ICF in studies of children with cerebral palsy CP

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ICF in studies of children with cerebral palsy
(CP)

• 4th Nordic-Baltic ICF conference
• Tallin 19-20 May 2005
• Sigrid Østensjø
• Oslo University College
• Norway

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Use of the ICF

• to assess measurement constructs and content of
  assessments used in the clinical studies
• to describe functioning and disability from a
  multidimensional perspective
• to examine associations between functions within
  and between the components
• to investigate the influence of the environment
  and the contribution of personal factors on
  everyday functioning

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Design

• Analyses of measures
• Documents
• Conceptual and content analyses
• Clinical studies
• Cross-sectional design
• 95 children with CP (age 2-7.5 years) and their
  parents

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CLINICAL STUDIES Health condition

• Cerebral palsy
• a group of non progressive, but
• often changing, motor impairment
• syndromes secondary to lesions
• or anomalies of the brain arising
• in the early stages of its
• development
• (Mutch et al.1992)

Health condition
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CLINICAL STUDIESClassification of CP
Activities
Body Functions

• Type of motor
• impairment
• spastic
• dyskinetic
• Topographical
• distribution
• hemiplegia
• diplegia
• quadriplegia

• Severity of gross motor
• limitations (GMFCS)
• level I (least limitations)
• to
• level V (most limitations)

(GMFCS Gross Motor Function Classification
System Palisano et al 1997)
(Surveillance of Cerebral Palsy in Europe 2000)
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CLINICAL STUDIESDistribution of type by severity
n95
GMFCS levels
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ICFFramework to organise assessments
Health condition
Body Functions Structures
Activities
Participation
Environmental Factors
Personal Factors
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CLINICAL STUDIES Main variables and measures
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ANALYSES OF MEASURES(1) What do the measures
measure?

• Using the ICF
• to clarify the conceptual basis and measurement
  constructs of the assessment tools used in the
  clinical studies
• to clarify the content of the assessment tools

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ANALYSES OF MEASURES PEDI
Domains
Self-care
Social function
Mobility
Measurement scales
Functional Skills
Caregiver Assistance
Modifications
PEDI Pediatric Evaluation of Disability
Inventory (Haley et al. 1992)
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ICF Concept and constructs of the PEDI
Activity
Participation
Environmental Factors
ICF Concepts
Capacity
Performance
Developmental framework
Type and extent of environmental modifications to
support daily life performance
Capacity to perform activities in daily life
Level of daily life performance
Measurement constructs
Functional Skills
Caregiver Assistance
Modifications
PEDI Scales
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ICFCapacity vs Performance

• Capacity
• indicates the highest probable level of
  functioning that a person may reach in a domain
  in the Activities and Participation list at a
  given moment. Capacity is
• measured in a uniform or standard environment,..
  
• Performance
• describes what individuals do in their current
• environment, and so brings in the aspect of a
• persons involvement in life situations.
• (ICF 2001, p. 214)

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ICF Content analyses of the PEDI

• PEDI Functional Skills Mobility
• Example item 9
• Gets in and out of adult sized chair/wheelchair
• Scoring criteria
• The child initiates transfer and completely
  climbs on and off adult-sized chairs and
  furniture, or completes transfers to and from the
  childs own wheelchair Give credit for this item
  if the child uses a sliding transfer from a
  wheelchair using arm support.
• Classification
• d4103 Changing basic body position. Sitting/
• d4200 Transferring oneself while sitting
• e1150 General products/technology for personal
  use in daily life/
• e1201 Assistive products/technology for personal
  mobility

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ICF Content analysis of the PEDI
PEDI Functional Skills Mobility 59 items d4
Mobility d410 Changing basic body positions
(15) d415 Maintaining a body position (6) d420
Transferring oneself (8) d430 Lifting and
carrying objects (4) d445 Hand and arm use
(2) d450 Walking (4) d455 Moving around (8)
d460 Moving around in different locations
(17) d465 Moving around using equipment (15)
Activities

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ICF Content analyses of the PEDI
PEDI Functional Skills Mobility b7
Neuromusculoskeletal and movement related
functions b789 Movement functions, other
specified and unspecified (3)
Body Functions

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ICF Content analyses of the PEDI
PEDI Functional Skills Mobility e1 Products
and technology e115 Products/technology for
personal use in daily life e155
Design/construction/building
products and technology of buildings
for private use e120 Products/technology for
personal indoor/outdoor
mobility and transportation e3 Support and
relationship e340 Personal care providers and
personal assistants

Environmental Factors
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PEDI scales - number of times and number of ICF
codes
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ANALYSES OF MEASURESModified Ashworth scale
(Modified from Ashworth 1964 and Bohannon and
Smith 1987)
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ICF Modified Ashworth scale (MAS)
Increase in muscle tone through passive stretching
Body Functions

• Individual MAS measurements
• b7350 Tone of isolated muscles and muscle groups
• Mas-index
• b7351 Tone of muscles of one limb

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ICF Range of motion (ROM)
Indirect measure of muscle shortening
Body Functions

• Individual ROM measurements
• b7100 Mobility of a single joint
• ROM-index
• b7101 Mobility of several joints

(ROM, measured with goniometry)
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ANALYSES OF MEASURESSelective Motor Control scale
(Boyd and Graham 1999)
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ICF Selective motor control (SMC)
Balance between muscle groups used for active
dorsiflexion of the ankle
Body Functions

• SMC measurement
• b7600 Control of simple voluntary movements

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(2) Functioning and disability according to the
ICF

• in relation to severity of gross motor
  limitations
• in relation to impairment type

