Motor Function Classification System Level Research Articles

Measuring advanced motor skills in children with cerebral palsy: development of normative data and percentile curves for the Challenge-20 assessment.

The Challenge-20 is an assessment of advanced motor skills of children with cerebral palsy. The purpose of this study was to develop age-related norms and percentile curves for the Challenge-20 with typically developing children ( n = 150, 7 through 11 years), and compare Challenge-20 scores of independently ambulatory children with CP, Gross Motor Function Classification System level I ( n = 135) and II ( n = 56) to these age norms. Younger TD children (7 years) scored lowest, and older children (11 years) scored highest on the Challenge-20 , showing similar developmental trajectories. Challenge-20 scores of 15% of children in GMFCS level I were situated above the lower 2.5th percentile curve of the typically developing children's Challenge-20 growth curve, that is, overlapping into the typically developing child zone. The Challenge-20 is sensitive to the progression of advanced gross motor skills in typically developing children. Children with cerebral palsy, GMFCS I follow similar, albeit lower, Challenge score trajectory to that of typically developing children, and in some cases come close to lower level abilities of typically developing children. The reference values with typically developing children extend the Challenge-20 's utility when assessing advanced gross motor skill of independently ambulatory children with cerebral palsy for physiotherapy intervention and physical activity planning and open the door to re-thinking more about advanced gross motor interventions for children with cerebral palsy in GMFCS levels I and II given their potential to progress along the developmental trajectory.

Exercise Testing in Children with Cerebral Palsy

Objectives: To examine if cardiorespiratory requirements assess during the 6-minute walking test (6WT) and the cardiopulmonary exercise test (CPET) before and after training are the same in children with cerebral palsy (CP). Methods: 24 children with CP (16 boys and 8 girls, with the mean age of 14.2±2 years (10 to 16 years) classified at gross Motor Function Classification System level I and II were recruted from a school for special education in France. Participants were randomly assigned both the cardiopulmonary exercise test (CPET) and the 6WT and were divided to either training group (n = 12) or the control group (n = 12). The training group met twice per week for 40 minutes of exercise training. Results: Cardiorespiratory data did not differ between the CPET and the 6WT before training (VO2 Peak: p=0.86; VE Peak: p=0.87 and HR Peak: p= 0.41) and after training (p=0,41, p=0,26 et p=0,65) respectively. Conclusions: These findings demonstrate that cardiorespiratory responses obtained during the 6WT and the CPT before and after training did no differ in children with cerebral palsy.

Epidemiology of cerebral palsy among children in the remote Gorkha district of Nepal: findings from the Nepal cerebral palsy register

Purpose To describe the epidemiology of cerebral palsy (CP) among children in Gorkha, Nepal. Methods We established the first population-based register of children with CP aged <18 y in Gorkha, Nepal (i.e., Nepal CP Register). Children with suspected CP underwent detailed neurodevelopmental assessment by a multidisciplinary assessment team. Socio-demographic, etiology, motor severity, rehabilitation, and educational status were documented. Results Between January and October 2018, 182 children with confirmed CP were registered (mean (standard deviation (SD)) age: 10 years 1 months (4 years 10 months), 37.4% females). The majority (88.3%) had CP acquired pre- or perinatally. Mean (SD) age of CP diagnosis was four years five months. Mothers who did not receive any formal schooling had 4.5, 3.1, and 6.3 times higher odds of having inadequate antenatal care, homebirth, and unskilled birth attendants, respectively, when adjusted for other factors. Most children had spastic CP (77.5%) and Gross Motor Function Classification System level III-V (54.9%). Overall, 45.8% had never received rehabilitation services, 58.0% of school-aged children were not attending schools. The median age of receiving rehabilitation services was three years zero months. Conclusions The delayed diagnosis and clinical severity indicate the overall poor health status of children with CP in Nepal which could be improved by ensuring early diagnosis and intervention. Implications for rehabilitation The first population-based cerebral palsy register in Nepal suggests diagnosis of CP is considerably delayed among children. The high burden of severe motor impairment and poor communication skill with limited access to timely rehabilitation among children with CP in Nepal is concerning. Capacity development of community-based health workers and mothers of children with CP could help implementing community-based programs for prevention and early diagnosis of CP, and to promote early intervention for children with CP in remote Gorkha, Nepal.

