Classificação da função motora e do desempenho funcional de crianças com paralisia cerebral / Classification of motor function and functional performance in children with cerebral palsy

OBJETIVOS: Classificar crianças com paralisia cerebral (PC) utilizando sistemas de classificação de mobilidade e de função manual; comparar os grupos de crianças com PC nos desfechos de função motora grossa e de desempenho funcional; avaliar a associação entre as classificações funcionais e os escores obtidos nos desfechos investigados. MATERIAL E MÉTODOS: Trinta crianças com PC foram classificadas pelos sistemas Gross Motor Function Classification System (GMFCS) e Manual Abilities Classification System (MACS) e divididas em três grupos, de acordo com a sua classificação em cada um destes sistemas em leve, moderado e grave. A função motora grossa foi documentada pelo teste Gross Motor Function Measure (GMFM-66), e as habilidades funcionais e assistência do cuidador em autocuidado e em mobilidade, pelo teste Pediatric Evaluation of Disability Inventory (PEDI). RESULTADOS: O teste one-way ANOVA demonstrou diferenças significativas entre os grupos nos resultados do GMFM-66 e do teste PEDI. Testes de comparação post-hoc (Scheffé) revelaram que crianças com comprometimento moderado (GMFCS) apresentaram habilidades funcionais e receberam assistência do cuidador semelhantes às crianças leves. Entretanto, crianças moderadas (MACS) assemelharam-se às graves. Índices de correlação de Spearman rank demonstraram associação inversa, significativa e de magnitude forte entre as classificações funcionais e os resultados dos testes PEDI e GMFM-66. CONCLUSÕES: Os resultados sugerem que as classificações funcionais MACS e GMFCS são bons indicadores da função manual e da mobilidade de crianças com PC, podendo ser úteis nos processos de avaliação e planejamento de intervenção.

OBJECTIVE: To classify children with cerebral palsy (CP) using classification systems for mobility and manual function; to compare groups of children with CP regarding gross motor function and functional performance outcomes; and to evaluate associations between the functional classifications and the scores obtained in the outcomes that were investigated. METHODS: Thirty children with CP were classified using the Gross Motor Function Classification System (GMFCS) and the Manual Abilities Classification System (MACS), and were divided into three groups, based on their classification (mild, moderate or severe) in each of these systems. Gross motor function was documented using the Gross Motor Function Measure (GMFM-66) test, while functional abilities and the caregiver's assistance regarding self-care and mobility were documented using the Pediatric Evaluation of Disability Inventory (PEDI). RESULTS: One-way ANOVA showed that the groups were significantly different regarding the GMFM-66 and PEDI results. Post-hoc comparison tests (Scheffé) revealed that the children with moderate impairment (GMFCS) had functional abilities and caregiver support that were similar to those of the mildly impaired children. However, the moderate children (MACS) were not different from the severe children. Spearman rank correlations showed strong and significant inverse associations between the functional classifications and the results from the PEDI and GMFM-66 tests. CONCLUSIONS: The results suggest that the MACS and GMFCS functional classifications are good indicators of the manual function and mobility of children with CP. These classifications may be useful in the processes of evaluation and intervention planning.

Changes in lower limb co-contraction and stiffness by toddlers with Down syndrome and toddlers with typical development during the acquisition of independent gait.

During gait acquisition, children learn to use their changing resources to meet the requirements of the task. Compared to typically developing toddlers (TD), toddlers with Down syndrome (DS) have functionally different musculoskeletal characteristics, such as hypotonia, and joint and ligament laxity, that could produce a reduced passive stiffness. The interplay between this inherently lower passive stiffness and the demands of walking may result in different strategies during gait acquisition. This study compared normalized global stiffness and lower limb's co-contraction indices (CCI) used by toddlers with TD (n=12) and with DS (n=12), during the early stages of gait acquisition. Stiffness and CCI were normalized by gravitational torque (mLg) in both phases of gait (stance, swing). Five longitudinal evaluations were conducted from the onset of locomotion until three months post-acquisition. All children were video taped and had electromyographic (EMG) recordings from muscle pairs of one leg, which were used to calculate CCI of hip, knee, ankle, and total leg CCI. Body and lower limb stiffness were calculated according to a hybrid pendulum resonance equation. Results from ANOVAs revealed no group differences on stiffness or on CCI's during stance but children with DS showed greater CCI during swing. Despite the structural musculoskeletal differences between toddlers with TD and with DS, the similarities observed in their processes of gait development suggest functional equivalences.

Neuromuscular mechanisms and anthropometric modifications in the initial stages of independent gait.

The gait acquisition is an important milestone of motor development. Structural modifications observed during this period add complexity to the process, and the child needs to use appropriate neuromuscular strategies to walk independently. The objective of this study was to document the longitudinal modifications in neuromuscular mechanisms and in functional anthropometric measures during independent gait acquisition in typically developing children. Twelve children were followed for 2 months after gait acquisition, with its initial period documented by the standardized test Alberta Infant Motor Scale. Quantification of the EMG signals of six muscles in the right lower limb allowed the calculation of the co-contraction indexes (CCI) considering pairs of antagonistic muscles, representing the hip, knee and ankle joints. The CCIs were summed up to yield a total index. Anthropometric measures were transformed into gravitational torque (mLg) values for stance and swing phases of gait. Statistical analyses included repeated measures ANOVA models with one factor (week post-acquisition) for the dependent variables mLg and normalized CCI (CCI/mLg). A significant increase was observed in the mLg during the period evaluated both in stance and swing phases (p=0.0001). In addition, there was a decrease in the value of the normalized hip and total CCIs in both phases of gait (p<0.05). The results revealed changes in the neuromuscular mechanisms used by typical children to deal with the demands involved in the process of gait acquisition.

Analise das intervencoes utilizadas para a promocao da marcha em criancas portadoras de paralisia cerebral: uma revisao sistematica da literatura / Analysis of the interventions used for grait promotion in children with cerebral palsy: a systematic review of the literature

Com o aumento da producao cientifica em reabilitacao, a literatura tem sido fonte de informacao para profissionais que atuam nessa area, indicando procedimentos validos e adequandos a determinada situacao clinica. O objetivo deste estudo foi realizar na literatura uma revisao sistematica de artigos cientificos que investigaram os efeitos de diferentes tipos de abordagens terapeutica nao-invasiva, visando a promocao da marcha em criancas portadoras de paralisia cerebral espastica. Foi realizada busca em diferentes bases eletronicas de dados entre janeiro de 1995 e maio de 2003.Com base nos criterios de inclusao, sete estudos forma selecionados e realizada analise da qualidade de evidencia por dois examinadores separadamente, utilizando a escala PEDro (ndice de concordancia Kappa K=0,95). Os resultados foram discutidos centrando-se nos seguintes pontos: tipo de investigacao metodologica utilizada, caracterizacao dos participantes dos estudos, descricao dos procedimentos terapeuticos e dos efeitos da intervencao e analise da informacao fornecida pelos estudos relacionando efeitos terapeuticos com funcionalidade. Os resultados desta revisao sistematica poderao nortear a atuacao clinica em paralisia cerebral, estimulando pratica com base em evidencias