Probability of independent walking and wheeled mobility in individuals with cerebral palsy.

AIM: To estimate the probability of independent walking and wheeled mobility in individuals with cerebral palsy (CP) at home and in the community in relation to age and gross motor function. METHOD: This was a longitudinal cohort study using data reported into the combined Swedish CP follow-up programme and national quality registry from October 2000 to October 2022. Walking, walking with aids, wheeled mobility, and assisted mobility defined independent or assisted mobility at home and in the community, based on the Functional Mobility Scale with additional data on wheelchair performance, were assessed. RESULTS: There were 52 858 examinations reported for 6647 individuals with CP (age range 0-32 years, follow-up period 0-22 years). Most children and adults in Gross Motor Function Classification System (GMFCS) levels I or II walked without assistive devices. The probability of dependence on others for mobility in the community was high for both children and adults in GMFCS levels III to V. INTERPRETATION: Although independent mobility is vital for participation and social inclusion, many children and adults with CP are dependent on others for mobility. We recommend clinicians, together with families and individuals with CP, explore how to increase access to independent mobility from an early age and continuously throughout the life course. WHAT THIS PAPER ADDS: • There is a high probability of independent walking in Gross Motor Function Classification System (GMFCS) levels I to II. • Mobility options vary most at home and in the community in GMFCS level III. • Being dependent on others for mobility is likely in GMFCS levels III to V.

Sit-to-stand performance in children with cerebral palsy: a population-based cross-sectional study.

BACKGROUND: Sit-to-stand (STS) is one of the most commonly performed functional movements in a child's daily life that enables the child to perform functional activities such as independent transfer and to initiate walking and self-care. Children with cerebral palsy (CP) often have reduced STS ability. The aim of this study was to describe STS performance in a national based total population of children with CP and its association with age, sex, Gross Motor Function Classification System (GMFCS) level, and CP subtype. METHODS: This cross-sectional study included 4,250 children (2,503 boys, 1,747 girls) aged 1-18 years from the Swedish Cerebral Palsy Follow-Up Program (CPUP). STS performance was classified depending on the independence or need for support into "without support," "with support," or "unable." "With support" included external support from, e.g., walls and furniture. Physical assistance from another person was classified as "unable" (dependent). Ordinal and binary logistic regression analyses were used to identify associations between STS and age, GMFCS level, and CP subtype. RESULTS: 60% of the children performed STS without support, 14% performed STS with support, and 26% were unable or needed assistance from another person. STS performance was strongly associated with GMFCS level and differed with age and subtype (p < 0.001). For all GMFCS levels, STS performance was lowest at age 1-3 years. Most children with GMFCS level I (99%) or II (88%) performed STS without support at the age of 4-6 years. In children with GMFCS level III or IV, the prevalence of independent STS performance improved throughout childhood. CP subtype was not associated with STS performance across all GMFCS levels when adjusted for age. CONCLUSIONS: Independent STS performance in children with CP is associated with GMFCS level and age. Children with CP acquire STS ability later than their peers normally do. The proportion of children with independent STS performance increased throughout childhood, also for children with GMFCS level III or IV. These findings suggest the importance of maintaining a focus on STS performance within physiotherapy strategies and interventions for children with CP, including those with higher GMFCS level.

Incidence and sequence of scoliosis and windswept hip deformity: which comes first in 4148 children with cerebral palsy? A longitudinal cohort study.

BACKGROUND: The aim was to analyse whether scoliosis or windswept hip deformity (WSH) occurs first for children with cerebral palsy (CP). METHODS: This longitudinal cohort study using data from 1994 - 2020 (26 years) involved 41,600 measurements of 4148 children (2419 [58.3%] boys) with CP born 1990 - 2018 and registered into the Swedish CP follow-up program. Children were followed from a mean age of 2.8 [SD 1.4] years, until they developed either scoliosis or WSH or were removed at surgery. RESULTS: WSH developed first in 16.6% of the children (mean age 8.1 [SD 5.0] years), and scoliosis in 8.1% (mean age 8.1 [SD 4.9] years). The incidence of WSH was higher than scoliosis across all levels I-V of the Gross Motor Function Classification System (GMFCS), both sexes, and for those with dyskinetic (20.0%) or spastic (17.0%) CP. The incidence of scoliosis was highest (19.8%) and developed earliest in children with GMFCS level V (mean age 5.5 [SD 3.5] years), and in children with dyskinetic (17.9%) CP (mean age 7.0 [SD 4.7] years). CONCLUSIONS: WSH presents earlier than scoliosis in most children with CP. Children with higher GMFCS level or dyskinetic CP are more likely to develop these deformities at a younger age.

