Sigrid Østensjø

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 childs 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.

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 childs 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.

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.

Goal-oriented rehabilitation of preschoolers with cerebral palsy—a multi-case study of combined use of the Canadian Occupational Performance Measure (COPM) and the Goal Attainment Scaling (GAS)

Purpose: To explore setting and implementing goals as an ongoing process, using the COPM and the GAS in combination. Methods: Multi-case study of a goal-setting approach, involving parents and service providers of 13 children (aged 23–50 months) with mild-to-moderate CP enrolled in a 9-month rehabilitation programme consisting of two blocks of setting and implementing goals. The childrens COPM reports and GAS goals and information from a questionnaire about implementation were analysed. Results: In the initial assessment, most problems prioritized by the parents in the COPM were phrased in terms of activities. The priorities for intervention changed during the process of setting and implementing goals. GAS goals were frequently integrated in everyday activities both at home and in kindergarten based on decisions on how to implement the goals. Changes in the childrens performance were recognized by a high proportion of goal attainment and a small, but clear change in the parents’ perception of performance. Parents and service providers reported many gains working towards concrete and measurable goals, but also some challenges. Conclusion: By using the COPM and GAS in combination, a dynamic and interactive process of setting and implementing goals in the context of everyday activities emerged.

A systematic review of measures of shoulder pain and functioning using the International classification of functioning, disability and health (ICF).

BackgroundShoulder pain is a common condition with prevalence estimates of 7–26% and the associated disability is multi-faceted. For functional assessments in clinic and research, a number of condition-specific and generic measures are available. With the approval of the ICF, a system is now available for the analysis of health status measures. The aims of this systematic literature review were to identify the most frequently addressed aspects of functioning in assessments of shoulder pain and provide an overview of the content of frequently used measures.MethodsMeaningful concepts of the identified measures were extracted and linked to the most precise ICF categories. Second-level categories with a relative frequency above 1% and the content of measures with at least 5 citations were reported.ResultsA set of 40 second-level ICF categories were identified in 370 single-item measures and 105 multi-item measures, of these, 28 belonged to activities and participation, 11 to body functions and structures and 1 to environmental factors. The most frequently addressed concepts were: pain; movement-related body functions and structures; sleep, hand and arm use, self-care, household tasks, work and employment, and leisure. Concepts of psycho-social functions and environmental factors were less frequently included. The content overview of commonly used condition-specific and generic measures displayed large variations in the number of included concepts. The most wide-ranging measures, the DASH and ASES were linked to 23 and 16 second-level ICF categories, respectively, whereas the Constant were linked to 7 categories and the SST and the SPADI to 6 categories each.ConclusionsThis systematic review displayed that measures used for shoulder pain included more than twice as many concepts of activities and participation than concepts of body functions and structures. Environmental factors were scarcely addressed. The huge differences in the content of the condition-specific multi-item measures demonstrates the importance of clarifying the content to select the most appropriate measure both in research and in clinical work. For clinical situations, we propose use of a wide-ranging condition-specific measure that conceptualizes assessments of shoulder pain from a bio-psycho-social perspective. Further research is needed to assess how patient-reported problems in functioning are captured in the commonly used measures.

Intensive training of motor function and functional skills among young children with cerebral palsy: a systematic review and meta-analysis

BackgroundYoung children with cerebral palsy (CP) receive a variety of interventions to prevent and/or reduce activity limitations and participation restrictions. Some of these interventions are intensive, and it is a challenge to identify the optimal intensity. Therefore, the objective of this systematic review was to describe and categorise intensive motor function and functional skills training among young children with CP, to summarise the effects of these interventions, and to examine characteristics that may contribute to explain the variations in these effects.MethodsTen databases were searched for controlled studies that included young children (mean age less than seven years old) with CP and assessments of the effects of intensive motor function and functional skills training. The studies were critically assessed by the Risk of bias tool (RoB) and categorised for intensity and contexts of interventions. Standardised mean difference were computed for outcomes, and summarised descriptively or in meta-analyses.ResultsThirty-eight studies were included. Studies that targeted gross motor function were fewer, older and with lower frequency of training sessions over longer training periods than studies that targeted hand function. Home training was most common in studies on hand function and functional skills, and often increased the amount of training. The effects of constraint induced movement therapy (CIMT) on hand function and functional skills were summarised in six meta-analyses, which supported the existing evidence of CIMT. In a majority of the included studies, equal improvements were identified between intensive intervention and conventional therapy or between two different intensive interventions.ConclusionsDifferent types of training, different intensities and different contexts between studies that targeted gross and fine motor function might explain some of the observed effect variations. Home training may increase the amount of training, but are less controllable. These factors may have contributed to the observed variations in the effectiveness of CIMT. Rigorous research on intensive gross motor training is needed.Systematic review registration numberCRD42013004023.

