Functional profiles of children with cerebral palsy in Jordan based on the association between gross motor function and manual ability

Cerebral palsy (CP) is the most common cause of physical disability in childhood [1]. A major challenge for delivering effective services for children with CP is the heterogeneity of the medical condition. Variety of clinical presentations can be observed in children with CP ranging from children who can ambulate and handle objects independently to children who have severe limitations in mobility and manual abilities further complicated by associated health conditions such as epilepsy and cognitive problems [2]. Therefore, it is useful to categorize children with CP into more homogeneous groups based on their functional profiles. The use of functional profiles in clinical sittings is expected to provide comprehensive description of abilities of children with CP which consequently may improve service planning and research.

Functional profiles of children with CP can be described utilizing functional classifications such as the Gross Motor Function Classification System- Expanded and Revised (GMFCS-E & R) [3, 4] and the Manual Ability Classification System (MACS) [5]. Functional classifications are consistent with the premises of the International Classification of Functioning, Disability, and Health (ICF) [6]. The ICF shifts the health professionals’ attention from focusing on primary motor impairments to functional activities and social participation which are considered the optimal outcomes of medical services for children with CP [6]. Functional classifications are useful in setting functional goals and planning services for children with CP in health care systems [3‐5].

Associations between the GMFCS-E & R and the MACS allow description of functional profiles of children with CP [7]. The GMFCS-E & R is the first activity-based classification system that was developed to classify children with CP in five levels based on their current performance in gross motor function [3]. Later, the MACS was developed in order to classify manual abilities of children with CP [5]. Both classifications demonstrated acceptable reliability and validity in classifying children with CP and the GMFCS-E & R is reliable to be used in Arabic language [8]. The GMFCS-E & R and the MACS describe different but complementary motor functions and between them, GMFCS-E & R and MACS provide a good description of the functional profiles of children with CP [9]. The associations between the two functional classifications vary based on the subtypes of CP. Previous research found that the strength of associations among the GMFCS-E & R and the MACS based on subtypes of CP were strong to moderate for quadriplegia and hemiplegia and poor to fair for diplegia [10, 7, 11, 12].

Although the GMFCS-E & R and the MACS are available in Arabic language they are not being used in any clinical sittings in Jordan. Health professionals are accustomed to use the traditional impairment-based classification of CP than the functional classifications [13]. Consequently, rehabilitation services for children with CP are focused on treating impairments rather than improving activity and participation of children [13]. For example, physiotherapists who provide services for children with spastic quadriplegia focus on stretching and strengthening more than mobility and activity of daily living training [13]. Utilizing functional profiles might therefore provide a framework to classify children with CP based on their levels of function, and tailor rehabilitation services in Jordan towards outcome that are meaningful to children with CP and their families.

To our knowledge this is the first study in a low-income and middle-income country to describe functional profiles of children with CP based on GMFCS-E & R and MACS. Functional profiles are expected to shift the focus of rehabilitation in Jordan from impairment-based towards function-based services. In addition, functional profiles can be used to guide service planning and to allocate limited resources in areas of major needs of children with CP. We hypothesized that the gross motor function and manual abilities will vary within subtypes of CP and age groups. Variations between the GMFCS-E & R and the MACS by subtypes indicate the need to use functional classifications in addition to motor subtypes to accurately classify children with CP. Variations between the GMFCS-E & R and the MACS based on chronological age of children indicate the presence of a variety of functional abilities supporting the need to use more than one classification system to classify children with CP accurately. The aims of this study; therefore, were to (1) to describe functional profiles of children with CP based on the GMFCS-E & R and the MACS; and (2) to examine associations and agreements between the GMFCS-E & R and the MACS for all participants then for subgroups based on subtypes of CP and chronological age of children.

Examination of functional profiles of children with CP in our study revealed that 53% of the participant children have severe limitation in gross motor functions (I.e., Levels IV and V GMFCS-E & R). This suggested that the majority of children who receive services in the public health care sector in Jordan have severe limitations in the gross motor functions. Describing functional profiles for children with CP in Jordan is expected to inform policy makers about the needs of children and their families. Implications for decision makers are to assure that public health care sector is being equipped to meet the extensive needs of children with severe limitation of function such as: wheelchairs, assistive devices, orthosis, and environmental modifications to enhance their functional activity and participation.

