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1. Evaluation of Children
With Cerebral Palsy
based on ICF
Dr. Mohammad Khayatzadeh Mahani, Assistant Professor in OT
Ahvaz Jundishapur University of Medical Sciences
Tehran, oct 2017 1
‫تخصصی‬ ‫کارگاه‬‫جدید‬ ‫رویکرد‬‫بوبات‬‫در‬
‫توانبخشی‬
‫مغزی‬ ‫فلج‬ ‫به‬ ‫مبتال‬ ‫کودکان‬

2. Single system Body function and structure
Neuromuscular system
 Muscle tone
 Muscle Recruitment Activity
 Timing and Sequencing
 Muscle fiber morphology
Musculoskeletal system
 Joint ROM (AROM and PROM)
 Muscle strength
 Skeletal Changes
New Bobath Concept 2

3. New Bobath Concept 3

4. Muscle fibers
 Type I: These fibers are known as slow twitch fibers. They are red in color
due to the presence of large volumes of myoglobin and Mitochondria. Due to
this fact they are very resistant to fatigue and are capable of producing
repeated low-level contractions by producing large amounts of ATP through
an aerobic metabolic cycle.
 Type IIa: These fibers are known as fast oxidative fibers and are a hybrid of
type I and II fibers. These red fibers contain a large number of mitochondria
and Myoglobin. They utilize both aerobic and anaerobic metabolism and so
produce fast, strong muscle contractions, although they are more prone to
fatigue than type I fibers.
 Type IIb: Often known as fast glycolytic fibers. they are white in color due to
a low level of myoglobin and mitochondria. They produce ATP at a slow rate
by anaerobic metabolism and break it down very quickly. This results in
short, fast bursts of power and rapid fatigue.
4
New Bobath Concept

5. Single system Body function and structure
Sensory system
 Vision
 Tactile
 Proprioceptive
 Auditory
 Vestibular
 Respiratory system
 Cardiovascular system
 Digestive system
 Integumentary System
 Arousal/Attention System
 perception
 Cognition
New Bobath Concept 5

6. Multi system Body function and structure
Posture
 Postural tone
 Postural control
 Postural alignment and orientation
 Symmetry
 Weight shifting
 Balance
Movement
 Movement strategies
 Involuntary Movements
 Selective Voluntary Control
 Intra and inter limb coordination
New Bobath Concept 6

7. Activity
 Gross Motor Function
Classification System
 Manual Ability Classification
System
 Gross Motor Function Measure
 Goal attainment Scale
Participation
 COPM
 PEDI
 CAPE/PAC
 School function
assessment
New Bobath Concept 7

8. GMFCS – E & R
Gross Motor Function Classification System
Expanded and Revised
 The Gross Motor Function Classification System (GMFCS)
for cerebral palsy is based on self-initiated movement,
with emphasis on sitting, transfers, and mobility
 Distinctions are based on functional limitations, the need
for hand-held mobility devices (such as walkers, crutches,
or canes) or wheeled mobility, and to a much lesser
extent, quality of movement.
New Bobath Concept 8

9. GENERAL HEADINGS FOR EACH LEVEL
 LEVEL I - Walks without Limitations
 LEVEL II - Walks with Limitations
 LEVEL III - Walks Using a Hand-Held Mobility Device
 LEVEL IV - Self-Mobility with Limitations; May Use Powered Mobility
 LEVEL V - Transported in a Manual Wheelchair
New Bobath Concept 9

10. Distinctions Between Levels I and II
 Compared with children and youth in Level I, children
and youth in Level II have limitations walking long
distances and balancing
 may need a hand-held mobility device when first
learning to walk
 may use wheeled mobility when traveling long
distances outdoors and in the community
 require the use of a railing to walk up and down stairs
 and are not as capable of running and jumping.
New Bobath Concept 10

11. Distinctions Between Levels II and III
 Children and youth in Level II are capable of walking
without a hand-held mobility device after age 4 (although
they may choose to use one at times).
 Children and youth in Level III need a hand-held mobility
device to walk indoors and use wheeled mobility outdoors
and in the community.
New Bobath Concept 11

12. Distinctions Between Levels III and IV
 Children and youth in Level III sit on their own or require
at most limited external support to sit, are more
independent in standing transfers, and walk with a hand-
held mobility device.
 Children and youth in Level IV function in sitting (usually
supported) but self-mobility is limited.
 Children and youth in Level IV are more likely to be
transported in a manual wheelchair or use powered
mobility.
New Bobath Concept 12

13. Distinctions Between Levels IV and V
 Children and youth in Level V have severe limitations in
head and trunk control and require extensive assisted
technology and physical assistance.
 Self-mobility is achieved only if the child/youth can
learn how to operate a powered wheelchair.
New Bobath Concept 13

19. Manual Ability Classification System (MACS)
 MACS describes how children with cerebral palsy (CP) use
their hands to handle objects in the home, school, and
community settings (what they do), rather than what is
known to be their best capacity. MACS describes five
levels.
 The levels are based on the children’s self-initiated
ability to handle objects and their need for assistance or
adaptation to perform manual activities in every day life.
New Bobath Concept 19