Knee and ankle range of motion and spasticity from childhood into adulthood: a longitudinal cohort study of 3,223 individuals with cerebral palsy.

BACKGROUND AND PURPOSE: Reduced range of motion (ROM) and spasticity are common secondary findings in cerebral palsy (CP) affecting gait, positioning, and everyday functioning. These impairments can change over time and lead to various needs for intervention. The aim of this study was to analyze the development path of the changes in hamstring length, knee extension, ankle dorsiflexion, and spasticity in hamstrings and gastrosoleus from childhood into adulthood in individuals with CP at the Gross Motor Function Classification System (GMFCS) levels I-V. METHODS: A longitudinal cohort study was undertaken of 61,800 measurements in 3,223 individuals with CP, born 1990-2017 and followed for an average of 8.7 years (range 0-26). The age at examination varied between 0 and 30 years. The GMFCS levels I-V, goniometric measurements, and the modified Ashworth scale (MAS) were used for repeated assessments of motor function, ROM, and spasticity. RESULTS: Throughout the follow-up period, knee extension and hamstring length exhibited a consistent decline across all individuals, with more pronounced decreases evident in those classified at GMFCS levels III-V. Ankle dorsiflexion demonstrated a gradual reduction from 15° to 5° (GMFCS I-IV) or 10° (GMFCS V). Spasticity levels in the hamstrings and gastrosoleus peaked between ages 5 and 7, showing a propensity to increase with higher GMFCS levels. CONCLUSION: Passive ROM continues to decrease to 30 years of age, most pronouncedly for knee extension. Conversely, spasticity reached its peak at a younger age, with a more notable occurrence observed in the gastrosoleus compared with the hamstrings. Less than 50% of individuals had spasticity corresponding to MAS 2-4 at any age.

Comparison of the six-minute walk test performed over a 15 and 30 m course by children with cerebral palsy.

BACKGROUND: The aim of this study was to compare performance on the six-minute walk test (6MWT) performed over 15 m and 30 m courses by children and youths with cerebral palsy (CP). METHODS: Children and youths with CP at Gross Motor Function Classification System levels I-IV performed the 6MWT in a straight 15 m-long corridor (first trial) and 30 m-long corridor (second trial). The intraclass correlation coefficient (ICC) and Bland-Altman plots were used to evaluate the agreement between the 6MWT results for the two corridor lengths. RESULTS: We included 82 children and youths with CP (36 girls, 46 boys), with a mean age of 11.7 years (SD 4.2, range 5-22 years). There was high agreement between the results of the two 6MWTs: ICC 0.93 (95% confidence interval 0.76-0.97). The total walking distance was longer for the 30 m course (median 399 m, range 44-687 m) than the 15 m course (median 357 m, range 24-583 m). CONCLUSIONS: We observed good agreement for the performance of the 6MWT in the 15 m and 30 m courses, although the total walking distance was greater for the 30 m course. We recommend that the same distance is used when evaluating changes in walking ability for an individual child. Both distances are appropriate when measuring endurance in children and youths with CP.

Eating and drinking ability and nutritional status in adults with cerebral palsy.

AIM: To describe eating and drinking ability in adults with cerebral palsy (CP) relative to sex, age, subtype, and severity of gross motor and hand function and nutritional status. METHOD: This was a cross-sectional study based on data of 2035 adults with CP, median age 26 years (range 18-78 years). The Eating and Drinking Ability Classification System (EDACS), Gross Motor Function Classification System (GMFCS), and Manual Ability Classification System (MACS) were used in addition to subtype, body weight, height, body mass index (BMI), skin fold thickness, and gastrostomy. Linear regression models were used to estimate associations between body weight and the other variables. RESULTS: More than half of the adults (52.5%) eat and drink safely and 32.4% have dysphagia with limitations to eating and drinking safety. Weight, height, and BMI decreased with increasing EDACS levels. In EDACS level V, 86% had a gastrostomy, 23.4% in EDACS levels III to V were underweight, whereas 42.3% in EDACS levels I to II had a BMI over 25, indicating overweight or obesity. Increasing EDACS levels and need of support during meals were associated with lower body weight. INTERPRETATION: Adults with CP should be routinely screened and treated for dysphagia to avoid nutritional complications. Being dependent on others during mealtimes is a risk factor for low body weight.

