Inter-rater agreement of the Arabic Gross Motor Classification System Expanded & Revised in children with cerebral palsy in Jordan

Abstract

Purpose: To examine the agreement among parents-report, research physiotherapists-report, and clinical physiotherapists-report using the Arabic-Gross Motor Classification System Expanded & Revised (GMFCS E&R) in classifying Jordanian children with cerebral palsy (CP). Methods: One-hundred and sixteen child with CP [mean age 4 years 7 months (SD?=?4 years 5 months)] participated in the study. Parents were asked to classify their children using the Arabic-GMFCS family report questionnaires. Clinical and research physiotherapists were asked to classify children using the Arabic-GMFCS E&R. Agreement between respondents was determined using Cohen’s linear weighted kappa statistic. Results: An excellent level of agreement was reported between research physiotherapists and clinical physiotherapists, substantial level of agreement between parents and research physiotherapists and moderate agreement between parents and clinical physiotherapists. Conclusions: The Arabic-GMFCS E&R is a reliable classification system that can be administrated by health care providers and parents of children with CP in Jordan to help plan services for children.

• Implications for Rehabilitation

• The Arabic GMFCS E&R is a reliable and user friendly system that can be administrated by health care providers and parents of children with CP in Jordan to guide services planning.

• Classifying the children with CP should be performed by the team members (including the family and the children when they are transitioning from childhood to adulthood) independently first, then discussed among and consensus can be reached.

• The Arabic GMFCS E& R is a reliable classification system that can be used in Jordanian health care system despite the fact that therapists who practice in these settings were not familiar with this classification.

     

Agreement between parents and clinicians for the motor functional classification systems of children with cerebral palsy

Purpose.?This study aimed to evaluate whether parental ratings of expanded and revised Gross Motor Function Classification System (GMFCS E&R) and Manual Ability Classification System (MACS) had agreement with clinicians’ ratings when classifying children with CP to these two well-known classifications of motor functioning and hereby to evaluate intertester reliability of the classification systems between clinicians and parents.

Method.?The process of study was designed to collect data from parents using the GMFCS E&R and MACS. The total participants consisted of 100 children with CP and their parents. The overall agreement between the parents and physiotherapist GMFCS and MACS scores was analysed using intraclass correlation coefficient (ICC).

Results.?The ICC value between parents and physiotherapist was 0.96 (95%% confidence interval [CI] 0.95–0.97) for GMFCS and 0.96 (95%% CI 0.94–0.97) for MACS and indicated excellent agreement.

Conclusions.?The excellent agreement between parents and clinicians indicated that parents and clinicians can talk in the same language for the motor functional classification systems of children with CP if careful administrations are provided.     

Reliability of GMFCS family report questionnaire

Purpose: To examine the reliability of the web-based GMFCS Family Report Questionnaire (GMFCS-FR) between 8 and 11 years old children, compared with the GMFCS-Expanded and Revised (GMFCS-E&R). Method: The GMFCS-FR was translated from the English GMFCS-FR into Danish after the CanChild guidelines; only the order of levels was chosen like in the GMFCS-E&R. Families of 30 children with spastic and dystonic cerebral palsy (age from 8 to 11 years, randomly selected from a cerebral palsy register) answered the GMFCS-FR and were later interviewed by two physiotherapists. Participants and non-responders were compared on basic parameters available from the Danish CP register. Inter-rater agreement and weighted κ was calculated in order to compare the translated GMFCS-FR with physiotherapist’s applied GMFCS-E&R. Results: The inter-rater agreement between the GMFCS-FR in Danish and the GMFCS-E&R was high (76%) and misclassification was minimal. There was a good agreement on the same or nearby levels (weighted κ?=?0.76 and 0.81). The family rated the same or less ability, when compared with trained physiotherapists. Conclusion: The GMFCS-FR is a reliable tool for GMFCS evaluation among 8–11 years old Danish children with CP. The tendency for less-ability rating by families is important when performing and comparing results from epidemiological studies based on GMFCS-FR and GMFCS-E&R.

