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Aim: To assess the responsiveness, concurrent validity, and feasibility of the Dyskinesia Impairment Scale (DIS) in non-ambulatory patients with dyskinetic cerebral palsy (CP)., Method: The study is a secondary analysis of data collected in the IDYS trial, a randomized controlled trial on the effects of intrathecal baclofen (ITB). The DIS and Barry-Albright Dystonia Scale (BADS) were conducted at baseline and after 3 months of ITB or placebo treatment. Responsiveness was assessed by comparing the effect sizes and correlation of change after treatment between the DIS and BADS. Concurrent validity was evaluated by assessing the correlations between scales. Feasibility was evaluated for each DIS item by the number of participants who successfully accomplished the item., Results: Thirty-three non-ambulatory patients (9 females, 24 males) with dyskinetic CP (ITB-treated: n=17, mean [SD] age: 14y 1mo [4y 1mo]; placebo-treated: n=16, mean [SD] age: 14y 7mo [4y]) were included in the study. The effect sizes for BADS and DIS were similar in The ITB-treated group (-0.29 and -0.22 respectively). Changes after treatment on the DIS dystonia subscale correlated with changes on the BADS (r=0.64; p<0.001). The DIS dystonia subscale and BADS correlated at baseline and follow-up (r=0.78; p<0.001 and r=0.79; p<0.001). Not all DIS activity items could be performed in this sample of patients., Interpretation: For non-ambulatory patients with dyskinetic CP, the responsiveness of the DIS equalled the responsiveness of BADS. Concurrent validity was adequate. Feasibility for activity items was restricted in patients with severe dyskinetic CP., What This Paper Adds: The Dyskinesia Impairment Scale (DIS) and Barry-Albright Dystonia Scale showed similar responsiveness in non-ambulatory patients with dyskinetic cerebral palsy (CP). No floor or ceiling effect was observed for DIS in non-ambulatory participants. The concurrent validity of DIS was adequate in non-ambulatory participants. Patients with dyskinetic CP in Gross Motor Function Classification System levels IV and V could not perform all DIS activity items., (© 2019 The Authors. Developmental Medicine & Child Neurology published by John Wiley & Sons Ltd on behalf of Mac Keith Press.)

Aim: To investigate the effects of continuous intrathecal baclofen (ITB) therapy in children with cerebral palsy (CP) and other neurological conditions., Method: This systematic review was conducted using standardized methodology, searching four electronic databases (PubMed, Embase, CINAHL, Cochrane Library) for relevant literature published between inception and September 2017. Included studies involved continuous ITB as an intervention and outcome measures relating to all International Classification of Functioning, Disability and Health: Children and Youth (ICF-CY) components., Results: Thirty-three studies were identified, of which one, including 17 children with spastic CP, produced level II evidence, and the others, mainly non-controlled cohort studies, level IV and V. Outcomes at body function level were most frequently reported. Results suggest continuous ITB may be effective in reducing spasticity and dystonia in CP, as well as other neurological conditions, and may improve the ease of care and quality of life of children with CP, but the level of evidence is low., Interpretation: Despite three decades of applying ITB in children and a relatively large number of studies investigating the treatment effects, a direct link has not yet been demonstrated because of the low scientific quality of the primary studies. Further investigation into the effects of continuous ITB at all levels of the ICF-CY is warranted. Although large, controlled trials may be difficult to realize, national and international collaborations may provide opportunities. Also, multicentre prospective cohort studies with a long-term follow-up, employing harmonized outcome measures, can offer prospects to expand our knowledge of the effects of continuous ITB therapy in children., What This Paper Adds: There is low-level evidence for continuous intrathecal baclofen (ITB) in children with cerebral palsy. Continuous ITB is effective in reducing spasticity and dystonia in non-controlled cohort studies. Evaluation of individual goals and systematic assessment of long-term effects in large cohort studies are required., (© 2018 The Authors Developmental Medicine & Child Neurology published by John Wiley & Sons Ltd on behalf of Mac Keith Press.)

