case study of cerebral palsy child

BRIEF RESEARCH REPORT article

Evidence-based early rehabilitation for children with cerebral palsy: co-development of a multifaceted knowledge translation strategy for rehabilitation professionals.

• 1 School of Physical and Occupational Therapy, Faculty of Medicine and Health Sciences, McGill University, Montreal, QC, Canada
• 2 Montreal Children’s Hospital, Research Institute of the McGill University Health Center, Montreal, QC, Canada
• 3 Centre for Interdisciplinary Research in Rehabilitation of Greater Montreal, Montreal, QC, Canada
• 4 Research Center of the Jewish Rehabilitation Hospital, Centre de Santé et de Services Sociaux de Laval, Laval, QC, Canada
• 5 Research Center of the Shriners Hospital for Children, Montreal, QC, Canada

Background: Cerebral palsy (CP) is the most common childhood physical disability. Early and evidence-based rehabilitation is essential for improving functional outcomes in children with CP. However, rehabilitation professionals face barriers to adopting evidence-based practices (EBP)s. The objective of this project is to develop a knowledge translation (KT) strategy to support CP-EBP among pediatric rehabilitation professionals.

Methods: We follow an integrated KT approach by collaborating with clinician- and patient-partners. Partners engaged in co-design through team meetings and content review via email. The KT strategy comprises two components: (1) An electronic (e)-KT toolkit was created from summarized evidence extracted from randomized clinical trials on early rehabilitation for children with CP, and (2) a multifaceted online KT training program developed with guidance from a scoping review exploring effective KT strategies.

Results: The e-KT toolkit summarizes twenty-two early interventions for children with or at risk for CP aged 0–5 years. Each module features an introduction, resources, parent/family section, and clinician information, including outcomes, intervention effectiveness, and evidence level. The KT training program includes three 10–15 min video-based training modules, text summaries, quizzes, and case studies. Site champions, identified as qualified rehabilitation professionals, were onboarded to support the site implementation of the training program. A champion-training booklet and 1-hour session were designed to equip them with the necessary knowledge/resources.

Conclusion: The tailored, multifaceted, and co-designed KT strategy aims to be implemented in pediatric rehabilitation sites to support professional's uptake of CP-EBPs. Lessons learned from its development, including the co-development process and multifaceted nature, hold potential for broader applications in rehabilitation.

1 Introduction

Cerebral palsy (CP) is the most common childhood physical disability with lifelong health impacts for the child and family ( 1 , 2 ). The clinical signs of CP progressively emerge in infancy as motor development occurs ( 2 ). In the first years of life for a child with CP, aberrant neural circuitry develops in brain regions due to the disuse of affected limbs ( 3 ). This can ultimately compromise motor learning and performance. Extensive animal and human research demonstrates that when provided early in life, intensive interventions can significantly improve motor and cognitive outcomes for children with CP ( 3 – 6 ). Furthermore, enhancing the health and functioning of children with CP through timely and evidence-based rehabilitation intervention can effectively optimize societal and individual healthcare costs ( 7 ). Rehabilitation professionals (i.e., physiotherapists, speech-language pathologists, and occupational therapists) often intend to offer evidence-based practices (EBP)s for children with CP. However, clinical settings often pose numerous barriers that impact the ability to stay up to date with EBPs, resulting in outdated and possibly ineffective rehabilitation interventions implemented instead. Additionally, this may result in delays in the implementation of EBPs, missing a critical period of brain plasticity.

Knowledge translation (KT), as the Canadian Institutes of Health Research outlines, constitutes a dynamic and iterative process encompassing synthesis, dissemination, exchange, and the ethically sound application of knowledge ( 8 ). The primary goal of KT is to improve the effectiveness of health services and products by “translating knowledge” to interested parties ( 8 ). Effective KT strategies are pivotal in actualizing research findings into practical applications ( 9 ). Previous research has pinpointed effective KT initiatives for rehabilitation professionals, such as workshops, EBP leaders (i.e., knowledge brokers, champions) and online tools, that have supported the uptake of early and evidence-based interventions for children with CP ( 10 , 11 ).

Numerous studies recognize that effective KT strategies should be adapted to the specific context and meticulously planned after comprehensively assessing barriers and facilitators ( 12 , 13 ). However, Imms et al. have underscored the challenges in tailoring a KT strategy for CP rehabilitation at the organizational level due to barriers in organizational activities, such as the absence of leaders in EBPs and access to resources. Thus, open-access, online KT tools, as a component of a KT strategy, may support the uptake of EBPs by engaging a broader population of rehabilitation professionals and can then be adapted to specific clinical contexts ( 10 ). For instance, in a single-masked clustered randomized clinical trial (RCT) within a specific organization ( 14 ), a multifaceted tailored KT strategy utilizing knowledge brokers, an online evidence library, and workshops significantly improved rehabilitation professionals’ EBP for children with CP. However, the transferability of multifaceted KT strategies to different organizations often remains to be discovered due to organizational barriers and differences ( 15 ). Given the provincial structure of the Canadian healthcare system, KT initiatives should aim to be implemented across the different provincial health jurisdictions to maximize impact and health outcomes.

There is a growing demand for effective KT initiatives in Canada to bridge the gap between research and clinical practice and optimize early and evidence-based rehabilitation interventions for children with CP. To that effect, we aimed to co-design and launch a multifaceted KT strategy, including an (1) electronic(e)-KT toolkit and (2) KT training program. This brief report aims to describe our co-design journey.

2.1 Theoretical approach

The development of the strategy is grounded in an integrated KT approach (iKT) ( 16 ), a robust method where knowledge-users are partners in the entire KT process ( 17 , 18 ). The Knowledge to Action (KTA) framework ( 19 ) provides a structured process for moving through the KT process and was used to develop the multifaceted KT strategy. It includes a seven-step action cycle: (1) Identify the problem; determine the gap; identify, review, and select knowledge; (2) Adapt to local context; (3) Assess barriers/facilitators to knowledge use; (4) Select, tailor, implement interventions; (5) Monitor knowledge use; (6) Evaluate outcomes; and (7) Sustain knowledge use ( 19 ). As presented in Figure 1 , to develop the e-KT toolkit and training program, we followed Step (1) Identify the problem; determine the gap; identify, review, and select knowledge; and Step (2) Adapt to local context ( 19 ).

Figure 1. Knowledge-to-Action framework: step 1 and step 2 . KT, knowledge translation; CP, cerebral palsy. Figure adapted from ( 19 ), licensed under CC-BY-SA.

2.2 Knowledge-user participation

Collaborations with five partners were established in our co-design process. Two were clinical experts: one occupational therapist with 11 years of experience in pediatric rehabilitation and one physical therapist with 13 years of clinical experience in pediatric rehabilitation. Two were patient partners: one mother of a 10-year-old boy with CP and one young adult with CP. One individual held the dual role of clinician- and patient-partner: occupational therapist with 5 years of clinical experience and a mother of a young child with developmental challenges undergoing diagnosis.

2.3 Study design and procedures

The report discusses the development of the e-KT toolkit, Early Intervention and Detection Toolkit for Cerebral Palsy (EDIT-CP). The complete e-KT toolkit will be hosted on ( https://www.childhooddisability.ca/edit-cp-toolkit/ ). The material available on the public site is subject to change based on this study and subsequent ones. This report focuses specifically on the EDIT-CP : Early Intervention e-KT toolkit. The EDIT-CP: Early Detection section for primary care physicians and families ( https://www.childhooddisability.ca/early-detection-of-cp/ ) is described elsewhere ( 20 ). Secondarily, this paper focuses on the development of the EDIT-CP: Early Intervention KT training program. As shown in Figure 2 , we present the KT strategy design in two parts: (1) e-KT toolkit and (2) KT training program.