Implications for Rehabilitation

• GMFCS Family Report Questionnaire for 6 to 12 years old children is a reliable tool for GMFCS evaluation of children with cerebral palsy.

• The tendency for less-ability rating by families, compared to rating by physiotherapist, is important for applying GMFCS in epidemiological studies on cerebral palsy.

     

Oropharyngeal dysphagia in children with cerebral palsy: comparisons between a high- and low-resource country

Purpose: There is paucity of research investigating oropharyngeal dysphagia (OPD) in young children with cerebral palsy (CP), and most studies explore OPD in high-resource countries. This study aimed at determining the proportion and severity of OPD in preschool children with CP in Bangladesh, compared to Australia.

Method: Cross-sectional, comparison of two cohorts. Two hundred and eleven children with CP aged 18–36 months, 81 in Bangladesh (mean?=?27.6 months, 61.7% males), and 130 in Australia (mean?=?27.4 months, 62.3% males). The Dysphagia Disorders Survey (DDS) – Part 2 was the primary OPD outcome for proportion and severity of OPD. Gross motor skills were classified using the Gross Motor Function Classification System (GMFCS), motor type/distribution.

Results: (i) Bangladesh sample: proportion OPD?=?68.1%; severity?=?10.4 SD?=?7.9. Australia sample: proportion OPD?=?55.7%; severity?=?7.0 SD?=?7.5. (ii) There were no differences in the proportion or severity of OPD between samples when stratified for GMFCS (OR?=?2.4, p?=?0.051 and β?=?1.2, p?=?0.08, respectively).

Conclusions: Despite overall differences in patterns of OPD between Bangladesh and Australia, proportion and severity of OPD (when adjusted for the functional gross motor severity of the samples) were equivalent. This provides support for the robust association between functional motor severity and OPD proportion/severity in children with CP, regardless of the resource context.

• Implications for Rehabilitation

• The proportion and severity of OPD according to gross motor function level were equivalent between high- and low-resource countries (LCs).

• Literature from high-resource countries may be usefully interpreted by rehabilitation professionals for low-resource contexts using the GMFCS as a framework.

• The GMFCS is a useful classification in LCs to improve earlier detection of children at risk of OPD and streamline management pathways for optimal nutritional outcomes.

• Rehabilitation professionals working in LCs are likely to have a caseload weighted towards GMFCS III–V, with less compensatory OPD management options available (such as non-oral nutrition through tubes).

     

Factor analysis of the WeeFIM in children with spastic cerebral palsy

Purpose: Determining the psychometric properties such as reliability and validity of Functional Independence Measure for Children (WeeFIM) instrument would help health professionals to understand the comprehensive assessment of children with spastic cerebral palsy (CP). The purpose of this study was to investigate the factor structure of the WeeFIM in children with spastic CP. Methods: Two hundred seven children (138 boys, 69 girls) with spastic CP were recruited in this cross-sectional study; their mean age (SD) was 9.10 (2.7) years. Data were collected through a questionnaire that included the WeeFIM. Of the 207 children, 57 (27%), 105 (51%), and 45 (22%) were quadriplegic, diplegic, and hemiplegic, respectively. In each of these groups, 49 (24%), 32 (15%), 31 (15%), 19 (9%), and 76 (37%) children were classified as Gross Motor Function Classification System (GMFCS) levels I–V, respectively. The factor structure of the WeeFIM was analyzed by exploratory factor analysis (EFA) and confirmatory factor analysis (CFA) by using AMOS 20.0. The reliability of WeeFIM was assessed by calculating the internal consistency of Cronbach’s α. Results: The internal consistency of Cronbach’s α was 0.98. The 1- and 2-factor models did not demonstrate adequate fit indices according to CFA. However, the 3-factor structure (i.e. self-care, motor, and cognitive factors) was supported by EFA and CFA, which explained 87.12% of the variance. The self-care factor included 6 items (eating, grooming, dressing upper, dressing lower, bathing, and toileting), the motor factor included 7 items (bladder and bowel management, bed/chair/wheelchair, toilet, tub/shower, walk/wheelchair, and stairs), and the cognitive factor included the same 5 items as the original cognitive domain. Conclusion: In children with spastic CP, 3 factors of the WeeFIM were determined by factor analysis. Therefore, self-care, motor, and cognitive domains should be treated as separate scales in children with spastic CP.

