Trunk control in children with cerebral palsy : a reliability study of the Trunk Impairment Scale

Background and objective. Standardized scales are useful for treatment planning and evaluation. The purpose of this study was to examine the reliability of the Trunk Impairment Scale (TIS) for children with cerebral palsy (CP). Design. This was an intra- and inter-observer reliability study. Methods. Video recordings of 25 children, 20 with CP and 5 with no motor impairment, in the age group 5–12 years of age, were analyzed by three observers on two occasions. Intraclass correlation coefficients (ICC [1,1] and [3,1]) with 95% confidence intervals, within-subject standard deviation, kappa values or percent agreement, and Bland Altman Plots were calculated. Results. The relative reliability (intra- and inter-observer reliability) was very high for the total score and subscale score of TIS: ICC [1,1] and [3,1] varied between .96 and 1.00. Kappa values for the items ranged from .45 to 1.00. The absolute reliability values for the parameters are reported. The Bland Altman analysis showed consistency of scores. Limitations. The study was limited to children aged 5–12 years. Moreover, the observers were not randomly selected, but selected on the basis of varying experience in physiotherapy. Conclusion. This study indicates that TIS is a simple and reliable measure of trunk performance for children with CP

Assessment of Trunk Controlin Children and Adolescents with Cerebral Palsy: A neglected perspective?

Et av hovedproblemene for mange barn, unge og voksne med cerebral parese (CP) er at de har redusert trunkus kontroll. Disse vanskene påvirker deres evne til å sitte og gå. Under gange er trunkus kontroll spesielt viktig, ettersom to tredjedeler av kroppsmassen er lokalisert i de øvre to tredjedeler av kroppshøyden, noe som gjør at kroppen har et høyt tyngdepunkt, og dermed blir ustabil. Likevel neglisjeres disse vanskene ofte når ressurskrevende behandlinger for å bedre gangfunksjonen vurderes. Slike behandlinger omfatter blant annet intramuskulære injeksjoner med botulinum toxin (BoNT-A), pumpebehandling med baklofen, ortopediskkirurgiske inngrep, og/ eller ortoser. Dette kan delvis skyldes at det er få etablerte metoder for å undersøke trunkus kontroll i daglig klinisk arbeid, og at det er få studier som har undersøkt trunkus kontroll under gange i CP populasjonen. Hovedmålet med denne avhandlingen har derfor vært å bidra til bedre undersøkelse og forståelse av trunkus kontroll hos barn og ungdom med CP, både i sittende og under gange. Mer spesifikt var målet å identifisere og evaluere kliniske verktøy som undersøker trunkus kontroll samt å evaluere påliteligheten (intra- og inter observatør reliabilitet) og gyldigheten (validitet) av et slikt verktøy; Trunk Impairment Scale (TIS). Videre var det et mål å undersøke trunkus kontroll under gange samt å undersøke sammenhengen mellom trunkus kontroll i sittende og under gange. I den første studien, en systematisk litteratur oversikt, identifiserte vi 22 kliniske verktøy som undersøker trunkus kontroll hos barn, ungdom og voksne med CP. Vi fant begrenset dokumentasjon av måleegenskapene til disse verktøyene, og informasjonen om egenskapen til å måle endring (responsiveness) var spesielt begrenset. Mangelen på verktøy som kan måle endring er en begrensning for gjennomføring av behandlingsstudier. I den andre studien fant vi at TIS, en av testene inkludert i den systematiske litteratur oversikten, viste høy inter- og intra observatør reliabilitet samt god validitet hos barn og ungdom med CP. I studie tre fant vi at barn og ungdom med CP hadde signifikante vansker med trunkus kontroll under gange, undersøkt med et 3-dimensjonalt askelerometer festet på nedre del av trunkus. Vanskene med trunkus kontroll ble reflektert gjennom økte trunkus akselerasjoner og mindre regularitet mellom steg, og de tenderte til å øke med økende alvorlighetsgrad av CP samt med økende gang hastighet. Til slutt, i studie fire, fant vi en moderat sammenheng mellom trunkus kontroll i sittende, undersøkt med en «del-test» av Trunk Control Measurement Scale og TIS, og trunkus kontroll under gange, undersøkt med et askelerometer festet på nedre del av trunkus. Av relevans for klinisk praksis er at funnene i denne studien tyder på at de mindre tidkrevende «del-skalaene» kan benyttes for å innhente informasjon om trunkus kontroll under gange. Det er et stort antall undersøkelsesverktøy beregnet på å undersøke trukus kontroll i ulike situasjoner tilgjengelig. Denne avhandlingen understreker at det er begrenset dokumentasjon av hvor godt disse verktøyene faktisk måler trunkus kontroll, og spesielt hvor gode de er til å måle effekt av behandling («responsiveness»). Våre resultater bekrefter at barn og ungdom med CP har vansker med trunkus kontroll både i sittende og under gange, og avhandlingen gir ny kunnskap om sammenhengen mellom disse to ulike oppgavene. Denne informasjonen bør føre til at fokuset i forbindelse med planlegging av intervensjoner som har til hensikt å bedre gangfunksjonen, utvides til også å omhandle en vurdering av pasientens trunkus kontroll