ICF Core Sets for the assessment of functioning of adults with cerebral palsy.

AIM: To report on the results of the online international consensus process to develop the comprehensive and brief International Classification of Functioning, Disability and Health (ICF) Core Sets for adults with cerebral palsy (CP). METHOD: An online iterative decision-making and consensus process involved 25 experts, including clinicians and researchers working with adults with CP, an adult with CP, and the parents of adults with CP from all six regions of the World Health Organization. The most relevant categories were selected from a list of 154 unique second-level candidate categories to develop the ICF Core Sets for adults with CP. This list resulted from evidence gathered during four preparatory studies, that is, a systematic literature review, a qualitative study, an expert survey, and an empirical study. RESULTS: The consensus process resulted in the comprehensive ICF Core Set containing 120 second-level ICF categories: 33 body functions; eight body structures; 50 activities and participation; and 29 environmental factors, from which the most essential categories, 33 in total, were selected for the brief ICF Core Set. For body functions, most of the categories were mental functions and neuromusculoskeletal and movement-related functions. Body structures were mostly related to movement. All the chapters of the activities and participation component were represented, with mobility and self-care as the most frequently covered chapters. For environmental factors, most of the categories addressed products and technology and services, systems, and policies. INTERPRETATION: The comprehensive and brief ICF Core Sets for adults with CP were created using a new online version of an established ICF Core Set consensus process. These Core Sets complement the age-specific ICF Core Sets for children and young people with CP and will promote standardized data collection worldwide.

Sequence of flexion contracture development in the lower limb: a longitudinal analysis of 1,071 children with cerebral palsy.

BACKGROUND: To prevent severe contractures and their impact on adjacent joints in children with cerebral palsy (CP), it is crucial to treat the reduced range of motion early and to understand the order by which contractures appear. The aim of this study was to determine how a hip-knee or ankle contracture are associated with the time to and sequence of contracture development in adjacent joints. METHODS: This was a longitudinal cohort study of 1,071 children (636 boys, 435 girls) with CP born 1990 to 2018 who were registered before 5 years of age in the Swedish surveillance program for CP and had a hip, knee or ankle flexion contracture of ≥ 10°. The results were based on 1,636 legs followed for an average of 4.6 years (range 0-17 years). The Cox proportional-hazards model adjusted for Gross Motor Function Classification System (GMFCS) levels I-V was used to compare the percentage of legs with and without more than one contracture. RESULTS: A second contracture developed in 44% of the legs. The frequency of multiple contractures increased with higher GMFCS level. Children with a primary hip or foot contracture were more likely to develop a second knee contracture. Children with a primary knee contracture developed either a hip or ankle contracture as a second contracture. CONCLUSIONS: Multiple contractures were associated with higher GMFCS level. Lower limb contractures appeared in specific patterns where the location of the primary contracture and GMFCS level were associated with contracture development in adjacent joints.

Prevalence of pain and interference with daily activities and sleep in adults with cerebral palsy.

AIM: To analyse the prevalence of pain, pain sites, pain severity, and pain interfering with work or daily activities and sleep in adults with cerebral palsy (CP). METHOD: This was a cross-sectional study based on data from 1591 adults (16-76y, median age 25y; 879 males, 712 females; Communication Function Classification System [CFCS] levels I-V) in the Swedish Cerebral Palsy Follow-up Program. Pain severity was rated for several body sites and pain interference with activities/work and sleep was also evaluated. Logistic regression was used to estimate the odds ratios (ORs) of the factors associated with the prevalence of pain and pain interfering with activities/work or sleep. RESULTS: Pain was reported in 1059 of 1591 adults; a higher proportion self-reported pain (69.9%) compared to proxy-reported pain (62.4%). More adults classified in CFCS level I (72.5%) reported pain compared to those in CFCS levels II to V (56.5-64.9%). Adults with severe/very severe pain had a sixfold risk of pain interfering with activity/work (OR=6.68; 95% CI 4.99-8.96) and sleep (OR=6.60; 95% CI 4.84-8.98). INTERPRETATION: Two-thirds of adults with CP experienced pain, which is likely to be underreported in individuals who do not communicate efficiently or rely on proxy reports. Pain strongly interfered with activities and sleep; thus, it must be assessed and treated more effectively.

