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Abstracts* of Poster Presentations at the 2012 Combined Sections Meeting

doi: 10.1097/PEP.0b013e318241c9f7

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

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R.A. Amundson, T.A. Kolobe, S. Arnold, I. McEwen, Rehabilitation Sciences, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA.

PURPOSE/HYPOTHESIS: The primary purpose of this study was to examine the concurrent validity of a new evaluative tool, the School Outcomes Measure (SOM) compared with the Pediatric Evaluation of Disability Inventory (PEDI) in preschool age children. The study also examined the consistency of children's motor performance across the two important childhood settings of home and school.

NUMBER OF SUBJECTS: Forty-four preschool age children with physical or combined physical and cognitive disability participated in the study. Five school-based pediatric physical therapists participated in data collection.

MATERIALS/METHODS: Tools used included the PEDI, SOM, and Gross Motor Function Classification System. PEDI and SOM data for each participant were collected within one week of each other. PEDI data were gathered by the primary investigator, then scored by a blinded, independent therapist. SOM data were collected by each child's school physical therapist relying on existing information and familiarity with the child's abilities and performance at school, then entered into the SOM database via a secured website. Interrater reliability was acceptable for both the PEDI and the SOM.

Spearman's rho (rs) and descriptive statistics were used to compare the measures. To investigate consistency of child performance across school and home settings, we used the correlational coefficient data, scattergrams comparing SOM and PEDI scores, and additional comparison of group means between participants grouped by age, level of severity, and established PEDI cutoff scores of 1 or 2 SD below the mean. All data analyses were performed using subscale scores, and calculations were completed using Microsoft Excel.

RESULTS: Moderate to very high positive correlation coefficients between a majority of the PEDI and SOM subscale scores (rs = .53 to rs = .92) suggest scores linearly co-varied positively. When participants were categorized into groups by age, by severity of physical disability, or by performance using PEDI cutoff scores, group mean SOM scores systematically varied and showed agreement with PEDI scores with few exceptions. For example, the PEDI cut-off score of 2 SD below the mean categorized approximately 75% of the children who also scored low on the SOM.

CONCLUSIONS: The moderate to high correlation coefficients and results of the PEDI and SOM cutoff score comparisons support a positive association between the SOM and the PEDI and consistent child motor performance across the home and school settings.

CLINICAL RELEVANCE: Physical therapists must measure outcomes to document the effects of their services, which requires validated and appropriate outcome or evaluative measures. Our findings suggest that the SOM as a minimal database can be used to measure motor outcomes children in preschool programs, making it one of few evaluative measures establishing validity for use in this population and setting. Lack of information about SOM cut-off scores that represent minimally clinically significant differences currently limits its usefulness.

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S.B. Antoszyk, Cabarrus County Schools, Concord, NC, USA.

BACKGROUND AND PURPOSE: Individuals with cerebral palsy (CP) need opportunities to participate in physical activities to prevent secondary health complications. Strength training helps prevent deconditioning and may increase function in children with CP. Physical therapists working in the school setting encounter difficulties incorporating exercise into a child's school schedule. This case report demonstrates the benefit of using a recumbent cycle during a physical education (PE) class to improve functional performance of an 8th grade girl with CP.

CASE DESCRIPTION: The student is a 14-year-old girl with CP who has difficulty participating in a PE class with typical peers. She ambulates independently with forearm crutches. The student, assisted by her PE teacher, used a recumbent cycle for 14 weeks during a set portion of her PE class. Outcome measures used to assess her walking, balance and gross motor abilities included the Gross Motor Function Measure (GMFM), Pediatric Balance Scale (PBS), Pediatric Reach Test (PRT), Timed Up and Go (TUG), Observational Gait Scale, 6- Minute Walk Test (6MWT), 30 Second Walk Test (30sWT) and Pediatric Quality of Life Inventory.

OUTCOMES: The student reduced her crouched knee position during ambulation. She made gains in the PRT demonstrated by an increase in the distance reached in sitting and a gain of one point on the PBS. GMFM also showed a 2.8% improvement in standing and walking with the use of her crutches. During the post-test the student reported that she felt she could walk faster and farther, however she had a decrease in the distance walked for all walking tests.

DISCUSSION: Lifelong fitness is a goal for all students in PE class. Physical therapists must find ways for the student with disabilities to obtain and sustain lifelong fitness. The progress made during the 14-weeks of recumbent cycling had limited impact on the student's functional abilities but did demonstrate some improvements in strength. The reduction of the crouch gait position and the increased ability to reach in sitting could indicate an increase in the strength of her hips and knees as a result of the recumbent cycling. This finding is consistent with the existing body of evidence on strength training and CP. A recumbent cycle represents a relatively inexpensive piece of equipment that is easily adapted for the adolescent student with CP. This case report demonstrates the value of incorporating a fitness activity into a PE class if adequate support for the intervention exists among teachers and school administrative personnel.

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D.M. Begnoche, Physical Therapy and Rehabilitation Sciences, Drexel University, Philadelphia, PA, USA; A. Wood, KenCrest Services, Philadelphia, PA, USA; R.J. Palisano, L.A. Chiarello, Physical Therapy and Rehabilitation Sciences, Drexel University, Philadelphia, PA, USA; D. Bartlett, The University of Western Ontario, London, ON, Canada; Chang HJ, Physical Therapy and Rehabilitation Sciences, Drexel University, Philadelphia, PA, USA.

PURPOSE AND HYPOTHESIS: Knowledge of therapy services received by young children with cerebral palsy (CP) and their participation in community recreational programs will inform therapists and families in decision-making.

NUMBER OF SUBJECTS: This study describes the physical and occupational therapy (PT/OT) and community recreational programs received by 399 children (23–74 months of age) with CP.

MATERIALS AND METHODS: Using data collected from a parent questionnaire, we examined where services were received and differences in intensity and focus based on children's Gross Motor Function Classification System level (I-V) and geographical region of residence (US/Canada).

RESULTS: 94% of children received PT and 86% received OT. Children received services through early intervention or school programs and hospitals, rehabilitation clinics or private therapy clinics. 33% of children received PT and 28% of children received OT in more than one setting. 64% of children were involved in community recreational programs; 43% participated in aquatics and 21% in horseback riding. There were no differences in community involvement based on children's motor ability. Therapists' focused a moderate to great extent on children's primary and secondary impairments, activity and structured play. Activity (i.e. mobility, and practice of specific tasks) was more of a focus for children in levels I-III than level V (p < .01). Self-care (i.e. dressing, toileting, bathing) was more of a focus for children in level I than level V (p < .01). There was less focus on environmental modifications and equipment (i.e. addressing physical barriers to participation) for children in level I compared to children in all other levels (p < .01). Regional differences for focus of therapy were found. The most commonly reported frequency of PT and OT was 2–4 times per month. Children received more minutes per month of PT (m = 272.3, sd = 235.0) than OT (m = 193.0, sd = 182.2). Children in level III received the most minutes of PT (m = 344.7, sd = 258.7) and children in level V received the most minutes of OT (m = 244.4, sd = 213.4). Children in level I received fewer minutes of PT than children in levels II-V (p < .01) and fewer minutes of OT than children in level V (p < .01). Children in the United States received more minutes of PT and OT compared to children in Canada (p < .01).

CONCLUSIONS: Differences in the amount and focus of therapy were found based on children's gross motor function level. Regional differences in intensity and focus of therapy may reflect how resources for public funded programs are allocated, family resources, and beliefs of providers and families.

CLINICAL RELEVANCE: The finding that almost a third of the children received therapy in more than one setting has implications for coordination of care. A higher focus on activity for children predicted to achieve some walking ability and on self-care for children with the least motor involvement might reflect parents' desire for children's independence in these areas. Additional research is recommended to understand how decisions regarding the intensity and focus of PT and OT are made.

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A.W. Bodkin, N. Denniston, Center for Gait & Movement Analysis, Children's Hospital Colorado, Aurora, CO, USA; J. Welch, Rose Medical Center, Denver, CO, USA; J.J. Carollo, Center for Gait & Movement Analysis, Children's Hospital Colorado, Aurora, CO, USA.

PURPOSE & HYPOTHESIS: Partial body weight support treadmill training (BWSTT) is a promising intervention to improve ambulation in children with cerebral palsy (CP). BWSTT is costly because of the equipment and personnel needed to provide the intervention. Up to three trainers may provide manual guidance, one to stabilize the pelvis and one each to advance the legs. A more feasible option may be the leg swing assist device (LSAD), a low-tech, non-motorized, non-computerized piece of equipment that advances the legs using a series of springs, cords and straps. The purpose of this study was to compare gait kinematics during BWSTT with 3 trainers to BWSTT using the LSAD and one trainer stabilizing the pelvis.

