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CHAPTER THREE MATERIALS AND METHODS 3.1 Participants
One hundred and seven children (64 males and 43 females) with cerebral palsy aged between 1 and 6 years old were involved in the study. The children satisfied inclusion criterion of a diagnosed cerebral palsy made by a paediatrician and referred for physiotherapy. Children with cerebral palsy who presented with co-mobid neuromuscular or musculoskeletal disorders (e.g spinal bifida, muscular dystrophy or myopathy) were excluded from the study. One hundred and seven primary caregivers of the children with cerebral palsy who could understand either Yoruba or English language took part in the study. They constituted the caregivers of children with cerebral palsy group (CCWCP). To serve as control to the CCWCP, 98 caregivers of age-matched children that did not have cerebral palsy and who could understand either Yoruba or English language were surveyed.
3.2 Materials
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motor functional ability of children with cerebral palsy in one of the five ordered levels (Palisano et al, 1997). Children with CP at level 1 are those who can perform all activities of their normally developing age matched peers (although with affected speed and quality of movement) whereas children at level 5 have difficulty controlling their head and trunk posture in most positions or achieving any voluntary control of movement. Levels 2, 3 and 4 fall between. The GMFCS scores are also based on four age bands: less than 2 years; 2-4 years; 4-6 years; and from 6-12 years. Validity of the instrument was tested using the Nominal group technique which yielded over 12/15 agreement, and the Delphi Method which resulted in more than 16/20 rating (Bartlett, 2006). This instrument has been used by the researcher in previous studies and no modification was made to this instrument for the purpose of the present study (Hamzat and Fatudimu, 2008). The Gross Motor Function Classification System (GMFCS) was used by the researcher to classify the children with cerebral palsy into their functional ability levels (Appendix ii).
Gross Motor Function Measure (GMFM): The GMFM was used by the researcher to assess the gross motor function of children with cerebral palsy on a monthly interval for 8 months (Appendix iii). It is a criterion-referencedmeasure constructed for the purpose of evaluating change in gross motor function among children with CP (Russel et al, 1989).
The GMFM consists of 88 items grouped into 5 sub-domains: (1) lying and rolling (17 items); (2) sitting (20 items); (3) crawling and kneeling(14 items); (4) standing (13 items);
and (5) walking, running,and jumping (24 items). The instrument is scoredby observation of a child's performance on each item. Items are scored on a 4-point ordinal scale as follow; 0 = does not initiate, 1 = initiates; 2 = partially completes and 3 = completes. The instrument was suitable for use as originally designed without need for modification
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The General Health Questionnaire (GHQ): This was used to assess the general health status (Appendix iv) of the caregivers of the children with cerebral palsy and that of caregivers of children without cerebral palsy. The instrument consists of 12 items which is scored on a 4 point ordinal scale of 0-3. Reliability coefficients of 0.78 to 0.95 have been reported for the GHQ in variousstudies (Jackson, 2007). The Yoruba translation of this instrument which has been used and validated by Hamzat and Mordi (2007) was administered without further modification by the researcher to those caregivers who did not understand English Language (Appendix v).
World Health Organization Quality of Life Questionnaire (WHOQol-Bref): This was used to assess the quality of life of both the caregivers of the children with cerebral palsy and also those of the caregivers of children without cerebral palsy (Appendix vi). The instrument consists of 26 items which is scored on a 5 point ordinal scale of 1-5. The Yoruba translation of this instrument (Appendix vii) was administered to those caregivers who could speak only Yoruba. The Yoruba translation of the instrument which had been validated by Akinpelu et al (2006) was used by the researcher as it is without any adjustment made to it.
The Boyd and Graham Selective Motor Control Instrument
This instrument (Appendix viii) was developed in 1999 by Boyd and Graham and used in this study to assess selective motor control (SMC) in children with cerebral palsy in the clinic. It was scored 0-4 where 4 was given if isolated selective dorsiflexion through available range, using a balance of tibialis anterior activity without hip and knee flexion was carried out. A score of 3 was assigned if dorsiflexion was achieved using mainly tibialis anterior activity but accompanied by hip and / or knee flexion. 2 was given if
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dorsiflexion occured by using extensor hallucis longus, extensor digitorum longus and some tibialis anterior activity. 1 was scored if there was limited dorsiflexion using mainly extensor hallucis longus and/or extensor digitorum longus. A score of 0 was given if no movement occurred. Smits et al (2009) obtained a weighted Kappa score of 0.61 and 0.72 respectively in separate studies to determine the reliability of the instrument.
Modified Tardieu Scale (MTS: Modified Tardieu Scale (MTS) was used to assess spasticity in children with cerebral palsy. Test-retest reliability of the Modified Tardieu Scale has been reported to range from moderate to very good (k = 0.52 - 0.87) (Mehrholz et al 2005; Wright et al, 2008)