Prognosis for Ambulation in Cerebral Palsy: A Population-Based Study

Yvonne W. Wu, MD, MPH*; Steven M. Day, PhD‡; David J. Strauss, PhD‡;
and Robert M. Shavelle, PhD, MBA‡

P
ABSTRACT. Objectives. To determine independent arents of children with cerebral palsy fre-
predictors of ambulation among children with cerebral quently ask whether their children will ever
palsy and to develop a simple tool that estimates the walk. For health care providers of children
probability that a child will walk. with cerebral palsy, knowledge of future ambulatory
Methods. In a retrospective study of all children with potential may help establish appropriate treatment
cerebral palsy who were not yet walking at 2 to 31⁄2 years
plans and long-range goals.
of age, while receiving services from the California De-
partment of Developmental Services during the years
Previous studies of ambulation in cerebral palsy
1987–1999, we analyzed medical and functional data involved relatively small numbers of patients re-
obtained annually by Department of Developmental Ser- cruited from single clinics,1–7 and the results were
vices physicians and social workers. Using logistic re- sometimes conflicting. For example, estimates of the
gression analyses, we determined independent predic- percentage of children with spastic quadriplegia who
tors of a child’s ability to walk well alone at least 20 feet, might eventually walk ranged from 0% to 72%, de-
without assistive devices, by age 6. We then estimated pending on the study population and study de-
the probabilities of walking at various levels of ability sign.3,4,7
over time, using multistate survival analysis. The validated Gross Motor Function Classification
Results. Of 5366 study subjects, 2295 (43%) were eval- System (GMFCS),8 with motor development curves
uated at age 6; 12.8% could walk independently and
based on the Gross Motor Function Measure
18.4% walked with support. Independent predictors of
successful ambulation included early motor milestones (GMFM),9,10 have improved our understanding of
such as sitting (odds ratio: 12.5; 95% confidence interval: gross motor development among children with cere-
5.8 –27.2) and pulling to a stand (odds ratio: 28.5; 95% bral palsy. However, we still lack a simple tool for
confidence interval: 13.4 – 60.4) when compared with lack predicting ambulation among children with cerebral
of rolling at age 2, cerebral palsy type other than spastic palsy. The GMFM calculates a score from 66 to 88
quadriparesis (odds ratio: 2.2; 95% confidence interval: separate items.11 Although the majority of children
1.5–3.1), and preserved visual function (odds ratio: 2.4; at GMFCS levels I and II will achieve the ability to
95% confidence interval: 1.1–5.4). Our ambulation charts walk 10 steps unsupported whereas less than one-
depict the probability of remaining nonambulatory, tran- half of children at GMFCS levels III, IV, and V will do
sitioning to 1 of 3 possible ambulatory states, or expiring
so,10 the exact probabilities of ambulating, with and
at all subsequent ages through age 14.
Conclusion. The ambulation charts provide a simple
without support, based on GMFCS levels have not
straightforward way to estimate the probability that a been reported. Finally, the GMFCS level determined
child with cerebral palsy who is nonambulatory at 2 to in the first years of life was shown to predict walking
31⁄2 years of age will eventually walk with or without ability at age 6 to 1212; however, ⬎38% of the 85
support. Pediatrics 2004;114:1264–1271; cerebral palsy, study participants were already walking, with or
ambulation, prognosis. without support, at 2 to 4 years of age, and the
positive predictive value of GMFCS level for ambu-
ABBREVIATIONS. GMFCS, Gross Motor Function Classification lation among individuals with more severe motor
System; GMFM, Gross Motor Function Measure; CDER, Client disability was as low as 62%.
Development Evaluation Report; DDS, Department of Develop- Certain clinical characteristics may be useful in
mental Services. predicting future ambulation, including location and
type of cerebral palsy, presence of epilepsy, degree of
cognitive impairment, and underlying cause of cere-
bral palsy.4,5,7,13 To our knowledge, no study has yet
From the *Departments of Neurology and Pediatrics, University of Califor- evaluated the independent or combined contribu-
nia, San Francisco, California, and the ‡University of California Life Expect- tions of these factors. Therefore, more data are
ancy Project, San Francisco, California. needed to generate estimates of prognosis for ambu-
Accepted for publication May 6, 2004.
doi:10.1542/peds.2004-0114 lation for children with cerebral palsy. In a retrospec-
Address correspondence to Yvonne W. Wu, MD, MPH, Division of Child tive cohort study of 5366 children with cerebral palsy
Neurology, Box 0136, University of California–San Francisco, 500 Parnassus who were not yet walking at 2 to 31⁄2 years of age, we
Ave, Room 411, San Francisco, CA 94143-0136. E-mail: wuy@neuropeds.
ucsf.edu
set out to determine predictors of ambulation and to
PEDIATRICS (ISSN 0031 4005). Copyright © 2004 by the American Acad- develop a simple tool for estimating the probability
emy of Pediatrics. that a child will walk.

