Gross+Motor+Function+in+Cerebral+Palsy

** Cerebral Palsy ** **:**
A static encephalopathy described as a group of permanent disorders that can cause high muscle tone, muscle contractures, joint instability, and musculoskeletal deformities. This can result in physical limitations that affect the overall movement and posture.

Clinical Question:
What is the prognosis of a child’s gross motor development with developmental delay related to Cerebral Palsy?

Inclusion Criteria:

 * English articles
 * Long duration studies
 * Sufficient sample size

Databases Consulted:

 * PubMed
 * Google Scholar
 * Cochrane Library

Search Terms:

 * Under Clinical Queries: Prognosis.
 * “Gross motor function; Developmental delay; Cerebral palsy; Prognosis; Motor development, Physical therapy interventions”


 * Boolean Terms: **
 * AND

Inclusion Decision Process:

 * ICC > 0.9
 * p value < 0.05
 * effect size (r) > 0.80 and < 1.20

Classification

 * Type:
 * Spastic (50% of cases)- increased muscle tone
 * Dyskinetic- Athetoid (20%)- involuntary movement in the extremities
 * Ataxic (10%)- involves entire body. Problems with balance and coordination.
 * Mixed (20%)
 * Severity:
 * Mild- A child can move without assistance. Their daily activities are not limited.
 * Moderate- child will need braces, medication, and certain adaptive equipment to achieve daily activities.
 * Severe- child will require a wheelchair and it will be very challenging to accomplish daily activities.
 * Body Parts Affected:
 * Hemiplegia- one arm and one leg involved on the same side
 * Diplegia- the legs are affected
 * Quadriplegia- both arms and legs affected
 * Monoplegia- only one arm or leg is affected
 * Triplegia- either both legs and one arm or both arms and one leg are affected

Gross Motor Function Classification System (GMFCS) Classification Levels:
There are 5 levels and for each level there are different age windows: Prior to 2 years old, 2-4, 4-6, and 6-12.

LEVEL 1:

 * <2 years old: || Learn to sit on floor and can play with objects with both hands. Can crawl and pull themselves up and by 18 months can walk. ||
 * 2-4 years old: || Children can sit on the floor without any help and will start to stand up and walk without any help too. ||
 * 4-6 years old: || Children can sit in a chair without help, and can move to the floor from the chair and start to run and jump. ||
 * 6-12 years old: || Can run, walk, climb stairs and jump without assistance but may still have some coordination deficits ||

LEVEL 2:

 * <2 years old: || Infants sit on floor with assistance or using their hands. May begin to crawl. ||
 * 2-4 years old: || Require assistance to sit on floor especially when using hands to manipulate objects. Can walk with assistive devices or holding onto furniture. ||
 * 4-6 years old: || Can sit in chair without assistance but need help to move to the floor. Can walk short bouts without support and can go up the stairs only if using hand rail. Cannot skip, run, or jump ||
 * 6-12 years old: || Can walk indoor/ outdoor w/o assistance but needs help in crowded and unfamiliar places. Must use rails to climb steps, and have only minimal abilities for running, jumping, skipping. ||

LEVEL 3:

 * <2 years old: || Child can roll and creep while on their stomach. Will need help when sitting up ||
 * 2-4 years old: || Can sit on the floor without assistance usually in the “W” position. Can also crawl on their hands and knees without moving their legs. Crawling is their preferred method to get around ||
 * 4-6 years old: || Can sit in a chair but will need help when using their hands. Can lift themselves from the chair with assistance from furniture. Can also walk by using a mobility device for assistance. ||
 * 6-12 years old: || Children can walk indoor and outdoors using a mobility device. Can climb stairs using the handrail. If walking long distances they will need to use a wheelchair or be carried. ||

LEVEL 4:

 * <2 years old: || Can roll from back to stomach but need help with sitting up. ||
 * 2-4 years old: || Can sit up when placed on the floor but will need to use their hands for support. They will need equipment for both sitting and standing. Their preferred method of moving is crawling and rolling. ||
 * 4-6 years old: || Can sit on a chair with trunk support and can move if holding onto a sturdy surface. Can walk short distances but adult supervision is highly recommended as they have balance problems and can’t turn well. ||
 * 6-12 years old: || They maintain the same mobility as when they were 6 but rely on assistive devices such as walkers and wheelchairs when in the community. ||

LEVEL 5:

 * <2 years old: || Voluntary control of movements are impaired. Infant can’t hold their head or trunk up w/o support. Also need help with rolling over. ||
 * 2-4 years old: || All areas of motor function are limited. It is hard for the child to sit without assistance, crawl, or have any type of independent mobility. ||
 * 4-6 years old: || Child can sit on a chair but will need special equipment to do so. They will have to be transported for daily activities since they have no independent mobility. ||
 * 6-12 years old: || Some children will be able to move via a powered wheelchair. Others will still not be able to move on their own. This will require additional equipment in some cases. ||

Video over the 5 Levels of classification: __ [] __

Prediction of Gross Motor Function
A study published by JAMA looked to describe the patterns of gross motor development in children with CP in order to help parents of children who have been diagnosed and help plan out their care. This study was a longitudinal cohort study of children with CP categorized by age and severity and observed for 4 years. The sample included 657 children age 1 to 13 who represented the full spectrum of CP conditions.

The GMFCS as described above was used for classification of the children. GMFM was also a measurement tool used to assess the gross motor function. It measures the gross motor function in lying and rolling, crawling and kneeling, sitting, standing, and walk-run-jump activities. GMFM- 66 was used which includes 66 items the child must complete, with 3 trials for each task. This test focuses on the overall achievement of the child’s gross motor function.

The children were assessed 4 different times throughout the duration of the study. From the data collected 5 different motor growth curves were created based on the GMFCS level. As one might predict a child’s estimated limit of development is lower as their severity of impairment increases. This graph depicts when children are expected to reach 90% of their gross motor function at their specific level. A small value ( in years) means a faster rate toward motor development limits. This graph shows a relationship between the faster the progress is to the child’s gross motor limit the higher their severity. Therefore there is a tendency for children with lower motor development to reach their limit more quickly than children with a higher potential.

The gross motor function curves…
 * Assist parents/health care professionals to make evidence-based management decisions more effectively
 * Assist in determining whether a child’s gross motor function is comparable to expectations for children with CP of the same age and GMFCS level
 * Provide information on the average change in gross motor function as children become older
 * Are recommended to be used in conjunction with other information when making decisions



Head-Shaft Angle of the Hip in Early Childhood
The head-shaft angle (the angle between the shaft of the proximal femur and a line perpendicular to the proximal femoral epiphysis) in children with normally developing hips and children with CP between the ages of 2 and 8 years of age was compared.
 * Head-shaft angle (HSA) has a predictive role in hip displacement in children with CP
 * Hip displacement is common in severe CP and may cause:
 * Pain
 * Degenerative OA
 * Problems with sitting, standing, walking



This study used an independent t-test to compare the HSA of the CP group with the reference group between boys and girls. Linear regression was used with age as the independent factor for both groups and a split outcome for the different GMFCS levels. It was found that between the ages of 2 and 8 years of age, HSA decreases in normal hips (~2 degrees per year) and CP children with GMFCS levels II to III, but does not change (or slightly increases) in GMFCS levels IV to V. For normal hips, there is a similar trend in healthy children between 8 and 16 years of age.

Scatter plot of linear regression, showing HSA of normal hips between 2 and 8 years of age: __Inner dotted line__ = prediction of 95% CI of mean __Outer dotted line__ = prediction of 95% CI of individual with normally developing hip

Shows HSA in follow-up intervals in normal hips and hips of children with CP.