Correspondence between Expected, Perceived, and Measured Effects of BoNT-A Treatment in Calf Muscles among Children and Adolescents with Cerebral Palsy: A Mixed Methods Study

(1) Background: Our study explores the relationship between expected, perceived, and measured effects of botulinum toxin A (BoNT-A) treatment and saline (placebo) in children and adolescents with cerebral palsy (CP) in the calf muscles of 20 children and adolescents with cerebral palsy (CP), aged 4–15 years, using the Gross Motor Function Classification System (GMFCS) I–II. (2) Methods: A mixed methods parallel database design was used. Quantitative and qualitative data were collected at baseline and four weeks after treatment. The primary quantitative measure was gross energy cost (EC) during walking, obtained from a 5-Minute Walk Test (5MWT), while qualitative semi-structured interviews were performed with each parent and child/adolescent individually. (3) Results: Four weeks after treatment, we did not find any correspondence between expected, measured, and perceived effects. Interestingly, parental perceptions of treatment effects were more consistent than the measured outcomes. We also observed a connection between parental treatment expectations and perceived effects, often related to reduced energy expenditure. Children tended to view their parents as treatment experts and had fewer expectations and perceptions themselves. (4) Conclusions: These findings support the importance of child-centered care, which entails actively listening to children’s expectations and perceptions during the treatment process

Effectiveness of resistance training in combination with botulinum toxin-A on hand and arm use in children with cerebral palsy: a pre-post intervention study

Background The aim of this pilot study was to examine the effects of additional resistance training after use of Botulinum Toxin-A (BoNT-A) on the upper limbs in children with cerebral palsy (CP). Methods Ten children with CP (9–17 years) with unilaterally affected upper limbs according to Manual Ability Classification System II were assigned to two intervention groups. One group received BoNT-A treatment (group B), the other BoNT-A plus eight weeks resistance training (group BT). Hand and arm use were evaluated by means of the Melbourne assessment of unilateral upper limb function (Melbourne) and Assisting Hand Assessment (AHA). Measures of muscle strength, muscle tone, and active range of motion were used to assess neuromuscular body function. Measurements were performed before and two and five months after intervention start. Change scores and differences between the groups in such scores were subjected to Mann–Whitney U and Wilcoxon Signed Rank tests, respectively. Results Both groups had very small improvements in AHA and Melbourne two months after BoNT-A injections, without differences between groups. There were significant, or close to significant, short-term treatment effects in favour of group BT for muscle strength in injected muscles (elbow flexion strength, p = .08) and non-injected muscles (elbow extension and supination strength, both p = .05), without concomitant increases in muscle tone. Active supination range improved in both groups, but more so in group BT (p = .09). There were no differences between the groups five months after intervention start. Conclusions Resistance training strengthens non-injected muscles temporarily and may reduce short-term strength loss that results from BoNT-A injections without increasing muscle tone. Moreover, additional resistance training may increase active range of motion to a greater extent than BoNT-A alone. None of the improvements in neuromuscular impairments further augmented use of the hand and arm. Larger clinical trials are needed to establish whether resistance training can counteract strength loss caused by BoNT-A, whether the combination of BoNT-A and resistance training is superior to BoNT-A or resistance training alone in improving active range of motion, and whether increased task-related training is a more effective approach to improve hand and arm use in children with CP