A Study on the Effect of a Regular Exercise Habit on Health-Related Quality of Life in Adults with Cerebral Palsy

This study aimed to investigate the effects of exercise habits and types on the HRQOL of adults with CP, based on the fact that regular exercise habits, such as exercise, physical activity, etc., during leisure time have a positive effect on the improvement of HRQOL. A total of 215 adults (164 Men and 51 Women; 50 Gross Motor Function Classification System (GMFCS) Level I, 116 Level II, 24 Level III, and 25 Level IV) with CP but ambulant were recruited for this study. The mean (± SD) age of the subjects was 35.74 ± 9.65 years. They were evaluated using Medical Outcomes Study Short Form–36 (SF-36), the world’s most popular questionnaire for measuring health status, which is used widely in research targeting all healthy and elderly individuals with disabilities and is also used for the evaluation of HRQOL. SF-36 includes 8 subscales with 36 questions. In addition, in order to investigate further into exercise habits and types, four more detailed questions were asked: presence of exercise habits at least once a week; duration of exercise in adults who have exercise habits with CP; weekly exercise frequency; time of a single exercise session. The following are the results of the analysis of variance to confirm the difference in HRQOL depending on the presence of exercise habits in adults with CP. A significant difference was found in all items, except for the BP item, among the subscales of the HRQOL (p &lt; 0.01), with higher values observed for those with exercise habits compared with those with no exercise habits. A significant difference was found in all items, except for BP, among the subscales of HRQOL (p &lt; 0.01). Additionally, a positive (+) correlation was found in RP, VT, RE, MH, and MCS (p &lt; 0.05) in terms of exercise duration in adults who have exercise habits with CP. In addition, a negative (−) correlation was found in SF, RE, and MCS (p &lt; 0.05) in terms of the weekly exercise frequency. However, no significant correlation was found in all subscales of HRQOL in terms of the time of a single exercise session. In conclusion, it has become clear from adults with CP that engaging in regular exercise at least once a week has a positive effect on improving all subscales of HRQOL except for BP. Efforts by individuals, groups, and families all need to be made in order for adults with CP to have regular exercise habits to improve their HRQOL.

Unilateral versus bilateral reconstructive hip surgery in children with cerebral palsy: A survey of pediatric orthopedic surgery practice and decision-making.

Purpose:This study explored whether surgeons favor unilateral or bilateral reconstructive hip surgery in children with cerebral palsy who have unilateral hip displacement.Methods:An invitation to participate in an anonymous, online survey was sent to 44 pediatric orthopedic surgeons. The case of an 8 year old at Gross Motor Function Classification System level IV with migration percentages of 76% and 22% was described. Surgeons selected their surgical treatment of choice and provided their rationale. Respondents were also asked to list and rank radiographic parameters used for decision-making and multidisciplinary team members involved in decision-making.Results:Twenty-eight orthopedic surgeons from nine countries with a mean 21.3 years (range, 5–40 years) of experience completed the survey. A “bilateral VDROs with a right pelvic osteotomy (PO) was selected by 68% (19/28) of respondents; risk of contralateral subluxation (9/19; 47%) and maintaining symmetry (7/19; 37%) were the most common rationales for bilateral surgery. The remaining 32% (9/28) chose a ‘right VDRO with a right PO’” with most of these (8/9; 89%) stating the left hip was sufficiently covered. Of 31 radiographic parameters identified, migration percentage, acetabular angle/index, Shenton line, neck shaft angle, and presence of open/closed triradiate growth plates were the most common. Physical therapists (68%) and physiatrists (43%) were most likely to be involved in pre-operative surgical consultation.Conclusion:There is a lack of agreement on management of the contralateral hip in children with unilateral hip displacement. Further studies comparing patient important outcomes following unilateral and bilateral surgery are required.Level of Evidence:V

Hip subluxation in Italian cerebral palsy children and its determinants: a retrospective cohort study.

