A clinical decision framework for the identification of main problems and treatment goals for ambulant children with bilateral spastic cerebral palsy.
Even with 3D gait lab data, PTs only agree on the main problem about half the time for kids with bilateral spastic CP, so add a structured consensus step.
01Research in Context
What this study did
Franki et al. (2014) asked physical therapists to pick the main problems and goals for kids with bilateral spastic cerebral palsy who could walk. They used a simple ICF checklist plus 3D gait lab data. Four therapists rated the same kids twice, with and without the gait numbers, to see if they could agree.
What they found
Agreement was only modest. About half the time the PTs named the same single main problem. Adding the fancy 3D gait reports helped a little, but goal ranking stayed hard. The team still had to talk it out to reach consensus.
How this fits with other research
Perez et al. (2015) found excellent agreement when testing a tweaked GMFM-88 for kids who also have visual impairment. Their ICCs hit 0.94–1.00, far above the 47 % overlap seen here. The difference is method: the GMFM-88 gives clear item scores, while the ICF framework leaves more room for judgment.
Himuro et al. (2017) also report strong reliability for the Japanese Functional Mobility Scale. Again, a fixed scale beat open-ended clinical reasoning. These studies do not contradict Inge et al.; they simply show that structured tools produce tighter agreement than broad ICF narratives.
Kantarcigil et al. (2016) moved assessment online and still reached good agreement for swallowing exams. The pattern is the same: when you give clinicians a defined protocol or recorded data, consensus rises. Inge’s work warns us that gait numbers alone are not enough; you still need a structured discussion step.
Why it matters
If you write PT goals for kids with CP, do not expect instant agreement after handing over a gait report. Build in a short team huddle or use a fixed scoring tool like the GMFM-88-CVI to anchor the talk. Extra data helps, but only if you pair it with a clear process.
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02At a glance
03Original abstract
The primary aim of the study was to investigate how a clinical decision process based on the International Classification of Function, Disability and Health (ICF) and the Hypothesis-Oriented Algorithm for Clinicians (HOAC-II) can contribute to a reliable identification of main problems in ambulant children with cerebral palsy (CP). As a secondary aim, to evaluate how the additional information from three-dimensional gait analysis (3DGA) can influence the reliability. Twenty-two physical therapists individually defined the main problems and specific goals of eight children with bilateral spastic CP. In four children, the results of 3DGA were provided additionally to the results of the clinical examination and the GMFM-88 (gross motor function measure-88). Frequency analysis was used to evaluate the selected main problems and goals. For the main problems, pair-wise agreement was calculated by the number of corresponding problems between the different therapists and using positive and negative agreement per problem. Cluster analysis using Ward's method was used to evaluate correspondence between the main problems and specific goals. The pair-wise agreement revealed frequencies of 47%, 32% and 3% for the identification of one, two or three corresponding main problems. The number of corresponding main problems was higher when additional information of 3DGA was provided. Most of the specific goals were targeting strength (34%), followed by range of motion (15.2%) and GMFM-D (11.8%). In 29.7% of the cases, therapists could not prioritize and exceeded the number of eight specific goals. Cluster analysis revealed a logic connection between the selection of strength as a main problem and as specific goal parameters. Alignment as a main problem was very often associated with specific parameters like ROM and muscle length and with hypertonia as a main problem. The results show a moderate agreement for the selection of main problems. Therapists are able to use the proposed model for a logic and structured clinical reasoning. Setting priorities in the definition of specific goals is revealed as a remaining difficulty. Further research is required to investigate the additional value of 3DGA and to improve priority setting.
Research in developmental disabilities, 2014 · doi:10.1016/j.ridd.2014.01.025