1264 PEDIATRICS Vol. 114 No. 5 November 2004

Downloaded from www.aappublications.org/news at Indonesia:AAP Sponsored on December 9, 2020
 METHODS Mortality information was obtained from annual computer files
from the State of California (1987–1999) and was linked to the
Study Population subjects in our study population on the basis of name, date of
Our retrospective cohort consisted of all children with cerebral birth, and Social Security number when available. All children
palsy who were not yet walking at 2 to 31⁄2 years of age (henceforth who stopped receiving an annual evaluation within the DDS and
referred to as age 2), when they received services from the State of who were not identified in the state mortality database were
California Department of Developmental Services (DDS), between considered to be lost to follow-up monitoring.
January 1, 1987, and December 31, 1999. The DDS provides early
intervention, occupational and physical therapy, equipment, case Statistical Methods
management, respite care, and social services for all state residents
with substantive disability resulting from cerebral palsy.14 Cere- We used logistic regression17 to determine predictors of full
bral palsy is defined as “a group of nonprogressive lesions or ambulation at age 6. All significant (P ⬍ .05) predictors of ambu-
disorders in the brain characterized by paralysis, spasticity, or lation in the univariate analyses were entered into the multivariate
abnormal control of movement or posture, such as poor coordi- model, and backward elimination was then used to determine the
nation or lack of balance. These disorders may be due to devel- variables most significantly and independently predictive of fu-
opmental anomalies of the central nervous system or injury of the ture ambulation (P ⬍ .10 was used as the cutoff for retention in the
brain during intrauterine life, the perinatal period, or within the model). Possible interactions were considered.
first few months of life, and are manifest prior to age 2 or 3 Next we estimated the probabilities of ambulation at various
years.”15(pVI.6.1) levels (eg, with and without support) at all ages through age 14,
using Aalen-Johansen estimators of long-term transition probabil-
ities.18,19 This nonparametric technique of multistate survival anal-
Measurements ysis accounts for censoring and death and is similar to the Kaplan-
Each year, individuals receiving services from DDS undergo a Meier estimator used in simple survival analyses.19 With this
comprehensive evaluation that generates a document called the technique, we created “ambulation charts” that illustrate the prob-
Client Development Evaluation Report (CDER).15(pVI.24.6) This re- abilities for different states of ambulation with time.20–22
port contains ⬎200 medical, functional, behavioral, and cognitive Finally, we partitioned the study cohort into 4 mutually exclu-
items and is completed by physicians and social workers. A staff sive groups on the basis of the early motor milestones that were
physician records data regarding medical diagnoses such as cere- found to be most strongly predictive of future ambulation. For
bral palsy and epilepsy, whereas a social worker determines the each of these subgroups, a separate ambulation chart was created
child’s functional, behavioral, and cognitive status. The data are to illustrate the prognosis for ambulation specific to each group.
obtained through interviews with family members or the child’s All statistical analyses were performed with SAS statistical anal-
caregivers, as well as through observation of the child when ysis software (version 6.12; SAS Institute, Cary, NC), and figures
possible. The inter-rater reliabilities for the motor function vari- were created with S-Plus (version 4.0; MathSoft, Seattle, WA). All
ables in the CDER exceed 0.85.16 study procedures were approved by the institutional review
We electronically searched all CDER records collected during board of the University of California, San Francisco.
the study period for children with cerebral palsy who were as-
signed an ambulation level of “does not walk” at age 2 years. If a RESULTS
child received 2 evaluations within this age range, we used data
from the earlier evaluation only. We were interested in congeni- Description of Cohort
tally acquired cerebral palsy and therefore excluded children with We identified 6480 children with cerebral palsy who
diagnoses suggesting cerebral palsy of postnatal origin (traumatic
brain injury, near-drowning, motor vehicle accident, brain tumor,
were nonambulatory at age 2 (Fig 1). After exclusion of
and other acquired injuries), as well as children with diagnoses those with an exclusion diagnosis, the remaining 5366
suggesting an underlying disorder other than cerebral palsy (au- children constituted our study cohort.
tism and degenerative disorders). The remaining children consti- The mean age at entry into the study was 2.7 years
tuted the final study population. (SD: 0.4 years), and male subjects represented 56% of
the study population (Table 1). At initial evaluation,
Clinical Information more than one-third of the children could not roll
Several clinical factors were considered potentially useful in over, 25% could roll but not sit, and approximately
predicting ambulation. These included type of cerebral palsy
(spastic, ataxic, dyskinetic including dystonia and choreoathetosis, one-third could sit with minimal or no support. The
hypotonic, or other), distribution of limb involvement (quadriple- majority (80%) had some functional hand use, al-
gia, diplegia, hemiplegia, triplegia, monoplegia, or other), pres- though most could not feed themselves. One-quarter
ence of spastic quadriplegia (yes or no), gross motor function of the children exhibited at least some expressive
(rolling, sitting, and standing milestones), expressive language
(use of words versus no use of words), hand use (raking motion or
language, 12% were legally blind, and 20% had a
better versus no functional use), ability to feed self (does so history of seizures. Spastic quadriplegia was the
independently, needs assistance, or unable), history of seizures most common type of cerebral palsy, constituting
(yes or no), and legal blindness (yes or no). 46% of our study population.