Figure 2. Diagram illustrating components of the EDIT-CP: early intervention multifaceted KT strategy. KT, knowledge translation; EDIT-CP, early detection and intervention toolkit for cerebral palsy.

2.3.1 EDIT-CP: early intervention e-KT toolkit

The co-development of the e-KT toolkit includes Step 1) Identify problem; determine the gap; identify, review, select knowledge of the KTA framework. The toolkit includes a subsection for rehabilitation professionals (occupational therapists, physical therapists, and speech-language pathologists) and a separate subsection for caregivers and families .

The e-KT toolkit prototype was inspired by StrokEngine ( www.strokengine.ca ), an e-KT toolkit that provides evidence-based information about stroke rehabilitation and has been shown to be highly usable and navigable from rehabilitation professionals' perspectives ( 21 ). Additionally, patients/families reported being satisfied overall with the patient/family modules of StrokEngine and conveyed that the platform is a valuable resource ( 22 ). The senior author (TO) has developed over fifteen StrokEngine learning modules, including sections for rehabilitation professionals and for patients/families. The author applied this experience when designing the KT module prototypes for the e-KT toolkit.

The process was initiated with a rapid literature review of existing evidence-based CP rehabilitation approaches. RCTs published between 2010 and 2020, reflecting the latest developments in the field on rehabilitation interventions for young children (average less than seven) with or at risk for CP, were included in this process. Moreover, the references in published systematic reviews were examined to extract additional citations.

In Step 2) Adapt to local context , one clinical expert and one patient/clinician partner were trained in using the PEDro scale ( 23 ) for quality ratings to generate the level of evidence for every intervention included in the module. In addition, they extracted data in pre-developed extraction forms and drafted standardized studies’ summaries and conclusions. Based on the extracted data, one module per intervention was constructed (e.g., constraint-induced movement therapy). For the caregivers/family section, a prototype was first designed collaboratively by one parent/clinician partner and author (TO) for one intervention module (i.e., constraint-induced movement therapy) following a question-and-answer format, previously shown to be useful and understandable in the context of a KT toolkit in rehabilitation ( 22 ). This draft was sent to a second patient-partner (young adult with CP), and their feedback was requested on the content's completeness, appropriateness, and understandability. They were offered the option to provide comments/make edits directly on the created prototype using the Track Changes option in Microsoft Word. A period of two weeks was allotted to provide feedback.

2.3.2 EDIT-CP: early intervention KT training program for rehabilitation professionals

In Step 1) Identify problem; determine the gap; identify, review, select knowledge , a scoping review was conducted by research team members (JH, AM and TO) exploring what KT strategies are used to promote evidence-based rehabilitation for children with CP and the impact of these strategies in promoting best practices ( 11 ). The Arksey & O’Malley framework ( 24 ), later expanded on by Levac et al. ( 25 ), was used to guide the review in six stages. The last stage included a consultation exercise where the summarized results were presented to rehabilitation professionals and researchers in this field for discussion and interpretation ( 25 ).

In Step 2) Adapt to local context , collaborative development activities with clinicians and patient-partners, including multiple review phases and online meetings, facilitated co-development. We developed a multifaceted KT training program using the e-KT toolkit to support rehabilitation therapists across Canada. The program includes a short online training course, weekly newsletters to prompt EBP, and support from EBP leaders. All course materials were translated from English to French and reviewed for accuracy by a qualified bilingual individual independent from the study.

The online training course includes tutorial videos, quizzes, and a text summary. The training course was designed and hosted on Thinkific, a user-friendly and accessible course design platform ( https://www.thinkific.com ) ( Figure 3 ). To create the videos, we used Animaker, a video and graphic design software ( https://www.animaker.com ). The training course content, including the videos, quizzes, and text summary, was first verified through direct feedback of content over email by researchers ( n  = 3) and clinician-partners ( n  = 2) to ensure suitability and acceptability. To access the course, interested parties must register via the platform's registration link, available at ( https://earlyinterventionsforcp.thinkific.com ). The registration process involves completing a form with basic information such as name and email address. Once registered, participants will receive instructions on how to access the training program materials. Please note that the availability of the course may change due to changes to funding and the learning module subscription. For questions and concerns regarding access to the training program or access to the French version, please email the corresponding author.

Figure 3. EDIT-CP online training course home page. EDIT-CP, early detection and intervention toolkit for cerebral palsy.

Based on our recent scoping review, reminders were shown to facilitate rehabilitation professionals' EBP uptake ( 11 ). Therefore, we designed a weekly newsletter to remind participating rehabilitation professionals about EBPs for children with CP and prompt them to use the e-KT toolkit to facilitate.

Moreover, to act as an EBP leader, we recruited a designated site champion for every site participating in the program. We recommend each site identify one champion, a qualified and accountable pediatric rehabilitation professional readily available to support local rehabilitation professionals' practical application of the e-KT toolkit and address any queries or concerns that may arise.

3.1 EDIT-CP: early intervention e-KT toolkit

The e-KT toolkit is hosted on the Childhood Disability LINK website, a platform that provides up-to-date, reliable information about different types of childhood disabilities ( https://www.childhooddisability.ca/edit-cp/ ). Twenty-two ( n  = 22) early interventions were identified across forty-one ( n  = 41) RCTs, and nineteen ( n  = 19) learning modules were developed ( Supplementary Appendix 1 ). Children with different severities of CP are presented in the modules, with interventions targeting children with Gross Motor Function Classification System (GMFCS) Level I-III in 59% of the studied outcomes ( Supplementary Appendix 2 ). Similarly, different types of CP are addressed in the early interventions, including spastic (in 20% of studied outcomes), ataxic (15%), dyskinetic (15%), mixed (10%), at risk for CP (14%) and diagnosed CP but type not specified (26%) ( Supplementary Appendix 2 ). In total, one hundred-and-eight ( n  = 108) summaries were developed across the modules and included evidence on seventy ( n  = 70) different outcomes, with gross motor function, occupational performance, global development, dysphagia/feeding, and bimanual performance as the most common intervention targets ( Supplementary Appendix 3 ). Regarding the quality of the included RCTs, 57.1% were high quality. Supplementary Appendix 4 presents the level and quality of evidence and common comparison interventions.

3.2 EDIT-CP : early intervention KT training program

The KT training program included an online course, site champions and a weekly newsletter (summarized in Table 1 ). The online course included three modules with approximately 10–15 minute (min) each of video content, followed by a short text summary of the video and a 5-question quiz. The course was estimated to be completed in 1 hour and 30 min. Informed by the scoping review findings, the course design followed a multifaceted, convenient, and integrated approach ( 11 ). Additionally, in accordance with a key finding from the scoping review, we included parent and clinician perspectives and input throughout the design and implementation of the training modules ( 11 ). Clinician-partners ( n  = 2) piloted the online course and felt the content was useful for practice. Specifically, feedback was given about Module 3.1, Case 2, and changes were made accordingly. One clinician-partner completed the course over a ‘lunch hour,’ suggesting it was easy and quick to complete.

Table 1. EDIT-CP KT training program.

Module 1 of the online course includes three sub-sections. Section 1.1 contains a 5 min video presenting a brief overview of the online course and the purpose of the e-KT toolkit. The section consists of background knowledge and emphasizes the importance of early interventions for young children with CP. The section ends with a 1-minute testimonial video from one parent partner and one rehabilitation therapist partner. As highlighted by our scoping review, including testimonials about the importance of evidence-based interventions for CP could incentivize rehabilitation professionals to complete the short course and use EBP ( 11 ). Furthermore, Section 1.2 further details the e-KT toolkit, with a second 5 min video about the design of the toolkit and an overview of the e-KT toolkit content. Section 1.3 includes a 5 min video explaining quality appraisal methods and evidence rating. This section explores how evidence was integrated and appraised to support rehabilitation professionals’ decision-making and confidence in selecting appropriate evidence-based interventions from the toolkit. After each sub-section, there is a short text summary, and at the end of the module, a fixed quiz related to the direct recall of the content to ensure completion.

