Assessment using the GMFM scale of children with Cerebral Palsy PDF

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Assessment using the GMFM scale of children with Cerebral Palsy....

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Assessment using the GMFM scale of children with Cerebral Palsy

To start this work first, we introduce the essentials of cerebral palsy; and secondly, we refer to the measurement instruments used in the evaluation of people with this disease. I.- CEREBRAL PARALYSIS (CP) DEFINITION Cerebral palsy (CP) is the most common cause of motor disability in children and will persist into adulthood1. In the 1950s Tardieu defined CP as those people suffering from anatomically stable brain lesions without genetic abnormalities; these injuries manifest as a motor deficiency predominant or even exclusive2. According to the WHO, CP is any restriction or absence, due to a deficiency, of the ability to perform an activity in the manner or within the range that is considered normal for a human being. Another definition is that established by the United Cerebral Palsy which names it as a group of chronic ailments that affect body movement and muscle coordination and that is caused by injuries in one or more specific areas of the brain, which generally occur during the fetal development, before, during or immediately after birth, or in the childhood years3. It is defined as a “movement and posture disorder due to an immature brain defect or injury” (Bax 1964) 4.

ALTERATIONS Disorder of normal motor development. The deficit in the maturation of the CNS will cause a modification or delay in motor evolution during childhood, due to the impairment in the performance and control of musculoskeletal movements as well as stability, postural control and coordination. Therefore, it is necessary in cerebral palsy patients during the first years of life, to take into account the alteration in motor development that they present. We can observe the main motor items achieved during infancy in the first 6 years of life in children5-6 in Annex I. People affected by CP may present other alterations such as intellectual disability, epileptic seizures, vision disorders and ocular motility, hearing, sensory, trophic disorders, skeletal deformities, language disorders, learning and perception difficulties 7.

ETIOLOGY

The cause of brain injury in this pathology is not always known. The possible causes that cause its appearance can be prenatal, perinatal or postnatal. Prematurity, genetic failure, chromosomal diseases, embryopathies (rubella, AIDS, etc.), maternal factors (advanced age, frequent abortions, etc.), physical agents

(radiation) and chemical agents (alcohol) stand out essentially in prenatal causes. Perinatal causes include fetal distress during prolonged labor, brain trauma, intracranial hemorrhage, and perinatal anoxia. And finally, in postnatal causes, it is important to mention meningitis and encephalitis, infectious diseases, trauma, dehydration, postnatal anoxia and bilirubin encephalopathy8.

TYPES OF CEREBRAL PARALYSIS In addition to the etiology and motor development of the child, it is important to know the different types of cerebral palsy, which we classify according to three factors: postural tone, type of alteration of reciprocal innervation, and distribution of the disease. To better understand the classification of children with CP we will define some important terms.

According to the distribution of the disease

Quadriplegia is defined as a compromise of the whole body, with the upper part being more involved, or at least equally involved as the lower part. The distribution is asymmetric. Due to increased upper-body engagement, head control is poor, as is eye coordination. They present difficulties in feeding, language and the articulation of the word. Diplegia is the involvement of the whole body but the lower half is more affected than the upper half. Control of the head, arms, and hands is generally little affected, and the spoken word may be normal. Hemiplegia is one-sided compromise. Cases of pure paraplegia (involvement of the lower limbs) and monoplegia are extremely rare in cerebral palsy4. According to the alteration of tone, balance and coordination Spastic Due to a lesion of the cerebral cortex, being the largest group affecting 75% of patients6. He has permanent hypertonia even at rest. The child is fixed in typical patterns due to the degree of co-contraction especially in the proximal joints. It can be spastic quadriplegia, spastic diplegia, and spastic hemiplegia.

