There are some very specific issues dealing with bony modeling and remodeling in children with spasticity and weakness, particularly those who are poorly ambulatory (GMFCS IV and V). There is a general concensus across several countries regarding monitoring and intervention protocol. If you are a medical professional it is critically important you are aware of the prevalence of hip subluxation and dislocation, and know when to refer to an orthopedic specialist.
Consensus Statement on Hip Surveillance in Children With Cerebral Palsy: Australian Standards of Care
and Supporting Information
Abstracts From the Second International Symposium on the Hip in Cerebral Palsy, DuPont Children's Hospital 2010
Hip Surveillance and Intervention Flow Chart
Classification of Function in Children With Disability
There are several tools used to classify the functional level of children with disability. The most common and seemingly most stable is the Gross Motor Functional Classification System (GMFCS) developed in 1997 by Palisano, Rosenbaum and colleagues through CanChild and McMaster University. If you are unfamiiar with determining functional level, or are searching for a way to classify functional mobility level in research design please start here.
CanChild>GMFCS - expanded and revised
GMFCS- er quick PDF
Fine motor/manual ability level can be determined using the MACS. This tool is somewhat newer than the GMFCS but adds a needed dimension.
MACS - quick PDF
Diagnosis Specific Information
- Movement Disorders
- General and multitopic
- Dystonia specific
(this section currently under construction- check back frequently for updates)
The evaluation of functional ability in children with neuromotor impairment requires a basic understanding of the difference between criterion referenced vs. norm referenced tests. The quick difference is that criterion referenced tests compare a child's first and subsequent scores to each other and provide a measure of change between those scores. More simply put, the child is compared to themselves, not others. A norm referenced test allows comparison of one child's scores to the scores of other children of like age and gender.
However, while most third party payors ask for norm referenced test scores, they are generally not appropriate for children who have sustained an injury to the central nervous system. This is because the population used to establish the normative values was "normal"- they did not have a neurological injury. Generalization (application) of results to a child unlike the population for which it was established is typically inappropriate. If you are unsure which to use, please check the psychometric properties of the test you have selected before proceeding.
Criterion referenced tests
One of the most common criterion referenced test approriate for chldren with cerebral palsy is the Gross Motor Function Measure or GMFM. There are two versions of the GMFM, the GMFM-88 and the GMFM-66, which is essentially a shortened 88. Both versions have 5 sections, A through E, that assess the main components of gross motor function. Use of the full 88 will provide a more complete picture of a child's function at a particular time and it has also been validated for children wtih Down Syndrome. Unfortunately though, each item is weighted a bit diffently, making assessment of difference scores a bit challenging. This was statistically addressed by the GMFM developers, with the result being the GMFM-66.
GMFM Score Sheets
So how do you know then if a child has made a clinically important change in functional ability if you are only comparing them to themselves? Thankfully, there are several good researchers who have done the work for you and established minimal change values for the total GMFM-66 scores and for the GMFM-88 dimension D and E scores. These indicate how much of a score change is required to indicate a true improvement or a minimal clinically important difference in functional ability. While I can not provide you with the full research article for free, here is the abstract. The article is available in Developmental Medicine and Child Neurology 2008, 50: 918-925. Look on page 922.