Outcome Measures Univariate Analyses

We defined full ambulation as the ability to walk well alone at The mean follow-up period was 5.8 years (SD: 3.6),
least 20 feet without assistive devices, on the basis of the CDER
definition for ambulation at level 4, ie, “Walks well alone at least and a total of 348 children (6.8%) had expired by the
twenty (20) feet; also balances well. Clients who have an unusual end of the study period. Of the 2295 children (43%)
or awkward gait but who are not in danger of stumbling or falling who were alive and evaluated at age 6, 8.5% had
should also be rated at this level. . . . If a client typically uses a achieved full ambulation (could walk well alone at
wheelchair, rate at level 1 (no ambulation).”15 least 20 feet without assistive devices), 4.3% could
First we analyzed full ambulation at age 6 as a dichotomous
outcome, among all children who survived and received a CDER walk unsteadily alone at least 10 feet without assis-
evaluation at age 6 during the study years. Then we considered 3 tive devices, and 18.4% could walk with support or
levels of ambulation, ie, 1) walks with support or assistive devices, assistive devices. Children whose outcomes at age 6
2) walks unsteadily alone at least 10 feet without assistive devices, were not available included 1128 (21%) who were not
and 3) walks well alone at least 20 feet without assistive devices
(full ambulation). We determined the probability of each of these yet 6 years of age at the end of the study period, 857
outcomes at various follow-up times by using multistate survival (16%) who were seen after age 7 but had not under-
techniques (see below). gone a CDER evaluation at age 6, 793 (15%) who

Downloaded from www.aappublications.org/news at Indonesia:AAP Sponsored on December 9, 2020

ARTICLES 1265
 TABLE 1. Clinical Characteristics of 5366 Children With Ce-
rebral Palsy Who Were Nonambulatory at 2 Years of Age
No. %
Gender
Male 3029 56.4
Female 2337 43.6
Ethnicity
White 1849 34.5
Hispanic 1946 36.3
Black 535 10.0
Asian 242 4.5
Other 454 8.5
Unspecified 340 6.3
Type of motor dysfunction
Spasticity 3348 62.4
Ataxia 110 2.1
Dyskinesis (dystonia or athetosis) 120 2.2
Hypotonia 884 16.5
Other (including mixed) 904 16.9
Location of motor dysfunction
Quadriplegia 3733 69.6
Diplegia 633 11.8
Hemiplegia 310 5.8
Monoplegia 83 1.5
Triplegia 62 1.2
Other 545 10.2
Rolling and sitting
Does not roll over 2086 38.9
Rolls front to back only 331 6.2
Rolls front to back and back to front 981 18.3
Sits with support at least 5 min 717 13.3
Sits independently at least 5 min 433 8.1
Assumes and maintains sitting position 818 15.2
Fig 1. Selection of the study cohort. *Children who were excluded Crawling and standing
sometimes had ⬎1 exclusion diagnosis. Does not crawl, creep, or scoot 3155 58.8
Crawls, creeps, or scoots 1370 25.5
Pulls to a stand 320 6.0
Stands with support 1 min 442 8.2
were lost to follow-up monitoring, and 293 (6%) who Stands unsteadily alone 1 min 47 0.9
had expired by age 6. Stands well alone 5 min 32 0.6
Univariate predictors for full ambulation included Hand use
No functional use of hand 1091 20.3
type and location of cerebral palsy, motor and lan- Rakes or grasps with hand 2574 48.0
guage function, and presence of visual impairment Has pincer grasp 911 17.0
(Table 2). As expected, motor milestones were par- Uses fingers independently 790 14.7
ticularly strong predictors of eventual ambulation. Eating
For instance, the odds of achieving full walking were Does not feed self 3352 62.5
Finger-feeds but needs assistance 762 14.2
26 times higher for children who were sitting with- Finger-feeds self without assistance 1252 23.3
out support at 2 years of age than for those who Expressive language
could not yet roll over at the initial evaluation. Uses no words 4027 75.0
Ataxia and hypotonic cerebral palsy were associated Says simple words at least 1339 25.0
Vision
with better prognoses for future ambulation than Legally blind 663 12.4
were spastic and dyskinetic cerebral palsy. Increas- Not legally blind 4703 87.6
ing hand function, the ability to feed self or say Seizures
simple words, lack of visual impairment, and lack of Seizures within the past year 916 17.0
seizures were also associated with better chances of History of seizures, none in past year 186 3.5
No history of seizures 4264 79.5
achieving full ambulation.