Implications for Rehabilitation

• The reliability and validity of the 3-factor WeeFIM were confirmed with spastic CP.

• Findings suggest that the WeeFIM should not be used as an overall summary score of activity daily living in children with spastic CP.

• It is recommended that those working in the field of rehabilitation assess self-care, motor, and cognitive domains separately and develop an appropriate intervention programs for each domain.

     

Walking activity of children with cerebral palsy and children developing typically: a comparison between the Netherlands and the United States

Abstract

Purpose: To compare walking activity of children with and without cerebral palsy (CP) between the Netherlands and the United States. Methods: A cross-sectional analysis on walking activity data from an international retrospective comparison study including a convenience sample of 134 walking children aged 7–12 years with spastic CP, classified as Gross Motor Function Classification System (GMFCS) level I (N?=?64), II (N?=?49) or III (N?=?21), and 223 typically developing children (TDC) from the Netherlands and the United States. Walking activity was assessed during a one-week period using a StepWatch? activity monitor. Outcomes were the daily number of strides, daily time being inactive and spent at low (0–15 strides/min), moderate (16–30 strides/min) and high stride rate (31–60 strides/min). Walking activity was compared between countries using multiple linear regression analyses. Results: Walking activity of TDC was not significantly different between countries. Compared to their American counterparts, Dutch children in GMFCS level I and II showed less walking activity (p?<?0.05), whereas Dutch children in GMFCS level III showed more walking activity (p?<?0.05). Conclusion: The absence of differences in walking activity between Dutch and American TDC, and the presence of differences in walking activity between Dutch and American children with CP suggest that between-country differences affect walking activity differently in children with CP.

• Implications for Rehabilitation

• Physical activity of children with CP should be promoted in both the United States and the Netherlands.

• The between-country differences in walking activity illustrate that apart from the severity of the CP walking activity seems to be influenced by environmental aspects.

• In the promotion of physical activity, practitioners should pay attention to environmental barriers that families may experience for increasing physical activity.

     

Child engagement in daily life: a measure of participation for young children with cerebral palsy

Abstract

Purpose: The objectives of this study were to determine the: (1) internal consistency and test–retest reliability of the Child Engagement in Daily Life measure; (2) construct validity of the measure (known groups methods), that is, the ability of the measure to discriminate participation in family and recreational activities and self-care among young children of varying age and motor ability and between children with and without cerebral palsy, and (3) stability and hierarchical ordering of the items for young children with CP to devise an interval-level scoring system. Methods: 429 children with CP and their parents and 110 parents of children without CP participated in this methodological study. Parents completed the Child Engagement in Daily Life measure and therapists assessed the children's gross motor function. Rasch analysis was used to create an interval-level measure. Results: Children's frequency in and enjoyment of participation in family and recreational activities and self-care varied by age and gross motor ability. Internal consistency of the domains of the measure was high, Cronbach alpha values ranging from 0.86 to 0.91; test–retest for participation in family and recreational activities was acceptable, ICC?=?0.70, and in self-care was high, ICC?=?0.96. The items in the measure had a good fit and a logical hierarchical ordering. Conclusion: Study results support the validity and reliability of the Child Engagement in Daily Life measure as an assessment of participation in family and recreational activities and self-care for young children with CP.

• Implications for Rehabilitation

• Participation in family and recreational activities and self-care for young children with cerebral palsy can be reliably and validly assessed using the Child Engagement in Daily Life measure.

• Service providers are encouraged to support young children's participation in family and recreational activities and self-care.

