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

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

Abstract

• Objective: To identify objectives for treatment of spasticity with botulinum toxin type A (BTX) in children with cerebral palsy (CP), standardize the objectives according to typology, and classify them according to the International Classification of Functioning for Children and Youth (ICF-CY), as well as to analyze treatment goals in relationship to CP clinical type, severity level, and age.
• Methods: 188 children were included in the study (mean age, 12 years; 42% female, 58% male). The diplegic type made up 38% of CP cases, the tetraplegic type 35%, and the hemiplegic type 24%. Children were mainly classified in the lowest and highest levels in the Gross Motor Function Classification System (GMFCS 1, 39%; GMFCS 5, 26%). Treatment objectives for individual therapies were discussed, identified, and transcribed in the therapeutic proposals. The objectives were then collected and subjected to an internal audit in order to standardize their denomination. Two trained health care providers expert in the use of the ICF-CY classification mapped the objectives to ICF-CY domains and categories. The objectives were then analyzed in relationship to CP clinical type, GMFCS level, and age.
• Results: Of the objectives, 88% (246) were in the “Body Functions” domain. In this domain, there were 28 typologies of objectives in 6 categories. Only 12% (32) of the objectives were in the “Activity” domain; there were 11 typologies in 5 categories. In diplegic and hemiplegic patients with mild disability (GMFCS 1), objectives were aimed at improving gait pattern. For quadriplegic patients with severe disability (GMFCS 5), objectives were aimed mainly at controlling deformities and improving health care provision. Objectives concerning pain treatment were proposed principally for patients with diplegic and quadriplegic type CP.
• Conclusions: The ICF-CY can be used to categorize treatment objectives proposed for patient improvement in the domains of Body Functions and Activity. Goal setting for BTX injections occurs mainly in the Body Functions domain and aims at finding changes in the gait pattern.

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 indications for BTX use are limited.

Patients with CP require rehabilitation that involves multiple disciplines and multiprofessional therapeutic programs (eg, pharmacologic, orthotic, physiotherapeutic). The complexity of both the program and the pathology requires choosing the appropriate treatment objectives. The International Classification of Functioning 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 documentation 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 specific and clear are important not only for the evaluation 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 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.