The study's aim was two-fold: to describe the trend of hip subluxation in the largest sample of Italian nonambulatory cerebral palsy (CP) children ever published; to investigate its determinants. This single-centre retrospective cohort study included patients with spastic or dyskinetic CP, Gross Motor Function Classification System (GMFCS) level IV or V, age 0-18 years, having been referred to our unit before March 2020. The hip subluxation was measured by means of the migration percentage (MP). Other data were gathered such as sex, CP subtype, GMFCS level, presence of drug-resistant epilepsy, age, use of walkers with weight relief or standing devices, previous botulinum injection or hip surgery, oral or intrathecal baclofen and hip pain. Multiple linear stepwise regression was performed and descriptive statistics are provided. Spastic CP had MP maximum increase in early ages, with GMFCS level V values persistently higher than level IV. The dyskinetic subtype showed a slower increase of the MP, with GMFCS level IV presenting similar or higher values, compared to level V. Age, CP severity and spastic subtype are the main determinants. The stepwise multiple regression analysis demonstrated that weight relief walking and standing assistive devices, combined with botulinum contributed to reduce the MP progression. Dyskinetic CP showed overall lower MP values and a more variable behaviour relative to age and GMFCS level, compared to the spastic subtype. Standing and walking assistive devices, with partial or total weight relief, combined with individually targeted botulinum injections, should be considered in the management of bilateral nonambulatory CP patients, to prevent hip subluxation or its recurrence after surgery.

Device-based and subjective measurements of sleep in children with cerebral palsy: a comparison of sleep diary, actigraphy, and bed sensor data.

To investigate how subjective assessments and device-based measurements of sleep relate to each other in children with cerebral palsy (CP). Sleep of children with CP, classified at Gross Motor Function Classification System levels I-III, was measured during 7 consecutive nights using 1 subjective (ie, sleep diary) and 2 device-based (ie, actigraphy and bed sensor) instruments. The agreement between the instruments was assessed for all nights and separately for school- and weekend nights, using intraclass correlation coefficients (ICC) and Bland-Altman plots. A total of 227 nights from 38 children with CP (53% male; median age [range] 6 [2-12] years), were included in the analyses. Sleep parameters showed poor agreement between the 3 instruments, except for total time in bed, which showed satisfactory agreement between (1) actigraphy and sleep diary (ICC > 0.86), (2) actigraphy and bed sensor (ICC > 0.84), and (3) sleep diary and bed sensor (ICC > 0.83). Furthermore, agreement between sleep diary and bed sensor was also satisfactory for total sleep time (ICC > 0.70) and wakefulness after sleep onset (ICC = 0.55; only during weekend nights). Researchers and clinicians need to be aware of the discrepancies between instruments for sleep monitoring in children with CP. We recommend combining both subjective and device-based measures to provide information on the perception as well as an unbiased estimate of sleep. Further research needs to be conducted on the use of a bed sensor for sleep monitoring in children with CP. van Rijssen IM, Hulst RY, Gorter JW, etal. Device-based and subjective measurements of sleep in children with cerebral palsy: a comparison of sleep diary, actigraphy, and bed sensor data. J Clin Sleep Med. 2023;19(1):35-43.

Utility of data linkage for orthopaedic service planning in the paediatric population with cerebral palsy at Starship Children's Hospital.

To determine the accuracy of orthopaedic surgical procedure coding (ICD-10-AM/ACHI/ACS) for children with cerebral palsy (CP) at Starship Children's Hospital, use data linkage with the New Zealand Cerebral Palsy Register (NZCPR) to obtain demographic and clinical information for children with CP requiring orthopaedic surgical services in the Auckland District Health Board catchment area, and to determine if trends in the clinical and demographic data are useful for future service planning for children with CP. Surgical admission data for children with CP aged 0-18 years at the time of their first procedure were extracted from Auckland District Health Board records for 2013-2018, and information on demographics and Gross Motor Function Classification System level were obtained from the NZCPR. The ICD-10-AM/ACHI/ACS codes for surgery/intervention were matched with the operation notes in the electronic health records using NHI numbers and assessed for accuracy. During the study period, 261 paediatric patients with CP underwent orthopaedic procedures, which could be grouped broadly into five categories (spine, upper limb, lower limb, Botulinum-A toxin injection only, and other) with a coding accuracy of 95%. Clinical and demographic data could be obtained from the NZCPR for 232 (88.9%) of the 261 patients. Using orthopaedic surgical procedure codes, we could identify broad categories of procedures received by children with CP and the demographic and clinical characteristics of these children, which will assist with service planning and identify trends in care delivery.