NUMBER OF SUBJECTS: Four children with diplegic CP, 2 boys and 2 girls, 7–16 years old, one each at GMFCS Levels I-IV.

MATERIALS AND METHODS EQUIPMENT: Bertec motorized treadmill; Robomedica body weight support system; Robertson harnesses; 9-camera Vicon Motion Capture system; leg swing assist device (Locomotion, Inc., Boulder, CO).

PROCEDURE: Each subject participated in 3 sessions. The first session was used to fit the harnesses and orient the child and family to BWSTT. At the second and third session BWSTT was conducted with manual guidance and LSAD. The order of assistance was randomized during the second session and reversed for the third. Treadmill speed, percent of BWS and guidance were modified until the best gait pattern was achieved, determined through observation by the principal investigator. Kinematic data of this pattern were captured during three 5-sec trials. The same procedure was repeated with the other method of assistance. The child returned a week later and the procedure was repeated.

DATA PROCESSING: Kinematic data were calculated and average sagittal plane kinematic curves at the pelvis, hips, knees and ankles (±1 SD) were produced for manual guidance and LSAD.

DATA ANALYSIS: Curves were analyzed visually to determine differences between the conditions and which curves were closer to age-matched normal curves.

RESULTS: Gait kinematics were closer to average with manual guidance compared to LSAD. The most significant difference was increased lower extremity extension, especially at the knees in stance phase. Differences were less noticeable with subjects at GMFCS Levels I-II compared to subjects at Levels III-IV.

CONCLUSIONS: This small pilot study suggests that manual guidance during BWSTT leads to more normal gait kinematics than the LSAD in children with CP. Kinematic differences between manual guidance and LSAD appeared less pronounced in subjects at GMFCS Levels I-II. Future studies with more subjects are needed to confirm these results and to investigate improving the design of low-tech, low-cost ways to enhance BWSTT.

CLINICAL RELEVANCE: This pilot study suggests a lower cost method of leg swing assistance during BWSTT may be nearly as beneficial as manual guidance in children with Level I and Level II CP while manual guidance may be more beneficial for individuals with Level III and Level IV CP.

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J. Booth, Physical Therapy, Quinnipiac University, North Haven, CT, USA.

BACKGROUND & PURPOSE: Research has been limited in demonstrating the carry over of lower extremity strengthening in children with cerebral palsy to improvements in function. This case report describes the effects of functional lower extremity strengthening on the ability to ambulate for a 12 year old male with spastic quadriplegic cerebral palsy. He had a Gross Motor Classification System (GMFCS)level of IV and was previously non-ambulatory.

CASE DESCRIPTION: A 12 year old male with cerebral palsy GMFCS IV received functional lower extremity strengthening twice a week for one year in an outpatient physical therapy setting with carryover provided by his school based physical therapist and family. The following outcomes were measured to document changes in gait ability: distance ambulated, speed and the amount of assistance required. The patient's goal was to walk across the stage with his sister at his 8th grade graduation.

OUTCOMES: The patient made incremental gains in ambulation over the course of the year. He progressed from being able to ambulate 3 feet/minute to 28.8 feet/minute with a Rifton Pacer Gait Trainer. Initially the patient required maximum assistance to advance the walker and minimum assistance for his lower extremities. At the completion of outpatient physical therapy services the patient required minimum assistance to steer the walker only.

DISCUSSION: The findings of this study suggest functional lower extremity strengthening is an effective treatment to improve ambulation in children with cerebral palsy GMFCS IV. The repetition of task specific functional activities resulted in improvements not only in gait but other areas of mobility as well.

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R.E. Cardinal, P. Altenburger, Department of Physical Therapy, Indiana University, Indianapolis, IN, USA;H.I. Krebs, Mechanical Engineering Department, Massachusetts Institute of Technology, Cambridge, MA, USA; T.A. Dierks, Department of Physical Therapy, Indiana University, Indianapolis, IN, USA.

PURPOSE/HYPOTHESIS: The purpose of this study was to investigate the effect of an upper extremity (UE) robotic training device on clinical and functional outcomes in children with Cerebral Palsy(CP).

NUMBER OF SUBJECTS: 11 children ranging in age between 4 and 10 completed the study. Participants met the following inclusion criteria: UE hemiplegic presentation, a modified Ashworth scale (MAS) score of 2 or less, wrist extension equal to or greater than 0o in the affected arm, and sufficient cognition to attend to a task for 40 minutes.

MATERIALS/METHODS: Subjects participated in 16 sessions of robot-mediated, task-specific training on the MIT-Manus shoulder-elbow robot. Training consisted of 1,040 repetitions with real-time impedance control per session. Pre, post and 1-month follow-up testing were performed for each subject. Clinical outcome measures included active range of motion (AROM), passive range of motion (PROM), manual muscle tests (MMT), MAS, and grip strength. Functional capacity measures included the pediatric adaptive Fugl-Meyer scale and the Pediatric Evaluation of Disability Inventory (PEDI). Spatial-temporal control pattern data was collected across all 8 treatment protocol quadrants.

RESULTS: Due to the preliminary nature of this data, results are reported as clinical change. 10 subjects demonstrated an increase AROM and PROM in at least 2 joints by 1-month follow-up. MMT revealed strength measures ranging from 3/5 to 5/5. By 1-month follow-up, for all measurements less than 5/5 at baseline, 80% increased by at least one MMT grade. For grip strength, 7 subjects doubled their strength by 1-month follow-up. Tone (MAS) decreased in at least 2 measured joints for 8 subjects from pre-test to 1-month follow-up. 2 subjects demonstrated an increase in MAS score in 1 joint each, while the final subject remained unchanged. Coordination (Fugl-Meyer) results indicated that 9 subjects improved by more than 2 points at 1- month follow-up. Parents reported via the PEDI an overall improvement in functional task performance for 10 subjects. 6 subjects reported a PEDI change of greater than 10 points. Spatial-temporal control patterns, assessing a child's refinement of UE movement showed marked improvement for all subjects by 1-month follow-up.

CONCLUSIONS: Early results indicate that the application of robotic-assisted training improved several clinical measures of the affected limb for children with CP. Improved clinical measures likely resulted in increased use of the affected limb, leading to improved functional performance. Changes in movement control capacity were captured by marked improvement in spatial-temporal control of the robotic device by the children.

CLINICAL RELEVANCE: As robotic-assisted therapies become more prevalent, appropriate utilization is paramount to ensuring positive, function-oriented outcomes. Additionally, a greater understanding of these therapies by clinicians who are not involved in robotics programs will enable appropriate and timely referrals for children who stand to benefit from this technology.

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T. Catalino, School of Physical Therapy, Touro University Nevada, Henderson, NV, USA; T.H. Kolobe, I. McEwen, Rehabilitation Science, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA; A. Fagg, School of Computer Science, University of Oklahoma, Norman, OK, USA.

PURPOSE/HYPOTHESIS: There are no intervention strategies or assistive devices known to advance early prone locomotion or allow autonomous exploration for children with CP during the first year of life. The self-initiated prone progression crawler (SIPPC) is a new robotic device that is intended to assist infants with or at risk for CP during attempts at prone locomotion. The purpose of this study was to examine and document the movement patterns that infants who are typically developing use to be proficient in using the SIPPC. Infants who use the SIPPC are in a prone position and propel the device with a combination of their hands, feet, or knees on the floor.

NUMBER OF SUBJECTS: 10 (500 vignettes)

MATERIALS/METHODS: Infants ages 4–7 months participated in the study and met an inclusion criterion of >.5 standard deviation on the Test of Infant Motor Performance when tested at 3–4 months of age. Infants were videotaped using the SIPPC twice a week for up to 12 weeks. A total of 500 vignettes were coded using the Movement Observation Coding System (MOCS). The MOCS is a 41 item checklist that assesses the infant's Posture and Support (subscale 1), Exploratory Selection and Progression of body part movement (subscale 2), and Mastery of Propulsion while moving the SIPPC (subscale 3). We used descriptive statistics and repeated measure Anova (with a Bonferroni adjustment) to examine movement patterns and how they changed over time.

RESULTS: The subscale and total MOCS scores fluctuated from week to week but increased over time. Time was significant for subscale 1 (F = 8.406, P = 0.000), subscale 2 (F = 5.204, P = 0.003), and subscale 3 (F = 5.011, P = 0.003). Initially the MOCS item data revealed high variability in movement patterns of the arms and legs, but the variability decreased as the infants became proficient in the use of the device Leg movements preceded arm movements. No reciprocal arm and leg movements were observed.

CONCLUSIONS: All infants learned to use the SIPPC for prone locomotion by the end of the study, as expected, but many did so prior to achieving independent prone locomotion without the SIPPC, suggesting that the device facilitated early mobility and exploration in infants who are typically developing.