Multivariate Analysis Ambulation Charts

To determine independent predictors of ambula- We then graphed the probabilities of achieving 3
tion, we entered all factors associated with ambula- levels of ambulation at various follow-up times. The
tion in the univariate analyses into a logistic regres- resulting ambulation chart (Fig 2) illustrates the
sion model. The clinical factors independently probability of remaining nonambulatory at subse-
associated with successful ambulation at age 6 in- quent ages or transitioning to 1 of the 4 possible
cluded early motor milestones such as the ability to states (expired, walks with support or assistive de-
sit or pull to a stand, the absence of spastic quadri- vices, walks unsteadily alone at least 10 feet without
plegia, and the absence of blindness (Table 3). Other assistive devices, or walks well alone at least 20 feet
variables, such as hand use, expressive language, without assistive devices). The ambulatory outcomes
and epilepsy, did not provide additional information at age 7 can be determined by examining the vertical
beyond that obtained from the significant predictors line depicted in Fig 2. As indicated by the line seg-
identified in the multivariate model. ments designated with the letters A through F, the

1266 PROGNOSIS FOR AMBULATION IN CEREBRAL PALSY

Downloaded from www.aappublications.org/news at Indonesia:AAP Sponsored on December 9, 2020
 TABLE 2. Univariate Odds Ratios for Achieving Full Ambulation by 6 Years of Age Among 2295
Children With Cerebral Palsy Who Were Nonambulatory at 2 Years of Age
Odds Ratio 95% Confidence Interval P Value
Gender
Male 1.0 Ref Ref
Female 1.0 0.7–1.3 .82
Ethnicity
White 1.0 Ref Ref
Hispanic 1.2 0.8–1.7 .43
Black 1.5 0.9–2.4 .10
Asian 1.4 0.7–2.7 .31
Other 1.2 0.7–2.2 .48
Unspecified 1.3 0.7–2.4 .50
Type of motor dysfunction
Spasticity 1.0 Ref Ref
Ataxia 3.7 1.7–8.3 .001
Dyskinesis (dystonia or athetosis) 1.0 0.3–3.2 .96
Hypotonia 2.4 1.7–3.5 .001
Other (including mixed) 1.7 1.2–2.5 .01
Location of cerebral palsy
Quadriplegia 1.0 Ref Ref
Diplegia 2.4 1.6–3.6 .0001
Hemiplegia 4.3 2.7–6.7 .0001
Monoplegia 3.3 1.3–8.2 .01
Triplegia 1.9 0.6–6.5 .29
Other 2.0 1.3–3.2 .002
Spastic quadriplegia
Present 1.0 Ref Ref
Absent 3.5 2.4–4.9 .0001
Rolling and sitting
Does not roll over 1.0 Ref Ref
Rolls but does not sit 4.2 1.9–9.1 .0003
Sits with support 7.6 3.4–16.9 .0001
Sits without support 26.1 12.6–54.0 .0001
Crawling and standing
Does not crawl, creep, or scoot 1.0 Ref Ref
Crawls, creeps, or scoots 3.1 2.1–4.6 .0001
Pulls to a stand at least 9.8 6.7–14.4 .0001
Hand use
No functional use of hand 1.0 Ref Ref
Uses raking motion or grasps 5.1 2.2–11.7 .0002
Has pincer grasp 10.5 4.4–24.6 .0001
Uses fingers independently 15.6 6.7–36.6 .0001
Eating
Does not feed self 1.0 Ref Ref
Finger-feeds but needs assistance 1.8 1.2–2.9 .007
Finger-feeds without assistance 2.9 2.1–4.0 .0001
Expressive language
Uses no words 1.0 Ref Ref
Says simple words at least 2.1 1.5–2.8 .0001
Vision
Legally blind 1.0 Ref Ref
Not legally blind 3.7 1.7–8.0 .001
Epilepsy
Seizures within the past year 1.0 Ref Ref
History of seizures, none in past year 0.3 0.1–1.4 .09
No history of seizures 1.1 0.7–1.6 .73
Odds ratios refer to the odds of being able to walk well alone at least 20 feet without assistive devices,
compared with the odds of not doing so by age 6. Ref indicates the reference group, with odds ratio
of 1.0 by definition.

