Socioeconomic status, environmental factors, and motor function in children with cerebral palsy.

To assess development of reaching and head stability in infants at very high risk (VHR-infants) of cerebral palsy (CP) who did and did not develop CP. This explorative longitudinal study assessed the kinematics of reaching and head sway in sitting in 37 VHR-infants (18 CP) one to four times between 4.7 months and 22.6 months corrected age. Developmental trajectories were calculated using linear mixed effect models. Motor function was evaluated with the Infant Motor Profile (IMP) around 13 months corrected age. Throughout infancy, VHR-infants with CP had a worse reaching quality than infants without CP, reflected for example by more movement units (factor 1.52, 95% CI 1.16-1.99) and smaller transport movement units (factor 1.86, 95% CI 1.20-2.90). Total head sway of infants with and without CP was similar, but infants with CP used more head movement units to achieve stability. The rate of developmental change in infants with and without CP was similar. Around 13 months, head control and reaching quality were interrelated; both were associated with IMP-scores. Infants with CP showed a worse kinematic reaching quality and head stability throughout infancy from early age onwards than VHR-infants without CP, implying that kinematically they do not grow into a deficit, but exhibit deficits from early infancy on. Reaching quality improves throughout infancy in all infants at high risk (VHR-infants). Infants with cerebral palsy (CP) show a worse reaching quality than VHR-infants without CP. Infants with CP achieve head stability differently from infants without CP. Infants with CP exhibit kinematic reaching problems from early age onwards.

Activate-CP: Let's Ride a Bike! Efficacy of a functional-electrical-stimulation cycling, adapted cycling and goal-directed training program for children with cerebral palsy

To describe the prevalence of cerebral palsy (CP), subtype distribution, motor and intellectual impairment, and epilepsy in adults with CP compared with children with CP. CP subtype and impairment data from the population-based CP register of western Sweden and population data from Statistics Sweden were used to compare surviving adults (n=581; 244 females, 337 males) born between 1959 and 1978, with the same cohort as children (n=723; 307 females, 416 males), andwiththe most recent cohort, born from 2007 to 2010 (n=205; 84 females, 121 males). Prevalence of CP in adults born between 1959 and 1978 was 1.14 per 1000. The occurrence of impairments differed between CP subtypes. Motor and intellectual impairment were closely related, regardless of subtype. Subtype distribution among survivors differed significantly from the original cohorts (p=0.002), and the most recent cohort (p<0.01), tetraplegia and dyskinetic CP being less common in survivors. Severe motor impairment, intellectual disability, and epilepsy were less common among survivors than in the original cohorts (p=0.004, p=0.002, p=0.037) and the most recent cohort (p=0.004, p=0.008, p<0.01). Data on prevalence, subtype distribution, and impairments in children with CP are not applicable to adults with CP. Population-based studies of adults with CP are needed. Cerebral palsy (CP) subtypes are differently distributed in adults compared to children. The prevalence of impairments in adults with CP is related to CP subtype. Spastic tetraplegia and dyskinetic CP are less common in adults than children. Severe motor impairment, intellectual disability, and epilepsy are less common in adults.

To examine interrater agreement and validity of the Functional Communication Classification System (FCCS) for young children with cerebral palsy (CP) aged 2 or 3 years. Speech-language pathologist (SLP) and parent FCCS ratings for 31 children with CP (aged 2y, n=16; aged 3y, n=15; 18 males, 13 females) were examined for interrater agreement using a weighted Cohen's kappa statistic. Relationships between FCCS (SLP) ratings and: (1) concurrent validity with the Language Use Inventory, a standardized pragmatic assessment for children aged 18 to 47 months, (2) gross motor and fine motor function, (3) associated impairments (visual and intellectual), and (4) primary expressive communication mode were examined using Spearman's correlation coefficients. Almost perfect interrater agreement between SLP and parent FCCS ratings were found (kw =0.94). Correlations with FCCS (SLP) were excellent for pragmatic function (rs =-0.83,p<0.001), intellectual function (rs =0.89, p<0.001), and primary expressive communication mode (rs =0.92,p<0.001). Correlations were good for gross motor function (rs =0.72,p<0.001) and visual impairment (rs =0.70,p<0.001) and fair for fine motor function (rs =0.53,p<0.002). Analysis was unwarranted for epilepsy (n=1 out of 31) and hearing-associated impairments (n=0 out of 31). The FCCS has excellent interrater agreement and validity for communication classification of children with CP aged 2 or 3 years and is highly suitable for surveillance and research purposes. What this paper adds The Functional Communication Classification System (FCCS) is a valid instrument for children with cerebral palsy (CP) aged 2 or 3 years. Excellent agreement exists between speech-language pathologist and parent FCCS ratings. The FCCS has excellent correlation with intelligence, pragmatic function, and primary expressive mode. Stronger correlations with the Gross Motor Function Classification System and vision exist for children aged 2 or 3 years. Weaker correlations with manual ability exist when compared to older children with CP.