CLINICAL RELEVANCE: Findings suggest that the SIPPC has potential to create opportunities for autonomous exploration for infants prior to independent creeping. The movement patterns used by the infants, which in some instances were similar to that reported in the literature on creeping, suggest that the support provided by the SIPPC may help bypass some of the stability problems often experienced by infants with or at risk for severe CP who otherwise would not experience prone locomotion. Subsequent research will test the hypothesis with children with severe CP and examine any association between the use of the SIPPC and other areas of development such as cognition, communication, and problem-solving. This study was funded by the Foundation for Physical Therapy.

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C. Cavaliere, Graduate Programs in Health Sciences, Seton Hall, South Orange, NJ, USA; S. Simpkins, Physical Therapy, University of Texas Southwestern Medical Center, Dallas, TX, USA; G.P. Zipp, Graduate Programs in Health Sciences, Seton Hall, South Orange, NJ, USA.

PURPOSE/HYPOTHESIS: The purpose of this study was to answer three related questions: 1. Is cardiac vagal tone a reliable measure of regulatory sensory processing in children with and without autism spectrum disorders (ASD)? 2. Do children with autism spectrum disorders process sensory information (physiologically and behaviorally) differently than typically developing children? 3. Is there a relationship between physiologic and behavioral measures of regulatory sensory processing in typically developing children and children with autistic spectrum disorders?

NUMBER OF SUBJECTS: Twenty six boys participated in the study, 15 typically developing boys and 11 boys with ASD.

MATERIALS/METHODS: Cardiac vagal tone was measured two times over a 4 week period during the administration of the Sensory Challenge Protocol (Miller, 1999). Behavioral responsivity to sensation was measured using the Short Sensory Profile (Dunn, 1997). Intraclass correlation coefficients were used to examine reliability of the vagal tone data, repeated measures analysis of variance was used to examine within group response patterns in vagal responsivity to sensation and t-tests and multivariate analysis of variance were used to look at between group differences in vagal measures and SSP scores. Pearson Correlation coefficients were also used to examine relationships between the cardiac vagal tone and scores on the short sensory profile.

RESULTS: Results of this study indicate that cardiac vagal tone is a reliable measure of regulatory sensory processing. Highlighting the fact that when viewed separately, the group of children with ASD demonstrated greater statistical reliability with a narrow range (.819-.916) as compared to the typically developing children (.525-.923). We also found that the group of children with ASD demonstrated significantly lower baseline vagal tone than typically developing children (p = .018). Further, we found the two groups responded differently to sensation, with a significant interaction effect for group by sensation (p = .013). Post hoc tests revealed a significant difference between the groups on vagal responsivity to vestibular stimulation, with the group of children with ASD demonstrating less reactivity to the stimulation. Additionally, the ASD group demonstrated significantly lower scores on all sections of the Short Sensory Profile except movement sensitivity. Lastly, several correlations between vagal responses on the domains of the SCP and SSP sections were noted.

CONCLUSIONS: The results of this study point to a relationship between physiology and behavior, suggesting that children with ASD demonstrate less physiologic flexibility which may play a role in the decreased behavioral flexibility seen in this population.

CLINICAL RELEVANCE: Defining the relationship between physiological and behavioral responses to sensation is an important preliminary step in designing intervention programs aimed at reducing abnormal responses to sensation for children with ASD.

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K. Chafin, A. Mitch, R. Sargent, Y. Chen, Physical Therapy, Georgia State University, Atlanta, GA, USA.

PURPOSE/HYPOTHESIS: Studies of adults and typically developing (TD) children found the number of hands or fingers used to grasp an object was influenced by the relationship between object size and hand size. Children with Down syndrome (DS) between 3 and 11 years have shown no differences in number of hands used to grasp different sized objects compared to TD children when the object size was body-scaled. To our knowledge, there are no studies examining the impact of body-scaled information on grasping action in toddlers with DS age 1 to 3 years. The purpose of this study was to examine whether body-scaled information affects the number of hands and fingers used to grasp different sized objects in toddlers with and without DS.

NUMBER OF SUBJECTS: Ten toddlers were included, 5 DS (mean age = 16 mo) and 5 TD (mean age = 16.3 mo)

MATERIALS/METHODS: Subjects were videotaped grasping 14 boxes, 1.4 cm to 13.5 cm. Number of hands and fingers used were recorded. An independent t-test was used to compare the differences between DS and TD.

RESULTS: As expected, toddlers with DS had significantly smaller hand length than toddlers without DS (p = .004 right hand, p = .007 left hand). As box size increased, both groups switched from one-hand to two-hand grasping. There was a significant difference between when this transition occurred between groups (p = .02). However, when the body-scaled ratio between object size and hand size was considered, the differences between groups disappeared (p = .18). Additionally, the number of fingers used to grasp boxes also increased with increasing box size across both groups, with a Spearmen correlation coefficient of 0.94.

CONCLUSIONS: Toddlers with DS show similar body-scaled grasping patterns as their age-matched peers with typical development. This indicates that the differences in grasping patterns between toddlers with and without DS may be attributed to differences in body size, in addition to motor and cognitive abilities.

CLINICAL RELEVANCE: When evaluating a child with DS, it should be considered that the delay in prehension may be due to not only cognition or motor planning abilities, but also hand size. When working on grasp/prehension, it may be necessary to use smaller objects/toys to allow the child to more accurately demonstrate ability level.

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D.D. Chapman, DPT, St Catherine University, Minneapolis, MN, USA.

PURPOSE/HYPOTHESIS: Infants with spina bifida (SB) are born with compromised nervous systems. They experience marked continuities – discontinuities in their motor development and significant delays in when they learn to walk. Our understanding of the developmental trajectories displayed by infants with SB is limited to descriptions of the leg movements and kicks they produce between one and eight months of age. Thus, the purpose of this study was to examine the ability of nine to 12 month old infants with lumbar or sacral SB to generate spontaneous leg movements and kicks, i.e. leg movements that involve hip and knee flexion and extension when they were seated in a specially designed infant seat compared to when they were supine or seated in a conventional infant seat over developmental time (four months).

NUMBER OF SUBJECTS: Following IRB approval, six infants with lumbar or sacral SB between nine and 12 months of age at entry into the study were recruited to participant in this longitudinal study.

MATERIALS/METHODS: The spontaneous leg movements of each infant were video-taped at 30 frames per second while they were supine, seated in a conventional infant seat, and seated in a specially designed infant seat one time per month for four consecutive months. All data were collected in the babies' homes at a time when they were expected to be alert and active. The video-taped data were then behavior coded to identify the frequency of total leg movements and total number of kicks as well as the frequency of six types of kicks, i.e. single, alternating, parallel leg and single, alternating, and parallel knee kicks. The total number of leg movements and kicks were analyzed using MANOVA procedures with repeated measures for context and age (p < .05).

RESULTS: As expected, these infants generated more leg movements and kicks when they were seated in the specially designed seat compared to when they were supine or seated in the conventional infant seat. This small sample of infants, like younger infants with SB, did not produce more leg movements over developmental time. They did demonstrate more single knee and single leg kicks than any other type of kick, but not over developmental time.

CONCLUSIONS: These results, consistent with earlier studies, show that nine to 12 month old infants with lumbar or sacral SB are sensitive to the movement context in which they are placed and are capable of re-organizing their multiple sub-systems when confronted with changes in their environment.

CLINICAL RELEVANCE: These data provide additional support for previous observations that revealed the negative impact a conventional seat has on the ability of infants with SB to move their legs and kick as well as the positive impact a specially designed seat has on these traits.

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J. Chen, M. Beuttler, L. Glynn, Chapman University, Orange, CA, USA.

PURPOSE/HYPOTHESIS: Based on the literature, the 4–6 year old age group is a period when the nervous system is fine tuning ankle and foot proprioception and concomitant postural responses leading to the emergence of mature postural control. Research studies examining the gastrocnemius-soleus muscle tendon unit (MTU) and postural control in this age group are limited. The purpose of this study was to determine if a relationship exists between the gastrocnemius-soleus MTU length and postural control in 5-year-old children. We hypothesized that there will be a relationship between MTU lengths and measures of postural control.

NUMBER OF SUBJECTS: Gastrocnemius-soleus MTU lengths and balance measures were assessed in 47 normally developing 5-year-old children.

MATERIALS/METHODS: MTU measurements were obtained when slack was removed from the MTU (A0) and with a fully lengthened MTU (AMax). Muscle extensibility was calculated from A0-AMax. The Balance Master System recorded balance measures utilizing the modified Clinical Test for Sensory Interaction on Balance test: (1) firm surface, eyes open (2) firm surface, eyes closed (3) foam surface, eyes open (4) foam surface, eyes closed. Outcome measures included center of gravity alignment (degrees) and sway velocity (degrees/second).

