ReviewGait classification in children with cerebral palsy: A systematic review
Introduction
One of the most striking features of cerebral palsy (CP) is the variability of its clinical presentation [1]. The diversity of gait deviations observed in children with CP has led to repeated efforts to develop gait classification systems to assist in diagnosis, clinical decision-making and communication [2], [3], [4], [5], [6], [7], [8], [9], [10], [11], [12], [13], [14], [15], [16], [17], [18], [19]. Gait classifications may enable clinicians to differentiate gait patterns into clinically significant categories that assist with clinical decision-making. This is possible when the underlying variables that define the classification groups can be modified by intervention. Gait classifications can also provide clinicians and researchers with a common language that quickly conveys a “clinical snapshot” of an individual's gait impairments. The term “gait classification” refers to a system that allows the allocation of gait patterns into groups that can be differentiated from one another based on a set of defined variables. This is distinct from gait indexes, assessment scores and scales, which score individual gait variables or provide an overall index to quantify deviations from normal gait without group allocation.
In order to understand the range and quality of existing gait classifications for children with CP, a systematic review of the available literature was performed. This was considered to be an essential step before the development of a new gait classification. The review was conducted to highlight both the positive qualities and limitations of previous classification systems and to provide evidence as to whether existing systems were adequate, required modification or required re-conceptualisation. The main aim was to critically evaluate the internal and external validity of existing gait classifications by critically appraising their design, sampling methods, content, construct, psychometric properties and clinical utility.
Section snippets
Search strategy
An electronic search of the following publication databases was performed in March 2005: MEDLINE (1966–March 2005), Embase (1988–Week 10, 2005), Current Contents (1993–Week 10, 2005), AMED (1985–March 2005), CINAHL (1982–March 2005), Health and Psychosocial Instruments (1985–December 2004), PsycINFO (1967–March 2005), Inspec (1987–Week 9, 2005) and Recal Bibliographic Database (1991–2005). Keywords used in the search strategy included cerebral palsy, gait, gait analysis, classification, gait
Search strategy yield
The electronic search of selected databases identified 333 published studies. A further five studies were identified from the targeted journal/proceedings search and a further two studies were found from the hand-search giving a yield of 340 publications. Following the application of a priori inclusion/exclusion criteria (Section 2.2), two reviewers (FD and MM) identified 18 studies for inclusion in the systematic review. The details of these studies are summarised in Table 2.
Descriptive aspects of reviewed studies
Subject
Sample definition
Adequate sample definitions and inclusion criteria were provided in only 4 of the 18 publications included in the evaluation [13], [15], [17], [18]. None of the studies provided information about the functional severity of participants. It was difficult to determine if the classifications from studies without adequate definitions applied to a wide spread of individuals of varying severity across the childhood and adolescent years or only to a select age group and severity.
Adequate documentation
Conclusions
Although CP gait classifications are used for diagnostic purposes, to streamline communication and to facilitate clinical decision-making, the overall methodological quality of the studies evaluated in this systematic review was low. No single classification system appeared to reliably and validly describe the full range of gait deviations in children with CP. Many classifications appeared to use arbitrary decisions to allocate patients into groups as opposed to using clinical decision-making
Acknowledgments
This work was supported by the CCRE Clinical Gait Analysis and Gait Rehabilitation NHMRC grant. Fiona Dobson received support from the Sir Robert Menzies Allied Health Sciences Scholarship and the Faculty of Health Sciences, La Trobe University.
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