Module 2, Section 2.1 of the course presents a clinical case study of a child with CP. A 10 min video walks through the case and how therapists (physiotherapists, occupational therapists, and speech-language pathologists) would use the e-KT toolkit to support the development of an evidence-based intervention plan. The case was reviewed and verified by clinician-partners (one physical therapist and one occupational therapist) to ensure appropriateness and accuracy. A short text summary follows the video and a second quiz.

Module 3 of the course includes two sections. Section 3.1 presents a second clinical case study of a child with CP. This is a more complex case of a patient with a different CP type, severity and rehabilitation goals. An 8 min video discusses the case and how therapists would use the e-KT toolkit to support the development of an intervention plan. The case was reviewed and verified by clinician partners (one physical therapist and one occupational therapist) to ensure appropriateness and accuracy. A 4 min video in Section 3.2 provides an overview of the course, summarizing learning goals and future directions for using the e-KT toolkit in practice. A short text summary followed each section, followed by a final quiz.

A weekly newsletter template was developed to encourage participating rehabilitation professionals to continue using the e-KT toolkit to be sent via email. Furthermore, new interventions added to the e-KT toolkit are highlighted in the newsletter, keeping participants up-to-date and intrigued.

The findings of our scoping review supported the inclusion of site champions as EBP leaders in the KT training program to support rehabilitation therapists in using the e-KT toolkit in practice at their site ( 11 ). To train clinical champions, we created a training booklet describing the e-KT toolkit's contents (toolkit homepage, intervention homepage, and specific interventions). Additionally, the booklet included a summary of the multifaceted KT training program and its purpose. Information about each module was summarized. Furthermore, champions were asked to complete the KT training course. The training booklet articulates the role of the champion and the resources they would need to be a champion at their clinical site. A research team member (JH) met with each champion online for a 1 h training session, summarizing the training booklet and the e-KT toolkit and answering any questions the champions had.

4 Discussion

This report presents the development of a multifaceted KT strategy aimed at bridging the gap between research and clinical practice in early rehabilitation for children with CP. The co-creation of the KT strategy, together with rehabilitation professionals patient and parent partners, reflects a comprehensive approach grounded in an iKT framework ( 16 ). Moreover, engaging in a scoping review and consultation process yielded valuable insights into existing KT efforts in pediatric CP rehabilitation, informing a tailored and multifaceted strategy. The design of this KT strategy aimed to emphasize the importance of ensuring usability and relevancy for rehabilitation professionals and caregivers. Furthermore, it is recognized that it may not be as effective for researchers to take the lead in disseminating knowledge in a clinical setting, and it is important to work together with healthcare organizations and have an EBP leader support the KT process. Overall, we aimed to reduce barriers in our KT strategy by engaging in co-development with knowledge users, highlighting usability and feasibility in the design and encouraging the role of EBP site leaders.

The active involvement of key knowledge users, including clinician experts and patient partners, in our co-design process was foundational to developing the KT strategy. Following the iKT process allows for a more significant impact, often resulting in an end-product utilized by a greater audience and influencing the policy environment ( 26 , 27 ). Involving knowledge-users in the KT development process ensures that the products developed reflect the unique perspectives, needs, and experiences of those living with CP and/or their caregivers ( 28 ). Additionally, including clinician-partner perspectives integrates real-world insights and practical considerations that may be overlooked, which was also essential for creating case study examples ( 29 , 30 ). By engaging with those directly involved in the care and rehabilitation of children with CP, we expect to enhance the potential for successful implementation, ensuring the toolkit is not only evidence-based but also user-friendly, accessible, and feasible within the local context. Research has shown that customizing KT to a particular organization may improve clinicians’ acceptance and adherence ( 31 , 32 ). Furthermore, working with knowledge users from the project's inception may lead to meaningful relationships and a sense of empowerment that can facilitate the research process ( 33 ). The iKT strategy integrates valuable perspectives and knowledge from parent and clinician partners by building respectful and honest relationships.

Following the KTA framework, Step 1) Identify the problem; determine the gap; identify review, we conducted a scoping review ( 11 ) prior to the final development of the KT training program. The scoping review explored current KT strategies for evidence-based pediatric rehabilitation for CP, aiming to identify the most effective approaches. This review also gave us insights into the barriers and facilitators faced by previous KT strategies ( 11 ). Further, the stakeholder consultation exercise added to the quality of our review and provided valuable perspectives and interpretations of the findings ( 25 ). The results revealed that adopting a tailored and multifaceted strategy and including an EBP leader or champion can enhance the implementation of KT ( 11 ). Conversely, the findings showed that a lack of protected time and funding was a common barrier to implementation efforts ( 11 , 34 ). Therefore, convenience and accessibility are essential in KT strategies to promote uptake. The results emphasized that the successful implementation of a KT strategy was intricate and necessitated a comprehensive understanding of local barriers and contextual implementation ( 11 ). Overall, the review informed the development of the KT training program, ensuring it is relevant and follows best practices for KT interventions and tools. Previous research has shown that a scoping review is an effective way to understand the researcher's KT needs and ensure that stakeholder needs are identified in supporting best practices ( 35 ).

With insight from the scoping review and through the adoption of an iKT approach, we focused on the user-friendliness and relevancy of the KT strategy. Jargon is often a significant barrier to accessing and applying research evidence into practice, as it can be challenging for many non-academic readers to appraise scientific text and terminology ( 36 ). When developing the KT strategy, research evidence was summarized by the research team using lay language and reviewed by parents and clinician-partners to ensure understandability. It is shown that incorporating the end-user's personal preferences and needs in the KT strategy's design is beneficial for acceptance and uptake ( 37 ). Thus, in the e-KT toolkit, a section for families presents frequently asked questions and concerns that are more pertinent to families and may not be answered within the content meant for rehabilitation professionals. Additionally, as lack of time is a commonly identified barrier for EBPs ( 38 ), we aimed to create a convenient strategy with short videos and summarized research. Furthermore, including clinical case studies in the KT training program added a practical dimension, using clinical reasoning and illustrating the application of EDIT-CP interventions in context-based scenarios ( 39 ). Evidence suggests that designing effective and interactive content (i.e., quizzes, one-on-one support) to promote learner interaction is essential in maintaining their motivation for online learning ( 40 ). Thus, a straightforward, practical, and self-directed learning strategy targeted to meet the needs of rehabilitation professionals and families can contribute to maintaining participants’ adherence to the KT intervention.

By including site champions as EBP leaders in the KT training program, we aim to support the adoption of EBPs by participating rehabilitation professionals. The strategic inclusion of an EBP leader is meant to actively facilitate the adoption of EBPs by rehabilitation professionals in clinical settings ( 41 ). Additionally, EBP leaders can offer a tailored approach to KT strategies (i.e., applying the information to the local context), promoting ongoing feedback within programs and identifying areas requiring support ( 11 ). It is found that by including site champions to lead the KT strategy within their healthcare context, the motivation for rehabilitation professionals to participate in the KT strategy will likely gain further traction. Further, rehabilitation professionals may learn about tools at their site for mastering the EBP or approach, such as learning strategies or training that may help to administer the treatment approach to their patients. The correlation between sustained EBPs and effective leadership ( 41 ) suggests that KT strategies with EBP leadership are more likely to have a long-term impact that is pivotal in catalyzing change ( 42 ). To effect this change, EBP leaders must navigate contextually sensitive environments and negotiate timely and feasible responses to diverse knowledge user needs ( 42 ).

