of motor disability. Larger studies are needed to investigate this further, especially in children. with more severe disabilities. Horseback riding should be considered for sports therapy in children with CP.     

Age‐related changes in energy efficiency of gait,activity, and participation in children with cerebral palsy

Aim The aim of this study was to use a prospective longitudinal study to describe age‐related trends in energy efficiency during gait, activity, and participation in ambulatory children with cerebral palsy (CP). Method Gross Motor Function Measure (GMFM), Paediatric Evaluation of Disability Inventory (PEDI), and Lifestyle Assessment Questionnaire‐Cerebral Palsy (LAQ‐CP) scores, and energy efficiency (oxygen cost) during gait were assessed in representative sample of 184 children (112 male; 72 female; mean age 10y 9mo; range 4–16y) with CP. Ninety‐four children had unilateral spastic CP, 84 bilateral spastic CP, and six had other forms of CP. Fifty‐seven were classified as Gross Motor Function Classification System (GMFCS) level I, 91 as level II, 22 as level III, and 14 as level IV). Assessments were carried out on two occasions (visit 1 and visit 2) separated by an interval of 2 years and 7 months. A total of 157 participants returned for reassessment. Results Significant improvements in mean raw scores for GMFM, PEDI, and LAQ‐CP were recorded; however, mean raw oxygen cost deteriorated over time. Age‐related trends revealed gait to be most inefficient at the age of 12 years, but GMFM scores continued to improve until the age of 13 years, and two PEDI subscales to age 14 years, before deteriorating (p<0.05). Baseline score was consistently the single greatest predictor of visit 2 score. Substantial agreement in GMFCS ratings over time was achieved (κ_lw=0.74–0.76). Interpretation These findings have implications in terms of optimal provision and delivery of services for young people with CP to maximize physical capabilities and maintain functional skills into adulthood.     

Intrathecal baclofen and motor function in cerebral palsy

Aim The aim of this retrospective analysis was to determine the impact of intrathecal baclofen (ITB) therapy on motor function in patients with cerebral palsy (CP). Method We studied 37 patients (18 males, 19 females) with CP treated with ITB (mean age at implant 13y 7mo, SD 7y). Eighteen patients were affected by spastic diplegia, 12 by spastic quadriplegia, six by dystonic quadriplegia, and one by hemidystonia. Nine participants were in Gross Motor Function Classification System (GMFCS) level II, 13 in level III, seven in level IV, and eight in level V. Motor function was assessed by the Gross Motor Function Measure (GMFM) before the treatment and 12 months after the implant. Results The collected data showed an increase in the total median GMFM score in the overall population (p<0.001) and in every GMFM dimension (p<0.05) except for dimension D (standing). The analysis by degree of impairment revealed that patients with severe impairment and those with mild to moderate impairment improved the total median GMFM score (p<0.001 and p<0.05 respectively). Analysis by age showed that the best improvements in GMFM scores were reached by patients younger than 18 years old (p<0.05). Spasticity and dystonia, assessed by means of the Ashworth and Barry–Albright Dystonia scales, significantly decreased 12 months after the implant (p<0.001 and p<0.05 respectively). Finally, a subjective questionnaire administered to patients/caregivers revealed an overall improvement in participants’ functional abilities. Interpretation The results suggest that ITB therapy is an effective treatment for managing spasticity and dystonia, and for improving motor function in children with CP.     