Level of Sitting Scale (LSS)
This test is designed to determine the prognosis of children’s functional skills and cognitive development based on the score they receive on the LSS. It is also used to observe and correct potential asymmetric posture adaptations and deformities. This test is based on the amount of support the child needs to maintain sitting position, as well as for those who can sit independently, the stability of the child while sitting. The test was performed with the children sitting on a therapeutic bench with their thighs supported to the back of the knees, feet unsupported. The sitting position was assessed with the hips and knees flexed so that the trunk is inclined to at least 60 degrees. That position was then held for 30 seconds (if possible), then the scores were categorized into 8 possible levels:


 * Level I Unplaceable
 * Level II Supported from head downward
 * Level III Supported from shoulders or trunk downwards
 * Level IV Supported at pelvis
 * Level V Maintains position, does not move
 * Level VI Shifts trunk forward, re-erects
 * Level VII Shifts trunk laterally, re-erects
 * Level VIII Shifts trunk backwards, re-erects

In a study conducted by Mendoza, et al. a total of 139 children were exposed to the LSS. Inclusion criteria consisted of children between the ages of 3-17 who were diagnosed with cerebral palsy. Exclusion criteria consisted of those who had a neuromotor disorder different than cerebral palsy, if they were scheduled for upcoming surgery that would affect sitting ability, or if they were planning to move out of the area. The following graph depicts the distribution of children with various types of cerebral palsy according to the Surveillance of Cerebral Palsy in Europe (SCPE) with the Levels of Sitting (LSS) levels. 

International Classification of Functioning Disability and Health, Child and Youth Version Model (ICF-CY)

 * Another way to describe functional independence based on 5 domains:
 * Mobility
 * Self-care
 * Communication
 * Comfort
 * Participation in community life
 * Children with CP and families also rank self-care, upper limb function, speech, general health, participation, assistive technology, and quality of life of similar importance to gross motor and neuromusculoskeletal-related functions.
 * Helpful tool to describe, discriminate, predict, or evaluate change over time.

PT Interventions and Treatment:

 * Much of the past studies have focused on interventions that occur after the age of two.
 * However, prior to two years old is now recognized as the “critical period” to provide interventions that allow plastic change in children with CP and other neurological pathologies. This is because, according to Yang et. al, the best estimate as to when the neural circuit completes myelination making it no longer receptive to interventions is at two years of age.
 * Therefore, greater improvements are reported in younger children.
 * Atleast 70% of children with CP experience problems with walking - need treatments focused on improving walking.

Past Interventions: passive stretching, Botox to reduce spasticity, braces, surgery

Current PT Interventions and Treatment:
Interventions now focus on multiple areas that affect the cognitive, motor, and sensory stimulation for the child.

Physical Therapy Approach - Activity, Activity, Activity
The physical therapy approach to the rehabilitation of children with cerebral palsy has shifted from the focus of repetition-based movements, which are important in the development of motor skills, to a more activity-based program that focus on three main points:


 * Preventing secondary musculoskeletal impairments and maximizing functional physical conditioning,
 * Fostering the cognitive, social, and emotional development of the child,
 * Developing, maintaining and perhaps restoring neural structures and pathways.

The Guide to Physical Therapy Practice published by the American Physical Therapy Association stated: “Progression to pathology - or from pathology to impairment to disability - does not have to be inevitable.” In fact, the state-of-science in neurorehabilitation suggests that “we are not even close to approaching the human limits for physical and neural recovery in many disorders”. The vital role that physical therapy plays in the this statement is made true with an activity-based program for children with cerebral palsy. This type of program not only revolves around the basics of consistent stretching and adequate loading the muscles and bones, but also involves the need for moderately intense cardiovascular training to maintain the patient's endurance and fitness. With this type of activity-based regimen, even though the body systems are not completely developed before the brain injury occurs, those with cerebral palsy who participate in an activity-based early intervention program have shown to exhibit a slower decline in physical functioning by establishing or reinforcing those functional motor pathways before they are “lost”.

Examples of Activity-Based Exercises
 * Strength or resistance training
 * Treadmills*
 * Cycling*

*Also addresses endurance and coordination in addition to strength.

