THE ROLE OF PHYSICAL THERAPY IN A PEDIATRIC PATIENT WITH OSTEOGENESIS IMPERFECTA FOLLOWING ORTHOPEDIC SURGERY
L.C. Drefus, Hospital for Special Surgery, New York, NY; S. Cassady, St. Ambrose University, Davenport, IA.
BACKGROUND & PURPOSE: Osteogenesis imperfecta (OI) is typically a genetic skeletal disorder of type I collagen. Recent medicine has identified up to 9 types of OI. Type IX OI is an autosomal recessive form due to a homozygous mutation in the PPIB gene with clinical features similar to type III or IV. Individuals with moderate to severe OI fight a cycle of fractures, muscle weakness, and skeletal deformities which challenges mobility. In the last decade bisphosphonate treatment, surgical rodding, and rehabilitation have resulted in improved function in children with OI. PT plays a crucial role in education, strengthening, aerobic fitness, and safe mobility. The purpose of this case study is to discuss the role of PT in the interdisciplinary care of a preschooler with type IX OI following bilateral femur and tibia osteotomies with intramedullary (IM) rodding. Emphasis is on therapeutic play interventions and changes in functional mobility and gait.
CASE DESCRIPTION: Patient is a 5 year-old female with type IX OI; characteristics include: history of 30 fractures, upper and lower extremity long bone bowing, muscle weakness, low muscle tone, ligament laxity, and white sclera. She has normal cognition, vision, hearing, and teeth. Patient was referred to this therapist as an outpatient at 3.5 yrs old. At the evaluation, she was non-ambulatory with crawling as her primary mode of mobility and bowing of left femur 63°, right femur 33°, and bilateral tibias 30° on radiographic films. By 3.8 yrs, she was walking 30 feet with HKAFO's and RW. At 3.9 yrs, she fractured bilateral femora and had two staged bilateral femur and tibia osteotomies with IM rodding at 4 yrs. Pre and post-operative PT focused on AROM, dynamic and core strengthening, safe weight-bearing in orthotics, mobility, and gait training through therapeutic play while observing OI precautions for safe mobility and strengthening. The Gross Motor Function Measure (GMFM) was completed with use of a rolling walker and orthotics. Walking was evaluated by the Gillette Functional Walking Scale (GFWS).
OUTCOMES: At 1-year post-op, patient improved strength, functional mobility, and ambulation measured by GMFM (35% to 87%) and GFWS (level 1 to 5). PT played a role in education, strengthening, and mobility training for the child to achieve her walking goal of 300 ft with solid AFO's and RW. Rehabilitation challenges included fractures, fear of movement, brace noncompliance, hyper-mobile joints, standing lumbar lordosis, proximal weakness, gait compensations, and ongoing fracture risk.
DISCUSSION: Literature reviews yielded no OI case studies specific to PT or OI validated standardized mobility tools. Future research on the validity of the GMFM and OI treatment protocols would be beneficial. A goal of this study is to discuss PT progression of therapeutic play, mobility, and gait following IM rodding of this child. An interdisciplinary care approach using bisphosphonate treatment, IM rodding, and rehabilitation showed positive functional mobility changes in a 5 year-old with type IX OI.
POSTURAL CONTROL DURING EARLY ARM MOVEMENTS IN THE FIRST MONTHS OF LIFE
S. Dusing, L. Thacker, Virginia Commonwealth University, Richmond, VA; J. Galloway, University of Delaware, Newark, DE; N. Stergiou, University of Nebraska at Omaha, Omaha, NE.
PURPOSE/HYPOTHESIS: The emergence of postural control is a hallmark of early infancy and an important foundation for functional behaviors including sitting, standing and walking. Fluctuations in postural sway as reflected in displacement of the center of pressure (COP) in supine can be used to describe postural control strategies used during early infancy. While preterm and full term infants differ in their postural control at 1–3 weeks of age, an understanding of the typical developmental trajectory for postural control is needed to further interpret group differences. The purpose of this study was to quantify the magnitude and repeatability of postural sway in typically developing infants while positioned in supine during early arm movements. Results will provide a foundation for comparing the development of postural control between high-risk preterm and full term infants in the first 6 months of life.
NUMBER OF SUBJECTS: Twenty-two infants born full term without medical complications participated in this study (mean gestational age 39.5 weeks, mean birth weight 7.2 pounds, 10 males).
MATERIALS/METHODS: Infants participated in monthly assessments of postural control, early arm movements, and motor developmental from 1 to 6 months of age. Postural control was quantified using the displacement of the COP while the infant was positioned in supine on a pressure sensitive mat sampling at 5 Hz. A combination of linear (root mean squared: RMS and Sway Path) and nonlinear (Approximate Entropy: ApEN) measures were used to quantify the magnitude and temporal structure of the fluctuations in the COP data, respectively. Behavioral coding was used to describe limb and head movements and reaching behaviors. Mixed Linear Models were used to quantify the impact of age on postural control.
RESULTS: The magnitude of COP displacement in the caudal cephalic (cc) direction decreased slightly while the sway path increased during in the first 3 months of life. The COP displacement in the cc direction became less repeatable during the first 3 months of life indicating the development of more variable postural control strategies over time. There were no significant changes in COP displacement in the medial lateral direction. Infants increased the amount of time their head and hands were in midline and increased toy contacts with increasing age.
CONCLUSIONS: Postural control strategies changed with increasing age, experience, and task demands. The less repeatable sway patterns are indicative of behavioral enrichment and adaptability to changing environment or task demands and may be a hallmark of typical development. Further research is needed to determine if such postural control strategies are absent or delayed in infants at high-risk for disabilities.
CLINICAL RELEVANCE: Clinicians should consider the role of variable postural control strategies in the development of motor skills in early infancy.
