Quality of goal setting in pediatric rehabilitation-A SMART approach.

BACKGROUND: Setting goals for treatment is often the core of the rehabilitation process. The quality of the set goals has however rarely been evaluated. The aims of this study were therefore to assess the quality of goals set in clinical practice of pediatric rehabilitation using SMART criteria (Specific, Measurable, Achievable, Relevant, and Timed) and to assess if the goals were considered relevant from both a client perspective and expertise perspective. METHODS: In a retrospective multicase study, a total of 161 goals from 42 children with disabilities (cerebral palsy, n = 22; Down syndrome, n = 16; and developmental disability, n = 4) were assessed. The children were 1.5-5.5 years and had previously participated in goal-directed, activity-focused therapy at four pediatric rehabilitation centers. Collaborative goal setting had been used to define the desired treatment outcome. The quality of the goals was assessed using defined SMART criteria. RESULTS: Specific: All goals could be reliably linked to International Classification of Functioning, Disability and Health-Children and Youth version chapters within the Activity/Participation domain. Measurable: A total of 75% of the goals were rated as having a well-defined scaling; in 20%, the scaling was less clear, and in 5%, a scaling could not be determined. Achievable: A total of 80% of the goals were attained. Relevant: All goals were set in collaboration with the family and could therefore be considered relevant from a client perspective. Relevancy judged from a professional perspective was strengthened by the fact that age, baseline status, and diagnosis had an influence on the choice of goals. Timed: All goals were set within a specific time frame. CONCLUSIONS: The goals set in clinical practice showed high quality with respect to the SMART criteria. The most difficult part was the construction of the goal attainment scale. The goals settled in clinical practice were considered relevant from both a client perspective and expertise perspective.

Rehabilitation planning for children and adolescents with cerebral palsy.

OBJECTIVE: To explore the types of procedures and practices in rehabilitation planning for children with cerebral palsy and how multidisciplinary team members experience them. DESIGN, SUBJECTS, AND SETTING: A qualitative research approach was used. Participants were members of multidisciplinary teams in neuropediatric wards at five university hospitals. METHODS: In order to explore the rehabilitation planning procedure within multidisciplinary teams, focus group interviews were conducted. The interviews were tape recorded and transcribed. Three content areas guided the interviews: goal setting, the different transition phases, and the use of the international classification of functioning, disability and health, child and youth version (ICF-CY). Qualitative content analysis was used to analyze the results. RESULTS: Three themes arose from the focus group discussions; challenging goal setting, transition without routines, and ICF-CY not in use. A family-centered service model had been adopted, but there was no clear procedure in the collaboration with parents. Goal setting was found to be challenging and the concern arose of how to integrate goals into the child's everyday life. There was a lack of systematic planning of the different transition phases. There was also a general variation in the rehabilitation planning procedures due to local and regional differences in practice. The ICF-CY was familiar, but not in formal use in clinical practice. CONCLUSION: There is a need to enhance the procedures and to systematize coordination of services in the rehabilitation process. The ICF-CY framework might help to optimize collaborative goal setting and to structure both procedures and documentation of the rehabilitation plans and goals.

Exploring the relationship of family goals and scores on standardized measures in children with cerebral palsy, using the ICF-CY.

AIM: To explore the relationships of family selected goals and scores on standardized measures using the ICF-CY as a classification system. METHODS: Goal attainment scaling (GAS)-goals (n = 110) of 22 children, 11 girls, 1-6 years, bilateral or unilateral cerebral palsy, GMFCS I-IV and MACS I-IV were linked to the ICF-CY. The children had participated in goal-directed therapy during 12 weeks. GAS-goals, baseline assessments and change scores from PEDI and GMFM-66 were used to explore the relationships. RESULTS: All GAS-goals were classified in the Activity and Participation domain within ICF-CY. The number of GAS-goals correlated to baseline scores in PEDI and GMFM-66. The change scores in PEDI and GMFM-66 correlated to goal attainment in the Mobility and the Self-Care chapter. CONCLUSIONS: The family goals were reflected in standardized measures. The combined use of standardized and individual measures offers a possibility to explore the focus in therapy and the impact in children with cerebral palsy.

Goal-directed functional therapy: a longitudinal study on gross motor function in children with cerebral palsy.