Intensive Training Schedule prior to 2 years old:
.
 * 1 hour/day, 4 days/week
 * Schedule to enhance locomotor ability
 * standing balance
 * supported walking on treadmill, over ground, and on ramps
 * specific engagement of affected leg by kicking, splashing, and stair climbing (add variability to keep children’s interest)
 * Large effect size in improvements in GMFM-66
 * (0.91) Component D -- Standing
 * (1.21) Component E -- Walking, running, jumping
 * Also found an increase in speed and number of steps as well as a decrease in gait abnormalities such as foot turnouts

Treatments focused on the ICF model: to determine functional independence

 * Functional independence includes aspects of activity, execution of tasks, and participation or involvement of life situations
 * PT Interventions should target at least 1 of the 3 domains in ICF model (dosing) to have positive effects
 * 1. Body structure and function
 * 2. Activity
 * 3. Participation
 * Interventions include a variety of methods (isometric, isotonic, isokinetic) __to improve structure, function, and activity__ (such as motor control, decreased spasticity, balance, and gait speed)
 * __Neurodevelopmental Therapy (NDT)__ improved all levels of ICF
 * 1) Interdisciplinary problem-solving approach to treat individuals with changes in sensorimotor, perceptual, and cognitive function, tone and patterns of movement resulting from CNS lesion
 * __Conductive Education (CE)__ - significant effects on GMF
 * 1) Integrates education and rehabilitation goals to assist with motor dysfunction to enable to attend school with maximal independence
 * __Voltja Therapy__
 * 1) Normal movement patterns (i.e. reaching, grasping, standing, walking)
 * __Functional and task-oriented training__
 * 1) Learning motor abilities meaningful in environment and to find solutions to motor problems
 * Setting __individual, measureable goals__ supports achievement of functional PT goals
 * __Hippotherapy__ - effective additional therapy to improve posture and postural control
 * __Hydrotherapy__ to help with lung function
 * __Skeletal loading interventions__
 * 1) Static activities, vibrating platforms, static and dynamic standers, combination of weight bearing and strengthening exercises
 * __Participation Based Interventions__ - improve activity and participation
 * 1) powered mobility cars for infants
 * 2) Community-based fitness programs
 * Changes in one level (i.e. body structure through quad strength) may affect other levels of the ICF as well (i.e. activity - ambulation)

GAME Therapy:

 * G.A.M.E. = Goals, Activity, and Motor Enrichment
 * Looks at early intervention and early enrichment education that includes:
 * 1) Goal-oriented intensive motor training
 * 2) ALWAYS early weightbearing from sit to stand from parent’s lap (even if standing is not a specific goal)
 * 3) Early activation of muscles of lower limb (concentric + eccentric) to enhance upright mobility development
 * 4) Parent Education
 * 5) On “missing components” of desired actions
 * 6) Coached to identify child’s voluntary attempts to move
 * 7) Understand usual trajectory of future motor skills
 * 8) Strategies to enrich the child’s motor learning environment
 * 9) Environmental Enrichment (EE) -- Enhance neuroplasticity and promote memory and motor function through high levels of complexity and variability in the arrangement of toys, platforms, and tunnels
 * 10) Practice reaching and grasping objects = standard in motor training
 * 11) Home environment set up to promote generated movements, exploration, and task success
 * As performance in any area improves, motor challenge and complexity is increased by either adding variability or altering the task and environment to encourage problem solving

In conclusion, these studies have shown:

 * Early intervention (prior to 2 years old) slows the decline in physical functioning
 * A turn from repetition-based physical therapy interventions to activity-based interventions
 * Interventions incorporate whole body systems (i.e. cognitive, motor, sensory stimulation) instead of focusing on one system (i.e. strength) at a time

[|__http://espn.go.com/video/clip?id=10072765__]
Works Cited

Alotaibi, Madawi, Toby Long, Elizabeth Kennedy, and Siddhi Bavishi. "The Efficacy of GMFM-88 and GMFM-66 to Detect Changes in Gross Motor Function in Children with Cerebral Palsy (CP): A Literature Review." PubMed. Disability and Rehabilitation, 2014. Web. 3 Apr. 2016.