COMPARISON OF THE PEDIATRIC BALANCE SCALE WITH THE BRUININKS-OSERETSKY TEST OF MOTOR PROFICIENCY SECOND EDITION
M. Franjoine, B. Young, K. Bruce, M. Reid, S. Smith, Daemen College, Amherst, NY; N. Darr, C. Fold, K. Ritz, E. Shaw, A. Stanfield, Belmont University, Nashville, TN.
PURPOSE/HYPOTHESIS: The Pediatric Balance Scale (PBS) is a 14-item, criterion referenced screening measure of functional balance for children. The PBS has excellent test-retest reliability, ICC(3,2) = 0.910; interrater reliability, ICC(3,2) = 0.996; and intrarater reliability, ICC(3,2) = 0.80 to 0.975 in children ages 30 months to 15 years. Comparison of PBS total scores with Peabody Developmental Motor Scales, 2nd Edition subtest raw scores revealed moderate to good correlations for children ages 3 to 5 years: Stationary (rS = 0.633; p < 0.01), Locomotion (rS = 0.518; p < 0.01), Object Manipulation (rS = 0.531; p < 0.01), and Sum of subtest raw scores (rS = 0.611; p < 0.0). The Bruininks-Oseretsky Test of Motor Proficiency, 2nd Edition (BOT-2) is a standardized norm referenced test of motor skills for children, ages 4 to 21 years. The purpose of this study was to investigate the concurrent validity of the PBS with the BOT-2.
NUMBER OF SUBJECTS: Fifty healthy children (29 boys, 21 girls), identified by their parents as developing typically (DT), participated in this study. Age range was 4 to 11 years (mean = 7.09±0.3 years.)
MATERIALS/METHODS: Prior to data collection, seven raters were trained to administer and score the PBS and the BOT 2. Interrater reliability was established within the group of seven raters and the primary investigators: PBS ICC(3,1) = 0.999 and BOT-2 ICC(3,1) = 0.995. The PBS and BOT-2 were individually administered to each child in two testing sessions less than 14 days apart; test order was randomized. Spearman's rank correlation coefficients (r) were used to compare the PBS total scores with point scores from four BOT-2 subtests: Bilateral Coordination, Balance, Running Speed and Agility, and Strength.
RESULTS: Moderate to good correlations were found when comparing PBS total scores with BOT-2 subtest point scores: Bilateral Coordination (rS = 0.625; p < 0.01), Balance (rS = 0.671; p < 0.01), Running Speed and Agility (rS = 0.777; < 0.01), and Strength (rS = 0.714; p < 0.01). An analysis of content of the two tests reveals four similar static standing items: standing with eyes closed, standing with feet together, standing with one foot in front, and standing on one foot. Correlations between these items on the PBS and BOT-2 were poor (rS = 0.164–0.390, p < 0.001), most likely due to differences in physical demands of the motor task, complexity of directions, and the cognitive abilities required for the BOT-2.
CONCLUSIONS: Moderate to good correlations were found between scores obtained from PBS and BOT-2 testing; however, caution is recommended when comparing individual item performance.
CLINICAL RELEVANCE: This study supports the use of the PBS as a screening tool for identification of potential balance dysfunction in children.
USE OF INSTRUMENTED GAIT ANALYSIS TO ASSESS DECLINE IN GAIT IN DUCHENNE MUSCULAR DYSTROPHY: A PILOT STUDY
E.M. Godwin, Y. Anziska, C.R. Spero, Orthopaedica and Rehabilitation, SUNY Downstate Medical Center, Brooklyn, NY.
BACKGROUND & PURPOSE: One of the most significant milestones in patients with Duchenne muscular dystrophy (DMD) is loss of ambulation. This adversely affects quality of life, accelerates weakness and may contribute to respiratory failure. We hypothesize that instrumented gait analysis performed at intervals over time could qualitatively evaluate gait patterns and identify subjects at risk for losing ambulation.
CASE DESCRIPTION: Seven ambulatory boys ages 5–15 with genetically confirmed DMD had instrumented gait analysis. Five of the seven had serial gait analyses at baseline and between 6 months and 1 year later. Two subjects, age 13 and 9 years had one analysis as they lost ambulation within 6 months. This 9 year old subject was the only subject not on corticosteroid (prednisone) therapy. A Vicon 3-D Motion Analysis System with 7 MX-13 Cameras, 2 AMTI OR-6 force plates and digital video analysis was used to collect the gait data.
OUTCOMES: For all subjects kinematic analysis demonstrated increased pelvic tilt, increased plantar flexion throughout the gait cycle and increased hip and knee flexion during swing phase. The most significant and consistent change across subjects and over time was the loss of knee flexion in loading response. The 5 subjects with serial analyses all demonstrated loss of knee flexion in loading over time. The loss of knee flexion at loading was on average 4o. (Peak knee flexion in loading response for an 8 year old is 10o). The 2 subjects who lost ambulation within 6 months of their gait analysis had no loading response; no knee flexion at loading with a flat curve. The younger children demonstrated variability in temporal-spatial data, whereas the older children demonstrated and abnormal temporal spatial data including decreased walking speed and stride length and abnormal kinetics with decreased force generation at hip, knee and ankle.
DISCUSSION: Instrumented gait may be useful for qualitatively analyzing gait deterioration in children with DMD. Based on gait analysis results interventions can be planned in the early stages such as to help prolong ambulation. Subjects who are demonstrating decline in gait parameters especially the lost of knee flexion at loading response should be closely monitored and begin to plan for treatment interventions and strategies when ambulation is no longer functional. Corticosteroid therapy in this small group of children seems to help prolonged ambulation. The most significant limitation of this study is the small sample size. This study is ongoing and will include an increased number of subjects who have serial analyses as well as six minute walk test data. In the future we will be able to demonstrate statistical support for our findings.
