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Pediatric Physical Therapy:
doi: 10.1097/PEP.0000000000000067

Abstracts* From the Dutch Society for Pediatric Physical Therapy

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

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Vrony de Jong, MPPTa, aUniversity for Professionals Avans+ Breda, the Netherlands (; Anneloes Overvelde, PhD, PPTa,b, bIQ Healthcare Radboud University Medical Centre, Nijmegen, the Netherlands

INTRODUCTION: It is impossible to imagine life today without computers. They are being used more and more, and by increasingly younger age groups. Nevertheless, daily life still requires the fundamental skill of handwriting. International research has shown that 12-27% of schoolchildren have problems with handwriting or with learning to write.1 In Dutch children, this percentage lies between 5 and 33%.1 Paediatric physiotherapists play a major role in the professional guidance of children with handwriting problems and parents often ask whether keyboarding (typing) a text is a good alternative for their child. Our present state of knowledge is that writing and keyboarding are 2 separate motor skills, which differ chiefly in perceptual-motor interaction.2 In order to be able to give adequate advice, we need to know more about the relationship between writing and keyboarding in Dutch children. Therefore, we performed an oriented study on a large group of Dutch primary schoolchildren.

AIM: This oriented, cross-sectional field research aimed to compare handwriting and keyboarding skills in Dutch primary schoolchildren aged from 7-8 years (group 4) to 11-12 years (group 8).

METHODS: Data were gathered from a total of 301 children (group 4: n = 60, mean age: 95.97 months (SD = 4.82), group 5: n = 64, mean age = 106.37 months (SD = 5.19), group 6: n = 77, mean age = 120.22 months (SD = 5.06), group 7: n = 60, mean age = 129.87 months (SD = 4.76) and group 8: n = 40, mean age = 145.28 months (SD = 5.33)). Two copying tasks and 2 essay tasks were administered to compare each participant's speed and accuracy of writing and keyboarding. The speed of text production was defined as the total number of characters written or typed, including errors, in 5 minutes. Accuracy was expressed as a percentage: the number of errors (incorrect key touches or unclear letterforms or punctuation) was subtracted from the total number of written or typed characters. Then the number of accurate characters was divided by the total number of characters and multiplied by 100.

RESULTS: In all the age groups, speed showed a significantly high correlation (copying task: r = .715, P<.001; essay task: r = .743, P<.001), whereas accuracy showed a significantly low correlation (copying task: r = .221, P <.001; essay task: r = .433, P<.001) between writing and keyboarding. On average, keyboarding was faster and more accurate than writing irrespective of the task. The difference in speed reached significance from group 6 upwards (copying task: P = <.001; essay task: P = <.001). There was a significant difference in accuracy between the 2 tasks in all the age groups (copying task: P = <.05; essay task: P = <.001), except for the copying task in group 5.

CONCLUSION: Research into Dutch primary schoolchildren (groups 4 to 8) showed a significant relationship between handwriting and keyboarding skills. Keyboarding was on average faster and more accurate than writing from group 4 upwards; from group 6 upwards, the difference was significant. These findings contradict the limited number of international studies in which it was reported that handwriting was faster than keyboarding in various age groups of children.3–6 This can be explained by the changes in Dutch children's behaviour over the past 10 years: they now spend more time using a computer and start at an earlier age. Therefore, they have become more skilled with keyboarding. Our study findings form a sound basis for further research. We recommend a design that not only assesses the motor process (speed and accuracy) but also the cognitive process (quality of the children's work).

1. Overvelde A, Van Bommel I, Bosga I, Van Cauteren M, Halfwerk B, Smits-Engelsman B, Nijhuis-van der Sanden R. KNGF Evidence Statement Motorische schrijfproblemen bij kinderen. Ned Tijdschr Kinderfys. 2011;121(2):1–65. Cited Here...

