The Impact of Environmental Setting on the Mobility of Children with Cerebral Palsy: Research Findings and Clinical Implications

Mobility of Children with Cerebral Palsy (CP)

  • Gross motor function of children with CP is highly variable. Children who are able to walk vary in their speed, endurance, and need for assistive devices. Children who are unable to walk may require transport by a caregiver or achieve independence by using manual or battery-powered wheelchairs.
  • In one study, children with CP and their families reported that improving mobility was their most important functional goal. (Pollock & Stewart, 1998).
  • Although the daily lives of children with CP include a variety of environmental settings, decisions on interventions to improve mobility have traditionally been based on examinations performed in clinical settings. 

The Environment

  • Awareness of the impact of the environment on individuals with disabilities is increasing (PL 105-17, 1997; Pollock & Stewart, 1998; Law et al., 1999; WHO, 2001).
  • A current trend in rehabilitation is to modify the individual's environment to encourage full participation in society (Kalscheur, 1992; Fougeyrollas, 1995; Pollock & Stewart, 1998; Law et al., 1999).
  • Even though interventions for children with CP are often provided in natural settings (PL 105-17, 1997; Pollock & Stewart, 1998) there is limited knowledge of the impact of environmental setting on mobility.

Person-Environment Interaction

  • Rather than viewing disability as a problem with the individual, disability may be conceptualized as a mismatch between the person and environment (Coster & Haley, 1992; Haley et al., 1994; Fougeyrollas, 1995; Law et al, 1996; Coster et al., 1998; Fougeyrollas et al.,1998; Law et al., 1999).
  • The concept of person-environment interaction is supported by persons with disabilities, advocacy groups (Law & Dunn, 1993; Law et al., 1999; Simeonsson et al., 2000) and the International Classification of Functioning, Disability, and Health (World Health Organization, 2001).
  • Figure 1 illustrates a conceptual framework for person-environment interaction in the performance of mobility:

Tablekc2003 2

Figure 1: Person-environment interaction in the performance of mobility

  • The construct of person includes the individual's capability and personal factors For children with CP, performance of mobility is influenced by their capability in all developmental domains (e.g. gross motor, fine motor, cognition, and vision) as well as personal factors (e.g. age, personality, preferences and lifestyle).
  • The environment includes the concepts of setting and context. For children, everyday settings include the home, school, and outdoor/community. Context refers to the physical, temporal, and social features of a particular setting.
  • The interaction of the person and the environment leads to the performance of an activity, such as mobility. Because the performance of mobility is needed in many activities of daily living, successful participation in society is contingent on the person-environment interaction.
  • Figure 2 presents a continuum of the physical, temporal and social contextual features of home, school, outdoors and community settings.
  • Children with CP may also be seen in a clinic setting for rehabilitation services. The contextual features of a clinic setting may be very different from home, outdoor and community settings.
  • Contextual features are related to the concept of "regulatory conditions"(Gentile, 1987), the features of the environment that impact on performance of mobility. Each of the contextual features presented in Figure 2 (distance, surfaces, obstacles, time constraints, and social expectations) is a regulatory condition for the performance of mobility.
  • For children with CP, mobility methods may depend on the regulatory conditions of a particular setting.

Contextual Features of Settings 

Figure 2: Contextual features of settings related to mobility

Research Findings

  • The impact of environmental setting on the mobility of children with CP was recently examined from the results of questionnaires completed by the parents of over 600 children with CP as part of the group of Ontario Motor Growth Study
  • The results provide evidence that the usual mobility methods (e.g. walking alone, walking with assistance of an adult, using a wheelchair) of children with CP differ depending on the setting:
  • Children tended to perform mobility methods requiring the most gross motor control (e.g. walking alone) at home, less gross motor control (e.g. walking with support) at school, and the least gross motor control (e.g. being pushed by an adult) in the outdoors/community.
  • Compared to the school setting, children were more dependent on adult assistance for mobility in the outdoors/community and less dependent at home.
  • Children in Gross Motor Function Classification System level III tended to demonstrate the most variability in mobility methods across settings.
  • The majority of children 4-12 years old and in Gross Motor Function Classification System levels III-V used wheelchair mobility at school and outdoors or in the community, however, only a small percentage self-propelled their wheelchair or used powered mobility.
  • 39% of children 4-12 years of age at level V were carried at home.
  • Capability (what a child CAN do) and performance (what a child DOES do) depend on the environmental setting (Tieman et al., 2002):
  • Children with CP generally performed different mobility methods than their gross motor capability. Capability was measured using selected items on the Gross Motor Function Measure (GMFM).
  • For example, children capable of crawling used other mobility methods, such as being pushed by an adult or using a wheelchair (in school and outdoors/community settings).
  • Among children who have similar gross motor capability, there were differences in performance across settings.
  • For example, among the children capable of walking alone, children walked alone to the greatest extent at home, to a lesser extent at school, and the least in the outdoors/ community.
  • As children move outside of the home setting, more demanding contextual features (physical features, temporal features, and social expectations) may influence mobility methods.

Clinical Recommendations

  • For examination of mobility in children with CP:
  • Utilize measures of both capability and performance
  • Examine mobility in the child's everyday settings.
  • Measure contextual features of everyday settings.
  • Identify personal factors that might influence mobility method.
  • For interventions to improve mobility in children with CP:
  • Goals and outcomes should reflect child and family needs for performance of mobility in everyday settings.
  • Address contextual features of everyday settings.
  • Address personal factors that may be influencing performance of mobility.

Future Research

Additional studies are needed to:

  • Better understand the relationship between capability and performance.
  • Determine contextual features of particular settings that are critical to performance of mobility.
  • Determine how contextual features of particular settings change as children get older.

Want to know more? Contact:

Peter Rosenbaum
CanChild Centre for Childhood Disability Research
Institute for Applied Health Sciences, Room 408
1400 Main St. W., Hamilton, ON L8S 1C7
Tel: 905-525-9140 x 27850 Fax: 905-524-0069

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