THE EFFECTS OF A BRIEF, INTENSIVE FES-ASSISTED CYCLING INTERVENTION ON CYCLING PERFORMANCE IN ADOLESCENTS WITH SPASTIC CEREBRAL PALSY: A CASE SERIES
A. Tokay Harrington, Interdisciplinary Program in Biomechanics and Movement Science, University of Delaware, Newark, DE; C.G. McRae, Research Department, Shriners Hospital for Children, Philadelphia, PA; S. Lee, Department of Physical Therapy, University of Delaware, Newark, DE.
BACKGROUND & Purpose: Recumbent cycling using Functional Electrical Stimulation (FES) assistance has been proposed as a means of exercise for children with cerebral palsy (CP) who may be unable to participate in traditional forms of exercise due to muscle weakness, abnormal muscle tone and poor motor control. Previous work in our laboratory has demonstrated the feasibility of this intervention. The purpose of this report is to examine the efficacy of a brief, intensive FES-assisted cycling training intervention on cycling performance.
CASE DESCRIPTION: Three adolescents (2 male) with spastic CP (one each of GMFCS Levels II, III and IV) participated in this study. Subjects completed a training program consisting of ten, 30-minute sessions of FES-assisted cycling using an instrumented recumbent tricycle placed on a trainer to allow for stationary cycling. Bilateral quadriceps femoris muscles were stimulated using surface electrodes with FES intensity set at the level required to achieve a motor-level contraction sufficient to extend the lower extremity. FES was timed to provide stimulation during the arc of motion in the cycling revolution when the quadriceps should be active. Visual feedback was provided to encourage subjects to achieve targeted power outputs during testing and training procedures. Subjects completed cycling tests with and without FES assistance before and after the training intervention. Incremental load cycling tests were performed to assess peak performance and constant load cycling tests were performed to assess submaximal, steady state cycling. Power output, heart rate and oxygen consumption data were collected for analysis.
OUTCOMES: Subjects completed incremental cycling tests without FES assistance and all subjects demonstrated increased peak power output (range: 18–192%) and increased peak VO2 (range: 4–65%) after training; changes in net peak heart rate were variable. In FES-assisted constant load tests, all subjects demonstrated increased average steady state power output (range: 51–186%) and one subject had an increase in net heart rate during steady state cycling after training, while two had a decreased net change in heart rate despite increased power output. In constant load cycling tests without FES assistance, one subject had increased power output during steady state cycling, two subjects increased their net change in steady state heart rate.
DISCUSSION: This case series illustrates the potential for improved volitional cycling performance following intensive FES-assisted cycling training in adolescents with CP. Although the conclusions that can be drawn are limited due to the nature of the case series, there were trends toward improved cycling performance in these three individuals. Future work will examine FES-assisted cycling training in a randomized, controlled design.
ACKNOWLEDGEMENTS: PODS II Scholarship (Tokay Harrington); NICHD R01HD043859 and Shriners Hospital Grant 9159(Lee); Shriners Hospital Fellowship Grant 10650(McRae)
EFFECTS OF ENVIRONMENT AND PERSONAL FACTORS ON MOTOR SKILL TEST SCORES AND ADMINISTRATION TIME IN YOUNG CHILDREN
R. Hickman, D. Mittelstadt, A. Parker, K. Pickett, H. Temkin, Physical Therapy, University of Nevada, Las Vegas, Las Vegas, NV.
PURPOSE/HYPOTHESIS: The purpose of this study was to test the hypotheses that young children will perform differently on tests of motor development such as the Peabody Developmental Motor Scales – 2nd Ed. (PDMS-2) (1) in quiet vs busy environments and (2) personal factors including temperament. We also hypothesized that PDMS-2 administration times would vary in quiet vs busy conditions.
NUMBER OF SUBJECTS: 34 children aged 18 to 59 months
MATERIALS/METHODS: Parents provided information about their child's history, temperament, and their concerns about their child's development. The PDMS-2 was administered to all subjects in quiet (closed) and busy (open) environments. Testing in closed environments was done in a quiet room or play area with no other activity. Testing in open environments was done in a classroom, open play area, or other busy areas. Order of environmental condition was randomized, with 2 weeks between administrations. ANOVAs were used to compare effects of environmental and personal factors on scores and administration times. Reliability of examiners on PDMS-2 was tested before and during data collection.
RESULTS: Children identified as extroverts had significantly lower total motor quotients (TMQ) and fine motor quotients (FMQ) in open environments (p ≤.002). There were no significant differences across environments in scores of children identified as introverts (p ≥.298). There was no interaction between gross motor quotient (GMQ) scores and test environment (p = .062). GMQ scores were significantly higher for extroverts compared to introverts (p = . 02). There was no difference between GMQ scores in closed vs open environments (p = .088). PDMS-2 administration time was significantly longer in open vs closed environments (p = .029) regardless of temperament. There was no significant difference in proportion of children receiving services under IDEA based on temperament (p = .328).
CONCLUSIONS: Testing in closed environments shortened test administration time for children regardless of temperament. Children identified as extroverts performed better in the closed environment. Children identified as introverts scored lower on the PDMS-2 than extroverts on all PDMS-2 quotients (TMQ, FMQ, and GMQ) regardless of test condition. Performance of introverts was not affected by environment.
CLINICAL RELEVANCE: The importance of environmental and personal factors is recognized at all ICF levels, in educational law, and best practices. It is important for therapists testing motor development of young children to consider how environmental conditions and children's personal factors may alter test outcomes and administration times, especially when pediatric physical therapy resources are limited. We recommend that clinicians consider administering the PDMS-2 and other motor tests in closed environments to optimize children's performance and conserve resources. Being able to complete an examination in the shortest time frame with the most accurate representation of the child's ability is beneficial to children, families, therapists, and program administrators.
HEALTH PROMOTION OF PEDIATRIC PATIENTS IN PHYSICAL THERAPY PRACTICE: A NATIONWIDE STUDY
G.M. Huber, S. McKenna, M. Shah, W.E. Healey, Department of Physical Therapy and Human Movement Sciences, Northwestern University, Chicago, IL.