Aim: To validate a detailed intramuscular needle placement protocol using passive muscle stretching and relaxing for botulinum neurotoxin type A (BoNT-A) treatment in the lower extremity of children with spastic cerebral palsy (CP), with verification by electrical stimulation., Method: A prospective observational study was performed in 75 children with spastic CP who received regular BoNT-A treatment under general anaesthesia (52 males, 23 females; mean age 8y 9mo, SD 3y 7mo, range 4-18y; mean body mass index 16.2, SD 3.7, range 7.7-26.7). A total of 1084 intramuscular needle placements using passive muscle stretching and relaxing were verified by electrical stimulation. Primary outcome was the positive predictive value., Results: Intramuscular needle placement in the muscles adductor brevis, adductor longus, gracilis, semimembranosus, semitendinosus, biceps femoris, rectus femoris, and lateral and medial heads of the gastrocnemius and soleus had a positive predictive value ranging from 85.7% to 100% (95% confidence interval ranging from 71.5-89.9% to 91.4-100%)., Interpretation: This validated detailed protocol for intramuscular needle placement using passive muscle stretching and relaxing for BoNT-A treatment in the lower extremity of children with spastic CP is reliable and has a high positive predictive value., (© 2016 Mac Keith Press.)

Aim: The aim of this study was to determine the longitudinal associations among fitness components and between fitness and mobility capacity in children with cerebral palsy (CP)., Method: Forty-six children (26 males, 20 females; mean age 9y 7mo [SD 1y 8mo]) with a bilateral (n=24) or a unilateral spastic CP (n=22) participated in aerobic and anaerobic fitness measurements on a cycle ergometer and isometric muscle strength tests (Gross Motor Function Classification System [GMFCS] level I [n=26], level II [n=12], level III [n=8]). Mobility capacity was assessed with the gross motor function measure (GMFM) and a walking capacity test. Associations over longitudinal measurements (three or four measurements over 1y) were determined since longitudinal data allow a more accurate estimation. The associations were determined using a mixed model with fixed effects (mobility capacity as dependent variables and fitness components as independent variables) and a random intercept., Results: In children with bilateral CP, changes in aerobic fitness were associated with changes in anaerobic fitness (p<0.001), and changes in aerobic fitness showed an association with changes in muscle strength (p<0.05). Anaerobic fitness was not associated with muscle strength. No associations between fitness components were found in unilateral CP. Anaerobic fitness and muscle strength were significant determinants for GMFM and walking capacity in bilateral but not in unilateral CP., Interpretation: The longitudinal associations between aerobic and anaerobic fitness and mobility indicate that increasing either aerobic or anaerobic fitness is associated with improvements in mobility in children with bilateral CP. While increasing anaerobic fitness might be beneficial for mobility capacity in children with bilateral CP, this is less likely for children with unilateral CP., (© 2015 Mac Keith Press.)

Aim: To assess spoken language comprehension in non-speaking children with severe cerebral palsy (CP) and to explore possible associations with motor type and disability., Method: Eighty-seven non-speaking children (44 males, 43 females, mean age 6y 8mo, SD 2y 1mo) with spastic (54%) or dyskinetic (46%) CP (Gross Motor Function Classification System [GMFCS] levels IV [39%] and V [61%]) underwent spoken language comprehension assessment with the computer-based instrument for low motor language testing (C-BiLLT), a new and validated diagnostic instrument. A multiple linear regression model was used to investigate which variables explained the variation in C-BiLLT scores. Associations between spoken language comprehension abilities (expressed in z-score or age-equivalent score) and motor type of CP, GMFCS and Manual Ability Classification System (MACS) levels, gestational age, and epilepsy were analysed with Fisher's exact test. A p-value <0.05 was considered statistically significant., Results: Chronological age, motor type, and GMFCS classification explained 33% (R=0.577, R(2) =0.33) of the variance in spoken language comprehension. Of the children aged younger than 6 years 6 months, 52.4% of the children with dyskinetic CP attained comprehension scores within the average range (z-score ≥-1.6) as opposed to none of the children with spastic CP. Of the children aged older than 6 years 6 months, 32% of the children with dyskinetic CP reached the highest achievable age-equivalent score compared to 4% of the children with spastic CP. No significant difference in disability was found between CP-related variables (MACS levels, gestational age, epilepsy), with the exception of GMFCS which showed a significant difference in children aged younger than 6 years 6 months (p=0.043)., Interpretation: Despite communication disabilities in children with severe CP, particularly in dyskinetic CP, spoken language comprehension may show no or only moderate delay. These findings emphasize the importance of introducing alternative and/or augmentative communication devices from early childhood., (© 2014 Mac Keith Press.)

