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Pediatric Physical Therapy:
doi: 10.1097/PEP.0b013e318268d908
Abstracts

Abstracts* of Poster Presentations at the 2012 Section on Pediatrics Annual Conference

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*Abstracts are presented in alphabetical order of the first author's last name.

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POSTER PRESENTATIONS

FIRST WE MUST WALK...OR DO WE?
C.A. Blow, University of Missouri, Columbia, MO; J. McElroy, University of Missouri, Columbia, MO.

PURPOSE: This review of literature addressed the following clinical question: Is training four point crawling necessary to prepare children for walking? In addition, did the literature identify possible areas of cognitive, social or perceptual impairment that might occur if a child did not experience 4 point crawling as a primary means of locomotion? Despite the well documented non-linear nature of development, the practice of training a child to crawl prior to walking persists in the treatment of children with neurological impairments. Assumptions that a child must follow the developmental sequence and crawl before they walk should be reexamined by therapists designing evidence based interventions.

DESCRIPTION: A search of the literature was completed using databases including PubMed, OVID, ERIC, CINAHL and Medline. Search terms included ‘crawling and motor development,' ‘crawling and walking', ‘creeping', ‘infant ambulation', ‘reading and walking', and combinations of the above. Twelve articles were identified for review based on their applicability to the clinical question. This review yielded no evidence that 4 point crawling facilitated the acquisition of walking in infants. Further, Adolph's work showed no relationship between any aspect of crawling (presence, proficiency, duration, or age of onset of crawling) and walking. Four point crawling and walking patterns are distinctly different. As such, skills learned in crawling do not transfer to walking. Specificity of learning was documented when babies who were able to traverse an incline, cross a perceived visual cliff, or reach across a veritable cliff in crawling could not transfer that learning to walking. Although there was a movement in the late seventies that espoused the benefits of crawling to enhance reading proficiency, no studies were found to support the claim. A positive link between spatial memory, object manipulation, social interaction skills and locomotion existed; however, a causal relationship was not established between these skills and crawling.

SUMMARY OF USE: The absence of any evidence that supports the training of crawling as a way to enhance motor development guides therapists to introduce walking interventions without waiting for achievement of 4 point crawling. While there was no evidence linking 4 point crawling and walking from a motor skill perspective there may be some cognitive benefits to experiencing crawling. Biomechanically, a child must be able to transition into the all fours position in preparation for pulling to stand. The research does not support withholding ambulation training until four point crawling has been achieved. More research is needed to determine whether the possible cognitive benefits are specific to 4 point crawling or only to locomotion and whether these benefits should influence Physical Therapists when planning interventions for the development of walking in infants.

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CHILDCARE PROVIDERS' ATTITUDES, BELIEFS AND BEHAVIORS FOLLOWING PRONE PLAY TRAINING: A PILOT STUDY
A.S. Both, A. Bruhl, S. Houlihan, Department of Rehabilitation Sciences, University of Toledo, Toledo, OH.

PURPOSE/HYPOTHESIS: Despite physical therapists growing concerns regarding positional plagiocephaly, many infants are not meeting daily guidelines for prone play. This includes an ever-increasing number of infants enrolled in childcare facilities. Currently, there is no research on childcare providers' attitudes, beliefs and behaviors regarding infant prone play or evidence if education can positively affect these domains. Therefore, the purpose of this pilot study is to examine the effectiveness of an educational session on influencing childcare providers' attitudes, beliefs, and behaviors.

NUMBER OF SUBJECTS: A convenience sample of 19 childcare providers, 7 with matched surveys, 9 with pre surveys only, and 3 with post surveys only participated in data collection. All participants were female, 25–61 years old, with .4 to 25 years of experience, and currently employed by a university based childcare facility.

MATERIALS/METHODS: A 29 question-childcare provider survey and was developed and used to assess 1) demographics, 2) general and prone specific positional beliefs, 3) comfort with and perceived value of prone play, and 4) behavioral routines. Participants completed the survey just prior to and 4 weeks after the educational session. A 30 minute educational session occurred once a week for six weeks until each participant completed one training session. The training emphasized the benefits of prone play, five key positions, and recommendations for inclusion in daily routines. Descriptive statistics and correlational statistics were used to evaluate the data.

RESULTS & CONCLUSIONS: Initial survey analysis revealed less positional knowledge in 3 of 5 key prone positions, especially in older childcare providers. Prior to training, prone positions were used during the day but the variable locations used were limited to primarily 3 of 5 common options studied. Following training, correct recognition of 5 key prone positions increased by 31.58% while the use of variable locations for prone play extended to 4 of 5 options studied. Overall, attitudes regarding prone play were positive prior to training and there were no significant changes after training. High pre-training knowledge scores were associated with younger participants (r = 0.8951, p = 0.015, n = 7) indicating that younger childcare providers were more informed prior to training than older coworkers. High post-training knowledge scores were associated with less work experience (r = 0.8707, p = 0.048, n = 7) indicating that novice childcare providers had greater knowledge post-training. Overall, there were positive changes in prone positional knowledge and behavior as a result of the educational session. It is difficult to generalize the findings due to the unique childcare setting studied and the small sample size.

CLINICAL RELEVANCE: Preliminary findings suggest that education provided by physical therapists may influence childcare providers' beliefs and behaviors regarding prone play and use in daily routines. This study enhances our understanding of training needs based on age and work experience.

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DEVELOPMENT OF AN EVIDENCE-BASED EDUCATIONAL TOOL: EARLY INTERVENTION UNDER THE TEAM-BASED PRIMARY SERVICE PROVIDER APPROACH
L.M. Brad, C.M. Dixon, L.L. Lovett, J.E. Tucker, Program in Physical Therapy, University of Central Florida, Orlando, FL.

BACKGROUND: The Team-Based Primary Service Provider (TBPSP) approach has created much debate as to its efficacy in providing early intervention (EI) services. The model was designed to provide family-centered care in the natural environment by a single provider representing the team.

PURPOSE/HYPOTHESIS: The objectives of this study were to: 1) obtain perspectives of parents and providers on TBPSP approach; and 2) create an evidence-based tool with recommendations for best practice when utilizing this approach.

NUMBER OF SUBJECTS: 17.