RESULTS: Significant correlations were found between A0 and center of gravity (COG) alignment under three conditions: (1) firm surface, eyes closed (r = −.28, r2 = .08, p = .05) (2) foam surface, eyes open (r = −.39, r2 = .15, p = .007) (3) foam surface, eyes closed (r = −.37, r2 = .13, p = .011). Significant correlations were found between A0-AMax and sway velocity under the firm surface, eyes open condition (r = .32, r2 = .10, p = .031). A shorter A0 was associated with anterior COG alignment and a more extensible MTU was correlated with faster sway velocity.

CONCLUSIONS: Gastrocnemius-soleus MTU length accounts for 8 – 15% of COG variability observed during postural control with sensory challenges. The correlations suggest that the shorter the taut MTU, the farther anterior their COG was placed. A change in A0 length from −5 to −10 degrees could influence the child standing with an anterior or posterior COG alignment. Our results suggest that children with a longer gastrocnemius-soleus MTU allow themselves to sway at higher velocities.

CLINICAL RELEVANCE: MTU length should be evaluated when intervening in balance programs for children secondary to the relationship to COG position and velocity of sway.

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L.A. Chiarello, Physical Therapy and Rehabilitation Sciences, Drexel University, Philadelphia, PA, USA; D. Bartlett, School of Physical Therapy, University of Western Ontario, London, ON, Canada; S.W. McCoy, Department of Rehabilitation Medicine, University of Washington, Seattle, WA, USA; R. Palisano, Physical Therapy and Rehabilitation Sciences, Drexel University, Philadelphia, PA, USA; L. Jeffries, School of Physical Therapy, Langston University, Langston, OK, USA; A. Fiss, Department of Physical Therapy, Mercer University, Atlanta, GA, USA; P. Rosenbaum, Department of Pediatrics, McMaster University, Hamilton, ON, Canada; Stoskopf B7, CanChild Centre for Childhood Disability Research, McMaster University, Hamilton, ON, Canada; Wilk P8, Department of Epidemiology and Biostatistics, University of Western Ontario, London, ON, Canada.

PURPOSE/HYPOTHESIS: To identify child, family, and service determinants that together explain participation and play of young children with cerebral palsy.

NUMBER OF SUBJECTS: A convenience sample of 429 children with CP (56% boys; mean age 3y 2mo, SD 11mo) participated, with a retention rate of 90% over one year. Children in GMFCS levels I & II were classified as Group 1; those in levels III, IV and V as Group 2. Ninety-two percent of the parents were mothers.

MATERIALS/METHODS: At Time 1, reliable therapist assessors collected data on primary impairments (balance, distribution of involvement, quality of movement and spasticity) and secondary impairments (muscle strength, range of motion and endurance). At the same time, parents provided information about their children's health conditions and adaptive behavior. Data were collected in homes or clinics in multiple sites across the US and Canada. Six months later, Time 2, parents were interviewed about their family life and the services their children received. At Time 3, one year after Time 1, assessors administered the Gross Motor Function Measure and the Test of Playfulness and parents completed the Child Engagement in Daily Life Measure, a measure of home and recreational participation. Structural equation modeling was used to test the hypothesized models.

RESULTS: Fit statistics indicated a good fit between the observed data and the structural models. For children in GMFCS levels I and II, the models explained the following total amounts of variance in the outcomes: 35% for intensity of participation, 28% for enjoyment of participation, and 22% for playfulness. For children in GMFCS levels III, IV, and V, the models explained the following total amounts of variance in the outcomes: 40% for intensity of participation, 38% for enjoyment of participation, and 44% for playfulness. Adaptive behavior, family ecology, and number of community programs had a direct effect on intensity of participation for children in both groups but gross motor ability only had a direct effect on intensity of participation for children in GMFCS levels III, IV, and V. Adaptive behaviour had a direct effect on enjoyment of participation for children in both groups; whereas extent services met children's needs had a direct effect for children in GMFCS levels I and II and family ecology had a direct effect for children in GMFCS levels III, IV, and V. Gross motor ability had a direct effect on playfulness for children in both groups; whereas health conditions had a direct effect for children in GMFCS levels I and II and adaptive behavior had a direct effect for children in GMFCS levels III, IV, and V.

CONCLUSIONS: The models accounted for a higher amount of variance in the outcomes for children with lower motor function.

CLINICAL RELEVANCE: To impact participation and playfulness, therapists are encouraged to broaden the focus of services to include not only development of motor abilities but also comprehensive interventions to support children's adaptive behavior and family ecology.

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S.K. Effgen, A. Daus, H. Mella, L. Smith, B. Sutton, Rehabilitation Sciences, University of Kentucky, Lexington, KY, USA.

PURPOSE/HYPOTHESIS: This survey sought to gain updated information about the practice of physical therapy in educational settings serving school-aged children; determine if the practice conditions fulfill the descriptions of “best practice” outlined in the literature; and compare therapists' statements about actual practices in their schools and what they believe to be ideal practices. The survey examined the opinions of therapists working in the school system about actual therapy practices related to the delivery of therapy services to students compared to what they believe as ideal therapy practice. Five categories were studied: evaluation, development of the Individualized Education Plan (IEP), service delivery, team dynamics, and administrative support.

NUMBER OF SUBJECTS: There were 561 responses from 48 states. The majority of school-based therapists were women, have a master's level degree, are members of the APTA Section on Pediatrics, and have an average of 13 years experience working in pediatrics.

MATERIALS/METHODS: A previously published survey with recent expert panel review and updates was used to gain information on the practice of physical therapy in educational settings. Letters and emails were sent to over 1000 APTA Section on Pediatrics members throughout the United States requesting participation in this online survey. Survey results were analyzed for comparison between actual and ideal practices using Wilcoxon Signed Rank Tests and McNemar's Test.

RESULTS: Significant differences were found between respondents' statements of actual therapy practice compared to their opinions of ideal practice in all five categories. The majority of service delivery was usually direct service in the natural environment and therapists did participate in the post secondary transition process. Evaluations were performed separately by each discipline, 91% believed evaluations should be done in the classroom, but 47% responded that they always or usually evaluated students outside of the natural environment. The actual practice use of direct/indirect/consult intervention was always or usually based solely on the needs of the student according to 95% of the respondents. Ninety percent of the therapists believed they were “adequately” meeting the physical therapy needs of the children they serve.

CONCLUSIONS: Responses indicate actual practice of physical therapy in schools does not consistently meet the description in the literature of “best practice” in any of the five categories. The causes of these significant discrepancies must be investigated.

CLINICAL RELEVANCE: The more positive correlations between actual and ideal practice were in the categories of service delivery and evaluation. Therapists indicated that they were adequately meeting the needs of the children and they were able to independently make service delivery choices. However, there is concern that the evaluation process appears to be discipline specific across the nation, although frequently done in natural environments. Major areas for discrepancy included team dynamics, administrative support, and IEP development.

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T. Ellis, A.M. Glanzman, Department of Physical Therapy, The Children's Hospital of Philadelphia, Philadelphia, PA, USA.

PURPOSE/HYPOTHESIS: The primary purpose of this study was to examine how demographic and injury characteristics relate to function, length of stay (LOS), and discharge destination (DD) in children following traumatic brain injury (TBI). The secondary purpose was to provide predictive tools, based on these findings, to aid the novice clinician in treatment planning in the acute care setting.

NUMBER OF SUBJECTS: Data was gathered from the Pennsylvania Trauma Outcome Study registry for all patients admitted to The Children's Hospital of Philadelphia between 1996 and 2010. The initial sample included 708 patients with TBI. The data of 281 children between the ages of 5 and 17-years-old were analyzed.

MATERIALS/METHODS: Independent variables of demographic and injury characteristics included: age at injury, gender, race, injury severity score (ISS), Glasgow Coma Score (GCS), days spent in the intensive care unit (ICU), cause of injury, number of fractures (#Fx), and occurrence of intubation (Int). Dependent variables included abbreviated FIM score, LOS, and DD. Statistically significant variables, included in analysis, were chosen based on correlation and confirmation by Independent Sample T-tests. Stepwise linear regression analysis was used to determine the contributions of the variables as predictors of abbreviated FIM score and LOS. Logistic regression analysis was used to determine the likelihood of discharging to home versus inpatient rehabilitation.

