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WALKING PROGNOSIS IN CEREBRAL PALSY: A 22-YEAR RETROSPECTIVE ANALYSIS Developmental Medicine and Child Neurology, 1994, 36, 130-134 130 Aloysio Campos da Paz, Jr. ‘Sduria Miranda Burnett Liicia Willadino Braga Establishing the prognosis for ambulation at an early age is an important step in the general approach to cerebral palsy, not only because a more comprehensive and rational treatment programme is better defined based on neurological potential, but also because all professionals dealing with developmental disabilities must be prepared to discuss the qu ‘concerning the future status of a child in terms of motor control. Cognitive and motor development are primarily dependent on the anatomical localization and extent of the brain damage. Despite early diagnosis and proper intervention, the disability is Permanent, and a variety of associated conditions influence the outcome of a child with cerebral palsy. Epilepsy resistant to anticonvulsants, mental retardation, severe visual impairment, malnutrition and lack of stimulation are some of the negative factors. Crothers and Paine (1959) reported a good walking prognosis for children with spastic hemiplegia and a poor prognosis for those with rigid and hypotonic types. Bleck (1975), in his study of 73 children with cerebral palsy or delayed motor development, concluded that the presence or absence of certain primitive reflexes and postural reactions after 12 months of age have a predictive value in relation to walking prognosis. Molnar (1979) found significant cor- relation between sitting at 24 months and ambulation. That study also concluded that the chances of a child achieving independent ambulation decrease after four or five years and that it is unlikely after eight years of age. In Badell-Ribera’s study (1985) of 50 children with spastic diplegia, sitting and crawling at 1/4 to 214 years of age was predictive of later ambulation in all cases. More recently, a prospective study of 74 neonates—survivors of intensive-care units—who were later diagnosed as having cerebral palsy re-examined factors that might predict the ambulatory potential of children with cerebral palsy at an early age. A positive relationship between sitting at two, and ambulation at eight, years of age was found. In addition, the persistence of any of the following primitive reflexes: tonic labyrinthine, asymmetrical tonic neck, symmetrical tonic neck and Moro; and absence of postural reactions had a. statistically significant correlation with _non- ambulatory status (Watt et al. 1989). The present study aimed to determine criteria for the establishment of the prognosis for ambulation based on the ages at which children with cerebral palsy attain some important gross motor tones, and 10 construct a chart for prognostic purposes. Method We cartied out a retrospective study of patients diagnosed as having cerebral palsy and followed from 1970 to 1992 at SARAH: National Institute for Medicine of the Locomotor System in Brasilia, Brazil. The definition of cerebral palsy used was ‘a disorder of posture and movement secondary to a static lesion of the developing brain’ (Bax 1964). Initially, 416 charts of patients with spastic cerebral palsy were analysed. At SARAR, each includes a protocol in which the type of motor disorder, topography and the ages of attainment of gross motor milestones are registered. During the first two years of life the children are routinely assessed by a specialized team twice a month. After 24 months of age, children who have not achieved ambulation continue to be evaluated and re-orientated twice-monthly, monthly or every two or six months, depending on the severity of the involvement. Alll the patients were seen individually to confirm the diagnosis, review the data collected from the medical records and verify their motor progress. Children who required revision of their diagnosis at this point were excluded from the study. Hemiplegic children were also excluded because theit good potential for ambu- lation is widely accepted. 