UPDATE-CLINICAL CLASSIFICATIONS FORCEREBRAL PALSY Deborah Gaebler-Spira

XIII International ORITEL ConferenceFoundational and First General Assembly of the Latin American Academy on Child Development and Disability

9/2/112 A Neural Interface for Artificial Limbs: Targeted Muscle Reinnervation

REHABILITATION INSTITUTE OF CHICAGO

2

OBJECTIVES

CP - descriptors

The context of the ICF

Classifications and relationships

How this moves us forward together

LET’S START

What do parents ask about?

• Diagnosis - what does my child have?

• Function - what can my child do?

CEREBRAL PALSY-DEFINITION-BAX-2001

Disorder of movement and posture resulting from a condition of non-progressive brain damage that occurred in infancy

Abnormality of tone

Inclusive-many etiologies

Brain lesion is static-musculoskeletal system changes

CLINICAL DESCRIPTION-START WITH

Predominant tone abnormality

Most children will have spasticity

Many have mixed tone disorders

Dyskinetic: involuntary movement disorder with varying tone

Mixed CP: combination of subtypes

Cerebral Palsy

Spastic Dyskinetic Ataxic

Bilateral Unilateral Hypokinetic Hyperkinetic

DiplegicQuadriplegic

TriplegicHemiplegic Dystonic Choreoathetosis

TOPOGRAPHY

Hemiplegia Diplegia Quadraplegia Triplegia

DEFINITION OF CEREBRAL PALSY

Cerebral palsy (CP) describes a group of permanent disorders of the development of movement and posture, causing activity limitation, that are attributed to non-progressive disturbances that occurred in the developing fetal or infant brain.

The motor disorders of cerebral palsy are often

accompanied by disturbances of sensation, perception, cognition, communication, and behavior, by epilepsy, and by secondary musculoskeletal problems.

Rosenbaum, et al. (2007)

HOW THAT CHANGES THE PERSPECTIVE

Creates an emphasis on activities, not just impairments

Creates the inclusion of sensory abnormalities

Attributes co-morbidities as important factors in prognosis

NEW/WHO/ICF

Health Condition (disorder or

disease)

Body Functions & Structures

Activities Participation

Environmental Factors Personal Factors

Interactions between components of the ICF

9/2/112 A Neural Interface for Artificial Limbs: Targeted Muscle Reinnervation

GMFC-GROSS MOTOR FUNCTION CLASSIFICATION

GMFCS

The Gross Motor Classification System

Developed to classify severity of functional limitation/disability in children with cerebral palsy.

Ages birth to 12 years

Not to be used as a diagnostic tool- describes gross motor function with an emphasis on movement initiation, sitting control and walking.

GMFCS

Reliable method of classifying based on function

Inherent meaning to families-therapists-physicans

Usual performance

FUNCTIONAL CLASSIFICATION OF CP

GMFCS Stratification according to functional level Observed at ages 2-12

GMFCS E&R

GMFCS LEVELS

Level I: Walks without assistive device indoors. Climbs stairs without limitation. Able to run and jump. Impaired speed, balance, coordination.

GMFCS LEVELS

Level II: Children walk indoors and climb stairs holding onto railing. Difficulty with walking on uneven surfaces and inclines or within crowds or confined spaces.

GMFCS LEVELS

Level III: Walks with assistive mobility devices on level surface. Limitations on uneven surfaces or inclines. May propel wheelchair manually. May use wheelchair for long distance transport.

GMFCS LEVELS

Level IV: Walks for short distances on a walker. Wheeled mobility for outdoors, school and community.

GMFCS LEVELS

Level V: All areas of motor function are limited. No independent mobility even with assistive technology.