PURPOSE: To investigate gross motor function and goal attainment in children with cerebral palsy before, during and after goal-directed functional therapy (GDT), to evaluate body functions, and explore relationships. METHOD: Prospective longitudinal intervention study. Twenty-two children, uni- or bilateral CP, 1-6 years (mean: 46 months SD: 16 months), classified in GMFCS and MACS level I-IV participated. Outcome measures were Gross Motor Function Measure (GMFM-66), performed at seven occasions, Goal Attainment Scale, assessments of passive range of motion, spasticity and selective motor control (SMC). Baseline, the GDT-intervention and the follow-up period were 12 weeks each. RESULTS: Improvements were demonstrated in GMFM-66 during the intervention (mean difference: 5.07, CI: 3.8-6.4, p < 0.001). The baseline and follow-up assessments were stable. Evaluations of ankle dorsiflexion displayed small improvement (mean difference: 9 degrees , CI: 5-13, p < 0.001). Estimations of spasticity and SMC did not demonstrate significant changes. Goal attainment to the expected level or higher was achieved in 93/110 goals and further improved at the long-term follow-up (103/110). CONCLUSION: Gross motor function improved during GDT, and was maintained 12 weeks later. The goals were reached to a high extent, and the children gradually progressed towards their goals after the end of the intervention. The therapy did not induce any deterioration of body functions.

Assessment of everyday functioning in young children with disabilities: an ICF-based analysis of concepts and content of the Pediatric Evaluation of Disability Inventory (PEDI).

BACKGROUND: Assessment of everyday functioning in children may depend to a considerable extent on the framework used to conceptualise functioning and disability. The Pediatric Evaluation of Disability Inventory (PEDI) has incorporated the mediating role of the environment on disability, using different measurement scales. The construction of the Functional Skills scales, which measure capability, and the Caregiver Assistance scales, which measure performance, was based on the Nagi disablement scheme. The International Classification of Functioning, Disability and Health (ICF) represents a new framework of functioning and disability that could be used to compare the measurement constructs and the content of different outcome measurements. PURPOSE: To examine the conceptual basis and the content of the PEDI using the ICF. METHOD: Phrases that describe the conceptual basis of the PEDI scales and of the ICF classifications were systematically collected and compared. Two researchers classified the item content of the Functional Skills scales independently before consensus was reached. RESULTS: The analyses indicate that the conceptual basis of the PEDI scales to a large extent match the ICF concepts of activity, participation and environmental factors. Both the PEDI and the ICF use the constructs of capacity and performance, but differ in how to operationalise these constructs. The classification of the Functional Skills scales shows that the PEDI primarily is a measure of activities and participation. The frequently use of environmental codes to classify the context of the requested functions demonstrates that the PEDI has incorporated the environment into the assessment. CONCLUSIONS: Our analyses indicate that the ICF could serve as a conceptual framework to clarify the measurement construct of the PEDI scales, and as taxonomy to describe and clarify the item content of the Functional Skills scales. Both as framework and taxonomy the ICF showed limitations in covering functioning in early childhood.

Functional therapy for children with cerebral palsy: an ecological approach.

The aim of this pilot study was to evaluate functional training for children with cerebral palsy (CP). The outcomes examined were goal-achievement, gross motor function, performance of everyday activities, caregiver assistance, parents' perception of family-centredness, and preschool assistants' feeling of competence in the care of the children. The outcome measures used were goal attainment scaling, Gross Motor Function Measure, Pediatric Evaluation of Disability Inventory (functional skills and caregiver assistance scales), Measure of Processes of Care, and a questionnaire. The intervention was carried out in the context of daily life settings, i.e. in an ecological framework. Fourteen children (three females, 11 males; age range 1y 6mo to 6y) with diplegia and tetraplegia, classified at Gross Motor Function Classification System levels II-V, participated in the five-month intervention. Frequency of training towards a specific goal varied between twice a day and 23 times a day, depending on the type of goal. Seventy-seven per cent of goals were fully attained. Gross motor function and performance of daily activities, including social function, improved significantly. A decrease in caregiver assistance was noted in relation to the children's mobility. Parents' perception of family-centredness improved in all domains. Furthermore, the children's preschool assistants felt more competent in their care of the children.

The use and impact of assistive devices and other environmental modifications on everyday activities and care in young children with cerebral palsy.