Aim: The aim of this study was to determine the developmental trajectories of expressive (speech) and receptive (spoken and written language) communication by type of motor disorder and intellectual disability in individuals with cerebral palsy (CP)., Method: The development of 418 participants (261 males, 157 females; mean age 9y 6mo [SD 6y 2mo], range 1-24y; Gross Motor Function Classification System (GMFCS) level I [n=206], II [n=57], III [n=59], IV [n=54], V [n=42]) was followed for 2 to 4 years in a longitudinal study. Communication performance was measured using the Vineland Adaptive Behavior Scales. The type of motor disorder was differentiated by type of CP as unilateral spastic (USCP, n=161), bilateral spastic (BSCP, n=202), and non-spastic (NSCP, n=55), while intellectual disability was determined by IQ or school type (regular or special). A multilevel analysis was then used to model the developmental trajectories., Results: The most favourable development of expressive communication was seen in USCP (vs BSCP β [SE]-2.74 [1.06], NSCP β [SE]-2.67 [1.44]). The difference between the development trajectory levels of children with and without intellectual disability was smaller for children with USCP than for those with BSCP and NSCP. For receptive communication, the most favourable development was found for all children with USCP and for BSCP or NSCP without intellectual disability (vs intellectual disability β [SE]-4.00 [1.16]). Development of written language was most favourable for children without intellectual disability (vs intellectual disability β [SE]-23.11 [2.85])., Interpretation: The development of expressive communication was found to be most closely related to type of motor disorder, whereas the development of receptive communication was found to be most closely related to intellectual disability., (© 2014 Mac Keith Press.)

Aim: Information regarding the selection procedure for selective dorsal rhizotomy (SDR) in children with spastic cerebral palsy (CP) is scarce. Therefore, the aim of this study was to summarize the selection criteria for SDR in children with spastic CP., Method: A systematic review was carried out using the following databases: MEDLINE, CINAHL, EMBASE, PEDro, and the Cochrane Library. Additional studies were identified in the reference lists. Search terms included 'selective dorsal rhizotomy', 'functional posterior rhizotomy', 'selective posterior rhizotomy', and 'cerebral palsy'. Studies were selected if they studied mainly children (<18y of age) with spastic CP, if they had an intervention of SDR, if they had a detailed description of the selection criteria, and if they were in English. The levels of evidence, conduct of studies, and selection criteria for SDR were scored., Results: Fifty-two studies were included. Selection criteria were reported in 16 International Classification of Functioning, Disability and Health model domains including 'body structure and function' (details concerning spasticity [94%], other movement abnormalities [62%], and strength [54%]), 'activity' (gross motor function [27%]), and 'personal and environmental factors' (age [44%], diagnosis [50%], motivation [31%], previous surgery [21%], and follow-up therapy [31%]). Most selection criteria were not based on standardized measurements., Interpretation: Selection criteria for SDR vary considerably. Future studies should describe clearly the selection procedure. International meetings of experts should develop more uniform consensus guidelines, which could form the basis for selecting candidates for SDR., (© 2013 Mac Keith Press.)