Interrater reliability for unilateral and bilateral tests to measure the popliteal angle in children and youth with cerebral palsy.

BACKGROUND: Short hamstring muscles can cause several problems for children with cerebral palsy. The results of the clinical measurement of hamstring length are often used in decision-making about treatment of children with cerebral palsy. There are different ways of performing this measurement. The aim of this study was to evaluate the interrater reliability of the unilateral and bilateral measurement of the popliteal angle in children and youth with cerebral palsy. METHODS: Two methods for estimating hamstring length using unilateral and bilateral measurements of the popliteal angle were applied in children with cerebral palsy. Both tests were applied bilaterally by two independent examiners on the same day for each child. The intraclass correlation coefficient (ICC) was calculated to evaluate the interrater reliability of both measurements. Seventy young people with cerebral palsy (32 females, 38 males, mean age 10 years 8 months, range 5-22 years) at Gross Motor Function Classification System levels I (n = 17), II (n = 31), III (n = 12) and IV (n = 10) were included. RESULTS: The interrater reliability was good for both measurements. The ICC values were 0.80 on the right and 0.86 on the left for the unilateral popliteal angle, and 0.82 on the right and 0.83 on the left for the bilateral popliteal angle. CONCLUSIONS: Both unilateral and bilateral measurement of the popliteal angle is a reliable method for estimating hamstring length in children and youth with cerebral palsy.

Knee and foot contracture occur earliest in children with cerebral palsy: a longitudinal analysis of 2,693 children.

Background and purpose - Joint contracture is a common problem among children with cerebral palsy (CP). To prevent severe contracture and its effects on adjacent joints, it is crucial to identify children with a reduced range of motion (ROM) early. We examined whether significant hip, knee, or foot contracture occurs earliest in children with CP.Patients and methods - This was a longitudinal study involving 27,230 measurements obtained for 2,693 children (59% boys, 41% girls) with CP born 1990 to 2018 and registered before 5 years of age in the Swedish surveillance program for CP. The analysis was based on 4,751 legs followed up for an average of 5.0 years. Separate Kaplan-Meier (KM) curves were drawn for each ROM to illustrate the proportions of contracture-free legs at a given time during the follow-up. Using a clustered bootstrap method and considering the child as the unit of clustering, 95% pointwise confidence intervals were generated for equally spaced time points every 2.5 years for each KM curve.Results - Contracture developed in 34% of all legs, and the median time to the first contracture was 10 years from the first examination. Contracture was most common in children with a higher Gross Motor Function Classification System (GMFCS) level. The first contracture was a flexion contracture preventing dorsiflexion in children with GMFCS level I or II and preventing knee extension in children with GMFCS level III to V.Interpretation - Early interventions to prevent knee and foot contractures in children with CP should be considered.

Development of a risk score for scoliosis in children with cerebral palsy.

Background and purpose - Children and young adults with cerebral palsy (CP) have an increased risk of developing scoliosis, with a prevalence ranging from 11% to 29%. Information on risk factors for the emergence and progression of scoliosis is inconclusive. This study aimed to develop a risk score based on 5-year-old children with CP to predict the risk of scoliosis before the age of 16.Patients and methods - This prospective registry study included 654 children with CP in Sweden born in 2000 to 2003 and registered with the Swedish CP follow-up program (CPUP) at the age of 5 years, including all Gross Motor Function Classification System (GMFCS) levels. 92 children developed a scoliosis before the age of 16 years. Univariable and multivariable logistic regressions were used to analyze 8 potential predictors for scoliosis: GMFCS, sex, spastic subtype, epilepsy, hip surgery, migration percentage, and limited hip or knee extension.Results - 4 predictors for scoliosis remained significant after analyses: female sex, GMFCS levels IV and V, epilepsy, and limited knee extension, and a risk score was constructed based on these factors. The predictive ability of the risk score was high, with an area under the receiver operating characteristics curve of 0.87 (95% CI 0.84-0.91).Interpretation - The risk score shows high discriminatory ability for differentiating between individuals at high and low risk for development of scoliosis before the age of 16. It may be useful when considering interventions to prevent or predict severe scoliosis in young children with CP.