MATERIALS/METHODS: Two surveys were developed to obtain the views of parents and providers from Early Steps in Brevard County, Florida. Both surveys incorporated questions with a Likert scale and free responses. Surveys were distributed to a convenience sample of providers and parents of children currently receiving services with a diagnosis of developmental delay and/or low birth weight. Descriptive statistics were performed. A review of the literature was conducted using search terms such as: TBPSP approach/model, service delivery models, family-centered care, natural environments, and EI. Survey responses were analyzed to ensure that concerns presented were addressed. The developed tool incorporated evidence-based practice, the history of EI services, approaches to service delivery, evidence on the TBPSP approach, and strategies for implementation.

RESULTS: Provider survey return rate was 40% (N = 14). The majority (77%) believed the transition to the TBPSP approach was positive and agreed (76.9%) that this approach was within their scope of practice. Fifty percent of providers agreed or strongly agreed that the TBPSP approach required learning of other disciplines. In addition, 50% of providers disagreed or strongly disagreed on the need for training before implementing the TBPSP approach and 61.6% agreed or strongly agreed that the TBPSP approach was intimidating to other therapists. Parent survey return rate was 21.4% (N = 3). Overall, they supported the TBPSP approach. All agreed that they were confident in carrying out their child's home program and were knowledgeable about the TBPSP approach. Parents felt services were beneficial for their child and were satisfied with the frequency of visits. The responses of both providers and parents were consistent with current research. Despite this fact, some discontent among providers exists, especially in the areas of role release and scope of practice. In general, the parents' responses were very positive concerning this approach which may be attributed to their sole exposure to this model.

CONCLUSION: Despite some inconsistencies, the provider responses validated the need for resources on the TBPSP approach. The educational tool was designed to meet these needs. Further research is needed on the effectiveness of resources to improve service delivery of this model.

CLINICAL RELEVANCE: The product of this research was a comprehensive evidence-based tool exploring strategies for best practice when providing early intervention services within the TBPSP approach.

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TIMING AND RHYTHMICITY INTERVENTION FOR MOTOR IMPAIRMENTS IN CHILDREN WITH AUTISM SPECTRUM DISORDER
L. Dannemiller, Physical Therapy Program, University of Colorado; P. LaVesser, JFK Partners, University of Colorado; E. Kinsey, JFK Partners, University of Colorado; R. Downey, JFK Partners, University of Colorado.

PURPOSE/HYPOTHESIS: It has become clear that many children with autism spectrum (ASDs) have motor impairments in addition to language and social deficits, yet there is little literature about effective physical therapy interventions for this population. The purpose of this study was to investigate whether an intervention that uses timing and rhythmicity, with repetition of motor tasks results in changes in functional motor skills in children with ASDs.

NUMBER OF SUBJECTS: Participants were seven children, age 10–14 with diagnosed ASDs and motor coordination impairment (based on DCDQ'07 scores), and adequate expressive and receptive language, and cognition to complete testing and intervention.

MATERIALS/METHODS: Participants received 12, 1 hr intervention sessions with Interactive Metromone (IM) from physical therapists, over approximately two months. The IM system is a computer-based training method designed to improve timing and rhythmicity that involves planning and carrying out a variety of simple motor tasks using feedback about the temporal accuracy of the movement. Participants were tested at the initiation of intervention, at the end of intervention and 2 months later with the IM assessments, Bruininks-Oseretsky Test of Motor Performance 2 (BOT-2) and the Canadian Occupational Performance Measure (COPM).

RESULTS & CONCLUSIONS: All seven participants improved in the timing of their movements recorded by the IM system. The average number of simple movement repetitions over 12 sessions was over 22,000. The average change in their millisecond scores from session 1–12 on the IM Long Form Assessment (LFA) was 62% (38–80% change) and most of the improvement happened over the first 6 sessions. Four out of seven participants changed more than one standard deviation in the Body Coordination composite area of the BOT-2. Two of seven participants changed greater than 40% on the Total Percentile Rank change of the BOT-2 at the end of intervention, while the other 5 changed less than 5%. There was not a strong correlation between% improvement in IM system LFA change and BOT-2 Total Percentile Rank change for individual participants. Average BOT-2 Total Motor Composite and Total Mean Percentile Rank were maintained two months after intervention. COPM data showed a positive average trend.

CLINICAL RELEVANCE: IM system intervention is one method of addressing timing deficits that may be beneficial for children with ASDs and motor impairments, particularly in the BOT-2 composite area of Body Coordination. It is possible that fewer sessions of intervention may be necessary. However, improvements in the IM timing scores did not strongly correlate to functional movement change on the BOT-2, indicating that more detailed analysis in the of area of timing deficits and timing related outcomes in this population may be needed to tailor interventions to deficits more specifically.

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TANDEM STANCE TIMED PERFORMANCE PROFILES FOR CHILDREN DEVELOPING TYPICALLY AGES 2 TO 13 YEARS
N. Darr, School of Physical Therapy, Belmont University, Nashville, TN; M.R. Franjoine, Physical Therapy Department, Daemen College, Amherst, NY; K.J. Freatman, Physical Therapy Department, Daemen College, Amherst, NY; C. Kibbler, Physical Therapy Department, Daemen College, Amherst, NY; A. Jagord, Physical Therapy Department, Daemen College, Amherst, NY.

PURPOSE/HYPOTHESIS: Physical therapists routinely examine the ability of children to attain and sustain tandem stance (TS) as a measure of static balance. TS is a commonly used item in standardized developmental assessments such as the BOT-2 and PDMS-2. A review of the literature revealed no recent timed reference values for TS in children. The purpose of this study was to examine the timed performance of TS in children ages 2 to 13 years.

NUMBER OF SUBJECTS: Data were collected on 312 children (151girls, 171 boys) who were developing typically per parent report.

MATERIALS/METHODS: Each child performed 1 TS practice trial followed by 3 TS timed trials, for a maximum of 2 minutes per trial. Test position was standardized using the TS protocol described within the Pediatric Balance Scale. Each child's best TS time in seconds (s) was used for data analysis. Children were divided into 12 groups in one-year increments. Descriptive statistics were calculated for each age group, and a one-way ANOVA with post hoc Bonferroni multiple comparisons identified significant differences among age groups for log-transformed data.

