Original Research

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

Journal of Clinical Outcomes Management. 2014 November;21(11)

References

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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.

Discussion

The results show that in the majority of cases, the objectives of treatment with BTX injections proposed by our group fell within the “Body Functions” domain, in the “b770 gait pattern” and “b710 joint mobility” categories. This focus has also been reported by other authors [18]. Furthermore, these results are analogous to those reported by Preston [15]. The objectives classifiable into the “Activity” domain were more limited in our group. The most represented categories were “d415 maintain body position,” as also reported by Preston, and “d540 dressing oneself.” Preston et al reported many more objectives in the Activity domain, also utilizing the “walking” category. A possible reason is that objectives may reflect more the expectations of professionals and less those of patients. Indeed, when objectives suggested by patients and families are taken into greater consideration, goals proposed in the Activity area notably increase [19]. It is probably necessary to evaluate the objectives relevant to the professionals and those significant to the families and children separately.

The discrepancies between our data and Preston’s also most likely reflect differences in the study population. In our study, those undergoing injections aimed at improving gait pattern are, for the most part, hemiplegic and diplegic patients with mild disabilities (GMFCS 1). Their elevated degree of autonomy in mobility probably accounts for the scarcity of objectives for improving walking autonomy. In the most severe cases, such as quadriplegia, objectives are mainly aimed at controlling deformities and facilitating health care provision. Pain reduction is another important aspect and concerned quadriplegic and diplegic patients with severe disability. In contrast, objectives related to muscle tone reduction were limited, as the main objective was not a reduction but the control of muscle shortening and the subsequent deformities. However, this can become a primary objective in cases of spastic hyperactivation (eg, in adductor muscles) or in the case of dystonia, to improve patient comfort.

From a practical point of view, the use of this methodology provides for a common language that facilitates the communication and sharing of therapeutic objectives between different professionals (physiatrists and physiotherapists) and between health care providers and families and/or patients. This is important, as physiotherapy is often complementary to BTX injections and the objectives must be shared with the family. This methodology can help the clinician in the decision-making process and allows determining with greater specificity what is to be measured to document the achievement of the objectives.

Future research in this field will be aimed at evaluating patient outcomes by means of the adoption of suitable instruments (measurement scales) in order to quantify results which are consistent, according to the ICF-CY classification, with the domain and the category undergoing analysis.