Characteristics of general movements in preterm infants assessed by computer-based video analysis

Background: Previous evidence suggests that the variability of the spatial center of infant movements, calculated by computer-based video analysis software, can identify fidgety general movements (GMs) and predict cerebral palsy. Aim: To evaluate whether computer-based video analysis quantifies specific characteristics of normal fidgety movements as opposed to writhing general movements. Methods: A longitudinal study design was applied. Twenty-seven low-to moderate-risk preterm infants (20 boys, 7 girls; mean gestational age 32 [SD 2.7, range 27–36] weeks, mean birth weight 1790 grams [SD 430g, range 1185–2700g]) were videotaped at the ages of 3–5 weeks (period of writhing GMs) and 10–15 weeks (period of fidgety GMs) post term. GMs were classified according to Prechtl’s general movement assessment method (GMA) and by computer-based video analysis. The variability of the centroid of motion (CSD), derived from differences between subsequent video frames, was calculated by means of computer-based video analysis software; group mean differences between GM periods were reported. Results: The mean variability of the centroid of motion (CSD) determined by computer-based video analysis was 7.5% lower during the period of fidgety GMs than during the period of writhing GMs (p = 0.004). Conclusion: Our findings support that the variability of the centroid of motion reflects small and variable movements evenly distributed across the body, and hence shows that computer-based video analysis qualifies for assessment of direction and amplitude of FMs in young infants

Effectiveness of resistance training in combination with botulinum toxin-A on hand and arm use in children with cerebral palsy: a pre-post intervention study

<p>Abstract</p> <p>Background</p> <p>The aim of this pilot study was to examine the effects of additional resistance training after use of Botulinum Toxin-A (BoNT-A) on the upper limbs in children with cerebral palsy (CP).</p> <p>Methods</p> <p>Ten children with CP (9–17 years) with unilaterally affected upper limbs according to Manual Ability Classification System II were assigned to two intervention groups. One group received BoNT-A treatment (group B), the other BoNT-A plus eight weeks resistance training (group BT). Hand and arm use were evaluated by means of the Melbourne assessment of unilateral upper limb function (Melbourne) and Assisting Hand Assessment (AHA). Measures of muscle strength, muscle tone, and active range of motion were used to assess neuromuscular body function. Measurements were performed before and two and five months after intervention start. Change scores and differences between the groups in such scores were subjected to Mann–Whitney U and Wilcoxon Signed Rank tests, respectively.</p> <p>Results</p> <p>Both groups had very small improvements in AHA and Melbourne two months after BoNT-A injections, without differences between groups. There were significant, or close to significant, short-term treatment effects in favour of group BT for muscle strength in injected muscles (elbow flexion strength, <it>p</it> = .08) and non-injected muscles (elbow extension and supination strength, both <it>p</it> = .05), without concomitant increases in muscle tone. Active supination range improved in both groups, but more so in group BT (<it>p</it> = .09). There were no differences between the groups five months after intervention start.</p> <p>Conclusions</p> <p>Resistance training strengthens non-injected muscles temporarily and may reduce short-term strength loss that results from BoNT-A injections without increasing muscle tone. Moreover, additional resistance training may increase active range of motion to a greater extent than BoNT-A alone. None of the improvements in neuromuscular impairments further augmented use of the hand and arm. Larger clinical trials are needed to establish whether resistance training can counteract strength loss caused by BoNT-A, whether the combination of BoNT-A and resistance training is superior to BoNT-A or resistance training alone in improving active range of motion, and whether increased task-related training is a more effective approach to improve hand and arm use in children with CP.</p