majority of children still could not walk by age 7 and by age 7 (Table 4). Similarly, among children who
8% had expired. Of the 27% who had achieved am- were unable to sit independently but who could roll
bulation by age 7, approximately one-third could at the study onset, 7% could walk without support
walk without support (Table 4). by age 7 and an additional 20% could walk with
We then created 4 separate ambulation charts, support. For children who were already pulling to a
each depicting the ambulatory potential of children stand by 2 years of age, the likelihood of walking
sharing a similar motor developmental profile at 2 with or without support by age 7 was as high as 75%.
years of age (Fig 3). As expected, children who were In a separate analysis, we found that, among all
not rolling by age 2 years demonstrated the lowest children who were alive, uncensored, and fully am-
probability of achieving ambulation and the highest bulatory at age 10, 65% had become fully ambulatory
mortality rate. However, a small proportion (2%) of by age 6 and 96% had at least walked with support
these children did eventually walk without support by age 6.

Downloaded from www.aappublications.org/news at Indonesia:AAP Sponsored on December 9, 2020

ARTICLES 1267
 TABLE 3. Multivariate Odds Ratios for Achieving Full Ambulation by 6 Years of Age Among
2295 Children With Cerebral Palsy Who Were Nonambulatory at 2 Years of Age
Odds Ratio 95% Confidence Interval P Value
Motor milestones
Does not roll 1.0 Ref Ref
Rolls, does not sit without support 4.6 2.2–9.6 .0001
Sits without support,* does not stand 12.5 5.8–27.2 .0001
Pulls to stand 28.5 13.4–60.4 .0001
Type of cerebral palsy
Spastic quadriplegia 1.0 Ref Ref
Other 2.2 1.5–3.1 .0001
Vision
Totally or legally blind 1.0 Ref Ref
Not blind 2.4 1.1–5.4 .03
Odds ratios refer to the odds of being able to walk well alone at least 20 feet without assistive devices,
compared with the odds of not doing so by 6 years of age. Ref indicates reference group, with odds
ratio of 1.0 by definition.
* Sitting refers to the ability to maintain a sitting position without support or the ability to achieve a
sitting position on one’s own.

Fig 2. Ambulation chart showing probabilities of various levels of ambulation with time for children who were initially nonambulatory
at a mean age of 2.7 years. Letters A through F indicate the various percentages of the 5 possible outcomes at age 7 (Table 4).

DISCUSSION future ambulation can be determined at each subse-

In this largest study of cerebral palsy and ambu- quent year of age with ambulation charts that reflect
lation reported to date, we found that, among chil- the experience of 5366 children with cerebral palsy,
dren who were not yet walking at age 2, 10% were 3152 of whom were monitored past age 6.
able to walk independently by age 6 to 7 and an Previous studies of cerebral palsy focused on
additional 17% could walk with support. The clinical persistent primitive reflexes, levels of motor func-
factors most useful in predicting future ambulation tion, and clinical type of cerebral palsy as predic-
were motor milestones at age 2 (ability to roll, sit, or tors of future ambulation.4–7,13 The ability to sit by
stand), the type of cerebral palsy, and blindness. On 2 years of age was emphasized as a particularly
the basis of motor function at age 2, the prognosis for strong predictor of ambulation. For instance, pre-

1268 PROGNOSIS FOR AMBULATION IN CEREBRAL PALSY

Downloaded from www.aappublications.org/news at Indonesia:AAP Sponsored on December 9, 2020
TABLE 4. Probability of Walking at 7 Years of Age, Stratified by Motor Milestones at 2 Years of Age
Ambulation Vertical Probability, %
at Age 7 Segment*
Entire Cohort Does Not Roll Rolls, Does Sits, Cannot Pull Pulls to Stand
(N ⫽ 5366) (N ⫽ 1733) Not Sit† to Stand (N ⫽ 615)
(N ⫽ 2382) (N ⫽ 636)
Walks well alone AB 6 1 4 11 28
Walks unsteadily alone BC 4 1 3 8 16
Walks with support CD 17 5 20 31 32
Does not walk DE 64 78 68 47 23
Died EF 8 15 5 2 2
* Refers to vertical segments depicted on Figure 2.
† Sitting refers to the ability to maintain a sitting position without support or the ability to achieve a sitting position on one’s own.