RESULTS & CONCLUSIONS: TS times increased significantly between ages 2 and 13 years (F = 17.588, p < 0.001). Marked differences in TS times occurred within and between age groups. TS times improved steadily between the ages of 2 and 5 years (7.71± 6.47 to 18±17.85s), although differences between age groups were not statistically significant. There was a large improvement in TS times in the 6 year old group (35.1± 34.32s), which resulted in statistically significant increases in TS times between children ages 2, 3, 4, and those ages 6 years and older (p < 0.001– p < 0.027). This was followed by a decrease in performance in the 7-year-old group (25.93±24.67s), which was not statistically significant. TS times then improved up through13 years of age (62.48±43.29s). Wide variability in TS performance, observed in all age groups, may be due to differences in balance capabilities, as well as, distractibility, boredom, and/or fatigue. TS performance profiles appear to be different than those previously reported for single limb stance.

CLINICAL RELEVANCE: The results of this study indicate TS ability continues to improve up through 13 years of age, with the greatest improvements between the ages of 5 and 6 years. There is also wide variability within each age group in children's ability to perform TS.

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THE EFFECTS OF HIPPOTHERAPY WITH A CHILD WITH MOTOR IMPAIRMENTS
P.A. DiBiasio, Department of Physical Therapy Education, Elon University, Elon, NC; S. Balkan, Department of Physical Therapy Education, Elon University, Elon, NC; F. Carlson, Department of Physical Therapy Education, Elon University, Elon, NC; A. Kasten, Department of Physical Therapy Education, Elon University, Elon, NC; M. Muenzer, North Carolina Therapeutic Riding Center, Mebane, NC.

BACKGROUND & PURPOSE: Hippotherapy is a physical therapy intervention utilizing a horse and equine movement to achieve therapeutic goals. It is used for individuals with a variety of limitations in activity and participation related to impairments in body structure and function. The movement of the horse mimics the movement of the human pelvis during walking. Activities performed while on the horse can help strengthen muscles of gait and postural control. Additional benefits of hippotherapy include: improvement in balance, muscle symmetry, decrease energy expenditure of gait, and improved function. This case report examines the effects of hippotherapy with a child with motor impairments as a pilot to a future study. The patient was a 4 year-old male with generalized low tone, speech, cognitive and motor delays, classified as level II Gross Motor Function Classification System. He presented with difficulty running, stair climbing, and utilizing playground equipment. Impairments included weakness, poor postural control, impaired balance and poor motor control. The patient wore bilateral supramalleolar orthoses and was receiving PT, OT, SP 1/week. His mother's goals were for him to jump on two feet, improve his playground skills, run and improve safety awareness. Hippotherapy sessions were covered by the patient's primary insurance provider. Additional barn fees were paid by a research grant from Elon University.

OUTCOMES: The Gross Motor Function Measure (GMFM), Pediatric Evaluation of Disability Inventory (PEDI) self care, mobility & caregiver assistance domains, & Pediatric Quality of Life Index Parent Report of Toddler (PedsQL) were assessed at baseline and post intervention. The patient participated in hippotherapy for 45 minutes twice a week for 6 weeks. Hippotherapy sessions were conducted at the North Carolina Therapeutic Riding Center by a licensed PT trained in hippotherapy through the American Hippotherapy Association with over 10 years of experience providing hippotherapy. Examples of individualized therapeutic activities included; varying the horse's walking speed and direction, changing patient's position on the horse (forward facing, side sitting and rearward facing), and work in sit to stand (stirrups added). Findings demonstrated a positive Minimal Clinically Important Differences in total GMFM Score (pre 77.56, post 80.18 MCID .7–2.7) as well as both PedsQL scales (Physical Health Summary Score pre 34.4, post 62.5 and the Psychosocial Summary Score pre 61.5, post 75 MCID 7.1–13.8). MCID was not achieved in the PEDI. There was a reasonable amount of variability in the participant's performance within each GMFM domain which could have been related to his cognitive ability.

DISCUSSION: Hippotherapy had a positive impact on the patient's gross motor function and quality of life. He and his mother reported enjoying work with the therapist at the barn, which they continued. The information gained from this study will benefit future research and aide to establish the efficacy of hippotherapy in general.

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THE EFFECTS OF PHYSICAL ACTIVITY ON PARENTAL REPORT OF HEALTH-RELATED QUALITY OF LIFE, SLEEP, AND PAIN IN NON-AMBULATORY CHILDREN
C.B. Dodds, Rocky Mountain University of Health Professions, Provo, UT; K.F. Bjornson, University of Washington and Seattle Children's Research Institute, Seattle, WA; J.K. Sweeney, Rocky Mountain University of Health Professions, Provo, UT; U.G. Narayanan, The Hospital for Sick Children, University of Tortonto, Bloorview Research Institute, Ontario, Canada.

PURPOSE/HYPOTHESIS: Participation in physical activity for children with motor disability is limited and progressively becomes more restricted as the severity increases. Lack of physical activity affects the health status of children with disabilities. Sleep abnormalities and pain, often experienced in children with disabilities, affect health status and are influenced by physical activity. The purpose of this study was to investigate health-related quality of life (HRQL), sleep characteristics, and pain severity in non-ambulatory children with multiple disabilities exposed to a community-based physical activity intervention.

NUMBER OF SUBJECTS: Twenty-nine children between the ages of 1 and 14 years were assessed with Gross Motor Function, Manual Ability, and Communication Function Classification Systems levels III, IV, V.

MATERIALS/METHODS: Children attended a 5 week summer day program and participated in supported physical activities such as cycling, aquatics, hippotherapy, standing, and others. The appropriate amount of support in the form of human assistance, adaptive equipment, assistive technology, and transportation was provided to allow for the greatest degree of energy expenditure. Parental report of the Caregiver Priorities and Child Health Index of Life with Disabilities (CPCHILD), Children's Sleep Habits Questionnaire (CSHQ), sleep diary, and Faces Pain Scale-Revised (FPS-R) were used to measure impact of the supported physical activity. Additional analyses explored the relationship between categories of physical activity (traditional, participatory, or activities of daily living) and HRQL, sleep durations, and pain severity.

