Measurements of Function in Children with Cerebral Palsy

Abstract: Cerebral palsy (CP) is a term for a group of conditions associated with motor disabilities, that are very heterogeneous, i.e. symptoms, severity, associated impairments, functional outcome and needs. The overall purpose of this thesis was to study the prevalence and gross motor function and to evaluate and adapt measurements in children with CP. The prevalence in Southern Sweden was 2.4 per 1000 children. Children born abroad had a three times higher prevalence and were more often severely disabled. All 167 children were classified with the Gross Motor Function Classification System (GMFCS). This showed that 59% of the children were mildly disabled (levels I and II), 14% moderately disabled (level III) and 27% severely disabled (levels IV and V). Significant differences between GMFCS levels and subgroups of diagnosis, aetiology, intellectual capacity, epilepsy and visual impairment were found. Severe motor disability was often combined with associated impairments such as mental retardation, epilepsy and visual impairment. Inter- and intra-rater reliability of the Gross Motor Function Measure (GMFM) was found to be satisfying, even with untrained testers. The Pediatric Evaluation of Disability Inventory (PEDI) was investigated to ascertain the content, relevance and applicability in Sweden. A strong correlation between the PEDI results obtained for non-disabled Swedish children and the corresponding American data was found. This suggests that the American normative data are appropriate for reference purposes in Sweden. The GMFM and PEDI were compared regarding responsiveness in children with CP after Selective Dorsal Rhizotomy (SDR). Both GMFM and PEDI were sensitive to changes in function over time, for the series as a whole and in the group with mild to moderate disability, although the PEDI detected significant changes earlier. In the group with more severe disability, changes were detected only with the PEDI, not with the GMFM. The GMFM and PEDI are considered to be complementary tools as they measure different aspects of function. The usefulness of the Wartenberg pendulum test was investigated in very young children with spastic diplegia undergoing SDR.The pendulum test, combined with EMG, was shown to be an objective and sensitive method for quantifying spasticity in knee extensor muscles at ages down to 2.5 years. Children with spasticity displayed significantly lower values than healthy children. All the pendulum parameters improved after SDR and became similar to those of the healthy children. Swing time was the most reliable and sensitive variable. The R2 ratio showed a correlation with the quadriceps reflex. The relative swing time was the only parameter showing a correlation with measurements for function. Standardised measurements should be used as a part of the clinical decision-making process and for evaluation. They have to be multidimensional to address the variation of dysfunction at each level of the disablement process.

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