Relationship between gross motor capacity and daily‐life mobility in children with cerebral palsy

Aim The aim of this study was to examine the relationship between gross motor capacity and daily‐life mobility in children with cerebral palsy (CP) and to explore the moderation of this relationship by the severity of CP. Method Cross‐sectional analysis in a cohort study with a clinic‐based sample of children with CP (n=116; 76 males, 40 females; mean age 6y 3mo, SD 12mo, range 4y 8mo–7y 7mo) was performed. Gross motor capacity was assessed by the Gross Motor Function Measure (GMFM‐66). Daily‐life mobility was assessed using the Pediatric Evaluation of Disability Inventory (PEDI): Functional Skills Scale (FSS mobility) and Caregiver Assistance Scale (CAS mobility). Severity of CP was classified by the Gross Motor Function Classification System (48% level I, 17% level II, 15% level III, 8% level IV, 12% level V), type of motor impairment (85% spastic, 12% dyskinetic, 3% ataxic), and limb distribution (36% unilateral, 49% bilateral spastic). Results Scores on the GMFM‐66 explained 90% and 84% respectively, of the variance of scores on PEDI‐FSS mobility and PEDI‐CAS mobility. Limb distribution moderated the relationship between scores on the GMFM‐66 and the PEDI‐FSS mobility, revealing a weaker relationship in children with unilateral spastic CP (24% explained variance) than in children with bilateral spastic CP (91% explained variance). Interpretation In children aged 4 to 7 years with unilateral spastic CP, dissociation between gross motor capacity and daily‐life mobility can be observed, just as in typically developing peers.     

Validity of a 1 minute walk test for children with cerebral palsy

The concurrent validity of a 1 minute walk test at a child's maximum walking speed was assessed in children with bilateral spastic cerebral palsy (BSCP). The distance covered during the 1 minute walk test was compared with the children's gross motor function as assessed by the Gross Motor Function Measure (GMFM). Twenty-four male and 10 female children with CP (mean age 11y, range 4 to 16y) participated in the study. Gross Motor Function Classification System (GMFCS) levels were; level I (n=3), level II (n=17), level III (n=10), and level IV (n=4). Participants had clinical diagnoses of symmetrical diplegia (n=19), asymmetrical diplegia (n=14), and quadriplegia (n=1). Results showed a significant correlation between GMFM score and the distance covered during the 1 minute walk (r=0.92; p<0.001). There was also a significant decrease in the distance walked with increasing GMFCS level (p<0.001). We concluded that the 1 minute walk test is a valid measure for assessing functional ability in children with ambulatory BSCP. Its cost-effectiveness and user friendliness make it a potentially useful tool in the clinical setting. Further study needs to address its reliability and ability to detect change over time.     

Stability of the Gross Motor Function Classification System after single‐event multilevel surgery in children with cerebral palsy

Aim There are conflicting reports about the stability of the Gross Motor Function Classification System (GMFCS) in children with cerebral palsy (CP) after orthopaedic surgery. We studied the stability of the GMFCS in children with bilateral spastic CP after single‐event multilevel surgery, using the Gait Profile Score (GPS) as the primary outcome measure. Method This was a retrospective cohort study of 107 children (46 females, 61 males) with bilateral spastic CP, classified as GMFCS level II or III, who underwent surgery at a single tertiary institution between 1997 and 2008. The mean age at surgery was 10 years 7 months (SD 2y 8mo). The primary outcome measure was the GPS. Changes in GMFCS level were studied at multiple time points before and after intervention. Results Gait dysfunction was partially corrected, with a mean improvement of 28% in the GPS. The GMFCS remained stable and unchanged in 95% of children and improved by one level in 5% of children. The improvement in GPS was three times the minimal clinically important difference. The mean age at final postoperative GPS assessment was 11 years 10 months (SD 2y 10mo) and at final GMFCS assessment was 15 years 7 months (SD 3y 9mo). Interpretation Stability of the GMFCS was confirmed in the majority of children with bilateral spastic CP after single‐event multilevel surgery, despite statistically and clinically significant improvements in gait dysfunction and functional mobility. This information is important in realistic goal‐setting and in counselling families.     