2. Longcamp M, Zerbato-Poudou MT, Velay JL. The influence of writing practice on letter recognition in preschool children: a comparison between handwriting and typing. Acta Psychol. 2005;119:67–79. PubMed | CrossRef Cited Here... |

3. Preminger F, Weiss PL, Weintraub N. Predicting occupational performance: handwriting versus keyboarding. Am J Occup Ther. 2004;58:193–201. View Full Text | PubMed | CrossRef Cited Here... |

4. Crook C, Bennett L. Does using a computer disturb the organization of children's writing? Br J Dev Psychol. 2007;25:313–321. Cited Here...

5. Connelly V, Gee D, Walsh E. A comparison of keyboarded and handwritten compositions and the relationship with transcription speed. Br J Educ Psychol. 2007;77: 479–492. View Full Text | PubMed | CrossRef Cited Here... |

6. Berninger VW, Abbott RD, Augsburger A, Garcia N. Comparison of pen and keyboard transcription modes in children with and without learning disabilities. Learn Disabil Q. 2009;32:123–141. PubMed Cited Here... |

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Anne de Kievit, MPT, PPT; Floriande Health Centre, Hoofddorp, The Netherlands; Ida M Bosga-Stork, MRes, PPT; Senior Lecturer Master Physical Therapy, Pediatric Physical Therapy program, University of Applied Sciences Utrecht, the Netherlands.

BACKGROUND AND STUDY AIMS: In general practice, headaches are the third most common pain complaints in children. It is estimated that by the age of 15 years at least 75% of all children have experienced a headache episode.1 Tension-type headaches (TTH) are the most commonly experienced type of headaches in adults as well as in children. The prevalence of TTH in children varies between 3 and 15%.2,3 TTH are known to have an impact on daily functioning in children. Some children report that pain not only reduces the amount of leisure time spent with friends, but also has negative effects on their daily activities.4 The pathogenesis of TTH is not clearly understood. Some studies suggest an association between headaches, emotional disorders and environmental factors.5 Research on the relationship between severity of headaches and quality of life in general is abundantly available, but research directed at TTP in children is rare. The aim of this pilot study was to inventory the relationship between severity of the tension-type headache in children, quality of life and participation in daily life.

METHODS: In this pilot study, 13 children (2 boys) with tension type headache were included (mean age: 10,6 years, range 9-14). The children were enrolled for treatment, either with or without a referral by a general practioner. For diagnostic purposes we used the International Headache Classification (ICHD-2). The severity of the headaches was scored by frequency (score 0 to 7 in days) and intensity (score 0 to 10 on numeric scale). Quality of life was evaluated by using the Pediatric Quality of life Inventory (PedsQl), participation was evaluated by the Pediatric Migraine Disability Assessment (PedMIDAS).

RESULTS: The mean score of the headaches frequency was 5 days (range 2-7) and mean score of the pain intensity was 6 (range 3-8). A significant positive relation was found between intensity as well as frequency of the headaches and quality of life (r = 0.74, P = 0.004 and r = 0.77, P = 0.003, respectively). However, no significant relations existed between the intensity and frequency of the headaches and participation in daily life.

CONCLUSIONS: In this pilot study we have shown that, in this group of children, the severity of the tension type headaches (measured by frequency and intensity) has an impact on the quality of life, measured by the PedsQl, but not on daily participation measured by the PedMIDAS. It is therefore advisable to use the PedsQl as well as a headache diary, to monitor children with TTP during treatment. The use of the participation questionairre PedMIDAS is debatable. Firstly, the PedMIDAS is validated for children with migraine and not for children with TTP. Secondly, the questionnaire PedMIDAS spans an evaluation period of 3 months and is therefore not vere usefull to evaluate therapy, because the treatment is often completed within 3 months. In addition, children found it difficult to fill out. It is therefore advisable to develop a more informative questionnaire for children with tension-type headaches.

