MONITORING CHANGES IN THE LOWER LEG MUSCLES OF CHILDREN WITH DUCHENNE MUSCULAR DYSTROPHY VIA PROTON TRANSVERSE RELAXATION TIME USING MRI
I. Arpan, S. Forbes, D. Lott, E. Senesac, S.D. Vos, C. Senesac, K. Vandenborne, Physical therapy, University of Florida, Gainesville, FL; S. Germain, Pediatrics, University of Florida, Gainesville, FL; G.A. Walter, Physiology & Functional Genomics, University of Florida, Gainesville, FL.
PURPOSE/HYPOTHESIS: Duchenne muscular dystrophy (DMD) is the second most common single gene disorder in Western countries. In DMD the absence of the protein dystrophin leads to early and progressive involvement of the skeletal muscles. Children with DMD typically have enhanced susceptibility to muscle damage and progressive fatty tissue infiltration both of which result in the elevation of proton transverse relaxation time (T2) during magnetic resonance imaging (MRI) in the skeletal muscles. Thus, T2 relaxation time may provide a useful tool for monitoring the disease progression in DMD. Furthermore, this noninvasive technique enables comparing various muscles at the same time. Thus, the goal of this study was to compare T2 relaxation time in the medial gastronemius (MG), soleus (SOL), tibialis anterior (TA) and peroneals (PER) of children with DMD and the healthy controls.
NUMBER OF SUBJECTS: Six healthy controls (10.95 ± 2.42 yrs) and thirty children with DMD (9.19 ± 2.44 yrs).
MATERIALS/METHODS: All the subjects underwent T2-weighted imaging (12–18 axial slices; TE's: 20, 40, 60, 80, and 100 ms) of their lower leg in a 3T magnet using a SENSE knee volume coil. T2 maps of the lower leg were developed using a custom-written IDL software. Then MG, SOL, TA and PER were manually traced on the obtained maps. The mean T2 value of the pixels within the traced regions of interest (ROI) was calculated. Independent sample t-tests were done to make age and mean T2 comparisons for the four muscles across the two groups.
RESULTS: There was no significant difference between the ages in the two groups (p = 0.12). The mean T2 of all four lower leg muscles was elevated (p < 0.05) in DMD subjects (MGDMD = 47.8 ± 8.1 ms, SOLDMD = 48.1 ± 5.5 ms, TADMD = 39.4 ± 4.6 ms, PERDMD = 46.7 ± 6.0 ms) in comparison to controls (MGCON = 39.7 ± 3.3 ms, SOLCON = 39.1 ± 1.8 ms, TACON = 32.2 ± 1.3 ms, PERCON = 39.1 ± 4.3 ms). The mean T2 of the TA was lower than SOL, MG and PER in the DMD subjects.
CONCLUSIONS: The elevated T2 values within the lower leg muscles of children with DMD in comparison to controls indicate the regions of damage, edema, and fatty tissue infiltration in the muscles due to diseased process. Furthermore the lower mean T2 of the TA compared to MG, SOL, and PER in DMD suggests that the TA is relatively preserved.
CLINICAL RELEVANCE: T2-weighted MRI may prove clinically useful in non-invasive monitoring of the subtle changes in the muscles during the disease progression and therapies in DMD patients.
EFFICACY AND TOLERABILITY OF MODIFIED CONSTRAINT-INDUCED THERAPY IN CHILDHOOD STROKE
H.L. Atkinson, Physical Therapy, The Children's Hospital of Philadelphia, Philadelphia, PA; R.N. Ichord, Neurology, The Children's Hospital of Philadelphia, Philadelphia, PA.
PURPOSE/HYPOTHESIS: Childhood stroke is a significant pediatric health issue, with a rate of 12.6 per 100,000 children and 24 per 100,000 neonates. 30–60% have ongoing physical disability. Recent research suggests that constraint-induced therapy (CIT) is a promising intervention that utilizes the strategy of massed practice with the overall goal of improvement in function. Further study is needed, especially in children, to determine the most effective, tolerable, and clinically feasible method of CIT. The purpose of this study is to determine the effect of a modified CIT (mCIT) protocol in children with hemiplegia due to stroke and to analyze the tolerability of the intervention to children and their caregivers.
NUMBER OF SUBJECTS: Five children were recruited with the following inclusion criteria: 5–18 years old, diagnosed with stroke, ≥6 months post insult, ≥20 degrees antigravity wrist extension, and ability to participate in all aspects of the study. Children were excluded if they had received botox injections in the 6 months preceding the study.
MATERIALS/METHODS: Study design was a prospective pilot pre-test post-test study. Children engaged in a mCIT protocol utilizing the principles of motor learning, repetition, shaping, feedback, and family education. Participants received an individualized program and participated in therapy 2 hours a day, 5 days/week, for 4 weeks. Children wore a soft mitt on the uninvolved arm for 5 hours/day, 7 days/week to increase opportunities for use of the involved hand. A home program was provided and a change in lifestyle was encouraged. Outcomes included measures of impairment and function (strength, Jebsen-Taylor Test of Hand Function and Bruininks-Oseretsky Test of Motor Proficiency-2 [BOT-2]), quality of life (child and parent versions of the Peds QL), perceived amount and quality of involved extremity use during participation in daily life skills (Motor Activity Log [MAL] and Pediatric Motor Activity Log), and perceived tolerability of mCIT (Caregiver Burden Survey and Child Tolerability Questionnaire).
RESULTS: Improvements in mean score were noted in all measures from pre-test to post-test. A decline in BOT-2 scores was observed from post-test to 3 month follow-up. Strength continued to improve at the 3 month follow-up and MAL and pedsQL maintained their post-test levels. Caregiver burden was perceived to be low and tolerance was good.
CONCLUSIONS: This pilot study demonstrated a clinically feasible method of delivering a modified version of CIT to children with stroke. Methodology was tolerated by the child and caregiver, and results showed positive trends toward improvement in function. Further research is needed in the context of a controlled trial to determine the efficacy of mCIT.
CLINICAL RELEVANCE: As larger studies are developed examining the effect of CIT on children, researchers should consider protocols that are feasible from a clinical perspective. This pilot project suggests a modified model based on successful studies in adults but includes necessary elements to make it potentially applicable to a pediatric population.
PHYSICAL THERAPY SERVICE UTILIZATION FOR CHILDREN WITH CEREBRAL PALSY IN AN OUTPATIENT MEDICAL SETTING
A.F. Bailes, Divsion of Occupational Therapy and Physical Therapy, Cincinnati Childrens Hosptial Medical Center, Cincinnati, OH.
PURPOSE/HYPOTHESIS: Information regarding physical therapy (PT) service utilization of children with cerebral palsy (CP) has not been systematically studied but has implications for service delivery, policy and staff training. Therefore the purpose of this retrospective study was to describe outpatient PT services used by children with CP in a large pediatric medical setting.
NUMBER OF SUBJECTS: Information for outpatient PT services was collected by retrospective review of electronic medical records of 416 children seen during January 1, 2008 through December 31, 2008 at this outpatient pediatric medical center with a diagnosis of CP.
MATERIALS/METHODS: Variables of interest were age, sex, GMFCS level and total number of PT therapy units (time, 4 units = 1 hour) billed. In addition, frequencies of each procedure billed were obtained including evaluation, tests and measures, therapeutic procedures, therapeutic activities, neuromuscular education, aquatic therapy, manual therapy, orthotics/casting, wheelchair management, and self care/home management.
RESULTS: Most of the 416 children seen were classified as Level I n = 150 (36%) followed by; Level II n = 60 (14%), Level III n = 54(13%), Level IV n = 78(19%), and Level V n = 74 (18%). The majority of the children 196 (47%) were between 512 years of age. 105 (25%) children were between 1 year and 5 years, 79 (19%) were between 12–18 years and 36 (9%) were greater than 18 years old. The total number of therapy units billed in the year was 14,339. The mean number of units billed per person by GMFCS level was as follows: Level I 29.45 (SD = 27.34, range 1–148), Level II 28.43 (SD = 25.48, range 2–94), Level III 59.02 (SD = 54.38, range 1–216), Level IV 46.1 (SD = 55.14, range 4–242), and Level V 19.36 (SD = 20.45, range 1–80). Therapeutic activities was the most frequently billed procedure 5381 (38%) followed by therapeutic procedures 3279 (23%), orthotics or casting 2638 (18%), neuromuscular education 1038 (7%), evaluation 804 (6%), tests and measures 282 (2%), aquatic therapy 325 (2%), manual therapy 247 (2%), self care/home management 284 (2%) and wheelchair management 62 (0.4%).
CONCLUSIONS: In this outpatient medical setting 47% of the children with CP seen for PT services were school age between 5–12 years. Thirty six percent were classified as GMFCS Level I; however children with GMFCS Level III had the highest mean number of therapy units in a year (59.02). The range of therapy units billed was wide for all GMFCS levels. The most frequent procedure billed was therapeutic activities for all GMFCS levels.
CLINICAL RELEVANCE: This retrospective study provides preliminary descriptive data on service utilization by children with CP in the outpatient medical setting. Future work will include obtaining additional information for the sample such as race and type of insurance so that patterns of service utilization can be explored.
RELATIONSHIP OF THERAPY TO POST-SECONDARY EDUCATION IN YOUNG ADULTS WITH PHYSICAL OR ORTHOPEDIC LIMITATIONS: A LONGITUDINAL ANALYSIS
K.F. Bjornson, Developmental Medicine/Child Health Behavior & Developement, University of Washington/Seattle Children's Research Institute, Seattle, WA; A. Kobayashi, W. Walker, Developmental Medicine, Seattle Children's Hospital, Seattle, WA; C. Zhou, Biostatistics, University of Washington/Seattle Children's Research Institute, Seattle, WA.
PURPOSE/HYPOTHESIS: Transition from adolescence to adulthood presents numerous challenges for persons with physical limitations. We examined the influence of school and community-based therapy services and related factors on participation in post-secondary education in young adults with physical or orthopedic limitations. Among young adults with physical or orthopedic impairments, including cerebral palsy (CP) and spina bifida (SB), school and community-based physical (PT) and/or occupational therapy (OT) provided at ages 13–16 years will be positively associated with enrollment in post-secondary education. Social skills and activities, independence in activities of daily living (ADL) and mobility will also be positively associated.
NUMBER OF SUBJECTS: A sample of 1510 youth representing an estimated population of 98,145 individuals in the population was followed from 2001 to 2007 including youth with CP (52%) and SB (8.5%).
MATERIALS/METHODS: A representative sample of youth participants from The National Longitudinal Transition Study 2 (NLTS2) with physical or orthopedic impairment and who received special education services was selected. Weighted survey data, to ensure representative sampling, was analyzed with descriptive statistics and logistic regression for complex survey data.
RESULTS: The average age at entry was 15.1 years (range 13–17) and 21.1years (range 19–23) at follow-up. At the first survey, 57% were male, 63% Caucasian, and 16% African-American. Therapy services were received by 34% of participants' ages 13–16 years. 58% had health insurance and 39% came from schools where less than a quarter of students qualified for free/reduced price lunches. Thirty-four percent came from families where the parents had completed high school. “Any type of post-secondary education” at age 19–21 years was the dependent variable for multivariable logistic regression with “received PT or OT in the last 12 months” at age 13–16 years the predictor of interest. At follow-up, 48% were participating in post-secondary education. Youth who received PT or OT services are 3.2 times more likely to participate in post-secondary education (OR = 3.2, p = .03). The covariates of arm and hand use [OR = 4.8], self-care skills [1.3], parental education [2.1], graduating high school [3.1] and overall social skills [1.2] were significantly associated with post-secondary secondary education.
CONCLUSIONS: Receiving PT or OT services at age 13–16 years was significantly associated with enhanced enrollment in post–secondary education at age 19–21 years among young adults of equivalent upper extremity function, parental education, graduation status and social skills. PT and OT services occurred primarily within the school and appear to be an important factor in achieving post-secondary academic success for children with physical impairments.
CLINICAL RELEVANCE: Speicial education services, including PT or OT, should focus on interventions to improve upper extremity function, self–care skills, and social skills to optimize later academic success.
PAID EMPLOYMENT IN YOUNG ADULTS WITH PHYSICAL LIMITATIONS: RELATIONSHIP TO SCHOOLBASED THERAPY
K.F. Bjornson, Pediatrics/Developmental Medicine, University of Washington, Seattle Children's Research Institue, Seattle, WA; A. Kobayashi, W. Walker, Pediatrics/Developmental Medicine, University of Washington/Seattle Childrens Hospital, Seattle, WA; C. Zhou, Biostatistics, University of Washington/Seattle Childrens Hospital, Seattle, WA.
PURPOSE/HYPOTHESIS: Persons with physical limitations experience unique challenges during the transition from adolescence to adulthood. One indicator of full participation in adult life is finding appropriate paid employment. We explored the influence of physical (PT) and occupational therapy (OT) services and related factors on the levels of paid employment in young adults with physical or orthopedic impairments. Among young adults with physical or orthopedic impairments, including cerebral palsy (CP) and spina bifida (SB), school and community-based PT and/or OT given at ages 13–16 years will be positively associated with paid employment post-high school. Social skills and activities, independence in activities of daily living (ADL) and mobility will also be positively associated paid employment post-high school.
NUMBER OF SUBJECTS: A sample of 1510 youth representing an estimated population of 98,145 individuals was followed from 2001 to 2007 including youth with CP (52%) and SB (8.5%).
MATERIALS/METHODS: A representative sample of youth participants from The National Longitudinal Transition Study 2 (NLTS2) with physical or orthopedic impairment and who received special education services was selected. Weighted data, to ensure representative sampling, was analyzed using descriptive statistics and logistic regression for complex survey data.
RESULTS: At enrollment 57% were male, 63% Caucasian, and 16% Afro-American. Thirty-four percent of participants received therapy services. 58% had some form of health insurance and 39% came from schools where less than a quarter of students qualified for free/reduced lunches. The average age at entry was 15.1 years (range 13–17) and 21.1years (range 19–23) at follow-up. Thirty-four percent came from families where the parents had completed high school. “Worked for pay in last two years or currently has a paying job” was the dependent variable for regression with “received PT or OT in the last 12 months” the predictor of interest. At follow-up, 43% of the sample had paid employment. Youth who received therapy services had no greater rate of employment at follow-up [OR = .43, p = .09]. Significant increases in paid employment post high school were found for the covariates of frequent social interactions [12.2]and high school graduation[OR = 4.2]. Non-Caucasian youth[.4], youth with limitations in expressive language skills[.5] and using a wheelchair[.06] had small but significantly lower rates of employment.
CONCLUSIONS: PT and OT services received at age 13–16 years were not significantly associated with paid employment at age 19–21 years among young adults with physical or orthopedic limitations. Their benefit appears to be small as compared to those derived from social interactions and high school graduation status.
CLINICAL RELEVANCE: PT/OT services for this population occur primarily within the school setting, thus individualized instruction should focus on social interaction, expressive language skills and successful completion of high school appears indicated for youth with physical limitations to promote future paid employment.
ESTABLISHMENT OF A COMPREHENSIVE SPECIAL NEEDS CAR SEAT PROGRAM IN AN ACUTE CARE SETTING
K. Born, K. Dautel,, Advocate Lutheran General Hospital, Park Ridge, IL.
Purpose: The purpose of the program is to provide safe transport for children placed in hip spica casts (HSC), which prevent them from being safely transported in a standard car seat, as well as consistent and efficient return of the car seats. This program employs a different equipment vending methodology than is typically used throughout acute care hospitals across the country.
DESCRIPTION: The hospital is faced with challenges to provide safe transport home to children ages 0–2 years and less than 20 pounds who are placed in a HSC due to surgery or trauma. A special car seat is needed to accommodate the cast. This problem is unique to children's hospitals who serve the needs of infants in HSCs and is encountered by the PTs who work to train the parent on proper positioning and care of their infant. The solution to this problem is unique in that their transportation needs are not addressed by standard durable medical equipment processes. The equipment is most often not covered by insurance and is difficult to obtain in a quick timeframe. Rental of this car seat is not available in the same way that a wheelchair might be rented. A car seat lending program protocol was developed to assist in the return of the special needs car seats. Four HSC special needs car seats and one over-the- counter car seat were obtained through a combination of donation and departmental purchase. Cooperation was developed between the attending orthopedic surgeons and the PT department to better serve the safety needs of these children and to assure the return of the car seats. Car seats are vended during the inpatient hospital stay on a first come, first serve basis. Communication is kept open between the PT department and the orthopedic surgeons' offices as to the number of car seats available at any given time. The PT department maintains close contact with the orthopedic surgeon's office in determining the length of need for each car seat. At the patient's cast off appointment with the surgeon, the patient is required to bring the car seat into the surgeon's office prior to the cast being removed. The car seat is then kept at the surgeon's office and will be returned to the PT department. This process ensures that the car seat is not only lended but returned in a timely manner.