Ataxic Pure ataxia is very rare and is initially confused awkwardly. The initial hypotonia is modified, later developing4 ataxia, dysmetria, incoordination from one year of age. Three subcategories are distinguished: ataxic diplegia, simple ataxia, and the disequilibrium syndrome. It often appears in combination with spasticity and athetosis8. Athetosic. They present an unstable and fluctuating type of postural tone4. Lesions affect the basal ganglia8. They lack sustained postural tone, proximal co-contraction, and stability due to impaired reciprocal innervation. The movements are jerky, uncontrolled and of extreme ranges, with poor control of the middle ranges4, in addition they present archaic reflexes8 producing contortion movements9. The following subtypes are distinguished: choreoathetosic form (chorea, athetosis, tremor), dystonic form and mixed form associated with spasticity. Hypotonic and mixed CP. Hypotonic CP is rare. It is characterized by muscular hypotonia with osteotendinous hyperreflexia, which persists beyond 2-3 years and is not due to neuromuscular pathology. Mixed CP is relatively frequent8, being a lesion of more than one part of the brain 9. Associations of ataxia and dystonia or dystonia with spasticity are the most common forms8. Depending on muscle tone, we found another classification distinguishing hypotonic CP (decreased muscle tone) or hypertonic (increased muscle tone) 9.

According the gravity

And the last classification that we will show is based on the severity, distinguishing light CP, where the affected person is not limited in ordinary activities, although he presents some physical alteration. Moderately severe CP, where the individual has difficulties in performing daily activities and needs means of assistance or support. And severe CP, where the subject is affected by a great limitation in daily activities7.

INCIDENCE Once the pathology is known, we must emphasize that it is the most frequent cause of motor disability in pediatrics, as we have mentioned previously1. According to the National Statistical Institute, currently (April 2013) the incidence in both sexes is 0.08%, with 82.2 people affected per 1000 inhabitants. The affected boys are 42.6 per thousand inhabitants and the affected girls are 39.6 per thousand inhabitants.

II. EVALUATION IN CEREBRAL PARALYSIS Taking into account its incidence and the severity of the disease, the need arises to evaluate the gross motor changes that children experience over time. The Bayley scales of child development, in any of its editions, have been widely used for discriminatory purposes in monitoring programs for children with neurological risk; But for the evaluation of changes in the evolution of children with CP, only 2 instruments out of 17 found in the literature in a review by Ketelaar et al., met the criteria of reliability and validity. These are the Gross Motor Function Measurement and the Pediatric Disability Assessment Inventory (PEDI), which serves as a complement to the previous one when evaluating functional behavior in children with disabilities. The recently developed Bimanual Motor Function Scale and Manual Ability Classification System can be of great help in assessing motor function of the upper extremities10. We can find the use of other scales as the Peabody Development Motor Scale (PDMS) 11, Pediatric Motor Activity Log, Pediatric Functional Independence Measure12, Test of Infant Motor Perfomance (TIMP) 13-14, the Alberta Infant Motor Scale (AIMS) 14 common. , the General Movements Assessment13, Timed up & Go (TUG) 15 and the WeeFIM16, a new version of the Functional Independente Measure (FIM) scale At the international level, the GMFCS17 classification system has been evidenced, which classifies into 5 levels of affectation from least to greatest severity with regard to general mobility. Also, the Gross Motor Function Measure (GMFM) is the first motor function assessment measure designed to quantify changes in gross motor skills in children with CP. Measurement is widely used internationally and is now the standard for interventions

clinics in PC14. The use of this scale has been verified by means of a bibliographic search in the databases PubMed, PEDro, COCHRANE and MEDLINE using the keywords: “cerebral palsy”, “GMFM”, “cerebral palsy”; so that, on the one hand, we obtain the necessary information to be able to explain the purpose and operation of the GMFM scale and, on the other, the classification of users, according to their motor dysfunctions in the Gross Motor Function Classification System (GMFCS) scale. Therefore, this scale can be used as a motor evaluation measure and / or as a classification scale of the level of impairment. Likewise, we can find it in an isolated way or in combination with other scales, at an international level, in the following articles “Evaluation of Gross Motor Function in children with Cerebral Palsy in the CIREN Psychomotor Evaluation Laboratory. Preliminary Report. ”18,“ GMFM in infancy: age-specific limitations and adaptations ”19,“ Backward walking treadmill therapy can improve walking ability in children with spastic cerebral palsy: a pilot study ”20,“ Cerebral Palsy ”21, in the revision “Gross Motor Function Classification System: impact and utility” 22, “The relationship between spasticity in young children (18 months of age) with cerebral palsy and their gross motor function development” 23,