5 Limitations

Through developing the KT strategy, we aim to reduce challenges associated with the uptake of early and evidence-based interventions for children with CP. By engaging in a comprehensive iKT, incorporating the perspectives of clinician- and parent-partners, and leveraging the findings from a thorough scoping review, we have crafted a strategy to address the identified barriers. We recognize the level of engagement and satisfaction of knowledge users’ was not measured as a part of iKT. Hence, the absence of reliable and identifiable evaluation procedures for iKT can complicate the assessment of its influence on the research process or long-term results ( 43 ). Further, we recognize challenges regarding the sustainability of the toolkit and long-term funding, underscoring the complexity of implementing KT initiatives. Additionally, given that our strategy is aimed to be open access and designed to achieve scalability, there may be questions about the quality of the learning experience as smaller-scaled individualized learning strategies may be more effective ( 44 ). To mitigate these challenges, attention must be given to a comprehensive sustainability and dissemination plan to implement our KT strategy across health systems in Canada effectively. Future research efforts are needed to evaluate the iKT process and feasibility of the e-KT toolkit and training program to promote successful implementation at a larger scale. As we move forward, sustaining and funding KT initiatives emerges as a critical area requiring innovative solutions and continued advocacy for widescale dissemination.

6 Conclusion

We recommend the inclusion of the EDIT-CP : Early Intervention e-KT toolkit on healthcare organization websites, providing accessible resources for rehabilitation professionals and caregivers. Further, the EDIT-CP: Early Intervention KT training program should be a part of professional development curriculums, supporting knowledge about the importance of early EBPs for children with CP. In line with the next step of the KTA framework, Step 3) Assess barriers to knowledge use ; a pre-post study is underway to evaluate the effectiveness, feasibility, and acceptability of the KT strategy in promoting EBP to support long-term implementation. The findings will inform modifications to the strategy; Step 4) Select, tailor, and implement interventions. Future directions of the project include Step 5) Monitor knowledge and Step 6) Evaluate outcomes , where strategic monitoring of knowledge utilization will be conducted, and evaluations will be carried out in collaboration with knowledge users. Lastly, Step 7) Sustain knowledge use is a continuous process where the research team updates the e-KT toolkit with emerging evidence.

By embracing a collaborative and evidence-driven approach grounded in iKT principles, this initiative endeavours to foster meaningful advancements in pediatric rehabilitation for children with CP. As we lay the foundation of a promising KT initiative, the lessons learned and the successes achieved offer a guide for rehabilitation professionals, researchers, and policymakers, ultimately supporting health outcomes for children living with CP and reducing the burden on the healthcare system.

Data availability statement

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

Author contributions

JH: Conceptualization, Data curation, Formal Analysis, Methodology, Validation, Writing – original draft, Writing – review & editing. AM: Supervision, Validation, Writing – original draft, Writing – review & editing. FP: Conceptualization, Data curation, Writing – review & editing. LD: Conceptualization, Writing – review & editing. KS: Data curation, Writing – review & editing. ND-O: Writing – review & editing, Data curation. ES: Methodology, Validation, Writing – review & editing. GI: Validation, Writing – review & editing. TO: Conceptualization, Data curation, Formal Analysis, Methodology, Writing – original draft, Writing – review & editing, Supervision, Validation.

The author(s) declare financial support was received for the research, authorship, and/or publication of this article.

This project is funded by the Canadian Institute for Health Research (CIHR) CGS-M Award (JH) and the Kids Brain Health Network (KBHN) Implementation Readiness Fund (TO, AM).

Acknowledgments

We wish to acknowledge Clarice Ribeiro Soares Araujo and Fadi Al Zoubi, who participated in the scoping review consultation exercise of this project and added great value to the project. Lastly, we would like to acknowledge Naomi Zuckerman and Akash Sasitharan, who supported the French translation of the KT training program content.

Conflict of interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Publisher's note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

Supplementary material

The Supplementary Material for this article can be found online at: https://www.frontiersin.org/articles/10.3389/fresc.2024.1413240/full#supplementary-material

Abbreviations

KT, knowledge translation; CP, cerebral palsy; EBP, evidence-based practice; EDIT-CP, early detection and intervention toolkit for cerebral palsy; KTA, knowledge-to-action; GMFCS, gross motor function classification system; iKT, integrated knowledge translation.

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Keywords: cerebral palsy, evidence-based practice, knowledge translation, rehabilitation, early interventions

Citation: Hanson JH, Majnemer A, Pietrangelo F, Dickson L, Shikako K, Dahan-Oliel N, Steven E, Iliopoulos G and Ogourtsova T (2024) Evidence-based early rehabilitation for children with cerebral palsy: co-development of a multifaceted knowledge translation strategy for rehabilitation professionals. Front. Rehabil. Sci. 5 :1413240. doi: 10.3389/fresc.2024.1413240

Received: 6 April 2024; Accepted: 17 July 2024; Published: 7 August 2024.

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© 2024 Hanson, Majnemer, Pietrangelo, Dickson, Shikako, Dahan-Oliel, Steven, Iliopoulos and Ogourtsova. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Tatiana Ogourtsova, [email protected]

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• Published: 07 August 2024

Muscle in children with cerebral palsy: current evidence, knowledge gaps, and emerging research opportunities

Focus on Cerebral Palsy

• Christopher M. Modlesky 1 &
• Alessandra B. Matias 1  

Pediatric Research ( 2024 ) Cite this article

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Cerebral palsy (CP) is associated with substantial deficits in muscle performance, as demonstrated by muscle weakness 1 and low power generation. 2 The major consequence is an inability or limited ability to execute basic daily activities. 3

Low muscle performance in children with CP stems from their smaller size, 1 higher infiltration of fat, 4 and lower voluntary neuromuscular activation 1 and mitochondrial capacity 5 , 6 when compared to typically developing children. Other contributing factors are spasticity, 7 long sarcomeres and collagen infiltration, which are associated with increased muscle stiffness, 8 and excessive co-contraction of muscles, 9 which is associated with fewer muscle synergies and a simplified motor control strategy. 10 Altered brain activation patterns, such as suppressed activation of the prefrontal cortex, may also contribute to poor muscle performance. 11 Muscle contractures, which represent a permanent shortening of the muscle-tendon complex, 12 are present in more than 1/3 of children with CP and begin to show significant signs of developing by four years of age. 13 When coupled with the limited participation in physical activity and early signs of increased chronic disease risk, such as cardiometabolic disease 14 and osteoporosis, 15 , 16 the critical need for early tracking and treatment of muscle in children with CP is evident. 16

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The completion of this manuscript was supported by the Eunice Kennedy Shriver National Institute of Child Health and Human Development (R01 HD090126) and the University of Georgia Athletic Association.

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Modlesky, C.M., Matias, A.B. Muscle in children with cerebral palsy: current evidence, knowledge gaps, and emerging research opportunities. Pediatr Res (2024). https://doi.org/10.1038/s41390-024-03422-x

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Cerebral Palsy Guidance

Answers and Assistance

New Study Shows Increased Prevalence of Cerebral Palsy in Extremely Preterm Infants

A recent study involving nearly 7,000 children nationwide found that cerebral palsy diagnoses are on the rise for one segment of the population. Extremely preterm infants are born between 28 and 31 weeks of gestation and are at higher risk for many complications. While the number of children diagnosed with cerebral palsy was decreasing, this study shows that many are still at high risk.

About Cerebral Palsy

Cerebral palsy is a group of neurological conditions caused by abnormal development of the brain or brain damage in unborn babies and very young babies. It is the most common childhood disability related to motor skills and movement.