272 patients ity (diplegia, triplegia and quadriplegia), ranging in age from one to 36 years, were considered eli inclusion in the study. The sample was subdivided into three groups: (1) those who had achieved independent ambulation; (2) those who had achieved ambulation only with assistance (sticks, crutches or walkers); and (3) those who had not achieved ambulation. Groups 1 and 2 included children who walked, regardless of the age at which they did so. The minimum age for a patient to be included in group 3 was eight years, because achieving independent ambulation after this age is unlikely (Bleck 1975, Molnar 1979). The variables studied were: (1) Age in months at the last clinical assessment. (2) Clinical type of cerebral palsy, classi- fied as spastic diplegia, spastic triplegia stic quadriplegia. Children with spastic quadriplegia were those with total body involvement. Children with minor involvement of the upper limbs were diagnosed as having spastic diplegia. Those with predominantly motor diffi- culties in three limbs (usually one upper limb and both lower limbs) were diag- nosed as having spastic triplegia (Bleck 1975). ) Age in months at which the child attained the following abilities: head balance—the child is placed prone on a firm surface and is able to lift head and shoulders from the surface using hands or elbows, holding the head up for more than 30 seconds (Bayley 1969); sitting— the child cannot sit unaided, but when put in position is able to maintain it steadily, without support (Bayley 1969); crawling— the child moves on hands and knees, with symmetrical hip flexion (symmetrical crawling), or moves in a pattern of reciprocal -crawl (Badell-Ribera 1985); walking with support—the child requires the aid of sticks, crutches or walkers to ambulate, and may use an orthosis for ankle support, but is capable of functional walking indoors and for limited distances outdoors; independent walking—the child can stand and does not need sticks, crutches or walkers for ambulation, may use an orthosis for ankle support, and is capable of walking outdoors. ‘According to the data analysis, walking prognosis was classified into three categories: good—the child will eventually walk independently or with support; guarded—prediction of the potential for ambulation at an early age is not possible; and poor—the child will not achieve ambulation. Because most variables studied are not continuous, we used x? tests for statistical analysis. Results Most of the patients with diplegia eventu- ally walked (x?=27-63, p<0-000001), bbut the patients with quadriplegia rarely became ambulatory (x°=217-59, p< 0000001), No significant statistical difference was observed for the triplegic group (x"= 1-5, p=0-21), which may be because of the small sample size (Table 1). Of the total population, 110 children Developmental Medicine ond Child Neurology, 1994, 36, 130-134 BI Walking Prognosis in Cerebral Palsy Aloysio Campos da Pez, Jr. etal 132 TABLE I Topography and ambulatory status Toposraphy Ambulatory Non Ga Ambulaiory N % Diplegia (N 9 9 omens eB Quadriplegia (N= 138) 37-27-1073 Total (N= 272) 18 5B 4 Fig. 1. Motor milestones: meon age at achievement. ‘Age (months) eal oy Motor seauaiton regpove: (eevee EE Per Fig, 2 Three different bands of prognosis defined ‘according f0 oges at which child atteins each ‘milestone. Achievement of head balance before hnine months indicetes good prognosis, and afer 20 months indicates poor prosnoss. Sitting by 24 ‘months indicaes @ favourable outcome and motor control of crawling before 30 months of oge may indicate good prognosis TABLE I Distribution of children by age at achievement of milestone and ambulatory status ——— Age (mts) ‘Ambulatory Non- ae Ambulatory ne N % Heed bolance <9 47 100 0 29 and $20 8 12 330 a) Siuing <24 © 10 89 0 224 and 536 MoM 12 >i 21 os eaesaal Crawling <30 4 10 00 0 230 and <61 He ae Nees3 ate ambulatory; the smallest group of patients (48; 18 per cent) comprised those walking with support. 63 patients (23 per cent), all diagnosed as having spastic quadriplegia, had attained no motor skills. ‘The mean age at attainment of each milestone differed between groups. Children who acquired the first motor skills early eventually walked, and those with significant delay in early milestone attainment did not (Fig. 1). All children who ‘developed head balance by nine months of age walked independently or with support, and those who did not achieve head balance until 20 months did not walk. All children who were able to sit at 24 months walked independently or with support; most who were unable to sit before 36 months of age did not walk. Children who achieved crawling by 30 months of age eventually walked, and those who failed to