Relationships among functional outcome measures used for assessing children with ambulatory CP.

In ambulatory children with cerebral palsy (CP), practitioners often examine outcomes using measures related to functions necessary for daily life. The Gross Motor Function Measure (GMFM) Dimensions D and E, Pediatric Outcomes Data Collection Instrument (PODCI) Parent and Child versions, Gillette Functional Assessment Questionnaire (FAQ) Walking subscale, Functional Independence Measure for Children (WeeFIM), Pediatric Quality of Life Inventory (PedsQL), temporal-spatial gait parameters, and O(2) cost during ambulation were selected for study. Cross-sectional data were collected in a prospective multicenter study of 562 participants with CP (339 males, 223 females), between 4 and 18 years of age (mean age 11y 1mo). There were 240 classified as Gross Motor Function Classification System Level I, 196 as Level II, and 126 as Level III. The tools that had the best interrelationships and underlying constructs predominately measured changes in physical function. These included portions of the FAQ, Parent PODCI, WeeFIM, and GMFM. GMFM Dimensions D and E exhibited a very strong relationship. Temporal-spatial gait parameters and O2 cost measures represented a different construct of physical function. The Child PODCI reports and both the Parent and Child PedsQL reports did not relate well to other measures, suggesting a pattern of answers not related to question content. The Parent PODCI, the FAQ Walking subscale, and GMFM Dimension E were found to be an appropriate minimum set of instruments for assessment of functional outcomes in patients with ambulatory CP.

Outcome assessments in children with cerebral palsy, part I: descriptive characteristics of GMFCS Levels I to III.

This prospective cross-sectional multicenter study assessed the relationships between Gross Motor Function Classification System (GMFCS) level and scores on outcome tools used in pediatric orthopedics. Five hundred and sixty-two participants with cerebral palsy (CP; 339 males, 223 females; age range 4-18y, mean age 11y 1mo [SD 3y 7mo]; 400 with diplegia, 162 with hemiplegia; GMFCS Levels I-III;) completed the study. The Functional Assessment Questionnaire (FAQ), Gross Motor Function Measure (GMFM) Dimensions D and E, Pediatric Quality of Life Inventory (PedsQL), the Pediatric Outcomes Data Collection Instrument (PODCI), Pediatric Functional Independence Measure (WeeFIM), temporal-spatial gait parameters, and O(2) cost were collected during one session. Descriptive characteristics are reported by GMFCS level clinicians can use for comparison with individual children. Tools with a direct relationship between outcome scores and GMFCS levels were the PODCI Parent and Child Global Function, Transfers & Basic Mobility, and Sports and Physical Function; PODCI Parent Upper Extremity Function; WeeFIM Self-care and Mobility; FAQ Question 1; GMFM Dimensions D and E; GMFM-66; O(2) cost; and temporal-spatial gait parameters. Child report scores differed significantly higher than Parent scores for six of eight PODCI subscales and three of four PedsQL dimensions. Children classified into different GMFCS levels function differently.

Outcome assessments in children with cerebral palsy, part II: discriminatory ability of outcome tools.

Discriminatory ability of several pediatric outcome tools was assessed relative to Gross Motor Function Classification System (GMFCS) level in patients with cerebral palsy. Five hundred and sixty-two patients (400 with diplegia, 162 with hemiplegia; 339 males, 223 females; age range 4-18y, mean 11y 1mo [SD 3y 7mo]), classified as GMFCS Levels I to III, participated in this prospective multicenter, cross-sectional study. All tools were completed by parents and participants when appropriate. Effect size indices (ESIs) for parametric variables and odds ratios for non-parametric data quantified the magnitude of differences across GMFCS levels. Binary logistic regression models determined discrimination, and receiver operating characteristic curves addressed sensitivity and specificity. Between Levels I and II, the most discriminatory tools were Gross Motor Function Measure (GMFM-66), velocity, and WeeFIM Mobility. Between Levels II and III, the most discriminatory tools were GMFM Dimension E, Pediatric Functional Independence Measure (WeeFIM) Self-Care and Mobility, cadence, and Gillette Functional Assessment Questionnaire Question 1. Large ESIs were noted for Parent and Child reports of Pediatric Outcomes Data Collection Instrument (PODCI) Sports & Physical Function, Parent report of PODCI Global Function, GMFM Dimension E, and GMFM-66 across all GMFCS level comparisons. The least discriminatory tools were the Quality of Life and cognition measures; however, these are important in comprehensive assessments of treatment effects.

Comparing functional profiles of children with hemiplegic and diplegic cerebral palsy in GMFCS Levels I and II: Are separate classifications needed?

The goal was to compare children with hemiplegia with those with diplegia within Gross Motor Functional Classification System (GMFCS) levels using multiple validated outcome tools. Specifically, we proposed that children with hemiplegia would have better gait and gross motor function within levels while upper extremity function would be poorer. Data were collected on 422 ambulatory children with cerebral palsy: 261 with diplegia and 161 with hemiplegia, across seven centers. Those with hemiplegia in each level performed significantly and consistently better on gait or lower extremity function and poorer on upper extremity and school function than those with diplegia. In GMFCS Level II, the group with hemiplegia walked faster (p = 0.017), scored 6.6 points higher on Dimension E of the Gross Motor Function Measure (p = 0.017), 6.7 points lower on Upper Extremity subscale of the Pediatric Outcomes Data Collection Instrument, and 9.1 points lower on WeeFIM self-care (p = 0.002). Basing motor prognosis on GMFCS level alone may underestimate lower extremity skills of children with hemiplegia, and overestimate those of children with diplegia.