Stability of the Gross Motor Function Classification System in adults with cerebral palsy

To determine the stability of Gross Motor Function Classification System (GMFCS) levels between approximately 12 years of age and adulthood (i.e. > 16y) using a matched chart review. Adult health records from the Ottawa Rehabilitation Centre were matched with childhood health records from the Ottawa Children's Treatment Centre (OCTC). Health records were available for 103 adults (52 males, 51 females) with cerebral palsy (CP; age range 17-38y; mean age 22y [SD 4y]) who had also been seen at the OCTC at a mean age of 12 years (SD 1y). GMFCS levels as adults were: Level I, n= 10; Level II, n= 24; Level III, n= 21; Level IV, n= 30; and Level V, n= 18. Adult participants were classified using the GMFCS at the time they were last seen by a rehabilitation specialist, sometime between June 2002 and June 2005. Corresponding paediatric charts were reviewed and classified by two independent raters blinded to the adult GMFCS levels. GMFCS levels around age 12 were: Level I, n= 20; Level II, n= 13; Level III, n= 22; Level IV, n= 35; and Level V, n= 13. Interrater reliability for childhood health records was determined with a quadratic weighted kappa and was 0.978. Stability of GMFCS levels was also assessed using the quadratic weighted kappa and was 0.895. The positive predictive value of the GMFCS at 12 years of age to predict walking without mobility aids by adulthood is 0.88. If the child is a wheelchair user at around age 12 years, the positive predictive value is 0.96 that the individual will still be a wheelchair user as an adult. This study supports previous findings that interrater reliability when using the GMFCS is very high. It also shows that the GMFCS level observed around the age of 12 years is highly predictive of adult motor function. This provides important information for individuals with CP, their families, and care providers as they plan for future care needs and rehabilitation intervention.     

Comparison of the Gross Motor Function Measure and Paediatric Evaluation of Disability Inventory in assessing motor function in children undergoing selective dorsal rhizotomy

This study was designed to compare assessment with the functional outcome measures Gross Motor Function Measure (GMFM) and Pediatric Evaluation of Disability Inventory (PEDI) over time, in children with cerebral palsy (CP) undergoing selective dorsal rhizotomy combined with individualised physiotherapeutic interventions. Using the Gross Motor Function Classification System (GMFCS), 18 children with spastic diplegia were divided into two groups according to age-related severity of motor function impairment. Data were collected preoperatively, and at 6 and 12 months postoperatively. Both instruments were sensitive to changes in function over time in the series as a whole and in the group with milder impairment, although the PEDI detected significant changes earlier. In the group with more severe impairment, changes in function were detected only with the PEDI, not with the GMFM. Thus, the instruments are to be considered complementary tests, because they measure different aspects of function.     

Self‐care and mobility skills in children with cerebral palsy,related to their manual ability and gross motor function classifications

Aim The aim of this study was to investigate the acquisition of self‐care and mobility skills in children with cerebral palsy (CP) in relation to their manual ability and gross motor function. Method Data from the Pediatric Evaluation of Disability Inventory (PEDI) self‐care and mobility functional skill scales, the Manual Ability Classification System (MACS), and the Gross Motor Function Classification System (GMFCS) were collected from 195 children with CP (73 females, 122 males; mean age 8y 1mo; SD 3y 11mo; range 3–15y); 51% had spastic bilateral CP, 36% spastic unilateral CP, 8% dyskinetic CP, and 3% ataxic CP. The percentage of children classified as MACS levels I to V was 28%, 34%, 17%, 7%, and 14% respectively, and classified as GMFCS levels I to V was 46%, 16%, 15%, 11%, and 12% respectively. Results Children classified as MACS and GMFCS levels I or II scored higher than children in MACS and GMFCS levels III to V on both the self‐care and mobility domains of the PEDI, with significant differences between all classification levels (p<0.001). The stepwise multiple regression analysis verified that MACS was the strongest predictor of self‐care skills (66%) and that GMFCS was the strongest predictor of mobility skills (76%). A strong correlation between age and self‐care ability was found among children classified as MACS level I or II and between age and mobility among children classified as GMFCS level I. Many of these children achieved independence, but at a later age than typically developing children. Children at other MACS and GMFCS levels demonstrated minimal progress with age. Interpretation Knowledge of a child’s MACS and GMFCS level can be useful when discussing expectations of, and goals for, the development of functional skills.     