PURPOSE: The study describes use of assistive devices and other environmental modifications, and their impact on everyday activities and care in young children with cerebral palsy (CP). METHOD: Ninety-five children (55 boys, 40 girls; mean age 58 months, SD 18 months) and their parents were studied using a cross-sectional design. The Pediatric Evaluation of Disability Inventory (PEDI) was applied to assess daily activities using the three measurement scales: functional skills, caregiver assistance, and modifications of the environment. Use of modifications was described related to the five severity levels of the Gross Motor Function Classifications System (GMFCS). Impact was rated on the Caregiver Assistance scale of the PEDI and on a five-point Likert scale. RESULTS: Out of the 1075 provided environmental modifications, 980 were in regular use to support mobility, self-care and social function among 84 children. The number increased with GMFCS levels; children at levels IV and V used 80% of the modifications, with large variations between the children at same level. Adaptations of housing and transportation facilitated effective use of assistive devices. Half of the parents rated the modifications to have moderate to very large effect on the child's mobility, 25% on self-care skills, and 20% on social function. Furthermore, 65% reported that the modifications lightened the caregiving for mobility, 75% for self-care and 25% for social function. Functional independence and care demands often benefited from different types of modifications. CONCLUSION: The variations in use and benefits of environmental modifications indicate need of comprehensive assistive technology assessments, including child factors, family factors, technology factors and service system factors.

Postural dysfunction in children with cerebral palsy: some implications for therapeutic guidance.

Postural problems play a central role in the motor dysfunction of children with cerebral palsy (CP). Therefore, they spend more time in sitting than in standing to perform vital tasks of daily life. The focus of this article is to describe the pathophysiology of postural control in sitting and outline some implications for management and treatment. In general, children with CP exhibit muscular activity counteracting forces that disturb equilibrium. Only 'non-sitting' children with severe CP lack such 'direction-specific' adjustments, possibly ruling out achievement of independent sitting. Most frequently, the children display dysfunctions in the adaptation of the adjustment. Typical characteristics of this adaptation in children with CP are a top-down recruitment of postural muscles, an excessive degree of antagonistic coactivation, and an incomplete adaptation of the EMG-amplitude to task specific constraints. Despite our knowledge on the pathophysiology underlying the postural problems in children with CP, little 'high-level' evidence (according to Sackett) exists on how different interventions can affect these problems. Therapeutic attention to promote motor performance in sitting focuses on adaptive seating, tilting of the support surface, and ample, variable training in motivating settings. The challenge facing us now is to provide evidence about the efficacy of specific treatment approaches facilitating that children reach an optimal level of functioning in daily life.

Development of postural adjustments in sitting position during the first half year of life.

Little is known about the development of postural adjustments during early ontogeny. We examined postural adjustments due to sudden perturbations during sitting in 40 healthy term infants (28 males, 12 females) assessed in groups of eight at 1, 2, 3, 4, and 5 months of age. Surface electromyograms of neck, trunk, and leg muscles were recorded while the infants were exposed to a random series of horizontal forward and backward displacements of the surface of support. Video recordings of spontaneous motor behaviour were analyzed. For part of the analyses, previously collected data on 26 infants aged 6 to 10 months were included. In general, postural adjustments at all ages were direction specific and showed large variation. Within the variation developmental changes could be observed, revealing a transient decrease in postural activity at 3 months of age. After this transition, direction-specific postural activity was correlated with spontaneous motor behaviour. This was true, in particular, for dorsal postural activity. The clinical relevance of these findings is discussed.

Motor impairments in young children with cerebral palsy: relationship to gross motor function and everyday activities.

In this study we assessed the distribution of spasticity, range of motion (ROM) deficits, and selective motor control problems in children with cerebral palsy (CP), and examined how these impairments relate to each other and to gross motor function and everyday activities. Ninety-five children (55 males, 40 females; mean age 58 months, SD 18 months, range 25 to 87 months) were evaluated with the modified Ashworth scale (MAS), passive ROM, the Selective Motor Control scale (SMC), the Gross Motor Function Measure (GMFM), and the Pediatric Evaluation of Disability Inventory (PEDI). Types of CP were hemiplegia (n=19), spastic diplegia (n=40), ataxic diplegia (n=4), spastic quadriplegia (n=16), dyskinetic (n=9), and mixed type (n=7). Severity spanned all five levels of the Gross Motor Function Classification System (GMFCS). The findings highlight the importance of measuring spasticity and ROM in several muscles and across joints. Wide variability of correlations of MAS, ROM, and SMC indicates a complex relationship between spasticity, ROM, and selective motor control. Loss of selective control seemed to interfere with gross motor function more than the other impairments. Further analyses showed that motor impairments were only one component among many factors that could predict gross motor function and everyday activities. Accomplishment of these activities was best predicted by the child's ability to perform gross motor tasks.

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.