Development of a Clinical Framework for the Assessment of Dyskinesia and Function in the Upper Limb in Children with Cerebral Palsy.

OBJECTIVE: Dyskinesia in cerebral palsy (CP) is a complex movement disorder that can significantly impact upper limb function. Despite a range of available tools, there is no consensus on best practice assessment of upper limb function in children with CP and dyskinesia. This study aimed to develop a clinical framework for the assessment of the impact of dyskinesia on upper limb function in children with CP. DESIGN: Modified Delphi study using expert consensus. METHODS: An expert panel of six highly experienced Australian therapists ranked assessment tools sourced from existing evidence-based literature using a five-point Likert scale. Tools rated as important for use "most" or "all" of the time, by 80% of respondents were accepted into the framework following two survey rounds and a third stage discussion. RESULTS: Of 21 tools, 12 were included in the framework under five categories: (i) screening for dyskinesia; (ii) measuring the severity of dyskinesia; (iii) Classifying upper limb functional ability; (iv) measuring upper limb functional ability; and (v) measuring upper limb movement. CONCLUSIONS: The framework for assessing the impact of dyskinesia on upper limb function in CP aims to guide clinicians to improve assessment consistency and facilitate individualized goal-directed management. Further studies with a larger number of expert clinicians and researchers will further strengthen the utility of the framework.

'Low-normal' motor skills in infants at high risk for poor developmental outcomes: A prevalence and prognostic study.

AIM: To investigate the prevalence and prognostic value of 'low-normal' motor skills in infants at high-risk for poor developmental outcomes. METHOD: Infants born extremely low-birthweight and extremely preterm discharged from neonatal intensive care between 2015 and 2018 completed the Alberta Infant Motor Scale (AIMS), Neuro-Sensory Motor Developmental Assessment (NSMDA) at corrected age 4, 8, and 12 months, and Griffiths Mental Development Scale at corrected age 12 months. RESULTS: Participating infants (n = 191) with a mean gestational age (95% confidence interval [CI]) of 26.80 weeks (26.60, 27.1) and mean birthweight (95% CI) of 869 grams (843, 895) included 45 (23.80%) infants small for gestational age. AIMS rated 50.32%, 35.37%, and 14.86% of infants within the 'low-normal' motor skills range (1-2 SD below the mean for age) at 4, 8, and 12 months respectively. Of the infants within the AIMS 'low-normal' skills range, 55.70%, 88.46%, and 59.10% were classified as having impairment by NSMDA at 4, 8, and 12 months respectively. Griffiths assessment at 12 months identified only 7.33% of infants with 'low-normal' skills and 3.33% with motor disability. Minimal motor impairment rating on the NSMDA at 4 or 8 months significantly predicted general development at 12 months. INTERPRETATION: High-risk infants with 'low-normal' motor skills may warrant referral to early intervention as associated impairment represents increased risk for poorer general development outcomes. WHAT THIS PAPER ADDS: High prevalence of 'low-normal' motor skill exists in high-risk infants. Clinical motor assessment validly identifies infants with motor impairment. Minimal motor impairment in high-risk infants is prognostic of general development. High-risk infants with 'low-normal' motor skills may warrant early intervention. Griffiths Scales of Child Development, Third Edition assessment at 12-months age may under-identify motor difficulties.

Are behaviour problems in extremely low-birthweight children related to their motor ability?