of Preschool Children's Participation in children with cerebral palsy ”16,“ GMFM e sua aplicação na avaliação motora de crianças com paralisia cerebral ”34. Various studies have been carried out with it, such as "Efficacy of GMFM 66 for the assessment of children with CP" 17, "Comparative study of the handling of the assessment scales of the psychomotor development of the child, used by physiotherapists of the Lisbon region and Vale do Tejo (Portugal) and Extremadura physiotherapists ”35 and“ Version of the Gross Motor Function Measure (GMFM): initial phase of its cross-cultural adaptation ”36. As we can see, the evaluation using this scale is scientifically evidenced, both internationally and nationally; either in isolation, in combination, to classify the level of affection or to check the gross motor skills performed by the users at a time and in their evolution. GMFM-GMFCS SCALE The GMFM scale is a clinical measure designed to assess changes in gross motor function in children with cerebral palsy. There are two versions, the original GMFM-88 with 88 items and the more recent GMFM-66 with 66 items. This scale has been designed and validated for children with cerebral palsy, but there is also evidence that the GMFM-88 version is valid for use with children with Down syndrome. The original validation includes a sample of children whose age is between 5 months and 16 years. The GMFCS for CP is based on movement that is voluntarily initiated, with an emphasis on sitting, transfers, and mobility. The primary criterion in defining five levels in this classification system has been that the differences between levels should be significant in everyday life. The differences are based on functional limitations, the need to use manual assistive devices for mobility or wheelchairs and, to a lesser extent, on the quality of movement36. The descriptive concepts used to designate the level of affectation with the GMFCS scale in the cases used in this work (4-6 years) is the following:

In level I the user sits and gets up from the chair without the need to support their hands, stands up from the floor or from the chair without the need for support, walks indoors and outdoors and climbs stairs and starts running and skip.

In level II the user sits in the chair with their hands free to manipulate objects, stands up from the floor or from the chair but often requires a stable surface to support or support themselves with their arms, walks indoors or outdoors on short distances and regular surfaces without the need for mobility aid and climbs stairs holding onto the handrail but is unable to run or jump. In level III the user sits in a normal chair but may need pelvic or trunk support to maximize manual function, sits and stands up leaning on a stable surface to support or propels himself with the hands, walks with a support device manual aid to mobility on smooth surfaces, climbing stairs with the help of another person, dependents to move outside the home or on uneven terrain. In level IV the user can sit in chairs but they need trunk supports to maximize manipulation, to sit or stand up they need help from the adult or a stable surface to propel themselves or support themselves with the arms, exceptionally they walk small sections with a walker and supervision The worst adults have difficulties turning and maintaining balance on uneven terrain, for community displacement they must be transported, autonomy of movement is only possible with self-propelled chairs. At level V physical deficiencies restrict voluntary control of movement and the ability to hold the head and trunk against the force of gravity, all areas of motor function are limited. Functional limitations in sitting and standing cannot be fully compensated by the use of assistive technology, they do not have independent movement possibilities and must be transported, and some may have some autonomy using a self-propelled chair equipped with extensive adaptations37.

OBJECTIVES The main objective of this work is to use the GMFM scale in the gross motor evaluation of children with CP and the sub-objective is to classify, according to the motor characteristics of each child, their level of impairment according to the GMFCS classification system.

METHODOLOGY To show the use of the GMFM scale, we performed the GMFM-88 test on three children diagnosed with different subtypes of CP, which are: spastic tetraplegia, spastic diplegia and spastic hemiplegia with ages between 4 - 6 years.

I. SUBJECTS SELECTION The three subjects evaluated in this work have a medical diagnosis of cerebral palsy and an age between 4-6 years. Two of the children have been selected by a physiotherapist from the Children's Physiotherapy Service of the Torrecárdenas Hospital; and the third by the CERNEP physiotherapist (Center for Neuropsychological Evaluation and Rehabilitation) Subject 1 is 35 weeks premature, being 4 years old during the scale. In addition, the diagnosis established by the doctor is cerebral palsy, hypertonic tetraplegia with a left predominance. Subject 2 is a large preterm being 6 years old during the evaluation. The medical diagnosis describes his pathology as cerebral palsy, spastic diplegia. Subject 3 is a head injury (TBI) suffered two years ago, the child is 5 years old when evaluated with the scale. His medical diagnosis is TBI, right hemiplegia.

