Utilization of the ICF-CY for the Classification of Therapeutic Objectives in the Treatment of Spasticity in Children with Cerebral Palsy

Methods

Our center in Bologna, Italy, specializes in the evaluation and advanced treatment of spasticity in neuromotor disability in children and young adults. Between 2010 and the first half of 2012, 217 children were admitted to our center for evaluation and BTX treatment of spasticity in the upper or lower limbs or both. Of these, 188 children who had been diagnosed with spastic CP were included in the prospective study. Twenty-nine patients with other pathologies (epileptic and degenerative encephalopathy, spastic paraparesis) were excluded. The enrolled patients and their families were informed about the study and written informed consent was obtained.

Patients were evaluated from a functional point of view by 3 expert physiatrists and 2 pediatric physiotherapists for eligibility for BTX injection according to the recommendations of Ferrari and Cioni [17]. Functional assessment included evaluation of impairments (spasticity, contractures, deformities), main motor functions (gait pattern, manipulation pattern), and capacity of carrying out the principal motor activities (walking, maintaining and changing body position, rolling, use of upper limbs), thus enabling the identification of specific and realistic objectives for treatment with BTX. The objectives were chosen by a physiatrist and a physiotherapist, shared among the health care providers and the patients and their families, and added to the written treatment proposals. For each child more than 1 treatment objective could be proposed. These proposals were then collected and audited so as to obtain a uniform denomination of the proposed therapeutic objectives. In a series of meetings among all the members of the research group, the descriptions/denominations of the therapeutic goals were standardized and shared, eliminating inexact descriptions or adding new ones as needed. Two trained health care providers expert in the use of the ICF-CY classification mapped these to the ICF-CY domains and categories (up to the 2nd level of categorization). Each interpretative disagreement was resolved by group discussion. Finally, the objectives were analyzed in relationship to clinical type, severity according to GMFCS, and age. The frequency of the individual objectives, domains, and categories was evaluated by means of descriptive statistics.

Results

The mean age of the children was 12 years; 42% were female and 58% were male. The diplegic type made up 38% of CP cases, the tetraplegic type 35%, and the hemiplegic type 24%. GMFCS distribution was as follows: Level 1 (mildest), 39%; Level 2, 11%; Level 3, 9%; Level 4, 25%; and Level 5, 26%. Among the 188 children with CP, a total of 278 objectives were identified. 88% (246) of these objectives were in the “Body Functions” domain, distributed among 6 ICF categories (Table 1). Thirty-two objectives fell under the “Activity” domain, distributed among 5 ICF categories (Table 2).

Body Functions Domain

The most represented category in the “Body Functions” domain was “b770 functions of gait pattern” (50%). There were 123 proposed objectives distributed among 11 typologies of objectives for a total of 123 proposed objectives in the functions of gait pattern category. 

The most frequent proposals were aimed at the reduction of equinus in the stance phase (n = 44) and reduce knee flexion in load (n = 17). The second most represented category was “b710 functions of joint mobility” (26%), in which 7 typologies of objectives were identified for a total of 64 objectives proposed, which were principally aimed at controlling joint deformities (Table 1).

In the “b715 functions of joint stability” category, 25 objectives were proposed for controlling hip lateralization while, in the “b720 functions of bone mobility” category, 4 typologies of objectives were identified out of a total of 15 proposed objectives aimed at improving the position of the pelvis. The “b280 pain sensation” category was also used to indicate 15 objectives aiming at alleviating knee, hip and spinal column pain. Finally, 4 objectives were aimed at tone reduction.

Activity Domain

As concerns the “Activity” domain, 38% of objectives were classified into the “d415 maintain body position” category (3 typologies and a total of 12 proposals), 25% were in the “d540 dress oneself ” category (2 typologies and a total of 8 proposals), 19% were in the “d440 fine use of the hands” category (3 typologies and a total of 6 proposals), 13% were in the “d445 use of hands and arms” category (2 typologies and 4 proposals) and, 6% of cases were classified into the “d510 wash oneself” category (2 proposals) (Table 2).

Analysis by Type, Severity, and Age

During the analysis of data related to clinical type, severity and age in the Body Function domain, the objectives aimed at improving gait pattern (“b770 functions of gait pattern”) were proposed for diplegic and hemiplegic patients with mild disability (GMFCS 1) (Figure 1 and Figure 2). These data refer to 30 hemiplegic and 29 diplegic patients with median age of 8 years (SD, 4 yr 1 mo). 

For quadriplegic patients with severe disability, the objectives aimed at controlling deformities in the “b710 functions of joint and bone mobility”or “b715 functions of joint stability” or “b720 functions of bone mobility” (Figure 3) categories. These data refer to 49 patients (39 GMFCS 5 and 12 GMFCS 4) with a median age of 7 years (SD, 4 yr 5 mo). 

For this population we also included the objectives in the categories “d415 mantain a bodily position,” “d510 washing oneself” and “d540 dressing oneself” (Figure 4). Objectives related to pain reduction represent important therapeutic goals of botulinum injections. They have been proposed especially for diplegic (9 patients) and quadriplegic types (7 patients) with a level of severity corresponding to GMFCS 4 and median age 16 (SD, 5 yr 1 mo). The most involved sites 

were the knees and hips.