Risk factors for hip displacement in cerebral palsy: A population-based study of 121 nonambulatory children.

Purpose:The aim was to evaluate which clinical and radiographic variables are independent (true) risk factors for hip subluxation in nonambulatory children below 5 years of age with cerebral palsy.Methods:Patients were recruited from a population-based hip surveillance program. Inclusion criteria were birth during 2002–2006, age below 5 years, and gross motor function classification system levels III–V. In all, 121 children (71 boys) met these criteria. Gross motor function classification system was level III in 29 patients, level IV in 28, and level V in 64. Anteroposterior radiographs at diagnosis and during follow-up were assessed, and only the worst hip of each patient was used for the analyses. The mean age at the initial radiograph was 2.5 years (range: 0.7–4.9 years), and the mean follow-up time was 4.0 years (range: 0.5–11.8 years).Results:At the last follow-up, 67 children had a clinically significant hip displacement, defined as migration percentage ≥40%. Univariable regression analysis defined these risk factors: gross motor function classification system level V, spastic bilateral cerebral palsy, initial migration percentage, yearly rate of migration percentage progression, and initial acetabular index. When these variables were analyzed with multivariable regression in 107 patients with initial migration percentage <50% and follow-up ≥1.0 year, the independent risk factors were initial migration percentage (p = 0.003) and yearly rate of migration percentage progression (p < 0.001).Conclusion:The parameters that need to be assessed in hip surveillance in children below 5 years of age are initial migration percentage and rate of migration percentage progression. Acetabular index and femoral head–shaft angle might be useful later for decision-making regarding choice of treatment.Level of evidence:Level II, development of diagnostic criteria.

Comparison of intrathecal baclofen pump insertion and selective dorsal rhizotomy for nonambulatory children with predominantly spastic cerebral palsy.

In nonambulatory children with predominantly spastic cerebral palsy (CP), the authors compared care needs, symptom burden, and complications after surgical treatment with either intrathecal baclofen (ITB) pump insertion or selective dorsal rhizotomy (SDR). The patients were treated at two Canadian centers with variability in practice pertaining to these surgical options. The authors performed a retrospective analysis of nonambulatory children with predominantly spastic quadriplegic or diplegic CP who underwent treatment with ITB or SDR. These two strategies were retrospectively assessed by comparing patient data from the two treatment groups for demographic characteristics, outcomes, and complications. A partial least-squares analysis was performed to identify patient phenotypes associated with outcomes. Thirty patients who underwent ITB and 30 patients who underwent SDR were included for analysis. Patients in the ITB group were older and had lower baseline functional status, with greater burdens of spasticity, dystonia, pain, deformity, bladder dysfunction, and epilepsy than patients in the SDR group. In addition, children who underwent SDR had lower Gross Motor Function Classification System (GMFCS) levels and were less likely to experience complications than those who underwent ITB. However, children treated with SDR had fewer improvements in pain than children treated with ITB. A single significant latent variable explaining 88% of the variance in the data was identified. Considerable baseline differences exist within this pediatric CP patient population. Factors specific to individual children must be taken into account when determining whether ITB or SDR is the appropriate treatment.

Epilepsy syndromes in cerebral palsy: varied, evolving and mostly self-limited.

