Vanessa A. Scholtes

Clinical assessment of spasticity in children with cerebral palsy: a critical review of available instruments.

This study reviews the instruments used for the clinical assessment of spasticity in children with cerebral palsy, and evaluates their compliance with the concept of spasticity, defined as a velocity‐dependent increase in muscle tone to passive stretch. Searches were performed in Medline, Embase, and Cinahl, including the keywords ‘spasticity’, ‘child’, and‘cerebral palsy’, to identify articles in which a clinical method to measure spasticity was reported. Thirteen clinical spasticity assessment instruments were identified and evaluated using predetermined criteria. This review consists of reports on the standardization applied for assessment at different velocities, testing posture, and quantification of spasticity. Results show that most instruments do not comply with the concept of spasticity; standardization of assessment method is often lacking, and scoring systems of most instruments are ambiguous. Only the Tardieu Scale complies with the concept of spasticity, but this instrument has a comprehensive and time–consuming clinical scoring system.

What makes a measurement instrument valid and reliable

High quality instruments are useful tools for clinical and research purposes. To determine whether an instrument has high quality, measurement properties such as reliability and validity need to be assessed, using standardised criteria. This paper discusses these quality domains and measurement properties using the standardised criteria that were recently published by the COSMIN group. Examples are given of studies evaluating the measurement properties of instruments frequently used in trauma. This paper presents a helpful tool for readers who want to evaluate or assess the quality of a measurement instrument on reliability and validity.

Effectiveness of functional progressive resistance exercise strength training on muscle strength and mobility in children with cerebral palsy: a randomized controlled trial

Aim  To evaluate the effectiveness of functional progressive resistance exercise (PRE) strength training on muscle strength and mobility in children with cerebral palsy (CP).

Evaluation of clinical spasticity assessment in Cerebral palsy using inertial sensors

Spasticity is clinically assessed using goniometry to measure the joint angle of the catch (AOC) during fast passive muscle stretch. The precision and accuracy of the goniometric AOC measurements are questionable, because of the inevitable joint repositioning after occurrence of the catch. This study aims to evaluate the use of goniometry in estimating the AOC in spasticity assessment of the medial hamstrings, soleus and gastrocnemius in twenty children with Cerebral palsy (CP), using inertial sensors (IS) as reference system. The IS were initially validated with an optoelectronic system to measure 3d-orientation and proved to be accurate within 1 degree. To evaluate the precision and accuracy of the goniometry, the joint angle measured with the goniometer after repositioning was compared to the joint angle measured simultaneously with the IS, and to the true AOC, detected and measured with the IS during the fast muscle stretch. Results showed that goniometry is an imprecise method to measure the true AOC in spasticity assessment. The error is mainly due to joint repositioning after the fast muscle stretch. For spasticity assessment, it is advised to apply inertial sensors when a precise measurement of the angle of catch is required.

Effectiveness of functional progressive resistance exercise training on walking ability in children with cerebral palsy: A randomized controlled trial

The objective of the study was to evaluate the effectiveness of functional progressive resistance exercise (PRE) training on walking ability in children with cerebral palsy (CP). Fifty-one ambulant children with spastic CP (mean age 10 years 5 months, 29 boys) were randomized to an intervention (n=26) or control group (n=25, receiving usual care). The intervention consisted of 12 weeks functional PRE circuit training, for 3 times a week. Main outcome measures were walking ability and participation. Secondary outcomes were muscle strength and anaerobic muscle power. Possible adverse outcomes were spasticity and passive range of motion (ROM). Muscle strength increased significantly in the training group compared to the control group, but walking ability, participation and anaerobic muscle power did not change. Spasticity and ROM remained unchanged, except for a significant decrease in rectus femoris length in the intervention group. It is concluded that twelve weeks of functional PRE-training does not improve walking ability, despite improved muscle strength.

Lower limb strength training in children with cerebral palsy--a randomized controlled trial protocol for functional strength training based on progressive resistance exercise principles.

BackgroundUntil recently, strength training in children with cerebral palsy (CP) was considered to be inappropriate, because it could lead to increased spasticity or abnormal movement patterns. However, the results of recent studies suggest that progressive strength training can lead to increased strength and improved function, but low methodological quality and incomplete reporting on the training protocols hampers adequate interpretation of the results. This paper describes the design and training protocol of a randomized controlled trial to assess the effects of a school-based progressive functional strength training program for children with CP.Methods/ResultsFifty-one children with Gross Motor Function Classification Systems levels I to III, aged of 6 to 13 years, were recruited. Using stratified randomization, each child was assigned to an intervention group (strength training) or a control group (usual care). The strength training was given in groups of 4–5 children, 3 times a week, for a period of 12 weeks. Each training session focussed on four exercises out of a 5-exercise circuit. The training load was gradually increased based on the childs maximum level of strength, as determined by the 8 Repetition Maximum (8 RM). To evaluate the effectiveness of the training, all children were evaluated before, during, directly after, and 6 weeks after the intervention period. Primary outcomes in this study were gross motor function (measured with the Gross Motor Function Measure and functional muscle strength tests) and walking ability (measured with the 10-meter, the 1-minute and the timed stair test). Secondary outcomes were lower limb muscle strength (measured with a 6 RM test, isometric strength tests, and a sprint capacity test), mobility (measured with a mobility questionnaire), and sport activities (measured with the Childrens Assessment of Participation and Enjoyment). Spasticity and range of motion were assessed to evaluate any adverse events.ConclusionRandomized clinical trials are considered to present the highest level of evidence. Nevertheless, it is of utmost importance to report on the design, the applied evaluation methods, and all elements of the intervention, to ensure adequate interpretation of the results and to facilitate implementation of the intervention in clinical practice if the results are positive.Trial RegistrationTrial Register NTR1403