To evaluate the effect of progressive resistance training of the ankle plantarflexors on gait efficiency, activity, and participation in adolescents with cerebral palsy (CP). Sixty-four adolescents (10-19y; 27 females, 37 males; Gross Motor Function Classification System [GMFCS] levels I-III) were randomized to 30 sessions of resistance training (10 supervised and 20 unsupervised home sessions) over 10 weeks or usual care. The primary outcome was gait efficiency indicated by net nondimensional oxygen cost (NNcost). Secondary outcomes included physical activity, gross motor function, participation, muscle strength, muscle and tendon size, and muscle and tendon stiffness. Analysis was intention-to-treat. Median attendance at the 10 supervised sessions was 80% (range 40-100%). There was no between-group difference in NNcost at 10 (mean difference: 0.02, 95% confidence interval [CI] -0.07 to 0.11, p=0.696) or 22 weeks (mean difference: -0.08, 95% CI -0.18 to 0.03, p=0.158). There was also no evidence of between-group differences in secondary outcomes at 10 or 22 weeks. There were 123 adverse events reported by 27 participants in the resistance training group. We found that 10 supervised sessions and 20 home sessions of progressive resistance training of the ankle plantarflexors did not improve gait efficiency, muscle strength, activity, participation, or any biomechanical outcome among adolescents with CP. Thirty sessions of progressive resistance training of the ankle plantarflexors over 10 weeks did not improve gait efficiency among ambulatory adolescents with cerebral palsy. Resistance training did not improve muscle strength, activity, or participation. Ninety percent of participants experienced an adverse event. Most adverse events were expected and no serious adverse events were reported.

CEREBRAL PALSY IS A SYNDROME OF VARIOUS MOTOR impairments manifested during early childhood. The notion that the condition is usually related to birth-related injury has been dispelled by sound epidemiological studies. Prenatal factors such as brain malformations and in utero injuries are significant contributors. Premature birth and multiple gestation pregnancies also play significant roles in the development of cerebral palsy. The medical and neurological classifications of cerebral palsy have focused on limb involvement and types of tone abnormalities, such as spasticity, choreoathetosis, and dystonia. However, little is known of the prognosis for gross motor function in children diagnosed as having cerebral palsy, particularly during the early stages when the diagnosis is first made. Consequently, clinicians have limited evidence with which to respond to anxious parents who wonder, “What does the future hold?”or who ask direct questions, such as, “Will my child ever walk?” The article by Rosenbaum et al in this issue of THE JOURNAL provides important prognostic information that clinicians can use in their communication with families. The study followed up a large cohort of children diagnosed as having cerebral palsy of varying severity over a 4-year period. This study deserves sound marks on all accounts: solid research design, validated measures, sound study execution, and rigorous data analysis. Of note, the authors relied on broad-based assessments of motor function, which had been validated on large cross-sectional groups of children with cerebral palsy. These validated tools have the advantage of being easily used by examiners with minimal training and clinical experience, and also have the benefit of stratifying individuals with this condition into severity groups. These attributes add up to an excellent set of tools from which to derive longitudinal data and solid scientific information on which to base prognosis for gross motor function. Based on 2632 motor function assessments in 657 children with cerebral palsy aged 1 to 13 years, the authors generated methodologically sound motor development curves that have ecological and statistical validity. The ability to predict rates and limits of motor function for a given level of cerebral palsy severity is a major advance in predictive capacity. Statistical patterns of gross motor development are desirable for their probabilistic underpinnings. Stratification by severity of motor impairment allows for a more accurate classification of the likely motor progression of a child. As the authors point out, the curves should help clinicians counsel families regarding their child’s possible gross motor outcomes. The study results also provide a sound basis on which to examine the effects of interventions on what amounts to the natural history of the condition. Rosenbaum et al also appropriately emphasize that the observation of independent, unaided motor function levels is only part of the total picture in patients with cerebral palsy. Quality and efficiency of movement, along with cognitive, emotional, and environmental factors are extremely important in function and outcome. The authors also mention the new World Health Organization’s International Classification of Functioning, Disability and Health, recognizing that cerebral palsy is a medical condition that usually results in some level of disability. Future clinical and research efforts in cerebral palsy and related conditions should not only assess capacities (as this study does), but also should address actual day-to-day activity levels and incorporate how well individuals are able to participate in life and societal activities. Only by addressing all of life’s functional dimensions can a true prognosis be discussed and individualized treatment plans devised. This is true for cerebral palsy and for many other illnesses and disabilities. For instance, our group recently adapted the World Health Organization disability classification approach as a service delivery model for patients with spina bifida. Clinicians who deliver the diagnosis of cerebral palsy (or other diagnoses that affect development of the nervous system) to parents have to be careful not to use this kind of prognostic information improperly. Planning interventions and judging progress over time are helpful in adjusting a family’s expectations regarding how much therapy is appropriate for a given child. The unstated goal of improving motor function at all costs (financial and otherwise) some-

