Utilization of the ICF-CY for the Classification of … · classifiedin the lowest and...

506 JCOM November 2014 Vol. 21, No. 11 www.jcomjournal.com

TreaTmenT ObjecTives

ABSTRACT• Objective:Toidentifyobjectivesfortreatmentofspas-

ticity with botulinum toxin type A (BTX) in childrenwith cerebral palsy (CP), standardize theobjectivesaccording to typology, and classify them accordingto the International Classification of Functioning forChildrenandYouth (ICF-CY),aswell as toanalyzetreatment goals in relationship to CP clinical type,severitylevel,andage.

• Methods:188childrenwereincludedinthestudy(meanage,12years;42%female,58%male).Thediplegictypemadeup38%ofCPcases,thetetraplegictype35%,and the hemiplegic type 24%. Children were mainlyclassifiedinthelowestandhighestlevelsintheGrossMotor Function Classification System (GMFCS 1,39%; GMFCS 5, 26%). Treatment objectives for in-dividual therapies were discussed, identified, andtranscribed in the therapeutic proposals. The objec-tiveswerethencollectedandsubjectedtoaninternalaudit inorder tostandardize theirdenomination.Twotrainedhealthcareprovidersexpert intheuseoftheICF-CY classification mapped the objectives to ICF-CYdomainsandcategories.Theobjectiveswerethenanalyzed in relationship to CP clinical type, GMFCSlevel,andage.

• Results:Oftheobjectives,88%(246)wereinthe“BodyFunctions”domain. In thisdomain, therewere28 ty-pologiesofobjectivesin6categories.Only12%(32)oftheobjectiveswereinthe“Activity”domain;therewere11typologiesin5categories.Indiplegicandhemiple-gicpatientswithmilddisability(GMFCS1),objectiveswereaimedatimprovinggaitpattern.Forquadriplegicpatientswithseveredisability (GMFCS5),objectiveswereaimedmainlyatcontrollingdeformitiesand im-proving health care provision. Objectives concerningpain treatmentwereproposedprincipally forpatientswithdiplegicandquadriplegictypeCP.

• Conclusions:TheICF-CYcanbeusedtocategorizetreatment objectives proposed for patient improve-mentinthedomainsofBodyFunctionsandActivity.Goalsetting forBTX injectionsoccursmainly in theBodyFunctionsdomainandaimsatfindingchangesinthegaitpattern.

Botulinum toxin type A (BTX) has been used for 20 years for the focal treatment of spasticity in patients with cerebral palsy (CP) [1–3]. While

numerous studies have shown the functional benefits of BTX treatment, especially if carried out in combination with other treatments (eg, physiotherapy, occupational therapy, serial casting), studies that focus on the indica-tions for BTX use are limited.

Patients with CP require rehabilitation that involves multiple disciplines and multiprofessional therapeutic programs (eg, pharmacologic, orthotic, physiothera-peutic). The complexity of both the program and the pathology requires choosing the appropriate treatment objectives. The International Classification of Function-ing for Children and Youth (ICF-CY) [4] is a unified and standard language and framework for clinical, public health, and research applications to facilitate the docu-mentation and measurement of health and disability in child and youth populations. As such, it can be used to inform clinical thinking, practice and research in the field of cerebral palsy [5], including being used as a tool for developing treatment plans and providing a common language for defining and sharing treatment objectives with patients and families [6]. Thamar et al [7] recently pointed out the value of adopting a standardized method of writing specific and measurable goals. Goals that are

Utilization of the ICF-CY for the Classification of Therapeutic Objectives in the Treatment of Spasticity in Children with Cerebral PalsyNicoletta Battisti, Sandra Bertana, Anna Rosa Colonna, Francesca Pulvirenti, Antonella Cersosimo, and Milena Pagnoni

From the IRCCS Institute of Neurological Sciences, Bellaria Hospital, Bologna, Italy.

www.jcomjournal.com Vol. 21, No. 11 November 2014 JCOM 507

specific and clear are important not only for the evalua-tion of efficacy but also for systematic evaluation of the quality of health services [8,9].

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 Environmen-tal Factors), which each contain heirarchically 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 pro-grams; 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 denomina-tion. 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 fami-lies. 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 de-nomination, classify them according to ICF-CY domains and categories, and establish their relative frequency. A fur-ther objective of the study was to analyze treatment goals in relationship to the clinical type (eg, hemiplegia, diple-

gia, 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 dis-ability 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 physiothera-pists for eligibility for BTX injection according to the recommendations of Ferrari and Cioni [17]. Functional assessment included evaluation of impairments (spastic-ity, 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 physio-therapist, shared among the health care providers and the patients and their families, and added to the writ-ten 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 uni-form denomination of the proposed therapeutic objec-tives. 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 accord-ing to GMFCS, and age. The frequency of the individual objectives, domains, and categories was evaluated by means of descriptive statistics.

