Intensive Therapy of the Lower Limbs and the Trunk in Children with Bilateral Spastic Cerebral Palsy: Comparing a Qualitative Functional and a Functional Approach.

Few studies have examined the effect of intensive therapy on gross motor function and trunk control in children with cerebral palsy (CP). This study evaluated the effects of an intensive burst of therapy on the lower limbs and trunk by comparing qualitative functional and functional approaches. This study was designed as a quasi-randomized, controlled, and evaluator-blinded trial. Thirty-six children with bilateral spastic CP (mean age = 8 y 9 mo; Gross Motor Function Classification II and III) were randomized into functional (n = 12) and qualitative functional (n = 24) groups. The main outcome measures were the Gross Motor Function Measure (GMFM), the Quality Function Measure (QFM), and the Trunk Control Measurement Scale (TCMS). The results revealed significant time-by-approach interaction effects for all QFM attributes and the GMFM's standing dimension and total score. Post hoc tests showed immediate post-intervention gains with the qualitative functional approach for all QFM attributes, the GMFM's standing and walking/running/jumping dimension and total score, and the total TCMS score. The qualitative functional approach shows promising results with improvements in movement quality and gross motor function.

Identification of joint patterns during gait in children with cerebral palsy: a Delphi consensus study.

AIM: This study aims to achieve an international expert consensus on joint patterns during gait for children with cerebral palsy (CP) by means of Delphi surveys. METHOD: In Stage 1, seven local experts drafted a preliminary proposal of kinematic patterns for each lower limb joint in the sagittal, coronal, and transverse plane. In Stage 2, 13 experts from eight gait laboratories (four in the USA and four in Europe), participated in a Delphi consensus study. Consensus was defined by a pre-set cut-off point of 75% agreement among participants. RESULTS: After the first stage, 44 joint patterns were presented in a first survey and 29 patterns reached consensus. Consensus improved to 47 out of 48 patterns in the third survey. Only one pattern, 'abnormal knee pattern during loading response', did not reach consensus. The expert panel agreed to define six patterns for the knee during swing, most of them representing characteristics of a stiff knee pattern. INTERPRETATION: The defined joint patterns can support clinical reasoning for children with CP as joint patterns during gait might be linked to different treatment approaches. Automating the classification process and incorporating additional trunk, foot, and electromyography features should be prioritized for the near future.

A study of whether video scoring is a reliable option for blinded scoring of the Gross Motor Function Measure-88.

OBJECTIVE: To investigate the agreement between live and video scores of the Gross Motor Function Measure-88. DESIGN: Reliability study. SUBJECTS: Forty children with bilateral spastic cerebral palsy. INTERVENTIONS: Fifty evaluations were administered according to the test guidelines, and were videotaped. After a minimum interval of one month, the video recordings were again rated by the same assessor. Two physical therapy students also each scored the recordings twice, with a minimal interval of one month. MAIN MEASURES: Agreement between live and video scores as well as inter-rater and intra-rater agreement of the video scores were assessed using intra-class correlation coefficients (ICC), standard error of measurements (SEM), and smallest detectable changes (SDC). Weighted kappa coefficients were used to analyse individual items. RESULTS: The live and video scores from the same assessor showed good to very good agreement for the total score (ICC, 0.973; SEM, 2.28; SDC, 6.32) and dimensions B (ICC, 0.938), D (ICC, 0.965), and E (ICC, 0.992) but lower agreement for A (ICC, 0.720) and C (ICC, 0.667). Live-versus-video agreement for the total score was higher than inter-rater agreement by video (ICC, 0.949; SEM, 3.15; SDC, 8.73) but lower than intra-rater agreement by video (ICC, 0.989; SEM, 1.42; SDC, 3.96). CONCLUSION: The Gross Motor Function Measure-88 can be reliably scored using video recordings. The agreement between live and video scores is lower than the intra-rater reliability using video recordings only. Future clinical trial results should be interpreted using the appropriate SEM and SDC values.

A randomized, single-blind cross-over design evaluating the effectiveness of an individually defined, targeted physical therapy approach in treatment of children with cerebral palsy.