     

Fatigue in the mothers of children with cerebral palsy

Purpose: To evaluate fatigue in the mothers of children with cerebral palsy (CP), and to determine its associations with clinical parameters of CP, depression and quality of life (QoL). Method: Ninety children (50 girls and 40 boys) with spastic CP and their mothers were included. Control group comprised mothers of healthy children. Gross motor function classification system (GMFCS) was used for determining functional status. Spasticity was evaluated by using modified Ashworth scale. Fatigue symptom inventory (FSI) was used for assessing maternal fatigue, Nottingham health profile (NHP) for maternal QoL, and Beck Depression Scale (BDS) for maternal depression. Results: Mothers of children with CP scored significantly higher in all FSI subgroups (intensity of fatigue, duration of fatigue and interference with QoL), all NHP subgroups and BDS (p?p?< 0.01). No association was found between FSI and clinical parameters of children with CP including age, gender, type of CP, tonus and functional impairment (p?>?0.05). Conclusions: Our findings indicate that fatigue levels of mothers with CP children are higher than those with healthy children and associated with depression and deterioration in QoL in terms of physical, social and emotional functioning. This should be considered while designing a family centred rehabilitation programme for children with CP.

• Implications for Rehabilitation

• Caring for a child with cerebral palsy has psychological, social and financial impacts on familiesand is associated with increased levels of fatigue among mothers.

• The capacity of current programs and services needs to be strengthened to accommodate theneeds of children with CP and their mothers in order to reduce fatigue of mothers.

• New programs need to be developed to provide psychosocial support for the mothers andto reduce their fatigue as they continue to care for their children.

• Provision of assistive technology devices (particularly suitable wheelchairs) will be useful inreduction of fatigue levels of mothers.

     

Effects of the standing program with hip abduction on hip acetabular development in children with spastic diplegia cerebral palsy

Purpose: Early identification and intervention with conservative measures is important to help manage hip dysplasia in children with a high adductor and iliopsoas tone and delay in weight bearing. The effect of a daily standing program with hip abduction on hip acetabular development in ambulatory children with cerebral palsy was studied. Method: The participants were 26 children with spastic diplegia cerebral palsy (CP), classified at Level III according to the Gross Motor Function Classification System (GMFCS). Thirteen children stood with hip abduction at least 1 h daily from 12 to 14 months of age to 5 years with an individually fabricated standing frame with hip abduction. Results: At the age of 5 years, radiologic results of the study group were compared with a comparison group of 13 children with spastic diplegia CP who had not taken part in a standing program. The migration percentage in all children who stood with abduction remained within stable limits (13–23%) at 5 years of age, in comparison to children who did not stand in abduction (12–47%) (p?Conclusions: The results indicate that a daily standing program with hip abduction in the first 5 years may enhance acetabular development in ambulatory children with spastic diplegia CP.

• Implications for Rehabilitation

• Abnormal acetabular development is a problem related to mobility problems and spasticity muscles around the hip.

• The literature suggests that postural management and standing programs could reduce levels of hip subluxation and increase function in children with cerebral palsy.

• A standing program with hip abduction can be a beneficial to develop more stable hips in children with spastic diplegic GMFCS level III.

     

Nutritional status of children with cerebral palsy in Turkey

Purpose: The aim of this study was to assess the nutritional status, and provide information regarding anthropometric measurements of cerebral-palsied children living in the city of Ankara, Turkey. Method: A total of 447 children with cerebral palsy (CP) were participated in this cross-sectional study. Participants were assessed for functional motor impairment by the gross motor function classification system (GMFCS). Assesment of nutritional status was based on the triceps skinfold thickness (TSF), arm fat area (AFA) estimates derived from TSF and mid-upper arm circumference measurements. TSF and AFA Z-scores were computed using reference data. Results: Cerebral-palsied children had lower TSF and AFA Z-scores compared to reference data from healthy children. The prevalence of underweight and overweight among boys was 8.3 and 9.5%, respectively, whereas it was 19.0 and 0.5% for girls. Underweight was more prevalent in the low functioning children than in moderate functioning children. Conclusions: The findings of this study indicate that cerebral-palsied children face nutritional challenges. Underweight is more prevalent than overweight among cerebral-palsied children. To optimize the outcomes of rehabilitation and prevention efforts, an understanding of the heterogeneity of nutritional status among children with CP is required.