crawl until 61 months did not (Table 11). The children who walked independently attained this function by 34 months of age (x? =57-8, p<0-000001), but it took up to 108 months for those who walked only with support. None of the children became ambulant after this, even with support. When we analysed the final results, we observed that it was possible to define parameters for predicting future motor status based on the ages that children with spastic cerebral palsy achieve head balance, sitting and crawling. From these data (Table I), we formulated a chart (Fig. 2) for use in the follow-up clinic: the physician can refer to the ages at which the child attains each selected milestone for an indication of locomotor prognosis. Discussion Cerebral palsy is not a disease but a clinical entity with different causes, types of motor involvement, levels of severity and associated conditions. Research in this field is complex because of difficulties in applying criteria for diagnosis or parameters for prognosis to all the clinical types. Even though our sample was restricted to patients with spasticity, there was still wide inter-individual variation. Nevertheless, we obtained clinical find- ings that can be used for prediction of the future ambulatory status of children with cerebral palsy. Almost all of the diplegic children in ‘our study attained ambulation, but the majority of the quadriplegic patients did not walk. The analysis of the relationshi between topography and motor outcome showed that this classification may be helpful in the evaluation of a child to establish walking prognosis, which agrees with previous observations (Molnar and Gordon 1976). However, it is important to take into account that it is not always possible to classify a child at an early age (Hartis 1987, Watt ef al. 1989). Further- more, agreement between examiners on the ‘classification of cerebral palsy according to type of motor involvement, topography and severity is not good (Alberman 1984, Blair and Stanley 1985). The present study, centred mainly on the assessment of the ages at attainment SUMMARY AA retrospective study was performed of 272 patients of gross motor milestones and correlation with outcome, offers an alternative method to the clinician for determination of locomotor prognosis Achievement of head balance by nine months of age was an important indicator of good motor prognosis, while its achievement after 20 months indicated a poor prognosis. Sitting by 24 months as an indicator of favourable outcome confirmed the findings of previous studies (Molnar 1979, Watt ef ai. 1989). It was also observed that most children who were not able to sit by 30 months did not achieve ambulation. The analysis of crawling was carried out on a smaller number of patients (63) because only part of the population studied acquired this skill. Nevertheless, we found that crawling at 30 months was a predictor for good prognosis. Children who did not craw! before 61 months did not walk. Early definition of locomotor prognosis in cerebral palsy allows short- and long- term functional goals of treatment to be established, and contributes towards a comprehensive approach to management. Accepted for publication Ist July 1993. ‘Acknowledgements ‘The authors are grateful to E. G. Catanho, S. M. Denucei, L. V. de Melo Pinbeiro, and L, Rosa e Sita fort pin olen the ata to MC. ‘Almeida and F. M. Bercott for statistical analysis: and to M. Forman for editorial assistance Authors’ Appointments i. (Cerebral Palsy Unit, SARAH/HAL, Bi Brazil *Correspondence to third author at SARAH/nsituto Nacional de Medicina do “Aparelho Locomotor, ‘SMHS 501 CEP: 70330.150, Brasiia-DF, Brazil to determine for the spas prognosis for ambulation based on the ages at which children with cerebral palsy attain important {105s motor milestones. The variables analysed were age at last clinical assessment, clinical type of cerebral palsy and ages at attainment of gross motor milestones. Achievement of head balance before nine months was an important parameter for good prognosis for walking and, after 20 ‘months of age, an indicator for poor prognosis. Siting by 24 months indicated a favourable ‘outcome, and motor control of crawling at 30 months of age was a predictor for good prognosis. Based on these data, a chart for walking prognosis in children with cerebral palsy is presented. RESUME Pronostic de marche dans I'IMC: onalyse