Development of a parent-report computer-adaptive test to assess physical functioning in children with cerebral palsy I: lower-extremity and mobility skills

The objective of this project was to develop computer-adaptive tests (CATs) using parent reports of physical function in children and adolescents with cerebral palsy (CP). The specific aims of this study were to (1) examine the psychometric properties of an item bank of lower-extremity and mobility skills for children with CP; (2) evaluate a CAT using this item bank; (3) examine the concurrent validity of the CAT with the Pediatric Outcomes Data Collection Instrument (PODCI) and the Functional Assessment Questionnaire (FAQ); and (4) establish the discriminant validity of simulated CATs with Gross Motor Function Classification System (GMFCS) levels and CP type (diplegia, hemiplegia, or quadriplegia). Parents ( n =190) of children and adolescents with spastic diplegic (48%), hemiplegic (22%), or quadriplegic (30%) CP consisting of 108 males and 82 females with a mean age of 10 years 7 months (SD 4y 1mo, range 2–21y) and in GMFCS levels I to V participated in item pool calibration and completed the PODCI and FAQ. Confirmatory factor analyses supported a unidimensional model for the 45 basic lower-extremity and mobility items. Simulated CATs of 5, 10, and 15 items demonstrated excellent accuracy (intraclass correlation coefficients [ICCs] >0.91) with the full item bank and had high correlations with PODCI transfers and mobility (ICC = 0.86) and FAQ scores (ICC = 0.77). All CATs discriminated among GMFCS levels and CP type. The lower-extremity and mobility skills item bank and simulated CATs demonstrated excellent performance over a wide span of ages and severity levels.     

Correlation between physical functioning and gait measures in children with cerebral palsy

The primary aim of this investigation was to assess the correlation between the POSNA Musculoskeletal Functional Health Questionnaire (POSNA) and gait analysis in children with cerebral palsy (CP). POSNA and computerized gait analysis were used to evaluate individuals with CP. Correlations were investigated between POSNA scales, gait parameters, and the Gillette Functional Assessment Questionnaire (FAQ) in 63 children (31 males, 32 females; mean age 9.17 years [SD 3.06], age range 3.75 to 16.44 years) with spastic CP. Twelve participants had hemiplegia, 29 diplegia, 12 quadriplegia, and 10 triplegia. The result of backwards stepwise multiple regression analysis indicated that the Log normalcy index (NI) was a significant predictor of the POSNA Global Function and Comfort scale. Energy expenditure (EE) did not add significantly to the prediction. The POSNA scales differentiated between the different topographical types of CP. The POSNA scale is a valid and useful clinical measure. Used in conjunction with the NI, EE, and FAQ, the POSNA scale provides a more complete appraisal of change in functioning.     

Fundamental movement skills and physical activity among children with and without cerebral palsy

Fundamental movement skills (FMS) proficiency is believed to influence children's physical activity (PA), with those more proficient tending to be more active. Children with cerebral palsy (CP), who represent the largest diagnostic group treated in pediatric rehabilitation, have been found to be less active than typically developing children. This study examined the association of FMS proficiency with PA in a group of children with CP, and compared the data with a group of typically developing children. Five FMS (run, jump, kick, throw, catch) were tested using process- and product-oriented measures, and accelerometers were used to monitor PA over a 7-day period. The results showed that children with CP spent less time in moderate to vigorous physical activity (MVPA), but more time in sedentary behavior than typically developing children. FMS proficiency was negatively associated with sedentary time and positively associated with time spent in MVPA in both groups of children. Process-oriented FMS measures (movement patterns) were found to have a stronger influence on PA in children with CP than in typically developing children. The findings provide evidence that FMS proficiency facilitates activity accrual among children with CP, suggesting that rehabilitation and physical education programs that support FMS development may contribute to PA-related health benefits.     

Cognitive and neuropsychological functioning in children with cerebral palsy

This article reviews the extant literature on intellectual functioning in different subtypes of cerebral palsy. Following a definition of the characteristics of each of three major cerebral palsy groups, typical neurologic and magnetic resonance imaging findings are reported. More recent studies that examine the intellectual and neuropsychological functioning of children within these classification groups are also reviewed. This review concludes that there remains a significant lack of precise information about the impact of cerebral palsy on the intellectual, motor, and neuropsychological functioning of children and that neuropsychological assessment can provide the necessary tools for such studies.     