Summary of Use: Since the initiation of this program, we have been able to adequately provide appropriate and safe transportation to twenty nine infants placed in a HSC since October 2006. All of our car seats have been returned by the families in satisfactory condition. Due to the successful nature of the program, surgeons from other area hospitals have contacted us in regards to our program. Importance to Members: The importance to PT is that PTs are often the health care professionals that are used for education on positioning and care of children in HSC. This positioning is often extended to knowledge on the safest means of transport home from the hospital. This program is designed to meet those unique safety needs in this population.
UPPER EXTREMITY MUSCLE ACTIVATION REVEALS MUSCLE PRE-ACTIVATION DURING A CUED TASK IN CHILDREN WITH HEMIPLEGIC CP: EVIDENCE OF USE OF A COMPENSATORY STRATEGY?
J.R. Charles, A.J. Butler, S.L. Wolf, Rehabilitation Medicine, Emory University, Atlanta, GA; B.M. Weissman, Pediatrics, Emory University, Atlanta, GA.
PURPOSE/HYPOTHESIS: Hypothesis: The latency to muscle activation in the hemiplegic upper limb of children with cerebral palsy(CP) to a cued response during a repetitive task would be substantially different than that seen in able-bodied, age-matched children.
NUMBER OF SUBJECTS: Five children with hemiplegic CP and five age-matched typically developing(TD) children (6–8 years).
MATERIALS/METHODS: All children squeezed a pediatric bulb dynamometer in response to an auditory signal. They first squeezed with the dominant hand followed by the non-dominant hand to two target forces (1 # and 3 # PSI) and at two frequencies (5 and 10 times/30s.). Muscle activation was recorded bilaterally for the anterior deltoid, biceps brachii, lateral triceps, extensor and flexor carpi radialis muscles. The frequency of muscle onset that occurred prior to the auditory beep (pre-activation) was determined for each muscle in each limb for each condition.
RESULTS: ANOVA analyses were used to determine the relation between the frequency of pre-activation for all conditions and the following variables:group(CP vs. TD)and muscle group (proximal v. distal). Children with CP demonstrated a significantly increased number of pre-activations in proximal vs. distal muscles in anticipation of an auditory cue compared to TD children for three of four conditions: (p = 0.009, p = 0.016, and p = 0.41) indicating a disruption of timing in UE muscle activation when using the dominant/less involved hand during a specific manual task.
CONCLUSIONS: A tendency for proximal muscles to pre-activate more often than distal musculature may be due to a need for CP children to exercise greater proximal control in executing a specific manual task. The increased occurrence of proximal muscle pre-activation in the lesser involved limb of CP children may indicate movement coordination problems in the dominant limb.
CLINICAL RELEVANCE: A greater understanding of the relationship between muscle function and motor performance can aid development of more effective therapeutic interventions to improve upper limb function.
SYMMETRICAL POSTURES AND MIDLINE MOVEMENTS ARE LESS COMMON IN INFANTS WITH NEONATAL STROKE
J. Heathcock, C. Chen,, The Ohio State University, Columbus, OH.
PURPOSE/HYPOTHESIS: Brain ischemia, hemorrhage and arterial ischemia are the most common forms of stroke during the neonatal period. Full-term infants who have had a stroke are at very high risk for neurological and sensorimotor deficits including cerebral palsy, epilepsy, language delay and behavioral abnormalities. These infants often have focal lesions as opposed to preterm infants who more commonly have multiple lesions. Focal lesions on one side of the brain most commonly results in hemiplegic cerebral palsy. Yet, the sensitivity of these lesions to future outcome is very low. As such, clinicians seek for better tools to identify motor behaviors in newborn infants with brain lesions. The purpose of this project is to investigate upper /lower limb symmetry and midline movements in full-term infants with and without neonatal stroke.
NUMBER OF SUBJECTS: Twelve full-term infants with typical development and 12 full-term with neonatal stroke participated in this experiment.
MATERIALS/METHODS: Infants were seen for 10 visits in this longitudinal study starting at 8 weeks of age. Infants were videotaped in supine for 8 trials of 30 seconds at 30 Hz. Small toys with various textures were placed in the infants hand (right and left side were randomized) for each trial. Upper and lower limb symmetry was analyzed using the Eshkol-Wachman Movement Notation every 10 frames resulting in 90 data points for each trial. Midline behaviors were analyzed for hands in midline, both hands touching the toy, and time of grasp.
RESULTS: Overall there was a very low percentage of symmetrical performance in both groups yet the infants with neonatal stroke demonstrated a lower percentage of symmetrical posture across every condition. Specifically, the infants with neonatal stroke showed less whole body symmetry, less upper limb symmetry and less lower limb symmetry. In addition, the infants with neonatal stroke demonstrated fewer midline behaviors including less time with both hands touching the toy and less time grasping the toy with both hands.
CONCLUSIONS: Symmetrical postures and midline behaviors are less common in infants who have had a neonatal stoke. These results suggest that systematic evaluation of symmetry and midline behaviors may be a valuable addition to neurological exams including APGAR, head circumference, and imaging.
CLINICAL RELEVANCE: The evaluation of symmetry may help to identify infants at risk for motor dysfunction, perhaps in combination with clinical measures. In addition, less symmetry and the absence of touching a toy with both hands may also be good indicators of neurological and sensorimotor deficits during young infancy.
ENDURANCE TRAINING USING BODY-WEIGHT SUPPORTED TREADMILL TRAINING IN A CHILD WITH CEREBRAL PALSY: A CASE REPORT
A. Cochran, B. Litwin, Physical Therapy, Nova Southeastern University, Ft. Lauderdale, FL.
BACKGROUND & PURPOSE: Cerebral Palsy (CP) is a non-progressive neurological disorder that mostly affects children. Children with CP exhibit significantly higher energy costs and lower endurance with ambulation when compared to those without the disorder. The intent of this case report was to investigate the effects of an 18 week outpatient endurance training program using Body-Weight Supported Treadmill Training (BWSTT) and supplemental aerobic exercises on endurance and functional gait in a child with cerebral palsy.
CASE DESCRIPTION: An 18 week outpatient endurance program was administered to a sedentary, cognitively aware eleven year-old female diagnosed with spastic diplegic cerebral palsy (CP). She was born at 25 weeks gestation and has received physical therapy since birth. Her surgical history includes bilateral muscle lengthening procedures and selective dorsal rhizotomy. She is visually impaired from damage to the optic nerve, more severe on right than left. Medication is used to control petit mal seizures and improve attention at school. She lives in a 2-story home with her parents and younger sibling. The subject is an independent ambulator utilizing bilateral custom foot orthotics. Her chief complaint was easy fatigability and inability to physically keep up with peers. Her parents reported signs of breathlessness and fatigue with stair climbing and low level recreational/social activities. On assessment, the subject demonstrated an elevated resting heart rate, and a deconditioned and delayed autonomic response to exercise. She presented with hips internally rotated, left knee hyperextended, RUE retracted with flexed elbow, kyphosis and mild scoliosis. On ambulation, she exhibited right foot drop and a bilateral trendelenburg sign. The endurance training program consisted of BWSTT augmented with various aerobic activities, education in self monitoring and energy conservation/ breathing techniques. Measures used to assess and determine progress included Physiological Cost Index (PCI), estimated VO2 peak and VO2 max, functional gait measures, and Six Minute Walk Test (6MWT). The subject was highly motivated and took an active role in the development of the treatment plan.
OUTCOMES: Following the 18 week program, the subject demonstrated decreased PCI and increased VO2 peak, VO2 max, walking speed, symmetry in step length, maximum treadmill duration and signs of improved parasympathetic cardiac modulation. The subject also demonstrated improved ability to self monitor and utilize breathing strategies to decrease dyspnea during activities.
DISCUSSION: Combining BWSTT with other aerobic activities may be an effective method to increase aerobic endurance and lower energy costs while improving functional gait in ambulatory children with spastic diplegic CP. The use of body weight support during aerobic training may provide a mechanism to increase intensity of exercise, notably treadmill speed and duration to improve endurance training outcomes in children with diplegic CP.
BODY WEIGHT SUPPORT TREADMILL TRAINING AS A MEANS OF EXERCISE FOR A NON-AMBULATORY 18 YEAR OLD MALE DIAGNOSED WITH CEREBRAL PALSY
P.A. DiBiasio, C.L. Lewis, S. Anderson, A. Bajdas, R. Delamarter, J. Valaer, Physical Therapy Education, Elon University, Elon, NC.
BACKGROUND & PURPOSE: Cerebral Palsy (CP) is a developmental disorder characterized by alterations in posture and motor control. Impaired motor control may also lead to reduced levels of physical activity, subsequently impacting health and well-being. Individuals with CP who are sedentary are at greater risk for impairments in body structure and function. Restrictions in activity and participation may be related to these impairments as well as documented risks of poor self-esteem. The benefits of physical activity and exercise are established in the literature. The purpose of this case study is to share our experiences using body weight support treadmill training (BWSTT) as a means of exercise.
CASE DESCRIPTION: The subject was a non-ambulatory 18-year-old male with CP who at the time was not receiving any therapy services. Outcome measures included family goals, heart rate, the Pediatric Quality of Life Inventory (PedsQL), the Pediatric Evaluation of Disability Inventory (PEDI), perceived exertion, the three-minute walk test and energy expenditure index (EEI). BWSTT sessions took place twice a week for six weeks with a reduction of approximately 40% of the subject's weight. Each training session consisted of a minimum of three sets of three minutes of walking on the treadmill at a self selected speed followed by three minutes of rest. The subject participated in 12 sessions over 6 weeks.
OUTCOMES: The subject increased training from three to five sets per session. He achieved a 30% increase in treadmill speed while decreasing peak working heart rate by 11%. Distance covered on the 3-minute walk test decreased slightly. EEI improved each session with a 67% decrease from session two to session twelve. The PedsQL parent report increased in all domains. The PedsQL self-report demonstrated a mild decrease in all domains, possibly related to comprehension. The PEDI showed slight improvements in self-care and mobility. Subjectively, the family reported during the study period the subject experienced spontaneous bowel movements, a previous source of discomfort and dependency on the use of a suppository.
DISCUSSION: There are significant barriers to participation in physical activity for non-ambulatory young adults with CP. The results of this case study indicate that BWSTT was a beneficial means of physical activity for this subject. What has been fascinating to us as clinicians and researchers is that this subject essentially worked at anaerobic intensities when walking. His functional ambulation skills were limited not only by issues related to motor control and his impairments in body structure and function, but by his resultant very high energy cost of ambulation. It is no surprise he was not a functional ambulatory considering the energy cost. However his remarkable decrease in EEI while on the treadmill over the 6 week study indicated potential for improvement and a positive training effect. BWSTT therefore was a feasible and effective means of exercise for this subject.
PLANTARFLEXION TORQUE IS IMPROVED BY WHEEL RUNNING IN MICE WITH DUCHENNE MUSCULAR DYSTROPHY
D. Dommer, T. Kelly, D. Ludowese, P. Neeser, J. Schoess, G. Cochrane, J. Call, D. Lowe, Physical Therapy, University of Minnesota, Minneapolis, MN.
PURPOSE/HYPOTHESIS: Duchenne Muscular Dystrophy (DMD) is a recessive X-linked disorder caused by the absence of dystrophin protein. The disease is characterized by a progressive decrease of muscle function due to repeated destruction and inadequate regeneration of muscle fibers. Muscle weakness and fatigue are main factors leading to loss of ambulation in DMD patients. It is uncertain how much physical activity DMD patients can safely participate in. The purpose of this study was to identify whether voluntary wheel running in mdx mice may slow loss of muscle function.
NUMBER OF SUBJECTS: 20 male mdx mice (10 sedentary controls, 10 runners), 4 weeks of age at the beginning of the study.
MATERIALS/METHODS: After twelve weeks of either rest or voluntary wheel running, mice were anesthetized to obtain in vivo measurements of muscle contractile function. To do this, the left common peroneal nerve was cut, and the posterior muscles of that leg were then stimulated via the sciatic nerve. The following torque measurements were made via a dynamometer: maximal isometric torque, torque at 12 frequencies (range 10 to 300 Hz), torque over a range of velocities from 1200 to 0 degrees/sec, active and passive torques at 9 joint angles between 20 degrees of plantarflexion and 20 degrees of dorsiflexion, and isometric torque during a fatigue protocol. After torque measurements, left gastrocnemius and soleus muscles were dissected and weighed. Differences between sedentary and runner mice were determined using t-tests.
RESULTS: Mdx mice given free access to a wheel ran between 1.6 to 5.2 km per day over the 12-week study. Runners produced 10.7% more maximal isometric plantarflexor torque compared to sedentary mdx mice (p = 0.012). Mdx mice that ran were also more resistant to fatigue of the plantarflexors (p<0.05). On the 60th fatiguing tetanic contraction, plantarflexors from mice that ran had only lost 47 ± 2% of their initial torque while the non-runners lost 58 ± 3% (p = 0.012). Plantarflexor torque in both groups recovered within 5 minutes of the protocol's end indicating fatigue and not injury. Many trends occurred for other torque parameters indicating functional improvements with wheel running (torque for stimulation frequencies from 40 Hz to 300 Hz, power at each given velocity, and peak active torque for each joint angle).
CONCLUSIONS: These results show that for mdx mice, voluntary running increased ankle plantarflexor isometric torque production and fatigue resistance. Fatigue resistance was likely improved from adaptations in mitochondrial oxidative capacity (see companion poster). Importantly, no outcome of our research indicated decreased muscle function as a result of wheel running. Further research in agreement with these findings may indicate that moderate physical activity is not detrimental and may even be beneficial for function of muscle in DMD patients.
CLINICAL RELEVANCE: Preservation of muscle function would ultimately prolong a DMD patient's unassisted ambulation and improve his quality of life.
A NATIONAL SURVEY OF SCHOOL-BASED PHYSICAL THERAPISTS AND SECONDARY TRANSITION PRACTICES
A.K. Doty, Kent State University, Kent, OH.
PURPOSE/HYPOTHESIS: Researchers in the fields of physical therapy and special education transition have stated the need to explore how therapy programs impact the outcomes for transition-age students. Limited information exists to determine the level of involvement and role of physical therapists in secondary transition. In what transition activities are physical therapists practicing with secondary students? What are the training needs of physical therapists in the area of transition practice? Is there a relationship between therapist characteristics (educational background, experience in school-based practice, experience in transition practice, education in transition practices, administrative support of the therapist, and characteristics of programs in which therapists work) and the therapist's involvement with transition-age students?
NUMBER OF SUBJECTS: The population of 1,229 school-based therapists from a national database of the APTA was given the Survey of School-Based Physical Therapists and Secondary Transition Practice.
MATERIALS/METHODS: The Survey of School-Based Physical Therapists and Secondary Transition Practices was developed using Dillman's tailored design techniques. Four contacts were made and yielded an 86% return rate.
RESULTS: Descriptive statistics were analyzed to describe demographic information, identify the scope of practice for physical therapists in the transition process, and identify training needs. Of the respondents, 576 therapists worked with transition age students. Overall involvement of PTs in secondary transition was measured by 28 survey items summed from the subscales of transition planning, evaluation, IEP/ITP, and Intervention of the survey. The range of possible totals for this subscale was 0–102 points and the mean score for these therapists was 55.96. The forward regression analysis explained 48.6% of the variance in therapist involvement with transition-age students.
CONCLUSIONS: Physical therapists working in secondary transition need to: (a) complete more comprehensive evaluations with students who have intensive support needs across a variety of future environments; and (b) expand collaborative service delivery beyond school environment to include a student's local community and provide interventions in the community to promote generalizability of skills. Administrative support and inservice training are the strongest predictors of therapist involvement with transition-age students. Education in PT, years of experience in school-based practice, and school-based practice with secondary age students were weak predictors of therapist involvement with transition-age students.
CLINICAL RELEVANCE: The results of this study should be viewed as baseline data in determining the scope of practice by physical therapists with secondary students, and predictors of physical therapist involvement with secondary students. Physical therapist involvement with transition age students is a rarely studied facet of the transition field and little was known about the characteristics of school-based therapists who serve this age group.
REHABILITATION OF A 3 YEAR OLD FOLLOWING HEART-LUNG TRANSPLANT
J. Eilbacher, H. Hanson,, Children's Hospital of Philadelphia, Philadelphia, PA.
BACKGROUND & PURPOSE: There are approximately six pediatric heart-lung transplants performed in the United States each year, and 177 pediatric recipients since 1988. In contrast, there are 300–400 pediatric heart transplants and over 50 pediatric lung transplants yearly. Children who receive heart-lung transplants are a unique population, given their multi-thoracic organ transplants and history of various heart and lung disease. There is a paucity of literature addressing the rehabilitation needs of young children following thoracic organ transplant of any type. The purpose of this case study is to present the rehabilitation course of a 3-year old following a heart-lung transplant; highlight the importance and literature supporting early mobilization, airway clearance, developmental interventions; and discuss medical team challenges and coordination.