20. MACS
 MACS intends to describe which level best
represents the child’s usual performance in home,
school and community settings.
 MACS level must be determined based on knowledge
about the child's actual performance in daily life. It
should not be done by conducting a specific
assessment but by asking someone who knows the
child and how that child performs typically.
 To determine the level of MACS, the child’s ability
to handle objects needs to be considered from an
age-related perspective.
 MACS intends to report the participation of both
hands in activities, not an assessment of each hand
separately.
New Bobath Concept
20

21. Level I:Handles objects easily and successfully.
 At most, limitations in the ease of performing manual
tasks requiring speed and accuracy.
 However, any limitations in manual abilities do not
restrict independence in daily activities.
New Bobath Concept 21

22. Level II: Handles most objects but with somewhat
reduced quality and/or speed of achievement
 Certain activities may be avoided or be achieved
with some difficulty
 alternative ways of performance might be used but
manual abilities do not usually restrict independence
in daily activities
New Bobath Concept 22

23. Level III: Handles objects with difficulty; needs
help to prepare and/or modify activities.
 The performance is slow and achieved with limited
success regarding quality and quantity.
 Activities are performed independently if they have been
set up or adapted.
New Bobath Concept 23

24. Level IV: Handles a limited selection of easily
managed objects in adapted situations
Performs parts of activities with effort and with limited
success.
Requires continuous support and assistance and/or adapted
equipment, for even partial achievement of the activity.
New Bobath Concept 24

25. Level V: Does not handle objects and has severely
limited ability to perform even simple actions
 Requires total assistance.
New Bobath Concept 25

26. Distinctions between Levels I and II
 Children in Level I may have limitations in handling very
small, heavy or fragile objects which demand detailed fine
motor control, or efficient coordination between hands.
 Limitations may also involve performance in new and
unfamiliar situations.
 Children in Level II perform almost the same activities as
children in Level I but the quality of performance is
decreased, or the performance is slower. Children in Level
II commonly try to simplify handling of objects, for
example by using a surface for support instead of handling
objects with both hands.
New Bobath Concept 26

27. Distinctions between Levels II and III
 Children in Level II handle most objects, although slowly
or with reduced quality of performance.
 Children in Level III commonly need help to prepare the
activity and/or require adjustments to be made to the
environment since their ability to reach or handle objects
is limited.
 They cannot perform certain activities and their degree
of independence is related to the supportiveness of the
environmental context.
New Bobath Concept 27

28. Distinctions between Levels III and IV
 Children in Level III can perform selected activities if the
situation is prearranged and if they get supervision and
plenty of time.
 Children in Level IV need continuous help during the
activity and can at best participate meaningfully in only
parts of an activity.
New Bobath Concept 28

29. Distinctions between Levels IV and V
 Children in Level IV perform part of an activity, however, they need help
continuously.
 Children in Level V might at best participate with a simple movement in
special situations, e.g. by pushing a simple button
New Bobath Concept 29

30. GMFM: Gross Motor Function Measure
 Development started in 1984
 Criterion-referenced test: evaluates performance of
motor skills on that day; useful for comparison over time
 Measures how much of a task the child can accomplish,
rather than how well the task is completed (quantity, not
movement quality)
New Bobath Concept 30

31. GMFM-88
88 items in 5 gross motor
dimensions
 lying and rolling
 crawling and kneeling
 Sitting
 Standing
 walking, running and jumping
GMFM-66
 Same dimensions, but 22
items eliminated (mostly
in lying position)
New Bobath Concept 31

32. Time required
 GMFM 88: approx. 45-60 minutes
 GMFM 66: faster, allows for some missing data (items that
are not tested)
 Can be completed in more than 1 session (ideally
complete all items within 1 week)
New Bobath Concept 32

33. Testing
 Items may be tested in any order, but be careful not to
miss any! (esp. when using the GMFM 88)
 Verbal encouragement or demonstration is permitted
 Maximum 3 trials for each item
 Spontaneous performance of any item is acceptable
New Bobath Concept 33

34. Scoring the GMFM
 Scores 0-3 or NT
 0- does not initiate task
 1- initiates task (<10%)
 2- partially completes task (10-99 %)
 3- completes task (100%)
 Sometimes generic scoring as above, other times specific
criteria for each level
 The score given is based on the best performance out of the 3
trials
 If undecided about what score to assign, choose the lower of
the 2 possible scores
 Any item that has been omitted or that the child is unable (or
unwilling) to attempt must be indicated as NT
New Bobath Concept 34

35. Item 36
On the floor: Attains sitting on
small bench
0 = does not initiate sitting
1 = initiates sitting
2 = partially attains sitting
3 =attains sitting
NT = Not tested
Generic Scoring Key
Initiates=completes less
than 10% of task
Partially completes=
completes >10% to less
than 100%
New Bobath Concept 35

36. #58: Standing:lifts R foot, arms free, 10 secs.
• 0= does not lift R foot, arms free
• 1= lifts R foot, arms free, < 3 secs.
• 2= lifts R foot, arms free, 3-9 secs.
• 3= lifts R foot, arms free, 10 secs.
New Bobath Concept 36