RESULTS: Data from 203 boys and 78 girls with a mean age of 10.88 (±3.413) years was analyzed. The following regression equations explained 54.8% of the variance in abbreviated FIM scores, and 73.8% of the variance in LOS. The respective equations are: Abbreviated FIM = 16.758−0.692(ICU)−0.740(#Fx)+0.213(GCS) and LOS = 1.234+0.914(ICU)+0.977(#Fx)+1.468(Int). The likelihood of being discharged home compared to inpatient rehab was evaluated at two different time points during a patient's admission. The first is at the conclusion of the ICU stay, which is represented by: 1/(1+e-z), where z = 2.072−0.220(#Fx) + 0.200 (GCS) −0.804(ICU). The second is at the end of the acute hospitalization, which is represented by: 1/(1+e-z), where z = −6.141 + 0.618(abbreviated FIM) + 0.800(#Fx)−0.412(ICU) −2.229(Int).

CONCLUSIONS: Injury characteristics including length of ICU stay, number of fractures, GCS and occurrence of intubation account for a portion of the variance in function and LOS of children following TBI. These factors can also help predict the likelihood of these children discharging to home versus inpatient rehabilitation at the end of their acute hospitalization.

CLINICAL RELEVANCE: For both the novice and experienced clinician, accurate prediction of functional outcomes, LOS and DD is an important part of planning during a patient's acute hospitalization. The predictive equations provided in this study may guide clinician's treatment plans both at the end of a patient's ICU and acute care stay in order to help anticipate outcomes and future rehabilitation needs.

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A. Flanagan, H. Altiok, J. Ackman, M. Peer, J. Krzak, A. Graf, S. Hassani, Harris GF, Research, Shriners Hospitals for Children, Chicago, IL, USA.

PURPOSE/HYPOTHESIS: Little has been reported about long-term outcomes or gait in individuals who have undergone Van Nes rotationplasty for proximal focal femoral deficiency (PFFD). The purpose of this study is to evaluate the function and quality of life of adults who underwent Van Nes rotationplasty as a child.

NUMBER OF SUBJECTS: Twenty participants (13 M, 7F), ranging in age from 16–57 years (average 31.2±11.3 years).

MATERIALS/METHODS: Participants completed the following outcome questionnaires: SF-36, Revised-Faces Pain Scale (R-FPS), Harris Hip Score, Oswestry back pain score, Prosthetic Evaluation Questionnaire© (PEQ©), and a demographic/history/body image questionnaire developed by the authors. Twelve of the 20 patients were evaluated by a physical therapist using lower extremity (LE) range of motion (ROM), hand held dynamometry (HHD), gait/motion analysis and Timed ‘Up& Go’ (TUG).

RESULTS: Rotationplasty was performed at an average age of 4.8±3.6 years. Demographic questionnaire: All adult participants were working full time in a variety of manual and office/desk jobs and no significant issues were noted for body image. Pain: Three participants reported pain on the R-FPS. The Harris Hip Score average was 93 out of 100, indicating excellent function. Forty-five percent of participants reported being pain free on the Oswestry back score. ROM: All participants had a decrease in hip flexion and abduction, as well as dorsiflexion and plantarflexion. Strength: Participants exhibited hip flexion/abduction and gastroc weakness. Hip adduction/extension and ankle dorsiflexion were stronger on the prosthetic side for half the participants. TUG: Participants scored an average of 8.4±1.7 seconds on the TUG, demonstrating a low fall risk. SF-36: Participants scored high in role-emotional, social functioning, physical functioning and reported minimal pain. PEQ©: Participants scored lower in satisfaction with the prosthesis. However, they reported that others perceived them well and they did not see themselves as a social burden. Motion Analysis: Temporal-spatial gait/motion parameters were similar to typical adult values with the exception of decreased cadence and increased double support time on both sides, as well as increased percent time to foot off and single support duration on the non-prosthetic side. On the prosthetic side, knee kinematics demonstrated an absent loading response and decreased peak extension in stance. Delayed peak flexion was observed on the non-prosthetic side in swing phase. All participants had a moderate decrease in hip flexion and a mild decrease in hip abduction.

CONCLUSIONS: Long-term follow up of adults who underwent Van Nes rotationplasty showed that they maintained a high level of function and quality of life. They presented with compensatory gait/motion deviations with absent loading response and decreased peak extension in stance on the prosthetic side.

CLINICAL RELEVANCE: Long-term functional and quality of life outcomes can identify the primary factors affecting individuals who have undergone rotationplasty surgery for congenital PFFD.

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A. Flanagan, J. Krzak, S. Hassani, Shriners Hospitals for Children, Chicago, IL, USA; A. Bagley, Shriners Hospitals for Children, Sacramento, CA, USA; G. Gorton, Shriners Hospitals for Children, Springfield, MA, USA; M. Romness, University of Virginia, Charlotte, VA, USA; C. Tylkowski, Shriners Hospitals for Children, Lexington, KY, USA; M. Abel, University of Virginia, Charlotte, VA, USA; Johnson B, Shriners Hospitals for Children, Salt Lake City, UT, USA; S. Ounpuu, Connecticut Children's Hospital, Hartford, CT, USA; D. Oeffinger, Shriners Hospitals for Children, Lexington, KY, USA.

PURPOSE/HYPOTHESIS: To assess if greater lower extremity strength and decreased body fat correlates with measures of activity and participation in ambulatory children with cerebral palsy (CP).

NUMBER OF SUBJECTS: Three hundred seventy-seven individuals with CP, Gross Motor Classification System (GMFCS) levels I-III (241 males, 136 females; 104 hemiplegic, 273 diplegic; mean age 12 years 9 months (SD 2y 9mo)) participated.

MATERIALS/METHODS: Strength was assessed using a hand held dynamometer. Body Mass Index (BMI) was calculated and body fat percentage was measured using bioelectrical impedance analysis. Activity and participation measures included gait analysis, Gross Motor Function Measure (GMFM-66), Pediatric Outcomes Data Collection Instrument, 1 Minute Walk Test (1MWT), and Timed ‘Up & Go’(TUG). Data were analyzed using Pearson correlations.

RESULTS: The group of children with diplegia showed fair to moderate correlations between overall strength and all activity and participation measures. Also, individual muscle groups demonstrated similar findings except there were no correlations between dorsiflexors and any measures of activity and participation, and hip extensors were only correlated with GMFM-66. When children with diplegia were divided into GMFCS Levels: Level I had a fair correlation between overall strength, hip abductor, knee flexor and extensor and ankle plantarflexor strength and the GMFM-66; Level II had a fair correlation between overall strength, hip abductor, knee flexor and ankle plantarflexor strength and the GMFM-66 as well as for knee flexor strength with walking speed and the TUG; and no correlations were seen for Level III. The group of children with hemiplegia showed overall strength correlations with GMFM-66, 1MWT and TUG. When individual muscle groups were reviewed for these children there was a correlation between hip abductors and the 1MWT; knee extensors and 1MWT, TUG, and GMFM-66; and ankle dorsiflexors and plantarflexors and the 1MWT. When children with hemiplegia GMFCS Level I were analyzed there were no significant correlations with strength and any measures of activity and participation; GMFCS Level II were not analyzed separately as there were only 20 participants. For all children, BMI and body fat percentage were moderately correlated with overall strength and not correlated with measures of activity and participation except for a correlation between body fat and PODCI global function score.

CONCLUSIONS: Relationships between strength and activity and participation indicate that strength is important to the functional abilities of children with CP and should be included in clinical assessment. A direct relationship between body composition and function was not established but higher percentage fat and BMI were associated with less strength.

CLINICAL RELEVANCE: There is evidence to support that individual and overall strength measures are correlated with measures of activity and participation for children with CP. Correlations tended to be stronger and more frequent for those with diplegia than hemiplegia.

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M. Gannotti, University of Hartford, West Hartford, CT, USA; T. Oshio, Education, University of Hartford, West Hartford, CT, USA; W.P. Handwerker, Anthropology, University of Connecticut, Storrs CT, USA.

PURPOSE/HYPOTHESIS: Parents of children with disabilities experience more stress than their peers. Parental stress is related to more corporal forms of punishment; and this type of parenting style has been shown to be associated with poorer social and developmental outcomes. Moderating factors of parenting style are cultural values, child temperament, parental health, and socioeconomic status. A better understanding of parenting styles of families of children with physical disability will provide important information for providing family centered care.

NUMBER OF SUBJECTS: 10,688 children from the pre-school wave, Early Childhood Longitudinal Study-Birth Cohort.

MATERIALS/METHODS: Reported diagnoses were used to identify children with typical development, physical disability, or other developmental issues. Children with physical disability were matched with children with typical development. Parenting practices were defined as activities that parents do with their children, including discipline, care-giving activities, household rules, nurturance, and outside activities. Descriptive statistics identified the similarities between the two groups in age, gender, race, and socioeconomic status. Consensus analysis identified the common pattern of parenting practices of the sample. Regression analysis identified factors associated with variation in parenting practices.

