New definitions of 6 clinical signs of perceptual disorder in children with cerebral palsy: an observational study through reliability measures.

BACKGROUND: Recently authors have begun to emphasize the non-motor aspects of Cerebral Palsy and their influence on motor control and recovery prognosis. Much has been written about single clinical signs (i.e., startle reaction) but so far no definitions of the six perceptual signs presented in this study have appeared in literature. AIM: This study defines 6 signs (startle reaction, upper limbs in startle position, frequent eye blinking, posture freezing, averted eye gaze, grimacing) suggestive of perceptual disorders in children with cerebral palsy and measures agreement on sign recognition among independent observers and consistency of opinions over time. DESIGN: Observational study with both cross-sectional and prospective components. SETTING: Fifty-six videos presented to observers in random order. Videos were taken from 19 children with a bilateral form of cerebral palsy referred to the Children Rehabilitation Unit in Reggio Emilia. PARTICIPANTS: Thirty-five rehabilitation professionals from all over Italy: 9 doctors and 26 physiotherapists. METHODS: Measure of agreement among 35 independent observers was compiled from a sample of 56 videos. Interobserver reliability was determined using the K index of Fleiss and reliability intra-observer was calculated by the Spearman correlation index between ranks (rho - ρ). Percentage of agreement between observers and Gold Standard was used as criterion validity. RESULTS: Interobserver reliability was moderate for startle reaction, upper limb in startle position, adverted eye gaze and eye-blinking and fair for posture freezing and grimacing. Intraobserver reliability remained consistent over time. Criterion validity revealed very high agreement between independent observer evaluation and gold standard. CONCLUSIONS: Semiotics of perceptual disorders can be used as a specific and sensitive instrument in order to identify a new class of patients within existing heterogeneous clinical types of bilateral cerebral palsy forms and could help clinicians in identifying functional prognosis. CLINICAL REHABILITATION IMPACT: To provide clinicians with a definition of 6 clinical signs found in children with cerebral palsy in routine rehabilitation settings. Future research should explore the link between these signs and motor prognosis (i.e., time to independent walking).

The term diplegia should be enhanced. Part I: a new rehabilitation oriented classification of cerebral palsy.

The classification systems for cerebral palsy (CP) need to be continuously updated, according to specific aims and to significant changes observed over the years in the panorama of CP. A simplification of CP categories, abandoning the use of the term diplegia, has been recently suggested. Conversely, in this paper a new proposal for classification of CP is briefly presented, where special attention is given to diplegia which is suggested to be divided into four main clinical forms, according to the patterns of walking observable in these subjects. The proposed classification was applied to a large population of 213 subjects with diplegia, among 467 cases of CP admitted to two reference centres for this disorder. The relative incidence of the four forms is reported. The adopted classification criteria, based on a primary ability of professionals working in rehabilitation, i.e. observation capacity, makes this approach simple and easy to use at all levels of the rehabilitation services for CP.

The term diplegia should be enhanced. Part III: inter-observer reliability of the new rehabilitation oriented classification.

AIM: The aim of this study was to validate a recent classification of gait in children with the spastic diplegic form of cerebral palsy (CP) by checking the reliability of different scorers in assigning subject walking performance to one of the four specific patterns described in the classification. METHODS: The gait patterns of 50 children and adolescents with CP (23 males, 27 females; age range 3-17 years) were selected among patients whose videos were stored in the archives of the Pisa and Reggio Emilia Hospitals. Only video recordings of gait with homogeneous features (duration of at least 90 s, simultaneous recordings on sagittal and frontal views, and other criteria) were taken for examination. The videos were blindly scored using an observational gait scale, at first by two of the authors of the classification system (defined as ''maximum experts''), then by ten expert observers, and finally by 206 professionals of rehabilitation after a one-day training on the classification. Cohen's kappa statistics (k) and intra class correlations (ICC) were calculated. RESULTS: Kappa and ICC indicate an almost perfect agreement both between the two maximum experts and among the ten expert observers. Good results were also obtained in the group of one-day trained scorers. Only a few cases were assigned to the ''unclassified'' category. The profession of the observer (doctor or therapist) and previous knowledge of the classification had no significant influence on reliability scores. CONCLUSION: The results suggest that the proposed classification can be reliably applied, even utilizing short video recordings, to arrange diplegic children into different patterns. Further studies are needed to validate the use of this classification system for clinical and research aims.