Original research



RESULTS

The mean age of the children was 12 years; 42% were female and 58% were male. The diplegic type made up 38% of CP cases, the tetraplegic type 35%, and the hemiplegic type 24%. GMFCS distribution

was as follows: Level 1 (mildest), 39%; Level 2, 11%; Level 3, 9%; Level 4, 25%; and Level 5, 26%. Among the 188 children with CP, a total of 278 objectives were identified. 88% (246) of these objectives were in the “Body Functions” domain, distributed among 6 ICF categories (Table 1). Thirty-two objectives fell under the “Activity” domain, distributed among 5 ICF categories (Table 2).

Body Functions DomainThe most represented category in the “Body Func-tions” domain was “b770 functions of gait pattern” (50%). There were 123 proposed objectives distributed among 11 typologies of objectives for a total of 123 proposed objectives in the functions of gait pattern cat-egory. The most frequent proposals were aimed at the reduction of equinus in the stance phase (n = 44) and reduce knee flexion in load (n = 17). The second most represented category was “b710 functions of joint mo-bility” (26%), in which 7 typologies of objectives were identified for a total of 64 objectives proposed, which were principally aimed at controlling joint deformities (Table 1).

In the “b715 functions of joint stability” category, 25 objectives were proposed for controlling hip lat-

Table 1. TherapeuticObjectivesintheBodyFunctionsDomain

Body Functions Frequency

b710 Functions of Joint Mobility

Toreduceequinusofthefeet 12

Toreducewindsweptofthelowerlimbs 6

Toreducehiphyperadduction 8

Toreducekneeflexion 16

Toreducewindsweptofthefeet 2

Toreducedeformityinwristflexion 11

Toreducedeformityinelbowflexion 9

b770 Functions of Gait Pattern

Toreduceequinusinstance 44

Toreducefootvarussupination 7

Toreducefootinversioninoscillation 7

Toreducekneeextensioninload 9

Toreducekneeflexioninload 17

Toreducehipflexioninstance 12

Toreducehiphyperadduction 6

Toreducepelvicsupraelevation 8

Toreducepelvicretraction 7

Toreducehipintra-rotation 4

Toreduceinclinationofthetrunkonthesideonwhichweightisapplied

2

b715 Functions of Joint Stability

Toreducehiplateralization 25

b720 Functions of Bone Mobility

Toreducepelvicretroversion 8

Toreducepelvicanteversion 1

Toreducepelvicsupraelevation 4

Toreducepelvicrotation 2

b280 Pain Sensation

Toreducepaininthespinalcolumn 1

Toreducepaininthehip 5

Toreducepainintheknee 8

Toreducepainintheshoulder 1

b735 Functions of Muscle Tone

Toreducedystonicspasms 4

TOTAL 246

Table 2. TherapeuticObjectivesintheActivityDomain

Activity Frequency

d415 Maintain a Body Position

Toincreasethecapacityofremainingseated 6

Toreduceassistanceinrisingfromasupineposition 2

Toincreaseautonomyintheerectposition 4

d440 Use of the Hands

Toimprovehandlingobjects 4

Toimproverelease 1

Toimprovetripodpinchgrip 1

d445 Use of Hands and Arms

Toincreasereach 3

Toimproveinvolvement 1

d510 Washing Oneself

Toreduceassistanceinwashing 2

d540 Dressing Oneself

Toreduceassistanceingettingdressed 6

Toincreasebracewearability 2

TOTAL 32


eralization while, in the “b720 functions of bone mobility” category, 4 typologies of objectives were identified out of a total of 15 proposed objectives aimed at improving the position of the pelvis. The “b280 pain sensation” category was also used to indicate 15 objectives aiming at alleviating knee, hip and spinal column pain. Finally, 4 objectives were aimed at tone reduction.

Activity DomainAs concerns the “Activity” domain, 38% of objectives were classified into the “d415 maintain body position” category (3 typologies and a total of 12 proposals), 25% were in the “d540 dress oneself ” category (2 typologies and a total of 8 proposals), 19% were in the “d440 fine use of the hands” category (3 typologies and a total of 6 proposals), 13% were in the “d445 use of hands and arms” category (2 typologies and 4 proposals) and, 6% of cases were classified into the “d510 wash oneself” category (2 proposals) (Table 2).