Fig 3. Ambulation charts showing probabilities of various levels of ambulation with time for children who were initially nonambulatory
at a mean age of 2.7 years, stratified according to early motor milestones at age 2. Rolling refers to the ability to roll over from front to
back or from back to front. Sitting refers to the ability to maintain a sitting position without support or the ability to achieve a sitting
position on one’s own.

vious studies found that 98 to 100% of children with cerebral palsy who eventually walked did not
who could sit by age 2 eventually walked with or sit until after age 2.4 Although most previous stud-
without support.3,7 Those studies were smaller, ies defined sitting as the ability to maintain a
however, and others found that ⬎60% of children seated position independently after being placed

Downloaded from www.aappublications.org/news at Indonesia:AAP Sponsored on December 9, 2020

ARTICLES 1269
in this position by others,3,7 not all studies pro- stand (GMFCS level II) had an ⬃40% chance of
vided a clear definition of sitting.4 achieving full ambulation by age 14, whereas very
In our study, the ability to maintain a sitting posi- few of those who could roll but not sit independently
tion independently at age 2 was a good prognostic (GMFCS level IV) eventually reached this goal.
sign for future ambulation. However, if a child was Previous work suggested that, on average, chil-
not also pulling to a stand at that age, then we found dren with cerebral palsy reach 90% of their motor
only a 50% chance of walking with or without sup- potential (as measured with the GMFM-66) by age 5
port by age 6. Among children who were both sitting and those with a greater degree of motor disability
and pulling to a stand at age 2, 76% could walk with have gross motor function curves that plateau even
or without support by age 6. earlier.10 Similarly, we found that, among those who
Our study is subject to a number of important achieved full ambulation by age 10, the majority had
limitations. First, children with milder motor dys- already done so by age 6 and almost all (96%) were
function might have been preferentially lost to fol- at least walking with support by age 6.
low-up monitoring. This would result in a study For families and practitioners caring for children
population with a greater proportion of severely af- with cerebral palsy, the ambulation charts can pro-
fected children, and the chance of walking would be vide useful information in a simple straightforward
higher than that depicted in our results. Second, way. On the basis of a child’s motor ability at age 2,
compared with the ethnic composition of California the probability that a nonambulatory child will walk
described in the 2000 census (60% white and 7% with or without support at any subsequent age
black), our cohort included a smaller proportion of through age 14 can be determined. Although it is
whites (35%) and an overrepresentation of blacks impossible to say where any individual child will be
(10%). Some of this discrepancy might be explained in the range of ambulation potential with time, these
by the different coding systems used to record eth- probabilities derived from a large population of sim-
nicity and race, as well as by the increased preva- ilarly affected children may help guide interventions
lence of cerebral palsy noted among blacks.23,24 such as physical therapy.
However, the ethnic disparity may also reflect the How ambulation potential changes as a child with
tendency of individuals of higher socioeconomic sta- cerebral palsy enters adolescence deserves additional
tus to forego state-sponsored services in favor of study. Adults with cerebral palsy often experience a
other benefits that are available to them through decline in walking ability, attributed to increasing
private insurance or other means. fatigue, inefficiency of ambulation, or increased joint
Other limitations include the fact that the inter- pains.25–27 However, this loss of ambulation is doc-
rater reliabilities of terms such as spastic quadriple- umented primarily among adults ⬎20 years of age,
gia and dystonic have not been adequately studied and studies of ambulation among children rarely
and the fact that specific details regarding the type of include adolescents. Our data suggest that, on aver-
sitting (eg, “W-sitting”) and the quality of ambula- age, children continue to gain ambulation potential
tion were not available to us. In addition, our data into their early teens. This is consistent with the
did not include neuroimaging findings or the types finding that some adults with cerebral palsy can
of physical therapy and spasticity treatments re- improve in walking ability even into their early
ceived. Finally, our measure of ambulation ability twenties.26 However, our study spanned a period of
did not provide information regarding the actual only 12 years, and a child who was 2 years of age at
amount of time that the child walked in various the beginning of the study could be monitored at
conditions and environments. These limitations are most until 14 years of age. Additional work is needed
offset by several strengths of the study, including to determine the prognosis for ambulation among
the large numbers, the ability to provide prognostic children with cerebral palsy as they enter their teen-
information regarding several different levels of age years.
ambulation with time, and the analysis of several
different types of clinical factors together in a multi-
variate model, to determine the most useful indepen- ACKNOWLEDGMENTS
dent predictors of future ambulation. Y.W.W. was supported in part by Neurological Sciences Aca-
demic Development Award K12 NSO1692.
In a comprehensive prospective study of gross We thank the California DDS for its cooperation and Drs. Peter
motor function among 657 children with cerebral Rosenbaum, Donna Ferriero, and Tom Newman for their careful
palsy,10 it was found that classification into 1 of 5 review of the manuscript.
GMFCS strata was useful for predicting the ability to
walk 10 steps unsupported. Specifically, children
who functioned at the higher GMFCS levels (I and II) REFERENCES
had an excellent chance of achieving this motor mile- 1. Badell-Ribera A. Cerebral palsy: postural-locomotor prognosis in spas-
tic diplegia. Arch Phys Med Rehabil. 1985;66:614 – 619
stone, with the assumption that they stayed within 2. Beals RK. Spastic paraplegia and diplegia: an evaluation of non-surgical
their GMFCS levels with time,12 whereas less than and surgical factors influencing the prognosis for ambulation. J Bone
one-half of children at GMFCS level III achieved this Joint Surg Am. 1966;48:827– 846
goal. Our results are consistent with those previous 3. da Paz AC Jr, Burnett SM, Braga LW. Walking prognosis in cerebral
findings. Although we did not include children at palsy: a 22-year retrospective analysis. Dev Med Child Neurol. 1994;36:
130 –134
GMFCS level I, because by definition those who 4. Molnar GE, Gordon SU. Cerebral palsy: predictive value of selected
could already walk at age 2 were excluded, our clinical signs for early prognostication of motor function. Arch Phys Med
children who could sit independently and pull to a Rehabil. 1976;57:153–158

