MOTOR PROFICIENCY AND FUNCTIONAL PERFORMANCE IN CHILDREN WITH 5P DELETION (CRI DU CHAT SYNDROME)
L.D. Abbruzzese, K. Quijano, Powell, K. Duffy, D.C. Krasinski, S.E. Kleppe, Physical Therapy, Columbia University, New York, NY.
PURPOSE/HYPOTHESIS: Cri du Chat syndrome (CdCS) is a rare genetic syndrome caused by a loss of material on the short arm of chromosome 5. The purpose of this study was to describe motor proficiency and functional abilities in individuals with CdCS.
NUMBER OF SUBJECTS: Twenty four individuals with CdCS aged 3-20 years (9.8 ± 4.8, 79% female) and a convenience sample of 20 age-matched peers, 3-20 years old (10.1 ± 4.9, 57% female) were recruited to participate in this study.
MATERIALS/METHODS: Fine motor control, coordination, balance, strength and agility were assessed using the Bruininks-Oseretsky Test of Motor Proficiency, Second Edition, Short form (BOT-2SF.) Functional performance of daily activities, including self-care skills, mobility and social function, were assessed using Part I of the Pediatric Evaluation of Disability Inventory (PEDI) given to parents and caregivers of the participants. An Analysis of Covariance, using age as the covariate, was used to determine between-group effects for mean BOT-2SF scores and PEDI scaled functional performance scores. A within-subjects comparison of the three PEDI sub groups was also analyzed.
RESULTS: The motor proficiency scores of the individuals with CdCS were significantly lower than peers without CdCS (p < 0.05). Out of a maximum of 88 points available on the BOT-2SF, individuals with CdCS scored between 0 and 42 (7.17± 10.7). Typically developing peers scored between 26 and 82 (67.1 ± 15.1). Total scaled PEDI scores for individuals with CdCS (.63 ± .19) were also significantly lower than age matched peers (.98 ±.06). A comparison of the PEDI functional skills sub-scales revealed a significant interaction effect . For individuals with CdCS, mobility skills were a strength (.80 ± .19), as compared to measures of self-care (.56 ± .25) and social function (.57 ± .19).
CONCLUSIONS: Motor proficiency and functional skill capabilities of individuals with CdCS are limited in comparison to peers of the same age, however these individuals are able to participate in a variety of functional mobility and self care tasks and engage with others socially.
CLINICAL RELEVANCE: The PEDI may be a useful assessment tool for identifying meaningful functional activity goals for individuals with CdCS. The BOT-2SF scores would have triggered referrals for rehabilitation services for all 24 subjects with CdCS, but may have had a floor effect, limiting the ability to assess individual strengths. Alternative assessment methods should be considered in the evaluation of individuals with CdCS in order to capture motor function and abilities that enable participation in daily activities.
TEMPORAL AND SPATIAL GAIT PARAMETERS IN CHILDREN WITH CRI DU CHAT SYNDROME UNDER SINGLE AND DUAL TASK CONDITIONS
L.D. Abbruzzese, R. Salazar, M. Aubuchon, A.K. Rao, Physical Therapy, Columbia University, New York, NY.
PURPOSE/HYPOTHESIS: Cri du Chat syndrome (CdCS) is a rare genetic syndrome caused by a loss of genetic material on the short arm of chromosome 5. Children with CdCS often demonstrate delayed gross motor skill acquisition and clumsiness. The purpose of this study was to describe temporal and spatial gait characteristics in individuals with CdCS and to explore how they respond to performing concurrent manual tasks while walking.
NUMBER OF SUBJECTS: 14 subjects with CdCS (10.3±5.7, range 3-20 years) and 14 age-matched controls (10.1±5.4, range 3-20 years) were recruited to participate in this study.
MATERIALS/METHODS: Walking velocity, cadence, step length, base of support, and percent time in double limb support were collected while subjects walked on the GAITRite® instrumented walkway (CIR Industries, Clifton, NJ, USA) which is a 2′ × 12′ mat that uses six embedded sensor pads to record data from each foot fall. Participants performed 3 trials of each task beginning with walking alone, secondly carrying a pitcher with a cup of water inside, and lastly carrying a tray with a cup. In the dual task conditions, instructions were to either walk without letting the water spill or without letting the cup tip over.
RESULTS: A repeated measures ANCOVA, using age as a covariate, revealed that individuals with CdCS walked with significantly increased cadence and decreased step length as compared to age-matched controls. There was not a main effect for velocity. There were significant task by group interaction effects for velocity and time in double limb support. Both groups slowed down in dual task conditions, however responded differently to the tray and pitcher versions of the manual task. Individuals with CdCS were slower than controls in the tray and single task conditions, but not the pitcher condition. Controls modified time in double limb support for both dual task conditions, however individuals with CdCS only altered double support time in the tray condition. All of the children with CdCS had one or more trials in which water spilled out of the cup.
CONCLUSIONS: Individuals with CdCS ambulate with the same velocity as age-matched controls with more frequent shorter steps. Individuals with CdCS did not adjust many of their gait parameters when walking and holding a pitcher with water, which may have been associated with the frequent water spills. It is not clear whether or not they have difficulty attending to task demands or have difficulty modifying their gait. By the third task condition involving carrying the tray and cup, individuals with CdCS were able to adjust their walking pattern to perform the task. This may have been an order effect since the presentation of task conditions was not varied.
CLINICAL RELEVANCE: Failure to adjust gait parameters under complex conditions may contribute to an appearance of “clumsiness” in individuals with CdCS and also may have implications for safety in everyday situations such as navigating a cafeteria with peers and carrying objects in a classroom.
CULTURAL CONSIDERATIONS IN THE PROSTHETIC MANAGEMENT OF AN ADOLESCENT WITH TIBIAL EWING'S SARCOMA
H. Aker, H. Atkinson, Physical Therapy, The Children's Hospital of Philadelphia, Philadelphia, PA.
BACKGROUND & PURPOSE: Cultural competence offers a framework for clinical decision making and is based upon the clinician's cultural desire, awareness, knowledge, and skill. Providing culturally competent care highlights the International Classification of Functioning, Disability, and Health (ICF) model by integrating the patient's environment into intervention and goals. By practicing culturally competent care utilizing the ICF model, patient participation needs and goals can be realized in a meaningful way. The purpose of this case study is to present the provision of culturally competent care for a patient from Saudi Arabia treated at a large pediatric medical center in the United States.
CASE DESCRIPTION: This report will present a 19 year-old female from Saudi Arabia who received medical and rehabilitative care in the United States for Ewing's sarcoma of the left distal tibia. She underwent left transtibial amputation and received a prosthetic device. Cultural knowledge played a significant role throughout the patient's course of therapy through goal writing, awareness of modesty, communication expectations, and religious practices. A unique challenge in prosthetic management will also be discussed in that the design of the patient's original prosthesis did not allow her to assume the proper kneeling position for Islamic prayer, which was her most important goal for therapy. This case will discuss how the physical therapist attempted to rectify this problem through both local and global coordination efforts.
OUTCOMES: The patient completed her medical care and returned home to Saudi Arabia after sixteen weeks of outpatient physical therapy. Although the patient demonstrated satisfactory outcomes for ambulation, balance, and stairs, her prosthetic device prevented her from assuming the proper kneeling position for prayers so her primary goal had an unsatisfactory outcome. However, a patented prosthesis designed specifically for the Islamic prayer position was identified and contact was made with the Saudi Arabian developer to allow the family to contact him after their return home.
DISCUSSION: Thorough examination, evaluation, and consideration of patient's daily life within the framework of the ICF model supports culturally competent goals and helps to limit ethnocentrically inclined care. In this case, having the medical and rehabilitative team consider the patient's primary desire of being able to assume the proper kneeling position for prayer during design of the original device would likely have led to a more satisfactory outcome for the patient. In addition, as healthcare continues to expand across borders it is important to not only consider resources within the local community, but also to consider global resources to maximize patient's meaningful functional outcomes.
MEASURINGN THE OUTCOMES OF STUDENTS: RASCH ANALYSIS OF THE SCHOOL OUTCOMES MEASURE (SOM)
S.H. Arnold, H.T. Kolobe, Rehab Sciences, OUHSC, Oklahoma City, E.V. Smith, Educational Psychology, University of Illinois at Chicago, Chicago, IL.
PURPOSE/HYPOTHESIS: A basic premise in measuring outcomes is that increases in scores imply improved performance, yet magnitude of change scores in many outcomes measures are difficult to interpret. The purpose of this study was to improve the precision of the School Outcomes Measure (SOM), a minimal data set designed to measure outcomes of students who receive school-based occupational therapy and physical therapy.
NUMBER OF SUBJECTS: Participants were 120 school-aged students classified according to the GMFCS.
MATERIALS/METHODS: Thirty five occupational therapists (OT) and physical therapists (PT), trained to administer the SOM, collected data from the students. We used Winsteps (Rasch software), to determine the item unidimensionality and hierarchy of item difficulty, examine fit statistics, and to compute logit scores for each item (Andrich, 1988). We also used the Principle Component Analysis (PCA) to determine item clusters while maximizing variance, and identify redundant items.
RESULTS: The results suggest that the SOM is a multidimensional scale. The 6-point rating scale model of the 41 items estimated 6 items misfit based on the standardized fit statistic (Zstd) greater than 2, and revealed three components. The items clustered into new constructs related to 1) functional mobility, such as moving on all types of surfaces, through doors, in the school and community, and while carrying lunch items, 2) assuming roles necessary to participate in the school, such as eating, toileting, and obtaining classroom materials, and 3) student learning behavior, such as staying on task, interacting appropriately, and expressing learning through handwriting or computer.
CONCLUSIONS: The PCA created clusters that were slightly different from subscales identified in the original version of the SOM. For example while Mobility and Self-Care were developed as two subscales, the PCA results suggest that items in these subscales represent two clusters of functional activity and participation. The items originally grouped as Behavior and Expresses Learning clustered into one construct of learning behavior. This distinction suggests that reading and writing, staying on task, and managing behavior in school requires students to take directions and may not necessarily be a function of a motor disability. The findings also suggest that removing the 6 misfitting items and items with low eigenvalues may also increase the precision of the SOM.
CLINICAL RELEVANCE: The SOM is intended to address the need for an outcomes tool to measure the outcomes of students receiving OT and PT in schools and to meet the IDEA mandate for accountability for outcomes of students with disabilities. As a minimal dataset it is also intended to meet the time constraint problem, expressed by therapists, in collecting valid student outcomes. The results of this study will not only improve the SOM's psychometrics, but will also aid interpretation of change scores and allow comparison of outcomes across children and schools.
REFERENCE DATA FOR NORMALLY DEVELOPING 5-YEAR-OLDS UTLIZING THE BALANCE MASTER mCTSIB
D. Atienza, N. Bennett, L. Glynn, M. Grant-Beuttler, Physical Therapy, Chapman University, Orange, CA.
PURPOSE/HYPOTHESIS: The purpose of this study is to report reference data for static balance control in normally developing 5 year-olds using the Balance Master. Documentation of the normal range of balance skills in different conditions may enable clinicians to detect potential balance issues during balance assessments when atypical development is suspected.
NUMBER OF SUBJECTS: 109
MATERIALS/METHODS: One hundred and nine 5-year-olds (mean age: 5.09 ± 0.16) completed the modified clinical test of sensory interaction on balance (mCTSIB) utilizing the Balance Master. Sway velocity and center of pressure (COP) were collected during three 10-second trials for each of the four condition of the mCTSIB; firm surface, eyes open and eyes closed, foam surface, eyes open and eyes closed.
RESULTS: Sway velocity was lowest for the firm surface, eyes closed condition and highest for foam surface, eyes closed condition. The mean COP for all conditions of the mCTSIB was toward the right and back of center. None of the children in our sample demonstrated a loss of balance during any of the testing conditions. No differences between sway velocity or COP were detected between males and females.
CONCLUSIONS: Reference data on this large sample will provide clinicians norms to detect potential balance issues in 5-year-old children using the Balance Master.
CLINICAL RELEVANCE: This data may assist in determining the need for further diagnostic tests to confirm potential pathological conditions or to suggest early interventions to help address balance deficits.
RISK MANAGEMENT CASE REPORTS ON DEVELOPING A PLAN FOR SAFE EMERGENCY EGRESS OF STUDENTS WITH MOBILITY CHALLENGES IN PUBLIC SCHOOLS
L.M. Bainer, Exceptional Children, Memphis City Schools, Memphis, TN.
BACKGROUND & PURPOSE: The U.S. Department of Education guides emergency management planning at public schools by identifying four steps to planning: mitigation and prevention, preparedness, response, and recovery. Incidents such as the 1999 Columbine High School massacre in Colorado and the terrorist attacks on the World Trade Center in New York City on September 11, 2001 continue to shape how schools perceive risk to students. In West Tennessee, in addition to fire, schools now plan for security lock down, as well as weather related incidents such as tornadoes and flooding. Earthquakes also pose a risk in West Tennessee. Planning egress of students with mobility impairments requires anticipating situations without access to an elevator, not just because the elevator may not safely operate during a fire, but because the distance to the elevator from the student's location may prohibit use, whether because evacuating traffic flow moves directionally away from the elevator, or because the fire may occur between the student and the elevator. As ergonomic, exercise, and mobility specialists, the physical therapist augments the district's successful implementation of safe evacuation. With planning and training, all students can safely exit, even those with mobility challenges.
CASE DESCRIPTION: The Director of Special Education assigned a Coordinator and the Lead OT-PT (a physical therapist) to work with the district team led by the Emergency Management Supervisor. The team combined efforts to write an emergency plan detailing the roles of school personnel in planning for students and staff that might require additional physical assistance during an evacuation.
OUTCOMES: The Lead OT-PT role expanded to shared authorship of the drafts, identification of the students and identification as well as implementation of the therapists' role at the local school. Physical therapists began affirming students initially identified through computer generated lists, selecting evacuation equipment, placing the equipment in coordination with school administration, individualizing training for staff and student, monitoring drills, and standardizing the written evacuation plan.
DISCUSSION: Identifying obstacles that arise during ongoing implementation should realize additional improvements in the execution of the emergency plan. Anticipating and following students enrolling in new schools at the start of a new school year each August as well as tracking student movement across the district during the school term poses challenges in the movement and acquisition of evacuation equipment and additional duties to collaborate with new school teams to plan and train. Therapists continue a collaborative effort to hone skills in the hope that repeated practice will bring to fruition the safe egress during evacuation of students with mobility challenges at school.
EFFECTS OF MANUAL TASK COMPLEXITY ON GAIT PARPAMETERS IN SCHOOL-AGED CHILDREN AND ADULTS USING THE GAITRite® ELECTRONIC WALKWAY: A PILOT STUDY
R. Bellows, K. Figueroa, J. Levy, E. Lim, L. Puccio, A.K. Rao, L.D. Abbruzzese, Columbia University, New York, NY.
PURPOSE/HYPOTHESIS: Dual task paradigms may be used by clinicians in order to reveal interference effects under increasing attentional load. The purpose of this pilot study was to 1) compare the effects of performing a concurrent manual task while walking on gait measures in children versus adults and 2) compare the dual-task interference effects of a simple versus a complex version of two manual tasks.
NUMBER OF SUBJECTS: A convenience sample of seven adults, ages 21-40, and seven typically developing children ages 7-10 were recruited to participate in this study.
MATERIALS/METHODS: Walking velocity, cadence, step length, base of support, and percent time in double limb support were collected using the GAITRite® instrumented walkway (CIR Industries, Clifton, NJ, USA) which uses six embedded sensor pads to record data from each foot fall. Subjects were asked to walk at their typical speed under five conditions: (1) Single task (2) Dual task-simple pitcher (SP) (3) Dual task- simple tray (ST) (4) Dual task- complex pitcher (CP) (5) Dual task- complex tray (CT). In the complex tasks, instructions were to walk without spilling water from a cup placed inside the pitcher or without tipping over a cup balanced on the tray. Subjects performed three trials under each of the five conditions beginning with the single task condition. The order of the SP, ST, CP and CT tasks were randomized in order to minimize an order effect. The average dual task cost was analyzed using a repeated measures ANOVA to determine main effects for complexity (simple vs. complex), type of manual task (pitcher vs. tray) and group (adult vs. child).
RESULTS: In the complex tasks, subjects reduced gait speed, took fewer steps, took smaller steps, and spent more time in double limb support. There was a significant group by complexity interaction indicating that the cost of the complex task was greater for children than adults. There was not a significant group difference for the simple version of the manual tasks.
CONCLUSIONS: Attention demanding tasks such as walking while carrying a tray with a cup on it or walking while not trying to spill a liquid inside a pitcher have a greater interference effect on gait characteristics in children than in adults. It is unlikely that the interference is due to the mechanical demands of doing a manual task while walking because the interference effects were found for the complex but not the simple versions of the tasks. Our preliminary analysis also suggests that the type of manual task may have an impact on dual task costs.
CLINICAL RELEVANCE: Like adults, children appear to be able to perform simple concurrent manual tasks while walking without disruption in gait. When devising a treatment plan or an assessment of dual task performance, a significantly challenging secondary manual task should be used if the goal is to elicit interference. Further study is required to determine the implications for patient populations.
REHABILITATION OF A CHILD WITH CEREBRAL PALSY FOLLOWING SELECTDIVE PERCUTANEOUS MYOFASCIAL LENGTHENING
K. Belsole, R.S. Van Zant, Physical Therapy, University of Findlay, Findlay, OH.
BACKGROUND/PURPOSE: Selective percutaneous myofascial lengthening (SPML) is a recently developed minimally invasive outpatient surgical procedure with high promise for reduction of spasticity in children with cerebral palsy (CP), unfortunately, little if any research is directed toward examining functional outcomes in children after SPML. This case report describes the physical therapy treatment of a child with spastic CP following SPML of the right lower extremity. The purpose of this retrospective analysis was to discuss the efficacy of the surgical procedure and subsequent rehabilitation and to identify significant outcomes.
CASE DESCRIPTION: The patient was a four year-old Caucasian female. She was born at 24 ½ weeks gestation and sustained bilateral intraventricular hemorrhages, grade III on right and IV on left. She was diagnosed with CP and presented with delayed motor skills since birth. She received physical, occupational and speech therapy through home healthcare intervention program and an outpatient rehabilitation center until the age of three. Her main functional deficits consisted of delayed motor skills, unsteady gait and tight right lower extremity musculature due to spasticity. She was able to ambulate with a tip-toe gait on the right without an assistive device, but was unable to ascend or descend stairs, jump or run without loss of balance. She sustained frequent minor injuries due to falls and became apprehensive during more complex functional activities. She underwent a SPML of the right knee and ankle, and was casted for six weeks. She then received a right ankle foot orthotic that she wore throughout the day. She was seen at an outpatient physical therapy clinic twice weekly for three months to improve lower extremity strength, range of motion (ROM) and dynamic gait activities.
OUTCOMES: Upon a two-month follow-up visit with the orthopedic surgeon, the child exhibited clinically significant improvements in right lower extremity ROM (popliteal angle: 45° to 35°, ankle equinus knee extended: −30° to 5°, ankle equinus knee flexed: −25° to 10°, dorsiflexion: 5° to 15°). Following her three month physical therapy intervention she demonstrated an improved gait pattern with heel-strike upon initial contact, improved step negotiation without the assistance of her upper extremities, improved balance with side stepping and increased gluteus medius strength: 3+/5 to 4/5.
DISCUSSION: The result of this case report showed that SPML along with static casting and subsequent physical therapy intervention was effective in reducing the effects of spasticity and improving gait quality as well as functional measures in an individual with spastic CP.
FEASIBILITY OF AN INTERDISCIPLINARY YOGA PROGRAM FOR PRE-SCHOOL AGED CHILDREN
M. Benedetto, M.E. O'Neil, Physical Therapy and Rehabilitation Sciences, Drexel University, Philadelphia, PA; R. Ideishi, Occupational Therapy, University of the Sciences, Philadelphia, PA; S. Ideishi, Occupational Therapy, Kencrest Services, Philadelphia, PA.
PURPOSE: To report on the design and procedural feasibility of a pre-school yoga program for young children in an underserved urban community. The Yoga program was developed for children aged 3-5 years old in a pre-school program (Head Start or Early Intervention) located in an underserved urban area. Due to declining governmental funding, children's ability to receive individual services may be impacted. It is important for physical and occupational therapists to establish feasible, innovative programs. This report describes the development and feasibility of a yoga program developed by an interdisciplinary team.
DESCRIPTION: Program Characteristics: 1) Personnel: The team consisted of a senior staff OT from the targeted pre-school, one PT and OT faculty and three DPT and OT students. The OT has experience with facilitating interdisciplinary programs that address activity and participation goals for the children. Both faculty members have experience in pediatrics. Students collaborated with the OT and PT/OT faculty in order to develop a program that met the needs of the children, teachers and clinicians. 2) Setting: Preschool program that serves 194 children with 92% living below the poverty line. The majority of children are Latino (65%) and African American (18%). The center serves two zip codes representing one of the poorest areas (poverty rate: 35%), with the largest percentage of Hispanic families (28%) in the city. 3) Participants: Yoga program participants included all children in the summer program (n = 71, 53% males, 47% females) from all six inclusive classrooms. Most children (65%) were from the Head Start Program. 4) Activities: Three series of poses (7-9 poses per series) were designed to address strength, balance, and motor planning. These series were “contextualized” in stories that were journeys to major city landmarks (airport, zoo, park) to motivate children, help transition between poses and have fun! Yoga sessions were supervised by the team and classroom teachers, and were implemented during regularly scheduled gross motor play time.
SUMMARY OF USE: Children participated in a summer yoga program for 10 sessions over 5 weeks. Design and implementation of the program was collaborative, fit into the daily school routine, with a potential for replication in similar settings. Feedback from teachers reported that the program format and frequency was appropriate and that children had better attention and transition skills in classroom behaviors.
IMPORTANCE TO MEMBERS: The yoga program is one possible innovative program for the delivery of PT and OT services for children in pre-school. While it is not meant to replace individual therapy sessions, it may serve as a group co-treatment approach for practice and carry-over of skill acquisition in challenging yet fun activities. Replication of the program among similar pre-school settings is realistic. Collaboration among PT/OT clinicians, students and teachers should be considered when optimizing service delivery to children.
IDENTIFICATION OF CAREGIVER ASSISTANCE LEVEL IN TYPICALLY DEVELOPING CHILDREN AS MEASURED BY THE PEDI
E. Casselle, K. Francesconi, A. Lopez, S. May, D. Armstrong, D. Redman-Bentley, Physical Therapy, Western University of Health Sciences, Pomona, CA.
PURPOSE/HYPOTHESIS: The purpose of the study is to: 1) identify functional skills within three domains that require caregiver assistance (CA) and the level of assistance provided, and 2) examine levels of caregiver assistance for different age groups.
NUMBER OF SUBJECTS: 20 children between the ages of 1 and 7.3 years (mean = 3.95, SD = 2.19) were included in the study; 55% were boys. Subjects display typical development (healthy with no history of disability or major medical problems, isolated blindness, or deafness).
