|Year : 2015 | Volume
| Issue : 2 | Page : 94-100
Relation of quality of upper limb to independent gross motor and manual ability function in children with spastic diplegia
Rajashree Fadnavis1, Gajanan Bhalerao2, Vivek Kulkarni1, Nilima Bedekar1
1 Sancheti Institute College of Physiotherapy, Sancheti Hospital, Pune, Maharashtra, India
2 Department of Physiotherapy and Rehabilitation, Sancheti Hospital, Pune, Maharashtra, India
|Date of Web Publication||7-Jan-2016|
Department of Physiotherapy and Rehabilitation, Sancheti Hospital, Pune, Maharashtra
Source of Support: None, Conflict of Interest: None
Background: Most of the children having spastic diplegia show variability in upper limb and upper trunk functions. Due to this variation in upper limb and upper trunk, the quality of upper limb function may affect and limit the independence of functional activities in these children. Hence, this study aimed to find the relation of the quality of upper limb function to independent gross motor and manual ability function in children with spastic diplegia.
Materials and Methods: Overall, 30 children (both girls and boys) who were diagnosed with spastic diplegia (age ranged 4 to 8 years) were included. Children having any musculoskeletal deformity of upper limb or fracture or who had undergone administration of botulinum toxin or soft tissue release surgery in last 6 months or who were unable to follow commands were excluded from this study. Included children were classified in gross motor function classification system (GMFCS) and manual ability classification system (MACS) level. The outcome measures used were quality of upper limb function, which was assessed using quality of upper extremity skills test, and self care was assessed using self care domain of functional skills with its caregiver assistance of pediatric evaluation of disability inventory (PEDI). The data were analyzed.
Results: Spearman coefficient of correlation was calculated. The quality was found having moderate correlation with GMFCS (−0.459) and MACS (−0.589), while it strongly correlated with self care domain of functional skills (0.647) and caregiver assistance of PEDI (0.666).
Conclusion: The quality of upper limb functions was affected in children with spastic diplegia. This was reflected on self care domain along with caregiver assistance of PEDI.
Keywords: Disability inventory, self care, spastic diplegia, pediatric, upper limb
|How to cite this article:|
Fadnavis R, Bhalerao G, Kulkarni V, Bedekar N. Relation of quality of upper limb to independent gross motor and manual ability function in children with spastic diplegia. Indian J Cereb Palsy 2015;1:94-100
|How to cite this URL:|
Fadnavis R, Bhalerao G, Kulkarni V, Bedekar N. Relation of quality of upper limb to independent gross motor and manual ability function in children with spastic diplegia. Indian J Cereb Palsy [serial online] 2015 [cited 2017 Apr 23];1:94-100. Available from: http://www.ijcpjournal.org/text.asp?2015/1/2/94/173446
| Introduction|| |
Spastic cerebral palsy is the most common and accounts 70-75% of all cases.  In topographical classification, spastic diplegia is known to have more difficulties in lower limb than upper limbs due to periventricular leukomalacia.  During normal development grasping, gripping and bimanual coordination required for the skillful activities of upper limb in daily life situations starts developing by the age of 6 months, which becomes adult like by age of 4 years.  Independence in the basic activities of daily living is fully developed by around 7 years of age. , Hence, this period of 4-8 years of childhood development is crucial for the acquisition of self-care skills, and it is difficult to achieve independence if fine and gross motor skills are significantly impaired. ,
Any atypical limb use during the critical periods of corticospinal tract development may result in abnormal upper limb movement synergies such as recruitment of excessive trunk movement (motor compensations). , Most of the spastic diplegic children are mobile with or without assistive devices and variability was seen in upper limb and upper trunk, while the lower trunk functioned in a similar pattern.  As a result, they perform activities of self-care, education, and social interaction with upper limb motor deficits seen in reaching, grasping, and prehension. , So will quality of upper limb skills be related to independent functioning? Thus, this study aimed to assess quality of upper limb skills in different levels of gross motor and manual ability classifications and in daily self-care skills, thus finding the relation of quality of upper limb to independent gross motor and manual ability function in self-care skills.