KEYWORDS: tension-type headache, quality of life, child, and participation

1. Ducro P., Cantwell-Simmons E. A review of studies evaluating biofeedback and relaxation training in the management of pediatric headache, Headache. 1989; 29: 428–433 Cited Here...

2. Linet M.S., Stewart W.F., Celentano D.D., Ziegler D., Sprecher M. An epidemiologic study of headache among adolescents and young adults. The Journal of the American Medical Association. 1989;261(15):2211–2216. PubMed | CrossRef Cited Here... |

3. Perquin C.W., Hunfeld J.A., Hazebroek-Kampschreur A.A., van Suijlekom-Smit L.W., Passchier J., Koes B.W., van der Wouden J.C. The natural course of chronic benign pain in childhood and adolescence: a two-year-population-based follow-up study. European Journal of Pain, 2003; 7(6): 551–559. Cited Here...

4. Frare M. Quality of life, coping strategies, and family routines in children with headache. Headache. 2002;42: 953–962 View Full Text | PubMed | CrossRef Cited Here... |

5. Pitrou I., Shojaei T., Chan-Chee C., Wazana A., Boyd A., Kovess-Masfety V. The associations between headaches and psychopathology: a survey in school children. Headache. 2010; 50: 1537–1548 Cited Here...

6. Engelen V., Haentjens M.M., Detmar S.B., Koopman H.M., Grootenhuis M.A., Health related quality of life of Dutch children: psychometric properties of the PedsQL in the Netherlands, BioMedCentral Pediatrics, 2009;9: 68

7. Hershey A.D., Powers S.W., Vockell A.L., LeCates S., Kabbouche M.A., Maynard M.K., PedMIDAS: development of a questionnaire to assess disability of migraines in children, Neurology, 2001;11:20342039

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J. Klarenbeek, MPPT, Fysiostad, Zwolle, the Netherlands; M.W. Versteegt, MSc, PT, De Vogellanden Centrum voor Revalidatie, Department Child Rehabilitation, Section Physical Therapy, Zwolle, the Netherlands; R. van Empelen, PhD, MA, PPT, Child Development and Exercise Center, Division of Pediatrics, University Children's Hospital and Medical Center Utrecht, Utrecht University, the Netherlands. Master Physical Therapy, University of Applied Sciences Utrecht, the Netherlands

BACKGROUND: Cerebral Palsy (CP) is characterised as a non-progressive disorder of movement and posture. Children with CP often suffer from a lack of balance compared with children that are typically developing. As balance skills are an integral part of gross motor abilities, poor balance causes difficulties with functional tasks involved in activities of daily life.1 Virtual reality training (VRT) has been described as one of the most recent and innovative developments in rehabilitation technology and has now emerged as a promising tool in pediatric physical therapy.2,3 The Nintendo Wii Fit system is an example of VRT.4 In a recent Dutch study, the Nintendo Wii Fit training was found to be effective in balance education in children with CP.4

METHOD: Data were collected from 11 children (age 12- 18 years) diagnosed with CP (GMFCS I-III). All children were treated in ‘De Vogellanden’ Rehabilitation Centre, Zwolle, the Netherlands. Ethical approval was obtained from the research committee of ‘De Vogellanden’. All children and their parents gave informed consent to participate in this study. The children were non-randomly divided into 2 groups. Children who had a Wii Fit at home were allocated to the first group. This group received the Wii-Fit intervention. The intervention sessions lasted 25 minutes and took place 4 times a week (2 sessions under guidance of a physiotherapist in ‘De Vogellanden’ and 2 sessions individually at home), during a 3-week period. To resemble the daily life situation as accurate as possible, we decided that the child would wear shoes and/or orthoses during the Wii Fit gaming sessions. The second group received conventional physiotherapy 4 times a week during a 3-week period. The Berg Balance Scale (BBS) was used to evaluate the children's balance functions. Balance functions were measured at baseline and after the 3-week period of intervention. During the test the children wore shoes and/or orthoses.