Implications for Rehabilitation

• Compared with their healthy peers, cerebral-palsied children, especially girls and those who are low functioning, frequently show poor growth.

• Growth and nutritional status should be monitored regularly as part of rehabilitation program for cerebral-palsied children.

     

Reliability and Validity of the Turkish Version of the Abiloco-Kids

ABILOCO-Kids is a scale that assesses the walking ability of children with Cerebral Palsy (CP) from the viewpoint of parental perception. The aim of this study was to translate the ABILOCO-Kids scale into Turkish and to establish its reliability and validity in children with CP. Turkish children were recruited in this study. ABILOCO-Kids is a scale developed by Caty and et al. This scale assess the walking ability of children with CP focusing on the activity domain of the International Classification of Functioning, Disability and Health (ICF). The ABILOCO-Kids scale was translated from English into Turkish using the forward-backward-forward method. The motor functions of the 63 children participating in the study were evaluated by the Gross Motor Function Classification System (GMFCS) and the Gross Motor Function Measurement-88 (GMFM-88). The ABILOCO-Kids scale was repeated in 30 children after one week to establish test-retest reliability. While internal and external construct validity were investigated using Rasch analysis and Spearman correlation coefficient, respectively; reliability was evaluated in terms of internal consistency by Cronbach’s alpha and Person Separation Index (PSI). All items of the ABILOCO-Kids were found to fit the Rasch Model (chi-square 14.35 (df?=?20), p?=?0.813). The internal construct validity was good, overall mean item fit residual was ?0.109 (SD: 0.719) and mean person fit residual was ?0.215 (SD: 0.817). The reliability was good with Cronbach’s Alpha of 0.98 and PSI of 0.99. When the test-retest was examined via Differential Item Functioning (DIF) by time, none of the items showed DIF. Spearman correlation coefficients of the ABILOCO-Kids scale in relation to the GMFM and GMFCS were r?=?0.824, p?<?0.001; r?=??0.788, p?<?0.001 respectively. The Turkish version of the ABILOCO-Kids scale is a valid, reliable and unidimensional scale for children with CP. This scale will allow the differences in the locomotion of children with CP to be evaluated from the perspective of the family.     

Reliability and cross-cultural validation of the Turkish version of Manual Ability Classification System (MACS) for children with cerebral palsy

Purpose.?To determine the reliability and cross-cultural validation of the Turkish translation of the Manual Ability Classification System (MACS) for children with cerebral palsy (CP) and to investigate the relation to gross motor function and other comorbidities.

Methods.?After the forward and backward translation procedures, inter-rater and test–retest reliability was assessed between parents, physiotherapists and physicians using the intra-class correlation coefficient (ICC). Children (N?=?118, 4 to 18 years, mean age 9 years 4 months; 68 boys, 50 girls) with various types of CP were classified. Additional data on the Gross Motor Function Classification System (GMFCS), intellectual delay, visual acuity, and epilepsy were collected.

Results.?The inter-rater reliability was high; the ICC ranged from 0.89 to 0.96 among different professionals and parents. Between two persons of the same profession it ranged from 0.97 to 0.98. For the test–retest reliability it ranged from 0.91 to 0.98. Total agreement between the GMFCS and the MACS occurred in only 45% of the children. The level of the MACS was found to correlate with the accompanying comorbidities, namely intellectual delay and epilepsy.

Conclusion.?The Turkish version of the MACS is found to be valid and reliable, and is suggested to be appropriate for the assessment of manual ability within the Turkish population.     

Environmental needs and facilitators available for children and adolescents with cerebral palsy: adaptation and validation of the European Child Environment Questionnaire (ECEQ) Spanish version

Abstract

Purpose: The objective of this study is to present the process of translating, adapting and validating the European Child Environment Questionnaire (ECEQ) in the Spanish context. Method: The participants were 200 parents of children and adolescents with cerebral palsy (CP) aged 8–18 years, from seven regions in Spain. The adaptation of the ECEQ original version was carried out through the translation and back translation into Spanish. Construct validity was assessed by Factor analysis, Rasch model, and analysing group differences in need and availability of environmental features (EFs) according to level GMFCS. Results: We obtained a high rate of parental response. The ECEQ Spanish version contains 59 items and we identified four domains: Products and technology – home, school and community – services, systems and policies, support and relations, and Attitudes. Seventeen items were dropped as they did not fit well into plausible domains. Construct validity in terms of distinguishing between groups with expected for both need and availability. Conclusion: The ECEQ Spanish version was more appropriate to assess the needs of and access to EFs in the following domains: Products and technology and services, systems and policies, and it proved less appropriate for the support and relations, and attitudes domains.