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RESULTS CLINICAL STUDIESFunctioning and
disability in relation to severity

• Significant differences between GMFCS levels
• I II (walks unaided) and
• III IV (walks with devices or moving on the
  floor) and
• V (severely limited self-mobility)
• range of motion (ICF b)
• selective motor control (ICF b)
• capacities in mobility, self-care, social
  function (ICF a)
• performance in mobility, self-care, social
  function (ICF p)
• not between GMFCS levels III IV and V
• muscle tone (ICF b)

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RESULTS CLINICAL STUDIESFunctioning and
disability in relation to type of spastic CP

• Significant differences between hemiplegic and
  diplegic CP
• range of motion (ICF b)
• muscle tone (ICF b)
• capacity in mobility (ICF a)
• performance in mobility (ICF p)
• Not in
• selective motor control (ICF b)
• capacity in self-care and social function (ICF
  a)
• performance in self-care and social function
  (ICF p)
• Significant difference in all functions between
  diplegic and quadriplegic CP

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RESULTS CLINICAL STUDIESEnvironmental
modifications in use

• Assistive devices and other modifications in use
• mobility (n440) classified in
• 3 ICF categories
• 27 ISO 9999 categories
• self-care (n340) classified in
• 2 ICF categories
• 17 ISO 9999 categories
• social function (n287) classified in
• 2 ICF categories
• 18 ISO 9999 categories

(ISO 9999 Technical aids for persons with
disabilities 2002)
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RESULTS CLINICAL STUDIESModifications classified
in ICF

• e1 Products and technology
• e1151 Assistive products/technology for personal
  use in
• daily life
• e1201 Assistive products/technology for
  personal indoor
• and outdoor mobility
• e1251 Assistive products/technology for
  communication
• e1401 Assistive products/technology for
  culture, recreation and sport
• e1550 Design/construction/building products and
  technology for entering and exiting
  buildings for private use
• e1551 Design/construction/building products and
  technology for gaining access to
  facilities in buildings for private use

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RESULTS CLINICAL STUDIESTotal number of
modifications in use in relation to severity

• Significant differences in use between GMFCS
• level I (walks without restrictions), and
• level II (walks without assistive devices,
  limitations
• in walking outdoors), and
• level III (walks with assistive devices,
  limitations in
• walking outdoors), and
• level IV (self-mobility with limitations,
  transported or using
• powered mobility outdoors), and
• No significant difference between GMFCS
• level IV and
• level V (self-mobility is severely limited even
  with
• assistive technology)

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(3) Use of the ICF to assess associations

• between two variables
• Motor impairments
• increase in muscle tone
• deviations in range of motion
• loss of selective motor control
• Motor impairments and capacities in
• mobility
• self-care
• social function
• Capacities and performance in
• mobility
• self-care
• social function

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RESULTS CLINICAL STUDIESRelation between two
variables

• A moderate, but clear relationship between
  increase in tone and deviations in range of
  motion
• An inverse, but less clear relationship between
  increase in tone and selective motor control
• Among the motor impairments, selective motor
  control showed the strongest relationship to
  capacities in mobility, self-care and social
  function
• A strong relationship between capacities and
  performance in mobility, self-care and social
  function

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(3) Use of the ICF to assess associations

• between several variables
• Capacities and performance in
• mobility
• self-care
• social function
• Predictor variables
• motor impairments (MAS, ROM, SMC)
• topographical involvement
• GMFCS levels
• learning difficulties
• age
• gestational age

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RESULTS CLINICAL STUDIESAssociations between
several variables

• GMFCS level was a much stronger predictor than
  severity of motor impairments and topograhical
  involvement of CP, of capacity and performance in
  mobility, self-care and social function.
• Learning difficulties, age and gestational age
  was the only factors besides movement functions
  with clear predictive value, particularly to
  explain variation in social function.

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(4) Use of the ICF to assess benefits from
modifications

• Impact on mobility, self-care and social function
  
• level of caregiver assistance
• childs functional independence
• caregiver demands

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RESULTS CLINICAL STUDIESBenefits from
modifications

• small impact on level of caregiver assistance
• larger impact on caregiver demands than on
  functional independence
• most benefits for mobility and least for social
  function
• caregiver demands and functional independence
  often benefited from different types of
  modifications

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Conclusions

• The ICF was useful in
• clarifying the measurement constructs and the
  content of the assessments
• describing functioning and disability from a
  multidimensional perspective
• assessing associations between functions within
  and between the components, and the contribution
  of other factors
• studying the impact of environmental
  modifications on functioning and on factors
  related to functioning
• The ICF showed limitations in
• covering the developmental perspective of
  functioning

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References

• Østensjø S, Carlberg EB, Vøllestad N. Everyday
  functioning in young children with cerebral
  palsy functional skills, caregiver assistance
  and modifications of the environment. Dev Med
  Child Neurol 200345603-612.
• Østensjø S, Carlberg EB, Vøllestad N. Motor
  impairments in young children with cerebral
  palsy relationship to gross motor function and
  everyday activities. Dev Med Child Neurol
  200446580-589.
• Østensjø S, Carlberg EB, Vøllestad N. The use and
  impact of assistive devices and other
  environmental modifications on everyday
  activities and care in young children with
  cerebral palsy. Disabil Rehabil 2005, in press.
• Østensjø S, Bjorbækmo W, Carlberg EB, Vøllestad
  N. Assessment of everyday functioning in young
  children with cerebral palsy an ICF based
  analysis of concepts and content of the Pediatric
  Evaluation of Disability Inventory (PEDI).
  Disabil Rehabil, accepted March 2005.