CASE DESCRIPTION: A 3-year old with dextrocardia, tricuspid atresia, and pulmonary vein stenosis following heart-lung transplant complicated by multiple infections. Six weeks following heart-lung transplant, he had a repeat lung transplant due to lung graft failure. We will discuss the post-operative rehabilitation course and the role of the physical therapist(PT) when caring for a child with complex medical and developmental needs.
OUTCOMES: The patient's outcome was reported using functional status, Six Minute Walk Test(6MWT), and Peabody Gross Motor Scales, 2nd edition(PDMS-2). 6MWT and PDMS-2 were not completed following heart-lung transplant, as he remained ventilation dependent for the majority of the time. By 4 weeks post-transplant, he was dependent for transfers and able to ambulate short distances with minimal assistance before re-intubation 2 weeks prior to second lung transplant. Two months after the second lung transplant, he presented with 6MWT of 137m (2L O2 via nasal cannula), PDMS-2 between 2nd and 16th percentile for gross motor domains, and was modified independent for all functional mobility except stairs and floor to stand. Four months post-re-lung transplant, he presented with 6MWT of 151m (no O2), PDMS-2 between the 9th and 25th percentile, and was modified independent for all functional mobility.
DISCUSSION: This case illustrates the role of the PT in the multidisciplinary transplant team along the continuum of care for patients post-heart and lung transplant. Throughout the care of this patient, the PT played a vital role in communication with the team and family in order to progress the patient toward functional goals. In the intensive care setting, mobilizing this patient while intubated and on non-invasive ventilation allowed the patient to perform strengthening and postural exercises while assisting with airway clearance techniques to maintain good pulmonary hygiene. This case also highlights the role of developmental interventions with patients who require thoracic organ transplantation. This patient demonstrated a delay in developmental milestones prior to his transplant and over the course of his post-transplant rehabilitation, demonstrated gains through physical therapy and family carryover.
HEART RATE CHANGES IN NON-AMBULATORY CHILDREN DURING THERAPEUTIC HORSEBACK RIDING
A. Fergus, M. Dymond, L. Everetts, C. Wells, L. McVey, Physical Therapy, Shenandoah University, Winchester, VA.
PURPOSE/HYPOTHESIS: Non-ambulatory individuals are at a greater risk for cardiovascular impairments and their secondary sequelae. The purpose of the present study was to examine the changes in heart rate that occurred with different activities during typical therapeutic riding (TR) sessions in three non-ambulatory children.
NUMBER OF SUBJECTS: Three non-ambulatory children participated in the study. Subject 1 was an 11-year-old female with spastic diplegic cerebral palsy (GMFCS level IV). Subject 2 was an 11-year-old male with spastic quadriplegic cerebral palsy, (GMFCS level V). Subject 3 was a 14-year-old female with a myelomeningocele who was modified independent for most activities of daily living.
MATERIALS/METHODS: Heart rate was recorded throughout a typical day for the three children using a digital heart rate monitor and an activity log was kept. Each subject participated in 8 weekly 1-hour TR sessions involving a variety of activities in which heart rate was continuously monitored. The TR instructors determined the activities performed during TR sessions. The duration of all activities was recorded and activities were analyzed for mobility vs. stationary body and or horse. Target heart rate was calculated as%HRR with lower limit being 41% based on the literature.
RESULTS: There were significant differences in heart rate achieved based on activities during TR (p<.05). Activities involving trotting increased heart rate to levels higher than that achieved with other activities. Task analysis suggested that those activities which involved the subject moving and the horse moving increased heart rate to a significantly greater extent than tasks involving a stationary subject and/or horse. The longest duration activity for all three subjects was the trail ride. Although there was a significant effect (p<.05) of activity on heart rate, there was no effect of duration of activity nor was there a significant interaction between activity and duration. However, durations for higher intensity activities such as trotting were consistently limited. Subject 1 achieved target heart rate range a total of 9 times in the 8 weeks of TR and the average duration of the activity when the target heart rate was achieved was only
1.17 +/1.71 minutes. Target heart rate was achieved for an average duration of 1.53 +/−1.82 minutes for a total of 19 times in the 8 weeks of TR for subject 2. Subject 3 achieved target heart rate only 3 times in the entire 8 weeks of riding for an average duration of 2.67 +/−1.15 minutes.
CONCLUSIONS: Significant increases in heart rate were achieved in non-ambulatory children during therapeutic riding. Activities in which both the subject and horse are moving are most effective at increasing heart rate.
CLINICAL RELEVANCE: Therapeutic riding can provide aerobic conditioning for children with disabilities. Activities involving movement of both the horse and subject should be selected to achieve cardiovascular benefits. Careful consideration of the duration of activities performed during therapeutic riding is needed to provide adequate cardiovascular training.
GROSS MOTOR DEVELOPMENT IN BABIES WITH CLUBFOOT
N.L. Garcia, G.O. Baird, M.L. McMulkin, B.J. Tompkins, P.M. Caskey, S.L. Mader,, Shriners Hospital, Spokane, WA.
PURPOSE/HYPOTHESIS: This study investigates the effect of the presence of a treated clubfoot disorder on attainment of gross motor skills as measured by the Alberta Infant Motor Scale and parent reported attainment of gross motor milestones. We hypothesized that babies with clubfoot would score slightly lower on the AIMS and would attain gross motor milestones slightly later than a group of typical babies.
NUMBER OF SUBJECTS: We recruited 71 babies to participate, and 52 completed the study. All babies were at least 36 weeks gestation at time of birth. 26 were typically developing children without medical diagnoses. 26 were babies diagnosed with and being treated for bilateral or unilateral clubfoot without other medical diagnoses.
MATERIALS/METHODS: The babies were assessed with the Alberta Infant Motor Scale at 3 month intervals beginning at 3 months until they walked independently, but no longer than 18 months. Parents were also asked to keep a record of when the baby reached 6 specific motor milestones. Scores at each testing period and age of reported skill attainment were compared between groups. Further data were examined to compare unilateral clubfoot vs. bilateral clubfoot diagnosis and AIMS score; babies treated for clubfoot using the Ponsetti method vs. the French or Dimeglio method and AIMS scores; severity of clubfoot disorder as measured by the Dimeglio score and AIMS scores; and AIMS scores of the typically developing group with the norms used in the AIMS manual.
RESULTS: There were no significant differences in AIMS scores between the clubfoot and control groups at 3 and 6 months, but at 9 and 12 months the clubfoot group scored significantly lower. There were no significant differences in the reported attainment of rolling; however, sitting, pulling to stand, crawling and walking were significantly later in the clubfoot group. Typically developing babies were significantly more likely to be walking at 12 months than babies with clubfoot. There were no significant differences in AIMS scores between unilateral and bilateral groups, or between groups treated with two different methods. The typical group scored significantly lower than the AIMS normative sample only at 3 months with no significant difference at 6, 9 or 12 months. There was no relationship between the severity of the disorder as measured by the Dimeglio score and AIMS score.
CONCLUSIONS: Treated idiopathic clubfoot is associated with a mild delay in attainment of gross motor skills at 9 and 12 months of age when typically developing babies begin pulling to stand and other upright antigravity activities. The delay is not related to unilateral or bilateral diagnosis, severity of disorder, or method of treatment. The normative sample of the AIMS is relevant for a typically developing group at 6, 9, and 12 months.
CLINICAL RELEVANCE: Parents and other evaluators of babies for gross motor skills can expect those with clubfoot to score lower on the AIMS than a typically developing child beginning at 9 months. They can expect babies with clubfoot to walk slightly later than a typically developing child but should occur by 18 months.
THE EFFECT OF WEIGHTED VESTS ON THE POSTURAL STABILITY OF ADOLESCENTS WITH AUTISM SPECTRUM DISORDER
M. Garrett, J.K. O'Connell, M. Wheeler, K. North, C. Carlton, Physical Therapy, Hardin-Simmons University, Abilene, TX.
PURPOSE/HYPOTHESIS: 1) To assess postural stability in adolescents with Autism Spectrum Disorder (ASD); 2) to evaluate the effect of a weighted vest on postural stability in adolescents with ASD.
NUMBER OF SUBJECTS: Seven junior high special education students (M = 4, F = 3) participated in the study.
MATERIALS/METHODS: Informed consent was obtained prior to testing. The Sensory Profile was completed by the classroom teacher to assess the subjects' response to various sensory experiences. Participants were allowed to practice on the testing equipment one week prior to data collection. On the testing day, demographic information was gathered to ensure participants had a primary classification of autism. Each participant was instructed to stand as still as possible on the Accusway PLUS¯ Balance Board with the lateral foot aligned with a foot tracing already on the board. If the participant had excessive movement the trial was restarted. Eight randomly ordered trials, lasting 20 seconds each, were completed: 1) board-eyes open; 2) board-eyes closed; 3) board with a foam pad-eyes open; 4) board with a foam pad-eyes closed; 5) board with eyes open-weighted vest; 6) board with eyes closed-weighted vest; 7) board with a foam pad-eyes open and vest 8) board with a foam pad-eyes closed and vest. The weighted vest was 8% of participant's body weight. A rest period of 1 minute was given between trials. Descriptive statistics were used to visually represent the mean sway area and standard deviation for the different test conditions. A Wilcoxen Signed Rank test determined if sway areas were significantly different between vest conditions. Pearson Correlation Coefficient was computed to determine the relationship between Sensory Profile Scores and sway area.
RESULTS: The Wilcoxon signed rank test did not reveal significant differences between vest and no vest conditions (p >.05). Although no values reached significance, a qualitative analysis of the board eyes open condition, demonstrated 6 of the 7 participants had a decreased sway area when wearing the vest. The Pearson Correlation Coefficient revealed a positive relationship between the visual score on the Sensory Profile and the conditions of board eyes closed (r = .787, p = 0.036), board eyes closed with vest (r = .896, p = 0.016) and foam eyes open with vest (r = .868, p = 0.011).
CONCLUSIONS: Sway area did not significantly change while wearing the weighted vest. However, the majority of participants improved, showing an increased postural stability with the added proprioception. The positive correlation between visual input with or without the vest suggest vision may be a distraction during balance activities in children with ASD who score high on visual input on the Sensory Profile.
CLINICAL RELEVANCE: Previous studies have shown weighted vests to correlate positively with improved behavior in children with ASD. Our study suggests a trend in decreased postural sway while wearing a weighted vest. This increased proprioception may improve postural stability during PT treatment in adolescents with ASD.
EFFECTS OF A PHYSICAL THERAPY INTERVENTION TO ENHANCE ANTICIPATORY POSTURAL CONTROL AND STANDING BALANCE IN AN ADULT WITH CEREBRAL PALSY: A CASE REPORT
G.L. Girolami, Kinesiology and Nutrition, University of Illinois at Chicago, Chicago, IL.
BACKGROUND & PURPOSE: Individuals with cerebral palsy have impaired balance and anticipatory (APAS)and compensatory (CPAs)postural adjustments, which interfere with the ability to prepare for internally and externally generated postural perturbations and to sustain independent standing balance (Bax et al, 2005). A search of the literature revealed training programs designed to improve compensatory postural adjustments and standing balance in individuals with cerebral palsy (Shumway-Cook et al, 2003, Woollacott et al, 2005), but no studies were found which describ training programs to improve APAs and standing balance in individuals with cerebral palsy. The purpose of this case report was to examine the effectiveness of an intensive physical therapy program to improve balance and APAs in an adult with cerebral palsy.
CASE DESCRIPTION: The patient is a 31 y/o male, with a diagnosis of spastic quadriplegia (GMFCS III). He receives physical, occupational and speech therapy, wears ankle foot orthoses and has had surgical lengthening of the hip flexor, hamstring and gastrocnemeius muscle groups. He uses a reverse walker for community ambulation, but would like to transition to forearm crutches in the home. Intensive physical therapy was provided four days per week, 90 minutes per day, over an 8 week period. The program was designed to improve balance and trunk stability in sitting and standing. Pre, mid and post testing was conducted using Goal Attainment Scales (measures individualized goal achievement on a 5 point scale), the Pediatric Reach Test (a measure of sitting and standing balance), electromyography (EMG) (provides the ability to document timing and sequencing of muscle activation), and video documentation and still photographs (provide objective documentation to measure changes in performance and alignment).
OUTCOMES: The patient showed positive changes on all outcome measures. GAS scores revealed improved performance on functional tasks including timed standing (2 sec to 90 sec); standing balance at an unstable support (3 sec to 38 sec); and reaching in standing (2 reaches to 7). Pre-test EMGs revealed no APAs in the trunk or upper leg prior to externally applied perturbations to the trunk in sitting and standing, but post test EMG traces documented the presence of APAs, prior to the perturbations. Video and still photographs showed improved alignment and ability to sustain posture during upper extremity abduction performed in bench sitting. The Pediatric Balance Test, showed no post test changes in forward reach in sitting or right sideways reach. but left sideways reach (the more involved side), improved by 4.4 inches.
DISCUSSION: The intensive physical therapy program was effective in improving sitting and standing posture and balance as measured by Goal Attainment Scaling, the Pediatric Reach Test and video documentation. EMGs showed evidence of anticipatory postural adjustments following the intensive intervention program.
DEVELOPMENT, QUALITY OF LIFE, AND EXERCISE TOLERANCE IN PEDIATRIC HEART TRANSPLANT PATIENTS: THE CASE FOR PEDIATRIC CARDIAC REHAB
H. Hanson, L. Neil,, The Children's Hospital of Philadelphia, Philadelphia, PA.
Purpose: The aim of this project was to determine: (1) The literature supporting how motor development, exercise tolerance/ endurance, lung function, quality of life, and donor and surgical factors influence children pre and post heart transplant; (2) Outcome measures that have be used to assess these factors; (3) identify the above factors that should be considered in the development of a cardiac rehab program.
DESCRIPTION: There are over 300 pediatric heart transplants performed in the United States each year, and there have been over 2,600 pediatric recipients over the last 10 years. Children born with complex congenital heart defects often require multiple cardiac surgeries or heart transplant, with the goal of improving the child's overall physical and functional status, quality of life, and increasing their lifespan. Multiple surgeries require hospitalizations which can impact a child's overall development, putting them at risk for delay in the acquisition of milestones and impact quality of life. A comprehensive review of 35 research articles in pediatric cardiopulmonary care was completed. Critical information from the articles, based on motor development, exercise tolerance/ endurance, lung function, quality of life, and donor and surgical factors, were placed into a computerized database as a literature review.
SUMMARY OF USE: The results of this literature review support the need for a multi-disciplinary team in the follow-up care of children post heart transplant, given that there are underlying issues that impact health related quality of life, neurodevelopmental outcomes, cognitive status, and exercise performance (including physical endurance and strength). Children post-heart transplant appear to benefit from a twelve-week exercise training program monitored for compliance and progress. The literature supports the need for additional evaluations from other therapy services including: occupational, physical, psychological, and speech therapy. These therapy services can address possible delays in visual-motor, fine motor, and gross motor development, overall quality of life, and language skills of children post transplant. While there were no consistent outcome measures were used across the literature, the selection of appropriate outcome measures is essential to monitor the effectiveness of a cardiac rehab program. Importance to Members: The current literature supports the need for a multi-disciplinary Cardiac Rehab Team approach to provide care for children pre and post heart transplant. The physical therapist plays a critical role on a cardiac rehab team in order to address exercise tolerance, endurance, strength, and development delays.
USE OF COMPRESSION GARMENTS TO MANAGE SKIN GRAFTING AND SURGICAL SCARS
H. Hanson, A. Leibrand,, The Children's Hospital of Philadelphia, Philadelphia, PA.
BACKGROUND & PURPOSE: Several pediatric pathologies can cause integumentary impairment, including burns, skin grafting and surgical incisions. Unfortunately, the healing process often leads to hypertrophic scarring, reduced pliability, and variable pigmentation, which can cause future impairments as growth occurs. Compression combined with silicone rapidly improves healing time, pliability, pigmentation, and hypertrophic scarring. The Vancouver Scar Scale (VSS) is the most widely used outcome measure to assess a scar with good interrater reliability (r = 0.81). The purpose of this case study is to illustrate the use of the VSS to assess the scars of 2 pediatric patients prior, during, and after a period of use of a custom compression garment for 2 different mechanisms of injury.