Several studies of cerebral palsy in children collected between the 1980s and early 2000s showed a decreasing trend in cases in most developed countries. Recent studies in the U.S. indicate that approximately one in 345 children have cerebral palsy.

The Nationwide Study of Cerebral Palsy

Prematurity and low birth weight are important risk factors for cerebral palsy. These babies are vulnerable to many complications, which can include brain damage or abnormal brain development. The earlier a baby is born, the greater the risk.

The most recent study of the risk of cerebral palsy collected information on nearly 7,000 children from 25 academic centers all over the country. Funded by the National Institutes of Health, the study included a broad representation of demographics across the country, with results that reflect national trends.

The researchers collected data for babies born extremely prematurely, before 27 weeks, but who also survived prematurity. The information was collected when the babies were between 18 and 26 months of age.

Increasing CP in Preterm Babies

The results showed the risk of cerebral palsy in this population increased by 11% every year from 2008 to 2019. Of the 6,927 children born extremely premature, 1,303, or 18.8% were later diagnosed with cerebral palsy. Others were diagnosed with different neurological conditions or symptoms, and only 53.3% of the children showed normal neurological functioning.

Why Is CP on the Rise for Extremely Premature Infants?

While the study didn’t set out to find a reason for this increase in diagnoses, the researchers had a possible explanation. They believe that improved medical care for the most vulnerable preterm babies may account for more cases of CP later. More babies now survive extremely premature births than previously.

Another aspect of the increased risk may also be an improved diagnosis of cerebral palsy. As a highly varied group of conditions with no single test, diagnosing cerebral palsy can be difficult. This is especially true for children with mild CP.

A similar study conducted in Denmark and published in 2024 found similar results and increasing numbers of premature babies being diagnosed later with cerebral palsy. The Danish researchers also hypothesized that better medical care all around and more proactive neonatal care specifically account for the increase as more preterm babies survive.

The new information about cerebral palsy risk might initially seem alarming, but it may actually be good news. It seems to indicate that more vulnerable infants are surviving being born preterm. More research is needed to determine how these surviving infants will fare later in life.

Lifelong Financial Assistance for Your Child's Birth Injury Cerebral Palsy

• https://www.cdc.gov/cerebral-palsy/risk-factors/index.html
• https://www.nichd.nih.gov/newsroom/news/052124-cerebral-palsy-increase-preterm-infants
• https://onlinelibrary.wiley.com/doi/full/10.1111/dmcn.16020

Written by Mary Ellen Ellis

Mary Ellen Ellis has been writing for CerebralPalsyGuidance.com since 2016. She is a graduate of the University of Michigan and holds undergraduate and graduate science degrees. As a freelance writer for over 10 years Mary Ellen has used her academic background to specialize in health and science writing. She is committed to making complex medical topics accessible to those who need it.

Mary Ellen feels honored to use her writing skills to shine a light on individuals and families affected by cerebral palsy, and bring awareness to the community.

We provide nationwide assistance

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Client background:

Tom is a 3 year old boy, born at 28 weeks. He has a diagnosis of evolving dyskinetic Cerebral Palsy, GMFCS V. Tom has a history of seizures.

Pia met Tom while teaching a therapist course about the Key to CP approach. Tom was a demo child, meaning he only spent about an hour with Pia.

Tom was not receiving direct Physical Therapy at home and he did not have any positioning equipment at the time. He was spending his days held by caregivers or on the floor.

Tom’s journey

See how doing the right thing, at the right time, in the right order helped set the stage for Tom to develop play and communication skills during an hour therapy session at Key to CP in this case study, or continue reading below.

Goals before treatment:

Family goals for Tom were to achieve better trunk and head control, to gain strength, and to achieve a level of independence.

It was quickly clear that Tom need support of his trunk in order to improve his head and trunk control for sitting and standing. At Key to CP we often use trunk orthoses to help the child gain upright control. For Tom, a TheraTogs garment was the obvious choice.

As soon as Tom was fitted with TheraTogs there was an immediate improvement in his head and trunk control. He became much more animated and was easily interacting with his parents and with me. He gained a whole new perspective of the world in just the 15 minutes it took to fit him with TheraTogs.

Tom’s parents were surprised to see the changes and they immediately ordered TheraTogs for him. They were also able to try a corner seat and a low table and Tom was happy and interactive.

What does this case teach us? If a child with poor trunk and head control is given the right trunk support, not only does their body control improve, but also their ability to interact with their environment. For Tom, TheraTogs brought his trunk muscles into mid-range alignment (where they are strongest) and the compression gave him sensory input. This tool allowed Tom to better experience his body in relation to his environment. 

It also teaches us that when children have to struggle less to maintain body control, they can focus on communication and learning more.

Tom is now able to develop communication and play skills, and he can participate in activities with his family. 

And it took less than an hour to bring about this transformation.

Doing the RIGHT thing

Adding TheraTogs and appropriate seating, and most importantly, abundant parent coaching

At the RIGHT time

Giving Tom an opportunity to PARTICIPATE and create positive neuroplastic changes during the first window of abundant brain growth and development

In the RIGHT order

Alignment, Awareness, Activation and Strength

Tom feels much more stable in TheraTogs. We have noticed lately how his head control is coming along and he is really looking up and engaging with everyone, especially his sister. He has been a lot more vocal too. And he is being much more aggressive with telling me he is hungry by sticking his tongue out. He is so content in his new chair that I almost cannot believe it. We feel energized and grateful to have found you. Tom's mother

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Clinical Examination of Children with Cerebral Palsy

Kailash sarathy.

Department of Paediatric Orthopaedics, Bai Jerbai Wadia Hospital for Children, Mumbai, Maharashtra, India

Chintan Doshi

Alaric aroojis.

Cerebral palsy (CP), a heterogeneous disorder of movement and posture, is one of the most important causes of disability affecting children. With a wide variability in the clinical presentation and a paucity of reliable diagnostic tests, decision-making in CP is fraught with difficulties and challenges. The plethora of musculoskeletal manifestations includes poor muscle function, spasticity, rigidity, muscle weakness, poor selective motor control, soft-tissue and joint contractures, torsional malalignments, and lever arm dysfunctions. Children with CP are at a high risk of further worsening and progression of these musculoskeletal abnormalities with the natural course of the disease. A comprehensive assessment that includes a combination of detailed medical history, functional assessment, clinical examination, analysis of gait, and radiological assessment is required to provide a favorable treatment outcome in these children. A close surveillance is essential so as to identify risk factors for the development and progression of musculoskeletal problems so that early interventions can be carried out to circumvent them. This review article is to highlight the importance of clinical examination in the assessment of children with CP.

Introduction

Cerebral palsy (CP) is defined as a qualitative motor disorder of movement and posture appearing before the age of 3 years, due to non-progressive damage of the brain, occurring before growth of the nervous system is complete. 1 The effect of the nonprogressive damage may however contribute to a misunderstanding of the secondary musculoskeletal pathology, which is not static but is most definitely progressive. 2 The presentation of patients with CP is highly variable, ranging from those with mild neurological deficit to those with severe involvement. The diagnostic matrix to be followed in case of CP includes a detailed history, gait analysis, physical examination of lower limbs, examination of upper extremities and spine, and additional tests for appropriate clinical evaluation. The above diagnostic matrix is an important pillar for decision-making in CP [ Figure 1 ].

Diagnostic flowchart in cerebral palsy

Search criteria

The authors identified the relevant articles using a protocol based on searching Cochrane Database of Systematic Reviews (1993–2017; www.cochrane.org ); Google Scholar; MEDLINE (1956–2016); and PubMed. Searches were also supplemented by hand searching. Interventions and keywords for investigation were identified using (1) contributing authors’ knowledge of the field; (2) internationally recognized CP websites such as the American Academy of Cerebral Palsy and Developmental Medicine ( www.aacpdm.org ); and (3) the top twenty hits in Google using the search terms “cerebral palsy” and “Clinical Examination” as an indicator of popular subject matter. The full search strategy is available from the authors on request.