PURPOSE/HYPOTHESIS: Health and wellness promotion (HP) is one approach used to address the growing epidemic of childhood obesity and Type II diabetes in the US. HP is listed in the Guide to PT Practice, but very little research has been done on how PTs incorporate HP activities into daily practice. The purpose of this study is to identify the types of HP activities PTs are doing with their patients, and identify facilitators and barriers to performing HP. We hypothesize that pediatric PTs are doing HP; and that education, clinical specialization, the type of clinic, and regional location influences the incorporation of HP into practice; and that there are barriers preventing PTs from practicing HP.
NUMBER OF SUBJECTS: 332
MATERIALS/METHODS: Survey methodology was used to answer the research questions. An email or postcard was sent to a randomized list of 1300 APTA pediatric section members asking them to go online and fill out our survey. Two reminder emails/postcards and an incentive were used to improve survey response. Data was analyzed using PASW.
RESULTS: 332 PTs completed the survey. The total response rate was 26%. Cronbach's α-coefficients were α ≥ 0.72 for applicable survey questions. Pediatric PTs do some form of HP activities in their practice. Respondents addressed the following topics with “most of their patients” in the last 7 days: 57% family/caregiver education; 22% physical activity and 1.3% nutrition and weight management. 74% did not address spiritual wellness with any patients. Respondents were more likely to have addressed HP in the last 7 days (Q3) and incorporate HP in written goals and plans (Q5) when they felt HP was important (r = 0.34, p < .005; r = 0.40, p < .005 respectively). Confidence in their ability to do HP also significantly correlated with Q3 (r = 0.28, p <.005) and Q7 (r = 0.48, p < .005). Highest earned degree was poorly correlated with Q3(r = 0.12, p < .05) and was not significant for Q7. Being a Pediatric Certified Specialists did not significantly correlate with Q3 and poorly correlated with Q7 (r = 0.16, p < .01). Regional location was not significantly correlated with any form of HP. More HP was done (Q3) if the caregivers were perceived as a barrier to adoption of HP behaviors (r = 0.17, p < .05).
CONCLUSIONS: Pediatric PTs are more likely to do some form of HP if they are confident in it or if they feel it is important to them. But although these pediatric PTs considered HP important they did not always incorporate it into their practice. PTs need to move beyond family/caregiver education and address other areas of HP. Nutrition/weight management and child safety were not consistently addressed. The lack of spiritual wellness could be due to the number of respondents working in the school setting.
CLINICAL RELEVANCE: PTs need to make the shift to engaging in more HP with the pediatric population so children can adapt to better health practices at an earlier age and do more of a holistic approach to therapy and address the whole child. This ultimately can reduce the growing epidemic of childhood obesity and Type II diabetes.
PHYSICAL THERAPIST ROLE AS EDUCATOR AND INSTRUCTOR IN PERSONNEL DEVELOPMENT MANDATE FOR EARLY START (PART C)
C. Lieb-Lundell, A.M. Edwards, Physical Therapy, University of St. Augustine, San Marcos, CA.
Purpose: To describe a training program for early intervention personnel that is provide by physical therapy as part of personnel development for the California early intervention system, i.e. Early Start. Description Each state participating in Part C of the Individuals with Disabilities Education Act (IDEA) must establish qualifications to assure that persons providing early intervention services are adequately prepared and trained as defined in 34 CFR 303.361. In the federal legislation physical therapy is listed as one of the 17 early intervention services available to families through Part C. However, physical therapists are more commonly not providing direct services to infants and families. Infant services are increasingly being provided by a single primary care provider, i.e. early interventionist, as systems look to cost savings to deliver mandated services. Therapists are seen as a valuable training resource for early intervention personnel development. The presentation will demonstrate training components that the physical therapist provides in the California Part C Early Start personnel development program and compare this to personnel training models from other states.
SUMMARY OF USE: The information presented will summarize subject areas that physical therapists can use to develop the motor component of a personnel training program thereby contributing content expertise to the early intervention system.
IMPORTANCE TO MEMBERS: As the resources and support for early intervention decrease, physical therapists must define and be available to be part of the multidisciplinary approach mandated by the IDEA legislation. Individual states are looking to single provider models in response to personnel shortages and the lack of funding for direct evaluation and intervention. In this environment physical therapy can provide consultation and training, clarify the physical therapist's role on the early intervention team and highlight the red flags that could indicate the need for physical therapist evaluation and intervention.
THREE-DIMENSIONAL LOWER EXTREMITY KINEMATICS DURING DROP LANDING IN ADOLESCENT FEMALES WHO ARE OBESE
A. Gross McMillan, D. Williams, M. White, Physical Therapy, East Carolina University, Greenville, NC.
PURPOSE/HYPOTHESIS: Compared to healthy weight peers, adolescents who are obese have been shown to have poorer balance, proprioception, and dynamic stability during gait. Knee injuries are the most common type of injury in this population. There have been no studies comparing effect of body mass in adolescent females on landing patterns. The purpose of this study was to investigate differences in landing patterns between adolescent females who were obese (OW) vs. healthy weight (HW). We hypothesize that obese adolescent females will demonstrate a different landing pattern than their healthy weight counterparts.
NUMBER OF SUBJECTS: 20 female subjects were recruited from a local healthy weight clinic and from the community. Subjects with musculoskeletal or neuromuscular dysfunction were excluded.
MATERIALS/METHODS: Three dimensional joint kinematics and kinetics were collected and analyzed. Subjects stood on a 12” platform with their first metatarsal heads on the edge of the platform. Subjects were instructed to lean forward until they felt the need to leave the platform, and to land with each foot on a force plate, with equal weight on each lower extremity. Ten successful trials were recorded for each subject. Triplanar total motion was calculated for the ankle, knee, and hip by adding frontal, sagittal, and transverse plane excursions at each joint. Percentage of total motion occurring in each plane was calculated by dividing excursion in each plane by the total triplanar excursion. Student's t-tests were used for between-group comparisons of the percentage of total motion in each plane at the ankle, knee, and hip, and of the actual angular excursions at each joint in each plane.