37. Scoring with aids/orthotics
 First complete the GMFM without the aid/orthoses, then
retest with aid/orthoses
 For repeat testing at a later dater, apply the same aid at
the same item number
 Aids/orthoses could have positive and negative effects
 Mark an “A” for the aided score on the score sheet
New Bobath Concept 37

38. GMFM-66
 Only 66 items administered (asterixed on score sheet)
 Enter scores into the computer program: Gross Motor
Ability Estimator (GMAE)
 Not possible to calculate the score with pencil and paper
New Bobath Concept 38

39. Case Summary Report
 Summarizes demographic data
 Summarizes score, including error (standard error and 95%
confidence interval)
 Graphs scores over time
New Bobath Concept 39

40. New Bobath Concept
40

41. Item Maps
 By item order or by difficulty order- by difficulty order is
the most useful
New Bobath Concept 41

42. Lower Motor
GMFM-66 Score
with 95%
Confidence
Intervals
Higher Motor
Ability
Ability
New Bobath Concept 42

43. Clinical Use of Item Maps and Case Summaries
• understand/interpret change
• identify relatively easier and more difficult ‘next
steps’ for a child
• discuss and communicate a child’s progress
• set appropriate goals and plan interventions
New Bobath Concept 43

44. Longitudinal Motor Growth Curves for Children with Cerebral Palsy by
GMFCS Level Using GMFM-66 (N=2624 observations)
New Bobath Concept 44

45. How can the Motor Growth Curves be used?
• Describe patterns of gross motor function for
children with cerebral palsy over time
• Estimate a child’s future motor capabilities
(prognosis)
• Compare child’s GMFM-66 score with children in the
sample of a similar age and severity
New Bobath Concept 45

46. GMFM-66 plateau
 Does not mean therapy is not needed!
 Work on quality, functional goals, equipment needs,
prevention of secondary problems.
New Bobath Concept 46

47. Goal Attainment Scale
New Bobath Concept 47

48. Plan of care in children
with Cerebral Palsy
(Goal Setting)
New Bobath Concept
48

49. New Bobath Concept 49

50. SMART targeting
 Specific
 Measurable
 Attainable/ Achievable
 Realistic/ Relevant/ Result based/ Reasonable
 Time-Bound/Trackable
New Bobath Concept 50

51. Specific
Ask yourself the questions, “who,
what, when, where and how?”
 For example, instead of ... “I
will exercise more this week”
 Use “I will walk for 20 minutes,
3 times this week at home”
New Bobath Concept
51

52. Measureable
 Choose a goal with measurable progress
and concrete criteria. Eg: "I want to
climb 1 flight of stairs independently”.
 For example, instead of“ I want to have
less pain”
 Use“ My pain will decrease from 5 to 3
on the pain scale” or
 Use“I will be able to sit for 6 hours
rather than my current 3 hours”
New Bobath Concept 52

53. Attainable (realistic)
 The goal should be something that is
challenging but also within your ability
to achieve
 Ask yourself the question, “Are the
client’s goals too difficult to be met,
considering their physical, cognitive,
social and environmental barriers?”
 For example, for a client with diplegic
CP, Instead of “I want to stand
independently.”
 Use“I will be able to stand with a walker
until the end of next month.”
New Bobath Concept 53

54. Relevant
 Ask yourself the question, “Is
this goal meaningful to the
client?”
 For example, instead of
“Decrease neck flexion so that
neck is positioned in neutral
flexion/extension.”
 Use “I will be able to hold my
head up so that I can eat and
swallow for all of my meals”
New Bobath Concept 54

55. Time-Bound
 Set a start date and a completion
date
 Ask yourself the question, “What
kind of time frame should be
used?”
 For example, instead of“ I want to
be able to walk independently”
 Use “I will be able to walk
independently without supervision
after having practiced for two
weeks.”
New Bobath Concept 55

56. Goal Examples
 Long Term Goal:
improve endurance and strength for postural control and
upper extremity function by maintaining position for 4
minutes with verbal cues.
 Short Term Goal:
Push self up into quadruped position with minimal physical
assistance and maintain position for 2 minutes while
engaging a simple cause/effect toy for 2 trials.
New Bobath Concept 56

57. Examples of Goals
 Long Term Goal (within 6 months):
The patient will walk 25 feet from the family room to the
kitchen with one hand held at dinner time 5 days per
week.
 Short Term Goals (within 3 months):
1. The patient will rise up to standing from the floor through
half-kneeling with supervision 4/5 trials for 3 consecutive
treatment sessions.
2. The patient will sit unsupported in short-leg sitting for 3
minutes to enable upright activities.
New Bobath Concept 57

58. New Bobath Concept 58
‫تخصصی‬ ‫کارگاه‬
‫توانبخشی‬ ‫در‬ ‫بوبات‬ ‫جدید‬ ‫رویکرد‬
‫مغزی‬ ‫فلج‬ ‫به‬ ‫مبتال‬ ‫کودکان‬
‫سپاسگزاریم‬
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