The most important aspect in the initial clinical evaluation of a child with CP is the medical and surgical history of the child. The history includes information regarding the birth, developmental milestones, other associated medical problems, surgical history, ongoing medications, and physiotherapy treatment.

The birth history includes important details about antenatal problems, perinatal history including whether child was preterm, full term, or post-term, and whether there were other associated factors leading to hypoxic injury to the brain such as prolonged labor, meconium aspiration. etc. Treatment of a child in the neonatal Intensive Care Unit after delivery is an important pointer in history. An immature or preterm infant with periventricular leukomalacia typically presents with spastic diplegia, whereas a child with periventricular hemorrhage is more likely to present with hemiplegia. 3 A full-term child with watershed ischemia may present with quadriparesis and that with focal ischemia may present with hemiparesis.

History of developmental milestones is important, as it signifies the stages of physical development as the child becomes more mature. The current functional activity level of the child provides a good insight for treatment, future prognosis, capacity, and goal setting. The earlier the child attains standing balance, the better is the outcome with respect to hip deformities. It is also important to acquire previous history of associated medical illness, physiotherapy records, and previous surgical records to accurately assess present deformities and compensations. Present functional ability at home, school, and in community as well as other functional skills such as walking, running, and stair climbing also affect treatment plans and outcome analysis.

Clinical Examination

Physical examination, especially in children with CP, has limitations and benefits. The information collected during physical examination is based on static responses, whereas functional activities, such as walking, are dynamic. The independence of gait analysis and physical examination measures supports the notion that each provides information that is important in the delineation of problems of children with CP. 4 The method of assessment, the skill of the examiner, and the participation of the child can all affect the usefulness of the examination.

Gait analysis

Gait analysis is commonly ignored in the examination of children with CP and is sometimes performed last in the examination sequence. However, gait analysis is most important as it indicates relative functional deviations rather than static physical examination. The first and most important part in the examination of a child with CP is observing the gait when the child walks into the consultation room. Gait analysis can be done with different techniques such as observational gait analysis, videographic gait analysis, and instrumented 3D gait analysis. 5 , 6 , 7 Observational gait analysis is performed by observing the gait cycle in both sagittal and coronal planes and observing joint angles at different stages of gait cycle at different levels. Videographic gait analysis is performed by observing gait in slow-motion video and analyzing the movements of different joints in both coronal and sagittal planes. The most comprehensive gait analysis is performed by instrumented 3D gait analysis with the use of reflective markers in a gait laboratory. However, 3D gait analysis requires a setup with a lot of infrastructure expenditure, and often sufficient findings can be obtained by observation and slow-motion videographic gait analysis on a day-to-day basis.

Gait patterns in cerebral palsy

Depending on the involvement of spasticity or contracture of different muscles, there are different patterns of gait observed in children with CP. Gait pattern variations related to topographical type of CP are best seen in contrast between unilateral spastic CP and bilateral spastic CP. 8

In spastic hemiplegia, there is more involvement distally and therefore true equinus is the basis of common patterns. Winters et al. described four gait patterns in spastic hemiplegics based on sagittal kinematics. 9

• Type 1 hemiplegia gait – Drop foot type

Type II hemiplegic gait. (a): Anteroposterior view showing right-sided hemiplegia with ankle equinus in stance. (b): Lateral view showing right-sided hemiplegia with ankle equinus in stance

• Type 3 hemiplegia gait – Stiff knee gait
• Type 4 hemiplegia gait – In sagittal plane, the ankle is in equinus, knee in flexion, hip in flexion and anterior pelvic tilt is present. In coronal plane, there is hip adduction and internal rotation.

Gait patterns in spastic diplegia

In spastic diplegia, there is more proximal involvement and therefore apparent equinus and crouch gait are seen commonly. 10 There are four common patterns of gait in spastic diplegia as described by Rodda et al. 11

• Type 1 – True equinus

Type II diplegic gait. (a): Anteroposterior view showing jump gait with bilateral hip and knee flexion and ankle equinus. (b): Lateral view showing jump gait with bilateral hip and knee flexion and ankle equinus

• Type 3 – Apparent equinus

Type IV diplegic gait. (a): Anteroposterior view showing crouch gait with bilateral hip and knee flexion and ankle dorsiflexion. (b): Lateral view showing crouch gait with bilateral hip and knee flexion and ankle dorsiflexion

Physical Assessment

A standard, detailed physical examination is crucial in assessing children with movement disorders, especially CP. The four primary reasons for the need to classify CP include (1) to provide a detailed description that can delineate the nature of the problem and its severity, (2) to provide predictions of both current and future service needs for an individual, (3) to provide comparison so that groups of patients with CP at one institution can be compared with those at another, and (4) to evaluate change so that one individual with CP can be evaluated at various times and change can be documented. 12

In CP, the Gross Motor Function Classification System, developed by Palisano et al. , 13 has been in use for over two decades. It is a five-level clinical classification system that describes the gross motor function of people with CP on the basis of self-initiated movement abilities. The purpose of this system is to classify the child's present gross motor function in a systematic and reliable manner and serves as a useful matrix for identification of where a child is at a specific point in time in relation to its age and gross motor function. Distinctions between levels are based on functional abilities; the need for walkers, crutches, wheelchairs, or canes/walking sticks; and to a much lesser extent, the actual quality of movement. The various levels that are described include:

• Level I – The child can walk indoors and outdoors and climb stairs without using hands for support and can perform usual activities such as running and jumping but has decreased speed, balance, and coordination
• Level II – The child can climb stairs with a railing but has difficulty with uneven surfaces, inclines, or in crowds and has minimal ability to run or jump
• Level III – The child walks with assistive mobility devices indoors and outdoors on level surfaces, able to climb stairs using a railing, and may propel a manual wheelchair but needs assistance for long distances or uneven surfaces
• Level IV – Here, the walking ability is severely limited even with assistive devices such as wheelchairs most of the time and may propel own power wheelchair, standing transfers, with or without assistance
• Level V – The child has physical impairments that restrict voluntary control of movements, has very poor head, neck, and trunk control, has impairment in all areas of motor function, and cannot sit or stand independently, even with adaptive equipment.

The physical examination itself can be categorized into the following:

Functional mobility assessment

Over the years, various simple categorical scales have been developed for the assessment of functional ability and functional mobility of children with CP. These scales were designed to be responsive to change and can be used to document the serial attainment of mobility and functional abilities, the deterioration or improvement in these skills after intervention, or other changes consequent on growth and development. The Functional Mobility Scale (FMS) had been described by Graham et al. 14 to classify the extent of mobility in children, taking into account the range of assistive devices a child might use for mobility. The scale is useful in documenting change over time following interventions such as orthopedic surgery or selective dorsal rhizotomy and was found to be highly sensitive to detect changes after operative intervention. 15

The FMS rates walking ability at three specific distances such as 5, 50, and 500 m and is further graded from 1 to 6 depending on the level of mobility. The scoring represents the child's mobility in the home, at school, and in the community setting. The walking ability of the child is rated at each of the three distances according to the need for assistive devices such as crutches, walkers, or wheelchairs.

The rating is from 1 to 6 which is described as follows:

1 – The child mostly uses a wheelchair but may stand for transfers and does some stepping supported by a caretaker or with the help of a walker; 2 – The child uses a walker or frame to ambulate; 3 – The child independently walks but with the help of crutches; 4 – The child walks independently but with the help of sticks (one or two); 5 – The child walks independently only on leveled surfaces; 6 – The child walks independently on all surfaces; C – The child crawls for mobility at home (5 m); N – Not applicable (e.g., the child does not complete 500 m).