EVALUATION Subject 1 is evaluated taking advantage of the treatment session, with the mother as a witness and with her physiotherapist. Subject 2 was evaluated with a recording of the child by his physiotherapist, who also participated in the evaluation. The recording required the written informed consent of the parents. Subject 3 was explored in his Physiotherapy center. The evaluation was carried out during a treatment session with the collaboration of your physiotherapist.

II. THE GMFM- GMFCS SCALE To correctly use this scale, it is necessary to know the rules of use. Mainly the child must be with the minimum possible clothes and without shoes, the items are made in the established order, 3 attempts can be made and the best of these three will be scored, direct facilitation is not allowed and for the first time you must pass the test without an orthosis as in the cases used in this work where the evaluation is carried out without an orthosis. Before examining children, examiners should be familiar with the scoring guidelines. The duration of the scan can last between 45-60 minutes. The material needed to perform the examination is a stopwatch, a large and small chair, colored tape, a 60 cm diameter ring, toys, a large table and / or bench, a ball, a bar or a cane, and a ladder with a handrail. The scoring system is from 0 to 3 points for each item, understanding as 0 the non-initiation of the movement, as 1 that initiates the movement but performs less than 10% of it, as 2 that partially performs the movement between 10 and 100 %, as 3 that completely performs the movement and as NT if the movement cannot be tested. The GMFM consists of 5 assessment dimensions where we distinguish the different skills that children perform, according to normal motor development, taking into account the positions of initiation of movement. These dimensions are: decubitus and rolling, sitting, quadruped and kneeling, standing and walking, running, jumping. It is possible to display the scale in ANNEX II. To obtain the final score, the results of each section must be added, obtaining the percentage of the 5 dimensions, once the percentages are obtained, the final calculation is achieved by adding these percentages and dividing them by 5 since they are 5 sections of the scale13 . For a better understanding, we will perform an example result below: DECUBITES AND TURNS---------------Punctuation: 30/51  58.8% SEATING-------------------------------------Punctuation: 24/57  40% QUADRUPEDIA AND KNEES -------- Score: 15/42  35.7% STANDING----------------------------------Punctuation:

10/39



25.6% WALK, RUN, JUMP------------------------Punctuation: 7/72  9.7% TOTAL SCORE: 58.8 + 40 + 35.7 + 25.6 + 9.7 = 169.8 / 5 = 33.96% When we use the GMFM scale, after evaluating and obtaining the score of each user, we continue with the classification of the level of impairment, for this we will explain below what the GMFCS classification consists of.

The objective of this scale is to determine the level that best represents the capabilities and limitations of the user based on global motor functions. It is an objective scale so it is important to classify the performance they perform at the time of the assessment and not judgments or forecasts of improvement. We will then assess the differences between the levels to help determine the level that approximates the user's actual motor situation. As motor function varies depending on the age of the users, this GMFCS scale offers different descriptions for each age group. In addition, the corrected age must be taken into account in premature children under 2 years of age. It is worth highlighting the differences between the levels to avoid confusion when classifying users, these differences can be found in Annex III. Once the differences between the two levels are known, we will avoid possible mistakes during the classification of the levels of each user. The qualifying items of each level depend on the age group of each user as we have mentioned before. In Table 1, we expose the characteristics of each age for a correct classification, having greater importance for this work, the age group between 4-6 years since the subjects have an age comprised or close to this range37.

0-2 YEARS LEVEL I

2-4 YEARS

4-6 YEARS

6-12 YEARS

12-18 YEARS

Come on. Go up and

Come on. Up and down

go down ramps and

ramps

Makes

Makes

transitions

transitions ay

I know sit Y Raise

to Y

since

without need

scalars

Y unused scalars

sitting

of to support

without use

railing. Runs

railing.

or

Run or jump

speed,

but speed,

...