The development of spasticity with age in 4,162 children with cerebral palsy: a register-based prospective cohort study.

Background and purpose - Spasticity is often regarded as a major cause of functional limitation in children with cerebral palsy (CP). We analyzed the spasticity development with age in the gastrosoleus muscle in children with CP. Children and methods - This is a longitudinal cohort study of 4,162 children (57% boys) with CP born in 1990-2015, monitored using standardized follow-up examinations in the Swedish surveillance program for CP. The study is based on 57,953 measurements of spasticity of the gastrosoleus muscle assessed using the Ashworth scale (AS) in participants between 0 and 15 years of age. The spasticity was analyzed in relation to age, sex, and Gross Motor Function Classification System (GMFCS) levels using a linear mixed model. Development of spasticity with age was modeled as a linear spline. Results - The degree of spasticity increased in most children over the first 5 years of life. At 5 years of age, 38% had an AS level of ≥ 2. The spasticity then decreased for 65% of the children during the remaining study period. At 15 years of age only 22% had AS ≥ 2. The level of spasticity and the rate of increase and decrease before and after 5.5 years of age were higher in children at GMFCS IV-V. Interpretation - The degree of spasticity of the gastrosoleus muscle often decreases after 5 years of age, which is important for long-term treatment planning and should be considered in spasticity management.

Demographic and modifiable factors associated with knee contracture in children with cerebral palsy.

AIM: To identify the prevalence of knee contracture and its association with gross motor function, age, sex, spasticity, and muscle length in children with cerebral palsy (CP). METHOD: Cross-sectional data for passive knee extension were analysed in 3 045 children with CP (1 756 males, 1 289 females; mean age 8y 1mo [SD 3.84]). CP was classified using the Gross Motor Function Classification System (GMFCS) levels I (n=1 330), II (n=508), III (n=280), IV (n=449), and V (n=478). Pearson's χ2 test and multiple binary logistic regression were applied to analyse the relationships between knee contracture and GMFCS level, sex, age, spasticity, hamstring length, and gastrocnemius length. RESULTS: Knee contracture greater than or equal to 5 degrees occurred in 685 children (22%). The prevalence of knee contracture was higher in older children and in those with higher GMFCS levels. Odds ratios (ORs) for knee contracture were significantly higher for children at GMFCS level V (OR=13.17), with short hamstring muscles (OR=9.86), and in the oldest age group, 13 years to 15 years (OR=6.80). INTERPRETATION: Knee contracture is associated with higher GMFCS level, older age, and shorter muscle length; spasticity has a small effect. Maintaining muscle length, especially of the hamstrings, is important for reducing the risk of knee contracture. WHAT THIS PAPER ADDS: Knee contracture occurs in children with cerebral palsy at all Gross Motor Function Classification System (GMFCS) levels. Knee contracture in children is associated with short hamstring muscles, higher GMFCS level, and older age. Short hamstring muscles present a greater risk for knee contracture than spasticity.

Pelvic obliquity and measurement of hip displacement in children with cerebral palsy.

Background and purpose - Pelvic obliquity, common in individuals with cerebral palsy (CP), changes the muscle force vector on the hip joint and probably affects the risk of hip dislocation. We evaluated a new method for measurement of hip displacement in CP that takes the pelvic obliquity into account: the pelvic adjusted migration percentage (PAMP). Children and methods - From the Swedish surveillance program for cerebral palsy (CPUP), the first pelvic radiograph of 268 children <18 years in southern Sweden during a 3-year period were evaluated. Pelvic obliquity, PAMP, and the migration percentage (MP) were measured. 50 radiographs were randomly selected for analysis of interrater reliability by three raters using the intraclass correlation coefficient (ICC). The correlations between PAMP/MP and pelvic obliquity were analyzed with Pearson correlation coefficients. Results - The interrater reliability for all 3 measurements was high (ICCs 0.88-0.97). The correlation between the high side of the pelvic obliquity and the difference between right and left hip displacement was higher for PAMP (r = 0.70) than for MP (r = 0.41). Interpretation - The new PAMP measurement showed high interrater reliability and a higher correlation with pelvic obliquity than MP. We suggest the use of PAMP at least in hips with a pelvic obliquity exceeding 5°.