FUNCTIONAL MOBILITY SCALE

Exercise Household Community

MACS-MANUAL ABILITY CLASSIFICATION

FINE MOTOR ARM PLACEMENT

MANUAL ABILITY CLASSIFICATION-MACS

Children with cerebral palsy use their hands when handling objects in daily activities

Assesses typical, not optimal performance

Ages 4-18 years

Eliasson et al. 2006

MACS

I. Handles objects easily and successfully

II. Handles most objects but with somewhat reduced quality and/or speed of achievement

III. Handles objects with difficulty; needs help to prepare and/or modify activities. The performance is slow and achieved with limited success regarding quality and quantity. Activities are performed independently if they have been set up or adapted.

IV. Handles a limited selection of easily managed objects in adapted situations. Performs parts of activities with effort and with limited success. Requires continuous support and assistance and/or adapted equipment, for even partial achievement of the activity.

V. Does not handle objects and has severely limited ability to perform even simple actions.

Requires total assistance

GMFCS DOES NOT PREDICT MACS

COMMUNUCATION CLASSIFICATION FUNCTION SYSTEM

Cooley Hidecker et al., 2009

VIKING SPEECH SCALE

Speech is not affected by motor disorder.

Speech is imprecise but usually understandable to unfamiliar listeners. Loudness of speech is adequate for one to one

Conversation. Voice may be breathy or harsh sounding but does not impair intelligibility. Articulation is imprecise; most consonants are produced, but deterioration is noticeable in longer utterances. Although difficulties are noticeable, speech is usually understandable to unfamiliar listeners out of context.

Speech is unclear and not usually understandable to unfamiliar listeners out of context. Difficulties controlling breathing for speech – can produce one word per utterance and/or speech is sometimes too loud or too quiet to be understood. Voice may be harsh sounding; pitch may change suddenly. Speech may be markedly hyper nasal. A very small range of consonants are produced. The severity of the difficulties makes the speech difficult to understand out of context.

No understandable speech.

WHY ARE THEY IMPORTANT

Meant to discriminate and categorize rather than 'assess’ (Damiano et al.,2006)

Easily applied, simple and quick classifications which may be performed by a physical therapist, the family or a related person, and provide information about the functional level of the child with CP (Morris et al., 2004b; Eliasson et al., 2006, Mutlu et al., 2010)

fulfill each other for a total and whole classification of children with CP (Morris et al.,2006; Kerem-Gunel et al., 2009)

Universal, translated and studied on many different languages (www.canchild.ca)

EDACS

I - Eats safely and efficiently

II - Eats and drinks safely but have limitations to efficiency

III - Eats and drinks safely but have limitations to efficiency and safety

IV - Eats and drinks with significant safety issues

V - Unable to eat safely-G tube

9/2/112 A Neural Interface for Artificial Limbs: Targeted Muscle Reinnervation

ICF

Environmental Factors Personal Factors

Body Function & Structure (Impairment)

Muscle strength (muscle test, dynamometer)

Spasticity(M.Ashworth, Tardieu)ROM(Goniometry )

Selective motor control (SCALE-TASC Tests )Perception, cognition

Postural problems

Activity(Limitation)GMFCS,FMS

MACS,CFCS,EADSC,.

Participation(Restriction)

Daily Living activities,Social roles in

community (children, student, friends,etc.)

WeeFIMPEDI etc.

OPTIMIZES MANAGEMENT

Sharpens aligns focus on function versus impairments

More useful than severity, type and distribution

INTERVENTION PLANNING

Assists with realistic goal therapy setting

Children with GMFCS 3 –community wheelchair

GMFCS 3,4-use walker part time

GMFCS 5 limited self mobility

GROSS MOTOR CURVES AND GMFCS

90% of final GMF achieved

THERAPY INTERVENTIONS

Secondary impairments vary with GMFCS level

Endurance, fatigue, weakness –can target better interventions for groups

Supports evidence based research

VARIATIONS IN MEDICAL AND SURGICAL NEEDS

Hip pathology increases with GMFCS level

Use of G-tube and co-morbidities increase with GMFCS levels

IN A VARIABLE DISORDER-ALLOWS-CLINICIANS-PARENTS

Common language Common groupings Common Goals