Aim: The aim of this study was to evaluate the long-term effect of selective dorsal rhizotomy (SDR) on the gross motor function of ambulant children with spastic bilateral cerebral palsy (CP), compared with reference centiles., Method: The study used a prospective cohort design and participants comprised 29 children classified using the Gross Motor Function Classification System (GMFCS) in level I (n=7), II (n=4), or III (n=18; 18 males, 11 females; median age at time of surgery 6 y 4 mo; range 2 y 10 mo-12 y 1 mo), who were examined 5 years and 10 years after SDR. We used individual centiles based on Gross Motor Function Measure (GMFM-66) scores and age, corresponding to the GMFCS levels. Individual improvement or deterioration was defined as a change of more than 20 centiles. Side effects experienced and additional treatment received after SDR were also recorded., Results: Five years after SDR, 10 out of 28 children showed improvement, and 10 years after SDR 6 out of 20 children had improved. Spinal side effects were noted in two children and hip subluxation in three. Additional treatments included subtalar arthrodesis (n=13), endorotational osteotomy of the tibia (n=5), and botulinum toxin treatment (n=13)., Interpretation: None of the children showed deterioration of gross motor function based on centile ranking. Five and 10 years after SDR, gross motor function in some children had improved more than would have been expected according to the reference centiles. This suggests, taking the limitations of this study into account, that the applied criteria for selection were adequate. However, the children still required additional treatment after SDR., (© 2013 Mac Keith Press.)

Aim: To assess ambulatory activity of children with cerebral palsy (CP), aged 7 to 13 years, and identify associated characteristics., Method:   Sixty-two children with spastic CP (39 males, 23 females; mean age 10y 1mo, SD 1y 8mo; age range 7-13y), classified as Gross Motor Function Classification System (GMFCS) levels I to III, participated. Ambulatory activity was measured during 1 week with a StepWatch activity monitor as steps per day, and time spent at medium and high step rates. Multiple linear regression analyses were performed following a backward selection procedure until only independent variables with p<0.05 remained in the model. Ambulatory activity outcome parameters served as dependent variables, and disease, personal, and environmental characteristics as independent variables. Ambulatory activity was corrected for body height., Results: Children took more steps during school days (5169 steps, SD 1641) than during weekend days (4158 steps, SD 2048; p<0.001). Higher GMFCS level, bilateral CP, and higher age were associated with lower ambulatory activity on school days (R(2) ranged from 43-53%), whereas bilateral CP, higher age, and no sport club participation were associated with lower ambulatory activity in the weekend (R(2) ranged from 21-42%). Correcting for body height decreased the association with age., Interpretation: Interventions should focus at increasing physical activity at the weekend for children with bilateral spastic CP., (© The Authors. Developmental Medicine & Child Neurology © 2012 Mac Keith Press.)

Aim: To assess the long-term outcome and adverse events of selective dorsal rhizotomy (SDR) in children with spastic cerebral palsy (CP)., Method: Studies were selected based on the following inclusion criteria: children with CP that underwent SDR with a follow-up period of at least 5 years. The following databases were searched: MEDLINE, Web of Science, Embase, PEDro, and the Cochrane library. Studies meeting the inclusion criteria were scored by two reviewers, who graded the level of evidence and the quality/conduct of the studies. Outcomes were classified according to the International Classification of Functioning, Disability and Health (ICF)., Results: Only three of the 21 studies who met the inclusion criteria allowed a tentative conclusion on outcome. There is moderate evidence that SDR has a positive long-term influence on the ICF body structure and body function domains but there is no evidence that SDR has an influence on the ICF activity and participation domains. Spinal abnormalities seem to be common, but no conclusion can be drawn about their relation to SDR., Interpretation: There is lack of evidence concerning the long-term outcomes after SDR. Future studies need to clarify the long-term influence of SDR - especially in the ICF domains of activity and participation., (© The Authors. Developmental Medicine & Child Neurology © 2011 Mac Keith Press.)

Aim: to identify the use and utility of language comprehension tests for unintelligible or non-speaking children with severe cerebral palsy (CP)., Method: severe CP was defined as severe dysarthria (unintelligible speech) or anarthria (absence of speech) combined with severe limited mobility, corresponding to Gross Motor Function Classification System levels IV to V. An electronic search in the databases of PubMed, PsychInfo, Embase, and CINAHL was made of studies published between January 1965 and December 2008. Indexing terms and free-text terms for 'cerebral palsy', 'language', and 'instrumentation' were used. Studies were included when (1) the focus was to investigate comprehension of spoken language of children (0-18 y) with severe CP, and (2) language tests were described., Results: twelve standardized tests and five experimental instruments were identified. All standardized tests were developed for children without limited mobility. Only the Peabody Picture Vocabulary Test - Revised was frequently used and feasible for older children with severe CP (> 9 y). The other tests were used occasionally. To establish utility, adaptations of standardized test procedures were necessary., Interpretation: language comprehension tests for children with severe CP are scarce. A language comprehension test specifically designed for these children is warranted.

