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