Children with CP, despite having a similar diagnosis, vary in their abilities and level of functioning within and across different environmental contexts such as home, school, or a community setting. 16 Capacity (what a child can do in standardized, controlled environment) may or may not be the same as performance (what a child actually does in his/her daily environment). The FMS is a performance measure and it is important to rate what the child actually does at the time of assessment and not what they can do or used to be able to do. The FMS has been found to be a reliable tool that can be used by clinicians to assess mobility in children with CP. 17

Muscle tone assessment

Tone can be defined as resistance to passive stretch at the relaxed state of muscle activity. It is difficult and cumbersome to assess the tone in CP children, as this can be influenced by apprehension and excitement in the child and the position in which the child is assessed. Hypertonia in a CP child can be due to spasticity, dystonia, rigidity, or a combination of the above features. First, the muscle contracture at rest is assessed by manual palpation of the muscle in testing. Second, the limb is moved slowly through its passive range and later at various speeds or velocity and catch or the resistance to passive motion is assessed. The spasticity assessment is commonly done using the Modified Ashworth scale 18 , 19 , 20 and the Tardieu scale. 21

Modified Ashworth scale

The Modified Ashworth scale, which is used to grade the amount of spasticity, is one of the commonly performed tests as it does not need any equipment and can be performed quickly, easily, and in a day-care clinic. The test is performed manually to determine the resistance of muscle to passive stretching. This was initially described as a measure of spasticity but depends on the speed at which the test is performed. In the original article, it was suggested that the movement of the limb segments should be performed through the full range of movement enough to be a test of spasticity during walking [ Table 1 ].

ROM=Range of motion

Due to the potential shortcomings of this test regarding reliability and chances of error in measurements, assessments of spasticity using this scale should be interpreted with caution. 19 , 20

Tardieu scale

This is a scale for measuring spasticity that takes into account the resistance to passive movement at both slow and fast speeds. As this test is simple and relatively easy to perform and recorded as an angle measure, it can be easily correlated with gait analysis, if required. The various parameters include the following:

• V1 – Velocity to stretch as slow as possible
• V2 – Velocity to stretch with the speed of limb segment falling with gravity
• V3 – Velocity to stretch as fast as possible (> natural drop)

Tardieu scale. (a): Clinical photograph showing Tardieu score at the ankle (R1). (b): Clinical photograph showing Tardieu score at the ankle (R2)

• R2 – Full range of motion (ROM) achieved when muscle is at rest and tested at V1 velocity [ Figure 5b ].

A large difference between R1 and R2 in outer and middle ROM indicates a larger dynamic component and a small difference between R1 and R2 in middle and inner ROM indicates a predominant fixed contracture.

The Tardieu scale has an excellent intra- and inter-rater reliability when assessed at the elbow and ankle joints of children with CP, with no difference noted between visual and goniometric measurements. 22 Training is associated with a highly significant improvement in reliability.

Although we use these scales routinely during the assessment of the CP children, they have some disadvantages because they are not standardized, stimulus is not well controlled, and they lack reliability and validity for all the muscle groups. They offer only qualitative and subjective information in measuring spasticity. 23

Analysis of range of motion and joint contractures

Assessing the muscle length and joint contractures is an integral part of the physical examination. 24 The muscle length is indirectly measured by assessing the ROM of the joint through which the muscle acts. These have to be undertaken with appropriate precautions and standardization, as abnormally false results and errors commonly arise due to faulty technique of examination. Reliability studies suggest that the standard error of measurement of passive joint range is of the order of 5°. 25 Although it is difficult to differentiate static and dynamic deformities in nonanesthetized child, a comprehensive static examination gives a good insight on the type of contracture and in planning the management of the same. 26

Hip deformity is one of the common presenting abnormalities in CP. Although the hips per se are normal at birth, late displacements occur due to abnormal balance, loss of selective motor control, and tone abnormalities. Thus, hip screening is an essential part of examination of a CP child, 27 especially in non-walkers and late walkers. The components of hip examination include the following:

Clinical photograph showing measurement of hip flexion deformity by the Thomas test

Clinical photograph showing Staheli prone extension test

On comparing the above tests, the Thomas’ test showed the best results in normal population whereas the Staheli's test was shown to have accurate results in children with CP. 32

The next part of assessment is to measure the amount of adductor contracture. With the patient in supine position, passive abduction of the hip is performed with the knee in extension and with the knee in 90° flexion (Phelp's Test) [Figure ​ [Figure8a 8a and ​ andb]. b ]. If abduction improves on knee flexion, the primary pathology lies in the medial hamstring muscles and gracilis. If both the measurements are the same, the prime pathology is in the adductor muscles.

Phelp's test. (a): Clinical photograph showing passive hip abduction with knees in extension. (b): Clinical photograph showing improved hip abduction with knee flexion

It has been proposed that, with a significant hip flexion contracture in combination with combined hip abduction of <80°, there is an increased risk of hip subluxation and chronic hip pain in the near future. 33

The commonly presenting deformity in knee is that of flexion contracture, which is more pronounced in a nonambulatory child. The first step in assessment is to differentiate true joint contracture from contracture due to muscle spasticity or tightness.

Clinical photograph showing knee flexion deformity

Popliteal angle test for hamstring contracture. (a): Clinical photograph showing unilateral popliteal angle. (b): Clinical photograph showing bilateral popliteal angle. Difference between the two measurements is the “hamstring shift”

In ambulatory children, a crouch gait develops as a part of the natural course of the disease, especially in diplegic children, in which there is a failure of plantar flexion–knee extension couple. 36 While contemplating crouch correction, other abnormalities such as lever arm dysfunction due to torsional malalignments, planovalgus feet, and muscle imbalance have to be kept in mind to provide overall improvement in the outcome. 37

Assessment of rectus femoris spasticity using Duncan-Ely's/Prone Rectus test [ Figure 11 ] is essential, as this in conjunction with hamstring contracture can result in a stiff knee gait pattern, which necessitates a different approach to management.

Clinical photograph showing prone rectus test. Note the pelvic rise on knee flexion indicating spasticity of the rectus femoris

Ankle and foot

The most common deformities seen in CP include equino-varus and plano-valgus. Assessment of equinus (gastro-soleus spasticity/contracture) is done by passive dorsiflexion of ankle with knee in extension and then with knee joint in 90° flexion (Silverskiold test) [Figure 12a and ​ andb]. b ]. A difference of 20°–30° shows a spastic gastrocnemius component.

Silverskiold test. (a): Clinical photograph showing degree of ankle equinus with knee in extension. (b): Clinical photograph showing correction of ankle equinus with knee flexion indicating predominantly gastrocnemius contracture

Muscle strength analysis and selective motor control

Assessment of muscle strength and selective motor control is an integral part of the examination protocol of children with CP. As muscle strength is directly proportional to motor function, strength evaluation is necessary for providing optimal functional outcomes. Muscle strength analysis is also required to assess the appropriateness for surgical interventions.

The Medical Research Council (MRC) grading for muscle strength assessment has been in use for decades. 38 The main disadvantage of this grading system is that it neither considers the ROM for which a movement can be performed nor defines the strength of resistance against which a movement can be performed. The MRC grading system consists of six grades (scale of 0–5) in relation to the maximum range expected for that muscle [ Table 2 ].