Seizures occur in approximately one-third of children with cerebral palsy. This study aimed to determine epilepsy syndromes in children with seizures and cerebral palsy due to vascular injury, anticipating that this would inform treatment and prognosis. We studied a population-based cohort of children with cerebral palsy due to prenatal or perinatal vascular injuries, born 1999-2006. Each child's MRI was reviewed to characterize patterns of grey and white matter injury. Children with syndromic or likely genetic causes of cerebral palsy were excluded, given their inherent association with epilepsy and our aim to study a homogeneous cohort of classical cerebral palsy. Chart review, parent interview and EEGs were used to determine epilepsy syndromes and seizure outcomes. Of 256 children, 93 (36%) had one or more febrile or afebrile seizures beyond the neonatal period and 87 (34%) had epilepsy. Children with seizures were more likely to have had neonatal seizures, have spastic quadriplegic cerebral palsy and function within Gross Motor Function Classification System level IV or V. Fifty-six (60%) children with seizures had electroclinical features of a self-limited focal epilepsy of childhood; we diagnosed these children with a self-limited focal epilepsy-variant given the current International League Against Epilepsy classification precludes a diagnosis of self-limited focal epilepsy in children with a brain lesion. Other epilepsy syndromes were focal epilepsy-not otherwise specified in 28, infantile spasms syndrome in 11, Lennox-Gastaut syndrome in three, genetic generalized epilepsies in two and febrile seizures in nine. No epilepsy syndrome could be assigned in seven children with no EEG. Twenty-one changed syndrome classification during childhood. Self-limited focal epilepsy-variant usually manifested with a mix of autonomic and brachio-facial motor features, and occipital and/or centro-temporal spikes on EEG. Of those with self-limited focal epilepsy-variant, 42/56 (75%) had not had a seizure for >2 years. Favourable seizure outcomes were also seen in some children with infantile spasms syndrome and focal epilepsy-not otherwise specified. Of the 93 children with seizures, at last follow-up (mean age 15 years), 61/91 (67%) had not had a seizure in >2 years. Children with cerebral palsy and seizures can be assigned specific epilepsy syndrome diagnoses typically reserved for normally developing children, those syndromes commonly being age-dependent and self-limited. Compared to typically developing children with epilepsy, self-limited focal epilepsy-variant occurs much more commonly in children with cerebral palsy and epilepsy. These findings have important implications for treatment and prognosis of epilepsy in cerebral palsy, and research into pathogenesis of self-limited focal epilepsy.

Trial of Erythropoietin for Hypoxic–Ischemic Encephalopathy in Newborns

BackgroundNeonatal hypoxic–ischemic encephalopathy is an important cause of death as well as long-term disability in survivors. Erythropoietin has been hypothesized to have neuroprotective effects in infants with hypoxic–ischemic encephalopathy, but its effects on neurodevelopmental outcomes when given in conjunction with therapeutic hypothermia are unknown.MethodsIn a multicenter, double-blind, randomized, placebo-controlled trial, we assigned 501 infants born at 36 weeks or more of gestation with moderate or severe hypoxic–ischemic encephalopathy to receive erythropoietin or placebo, in conjunction with standard therapeutic hypothermia. Erythropoietin (1000 U per kilogram of body weight) or saline placebo was administered intravenously within 26 hours after birth, as well as at 2, 3, 4, and 7 days of age. The primary outcome was death or neurodevelopmental impairment at 22 to 36 months of age. Neurodevelopmental impairment was defined as cerebral palsy, a Gross Motor Function Classification System level of at least 1 (on a scale of 0 [normal] to 5 [most impaired]), or a cognitive score of less than 90 (which corresponds to 0.67 SD below the mean, with higher scores indicating better performance) on the Bayley Scales of Infant and Toddler Development, third edition.ResultsOf 500 infants in the modified intention-to-treat analysis, 257 received erythropoietin and 243 received placebo. The incidence of death or neurodevelopmental impairment was 52.5% in the erythropoietin group and 49.5% in the placebo group (relative risk, 1.03; 95% confidence interval [CI], 0.86 to 1.24; P=0.74). The mean number of serious adverse events per child was higher in the erythropoietin group than in the placebo group (0.86 vs. 0.67; relative risk, 1.26; 95% CI, 1.01 to 1.57).ConclusionsThe administration of erythropoietin to newborns undergoing therapeutic hypothermia for hypoxic–ischemic encephalopathy did not result in a lower risk of death or neurodevelopmental impairment than placebo and was associated with a higher rate of serious adverse events. (Funded by the National Institute of Neurological Disorders and Stroke; ClinicalTrials.gov number, NCT02811263.)

