Cerebral Palsy Infographic- Cerebral Palsy: A Gude For Parents
Measurement Model Tests Children Cerebral Palsy Lessons
Transcript of Measurement Model Tests Children Cerebral Palsy Lessons
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! The Move & PLAY Study was supported throughfunds from the Canadian Institutes of HealthResearch (MOP 81107) and the US Department ofEducation, National Institutes of Disability andRehabilitation Research (H133G060254)
! Ethics approval was obtained from each academicinstitution and multiple clinical sites (n = 21approvals)
Acknowledgements
! Introduction: utility of conceptual models in clinicaldecision making from Move & PLAY
! Description of measurement model and tests/measures! Outcomes:
! Abbreviated version of the GMFM ! Child factors:
! Associated Health Conditions! Primary Impairments (distribution of involvement, spasticity,
quality of movement, balance)! Secondary Impairments (strength, endurance, range of
motion)! Discussion: utility of these tests/measures in clinical
decision making
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but the GMFM and GMFCS are notsufficient to inform decision-making
X
Personal Factors
Fixed
Modifiable
Activities=Capabilities(action by an individual)
Participation(involvement in a life
situation
Environmental Factors
Fixed
Modifiable
Impairments Activity Limitations Participation Restrictions
Disability
Function
Body Functions (physiological& psychological) Structure
Aspects of the Person Mediators Outcomes
PrimaryImpairments
SecondaryImpairments
Personal Factors
Environment Physical, Social, Attitudinal
RehabilitationServices
Activity
Participation
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Child CharacteristicsRelating to
Primary Impairments
Change inBasic Motor Abilities
Child CharacteristicsRelating to SecondaryImpairments
Participation
Activity
Child CharacteristicsRelating toPrimary Impairments
Change inBasic Motor Abilities
Child CharacteristicsRelating to SecondaryImpairments
Participation
ActivityChild PersonalityCharacteristics
Child CharacteristicsRelating toPrimary Impairments
Change inBasic Motor Abilities
Child CharacteristicsRelating to SecondaryImpairments
Participation
ActivityChild PersonalityCharacteristics
Family Ecology
Child CharacteristicsRelating toPrimary Impairments
Change inBasic Motor Abilities
Child CharacteristicsRelating to SecondaryImpairments
Participation
ActivityChild PersonalityCharacteristics
Family Ecology
Health Care Services
but are physical therapists limited toconsidering outcomes of motor developmentalone?
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Population of Interest: Cerebral Palsy
Cerebral palsy (CP) describes a group of disorders of thedevelopment of movement and posture, causing activitylimitation, that are attributed to non-progressivedisturbances that occurred in the developing fetal orinfant brain. The motor disorders of cerebral palsy areoften accompanied by disturbances of sensation,perception, cognition, communication, and behaviour, byepilepsy, and by secondary musculoskeletal problems.
(Rosenbaum et al. 2007, page 9)
Outcomes of interest
Gross Motor Function
Also: self-care, participation and play
Selection of Indicators
Original conceptual model (Bartlett and Palisano, 2000)
Consensus among physical therapists
(Bartlett and Palisano, 2002) Research literature
Parsimony
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What does the literature say about influences on motordevelopment in young children with CP? Influences on motor development (continued)
Selection of Measures (Andresen, 2000)
Valid for children with CP and their families Reliable when used by the specified raters Feasible to administer in a community setting Length and content acceptable Easy to administer, score, and interpret If a determinant, has properties of a discriminative
tool, sensitive to variations among children andfamilies, not subject to ceiling or floor effects
If an outcome, has properties of an evaluative tool(i.e. is sensitive to change)
Development of Measures
Psychometric substudies
Pilot Testing
With children & families, as wel l as therapists
Review
By parent consultants
To present how we measured:
Abbreviated version of the Gross Motor FunctionMeasure
Associated health conditions
Body structures & functions factors (primaryimpairments)
Secondary impairments
To present some descriptive data and a case study
Purpose
! A convenience sample of 430 children with CP 18months to 5 years (mean age 3 y, 2 mo, 57% boys) andtheir caregivers (92% mothers) participated
! Recruited from multiple sites across Canada and theUnited States
! Across Gross Motor Function Classification System(GMFCS) levels: I = 154, II = 50, III = 53, IV = 76, and
V = 97 (Palisano et al. 1997)
! Sample is comparable to population-based studies ofchildren with CP from Canada, Australia and Sweden(based on the GMFCS levels)
Participants: Descriptive Data
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! 40-month-old boy with spastic diplegia, GMFCSlevel III
! Lives with two adults and one sibling
! Annual household income: $15,000 29,000(USD)
Participant: Case Study Juan
! Observational prospective study! Trained and reliable raters measured child
characteristics of primary impairments,secondary impairments, and gross motorfunction
! Parents completed an endurance questionnaire(secondary impairment) and a health conditionsquestionnaire
Methods
Focus on aspects of the child Measuring Gross Motor Function
! Developed a modified score form with the items indifficulty order: easiest to hardest
! Columns on left indicate dimension
! Entry points suggested for GMFCS and age
! Basal = 3 consecutive 3s
! Ceiling = 3 consecutive 0s
! Minimum of 15 items need to be scored
! Each item: CAPS start position, after colon maximum function for score of 3
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Psychometric Testing of the GMFM-66-B&C(Brunton and Bartlett, 2011)
Concurrent validity with GMFM-66
ICC = 0.987 (95% CI 0.972 - 0.994)
Test-retest reliability
ICC = 0.994 (95% CI 0.987 0.997)
Interrater reliability
ICC = 0.970 (95% CI 0.932 0.986)