• Implications for Rehabilitation

• Identification of barriers and environmental facilitators are key aspects to ensure the participation of children and adolescents with CP.

• The ECEQ is a useful tool for identifying needs and availability of the environmental features for children and adolescents with CP in Spain.

• This tool contains 59 items that are consistent with ICF framework.

• The Spanish version of ECEQ provides valuable information, which could be helpful to guide public services and organization services in order to optimize participation of children and adolescents with CP.

     

The course of health-related quality of life of preschool children with cerebral palsy

Purpose: The purpose of this paper is to describe the course of the health-related quality of life (HR-QoL) of children with cerebral palsy (CP) between the ages of 2.5 and 4.5 years, at both group and individual level. We also examined whether CP characteristics are helpful in understanding which children show a decrease in HR-QoL. Methods: HR-QoL of 72 children with CP was measured using the TNO-AZL Preschool children Quality of Life (TAPQOL) questionnaire at the ages of 2.5, 3.5 and 4.5 years. The course of HR-QoL was compared between groups with different CP characteristics. Results: Median scores for 10 of the 12 domains of the TAPQOL were found to be stable between ages 2.5 and 4.5 years. However, individual children showed great changes in HR-QoL at these ages, for all domains. A larger proportion of children with less severe CP showed a decrease in HR-QoL for the behaviour problems domain (p = 0.02), and a larger proportion of unilaterally affected children showed a decrease in HR-QoL regarding the anxiety (p < 0.001) and social functioning (p = 0.01) domains. Conclusions: Although the median HR-QoL of children with CP is generally stable at these ages, much variation in the course of HR-QoL exists between individual children. There is no clear association between motor functioning or limb distribution and a decrease in HR-QoL.

Implications for Rehabilitation

• Although preschool children with cerebral palsy (CP) generally have a fairly good health-related quality of life, large individual differences in the course of health-related quality of life exist.

• The type of CP or the level of motor disabilities is not related to the course of health-related quality of life.

• Because of its subjective nature, for young children with CP health-related quality of life is to be determined by asking their parents, not by doctor’s estimation depending on disease-specific factors.

     

Transcultural adaptation and validation of the Korean version of Caregiver Priorities & Child Health Index of Life with Disabilities (CPCHILD)

Abstract

Purpose: The aim of this study was to translate and transculturally adapt the Caregiver Priorities & Child Health Index of Life with Disabilities (CPCHILD) questionnaire into Korean language, and to test the reliability and validity, including the internal consistency, known-group validity and factor analysis of the Korean version of the CPCHILD. Methods: A Korean version of CPCHILD was produced according to internationally accepted guidelines. For validity testing, 194 consecutive parents or caregivers of children with cerebral palsy (CP) were recruited and completed the questionnaire. Internal consistency, test–retest reliability, and known-groups validity were evaluated and factor analysis was performed to validate the Korean version of the CPCHILD. Results: In terms of internal consistency, a Cronbach's alpha was above 0.90 in all domains of the CPCHILD (range 0.921 to 0.966), except the 5th domain (0.628). In terms of known-groups validity, the total score of the CPCHILD was significantly different according to the Gross Motor Function Classification System (GMFCS) level (p?<?0.001). Intra-class correlation coefficient spanned from 0.517 to 0.801. Factor analysis showed that the five-factor solution of the CPCHILD explained 76.7% of the variance with 59.0, 6.5, 5.1, 4.2 and 3.2% of variance by each components number. Conclusions: The Korean version of CPCHILD was found to be a reliable and valid questionnaire of caregivers’ perspectives on the health-related quality of life in severely affected children with CP. However, the Korean version of CPCHILD contains some redundant items, and factor analysis suggested a five-domain questionnaire.

