The natural history of gross motor development in children with cerebral palsy aged 1 to 15 years

Abstract

The aim of this study was to explore motor development in children with cerebral palsy (CP) using developmental curves for CP, subtypes, and the five severity levels of the Gross Motor Function Classification System (GMFCS). The Gross Motor Function Measure (GMFM) and the GMFCS were applied to 317 children (145 females, 172 males) with CP, aged between 1 and 15 years. The CP type distribution was spastic diplegia in 157 (49%), spastic hemiplegia in 101 (33%), spastic tetraplegia in 11 (3%), dyskinesia in 38 (12%), and ataxia in 10 (3%). Forty‐five physiotherapists were trained in the GMFM and intra‐ and interrater reliability was tested. The GMFM was measured prospectively every 6 months up to the age of 4 years and once a year thereafter. Developmental curves were constructed for 258 children with spastic CP. About three‐quarters of the children at GMFCS Level I reached 90% of the maximum GMFM score at 5 years of age. The performance peaked at 7 years of age. Children at GMFCS Level II reached 90% at a median age of 5 years, which was also the upper limit, reached by about three‐quarters at 7 years of age. The majority of children at GMFCS Level III reached 80% of the GMFM by 7 years of age and most of the children at GMFCS Level IV reached 30% at 5 years and remained there. The median score for children at GMFCS Level V was 20%. The intra‐ and interrater reliability for the GMFM 88 among physiotherapists were Spearman's rank correlation coefficient 0.91 and 0.99 respectively. There were 931 measurements with a median of 2 (1–11) per child. The gross motor development was demonstrated for the five GMFCS levels in children with spastic CP. These kind of curves may be useful for monitoring and predicting motor development, for planning treatment, and for evaluating outcome after interventions.

Classification of cerebral palsy: association between gender, age, motor type, topography and Gross Motor Function

“…As for the relation between body topography and motor levels, most hemiplegic children were predominantly motor level I, which has also been found in other studies [17][18][19]25 . In this study there was only one child with hemiplegics cP different from level I and she was classified in Motor level III according to the GMFcS.…”

“…other studies report that diplegic children are the majority 14,[18][19][20] . diplegia affects principally, or especially the lower limbs because of the serious injury in periventricular areas and subcortical white matter; its main causes are cerebral ischemic and hemorrhagic phenomena and fetal or post-natal hydrocephaly especially in preterm newborn children 5,17 .…”

“…The child was 8 months old and had late development; it is possible that such condition reaches the lowest lower limbs because of its neurological maturation. himmelmann et al 25 found out cases of hemiplegia in all motor levels; Beckung et al 19 established that the cases varied between levels I and IV; howard et al 16 found levels I, II, III and V and Voorman et al 18 classified the cases under levels I, II and III. diplegic children in this study were similar (with no significant difference) in the first four levels and there were no examples of level V; in their study Voorman et al 18 had the same results and only 3 cases (6.4%) were level V. In their study himmelmann et al 25 had diplegic children in all levels, most of them were level II (37.5%) and only 4.9% of the children were classified in level V. Similar results were found in the study of Beckung et al 19 in which they observed that most children were classified in the first two levels while only 4% were classified in level V. The results in the study of howard et al 16 were very similar in the first three levels; only 4 cases (5%) were level IV and no diplegic children were level V.…”

“…hypotonic, dyskinetic and mixed ones did not influence in the relation between body topography and motor level. In the studies of Beckung et al 19 the participants were divided according to motor type and the spastic ones were divided according to topography; quadriplegic spastic ones were all level V, dyskinetic children were classified from level I to V, with a predominance of level III and the ataxic ones were classified in levels I and II; there were no cases of mixed cerebral palsy. himmelmann et al 25 had similar results, in that quadriplegic spastic children were classified in levels IV and V and most of them were level V; diskinetic children were classified in all levels but the majority was levels IV and V. The study of howard et al 16 reported that most of quadriplegic spastic children were level IV and V, diskinetic children were levels II, III and IV and the mixed ones were all levels; the ataxic children were classified in the first three levels and the hypotonic ones were all levels except level II.…”

“…regarding the relation between motor level and age, our study found a certain tendency to association through Fisher' s exact test (p=0.075) although it did not present significance. The study of Beckung et al 19 used the GMFM 26 to evaluate children's motor performance and it showed that age is important in motor prognosis in children with cerebral palsy. children were evaluated every 6 months up to 4 years old and every year afterwards; development graphs were drawn for 258 spastic children.…”