RESULTS: 448 children (265 males) were identified as having physical disability. No significant differences existed between matched controls and children with disability on racial background, socioeconomic status, or parent type. Consensus analysis identified the common pattern of parenting activities were that parents did not spank, hit back, yell, ignore, put to work, or make fun of their children as a punishment. Parents used timeout, talking, taking away privileges, warning children and making them apologize when children misbehaved. Parents maintained rules set about eating, bedtime, chores, and watching television. They reported playing with children, preparing food for them, going to religious services, reading, singing songs, and telling stories with their children. They reported not being involved in organized exercise and art classes. Regression analysis identified child race, socioeconomic status, parental depression, child temperament, influence of religion, social support of friends, and physical disability as explaining 23% of the variance in parenting activities (R2 = .23, F8 = 30.4, p < .001).

CONCLUSIONS: Less corporal parenting practices were present with higher socio-economic status, social support of friends, influence of religion on child rearing, a more easy going child, and physical disability. More corporal parenting practices were present in families whose children were not Caucasian, with parental depression, and with difficult children.

CLINICAL RELEVANCE: Influences on child parent interactions are multi-factorial. Physical therapists should be mindful of the importance of social support and parental mental health in maximizing parent child interactions.

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T.J. Gilbertson, D. Rios, E.D. Brown, R. Price, S.W. McCoy, C. Moritz, Rehabilitation Medicine, University of Washington, Seattle, WA, USA.

BACKGROUND & PURPOSE: Neural plasticity and motor-learning research suggests that task-specific practice should control the intensity, repetition, timing, difficulty, and salience. Based on these principles, we explored the effects of task-specific practice using ‘Neurogame Therapy’ for the rehabilitation of wrist/hand movements in children with cerebral palsy (CP). Our portable system used surface electromyography (sEMG) to control computer games in patterns chosen for therapy, which may be an effective intervention for children with CP.

CASE DESCRIPTION: Four children with CP participated in the study (2 girls, 2 boys, 9–14 y/o). Each child had unilateral involvement of one wrist/hand and level III upper extremity function using the Manual Ability Classification System (MACS). Children were assessed twice before the intervention, immediately after the intervention, and during a follow-up test one month later. Children practiced using voluntary activation of wrist flexors and extensors to control the movement of a popular computer game for 1–2 weeks in the laboratory followed by 3–4 weeks at home. Outcome measures included agonist/antagonist independent control during game play, functional hand activity via the Shriners Hospital Upper Extremity Evaluation (SHUEE), maximal voluntary contractions (MVC), and satisfaction with individual goals via a modified Canadian Occupational Performance Measure (COPM). Outcome measures for each participant were compared among pre, post, and follow-up tests.

OUTCOMES: Game play adherence was monitored and all children played the game as much or more than requested at home (3–5 × week). They also rated the game therapy very highly for both enjoyment and for its positive effect on their hand function in general activities. One goal of game play was independent activity of antagonist muscles about the wrist, and all subjects eventually demonstrated nearly 70% independent activity during game play. For example, the first subject showed independent activity of his wrist muscles only 5–20% of the time at the beginning of the intervention, but improved to using his muscles independently 60–70% of the time by the end. All subjects that did not start near the ceiling improved by 6–30% in at least one measure of the SHUEE. For example, sub-scores on the Dynamic Positional Analysis for the fourth subject improved by 18% and 20% at the wrist and elbow, respectively. When MVCs were tested before and after game training (3 of 4 subjects), maximal EMG activity increased by 2- to 12-fold after game training. Finally, 3 of 4 subjects reported improved scores on activities selected for the COPM following the intervention.

DISCUSSION: Neurogame therapy is feasible and enjoyable for children with CP, and facilitates repetition and intensity of intervention. All participants improved their muscle coordination, which lead to notable changes in hand function. Neurogame therapy, which leverages neuroplasticity and motor learning principles, also appeared to increase participants' motivation to perform therapy.

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J.F. Greany, K. Check, K. Manske, K.A. Greany, Health Professions, University of Wisconsin - La Crosse, La Crosse, WI, USA.

PURPOSE/HYPOTHESIS: Children with autism spectrum disorders (ASD) display impairments in gross motor, social, and communication skills. Martial arts have been shown to improve balance, strength, and psychosocial skills in children who are neurotypical. Parents of children with ASD have reported benefits from martial arts participation. The goal of this pilot study was to evaluate the effect of martial arts on physiological, social and cognitive domains in a group of children with Autism Spectrum Disorder (ASD).

NUMBER OF SUBJECTS: Six children (4–10 years; 5 males, 1 female) with ASD attended 45-minute martial arts sessions taught by an experienced instructor 2x/week for 11 weeks.

MATERIALS/METHODS: Children were assessed pre/post for single leg stance time and postural sway. Postural sway was evaluated with eyes open, eyes closed and with a cognitive challenge (holding full cup of water). Parents completed the following behavioral surveys prior to and at the conclusion of the intervention: Autism Treatment Evaluation Checklist (ATEC), Social Skills Rating System-Parent Form (SSRS-PF), and Clinical Global Impression (CGI). Data were analyzed using paired t-tests.

RESULTS: Single leg stance time improved on both the right (9.0 ± 4.6 to 19.5 ± 12.1 sec, p = 0.04) and left (7.5 ± 5.1 to 13.4 ± 6.5 sec, p = 0.005). Postural sway showed no statistically significant differences for any of the three conditions. The SSRS-PF showed improvements in the Assertion (initiating behaviors, and responding to the actions of others positively)subscale score (9.5 ± 4.7 to 14.2 ± 2.7; p = 0.03) as well as the overall Standard Score for Sociability (72.0 ± 16.9 to 90.3 ± 12.0, p = 0.04). The Sociability subtest score of the ATEC showed a 49% improvement (13.2 ± 3.9 to 6.0 ± 2.8, p = 0.01) for subjects (n = 5). 67% of parents reported “moderate improvement” and 33% reported “minimal-slight improvement” on the Global Improvement Scale; 67% of parents also reported moderate improvement with social interaction, play skills, and gross motor skills on GIS scale.

CONCLUSIONS: The results of this pilot study suggest martial arts may improve single limb balance in children with autism spectrum disorder. Martial arts may also help with certain stereotypical characteristics of ASD, such as assertion and social skills.

CLINICAL RELEVANCE: Martial arts participation for children with ASD may assist in gross motor development and social skill acquisition. Further studies with more subjects should be conducted to confirm these preliminary findings.

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K. Grinde, J. Myhre, Developmental and Rehabilitation Services, Children's Hospitals and Clinics of Minnesota, Maple Grove, MN, USA; M. Liu, Research and Sponsored Programs, Children's Hospitals and Clinics of Minnesota, Minneapolis, MN, USA.

PURPOSE/HYPOTHESIS: Constraint-induced movement therapy has been used to treat upper extremity impairments in children with hemiparesis. The trunk and lower extremity are often impacted as well and should be considered in treatment to maximize outcome. The purpose of this study is to determine if there is significant change in gross and fine motor function for children with hemiparesis who were treated with a full program of pediatric constraint-induced movement therapy (fPCIMT) where both gross and fine motor impairments were addressed.


MATERIALS/METHODS: A retrospective study was conducted on children treated with fPCIMT from 2008–2010, who were between the ages of 17–86 months and had hemiparesis. Treatment was conducted by one physical therapist and consisted of structured skill development that included intense shaping and repetition of gross and fine motor skills 6 hours per day for 21 days of treatment. The children wore a univalved cast on the unaffected arm 24 hours each day. Pre (day 1) and post (day 21) treatment outcomes were measured using the Peabody Developmental Motor Scales-2 (PDMS-2). Upper extremity skills were tested separately for left and right hands. Ten children treated during 2010 were also tested with the Assisting Hand Assessment (AHA). A second physical therapist assisted with casting and testing. Wilcoxon Signed Ranks Test was used to compare the changes in gross and fine motor skill scores from pre to post treatment.

RESULTS: The median motor skill score for all subtests of the PDMS-2 and AHA improved significantly from pre to post treatment (p-value < 0.001). The median change in age equivalency on the PDMS-2 was: stationary 7 months, locomotion 5 months, object manipulation affected hand 8.5 months, object manipulation non-affected hand 7.5 months, grasping affected hand 10.5 months, grasping non-affected hand 6 months, visual-motor integration affected hand 10.5 months, visual-motor integration non-affected hand 4.5 months. The median change in the sum score on the AHA was 13 and the change in scaled score percentile was 20.

CONCLUSIONS: Children treated with fPCIMT that addressed both fine and gross motor impairments demonstrated improvement in fine motor skills. In addition, they also improved in gross motor skills.

CLINICAL RELEVANCE: It is possible to affect change in both gross and fine motor skills during fPCIMT. This protocol shows clinically significant change and should be considered as a treatment option when determining evidence-based care.