Analysis by Type, Severity, and AgeDuring the analysis of data related to clinical type, sever-ity and age in the Body Function domain, the objectives aimed at improving gait pattern (“b770 functions of gait pattern”) were proposed for diplegic and hemiplegic patients with mild disability (GMFCS 1) (Figure 1 and Figure 2). These data refer to 30 hemiplegic and 29 diplegic patients with median age of 8 years (SD, 4 yr 1 mo). For quadriplegic patients with severe disability, the objectives aimed at controlling deformities in the “b710 functions of joint and bone mobility”or “b715 functions of joint stability” or “b720 functions of bone mobility” (Figure 3) categories. These data refer to 49 patients (39 GMFCS 5 and 12 GMFCS 4) with a median age of 7 years (SD, 4 yr 5 mo). 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 in-jections. They have been proposed especially for diplegic

Figure 1. Objectivesintheb770functionsofgaitpatterncategoryforhemiplegicpatients(GMFCS1).

Figure 2. Objectivesintheb770functionsofgaitpatterncategoryfordiplegicpatients(GMFCS1).

Original research

Toreducepelvicretraction

Toreducehiphyperadduction

Toreducehipflexioninload

Toreducekneeflexioninstance

Toreducekneeextensioninload

Toreducefootinversioninoscillation

Toreducefootvarus-supination

Toreduceequinusinstance

Toreducepelvicsupraelevation3

2

2

4

4

9

6

5

23

Toreduceinclinationofthetrunk

Toreducepelvicretraction

Toreducesupraelevationofthepelvis

ToreducehipintrarotationToreducehiphyperadduction

Toreducehipflexioninstance

Toreducekneeflexioninload

Toreducekneeextensioninload

ToreducefootinversioninoscillationToreducefootvarus-supination

Toreduceequinusinstance

2

4

6

4

4

2

3

3

88

21



(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 objec-tives 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 re-ported 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 dress-ing 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 popula-

Figure 3. Objectivesproposedfortetraplegicpatients(GMFCS5)intheBodyFunctionsdomain.

Figure 4. Objectivesproposedfortetraplegicpatients(GMFCS5)intheActivitydomain.

Toreducewindsweptofthefeet

Toreduceequinus

Toreducekneeflexion

Toreducehiphyperadduction

Toreducewindsweptofthelowerlimbs

Toreducepelvicrotation

Toreducepelvicsupraelevation

Toreducepelvicanteversion

Toreducepelvicretroversion

Toreducehiplateralization

2

9

15

8

6

2

1

4

8

25

b72

0b

710

b71

5

Toreduceassistanceingettingdressed

Toreduceassistanceinwashing

Toincreaseautonomyintheerectposition

Toreduceassistanceinrisingfromasupineposition

Toincreasethecapacityofremainingseated

d41

5d

510

d54

0

0 1 2 3 4 5 6

6

2

4

2

1


tion. 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 objec-tive 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 meth-odology provides for a common language that facilitates the communication and sharing of therapeutic objectives between different professionals (physiatrists and physio-therapists) and between health care providers and fami-lies and/or patients. This is important, as physiotherapy is often complementary to BTX injections and the objec-tives 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 evalu-ating 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.

ConclusionAs it has already been pointed out by various authors [10–15], the ICF-CY is a useful instrument for the classi-fication of proposed therapeutic objectives into domains and categories, in order to standardize the language and to increase the sharing of the aims between the health care providers and between providers and families/ patients. The most commonly followed approach calls for the use of functional profiles at the beginning of the care planning process, in order to establish the priorities and objectives of the interventions to be carried out. In order to streamline and facilitate procedures in clinical practice, many have proposed the use of core sets, but

the validation procedure is complex and not always pos-sible in all centers. Recently, Preston et al were the first to propose using the ICF-CY for classifying the objec-tives of an individual program. The procedure utilized is simple, easily reproducible, and allows identifying and classifying the objectives into categories using the ICF-CY. Furthermore, it is focused on an individual program and not on the entire articulation of programs, making interpretation of the data more linear. Our proposal is similar because it is focused on the analysis of an individ-ual therapeutic program and because it utilizes the ICF classification system to classify the objectives; however, it achieves a higher degree of detail and standardization of the objectives.

In conclusion, the classification structure of the ICF-CY furnishes a useful and recognized instrument for categorizing the objectives of the interventions to be carried out. The classification of the objectives is specific for each pathology and for each individual program. The standardization of the objectives themselves and the use of the ICF-CY categories only for classification represents a possible methodologic alternative to the use of ICF-CY individual categories and sub-categories for identifying these objectives (core sets), as proposed by other authors. This procedure offers greater detail and a greater degree of standardization, which is important for the successive and systematic evaluation of treatment results.

Corresponding author: Nicoletta Battisti, Via Altura 3, 40139 Bologna, Italy, [email protected].

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