Josse De Cat

A clinical tool to measure trunk control in children with cerebral palsy: the Trunk Control Measurement Scale.

In this study the psychometric properties of the Trunk Control Measurement Scale (TCMS) in children with cerebral palsy (CP) were examined. Twenty-six children with spastic CP (mean age 11 years 3 months, range 8-15 years; Gross Motor Function Classification System level I n = 11, level II n = 5, level III n = 10) were included in this study. To determine the discriminant ability of the TCMS, 30 typically developing (TD) children (mean age 10 years 6 months, range 8-15 years) were also included. For inter-rater reliability, two testers scored all children simultaneously. To determine test-retest reliability, participants were reassessed on a second test occasion. For construct validity, the Gross Motor Function Measure (GMFM) was administered. Intraclass correlation coefficients (ICC) ranged from 0.91 to 0.99 for inter-rater and test-retest reliability. Kappa and weighted kappa values ranged for all but one item from 0.45 to 1. The standard error of measurement was 2.9% and 3.4%, and the smallest detectable difference for repeated measurements was 8% and 9.43% between raters and test-retest, respectively. Cronbachs alpha coefficients ranged from 0.82 to 0.94. Spearman rank correlation with the GMFM was 0.88 and increasing coefficients were found from dimension B to E. Subscale and total TCMS scores showed significant differences between children with CP and TD children (p < 0.0001). The results support the reliability and validity of the TCMS in children with spastic CP. The scale gives insight into the strengths and weaknesses of the childs trunk performance and therefore can have valuable clinical use.

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.

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 Wards 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.

Botulinum toxin type A treatment in children with cerebral palsy: evaluation of treatment success or failure by means of goal attainment scaling

BACKGROUND There is considerable variability in the amount of response to BTX-A treatment between and within patients with cerebral palsy (CP). AIMS The purpose of this retrospective cohort study was to evaluate the clinical responsiveness of Botulinum toxin type A (BTX-A) treatment in children with CP and specifically delineate features of treatment success and failure. METHODS Four hundred and thirty-eight children (251 boys, 187 girls; mean age 8 years 2 months, SD 4 years) were included into the study. Goal Attainment Scaling (GAS) was used to classify and evaluate treatment efficacy. Two study groups were defined: one group with an excellent response (GAS≥60.0) and one group with a lack of response (GAS≤40.0) to BTX-A. RESULTS Seventy-five patients (17.1%) had an excellent response and treatment was found to be unsuccessful for 31 patients (7.1%). Children with a lack of response to BTX-A were significantly older compared to children with a high responsiveness (p=0.0013). In the latter group, more children received multi-level injections and fewer children had injections in proximal parts of the lower limb compared to the low responsiveness group (p=0.0024). Moreover, there was a significant difference in the use of different types of casts between both study groups (p=0.0263). CONCLUSION Age, level of treatment and casting seem to be crucial features of BTX-A treatment success or failure in children with CP.

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

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.

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 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.