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L. Harrison, R. Eskritt, A. Ettmayer, S. Hindman, A. Klopp, B. Kratz, S. LaCombe, L. Nelson, Concordia University Wisconsin, Mequon, WI, USA.

PURPOSE/HYPOTHESIS: Individuals with intellectual and developmental disability (IDD) are at increased risk for osteoporosis and resultant fractures. Prevalence of osteoporosis in adults with IDD (ages 40–60) is reported to be 17–23%. Dual energy x-ray absorptiometry (DEXA) is the gold standard measurement for diagnosing osteoporosis. Quantitative ultrasound (QUS) can be a favorable alternative to DEXA when performing community screenings for osteoporosis. Effective screening for osteoporosis and the identification of risk factors in individuals with IDD could lead to early intervention. The purpose of this study was to screen for osteoporosis and identify associated risk factors in athletes who participate in Special Olympics.


MATERIALS/METHODS: Retrospective analysis was performed on data collected during a free health screening offered to Special Olympics athletes at one of their state sport tournaments in June 2009. Data included calcaneal bone density measured by quantitative ultrasound (QUS), gender, height, weight, waist circumference, body mass index (BMI) and smoking history. Prevalence of positive screens for osteoporosis in the sample was calculated using a QUS cut-off score of −1.5. Associations between risk factors and bone density were calculated using Pearson product-moment correlations. Stepwise multiple linear regression analysis was performed to determine whether significant risk factors for low bone density could be identified.

RESULTS: Complete data were available for 154 athletes-70 females (mean age 34+/−11 years), 84 males (mean age 32+/−12 years). Eleven percent of the participants screened positively for osteoporosis. BMI and abdominal circumference were the only risk factors significantly correlated to bone density measurements (QUS). Results of stepwise multiple linear regression analysis identified BMI as the only independent predictor of bone density (β = −1.069, R2 = .038, p = .015).

CONCLUSIONS: Prevalence of potential osteoporosis in the sample was lower than reported in the literature for individuals with disabilities. Perhaps the increased activity level of the athletes contributed to decreased risk for the disease. BMI and abdominal circumference were the only risk factors significantly correlated to bone density measurements. BMI was the only significant predictor of bone density. The value of using BMI as a simple predictor for low bone density, in lieu of a direct measurement, was not supported by the findings given the low R2 for the regression model. Further study may be useful in identifying additional risk factors with a stronger predictive value.

CLINICAL RELEVANCE: A simple clinical predictor of low bone density would facilitate identification of individuals with IDD who may benefit from targeted education related to fracture prevention and exercise. BMI does not seem to be that simple predictor in this population. The increased activity level of the athletes may have contributed to the lower prevalence of potential osteoporosis found in this study.

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L.Y. Hsu, B. Dellon, R. Price, D. Rios, D. Kartin, T. Jirikowic, S.W. McCoy, Rehabilitation Medicine, University of Washington, Seattle, WA, USA.

PURPOSE/HYPOTHESIS: Sensorimotor Training to Affect Balance, Engagement and Learning (STABEL) is a novel virtual reality system with a movable standing surface. Both the visual display and support surface can be controlled for distortion of sensory input during standing balance. It is designed to train the ability to use sensory information during balance. The purpose of this pilot study was to describe the immediate training effect of the STABEL on the ability to use sensory information during balance in children with Fetal Alcohol Spectrum Disorder (FASD) and children with typical development (TD). The hypothesis was that children's balance control during varied sensory manipulations would improve after practice with the STABEL system.

NUMBER OF SUBJECTS: A sample of convenience of 7 children with FASD and 8 children with TD who had no fetal alcohol exposure, age 8–16 years, participated.

MATERIALS/METHODS: All children were tested during two sessions of the Multi-Modal Balance Entrainment and Response (MuMBER) system. Within the MuMBER, the ability to weight and re-weight sensory input during standing balance is measured by determining the amplitude and timing with which children match their body sway frequency to small frequency visual, tactile, and support surface oscillations. A Qualysis motion analysis system captured body sway movements by tracking markers on children's head, neck, sacrum and heels. Between the pre and post MuMBER tests, they received three sessions of STABEL intervention, which included playing STABEL when standing on foam, and on two different pressure levels of an adjustable pressure tilt board. During the STABEL, children moved their bodies to drive a virtual plane through hoops. Outcome measurements included velocity and area of postural sway and gain for visual, tactile and support surface oscillations. Independent t tests were used to compare differences between performances on MuMBER in pre and post intervention sessions and the differences between the two groups.

RESULTS: Children with FASD showed significantly larger and faster postural sway and higher gain of vestibular stimuli than children with TD both in pre and post sessions of MuMBER testing (FASD: p = 0.008–0.038; TD: p = 0.003–0.031). After STABEL training, both groups showed significantly decreased area and velocity of postural sway (FASD: p = 0.014–0.027; TD: p = 0.001–0.040), but only children with TD demonstrated significantly lower gain of vestibular stimuli (p = 0.003–0.026).

CONCLUSIONS: Children with FASD and children with TD showed similar patterns of change during MuMBER testing after the STABEL. Children with TD, however, showed greater improvement than children with FASD. This may imply that children with FASD need more STABEL practice to change sensory postural control.

CLINICAL RELEVANCE: After practicing on the STABEL, children with FASD and children with TD improved their postural control during multiple sensory disturbances. Longer exposure to the STABEL and the long-term effect need to be explored.

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R.W. Johnson, Physical Therapy, Stony Brook University, Stony Brook, NY, USA.

PURPOSE/HYPOTHESIS: Individuals With Disabilities Education Improvement Act of 2004 (IDEA) places greater emphasis on transition planning than previous editions of the law. The purpose of this study was to develop and determine content validity for a student self-report outcome measure designed for transition planning at the secondary level. This assessment examines the need for assistance when performing community activities and determines the frequency and the need for assistance when participating in the community.

NUMBER OF SUBJECTS: 54 Physical Therapy Expert Reviewers Representing Seven Regions of the Country.

MATERIALS/METHODS: The development of CAPA consisted of three phases. Phase I identified domains, and developed items and scales. Phase II was a pilot study that examined the content validity of Community Activities and Participation Outcome Measure (CAP). Phase II had four steps. In step one the researcher identified and contacted 16 expert jury members. In step two a questionnaire was developed and disseminated. In step three, jury member responses were analyzed and in step four CAP was revised and prepared for retesting as CAPA. Phase III was a nationwide study designed to determine content validity of CAPA. Phase III had four steps. In step one, a new questionnaire was developed. In step two, expert reviewers were identified in seven regions of the country. Jury member responses were analyzed in step three and CAPA was revised based on jury responses in step four.

RESULTS: CAPA consists of 5 Community Domains that assess the need for assistance when performing activities and 3 Community Domains that measure the frequency of participation and the need for assistance when participating. Activity domains include self care, household, health care, mobility and transportation. Participation domains include leisure/recreation, work/volunteer and socialization. Fifty-four content reviewers from the seven regions of the nation completed a questionnaire with 9 closed ended and 8 open ended questions. One hundred percent of the reviewers agreed that CAPA could determine a student's ability in community activities and determine a students participation in the community. One hundred percent of the reviewers determined that the activity descriptors and scale definitions were clear and easy to comprehend. Ninety-eight percent of the reviewers believed the participation descriptors and scale definitions were clear and easy to comprehend. One hundred percent of the reviewers determined the assessment was clinically feasible.

CONCLUSIONS: The CAPA demonstrates content validity.

CLINICAL RELEVANCE: Transition planning often begins with determining the student's interests and abilities. The Community Activity and Participation Analysis will permit the physical therapist to participate in transition planning for high school students as they plan for future activities in the community. The self-report may encourage students in taking a more active role in determining their postschool plans.

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N.H. Lindgren, K. Axelsen, OASD, Reedsville, WI, USA.

BACKGROUND & PURPOSE: Research indicates that on-task time may be facilitated using alternate seating and sensory strategies, but there is very limited evidence using the standing position, rhythmic motions, or aerobic exercise. This case report describes how a standing desk was integrated into a kindergarten classroom as an intervention strategy to improve attention (time on task) and upright postures in a student with limited body awareness, attention, and balance.

CASE DESCRIPTION: Implementation of a standing desk program for a 6-year-old Child with poor body awareness, poor attention, poor balance, and autism.

INTERVENTION: A standing desk was utilized in the classroom as part of the physical therapy intervention plan.

OUTCOMES: The student is able to stand and swing a footrest while doing his classroom work. Improvements were noted in on-task time and time in upright postures during observation sessions. Student and teacher subjective comments were favorable. It was noted the student performed best in positions of standing or lying on the floor.