Profile of children with cerebral palsy at a tertiary hospital in eastern Nepal

BackgroundThe clinical spectrum of Cerebral palsy (CP) can differ in various places depending upon knowledge of the people and resources for prevention, diagnosis and management. Although studied extensively in high-resource countries, adequate data related to CP from resource-constraint settings are lacking. This study aims to describe the profile of children with CP at a tertiary care center in eastern Nepal.MethodsThis was a hospital-based cross-sectional descriptive study done from 2017 to 2018. Children 6 months to 15 years who presented with CP were enrolled and their clinical details recorded and described.ResultsAmongst 110 children with CP, 74.54% were male. Majority (76.36%) were 5 years or below with the median age being 3(2.00–4.75) years. Children with spastic quadriplegia (44.44%) and Gross Motor Function Classification System level III (41.81%) were most common. Etiologically, perinatal factors (64.54%) like perinatal asphyxia (35.45%) and prematurity (20.90%) and postnatal infections (25.45%) were common. The common comorbidities were intellectual disability (71.81%) and epilepsy (66.36%). The main treatment modalities were: antiepileptics (59.09%) and centre-based physiotherapy sessions (35.45%). School education was provided in 23.07% with special education in 11.53%.ConclusionsThis study describes the profile of CP at our centre in eastern Nepal. Predominance of perinatal complications and postnatal infections points towards the urgent need to further improve the perinatal and neonatal health care delivery system and practices.

Epilepsy and proxy-reported health-related quality of life in children and young people with non-ambulatory cerebral palsy.

To assess the association between epilepsy characteristics and proxy-reported health-related quality of life (HRQoL) in children and young people with non-ambulatory cerebral palsy (CP) and seizures. This was a cross-sectional study of 164 children and young people (74 females, 90 males; mean age 10 years 6 months, range 2-21 years, SD 5 years 5 months). Caregivers completed the Child Health Index of Life with Disabilities (CPCHILD) in an outpatient setting. We utilized univariable linear regression and multivariable modeling to study relationships between variables and CPCHILD scores. Gross Motor Function Classification System levels were 37% IV and 63% V. Sociodemographic factors included the Child Opportunity Index (median 51, interquartile range [IQR] 25-80). A median of 2 (IQR 1-3) antiseizure medications (ASMs) were used, and days with seizures ranged from 0 (30%) to 28 (20%) days in the previous 4 weeks. Total CPCHILD scores decreased 2.3 points for each ASM (95% confidence interval [CI] -4.1 to -0.42). Compared to persons with focal epilepsy, those with generalized epilepsy had lower total CPCHILD scores (-5.7; 95% CI -11 to -0.55). Number of days with seizures was not associated with total CPCHILD scores. Proxy-reported HRQoL was affected by epilepsy-specific features in children and young people with severe CP. Health-related quality of life (HRQoL) was lower with increasing numbers of antiseizure medications. Overall quality of life (QoL) scores were lower by a similar amount, independent of seizure frequency. HRQoL was lower in persons with recent hospital admissions for epilepsy.

Characteristics of sit-to-stand movement are associated with trunk and lower extremity selective control in children with cerebral palsy: a cross-sectional study.

Even though the effect of several factors on sit-to-stand (STS) performance of children with CP has been previously explored, the potential role of lower extremity selective control, trunk control and sitting function on the performance of STS has not been examined. This study aimed to investigate the association of trunk control and lower extremity selective motor control with STS performance in children with CP. We recruited 28 children with CP aged between 4 and 10 years whose Gross Motor Function Classification System levels were I and II and 32 age-matched typically developing (TP) children. Trunk control, sitting function, selective control of the lower extremities and STS were evaluated with Trunk Control Measurement Scale (TCMS), sitting section of Gross Motor Function Measure-88 (GMFM-88), Selective Control Assessment of the Lower Extremity (SCALE) and the STS outcomes of a force platform [weight transfer time, rising index, and center of gravity (COG) sway velocity], respectively. In all evaluations, children with CP demonstrated lower scores than TD children. A moderate correlation was found between total scores of TCMS, GMFM-88 sitting section scores and COG sway velocity during STS and a fair correlation between SCALE total scores and COG sway velocity in the CP group ( r = -0.51, r = -0.52, r = -0.39, respectively). A fair correlation was found between SCALE total scores and the weight transfer time during STS in children with CP ( r = -0.39). Based on these results, improving trunk and lower extremity selective control may enhance STS performance in children with CP.