In congruence to research performed in other countries, we found a strong correlation yet poor agreement between the GMFCS-E & R and the MACS [7, 9‐12]. This indicates that the two classifications complement each other and describe different types of activities of daily living which are ambulation and manual abilities of children with CP. The utilization of the two classifications by health professionals in Jordan is recommended to provide an accurate description of the functional performance of children with CP. Current rehabilitation practices in Jordan are based on traditional classifications of CP rather than functional classification, with focus on impairment rather than function-based interventions. Using functional classifications in practice is expected to shift the focus of rehabilitation professionals from impairment-based to functional-based practices, consequently, improving outcomes of services.

Functional profiles were differentiated based on subtypes of CP but the observed patterns were not consistent with the subtype’s definitions. The most common functional profile of children with diplegia was “manual abilities better than gross motor function”. This functional profile is consistent with the definition of diplegia, yet 30% of the children demonstrated other functional profiles. Also, the most common functional profile in the group of children with quadriplegia was “manual abilities better than gross motor function”. Although the term quadriplegia indicates involvement of both upper and lower extremities due to extensive injuries of the sensorimotor areas of the brain [7], 35% of children with spastic quadriplegia had equal fine and gross motor abilities, and 6% had gross motor functions better than manual abilities. These findings suggests that subtypes of CP include children with different functional abilities, highlighting the importance of using more reliable and accurate functional classifications to describe children with CP. A recommendation for health professionals is to combine traditional classifications with more reliable functional classifications when evaluating children with CP to provide comprehensive description of children with CP and guide service planning.

Functional profiles of children were differentiated based on children’s chronological age. Forty five percent of children with CP between two and four years of age demonstrated a profile of “equivalent gross motor and manual abilities”, whereas 61% of the children between four and six years of age and 83% of children older than six years demonstrated a profile of “manual abilities better than gross motor function”. This indicates that children in older age groups demonstrate better manual abilities than gross motor functions. Manual abilities and hand functioning require higher cognitive abilities and motor control than gross motor functions and occur at older ages which might explain increasing percentages of children in advanced manual abilities profiles in older age groups [9]. These findings should be interpreted with caution due to the convenience sampling method used in recruitment; most of the participants were recruited from physiotherapy clinics were children are usually referred due to gross motor function rather than manual abilities limitation. The influence of children’s age should be further examined with a population-based sample to confirm our findings.

Applications of functional profiles of children with CP can inform clinicians, researchers, and policy makers in Jordan. Clinicians can use the functional profiles to select appropriate treatment approaches based on child’s level of function, and to inform parents and help them to set up goals and plan for their children. For example children with better functional profiles (i.e. better gross motor and fine motor abilities) are more likely to function well in everyday activities in home, school, and community requiring services that are more focused on participation outcomes and integration in the community. Whereas children with limited functional profiles (i.e. profiles of limited gross motor and fine motor abilities) are more likely to demonstrate limitations in activity and require more assistance requiring more intensive treatment plans that focuses on activities of daily living and independency [17, 18]. The use of functional classifications among clinicians can improve communication and coordination of services. Researchers can use functional profiles in clustering children with CP in homogeneous groups to conduct focused intervention studies. Policy makers can use functional profiles to anticipate needs of children with CP and their families and to insure availability, accessibility, and coordination of services required to fulfill these needs.

This study shows important strengths in that participant children were all classified by criterion tested physio- and occupational therapists with parents’ consensus on classifications levels. In addition, participant children had the GMFCS-E & R and the MACS levels determined by the same therapist. The results of the study should be considered in light of some limitations in relation to sample size and selection of participants which might limit generalization of results. This also raises the need for population-based sample to be able to examine the national profiles of children with CP in Jordan and allow for international comparisons.

Health professionals in Jordan are encourage to use both the GMFCS-E & R and MACS in addition to traditional subtypes classification in order to classify children with CP with focus on function rather than impairment. Both the GMFCS-E & R and the MACS provide complementary but distinctive information related to mobility and handling of children with CP, supporting the need to use the two classification to provide comprehensive description of abilities of children with CP. Functional profiles of children with CP provide a practical and easy way for assessment to plan for services, guide provision of interdisciplinary and comprehensive services for children with CP, and enhance communication among professionals who provide services for children with CP and their families in Jordan.