RESULTS & CONCLUSIONS: Participants demonstrated significant improvements in HRQL (p < .05), sleep durations (p < .0001), and pain scores (p < .05). One thousand minutes of physical activity over 5 weeks predicted a 5 to 8 point increase in total HRQL scores (p < .005 to.03). Short term, intensive, and supported physical activity improved parental report of HRQL, sleep duration, and pain severity in non-ambulatory children with multiple disabilities. It appears forty minutes of daily physical activity enhanced parental report of HRQL, but not sleep duration or pain.

CLINICAL RELEVANCE: Although further study with a control group is necessary, pediatric physical therapists have the expertise, and thus responsibility, to develop, implement, and oversee physical activity opportunities in children with multiple disabilities; traditional custodial care for these children is not sufficient.

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EXAMINING THE EFFECTS OF PHYSICAL ACTIVITY IN CHILDREN WITH MULTIPLE DISABILITIES
C.B. Dodds, College of Health Professions, Medical University of South Carolina, Charleston, SC; H. Wise, College of Health Professions, Medical University of South Carolina, Charleston, SC; C. Cormack, College of Nursing, Medical University of South Carolina, Charleston, SC.

PURPOSE/HYPOTHESIS: Children with multiple disabilities constitute 13 to 18% of the pediatric population. Diminished physical activity (PA) opportunities and quality of life are documented for children with multiple disabilities. A collaborative rehabilitation education school model was developed allowing for emphasis on PA in children with multiple disabilities. Preliminary findings from this model imply that parental report of health related quality of life (HRQL) improved with PA; however respite opportunity offered through school attendance could have influenced parental report of HRQL. With no control condition in preliminary studies, the question remained whether respite or PA enhanced HRQL. This pilot study controlled for the respite opportunity and investigated the impact of PA on children with multiple disabilities.

NUMBER OF SUBJECTS: 8.

MATERIALS/METHODS: Children involved in the intervention group attended school for 7 hours a day and participated in 120 or greater minutes of supported PA, such as cycling, aquatics, standing, ambulation, and more. The appropriate amount of human assistance, adaptive equipment, and assistive technology was provided to support each participant's individualized PA needs, but allowed for the greatest degree of energy expenditure. Children serving within the control group attended traditional school programs for 7 hours daily where PA opportunities occurred as part of the typical school day routine. Health related quality of life was measured by means of the parental report of the Caregiver's Priorities and Child Health Index of Life with Disabilities (CPCHILD). Administration took place during the first month of school and 8 weeks later. Paired and unpaired t-tests tested significance.

RESULTS & CONCLUSIONS: The mean school attendance over 8 weeks for the intervention and control groups was 33 and 37 days. The total and domain CPCHILD mean scores at baseline were greater for the control group than intervention group, but were not significant (p>.05). Following 8 weeks, total and domain CPCHILD mean scores were unchanged for the control group (p>.05), improved for the intervention group (p = .002 to.05), and increased for the intervention group as compared to the control group for total and 3 domain CPCHILD scores, although not significantly (p>.05). Although statistical significance was not achieved between groups, possibly a result of the small sample size, it appears that 120 minutes of PA enhanced parental report of HRQL in children with multiple disabilities. Respite opportunity through school attendance was similar for groups and does not appear to explain improvement of parentally reported HRQL for children with multiple disabilities.

CLINICAL RELEVANCE: PA appears to have a positive impact of HRQL in children with multiple disabilities and further study with larger sample is warranted. Physical therapists have the knowledge base and a responsibility to improve PA participation for children with multiple disabilities.

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SUPERVISED GRADED RETURN TO ACTIVITY FOLLOWING CONCUSSION
K.D. Engel, M.M. Schultz, Gillette Children's Specialty Healthcare, Lakeville, MN.

PURPOSE: Providers are beginning to understand the long term and possibly devastating effects of concussion. These sequela are even more pronounced on the developing brain (Purcell, 2009), and there is increasing evidence that children and adolescents may have significantly extended periods of recovery as compared to adults (Halstead, 2010; Sim et al, 2008; Field et al, 2003; Fazio et al, 2008; McClincy et al, 2006). Although the Zurich Consensus Statement from 2008, states that “evaluation and management recommendations contained [t]herein could be applied to children and adolescents down to the age of 10 years”, it is important to note that the recommendation for stepwise return to play occurs only after the athlete is completely symptom-free (McCrory et al. 2008). The Return to Activity Protocol includes supervised graded aerobic activity, balance assessments and drills, agility activities, and oculomotor and vestibular exercises.

DESCRIPTION: Physical therapists work in collaboration with nurse practitioners to determine when it is appropriate for children to return to activity following a concussion. Patients are referred to physical therapy from Gillette Childrens Specialty Healthcare's Neurotrauma Clinic based on their scores on the ImPACT (Immediate Postconcussion and CognitiveTesting) and presence of concussive symptoms. At initial evaluation, balance, coordination, strength, and oculomotor/vestibular function are assessed. A graded four-stage protocol is implemented, which includes aerobic exercise (see table), strengthening, balance and coordination drills and vestibular or oculomotor exercise if indicated. Stages are initiated with physical therapist supervision and continued at home. Patients return every 3–5 days to advance to the next stage. Progression through the protocol may be adjusted based on the presence of concussive symptoms. After successfully completing all four stages, patients are released to participate in non-contact activity. They return to neurotrauma clinic for repeat ImPACT and clearance for return to full contact sports.

SUMMARY OF USE: This protocol is utilized with patients ages 12–18. From January 1, 2011 through April 30, 2012, we have evaluated 377 new patients and performed 748 treatments. The protocol monitors the patient as they gradually return to activity to assist in identifying any persistent concussive issues. It allows for the athlete to safely return to their prior level of function in sports. Concussion is no longer being dismissed as inconsequential, especially in children and adolescents. Consequently, referrals to clinics with the expertise to successfully return an athlete to activity are growing. Without gradual progression to sports and careful monitoring of concussive symptoms, these athletes are at risk for second impact syndrome, difficulty in school and occupation, and orthopedic injury.

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STUDENT PRO BONO CLINIC AS A 6 WEEK LAB PRACTICAL
S. Fleming Walsh, Department of Physical Therapy, University of Findlay, Findlay, OH; J.A. Lammers, Department of Physical Therapy, University of Findlay, Findlay, OH.