MATERIALS/METHODS: Children were recruited from Woman's, Infants and Children Program (WIC) in Pomona, CA. They were equally divided into three groups by age (1-2.5, 2.6-5, and 5.1-7.5 years). Investigators used the Pediatric Evaluation of Disability Inventory (PEDI) to interview parents/guardians. All data collection took place at the Western University of Health Sciences Physical Therapy Research Lab in Pomona, CA. Data was analyzed using the SPSS v 17 and MicroSoft Excel programs.
RESULTS: Preliminary analysis of data reveals that specific functional tasks may require a higher level of caregiver assistance than expected for 50% or more of the children. The number of children requiring supervision to total CA per task revealed: 1) Only 3/20 required no assistance for self-care skills; two required an average of greater than moderate CA, 2) Only 4/20 required no assistance for mobility skills; only 1 required an average of greater than moderate CA, 3) All children required some level of CA for social function; three required an average of greater than moderate CA. Items where ≥ 50% of children required maximal to total CA included: 6 skills in self-care, 0 skills in mobility, and 8 skills in social function. Additional analyses will examine level of caregiver assistance based on the three age groups.
CONCLUSIONS: Adjusting for age, we expected that only younger children would require maximal or total CA, however, the tasks revealed that many children above the age of 2.5 years required maximal/total assistance. The results demonstrate that these children are at a lower performance level.
CLINICAL RELEVANCE: Assessing young children with developmental disabilities is often based upon knowledge of typical development. This study demonstrates the importance of identifying the level of assistance required for specific tasks in typically developing children. This study may serve as a basis for expected performance in children with disabilities.
CORTICAL VOLUME DIFFERENCES AND PRESENCE OF MOTOR-EVOKED POTENTIAL IN PEDIATRIC STROKE
J.M. Cassidy, B.T. Gillick, J. Carey, Department of Physical Therapy and Rehabilitation Science, University of Minnesota, Minneapolis, MN; B. Battista, C. Brown, J. Calmes, J. Cupit, Department of Physical Therapy, University of Minnesota, Minneapolis, MN.
PURPOSE/HYPOTHESIS: Repetitive transcranial magnetic stimulation (rTMS) is under investigation as an intervention to promote recovery from stroke. It is important to determine the stroke characteristics amenable to this intervention. As part of a larger investigation, the purpose of this study was to detect any volumetric differences in the primary motor cortex (M1) and posterior limb of the internal capsule (PLIC) between subjects that demonstrated a motor-evoked potential (MEP) elicited by transcranial magnetic stimulation (Responders) and subjects without an MEP (Non-responders). We hypothesized that there would be a difference in M1 and PLIC volumes between Responders and Non-responders, suggesting that greater loss of neural substrate, along the corticospinal tract, may be a characteristic that influences who would be eligible for rTMS.
NUMBER OF SUBJECTS: 17 Responders (10 males, 7 females, mean ± SD age of 10.59 ± 2.88 years) and 10 Non-responders (6 males, 4 females, mean ± SD age of 10.40 ± 2.87 years) with cortical ischemic stroke and >10 degrees of active flexion and extension of the wrist and index finger metacarpophalangeal joint participated.
MATERIALS/METHODS: MEPs were elicited using single-pulse transcranial magnetic stimulation (TMS). Anatomical magnetic resonance imaging scans were collected for each subject. Brain imaging software was used to define M1 and PLIC regions and their ipsilesional and contralesional volumes. Subjects were placed into 2 strata (Responders or Non-responders). Ipisilesional/contralesional (I/C) ratios were calculated separately for M1 volume and PLIC volume for each subject. Between-group data were analyzed using a 2-Tailed Independent T-test with alpha = .05.
RESULTS: The M1 I/C ratio was 0.757 for Responders and 0.439 for Non-responders (p = 0.004). The PLIC I/C ratio was 0.687 for Responders and 0.295 for Non-responders (p = 0.001). These results indicate that reasonable integrity of the corticospinal tract is needed to generate an MEP. However, one 8-year-old Non-responder had an M1 I/C ratio of 0.761 and a PLIC ratio of 0.649. The explanation for no MEP in this child is likely due to incomplete neural development associated with her age.
CONCLUSIONS: Pediatric subjects with chronic cortical ischemic stroke in whom an MEP can be elicited have a greater volume of neural tissue in M1 and PLIC compared to Non-responders.
CLINICAL RELEVANCE: Diminished volumes of M1 cortex and PLIC regions in Non-Responders suggest that the absence of an MEP is due to a loss of corticospinal tract neural substrate, although age must also be considered. Knowledge of the infarct location and volume may be important in determining who is a candidate for rTMS. Interestingly, all subjects possessed voluntary movement of their paretic index finger, underlining the importance of possible ipsilateral control of the paretic limb or other cortical reorganization (e.g. reticulospinal pathways) to assume control of these movements.
MANUAL THERAPY, MOBILITY, AND STRENGTH TRAINING IN AN ADOLESCENT WITH ARTHROGRYPOSIS
M. Crandall, Inpatient Physical Therapy Rehabilitation, Children's Hospital of Michigan, Detroit, MI; L.M. Brindley, J. Freund, Elon University, Elon, NC.
BACKGROUND/PURPOSE: This case report describes the effects of manual therapy, mobility, and strength training on ambulation and function of an adolescent with arthrogryposis during inpatient rehabilitation. Arthrogryposis is a collective term for many non-progressive disorders that present with multiple joint contractures at birth. There is limited research on physical therapy interventions for adolescents with arthrogryposis.
CASE DESCRIPTION: The patient was a 13 year old female with a diagnosis of arthrogyposis. Her goal was to become more independent. She had decreased shoulder, hip, and knee range of motion (ROM) and severe postural deficits which limited her activities of daily living. Her primary mode of ambulation was a manual wheelchair. She wore ankle foot orthoses for standing and transfers, required minimal assist with sit to stand transfers and could maintain standing with bilateral upper extremity support for 1 minute. Her maximum ambulation distance was 6.1 meters with a reverse walker, minimal assistance and multiple rest breaks. The patient participated in 45 minute physical therapy sessions twice a day, 5 days a week and one session on Saturdays for 6 weeks for a total of 65 treatment sessions. Interventions included: strength training, functional mobility training, and manual therapy. She also participated in occupational and recreational therapy.
OUTCOMES: The following outcomes improved pre to post intervention: left hip extension (−12 to 28 deg), right hip extension (−20 to 21 deg), maximum ambulation distance with a rolling walker (6.1 to 65.5 meters), standing balance (bilateral upper extremity support for 1 minute to intermittent single upper extremity support for 10 minutes), sit to stand transfers (minimal assist to supervision), and WeeFIM locomotion score (1 to 5). The occupational therapist also reported improvements in the following WeeFIM scores: upper body grooming and dressing (4 to 6), bathing (4 to 5), toileting and toilet transfers (5 to 6), and lower body dressing (2 to 6).
DISCUSSION: Physical therapy interventions of manual therapy, mobility and strength training, along with occupational and recreation therapy, may be effective in improving functional mobility in adolescents with arthrogryposis. Improvements in transfers and ambulation represented a functionally meaningful change providing increased independence in self care. Adequate to excellent interrater and intrarater reliability is reported for the WeeFIM, but validity and the minimal clinically important difference has not been determined. This case report provides support for continued research on physical therapy interventions for adolescents with arthrogryposis.
THE EFFECTS OF AQUATIC THERAPY ON FUNCTIONAL MOBILITY OF CHILDREN WITH CEREBRAL PALSY: A SYSTEMATIC REVIEW
C. Cook, M. Giampietro, H. Titcomb, D.P. Miller, Univ. of Scranton, Scranton, PA.
PURPOSE/HYPOTHESIS: The purpose of this systematic review was to assess the effectiveness of aquatic therapy-based interventions on the functional mobility of children with cerebral palsy (CP).
NUMBER OF SUBJECTS: N/A
MATERIALS/METHODS: A literature search of CINAHL, MEDLINE, NURSING@OVID, and Proquest (2002-2012) was conducted to identify studies evaluating the effectiveness of aquatic therapy-based interventions on functional mobility of children with CP. Inclusion/Exclusion criteria were: subjects 18 years of age or younger with a diagnosis of CP and ability to ambulate with or without a device, an aquatic intervention, and at least one measure of functional mobility or gait capacity. Three reviewers independently assessed each study for methodological quality based on PEDro guidelines.
RESULTS: The search produced 66 titles and abstracts for review. Eleven studies were selected for further evaluation through the abstract review process. Following a detailed appraisal, 7 studies fulfilled the inclusion/exclusion criteria and were included in the systematic review. Four of the studies were a single-subject design. Two of the studies were a case-series design. One study was a systematic review. The quality assessment included PEDro scores of 3 for all articles. A mixed variety of CP diagnoses were included across studies. A variety of aquatic therapy-based interventions were used across studies. Sample size ranged from 1-16 in the single-subject and case-series studies. The systematic review included 11 studies with sample sizes ranging from 1-50 subjects. Studies included outcome measures such as standardized functional tests and measures of gait parameters, vital capacity, endurance, and energy expenditure.
CONCLUSIONS: Our systematic review on the effect of aquatic therapy-based interventions on functional mobility of children with CP showed positive trends towards improvement and an absence of adverse effects for this population. There is a weak level of evidence supporting the effectiveness of aquatic therapy-based interventions to improve functional mobility of children with CP. Study limitations included small sample size and a lack of uniform outcome measures and intervention guidelines. More research is needed to determine the effectiveness of this intervention and to establish standardized intervention guidelines.
CLINICAL RELEVANCE: Aquatic therapy-based interventions may be beneficial for children with CP due to the physical properties of water (buoyancy, resistance, and hydrostatic pressure) which may aid in the ability of this population to participate in a safe, effective, and enjoyable activity. Aquatic therapy-based interventions show promise as an adjunct to a physical therapy program targeting functional mobility in ambulatory children with CP.
ASSESSMENT OF SPATIAL AND TEMPORAL GAIT PARAMETERS IN CHILDREN WITH RETT SYNDROME: A CASE STUDY
J.E. Cook, V. Vardaxis, Department of Physical Therapy, Des Moines University, Des Moines, IA.
BACKGROUND/PURPOSE: Children with Rett Syndrome who present with limited muscle function, motor control and coordination of movement often have abnormal gait. The purpose of this study was to determine if gait parameters can be reliably measured to define gait characteristics in a child with Rett Syndrome.
CASE DESCRIPTION: The child subject was a 7 year old female with the diagnosis of Rett Syndrome and a history of seizure activity with a height of 115 cm, and a weight of 25.2 kg with a BMI of 19.1 kg/m2 reported from her most recent medical records. Upon initial examination the child ambulated with assistance for direction and occasional assistance to prevent falling. She wore bilateral articulating ankle foot orthotics with a 90 degree plantarflexion stop. For safety reasons, the child wore a gait belt in the laboratory and the therapist had contact with the gait belt for safety from behind the patient during all gait activities. She had no increase in muscle tone during quick stretch reflexes of the lower extremities except when assessing the ankle plantarflexors, where she presented with a modified Ashworth Scale score of 1+ bilaterally. Her gait kinematics were collected over 3 separate days using Cortex-64 software with an eight-camera Motion Analysis Eagle system (Motion Analysis Corporation, Santa Rosa, CA). Each session was 3 to 4 days apart. The steps accepted for gait analysis were those steps that the child walked forward without assistance or directional guidance.
OUTCOMES: Mean and standard deviation for the following gait parameters over the 3 days were: stride length (cm) = 52.04 ±7.19; cadence (steps/minute) = 94.42 ±10.98; velocity (cm/s) = 41.15 ±7.60; right step time (seconds) = .64±.08; left step time (seconds) = .65±.08; right step length (cm) = 23.61±.5.31; left step length (cm) = 29.14 ±7.18. The coefficient of variation for the following gait parameters on days 1, 2, and 3 were the following respectively: stride length = 14.99%, 13.25%, 14.24%; cadence = 11.46%, 11.74%, 10.20%; velocity = 20.98%, 19.12%, 12.54%; right step time = 16.67%, 11.29%, 11.03%; left step time = 10.76%, 14.98%, 11.42%; right step length = 19.10%, 17.10%, 22.22%; left step length = 21.15%, 24.46%, and 27.02%.
DISCUSSION: We observed considerably high variability in the gait parameters assessed (stride length, cadence, velocity, step time and step length) in all three sessions. The variability observed was also asymmetrical, with higher variability and longer step length on the left side. The lack of consistency in her gait parameters reflects a rather chaotic stepping pattern that required frequent correction and adjustment from the prior steps taken. This study offers initial data in determining the variability in gait parameters in a child with Rett Syndrome and gait analysis may be useful to quantify changes in this variability resulting from the disease progression or clinical intervention.
EFFECTIVE PARENT INSTRUCTION AND EARLY REFERRAL OF POSITIONAL PLAGIOCEPHALY: A SURVEY OF PEDIATRICIANS' PRACTICES
P. DiBiasio, Elon University, Elon, NC; J.T. Jennings, Responsible Health for Children, Fairfield, OH; S. Attermeier, Pediatric Physical Therapy, Inc., Hillsborough, NC.
PURPOSE/HYPOTHESIS: The Back to Sleep (BTS) policy initiated in1992 reduced the rate of Sudden Infant Death Syndrome by 50%. An unforeseen consequence of BTS is the increased incidence of cranial abnormalities. From 1992 to 1994, the incidence of positional plagiocephaly (PP) increased by 6-fold. By 2007, the incidence of PP was 6.1%-13% at birth, but increased to 22.1% at 7 weeks after birth. Torticollis, facial asymmetry, developmental delay and spinal abnormalities can be associated with PP. The purpose of this study was to determine whether pediatricians are employing early, conservative intervention strategies to prevent PP. Early conservative strategies can reverse an infant's positional preferences and prevent the development of PP and its associated sequelae.
NUMBER OF SUBJECTS: Two-hundred and four pediatricians across the nation completed the survey.
MATERIAL/METHODS: Surveys were distributed via paper or electronically in 7 states by American Academy of Pediatrics (AAP) Chapter representatives to approximately 6000 pediatricians. Pediatricians completed an 8 question multiple choice survey created by Judy Towne Jennings, MA, PT, entitled, “A Survey of Physicians Practices Regarding Infant Plagiocephaly”. The survey was designed to document practices regarding tummy time instruction of newborns & referral practices regarding PP. Data were hand-tabulated. The study was conducted from July of 2010 to April of 2011.
RESULTS: Results showed that 92% of respondents discuss the importance of tummy time with parents of newborns, and 45% recommend starting tummy time before infants are 1 month old. Of pediatricians who discuss tummy time, only 18% gave in-depth instructions about how to implement it. Percent of infants presenting with plagiocephaly who were initially referred to another MD (47%), a physical therapist (35%), or an occupational therapist (3%). The majority of pediatricians, who referred (22% indicated no referrals) did not use the early intervention strategy of immediate referral for PP, but waited until infants were at least 4 months old before making a referral.
CONCLUSIONS: The results of this study indicate that early intervention prevention and referral strategies for PP are inconsistently implemented by the majority of pediatricians who participated. The study population is not representative of pediatricians across the country therefore results must be considered carefully. A more global survey would be beneficial to ascertain practice patterns.
CLINICAL RELEVANCE: As of April 2011, pediatricians were implementing the AAP plagiocephaly management strategies of 2005, however, these have evidently not prevented the escalation of the incidence of PP. Given the high incidence, cost to families & the healthcare system, and the widely reported negative medical outcomes, the need for prevention of PP has been well established. No universal method of treating PP is evident and there appears to be great potential for an earlier, more aggressive protocol including an early referral to physical therapy.
THE EFFECT OF YOGA POSTURES ON BALANCE, STRENGTH, COORDINATION AND FLEXIBILITY IN TYPICAL CHILDREN AGES 10-11 YEARS
B. Donahoe-Fillmore, C. Brahler, J. Burgei, A. Domsitz, M. Hamm, K. Lies, S. Strayer, Physical Therapy, University of Dayton, Dayton, OH.
PURPOSE/HYPOTHESIS: The purpose of this study was to investigate the effects of yoga practice on balance, strength, coordination and flexibility in typical children in 5th grade.
NUMBER OF SUBJECTS: A convenience sample of 26 children (12 male, 14 female; 10-11 years old), who were enrolled at a Midwestern Catholic elementary school, participated.
MATERIALS/METHODS: Subjects participated in a 40 minute yoga class, led by the same registered yoga instructor, 3x/week for 8 weeks. All sessions were conducted in the school basement. Pre and post measurements were collected on balance, strength and coordination, using the Bruninks-Oseretsky Test of Motor Proficiency, second edition, and flexibility, using the sit and reach test and the 90/90 hamstring flexibility test. Means, standard deviations, 95% confidence intervals and p-values were computed for all variables. Paired samples t-tests were run to determine if there was a statistically significant within-subject change from pre to post test for any of the dependent variables.
RESULTS: There was a statistically significant within-subject difference from pre test to post test for balance (p = 0.02), sit and reach (p = 0.001), popliteal angle right (p = 0.004), and popliteal angle left (p = 0.012). There were no statistically significant differences in strength and bilateral coordination from pre to post test measurements.
CONCLUSIONS: The greatest improvements observed in the present study were seen in the areas of balance and flexibility and subjects achieved the normative values expected for their age range in these areas following the yoga intervention. No significant changes were noted in strength and coordination. Many of the yoga postures emphasized positions that facilitated muscle stretching, core stability, and static balance. This in conjunction with the short duration of the study may explain the current findings.
Future studies should include a larger sample size, an increased intervention period and subjects with impairments.
CLINICAL RELEVANCE: Yoga may be a beneficial form of exercise in the school-based setting for improving balance and hamstring flexibility in typical children.
A SYSTEMATIC REVIEW OF THE EFFECTIVENESS OF VIRTUAL REALITY ANALGESIA IN THE PEDIATRIC BURN POPULATION DURING PHYSICAL THERAPY
K. Dorsett, E. Hickey, H. Hoffman, A. Maggipinto, C. Moore, R.M. Hakim, Physical Therapy, University of Scranton, Scranton, PA.
PURPOSE/HYPOTHESIS: The purpose of this systematic review was to assess the effectiveness of virtual reality (VR) based interventions on burn pain analgesia in pediatric populations while undergoing physical therapy (PT).
NUMBER OF SUBJECTS: N/A
MATERIALS/METHODS: A literature search of CINHAL, Cochrane Library, Google Scholar, MEDLINE, PubMed, and Science Direct (2000-2011) was conducted to identify studies evaluating the effectiveness of VR on burn analgesia. Inclusion criteria were: English, peer-reviewed articles, participants under 21 years of age, and PT intervention that included some form of VR for burn pain analgesia. Studies were excluded if they did not report a pain measure. Five reviewers independently rated each study and came to a consensus for methodological quality based on PEDro scores.
RESULTS: A total of 775 articles were screened for eligibility in this review. Fourteen articles were selected for further evaluation. Two additional articles were identified through hand searching. Following a detailed appraisal, six studies fulfilled the inclusion/exclusion criteria and were included in this systematic review. The quality assessment ranged from a PEDro score of 3 to 5/10 with an average of 4.5. Studies focused on pain management during wound care or dressing changes (4) and during range of motion (ROM) activities (2). A variety of VR systems using a head mounted device were used across all studies reviewed. Sample size ranged from 2 to 54 with a total 167. All studies were conducted in inpatient rehabilitation settings. One study used a VR-based intervention with a control group and 5 used a within-subject crossover design. All studies used a subjective pain rating scale. Outcome Measures included: Faces Scale, Graphic Rating Scale (GRS), Visual Analog Scale (VAS), Faces, Legs, Activity, Cry and Consolability (FLACC) scale, Range of Motion (ROM) using goniometry, Presence Questionnaire (PQ), and behavioral observations by caregivers to measure pain. Four studies measured the overall effectiveness of the VR systems (i.e., comfort, fun, and realness). All six studies found statistically significant results for decreased pain during PT intervention with VR as compared to treatment without VR.
CONCLUSIONS: There is moderate evidence to recommend VR as an adjunct to pharmacological analgesia to decrease pain in pediatric burn patients undergoing dressing changes and ROM exercises. However, there were small sample sizes and low feasibility due to the lack of availability and increased cost of specific VR applications. More randomized, controlled clinical trials are needed to determine the optimal duration, type of system, and clinical application of VR.
CLINICAL RELEVANCE: Head mounted VR systems provide a safe, interactive, and immersive environment which may offer a distraction to pain during treatment sessions. Use of a VR-based system shows promise as an adjunct to conventional pharmacological interventions to decrease pain in pediatric burn patients during PT interventions.
EXPANSION OF NORMATIVE DATA OF FIVE TESTS OF PEDIATRIC GROSS MOTOR FUNCTION
M.H. Doyle, F. Covino, A. Itzkowitz, M. Lieberstein, G. Weingarten, C. Vialu, Office of Related and Contractual Services, New York City Department of Education, Long Island City, NY; S. Kaplan, School of Health Related Professions, University of Medicine and Dentistry of New Jersey, Newark, NJ.
PURPOSE/HYPOTHESIS: Five standardized tests of functional mobility have been reported as valid, reliable tools for examining school-aged children: Timed Up and Down Stairs (TUDS), Timed Up and Go (TUG), Timed Floor to Stand (TFS), Thirty-Second Walk Test (30SWT), and Shuttle Run (SR). The purpose of this study is to expand the normative data for these 5 mobility tests, using larger sample sizes than previously reported, from an urban, ethnically and culturally diverse student population.
NUMBER OF SUBJECTS: A sample of convenience of 730 subjects (age range 5 to 10 years) from 9 New York City public schools participated in this study. According to parental report, the participants had no orthopedic surgeries or injuries within the past 6 months, and no history of a genetic or neurological disorder.
MATERIALS/METHODS: Prior to data collection, 5 raters were trained to administer and score the TUDS, TUG, TFS, 30SWT, and SR. All 5 raters were physical therapists. Inter-rater and intra-rater reliability was established. Testing was conducted in the participating schools on two separate days: the TUG, TFS, and TUDS were administered on the first day, and the SR and 30SWT were administered on the second. Testing order was randomized within each testing day. Testing days were scheduled no more than 2 months apart. For the purpose of determining norms, the data was grouped according to the age of the students at the time of testing. Three groups were created: Group I (5 to 6 years of age), Group II (7 to 8 years), and Group III (9 to 10 years). Data collection will be completed in June 2012. Data analysis will be completed by August 2012. Descriptive statistics will be used to determine the mean and standard deviation for performance of each of the 5 tests in each age group. This data will provide normative values for each of the functional tests. Linear regression will be performed to determine the relationship between test performance and age. Future data analysis may explore relationships between test performance and factors other than age, such as gender, BMI, or ethnicity.
RESULTS: To be determined.
CONCLUSIONS: To be determined.
