Tests & Measures: A Resource for Pediatric Physical Therapy Practitioners

Edinburgh Visual Gait Score

Update:

The minimal clinically important difference (MCID) for the Edinburgh Visual Gait Score (EVGS) has varied in the literature from 3-15 points.  Robinson et al. (2017) proposed an MCID of 2.4 for the EVGS based on correlation with the Gross Motor Function Classification System (GMFCS) and the Function Assessment Questionnaire (FAQ) which have been shown to correlate with the EVGS.¹

All other previous information is accurate and up to date.

 

Article Review

Evaluation of group versus individual physiotherapy following lower limb intra-muscular Botulinum Toxin-Type A injections for ambulant children with cerebral palsy: A single-blind randomized comparison trial²

Purpose

The aim of the study is to compare and contrast the efficacy of group versus individual physiotherapy after Botulinum Toxin-Type A (BoNT-A) injections in the lower extremity for ambulatory children with spastic cerebral palsy (CP).

Study Population

Inclusion Criteria were:

1. Age 4-14 years old
2. Diagnosis of CP, spastic motor
3. Were ambulatory (GMFCS Level I-III)
4. Received lower extremity BoNT-A for spasticity management
5. Able to commit to six weeks of group or individual physiotherapy

Exclusion Criteria were:

1. Unable to complete evaluation assessments
2. Had received orthopedic or neurological surgery and/or spastic management (Baclofen, BoNT-A) within the past six months
3. Had intellectual or behavioral difficulties limiting their ability to participate in physical therapy
4. Had co-morbidities which prevented safe exercise

Methods

Randomized comparison trial in which the children were randomly allocated to group or individual intervention by coin flipping. The children received BoNT-A injections to one or more lower extremity muscles as needed and determined by their doctor. Serial casting and orthoses were worn as indicated after injections. The individual group received treatment by the child’s usual physiotherapist. The Group physiotherapy consisted of a group of four to six children with one physiotherapist and one assistant (allied health assistant, physiotherapist or physiotherapist student). Each group received six weekly 1-hour sessions for a total of six hours.

Outcome Measures

Primary

1. Canadian Occupational Performance Measure (COPM)
2. Edinburgh Visual Gait Score for Cerebral Palsy (EVGS)

Secondary

1. Pediatric Reach Test (PRT)
2. One Minute Fast Walk Test (1MFWT)
3. Domains D (standing) and E (walking, running and jumping) of the Gross Motor Function Measure-88
4. Cerebral Palsy Quality of Life Questionnaire for Children (CP QOL-Child)

Outcomes were recorded at three intervals: 0-2 weeks prior to injections, on completion of physiotherapy (10-12 weeks post injection) and 26 weeks post injection.

Intervention

Therapists were given the following general protocol but were allowed to select the exercises in each category based on their clinical judgement and experience.

1. Warm-up (5 minutes)
2. Lower limb flexibility (10 minutes)
3. Four circuit stations addressing (20 minutes total)
   • Functional strength
   • Balance
   • Targeted motor control
   • Fitness/agility
4. Cool down (5 minutes)
5. Review of home exercise program (5 minutes)
   • Three individualized, goal-related activities to be completed three times a week.

 

Results

There were no differences between groups for demographic and baseline characteristics.

COPM showed no differences post intervention between groups. At 26 weeks follow up, the group had statistically significant, but not clinically significant, improvements compared to the individual.

There were no statistically significant differences between or within groups at any point according to the Edinburgh Visual Gait Score.

CP QOL-Child group PT scores were significantly different compared to the individual at 10 weeks, no differences between groups.

PRT showed significant gains within group at 10 and 26 weeks for the individual PT scores.

Group PT had significantly different scores from baseline at 26 weeks on the 1MFWT.

Overall, there were not enough significantly statistical differences between individual and group physiotherapy to conclude which may be more effective after BoNT-A injections.

Strengths

The study included statistical significance as well as MCID values to relate the statistical analysis to meaningful changes in the patient’s life. The study provided details for the structure of the intervention in time increments. The interventions were targeted to each child for the individual intervention based on their specific needs.

Limitations

The individual interventions were carried out by the child’s usual physiotherapist who was allowed to select the specific exercises performed based on general guidelines. Therefore, each child might have been receiving different treatment. The study stated that the sessions were one hour long but the guidelines only add up to 45 minutes; it is unsure if the extra 15 minutes were for rest breaks or not. The HEP was included in both groups but was not well standardized or documented. The charts given in the article did not label the groups that were statistically significant.  The sample size was only 33 participants and there was a greater prevalence of unilateral CP in the group intervention as opposed to the individual intervention; A larger sample size could have shown more accurate results.

Overall Conclusion

The study found no clinically meaningful difference between group and individual physiotherapy after lower extremity BoNT-A injections. Weekly one-hour sessions and a targeted HEP did not create significant changes in lower extremity function, gait and self-reported concerns about performance.

References

1. Robinson LW, Clement ND, Herman J, Gaston MS. The edinburgh visual gait score – the minimal clinically important difference. Gait & posture. 2017;53:25-28.
2. Thomas RE, Johnston LM, Sakzewski L, Kentish MJ, Boyd RN. Evaluation of group versus individual physiotherapy following lower limb intra-muscular botulinum toxin-Type a injections for ambulant children with cerebral palsy: a single-blind randomized comparison trial. Research in developmental disabilities. 2016;53-54:267-278. doi:10.1016/j.ridd.2016.02.014.