CASE DESCRIPTION: Case One: An 8 year-old male status-post skin grafting to the anterior medial left ankle from a thigh autograft. The mechanism of injury was a pedestrian vs. motor vehicle where a commercial trunk rolled over the foot. No orthopedic injury occurred; however, the shoe had to be debrided from the foot. The wound was cleaned, a wound vac was placed for a month, then a skin graft was placed. Once the skin graft site closed, a compression garment with silicone insert over the graft area was ordered, and applied for 23 hours per day. Case Two: A 13 year-old African-American female status-post T2-T8 postero-lateral fusion with corpectomy and cage placement at T5 for thoracic tuberculosis with kyphosis. Following recovery and rehabilitation, she presented with a hypersensitive, hypertrophic surgical scar. A compression garment with a silicone insert over the mid-thoracic area was ordered, and applied for 23 hours per day. The VSS was used to assess the scar status prior, during, and after the use of both garments.
OUTCOMES: Case One: The VSS prior to compression was 5. The VSS was measured and improvement of the scar healing noted each week for 7 weeks. At this time, strength, balance, functional, and range of motion goals had been met, and he was followed monthly for scar management. After 3 months of compression, the VSS was 1, demonstrating improvement in scar healing. Case Two: The VSS was 12 prior to compression. The compression garment was fit to provide maximum compression at the mid-scapula area with use of elastomere molded behind the silicone. After 18 weeks of compression, the VSS was 5, demonstrating improvement in scar healing.
DISCUSSION: The use of compression garments for scars in these 2 cases showed improvement in healing of the scars, especially in pigmentation, pliability, and hypertrophic scarring. The potential for future impairments, such as range of motion limitations due to significant scarring in patients with skin grafting and surgical scars is one of great concern. The VSS is an outcome measure that enables tracking of the effectiveness of compression as an intervention for scarring. Both of the scars in this case study demonstrated significant improvement in the VSS, likely reducing the risk of future impairments.
MOTOR CHARACTERISTICS OF YOUNG CHILDREN WITH AUTISM SPECTRUM DISORDERS ARE MUCH LOWER THAN NORMAL REFERENCES
J. Heathcock, A. Lane,, The Ohio State University, Columbus, OH.
PURPOSE/HYPOTHESIS: Motor characteristics of young children with Autism Spectrum Disorder (ASD) may contribute to behavioral and communication difficulties associated with these disorders and may even be indicative of future autism phenotype. Further examination of this issue is warranted. This study seeks to begin a program of research collaboration between the investigators that will characterize the motor performance of young children with ASDs. This pilot study will describe patterns of motor performance of young children referred to a neurodevelopmental clinic for diagnosis of a possible ASD and examine the relationship of these patterns to key autism symptoms including social and communication impairment, autism severity and adaptive behavior.
NUMBER OF SUBJECTS: Children aged 6 months to 5 years evaluated for a possible ASD between June 1, 2007 and May 30, 2009 at a major Autism Center in a large city.
MATERIALS/METHODS: This study was conducted using a retrospective chart audit. The following data were sourced from each file: date of birth, date of evaluation, age at evaluation, diagnosis given at the end of the clinic evaluation, diagnostic criteria met, autism severity, motor performance scores (taken from the Bayley Scales of Infant Developmental – III (BSID-III): gross-motor and fine-motor domains), adaptive behavior scores (reported by parents using the BSID – III), social, communication and language scores (reported using the BSID-III: social emotional, expressive and receptive communication domains and the Rosetti Infant-Toddler Scale of Early Language) and cognitive level (reported using the BSID-III: cognitive domain).
RESULTS: Thirty charts were found to have complete data. The average age of participants was 31.9 months, with a range 19–41 months. Preliminary results from the fine and gross motor section of the BSID III suggest that children with ASD show significant delays in motor development. Specifically, on average, infant with ASD demonstrated a change score of 6 months below age equivalence for gross motor and 8.4 months below age equivalence for fine motor. Item analysis reveled that certain infants with ASD had more difficulty with individual items on the BSID and may suggest behavioral phenotypes.
CONCLUSIONS: Poor motor performance and different motor characteristics may be more common place in young children than previous thought.
CLINICAL RELEVANCE: Poor motor performance using current assessment tools may be present in the majority of very young children with ASD. In addition, behavior phenotypes may emerge and guide intervention.
ADAPTIVE SPORTS FOR INDIVIDUALS WITH CEREBRAL PALSY (CP)
J.E. Miros, S.K. Hickey, CP Sports and Rehabilitation, St. Louis Children's Hospital, St. Louis, MO.
Purpose: To help clinicians understand the role of group physical activities for individuals with CP who range in age from five to twenty-one years old. This presentation will also teach clinicians how and why to start adaptive sports programs in their area. This presentation will outline the social, psychological, and physical benefits of a sports program. Research has shown that exercise programs can lead to changes in strength and may have an impact on daily function of children with CP.
DESCRIPTION: Under the leadership of Dr. Janice Brunstrom-Hernandez, we have developed a sports program for individuals with CP. Our goal is to present strategies developed in our sports program to optimize participation and family involvement. We will discuss numerous program formats that we have piloted and implemented, such as adaptive dance, swim, martial arts, tennis and basketball classes. Various approaches for children in different Gross Motor Function Classification Scale (GMFCS) levels will be discussed and many examples provided. Descriptions of activities will be discussed for varying levels of ability ranging from individuals who ambulate with an assistive device to individuals utilizing wheelchairs.
SUMMARY OF USE: Detailed information will be provided on resources and equipment that can be utilized to facilitate maximal participation regardless of skill level. We will also discuss the social and psychological benefits of sports participation. Knowledge will be shared from working with individuals with CP in a sports program format. Input will be offered on what has been successful in motivating individuals with CP and their families to become energized about being more independent and physically fit through sports activities. Importance to Members: This presentation is relevant to clinicians treating individuals with CP who want to learn how to play and adapt sports and/or be independent with sports activities.
THE ADDITION OF SOMATOSENSORY STIMULATION TO REPETITIVE TASK PRACTICE ENHANCES HAND FUNCTION IN CHILDREN WITH HEMIPLEGIA: A CASE SERIES
L.R. Hoffman, D. Bondurant, R. Fournier, J. Harvey, M. Juarez, E. Mcguinn, S. Scalisi, School of Physical Therapy, Regis University, Denver, CO.
BACKGROUND & PURPOSE: Introduction. The purpose of this study was to determine if somatosensory stimulation (SS) enhances the effects of repetitive task practice (RTP) in children with hemiplegia.
CASE DESCRIPTION: Four participants with Manual Ability Classification System (MACS) levels I-III participated in this case series. All participants were between the ages of 4–16 y.o., had hemiplegia, impaired hand function, and were able to grasp and release a 1 inch cube. Each participant attended three treatment sessions: SS and RTP, SS and sham RTP, and RTP and sham SS.
OUTCOMES: Clinical outcomes assessed before and after each intervention included: unimanual hand function, bimanual hand function, and pinch grip strength. SS followed by RTP elicited improvements in pinch strength and bimanual skills in all 4 participants, but had less effect on unimanual skills. RTP alone improved pinch strength in children with MACS levels I and II and improved bimanual function in children with MACS level III. SS alone had little effect on any of the outcome measures.
DISCUSSION: Children with hemiplegia can improve in hand function with either RTP or a combination intervention of RTP preceded by SS. The results suggest that some children may receive greater benefits with a combination intervention. This finding is consistent with results from other patient populations.
CURRENT PEDIATRIC PHYSICAL THERAPY INTERVENTIONS FOR YOUNG CHILDREN WITH CEREBRAL PALSY AND RELATIONSHIP TO GROSS MOTOR AND SELF-CARE ABILITIES: A PILOT STUDY
L. Jeffries, School of Physical Therapy, Langston University, Langston, OK; S. Westcott McCoy, Rehabilitation Medicine, University of Washington, Seattle, WA.
PURPOSE/HYPOTHESIS: The purpose was to describe pediatric physical therapy (PT) interventions and activities used with young children with cerebral palsy (CP) and explore the associations of these interventions with change in the children's gross motor and self-care abilities across one year.
NUMBER OF SUBJECTS: Eighteen physical therapists (mean age = 41.72, SD = 10.33) participated in this study. They collected data on 22 children with CP (mean age = 36.3 months, SD = 13.5); Gross Motor Function Classification System (GMFCS) levels I: 6; II: 3; III: 1; IV: 4; V: 8, who participated in a multi-site study entitled: Move & PLAY.
MATERIALS/METHODS: The Physical Therapy Interventions for Pediatrics (PTIP) manual and form were used to document the PT interventions and activities. Prior to data collection the PTs obtained > 70% agreement on the PTIP form based on video analysis. The PTs then used the PTIP each time they saw the child or performed activities related to the child's care. Child data collected in the Move & PLAY study included age, GMFCS level, the Gross Motor Function Measure (GMFM), and the Self-Care: Activities of Daily Living (SC-ADL) subscale of the Child Engagement in Daily Life Measure. PTIP data were collected for a median of 9 months (min-max = 3–12 months). For analysis data were extrapolated to reflect 12 months of services.
RESULTS: Therapists (88%) reported the PTIP took less than 10 minutes to complete. PT services were found to have a 12 month frequency median = 33 visits/child (range = 69), median visits/month = 2.8 (range = 5.8), and median minutes/session = 52 (range = 30). Therapists spent a median of minutes/year (range) of 143 (2135) in contextualized activities, 285 (4470) with the care givers involved in the PT session, and 188 (935) on documentation. The top three activities (median minutes/yr; range) used were sitting (125; 1780); standing/pre-gait (115; 645); and transitions/transfers (85; 825). The most frequent interventions (% time used/year; range) were motor learning (89%; 100%); functional strengthening (80%; 42%); postural awareness (74%; 64%); and balance reactive (67%; 45%). Exploratory correlations and regression analyses suggest significant relationships between GMFCS levels and SCADL outcomes (r = −0.71) and the average duration (visits/month) with GMFM (r2 = .33) and SC-ADL (r2 = .32) outcomes. SC-ADL improvement was also significantly correlated with the average duration of session/month (r = 0.59; r2 = .43).
CONCLUSIONS: This pilot study demonstrated the successful use of the PTIP system as a means of documenting PT activities and interventions. The PTIP form was easy to complete yielding rich descriptive and exploratory correlation results.
CLINICAL RELEVANCE: Consistent documentation of PT activities and interventions and child outcomes could produce helpful information to guide provision of clinical PT services and provide insight for future research.
FUNCTIONAL ELECTRICAL STIMULATION ASSISTED CYCLING IN AN ADULT WITH SPASTIC DIPLEGIC CEREBRAL PALSY
T.E. Johnston, S.F. Wainwright,, University of the Sciences in Philadelphia, Philadelphia, PA.
PURPOSE/HYPOTHESIS: Determine the outcomes of cycling assisted by functional electrical stimulation (FES) for an adult with cerebral palsy (CP) using a mixed quantitative and qualitative design.
NUMBER OF SUBJECTS: A 49 year old man with spastic diplegia classified as GMFCS Level II participated in this at-home intervention study.
MATERIALS/METHODS: After receiving training on its use, the participant exercised with an FES cycle at home for 30 minutes, 3 times per week for 12 weeks. During cycling, the participant volitionally cycled at the highest possible resistance level and FES was provided to augment his volitional effort to allow him to cycle more vigorously. Stimulation was delivered to the bilateral quadriceps, plantarflexor, and gluteal muscles, and was activated at the appropriate degree of the revolution. Pre and post intervention, quantitative data collected included gait spatiotemporal parameters, the Timed Up and Go (TUG), a 6 minute walk test (6MWT), isometric muscle strength, percent lean tissue, the SF-36, and the Canadian Occupational Performance Measure (COPM). Pre and post-intervention qualitative semi-structured interviews were conducted.
RESULTS: The participant showed improvements in several measures. The time to complete the TUG decreased from
11.9 ± 0.4 to 9.0 ± 0.8 s, barefoot gait speed improved from 111.8 ± 8.3 to 120.7 ± 4.3 cm/s, and the distance during the 6MWT increased by 20.1 m. Maximal strength improved from 583 to 714N for the quadriceps, 264 to 313N for the hamstrings, 103 to 115N for the dorsiflexors, and declined from 204 to 195N for the plantarflexor muscles. Percent lean tissue remained stable (pre: 72.2%, post: 73.3%). The total SF-36 score improved from 62.1 to 77.6, and the participant rated his satisfaction and performance on the COPM as improved for 4 out of his 5 goals. Complimentarity of these quantitative results was identified through qualitative results within the functional mobility realm. The participant reported greater ease of walking “I'm not dragging my legs as much.” (related to improved muscle function) and fewer falls. Contradictory to the improvements noted at the impairment and functional limitation levels was the development of low back pain that the participant attributed to positioning during cycling: “In the beginning I tried to up the resistance and I started to get back pain…I think that the main problem was that this chair was at a 90 degree angle; every time I pedaled I was having so much pain.”
CONCLUSIONS: Results of this case study suggest that FES cycling may be effective in improving impairments that translate into improved functional performance. Potential issues with cycle design should be addressed.
CLINICAL RELEVANCE: Cycling with functional electrical stimulation (FES) is most commonly used as an intervention tool for people with complete spinal cord injury; however there are recent reports of its use in people following stroke and with multiple sclerosis to improve strength and function. There are no reports of its use and possible benefits for ambulatory adults with cerebral palsy (CP).
THE EFFECTS OF TAEKWONDO ON STRENGTH, COORDINATION, BALANCE, AND FLEXIBILITY IN HEALTHY CHILDREN 7–12 YEARS OLD: A PILOT STUDY
K. Kaneshiro, C. Soto, W. Steward, D. Fay, A.T. Still University, Mesa, AZ.
PURPOSE/HYPOTHESIS: Optimal physical fitness is a keystone in the promotion of normal development and a healthy lifestyle in the pediatric population. There are many different types of activities and programs that challenge both health-fitness and motor fitness. While different forms of martial arts have been reported to improve several motor fitness components, there is limited research exploring the effect of one of the more popular forms, Taekwondo (TKD). The purpose of this study was to determine the measurable changes that occur in strength, coordination, balance, and flexibility in healthy children 7–12 years of age after 12 weeks of TKD training.
NUMBER OF SUBJECTS: A total of 14 typically developing children between the ages of 7 to 12 enrolled in this study. Experimental subjects (n = 7) were enrolled after signing up for introductory TKD classes through a local American Taekwondo Association (ATA) school. Age and gender matched controls (n = 7), who were not participating in TKD or any other new sport during the testing period, were selected for comparison.
MATERIALS/METHODS: Both groups were pre and post-tested using the Balance, Bilateral Coordination, Running Speed and Agility, and Strength subtests of the Bruininks-Oseretsky Test of Motor Proficiency, Second Edition, as well as the YMCA Sit and Reach test. After pre-testing, the TKD group attended classes taught by certified ATA instructors over a 12 week period. Control subjects continued with their usual activities over the same period of time. Independent sample t-tests were used to test for group differences at baseline. Wilcoxen signed rank tests were used for within group comparisons and between group differences were analyzed with a Mann-Whitney U test (p <.05). Cohen's d was also calculated for group comparison effect sizes.
RESULTS: Both groups were similar at baseline with no statistical differences found. The TKD group showed significant change between pre and post-testing for the Body Coordination and Strength and Agility composites while the control group showed no significant change in any area. When comparing the amount of change between groups, the TKD group demonstrated statistically significant greater improvements in the Strength subtest and the Strength and Agility composite. Athough not significant, greater change was also seen in the subtests of Bilateral Coordination, Balance, and Running Speed and Agility, with large effect sizes reported for all areas (d>.80).
CONCLUSIONS: Healthy children 7–12 years of age who participated in 12 weeks of TKD training demonstrated significant gains in both Body Coordination and Strength and Agility. The amount of change reported in all subtests was greater in the TKD subjects than the control group and the large effect sizes indicate that reproduction of this study on a larger scale is warranted.
CLINICAL RELEVANCE: These findings suggest that TKD training may be an effective alternative to traditional exercise to improve health-related and motor fitness in healthy children.
CLINICAL INSTRUCTORS' PERSPECTIVES: WHAT SHOULD WE BE TEACHING IN PEDIATRICS?
L.K. Kenyon, Grand Valley State University, Grand Rapids, MI; M. Hellman, M. Tovin, R. Rosenthal,, Nova Southeastern University, Fort Lauderdale, FL.
PURPOSE/HYPOTHESIS: As physical therapist education programs strive to prepare students for entry-level autonomous practice across the lifespan, research is needed to guide and direct the inclusion of pediatric content in the entry-level curriculum. The purpose of this study was to explore clinical instructors' perspectives regarding the specific pediatric content that should be included in the entry-level curriculum of physical therapist education programs in the United States.
NUMBER OF SUBJECTS: This mixed methods study was conducted using 2 groups of participants. Group I included 9 purposively selected clinical instructors who participated in both the qualitative and quantitative aspects of the study. Group II participated in only the quantitative aspect of the study and consisted of 278 clinical instructors representing all 50 states and the District of Columbia. All participants were licensed physical therapists who had served as clinical instructors in the area of pediatrics.