• Implication for Rehabilitation

• The Korean version of CPCHILD is a reliable, internally consistent, valid instrument for assessing the health-related quality of life in severely affected children with CP from the perspective of caregivers.

• After the transcultural adaptation and validation of the Korean CPCHILD, it can be reliably used in clinical and research settings to evaluate the health-related quality of life in Korean patients 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.

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.

     

Sociometric status and the attribution of intentions in a sample of adolescents with cerebral palsy

Purpose To examine how cerebral palsy (CP) and sociometric status at age 10 explain the development of a cognitive bias across two groups of adolescents aged 15.

Method Children with CP (N?=?60) and without CP (N?=?57) are part of a follow-up study. Three categories of sociometric status (popular, average, rejected) were obtained by conducting a class-wide interview in the class of the target children at age 10. At 15 years old, the same children (CP and non-CP) were asked to complete the Home Interview With Child questionnaire measuring a cognitive bias (hostile attribution of intentions (AI)).

Results Children with CP, especially girls, were significantly more rejected and less popular than controls at age 10. At age 15, among all participants, sociometric rejected and popular children tended to have a higher percentage of hostile AI than sociometric average children.

Conclusions There were no significant results for the combined effect of CP and sociometric status on the development of hostile AI at age 15. However, knowing the risk incurred by children with CP of being socially rejected, attention should be paid in the rehabilitation process to opportunities for social participation to facilitate the development of social competence.

• Implications for Rehabilitation

• Level I or II cerebral palsy (CP) is a condition that affects not only motor abilities but also social competence in children.

• Sociometric status in a group tends to affect the development of the ability to interprete intentions of others during adolescence.

• Sociometric measures in the class of children with CP could be a useful tool in the rehabilitation process in order to better define social participation opportunities.

• To improve social participation attempts, rehabilitation interventions should target social initiating skills, flexibility in interpreting peers’ behaviours, and ability to react effectively to negative peer treatment.

     

Effects of lateral electrical surface stimulation on scoliosis in children with severe cerebral palsy: a pilot study

Purpose: To evaluate the effects of lateral electrical surface stimulation (LESS) on scoliosis and trunk balance in children with severe cerebral palsy (CP).

Methods: Children with severe CP (GMFCS level IV or V) and stationary or progressive scoliosis were enrolled. Children were recommended of two sessions of LESS/day, 1?h/session, for 3 months at home: at 40–80?mA intensity, 200?μs pulse width, 25?Hz frequency, on for 6?s and then off for 6?s on the convex side of the trunk curve. Radiologic (Cobb’s, kyphotic, and sacral angles) and functional [gross motor function measurement (GMFM)-88 sitting score, and trunk control measurement scale (TCMS)] measurements were evaluated at 4 periods: (a) 3 months before, (b) just before, (c) 1 month after, and (d) 3 months after LESS.

Results: The median Cobb’s angle of 11 children (median age, 9 years) was 25°, and it showed significant improvements after both 1 and 3 months of LESS. The LESS intensity correlated with the improvement of GMFM-88 siting score. The parents or main caregivers of the children believed LESS had several positive effects without major adverse effects.

Conclusions: LESS is effective in scoliosis in children with severe CP and it may improve trunk balance.

• Implications for rehabilitation

• Scoliosis is a very complicated problem for the children with severe CP.

• They do not have many options for treatments and scoliosis is usually refractory.

• Lateral electrical surface stimulation (LESS) is effective in scoliosis in children with severe CP and it may improve trunk balance.

• LESS may be another option of managing stationary or progressive scoliosis in the children with severe CP who are unable to undergo surgery.