Damiano, Diane L. Activity, Activity, Activity: “Rethinking Our Physical Therapy Approach to Cerebral Palsy.” PHYS THER. 2006; 86: 1534-1540. Originally published online January 1, 2006. doi: 10.2522/ptj.20050397

Franki, Inge, Kaat Desloovere, Josse De Gat, Hilde Feys, Guy Molenaers, Patrick Calders, Guy Vanderstraeten, Eveline Himpens, and Christine Van Den Broeck. "The Evidence-base for Conceptual Approaches and Additional Therapies Targeting Lower Limb Function in Children with Cerebral Palsy: A Systematic Review Using the International Classification of Functioning, Disability and Health as a Framework." PubMed. J Rehabil Med, 20 Mar. 2012. Web. 3 Apr. 2016.

Gannotti, Mary E., Jennifer B. Christy, Jill C. Heathcock, and Thubi H.A. Kolobe. "A Path Model for Evaluating Dosing Parameters for Children with Cerebral Palsy." PubMed. Journal of the American Physical Therapy Association, 8 Nov. 2013. Web. 3 Apr. 2016.

Montero Mendoza et al. “Association between gross motor function and postural control in children with Cerebral Palsy: a correlational study in Spain.” BMC Pediatrics. 2015; 15:124. Doi: 10.1186/s12887-015-0442-4

Morgan, Catherine, Iona Novak, Russell C. Dale, Andrea Guzzetta, and Nadia Badawi. "GAME (Goals - Activity - Motor Enrichment): Protocol of a Single Blind Randomized Controlled Trial of Motor Training, Parent Education, and Environmental Enrichment for Infants at High Risk of Cerebral Palsy." PubMed. BioMedCentral Neurology, 2014. Web. 7 Apr. 2016.

O'Connor, Bridget, Claire Kerr, Nora Shields, and Christine Imms. "A Systematic Review of Evidence-based Assessment Practices by Allied Health Practitioners for Children with Cerebral Palsy." PubMed. Developmental Medicine and Child Neurology, 2015. Web. 3 Apr. 2016.

Palisano, R.J., Hanna, S.E., Rosenbaum, P.L., Russell, D.J., Walter, S.D., Wood, E.P., Raina, P.S., Galuppi, B.E. “Validation of a Model of Gross Motor Function for Children with Cerebral Palsy.” PubMed. Journal of the American Physical Therapy Association, 2000. Web. 9 Apr. 2016.

Rosenbaum PL, Walter SD, Hanna SE, et al. Prognosis for Gross Motor Function in Cerebral Palsy: Creation of Motor Development Curves. JAMA. 2002;288(11):1357-1363. doi:10.1001/jama.288.11.1357.

Valentin-Gudiol, M., C. Bagur-Calafat, M. Girabent-Farres, M. Hadders-Algra, K. Mattern-Baxter, and R. Angulo-Barroso. "Treadmill Interventions with Partial Body Weight Support in Children under Six Years of Age at Risk of Neuromotor Delay: A Report of a Cochrane Systematic Review and Meta-analysis." Cochrane Libraries. European Journal of Physical and Rehabilitation Medicine, 2013. Web. 5 Apr. 2016.

Van der List, J.P., Witbreuk M.M., Buizer, A.I., Van der Sluijs, J.A. “The head-shaft angle of the hip in early childhood: a comparison of reference values for children with cerebral palsy and normally developing hips.” PubMed. The Bone & Joint Journal, 2015. Web. 9 Apr. 2016.

Yang, Jaynie F., Donna Livingstone, Kelly Brunton, Dasom Kim, Barbara Lopetinsky, Francois Roy, Ephrem Zewdie, Susan K. Patrick, John Andersen, Adam Kirton, Joe-Man Watt, Jerome Yager, and Monica Gorassini. "Training to Enhance Walking in Children with Cerebral Palsy: Are We Missing the Window of Opportunity?" PubMed. Seminars in Pediatric Neurology, 2013. Web. 5 Apr. 2016.