CLINICAL RELEVANCE: Expanding the normative data for the TUG, TFS, TUDS, SR, and 30sWT will create norms with greater statistical power. Norms that are reflective of an urban school population will provide school based physical therapists in New York City and other urban areas with a more accurate basis for comparison when determining whether a student's motor performance deviates from that of his/her same-aged peers. These norms may also be utilized for objective documentation of a student's mobility status. This objective information will assist school assessment teams in making decisions regarding the need for school-based physical therapy services.
POSTGURE AND MOVEMENT EXPERIENCE ADVANCE OBJECT EXPLORATION AND MOTOR DEVELOPMENT IN THE LATE PRETERM INFANT: A PROSPECTDIVE CASE SERIES REPORT
S.C. Dusing, Physical Therapy, Virginia Commonwealth University, Richmond, VA; M.A. Lobo, J.C. Galloway, Physical Therapy, University of Delaware, Newark, DE.
BACKGROUND/PURPOSE: Infant born late preterm (34-36 weeks of gestation) account for 350,000 birth per year and are at risk for developmental delays, cerebral palsy, coordination and motor learning problems. However, late preterm infants are generally not included in intervention based research studies. Research is needed to evaluate the need for and efficacy of intervention to improve developmental outcomes for these infants. The purpose of this case series was to 1) Describe a movement intervention program provided by parents from 2 to 8 weeks of adjusted age 2) Quantify outcomes using a comprehensive assessment plan 3) Evaluate the general feasibility of using this intervention and set of outcome measures for future studies.
CASE DESCRIPTION: Two late preterm infants born at 36 weeks of gestation participated in a parent delivered movement program from 2 to 8 weeks of adjusted age. Parents were provided with an activity book and encouraged to complete the activities five day per week with their infant for 20 minutes each day. Developmental, postural control, reaching and object exploration assessments were completed at baseline, post-intervention, and follow-up visits. Data from four additional infants, 2 LPT and 2 full term, are presented for comparison.
OUTCOMES: The assessment and intervention protocol used in this study was well tolerated by the infants and families. Parents reported completing the activities at eighty to ninety percent of the frequency recommended. One infant's scores on the Test of Infant Motor Performance improved from below average to the average range, while the other infants scores were in the average range at all visits. One infant had gross motor delays at 12 months of adjusted age. Postural control, measured using variability of the center of pressure displacement, was similar to full term infants. Reaching and object exploration increased after participation in the movement program. Multiple sessions were needed to complete the outcome measures especially at younger ages.
DISCUSSION: Parents integrated our developmental play activities into their care giving to complete 20 minutes of defined activities per day with their very young infants. The LPT infants who participated in the movement program demonstrated developmental gains in postural control, reaching, and object exploration, which were different than gains seen in LPT infants who did not participate in the movement program. The combination of norm-referenced and behavioral measures of development, postural control, reaching, and object exploration used in this study documented changes in motor behaviors during and after completion of the movement program. These measures were feasible and may be useful in future studies investigating the efficacy of this or other interventions designed for very young infants.
THE EFFECT OF HEEL LIFTS ON THE ABILITY OF AN ADOLESCENET WITH SPASTIC QUADRIPLEGIC CEREBRAL PALSY TO STAND INDEPENDENTLY
L. Elbaum, Physical Therapy, FIU, Miami, FL; M. Harrell, L. Ferreiro, C. Gimenez, Rehabilitative Services, Miami Childrens Hospital, Miami, FL.
BACKGROUND/PURPOSE: Many people with spastic cerebral palsy (SCP) are unable to stand independently. Clinicians, family members and the subject of this study, a 15-year old boy with a primary diagnosis of spastic, diplegic cerebral palsy (SCP), were all pleasantly surprised when he was able to stand without crutches or assistance for the first time in his life during a recent physical therapy session when ½′′ lifts were placed under his heels; he was unable to do so without the lifts. The use of heel lifts was inspired by a continuing education program that cited the work of Owen, and suggested that ankle foot orthoses (AFOs) for children with SCP should be “tuned”; that is, designed to facilitate shank to vertical angle (SVA) of 7 to 15 degrees during midstance, even if this requires heel lifts for people with limited dorsiflexion. The purpose of this study was to supplement the clinical observation by describing the differences in posture and the behavior of the center of pressure (COP) while the subject attempted to stand independent with and without heel lifts.
CASE DESCRIPTION: The subject was a 15-year old boy with a primary diagnosis of spastic diplegic cerebral palsy. He had several limitations of motion. Knee extension with hips flexed to 90 degrees lacked 55 deg.(R) and 45 deg (L) Ankle dorsiflexion with knee extended was limited to −10 (R) and 8 (L). He was classified as a GMFCs Level II. He ambulated independently with two AFOs and a posterior walker in the community and forearm-cuff crutches at home.
OUTCOMES: The subject was unable to maintain bilateral standing balance for more than 10 seconds without the heel lifts; with heel lifts he was able to stand independently for 30-second periods. Relative to standing posture without lifts, with lifts he demonstrated similar ankle position, increased knee flexion and SVA, and decreased hip flexion, anterior tilt, and trunk flexion. COP excursion decreased dramatically, especially in the anterior-posterior direction.
DISCUSSION: It is unlikely that the improvement in balance was due to a sudden change in the postural control system. It is more likely that the heel lifts engendered a change in posture which simplified the tasks involved in postural control. In the typical posture of non-disabled adults, if the foot is in full contact with the ground, plantar flexion of the ankle must be accommodated by posterior lean of the shank (a negative SVA) and hyperextension of the hip; a lack of accommodations would tend to cause a backwards fall. For this subject, the addition of heel lifts allowed for plantarflexion without these accommodations, which were unavailable to him because of limited joint motion. The study was limited in depth and scope, but does suggest that some children with SCP might benefit from the use of of heel lifts and/or consideration of the SVA in addition to joint angles when prescribing and evaluating AFOs.
DURABILITYI OF OUTCOMES FOLLOWING A 3 WEEK CONSTRAINT INDUCED THERAPY PROGRAM
A. Fassett, J. Semel, L. Beck, P. Zumpol, Pediatric Outpatient Rehabilitation, St. Charles Hospital and Rehabilitation, Port Jefferson, NY.
PURPOSE/HYPOTHESIS: Constraint Induced Movement Therapy (CIMT) has been shown to be an effective treatment to improve upper extremity function in adults with Hemiplegia. Limited research exists on the effectiveness of CIMT with children diagnosed with Spastic Hemiplegic Cerebral Palsy and the durability of its effects. Thus, the goals of this research were to: 1) investigate the effectiveness of 3 week CIMT program, 2) determine the durability of outcomes over a 6 month period, and 3) determine whether CIMT is effective method for children 3.9-9.10 years old.
NUMBER OF SUBJECTS: 7
MATERIALS/METHODS: Children wore bi-valved fiberglass casts on their unaffected hand for 6 hours for 15 consecutive weekdays. The Quality of Upper Extremity Skills Test (QUEST) was used at pretest, posttest, and 6 month posttest to evaluate and measure improvement. Children were provided with 1:1 aides to assist them with fine motor, visual motor, gross motor, and self-help activities. Children also engaged in daily strengthening and weight bearing therapeutic exercise.
RESULTS: According to data analysis of the QUEST, participants improved in overall score by an average of 15.87 points from pretest to posttest. In addition, all participants improved in the dissociative movements subtest. The largest reported functional gains were made in the subtests of weight bearing (+26.86 points), and grasping (+19.58 points) at posttest. At 6 month posttest (N = 5), participants maintained gains in all subtests of the QUEST. Four out of five participants demonstrated further improvement in the protective extension subtest. Two participants also improved on overall score at 6 month posttest. Per parent report, 4 out ot 5 participants demonstrated improved use of the affected hand during and after the program. On the QUEST hand function subtest, all of the participants at 6 month posttest maintained improved bilateral hand function acquired in the 3 week program.
CONCLUSIONS: A 3 week CIMT program is an effective treatment in improving upper extremity function in children who are diagnosed with Spastic Hemiplegic Cerebral Palsy. Data analysis revealed that all participants improved from pretest to posttest, and maintained gains from posttest to 6 month posttest. CIMT improves affected hand use which may be correlated to improved bilateral hand use. CIMT was effective method for children in this study whose ages ranged from 3.9-9.10 years old. Bi-valved casts, worn for 6 hours daily, were an effective method of constraint.
CLINICAL RELEVANCE: Outcomes from this 3 week CIMT program showed a durability of improved upper extremity function for at least 6 months following initial posttest. Results indicate that this CIMT program is positively correlated with improvement of skills in the affected upper limb in children diagnosed with Spastic Hemiplegic Cerebral Palsy.
VASTUS LATERALIS AND VASTUS INTERMEDIUS FASCILE LENGTH AND PATELLAR TENDON LENGTH IN TYPICALLY DEVELOPING CHILDREN AGES 7-17
K.E. Fortuna, W. Orr, R. Dechellis, S. Horsfield, J. Howman, M. Courtney, G.S. Chleboun, Ohio University, Athens, OH.
PURPOSE/HYPOTHESIS: The purpose of this study was to determine the relationship between quadriceps muscle fascicle length and patellar tendon length in typically developing children ages 7-17. This study is descriptive in nature with the eventual goal of comparing these results to data from children with spastic cerebral palsy who have patella alta.
NUMBER OF SUBJECTS: Eighteen typically developing children participated (9 males, 9 females, mean age = 11.7±3.3).
MATERIALS/METHODS: Vastus lateralis (VL) and vastus intermedius (VI) muscle fascicle length and patellar tendon length were measured using ultrasound imaging. Images were recorded from the right lower extremity with the knee positioned at 0°, 15°, 30°, 45°, 60°, 75° and 90° of knee flexion with the leg supported by a treatment table to prevent quadriceps muscle activity. The patellar tendon was imaged using a panoramic feature. VL and VI fascicle length were measured from superficial to deep aponeurosis. The patellar tendon length was measured from the deepest attachment on the patella to the tibial tubercle. Image J (a Java based version of the public domain NIH Image Software) was used for all fascicle and tendon measurements. Femur length was measured on the skin for normalization of fascicle length; patella length and patellar tendon length were measured on the surface of the skin for comparison purposes.
RESULTS: Muscle fascicle length increased in both the VL and VI as the knee was flexed from 0-90° (p < 0.05). Fascicle length was not different across positions between male and female subjects. Data was separated into two age groups: 7-12 (pre-adolescent, n = 9) and 13-17 (adolescent, n = 9). VL and VI fascicle length were longer in adolescents than pre-adolescents (VL: 0° 8.9±2.2cm vs. 7.7±1.7cm, 45° 12.4±2.2 vs. 9.0±2.5, 90° 12.9±1.8 vs. 11.2±2.5; VI: 0° 9.3±1.8 vs. 8.3±2.2, 45° 11.3±2.5 vs. 9.9±1.7, 90° 12.8±2.0 vs. 10.2±1.3; p < 0.05). This effect was removed when data was normalized to femur length. The patellar tendon length remained unchanged across the 7 different knee angles (p > 0.05).
CONCLUSIONS: As expected, the relationship of fascicle length to patellar tendon length decreased as the knee was extended. The normative data for pre-adolescents is similar to other published reports.
CLINICAL RELEVANCE: The identification of the change in fascicle length and the lack of change in patellar tendon length with knee position provides normative data for the comparison between typically developing children and children with cerebral palsy. Children with cerebral palsy have a high prevalence of patella alta. If the VL and VI muscles adapt to the patella alta by shortening, then muscle function and therefore functional movement tasks will be effected. A decrease in fascicle length could lead to a decrease in muscle excursion and thereby limit the force generation through the extremes of motion.
IMPAIRED ACCURACY DURING GOAL-DIRECTED ANKLE MOVEMENTS IN CHILDREN IS EXPLAINED BY ALTERED ACTIVATIO HOF THE TIBIALIS ANTERIOR MUSCLE
E.J. Fox, M. Kwon, ChenY, M.A. Costanzo, H. Mora, B.A. Forster, E.A. Christou, Applied Physiology & Kinesiology, University of Florida, Gainesville, FL.
PURPOSE/HYPOTHESIS: Accuracy during goal-directed movements of the ankle is a critical component of daily activities and is a requisite for mobility and gait adaptations. Although it is well-known that children exhibit impaired movement control compared with adults, the ability of children to perform discrete goal-directed movements of the ankle is not well-understood. The purpose of this study was to compare movement accuracy and variability, as well as the activation of agonist and antagonist muscles in young adults and children during goal-directed movements of the ankle.
NUMBER OF SUBJECTS: Ten young adults (20.0 ± 0.9 yrs, 4 males) and 7 children (9.7 ± 0.8 yrs, 5 males) participated.
MATERIALS/METHODS: During a single test session, subjects attempted to accurately match the peak displacement of the foot to a spatiotemporal target by performing an ankle dorsiflexion movement. The targeted displacement (spatial) was 9° of ankle dorsiflexion and the targeted time (temporal) was 180 ms. Subjects received visual feedback for 5 s after each trial. Surface EMGs were recorded from the tibilis anterior (agonist) and soleus (antagonist) muscles. Endpoint accuracy was quantified as the overall error, which was calculated from the orthogonal relationship of the position and time errors (absolute deviation from the target). Endpoint variability was calculated as the coefficient of variation across trials for the peak displacement (spatial) and time to peak displacement (temporal).
RESULTS: Children exhibited greater overall error, as well as greater temporal error and positional variability compared with young adults (P < 0.05). The amplitude of tibialis anterior muscle was greater in children (P < 0.05), but the duration of activation and the time to peak activation was shorter. The amplitude of soleus activation also was greater in children. The greater overall error and temporal error in children was predicted by the duration of the agonist muscle (R2 = 0.72 and 0.62, respectively).
CONCLUSIONS: In conclusion, compared with young adults, children were less accurate during goal-directed movements of the ankle and differences were largely explained by altered activation of the agonist muscle.
CLINICAL RELEVANCE: The muscle activation differences may be due to immaturity of the cortico-motor systems in children. Understanding motor control in healthy children is critical so that findings may be applied to the study of children with neuromuscular impairments. [Supported by NIA R01 AG031769-01 to EA Christou]
CHILDREN WITH SEVERE INCOMPLETE SPINAL CORD INJURY EXHIBIT GREATER LOWER EXTREMITY MUSCLE ACTIVATION DURING LOCOMOTOR TASKS COMPARED WITH TESTS OF VOLUNTARY, ISOLATED JOINT MOVEMENTS
E.J. Fox, S. Trimble, A. Behrman, Physical Therapy, University of Florida, Gainesville, FL; N.J. Tester, Brain Rehabilitation Research Center, Malcom Randall VAMC, Gainesville, FL; S.A. Kautz, Health Sciences and Research, Medical University of S. Carolina and the Ralph H Johnson VAMC, Charleston, SC; D.R. Howland, Neuroscience, College of Medicine, McKnight Brain Institute, University of Florida and the Malcom Randall VAMC, Gainesville, FL.
PURPOSE/HYPOTHESIS: Following spinal cord injury (SCI), tests of voluntary, isolated joint movement and strength are used to assess descending supraspinal input to the lower extremities (LE); outcomes are used to predict walking function. Walking, however, also is controlled by spinal neural networks and sensory input. In adults with SCI, sensory input associated with walking can induce activation of muscles below the spinal cord lesion to a greater extent than during tests of voluntary joint movements. Ongoing work in our laboratory suggests that children with incomplete SCI (ISCI) also may be responsive to locomotor-specific input. Our purpose was to compare LE muscle activation during tests of voluntary, isolated joint movement with muscle activation during locomotor tasks. We hypothesized that children with ISCI would demonstrate greater muscle activation during locomotor tasks and that the greatest activation would occur during tasks requiring LE weight-bearing.
NUMBER OF SUBJECTS: Five children with severe, chronic, incomplete SCI participated (5 males; 9 ± 3 yrs of age).
MATERIALS/METHODS: Electromyograms (EMGs) were recorded in 6 LE muscles during attempted isolated joint movements (hip flexion, knee extension, ankle dorsiflexion) and locomotor tasks (supine reciprocal LE flexion/extension, pedaling, treadmill walking, overground walking (n = 2)). Mean amplitudes of EMGs were calculated and compared.
RESULTS: The mean amplitudes of EMGs recorded during the locomotor task were higher than amplitudes during attempted isolated joint movements (P < 0.05). During these tests, the children either were unable to move, or they performed synergistic, multi-joint movements. Across the locomotor tasks, the mean EMG amplitudes were higher during tasks requiring LE weight-bearing (P < 0.05). Amplitudes were highest during treadmill and overground walking.
CONCLUSIONS: Muscle activation during tests of voluntary, isolated joint movement in children with ISCI does not necessarily reflect the potential to activate LE muscles during upright, weight-bearing locomotor tasks.
CLINICAL RELEVANCE: Our findings indicate that tests of LE muscle activation in children with ISCI should include assessments of activation during locomotor tasks. Weight-bearing locomotor tasks provide sensory input that may enhance or modulate the activation of muscles below the spinal cord lesion. Interventions that aim to promote LE muscle activation after pediatric SCI should therefore, incorporate weight-bearing locomotor tasks.
THE EFFECT OF PLAYGROUND ENVIRONMENTS ON THE PHYSICAL ACTIVITY AND SUPPORT NEEDS OF AMBULATORY CHILDREN WITH CEREBRAL PALSY
S. Fuller, E. Pisani, Bradley University, Peoria, IL; B. Pratt, Rocky Mountain University of Health Professions, Provo, UT; N. Hartshorne, Delta College, Saginaw, MI; P. Mullens, University of Washington, Seattle, WA; M. Schilling, Central Michigan University, Mt Pleasant, MI.
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 research hypotheses were that walking activity and independent play would increase on an ADA-compliant playground.
NUMBER OF SUBJECTS: Five seven- to eight-year-old children (4 males, 1 female) 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 StepWatch 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 analysis (celeration lines and 1-tailed probability table (p < 0.5)) for single subject designs were used for data analysis. An effect size was calculated to quantify the magnitude of change between conditions.
RESULTS: Level of support for the hypotheses varied on the basis of the outcome measurement and participant. Four of the five participants showed an increase in the number of steps taken on an ADA-compliant playground. All participants exhibited increased medium and/or high activity levels during play on an ADA-compliant playground. Three of the five participants demonstrated greater independent play on an ADA-compliant playground.
CONCLUSIONS: 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 effect 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, especially those working in school settings, 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. Additionally, physical therapist should advocate for school and community playgrounds designed to meet the diverse recreation needs of children and adults in the community.
INTRA-LIMB COORDINATION CHANGES AFTER BOTULINUM IN TWO CHILDREN WITH SPASTIC DIPLEGIC CEREBRAL PALSY
D.J. Gosselin, B. Long, Doctor of Physical Therapy, Winston Salem State University, Winston-Salem, NC; B. Gyr, Orthopedics, Wake Forest Baptist Medical Center, Winston-Salem, NC; M. Tanaka, Engineering and Technology, Western Carolina University, Cullowhee, NC.
BACKGROUND/PURPOSE: Patients with cerebral palsy (CP) commonly have poor selective motor control (SMC) resulting in reduced coordination between joints during movement tasks. Reduced joint coordination, or the inability to dissociate adjacent joints, results in massed synergistic strategies of movement during walking. These less mature patterns are not efficient strategies for many phases of gait, therefore, improved coordination between joints may allow for favorable changes during the gait cycle. Chemodenervation using botulinum toxin A (BoTN-A) is a commonly used intervention to reduce muscle spasticity. By reducing the hyper-excitability of the stretch reflex, SMC may improve, allowing for better disassociation between lower extremity joints. The purpose of this case study is to examine the effects of intra-muscular BoTN-A injections on intra-limb coordination during walking in two patients with spastic diplegic CP.
CASE DESCRIPTION: Three-dimensional gait analysis was performed pre and five-weeks post intervention, on two 6-year-old patients with spastic diplegic CP. The intervention consisted of BoTN-A injections bilaterally in the medial hamstrings, rectus femoris, and gastrocnemii with post-injection casting. Continuous relative phase analysis, a measure of coordination, was found between the hip-knee and knee-ankle for each leg. Root mean square (rms) differences were calculated between patient data and a database of typical walkers. The rms difference between the patient and the typical population was also calculated following BoTN-A treatment. Both pre and post treatment data were compared to the typical data set using an analysis of the means and a visual analysis. Changes of one or more standard deviations in either direction were thought to represent true clinical differences rather than variability due to testing.
OUTCOMES: It is proposed that an increase in rms value, further away from the normative value, may demonstrate worsening intra-limb coordination while decreases in the rms value may demonstrate improved coordination. The average rms value for the database of typical children was 15.63 ± 3.76 for the hip-knee and 21.86 ± 7.14 for the knee-ankle. Both subjects demonstrated higher rms values compared to the norms at the hip-knee and knee-ankle pre and post BoTN-A for the left and right. After the intervention Subject 1 showed clinically significant increases in rms values bilaterally at the hip-knee and no significant differences for the knee-ankle coordination. Subject 2 demonstrated no clinically significant differences at the hip-knee, bilaterally, but did demonstrate clinically significant decreases bilaterally at the knee-ankle.
DISCUSSION: BoTN-A may have benefits for increasing the intra-limb coordination at the knee-ankle for some children with spastic diplegia. This case study demonstrates that there are likely factors, other than spasticity, that contribute to a child's response to BoTN-A and, that in some cases, intervention with BoTN-A may result in decreases in intra-limb coordination.
EFFECTS OF RESISTANCE TRAINING ON LOWER EXTREMITY MUSCLE STRENGTH IN ADOLESCENTS WHO ARE OBESE
A. Gross McMillan, Physical Therapy, East Carolina Univ, Greenville, NC; N. Hodges, Physical Therapy, VA Community Based Outpatient Clinic, Greenville, NC.
PURPOSE/HYPOTHESIS: Adolescents who are obese have been shown to have lower relative strength in hip abductors and ankle plantarflexors (PFs) compared to their healthy weight peers. These strength deficits are hypothesized to contribute to movement characteristics of adolescents who are obese during walking (i.e., collapse of the hip into adduction and knee into valgus during stance), which place them at risk for musculoskeletal dysfunction and pain. The purpose of this study was to determine the effect of a resistance training program on muscle strength in adolescents who were obese. We hypothesized that after an 8 week training program, adolescents who were obese would exhibit greater increases in lower extremity strength (compared to their obese peers who did not train), and would maintain this strength for at least 8 weeks following program termination.
NUMBER OF SUBJECTS: Twenty four subjects who were obese (Age = 14.7+/- 2.0 yrs [TRNG], 14.5+/- 1.7 yrs [CTRL]; BMI for age/gender >95%) completed the study.