RESULTS: In total 11 Dutch children were treated and tested. The first group (n = 6) included 3 girls and 3 boys. The second group (n = 5) included 2 girls and 3 boys. The average age in the first group was 16.5 years (SD = 0.77 years, range 13-18 years) and 14.8 years (SD = 0.92 years, range 13-18 years) in the second group. Balance scores improved significantly (P = 0.04) in the Wii-Fit group. The median score on the BBS increased from 49 (42-55) at baseline to 49.5 (43-56) after the training. Changes over time in balance scores in the second group were not significant (P = 0.08). The median score on the BBS increased from 49 (47-54) at baseline to 51 (49-54) after the training. No significant training effect was found between both groups after the 3-week period of intervention (P = 0.85).

CONCLUSION: The results indicate that the Nintendo Wii Fit has the potential to be used as a rehabilitation tool in balance education for children with CP even if the children wear shoes and/or orthoses during the training. It is not recommended that VRT will replace conventional physiotherapy, however it can serve as a proven effective complimentary rehabilitation tool.4

1. Gan SM, Tung LC, Tang YH, Wang CH. Psychometric properties of functional balance assessment in children with cerebral palsy. Neurorehabilitation and neural repair. 2008;22(6):745–53. PubMed | CrossRef Cited Here... |

2. Howcroft J, Klejman S, Fehlings D, et al. Active video game play in children with cerebral palsy: potential for physical activity promotion and rehabilitation therapies. Archives of Physical Medicine and Rehabilitation. 2012;93(8):1448–56. PubMed | CrossRef Cited Here... |

3. Parsons TD, Rizzo AA, Rogers S, York P. Virtual reality in paediatric rehabilitation: A review. Developmental Neurorehabilitation. 2009;12(4):224–238. Cited Here...

4. Jelsma J, Pronk M, Ferguson G, Jelsma-Smit J. The effect of the Nintendo Wii Fit on balance control and gross motor function of children with spastic hemiplegic cerebral palsy. Developmental Neurorehabilitation, 2012;15(1)1–11. Cited Here...

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Lieke van de Wetering-Martens1,2, Master Pediatric Physical Therapy; Bouwien Smits-Engelsman, Senior Lecturer1,3; Gillian Petersen-Ferguson, Senior Lecturer4; 1Master of Pediatric Physical Therapy, Avans+ Breda, Heerbaan 14, 4817 NL, Breda; 2Pediatric Physical Therapist, FysioCentrum Heesch, Verdilaan 48, 5384 CJ, Heesch; 3Department of Kinesiology, KU Leuven, Belgium; 4Department of Health and Rehabilitation Sciences, University of Cape Town, South Africa Email:

BACKGROUND: Motor imagery (MI) can be defined as a dynamic process in which an individual mentally simulates the performance of a discrete motor action or sequence of movements.1 MI develops with age and through varied movement experiences.2 Recent studies, examining MI in children living in prosperous circumstances, show that children with developmental coordination disorder (DCD) have a limited ability to use internal models.3 In South Africa low socio-economic circumstances are reported and children have less opportunity to develop motor skills through participation in organised sports and free play.4 Based on this difference in circumstances it is questioned if MI and motor skill performance will be different in children with and without DCD in South Africa.

PURPOSE: Because of the assumption that children who are living in low socio-economic circumstances have less opportunity to gain motor experience and thus have less opportunity to develop MI, this study aimed to determine whether there is a difference in motor imagery performances of South African children with and without DCD, who are living in low socio-economic circumstances.

METHODS: The Visual Guided Pointing Task (VGPT) was used to determine MI-ability and speed-accuracy trade-offs (Fitts' Law) in children aged 6 to 10 years old with DCD (n = 28) and age- and gender-matched children that were typically developing (TD) (n = 28) in Cape Town, South Africa.