Case Study: JuanInterpreting Change over Time
I II III IV V
N 147 78 107 121 117
mean change 3.0 0.8 3.3 2.5 3.6
sd change 15.6 15.5 12.4 11.8 13.2
probability interval of change in percentiles
50% 10.5 10.5 8.4 8.0 8.9
80% 20.0 19.9 15.9 15.1 16.9
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Time 1 1 Year LaterGMFM-66 46.9 49.0
Percentile 40th 45 th
! Change in GMFM score of 2.1 points
! GMFM-66 scores translate to percentile ranks of 40thand 45th, a difference of 5
! This amount of change means that Juan is developing asmight be expected (within + 16)
Health Conditions
We aimed to understand the functional impacts ofco-morbidities and associated health problems
Instrument was based on both the internationalconsensus definition of CP and the WHOsInternational Classification of Functioning,Disability and Health (to frame health conditionsfrom a functional perspective)
Measuring Health Conditions (Wong et al. in press)
Trained interviewers asked the parent: Does your child have problems:
seeing hearinglearning and understanding speaking or communicatingcontrolling emotions with seizuresinvolving the mouth with teeth and gumswith digestion with growthsleeping with repeated infectionsbreathing with skin
with the heart with pain
Item Responses and Analysis
Each of 16 items: Yes or NoTotal number of health conditions
If yes, parents were asked to what extent does thisproblem affect your childs daily activities:
1 not at all 2 to a very small extent 3 to a small extent 4 to a moderate extent 5 to a fairly great extent 6 to a great extent 7 to a very grea t exten t
Average extent affecting daily activities
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Results of theHealth Conditions Questionnaire
(Wong et al. In Press)
All children with CP, regardless of GMFCS level,have more health conditions and experience agreater impact than children without CP
Family income is associated with the total numberof health problems of children across all groups
Adjusted R 2 = 0.47 (p = 0.047)
Number of Health Conditions
Average Impact of Health Conditions
! Juan has 8 health conditions, as reported by his parent
! This is double the median value for most children in levelIII (and is consistent with what is known about childrenin low socioeconomic groups)
! The average impact of these conditions is 1.75(experienced by fewer than 25% of children in level III)
! Interpretation of the impact of health conditions is betterdone by looking at individual problems and cumulativeeffects for individual children
Case Study: Juan
! 8 health conditions:
Seeing small extent
Learning and Understanding very small extent
Speaking / communicating moderate extent
Emotions / behaviour moderate extent
Digestion small extent
Sleeping very great extent
Heart problems (prior patent ductus) not at all
Pain moderate extent
Case Study: (continued)
! For Children in GMFCS levels I & II, healthconditions are related
! Moderately to self-care and playfulness
! For Children in GMFCS levels III, IV & V, healthconditions are related
! In a small way to self-care
Preliminary Results re: relationships ofHealth Conditions with Outcomes
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Primary Impairments
Measuring Quality of Movement
Gross Motor Performance Measure (Boyce et al. 1999)(similar items as on the Gross Motor Function Measure)
1. Co-ordination: refers to the smooth and controlled useof movements in motor performance. Takes intoaccount timing, velocity, direction, force and amplitude
2. Dissociated movement: refers to isolated movement ofone part of the body independent from another part(one limb from the other, or segment of one from ortrunk independent from another segment).
Scored from 0 (severely abnormal) to 3 (normal withoutcues)
Averaged across available items / averaged both
Observations about MeasuringQuality of Movement
! Required extensive training by Virginia Wright (thenof Bloorview KidsRehab in Toronto)
! Performance on criterion testing target > 80% Agreement 15% completed at first attempt All but one completed after two attempts
! Perceived to be difficult to learn
Quality of Movement
! Juan, at 3 years 4 months, obtained 1.5 on bothcoordination and dissociation
! This results in an average score of 1.5 (i.e.between mildly and moderately abnormal interms of quality of movement)
! Compared to the group data on the previousslide, this is the median value for young childrenin GMFCS level III
Case Study: Juan Measuring Spasticity
Modified Ashworth Scale (Bohannon and Smith, 1987) Elbow flexors and hamstrings (one score representative of 3)one of each / averaged
! 6 point ordinal scale (0 to 4) 0 = no increase in tone (1) 1 = slight (2) 1+= slight + (3) 2 = considerable (4) 3 = more marked (5) 4 = rigid (6)
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Modified Ashworth Scale
! Juan obtained the following item scores:! Right elbow 2
! Left elbow 1
! Right hamstring 4
! Left hamstring 3
! His average spasticity score is 2.5
! This is also the median value for spasticity forchildren in level III
Case Study: Juan
Distribution of Involvement
Monoplegia 1
Hemiplegia 2
Diplegia 3
Triplegia 4
Quadriplegia 5
! Juan has spastic diplegia
! Not an unusual distribution of involvement forchildren in level IIII
Case Study: Juan
Over to Sally:
Early Clinical Assessment of Balance
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Reactive Postural Adjustments (RPA)
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Secondary Impairments
To be presented by Lynn and Doreen after the break
References continued
References continued References continued
Westcott, S.L. & Burtner P. (2004) Postural control for children: Implications forpediatric practice. Physical and Occupational Therapy for Children . 2004; 24,5-55.
Liu W.Y. Anticipatory Postural Adjustments in Children with Cerebral Palsy andChildren with Typical Development during Forward Reaching Tasks in Standing.
MCP Hahnemann University PhD Dissertation, 2001.
Horak, F.B. (2006) Postural orientation and equilibrium: What do we need to knowabout neural control of balance to prevent falls? Age & Ageing . 2006;35-S2, ii7-ii11.