Incidence of scoliosis in cerebral palsy.

Background and purpose - Surveillance of scoliosis in individuals with cerebral palsy (CP) is important for ensuring timely diagnosis and identification of curve progression. We analyzed the incidence of scoliosis in relation to age, sex, and gross motor function in a population-based cohort of individuals with CP. Patients and methods - This was a prospective register study of all 1,025 individuals born 1990-2012 in southern Sweden (1.4 million inhabitants) in the Swedish surveillance program for CP, which included >95% of the total population of people with CP in the area. Annual clinical examinations and radiographic measurement of the Cobb angle of those with a moderate or severe scoliosis were registered. We determined the incidence of scoliosis related to age, sex, and the Gross Motor Function Classification System (GMFCS) level. Results - The inclusion criteria were fulfilled by 962 individuals. The number of people (140/962) with scoliosis increased up to 20-25 years of age. The incidence of scoliosis was related to age and GMFCS level. In individuals at the lowest level of gross motor function (GMFCS V) scoliosis was seen in 10/131 before 5 years of age and at the age of 20 years 75% of these individuals had a Cobb angle ≥40°. No one in the highest level of motor function (GMFCS I) developed a Cobb angle ≥40° Interpretation - Surveillance programs for scoliosis in CP should be based on age and GMFCS level and should be initiated at a young age and continued into adulthood.

Psychometric evaluation of the Posture and Postural Ability Scale for children with cerebral palsy.

OBJECTIVE: To evaluate construct validity, internal consistency and inter-rater reliability of the Posture and Postural Ability Scale for children with cerebral palsy. DESIGN: Evaluation of psychometric properties. SETTING: Five child rehabilitation centres in the south of Sweden, in November 2013 to March 2014. SUBJECTS: A total of 29 children with cerebral palsy (15 boys, 14 girls), 6-16 years old, classified at Gross Motor Function Classification System (GMFCS) levels II (n = 10), III (n = 7), IV (n = 6) and V (n = 6). MAIN MEASURES: Three independent raters (two physiotherapists and one orthopaedic surgeon) assessed posture and postural ability of all children in supine, prone, sitting and standing positions, according to the Posture and Postural Ability Scale. Construct validity was evaluated based on averaged values for the raters relative to known-groups in terms of GMFCS levels. Internal consistency was analysed with Cronbach's alpha and corrected Item-Total correlation. Inter-rater reliability was calculated using weighted kappa scores. RESULTS: The Posture and Postural Ability Scale showed construct validity and median values differed between GMFCS levels (p < 0.01). There was a good internal consistency (alpha = 0.95-0.96; item-total correlation = 0.55-0.91), and an excellent inter-rater reliability (kappa score = 0.77-0.99). CONCLUSION: The Posture and Postural Ability Scale shows high psychometric properties for children with cerebral palsy, as previously seen when evaluated for adults. It enables detection of postural deficits and asymmetries indicating potential need for support and where it needs to be applied.

Physical risk factors influencing wheeled mobility in children with cerebral palsy: a cross-sectional study.

BACKGROUND: There is a lack of understanding of the factors that influence independent mobility and participation in meaningful activities. The purpose of this study was to analyse physical factors influencing independent use of manual and power wheelchairs in a total population of children with cerebral palsy (CP). METHODS: A cross-sectional study based on the most recent examination of all children with CP, born 2002-2013, reported into the Swedish cerebral palsy registry (CPUP), from January 2012 to June 2014. There were 2328 children (58 % boys, 42 % girls), aged 0-11 years, at all levels of gross motor function and hand function. Hazard ratios adjusted for age and sex were used to calculate the risk for not being able to self-propel based on Gross Motor Function Classification System (GMFCS) levels, upper extremity range of motion and hand function including Manual Ability Classification System (MACS), House functional classification system, Thumb-in-palm deformity, Zancolli (spasticity of wrist/finger flexors) and bimanual ability. RESULTS: In total 858 children used wheelchairs outdoors (692 manual, 20 power, 146 both). Only 10 % of the 838 children self-propelled manual wheelchairs, while 90 % were pushed. In contrast 75 % of the 166 children who used power mobility outdoors were independent. Poor hand function was the greatest risk factor for being unable to self-propel a manual wheelchair, while classification as GMFCS V or MACS IV-V were the greatest risk factors for not being able to use a power wheelchair independently. CONCLUSIONS: The majority of children with CP, aged 0-11 years did not self-propel manual wheelchairs regardless of age, gross motor function, range of motion or manual abilities. Power mobility should be considered at earlier ages to promote independent mobility for all children with CP who require a wheelchair especially outdoors.