MATERIALS/METHODS: Subjects were matched by gender, Tanner stage and age, then randomized to either a control (CTRL, n = 9) or training (TRNG, n = 15) group. The TRNG group performed resistance exercise (hip abductors, hip extensors, knee extensors, PFs) 3x/week for 8 weeks. Training protocol was based on recommendations from the American College of Sports Medicine and the American Academy of Pediatrics. Using the HUMAC Norm (Computer Sports Medicine, Stoughton MA), absolute strength of each muscle group was measured before training (PRE) and immediately after training (POST 1), and at 8 weeks after training (POST 2). Relative strength was calculated by dividing absolute strength by subject's mass. Paired t tests were used to determine changes in each group with training/over time.
RESULTS: Subjects in TRNG group significantly increased relative strength of hip abductors (p = 0.004 right, p = 0.05 left) and knee extensors (p = 0.02 right, p < 0.000 left); CTRL subjects significantly increased relative strength of right knee extensors (p = 0.04) and left hip extensor (p = 0.009). At POST 2, there were no significant differences in relative strength in either group compared to PRE values.
CONCLUSIONS: Obese adolescents significantly increased muscle strength in bilateral hip abductors and knee extensors with training but did not maintain changes 8 weeks after training. Hip extensor and PF muscle groups were difficult to measure and strengthen: subjects used compensatory strategies during both measurement and training sessions. The training protocol may have been too conservative: subjects typically rated difficulty at <4 (Somewhat Hard) on Borg's Rating of Perceived Exertion.
CLINICAL RELEVANCE: To increase and maintain strength in lower extremities, adolescents who are obese may benefit from resistance exercise over longer than 8 weeks, perhaps using more aggressive protocols than used in this study. Ongoing data analysis in this project will determine the effects of strength changes on walking characteristics, which is the overall reason for increasing muscle strength in this population.
EFFECTS OF INCREASED MUSCLE STRENGTH ON HIP AND KNEE MOTION DURING STANCE PHASE IN ADOLESCENTS WHO ARE OBESE
A. Gross McMillan, M.D. Rountree, M.B. Carlton, D. Williams, Physical Therapy, East Carolina Univ, Greenville, NC.
PURPOSE/HYPOTHESIS: Adolescents who are obese exhibit movement characteristics during walking (i.e., collapse of the hip into adduction during stance, and decreased knee flexion during loading response), which place them at risk for musculoskeletal dysfunction and pain. Strength deficits in lower extremity musculature have been hypothesized to contribute to these gait characteristics. Adolescents who were obese were able to increase their hip abductor and knee extensor muscle strength after 8 weeks of resistance training. The purpose of this study was to determine the effect of increased hip abductor and knee extensor strength on frontal plane hip excursion and sagittal plane knee excursion (respectively) during stance phase of walking in adolescents who were obese. We hypothesized that, compared to obese peers who did not train, adolescents who completed an 8 week resistance training program would exhibit 1) decreased frontal plane hip excursion and 2) increased sagittal plane knee excursion during stance phase of walking.
NUMBER OF SUBJECTS: Of the 32 subjects enrolled in this study, data from 18 subjects who were obese (age = 14.5+/- 1.5 yrs [TRNG], 14.4 +/- 1.7 yrs [CTRL]; BMI for age/gender > 95%) are included in this study.
MATERIALS/METHODS: Subjects were matched by gender, Tanner stage and age, then randomized to either a control (CTRL, n = 7) or training (TRNG, n = 11) group. The TRNG group performed resistance exercise (hip abductors, hip extensors, knee extensors, PFs) 3x/week for 8 weeks, with resultant significant increases in strength of hip abductors and knee extensors (data submitted separately). An 8 camera Qualisys Motion Analysis System (Qualisys International, Gothenbury, Sweden) was used to measure lower extremity angles during walking before (PRE) and after (POST 1) training. Data were normalized and averaged across trials for each subject. Frontal plane hip excursion was defined as the difference between maximum hip adduction and hip angle at initial contact (IC). Sagittal plane knee excursion was defined as the difference between maximum knee flexion and knee angle at IC. Paired t tests were used to determine changes in these variables in each group with training/over time.
RESULTS: No significant differences were found in hip and knee excursion variables in either group.
CONCLUSIONS: Though obese adolescents significantly increased strength in bilateral hip abductors and knee extensors with training, no differences were found in hip and knee excursion during stance. Greater strength changes, and perhaps specific gait training, may be needed to alter gait pattern, given the stable nature of human gait.
CLINICAL RELEVANCE: Increases in hip abductor and knee extensor strength in adolescents who were obese did not lead to changes in hip and knee excursions during stance phase of walking. Greater increases in strength of these and other muscles and/or gait training to encourage use of this increased strength might alter gait patterns in these adolescents, thus decreasing their risk for musculoskeletal dysfunction.
THE USE OF STOCHASTIC NOISE DURING INTERVENTION TO IMPROVE SITTING POSTURAL CONTROL IN CHILDREN WITH CEREBRAL PALSY
R. Harbourne, S.L. Willett, University of Nebraska Medical Center, Omaha, NE; B. Ryalls, N. Stergiou, University of Nebraska at Omaha, Omaha, NE.
PURPOSE/HYPOTHESIS: The purpose of this study was to compare two interventions for advancing postural control in children with severe or moderate cerebral palsy (CP). Children were randomized to two groups, both of which received a perceptual motor intervention directed to improving sitting postural control. In addition, one group received additional stochastic noise at the sitting surface. We further hypothesized that these improvements in postural control would coincide with changes in play, which would serve as an indicator of cognitive change.
NUMBER OF SUBJECTS: Thirty-one children with severe (N = 16) or moderate (N = 15) CP between the ages of 1-6 years (Age: 2.3 + 1.5 years; range 1-6 years) participated in this study.
MATERIALS/METHODS: Children entered the study when they were able to sit propping on their arms for support for at least 10 seconds. Each child participated in two perceptual-motor intervention sessions, one hour each session, per week, for 12 weeks.
Gross motor function was measured using the Gross Motor Function Measure-88 (GMFM), sitting dimension. Play was assessed using a modified structured play assessment called the Play Assessment of Children with Motor Impairments (PACMI). The GMFM sitting dimension and play scores were the outcome variables of interest.
RESULTS: There were no significant differences between the groups with stochastic noise and without the stochastic noise for either the GMFM sitting scores or the play measure. However, both groups made significant changes from pre to post testing in the GMFM sitting section (P = 0.000), and the play scale (P = 0.002). GMFM sitting scores increased an average of 10 points (SD = 6).
CONCLUSIONS: Although stochastic noise has been shown to improve standing postural control for adults with neurologic deficits and balance problems, children with severe or moderate CP did not appear to be differentially responsive to it to improve sitting postural control. However, children with CP did make significant changes in sitting function with a twice weekly perceptual motor intervention provided over 3 months. In conjunction with the sitting progression, play skills also increased significantly, leading to the conclusion that greater sitting independence can affect functional play.
CLINICAL RELEVANCE: This study provides support for focused intervention on sitting postural control in children with severe CP. In addition to improving motor skill, improvement in sitting can affect object interaction and learning via improvement in play skills which coincide with better sitting control.
INDICATORS OF CLINICALLY RELEVANT HYPOTONIA IN CHILDREN
A. Holmstrom, M.T. Murray, A.J. Szmiot, J.J. McElroy, 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. The purpose of this study was to determine indicators used by pediatric PTs to identify clinically relevant hypotonia in children.
NUMBER OF SUBJECTS: 140 pediatric physical therapists
MATERIALS/METHODS: Data were collected using an anonymous survey. The following questions were posed: 1. What are the most common clinical and functional characteristics that you look for when evaluating a child for hypotonia?, 2. Do you use a single indicator or multiple indicators to determine if a child has hypotonia? Requests for participants were disseminated by word-of mouth and through the Pediatric Section eblast, American Physical Therapy Association. Survey responses were submitted via email and an online tool. Responses were grouped by the investigators into 16 categories according to body system and functional similarities. Categories were then ordered by response frequency.
RESULTS: Respondents had a mean of 19 years of pediatric experience (range 1-45). They each submitted multiple indicators (mean 7, range 2-20). The most common category of indicators was excessive range of motion (81%). Other frequently submitted indicators were in the categories of “decreased anti-gravity movements” (73%), “postural mal-alignment” (71%), and “quality of movement” (53%). All other indicators were submitted by less than 50% of the respondents. Almost all respondents stated they used multiple indicators to determine if a child had hypotonia. A single indicator of “decreased resistance to passive movement and tone” was used by 3 therapists.
CONCLUSIONS: Although hypotonia is defined as the presence of low muscle tone, a measurement of muscle tone was not listed as the sole indicator of clinically relevant hypotonia by a most of the survey respondents. Instead, the most commonly identified indicators used were based on body system impairments such as joint range, movement quality, and movement quantity as well as functional indicators including sitting and standing posture. Indicators used by clinicians differentiate between hypotonia that impacts developmental and functional skills versus levels of hypotonia compatible with typical development. Additional research is needed to refine indicator categories of clinically relevant hypotonia in children.
CLINICAL RELEVANCE: Identification and categorization of hypotonia indicators provides a basis for development of a clinical measurement tool to facilitate early referral and therapeutic intervention of children with clinically relevant hypotonia. Such a measurement tool will assist medical professional in consistency of identification and treatment planning to address functional limitations associated with clinically relevant hypotonia.
IMMEDIATE RESPONSE TO SENSORIMOTOR TRAINING TO AFFECT BALANCE, ENGAGEMENT, AND LEARNING FOR CHILDREN WITH FETAL ALCOHOL SPECTRUM DISORDERS
L. Hsu, R. Price, B. Dellon, D. Kartin, T. Jirikowic, S.W. McCoy, Rehabilitation Medicine, University of Washington, Seattle, WA.
PURPOSE/HYPOTHESIS: Sensorimotor Training to Affect Balance, Engagement and Learning (STABEL) is a novel virtual reality system with a compliant standing surface designed to train the ability to use specific sensory information during balance. The visual display and support surface are controlled to distort sensory input during standing balance. Within this study we examined the effects of STABEL to improve use of vestibular information during standing balance in children with and without Fetal Alcohol Spectrum Disorder (FASD) by comparing the results of a STABEL training session to a control session.
NUMBER OF SUBJECTS: A sample of convenience of 4 children with FASD and 4 children without FASD, age 8-16 years, participated.
MATERIALS/METHODS: Children visited our laboratory twice. In the first visit, they were tested pre and post STABEL on the Multi-Modal Balance Entrainment and Response (MuMBER) system. In the MuMBER, the ability to weight sensory input during standing balance is measured by determining the amplitude with which children match their body sway frequency to small frequency visual, tactile, and support surface oscillations. The frequency of the three sensory stimuli was varied for six sensory conditions. A Qualysis motion system captured body sway movements by tracking markers on children's head, neck, sacrum and heels. In the STABEL, children wore virtual reality goggles and moved their bodies to drive a virtual airplane. The visual background and compliance of the surface were manipulated. In the second visit, instead of the STABEL, children did a 30-minute walk between pre and post MuMBER testing. Outcome measurements were velocity and area of postural sway and fractions of the magnitude of body sway oscillations at the frequency of visual, tactile and support surface stimuli over the sum of the peak frequencies of body sway movement. The fractions represent children's weighting of the sensory stimuli. Change scores for pre to post MuMBER variables during STABEL and control sessions were calculated. Mixed repeated measure ANOVAs were used to compare MuMBER change scores between STABEL and control sessions and within all different sensory conditions.
RESULTS: There were no statistically significant differences on the MuMBER change scores between STABEL and control sessions. However, examination of the sensory weighting patterns within different sensory conditions revealed differences between STABEL and control sessions.
CONCLUSIONS: The results support that STABEL may change the patterns of sensory weighting in children. However, a higher dosage of practice may be needed to significantly improve sensory use during postural control.
CLINICAL RELEVANCE: The STABEL intervention was found to be acceptable and fun by children and appears to affect the sensory integration during standing postural control. Longer exposure to the STABEL and the long-term effect of this type of practice need to be explored.
IMPACT OF SOCIAL FACTORS ON MEDICAL AND FUNCTIONAL OUTCOMES AMONG CHILDREN WITH CEREBRAL PALSY
D.S. Hurley, Department of Physical Therapy & Human Movement Sciences, Northwestern University, Chicago, IL; S.C. Bauer, Lurie Children's Hospital, Chicago, IL; D. Gaebler-Spira, The Rehabilitation Institute of Chicago, Chicago, IL; M.E. Msall, Department of Developmental and Behavioral Pediatrics, University of Chicago, Chicago, IL.
PURPOSE/HYPOTHESIS: Compare medical and functional outcomes of school age children (3-21) from the Cerebral Palsy Research Registry (CPRR) by social economic status (SES).
NUMBER OF SUBJECTS: 501 children enrolled in the CPRR were recruited; 299 had a complete data sets that could be used for analysis. Social Disadvantaged group- residence in a city whose mean household income was <$46,000 (200% of federal poverty level). Social Advantaged group-residence in a city whose mean household income was >$46,000.
MATERIALS/METHODS: Three ordinal logistic regression models were analyzed using the STATA program: Model 1 with SES as the outcome variable; Model 2 with gestational age as the outcome variable; Model 3 with maternal education as the outcome variable. Each model used the same 10-predictor variables (seizures, vision, hearing, feeding, respiration, expressive language, receptive language, behavior, GMFCS, MACS). A t-test comparing two sample means was conducted.
RESULTS: Respiratory and auditory (P-values 0.05, 0.02) co-morbidities and limitations in manual abilities, receptive language and behavior (P-values 0.03, 0.04, 0.03) were significantly associated with SES. Respiratory status (P-value 0.04) was significantly associated with gestational age. GMFCS (P-value 0.01) was significantly associated with maternal education.
CONCLUSIONS: High rates of medical, developmental, and functional co-morbidities occur in child with cerebral palsy, regardless of their socioeconomic status. Future studies are needed to determine how associated conditions within the GMFCS and MACS levels impact on participation and self-efficacy.
CLINICAL RELEVANCE: Understanding the relationship between medical and functional outcomes with SES can promote changes in social policy and create targeted interventions.
THE USE OF VIRTUAL REALITY AS AN ANALGESIC DURING PHYSICAL THERAPY TREATMENT OF CHILDREN WITH BURN INJURIES
J. Keller, Temple University, Palmyra, NJ.
PURPOSE: For children with burn injuries, does the addition of virtual reality to traditional analgesic methods during physical therapy treatment decrease reported pain?
DESCRIPTION: Number of subjects: 5 studies.
MATERIALS/METHODS: CINAHL, PEDro, and PubMed were searched using the terms “virtual reality” and “burns.” Limits set included English language, human subjects, randomized control trial (RCT), and publication date between 2001-2011. Inclusion criteria were children (<19 y.o.), patients receiving supervised ROM and/or dressing change, burns of any degree and cause, and pain-related outcome measures. Validity of each study was done utilizing the PEDro scale. Pain was the only outcome utilized.
RESULTS: Five studies were included: four level I, and one level IIa. PEDro scores were distributed as follows: 5/10 (n = 1), 6/10 (n = 1), 7/10 (n = 3). Significant decreases in reported pain with the use of virtual reality were found in two of the five studies. A third found a significant decrease only during long dressing times. Two studies found decreases in pain with the use of virtual reality, but state that there may be a difference in pain when virtual reality is utilized at different times of treatment (i.e. prior to treatment, during treatment) and with different types of devices (i.e. hand-held, full-immersion).
SUMMARY OF USE: The addition of virtual reality to traditional analgesic methods during PT treatment leads to clinically significant decreases in reported pain in pediatric burn patients. Length of time of treatment, sequence in which virtual reality is integrated, and the type of virtual reality may impact reported pain level.
IMPORTANCE TO MEMBERS: The field may benefit from future research determining what factors may affect the efficacy of virtual reality for treatment of this population, especially regarding the length of time of treatment, the sequence of delivery of virtual reality, and the type of virtual reality.
THE IMPACT OF A VISUAL TARGET ON CHILDREN'S LIMITS OF STABILITY IN SITTING: A PILOT STUDY
L.K. Kenyon, S. Brooks, K. Rustem, A. Semelbauer, B. Baker, Department of Physical Therapy, Grand Valley State University, Grand Rapids, MI; B.M. Ashby, School of Engineering, Grand Valley State University, Grand Rapids, MI.
PURPOSE/HYPOTHESIS: Seated postural control is a critical component of independence for children with developmental delays and conditions. Limited research exists related to the specific procedures that must be followed to accurately assess seated postural control in children. The purpose of this pilot study was to compare children's limits of stability in sitting with and without use of a visual target.
NUMBER OF SUBJECTS: Eight subjects between the ages of 60-78 months who did not have a known neurologic or developmental diagnosis were included in the study. Subjects were screened using the DENVER II to ensure their ability to complete age appropriate activities.
MATERIALS/METHODS: This pilot study used a cross-sectional, exploratory design. The “Limits of Stability” assessment mode of the NeuroCom Balance Master was adapted to collect data in sitting in 4 directions of lean (forward, backward, left lateral, right lateral) under 2 different test conditions: with and without a visual target. Feedback from the NeuroCom computer screen was utilized as the visual target. A standard NeuroCom box was positioned within the pre-designated placement lines on the Activity Platform of the NeuroCom. Subjects sat in a short sitting position with feet off the ground. Each subject completed 5 completely randomized trials under each test condition. Statistical Analysis: Results were analyzed using paired t-tests (p < 0.05) for inter-subject data comparison and Wilcoxin Signed Ranks tests (p < 0.05) for intra-subject data comparison.
RESULTS: Although subject performance was found to be variable among trials, inter-subject analysis indicated a significant difference in scores between the two test conditions in the right lateral and backward directions indicating greater movement with the use of a visual target. Intra-subject analysis also demonstrated a statistically significant difference between the two test conditions for several individual subjects in the right lateral and backward directions with greater movement when utilizing a visual target.
CONCLUSIONS: Although the findings demonstrate that the use of visual targets may be effective in encouraging maximum seated limited performance of young children, performance during limits of stability testing in these subjects was variable. Inter-subject differences, environmental conditions, and the need to adapt the Balance Master “Limits of Stability” program may have contributed to the findings. Given that the “Limits of Stability” program of the Balance Master was developed to assess limits of stability in standing, the authors feel that a customized program designed to assess limits of stability in sitting may provide more accurate results and allow for more definitive development of optimal assessment protocols for use in children.
CLINICAL RELEVANCE: These findings will assist therapists in developing protocols for optimal testing of children's limits of stability in sitting.
PERSPECTIVES OF ACADEMIC FACULTY AND CLINICAL INSTRUCTORS ON ENTRY-LEVEL DPT PREPARARATION FOR PEDIATRIC PHYSICAL THERAPIST PRACTICE
L.K. Kenyon, Department of Physical Therapy, Grand Valley State University, Grand Rapids, MI; R.L. Dole, Institute for Physical Therapy Education, Widener University, Chester, PA; S.P. Kelly, College of Health Sciences, University of Indianapolis, Indianapolis, IN.
PURPOSE/HYPOTHESIS: The purpose of this study was to capture the perspectives of pediatric academic faculty in Doctor of Physical Therapy (DPT) programs and pediatric clinicians who have served as clinical instructors (CIs) for DPT students during pediatric clinical education experiences. The aim of the study was to develop a consensus on the knowledge, skills, and abilities that are expected of DPT students at various points in the curriculum: prior to starting a fulltime pediatric clinical education experience, after completing a fulltime pediatric clinical education experience, and at the end of a DPT program regardless of whether a pediatric clinical education experience was completed.
NUMBER OF SUBJECTS: Twelve academic faculty who provided pediatric instruction in an accredited DPT program and 16 (CIs) who had supervised DPT students in a pediatric clinical setting completed the study.
MATERIALS/METHODS: The study was conducted using a Delphi method. Three rounds of a Web-based survey were used to achieve consensus. The first round of the survey consisted of open-ended items asking participants to identify elements felt to be essential for DPT students to demonstrate related to pediatric physical therapy at the identified points in the curriculum. In the second round, participants indicated their level of agreement with each element identified in the first round of the survey. Elements that achieved consensus were included in the third and final round of the survey in which participants were asked to rate the level of proficiency (Beginning, Developing, Intermediate, or Advanced Proficiency) that DPT students should demonstrate related to pediatrics at each of the identified points in the curriculum. Consensus in both the second and third rounds was defined as agreement among ≥70% of respondents in one of the groups (academics or CIs) or in both groups combined.
RESULTS: The consensus revealed participants perspectives pertaining to the depth and breadth of pediatric content in entry-level curricula and outlined expectations regarding students' abilities to execute elements of the patient/client management model within pediatric physical therapist practice. Differences were noted in the participants' expectations related to pediatrics at each of the identified points in the curriculum. Consensus was most often achieved in areas related to professional behaviors and least often with psychomotor skills.
CONCLUSIONS: Despite being able to identify that there would be differences in the essential knowledge, skills, and abilities before and after a clinical experience in pediatrics, participants appeared to have expectations for proficiency in pediatric physical therapist practice for all DPT graduates regardless of whether a pediatric clinical was completed.
CLINICAL RELEVANCE: The results of this study may assist physical therapist faculty in preparing students for entry-level practice in pediatrics.
DEVELOPMENT OF ITEMS THAT ASSESS PHYSICAL FUNCTION IN CHILDREN WHO ARE WHEELCHAIR USERS
C.I. Kerfeld, B. Dudgeon, D. Kartin, Department of Rehabilitation Medicine, University of Washington, Seattle, WA; J. Engel, Department of Occupational Science & Technology, University of Wisconsin-Milwaukee, Milwaukee, WI.
PURPOSE/HYPOTHESIS: Outcome measures are currently used by pediatric physical therapists to assess physical function related to mobility (PFM) of children, but few are child-report or have been tested to ensure they are appropriate for children who are wheelchair (WC) users. The purpose of this study was to assess the content, format, and comprehension of the Patient Reported Outcomes Measurement Information System (PROMIS) pediatric PFM items and responses for children who are WC users.
NUMBER OF SUBJECTS: A convenience sample of 14 children, ages 8-12, participated in cognitive interviews (CI). Each child used a WC for their primary means of mobility at least three consecutive months, had one of the following parent-reported diagnoses: cerebral palsy, spinal cord injury, spina bifida, congenital muscular dystrophy, spinal muscular atrophy, or Ollier disease and was able to read English at the 2nd grade level.
MATERIALS/METHODS: The children responded to the 26 PROMIS pediatric PFM items in paper and pencil format followed by a CI protocol of questions and spontaneous probes to encourage them to verbalize their thought processes when answering the items. The questions and probes addressed four main topics: item clarity, timeframe, item content, and response format. The Questionnaire Appraisal System (QAS) was used to code all of the CI.
RESULTS: Qualitative systematic analysis identified themes surrounding the clarity, assumptions, and sensitivity of the items. The children requested items be more specific and include more options for reporting adaptive ways of performing and participating. How they would answer the items depended on the situation and the environmental supports and constraints they may have experienced. Issues of wheelchair transfers and handling of barriers such as stairs needed to be addressed in different ways. The children rejected words such as “walk” and qualified their answers by saying “I can't walk, but in my WC, I can go or wheel”.