| Materials and methods|| |
After institutional ethical clearance, an observational cross sectional study of 30 children with both girls and boys diagnosed as spastic diplegia from the age of 4 years and above till 8 years were included. Children having any musculoskeletal deformity of upper limb or fracture or who had undergone BOTOX or release in last 6 months or who were unable to follow commands were excluded. The flowchart depicts the screening, sampling, and assessment in the study. Included children were classified in gross motor function classification system (GMFCS) and manual ability classification system (MACS) level; thus, giving level of independence. The children in both level 1 and 2 of both classifications were considered independent. ,, The quality of upper limb function was assessed using quality of upper extremity skills test (QUEST), which has four components of dissociation, grasps, weight bearing, and protective extension.  The self-care was assessed using self-care domain of functional skill of pediatric evaluation of disability inventory (PEDI) and the level of assistance was assessed using its caregiver assistance. It was administered through various procedures such as structured interview with parents, observations of the child by caregiver's teachers or therapist, and professional judgments by the therapist or the teachers. PEDI is a valid assessment of functional activities in children with disabilities with high interrater reliability for the summary scores (from 0.85 to 0.98) when administered as a parent interview. Its each individual domain of functional skills is reliable. The reliability of self-care domain is 0.94. , A statistical analysis was performed using SPSS version 12.0 (SPSS Inc,Chicago,IL,USA) and correlation between quality and MACS, GMFCS and self-care component of PEDI was calculated. In addition, the individual components of QUEST were correlated with MACS, GMFCS, and self-care component of PEDI. Nonparametric test of Spearman's coefficient of correlation was used for all the variables.
| Results|| |
A total of 30 children were included in the study and were assessed for quality of upper limb skills. The mean distribution of children according to age, QUEST, and self-care and caregiver components of PEDI in different level of GMFCS and MACS is given in [Table 1]. The independence in gross motor and manual ability was considered according to GMFCS and MACS levels, respectively, along with their self-care activities and caregiver assistance are represented in [Table 2]. The correlation of QUEST with GMFCS, MACS, and self-care domain of functional skills along with caregiver assistance of PEDI are shown in [Table 3]. The correlation of different components of QUEST with GMFCS, MACS, and self-care domain of functional skills along with caregiver assistance of PEDI are represented in [Table 4]. The distribution of hand rating of dominant side and bilateral hands components of QUEST in different levels of GMFCS and MACS is represented in [Table 5].
|Table 1: Distribution of spastic diplegic children in relation to QUEST scores, functional skills scores, and caregiver assistance scores in PEDI with their number and mean age as per levels of GMFCS and MACS |
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|Table 2: Distribution of QUEST scores, self-care component of functional skills, and caregiver assistance as per independent and dependent levels of GMFCS and MACS |
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|Table 3: Correlation of QUEST with GMFCS, MACS, and self-care domain of functional skills along with caregiver assistance of PEDI |
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|Table 4: Correlation of different components of QUEST with GMFCS, MACS, and self-care domain of functional skills along with caregiver assistance of PEDI |
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|Table 5: Distribution of hand rating of dominant side and bilateral hands components of QUEST in different levels of GMFCS and MACS |
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| Discussion|| |
To be independent is an ultimate goal of life, which is reliant on the ability to perform gross motor and manual ability functions self-sufficiently. From the age of 4 years and onward, children intend to be independent with their self-care activities. , However, there are many parameters which restricts this freedom, especially in children with spastic diplegia. Earlier literature has focused on relation among gross motor, manual ability, and self-care skills in children with spastic cerebral palsy.  However, relation of quality of upper limb with independent functioning in self-care skills was least spoken. Hence, this study focused to target the independent functioning in diplegics with respect to quality of upper limbs.