RESULTS: There was no significant difference (p = 0.31) between total triplanar ankle excursion between groups. Significant differences (p = 0.03) were found in the percentage of frontal plane ankle motion between the OW group and the HW group compared to their total triplanar ankle motion. There was a significant difference (p = 0.01) between total triplanar knee excursion between groups. Significant differences (p = 0.00) were found in the percentage of transverse plane knee motion between the OW group and the HW group compared to their total triplanar knee motion. There was a significant difference (p = 0.00) between total triplanar hip motion between groups, but no difference in the percentages of motion contributed by each plane.
CONCLUSIONS: Overweight adolescent females demonstrate significantly higher percentage of frontal plane motion at the ankle, lower percentage of transverse plane motion at the knee, greater total excursion at the knee, more total hip excursion and higher sagittal and transverse plane hip excursions.
CLINICAL RELEVANCE: Obesity significantly affects lower extremity motion during landing. Exercise considerations should be focused on ankle and hip control in these individuals.
TO DECLINE OR NOT TO DECLINE: A POTENTIAL MECHANISM BY WHICH TORQUE OUTPUT IS PRESERVED IN CEREBRAL PALSY
N.G. Moreau, H. Knight, Health Professions, Medical University of South Carolina, Charleston, SC; M. Olson, Kinesiology, Southern Illinois University, Carbondale, IL.
PURPOSE/HYPOTHESIS: We have previously shown that the rate of decline in peak torque (PT) of the knee extensors and flexors during an isokinetic fatigue protocol is less in individuals with cerebral palsy (CP) compared to typically developing (TD). However, the electromyographic (EMG) activity during repetitive maximal contractions has not been examined, particularly, the contribution of the antagonist muscles. The purpose of this study was to examine agonist and antagonist muscle activity during repetitive knee flexion (KF) and knee extension (KE). We hypothesized that the EMG pattern of the antagonist muscle group would contribute to the differences in fatigability.
NUMBER OF SUBJECTS: Nine ambulatory individuals with CP (mean age: 17.2; SD: 4.3 years) and 11 age-matched TD (mean age: 17.3; SD: 5.0 years).
MATERIALS/METHODS: Fatigue protocol consisted of reciprocal, concentric knee extension and flexion at 60 deg/s for 50 repetitions on an isokinetic dynamometer. Percentage decline in PT and the rate of decline (slope) were examined separately for KF and KE and normalized to maximal PT to account for strength differences between groups. EMG activity of the rectus femoris (RF), vastus medialis (VM), and biceps femoris (BF) for each repetition were normalized as a percentage of maximum EMG activity of that muscle during the trial while acting as an agonist. Antagonist EMG activity, or cocontraction, was calculated as the ratio of the mean absolute EMG value of the muscle while acting as an antagonist to that while acting as an agonist. Independent t-tests were used to compare between groups with alpha level = .05.
RESULTS: Percentage decline and rate of decline in PT for KE was significantly greater in TD (FI: 60%; Slope: -.013) as compared to CP (FI: 25%; Slope: -.006). The rate of decline in agonist RF and VM EMG was not significantly different between groups. However, the rate of decline in antagonist BF EMG was significantly greater in CP (73% to 45%) as compared to TD (16% to 14%). For KF, there were no statistically significant differences between groups.
CONCLUSIONS: Net torque during repeated contractions is the result of both agonist and antagonist activity. The results suggest that the greater linear decrease in KE torque during the protocol in TD is due to a decline in agonist EMG activity with constant antagonist activity, resulting in greater levels of relative opposing force from the antagonist. In contrast, in CP, declining agonist EMG occurs in conjunction with declining antagonist activity, decreasing the relative opposing force and resulting in a lesser decline in net torque.
CLINICAL RELEVANCE: This study is the first to describe disparate EMG patterns during an isokinetic fatigue protocol in people with CP compared to TD. The decline in EMG activity of the antagonist BF during repeated contractions illustrates a potential mechanism by which net torque is preserved in those with CP who are inherently weaker. Future studies should investigate whether repeated training can optimize this occurrence in order to decrease overall cocontraction levels.
THE USE OF THERATOGS VERSUS TWISTER CABLES IN THE TREATMENT OF IN-TOEING DUE TO INTERNAL TIBIAL TORSION DURING GAIT IN A CHILD WITH SPINA BIFIDA: A CASE STUDY
A. Richards, S. Morcos, Rehabilitation Services, Childrens Hospital Los Angeles, Los Angeles, CA.
BACKGROUND & PURPOSE: The focus of orthopedic intervention of patients with myelomeningocele has shifted from preventing and correcting lower extremity deformities to maximizing mobility and independence. In ambulatory children with higher-level lesions, rotational deformities of the lower extremities, specifically tibial torsion, are most commonly seen through in-toeing. The standard of care is solid AFOs with Twister Cables (TC). A new trend in treatment consists of the use of TheraTogs¯ (TT), an orthotic undergarment used for correction in alignment and muscular imbalance through a trunk system and customized external strapping; primarily used with the cerebral palsy population. Although both treatment interventions decrease general in-toeing there is no current data to compare the source of alignment correction in patients with spina bifida. Therefore, the purpose of this case study is to determine if TheraTogs can have similar effects as Twister Cables with correction of in-toeing due to internal tibial torsion during gait in a child with spina bifida.
CASE DESCRIPTION: Patient is a 2-year-old female with L4 spina bifida who is an independent ambulator with bilateral in-toeing. She presents with thigh-foot angles of L:15° and R:10°, used to measure foot progression in gait. The study consisted of two 90-minute gait analyses testing at the Childrens Hospital John C. Wilson Jr. Motion Analysis Laboratory. The kinematic data was acquired using an 8-camera VICON 3-dimensional motion analysis system. Baseline data was collected with AFOs only. Data was then collected following 6 weeks use of TC and AFOs and after 6 additional weeks with TT and AFOs.