OBJECTIVE: A pilot study to compare the effectiveness of an individual therapy program with the effects of a general physical therapy program. DESIGN: A randomized, single-blind cross-over design. PARTICIPANTS: Ten ambulant children with bilateral spastic cerebral palsy, age four to nine years. INTERVENTION: Participants were randomly assigned into a ten-week individually defined, targeted or a general program, followed by a cross-over. MAIN OUTCOME MEASURES: Evaluation was performed using the Gross Motor Function Measure-88 and three-dimensional gait analysis. General outcome parameters were Gross Motor Function Measure-88 scores, time and distance parameters, gait profile score and movement analysis profiles. Individual goal achievement was evaluated using z-scores for gait parameters and Goal Attainment Scale for gross motor function. RESULTS: No significant changes were observed regarding gross motor function. Only after individualized therapy, step- and stride-length increased significantly (p = 0.022; p = 0.017). Change in step-length was higher after the individualized program (p = 0.045). Within-group effects were found for the pelvis in transversal plane after the individualized program (p = 0.047) and in coronal plane after the general program (p = 0.047). Between-program differences were found for changes in the knee in sagittal plane, in the advantage of the individual program (p = 0.047). A median difference in z-score of 0.279 and 0.419 was measured after the general and individualized program, respectively. Functional goal attainment was higher after the individual therapy program compared with the general program (48 to 43.5). CONCLUSION: The results indicate slightly favorable effects towards the individualized program. To detect clinically significant changes, future studies require a minimal sample size of 72 to 90 participants.

A clinical decision framework for the identification of main problems and treatment goals for ambulant children with bilateral spastic cerebral palsy.

The primary aim of the study was to investigate how a clinical decision process based on the International Classification of Function, Disability and Health (ICF) and the Hypothesis-Oriented Algorithm for Clinicians (HOAC-II) can contribute to a reliable identification of main problems in ambulant children with cerebral palsy (CP). As a secondary aim, to evaluate how the additional information from three-dimensional gait analysis (3DGA) can influence the reliability. Twenty-two physical therapists individually defined the main problems and specific goals of eight children with bilateral spastic CP. In four children, the results of 3DGA were provided additionally to the results of the clinical examination and the GMFM-88 (gross motor function measure-88). Frequency analysis was used to evaluate the selected main problems and goals. For the main problems, pair-wise agreement was calculated by the number of corresponding problems between the different therapists and using positive and negative agreement per problem. Cluster analysis using Ward's method was used to evaluate correspondence between the main problems and specific goals. The pair-wise agreement revealed frequencies of 47%, 32% and 3% for the identification of one, two or three corresponding main problems. The number of corresponding main problems was higher when additional information of 3DGA was provided. Most of the specific goals were targeting strength (34%), followed by range of motion (15.2%) and GMFM-D (11.8%). In 29.7% of the cases, therapists could not prioritize and exceeded the number of eight specific goals. Cluster analysis revealed a logic connection between the selection of strength as a main problem and as specific goal parameters. Alignment as a main problem was very often associated with specific parameters like ROM and muscle length and with hypertonia as a main problem. The results show a moderate agreement for the selection of main problems. Therapists are able to use the proposed model for a logic and structured clinical reasoning. Setting priorities in the definition of specific goals is revealed as a remaining difficulty. Further research is required to investigate the additional value of 3DGA and to improve priority setting.

Can the Dyskinesia Impairment Scale be used by inexperienced raters? A reliability study.