The goal of the classifications in the assessment of cerebral palsy children is to assist in the communication between clinicians, select homogeneous groups of children for clinical research trials, facilitate the development of rating scales to assess improvement or deterioration with time, and eventually, to better match individual children with specific therapies.  Children categorized in levels 1 and 2 of GMFCS and MACS classifications were considered independent [Table 2]. However, in this study, it was found that in functional situation, where upper and lower limbs works in coordination, this complete independence was still not evident. This was reflected on self-care skills scores in PEDI where even minimal caregiver assistance in the form auditory cues was required to hasten the task being performed. On analysis, the component which seemed to reduce independence was quality as assessed with QUEST. This could explain why the quality of upper limbs plays a key role in bringing about smoothness and fluidity to performed movement. While spastic diplegics categorized in level 3, 4, and 5 [Table 2], who were considered dependent on gross motor and manual ability classifications, were found to have further involvement of self-care skills. This could be because as the quality of upper limbs reduces in standing, child spends more time in W-sitting providing wide base of support (BOS) with hands free to support, reach, manipulate, and play. The position produces inefficient lower trunk extension due to which the overhead reach, erect sitting, and lower trunk weight shift becomes difficult.  Thus in our study, children classified in higher levels required greater assistance as observed on PEDI with the quality of upper limbs being further reduced.
However, most of the studies showed that there are very few spastic diplegics who fall in GMFCS level 4 category. ,,, Palisano et al. mentioned that children initially classified in Levels 2, 3, and 4 were more likely to be reclassified if under the age of 6 years as they could produce changes in usual methods of mobility over a 3-4-year period along with therapy.  This could be, because children below 4 years in GMFCS are categorized on basis of quality of movement and ease of sitting, crawling, pulling to stand, cruising, and not on ability to walk alone.
To check what actually affects the quality of upper limbs, so that can be focused in the therapy, this study correlated GMFCS scores and QUEST and found moderate inverse correlation (r = −0.459), which implied that higher the deficit of gross motor function, the quality of upper limb skills further reduces. The correlation of MACS scores with QUEST showed a moderate inverse correlation (r = −0.586) suggesting that if the manual ability was affected, the quality also reduced. On correlating the scores of self-care domain of functional skills (r = 0.647) along with caregiver components (r = 0.666) of PEDI with QUEST, a strong correlation was obtained indicating that better quality of upper limb will lead to better functioning in daily activities. Thus it is the functional activity, which is being performed defines the quality of upper limb [Table 3].
Accordingly, we found that quality of upper limb plays a noteworthy role in independent functioning. To elaborate quality, this study explored the four components of QUEST and found its correlation with GMFCS, MACS, and self-care component of PEDI [Table 4].
In this study, the first component of QUEST, i.e., dissociation showed a weak correlation with GMFCS, while with MACS and self-care and its caregiver components of PEDI, a moderate correlation was observed. This could be due to poor individuation which results in excessive and unintended motion at linked body segments.  Spastic diplegic show complete isolation of movement at each joint of each limb, but when movements are initiated with lower extremities as BOS there is lack of individuation which affects the relation with GMFCS. , The dissociation component of QUEST assessed only individual joints, but the MACS involved the ability to handle objects with both the hands functionally, which eventually influenced the relation of MACS with dissociation component.  However, most of the activities of daily living involve trunk and both the upper extremities, while in spastic diplegic, trunk rotation was found to be significantly affected due to locking of upper part of lumbar spine, rib cage elevation, and weak obliques.  Thus, justifying the relation of dissociation component of QUEST with PEDI.
The second component of QUEST, i.e. grasp also showed a weak correlation with GMFCS, while a moderate correlation was seen with MACS, but a strong correlation was obtained with self-care component and its caregiver assistance. This could be because the presentation of posture and function of upper limb worsens only when the lower body becomes responsible for BOS and initiates movement. While in QUEST, the grasp was assessed in sitting or ring sitting where the BOS remained stable and it did not influence the upper limb.  Thus, explaining why the GMFCS was weakly correlated with grasp component. MACS judged manual ability on the basis of handling the object irrespective of pattern of grasp, (primitive or mature) or alignment of trunk, but in this study while assessing the grasp component of QUEST, the trunk alignment was considered. However, in our study, still a moderate correlation was seen between MACS and grasp component because these children attempted pivoting in prone, but due to lack of active lower limbs movements the thenar muscles did not elongate sufficiently. A strong correlation of grasp component with PEDI could be because these children show inability to elongate thenar muscle sufficiently and due to habitual walking by substituting with the upper body the perception of grasps and grips are affected.  Rather than simultaneously activating grip and lift forces they sequentially coordinate, leading to disorganization in most items of self-care activities; thus, increasing the assistance. 