OUTCOMES: On average, normal values for foot progression, maximum knee extension and hip rotation during the stance phase of gait are (-)14.02, 2.09 and (-)2.36°, respectively, with a negative indicating external rotation and a positive indicating flexion. Collected data for foot progression, maximum knee extension and hip rotation were as follows: AFOs was R:0.23 L:37.74, R:14.25 L:6.03, R:(-)11.27 L:(-)3.51, respectively; TC and AFOs was R:(-)12.11 L:5.29, R:(-)1.66 L:1.32, R(-)8.72 L:(-)7.65, respectively; TT and AFOs was R:(-)29.80 L:12.76, R:22.67 L:26.35, R:(-)24.93 L:(-)22.58, respectively.
DISCUSSION: The data was clinically significant in suggesting both TC and TT can effectively correct for in-toeing during gait. However, TT effected foot progression as it decreased in-toeing by excessively externally rotating the hips, thereby masking the influence of internal tibial torsion. On the other hand, TC effected foot progression through external torsion at the tibia, while obtaining less external rotation at the hips. In addition, TC and AFOs obtained more optimal knee extension in the stance phase of gait while the TT and AFOs increased knee flexion in stance. Our data suggests that correction of in-toeing due to internal tibial torsion is optimal through the use of twister cables and AFOs in a child with spina bifida.
CONSTRUCT VALIDITY OF A BATTERY FOR FITNESS ASSESSMENT OF CHILDREN AND TEENAGERS WITH OBESITY
S.B. Rothbart, K. Magram, N. Horowitz, C. Papincak, E. Kohn, Physical Therapy Program, Hunter College/Graduate Center of the City University of New York, New York, NY; E.E. Schwabe, In-Patient Rehabilitation, New York Presbyterian Hospital/Weil Cornell Medical College, New York, NY.
PURPOSE/HYPOTHESIS: The purpose of this study was to develop and establish construct validity of the New York Presbyterian-Health for Life (NYP-H4L) Fitness Battery. We hypothesized that the NYP-H4L Fitness Battery would reflect the following dimensions of fitness: strength, flexibility, endurance and posture. We also hypothesized that the battery could be efficiently administered in a timely manner to groups of children and teenagers with obesity.
NUMBER OF SUBJECTS: Forty-seven children (ages 8–12; n = 34) and teenagers (ages 13–18; n = 13). Participants were referred to the Health for Life Program by their pediatricians. Health for Life is a 10-week training program about exercise, diet, and weight management recommendations run by physicians, physical therapists, dietitians and social workers.
MATERIALS/METHODS: A systematic literature review found tests and measures which met a priori inclusion criteria and reflected the dimensions of fitness. A panel of experts approved the fitness battery for field testing. Subjects were assessed with the NYP-H4L Fitness Battery before participating in Health for Life. Principal component analysis with a Varimax rotation method was conducted to establish construct validity. MANOVA was used to verify if gender or age group differences occurred.
RESULTS: Several fitness tests met the inclusion criteria of the systematic review and reflected the dimensions of fitness. Principal component analysis verified the battery captured three dimensions of fitness: 1) endurance/strength (Eigenvalue = 2.691); 2) flexibility (Eigenvalue = 1.68); and, 3) exertion (Eigenvalue = 1.49). These components reflected 58.6% of the variability of the sample. MANOVA showed that: gender was not a discriminatory factor; age group differences occurred only for number of laps for the shuttle run. This number was correlated to body mass index (rho = (-)3.29, p = 0.03). Posture could not be adequately scored.
CONCLUSIONS: The NYP-H4L Fitness Battery was a valid measure of fitness for children and teenagers with obesity. Our findings support the hypotheses because the battery showed construct validity and could be administered to groups of children and teenagers in a time-efficient manner. We see potential in future use of the fitness battery with similar populations after its ability to detect change is determined.
CLINICAL RELEVANCE: The NYP-H4L Fitness Battery can be administered in a timely fashion within a clinical or school setting. The battery reflects the dimensions of fitness that include strength/endurance, flexibility and endurance. The battery can be administered to boys and girls with obesity within the 8–18-year old age range.
THE EFFECTS OF HIPPOTHERAPY ON BEHAVIOR, SENSORY PROCESSING, AND POSTURE IN A CHILD WITH PERVASIVE DEVELOPMENTAL DISORDER: A CASE REPORT
T. Rydant, D.A. Nervik, PT, Franklin Pierce University, Concord, NH.
BACKGROUND & PURPOSE: Pervasive Developmental Disorder (PDD) is a form of autism spectrum disorder; a developmental disability that affects a child's communication, social, and behavior skills. Difficulties with sensory processing and atypical postural or motor skills are also often involved. Hippotherapy is becoming a popular intervention used in physical therapy for a variety of conditions, including PDD and Sensory Processing Disorder (SPD). The purpose of this case report is to evaluate the effectiveness of hippotherapy on behavioral skills, posture, sensory processing, and core strength in a child with PDD.
CASE DESCRIPTION: The subject was a 9-year-old boy diagnosed with PDD, anxiety, SPD, and decreased core stability. The subject attended one hour, once weekly hippotherapy sessions for six weeks. Sessions consisted of grooming and riding skills, and core strengthening exercises. A bareback pad was utilized instead of a standard saddle as it provides increased physical contact with the horse with increased sensory input and less external support; therefore increasing the subject's challenge to maintain posture/balance while providing increased proprioceptive and tactile input. A variety of core strengthening exercises were done both in the clinic and in a home exercise program. Effects of hippotherapy were measured using The Clinical Observations of Motor and Postural Skills (COMPS), the Long and Short Sensory Profile tools, Postural analysis, and subjective reports.