CONCLUSIONS: The CI provided valuable information about the appropriateness of the PROMIS pediatric PFM items for children who are WC users. As pediatric physical therapists develop and use child-reported outcome measures, they should explore what is important for children who are WC users regarding their views on physical functioning, the influences of the environment, and variability in the use of devices to assist with functional mobility.
CLINICAL RELEVANCE: This study supports future research and development of pediatric PFM items that may include item calibration, development of short forms, and use of item response theory to either develop an algorithm for item selection in computer adaptive testing or a separate item bank for children who are WC users. Improved child-reported outcome measures of PFM for children who are WC users may have direct clinical relevance in examining the effectiveness of pediatric rehabilitation interventions.
THE EFFECT OF BACKPACK WEIGHT ON WALKING ENDURANCE AND PERCEIVED EXERCTION IN CHILDREN FOLLOWING A 6 MINUTE WALK
F. Kistner, School of Physical Therapy, Massachusetts College of Pharmacy and Health Sciences, Worcester, MA; I. Fiebert, K.E. Roach, J.G. Moore, Department of Physical Therapy, University of Miami, Coral Gables, FL.
PURPOSE/HYPOTHESIS: Backpacks are associated with kinematic changes, as well as complaints of back and neck pain. There is concern about the negative effects of backpack use on children, as a history of backpain in childhood is the strongest predictor of having musculoskeletal discomfort and back pain as an adult. This study was designed to examine the effects of loaded backpacks, weighing up to 20% of a child's body weight(BW) on the walking endurance, perceived exertion, and subjective complaints of elementary schoolchildren after a 6 Minute Walk Test (6MWT).
NUMBER OF SUBJECTS: A convenience sample of 62 healthy primary schoolchildren, 41 female, 21 male, ages 8 through 11 (mean age = 9.77 ± 1.07 years) were recruited from local elementary schools and local youth groups.
MATERIAL/METHODS: After obtaining informed consent, the subjects walked for 6 minutes at a free walking speed unloaded and then while carrying a backpack load containing either 10%, 15%, or 20% BW of each respective subject. Subjective complaints were assessed using an OMNI scale of perceived exertion and a VAS pain scale after the 6MWT. Walking endurance was measured using the 6MWT distances. The backpack loads were randomly assigned over three data collection sessions so that each subject participated at all weight conditions.
RESULTS: A repeated measures ANOVA was used to examine differences in OMNI perceived exertion scores, 6MWT distance, and VAS pain scores among the weights after walking 6 minutes, followed by pairwise comparisons to examine the effects at each weight. Each subject participated in all conditions over three consecutive weeks of data collection. Data analysis revealed statistically significant differences as the backpack loads increased from 10%BW to 15%BW to 20%BW. Subjects demonstrated increased complaints of pain and perceived exertion after the 6MWT, as well as decreased functional endurance as the backpack loads increased. The mean 6MWT distance decreased from 451.13 feet while unloaded to 410.63 feet while carrying the 20%BW backpack, a decrease in walking endurance of 8.97%. The mean OMNI score of perceived exertion increased from 1.3 (out of 10) after an unloaded 6MWT to 3.5 after a 6MWT while carrying the 20%BW backpack.
CONCLUSIONS: Loaded backpacks contribute to increased subjective complaints and decreased functional endurance in children. The findings of this study indicate that typical backpack loads containing 10%BW or more put children at increased risk for discomfort and pain, the latter of which is a strong predictor for backpain in adulthood.
CLINICAL RELEVANCE: The lack of federal guidelines for weights carried by children mean that children are permitted to carry backpacks everyday at loads that have been linked to complaints of spinal pain in youth and adults. Schools and physical therapists should take seriously the complaints of pain by children due to backpack usage. This study was supported in part by the iTrace Foundation, Inc.
SIX-MINUTE WALK DISTANCE (6MWD) IN CHILDREN WITH JUVENILE IDIOPATHIC ARTHRITIS (JIA) AND HEALTHY CHILDREN LIVING IN THE UNITED STATES
S.E. Klepper, K.L. Bigarel, Rehab Medicine, Columbia University, New York, NY.
PURPOSE/HYPOTHESIS: JIA results in joint inflammation, pain, muscle weakness, and limited mobility. Research documents impaired aerobic capacity in children with JIA even during inactive disease. While actual or predicted measures of peak oxygen uptake are the gold standard for aerobic capacity, these methods are often not possible in the clinic. The six-minute walk test (6MWT) is increasingly used to measure functional exercise capacity in children with chronic diseases. Researchers in the Netherlands found the 6MWT measures submaximal aerobic capacity at a high level (80%) of intensity in children with JIA and report lower values in these children than in healthy controls. However, a recent study reporting differences in 6MWD in healthy children living in different countries suggest the need to compare children with JIA to controls living in the same country. The purposes of this study were to compare 6MWD in children with JIA and healthy children living in the US and to examine relationships between 6MWD and personal attributes in children with JIA.
NUMBER OF SUBJECTS: Children with JIA: 26; Healthy Children: 100
MATERIALS/METHODS: Children with JIA, age 5 to 12 years were recruited through area pediatric rheumatology clinics. Healthy children were recruited through local schools and friends of children with JIA. Height in meters (m) and weight in kilograms (kg) were measured and recorded to the nearest two decimal points. Resting and post-walk heart rate (HR) were recorded in children with JIA. The 6MWT was administered following the American Thoracic Society guidelines. Total distance (m) covered in six minutes was recorded. Participants completed two 6MWTs with a 15-minute rest between tests; mean score of the two tests was used for analysis. Descriptive statistics and independent Mann-Whitney U tests were used to analyze differences in 6MWD between groups. Spearman correlations were used to examine the relationship between walk distance and other variables in children with JIA.
RESULTS: No significant differences were found between the groups on any variable. Mean 6MWD (m) was 524.34 (69.54) for children with JIA and 518.5 (72.56) for healthy controls. There were no significant differences between the groups on age, height, or weight. Only pre-post walk HR change was significantly associated with 6MWD in children with JIA.
CONCLUSIONS: Our results indicated there was no significant differences in the 6MWD between this sample of children with JIA and healthy controls living in the same geographical area. However, because of the small sample size this study should be replicated in larger groups of children with JIA as well as older adolescents.
CLINICAL RELEVANCE: The is the first study to compare 6MWD in children with JIA living in the US to a comparable control group of healthy children. The findings provide useful information to clinicians working with this clinical population. Pre-to-post heart rate change as well as changes in 6MWD over time may be useful indicators of functional walking capacity in children with JIA.
A COMPARISON OF GAIT AND LOWER EXTREMITY MUSCLE ACTIVITY WITH SOLID, DYNAMIC, AND NO ANKLE-FOOT ORTHOSES IN CHILDREN WITHOUT IMPAIRMENTS: A PRELIMINARY STUDY
S. Laudicina, K. Coleman, C. LaPorte, B. LeVeau, Physical Therapy, Alabama State University, Montgomery, AL.
PURPOSE/HYPOTHESIS: Ankle-foot orthoses (AFOs) are commonly used to improve functional mobility in children with various neuromuscular or musculoskeletal impairments. The purpose of this study was to compare the lower extremity muscle activity and gait characteristics of children without musculoskeletal or neuromuscular impairments while wearing no AFO, Kiddie Gait AFO, and prefabricated off the shelf AFO.
NUMBER OF SUBJECTS: Eleven children (6 males and 5 females mean age of 5.55 ± 1.578 years) without musculoskeletal or neuromuscular impairments participated in this study.
MATERIALS/METHODS: Subjects ambulated 16 feet on the GAITRite electronic walkway to record gait characteristics Electromyographic (EMG) data was simultaneously collected via Noraxon Telemyo 2400 on the tibialis anterior, medial gastrocnemius, biceps femoris, and vastus medialis to determine peak muscle activity. Subjects performed three gait trials: unmodified prefabricated AFO, unmodified Kiddie Gait, and no AFO. An analysis of variance with post hoc Newman-Keuls Multiple Comparison Test was used to compare the Kiddie Gait, the prefabricated AFO, and the Norm (no AFO). T-tests compared the gait characteristics of the AFO side to the non-AFO side for the separate conditions of wearing the Kiddie Gait and the prefabricated AFO.
RESULTS: Areas of significant difference for gait included: stride length (mean = 109.2 ±14.22 cm) (p = 0.0413) and heel off/on percent (mean 18.94 ± 6.642%) (p = 0.0399) when comparing Kiddie Gait side to the non AFO side; and swing time (mean = 0.3739 ± 0.04443 sec) (p = 0.0424), swing percent of cycle (mean = 40.11±1.658%) (p = 0.0436), and stance percent of cycle (mean = 59.88±1.647%) (p = 0.0392) when comparing the Kiddie Gait, the prefabricated AFO, and no AFO. A significant difference was found in muscle activity for the tibialis anterior (mean = 195.1±54.31) (p = 0.0194) when comparing the Kiddie Gait, the prefabricated AFO, and no AFO.
CONCLUSIONS: In children without impairments, the use of the Kiddie gait increased muscle activity for the tibialis anterior. The Kiddie Gait also increased percent of time in swing phase, decreased percent of time in stance phase, and increased stride length.
CLINICAL RELEVANCE: These results indicate that the Kiddie Gait may increase propulsion during ambulation. Although these results cannot be applied to children with impairments, the study will provide baseline data for future research.
ENERGY COSTS OF LOWER LEG CASTING IN CHILDREN
C. LaPorte, D. Johnson, K. Koen, L.S. Hardy, G. Rodgers, Physical Therapy, Alabama State University, Montgomery, AL.
PURPOSE/HYPOTHESIS: The purpose of this study was to investigate the effects of lower leg casting on energy cost in healthy children by comparing the Physiological Cost Index (PCI), predicted VO2max, and gait speed values with and without the lower leg casting applied to the dominant lower extremity. The authors hypothesized the Physiological Cost Index would increase, and predicted VO2max and gait speed would decrease following a Quarter-Mile Walk (QMW) with lower leg casting.
NUMBER OF SUBJECTS: Eleven participants (mean age 8 years, age range 4-13 years) completed this study
MATERIALS/METHODS: Six of the 11 subjects completed the QMW without lower leg casting prior to completing the QMW with the lower leg casting. Five of the 11 subjects completed the QMW with lower leg casting prior to completing the QMW without lower leg casting to prevent a learning effect. Subjects were casted with the dominant foot at 90° using 3M Soft Cast material. A Hely & Weber cast shoe was applied to perform the QMW with lower leg casting. Resting heart rate, walking heart rate, and time to complete the QMW were taken and formulas for PCI, predicted VO2max and gait speed were used to determine results.
RESULTS: Physiological Cost Index increased from 0.2809 beats/meter when walking without the lower leg casting to 0.3155 beats/meter when walking with lower casting applied; however, the difference was not significant (p = 0.6341). Predicted VO2max decreased from 40.58 ml/kg/min to 32.68 ml/kg/min without and with lower leg casting applied respectively (p = 0.1714). Gait speed decreased without lower leg casting applied from 1.303 m/s to 1.159 m/s with lower leg casting applied (p = 0.1036); however, there was no significant difference in either predicted VO2max or gait speed values.
CONCLUSIONS: Although there was not a statistically significant difference in the findings, from an energy cost perspective there is a practical or clinical significance to the findings. The increase in PCI and decrease in predicted VO2max and gait speed indicate an increased energy cost when walking with lower leg casting.
CLINICAL RELEVANCE: Children are often placed in lower leg casts due to physical impairments including fractures and serial casting for spasticity management. Therefore it is important for the clinician to understand that increased energy is required and endurance and aerobic capacity should be addressed and monitored in the course of treatment.
IDIOPATHIC INFANTILE SCOLIOSIS (IIS) : RETROSPECTIVE ANALYSIS OF CONSEQUENCES TO MOTOR DEVELOPMENT
R.K. Lelonek, M. Taylor, Physical Therapy, Gannon University, Erie, PA.
PURPOSE: To report the consequences of serial body casting on motor development in a child diagnosed with idiopathic infantile scoliosis.
DESCRIPTION: (Descriptive) Serial casting is currently the most clinically accepted intervention in the management of infantile scoliosis yet; little to no evidence exists on its impact to motor development. Motor development of a child with infantile scoliosis who was serial casted for twelve consecutive months was compared and contrasted to typical motor development. Using the Alberta Infant Motor Scale (AIMS) as a reference, adaptive strategies were noted and diagramed suggesting functional alternatives for participation.
SETTING: Early intervention (EI). Participants: Child with IIS (n = 1) participated in this study.
MAIN OUTCOME MEASURES: Developmental milestones and alternative movement strategies using the Alberta Infant Motor Scale.
SUMMARY OF USE: Results: An eleven month old child was referred to EI because of significant gross motor delay (below the 5th percentile on the AIMS compared to age-matched peers). Clinical examination further revealed notable thoracic convexity which was confirmed radiographically. (Cobb angle was equal to 330 with rib vertebral angle equal to 240.) ISS was managed with continual serial casting for the next twelve months. PT was initiated concurrently to improve gross motor independence and outcome was charted monthly utilizing the AIMS as a reference. Gross motor progress ensued but strategies varied to what might be typically expected given significant restrictions in spinal mobility secondary to spinal casts. Some alternative strategies included: play in heel sit rather than ring sit, preference for unilateral manipulation of toys in quadruped rather than transition to sit for bilateral manipulation, and transition from standing to kneeling rather than standing to sitting. Utilizing the AIMS, attainment of typical motor skills was documented. Alternative functional strategies that were consistently observed were diagramed and integrated onto the AIMS score sheet to best depict this child's capabilities and progress along the prone, sitting, and standing continuums.
IMPORTANCE TO MEMBERS:
CONCLUSION: There are numerous paths to independent function and participation. From a systems perspective this data clearly illustrates variability in gross motor development in response to the management of impairments in body function and structure. Further as the concept of typical development is broadened, it is imperative to document these variable patterns. The AIMS, because of its construction, may be the optimal tool of choice, readily allowing for meaningful visual comparative analysis across four developmental positions.
SENSORY PROCESSING DYSFUNCTION IN CHILDREN WITH IDIOPATHIC TOE-WALKING
A.Y. Len, Mosaic Tree Company, Brooklyn, NY; S. Rao, Physical Therapy, New York University, NYC, NY.
BACKGROUND/PURPOSE: Children with Idipathic Toe-walking (ITW) are often referred for Physical Therapy (PT). While most clinicians focus on musculoskeletal impairments in this population, very limited evidence is available assessing Sensory Processing Dysfunction (SPD) relevant to gait and PT intervention. In this prospective case series, we assessed SPD in children with ITW.
CASE DESCRIPTION: Five children with a primary complaint of ITW no neurologic or developmental problems (mean age: 4.6 years, 2 female) were included in the study. Assessment was performed by a Licensed, SIPT certified PT in an outpatient pediatric practice. Physical exam included measurements of peak dorsiflexion (DF) with knee flexed (KF) and extended (KE), presence of Babinski sign documented. Caregiver completed three questionnaires: Intake (Iq), Sensory Profile (SP), Sensory Processing Measure (SPM). Children were videotaped while navigating an obstacle course (walk on flat surface, carpet, balance beam, jump off 4” step, step over hurdle, stand to squat transition). Standardized assessment tools included: SIPT (to assess sensory processing and praxis abilities), Peabody DMS-2 (to assess gross motor (GM) skills), Bruininks OT-2 (strength and agility section). All procedures were IRB approved.
OUTCOMES: Mean peak DF with KF was 17 degrees, KE was 4 degrees. A positive Babinski sign present in 0/5 subjects. As per Iq falling and tight calf muscles reported in 5/5 subjects. On SP: 5/5 subjects presented with at least probable difference in processing sensory input. On SPM: 4/5 subjects had sensory processing difficulties in at least one area, Vision and Touch in 3/5 subjects, Balance in 2/5 subjects (T60-69). Obstacle course navigation: quantitative assessments using digital video found that subjects toe-walked during 28.3% of all steps; qualitative assessments indicated the presence of gait deviations, such as loss of alternating reciprocal pattern, excessive use arms or trunk lean for balance. SIPT results demonstrated that 5/5 children have SPD (scores < −1.0SD) with Tactile Processing most impacted, but with typical Proprioception abilities. 5/5 subjects had delay in Postural Praxis, and in 4/5 subjects Standing and Walking Balance was affected. On PDMS-2, 5/5 children presented with GM delay (mean = 2nd percentile). On BOT-2, 5/5 subjects demonstrated average Strength level; 3/5 demonstrated below average performance in Agility skills.
DISCUSSION: This is the first study to use standardized assessment tools to examine SPD in children with ITW. SIPT is a well-established tool with high reliability, a gold standard in assessment of SPD. The chief findings of our study indicate that children with ITW show modest impairments in ankle DF and overall strength, but substantial impairments in sensory processing, specifically touch. Lack of impairment in proprioception suggests that toe walking may be a compensatory strategy. These findings may have significant clinical implications. In future studies, we propose to assess the effect of Ayres Sensory Integration Treatment Approach on ITW.
POSTURAL ALIGNMENTS IN CHILDREN WITH SPASTIC CEREBRAL PALSY USING BIMANUAL ACCESS DEVICE TO DRIVE THE POWER WHEELCHAIR
W. Liu, F. Chen, Y. Lin, H. Lien, Y. Yu, Department of Physical Therapy and Graduate Institute of Rehabilitation Science, Chang Gung University, Taiwan, Tao-Yuan, TAIWAN; C. Kuo, Department of Electrical Engineering, National Taiwan University of Science and Technology, Taipei, TAIWAN.
PURPOSE/HYPOTHESIS: Limited studies had showed there were correlations between handedness and convexity of scoliosis in children with disabilities. It indicated that asymmetrical functional usage of the upper extremities might lead to asymmetrical postural alignments. Therefore, an innovative bimanual access device was designed with the intention to promote symmetrical usage of the upper extremities and postural alignments in children with cerebral palsy (CP). In order to control this innovative bimanual access device, children need to manipulate two unilateral joystick devices simultaneously. The purpose of this study was to examine the postural alignments in children while driving the power wheelchair by using either the unilateral joystick or this bimanual access device.
NUMBER OF SUBJECTS: Twelve typically developing (TD) children (7.3±2.8 years old; 4 boys and 8 girls) and eighteen children with spastic CP (8.8±2.2 years old; 13 boys and 5 girls; 9 with spastic diplegia and 9 with quadriplegia) participated in this study.
MATERIALS/METHODS: A commercial-available power wheelchair was modified in order to be controlled by this new bimanual access device, as well as the unilateral joystick. All children drove the same adjustable power wheelchair in two conditions (the unilateral joystick vs. the bimanual access device). The modified Seated Postural Control Measure (SPCM) (Fife et al. 1991) was used to quantify the postural alignments of children during driving the power wheelchair forward for 3m by one rater. Good intra-rater reliability was estabished (ICC = 0.76) prior to the start of the study. Repeated ANOVA was used for statistical analysis.
RESULTS: One child with severe spastic quadriplegia was excluded because of failing to manipulate the bimanual access device. As expected, children with TD demonstrated better postural alignments than children with spastic diplegia CP (p = 0.033) did, as well as children with spastic quadriplegia CP (p < 0.0005) according to the total scores of SPCM in the bimanual access device condition. Overall, children had higher the anterior view and total scores of the SPCM in the bimanual access device condition than in the unilateral joystick condition (p = 0.016 and 0.048 for the anterior view and total scores respectively). Post hoc analysis of the groups indicated that statistically significant higher scores of anterior view (p = 0.035) and total score (p = 0.019) of the SPCM in the bimanual access device for the children with spastic diplegia.
CONCLUSIONS: Based upon the preliminary findings, the results suggested that this new innovative bimanual access device might be beneficial for some children with spastic diplegia CP to gain a better postural alignment.
CLINICAL RELEVANCE: These findings warrant future studies to test the impact of preventing asymmetrical postural alignments of using this bimanual access devices in children with spastic diplegia CP longitudinally. In addition, it needs to recruit more children with CP to identify the targeting candidates for this new innovative bimanual access device for power wheelchair.
TRANSCUTANEOUS ELECTRICAL STIMULATION (TENS) IN NEONATAL SWINE: A SAFETY STUDY TO ASSESS SKING INTEGRITY AND CARDIORESPIRATORY PARAMETERS
L. Lowe, C.C. Yates, Physical Therapy, University of Central Arkansas, Conway, AR; A. Mitchell, R.W. Hall, Center for Translational Neuroscience, University of Arkansas for Medical Science, Little Rock, AR.
PURPOSE/HYPOTHESIS: The use of transcutaneous electrical nerve stimulation (TENS) is a widely used non-pharmacological therapy for alleviating pain in adults and children. However, TENS therapy remains minimal and the effects unknown in the neonatal population. This study was designed to investigate the safety of TENS therapy on the skin integrity and cardiopulmonary parameters of neonatal swine.
NUMBER OF SUBJECTS: TENS unit electrodes were placed on the flank of 3-day-old York piglets (n = 6, 1.8-2.3 kg). Each of the piglets served as their own control.
MATERIALS/METHODS: Each piglet was anesthetized using an IM mixture of Telazol (50 mg/ml), Ketamine (25 mg/ml), Xylazine (5 mg/ml). Sedation was maintained using an IV mixture of Midazolam (0.3 mg/kg/hr), and Fentanyl (5 mcg/kg/hr). Four electrodes were placed on the right flank and 4 electrodes were placed on the left flank. The Empi Select TENS unit was set to stimulate the right flank with a 3.5 mA current for 10 minutes. The left flank did not receive stimulation. Heart rate variability (DL900 Holter Monitor) and pulse oximeters (OxiMax N-600x Pulse Oximeter) were used to monitor physiological changes before and after stimulation. Heart rate variability recordings were analyzed by Norav software to determine low frequency/high frequency (LF/HF) ratios. Activity level, clinical gait analysis, appetite, and attitude (vocalization) were assessed 6 hours and 24 hours post-stimulation to determine changes in behavior. The Draize Scale was used to assess changes in the skin such as erythema and edema and scores were obtained at baseline, 30 minutes, 1 hour and 24 hours post stimulation. Photographs of the affected areas were also taken at the time points that the Draize Scale was assessed.
RESULTS: There were no discernable differences in physiological and behavioral parameters, nor were there any changes in the integrity of the skin when compared before and after receiving TENS therapy.
CONCLUSIONS: This study suggests that non-invasive electrical stimulation of neonatal piglets is safe and could be investigated as a potential non-pharmacological analgesic in the infant population.
CLINICAL RELEVANCE: This study suggests the safety of non-invasive electrical stimulation (TENS therapy) of neonatal piglets. This study provides a foundation for a safety and efficacy study of non-invasive electrical stimulation to acupuncture points in infants to reduce pain for routine painful procedures such as heelsticks.
This research is funded by the MayDay Fund and the Center for Translational Neuroscience, (5P20RR020146-09) and the National Institute of General Medical Sciences (8 P20 GM103425-09) from the National Institutes of Health.