Clinical tools to assess balance in children and adults with cerebral palsy: a systematic review

We aimed to review tools used to assess balance in clinical practice in children and adults with cerebral palsy (CP), to describe their content and measurement properties and to evaluate the quality of the studies that have examined these properties. CINAHL, Embase, and PubMed/MEDLINE were searched. The COnsensus‐based Standards for selection of health Measurement INstruments (COSMIN) was used to assess the ‘quality of studies’ and the Terwee criteria were used to assess the ‘result of studies’. Twenty‐two clinical balance tools were identified from 35 papers. The content and focus of the tools varied significantly. There was moderate or limited levels of evidence for most of the measurement properties of the tools; the strongest level of evidence was found for the Trunk Control Measurement Scale and the Level of Sitting Scale, in the category ‘maintain balance’, the Timed Up and Go and the Segmental Assessment of Trunk Control in the categories ‘achieve balance’ and ‘restore balance’ respectively. Information on responsiveness was scarce. Further studies providing better evidence for reliability and responsiveness for clinical balance tools are needed. In the meantime, results of studies evaluating effects of treatment of balance in individuals with CP should be interpreted with caution.     

Clinical tools designed to assess motor abilities in children with cerebral palsy

Objective: This systematic review aimed to list the tools used by rehabilitation professionals to test motor abilities in children with cerebral palsy (CP), to determine if these tools have psychometric properties specifically measured for CP, and to identify the main characteristics of these tools. Method: Web of Science, PEDro, PubMed/MEDLINE, Science Direct, and SciELO databases were searched to identify the tools. PubMed/MEDLINE was then searched to identify the studies assessing those tools’ psychometric properties. The agreement-based standards for the selection of health measurement tools and the Terwee criteria were used to assess the quality and the results of each included study, respectively. Results: Eighteen tools were identified. The psychometric properties of many of the tools used with children with CP have not been evaluated for this population. Conclusion: The psychometric properties evaluated often have a poor methodological quality of measurement. Overall, we suggest the tools with most empirical support to evaluate children with CP.     

Effects of robotic therapy on upper-extremity function in children with cerebral palsy: A systematic review

Objective: To systematically examine the effects of robotic therapy on upper extremity (UE) function in children with cerebral palsy (CP). Methods: A systematic literature search was conducted in Pubmed, CINAHL, Cochrane, PsychInfo, TRIP, and Web of Science up to July 2013. Studies of children with CP, using robotic therapy and measures of UE were included. Results: Nine articles using three different robotic systems were included. Of these, seven were case studies. Overall, robotic therapy showed the potential effects as all studies reported at least one positive outcome: a moderate effect in improving reaching duration, smoothness, or decreased muscle tone, and a small to large effect in standardized clinical assessment (e.g. Fugl-Meyer). Conclusion: This review confirms the potential for robotic therapy to improve UE function in children with CP. However, the paucity of group design studies summons the need for more rigorous research before conclusive recommendations can be made.     

Everyday functioning in young children with cerebral palsy: functional skills,caregiver assistance,and modifications of the environment

Everyday functioning is described in 95 children with cerebral palsy (CP; 55 males and 40 females; mean age 58 months, SD 18 months, range 25 to 87 months) using the three scales of the Pediatric Evaluation of Disability Inventory (PEDI): Functional Skills, Caregiver Assistance, and Modifications of the Environment. Types of CP in the children were hemiplegia, (n=19), spastic/ataxic diplegia, (n=44), spastic quadriplegia, (n=16), dyskinetic, (n=9), and mixed (n=7). Symptoms were grouped by severity according to the Gross Motor Function Classification System (GMFCS): 23% were classified at level I, 21% at level II, 10% at level III, 23% at level IV, and 23% level V. A large variability in functioning in mobility, self-care, and social function was seen because of the heterogeneity of children with CP. Limitations in achievement of activities, need for assistance, and use of assistive devices increased progressively with GMFCS level. Furthermore, these children differed to a great extent from the normative sample of the PEDI. Stepwise regression analysis showed that the GMFCS was a good predictor of everyday functioning with age and learning problems as significantly contributing factors, particularly in self-care and social function. In conclusion, the three scales of the PEDI represent different but strongly related aspects of everyday functioning in young children with CP.     