Sequence of flexion contracture development in the lower limb: a longitudinal analysis of 1,071 children with cerebral palsy

BackgroundTo prevent severe contractures and their impact on adjacent joints in children with cerebral palsy (CP), it is crucial to treat the reduced range of motion early and to understand the order by which contractures appear. The aim of this study was to determine how a hip–knee or ankle contracture are associated with the time to and sequence of contracture development in adjacent joints.MethodsThis was a longitudinal cohort study of 1,071 children (636 boys, 435 girls) with CP born 1990 to 2018 who were registered before 5 years of age in the Swedish surveillance program for CP and had a hip, knee or ankle flexion contracture of ≥ 10°. The results were based on 1,636 legs followed for an average of 4.6 years (range 0–17 years). The Cox proportional-hazards model adjusted for Gross Motor Function Classification System (GMFCS) levels I–V was used to compare the percentage of legs with and without more than one contracture.ResultsA second contracture developed in 44% of the legs. The frequency of multiple contractures increased with higher GMFCS level. Children with a primary hip or foot contracture were more likely to develop a second knee contracture. Children with a primary knee contracture developed either a hip or ankle contracture as a second contracture.ConclusionsMultiple contractures were associated with higher GMFCS level. Lower limb contractures appeared in specific patterns where the location of the primary contracture and GMFCS level were associated with contracture development in adjacent joints.

Mathematical Modeling of Indications for Reconstructive Surgery of the Hip Joints in Patients with Cerebral Palsy

Summary. Relevance. Early detection of hip pathology in patients with cerebral palsy is an effective way to prevent spastic hip dislocation.&#x0D; Objective: to improve the diagnosis of diseases of the hip joints in cerebral palsy through the clinical and radiographic screening based on mathematical modeling.&#x0D; Materials and Methods. The total number of patients was 47 (86 joints). We carried out a clinical and radiographometric examination of the hip joints with our own method and using standard anteroposterior radiographs, which were used to determine the parameters of the hip joint. Mathematical modeling of indications for reconstructive surgery using logistic regression was also performed.&#x0D; Results. The mathematical model “probability of indications for surgical interventions” was developed on the basis of the studied indicators and factors of influence.&#x0D; Conclusions. A mathematical model for screening of hip joints based on the acetabular angle (AA), neck-shaft angle (NSA), femoral torsion (FT), migration percentage (MP), gross motor function classification system (GMFCS) level, gait, and age is proposed; the accuracy of 90.6% is valid for establishing correct indications for surgery (the critical level of indicators is &gt;16.95 ̊ for AA, &gt;45 ̊ for FT, &gt; 141.63 ̊ for NSA, &gt;30 % for MP, and ≤11 years for age).

The effect of motor and functional independence of disabled children on musculoskeletal disorders in pediatric caregivers: A cross-sectional study