Adaptive behavior in 10–11 year old children born preterm with a very low birth weight (VLBW)

Self-concept is the perception that individuals have of themselves across different aspects of life such as academic performance or appearance. The Self-Concept Feedback Loop proposed for this research program conceptualised self-concept as developing through an interactive and iterative process involving social experiences and the cognitive processes of individuals. Through this process, individuals evaluate their behaviour or attributes against their internal standards. Subsequently, this evaluation influences their self-concept. In the general population, low self-concept has been linked to a range of negative outcomes, including poor academic achievement, and behaviour and mental health problems. However, research into the self-concept of children with cerebral palsy (CP) is rare. The motor and accompanying impairments associated with CP limit participation opportunities for children with CP, creating a unique social experience for these children that are likely to differ from typically developing (TD) children. Given this unique social experience, children with CP may perceive their self-concept differently from TD children as well as be at potential risk for low self-concept. The overall aim of this research program was to examine the self-concept of children with CP after identifying or developing a CP-specific self-concept instrument suitable for this purpose. In Study 1, a systematic review was undertaken to identify self-concept instruments suitable for children with CP. Five studies that measured the self-concept of preadolescent children with CP that had population-specific psychometric data were identified. Examination of the psychometric properties of the instruments utilised in those studies identified no CP-specific self-concept instruments, whilst existing instruments developed for TD children did not have strong psychometric support for their use with children with CP. In Study 2, a three-round Delphi consensus survey was conducted to identify self-concept domains relevant to children with CP. Three groups were recruited: professionals working with children with CP (n=21), caregivers of children with CP (n=18), and children with CP (n=12, 7 boys). Findings demonstrated that children with CP generally conceptualise self-concept using similar domains to TD children. However, several CP-specific domains were identified. Based on these findings, it was determined that the construction of a population-specific instrument which incorporates CP-specific domains was necessary in order to provide a comprehensive evaluation of self-concept for children with CP. The myTREEHOUSE Self-Concept Assessment (myTREEHOUSE) was developed using classical test theory based on the rational-empirical approach. Self-concept is measured by the child’s appraisal of their performance for 26 items across eight domains. The child’s appraisal is rated from three perspectives: Personal, Social, and Perceived. In addition, children also complete an Importance Rating. The discrepancy between the Importance Rating and the Personal Performance Perspective for each item is summed to achieve a Personal Concern Score which indicates the presence and severity of self-concept concerns. In Study 3, the validity and reliability of myTREEHOUSE was examined. Support for face and content validity was ascertained through semi-structured interviews with seven experts. myTREEHOUSE demonstrated strong internal consistency assessed with 50 children with CP (29 boys). Moderate test-retest reliability was demonstrated with a subset of 35 children (20 boys). Study 4 explored the profile of self-concept using myTREEHOUSE for 50 children with CP (29 boys) in relation to age, gender, and motor, communication, and cognitive function. Children with CP in this cohort reported high self-concept. Findings also demonstrated that self-concept was not associated with age, gender, motor function, or communication function. Cognitive function was found to be associated with the self-concept domains of Social Skills and Learning Skills. Study 5 investigated the relationship between self-concept and quality of life measured using two population-specific instruments; myTREEHOUSE for self-concept and CP QOL-Child for quality of life. Higher self-concept was associated with higher quality of life in this cohort of 25 children with CP (13 boys). The relationships between self-concept with child-reported quality of life were stronger than proxy-reported quality of life. Through this research program, it was ascertained that existing self-concept instruments are not suitable for children with CP, given their weak psychometric data and the absence of CP-specific domains. In response, the myTREEHOUSE Self-Concept Assessment was developed and preliminary validation undertaken. Findings from this research program present the first self-concept profile of children with CP and provide a deeper understanding about how these children perceive their self-concept and quality of life.