Reliability and Validity of the IKDC, KOOS, and WOMAC for Patients With Meniscal Injuries

Background: Several patient-reported outcome measurements are used to measure functional outcome after treatment of meniscal injuries. However, for comparison of study results, there is a need for a uniform and standardized approach of measuring functional outcome. Selection of the instrument should be based on the quality of its measurement properties, and only the best instrument can be justified to be used. Purpose: This study aimed to determine and compare the measurement properties of the Dutch-language versions of the International Knee Documentation Committee (IKDC) Subjective Knee Form, Knee Injury and Osteoarthritis Outcome Score (KOOS), and Western Ontario and McMaster Universities Arthritis Index (WOMAC) in a homogeneous group of patients with meniscal tears. Study Design: Cohort study (design); Level of evidence, 2. Methods: Patients on the waiting list for meniscal surgery and patients between 6 weeks and 6 months after meniscal surgery were included (n = 75). Patients were excluded if they received an arthroplasty or had surgery on the anterior cruciate ligament. Internal consistency (Cronbach alpha), test–retest reliability (intraclass correlation coefficient [ICC]), measurement error (SEM), smallest detectable difference (SDD), content validity, construct validity (factor analysis and hypothesis testing), and floor and ceiling effects were determined. Results: Results for the IKDC, KOOS dimensions, and WOMAC dimensions, respectively, were as follows: Cronbach alpha = .90, .72-.95, and .84-.95; ICC = 0.93, 0.84-0.89, and 0.77-0.89; SEM = 5.3, 7.0-12.6, and 7.3-12.2; SDD = 14.6, 19.4-35.0, and 20.2-33.9; hypotheses testing confirmation = 100%, 86%, and 85%. Floor effects within the SDD from the minimum score were found for the KOOS Sports/Recreation and Quality of Life dimensions. Ceiling effects within the SDD from the maximum score were found for the KOOS Activities of Daily Living and for all WOMAC dimensions. Conclusion: The IKDC showed the best performance on all measurement properties, implying that the IKDC, rather than the KOOS or WOMAC, should be used to assess functional outcome in patients with meniscal tears.

Reliability of Isometric Lower-Extremity Muscle Strength Measurements in Children With Cerebral Palsy: Implications for Measurement Design

Background Children with cerebral palsy (CP) typically show muscle weakness of the lower extremities, which can be measured with the use of handheld dynamometry (HHD). Objective The purposes of this study were: (1) to determine test-retest reliability and measurement error of isometric lower-extremity strength measurements in children with CP with the use of HHD and (2) to assess implications for measurement design. Design A test-retest design was used. Methods Fourteen children with hemiplegic (n=6) or diplegic (n=8) spastic CP (Gross Motor Function Classification System levels I–III), ages 7 to 13 years, were assessed for isometric strength on 2 separate days (occasions) with the use of HHD, with 3 trials per muscle group. The intraclass correlation coefficient, standard error of measurement, and smallest detectable difference (SDD) were calculated for different measurement designs. Results Intraclass correlation coefficient values of single measurements for all muscle groups ranged from .70 to .90, and the SDD was large (>30%). Regarding measurement error, the largest source of variability was found for occasion. A 2-occasion mean decreased the SDD by 9% to 14%. For trials, a greater improvement in SDD was found when 2 trials were averaged instead of 3. A measurement design of 2 trials–2 occasions was superior to the often-used approach of 3 trials–1 occasion. Limitations The small sample size was the major study limitation. Conclusions Handheld dynamometry is reliable and can be used to detect changes in isometric muscle strength in children with CP when using the mean of at least 2 trials. To further improve reliability, taking the average of 2 occasions on separate days is recommended, depending on group size and muscle group.

The importance of addressing heteroscedasticity in the reliability analysis of ratio-scaled variables: an example based on walking energy-cost measurements

Aim  When analysing the reliability of ratio‐scaled variables, such as walking energy cost, variability of the error term often increases with increasing mean values. This phenomenon is called heteroscedasticity, and it makes the analysis of reliability more complicated. This study presents an examination of heteroscedasticity for walking energy cost before analysing the reliability.

Emerging Designs in Orthopaedics: Expertise-Based Randomized Controlled Trials

In this article, we discuss the limitations of conventional randomized controlled trials (RCTs) in the surgical field. Surgeons are often believers in certain surgical techniques and therefore can be reluctant to learn new interventions. In expertise-based trials, the patients are randomized to surgeons with expertise in the intervention under investigation. In conventional RCTs, patients are randomized to an intervention, and surgeons will perform this intervention regardless of whether this is the surgery they typically undertake. Conventional randomization may lead to surgery performed by a less experienced or less motivated surgeon, resulting in differential expertise bias. Expertise-based trials can overcome these limitations if potential pitfalls are taken into account.