     

Sequence memory skills in Spastic Bilateral Cerebral Palsy are age independent as in normally developing children

Purpose: To study the development of sequence memory skills in a group of participants with Spastic Bilateral Cerebral Palsy (CP) and their matched controls (TD). Sequence memory skills are defined as a blend of implicit and explicit competences that are crucial for the acquisition and consolidation of most adaptive skills along the lifespan. Method: A computerized sequence learning task was administered to 51 participants with CP (age range: 4.1–14.7) and their controls. General performance, accuracy and learning strategy were analyzed, as well as cognitive competencies (IQ and explicit visual spatial memory). Results: Explicit learning developed along with age in all participants. Sequence learning skills were age independent and unevenly distributed among CP participants: most TD (96.1%) and only about half (58.8%) of CP participants succeeded in sequence learning, in dynamic relation with cognitive and manipulation abilities. Conclusion: Sequence memory skills should be verified to plan therapeutic strategies. Therapeutic plans based on implicit learning (more resistant to disruption and stress) could be effective and highly advantageous for most but not for all CP children. Independently from age, many CP children could fix sequences more efficiently by explicit strategies, a more effortful but probably more effective way.

Implications for Rehabilitation

“Sequence memory skills in Spastic Bilateral Cerebral Palsy (CP) are age-independent as in normally developing children”

• Sequence memory skills (a blend of explicit and implicit components) represent a basic competence whose impairment could in a dynamic perspective affect multiple motor and non-motor developmental features.

• The prevalence and importance of implicit learning as a point of strength in therapeutic choice has been formerly emphasized: implicit learning is far more resistant to disruption and stress during rehabilitation and therefore potentially far reaching.

• Sequence memory skills are unevenly distributed in our clinical group.

• A majority of CP participants (58.8%) can rely on efficient sequence learning and therefore may specifically benefit from therapeutic programs privileging implicit learning (that is, relying on progressive and not necessarily explicit consolidation of sequences).

• In those children failing to fix sequences, sequence learning skills need to be specifically supported and explicit strategies (such as for example verbal and visual guides along the task) could be helpful to support consolidation.

     

Combining strength training and botulinum neurotoxin intervention in children with cerebral palsy: the impact on muscle morphology and strength

Purpose: Investigate the combination effects of strength training and Botulinum Toxin Type-A (BoNT-A) on muscle strength and morphology in children with Cerebral Palsy (CP). Methods: Fifteen children receiving BoNT-A, classified as Spastic Diplegic CP, GMFCS I-II, and aged 5–12 years were recruited for this study. Randomly allocated to 10 weeks of strength training either before or after BoNT-A, children were assessed over 6 months. Eight of the 15 children also completed a control period. The Modified Ashworth Scale measured spasticity. The Goal Attainment Scale (GAS) assessed achievement of functional goals. Magnetic Resonance Imaging assessed muscle volume (MV). Instrumented dynamometry assessed strength. Results: Spasticity was significantly reduced following BoNT-A injection (p = 0.033). Children made significant isokinetic strength gains (mean p = 0.022, ES = 0.57) in the intervention period compared to the control period (mean p = 0.15, ES = 0.56). Irrespective of timing, significant strength improvements were seen immediately (10 weeks) and over 6 months for all children. This was also the case for improvements in the GAS (immediately: mean p = 0.007, ES = 4.17, 6 months: mean p = 0.029, ES = 0.99), and improvements in MV in all assessed muscles. Conclusion: The simultaneous use of BoNT-A and strength training was successful in spasticity reduction, improving strength and achieving functional goals, over and above treatment with BoNT-A alone. Muscles targeted for BoNT-A injection should be included in strength training.

Implications for Rehabilitation

Cerebral Palsy

• Botulinum toxin type-A (BoNT-A) and strength training are available interventions that, on their own have found success in managing spasticity and muscle weakness (both significant motor impairments), respectively in children with Cerebral Palsy (CP).

• This study has demonstrated that the concurrent treatment of BoNT-A and strength training can achieve positive outcomes in terms of strength, spasticity and for the achievement of set functional goals.

• The results of this study show that the improved muscle strength can be associated with hypertrophy, which could indicate the potential role of strength training in altering the rate of muscle growth, in an aim to improve the failure of muscle growth associated with CP.

• Home based strength training, based on a child’s individual goals is shown to be successful in improving strength and goal attainment for children with CP.