INVESTIGATION OF MOTOR PATTERNS IN INDIVIDUALS WITH AUTISM SPECTRUM DISORDER
M. Mandich, B. Cecil, D. Friebe, T. George, C. Harshbarger, N. Isiminger, C. James, J. Moon, E. Paff, R. Parker, A. Small, L. Swaim, M. Thomas, C. Mancinelli, Physical Therapy, West Virginia University, Morgantown, WV; S. Poe, Pediatrics, West Virginia University, Morgantown, WV.
PURPOSE/HYPOTHESIS: The most recent statistics on Autism Spectrum Disorder (ASD) report prevalence as high as 1 in 88, so pediatric physical therapists are increasingly asked to treat children for associated motor control issues. However, guidance for intervention is typically generic, emphasizing balance, coordination and acquisition of motor skills. The purpose of the present study was to obtain discrete information about how children with ASD perform on objective tests of motor performance as compared with normal controls, to obtain more specific guidance for physical therapy.
NUMBER OF SUBJECTS: The study was a comparative matched pairs design. Ten children with a diagnosis of ASD were matched by age and gender to a control group. The ages of children studied ranged from 6 to 17 years. Children with a specific diagnosis of Asperger's syndrome were excluded, as previous reports have suggested a differing motor profile in those individuals.
MATERIALS/METHODS: After receiving IRB approval and informed consent, all subjects were administered the Bruninks-Oseretsky Test of Motor Proficiency 2, Short Form (BOT-2 SF). The BOT-2SF is a standardized test of motor proficiency which has acceptable reliability and validity. The test examines four categories of motor function [fine manual control, manual coordination, body coordination and strength/agility], divided into 8 subtests. All children then participated in Limits of Stability (LOS) testing on the SMART Balance Master system. Finally, an analysis of gait at comfortable or normal walking speed (CWS) and fast walking speed (FWS) was completed using the GAITRite gait analysis system.
RESULTS: Comparisons between pairs did not show a significant difference in either balance testing or gait at fast speed. Self-selected walking speed was slower for children with ASD (p < .0089); however, this trend did not reach significance when an outlier was removed. On the BOT-2SF, all children in the control group showed average performance whereas only one child in the ASD group scored “Average”. The remainder of the children in the ASD group were classified as “Below Average” (n = 6) or “Way Below Average” (n = 3) as well as having significant differences from controls in all categories of motor function. From least to most significance, differences were: manual coordination (p < .0426), fine manual control (p < .0247), body coordination (p < .0119) and strength and agility (p < .0005).
CONCLUSIONS: The results of the present study support the premise that children with ASD have motor difficulties well into their school age years. The findings were surprising in that strength and agility was the single difference of greatest significance between the two groups.
CLINICAL RELEVANCE: Most intervention programs for children with an ASD diagnosis focus on achievement of advanced motor milestones involving balance and coordination. Although it is possible that the findings on the strength and agility section of the BOT-2SF reflect a praxis problem, rather than a true strength deficit, working on activities which strengthen core muscles is clearly warranted.
EFFECTGS OF HOME-BASED, INTENSIVE, SHORT-TERM LOCOMOTOR TREADMILL TRAINING ON WALKING FUNCTION IN YOUNG CHILDREN WITH CEREBRAL PALSY: A QUASI-RANDOMIZED CONTROLLED TRIAL
K. Mattern-Baxter, Physical Therapy, Sacramento State University, Sacramento, CA; S. McNeil, Easter Seals, Sacramento, CA; J.K. Mansoor, Physical Therapy, University of the Pacific, Stockton, CA.
PURPOSE/HYPOTHESIS: This is the first quasi-randomized controlled trial examining if an intensive, home-based program of treadmill training helps pre-ambulatory children with cerebral palsy (CP) under 3 years improve gross motor skills related to walking, increase walking speed and decrease reliance on outside support for walking.
NUMBER OF SUBJECTS: Thirteen children with CP ages 13.5 to 32 months with Gross Motor Function Classification System (GMFCS) levels I, II and III participated in the study. Seven children were assigned to the intervention group and six matched for age and GMFCS level served as controls.
MATERIALS/METHODS: All children were tested in their homes pre-intervention and at a 6-week, 10-week and 25-week follow-up. Outcome measures included the Gross Motor Function Measure-66 (GMFM-66) Dimensions D/E, the Mobility Scale of the Pediatric Evaluation of Disability Inventory (PEDI), the Timed 10-meter Walk Test (10MWT) and the Functional Mobility Scale (FMS). All children received their weekly scheduled physical therapy sessions at their homes. In addition, children in the intervention group walked on a portable treadmill in their homes 6 times per week, twice daily for 10-20 minute sessions, for 6 weeks. The intervention was carried out by the children's parents with weekly supervision by a physical therapist. Statistical differences between treatment and control groups for GMFM and PEDI were tested using two-way repeated measures ANOVA and for the 10MWT and FMS using non-parametric analyses.
RESULTS: No significant differences were observed between the groups for any of the outcome measures at study onset. There was no control versus treatment effect for GMFM D/E. There was a significant effect of treatment for the PEDI (p = 0.03) with significant improvement at the 6- and 10-week follow-up (p < 0.05). The FMS was significant at the 6-week follow-up (p = 0.02). The 10MWT approached significance at the 10-week follow-up (p = 0.08).
CONCLUSIONS: The results of this study show that intensive, home-based treadmill training carried out by parents in addition to regular physical therapy sessions can accelerate the attainment of walking skills, increase walking speed, and decrease the amount of support used for walking in pre-ambulatory children with CP under age 3.
CLINICAL RELEVANCE: Home-based treadmill training can provide high intensity, task-specific training with multiple repetitions, when carried out by the parents with supervision of a physical therapist. The results of this study illustrate that a 6-week, intensive, home-based treadmill training protocol can accelerate the attainment of walking skills, increase walking speed and decrease the amount of support needed for walking in children with CP under 3 years of age. Future research should investigate optimal dosing parameters for home-based treadmill intervention, and examine the effects of treadmill training on gait parameters, activity level and participation.
PT INTERVENTION TO ADDRESS POSTERIOR FOSSA SYNDROME SYMPTONS STATUS POST BRAIN TUMOR RESECTION
D.B. McCarty, L. Case, J. Edelschick, Department of Physical and Occupational Therapy - Pediatric Service, Duke University Medical Center, Durham, NC.
BACKGROUND/PURPOSE: Sixty percent of all pediatric brain tumors originate in the posterior fossa. Neurosurgery to remove the tumor is often the first choice in treatment, followed by radiation and/or chemotherapy. Posterior Fossa Syndrome (PFS) is a post-operative syndrome related to insult to the posterior fossa involving a variety of symptoms including speech disturbances, dysphagia, decreased movement, and emotional lability. It is important for the pediatric acute physical therapist (PT) to recognize these symptoms in post-operative patients, to alert the medical team about neurological changes, to separate PFS symptoms from baseline symptoms, and to anticipate the patient's changing therapeutic needs. Knowledge of the syndrome is also important for PT recommendations at discharge and for parent education.
CASE DESCRIPTION: The patient was a 15 year old male who presented to the Emergency Department with a three week history of nausea, vomiting, lethargy, constipation, and headaches. He was diagnosed with an infratentorial Grade IV medulloblastoma and underwent brain tumor resection the next day. During the PT evaluation two days later, the patient demonstrated extreme lethargy, disorientation, inability to form words, non-responsiveness to questions, and dependence on caregivers for all purposeful movement. The patient's quality of movement was characterized by impulsivity, strong extension patterns, and significant ataxia. Initial treatment focused on caregiver education regarding the patient's strong postural preference, positioning strategies, and basic gross motor skill facilitation. Therapeutic intervention adjusted with patient progress over 8 weeks and included motor sequence problem-solving, joint proprioceptive input, gait training, and strength/coordination exercises. The platform presentation will further describe movement characteristics typical of PFS and treatment strategies through brief video clips of PT sessions with this patient and others with PFS. (Parental consent obtained prior to making videos).
OUTCOMES: The patient made significant gains during his inpatient stay as a result of natural progression of PFS and intensive therapy. Initially, the patient was dependent for all gross motor skills. At discharge, he required minimal assist for unsupported sitting and level transfers and required maximal assist for higher level gross motor skills. Changes were tracked with the Functional Independence Measure. The patient was transferred to a rehabilitation hospital where therapy was continued for 2 weeks prior to discharge.
DISCUSSION: The patient continued to make mobility gains over the 5-6 months following initial surgical resection, but his mobility had not yet reached baseline (prior to tumor resection). Because of the high variability of outcomes for children diagnosed with PFS, the effects of PT treatment on PFS have not been quantified at this time. Continued research in this area is needed to determine the average length of PFS symptoms following surgery, the best treatment interventions, and the causes of PFS.
THE USE OF WHOLE BODY VIBRATION TO PROMOTE PURPOSEFUL VOLUNTARY STEPPING FOLLOWING GLOBAL ANOXIC BRAIN INJURY: A CASE REPORT
T.L. Millard, S.D. Palma, J. Stradley, M. Boyd, C. Rovinelli, T. Ledford, Physical Therapy, North Georgia College & State University, Dahlonega, GA.
BACKGROUND/PURPOSE: The purpose of this study was to investigate the impact of whole body vibration (WBV) on body weight supported (BWS) treadmill stepping in children with motor disorders secondary to global anoxia. After anoxic brain injuries (ABI), children lose the ability to initiate the purposeful voluntary movement necessary to promote neuroplastic change and optimal recovery. Research suggests that the use of WBV may augment voluntary muscle contraction in individuals with CNS dysfunction and may enhance stepping facilitated through BWS treadmill walking.
CASE DESCRIPTION: Two 4 year old males, 1 and 2 years post ABI, participated in the study. Study intervention was delivered in addition to each child's current physical therapy intervention. Both children displayed decorticate posturing at rest, communicated with eye blinks, initiated stiff random movements of the extremities, and required support to maintain an erect head and sitting and standing. A single subject repeated measures design was used. One subject received intervention three times a week for 2 weeks and one subject received intervention one time a week for 6 weeks. WBV was delivered with each child positioned in a BWS system standing on the Galileo WBV platform with knees flexed to 45 degrees for 15 minutes. Frequency was increased in 2 minute increments from 6 Hz to 10 Hz and decreased from 10Hz to 6 Hz in one minute intervals. Pretest measures were taken immediately prior to WBV. Posttest measures were taken immediately after WBV, 20 minutes after WBV and 40 minutes after WBV. Pre and posttest measures included the Tardieu Scale, knee passive range of motion (PROM), and a 0 to 7 point stepping scale developed for the study. Stepping was scored through video analysis.
OUTCOMES: Knee PROM range of motion remained consistent for both children throughout the study at approximately 135 degrees. Tardieu measurements demonstrated a trend for decreased hamstring spasticity following WBV for both children with palpable resistance to stretch occurring closer to full PROM. Stepping initiation improved in both children with greatest stepping occurring at the 40 minute posttest time. For child one the calculated stepping initiation percent change from pretest was: +30% at posttest 1; +46% at posttest 2; +93.7% at posttest 3. For child two the calculated stepping initiation percent change from pretest was: +67.0% at posttest 1; +71.0% at posttest 2; +105.0% at posttest 3.
DISCUSSION: Results suggest WBV application prior to BWS treadmill training can improve the ability of children after ABI to initiate voluntary purposeful stepping. WBV effects may promote or enhance purposeful movement initiation throughout a typical hour long physical therapy treatment session. Further research is necessary to determine the significance of the outcomes from this study and the appropriate use of WBV for children after ABI.
WHEN MIGHT DIRECTIONAL VARIABILITY IN TREADMILL STEPPING WITH INFANTS BE INTRODUCED?
V.A. Moerchen, Z. Perez, M. Riordan, K.L. Kolar, Kinesiology, Univ of WI-Milwaukee, Milwaukee, WI.
PURPOSE/HYPOTHESIS: One limitation of treadmill intervention with infants relates to ecological validity. Expanded directionality of stepping may address one aspect of this limitation. We have previously demonstrated that infants can produce backward steps on a treadmill from 4 months of age onward, with step frequency and complexity increasing with age in a pattern parallel to but quantitatively less than with forward stepping. In this study we describe a developmental trajectory and propose developmental transition points in backward stepping that might inform inclusion of backward stepping in intervention using the treadmill with populations at risk for delayed development of gait.
NUMBER OF SUBJECTS: 12 typically developing infants.
MATERIALS/METHODS: This was a longitudinal study. Infants were tested at 4 mo, 6 mo, 8 mo, 10 mo, and at onset of walking. Six, 30-second trials of body weight-supported forward and backward treadmill stepping were captured at 1800 Hz. Dependent variables included step types, step frequencies, and step locations, as well as developmental motor levels (Bayley). Analyses included RM-ANOVAs and cluster analyses.
RESULTS: The location of backward steps shifted from in place to behind the hip with age (p < 0.05) and with the attainment of sitting (p < 0.05) and standing (p < 0.01). Individual profiles and group means demonstrate 2 transition points in the control of backward stepping across the first year.
CONCLUSIONS: Backward stepping on a treadmill seems to introduce a biomechanically difficult task for infants compared to traditional forward stepping. The advantage of backward stepping is that it introduces directional variability to the treadmill context. Backward stepping may also facilitate a more controlled dissociation between legs in a manner that exceeds that required for forward stepping, and that may be relevant to work with clinical populations.
CLINICAL RELEVANCE: Functional variability in the control of gait includes the ability to step in all directions to manage challenges to balance and direction while moving overground. To date, infant treadmill intervention has only been focused on forward stepping. Our results, however, suggest that backward stepping may not only increase the ecological contribution of treadmill stepping to gait training in children at risk for delays in the acquisition of gait, but may also provide a task that facilitates enhanced lower extremity dissociation and control, particularly related to step location during backward stepping. Transition points and corresponding motor skill development are identified to guide future clinical trials inclusive of directional stepping.
ANTHROPOMETRICS AND CONSISTENT REACHING PERFORMANCE IN YOUNG CHILDREN WITH AND WITHOUT NEOMATAL STROKE
S. Mrowzinski, C. Chen, J. Heathcock, Physical Therapy, Ohio State University, Hilliard, OH.
PURPOSE/HYPOTHESIS: Infants with neonatal stroke are at high risk for hemiplegic cerebral palsy (CP). Interestingly they often display a period of neurological asymptomatology. Therefore, infants do not always demonstrate identifiable early behaviors that point to CP until 2 years of age. Anthropometrics serve as a quick, reliable method of determining infant growth. Specifically, head circumference is a valid measure of total brain volume and an important predictor of motor skill development. Body weight, length, and arm volume measure overall growth and may serve as important factors in the development of early reaching behaviors. The purpose of this study is to determine if there are any anthropometric indicators that may differentiate early and consistent reaching performance in infants with and without stroke.
NUMBER OF SUBJECTS: 22 full-term infants completed this longitudinal project. 17 infants were typically-developing (FT) and 5 had a neonatal stroke (NS).
MATERIALS/METHODS: Infants visited the lab every other week from 2-7 months old, 10 times for a total of 220 visits. Height, weight, arm length and circumference, and head circumference were measured at each visit. Upper arm and forearm cylindrical volumes were calculated from arm circumference and length. The number of voluntary reaches was also measured at each visit. Consistent reaching was operationally defined as 5 hand-toy contacts within 90 seconds. Infants could contact the toy 5 times with both or either arm meaning that infants with neonatal stroke could have contacted the toy with only their less involved arm. During the week of consistent reaching, anthropometric variables were compared between groups.
RESULTS: FT infants showed larger measurements from the NS group in every anthropometric measure. A Mann-Whitney test showed a significant difference in body weight with FT (14.7 ±2.1 lb) heavier than NS (13.0 ±1.0 lb), p = 0.024. Despite FT always showing larger measurements than NS, there were no statistical differences between groups for head circumference 16.2 ±0.6 in vs 15.8 ±0.3 in, upper arm volume 153.9 ±41.2 cm3 vs 137.6 ±31.8 cm3, or height 24.5 ±1.8 in vs 22.6 ±1.3 in.
CONCLUSIONS: The results suggest that size of the head and arms does not differ in infants who have a history of neonatal stroke when compared to those who do not during the week of consistent reaching. Overall, infants with a history of NS may be smaller.
CLINICAL RELEVANCE: These results may suggest that total head circumference during early reaching in infants with NS mimics typical development. It is unknown what specific differences in brain structure and functional development are different between groups and if the similarity in head size may be an important component for the brain's plasticity and development capabilities. Head circumference and arm volume may not be useful as a method for distinguishing infants who have had a neonatal stroke when compared to full-term, typically-developing infants. Anthropometrics may be used in combination with other clinical tools to determine infants at risk for developmental delay.
WALKING FUNCTION AND MUSCULOSKELETAL DEVELOPMENHT 5-7 YEARS POST-LOCOMOTOR TRAINING IN A CHILD WITH INCOMPLETE SPINAL CORD INJURY
J. Nair, E.J. Fox, S. Trimble, C.R. Senesac, M. Spiess, M. Rademaker, C. Howland, D. Lott, Physical Therapy Department, University of Florida, Gainesville, FL; N.J. Tester, Brain Rehabilitation Research Center, Malcom Randall VAMC, Gainesville, FL; K. Vandenborne, D.R. Howland, Department of Neurological Surgery, University of Louisville, Louisville, KY.
BACKGROUND/PURPOSE: We previously reported on a child with cervical incomplete spinal cord injury (SCI), who was injured at 3.5 years, underwent locomotor training (LT) at 16 months post-injury and recovered walking with a reverse rolling walker. We further reported ongoing walking recovery and attenuation of musculoskeletal complications 1 and 2 years post-LT. Follow-up of this child during critical years of growth and development is necessary to describe long-term consequences of walking recovery in pediatric SCI and to identify subsequent therapy needs. As nearly 100% of children with SCI prior to age 5 develop scoliosis and over 50% develop hip dysplasia, we were especially interested in the child's musculoskeletal health. In addition, we asked what impact age, growth, and increasing complexity of social and educational demands have on the child's walking capacity and function in the home and community. The purpose of this report is to describe the child's walking function, musculoskeletal development and health 5 and 7 years post-LT and to identify areas requiring subsequent intervention.
CASE DESCRIPTION: The child was re-evaluated 5 and 7 yrs post-LT for walking ability, general growth, motor development and musculoskeletal development. Outcome measures included motor function; walking speed, endurance, and independence; gross motor function including assessment of trunk control.
OUTCOMES: At 5 and 7 yrs post-LT, the child continues to ambulate independently with a rolling walker in the community; he has introduced wheelchair mobility to school. His Lower Extremity Motor Score remains unchanged at 4/50. X-ray reports are negative for scoliosis and hip dysplasia. His height is within age appropriate norms (percentile at age: 75th at 8 yrs, 50th at 10 and 12 yrs) but his weight percentile decreased (percentile at age: 90th at 8 yrs, 95th at 10 yrs, 25th at 12 yrs). He increased his step length and gait speed (0.45 m/s at 2 yrs- to 1.1 m/s at 5 yrs-post LT). He has reduced arm and trunk compensations while walking. He walked 163m during a 6-Minute Walk Test at 5 yrs post-LT. The child can now perform trunk extension and hold an upright posture, yet lacks abdominal flexion against gravity (Neuromuscular Recovery Scale). Gross Motor Function Measure scores improved from 65% at 2 yrs post-LT to 78% at 5 yrs According to report, recent demands for mobility at school and two surgeries (bladder/eye) have influenced time spent walking.
DISCUSSION: At 5 and 7 yrs post-LT the child continues to walk with improved speed and endurance, yet reduced compensations compared to 2 yrs post-LT. The child has not developed the usually expected scoliosis and hip dysplasia in pediatric SCI under age 5. In contrast, he has improved trunk control with near normal physical growth profile. While current outcomes are promising, the effects of adolescent growth spurts and social/educational demands will increase and the consequences of convalescence on mobility appear to be significant.
PROXIMAL AND DISTAL ENVIRONMENTAL CORRELATES OF ADOLESCENET OBESITY
K.C. Nesbit, Physical Therapy, Loudoun County Public Schools, Waterford, VA; T.H. Kolobe, S.H. Arnold, Rehabilitation Sciences, University of Oklahoma Health Sciences Center, Oklahoma City, OK; S. Sisson, Department of Nutritional Sciences, University of Oklahoma Health Sciences Center, Oklahoma City, OK; M.P. Anderson, Biostatistics and Epidemiology, University of Oklahoma Health Sciences Center, Oklahoma City, OK.
PURPOSE/HYPOTHESIS: To determine how proximal (home) and distal (neighborhood) environmental characteristics interact to influence obesity in early and middle adolescents, ages 11-17.
NUMBER OF SUBJECTS: 39,542 children aged 11-17 from households identified from 2.8 million randomly generated landline telephone numbers from the Centers for Disease Control and Prevention's (CDC) National Immunization Survey (NIS) sampling frame.
MATERIALS/METHODS: Descriptive cross-sectional study design using data extracted from the 2007 National Survey of Children's Health (NCSH). Univariate logistic regression models and multiple logistic regression were used to examine the relationship between adolescent obesity and environmental factors, the relative strength of the direct and indirect association with adolescent obesity, and the influence of age and gender.
RESULTS: Proximal environmental factors were stronger correlates of adolescent obesity than distal environmental factors. The influence of TV watching time on obesity for middle adolescents was stronger than for early adolescents (OR 0.71, 95% CI 0.94-1.0). The effect of TV watching time on obesity for boys was stronger than for girls (OR 1.07, 95% CI 1.03-1.10). Sedentary behavior related to TV watching time was the strongest correlate of adolescent obesity overall.
CONCLUSIONS: The results of this US population-based study reveal the importance of proximal environmental characteristics on adolescent obesity relative to distal environmental characteristics, and the overall consistency of the influences of proximal and distal environmental factors on obesity across age groups and gender.
CLINICAL RELEVANCE: The results of this US population-based study begin to fill the gap in adolescent obesity research with an improved understanding of the relatedness and relative importance of home and neighborhood environmental correlates of adolescent obesity. Home, family, and community influences on adolescent obesity highlight the multidimensional nature of interactions with the environment during this stage of development. Insight into the influence of proximal and distal environmental attributes can inform theory for adolescent obesity intervention planning. Our findings suggest that obesity intervention strategies for adolescents should target sedentary behavior as well as opportunities for physical activity with a focus on the groups at a higher risk for obesity-early adolescents and boys.
PHYSICAL ACTIVITY PERFORMANCE AMONG HEALTHY WEIGHT, OVERWEIGHT AND OBESE MINORITY MIDDLE SCHOOL BOYS AND GIRLS
A. Nunez-Gaunaurd, Research, iTrace Foundation, Inc, Plantation, FL; Kirk-N. Sanchez, Physical Therapy, University of Miami, Coral Gables, FL.