OUTCOMES: The subject showed significant improvements on four out of six of the COMPS subtests after completing 6 weeks of intervention, with a total pre-intervention score improving from −1.26 to a total post-intervention score of .92. Scores on both the long and short versions of the Sensory Profile were also improved with several sub categories on the short test improving to score in the typical performance range after intervention and certain sub tests on the long version improving by 1 or 2 standard deviations post intervention. Increased core strength was demonstrated by improved posture while riding and in standing postural assessment as well as improved performance and repetitions in core strengthening exercises. Examination of postural photographs demonstrated objective changes in posture. Subjective improvements were reported by the subject's mother in behavioral and social skills including a decrease in anxiety and an increased in calmness after riding lessons.
DISCUSSION: This case report describes improvements in posture, stability, behavior, and sensory function in a nine year old male diagnosed with PDD and SPD after a six week intervention of hippotherapy. The positive improvements seen in the variety of outcome measures suggests hippotherapy in conjunction with core strengthening exercises may be an effective intervention to improve function for children with PDD and SPD. Future research is needed.
WII GAMING SYSTEM FOR CHILDREN WITH DEVELOPMENTAL DELAY: A RANDOMIZED SINGLE-BLINDED CONTROLLED TRIAL
Y. Salem, S. Jaffee Gropack, Division of Physical Therapy, Long Island University, Brooklyn, NY; D.A. Coffin, ACE PreSchool/ACE HeadStart, Hospital Clinic Home Center Instructional Corp., Brooklyn, NY; E.M. Godwin, Human Performance Laboratory, SUNY Downstate Medical Center, Brooklyn, NY.
PURPOSE/HYPOTHESIS: Physical therapists have begun to use the Nintendo Wii gaming system with adults and children as part of their regular treatment. However, limited evidence is available on the efficacy of virtual reality gaming system in children with developmental delay. The purpose of this randomized single-blinded controlled trial was to determine the feasibility and preliminary effectiveness of a low cost gaming system using the Nintendo Wii gaming system in young children with developmental delay.
NUMBER OF SUBJECTS: Forty children with developmental delay (ages 36–58 months) who attended a segregated or integrated preschool participated in this study.
MATERIALS/METHODS: Children were randomly assigned to an intervention/Wii group (n = 20) or a control group (n = 20). Intervention consisted of 2 weekly sessions for 10 weeks. Intervention was performed using the Nintendo Wii Fit games software, including balance, strength training, and aerobics games. Participants were evaluated one week before and one week after the program by a blind investigator. Primary outcomes were walking speed, Timed Up & Go test, Timed One Legged Stance, Timed Up and Down Stairs, Five Times-Sit-to-Stand test, Two-Minute Walk test, and grip strength.
RESULTS: The two groups were homogenous regarding all parameters at baseline. The training was feasible and enjoyable for those participated in the study. There were no adverse effects or injury reported over 267 training sessions. Significant improvements for walking speed, Timed One Legged Stance, Timed Up and Down Stairs, Two-Minute Walk test, and grip strength were observed in both groups. Relative to the control group, participants in the Wii group had statistically significant improvements in Timed One Legged Stance and grip strength.
CONCLUSIONS: This study demonstrated that the use of the Wii gaming system is feasible, safe, enjoyable and potentially efficacious in enhancing motor function in young children with developmental delay. The potential application of the Wii gaming system to increase intensity of therapy or as a rehabilitation tool in children homes and rural settings is an area worthy of investigation.
CLINICAL RELEVANCE: The findings of this study support the use of the Wii as a feasible, safe, and potentially effective therapeutic tool to augment the rehabilitation of young children with developmental delay. The promising results of this study suggest that further studies are warranted to validate the potential benefits of a low cost, commercially available gaming system as a treatment strategy to supplement rehabilitation of children with disabilities.
COMPARATIVE EFFICACY OF INTENSIVE ROBOTIC GAIT TRAINING AND STRENGTHENING PROGRAMS IN CHILDREN WITH CEREBRAL PALSY
J. Schmit, Occupational and Physical Therapy, Cincinnati Children's Hospital Medical Center, Cincinnati, OH.
PURPOSE/HYPOTHESIS: Evidence suggests that massed, task-specific practice improves function, though the precise effects of many physical therapy-based interventions are unknown. Current strategies demonstrating utility in the development of gross motor function include strengthening and robotic gait training. The purpose of this study is to comparatively examine the efficacy of two intensive programs emphasizing these tactics in children with cerebral palsy (CP). It is hypothesized that they will differentially impact selected outcomes. An enhanced understanding of their relative effects will facilitate the establishment of a plan of care best suited to meet the unique needs of children with CP.
NUMBER OF SUBJECTS: Eighteen children with CP participated in this study.
MATERIALS/METHODS: Nine children were referred for participation in the Strengthening Program of Intensive Developmental Exercise and Activities for Reaching Maximum Potential (SPIDER), characterized by lower extremity and core strengthening, balance activity, and functional skill. Nine additional children were referred for participation in the RoboDOG program (Robotically Driven Orthosis for Gait), wherein stepping is facilitated by a powered lower extremity exoskeleton, over a treadmill. In both interventions, patients participated in an 18 session episode of care, delivered twice or thrice weekly. Comparative analysis was conducted using a mixed analysis of variance (ANOVA, between: SPIDER versus RoboDOG; within: pre- versus post-test scores). Separate ANOVAs were performed for each dependent variable (six minute walk test, Gross Motor Function Measure, and Canadian Occupational Performance Measure).
RESULTS: ANOVA results suggest that following either intervention, participants globally demonstrated improvement trends in gross motor function and COPM measures (p>.05). A superiority of intervention type was detected only in COPM performance, wherein participants in the RoboDOG program demonstrated higher performance scores, per caregiver interview (p>.05). Six minute walk test analyses indicated neither treatment efficacy, nor a superiority of intervention type. However, a significant interaction effect indicates that at post-assessment, the SPIDER program demonstrated a trend toward greater six minute distance relative to RoboDOG participants, whose scores were grossly unchanged following training (p>.05).