1270 PROGNOSIS FOR AMBULATION IN CEREBRAL PALSY

Downloaded from www.aappublications.org/news at Indonesia:AAP Sponsored on December 9, 2020
 5. Trahan J, Marcoux S. Factors associated with the inability of children 16. Harris CW, Eyman RK, Mayeda T. An Interrater Reliability Study of the
with cerebral palsy to walk at six years: a retrospective study. Dev Med Client Development Evaluation Report. Pomona, CA: California Depart-
Child Neurol. 1994;36:787–795 ment of Developmental Disabilities; 1983
6. Bleck EE. Locomotor prognosis in cerebral palsy. Dev Med Child Neurol. 17. Hosmer D, Lemeshow S. Applied Logistic Regression. New York, NY:
1975;17:18 –25 Wiley; 1989
7. Watt JM, Robertson CM, Grace MG. Early prognosis for ambulation of 18. Aalen OO, Johansen S. An empirical transition matrix for nonhomoge-
neonatal intensive care survivors with cerebral palsy. Dev Med Child neous Markov chains based on censored observations. Scand J Stat.
Neurol. 1989;31:766 –773 1978;5:141–150
8. Palisano R, Rosenbaum P, Walter S, Russell D, Wood E, Galuppi B. 19. Anderson PK, Borgan O, Gill RD, Keiding N. Statistical Models Based on
Development and reliability of a system to classify gross motor function Counting Processes. New York, NY: Springer-Verlag; 1993
in children with cerebral palsy. Dev Med Child Neurol. 1997;39:214 –223 20. Strauss D, Ashwal S, Shavelle R, Eyman RK. Prognosis for survival and
9. Russell DJ, Rosenbaum PL, Cadman DT, Gowland C, Hardy S, Jarvis S. improvement in function in children with severe developmental dis-
abilities. J Pediatr. 1997;131:712–717
The Gross Motor Function Measure: a means to evaluate the effects of
21. Strauss D, Shavelle R. An extended Kaplan-Meier estimator and its
physical therapy. Dev Med Child Neurol. 1989;31:341–352
applications. Stat Med. 1998;17:971–982
10. Rosenbaum PL, Walter SD, Hanna SE, et al. Prognosis for gross motor
22. Strauss DJ, Shavelle RM, Anderson TW. Life expectancy of children
function in cerebral palsy: creation of motor development curves.
with cerebral palsy. Pediatr Neurol. 1998;18:143–149
JAMA. 2002;288:1357–1363
23. Wu YW, Escobar GJ, Grether JK, Croen LA, Greene JD, Newman TB.
11. Russell D, Rosenbaum PL, Avery L, Lane M. The Gross Motor Function
Chorioamnionitis and cerebral palsy in term and near-term infants.
Measure: GMFM-66 and GMFM-88 (Users’ Manual). London, United JAMA. 2003;290:2677–2684
Kingdom: Mac Keith Press; 2002:159 24. Murphy CC, Yeargin-Allsopp M, Decoufle P, Drews CD. Prevalence of
12. Wood E, Rosenbaum P. The Gross Motor Function Classification Sys- cerebral palsy among ten-year-old children in metropolitan Atlanta,
tem for cerebral palsy: a study of reliability and stability over time. Dev 1985 through 1987. J Pediatr. 1993;123:S13–S20
Med Child Neurol. 2000;42:292–296 25. Bottos M, Feliciangeli A, Sciuto L, Gericke C, Vianello A. Functional
13. Sala DA, Grant AD. Prognosis for ambulation in cerebral palsy. Dev Med status of adults with cerebral palsy and implications for treatment of
Child Neurol. 1995;37:1020 –1026 children. Dev Med Child Neurol. 2001;43:516 –528
14. California Department of Developmental Services. Information about 26. Strauss D, Ojdana K, Shavelle R, Rosenbloom L. Decline in function and
developmental disabilities. Available at: www.dds.ca.gov/general/ life expectancy of older persons with cerebral palsy. NeuroRehabilitation.
info㛭about㛭dd.cfm 2004;19:69 –78
15. California Department of Developmental Services. CDER Manual. 27. Murphy KP, Molnar GE, Lankasky K. Medical and functional status of
Sacramento: California Department of Developmental Services; 1986 adults with cerebral palsy. Dev Med Child Neurol. 1995;37:1075–1084