To determine the prevalence of drooling, swallowing, and feeding problems in persons with cerebral palsy (CP) across the lifespan. A systematic review was conducted using five different databases (AMED, CINAHL, Embase, MEDLINE, and PubMed). The selection process was completed by two independent researchers and the methodological quality of included studies was assessed using the STROBE and AXIS guidelines. Meta-analyses were conducted to determine pooled prevalence estimates of drooling, swallowing, and feeding problems with stratified group analyses by type of assessment and Gross Motor Function Classification System level. A total of 42 studies were included. Substantial variations in selected outcome measures and variables were observed, and data on adults were limited. Pooled prevalence estimates determined by meta-analyses were as high as 44.0% (95% confidence interval [CI] 35.6-52.7) for drooling, 50.4% (95% CI 36.0-64.8) for swallowing problems, and 53.5% (95% CI 40.7-65.9) for feeding problems. Group analyses for type of assessments were non-significant; however, more severely impaired functioning in CP was associated with concomitant problems of increased drooling, swallowing, and feeding. Drooling, swallowing, and feeding problems are very common in people with CP. Consequently, they experience increased risks of malnutrition and dehydration, aspiration pneumonia, and poor quality of life. Drooling, swallowing, and feeding problems are very common in persons with cerebral palsy (CP). The prevalence of drooling, swallowing, and feeding problems is 44.0%, 50.4%, and 53.5% respectively. There are limited data on the prevalence of drooling, swallowing, and feeding problems in adults. Higher Gross Motor Function Classification System levels are associated with higher prevalence of drooling, swallowing, and feeding problems. There is increased risk for malnutrition, dehydration, aspiration pneumonia, and poor quality of life in CP.

This study aims to explore the determinants of gross motor function in ambulatory children with spastic cerebral palsy (CP). Sixty-eight children diagnosed with spastic CP type were included in the study. Sociodemographic and clinical information of children with CP and their families was recorded. Children's gross motor function level was classified using the Gross Motor Function Classification System; gross motor function was assessed using the Gross Motor Function Measure-66 (GMFM-66); and parental quality of life was assessed using the Paediatric Quality of Life Scale Family Effects Module (PedsQL-FIM). No significant differences were observed in gross motor function or parental quality of life between hemiparetic and diparetic CP groups. However, children residing in urban areas showed significantly higher gross motor function and parental quality of life compared to those in rural areas (p < 0.05). Moderate correlations were found between gross motor function and physical functioning as well as place of residence (p < 0.05). Multiple regression indicated that physical functioning and urban residence were significant predictors of gross motor function, accounting for 37.9% of the variance in the GMFM-66 score. This study shows that the quality of life of parents of children and residence in the urban area are independent predictors of gross motor function in children with CP. These findings highlight the importance of considering family well-being and environmental factors when developing interventions to improve gross motor function outcomes in children with CP. NCT06439446.

Purpose: This study aimed to examine the association between motor and mental functioning in toddlers with cerebral palsy (CP).Methods: The Mental and Motor Scales of the Bayley Scales of Infant Development–Second Edition (BSID-II) were administered.Subjects: Seventy-eight toddlers with CP (mean age 2 years 7 months, SD 1 month; 43 boys, Gross Motor Function Classification System (GMFCS) levels I–V).Results: Spearman correlation coefficient between mental and motor functioning was 0.67 (p < 0.01). Sixty-five percent (51/78) of the children performed at the same level in mental and motor functioning, of whom 36 performed significantly delayed and 15 within normal limits. Thirty-five percent of the children were more delayed in motor functioning than in mental functioning.Conclusion: In toddlers with CP, an association was found between mental and motor functioning. When motor and mental functioning did not develop synchronously, it was always in favour of mental functioning. This study emphasizes the importance of examining both mental functioning and motor functioning separately of pre-school children with CP.