BACKGROUND: The Dyskinesia Impairment Scale (DIS) is a new scale for measuring dystonia and choreoathetosis in dyskinetic Cerebral Palsy (CP). Previously, reliability of this scale has only been assessed for raters highly experienced in discriminating between dystonia and choreoathetosis. AIMS: The aims of this study are to examine the reliability of the DIS used by inexperienced raters, new to discriminating between dystonia and choreoathetosis and to determine the effect of clinical expertise on reliability. METHODS: Twenty-five patients (17 males; 8 females; age range 5-22 years; mean age = 13 years 6 months; SD = 5 years 4 months) with dyskinetic CP were filmed with the DIS standard video protocol. Two junior physiotherapists (PTs) and three senior PTs, all of whom were new to discriminating between dystonia and choreoathetosis, were trained in scoring the DIS. Afterward, they independently scored all patients from the video recordings using the DIS. Reliability was assessed by (1) Intraclass Correlation Coefficient (ICC), (2) Standard Error of Measurement (SEM) and Minimal Detectable Difference (MDD) and (3) Cronbach's alpha for internal consistency. RESULTS: Interrater reliability for the total DIS, and for the dystonia and choreoathetosis subscales was good for the junior PTs and moderately high to excellent for the senior PTs. SEM and MDD values for the total DIS were 6% and 15% respectively for the junior PTs and 4% and 12% respectively for the senior PTs. Cronbach's alpha ranged between 0.87 and 0.95 for the junior PTs and between 0.76 and 0.93 for the senior PTs. CONCLUSIONS: Reliability of the DIS scores for the inexperienced junior and senior PTs was sufficient in comparison with scores from the experienced raters in the previous study, indicating that the DIS can be used by inexperienced PTs new to discriminating between dystonia and choreoathetosis, and also that its reliability is not dependent on clinical expertise. However, based on the measurement errors and questionnaire data, familiarity with operational definitions of dystonia and choreoathetosis is crucial to improve scoring reliability.

The evidence-base for basic physical therapy techniques targeting lower limb function in children with cerebral palsy: a systematic review using the International Classification of Functioning, Disability and Health as a conceptual framework.

OBJECTIVE: This systematic review provides an overview of the effectiveness of basic techniques used in lower limb physical therapy of children with cerebral palsy. It aims to support the development of clinical guidelines for evidence-based physical therapy planning for these children. DATA SOURCES AND STUDY SELECTION: A literature search in 5 electronic databases extracted literature published between January 1995 and December 2009. Studies were evaluated using the framework recommended by the American Academy for Cerebral Palsy and Developmental Medicine (AACPDM), which classifies outcomes according to the International Classification of Functioning, Disability and Health. DATA EXTRACTION: Three independent evaluators rated the strength of evidence of the effects according to the AACPDM levels of evidence classification, and the quality of the studies according to the AACPDM conduct score system. DATA SYNTHESIS: A total of 83 studies was selected and divided into categories (stretching, massage, strengthening, electrical stimulation, weight-bearing, balance-, treadmill- and endurance training). Interventions targeting problems at body function and structure level generally influenced this level without significant overflow to activity level and vice versa. CONCLUSION: The more recent studies evaluating strength training mainly demonstrated level II evidence for improved gait and gross motor function. There was limited evidence for specific information on intensity, duration and frequency of training.

The evidence-base for conceptual approaches and additional therapies targeting lower limb function in children with cerebral palsy: a systematic review using the ICF as a framework.

OBJECTIVE: This systematic review provides an overview of the effectiveness of conceptual approaches and additional therapies used in lower limb physical therapy of children with cerebral palsy and supports the development of clinical guidelines. DATA SOURCES AND STUDY SELECTION: A literature search in 5 electronic databases was performed, extracting literature published between 1995 and 2009. Studies were evaluated using the framework recommended by the American Academy for Cerebral Palsy and Developmental Medicine (AACPDM), which classifies outcomes according to the International Classification of Functioning, Disability and Health (ICF). DATA EXTRACTION: Three evaluators rated the strength of evidence of the effects according to the AACPDM levels of evidence classification, and the quality of the studies according to the AACPDM conduct score system. DATA SYNTHESIS: A total of 37 studies used conceptual approaches (neurodevelopmental treatment (NDT), conductive education, Vojta therapy, sensory integration, functional training and goal-oriented therapy) and 21 studies focused on additional therapies (aquatic therapy and therapeutic horse-riding). CONCLUSION: Level II evidence was found for the effectiveness of therapeutic horse-riding on posture and for NDT and functional training on gross motor function. Goal-oriented therapy and functional training were effective on the attainment of functional goals and participation. With level IV evidence, NDT was effective on all levels of the ICF.