Aim: to identify the use and utility of language comprehension tests for unintelligible or non-speaking children with severe cerebral palsy (CP)., Method: severe CP was defined as severe dysarthria (unintelligible speech) or anarthria (absence of speech) combined with severe limited mobility, corresponding to Gross Motor Function Classification System levels IV to V. An electronic search in the databases of PubMed, PsychInfo, Embase, and CINAHL was made of studies published between January 1965 and December 2008. Indexing terms and free-text terms for 'cerebral palsy', 'language', and 'instrumentation' were used. Studies were included when (1) the focus was to investigate comprehension of spoken language of children (0-18 y) with severe CP, and (2) language tests were described., Results: twelve standardized tests and five experimental instruments were identified. All standardized tests were developed for children without limited mobility. Only the Peabody Picture Vocabulary Test - Revised was frequently used and feasible for older children with severe CP (> 9y). The other tests were used occasionally. To establish utility, adaptations of standardized test procedures were necessary., Interpretation: language comprehension tests for children with severe CP are scarce. A language comprehension test specifically designed for these children is warranted. Cite this as: Dev Med Child Neurol 52: e267-e277.

Aim: the objective of this study was to assess the validity of a mobility questionnaire (MobQues) that was developed to measure parent-reported mobility limitations in children with cerebral palsy (CP)., Method: the parents of 439 children with CP (256 males and 183 females; age range 2-18y; Gross Motor Function Classification System [GMFCS] levels I-IV) completed the mobility questionnaire (MobQues). To assess content validity, we linked all meaningful concepts of the MobQues items to the International Classification of Functioning, Disability and Health (ICF). To assess construct validity, we compared the total scores of the two versions of the MobQues (MobQues47 and MobQues28) according to GMFCS level, and determined Pearson's correlation coefficient (r) with the Gross Motor Function Measure-66 (GMFM-66)., Results: content validity was demonstrated by the fact that 46 of the 47 MobQues items were linked to categories in the 'Mobility' chapter of the ICF. Construct validity was demonstrated by the finding that MobQues scores decreased with increasing GMFCS levels (p<0.001). In a subgroup of 162 children, positive correlations were found between total scores and the GMFM-66 (MobQues47, r=0.75; MobQues28, r=0.67, p<0.001)., Interpretation: the results of this study provide evidence supporting the content and construct validity of the MobQues as a measure of mobility limitation in children with CP.

Aim: To evaluate the effectiveness of functional progressive resistance exercise (PRE) strength training on muscle strength and mobility in children with cerebral palsy (CP)., Method: Fifty-one children with spastic uni- and bilateral CP; (29 males, 22 females; mean age 10 y 5 mo, SD 1 y 10 mo, range 6 y 0 mo-13 y 10 mo; Gross Motor Function Classification System levels I-III) were randomized to the intervention group (n=26) or the control group (n=25, receiving usual care). The intervention group trained for 12 weeks, three times a week, on a five-exercise circuit, which included a leg-press and functional exercises. The training load progressively increased based on the child's maximum level of strength, determined by the eight-repetition maximum. Muscle strength (measured with hand-held dynamometry and a six-repetition maximum leg-press test), mobility (measured with the Gross Motor Function Measure, two functional tests, and a mobility questionnaire), and spasticity (measured by the appearance of a catch) were evaluated before, during, directly after, and 6 weeks after the end of training by two blinded research assistants., Results: Directly after training, there was a statistically significant effect (p<0.05) on muscle strength (knee extensors +12% [0.56 N/kg; 95% confidence interval {CI} 0.13-0.99]; hip abductors +11% [0.27 N/kg; 95% CI 0.00-0.54]; total +8% [1.30 N/kg; 95% CI 0.56-2.54]; six-repetition maximum +14% [14%; 95% CI 1.99-26.35]), but not on mobility or spasticity. A detraining effect was seen after 6 weeks., Interpretation: Twelve weeks of functional PRE strength training increases muscle strength up to 14%. This strength gain did not lead to improved mobility.