Psychometric evaluation of spinal assessment methods to screen for scoliosis in children and adolescents with cerebral palsy.

BACKGROUND: In cerebral palsy (CP) there is an increased risk of scoliosis. It is important to identify a progressive scoliosis early-on because the results of surgery depend on the magnitude of the curve. The Swedish follow-up program for cerebral palsy (CPUP) includes clinical examinations of the spine. The reliability and validity of the assessment method have not been studied. In this study we evaluate the interrater reliability of the clinical spinal examination used in CPUP and scoliometer measurement in children with CP and we evaluate their validity compared to radiographic examination. METHODS: Twenty-eight children (6-16 years) with CP in Gross Motor Function Classification System levels II-V were included. Clinical spinal examinations and scoliometer measurements in sitting position were performed by three independent examiners. The results were compared to the Cobb angle as determined by radiographic measurement. Interrater reliability was calculated using weighted kappa. Concurrent validity was analyzed using the Cobb angle as gold standard. Sensitivity, specificity, area under receiver operating characteristic curves (AUC) and likelihood ratios (LR) were calculated. Cut-off values for scoliosis were set to ≥ 20° Cobb angle and ≥ 7° scoliometer angle. RESULTS: There was an excellent interrater reliability for both clinical examination (weighted kappa = 0.96) and scoliometer measurement (weighted kappa = 0.86). The clinical examination showed a sensitivity of 75 % (95 % CI: 19.4-99.4 %), specificity of 95.8 % (95 % CI: 78.9-99.9 %) and an AUC of 0.85 (95 % CI: 0.61-1.00). The positive LR was 18 and the negative LR was 0.3. The scoliometer measurement showed a sensitivity of 50 % (95 % CI: 6.8-93.2 %), specificity of 91.7 % (95 % CI: 73.0-99.0 %) and AUC of 0.71 (95 % CI: 0.42-0.99). The positive LR was 6 and the negative LR was 0.5. CONCLUSION: The psychometric evaluation of the clinical examination showed an excellent interrater reliability and a high concurrent validity compared to the Cobb angle. The findings should be interpreted cautiously until research with larger samples may further quantify the psychometric properties. Clinical spinal examinations seem appropriate as a screening tool to identify scoliosis in children with CP.

Interrater reliability and construct validity of the Posture and Postural Ability Scale in adults with cerebral palsy in supine, prone, sitting and standing positions.

OBJECTIVE: To evaluate reliability, internal consistency and construct validity of the Posture and Postural Ability Scale for adults with cerebral palsy. DESIGN: Psychometric evaluation of a clinical assessment tool. SETTING: Rehabilitation centres in Sweden and Iceland. SUBJECTS: Thirty adults with cerebral palsy aged 19-22 years, six people at each level I-V of the Gross Motor Function Classification System. MAIN MEASURES: The Posture and Postural Ability Scale contains a 7-point ordinal scale for postural ability in supine, prone, sitting and standing, and items for assessment of posture. Posture and postural ability was rated from photos and videos by three independent assessors. Interrater reliability was calculated using weighted kappa. Internal consistency was analysed with Cronbach's alpha if item deleted and corrected item-total correlation. Construct validity was evaluated based on known groups, using Jonckheere Terpstra for averaged values of the three raters relative to the Gross Motor Function Classification System. RESULTS: There was an excellent interrater reliability (kappa = 0.85-0.99) and a high internal consistency (alpha = 0.96-0.97, item-total correlation = 0.60-0.91). Median values differed (P < 0.02) between known groups represented by the levels of gross motor function, showing construct validity for all items. CONCLUSION: The Posture and Postural Ability Scale showed an excellent interrater reliability for experienced raters, a high internal consistency and construct validity. It can detect postural asymmetries in adults with cerebral palsy at all levels of gross motor function.