In the literature regarding rehabilitation (especially in adults) and, more recently, in the literature on CP [10], core sets derived from ICF that are condition- and setting-specific are increasingly being used. They are used for the evaluation of the functional profiles of patients and documentation of the results of rehabilitative treatment, and also for defining the objectives of the treatment. Some authors [11–14] have explored in detail the possibility of using the core sets for formulating treatment objectives and assessing outcomes. However, using the core sets is complicated and their use in day-to-day clinical settings is limited. In a recent study, Preston et al [15] sought to define a sub-set of functional goals and outcomes relevant to patients with CP undergoing BTX treatment that could be more appropriate for use. In this retrospective analysis, they used the ICF-CY to classify treatment goals into corresponding domains and categories. The ICF-CY contains 4 major components (Body Structure, Body Function, Activities and Participation, and Environmental Factors), which each contain hierarchically arranged chapters and category levels. The authors found that the goals were mainly in the domain of “Body Functions,” specifically “functions of joint mobility” and “functions of gait pattern.” Those in the “Activity” domain were in the “walking” and “changing body positions” categories. This study was the first to focus on CP as a pathology and on the objectives of the individual therapeutic programs; other reports in the literature deal with the entire articulation of treatment. The authors limited themselves to the identification of the domain and the category of the objectives but did not report in detail their denomination. A greater degree of specificity and standardization in the description of the objectives would be useful from a practical point of view both for comparing results and for improving communication between the health care providers, and between these professionals and the families. The authors also did not assess for the various clinical types of CP.
The aim of the present study involving patients having CP and undergoing BTX injections was to identify the treatment objectives, standardize them according to denomination, classify them according to ICF-CY domains and categories, and establish their relative frequency. A further objective of the study was to analyze treatment goals in relationship to the clinical type (eg, hemiplegia, diplegia, quadriplegia), level of severity according to the Gross Motor Function Classification System (GMFCS) [16], and age.
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.