MATERIALS/METHODS: A sequential explanatory design was used to conduct the study. Participants in both groups completed a Web-based survey designed to elicit feedback on the importance of including specific pediatric content areas in entry-level curricula. Respondents rated these content areas using a 5-point Likert scale. Additional open items on the survey gathered information regarding respondents' perspectives on how academic programs could best prepare students for pediatric clinical education experiences. Survey responses were analyzed using percentages for each category on the Likert scale and by grouping the responses to open items by thematic categories. In addition to completing the Web-based survey, clinical instructors in Group I participated in a one-on-one qualitative interview that further explored their responses to the survey. Audio-recordings of the interviews were transcribed verbatim and analyzed using the constant comparative method. NVivo 8 software was used to organize, store, and visualize data.
RESULTS: The participants provided specific recommendations pertaining to the depth and breadth of pediatric content in entry-level curricula. They also outlined their expectations regarding students' abilities to execute elements of the patient/client management model within pediatric physical therapist practice. Based on the analysis of the integrated data types, a conceptual model was created to depict the participating clinical instructors' perspectives regarding the specific pediatric content that should be included in the entry-level curriculum of physical therapist education programs in the United States.
CONCLUSIONS: Clinical instructors' perspectives offer valuable insights that can be used to guide and direct entry-level curricular content in pediatrics.
CLINICAL RELEVANCE: The results of this study will assist physical therapist faculty in preparing students for entry-level practice in pediatrics.
PT SCHOOL-BASED SERVICES: ELIGIBILITY AND GRADUATION CRITERIA
D.C. Krasinski, J. Chen, Program in Physical Therapy, Columbia University, New York, NY.
PURPOSE/HYPOTHESIS: The 1990 Individuals with Disabilities Education Act (IDEA) states that a related service is: “...required to assist a student with a disability to benefit from special education.” It differentiates between PT services provided to support a student's functioning in the educational program, and the medical and rehabilitative support that doesn't relate directly to a student's learning and school performance. The purpose of this study was to identify policies and procedures used to determine when a student would (eligible) or would not (ineligible/ graduation) benefit from school-based PT services.
NUMBER OF SUBJECTS: The search identified 15 school district manuals (11 combined PT /OT, 4 PT only), from 14 states.
MATERIALS/METHODS: School district PT practice manuals were identified and obtained via internet searches (Google and Yahoo Search Engines; State Department of Education Websites), online postings (PhyscialTherapist.com, PhysicalTherapyWebSpace.com, MyPhysicalTherapySpace.com and MedicalMingle.Com) and email correspondences (APTA State Pediatric Representatives, APTA Pediatric Listserv). Manuals were reviewed and frequencies calculated for a) eligibility and graduation criteria and b) recommended examination tools.
RESULTS: 54 eligibility criteria were identified. A student would most frequently benefit from PT services if they had difficulty with: mobility &/or access to physical environment (N = 12), independent living/self help/ADL's (N = 11); gross motor delay or coordination (n = 10); fine motor delay/visual motor integration (N = 9), positioning (N = 7), balance (N = 3) and transfers (N = 2). 15 non-specific graduation criteria were identified. A student would most frequently be ineligible for PT services when: services are no longer necessary (N = 13), student is self-reliant or met goal (N = 5), problems no longer interfere with educational performance (N = 6) and student shows no potential for change (N = 5) or minimal to no measurable progress or lengthy plateau (N = 3). 28 examination tools were recommended with the Peabody Developmental Motor Scales (N = 4) and Gross Motor Function Measure (N = 3) the most frequently mentioned. Generic examination methods were recommended: observation (N = 13) norm-referenced (N = 6), standardized tests (N = 7), and criterion-referenced (N = 4).
CONCLUSIONS: Of the manuals reviewed, identified eligibility and graduation criteria were identified. The eligibility criteria are highly variable indicating a lack of agreement in consideration of which variables are important to measure and lack of standardization in their measurement. Similarly, little attention was given to graduation criteria; criteria were non-specific and difficult to operationalize.
CLINICAL RELEVANCE: The remarkable variety in eligibility criteria and examination tools can result in inconsistency, confusion, and controversy related to exactly who qualifies for services and when services are no longer required or beneficial.
RELIABILITY OF THE TEST OF INFANT MOTOR PERFORMANCE SCREENING ITEMS IN INFANTS WITH SPINAL MUSCULAR ATROPHY
K.J. Krosschell, Department of Physical Therapy and Human Movement Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL; C.B. Scott,, CBS Squared, Inc, Fort Washington, PA; J.A. Maczulski,, Pediatric Occupational Therapy Services, Chicago, IL; T.O. Crawford, Departments of Neurology and Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD; J.T. Kissel, B. Elsheikh, Department of Neurology, Ohio State University Medical Center, Columbus, OH; G. Acsadi, Departments of Neurology and Pediatrics, Wayne State University School of Medicine, Detroit, MI; P.S. Kishnani, Division of Pediatrics and Medical Genetics, Duke University Medical Center, Durham, NC; E.C. Smith, Department of Neurology, Duke University Medical Center, Durham, NC; J. von Kleist-Retzow, Department of Pediatrics, University of Cologne, Köln, GERMANY; G. D'Anjou, Division of Pediatric Neurology, Hôpital Sainte-Justine Montréal, Montréal, Quebec, CANADA; M. Schroth, Department of Pediatrics, University of Wisconsin School of Medicine, Madison, WI; S.P. Reyna, K.J. Swoboda, Department of Neurology, University of Utah School of Medicine, Salt Lake City, UT.
PURPOSE/HYPOTHESIS: It has been previously demonstrated that the Test of Infant Motor Performance (TIMP) can be administered reliably in infants with Type I SMA (Finkel, 2008), however the test proved stressful due to the length of the test and positions that the infants were required to tolerate. In the SMA CARNI-VAL Type I study we explored use of the shorter, screening version of the TIMP, the Test of Infant Motor Performance Screening Items (TIMPSI). The TIMPSI has demonstrated strong predictability for scores on the TIMP and has demonstrated reliability, validity and sensitivity when used in high-risk infants (Campbell, 1997). Reliability in infants with SMA has not been explored. Items on the test cover a span of motor function that is appreciably affected by weakness in these infants, while at the same time covering a range of function deemed clinically relevant. Due to the shorter nature of the test we predicted it would be well tolerated, could be reliably administered and would demonstrate test-retest stability over a short nonintervention period. In addition, we predicted that TIMPSI score would be related to need for ‘urgent' ventilation and ability to lift arms, bend elbows and reach.
NUMBER OF SUBJECTS: Thirty-eight infants 1–18 months of age (mean 6 ± 3.23 mo) diagnosed with SMA Type I.
MATERIALS/METHODS: All infants were tested twice using the TIMPSI during screening visits (S1 and S2) prior to the initiation of study treatment. Mean interval between visits was 4 days. Reliability was assessed as test-retest reliability using the Pearson product-moment correlation if the data were normal or Spearman's rank correlation for non-normal data (both noted as r). Inter-rater reliability was assessed using inter-class correlation (ICC). Relatedness of total TIMPSI score to need for ventilation and ability to lift arms, bend elbows and reach was explored using ANOVA.
RESULTS: The total TIMPSI score had a range of 7–55 with a mean of 29.5 at S1 and 31.2 at S2; test-retest reliability was r = 0.95 and ICC = 0.98. TIMPSI screening score had a range of 0–29 with a mean of 13.7 at S1 and 14.2 at S2; test-retest reliability was r = 0.91 and ICC = 0.95. TIMPSI easy score had a range of 2–26; S1 mean 14.7 and S2 mean 14.9; test-retest r = 0.81 and ICC = 0.91. TIMPSI hard score was categorical with a range of 0–5; median at S1 and S2 was 2 with test-retest r = 0.65 and ICC = 0.82. TIMPSI score was not related to need for ventilation, but was related to the ability to reach in supine (p = 0.004) and supported sitting (p = 0.013).
CONCLUSIONS: The TIMPSI score is reliable, well tolerated, and can be safely administered in infants with Type I SMA. Scores are not related to need for ventilation but are related to ability to reach. Validity and sensitivity to change require further assessment.
CLINICAL RELEVANCE: The TIMPSI can reliably assess motor function in infants with Type I SMA. A range of scores across patients and ages was noted suggesting that the TIMPSI may capture the functional variability demonstrated by these infants without floor or ceiling effects.
SKELETAL MUSCLE OXIDATIVE CAPACITY IS IMPROVED BY WHEEL RUNNING IN MICE WITH DUCHENNE MUSCULAR DYSTROPHY
M. Liebaert, K. Wagner, R. Larson, W. LaVigne, A. Pagliaccetti, G. Cochrane, K. Baltgalvis, D. Lowe, Physical Therapy, University of Minnesota, Minneapolis, MN.
PURPOSE/HYPOTHESIS: Duchenne Muscular Dystrophy (DMD) is an X-linked disorder caused by the absence of the protein dystrophin. DMD is characterized by muscle weakness, fatigue, and loss of ambulation by ∼12 years of age. If dystrophic muscles could undergo exercise-induced adaptations, ambulation and quality of life could be improved. However, exercise is rarely prescribed for fear of injuring the already diseased muscle. An animal model for DMD is the mdx mouse. The objective of this study was to investigate adaptations of mdx mice to voluntary endurance exercise. We hypothesized that runner (Run) mdx mice would be more active in their cages and have greater mitochondrial enzyme activities compared to non-wheel running, sedentary (Sed) mdx mice.
NUMBER OF SUBJECTS: 20 male mdx mice (10 Sed, 10 Run), age 4 weeks at the beginning of the study.
MATERIALS/METHODS: Sed mice were put in cages without wheels and Run mice were put in cages with wheels for 12 weeks. At the 8-week time point, each mouse was put into an activity chamber for 24 hours to measure cage activities through disruption of infrared sensors in the x-, y-, and z-axes. At the end of the study, citrate synthase (CS) and beta-Hydroxy Acyl-CoA Dehydrogenase (β-HAD) activities were measured in the tibialis anterior (TA) and gastrocnemius muscles to reflect oxidative capacity. T-tests were used to determine differences between Sed and Run mice.
RESULTS: Run mice averaged 3.40 ± 0.11 km/day over the duration of the 12-week study, ranging between 1.4 and 5.2 km/day. Running distance peaked at day 12 and thereafter a slow decrease in km/day occurred, which is typical for mouse wheel running. There was no difference in any type of cage activity between the Sed and Run mice (P≥0.283). All mdx mice, whether runners or not, spent 210 ± 17 min/day doing non-wheel running cage activities and ambulated 0.42 ± 0.07 km/day about the cage. In addition, mice reared and jumped on average 79 ± 13 and 2120 ± 432 counts per day, respectively, again with no difference between groups. Gastrocnemius muscle oxidative capacity, as indicated by CS and β-HAD enzyme activities, were 22% and 26% greater, respectively, in muscles from Run compared to Sed mice (P≤0.036). Mitochondrial enzyme activities were not improved with wheel running in the TA muscle (P≥0.839).
CONCLUSIONS: The results provide support that voluntary wheel running does not further injure diseased muscle of mdx mice because there were no significant differences in cage activities between the Sed and Run mice. The running, however, was not sufficient to induce increased cage activities such as ambulation or jumping. The increase in mitochondrial enzyme activities in the gastrocnemius muscle allows the muscle to generate ATP efficiently and would theoretically reduce fatigue (see companion poster).
CLINICAL RELEVANCE: These results indicate that physical therapy for DMD patients including voluntary endurance type exercise might have some effectiveness in decreasing the progression of muscle weakness and fatigue, which may prolong ambulation.
VALIDITY OF THE SCHOOL-PHYSICAL THERAPY INTERVENTIONS FOR PEDIATRICS DATA SYSTEM FOR USE IN CLINICAL IMPROVEMENT DESIGN STUDIES
S.W. McCoy, M. Linn, Rehabilitaiton Medicine, University of Washington, Seattle, WA.
PURPOSE/HYPOTHESIS: The purpose of this study was to examine face and content validity of the School-Physical Therapy Interventions for Pediatrics (S-PTIP) data collection system. This manual and form were adapted from the Pediatric Physical Therapy Intervention Activities form, which was developed for use within clinical practice improvement design research.
NUMBER OF SUBJECTS: An expert panel of eight physical therapists from across the USA, identified through their participation in the Section on Pediatrics School Based Practice Special Interest Group, reviewed the S-PTIP for face validity. These therapists had an average of 21.1 years practicing in pediatric PT. Forty-seven practicing school-based pediatric physical therapists were mailed the revised S-PTIP to determine the content validity.
MATERIALS/METHODS: After reviewing the materials, the panel of experts completed a questionnaire assessing the accuracy and clarity of the S-PTIP manual and form. Revisions were made based on the panel's review. The revised S-PTIP manual and form were sent to the group of practicing school physical therapists. Each therapist was asked to review the manual carefully and then record their interventions and activities on the data form for three children on their current caseload. After the use of the form, the therapists were asked to complete a content validity questionnaire. A second round of revisions were made again after receiving the surveys and feedback.
RESULTS: Major revision of the S-PTIP manual and form were made based on the expert panel's suggestions related to making the form reflect school terminology for physical therapy. Use of the form on children within actual school practice was found to be acceptable by school based physical therapists. Further revisions were suggested and incorporated into the manual and form.
CONCLUSIONS: The results of this study suggest that the S-PTIP data collection form is a valid tool for reflecting the interventions and activities used by school-based pediatric physical therapists with children receiving therapy within school settings. However, the clinicians expressed that revisions would be necessary to make this into an adequate form if it was used in isolation for documentation.
CLINICAL RELEVANCE: The S-PTIP data collection system has the potential to provide a wealth of information spanning research, clinical and administrative contexts. We plan to use the revised version of the S-PTIP to collect descriptive data on interventions and activities and examine the associations of these with outcomes for students with disabilities that are receiving services in the school setting.
DEVELOPMENTAL IMPACT OF A CAREGIVER-PROVIDED POSTURAL TRAINING PROGRAM IN INFANCY
M.A. Lobo, C. Galloway, Physical Therapy, The University of Delaware, Newark, DE.
PURPOSE/HYPOTHESIS: Postural control is a crucial component of development whose developmental timeline is experience dependent. The ways caregivers handle and position their infants significantly impacts it. The purpose of this study was to determine the effects of a caregiver-provided postural training program. We hypothesized caregivers who used advanced handling and positioning techniques would have infants with better motor development throughout the first year of life.
NUMBER OF SUBJECTS: 28 healthy, full-term infants and their caregivers participated. Infants began at 2 months of age. All caregivers signed informed consent.
MATERIALS/METHODS: Infants were randomly assigned to one of 2 groups. Caregivers in the postural training group performed 15 min/day for 3 weeks of activities to advance postural control for their infants. Caregivers in the social training group performed 15 min/day for 3 weeks of activities talking with their infants in supine. Infants were assessed 6 times from 2 through 5 months of age, then followed via monthly phone calls to track milestone achievement. Home assessments included the Alberta Infant Motor Scale (AIMS) and reaching assessments. Follow-up data was collected using a form from The University of Manitoba's Infant Milestone Study. Visits were video recorded and a trained physical therapist scored the AIMS. Trained research assistants coded reaches. Mann-Whitney U tests compared social and postural training groups for all variables with only results ≤.05 reported.
RESULTS: Groups were not different at the start of the study in age or development. After training, postural infants had greater advancements in prone. This group continued to advance after the training ended. In the 2 months following training, they had greater advancements in prone and sitting, object manipulation, hands to midline, and head righting. These advances continued through 10–15 months of age with earlier onsets of transfer of objects between hands, creeping, and walking.
CONCLUSIONS: 1) Postural control can be advanced by educating caregivers to use different handling and positioning techniques, and 2) By advancing perceptual-motor development in infants and altering caregiver handling and positioning techniques, one can instill broad and long-lasting developmental changes.
CLINICAL RELEVANCE: For infants born at risk, these findings confirm that caregivers are critical components of the developmental process. When therapists observe caregiver-infants challenges, such as impaired perceptual-motor ability of infants, inability of infants to communicate clear signals about their abilities and needs, or impaired ability of caregivers to interpret or respond to these signals, early interventions should be jointly aimed at educating caregivers and enabling infants.
LONGITUDINAL ASSESSMENT OF PHYSICAL ACTIVITY IN CHILDREN WITH DUCHENNE MUSCULAR DYSTROPHY
D. Lott, J. Urcuyo, C. Senesac, J. Deol, K. Vandenborne, Physical Therapy, University of Florida, Gainesville, FL.
PURPOSE/HYPOTHESIS: Quantifying activity level and energy expenditure in children with Duchenne muscular dystrophy (DMD) is an important aspect of monitoring disease progression and the potential impact of therapeutic interventions. However, little research exists in this area, and we could find no studies that examined longitudinal assessment of physical activity in this patient population. The purpose of this study was to compare different durations (6 months versus 12–18 months) of assessing physical activity in children with Duchenne muscular dystrophy (DMD).