The Functional Mobility Scale: ability to detect change following single event multilevel surgery

The aim of this study was to examine the ability of the Functional Mobility Scale (FMS) to detect change in children with cerebral palsy (CP) undergoing single event multilevel surgery (SEMLS). A retrospective study was conducted of gait laboratory records and video assessments for a consecutive sample of children with CP aged 4 to 18 years who were managed by multilevel surgery. FMS ratings and Gross Motor Function Classification System (GMFCS) levels were recorded preoperatively and at regular postoperative time points. The sample comprised 66 children (32 females, 34 males) with spastic diplegia, GMFCS Levels I (n=18), II (n=24), and III (n=24). The mean age at surgery was 10 years (SD 2y 6mo, range 6-16y). For each FMS distance (5, 50, and 500m) odds ratios showed significant deterioration in mobility at 3 and 6 months postoperatively. Mobility then improved to baseline levels by 12 months and improved further by 24 months postoperatively. GMFCS level remained stable throughout most of the postoperative period for children classified as GMFCS Level III preoperatively but not for children classified as Levels I or II. The FMS was found to be a clinically feasible tool for quantifying change after SEMLS in children with CP.     

The relationship of cerebral palsy subtype and functional motor impairment: a population-based study

Aim  Traditionally, cerebral palsy (CP) had been classified according to the distribution and quality of motor impairment. A standardized functional classification of gross motor skills has recently been validated – the Gross Motor Function Classification System (GMFCS). The relationship between the neurological subtype of CP and GMFCS level remains undefined in CP.
Method  The Quebec Cerebral Palsy Registry (Registre de la paralysie cérébrale au Québec [REPACQ]) over a 4-year birth interval (1999–2002 inclusive) identified 301 children with CP. Information on both CP subtype and GMFCS level was available for 243 children (138 males, 105 females) with final data extraction at a mean age of 44 months (SD 14mo, range 24–79mo). Proportions of children with a particular CP subtype at GMFCS levels I to III versus levels IV to V were determined and compared.
Results  CP subtype versus GMFCS levels I to III or IV to V was distributed proportionally as follows: spastic diplegic, 51/52 (98%) versus 1/52 (2%); spastic quadriparetic, 20/85 (24%) versus 65/85 (76%); spastic hemiplegic, 76/77 (99%) versus 1/77 (1%); dyskinetic, 4/16 (25%) versus 12/16 (75%); other (triplegic or ataxic–hypotonic), 10/13 (77%) versus 3/13 (23%). These distributions (proportions) all yielded significant ( p <0.001) Pearson χ² values.
Interpretation Neurological subtype is a powerful predictor of functional status related to ambulation. This has implications for counseling families.     

Early motor repertoire is related to level of self-mobility in children with cerebral palsy at school age

Aim  To determine the predictive value of the early motor repertoire for the level of self-mobility in children with cerebral palsy (CP) at school age.
Method  Video recordings were made at 11 to 17 weeks post-term of 37 preterm infants (20 males, 17 females) who later developed CP. The early motor repertoire was assessed by obtaining a motor optimality score. At 6 to 12 years, children were classified according to the Gross Motor Function Classification System (GMFCS).
Results  Of 37 children (mean gestational age 29.1wks, SD 1.9; mean birthweight 1273g, SD 324), nine had unilateral and 28 had bilateral spastic CP. Twelve children were in GMFCS level I, three level II, 10 level III, four level IV, and eight level V. The absence of the age-adequate motor repertoire, a cramped motor repertoire, an abnormal kicking pattern, and a non-flat supine posture were associated with lower levels of self-mobility (χ² for trend test, p <0.05). Predictive for a low level of self-mobility was a cramped motor repertoire/non-flat supine posture (positive predictive values [PPV] 100%, negative predictive values [NPV] 54%). Predictive for a high level of self-mobility was a non-cramped repertoire/flat supine posture (PPV 80%, NPV 74%).
Interpretation  Several aspects of the motor repertoire at 11 to 17 weeks post-term predicted the degree of functional limitations in children with CP at school age.     