CONCLUSIONS: The results of this study indicate that both strengthening and robotic gait training can result in improvements in gross motor function and in occupational status. Robotic gait training is associated with greater increase in performance of valued activity, whereas the SPIDER program elicits a larger pre- to post- divergence in walking endurance.
CLINICAL RELEVANCE: These results lend further support to the utility of strengthening and robotic gait training as intervention strategies in the habilitation of children with CP. They also illustrate the importance of goal-specific treatment planning, as the approaches appear to differentially influence outcomes.
GILLETTE FUNCTIONAL ASSESSMENT QUESTIONNAIRE: LINKING CLASSIFICATION LEVELS TO PERFORMANCE OF FUNCTIONAL SKILLS IN CHILDREN WITH DISABILITIES
J. Stout, T.F. Novacheck, Cemter for Gait and Motion Analysis, Gillette Children's Specialty Healthcare, St. Paul, MN; G. Gorton, Shriner's Hospital for Children – Springfield, Springfield, MA; A. Bagley, Shriner's Hospital for Children – Northern California, Sacramento, CA; R.C. Tervo, Department of Pediatrics, Gillette Children's Specialty Healthcare, St. Paul, MN; C.A. Tucker, Temple University, Philadelphia, PA.
PURPOSE/HYPOTHESIS: The Gillette Functional Assessment Questionnaire (FAQ) is a self- or proxy-report tool commonly used to describe walking ability and functional skills in children with disabilities. It consists of a 10-level walking scale and 22-item skill set of gross motor activities. Item response theory (IRT) analysis maps person ability and item difficulty to a common interval scale. The purpose of this report is to demonstrate the relationship between existing classification systems (Gross Motor Function Classification System (GMFCS) and FAQ walking level) and IRT person-item mapping of the FAQ 22 item skill set.
NUMBER OF SUBJECTS: 485 subjects (289 with diagnosis of cerebral palsy, 196 with diagnosis of orthopaedic or neuromuscular disorder).
MATERIALS/METHODS: An IRB approved medical record review of FAQ walking scale, 22-item skill set, and Pediatric Outcome Data Collection Instrument (PODCI) data of a group of children/adolescents. All data were obtained by proxy report or legal guardian as part of information collected during routine clinical gait analysis in a hospital setting. IRT analysis using Winsteps software was used to determine the person-item mapping for the FAQ 22-item skill set and PODCI items. The GMFCS and FAQ walking scale were used to group the subjects and produce confidence intervals that identify the average ability level by either classification system.
RESULTS: Confirmatory factor analysis indicated that the underlying construct of the FAQ is consistent with a single factor. The FAQ 22-item skill items map to the range of community ambulation levels of the GMFCS and FAQ walking level classification groups. The PODCI items include skills at household or therapy levels of ambulation.
CONCLUSIONS: The FAQ is a valid instrument to determine level of motor or walking ability. The level of walking achieved will map to a set of skills the child will most likely perform. No ceiling effects and were minimal floor effects were noted. The combination of PODCI and the FAQ together span a broader range of walking abilities.
CLINICAL RELEVANCE: The validity of the FAQ as an instrument to assess motor and walking function is established. The psychometric properties support its usefulness in computer adaptive testing designs.
PREDICTION OF ADAPTIVE MOTOR SKILL PERFORMANCE IN SCHOOL-AGED CHILDREN WITH LOW BIRTH WEIGHT WITHOUT MAJOR NEUROSENSORY IMPAIRMENT
M.S. Swiggum, Lynchburg College, Lynchburg, VA; T. Roddey, P. Gleeson, K. Mitchell, Texas Woman's University, Houston, TX.
PURPOSE/HYPOTHESIS: The purpose of this multiple regression analysis was to identify the variables present at entry to early intervention associated with adaptive motor skill performance at kindergarten age in children born with low birth weight without identified neurologic abnormalities. It was hypothesized that at least one variable from the categories of biologic, environmental, and behavioral risks would be a significant predictor of reported adaptive motor skills and that a significant prediction model would emerge.
NUMBER OF SUBJECTS: Three-hundred-and-forty-one children, representing a subset of the 3,338 children enrolled in the National Early Intervention Longitudinal Study (NEILS), met the inclusion criteria for this study.
MATERIALS/METHODS: Predictor variables were extracted from the Enrollment Family Interview and the Kindergarten Family Interview of the NEILS. Predictor variables were classified as biologic (birth weight, gestational age, length of hospitalization, gender), environmental (maternal optimism, caregiver perception of social support, caregiver perception of child rearing skills, maternal education, and income), and behavioral (ability to focus, sleep disturbances, ability to be soothed, responsivity to sensory stimulation). The dependent variable, adaptive motor skills, was divided into three categories: fine motor, dressing, and functional mobility skills. For each category of dependent variable, four separate multiple regression analyses were performed, one for each category of predictor variable and a composite representing the individual predictor variables with the highest part correlations. The alpha level was set at p = .01 for each test
RESULTS: The hypotheses were supported. Maternal optimism was the strongest predictor of fine motor skills (r = .287, p≤.0005) and one of two of the strongest predictors of functional mobility skills (r = .178, p≤.0005). Gender and ability to focus emerged as relatively strong and significant biological and behavioral predictors, respectively. Environmental variables as a group explained the greatest percentage of variance in categories of the dependent variable (dressing 11.6%, fine motor 12%, functional mobility skills 6.2%).
CONCLUSIONS: Gender, maternal optimism, and ability to focus emerged as the strongest significant predictors of adaptive motor skills in children born with low birth weight at kindergarten age. Environmental variables as a group predicted the greatest percentage of variance in adaptive motor skills.
CLINICAL RELEVANCE: The results of this study can be used to guide early intervention and identification efforts and future research. Interventions to monitor and support maternal optimism and infant attention should be included in high risk follow up clinics and early intervention programs. Male children born with low birth weight warrant close monitoring and perhaps different criteria for risk identification and intervention.