PURPOSE: Many of our students have limited experience with people that have neuromuscular disorders. Students report a fear of how to apply neuromuscular theory and a reluctance to work where this is the primary patient load. The purpose of the pro bono clinic is for the DPT students to get hands on experience applying theory to patients with a neurological diagnosis throughout the lifespan concurrent with academic preparation. An additional purpose is to fill a community need for pro bono services.

DESCRIPTION: Students are divided into groups of 2 or 3. Patients are recruited through area PTs. Patients have ranged in age from 6 mos-86 yrs with wide ranging diagnoses such as SCI, TBI, CP, down syndrome, other developmental disorders and MS. The student groups receive patient information including age, dx, and contact info early in the semester. Each group is responsible for contacting the patient, treatment planning, and preparation of treatment location with equipment. They examine and subsequently treat this patient in the hour allotted during class lab time for 6 wks with direct supervision by a licensed PT. Prior to treatment; they plan their intervention. During the lab session, the supervising PT maintains patient safety, and facilitates hands on application specific to each patient. After the treatment session, the lab session continues with critical thinking discussions with faculty and lab assistants. During the experience, each group is required to use at least 1 standardized assessment tool with their patient and develop a home program for the patient. Each week students submit written patient documentation including examination, progress and discharge notes. They also do weekly written self-examinations including questions such as list and briefly describe 2 things: you did well this session, which you wish you could have done better, and you are going to do this week to show growth in your treatment of patients. Weekly the students are assessed on body mechanics, safety, communication, critical thinking, documentation and self-assessment. The students follow up with the patient's primary care provider regarding progress and recommendations for future follow up. Students also observe their peers treating patients at another point in the lifespan, documenting their movement analysis, problem solving possible causes of the movement disorder, and providing alternative suggestions for treatment. Lastly this process is concluded by student groups leading a class debate regarding a unique treatment or issue related to their patient diagnosis.

SUMMARY OF USE: This process has been in place for over 8 yrs and has been consistently rated highly by all student evaluations. Our students go out to their neuro clinical very shortly after this course. Clinical instructors report that our students are very well prepared in this area and easily make the leap to clinical practice. At the conclusion of this course, the fear of moving to their neuro clinical is greatly reduced. The poster will describe how this can be successfully implemented with a cohort size of 32.

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INTERPROFESSIONAL EDUCATION IN EARLY INTERVENTION: EFFECTIVENESS OF A MULTIMEDIA EDUCATIONAL MODULE ON INFANT MOTOR DEVELOPMENT
A. Golub-Victor, S. Larrieux, N. Sterner, Department of Physical Therapy, Northeastern University, Boston, MA.

PURPOSE: Early Intervention (EI) services are provided to eligible infants and toddlers and their families under Part C of the Individuals with Disabilities Education Act. EI providers of various disciplines must be competent in infant/toddler development, evaluation and assessment, family-centered services and supports. Research suggests that appropriate training of EI providers requires an interprofessional approach. Multiple studies support the use of multimedia to enhance learning. The purpose of this project was to develop a multimedia educational module on typical infant motor development and to determine its effectiveness in meeting the learning needs of an interprofessional group of students enrolled in a higher education EI certification program course.

DESCRIPTION: An educational module on infant motor development consisting of a DVD of a typically developing infant and an accompanying student manual was developed by physical therapy (PT) faculty and students. To pilot the module, non-PT students enrolled in a higher education EI certification program were provided the educational module during a class. Prior to participating in the module, each student was asked to complete a pre-survey consisting of questions regarding his/her discipline and educational background, primary learning style, preferred teaching methods, opinion on the use of video to learn human development, confidence identifying certain aspects of gross motor skills, and prior exposure to motor development in the EI curriculum. After completing the pre-survey, students were shown the DVD; motor skills were identified by sub-titles and oral narration by PT faculty with expertise in the area. Students were encouraged to follow along with the student manual. Students then completed a post-survey to gather information about teaching effectiveness including consistency with preferred learning style and any perceived change in confidence in identifying typical infant motor development. Students represented various disciplines including speech/language pathology, school psychology, psychology, and human services. The majority of students identified writing as their preferred learning style and use of video clips with instruction as the preferred teaching method. Students agreed that video would be helpful to learn gross motor development. The majority of the participants felt neutral about their exposure to infant gross motor development thus far in the EI curriculum. Postsurvey results indicate that the majority of students felt the DVD and accompanying student manual were beneficial to learning about infant motor development and it provided information in their preferred instructional method.

SUMMARY OF USE: The creation and use of a multimedia educational module on infant motor development developed by PT faculty and students met the learning needs of an interprofessional group of students in an EI training program. The results provide support for use of multimedia to enhance learning and suggest that an interprofessional approach to EI personnel preparation is effective.

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INDICATORS OF CLINICALLY RELEVANT HYPOTONIA IN CHILDREN
A.R. Holmstrom, Department of Physical Therapy, University of Missouri, Columbia, MO; M.T. Murray, Department of Physical Therapy, University of Missouri, Columbia, MO; A.J. Szmiot, Department of Physical Therapy, University of Missouri, Columbia, MO; J.J. McElroy, Department of Physical Therapy, University of Missouri, Columbia, MO.

PURPOSE/HYPOTHESIS: Hypotonia is associated with developmental delay, motor dysfunction, and limited functional skills in children. Indicators of hypotonia significant enough to justify therapeutic intervention are not defined in the literature. Thus, signs of hypotonia that impact function are under-identified by medical professionals. The purpose of this study was to determine the indicators used by pediatric PTs to identify clinically relevant hypotonia in children.

NUMBER OF SUBJECTS: Ninety PTs from 31 states responded to this survey. Mean years of pediatric experience was 21 (range 1–45).

MATERIALS/METHODS: Data were collected using an anonymous survey, which posed the following questions: What are the most common clinical and functional characteristics that you look for when evaluating a child for hypotonia? Do you use a single indicator or multiple indicators to decide if a child has hypotonia? Requests for participants were disseminated by word-of mouth and through the Pediatric Section, American Physical Therapy Association. Survey responses were submitted via email and using an online tool. This study was approved by the University of Missouri Health Sciences IRB.