Background/Aim: There are conflicting results regarding the effect of motor and functional independence levels of disabled children on the burden of care. In addition, this burden, as well as musculoskeletal problems of pediatric caregivers, has not been examined in detail. The aim of this study is to examine the effects of motor and functional levels of the disabled child.&#x0D; Methods: The study was planned as a single-blind, multicenter, cross-sectional study. Children between ages 1-12 with physical disabilities from various problems, and 65 caregivers over the age of 18 who cared for them for at least 6 months, were included. Caregivers were divided into two groups, as per the BAKAS Caregiver Impact Scale score as high care burden (n = 33) or low care burden (n = 32). The motor level of the disabled child was determined by the Gross Motor Function Classification System, and the functional level of the Pediatric Functional Independence Measurement. The Nordic Musculoskeletal Questionnaire was used to evaluate musculoskeletal problems in caregivers.&#x0D; Results: There was no significant difference between the Gross Motor Function Classification System levels of children in groups (P &gt; 0.05). The Pediatric Functional Independence Measurement scores of children in the high care burden group were significantly lower than those in the low care burden group (P &lt; 0.05). According to a comparison of pain in parts of the body for 12 months, using the Nordic Musculoskeletal Questionnaire, the percentage of pain in the neck, shoulder, back, elbow, hand, hip, and foot regions of caregivers was significantly higher in the group with a high care burden (P &lt; 0.05). There was no significant difference between percent of low back and knee pain in the last 12 months (P &gt; 0.05). A weak positive correlation was found between the BAKAS Caregiver Impact scores and the Pediatric Functional Independence Measurement of children with disabilities (r = 0.26; P = 0.03).&#x0D; Conclusion: The lower functional level of the disabled child may cause an increase in caregiver burden of both the caregivers and musculoskeletal disorders.

Improved Sitting Balance in Children with Cerebral Palsy: Body Functions to Activity and Participation

AbstractThe aim of this study is to evaluate the changes in activity and participation domains of International Classification of Functioning (ICF), Disability and Health, in children with cerebral palsy (CP) who received integrated botulinum toxin A (BoNT-A) treatment with intensive rehabilitation with a treatment goal of improved sitting balance. In this prospective observational study, 29 patients with CP (mean age: 6.7 ± 3.8 years) and the Gross Motor Function Classification System (GMFCS) levels of IV and V were included. The primary outcome measures were the mean changes from baseline to posttreatment weeks 10 to 12 of the Child and Adolescent Scale of Participation (CASP) and Caregiver Priorities and Child Health Index of Life with Disabilities (CPCHILD). The modified Ashworth scale (MAS) and Tardieu scale (TS) results at 6 to 8 weeks of posttreatment were the secondary outcome measures. Statistically significant improvements in home and community participation of CASP (p &lt; 0.001 and 0.001), CPCHILD (p &lt; 0.01), MAS (p &lt; 0.001), and all parameters of TS (p &lt; 0.05) were recorded after treatment. The result of this prospective, observational study showed that the functional improvements in sitting balance by the integrated BoNT-A treatment provides positive effects on activity and participation levels of the patient and quality of life of patients and their families.

Participation of children and young people with cerebral palsy in activities of daily living in rural Uganda.

To compare the participation attendance and involvement of children and young people with and without cerebral palsy (CP) in a low-resource area of Uganda. Eighty-two children and young people with CP aged 6 to 22 years (49 males, 33 females) and 81 age- and sex-matched peers without CP (6 to 22 years; 48 males, 33 females) participated in this population-based, cross-sectional study. Data on attendance and involvement in 20 home and community activities were obtained using Picture My Participation, an instrument intended to measure participation in children with disabilities, particularly in low- and middle-income countries. Non-parametric statistical methods were used to assess between-group differences. Effect size estimates were calculated. Pooled attendance across all activities was lower in children and young people with CP than in children and young people without CP (p < 0.001) and for each activity item (p=0.004 to p < 0.001). The effect sizes for each activity were 0.2 to 0.7. Between-group differences were larger for community activities than for home activities. Pooled involvement across all activities was less in the group with CP (p < 0.001) and for each activity (p=0.014 to p < 0.001). The effect sizes for each activity were 0.2 to 0.5. Children and young people in Gross Motor Function Classification System (GMFCS) levels I and II had higher attendance (p < 0.001) and involvement (p=0.023) than those in GMFCS levels III to V. Participation of young people living with CP in Uganda was restricted, especially for community activities. There is a need to identify context-specific participation barriers and develop strategies to overcome them. Children and young people with cerebral palsy (CP) attended all activities less than their peers without CP. Differences in attendance were larger for community-based activities than home activities. When attending activities, children and young people with CP were less involved than their peers. Children and young people with milder impairments attended less frequently than their peers without CP. Children and young people with milder impairments attended more frequently than their peers with severe impairments.