PURPOSE/HYPOTHESIS: Minority children in the US are disproportionally overweight and obese. The CDC recommends that children engage in 60 minutes of moderate-vigorous activity daily. BMI-referenced recommendations for maintaining a healthy weight range for 6-12 yr old girls/boys are 12,000/15,000 steps/day. Boys and girls have different determinants for appropriate levels of PA. The purpose of this study was to describe physical activity (PA) performance, as measured by StepWatch Step Activity Monitor (SAM), and to compare gender differences, duration, intensity and frequency of PA among healthy weight, overweight and obese minority middle school children.
NUMBER OF SUBJECTS: Sixty-eight middle school children.
MATERIALS/METHODS: Children were recruited from two middle schools and wore the SAM for 7 days. PA data collected included; total steps/day, steps/day and minutes/day of PA at moderate-high and high activity, and sedentary minutes. Children were categorized as healthy weight if BMI for age was >5% and <85%, overweight if BMI for age was ≥85% and <95%, and obese if BMI for age was ≥95%.
RESULTS: Participants were an average of 12 years old, 37 boys/31 girls and 92% of Hispanic ethnicity. Fifty-four percent were classified as healthy weight, 23% overweight and 22% obese. The mean steps/day in moderate-high PA was lower among obese children when compared to overweight and healthy weight children, but differences were not statistically significant, (11,977 vs 12,187 vs 13,240 steps/day, p = .358). When combining all overweight and obese children into one group, mean total steps/day were lower (12,848 vs 14,214, p = .043) and minutes in sedentary time were higher (1,016.3 vs 986.18, p = .038) for the overweight/obese children than healthy weight children. Girls took fewer steps/day than boys (10,668 vs 13,969, p < .001) and spent less time in PA at all intensities (Moderate PA; 126 vs 170 min., p < .001) and greater sedentary duration (1052.1 vs 1010.5 min., p < .001). Significant differences in steps and minutes in high PA were observed between healthy weight and obese group for boys only, (5560 vs 4237 steps, p = .03 and 56 vs 43 min., p = .04). Only 24% of obese children met daily step recommendations to maintain a healthy weight compared to 32% of healthy weight children.
CONCLUSIONS: These results support the assumption that Hispanic children who are overweight or obese engage in less PA when compared to their healthy weight peers. The PA trends suggest a possible dose response to PA. We also confirmed that Hispanic boys are much more physically active in all PA intensities and less sedentary when compared to girls. A high proportion of minority children did not meet daily step recommendations.
CLINICAL RELEVANCE: Daily walking and PA decreases as BMI increases. Greater efforts are necessary to engage Hispanic girls in PA participation. These findings support the development of health and wellness program that account determinants for PA specific to boys and girls.
THE EFFECT OF AQUATIC EXERCISE ON SLEEP HABITS IN CHILDREN WITH AUTISM SPECTRUM DISORDER
K.N. Oriel, K. Noel, K. Zeisloft, Physical Therapy, Lebanon Valley College, Annville, PA; Wood J. Kanupka, N. Horrocks, J. Upton, S. Young, Teacher Education, Lebanon Valley College, Annville, PA.
PURPOSE/HYPOTHESIS: There is an extensive amount of evidence documenting sleep disturbances among children with Autism Spectrum Disorder (ASD). These sleep disturbances have a direct impact on behavior in this patient population. The purpose of this study was to determine if children with ASD who participate in an aquatic exercise program have improvements in sleep latency, staying asleep, and sleep duration.
NUMBER OF SUBJECTS: Participants were recruited through flyers sent to local schools and support groups. Inclusion criteria included a diagnosis of ASD, parent report of sleep dysfunction, and between the ages of 6-11 years. Participants included 8 children with ASD, including 5 males and 3 females, with a mean age of 9 years 4 months.
MATERIALS/METHODS: The Children's Sleep Habits Questionnaire (CSHQ) was administered in order to quantify the degree of sleep disturbance among each participant. An A-B-A withdrawal design was utilized. Each phase lasted for 4 weeks, with A1 being the control phase before treatment, A2 being the control phase after treatment, and B being the treatment phase. The treatment consisted of 60 minutes of aquatic exercise 2X/week. Phone calls to the parents of the participants were made 2X/week throughout the duration of the study. Parents were asked questions related to sleep latency, number of nighttime awakenings, and sleep duration. A One Way Repeated-Measures ANOVA was utilized to determine if differences existed between phases; post hoc testing (utilizing Tukey's Honestly Significant Difference) was performed when warranted.
RESULTS: Participants had a mean score of 55.3 on the CSHQ. A statistically significant difference existed between phases for sleep latency (p < 0.001) and sleep duration (p < 0.001). For sleep latency, post hoc testing revealed that differences existed between A1 and B (38.95 minutes vs. 21.70 minutes) and A1 and A2 (38.95 minutes vs. 25.91 minutes). For sleep duration, post hoc testing revealed differences existed between A1 and B (8.23 hours vs. 9.61 hours) and A1 and A2 (8.23 hours vs. 9.15 hours). There were no statistically significant differences between phases for number of nighttime awakenings (p = 0.085).
CONCLUSIONS: Results of this study suggest that participation in an aquatic exercise program may improve the sleep habits of children with ASD. The participants in this study fell asleep faster and slept longer following aquatic exercise. While a statistically significant difference was not observed for number of nighttime awakenings, visual analysis of the data revealed a trend toward a decreased number of awakenings during the treatment phase.
CLINICAL RELEVANCE: Disturbed sleep can negatively impact the daytime behaviors of children with ASD. Aquatic exercise should be considered for this patient population as an option in assisting to manage sleep issues.
A DESCRIPTION OF DIET AND EXERCISE PERCEPTIONS AMONG TYPICALLY DEVELOPING PRESCHOOLERS
K.N. Oriel, A. Bonenberger, K. Henninger, K. Markovic, Physical Therapy, Lebanon Valley College, Annville, PA.
PURPOSE/HYPOTHESIS: The preschool period (3-5 years) is considered a critically important period in which children develop their diet and exercise habits. The purpose of this study was to describe the diet and exercise perceptions of typically developing preschool aged children.
NUMBER OF SUBJECTS: Participants included 130 children who were recruited from 10 randomly selected preschools in Central Pennsylvania, and included 69 males and 61 females (mean age 4.5 years).
MATERIALS/METHODS: All children who were enrolled in the selected preschool classrooms were invited to participate. The children who returned a consent form and demographic questionnaire were interviewed by the researchers. Each participant's height and weight were measured to allow for Body Mass Index (BMI) calculation. The interview consisted of three parts, including: 1) definition of “healthy”, 2) diet perceptions (identification of healthy/unhealthy foods; food choice if given a healthy and unhealthy option), and 3) exercise perceptions (identification of activities were good exercise/not good exercise; activity choice if given an active and sedentary option). Data were analyzed using descriptive statistics in SPSS 17.0.
RESULTS: Results of the demographic questionnaire indicated that the majority of participants had a healthy BMI (71.5%), had a playground within walking distance of their home (60.8%), ate 5 or more meals together as a family (79.1%), spent 1-2 hours a day watching television (79.2%), and ate fast food 1-2 times per week (66.2%). During interviews with participants, each child was first asked what being healthy meant to them. The majority of participants referenced food (45.7%), while 11.6% described some aspect of physical health. Regarding diet perceptions, participants were able to identify healthy foods as healthy 83% of the time, and identify unhealthy foods as unhealthy 55% of the time. Sixty percent of participants made a healthy food choice from healthy/unhealthy options the majority of the time. Regarding exercise perceptions, participants were able to correctly identify good forms of exercise 86% of the time, and correctly identify sedentary activities as poor forms of exercise 53% of the time. Sixty percent of participants chose the activity that was a good form of exercise when given an active and sedentary option.
CONCLUSIONS: Overall, the majority of preschooler's in this study were able to correctly identify healthy/unhealthy food options and differentiate between active and sedentary activities. While the majority of participants also made healthy food and activity choices, 40% of participants made unhealthy food choices and chose a sedentary activity when given an option.
CLINICAL RELEVANCE: Given the childhood obesity epidemic, it is growing increasingly important to understand the perceptions of children regarding diet and exercise. Evidence suggests that children begin developing habits at the age of three that will stay with them through adulthood. It is essential to understand the perceptions of preschoolers so that appropriate interventions can be targeted.
STRUCTURAL AND DEVELOPMENTAL CORRELATES OF FIDGETY MOVEMENTS IN HIGH RISK PREMATURE INFANTS
C. Peyton, Therapy Services Department, University of Chicago Medical Center, Chicago, IL; E. Yang, Department of Pediatric Neuroradiology, University of Chicago Medical Center, Chicago, IL; J. Piantino, M. Schreiber, Department of Neonatology, University of Chicago Medical Center, Chicago, IL; L. Adde, Department of Laboratory Medicine, Children and Women's Health, Faculty of Medicine, Norwegian University of Science and Technology, Trondheim, NORWAY; Fjørtoft T, Department of Clinical Services, Physiotherapy Section, St. Olav University Hospital, Trondheim, NORWAY; A. Drobyshevsky,
Evanston Northshore Hospital, Evanston, IL; M.E. Msall, Department of Developmental and Behavioral Pediatrics, University of Chicago Medical Center, Chicago, IL.
PURPOSE/HYPOTHESIS: The quality of infant general movements, specifically fidgety movements (FMs), may be a marker of early brain impairment and may reflect the integrity of corticospinal or reticulospinal pathways. Diffusion tensor imaging (DTI) has shown disrupted thalamocortical connectivity and abnormalities of descending cortiocospinal tracts in young children with cerebral palsy. DTI has not yet been used to compare structural white matter tract integrity with the FMs and neuromotor status of high-risk, premature infants. Our objective was to describe the relationship of the presence (FM+) or absence (FM−) of FMs among high risk premature infants at 10-15 weeks post term, their performance on the Test of Infant Motor Performance (TIMP), and MRI measures of white matter tract structure as measured by DTI at term age equivalent.
NUMBER OF SUBJECTS: Nine infants, less than 32 weeks gestation with birthweights between 575grams and 1300grams received term-age equivalent diffusion tensor imaging MRI; three had bronchopulmonary dysplasia, two had necrotizing enterocolitis and intraventricular hemorrhage grade 3 or 4, one had periventricular leukomalcia and one severe retinopathy of prematurity.
MATERIALS/METHODS: The infants received a cerebral MRI with Diffusion Tensor Imaging scan on a 3T Phillips Achievea MRI using a SENSE MRI coil array, at term age. Tracts of internal capsule, posterior thalamic radiations and corona radiate were graded by an experienced pediatric neuroradiologist masked to neurodevelopmental status.
Video recordings at 10-15 weeks post term age were classified based on absent or present FMs using the Prechtl's approach of general movement assessment. The Test of Infant Motor Performance (Version 5.1) was administered at the same session as the video recordings by an experienced tester.
RESULTS: Five infants were FM− and four had FM+. In three cases of FM+ all white matter tracts were normal. In three cases, FMs were graded as FM− and tracts of the internal capsule, posterior thalamic radiations and corona radiatie were abnormal. In two children white matter tracts were normal with FM- at 10 weeks. One child had FM+ and mildly abnormal white matter tracts. Two children had below average TIMP scores and seven children had average TIMP scores. Of the two infants who had below average TIMP scores, both had abnormal white matter tracts. In the seven infants with average TIMP scores, five had normal white matter tracts, and two had abnormal white matter tracts.
CONCLUSIONS: FMs may be related to both sensory and motor pathways and may provide a valuable early developmental biomarker for understanding difficulties in both early motor skills as well as their adaptive correlates. Further investigations are required to determine the relationship between early motor assessments, MRI and long term neurodevelopmental outcome.
CLINICAL RELEVANCE: DTI may be a useful tool in understanding more about the neural basis for developmental disability at an early age.
HIP RANGE OF MOTION AND GROSS MOTOR FUNCTION AND THEIR RELATIONSHIP TO AGE IN CHILDREN WITH HUTCHINSON-GILFORD PROGERIA SYNDROMS (HGPS)
C.A. Ploski, S. Riley, Department of Physical and Occupational Therapy Services, Boston Children's Hospital, Boston, MA; M.E. Kleinman, Critical Care Medicine, Boston Children's Hospital, Boston, MA; L. Gordon, Department of Pediatrics, Department of Pediatrics, Providence, RI; M. Kieran, Pediatric Medical Neuro-Oncology, Dana Farber Cancer Institute, Boston, MA.
PURPOSE/HYPOTHESIS: HGPS is a rare autosomal-dominant disorder segmental aging disease, characterized by multisystem involvement. Early death at a mean age of 13 years is a result of heart attack or strokes. Children may appear normal at birth, but signs are usually present by 6 months of age. Musculoskeletal manifestations appear during year one and include skeletal dysplasia and joint contractures. Hip abnormalities are well documented and include coxa magna, coxa valga, hip dislocations and avascular necrosis of the femoral head. However there is no evidence of degenerative joint disease. To date there have been no studies characterizing gross motor performance. We therefore sought to characterize and quantify hip ROM limitations and GMFM-88 performance as well as to determine if there is a relationship between hip ROM and GMFM performance and age.
NUMBER OF SUBJECTS: 24
MATERIALS/METHODS: Lower extremity range of motion, the Gross Motor function Measure-88 (GMFM-88) were used to assess baseline status in this cohort of children prior to the onset of drug therapy.
RESULTS: Subjects in this study all presented with hip ROM abnormalities (n-24). Hip ROM deficits were most pronounced in hip internal rotation (n = 18, mean 13 + 18 degrees). Hip ROM measurements did not show any relationship to age. Subjects under 5 were excluded from the GMGM-88 analysis. This eliminated any low scores related to motor development. Although as a group, subjects over 5 years of age (n = 18) showed deficits in all categories on the GMFM-88, scores do not show any relationship to age.
CONCLUSIONS: The subjects in this study represent the largest prospective cohort to date with HGPS. Joint contractures are a pervasive component of the disease and are likely the result of skeletal dysplasia and extracellular matrix abnormalities in HGPS. Deficits existed in all individuals in hip ROM and GMFM-88 scores. There was a high degree of individual variability that does not appear to correlate with age. However, though the genetic cause of HGPS is exactly the same in all subjects, variability between patients implies that epigenetic influences partially govern disease extent and rate of progression.
CLINICAL RELEVANCE: HGPS is a rare progressive disorder and little is known about the gross motor function of the children and the relationship of clinical findings to age. This study provides information which contributes to the description of the disease phenotype.
MEASURING HOPE AMONG PARENTS OF CHILDREN WITH AUTISM AND DOWN SYNDDROME
T.E. Saeed, V.A. Moerchen, Kinesiology, Univ of WI-Milwaukee, Milwaukee, WI.
PURPOSE/HYPOTHESIS: Understanding resilience among families of children with atypical development, such as Down syndrome and Autism, is important for providing family-centered care. Examining family resilience based on hope, in contrast to more typical considerations of stress, considers the inner resources a parent brings to caring for their child. The Hope Scale modified for this study examines hope as an interaction of determination (agency) and planning (pathways). We hypothesized that parents of children with Down syndrome would have a higher pathways score than parents of children with autism, as a function of the difference in social/relational stressors between autism and Down syndrome.
NUMBER OF SUBJECTS: Thirteen parents of children with autism (AU) and 12 parents of children with Down syndrome (DS) participated in this study. Respondents were predominantly mothers (12/13 AU and 11/12 DS). Mean age (years) of children and parent respondents by group were AU: 9.2 child/41.6 parent and DS: 7.1 child/39.8 parent. Racial and ethnic diversity was greater in the AU group (50% Caucasian) than in the DS group (92% Caucasian). Marriage status and educational levels were comparable between groups.
MATERIALS/METHODS: Parents completed both the original Hope scale (Snyder, 1991), the modified Hope scale for parents, the WHO-Quality of Life (BREF), select items from the Parenting Stress Scale (PSS:A; Miles et al), the Parent Worry scale (Miles et al), and a demographics form. Group differences on hope, stress, and worry variables were examined using a repeated measures ANOVA.
RESULTS: Hope scores for parents in both groups were higher for their children than for themselves (p < 0.05). There were no significant differences in hope or in the agency and pathways construction of hope between the two groups. Additionally both groups reported highest stress in personal and family life (p < 0.05), followed by stress related to managing their child's behavior and communication. Parents in the AU group reported more worry and stress than parents in the DS group (p < 0.05).
CONCLUSIONS: This pilot study was reasoned from a resiliency model of family functioning, and is part of a larger series of studies examining the impact of intervention for a child on the overall adaptive capacity and resilience of the family. This study suggests that stressors can differ between diagnostic groups and yet impact hope similarly.
CLINICAL RELEVANCE: The results of this pilot study have implications for the role of intervention in supporting resilience and self-management among parents of children with special needs.
INFANT LEARNING OF TASK-SPECIFIC LEG ACTION: INFLUENCE OF PREMATURITY
B.A. Sargent, L. Fetters, N. Schweighofer, Biokinesiology and Physical Therapy, University of Southern California, Los Angeles, CA.
PURPOSE/HYPOTHESIS: Infants born preterm with very low birth weight are at high risk for developing spastic diplegic cerebral palsy, which is characterized by walking limitations due to a reduced ability to selectively move the joints of the legs; ie. flexing the hip while extending the knee. Previous research demonstrates that full-term infants will exhibit more selective leg coordination when their leg actions are reinforced with activation of an overhead infant mobile, however it is unknown whether preterm infants at risk for cerebral palsy can exhibit more selective leg coordination. The purpose of this study is to determine the ability of 3-month old full-term infants and preterm infants with very low birth weight to: (1) learn the contingency between leg action and mobile activation, and (2) demonstrate a greater degree of selective hip-knee joint coordination when leg actions are reinforced with mobile activation.
NUMBER OF SUBJECTS: Ten full-term infants and ten preterm infants with very low birth weight participated at corrected age 3.5 months ± 1 week (corrected age determined for preterm infants by subtracting number of days premature from chronological age).
MATERIALS/METHODS: Each infant participated in 2 sessions of mobile reinforcement on consecutive days. During each session, the infant was positioned supine under an overhead infant mobile. The first session consisted of a 2-minute baseline non-reinforcement condition in which the infant mobile did not activate in response to the infant's leg actions and a 6-minute reinforcement condition in which the infant mobile rotated and played music when the infant moved either foot a certain height above the table. The height was individualized to each infant's baseline leg actions. The second session consisted of a 2-minute non-reinforcement condition, 6-minute reinforcement condition, and 2-minute non-reinforcement condition.
RESULTS: A high proportion of full-term and preterm infants increased the frequency of mobile activation over 2 days to meet learning criteria. Full-term infants and some preterm infants who learned the task demonstrated a greater degree of selective hip-knee joint coordination during the reinforcement condition on the second day as compared to the first day.
CONCLUSIONS: Some 3-month old preterm infants with very low birth weight, at risk for cerebral palsy, can demonstrate a greater degree of selective hip-knee joint coordination when participating in a task in which their leg actions are reinforced with mobile activation.
CLINICAL RELEVANCE: These results provide the scientific foundation for the development of a therapeutic intervention which will allow physical therapists to reinforce selective leg actions of infants at high risk for cerebral palsy in order to encourage more typical movement strategies of the legs, prevent atypical movement strategies, and optimize motor skill development.
ASSOCIATION BETWEEN LOWER EXTREMITY IMPAIRMENT, AND THE PEDIATRIC BALANCE SCALE: A PILOT STUDY IN CHILDREN WITH SPASTIC CEREBRAL PALSY
N.J. Smith, A.M. Glanzman, Physical Therapy, The Children's Hospital of Philadelphia, Philadelphia, PA.
PURPOSE/HYPOTHESIS: The authors hypothesize that lower extremity impairment in children with cerebral palsy is related to balance, as measured by the Pediatric Balance Scale, a reliable measure of balance in children. This study is designed to determine the degree of association between lower extremity impairments (spasticity, passive range of motion, and strength), and balance in children ages 4 to 10 with spastic cerebral palsy.
NUMBER OF SUBJECTS: Five children with spastic cerebral palsy (4 with hemiplegia and 1 with diplegia).
MATERIALS/METHODS: Inclusion criteria included: 1) age 4 to 10 years; 2) diagnosis of spastic cerebral palsy; 3) Gross Motor Function Classification System level I, II, or III; and 4) able to follow simple verbal commands. Spasticity, range of motion, and muscle force were measured by the Ashworth scale, goniometry, and make test hand-held dynamometry, respectively. All impairment measures were assessed bilaterally. Functional balance ability was assessed using the Pediatric Balance Scale. Descriptive statistics, Spearman's rho, and confidence intervals and were used to analyze dominant and non-dominant lower extremities in relation to balance scores.
RESULTS: Negative relationships were found between non-dominant knee extension maximal and mean muscle force, and balance abilities (r = −0.975, 95% CI −0.998 to −0.664, p = 0.005 and r = −0.872, 95% CI −0.991 to 0.044, p = 0.054 respectively). Negative relationships were also found between non-dominant ankle plantar flexion maximal and mean muscle force, and balance abilities (r = −0.821, 95% CI −0.987 to 0.222, p = 0.089 and r = −0.975, 95% CI −0.998 to −0.664, p = 0.005 respectively). Positive relationships were found between dominant knee flexion maximal and mean muscle force and balance abilities (r = 0.872, 95% CI −0.044 to 0.991, p = 0.054). In addition, height and weight were associated with balance abilities (r = 0.975, 95% CI 0.664 to 0.998, p = 0.005).
CONCLUSIONS: A trend was noted in the association between strength and balance, such that hamstring strength of dominant limbs appears to support balance abilities. Significant negative associations were noted between strength of the non-dominant limb and balance which could have been the result of the influence of spasticity on the measurement of strength. No associations were noted with either spasticity or flexibility potentially related to the limited variability in the Ashworth scale and the limited number of subjects. A greater number of research subjects and future studies are needed to confirm these findings.
CLINICAL RELEVANCE: These findings represent an avenue for further research given the potential of weakness as a therapeutic target. This study also supports the use of the Pediatric Balance Scale in populations with cerebral palsy.
QUALITATIVE OUTCOMES OF SELECTIVE PERCUTANEOUS MYOFASCIAL LENGTHENINGS IN INDIVIDUALS WITH CEREBRAL PALSY
C. Stiller, L. Harrington, K. Yarskinsky, S. Yorke, Oakland University, Rochester, MI.
PURPOSE/HYPOTHESIS: Selective Percutaneous Myofascial Lengthening (PERCS), a relatively new surgical procedure for children with cerebral palsy, is an outpatient orthopedic surgery that involves making minute incisions into the myofascia, leading to increases in muscle length with minimal risk. The few studies that have been conducted on this surgery suggest improvements in function following PERCS. No studies have been conducted on PERCS outcomes or the role of physical therapy (PT) following the surgery from the viewpoint of the individuals who have had PERCS or their parents. The purposes of this qualitative study were to explore and compare parent and child perceptions about PERCS and the role of PT following PERCS.
NUMBER OF SUBJECTS: 8 individuals who were part of a concurrent quantitative study that examined clinical outcomes following PERCS and their parents.