RESULTS & CONCLUSIONS: Respondents submitted a variety of indicators (mean 10, range 2–20). Indicators were grouped by the investigators into 16 categories by body system and functional similarities. Categories were prioritized by response frequency. The most common category of indicators was excessive range of motion (81%). Other frequently submitted indicators were grouped as decreased anti gravity movements (69%), postural mal-alignment (60%), and quality of movement (53%). All other indicators were submitted by less than 50% of the respondents. Eighty-nine out of ninety respondents used multiple indicators to identify hypotonia in children. Only one therapist used a single indicator, which was decreased resistance to passive movement. Clinically relevant hypotonia was identified by PTs using multiple secondary, associated, or functional indicators rather than a single measurement. Although hypotonia is defined as the presence of low muscle tone, a direct measurement of muscle tone was not a strong indicator listed among respondents. Therapists used indicators based on both body system impairments such as joint range, movement quality, and movement quantity as well as functional indicators including sitting and standing posture. Additional research is needed to further refine indicator/category combinations to improve identification of clinically relevant hypotonia in children.

CLINICAL RELEVANCE: Signs of hypotonia that impact function are under-identified by medical professionals. Indicators of hypotonia significant enough to justify therapeutic intervention are not defined in the literature. Knowledge of indicators of clinically relevant hypotonia such as excessive range of motion, movement quality, movement quantity, and antigravity posture/function can facilitate early identification and referral for therapeutic intervention.

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UTILIZATION OF AMTRYKES® IN THE HOME SETTING
C. LaPorte, Department of Physical Therapy, Alabama State University, Montgomery, AL; D.C. Johnson, Department of Physical Therapy, Alabama State University, Montgomery, AL.

PURPOSE: The purpose of this survey was to gather follow-up information on the utilization of AmTrykes® as part of the individual's home exercise program.

DESCRIPTION: AmTrykes® are therapeutic tricycles, which are utilized by individuals unable to ride a traditional bicycle. These therapeutic tricycles are fitted specifically for the individual by an occupational therapist and/or physical therapist who also assist in prescribing use and negotiating therapeutic goals. Local community service organizations, usually AMBUCS (American Business Clubs) chapters, help with purchasing the AmTrykes® which are then used by the recipient at home or school. According to AMBUCS from 2008–2010, charitable sources provided 6894 AmTrykes® nationally. The Birmingham AMBUCS and Montgomery River Region AMBUCS chapters in Alabama dispensed approximately 265 tricycles during this same time period. Mailed surveys were sent to 217 recipients of AmTrykes® who received a tricycle from the Birmingham AMBUCS or the Montgomery River Region AMBUCS chapters in the previous 18 months, and were to be completed by the recipient or their guardian. Follow-up e-mails were also sent as a reminder. The return rate for the survey was 30%. Descriptive statistics were used to analyze survey results. The results of this study indicated that 92% of the recipients benefited from increased exercise opportunities by utilizing the AmTrykes®. The majority of respondents identified use of the AmTryke® at 1–3 hrs/week. Eighty-two percent (82%) of the respondents reported the AmTrykes® increased the recreational opportunities for the family as well as the individual. An increase in functional status was reported by 76% of the respondents. Overall, positive satisfaction with the AmTrykes® was reported by 93.7% of the respondents.

SUMMARY OF USE: The results of this survey indicate that recipients as a part of the home exercise program are using AmTrykes®. Results of this survey suggest that use of the AmTrykes® provide increased recreational opportunities not only for the recipient but for the family as well. Clinical Implications: AmTrykes® are positively received as an adjunct to the home exercise program as a means to increase activity and provide inclusion of the recipient in family/community exercise activities. Further research, including perceptions of occupational therapists and physical therapists, is warranted to investigate the therapeutic benefits of the AmTrykes®.

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5 CASE SERIES—IDIOPATHIC TOE WALKING AND SENSORY PROCESSING DYSFUNCTION
A. Y. Len, Mosaic Tree Company, Brooklyn, NY; Rao, S. Department of Physical Therapy, New York University, NY.

BACKGROUND & PURPOSE: Up to now there have only been anecdotal reports of link between Idiopathic Toe Walking (ITW) and Sensory Processing Dysfunction (SPD) (Shulman, 1997; Montgomery, 1978; Williams, 2010). This case series examines the presence sensory integration dysfunction (SPD) in children with idiopathic toe walking (ITW). Five children between ages of 4 and 6 with ITW without suspected neurologic or developmental problems were assessed in a clinic by a licensed Physical Therapist who is certified in administering Sensory Integration and Praxis Tests (SIPT) and has advanced training in Sensory Integration. This is a first study to use standardized assessment tools to document a link between ITW and SPD. SIPT is a well-established tool with high reliability considered to be a gold standard in assessment of SPD (Ayres, 1989).

OUTCOMES: Assessment consisted of administration of the following standardized assessment tools: SIPT to assess child's sensory processing and praxis abilities, BOT-2 - strength and agility section (to measure overall strength and agility), PDMS-2 (to assess milestone acquisition and overall gross motor development) and Sensory Profile Parent Questionnaire. On the SIPT, all 5 children demonstrated sensory processing difficulties with tactile processing being the most impacted while presenting within average proprioception (KIN) abilities (1 case unable to assess KIN). All 5 children also presented with delay in Postural Praxis and Standing and Walking Balance 4 of 5 cases. On Sensory Profile: All 5 children presented with at least probable difference in the way they process sensory information. On BOT-2, all 5 children demonstrated average strength level with 3 out 5 children in below average range in agility. On PDMS-2, all 5 children presented with delays in gross motor milestones.

DISCUSSION: Tactile system has a major role in providing feedback during ambulation. SIPT results show that children with ITW seem to have significant difficulty processing tactile information while their kinesthesia scores are within normal ranges. We suggest children with ITW are attempting to use proprioceptive system via weight bearing through metatarsals to help navigate surfaces. It also seems that while their overall strength falls within average, agility and balance are significantly affected and impact gross motor milestone acquisition. Currently, all treatment recommendations focus on the remediation of decreased ROM. However, if the SPD is one of the underlying issues for ITW, a non-invasive treatment approach such as Ayres Sensory Integration should be explored.