Problems in functioning after a mild traumatic brain injury within the ICF framework: the patient perspective using focus groups

Purpose: To describe problems in body functions, activities, and participation and the influence of environmental factors as experienced after mild traumatic brain injury (TBI), using the ICF framework. To compare our findings with the Brief and Comprehensive ICF Core Sets for TBI. Methods: Six focus-group interviews were performed with 17 participants (nine women, eight men, age ranged from 22 to 55 years) within the context of an outpatient rehabilitation programme for patients with mild TBI. The interviews were transcribed verbatim and analysed using the ICF. Results: One-hundred and eight second-level categories derived from the interview text, showing a large diversity of TBI-related problems in functioning. Problems in cognitive and emotional functions, energy and drive, and in carrying out daily routine and work, were frequently reported. All ICF categories reported with high-to-moderate frequencies were present in the Brief ICF Core Set and 84% in the Comprehensive ICF Core Set. The reported environmental factors mainly concerned aspects of health and social security systems, social network and attitudes towards the injured person. Conclusions: This study confirms the diversity of problems and the environmental factors that have an impact on post-injury functioning of patients with mild TBI. Implications for Rehabilitation Disabilities related to cognitive and emotional functions, energy and drive, and carrying out daily routine and work should be addressed in rehabilitation of people with mild traumatic brain injury (TBI). Attention should be given to environmental facilitators and barriers for activities and participation. Participation in everyday life after a mild TBI, including social- and work-participation, constitutes a challenge where multidisciplinary rehabilitation efforts should be considered. The Brief Core Set does not attain all frequently observed categories of functioning among people with mild TBI.

Motor Training and Physical Activity Among Preschoolers with Cerebral Palsy: A Survey of Parents’ Experiences

ABSTRACT Objective: To describe motor training and physical activity among preschoolers with cerebral palsy (CP) in Norway, and assess associations between child, parent, and motor intervention characteristics, and parent-reported child benefits from interventions. Method: Survey of 360 parents and data from the Norwegian CP follow-up program. The response rate was 34%. Results: During the six months preceding the time of the survey, 75% of the children performed gross-motor training, 73% fine-motor training, 80% manual stretching, and 67% participated regularly in physical activities. The training was highly goal-directed, intensive, frequently incorporated in daily routines, and often with a high level of parental involvement. The use of goals was associated with higher parent-reported child benefits for all types of interventions. Moreover, the positive relationship, which was indicated between frequency of training, parent education, and parent-reported child benefits of gross-motor training, was not seen for fine-motor training. Conclusion: Parent-reported child benefits support goal-directed motor interventions, and the use of everyday activities to increase practice of motor skills.

Family-centred practices in the provision of interventions and services in primary health care: A survey of parents of preschool children with cerebral palsy.

The aims of this study were to explore how parents of preschoolers with cerebral palsy (CP) experienced the level of family-centred services using the Measure of Processes of Care (MPOC-20) within primary health care in Norway and to examine the relationships between these experiences and the provided everyday skills interventions and services. A survey was sent to 360 parents of preschool children with CP. The response rate was 34%. Of the MPOC scales respectful and supportive care and coordinated and comprehensive care received the highest ratings, and providing general information received the lowest. Our findings indicate lower levels of family centredness in primary health-care contexts than that reported in specialist health care. Significant positive associations were found between all the five MPOC-20 scales and the parents’ satisfaction with the amount of service coordination (p = .000–.004). The high scores for respectful and supportive care and the low scores for general information indicate that the families experienced relational help giving practices to a larger extent and participatory practices to a lesser extent. To increase the participatory aspects of family-centred practice, further research needs to address facilitators and barriers of information sharing and ways of giving this information both in specialist and primary health care.