AIM: To investigate whether behaviour problems are independently related to mild motor impairment in 11-13-year-old children born preterm with extremely low birthweight (ELBW). METHODS: The cross-sectional study included 48 (27 males) non-disabled, otherwise healthy ELBW children (<1000 g) and 55 (28 males) term-born peers. Parents reported behaviour using the Child Behaviour Checklist (CBCL). Children completed the Movement Assessment Battery for Children (Movement ABC). RESULTS: Extremely low birthweight children had poorer behaviour scores (CBCL Total Problem T score: mean difference = 5.89, 95% confidence interval = 10.29, 1.49, p = 0.009) and Movement ABC Total Motor Impairment Scores (ELBW group median = 17.5, IQR = 12.3; term-born group median = 7.5, IQR = 9, p < 0.01) than term-born peers. Behaviour was related to motor score (regression coefficient 2.16; 95% confidence interval 0.34, 3.97, p = 0.02) independent of gender, socio-economic factors or birthweight. Motor score had the strongest association with attention (ρ = 0.51; p < 0.01) and social behaviours (ρ = 0.50; p < 0.01). CONCLUSION: Behaviour problems of otherwise healthy 11- to 13-year-old ELBW children are not related to prematurity independent of their motor difficulties. Supporting improved motor competence in ELBW preteen children may support improved behaviour, particularly attention and social behaviours.

Fitness limitations in non-disabled extremely low birthweight adolescents.

AIM: This study aims to compare non-disabled otherwise healthy extremely low birthweight (ELBW) (<1000 g) children and term-born peers in an investigation of relationship between cardiorespiratory endurance and parent report of competence. METHODS: Forty-eight of 105 eligible ELBW 11- to 13-year-old children (27 male) and 55 term-born school peers (28 male) completed a 20-m shuttle run, anthropometric measures, respiratory function tests and the Motor Assessment Battery for Children. Parents completed the Child Behavior Checklist (CBCL). RESULTS: The ELBW group had poorer cardiorespiratory endurance (P = 0.002), growth (P = 0.002), respiratory function (P = 0.003) and motor ability (P < 0.001) than term-born peers. Parents reported the ELBW children to be less competent than term-born peers: CBCL total T score mean difference -9, 95% confidence interval -14, -5 (P < 0.001). Cardiorespiratory endurance predicted competence (regression coefficient 0.865; 95% confidence interval 0.352, 1.378; P = 0.001) independent of prematurity, growth, respiratory function, motor score, gender and socio-economic status. Cardiorespiratory endurance had association with social competence for all participating children, but was related to CBCL Activities Competence only for the ELBW children who were the significantly less fit group. CONCLUSIONS: The poor cardiorespiratory endurance prevalent in non-disabled otherwise healthy ELBW children is associated with general competence independent of prematurity and of the impact of other mild physical deficits, gender or socio-economic status. The relationship demonstrated between cardiorespiratory endurance and competence to engage in general activities of daily living, seen only in the less fit ELBW children, identifies the fitness levels in non-disabled ELBW children as a barrier to participation.

Perinatal events and motor performance of children born with ELBW and nondisabled.

PURPOSE: To explore the relationship between perinatal variables and motor performance in children who were born with extremely low birth weight (ELBW) and were nondisabled at 1 and 4 years. METHODS: Children without neurological or cognitive impairment (n = 48) born weighing less than 1000 g between 1992 and 1994 were assessed at 1 and 4 years corrected age using the Neurosensory Motor Developmental Assessment (NSMDA). Scores were used to categorize motor performance as normal or abnormal. RESULTS: Chronic lung disease (CLD) of prematurity, necrotizing enterocolitis (NEC), and patent ductus arteriosus were associated with NSMDA category at 1 year. Chronic lung disease, male gender, and NEC were associated with NSMDA category at 4 years. Multiple regression analyses revealed that CLD and NEC were independently associated with abnormal motor outcomes at 1 year. CONCLUSIONS: Early assessment and motor therapy is recommended for infants with CLD, because of its effect on motor performance in this otherwise healthy group of children born with ELBW.

Perinatal factors in non-disabled ELBW school children and later performance.