Selective Control Assessment of the Lower Extremity (SCALE): development,validation, and interrater reliability of a clinical tool for patients with cerebral palsy

Normal selective voluntary motor control (SVMC) can be defined as the ability to perform isolated joint movement without using mass flexor/extensor patterns or undesired movement at other joints, such as mirroring. SVMC is an important determinant of function, yet a valid, reliable assessment tool is lacking. The Selective Control Assessment of the Lower Extremity (SCALE) is a clinical tool developed to quantify SVMC in patients with cerebral palsy (CP). This paper describes the development, utility, validation, and interrater reliability of SCALE. Content validity was based on review by 14 experienced clinicians. Mean agreement was 91.9% (range 71.4–100%) for statements about content, administration, and grading. SCALE scores were compared with Gross Motor Function Classification System Expanded and Revised (GMFCS‐ER) levels for 51 participants with spastic diplegic, hemiplegic, and quadriplegic CP (GMFCS levels I – IV, 21 males, 30 females; mean age 11y 11mo [SD 4y 9mo]; range 5–23y). Construct validity was supported by significant inverse correlation (Spearman's r=‐0.83, p<0.001) between SCALE scores and GMFCS levels. Six clinicians rated 20 participants with spastic CP (seven males, 13 females, mean age 12y 3mo [SD 5y 5mo], range 7–23y) using SCALE. A high level of interrater reliability was demonstrated by intraclass correlation coefficients ranging from 0.88 to 0.91 (p<0.001).     

Motor function after selective dorsal rhizotomy: a 10-year practice-based follow-up study

Aim The aim of this study was to explore changes in motor function up to 10 years after selective dorsal rhizotomy (SDR). Method The participants comprised 29 children (20 males, nine females) with bilateral spastic diplegia who were consecutively operated on at a median age of 4 years and 3 months and followed until a median age of 15 years. SDR was combined with physiotherapy and regular follow‐up visits. The distribution of preoperative Gross Motor Function Classification System (GMFCS) levels was as follows: I, n=1; II, n=7; III, n=8; IV, n=12; and V, n=1. Muscle tone in hip flexors, hip adductors, knee flexors, and plantar flexors was assessed with the modified Ashworth scale, passive range of motion in hip abduction, popliteal angle, maximum knee extension, dorsiflexion of the foot was measured with a goniometer, and gross motor function was assessed using the Gross Motor Function Measure (GMFM‐66). The results were compared with preoperative values, taking into account age at the time of SDR. Results After 10 years, muscle tone in hip flexors, hip adductors, knee flexors and plantar flexors was normalized in 19, 24, 13 and 23 participants respectively; mean change in passive range of motion ranged from ?2.0° to 8.6°, and the mean increase in GMFM‐66 was 10.6. Changes in GMFM‐66 were associated with preoperative GMFCS level and GMFM‐66 scores. Interpretation Children who underwent SDR and physiotherapy and were regularly followed up by an experienced team showed improved gross motor function for up to 10 years postoperatively.     