Aim: To give an overview of indications for the use of botulinum toxin A (BoNT-A) treatment for children with obstetric brachial plexus injury (OBPI), and to present the best available evidence of the effectiveness of this treatment., Method: Searches were performed in Cinahl, Cochrane Library, Embase, PubMed, and Web of Science, using the keywords 'botulinum' and 'plexus', to identify articles reporting on the use of BoNT-A as a treatment for children with OBPI. Studies found through the references of related articles were also selected., Results: Ten full-text papers and six congress abstracts were included, involving 343 children. Four groups of indications could be identified: internal rotation/adduction contracture of the shoulder, limited active elbow flexion, limited active elbow extension, and pronation contracture of the lower arm. Overall, positive results were reported for all except the indication for limited active elbow extension. However, only one study was comparative in nature; all others were classified as having a low level of evidence. There was a large variation in outcome measures., Interpretation: To provide better evidence for the already partly promising results of BoNT-A treatment for children with OBPI, multicentre randomized controlled trials are needed.

Aim: The objective of this longitudinal study was to describe the course of social functioning and communication in children with cerebral palsy (CP) over a 3-year period, its difference with the normative course, and its relationship with disease characteristics and personal and environmental factors., Method: Participants in this study were 110 children with CP (70 males, 40 females) with a mean age of 11 years and 3 months (SD 1y 8mo). Social functioning and communication were measured with the Vineland Adaptive Behavior Scales. Comparisons were made with normative data; data were analysed with generalized estimating equations. According to the Gross Motor Function Classification System (GMFCS), 50 of the 110 children were categorized as GMFCS level I, 16 as level II, 13 as level III, 13 as level IV, and 18 as level V., Results: The course of social functioning over a 3-year period showed an increase in restrictions in children with CP (p<0.001). Restrictions in communication increased more in children with the most severe forms of CP (p<0.001). In addition to disease characteristics (GMFCS category, presence of epilepsy, and speech problems), personal factors (externalizing behaviour problems) and environmental factors (having no siblings, low parental level of education, and parental stress) were associated with greater restrictions in social functioning and communication., Interpretation: The results indicate that it is important to focus not only on the medical treatment of children with CP, but also on their behavioural problems and social circumstances, and to support the parents so that social functioning and communication in these children may be improved.

Aim: The objective of this study was to assess the reliability of a mobility questionnaire (MobQues) that was developed to measure the mobility limitations of children with cerebral palsy (CP) as rated by their parents. A clinical version of the questionnaire, consisting of 47 items (MobQues47), is available, as well as a research version with 28 items for a specific population (MobQues28). Total scores are expressed on a scale of 0 to 100., Method: We assessed the interrater reliability between both parents of 289 children with CP (168 males, 121 females, age range 2-13 y, Gross Motor Function Classification System levels I-IV) and the intrarater reliability within a subgroup of 38 parents (of 23 children) who completed the MobQues twice., Results: For the interrater reliability, high intraclass correlation coefficients (ICCs) were found for the MobQues47 (ICC 0.92) and MobQues28 (ICC 0.87). The standard error of measurement (SEM) was 7.8 and 8.9 respectively. As expected, the intrarater reliability was higher, as represented by higher ICCs (0.96-0.99) and lower SEMs (3.5-4.9) for both MobQues versions., Interpretation: The results of this study indicate that the MobQues is a reliable instrument to measure the mobility limitations of children with CP.