NUMBER OF SUBJECTS: Ten ambulatory boys with DMD (mean age 7.8 ± 1.4 years) participated.
MATERIALS/METHODS: All 10 subjects wore a dual axis accelerometer (ActiGraph GT1M) for 5–7 days to measure Total and Peak Activity counts as well as Total and Peak Step counts. In addition, an estimate of energy expenditure was determined (in METs) by the Freedson child energy expenditure prediction equation. A daily average for the 5–7 days of monitoring was determined for all variables of interest for each subject. Five of the subjects (mean age 8.2 ± 1.0 years) were re-tested at 6 months (MONTH), and the other five subjects (mean age 8.3 ± 1.8 years) were re-tested at either 12 or 18 months (YEAR). Percentage change in each variable was calculated for each subject relative to the initial testing session. Means and standard deviations were determined for both groups for the percentage change in each variable over the time tested. Only descriptive analyses were performed due to the small sample sizes at this time.
RESULTS: Total activity counts reduced by 22.3 ± 18.5% for the YEAR subjects, while it increased 12.3 ± 33.8% in the MONTH group. Peak Activity counts decreased 19.0 ± 29.2% in the YEAR group compared to an increase by 14.1 ± 29.1% in the MONTH subjects. Total Step counts and Peak Step counts decreased in the YEAR group (11.8 ± 22.0% and 3.7 ± 26.8% respectively), but these variables increased in the MONTH group (5.8 ± 25.2% and 0.71 ± 12.7%). Estimated energy expenditure was decreased over time for the participants in the YEAR group (7.8 ± 2.7%) as well as for those in the MONTH group (1.7 ± 2.3%).
CONCLUSIONS: It appears that follow-up assessment for physical activity level in boys with DMD should be of at least one year's duration or longer in order to provide a useful determination of change from the disease progression over time.
CLINICAL RELEVANCE: The preliminary results from this study provide a general guideline for clinicians working with children with DMD regarding when to reassess activity levels in this patient population. Further research is warranted to explore how these changes in activity/step count and energy expenditure relate to functional mobility. In addition, activity/step count and energy expenditure may be useful outcome measures for boys with DMD to assess the effects of therapeutic interventions.
MOVING WITH POWER
N.C. Mahler, Physical Therapy, Grand Valley State University, Grand Rapids, MI; C. Ripmaster, Physical Therapy, Lincoln Developmental Center, Grand Rapids, MI; J.D. Peck, Physical Therapy, Grand Valley State University, Grand Rapids, MI; J. Farris, Engineering, Grand Valley State University, Grand Rapids, MI.
Purpose: Children with severe physical and cognitive disabilities often are not given the opportunity to practice powered wheelchair mobility. This report describes a wheelchair trainer platform that accepts a child's customized wheelchair, provides a variety of power controls, permits the child to explore powered mobility, and allows the PT to make a recommendation regarding the future provision of a powered wheelchair.
DESCRIPTION: The wheelchair trainer has a ramp that easily allows the child's customized wheelchair to back up onto the trainer's base and then be strapped down for stability. The ramp fits a variety of sizes and types of chairs. The trainer has a switch adapter that allows for the use of joysticks, buttons, and gooseneck switches. The PT can manipulate the directions, speeds, and placements of these switches to best accommodate each child. The trainer also has emergency stop buttons on the device itself and on a remote control to ensure the safety of the child during independent play. This trainer is significant because any customized manual chair can be powered for driving trials so that the PT may make an informed recommendation for or against a power wheelchair.
SUMMARY OF USE: The trainer has been trialed with a variety of children of different diagnoses, ages, and functional abilities. Over the past year, modifications to the trainer have been recommended and the third generation is being designed. A typical trial allowed the child to first explore and manipulate the switches independently. When necessary, the PT helped the child activate the switches. During switch manipulation, the PT gave cues, like going forward, stopping, or turning. The cues helped the child realize that they had control of their movement and could explore their environment. With each child, a record was kept that included information about switch types, placement, what the child accomplished, and what the next session should do. The PT made an effort to see each child approximately 20 min a day once per week. The design of an assessment tool has begun to determine the child's specific areas of success and difficulty with powered wheelchair mobility. This tool will measure improvements made over time with the trainer and will help determine which children are most likely to succeed. Importance to Members: Because the trainer permits the child to remain stabilized in their customized seating during powered wheelchair driving practice, the child's chance of success is maximized. Because one trainer can serve to test and train multiple children, allocation of scarce funding will be improved when trials on the trainer suggest that a child will or will not be ultimately successful in managing powered mobility. The trainer will help PTs make more informed recommendations about provision of powered wheelchairs for children. Successful powered mobility for the child can lead to further cognitive and physical gains, as well as decrease the burden on caregivers.
THE EFFECTS OF SHOE DESIGN ON GAIT, STABILITY, AND LOADING IN NEW WALKERS
C.M. McCarthy, M. Buckland, H. Hillstrom, J. Frey, Pediatric Rehabilitation, Hospital for Special Surgery, New York, NY; J. Song,, Temple University, Philadelphia, PA; C. Choate, P. Scherer,, Samuel Merritt University, Oakland, CA.
PURPOSE/HYPOTHESIS: This study examined the effect of different shoe structures on gait patterns, plantar pressures and stability during functional tasks in early walkers. H1: Torsional flexibility will be different for each shoe design. H2: There will be good interrater reliability when assessing stumbles/falls. H3: Footwear will affect the number of stumbles/falls, gait parameters, and plantar pressures.
NUMBER OF SUBJECTS: 25 children.
MATERIALS/METHODS: Inclusion criteria: children independently walking <5 months without pathology or developmental delay. Four different shoes were evaluated for torsional flexibility. The following tests were completed in all shoes and barefoot (BF). An obstacle course included sit to stand, stepping up/down, walking along uneven/even surfaces, and up/down a ramp. The data was captured using 2 hi-def video cameras. The number of stumbles/falls was assessed with Dart Fish software. Gait parameters (GaitMatII) and plantar pressures (EMed X for BF, Pedar X for shoes) were also recorded.
RESULTS: Average(sd) age was 15.2(2.0) months. Torsional flexibility differences amongst shoes were found. The order from most to least flexible was: ultraflex (UF), midflex (MF), lowflex (LF), stiff. Interrater reliability was good (ICC = 0.75) when assessing stumbles/falls. The cumulative number of stumbles/falls were 20(BF), 22(UF), 29(MF), 29(LF), 27(stiff) and was not significantly different between conditions (p = 0.796). When comparing stability in children walking <2 months vs. walking >2 months, the children walking >2 months had significantly less stumbles/falls (p = .039). Gait parameters varied significantly when comparing shod to BF. Step length and stance time were shorter for BF as compared to shod (p<.004). Step width was wider in UF than LF (p<.001). Stance time was shorter for UF compared to MF (p<.001). Velocity was significantly different amongst all conditions with BF and UF being the fastest (p = .006). Plantar pressures were significantly different in all areas and conditions except for the 5th metatarsal head (p<.001). The highest pressures were found in BF and UF. The lowest pressures were found in the stiff shoe.
CONCLUSIONS: The large variability in the number of stumbles/falls resulted in no significant differences for this measure. The differences in gait parameters were found between BF and shod conditions. Children walked faster when BF and in UF, suggesting they were more comfortable in these conditions. Stance time was shortest in BF which correlates with the faster velocity. However, even though they walked faster in BF, they had a significantly shorter step length resulting in an increased cadence. Plantar pressures were significantly higher in BF and UF which may provide the child increased proprioception and stability.
CLINICAL RELEVANCE: New walkers were more stable when BF. They stumbled and fell the least and walked faster when BF. The increased feedback may allow them to adapt better to different surfaces. Plantar pressures were highest when BF, which may enhance proprioception. When a child requires the use of a shoe, a flexible shoe mimics BF best.
DEVELOPMENT OF THE EARLY CLINICAL ASSESSMENT OF BALANCE FOR YOUNG CHILDREN WITH CEREBRAL PALSY
S.W. McCoy, Rehabilitation Medicine, University of Washington, Seattle, WA; D. Bartlett,, University of Western Ontario, London, Ontario, CANADA; M. Team,, Multiple Unversities, Multiple Cities, PA.
PURPOSE/HYPOTHESIS: Because no complete clinical test of postural control exists for young children with cerebral palsy (CP) across all the severity levels of the Gross Motor Function Classification System (GMFCS), we developed and assessed the validity of the Early Clinical Assessment of Balance (ECAB), a 13-item therapist administered measure. The ECAB was developed for the Movement and Participation in Life Activities of Young children with cerebral palsy (Move & PLAY) study, examining the determinants of gross motor, self-care, and play abilities of children with CP.
NUMBER OF SUBJECTS: A convenience sample from US and Canadian Move & PLAY study sites of 406 children with CP, ages 1.5–5 years (mean = 38.1 months; SD = 11.4), and classified into GMFCS levels with 138 in Level I, 49 in Level II, 51 in Level III, 76 in Level IV, and 92 in Level V participated.
MATERIALS/METHODS: As a part of the Move & PLAY study, physical and occupational therapists who trained and reached 80% agreement for scoring items from videotapes on the tests collected data on children within their homes or clinics. During data collection, children in GMFCS levels I-III were scored on all items from the Pediatric Balance Scale (PBS); children in GMFCS levels III-V were scored on the Equilibrium section of the Movement Assessment of Infants (MAI). After data collection, based on confirmatory factor analysis of the data, the Move & PLAY team's theoretical analysis of postural control across the age and severity span, reduction of respondent burden by decreasing the number of items, maintenance of spread of the data across GMFCS levels, and the desire to create one test of balance across all participants, the items from the two tests were decreased and merged to create the ECAB. Descriptive and comparison statistics were completed to determine if the ECAB scores differentiated children across the GMFCS levels.
RESULTS: Seven items from the MAI and six from the PBS were retained for the ECAB. PBS items were weighted to represent the progression of postural control. The ECAB covered postural control development from head control through sitting protective responses from the MAI to higher-level sitting and standing balance on the PBS. ANOVA results confirmed statistically significant (p<0.05) differences in scores among GMFCS levels. Post hoc Scheffe tests revealed statistically significant differences among all GMFCS levels.
CONCLUSIONS: The ECAB was developed from components of the MAI equilibrium section and the PBS to allow testing of postural control from the development of head control through dynamic standing balance. The ECAB differentiates between children with CP from all GMFCS levels, demonstrating the validity of the test.
CLINICAL RELEVANCE: The ECAB has evidence of validity for testing the construct of postural control in young children with CP, which supports clinical use. Future research should include formal testing of reliability and examination of standard error of the measurement and clinically meaningful change scores to facilitate clinical use for evaluation of progress.
THE EFFECTIVENESS OF TAPING, STRAPPING, AND GARMENTS IN THE PHYSICAL THERAPY CARE OF CHILDREN WITH NEUROMUSCULAR DISORDERS: A SYSTEMATIC REVIEW
B. McNeal, S. Harmon, K. Krus, R. Wambolt, Physical Therapy, Southwest Baptist University, Bolivar, MO.
Purpose: The purpose of this systematic review was to investigate the effective use of taping, strapping, and garments as an alternative to traditional orthotics, such as AFO's, as well as surgery and injections. This research is important because taping, strapping, and garments are potentially less cumbersome than other devices and they may allow more independence in activities of daily living. Many clinicians are already using or have an interest in applying these types of interventions. Therefore, a review of research in this area is needed in order to justify the use of taping, strapping, and garments and to give clinicians guidelines for appropriate application of these interventions.
DESCRIPTION: After searching multiple databases and setting limiting criteria, seven studies were deemed appropriate for this systematic review. All studies were published between the years 2000 and 2009. The articles were evaluated using the 2008 American Academy for Cerebral Palsy and Developmental Medicine (AACPDM) methodology to give each a level of evidence as well as a conduct rating.
SUMMARY OF USE: Most studies focused on the “activities and participation” category of the ICF. Three of the seven studies included in this review investigated the use of various types of therapeutic taping, one examined strapping (with TheraTogs), and three looked at Lycra garments. Although improvements were shown in all studies, most were either not statistically significant or not statistically analyzed. One study was a Level II randomized controlled trial that was rated as moderate in strength, according to AACPDM standards, while the other six studies were Level IV case series. All studies examined only immediate results.
IMPORTANCE TO MEMBERS: The current available research does not strongly support any specific clinical parameters for the use of taping, strapping, and garments for the treatment of children with neuromuscular disorders. Studies regarding their use are relatively weak. More Level I and II research is needed in this area, as well as more long-term follow-up studies, in order to show evidence for the use of these interventions to provide quality care for children with neuromuscular disorders.
EFFECTIVENESS OF A STRENGTH-TRAINING INTERVENTION FOR A SEVEN-YEAR-OLD GIRL WITH GROSS MOTOR DELAYS CONSISTENT WITH DEVELOPMENTAL COORDINATION DISORDER: A CASE STUDY
S. Menz, K. Hatten,, Starfish Therapies, San Francisco, CA; M. Beuttler,, Chapman University, Orange, CA.
BACKGROUND & PURPOSE: Developmental coordination disorder (DCD) affects up to 6% of children ages 5–11 and is characterized by significant delays in motor skills. Despite international agreement on the use of DCD to describe children with motor coordination difficulties, there is little agreement regarding its cause or the effectiveness of interventions. Top down or bottom up approaches have been used by physical therapists to teach gross motor skills at an activity level rather than targeting specific deficits, such as strength, at a body structure and function level. While strength-training has been determined to be a safe intervention for children, there is little evidence of its effect on gross motor skills in this population. The purpose of this study was to determine if a strength-training intervention for a child with motor coordination difficulties would result in improved gross motor function following 24 sessions.
CASE DESCRIPTION: A strength-training intervention using the Universal Exercise Unit (UEU) was initiated for a seven-year-old girl with diagnoses of apraxia and hypotonia. The child had a history of limited progress with physical therapy using an activity level approach and at pre-test demonstrated gross motor delays consistent with DCD.
OUTCOMES: Following 24 strength-training sessions, the child demonstrated improvements in performance on all post-test measures, including an increase in age equivalents on standardized assessments by a range of 6 to 28 months. In addition, at post-test, gross motor delays were no longer consistent with DCD when measured with the BOT-2 and the DCD-Q.
DISCUSSION: Gains were demonstrated in strength measures between pre and post-test however, a greater magnitude of change was noted in gross motor function after the completion of the strength-training program. The child showed qualitative improvements in posture and motor unit recruitment during gross motor tasks and was able to demonstrate more efficient and successful motor performances. Based on changes in gross motor function from pre- to post-test, strength-training was found to be an effective intervention for a child with motor coordination difficulties. Future studies are necessary to determine its effectiveness across this heterogeneous population.
FEASIBILITY OF WII FIT INTERVENTION IN DIFFERENT AGE GROUPS OF INDIVIDUALS WITH CEREBRAL PALSY: A CASE SERIES
A. Murphy, A. Russell, J. Vice, A. Zipse, M. Finley, K. Martin, Krannert School of Physical Therapy, University of Indianapolis, Indianapolis, IN.
BACKGROUND & PURPOSE: Traditional intervention for cerebral palsy (CP) is individualized due to variability of the condition. Rehabilitation sessions focus on mobilization, stretching, strengthening, and gait training in order to improve motor control and decrease spasticity. Virtual reality (VR) gaming has gained widespread popularity among all age groups. VR simulates real world experiences and has been shown to increase patient motivation and adherence to home programs. Currently, only one case report has been published describing outcomes of using the Wii VR gaming system in rehabilitation of an adolescent with CP. The purpose of this case series was to investigate the feasibility of the Wii Fit system with various age groups with CP.
CASE DESCRIPTION: Six participants with CP (5 males, 1 female; Gross Motor Function Classification System [GMFCS] levels I-III, ages 5–25 years) participated. Three groups were classified: preschoolers (mean age = 5.5 years); teenagers (15.5 years) and young adults (24.5 years). Timed Up and Go (TUG), Berg Balance Scale (BBS), and spatiotemporal characteristic of gait using the GAITRite were administered prior to the intervention. Participants performed a one-time, thirty-minute intervention utilizing the Wii Fit games. Five games were played for 5 minutes each followed by an additional 5 minute game of choice. Games involved medial-lateral and anterior-posterior weight shifts, and/or vertical movement components. Manual and verbal cues were provided based on the participants' needs.
OUTCOMES: Overall, adults performed best on the BBS (adult mean score = 53) and TUG (adult mean score = 6.2 sec). The preschoolers and teenagers performed similarly on the BBS (preschoolers = 46, teenagers = 44), but not the TUG (preschoolers mean score = 7.1,teenagers mean score = 10.55). As GMFCS level increased, performance on balance-related measures and Wii games decreased.