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ACCELEROMETER POSITION VS. VO2000: A MEASURE OF ENERGY EXPENDITURE DURING HIPPOTHERAPY THERAPEUTIC EXERCISE
T.L. Millard, D.M. Hayes, K. Fitzgerald, M. Perry, C. Thomas, B. Vinson, North Georgia College & State University, Dahlonega, GA.

PURPOSE/HYPOTHESIS: Monitoring and sustaining the dose-response relationship required to promote fitness induced improvements during hippotherapy is a challenge. Oxygen uptake and heart rate are standard methods for estimating energy expenditure (EE) during exercise, but encounter limitations when applied during hippotherapy. Regular VO2 monitoring is costly and cumbersome. Engaging with horses may artificially elevate heart rate. Accelerometry has been validated as another useful measurement device to estimate EE in cycling and walking and may be appropriate to estimate EE during hippotherapy for individuals with a wide range of disabilities due to the instrument being independent of the barriers previously listed. This study examined the validity of the Actigraph GT3X accelerometer as a means of estimating EE compared to heart rate and VO2 estimates during a hippotherapy session. The influence of accelerometer position (umbilicus versus axillary) was considered.

NUMBER OF SUBJECTS: Nine participants with varying disabilities (cerebral palsy, autism and Down syndrome) were chosen from a convenience sample at a local hippotherapy program. Mean age was 12.2 +/- 7.2. All participants met inclusion criteria: appropriate VO2000 mask fitting, ability to understand and follow verbal instructions, cooperation when wearing the VO200 mask and previous participation in hippotherapy activities. Participants were rated as high (independent ambulation) or low functioning (wheelchair dependent).

MATERIALS/METHODS: The relationship between oxygen consumption (VO2000), heart rate (Armstrong Medical AD-1000 Pulse Oximeter Sims BCI Inc.) and triaxial accelerometry (Actigraph GT3X) was measured during a standardized 30 minute hippotherapy session. The session included walking, trotting, circle and figure 8 activities. Horses were standardized for height, girth and stride length. Data (heart rate, METs from VO2, and overall METs and counts/minute using accelerometer) were analyzed with intraclass correlation and ANOVA.

RESULTS & CONCLUSIONS: A strong positive rate of agreement between the two accelerometer positions existed (ICC (3,1) = 0.85, p < 0.01).. A significant relationship was found between heart rate and accelerometer counts during walking and trotting activities. Accelerometer data showed significant difference in energy expenditure across several activities with trotting activity being the highest level. Preliminary conclusions reveal the Actigraph GT3X accelerometer to be a simple and useful measurement tool for measuring EE in children with disabilities during a hippotherapy session independent of trunk position.

CLINICAL RELEVANCE: Information about how EE changes across various types of activities used in hippotherapy will enhance the ability to develop appropriate and safe exercise programming. Trotting activities may be required to induce a fitness change during hippotherapy sessions.

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EARLY INTERVENTION PHYSICAL THERAPY FOR AN INFANT BORN PRETERM, EXTREMELY LOW BIRTH WEIGHT WITH INTRAVENTRICULAR HEMORRHAGE
L.K. Phelps, Department of Physical Therapy, Drexel University, Philadelphia, PA; C. Ceely, Montgomery County Infants & Toddlers Program, Gaithersburg, MD.

BACKGROUND & PURPOSE: Early intervention is federally mandated under the Individuals with Disabilities Act (IDEA), yet research on its efficacy is limited. The purposes of this case report are to (1) present the case of a child's treatment and progress with Early Intervention Physical Therapy, and (2) address the question of how to distinguish true change as a result of intervention from the changes seen with normal growth and development.

CASE DESCRIPTION: The child, twelve months old at the time of this report, was born at 25 weeks gestation weighing 600 grams after a complicated pregnancy. His early health was complicated by a grade II intraventricular hemorrhage (IVH), bronchopulmonary dysplasia, and retinopathy of prematurity. At four months of age, the Mullen Scales of Learning (MSEL) and Ages and Stages Questionnaire (ASQ) were administered, revealing global developmental delays. He received physical therapy services once per week for eight months, focusing on parent coaching for strategies to develop his independent movement.

OUTCOMES: The MSEL and ASQ were re-administered at twelve months, revealing that the child still had significant motor delays. Considerable qualitative changes were noted with therapists' observations.

DISCUSSION: Though the child had not caught up developmentally to his peers after intervention, he demonstrated predictable skill mastery with increased control of his movement patterns. His developmental skills had surpassed many prognostic expectations of children with similar birth history. More research needs to be done to investigate the effectiveness of early intervention, as well as the validity of the MSEL and ASQ.

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THE EFFECT OF PLAYGROUND ENVIRONMENTS ON THE PHYSICAL ACTIVITY AND SUPPORT NEEDS OF AMBULATORY CHILDREN WITH CEREBRAL PALSY
B. Pratt, Rocky Mountain University of Health Professions, Provo, UT, and Department of Physical Therapy, Bradley University, Peoria, IL; N. Hartshorne, Department of Psychology, Delta College, Saginaw, MI; P. Mullens, Rocky Mountain University of Health Professions, Provo, UT, and Department of Physical Therapy and Rehabilitation, University of Washington, Seattle, WA; M. Schilling, Department of Recreation, Parks & Leisure, Central Michigan University, Mt. Pleasant, MI; S. Fuller, Department of Physical Therapy, Bradley University, Peoria, IL; E. Pisani, Department of Physical Therapy, Bradley University, Peoria, IL.

PURPOSE/HYPOTHESIS: To compare the effect of playground environments on the physical activity and support needs of ambulatory children with cerebral palsy during playground play. The hypotheses were that physical activity and independent play would increase on an ADA-compliant playground.

NUMBER OF SUBJECTS: Five seven- to eight-year-old children with cerebral palsy (GMFCS level II).

MATERIALS/METHODS: An alternating treatment, single-subject design was used. During six data collection sessions, participants played for 30 minutes on an ADA and non-ADA compliant playground with an intervening rest period. A Step Watch was used to measure step activity patterns within the playground context. Participant support needs were measured using behavioral mapping, an observation method of collecting data on targeted behaviors and locations simultaneously. Visual and statistical analyses for single subject designs were used for data analysis. An effect size was calculated to quantify the magnitude of change between conditions.