Introduction: Activities of Daily Living (ADL) in children with Cerebral Palsy (CP) include a variety of environmental settings. Environmental setting plays an important role in clinical assessment and therapeutic intervention to improve the mobility in children with CP. There are various environmental factors like movable surfaces, stairs, carpeting, physical obstacles, which facilitate or constrain the mobility of children with CP. Aim: To study the differences in motor function and gait speed at different environmental settings and find out the usual mobility methods of children with CP in home, school and community settings. Materials and Methods: A cross-sectional study was conducted in the Outpatient Department (OPD) of Paediatrics at Rajah Muthiah Medical College and Hospital, Annamalai University, Chidambaram, Tamil Nadu, India. The duration of the study was seven months, from February 2022 to August 2022. A total of 50 CP children aged between 4-12 years were included and demographic details were collected. Type of CP, gross motor function, gait speed and methods of mobility were evaluated at home, community and school in all the children with CP. Gross Motor Function Measurement (GMFM 88-E), One-Minute Walk Test (1MWT) and parent checklist for mobility methods were used as outcome measures to collect the data and analysed with Wilcoxon signed-rank test and Friedman test. Results: The mean age of the study population was 8.34±1.62 years, which included 29 (58%) male children and 21 (42%) female children. Gross motor function and gait speed varied across the environment and statistically significant differences (p-value=&lt;0.001) were observed in the home, community and school. Results related to methods of mobility showed that, most of the children, 38 (76%) walk alone in the home and are carried by adults in the community 30 (60%) and use all mobility methods in school. Conclusion: The present study concluded that, the gross motor function, gait speed and methods of mobility varied across the different environmental settings (home, community and school). Motor function and gait speed were better at home, followed by the school than the community. The common method of mobility was walking alone at home and being carried by adults in the community

Respiratory problems have a significant impact on morbidity and mortality in patients with cerebral palsy (CP). In particular, recurrent aspiration, impaired airway clearance, spinal and thoracic deformity, impaired lung function, poor nutritional status, and recurrent respiratory infections negatively affect respiratory status. Bronchopulmonary dysplasia may contribute to pulmonary problems, but asthma is not more common in CP than in the general population. We discuss treatment options for each of these factors. Multiple coexisting and interacting factors that influence the respiratory status of patients with CP should be recognized and effectively addressed to reduce respiratory morbidity and mortality. WHAT THIS PAPER ADDS: Respiratory problems are a significant cause of morbidity in patients with cerebral palsy (CP). Respiratory status in patients with CP is influenced by recurrent aspiration and impaired airway clearance. Spinal and thoracic deformity, impaired lung function, poor nutrition, and respiratory infections also negatively affect respiratory status. These factors should all be addressed to reduce respiratory problems in patients with CP.

BackgroundThe severity of physical and mental impairments and oral problems, as well as socioeconomic factors, may have an impact on quality of life of children with cerebral palsy (CP). The aim of this research was to assess the impact of impairments and oral health conditions, adjusted by socioeconomic factors, on the Oral Health-Related Quality of Life (OHRQoL) of children with CP using their parents as proxies.MethodsSixty children, between 6-14 years of age were selected. Their parents answered a children’s OHRQoL instrument (5 domains) which combines the Parental-Caregivers Perception Questionnaire (P-CPQ) and Family Impact Scale (FIS). The severity of dental caries, type of CP, communication ability, gross motor function, seizures and socioeconomic conditions were assessed.ResultsConsidering the total score of the OHRQoL instrument, only the reduction of communication ability and dental caries severity had a negative impact on the OHRQoL (p < 0.05). Considering each domain of the instrument, the severity of the type of CP and its reduction of communication ability showed a negative impact on oral symptoms and functional limitations domains (p < 0.05). Seizures have a negative impact on oral symptoms domain (p = 0.006). The multivariate fitted model showed that the severity of dental caries, communication ability and low family income were negatively associated with the impact on OHRQoL (p = 0.001).ConclusionsThe severity of dental caries, communication ability, and family income are conditions strongly associated with a negative impact on OHRQoL of children with CP.

To determine the effects of motor and intellectual functions on the effectiveness of comprehensive rehabilitation (CR) in young children with cerebral palsy (CP). This longitudinal cohort study recruited paediatric patients with a confirmed diagnosis of CP. Baseline gross motor function was classified using the Gross Motor Function Classification System. Baseline intellectual level was evaluated using the Developmental Quotient (DQ) via the Gesell Development Scale. Children underwent CR for 3 months and then their motor and intellectual functions were assessed using the Gross Motor Function Measure, Fine Motor Function Measure and DQ. The changes from baseline were calculated. Forty-eight children with CP were recruited to this study. Greater improvements in motor function were associated with a lower baseline level of intellectual impairment. Motor and intellectual function in children with CP was significantly improved when treatment was started before 12 months of age. There might be a close and reciprocal relationship between the baseline levels of impairment of motor and intellectual function with regard to the effectiveness of CR. Early intervention is important to gain a good outcome in children with CP.