DISCUSSION: Several variables including age, GMFCS level, cognition and attention span, and motivation may affect the participants' performance on the Wii Fit games. Teenagers and young adults did not require significant cues; however, the preschoolers required more assistance through constant manual and verbal cues to complete and be successful in the Wii Fit games. The most difficult component skill for all participants was the graded weight shifts in a circular motion (Hula Hoop game). All participants also had some difficulty with medial-lateral weight shifts because they had a stronger, favored side of the body. The Wii Fit intervention is feasible for teenagers and young adults to perform independently, and it may serve as a valuable option for home balance training. Preschoolers and individuals at a higher GMFCS level may benefit from this intervention as well; however, more assistance will most likely be required.
FEASIBILITY OF GAIT TRAINER AND SUPPORTED WALKER USE IN CHILD CARE SETTING
G. Paleg, Physical Therapy, Montgomery County Public Schools, Silver Spring, MD.
BACKGROUND & PURPOSE: Body weigh support and treadmill training has been shown to be effective in inducing earlier independent gait in children with Down syndrome and shows promise for infants and toddlers with other diagnoses including cerebral palsy, spinal cord injury and developmental delay. There have been no published studies describing the use of this technique in natural environments including child care settings.
CASE DESCRIPTION: A retrospective chart review of 10 children who used gait devices requiring daily adjustments (gait trainer and/or support walker) at the Family Infant Child Care Center (FICCC) was completed. Logs were reviewed to note compliance, adverse incidents, and length of use. Interviews were conducted with the staff to determine what they found difficult, and what they liked about using this equipment with their children.
OUTCOMES: Scores on the Mullen Early Scales of Learning indicated that children accelerated their development in the areas of social skills, fine motor and receptive language. While impossible to determine statistical significance in a descriptive of case series, the children did appear to walk 2–4 months earlier than predicted by their diagnoses and retrospectively determined GMFCS levels. The care givers were able to use the devices safely and felt their efforts resulted in positive change in the children. Two children over 4 years “tipped” their devices, without injury, 2 of 10 children walked independently, but never crawled and 8 of 10 progressed to GMFCS levels 1–4.
DISCUSSION: This small descriptive case series describes a natural environment setting (child care) where gait trainers and support walkers were effectively used by minimally trained non-professionals with a positive result in child development and with minimal negative consequences.
DIFFERENCES IN MOTOR PERFORMANCE IN PRESCHOOL CHILDREN WITH MOTOR DELAY WHEN TESTED IN AN INDIVIDUAL VERSUS A GROUP SETTING WITH TYPICALLY DEVELOPING PEERS
L. Quinn, A. Schippers, M. Wagoner, D. Brooks, T. Wilkinson, D. Fay,, A.T. Still University, Mesa, AZ.
PURPOSE/HYPOTHESIS: This study evaluated if there is a difference in motor skill performance when assessment occurs in an individual versus a group setting with typically developing peers. While previous findings suggested a benefit to group assessment, a possible order effect of testing could not be ruled out. An additional purpose of this study was to determine if testing order biased previous findings.
NUMBER OF SUBJECTS: A total of 20 preschool-aged children with documented motor delay were recruited from a public school preschool program. For the creation of group settings, 42 typically developing children were also recruited from the same program.
MATERIALS/METHODS: Ten different motor skills were assessed through items from the Stationary, Locomotion, and Object Manipulation categories of the Peabody Developmental Motor Scales-2. During the first phase, 12 children with delay were tested in an individual setting and retested in a group setting with 2 to 4 typically developing peers. In the second phase, 8 children with delay were tested in the group setting followed by the individual setting. Performance was videotaped and later scored by researchers blinded to the study's purpose. A Mann Whitney U Test was used to assess for an order effect and Wilcoxen Signed Rank Tests were used to analyze score differences by testing environment.
RESULTS: No statistically significant difference was found between the two phases of the study supporting that findings were not a result of testing order. A statistically significant difference was found between the performance of motor skills in the group versus individual setting (p <.05). Specifically, 14 of the 20 children showed overall improved performance in the group. When analyzed by skill category, statistically significant differences were found in Locomotion and a positive trend was seen in Object Manipulation. No statistical significance was present in the Stationary category. Although no difference reached statistical significance, performance on 9/10 skills improved in the group setting with positive statistical trends seen for catching a ball and jumping forward.
CONCLUSIONS: Overall performance on motor skills was significantly better in the group versus individual setting, with the greatest impact seen on locomotion skills. Potential score differences related to group interaction could have meaningful clinical relevance. If the same percentage of items showed score increases during administration of the entire PDMS-2, changes in final scores would be outside the SEM reported in the manual.
CLINICAL RELEVANCE: Testing a child in an individual setting may not accurately represent his or her performance in a natural environment. While most children improved in the group setting, not all did, indicating responses to the environment were individual. Assessment in a group setting should be at least part of the evaluation process to provide a clear picture of the child's true performance.
POWER MOBILITY AND SOCIALIZATION TRAINING IN A PRESCHOOL CLASSROOM FOR A CHILD WITH CEREBRAL PALSY
C. Ragonesi, J.C. Galloway, Physical Therapy, University of Delaware, Newark, DE; X. Chen, S. Agrawal, Mechanical Engineering, University of Delaware, Newark, DE.
BACKGROUND & PURPOSE: The effect of immobility on a child's socialization is an important issue in pediatric rehabilitation. In a previous study, we found it was feasible for a 3 yr old child with cerebral palsy (CP) to use a power mobility device in a preschool classroom but also noted a lack of typical socialization with the mobility device (Ragonesi et al 2010). The purpose of this follow-up case report was to determine the feasibility of providing additional adult-directed mobility and socialization training for this child. We hypothesized that classroom mobility and socialization would increase during training and remain high after training.
CASE DESCRIPTION: Participants: one 3-year-old child with spastic quadriplegic CP (GMFCS level III), one age/gender matched typically developing comparison peer, two preschool teachers, all from same preschool classroom. Informed consent was obtained before participation. Procedure: Pre Training (13 days). Training (10 days): adult-directed mobility and socialization training was provided in the classroom by therapists and teachers. Post Training (7 days). Assessment: Filmed classroom during morning free play. Coded for following variables: Mobility: 1) time spent in mobility device, and 2) time spent driving. Socialization: minutes spent in 1) solitary, 2) parallel play/aware (within 3 feet of peer but not interacting), 3) teacher interactions and 4) peer interactions.
OUTCOMES: During Training: a) Driving time did not appear to change compared to Pre Training, however the child b) spent ∼75% of time interacting with peers and teachers, as compared to ∼50% during Pre Training, c) increased teacher and peer interaction time across the Training phase, and d) interacted more over all than the comparison peer. Post-training: Driving time was ∼15% more than during Training, however the child b) spent ∼66% of time not interacting, c) decreased teacher and peer interaction time across Post Training days, and d) interacted less over all than the comparison peer.
DISCUSSION: Short-term, adult-directed power mobility and socialization training appears feasible for a preschool classroom. During training, socialization may have increased but mobility did not. Longer duration and/or more peer-mediated training may be more effective at coupling mobility and socialization. These preliminary findings combined with the previous case report (Ragonesi et al 2010) raise an important issue for therapists and educators working with children using power mobility: Intervention focused on either socialization or power mobility may increase each, but may not ultimately result in the use of mobility for socialization. We suspect that immobility and atypical socialization co-development during the first years of life. We propose starting power mobility earlier than 3 yrs of age within natural environments in conjunction with peer-mediated services to allow for a more typical co-development of mobility and socialization. Project funded in part by NSF and NIH.
INITIAL EFFECTS OF INTENSIVE POWER MOBILITY TRAINING FOR AN INFANT AT RISK FOR CEREBRAL PALSY
C. Ragonesi, C. Galloway,, University of Delaware, Newark, DE.
BACKGROUND & PURPOSE: The emergence of mobility via crawling and walking is a causal factor in developmental changes across domains (Campos et al 2000). The use of power mobility rarely begins before 3 yrs of age. Starting power mobility training earlier may further reduce immobility-related developmental delays. Our previous work focused on the feasibility and long term effects of training children 3 years and younger (Lynch et al 2009, Ragonesi et al 2010). The purpose of this case report was to determine the feasibility and initial effects of intensive driving training with an infant less than 1 yr old.
CASE DESCRIPTION: Participant: one 10-month-old female infant (gestational age 29 weeks) with delayed sitting, crawling and reaching. Procedure: 15 consecutive 1-hour training days in a childcare center gym and outdoor playground. Training used a commercial pediatric power chair (Koala, Permobil Inc.) with standard joystick and seating. Training combined a) structured driving including hand over hand assistance with b) exploration of the joystick and other objects while sitting in the chair. Parents also completed a home program of reaching training 15 minutes/day. Analysis: We filmed training sessions and coded for the following variables: 1) number of independent joystick contacts, 2) number of times infant looked at the joystick, 3) seconds of independent driving, and 4) seconds spent crying.
OUTCOMES: Preliminary analysis compared the first three sessions to the last three sessions. We report median values with maximum values in parentheses. From the first to last sessions, joystick contacts increased from 6 (11) to 19 (41); times looking at the joystick increased from 1 (6) to 6 (24); independent driving time increased from 6 (9) to 19
(97) seconds; crying time decreased from 14 (74) to 0 (0) seconds. Parents reported behavioral changes at home including: increased sitting stability, and increased reaching and grasping with her more involved hand, which was the hand used to drive.
DISCUSSION: These findings coupled with previous work strongly suggest that power mobility training is feasible for very young infants, even for those with significant postural and reaching impairments. Our outcomes suggest that training may prompt a range of motor, perceptual, cognitive and emotional changes that advance both specific driving skills (ex. attention to and activation of the joystick), and more general areas of development (ex. sitting posture and positive affect). We propose that both specific and general training effects may be necessary for infants to advance from consistent joystick interaction, to purposeful driving, to independent exploration. To expedite this process, we suggest therapists consider matching the social and physical environment, appropriate training duration, features of the mobility device, and training activities to each infant's changing abilities and temperament. Our future work will test these findings. Project funded in part by NIH.
EFFECTS OF SENSORY LEVEL ELECTRICAL STIMULATION ON MUSCLE CROSS- SECTIONAL AREA, STRENGTH AND METABOLITE PRODUCTION IN CHILDREN WITH CEREBRAL PALSY
M.A. Turk, PM&R, Upstate Medical University, Syracuse, NY; L. Romeiser Logan,, Rocky Mountain University of Health Professions, Provo, UT; R. Ploutz-Snyder, L. Ploutz-Snyder,, Universities Space Research Association, Houston, TX.
PURPOSE/HYPOTHESIS: To determine if chronic sensory level electrical stimulation (TES) has an effect on muscle structure or function in children with mild to moderate spastic cerebral palsy (CP) Hypotheses were: treated leg would be stronger; cross sectional area would increase on treated side; spasticity would not change.
NUMBER OF SUBJECTS: Volunteer sample of 13 children with mild-moderate diplegic CP ages 4–12y (m = 7 years) 12 children completed the 6 month program.
MATERIALS/METHODS: Subjects were randomly allocated to have their weaker or stronger legs treated. Strength and resistance to passive movement were assessed with Biodex dynamometer, cross-sectional area and T2 values (measure of efficiency with magnetic resonance imaging MRI) Evoked response and co-activation were measured with surface electrical stimulation and electromyography. Ashworth scores were recorded. Data were analyzed with STATA using mixed-effects statistical modeling. Somers d non-parametric measure of association complemented these analyses.
INTERVENTION: Sensory level electrical stimulation to the quadriceps muscle for 6 months at night. (hours of use 6252100 m = 1198).
RESULTS: A significant interaction effect was noted for increased resistance to passive movement on the treated leg relative to the untreated leg in quadriceps (p = .047) and hamstrings.(p = .023) Similar effects, not reaching traditional levels of significance were found for increased co-activation during quadriceps contraction (p = .158). Poorer muscle efficiency on T2 values pre-post overall were seen in the quadriceps (p = .029) and to a lesser degree by leg treated in the hamstring (p = .078). Central activation showed opposing trends with the treated leg increasing relative to a decreasing untreated leg (p = .123). Strength changes were variable with some children increasing and others decreasing. In the aggregate, hamstrings increased in strength significantly (p = .023 15% SD.5) and quadriceps showed a tread for decrease (p = .099 5% SD.6) with no change in treated leg. Cross sectional area was significantly increased pre-post overall (quadriceps p<.001 10.7% SD7.2), there was no significant difference by treated leg. Body weight remained the same over the 6 month period in 6/12 children. Somers d measures of association were significant among weight and CSA (p<.001), strength and weight (p<.05) and strength and CSA (p<.001) Weight change and CSA change were weakly correlated. (p = .151)
CONCLUSIONS: This research demonstrates that sensory level stimulation increases resistance to passive motion and co-activation. Strength measures were highly variable in this group of children, however it is concerning that some children decreased strength and cross sectional area significantly over a 6 month period.
CLINICAL RELEVANCE: We suggest that more children with CP be followed with precise measurements of strength, spasticity and muscle volume over time.
SKILL MASTERY OF TYPICALLY DEVELOPING CHILDREN USING THE GILLETTE FUNCTIONAL ASSESSMENT QUESTIONNAIRE: ESTABLISHING STANDARDS IN YOUNG CHILDREN
J. Stout, T.F. Novacheck, James R. Gage Center for Gait and Motion Analysis, Gillette Children's Specialty Healthcare, St. Paul, MN; R.C. Tervo, Department of Pediatrics, Gillette Children's Specialty Healthcare, St. Paul, MN.
PURPOSE/HYPOTHESIS: The Gillette Functional Assessment Questionnaire (FAQ) is an outcome tool used to measure the functional impact of walking. It was designed for use with children with disabilities. It consists of a 10-level walking scale and a 22-item advanced skill set. The skill set spans a range of motor development. Some, but not all of the skills have published normative data. The purpose of this study is to describe the performance of typically developing (TD) infants, toddlers, and pre-school children using the FAQ to: 1) establish normative data based on age for the 10level walking scale and 2)establish the range and type of skills a child would be expected to perform based on walking scale level.
NUMBER OF SUBJECTS: 451 infants, toddlers, & pre-schoolers (234 male, 217 female)
MATERIALS/METHODS: A cross-sectional survey design was used. Institutional Review Board approval was obtained. FAQ data from 536 pre-school children (8 months to 6 years) were collected at 20 child-care, hospital or home-school settings. 451 had no co-morbidities and were used for analysis. All data was collected by proxy-report from parent/legal guardian. Item difficulty of the 22-item skill set was determined by a rank ordering of the total number of children able to perform each skill. Progression of skill development was determined by grouping subjects by age. Grouping by FAQ walking level identified which skills map to a particular level of walking.
RESULTS: Twelve skills of the 22-item set are achieved by the age of 3 years and 19 of 22 skills are achieved by the age of 6 years. FAQ walking level 6 ambulation (routine household-limited community)is achieved by 18 months of age. Skill set item difficulty maps to FAQ walking levels with expected addition of skills at more advanced levels of walking. The easiest skill in the 22-item skill set was the ability to walk carrying an object which 83% of the preschoolers were able to perform. The skill maps to walking level 3. The most difficult skill to perform was the ability to jump rope which only 6% of the pre-schoolers were able to perform. The skill is only achieved by the small percentage achieving a level 10 on the walking scale.
CONCLUSIONS: Typically developing children exhibit a developmental progression across all levels of the FAQ walking scale and the 22-item skill set. Ability to perform some of the skills extends beyond the pre-school years.
CLINICAL RELEVANCE: This information establishes a base of interpretation when the instrument is used to assess function in children with disabilities. Interpreters of performance on the 22-item skill set of the FAQ should consider both walking level and the age of the child.
DANCE PRACTICE IMPROVES POSTURAL CONTROL IN A CHILD WITH CEREBRAL PALSY
K. Stribling, J. Christy, Physical Therapy, University of Alabama at Birmingham, Birmingham, AL.
BACKGROUND & PURPOSE: Dancing is a functional and fun way to practice various planes of movement. No studies have been done to determine if dancing improves postural control and movement in children with neurological disorders. The purpose of this case study was to investigate the effect of dance instruction on postural control and movement quality in a child with cerebral palsy (CP).