THE POLITICS OF CONSUMPTION

“American output per worker hour increased by 60% from the 1870s to 1900. It
rose again another 69% in the next 20 years. That productivity, more than legal
reforms, became the base for the consumers’ democracy. The decline of a political
vision of social equality made a culture of mass consumption seem a natural and
inevitable alternative. Increasingly more fragmented, mobile, and unorganized,
Americans joined ‘consumption communities’ that did not require an active citi-
zenry but were comprised, according to historian Daniel Boorstin, of ‘people who
have a feeling of shared well-being, shared risks, common interests, and common
concerns that come from consuming the same kinds of objects.’ Americans defined
their status and dismissed boredom and anxiety by joining the crowd who bought
Life Savers . . . or Lincolns.”

Cross G. An All-Consuming Century. New York, NY: Columbia University Press; 2000

Submitted by Student

Downloaded from www.aappublications.org/news at Indonesia:AAP Sponsored on December 9, 2020

ARTICLES 1271
 Prognosis for Ambulation in Cerebral Palsy: A Population-Based Study
Yvonne W. Wu, Steven M. Day, David J. Strauss and Robert M. Shavelle
Pediatrics 2004;114;1264
DOI: 10.1542/peds.2004-0114

Updated Information & including high resolution figures, can be found at:
Services http://pediatrics.aappublications.org/content/114/5/1264
References This article cites 21 articles, 0 of which you can access for free at:
http://pediatrics.aappublications.org/content/114/5/1264#BIBL
Subspecialty Collections This article, along with others on similar topics, appears in the
following collection(s):
Neurology
http://www.aappublications.org/cgi/collection/neurology_sub
Rheumatology/Musculoskeletal Disorders
http://www.aappublications.org/cgi/collection/rheumatology:musculo
skeletal_disorders_sub
Permissions & Licensing Information about reproducing this article in parts (figures, tables) or
in its entirety can be found online at:
http://www.aappublications.org/site/misc/Permissions.xhtml
Reprints Information about ordering reprints can be found online:
http://www.aappublications.org/site/misc/reprints.xhtml

Downloaded from www.aappublications.org/news at Indonesia:AAP Sponsored on December 9, 2020

 Prognosis for Ambulation in Cerebral Palsy: A Population-Based Study
Yvonne W. Wu, Steven M. Day, David J. Strauss and Robert M. Shavelle
Pediatrics 2004;114;1264
DOI: 10.1542/peds.2004-0114

The online version of this article, along with updated information and services, is
located on the World Wide Web at:
http://pediatrics.aappublications.org/content/114/5/1264

Pediatrics is the official journal of the American Academy of Pediatrics. A monthly publication, it
has been published continuously since 1948. Pediatrics is owned, published, and trademarked by
the American Academy of Pediatrics, 345 Park Avenue, Itasca, Illinois, 60143. Copyright © 2004
by the American Academy of Pediatrics. All rights reserved. Print ISSN: 1073-0397.

Downloaded from www.aappublications.org/news at Indonesia:AAP Sponsored on December 9, 2020