Relation between physical fitness and gross motor capacity in children and adolescents with cerebral palsy

Aim  To examine the relation between physical fitness and gross motor capacity in children with cerebral palsy (CP) who were classified in Gross Motor Function Classification System levels I or II.
Method  In total, 68 children with CP (mean age 12y 1mo, SD 2y 8mo; 44 males, 24 females; 45 classified as having spastic unilateral CP, 23 as having spastic bilateral CP) participated in this study. All participants performed a maximal aerobic exercise test (10m Shuttle Run Test), a short-term muscle power test (Muscle Power Sprint Test), an agility test (10×5m sprint test), and a functional muscle strength test (30s repetition maximum) within 2 weeks. Gross motor capacity was concurrently assessed using dimensions D (standing) and E (walking, running, and jumping) of the 88-item version of the Gross Motor Function Measure (GMFM).
Results  No relation between aerobic capacity, body mass index, and dimensions D and E of the GMFM was found. The correlations between short-term muscle power, agility, functional muscle strength, and dimensions D and E of the GMFM were moderate to high ( r ∼0.6–0.7).
Interpretation  The relations found between short-term muscle power, agility, functional muscle strength, and gross motor capacity indicate the importance of these components of physical fitness, and may direct specific interventions to maximize gross motor capacity in children and adolescents with CP.     

Comparison of efficacy of Adeli suit and neurodevelopmental treatments in children with cerebral palsy

This study compared the efficacy of Adeli suit treatment (AST) with neurodevelopmental treatment (NDT) in children with cerebral palsy (CP). Twenty-four children with CP, Levels II to IV according to the Gross Motor Function Classification System (GMFCS), were matched by age and functional status and randomly assigned to the AST or NDT treatment groups. In the AST group (n=12; eight males, four females; mean age 8.3 y [SD 2.0]), six children had spastic/ataxic diplegia, one triplegia and five spastic/mixed quadriplegia. In the NDT group (n=12; nine males, three females; mean age 8.1 y [SD 2.2]), five children had spastic diplegia and seven had spastic/mixed quadriplegia. Both groups were treated for 4 weeks (2 hours daily, 5 days per week, 20 sessions). To compare treatments, the Gross Motor Function Measure (GMFM-66) and the mechanical efficiency index (EIHB) during stair-climbing were measured at baseline, immediately after 1 month of treatment, and 10 months after baseline. The small but significant time effects for GMFM-66 and EIHB that were noted after 1 month of both intensive physiotherapy courses were greater than expected from natural maturation of children with CP at this age. Improvements in motor skills and their retention 9 months after treatment were not significantly different between the two treatment modes. Post hoc analysis indicated a greater increase in EIHB after 1 month (p=0.16) and 10 months (p=0.004) in AST than that in NDT, predominantly in the children with higher motor function (GMFCS Levels II and III). The results suggest that AST might improve mechanical efficiency without a corresponding gain in gross motor skills, especially in children with higher levels of motor function.     

Reliability and validity of the Trunk Impairment Scale in children and adolescents with cerebral palsy

Standardized clinical tools are useful for treatment planning and evaluation, however clinical tools to assess quality in trunk movements in children with cerebral palsy (CP) are sparse. We have recently reported good intra- and inter-observer reliability of the Trunk Impairment Scale (TIS) in 5–12 year old children with CP. The aim of this study was to assess reliability in adolescents (13–19 years old), and to assess the construct validity in children and adolescents in the whole age spectrum from 5 to 19 years. Video recordings of 17 children with CP with Gross Motor Function Classification (GMFCS) level I–IV were analyzed by three observers on two occasions. For construct validity the TIS was compared with Gross Motor Function Measure (GMFM), in 37 children with GMFCS levels I–IV. Intraclass correlation coefficients varied between 0.82 and 0.98, and 86% of the kappa values varied between 0.61 and 1.00, suggesting high inter- and intra-observer reliability. The smallest detectable difference (SDD) of the TIS (scale range 0–23) varied between 2.55 and 3.82 for intra- and 4.07–8.23 for inter-observer observations. The high inter-observer SDD was partly due to consistently lower TIS scores by one observer. The correlation between the TIS total score and the dimension scores of the GMFM was high (Spearman's rho: 0.80–0.87), while decreasing GMFCS levels were associated with increasing total TIS score; both findings indicating good construct validity of the TIS. This study suggests that the TIS is a reliable and valid measure of trunk control for both children and adolescents with cerebral palsy.