RESULTS: Children that were TD were faster in both executed and imagined conditions than children with DCD (F(1, 54) = 7.484, P < .01), with the greatest difference reported in the executed condition (F(1, 54) = 6.564, P = .013). Imagined movements were always faster than executed movements for both groups (F(1, 54) = 114.969, P < .001). Correlation in movement time between the 2 conditions was higher for children that are TD (r = .710, P = <.0001) than for children with DCD (r = .264, P = < .0001). Executed movements obeyed Fitts' Law (R2 = .50, SD = .25) whereas imagined movements did not (R2 = .14, SD = .18) in both groups.

CONCLUSION: Findings suggest children with DCD show decreased ability to imagine the time needed to complete goal-directed movements. Studied children that were TD show atypical performance in imagined conditions, probably explained by age and/or movement experience.

1. Jeannerod M., The representing brain: neural correlates of motor intention and imagery. Behavioral and Brain Sciences 1994;17(2):187–202. PubMed | CrossRef Cited Here... |

2. Caeyenberghs K., Tsoupas J., Wilson P.H., Smits-Engelsman B.C.M., Motor imagery development in primary school children. Developmental Neuropsychology 2009;34(1):103–121. PubMed | CrossRef Cited Here... |

3. Wilson P.H., Ruddock S., Smits-Engelsman B.C.M., Polatajko H., Blank R. Understanding performance deficits in developmental coordination disorder: a meta-analysis of recent research. Developmental Medicine & Child Neurology 2013;55(3):217–228. View Full Text | PubMed | CrossRef Cited Here... |

4. McVeigh J.A., Norris S.A., de Wet T. The relationship between socio-economic status and physical activity patterns in South African children. Acta Paediatrica 2004;93(7):982–988. View Full Text | PubMed | CrossRef Cited Here... |

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Melanie Wolffs1,2,3, Master Pediatric Physiotherapy; Dorothee Jelsma4,5; Bouwien Smits-Engelsman, PhD4, Professor; 1Master Pediatric Physiotherapy Course, Avans+, Breda, the Netherlands; 2Pediatric Physiotherapist, Stichting Koraalgroep, Maasveld, Maastricht, the Netherlands; 3Pediatric Physiotherapist, Fysiotherapie Maatschap Snijders, Stein, the Netherlands; 4Faculty of Kinesiology and Rehabilitation Sciences, Katholieke Universiteit Leuven, Gebouw De Nayer (GDN), Belgium; 5Developmental and Clinical Neuropsychology, University of Groningen, the Netherlands

BACKGROUND: Developmental coordination disorder (DCD) is a diagnosis described in the Diagnostic and Statistical Manual (DSM-V).1 The prevalence of school-aged children with impaired motor development or DCD in developing countries is 5-15%.2,3 In this article the term mild motor coordination problems is used for children who have a low score on the Movement Assessment Battery for Children 2 (MABC-2), comparable with the DCD cut-off point (p ≤ 16), but who are not (yet) diagnosed with DCD. The different treatment methods for DCD can roughly be divided into 2 types: process-oriented and task-oriented approaches.3 The task-oriented approach targets the interactions between the child, the task and the environment.4 The most commonly used are the “Cognitive Orientation to daily Occupational Performance” (CO-OP) and “Neuromotor Task Training” (NTT), both especially developed for children with DCD. The meta-analysis of Smits-Engelsman et al. showed an almost 7 times larger mean effect size for task-oriented approaches compared to process-oriented approaches in children with DCD.5 The use of virtual reality is increasing in pediatric rehabilitation.6 Since children with DCD rely on feedback, virtual reality might be a good intervention tool to enhance motor learning in these children.2 The games give immediate knowledge of results of the games played, which may enhance motivation to repeat the game. The pediatric physical therapist is able to control the task in the virtual environment.7 Hammond et al. showed that gross motor performance improved after a Wii intervention in children with DCD.8 Whether children with different backgrounds benefit equally from virtual reality intervention is still unknown. South African children, living in a township, are usually less familiar with playing virtual reality games than Dutch children. It is interesting to analyze the assumed benefit of a Wii intervention in children with DCD from these different backgrounds.