Skeletal maturation in children with cerebral palsy and its relationship with motor functioning

The objective of this study was to describe skeletal maturation in relation to chronological age in children with cerebral palsy (CP) aged 9 to 16 years, and to analyze the relationship between skeletal maturation and motor functioning. The skeletal age of 100 children with CP (37 females, 63 males; age 9, 11, or 13 y; 73 ambulant, 27 non-ambulant) was determined over a period of 3 years based on X-rays of the hand (Greulich and Pyle technique). Motor functioning was measured with the Gross Motor Function Measure-66. The skeletal age of females with CP was significantly higher than their chronological age, but this did not apply to males. Longitudinal analysis showed no difference in the course of skeletal age in relation to chronological age over a 3-year period for sex or for level of ambulation. No association was found between changes in skeletal age and changes in gross motor function over the 3-year period. Skeletal age during (pre-)puberty in females with CP is advanced in relation to chronological age. No evidence was found that children with CP are at risk for deterioration in gross motor function as a result of skeletal maturation during puberty.     

Neuromuscular electrical stimulation and dynamic bracing for the management of upper-extremity spasticity in children with cerebral palsy

A prospective study was designed to determine whether the combined use of neuromuscular electrical stimulation (NMES) and dynamic bracing was more effective than use of either alone in reducing upper-extremity spasticity in children with spastic hemiplegic cerebral palsy. Twenty-four patients (12 males, 12 females; mean age 8y 7mo [SD 4y 2mo]; age range 3-18y) diagnosed with spastic hemiplegic CP were randomly allocated to three groups: group 1 had two 30-minute sessions of NMES a day applied on the antagonist extensors without bracing; group 2 had two 30-minute sessions of dynamic bracing per day; and group 3 had two 30-minute sessions of NMES and dynamic bracing every day. Treatment was continued for 6 months in all groups and applied only to the affected extremity. Patients were evaluated before therapy, at monthly intervals during the therapy, and 3 months after completion of the therapy. Three measures of outcome were taken: the Melbourne Assessment, grip strength, and posture evaluation with Zancolli's classification. The therapist performing the outcome assessments was blinded as to groups. Statistically significant differences were found in all three measures for only those treated with combined NMES and dynamic bracing. However, this significant effect lasted for only 2 months after discontinuation of the treatment. We conclude that the combined use of NMES and bracing is more effective than either alone but requires continuous application.     

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.     

Sleep in children with cerebral palsy: a review

Children with neurodevelopmental disabilities, such as cerebral palsy, are considered to be a population at risk for the occurrence of sleep problems. Moreover, recent studies on children with cerebral palsy seem to indicate that this population is at higher risk for sleep disorders. The importance of the recognition and treatment of sleep problems in children with cerebral palsy cannot be overemphasized. It is well known that the consequences of sleep disorders in children are broad and affect both the child and family. This review article explores the types and possible risk factors associated with the development of sleep problems in children with cerebral palsy and the impact of this disorder on the child and family. In addition, a brief summary of current diagnostic and treatment modalities is provided. Finally, the characteristics, diagnostic techniques, and management of sleep-related breathing disorders in children with cerebral palsy are discussed.     

The relationship between quality of life and functioning for children with cerebral palsy

Given that quality of life (QOL) is commonly confused with functioning, the aim of this study was to examine the association between functioning and QOL domains for children with cerebral palsy (CP). Two hundred and five parents of children aged 4 to 12 years with CP and 53 children aged 9 to 12 years with CP, completed the Cerebral Palsy Quality of Life Questionnaire for Children. Children were distributed reasonably evenly between sex (male, 54.6%) and Gross Motor Function Classification System levels (I 17.8%, II 28.3%, III 14.1%, IV 11.2%, and V 27.3%). For parent proxy-report, all domains of QOL were significantly associated with functioning level except access to services. For child self-report, feelings about functioning, participation and physical health, and pain and feelings about disability, were significantly associated with functioning level. Physical type domains of QOL accounted for more of the variance in functioning than psychosocial type domains. Children with CP have the potential to report a high psychosocial QOL score even if they have poor functioning.