AIM: To determine the association between perinatal events and subsequent motor performance, cardiorespiratory endurance and respiratory function in non-disabled extremely low birthweight (ELBW) school children at 12 years of age. METHODS: Forty-eight ELBW infants were included in this study. The Movement Assessment Battery for Children (MABC), VO(2) max score as a measure of cardiorespiratory endurance and respiratory function testing were performed and perinatal variables were extracted from the children's hospital files. Children with MABC score ≤ 15th centile were described as having suspect motor performance. Children were classified as being unfit with a VO(2) max > 1 standard deviation below the mean according to gender and age. Perinatal risk factors were explored as risk factors for motor outcome, cardiorespiratory endurance and respiratory function. RESULTS: MABC category was significantly related with gender (P = 0.005) and chronic neonatal lung disease (P = 0.013). Multiple regression analysis showed motor outcome at 12 years to be independently related to male gender (P = 0.03) and chronic neonatal lung disease (P = 0.045). Sixty-five percent of all the children were identified as unfit. Chronic neonatal lung disease was significantly related to cardiorespiratory endurance (P = 0.03) and predicted VO(2) max at 12 years (P = 0.05). No perinatal factors were significantly related to respiratory function variables. CONCLUSION: Male gender and chronic neonatal lung disease were associated with later motor outcome of ELBW school children. It is suggested that objective and consistent follow-up from childhood through preadolescence are important to address motor and fitness issues especially for male children born with ELBW.

The long-term predictive validity of early motor development in "apparently normal" ELBW survivors.

BACKGROUND: Within the able majority of ELBW survivors, there is a lack of identified predictors of which children will require extra support despite having escaped significant disability. AIMS: Investigate the predictive validity of early motor scores, compared to that of perinatal descriptors or early growth, on long-term motor impairment in non-disabled ELBW (<1000g) children. STUDY DESIGN: Prospective longitudinal study. OUTCOME MEASURES: 48 non-disabled ELBW children (27 male) completed the Neurosensory Motor Developmental Assessment (NSMDA) at 8 months, 2 years and 4 years post term and The Motor Assessment Battery for Children (MABC) at 11-13 years of age. Other possible predictors of long-term outcomes (gestational age, birthweight, multiple birth, head circumference measures and gender) were retrieved from the records. RESULTS: Early motor assessment (NSMDA score) independently predicted the MABC total score at 11-13 years of age with a positive predictive value of 87% by 4 years post term. There was increased risk of long-term motor impairment associated with male gender but the degree of prematurity, multiple birth status or early growth measures did not predict motor outcome. Postural control and sensory motor scores at 4 years post term, rather than neurological score, were associated with long-term motor outcomes for the ELBW children at 11-13 years of age. CONCLUSIONS: Early motor scores are valid markers of long-term motor outcomes for "apparently normal" ELBW children. Early postural competence and sensory motor function are discriminating in regards to long-term motor function in neurologically normal ELBW children.

Motor coordination difficulties and physical fitness of extremely-low-birthweight children.

Motor coordination difficulties and poor fitness exist in the extremely low birthweight (ELBW) population. This study investigated the relative impact of motor coordination on the fitness of ELBW children aged 11 to 13 years. One hundred and nine children were recruited to the study: 54 ELBW participants (mean age at assessment 12y 6mo; 31 male, 23 female; mean birthweight 769g, SD 148g; mean gestational age 26.6 weeks, SD 2.1 weeks) and 55 comparison children (mean age at assessment 12y 5mo; 28 males, 27 females; at least 37 weeks' gestation). All children completed the Movement Assessment Battery for Children (MABC), functional tests of postural stability and strength, growth measures, and tests of respiratory function. Maximal oxygen uptake (VO(2)max) was calculated from a 20m shuttle run test as a measure of fitness. The ELBW group had greater problems with postural stability (p=0.001) and motor coordination (p=0.001), with 70% rated as having a definite motor problem on the MABC brackets (those who scored less than the 5(th) centile on the MABC). The ELBW was also less fit than the comparison group (p=0.001), with 45% below the 10th centile for VO(2)max. There were differences between the groups for growth, strength, and particularly respiratory function. However, respiratory function did not significantly correlate with VO(2)max in the ELBW group. Motor coordination was the most powerful predictor of VO(2)max in both the ELBW (p=0.001) and the comparison groups (p=0.001).