CASE DESCRIPTION: The subject was an 11 year old female with spastic triplegic type of CP, GMFCS level II. She was not receiving any therapy at the time of the dance instruction. Areas of weakness included no active extension in the right wrist, 3/5 strength right ankle dorsiflexors, 3-/5 strength bilateral hip rotators/abductors; 2/5 strength bilateral hip extensors/adductors. Range of motion limitation included a pronation contracture of the right forearm 30 degrees from neutral. In standing, the subject presented with bilateral calcaneal eversion (10 deg), bilateral knee flexion (10 deg), posteriorly tilted pelvis (20 deg), forward head/shoulders, and thoracic kyphosis. The subject had difficulty with frontal/transverse plane movements as well as walking backward. A DPT student with previous dance experience provided one on one dance instruction. Exercises were done to music in the sagittal, frontal and transverse planes focusing on somatosensory awareness and movement quality. Two 1-hour sessions were completed each week for 8 weeks. The final session included a performance of a learned routine for family and friends.
OUTCOMES: Outcomes tested before and after the intervention included Computerized Dynamic Posturography using the SMART Balance Master (NeuroCom). Tests included the Sensory Organization Test (SOT), Limits of Stability (LOS), and Adaptation Test. These tests quantify sway, reaction times and movement direction using a force platform and 100 Hz sampling rate. At post-test, improvements were seen especially in SOT condition 3 (i.e. sway surround, stable platform) to include less sway, improved use of ankle strategy and better control of center of gravity, implying improved use of somatosensory information. The LOS test (i.e. ability to lean in various directions) also improved. Before the intervention, the subject was unable to lean right or back. After, she could lean in all directions and improved end point excursion and directional control. The reaction time in response to a sudden and unpredictable toes down perturbation (i.e. adaptation test) also improved. In addition to Computerized Dynamic Posturography, six specific movement strategies were assessed. Improvements were seen in deep breathing, quality and speed of distal to proximal initiation of movement, trunk flexion/extension/lateral flexion, and isolation of upper/lower body from trunk.
DISCUSSION: This dance intervention appears to have improved somatosensory effectiveness, center of gravity control and ability to move in various planes. Clinicians could easily incorporate these principles into treatment plans, home programs and community integration for children with CP.
TONIC VIBRATION REFLEX IN CHILDREN WITH HEMIPLEGIA
N. Surico, M. Alcaro, C. Lucido, L. Meiksins, T.S. Moulton, J.G. McPherson, J.P. Dewald, Physical Therapy and Human Movement Sciences, Northwestern University, Chicago, IL.
PURPOSE/HYPOTHESIS: It has been demonstrated indirectly that the excitability of motoneurons (MN) innervating the paretic upper limb of individuals with adult-onset hemiplegia is increased over that of the non-paretic limb. It is unknown however if children with hemiplegia exhibit similar asymmetries in MN excitability. Therefore, this study sought to test for signatures of differential MN excitability between the paretic and non-paretic upper limbs in this population. The tonic vibration reflex (TVR) has been shown to be capable of detecting changes in MN excitability in the upper limbs of individuals with chronic hemiparetic stroke while also permitting mechanistic inferences to be made. Consequently, this study utilized the TVR response as a probe to investigate MN excitability in the upper limbs of children with hemiplegia.
NUMBER OF SUBJECTS: 7 participants (5 children with hemiplegia, 2 typically developing children), ranging in age from 711 years.
MATERIALS/METHODS: Participants were placed in a standardized isometric resting position. A 112 Hz vibrator was placed on the biceps tendon and 35 TVR trials were collected per limb. Each trial included 2s of baseline recording, 8s of vibration, and 5s of post-vibration recording. Isometric elbow flexion torque (EFT) and biceps EMG were recorded for all trials. Spasticity was evaluated using the Modified Ashworth Scale (MAS) on all participants.
RESULTS: EMG and EFT data were analyzed over two windows: V-ON (7.5–8sec following vibration initiation), and VOFF (4.5–5s following vibration termination). Repeated measures ANOVAs with factors of trial and limb were used to test for an effect of limb on V-ON and V-OFF EMG and torque responses. A trend towards increased EMG and EFT was observed in the paretic limb (EMG p = 0.163; EFT p = 0.171) during V-ON, however no differences between limbs were observed during V-OFF. Ensemble window averages, expressed as% max, were as follows (V-ON/OFF): BIC paretic = 8.9/0.5, non-paretic = 3.2/0; EFT paretic = 2.5/0.9, non-paretic = 0.31/0.07. There were no differences in any condition for the typically developing children. MAS ranged from 0–1+ across CH participants.
CONCLUSIONS: Increased EMG and EFT responses were present during vibration in the paretic limb but not in the non-paretic limb or those of control participants. Although only 5 children were tested, this trend suggests that children with hemiplegia have increased MN excitability on the paretic side, possibly due to an increased influence of bulbospinal pathways following injury.
CLINICAL RELEVANCE: Participants in the study demonstrated only mild spasticity on the MAS, but the amplified TVR responses suggest that increased MN excitability was still present. As such, the MAS should not be considered a definitive test for the presence of altered MN excitability. Future research is needed to determine fully the potential effects of increased MN excitability on volitional movement.
LOCOMOTOR TRAINING: FROM NON-AMBULATORY, 3 YEARS POST-TRANSVERSE MYELITIS ONSET AT 6 MONTHS, TO STEPPING AND INITIATION OVERGROUND
S.A. Trimble, E.J. Fox, K.V. Day, M. Spiess, C. Senesac, A.L. Behrman, Physical Therapy, University of Florida, Gainesville, FL; D.R. Howland, Neuroscience, McKnight Brain Institute, University of Florida, Gainesville, FL; S. Suter, Physical Therapy, Shands Healthcare, Gainesville, FL; N. Tester, Brain Rehabilitation Research Center, Malcom Randall VA Medical Center, Gainesville, FL; J.S. Johns, Spinal Cord Injury Center, Brooks Health System, Jacksonville, FL; L. Spierre, College of Medicine, Pediatrics, University of Florida, Jacksonville, FL.
BACKGROUND & PURPOSE: Locomotor training (LT) is an emerging rehabilitation strategy for individuals with neurologic dysfunction, i.e. spinal cord injury (SCI). LT targets activation of muscles below the level of the lesion via intense task-specific practice affording afferent input to the neural axis to generate a stepping response. The literature reports benefits in adults with chronic, incomplete SCI (ISCI), however only one published case study reports restoration of walking in a child 16 months post motor ISCI at 3.5 years (Behrman et al. 2008, Fox et al. 2010). The purpose of this case report is to extend the application of LT in the pediatric population by describing its effect on recovery after transverse myelitis (TM).
CASE DESCRIPTION: At 6 months, the child developed TM resulting in ISCI (C1-T7, AIS B). He required intermittent ventilator support during the first year post injury and received OT and PT 2–3x/week since onset. At age 3, the child was enrolled in the Kids STEP Study, a study of LT in non-ambulatory children post-SCI. Upon evaluation, he demonstrated bilateral lower extremity (LE) synergy extension movements and could partially support his weight, but was unable to perform voluntary, isolated joint movements (Lower Extremity Motor Score (LEMS) = 0/50). He could not initiate LE flexion or step, but could short-sit flexed without upper extremity (UE) support, 10 secs.
OUTCOMES: Following 45 LT sessions daily using a treadmill, partial body weight support, and manual assistance as well as stepping practice overground, the child performed his first volitional steps. With full support for trunk control and balance in upright, the child initiated and completed swing and stance phase of steps. Post-100 sessions, the child exhibited volitional, reciprocal stepping with a reverse rolling walker for 10–15 consecutive steps, requiring minimal assist for trunk support, balance, and foot placement. He could short-sit with flexed posture without UE support and reach outside of his base of support, 30–60 secs. Volitional LE movements remained dominated by synergy patterns though he demonstrated active, isolated dorsiflexion on the right (LEMS = 5/50). At home, the family reports he takes 20–30 steps/day with a walker and support for trunk control. The child continues to participate in LT with the goal of independent ambulation.
DISCUSSION: This is the first report of a non-ambulatory child nearly 3 years post TM developing stepping and initiating overground stepping in response to LT. Despite early disease onset and, thus lack of prior walking experience and normal neuromuscular development, intense LT promoted walking recovery. Based on standard clinical assessments, this child has surpassed expectations and recovery may be ongoing. Furthermore, improvements in trunk control and locomotor function may have durable effects and also attenuate secondary complications that are prevalent in children injured at a young age.
WITHIN-DAY VARIABILITY OF PAIN INTENSITY IN CHILDREN WITH JUVENILE IDIOPATHIC ARTHRITIS
S.M. Tupper, P. Pahwa, Community Health and Epidemiology, University of Saskatchewan, Saskatoon, Saskatchewan, CANADA; A.M. Rosenberg, College of Medicine – Pediatrics, University of Saskatchewan, Saskatoon, Saskatchewan, CANADA; C.L. von Baeyer, Psychology, University of Saskatchewan, Saskatoon, Saskatchewan, CANADA; A.D. Baxter-Jones, Kinesiology, University of Saskatchewan, Saskatoon, Saskatchewan, CANADA; J.N. Stinson, Nursing, University of Toronto, Toronto, Ontario, CANADA; A.J. Busch, Physical Therapy, University of Saskatchewan, Saskatoon, Saskatchewan, CANADA.
PURPOSE/HYPOTHESIS: Many youth with Juvenile Idiopathic Arthritis (JIA) endure an unpredictable course of chronic pain and disability throughout the duration of their disease. Within-day variability of pain intensity has been reported in previous research involving children with JIA; however, no studies were identified that described this variability or investigated for contributing factors. A number of factors known to influence pain intensity have predictable circadian (roughly 24 hour) rhythms, and adult forms of arthritis display clinically relevant within-day patterns of pain. If time of day is a significant factor in pain intensity variability, future pain research in children with JIA must ensure that pain measures are representative of the whole day pain experience in order to avoid measurement bias. Significance of time of day would also support future research into possible mechanisms of disease, such as altered hypothalamic-pituitary-adrenal axis function. The goal of this research was to evaluate within-day variability of pain intensity in children with JIA for time of day effects using the single cosinor procedure.
NUMBER OF SUBJECTS: 112
MATERIALS/METHODS: Data was collected as part of a study on the construct validity of an electronic pain questionnaire. Children with JIA answered a brief pain questionnaire three times per day for up to three weeks. The first week of pain intensity data for each participant was analyzed as separate time series. Significance of fit was assessed by the zero-amplitude test. Logistic regression was used to determine the contribution of participant age, sex, illness duration, disease severity, disease subtype and number of active joints to the prediction of a positive zero-amplitude test. Monte Carlo simulation with bootstrapping was conducted to determine if the prevalence of positive cosinor in clinical data exceeded that found by chance.
RESULTS: One hundred twelve children (ages 8 to 18) participated. Eighty-four series were included in the analysis. Nineteen (22.6%) time series had a positive zero-amplitude test (p<0.05). Peak pain occurred in the morning in 60% of the positive series. Wide variability was observed in mesor and amplitude of the series. Age was the only significant predictor (p = 0.036; β = 0.301) of a positive zero-amplitude test. Cosinor analysis of simulated data resulted in an overall proportion of 6.0% of positive cosinor (range 0 to 14.1%) in the 1000 simulated matrices. The proportion of positive cosinor in the clinical data (22.6%) exceeded that of the simulated data.
CONCLUSIONS: Approximately 1 in 4 children with JIA display a robust within-day pattern of pain that can be described by cosinor analysis. For this subgroup, time of day is a significant contributor to variability in pain intensity. Further investigation of factors contributing to within-day variability of pain intensity is needed in this population.
CLINICAL RELEVANCE: Time of day of measurement should be considered as a potential source of variability of pain intensity in future studies involving children with JIA.
A SYSTEMATIC REVIEW OF MOTOR IMPAIRMENTS IN CHILDREN WITH AUTISM SPECTRUM DISORDER
P.A. Weaver, G.C. Frey, Department of Kinesiology, Indiana University, Bloomington, IN.
PURPOSE/HYPOTHESIS: The purpose of this systematic review is to identify the current significance of motor impairments in children with autism spectrum disorder (ASD).
NUMBER OF SUBJECTS: A sample size of 997 subjects from 15 studies included 455 children with ASD and 542 children in comparison groups. Of the gender demographics available, there were a total of 679 males and 130 females.
MATERIALS/METHODS: Computerized keyword searches were conducted in 7 EBSCOhost Research Databases resulting in a total of 769 citations. The inclusion criteria to retain a study for the review were children participants less than 18 years of age, investigation of motor or movement impairments using standardized measures, and a diagnosis of Autistic disorder, Asperger's syndrome, or Pervasive Developmental Disorder-Not Otherwise Specified (PDD-NOS). Articles that met the criteria but dated prior to the year 2000 were detailed in the background literature section. The authors screened all titles and abstracts and retained 15 studies published from 2001 to 2010.
RESULTS: Studies accumulatively from the last ten years have revealed significant motor impairments in 53–100% of children with ASD in overall gross motor development, locomotor skills, object control skills, coordination, and abnormal posturing of body parts. The measuring instruments used for testing motor function were not congruent across studies, yet the end results were similar in finding motor impairments among the ASD population compared to normative data and comparison groups. Furthermore, children with ASD and other diagnoses such as Attention Deficit Hyperactivity Disorder, Developmental Coordination Disorder, Developmental Delay, and Specific Developmental Disorder of Motor Function were not significantly different in motor function between each group, but were all reported to be more impaired with motor skills than their typically developing peers.
CONCLUSIONS: Young and school-aged children with ASD are clearly at a risk to demonstrate a variety of motor impairments. All children with ASD will benefit from motor assessments similar to other children at risk for motor problems. As the Diagnostic and Statistical Manual of Mental Disorders –Fifth Edition (DSM-V) is in the revision stages and the three categories of Autistic disorder, Asperger's disorder, and PDD-NOS become one diagnosis of ASD, it is crucial that motor impairments be described at a minimum as an associated feature in the diagnostic manual. This inclusion of motor impairments in the DSM-V and other diagnostic manuals will prevent these symptoms from going unnoticed. It will allow for earlier recognition and treatment of motor delays or deficits in children with ASD through more frequent motor assessments.
CLINICAL RELEVANCE: Physical therapists are the practitioners of choice for diagnosis and intervention relating to motor and movement impairments. With over 50% of children with ASD having motor difficulties, those children needing physical therapy will benefit from evaluation and treatment beginning in early intervention and continuing as indicated in clinics or schools.
OUTCOMES OF A MINIMALLY INVASIVE MULTILEVEL SURGERY IN CHILDREN WITH CEREBRAL PALSY
D.L. Wild, Physical Therapy, University of Texas Medical Branch, Galveston, TX; C.P. Baker, Physical Therapy, University of Texas Medical Branch, Galveston, TX.
PURPOSE/HYPOTHESIS: Children with spastic CP usually present with muscle stiffness which eventually leads to decreased range of motion (ROM) in the knee and ankle joints interfering with gait and functional mobility. Typical orthopedic interventions include invasive single event multi-level surgeries to address muscle tightness; which can require prolonged painful recovery time. Selective Percutaneous Myofascial Lengthening surgery (SPML) is a minimally invasive surgery in which micro-incisions are made into the myofascia of the affected muscles. The purpose of this study was to assess changes in dynamic ROM of the knee and ankle and functional mobility following SPML surgery in a group of children with spastic CP.
NUMBER OF SUBJECTS: 31(62 extremities) children mean age of 8.5 years of age (4–18 years of age).
MATERIALS/METHODS: Subjective and objective measures were obtained from medical records and video tapes of gait. Pre-operative and follow–up videos of gait for 31 children with CP (62 extremities) who underwent SPML surgery from 2006 to 2008 were evaluated retrospectively, using a computer program to measure joint angles. Most children were walking within 24 to 72 hours after surgery; average time of follow-up was 7.5 months (range 4–13 months). The outcome measures considered for this study included sagittal plane kinematic parameters of the knee and ankle joint and functional mobility, using the Functional Mobility Scale (FMS). Mixed model for repeated measures for the knee and ankle joint parameters were used to estimate the change in ROM. Wilcoxin signed rank tests were used to examine the difference between pre and post-operative FMS scores. Medical records indicated that most children received physical therapy interventions following the procedures, but the treatments were not standardized.
RESULTS: Statistically significant differences in ROM were found for most joint measurements at p<0.05 in pre and post-operative comparisons, except for plantarflexion at toe-off. FMS ratings significantly improved (p<0.05) by 1 level at 5 meter, 50 meter, and 500 meter distances, indicating an increase in functional mobility.
CONCLUSIONS: The results of this study indicate that the minimally invasive SPML surgery designed to lengthen tight muscles of the lower extremity in children with CP positively affected dynamic ROM of the knee and ankle during gait. Additionally, improvement was noted in functional mobility at all distances.
CLINICAL RELEVANCE: There are many options available to manage the secondary impairments of lower extremity muscle tightness in children with spastic cerebral palsy. This study offers information regarding the positive outcomes of a minimally invasive surgical procedure for children with spastic CP, adding to the knowledge of treatment options available to children with cerebral palsy. Therapists working with children post SPML should expect increases in ROM and improvements in functional mobility.