rétrospective de 22 ans Une étude rétrospective a été réalisée chez 272 patiems spastiques pour déterminer les crtéres de Pronostic pour la marche, basés sur IMige auquel les enfants IMC franchissent les étapes de la Developmental Medicine and Child Neurology, 1994, 36, 130-134 133 3 : g 8 ‘ é i $ x i g é 134 ‘motricité globale. Les variables analysées étaient Mage a la dernigre évaluation clinique, le type clinique d"IMC et les ages ob apparaissaient les reperes de la motricité générale. La bonne tenue de ‘te avant I'ége de neuf mois apparut un paramétre de bon pronostic pour la marche et, apres 20 ‘mois, un facteur de mauvais pronistic. S'asseoir & 24 mois indiquait un devenit favorable et un bon ‘ontrdle du ramper a 30 mois était une indication de bon pronostic. En s'appuyant sur ces données, tun tableau de pronostic de marche chez les enfants IMC est présenté, ZUSAMMENFASSUNG Prognose fur das Laufen bei Cerebralparese: eine retrospektive Analyse iber 22 Jahre Bei 272 spastischen Patienten wurde cine reirospektive Untersuchung durchgefurt, um Kriterien, basierend auf den Alterstufen, in denen Kinder mit Cerebralparese wichtige groBmotorische Meilensteine erreichen, herauszufinden, die eine Prognose fur das Laufenlernen zulassen. Die analysierten Variablen waren Alter bei der letzten klinischen Untersuchung, Klinische Form der Cerebralparese und Altersstufen, in denen groimotorische Meilensteine errcicht wurden, Kopfkontrolle vor dem neunten Monat war cin wichtiger Parameter fur eine gute Prognose fur das Laufen und nach dem 20sten Monat ein Indikator fr eine schlechte Prognose. Sitzen bis zum 24sten Monat zeigte einen gunstigen Outcome an und motorische Kontrolle beim Krabbein mit 30 Monaten war ein Parameter fur cine gute Prognose. Basierend auf diesen Daten wird eine Prognosetabelle fur das Laufenlernen bei Kindern mit Cerebraiparese vorgestelt. RESUMEN Prondstico de la marcha en ta parilisis cerebral: andlisis retrospectivo de 22 anos Se llevé a cabo un estudio retrospectivo de 272 espdsticos para determinar los crtetios para establecer el prondstico de la ambulacién, basado en las edades en que los nitos con pardlisis cetebral alcanzaban los hitos motores mas importantes. Las variables analizadas eran la edad de la ‘ltima evaluacién clinica, el tipo de paralisis cerebral y las edades de los principales hitos motores. alcanzados. El conseguir la cabeza erguida antes de los neuve meses fue un importante pardmetto para un buen pronéstico de la marcha y si le hacia después de los 20 meses era un indicador de mal Prondstico. 1a sedestacion a los 24 meses indicaba un prondstico favorable y la capacidad para arrastrarse era un predictor de buen prondstico. Basindose en estos datos se presenta un mapa pa 1 prondstico de la deambulacién en ninos con paralisis cerebral. References ‘Alberman, E, (198) “Describing cerebral pases: ‘method of clasiving and cousin.” Stanley, FE. Alberman, E(Eds.) The Epidemiology of tre Cerebral "Posies. Clee. in Developmental Medic, No.7. London Mac Keth Pes. ih Baddel'Ribera, A. (1985) ‘Cerebral palsy esturaliocomotor prognosis “in, spasnc Gplegia” Archiver of Phrstca! Medkine and Rehebilation, 66, 614-619. Bax. M.C.O-(1960)"Terminoiogy and clasifiation ‘of cerebral palsy” Developmental Medicine and hid Neurology, 6 95-299. (Annotation) Bayley, N. (1969) Monual for the Bayly Scots of Infant Deropment New York: Psychologica ‘rporanon Bla, B Sianfey, F. (1985) “Interobserver agree tment in the tiasfeaion of cerebral. pay Developmental Medicine and Child: Newolog), HH sis-on Blech, EE’ (1915) ‘Locomotor prognosis in Cetcbrol palsy” Developmental” Medeine on Child Neurology, 17, 18-25. C815) Ori resement of Cerebral Paty, Phiadeipha, PAC WB Saunders Cones, By Paes Re'S. (195) ‘The Narra History of CerbePaisy. (Reprinted Claes {nDevelpmental etn No 2) Condon at th ree Harr, 5 {1967 Early nearomotar predic. of cerebral palty” in low bcthweght nan Beveopmtntal Medicine and Chid Neurol), Matar. E979) ‘Cerebral od ‘Molar GE: 1978) Cerebral ply: propos aw io judge it Pech Annas. & 3-406 "Gordan: U! (99) ‘Cerebral psy: predic value of” ected velineal signs for ealy Brotostiation of motor function Archies 9 Pitre! Mediome ond Reheiahon Sh Isis ‘Watt... Robertson, C.M.T., Grace, MG. A st) prognosis. for” ambulation” of neeaal eene artyras wh ere 3 al Medicine and Reurology, 31 66713

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