Medical Research Council grading of muscle power

In children with CP, who have poor comprehension and in whom isolated muscle testing is cumbersome, manual muscle testing using Kendall scale is used. 39 It is a 10-point scale which provides a simpler way to assess muscle strength or muscle imbalance [ Table 3 ]. However, it relies heavily on the examiner's judgment and experience, the amount of force generated, and the accuracy of patient positioning. It is subjective and prone to have a significant examiner bias. Studies have shown that clinically small but significant differences in strength may not be detected by this method. However, under strict evaluation protocols, this method was still found to be useful. 40 For children who are under the age of 5, and who cannot follow complex directions for maximal force production, the manual muscle testing method, as well as any other method of strength assessment, is still a vague screening tool. In recent studies, use of a handheld dynamometer has been shown to provide more reliable results in assessing muscle strength, especially the isometric strength. 41

Kendall Scale

Selective motor control

In children with CP, the reduced ability to control and isolate movements provides great hindrance in muscle strength assessment. The typical scale for muscle group selectivity is given as follows:

• Grade 0 – No ability/only patterned movement observed
• Grade 1 – Partial ability/partially isolated movements
• Grade 2 – Complete ability/completely isolated movements.

To assess the overactivity of tibialis anterior muscle (varus/supination), confusion test is used. Here, due to loss of selective motor control, resistance to hip flexion causes the overactive tibialis anterior muscle to act and there is dorsiflexion at the ankle and forefoot supination.

Recently, a newer assessment scheme has been put forth, the Selective Control Assessment of Lower Extremities, which gives a comprehensive scheme for the motor function assessment. 42

Torsional profile and concept of lever arm dysfunction

“Lever arm dysfunction” is a term originally coined by Gage in 1991 43 to describe the particular orthopedic deformities that arise in an ambulatory child with CP. Lever arm dysfunction describes a general class of bone modeling, remodeling, and or traumatic deformities that include hip subluxation, torsional deformities of long bones, and/or foot deformities. Since muscles and ground reaction forces (GRFs) must act on skeletal levers to produce locomotion, abnormalities of these lever arm systems greatly interfere with the child's ability to walk.

In CP, the muscles and the GRFs are neither appropriate nor adequate because of contractures, poor selective motor control, and abnormality of the bony lever arms due to bony malalignments. Among the malalignments, excessive femoral anteversion (FAV) and tibial torsion are the two commonly described conditions in literature. 44 Excessive FAV and coxavalga can produce intoeing gait and hip instability. 45

The Craig's test/Trochanteric prominence test [ Figure 13 ] has been used for the assessment of FAV. With the patient in prone position and knee at 90° flexion, the angle between the vertical line and long axis of the leg at the greatest prominence of the greater trochanter palpated laterally measures the amount of FAV. In recent studies, it has been found that trochanteric prominence test in combination with hip internal rotation X-rays is a better predictor of FAV and neck-shaft angle as compared with computed tomography. 46

Clinical photograph showing Craig test to measure femoral anteversion

Tibial torsion malalignment can be assessed clinically by the following:

Clinical photograph showing Thigh Foot Angle test to measure tibial torsion

• Bi-malleolar axis method – With the knee in full extension, the leg is rotated to align the femur bi-condylar axis horizontally. The angle between the horizontal and bimalleolar axis measures the tibial torsion 47
• Second toe test – With the patient in prone position, the leg is rotated so that the 2 nd toe points vertically down. Now with the thigh held and knee flexed, the angle between the vertical line and the leg axis gives the measure of tibial torsion.

Standing balance and equilibrium

To conclude the physical examination, assessment of posture, trunk balance, and position of the pelvis and lower extremities in standing position (static) and during walking (dynamic) in both planes gives overall information regarding motor control and compensatory mechanisms. Children with CP tend to have delayed and reduced posterior equilibrium responses. A comprehensive analysis of equilibrium in all planes should be done before planning for any modality of treatment.

Upper-limb Examination

The upper extremity examination includes an assessment of tone, ROM of joints, strength of muscles, and assessment of upper-limb functions. Assessment of tone is by the Ashworth scale similar to that for lower extremity muscles. ROM is assessed at each of the joints at shoulder, elbow, forearm, wrist, and hand.

Assessment of upper-limb function

The Manual Ability Classification System describes how children with CP use their hands to manipulate relevant and appropriate objects for activity of daily living, classifying them into five levels 48 [ Table 4 ]. Other assessment scales for upper-limb evaluation are Assisting Hand Assessment score, Quality of Upper Extremity Skills Test (QUEST), Melbourne Assessment of Unilateral Upper limb Function, and Shriners Hospital Upper Extremity Evaluation.

Manual Ability Classification System scoring system

Spine Examination

Spine deformities are a common presentation in CP. They present in varied patterns – scoliosis, kyphosis, lordosis, pelvic obliquity, and a combination of these. Scoliosis is the most common spinal deformity in patients with CP. 49 The incidence of scoliosis increases with increasing severity of the disease. The classic curve pattern is a long C-shaped curve that is often kyphoscoliotic or lordoscoliotic. The curve progression is gradual; however, it can become rapid with onset of puberty, deteriorating neurological function, or spending prolonged time in wheelchair. Scoliosis developing at a younger age (<15 years of age) has a higher risk for progression, and progression can be seen even after skeletal maturity in severely affected children. 50 Nonoperative management of spinal deformity can be achieved by sitting modifications and bracing. However, nonoperative management does not halt the progression of deformity. Surgical management depends on factors such as patient's age, functional capabilities, curve pattern, and other comorbidities.

Conclusions

A detailed bi-annual examination of all children with CP is essential. The frequency of examinations should be more if the child is nonambulant, has deterioration on subsequent examination, or undergoes any surgical management. Although strict guidelines have not been established for a streamlined physical assessment of children with CP, a comprehensive clinical examination using the described diagnostic matrix should be undertaken by every clinician before contemplating the management of these children.

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[A case-control study on cerebral palsy in children]

Affiliation.

• 1 National Center for Maternal and Infant Health, Beijing Medical University, Beijing 100083.
• PMID: 11864484

Objective: To identify the risk factors for cerebral palsy (CP) in children.

Methods: A population-based 1:2 matched case-control study was conducted during May to June 1997 in southern Jiangsu Province of China.

Results: Risk factors for CP in children could be summarized into four categories, i.e.; (1) fetal growth retardation, preterm delivery and low birth weight; (2) asphyxia at birth, intracranial hemorrhage, ischemic and hypoxic encephalopathy and hyperbilirubinemic encephalopathy; (3) delivery with vaccum suction and traumatic brain injury; and (4) other prenatal factors.

Conclusion: The first and second categories of risk factors correlated strongly and reproducibly with CP in children. It is emphasized that antenatal care be enforced to prevent occurrence of risk factors, such as low birth weight, etc., and the newborns with asphyxia be vigorously rescued and put under close supervision. For risk factors in the third category, the key measures should be obstetric practice and health education for the parents. But, little about the knowledge of the risk factors in the fourth category has been understood, which could be associated with those in the first two categories.

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🧩 hurdle organization encourages independent living for adults with autism, 5.8 million adults diagnosed with autism in us, only 5% living independently, per cdc, crystal moyer.

OCOEE, Fla. – Living with autism can be challenging, with many obstacles to overcome and not a lot of support in some cases.

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Both Ed and Shane are living independently, but that’s not the case for most adults with autism.

According to the CDC , about 5.8 million adults were living with autism last year. The National Institute of Health posted a study showing only 5% were living independently. That’s why Ed and Shane created the organization, HURDLE to spread awareness. It’s a nonprofit motivational speaking group promoting autism awareness and mental health motivation.

“HURDLE is an acronym: Hard work, understanding, realization, determination, leadership and education. All of those five elements are the keys to succeed,” Shane said. “I hope to share the message of motivation and inspiration to everybody else that, no matter the disability, autism or cerebral palsy, you name it. Hurdles will be out there and those do not define who you are.”

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