RESULTS & CONCLUSIONS: Four of five participants showed an increase in steps taken on an ADAAG-compliant playground. All participants exhibited increased medium and/or high activity levels during play on an ADA-compliant playground. Three of five participants demonstrated greater independent play on an ADA-compliant playground. Children with ambulatory cerebral palsy (GMFCS II) may benefit from an ADA-compliant playground to increase their physical activity and its intensity. Less clear is the affect of an ADA-compliant playground on the degree of independent play. Further research is needed to determine the most important variables that positively influence community-based physical activity for children with ambulatory cerebral palsy.

CLINICAL RELEVANCE: Pediatric physical therapists are in the unique position to support and develop the physical activity behaviors of children with cerebral palsy. Playground skills should be a part of the assessment and intervention of children with ambulatory cerebral palsy because of the importance of regular physical activity for health.

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EDUCATIONAL COLLABORATION AND INITIAL DEVELOPMENT OF FIELD TRIP ACCOMMODATIONS CHECKLISTS—A CASE REPORT
K.D. Ward, Department of Physical Therapy, University of the Sciences, Philadelphia, PA.

BACKGROUND & PURPOSE: Many students with disabilities experience barriers that impede participation in educational curriculum and school field trips (Law et al., 2007). Students with disabilities may require individual accommodations to ensure their ability to access and participate in school field trip experiences. This case review reflects upon an experience in school-based practice in which more careful collaboration among educational team members may have aided field trip planning. This situation resulted in the initial development of Field Trip Accommodations Checklists that may be further developed to aid field trip planning.

OUTCOMES: During the 2010–2011 school year, elementary school teachers in one school planned a grade-wide field trip. This grade included one student diagnosed with Spinal Muscular Atrophy (SMA) Type 3, who was able to ambulate for short distances but experienced significant fatigue, was unable to maintain pace with peers, and used a power wheelchair for longer distances. During planning, the teacher making arrangements was not fully aware of this student's needed accommodations and did not seek out consultation from knowledgeable individuals. Shortly afterwards, the school-based physical therapist became aware of the upcoming school field trip and the confusion regarding needed accommodations for this particular student. More thorough consultation and coordination between all school staff involved may have helped avoid unnecessary confusion and may have helped facilitate smoother field trip planning (Mukherjee, Lightfoot, & Sloper, 2002; Sellers, 1980). As a result of this situation, the student's individual assistant and school-based physical therapist determined that a list of needed accommodations and a description of field trip sites may be helpful in future planning, thus resulting in development of the Field Trip Accommodations Checklists. The checklists consist of two separate forms: The Student Form for individual student accommodations and The Field Trip Site Form for site and activity descriptions. These checklists take into consideration students with mobility, sensory, behavioral, or health needs, thus reflecting the wide range of needs associated with students with disabilities (Law et al., 2007). The Student Form includes mobility, sensory, behavioral, and health considerations and includes notations for specific assistance and planning needs and an action plan for field trip planning. The Field Trip Site Form includes mobility and sensory considerations that are encountered typically or that are able to be accommodated.

DISCUSSION: Students with disabilities should be provided accommodations to help access and participate in all aspects of their educational curriculum, including school field trips. These students may experience multiple needs that should be considered in the planning of school field trips. Careful team communication and collaboration, in conjunction with the use of Field Trip Accommodations Checklists may help facilitate planning for school field trips for students with disabilities.

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OUTCOMES OF A MINIMALLY INVASIVE MULTILEVEL SURGERY IN CHILDREN WITH CEREBRAL PALSY
D.L. Wild, C.P. Baker, Department of Physical Therapy, University of Texas Medical Branch School of Health Professions, Galveston, TX.

PURPOSE/HYPOTHESIS: Cerebral palsy is a neurodevelopmental condition defined as a disorder of posture and movement caused by a non-progressive abnormality of an immature brain which can result in spasticity. Children with spastic CP usually present with muscle stiffness which eventually leads to decreased range of motion (ROM) in the knee and ankle joints interfering with gait and functional mobility. Typical orthopedic interventions include invasive single event multi-level surgeries to address muscle tightness; which can require prolonged painful recovery time. Selective Percutaneous Myofascial Lengthening surgery (SPML) is a minimally invasive surgery in which micro-incisions are made into the myofascia of the affected muscles. The purpose of this study was to assess changes in dynamic ROM of the knee and ankle and functional mobility following SPML surgery in a group of children with spastic CP.

NUMBER OF SUBJECTS: 31 children mean age of 8.5 years of age.

MATERIALS/METHODS: Subjective and objective measures were obtained from medical records and video tapes of gait. Pre-operative and follow–up videos of gait for children with CP (62 extremities) who underwent SPML surgery from 2006 to 2008 were evaluated retrospectively, using a computer program to measure joint angles. Most children were walking within 24 to 72 hours after surgery; average time of follow-up was 7.5 months (range 4–13 months). The outcome measures for this study included sagittal plane kinematic parameters of the knee and ankle joint and functional mobility, using the Functional Mobility Scale (FMS). Mixed model for repeated measures for the knee and ankle joint parameters were used to estimate the change in ROM. Wilcoxin signed rank tests were used to examine the difference between pre and post-operative FMS scores. Medical records indicated that most children received physical therapy interventions following the procedures, but the treatments were not standardized.

RESULTS & CONCLUSIONS: Statistically significant differences in ROM were found for most joint measurements at p < 0.05 in pre and post-operative comparisons, except for plantarflexion at toe-off. FMS ratings significantly improved (p < 0.05) by 1 level at 5 meter, 50 meter, and 500 meter distances, indicating an increase in functional mobility. The results of this study indicate that the minimally invasive SPML surgery designed to lengthen tight muscles of the lower extremity in children with CP positively affected dynamic ROM of the knee and ankle during gait. Additionally, improvement was noted in functional mobility at all distances.

CLINICAL RELEVANCE: There are many options available to manage the secondary impairments of lower extremity muscle tightness in children with spastic cerebral palsy. This study offers information regarding the positive outcomes of a minimally invasive surgical procedure for children with spastic CP, adding to the knowledge of treatment options available to children with cerebral palsy. Therapists working with children post SPML should expect increases in ROM and improvements in functional mobility.

© 2012 Lippincott Williams & Wilkins, Inc.

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