Aim: To investigate the predictive value of motor testing at 1 year for motor and mental outcome at 2 years after perinatal hypoxic-ischaemic encephalopathy (HIE) in term neonates., Method: Motor and mental outcome at 2 years was assessed with the Bayley Scales of Infant Development, 2nd edition (BSID-II) in 32 surviving children (20 males, 12 females; mean gestational age 40.2 wk, SD 1.4; mean birthweight 3217g, SD 435) participating in a prospective cohort study of HIE. The predictive value of three motor tests (Alberta Infant Motor Scale [AIMS], BSID-II, and the Neurological Optimality Score [NOS]) at 1 year was analysed, in addition to predictions based on neonatal Sarnat staging and magnetic resonance imaging (MRI). Poor motor test results were defined as an AIMS z-score of <-2, a psychomotor developmental index of the BSID-II of <70, or a NOS of <26. Poor motor and poor mental outcome at 2 years was defined as a psychomotor developmental index or mental developmental index of the BSID-II of <70., Results: Twelve children, all with Sarnat grade II, had a poor motor outcome and 12 children, of whom one had Sarnat grade I, had a poor mental outcome at 2 years. Nine children had cerebral palsy, of whom five had quadriplegia, three had dyskinesia, and one had hemiplegia. Poor motor tests at 1 year increased the probability of a poor motor outcome from 71% (range 92 to 100%), and a poor mental outcome from 59% (range 77 to 100%) in children with Sarnat grade II and abnormal MRI, assessed with the AIMS and BSID-II or NOS respectively., Interpretation: Additional motor testing at 1 year improves the prediction of motor and mental outcome at 2 years in children with Sarnat grade II and abnormal MRI.

Aim: The aim of this study was to describe the course of motor performance and analyse its relationship with motor capacity over a period of 3 years in 104 children (66 males, 38 females; 43% of those initially invited) with cerebral palsy (CP) aged 9, 11, and 13 years at the start of the study. Forty-one had hemiplegia, 42 diplegia, 21 tetraplegia; 83 spastic CP, 17 dyskinetic/mixed, and four ataxic CP. Gross Motor Function Classification System (GMFCS) levels were I, n=49; II, n=15; III, n=10; IV, n=12; and V, n=18., Method: Motor performance (what a child does do) was determined using the gross motor skills subscale of the Vineland Adaptive Behavior Scales and motor capacity [what a child can do] was determined using the Gross Motor Function Measure-66 (GMFM-66). The measurements were performed annually over a period of 3 years., Results: The course of motor performance in mildly affected children (GMFCS level I) was more favorable than in more severely affected children. An increase in motor capacity was significantly related to an improvement in motor performance over the 3 years., Interpretation: Training motor capacity in children with CP seems to be important for improving motor performance. Interventions should also focus on environmental adaptations and improving mobility equipment. A limitation of this study was that the instruments used did not contain the same items on capacity and performance level.

The objective of this study was to describe skeletal maturation in relation to chronological age in children with cerebral palsy (CP) aged 9 to 16 years, and to analyze the relationship between skeletal maturation and motor functioning. The skeletal age of 100 children with CP (37 females, 63 males; age 9, 11, or 13 y; 73 ambulant, 27 non-ambulant) was determined over a period of 3 years based on X-rays of the hand (Greulich and Pyle technique). Motor functioning was measured with the Gross Motor Function Measure-66. The skeletal age of females with CP was significantly higher than their chronological age, but this did not apply to males. Longitudinal analysis showed no difference in the course of skeletal age in relation to chronological age over a 3-year period for sex or for level of ambulation. No association was found between changes in skeletal age and changes in gross motor function over the 3-year period. Skeletal age during (pre-)puberty in females with CP is advanced in relation to chronological age. No evidence was found that children with CP are at risk for deterioration in gross motor function as a result of skeletal maturation during puberty.

This study reviews the instruments used for the clinical assessment of spasticity in children with cerebral palsy, and evaluates their compliance with the concept of spasticity, defined as a velocity-dependent increase in muscle tone to passive stretch. Searches were performed in Medline, Embase, and Cinahl, including the keywords 'spasticity', 'child', and 'cerebral palsy', to identify articles in which a clinical method to measure spasticity was reported. Thirteen clinical spasticity assessment instruments were identified and evaluated using predetermined criteria. This review consists of reports on the standardization applied for assessment at different velocities, testing posture, and quantification of spasticity. Results show that most instruments do not comply with the concept of spasticity; standardization of assessment method is often lacking, and scoring systems of most instruments are ambiguous. Only the Tardieu Scale complies with the concept of spasticity, but this instrument has a comprehensive and time-consuming clinical scoring system.