The third component of QUEST, i.e., weight bearing showed a moderate correlation with GMFCS, while MACS, self-care component, and its caregiver assistance showed strong correlation. The moderate correlation of weight bearing with GMFCS could be due to the reason that diplegics face difficulties in fine-tuning the degree of postural muscle contraction to the task specific conditions. However, the postural control is intact and they could access to direction-specific postural adjustments appropriately.  Thus, they attempt and show symmetry with posture, but skills are not yet refined. A strong correlation of weight bearing with MACS was seen because diplegics often voluntarily stiffen their arms while trying to do what lower extremities cannot do; thus, on shifting the weight, the manual skills are further affected.  Spastic diplegics shift weight from the upper trunk and upper limbs with many a times disconnection from lower trunk and lower limb. Thus, affects the ability to perform self-care activities as it is further challenged. As a result, more assistance was required. This could suggest why a moderate correlation of weight bearing component with self-care components of functional skills along with care giver assistance of PEDI were seen in this study.
The fourth component of QUEST, i.e., protective extension showed weak correlation with GMFCS and self-care component along with its caregiver assistance of PEDI, while only MACS showed a moderate correlation. When any perturbation is given to displace the center of gravity out of BOS, the feed forward system is challenged in an attempt to recover the postural control. From 5 years onward, a mild preference for top-down recruitment emerges, while in spastic diplegics, differences were observed in recruitment order, latencies to activate postural muscle, along with a higher level of antagonistic co-activation.  Thus, a weaker correlation was seen between GMFCS and protective extension component of QUEST. The spastic diplegics tend to adopt a high guard posture in challenging tasks affecting the manual ability; thus, a moderate correlation was seen between MACS and protective extension.  If child adopts high guard posture, there would be difficulty in performing any task and the assistance required would be increased. This explains why, weak correlation was seen with protective extension and self-care skills of functional domain along with its caregiver assistance in PEDI.
In this study, other components of QUEST such as hand function rating, spasticity rating, and cooperativeness rating, which are subjective in nature were assessed.  Hand function rating showed a decrease in ranking in lower MACS and GMFCS level when the mean of dominance and bilateral hand rating were represented in the levels of GMFCS and MACS [Table 5]. This could be due to inefficient weight shift and decreased dissociation, the reduced functioning; thus, hampering the activity level. The spasticity measured in children with spastic diplegia for upper limb could be because of voluntary overuse of upper limb to stabilize them in challenging situation. In many studies, it is referred as apparently spastic. However, this apparent spasticity has a minimal effect on the quality of upper limb. 
As opposed to this, study done by Carnahan et al., ranked most spastic diplegic children in lowest level of GMFCS and MACS category.  This may be because as most of these children attend normal school and rarely come for therapy. While in this study, sample was collected from special schools and rehabilitation centers and camp; so these children could not be traced. Thus a further study, with significant birth history in the same population could be conducted across all the schools in a region.
Thus, most of the diplegic showed reduced quality in the upper limbs, which was eventually portrayed in independent functioning of self-care activities, even though if it is not a primary deficit.
Thus, we concluded that although GMFCS and MACS levels, 1 and 2, are considered independent, the functioning in self-care activities was still affected, as quality of upper limbs was found to be affected. As child becomes dependent, the levels of GMFCS and MACS increased while the quality of upper limbs skills further reduced. Clinically, we can imply that the quality of upper limb should be focused along with lower limb in diplegics.
The authors would like to thank Principal at Savali association for MR and HCP at Kothrud, Awakening Jagruti at Hadapsar and Apang Kalyankari Sanstha at Wanowrispecial schools; pediatric neurological camp at Nanded; Paediatric Department at Sancheti Hospital for permitting to conduct the study and the children who participated in this study. And, also special thanks to Dr. Rachana Dabadghav for helping with the statistics.
Financial support and sponsorship
Sancheti Institute College of Physiotherapy.
Conflicts of interest
Author Dr. Gajanan Bhalerao is one of the reviewers in Indian Journal of Cerebral Palsy.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]