MATERIALS/METHODS: Subjects participated in interviews about their experiences following PERCS. Guiding questions for the interviews were developed based on a review of the literature and input from two pediatric physical therapists. Interviews were conducted with one to two subjects; and most individuals were interviewed separately from their parents. Interviews were videotaped and transcribed. Transcribed data was analyzed by all researchers using the constant comparative method of qualitative analysis until a consensus regarding themes and concepts was reached.
RESULTS: Both the individuals who had PERCS and their parents agreed that they would recommend PERCS. They felt it was successful; met or exceeded their expectations; and resulted in a variety of physical, functional, psychological, and social changes. Most subjects felt that physical therapy was valuable following PERCS, however, a few of the subjects felt that PT did not have a great impact on improvements following PERCS. A conceptual framework was developed based on study results, a review of the literature, and the International Classification of Functioning, Disability and Health (ICF) Model.
CONCLUSIONS: Participants believed that PERCS makes a difference in all aspects of a child's life. Physical therapists have a role in post-surgical management of PERCS as a potential bridge between structural changes from PERCS and physical, functional, environmental and contextual factors of the ICF Model.
CLINICAL RELEVANCE: This study's conceptual framework demonstrates the importance of establishing therapeutic interventions that incorporate individual and family goals in relation to improving impairments and functional skills in all contexts, and emphasizes the role of PT as the bridge between the surgery itself and real world function within the context of the ICF model of disability. Understanding the physical, functional, psychological, and social outcomes of PERCS can help inform PT practice and improve support for family goals and the individual's development in all areas. Furthermore, the results support the American Physical Therapy Association and World Health Organization philosophies regarding the importance of ICF model in health care.
EFFECT OF PARTIAL BODY WEIGHT SUPPORT TREADMILL TRAINING AND STRENGTH TRAINING IN CHILDREN WITH CEREBRAL PALSY
W. Stuberg, M. Kurz, Physical Therapy, Munroe-Meyer Institute for Genetics and Rehabilitation, University of NE Medical Center, Omaha, N.
PURPOSE/HYPOTHESIS: Partial body weight support treadmill training (PWSTT) and strength training (ST) are two interventions that have been shown to have positive effects on the walking skills of children with cerebral palsy (CP). While improvements in walking speed, stride length and cadence have been documented, little is known about the effects of either training program on community participation. The optimal parameters for the interventions have yet to be identified to maximize positive clinical change. The purpose of this study was to determine the effects of PWSTT and ST program on a group of children with CP related to changes gait, activity and participation.
NUMBER OF SUBJECTS: Eleven children diagnosed with spastic diplegic CP, GMFCS levels I-III, age 12.1 years (range 6 to 16 years).
MATERIALS/METHODS: All subjects were randomly assigned to either a six week, three time per week PWSTT program or a six week, three time per week ST program. An eight week no intervention phase was included between interventions. The PWSTT program began at no more than 40% body weight support and was systematically reduced to no less than 5%. Training intensity did not exceed 75% of the child's predicted heart rate maximum. Treadmill speed was begun at self-selected velocity and progressed as tolerated over the six weeks. Walking duration was 30 minutes. ST was begun at 65% of a one rep maximum load with four sets of five repetitions. Progression of the weight was reset every two weeks dependent on retest one rep maximum scores. The ST program included hip and knee extension, hip flexion and ankle plantarflexion. Strength testing using a hand-held dynamometer of select leg muscles, a 10 m walk test, a six minute walk test and the Children's Assessment of Participation and Enjoyment (CAPE) were administered immediately before and following each intervention phase.
RESULTS: A significant improvement in strength scores and distance walking during the six minute walk test were seen following both interventions. The PWSTT intervention also significantly improved the 10 m walk test scores of the children, but not ST. The only significant change in participation with the CAPE was seen for the ST group in the dimension of intensity of participation. No significant change was seen in the diversity of activities, nor enjoyment of activities following either intervention. The two interventions were found to be equivalent for the improvements in strength, and the six meter walk test.
CONCLUSIONS: The results of this study provide additional support for the use of PWSTT and ST to improving select gait parameters in children with spastic diplegic CP. Neither protocol showed consistent positive results on community participation as measured by the CAPE.
CLINICAL RELEVANCE: Therapists should be aware that improvements in select gait parameters following either a PWSTT or ST program will not necessarily improve participation of children with CP in the community. Additional factors need to be examined to improve community participation.
RELATIONSHIP BETWEEN LOWER EXTREMITY MUSCLE STRENGTH AND BALANCE IN 6 AND 8 YEAR OLD CHILDREN
S.A. Talley, K. Duhaime, E. MacIntyre, K. Nycek, Physical Therapy Program, Wayne State University, Detroit, MI.
PURPOSE/HYPOTHESIS: Lower extremity (LE) muscle strength has been shown to be significantly correlated with motor function in healthy preschool children. While strength and balance have been studied independently, there are no studies which examine the relationship between LE muscle force and balance in young children. The purpose of this study was to examine the relationship between LE muscle strength and postural sway in 6 and 8 year old (YO) children.
NUMBER OF SUBJECTS: Forty typically developing children were recruited from a suburban public school. Twenty participants (50% female) were 6 YO (76.8 +/- 2.78 mos) and twenty (50% female) were 8 YO (100.8 mos +/- 3.12 mos). Height and weight were measured and dominant leg and ethnicity were recorded. Children with known neurological or other conditions which would prevent participation were excluded from the study.
MATERIALS/METHODS: The strength of 8 LE muscle groups were measured in the preferred leg using a Lafayette hand-held dynamometer using a “make” test. Standardized positions and stabilization were used. The mean force in kg was computed from 3 trials each for ankle dorsiflexion, plantarflexion, inversion, eversion, knee extension, knee flexion, hip abduction and hip adduction. Postural sway was measured using a portable Balance Master System. Four conditions were tested: bipedal stance with eyes open and eyes closed and tandem stance with eyes open and eyes closed. Center of pressure displacement was measured during three 10-second trials in each position and the mean was recorded in degrees per second.
RESULTS: Alpha was set at 0.05. LE strength was significantly stronger in the 8 YOs for all muscle groups except hip abduction, increasing from 14.7% − 25.4%. Postural sway decreased in all conditions in the 8 YOs, but only significantly for the bipedal stance - eyes closed condition. When adjusted for height, postural sway also decreased significantly in the two tandem stance conditions. There was only one significant correlation between muscle strength and postural sway: ankle eversion and tandem stance-eyes closed (r = −.38).
CONCLUSIONS: Normative data for LE muscle strength and postural sway is provided for typically developing 6 and 8 YO children. LE muscle strength was significantly stronger in the 8 YOs compared to the 6 YOs for all but one movement. The rank order of muscles producing the greatest to the least force did not change. Knee extension consistently produced the greatest force while ankle inversion generated the smallest force in both groups. Postural sway decreased significantly in the 8 year old group in the bipedal stance-eyes closed condition.
CLINICAL RELEVANCE: Activity limitations and participation restrictions have been observed in children with conditions resulting in LE muscle weakness. Normative data on muscle strength and balance in children is needed for comparative purposes. Understanding the relationship between muscle strength and balance in children may help physical therapists identify interventions to improve function in children with impairments of strength and balance.
POSTURAL ALIGNMENT IN KINDERGARTEN THROUGH SIXTH GRADE CHILDREN
A. Taylor, D. Parker, K. Richardson, S. Koh, D. Cipriani, J. Brechter, Physical Therapy, Chapman University, Orange, CA.
PURPOSE/HYPOTHESIS: The purpose of this study was to measure posture in children, and to determine if the incidence and severity of postural malalignments change between grade levels. It was hypothesized that the incidence of postural deviations, using Kendall's reference points as the template for ideal postural alignment, increase as children age.
NUMBER OF SUBJECTS: Thirty-eight children (mean age: 9, range: 5-12) participated and were divided into two groups (K-2nd grade: n = 9, 3rd-6th grade: n = 29).
MATERIALS/METHODS: Upon arrival, weight and height were measured for each volunteer. Reflective markers were placed on designated anatomical landmarks and photos were taken of each subject in four views. In order to achieve a “relaxed posture,” subjects were instructed to march three times prior to taking each photo. Right sagittal and anterior views were analyzed. The markers were digitized for frontal and right sagittal views using Vicon Motus and custom spatial models to calculate sagittal and frontal plane angles including ankle, knee, hip, thigh, trunk, pelvic tilt and forward head angles plus forward shoulder distance (mm from acromion marker). MANOVA and pairwise comparison were used for group comparisons (trunk and lower extremity angles); t-test was used for forward shoulder (normalized to anterior to posterior trunk depth) and Pearson correlation was used for weight and midline distances.
RESULTS: Significant differences were found in the sagittal view for forward head (K-2nd grade = 66.9°+12°; 3rd-6th grade = 74°+10°) and pelvic tilt angles (K-2nd grade = 8.2°+6.7°; 3rd-6th = 14°+7°). Weight correlated with lower extremity distances from midline at the knee, ankle, and 5th metatarsal (r ranges = .312-.461). Distinct trends denoted differences in pelvic obliquity (K-2nd grade = 1.3°+2.5°; 3rd-6th grade = −.4°+2.2°) and greater normalized forward shoulder in (K-2nd grade = .03%+.07%; 3rd-6th grade = .06%+.07%).
CONCLUSIONS: Postural mal-alignments increase with age in children, perhaps from increased time spent performing forward activities. Anteriorly, correlating weight and midline distances appear to indicate that larger children place their legs further apart.
Trends for forward shoulder also suggest that deviations increase with age, with mean values double or more in 3rd-6th grades, while frontal plane pelvic obliquity tends to be larger in K-2nd grades. Large variances contribute to lower power and warrant additional subjects especially in K-2nd grades.
CLINICAL RELEVANCE: Deviations in postural alignment may begin in elementary school and progress with age. These findings suggest a need for assessment and prevention programs for postural deviation in school-age children.
A RELIABILITY STUDY OF COMMON LOWER EXTREMITY MEASUREMENTS IN CHILDREN WHO ARE NON-OBESE AND OBESE AGES 8-12 YEARS
J.E. Tucker, M. Moore, J. Rooy, A. Wright, Health Professions - Program in Physical Therapy, University of Central Florida, Orlando, FL; L. Werk, Nemours Children's Clinic, Orlando, FL.
PURPOSE/HYPOTHESIS: The purposes of this study were to determine inter and intrarater reliability, as well as obtain descriptive statistics of Craig's test (CT), tibio-femoral angle (TFA), the Foot Posture Index-6 (FPI), and the Sit and Reach (SR) test in children who were obese and non-obese ages 8-12 years.
NUMBER OF SUBJECTS: 15 children who were obese, 21 children who were non-obese
MATERIALS/METHODS: A convenience sample of 26 children who were non-obese (a calculated BMI less than 85% for age and gender) and 15 children who were obese (calculated BMI above 95% based on age and gender) were included in the study. The children who were obese were enrolled from the Nemours Healthy Choices Clinic and those who were non-obese were recruited from the community. Five children who were non-obese were excluded due to a calculated BMI of greater than 85%. Height and weight were recorded for all subjects. Four measurements were collected on each child: CT, TFA, FPI, and SR test. Each was performed three times by each rater for a total of nine times, with the exception of the SR test, which was measured only three times total in order to eliminate a stretch response. An inclinometer, goniometer and yard stick were used in this study. All data was analyzed using IBM SPSS Statistic Version 19. The continuous variables for each measurement were compared using Intra Class Correlation Coefficients (ICC). ICC model 2,k and the 95% confidence interval were calculated to determine interrater reliability for each clinical test. For intrarater reliability, an ICC model 3,k and a 95% confidence interval were calculated. In addition, descriptive statistics of the individual measurements for each cohort were also analyzed.
RESULTS: The results indicated substantial intrarater reliability of all tests for both cohorts. Interrater statistics for the subjects who were obese showed substantial reliability of SR(0.99), TFA(0.844), and FPI(0.855). For the subjects who were non-obese, moderate reliability was found for TFA(0.657) and FPI(0.788) with the SR being substantial (0.996). CT reliability was moderate (0.604) for the subjects who were obese and slight for the subjects who were non-obese (0.372).
CONCLUSIONS: The reliability values established were consistent with current research. The CT was the only measurement that received lower than moderate interrater reliability which was also reported in the literature. Values for TFA and CT were noted to be higher in subjects who were obese. In addition, the values for SR were lower in the subjects who were obese.
CLINICAL RELEVANCE: Lower extremity musculoskeletal misalignments are often found in children who are obese. Examining the reliability of lower extremity measurements for these misalignments using the CT, TFA, FPI and SR provides insight into the usefulness of these measures for future research and clinical practice.
PHYSICAL THERAPY INTERVENTIONS FOR STUDENTS WITH SPINAL MUSCULAR ATROPHY TYPE II AND III IN THE EDUCATIONAL SETTING
K.D. Ward, Department of Physical Therapy, University of the Sciences, Philadelphia, PA; C. Nugent, Bucks County Intermediate Unit #22, Doylestown, PA.
PURPOSE: To present an evidence-based practice pattern with recommendations for physical therapy interventions to improve accessibility and participation in educational programs for students with Spinal Muscular Atrophy (SMA) Type II or III.
DESCRIPTION: SMA is a neuromuscular disease that affects the large anterior horn cells in the spinal cord. Students with SMA present with a wide variety of impairments and activity and participation limitations dependent upon the type, severity, and progression of their disease. Physical therapy services in the educational environment include collaboration with students and their families and educational team; student-related instruction; and procedural interventions. Services should be individualized and should take into consideration the specific environmental and personal expectations for that student. It is also important to acknowledge that needs may change over time based on disease progression, maturation, environmental changes, and curricular and extracurricular expectations and opportunities. Therapists should work in collaboration to develop appropriate functional goals, to identify areas for intervention and adaptation, and to identify needs for student-related instruction. Procedural interventions should aim to increase accessibility and participation by maintaining muscle strength and health and by minimizing secondary impairments such as contractures and skeletal changes.
This practice pattern provides evidence-based recommendations for PT services based on the International Classification of Functioning, Disability and Health (ICF) framework and the Guide to Physical Therapist Practice. The practice pattern includes a detailed layout of potential barriers and facilitators to accessibility and participation in the educational environment; describes activity and participation expectations in elementary, middle school, and high school; describes need for student-related instruction to the student, to the family, and to school personnel; and examines evidence-based procedural interventions including adaptive equipment, positioning, contracture management, therapeutic exercise, electrical stimulation, and aquatic therapy.
SUMMARY OF USE: This practice pattern provides therapists working in the educational setting an evidence-based description of factors affecting accessibility and participation, activity and participation expectations, and recommendations for physical therapy services including communication, coordination, and documentation, student-related instruction, and procedural interventions.
IMPORTANCE TO MEMBERS: This evidence-based practice pattern will assist the clinical decision making of physical therapists working in the educational setting with students with SMA. Furthermore, this practice pattern, which is based on the evidence in published literature, will help support the justification of physical therapy and particularly the need for consultative-based services.
THE EFFECTS OF HIPPOTHERAPY ON GAIT AND GROSS MOTOR FUNCTION IN CHILDREN WITH DOWN SYNDROME: CASE REPORTS
C.N. Whalen, M. Basso, Physical Therapy, The Ohio State University, Columbus, OH.
PURPOSE/HYPOTHESIS: Down syndrome is a genetic disorder that may result in gross motor deficits from muscle hypotonia, ligamentous laxity, and joint instability. Children with Down syndrome often have delayed motor milestones, delayed reaction times, balance and postural deficits, abnormal gait patterns, generalized slowness of movement, and/or lack coordination. Hippotherapy is an intervention that has positive benefits on these impairments in children with cerebral palsy but its effect in Down syndrome has been largely unstudied. Therefore, the purpose of this study was to evaluate the efficacy of an 8-week hippotherapy intervention on gross motor function and the spatiotemporal parameters of gait in three children with Down syndrome.
NUMBER OF SUBJECTS: Three children (1 male and 2 female) with Down syndrome ages 3, 4, and 11 years.
MATERIALS/METHODS: Each child participated in an 8-week hippotherapy program. GMFM-88, 10-meter walk test (gait speed), and pedograph data (step length, stride length, heel to heel base of support, path deviation, and toe-in/toe-out angle) were recorded pre- and post-intervention. The GMFM-88 included dimensions A (lying & rolling), B (sitting), C (crawling & kneeling), D (standing), and E (walking, running, & jumping).
RESULTS: At post-test all three children demonstrated significant improvements in GMFM-88 total scores (p = 0.013), and significant improvements in dimensions C (p = 0.030), D (p = 0.019), and E (p = 0.007). Right step length significantly increased after the intervention (p = 0.0001). Additionally, increases in gait speed and improvements in the spatial parameters of gait (base of support, hip rotation, path deviation) occurred but failed to reach significance due to high variability. However, these gains resulted in moderate to large effect sizes.
CONCLUSIONS: Hippotherapy in children with Down syndrome appears to have positive effects on the spatiotemporal parameters of gait and gross motor skills with greatest improvements in standing, walking, running, and jumping. Randomized-controlled trials with larger sample sizes are warranted to confirm the results of this study.
CLINICAL RELEVANCE: Based on the results of this study, clinicians are encouraged to use hippotherapy as a potential intervention for children with Down syndrome who have gross motor and gait impairments.
INTERVENTION FOR POSTURAL CONTROL IN SITTING AND INTERACTION WITH PLAY IN CHILDREN WITH SEVERE OR MODERATE CEREBRAL PALSY
S.L. Willett, R. Harbourne, A. Beyersdorf, Munroe Meyer Institute, Omaha, NE; B. Ryalls, N. Stergiou, University of Nebraska, Omaha, Omaha, NE.
PURPOSE/HYPOTHESIS: Play skills and the ability to manipulate objects is crucial for facilitating learning during early development. Recent studies of school success indicate that one of the most important predictors of school performance is the ability to manipulate objects. Sitting postural control is fundamental to the child's ability to reach, grasp, and explore the properties of objects in the learning environment. The purpose of this study was to determine the relationship between play and object interaction with the development of sitting posture in young children with severe or moderate cerebral palsy.
NUMBER OF SUBJECTS: Thirty-one children between the ages of 1-6 years were enrolled. Sixteen subjects were classified with severe CP (GMFCS 5) and fifteen were classified with moderate CP (GMFCS 3 and 4).
MATERIALS/METHODS: Children entered the study when they were able to prop sit for at least 10 seconds. Each child participated in twice weekly, one hour perceptual motor treatment sessions for 12 weeks. Sitting postural control was measured via an AMTI force platform to collect postural sway data. A nonlinear variable, the Approximate Entropy (ApEn) in the anterior-posterior direction, was calculated from the center of pressure sway time series to determine regularity in postural sway. Gross motor function was measured using the Gross Motor Function Measure-88 (GMFM), and the sitting dimension was the outcome variable of interest. Play was assessed using a modified structured play assessment based on the PIECES assessment tool. Linear regression modeled the contribution of play skills and sitting stability to the acquisition of sitting function at the end of the intervention phase.
RESULTS: GMFM sitting dimension scores increased significantly from pre to post intervention (mean = 9.48, SD = 8.47, t = 6.23, p = 0.00). Play scores pre-intervention accounted for a significant portion of the variance in the GMFM scores (t = 3.21; p = 0.003), and the change in ApEn scores also accounted for a significant portion of the variance (t = −2.83,; p = 0.009), together accounting for 40% of the variance in the GMFM post-intervention sitting scores.
CONCLUSIONS: Intervention to improve sitting skills for children with CP should include not only a focus on neuromuscular coordination and postural control, but should also focus on scaffolding play and object manipulation skills that will help to drive the development of sitting. Changes in postural control toward greater regularity that are measureable via postural sway appear to contribute to a functional change in sitting postural control.
CLINICAL RELEVANCE: Gaining postural control in sitting influences a child's play and learning abilities. Children who have greater stability in sit have more opportunities for manual exploration with their hands; and greater opportunity to explore in this manner has an impact upon early learning.
IS NEURAL AND VISCERAL MANIPULATION EFFECTIVE FOR INFANTS WITH CONGENITAL MUSCULAR TORTICOLLIS?: A PILOT FEASIBILITY STUDY
J. Zollars, J.A. Zollars, Physical Therapy, Inc., Albuquerque, NM; P. Burtner, G. Stockman, J. Brown, P. Gruner, Occupational Therapy, University of New Mexico, Albuquerque, NM; J. Lowe, Pediatrics, University of New Mexico, Albuquerque, NM
PURPOSE/HYPOTHESIS: Manual stretching has been shown to be an effective treatment for infants with congenital muscular torticollis (CMT); however infants often experience pain with this intervention. This study was designed to investigate changes in neck range of motion (ROM) in infants with CMT following a neural and visceral manipulation (NM/VM) treatment protocol administered with no observable pain behaviors (crying, withdrawing body movements, facial expressions).
NUMBER OF SUBJECTS: Ten infants (6 boys, 4 girls) with CMT recruited as a convenience sample (N = 10; Age: 4.4 mos. ± 2.3 mos.)
MATERIALS/METHODS: Research design was a pilot cohort pre, immediate post and 4 months post intervention with no control group. Ten infants with CMT received 30-50 minutes of NM/VM treatment every other week for a total of 8 sessions. Each infant was assessed with specific palpation techniques before and during treatment by the treating research therapist. Specific tissue areas of neck, head, trunk and extremities that were found to be restricted were the focus of intervention. With the exception of positioning alternatives during sleep, and “tummy time”, the parents were not instructed in home exercises. Neck ROM was measured by still photography before intervention, immediately following intervention (8 treatment sessions), and 4 months post intervention. Active and passive neck rotation and lateral flexion ROM were assessed by still photography. Measurements were collected as pairs of images (neutral and end point ROM) and compared by a computer program that calculated the angle of the lines created by two stable reference points on each infant using the equation [atan2 ((y2 − y1)/(x2 − x1)) * 180/π)]. Changes in the neck ROM measures across sessions were determined by repeated measures analysis of variance (ANOVA).
RESULTS: Statistically significant improvements from baseline were present immediately post intervention in active neck rotation (p = .002), passive neck rotation (p = .008) and lateral flexion (p < .001) in the infants' involved side with most limited ROM at baseline. Significant increases in all neck ROM measures were maintained 4 months post intervention as compared to baseline measures (p > .001).
CONCLUSIONS: Our pilot data provides preliminary support for the use of NM/VM in infants with CMT, and may be an alternative to traditional manual stretching which often is painful. No infants cried or demonstrated pain behaviors during the therapy sessions. Parents of some infants reported visible postural improvements in crawling/walking after 4 sessions of intervention and decreased spitting up after 1-2 sessions. Future studies comparing NM/VM to manual stretching in a larger sample infants with CMT is warranted to further support this intervention.
CLINICAL RELEVANCE: Based on this preliminary analysis, therapists might consider using neural and visceral manipulation in treatment of infants with torticollis.
KEYWORDS: Visceral manipulation, neural manipulation, torticollis