PURPOSE: There is still little evidence about the effectiveness of the Wii intervention in children with DCD and mild coordination problems. The aim of this study was twofold. 1) To examine the effect of a 6-week Wii intervention on motor performance, in 5-10-year-old children with mild coordination problems. 2) To examine the difference in treatment effect in Dutch and South African children.

METHODS: A 2-group design with multiple measurement moments was used to test for differences between groups (the Netherlands (NL), n = 14 and South Africa (SA), n = 18), and for changes over time. Outcome measures were Ski Slalom Test (seconds and missed gates), MABC-2 and Enjoyment Scale. Assessments were recorded at baseline (T0), pre- (T1) and post intervention (T2). The non-intervention period (T0-T1) and the intervention period (T1-T2) were both 6 weeks. The children received 30 minutes of Wii-training, 3 times a week, for 6 weeks. For statistical analyses the Friedman Test and Wilcoxon Signed Ranks Test were used.

RESULTS: All children completed the study. Both groups were comparable for age, length, weight, Ski Slalom Test (seconds and missed gates) and total standard score on the MABC-2 at baseline. They differed only significantly in gender and there was a difference on the MABC-2 component balance; the children from the SA group scored better compared to the NL group. The total group improved significantly on the Ski Slalom Test (P = 0.001) and MABC-2 (P = 0.029) after intervention. If the data were analyzed for the 2 groups separately, the SA group improved more on the Ski Slalom Test (NL group P = 0.045, SA group P = 0.010), while only the NL group improved significantly on the MABC-2 (P = 0.006) after intervention.

CONCLUSION: The Wii is an effective, task-oriented therapy tool to enhance a clinical improvement on the MABC-2 in children with mild motor coordination problems in combination with the auditory, manual and visual feedback of the pediatric physical therapist.

1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. Text revision. 5th edition. Washington DC: American Psychiatric Association; 2013. Cited Here...

2. Straker LM, Campbell AC, Jensen LM, et al. Rationale, design and methods for a randomized and controlled trial of the impact of virtual reality games on motor competence, physical activity, and mental health in children with developmental coordination disorder. BMC public health 2011;11:654. PubMed | CrossRef Cited Here... |

3. Zwicker JG, Missiuna C, Harris SR, et al. Developmental coordination disorder: a review and update. European journal of paediatric neurology 2012: 1–9. Cited Here...

4. Peens A, Pienaar AE, Nienaber AW. The effect of different intervention programmes on the self-concept and motor proficiency of 7-9-year-old children with DCD. Child: care, health and development 2008;34(3):316–328. View Full Text | PubMed | CrossRef Cited Here... |

5. Smits-Engelsman BMC, Blank R, Kaay van der AC, et al. Efficacy of interventions to improve motor performance in children with developmental coordination disorder: a combined systematic review and meta-analysis. Developmental medicine and child neurology. 2012:1–9. Cited Here...

6. Levac D, Pierrynowski MR, Canestraro M, et al. Exploring children's movement characteristics during virtual reality video game play. Human movement science 2010;29:1023–1038. Cited Here...

7. Deutsch JE, Borbely M, Filler J, et al. Use of a low-cost, commercially available gaming console (Wii) for rehabilitation of an adolescent with cerebral palsy. Phys ther 2008;88:1196–1207. PubMed | CrossRef Cited Here... |

8. Hammond J, Jones V, Hill EL, et al. An investigation of the impact of regular use of the Wii Fit to improve motor and psychosocial outcomes in children with movement difficulties: a pilot study. Child: care, health and development 2013:1–11. Cited Here...

© 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins and the Section on Pediatrics of the American Physical Therapy Association.


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