DISCUSSION: This study offers initial data to support the theory that a constant rhythmic motion (a sensory-motor strategy using a simple swinging footrest attached to a standing desk) can enhance the student's ability to block out distractors, reduce the amount of impulsive off-task behaviors, and improve focus and on-task behavior time. The standing work position appears to engage more of the total body musculature, leading to more upright posture time. This may facilitate a calm engagement for the student, with possible carryover effect. Therefore, the use of a standing desk contributed to positive learning experiences for this child.

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B. Litwin, C. Brown, T. Dunick, A. Merritt, Nova Southeastern University, Plantation, FL, USA.

BACKGROUND & PURPOSE: Evidence shows adolescents that are overweight often develop into adults that are obese and prone to a myriad of weight related co-morbid conditions. While aerobic exercises are often used in the management of obesity, there is little evidence indicating how to evaluate cardio-respiratory fitness in adolescents that are overweight. The purpose of this study was to determine if the one mile run/walk test (RWT) can be used to measure cardio-respiratory fitness in adolescents that are overweight.

CASE DESCRIPTION: The subject of this study, MK, was a 16 year old female recruited from a sample of convenience. MK was 5′ 3′′ and 165 pounds, with a BMI of 29.2. She was living at home with her parents and did not exercise other than participation in a high school physical education program for 1 hour 2×week. Her chief complaint was decreased physical endurance and lack of ability to “keep up” with peers during physical activities. She did not take any medication and was independent in all functional activities. She reported an active social life and doing well in school. Following a 15 minute warm up consisting of general stretching, MK was instructed in the rate of perceived exertion scale (RPE), and baseline measures including blood pressure (BP), heart rate (HR), respiratory rate (RR), and oxygen saturation (SpO2)were taken. The subject then performed the 1 mile RWT in an air-conditioned gymnasium, while encouraged by the researchers to run/walk as fast as possible around a pre marked circuit. HR, RPE, SpO2, and RR were assessed every 2 minutes during the RWT, with all measures assessed (including BP) at termination and 5 minutes post test. Following a rest period to allow MK to return to pre test measures, the subject completed the Oslo Protocol Treadmill Test (OPTMT). A metabolic cart was used to measure oxygen consumption (VO2), HR monitor to measure HR and pulse oximeter to measure SpO2 every 2 minutes during and at 5 and 10 minutes post test. The subject ran/walked on the TM until she reached 85% of target heart rate (THR) calculated at 173bpm. The speed or grade on the TM was adjusted every 2 minutes in accordance with the Oslo protocol.

OUTCOMES: The subject met THR on the TM test and achieved 97% of THR (169 bpm) during the 1 mile RWT, with THR achieved faster during the TM test (8 min) as compared to the one mile walk/run test (15 min 3 sec). A greater increase in BP and HR during the TM test may have been due to higher resting values at start of the test.

DISCUSSION: Results indicate the 1 mile RWT may provide a low cost, easily administered means to assess cardio-respiratory fitness in adolescents that are overweight. The 1 mile RWT allows clinicians to conduct a cardio-respiratory fitness test in ‘field’ conditions, without the need for special equipment. Further research should be conducted using a larger sample to measure oxygen consumption during the 1 mile RWT to establish the validity of this test as a measure of cardio-respiratory fitness in this population.

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D. Lott, R. Willcocks, Physical Therapy, University of Florida, Gainesville, FL, USA; A.T. Harrington, The Children's Hospital of Philadelphia, Philadelphia, PA, USA; K. Zilke, Shriners Hospitals for Children, Portland, OR, USA; C. Senesac, Physical Therapy, University of Florida, Gainesville, FL, USA; R. Finkel, The Children's Hospital of Philadelphia, Philadelphia, PA, USA; B. Russman, Shriners Hospitals for Children, Portland, OR, USA; H.L. Sweeney, Department of Physiology, University of Pennsylvania, Philadelphia, PA, USA; K. Vandenborne, Physical Therapy, University of Florida, Gainesville, FL, USA.

PURPOSE/HYPOTHESIS: Assessing mobility in children with Duchenne muscular dystrophy (DMD) is a key component to determining disease progression and the potential impact of therapeutic interventions. Physical therapists, neurologists, and other clinicians treating boys with DMD have used brief timed functional tests for decades to obtain this information. However, the results of these tests are at times questioned regarding their sensitivity and their ability to capture “real-life” mobility for these children. Recently, the six-minute walk test (6MWT) has been proposed to be a new outcome measure for this patient population. We could find no information in the literature regarding the association between the 6MWT and more traditional tests of functional ability in children with DMD. The purpose of this study was to examine the relationship between traditional functional assessments and the 6MWT in boys with DMD.

NUMBER OF SUBJECTS: Twenty ambulatory boys with DMD (mean age 8.6 ± 2.1 yrs) participated in this study as part of a larger multi-center research design.

MATERIALS/METHODS: More traditional timed functional tests for this study included: the 10m walk/run, ascending 4 steps, and supine to stand. Subjects performed three trials, and the fastest time for each test was used for analysis. The 6MWT was performed in a hallway that was marked with a piece of tape 25m in length as a line down the center of the walkway. Cones were set at each end of the tape, and arrows were also taped to the floor at each end to indicate the direction of movement for the test. The subjects were instructed to go as far as they could in 6 minutes without running or jogging. Means and standard deviations were determined for each test. Pearson correlation coefficients were used for determining the association between the three functional tests and the 6MWT.

RESULTS: Means ± standard deviations for the 20 subjects were: 6.3 ± 1.7 s for the 10m walk/run, 5.0 ± 2.6 s to ascend 4 steps, 7.6 ± 6.0 s for the supine to stand test, and 362 ± 64 m for the 6MWT. Correlation coefficients with the 6MWT were: −0.85 (10m walk/run), −0.74 (ascend 4 steps), and −0.57 (supine to stand).

CONCLUSIONS: Correlations with the 6MWT were good to excellent for the 10 m walk/run test and moderate to good for both the 4 step ascent time as well as for supine to stand time. Further testing should be done using regression modeling for predicting mobility outcomes in this patient population. Examining the longitudinal changes in these measures and how they relate to one another will be useful in assessing the impact of novel therapeutic interventions in clinical trials.

CLINICAL RELEVANCE: Clinically meaningful functional assessment tools measured by physical therapists that are reliable and predictive of the future clinical course are needed as novel treatments are being tested for patients with DMD. However, it is important to determine how these tests relate to one another and the best means for assessing mobility in this patient population.

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A. Lubetzky-Vilnai, T. Jirikowic, R. Price, B. Dellon, M. Ciol, D. Rios, D. Kartin, S.W. McCoy, Rehabilitation Medicine, University of Washington, Seattle, WA, USA.

PURPOSE/HYPOTHESIS: The purposes of this study were: to describe and compare performance on clinical measures of balance, sensorimotor activity, and participation between children with Fetal Alcohol Spectrum Disorder (FASD) and children with typical development (TD) of the same age and sex; and to investigate the psychometrics of the Dynamic Gait Index (DGI), as it had not been previously used with children.

NUMBER OF SUBJECTS: Ten children with FASD and 10 age and sex matched children with typical development, between 8 to 15 years-old, participated. Inter-rater reliability of the DGI was evaluated for 16 children; 11 returned for a retest.

MATERIALS/METHODS: The performance of children with FASD to children with TD was compared on the following measures: Child Assessment of Participation and Enjoyment, Movement Assessment Battery for Children (MABC), Sensory Processing Measure (SPM), Pediatric Clinical Test of Sensory Interaction for Balance, and DGI using paired t-tests and Wilcoxin Signed Rank tests. Two examiners scored simultaneously for DGI inter-rater reliability, and one scored a second test a week later for test-retest reliability. Intraclass correlation coefficients for the total sample and percent agreement by group were calculated.

RESULTS: Children with FASD demonstrated greater variability and trends toward poorer performance across all clinical measures. Statistically significant differences were seen on the MABC checklist and the SPM total score (P < 0.01), indicating that parent-perceived functional motor impairments on a daily basis were significantly greater for children with FASD than for children with TD. A significant difference on the DGI total score between children with FASD and TD (P = 0.02) indicated subtle effects of postural control dysfunction during gait in the children with FASD. Inter-rater and test-retest reliability of the DGI were moderate to good, (ICC(2,1) = 0.82, and 0.71, respectively), but percent agreement varied by group.

CONCLUSIONS: Results suggest the need to further examine the influences of sensory systems on the efficiency of balance and movement in children with FASD, especially under inaccurate or conflicting sensory conditions. The DGI is a potentially sensitive test of postural control effects on activity, but needs to be further explored.

CLINICAL RELEVANCE: Description of the sensorimotor performance of children with FASD assists to better understand the influence of sensory adaptation during balance on movement. Our findings lay the groundwork for development of targeted clinical interventions to remediate balance and movement impairments in children with FASD. The DGI with modifications for use with children is feasible and appears valid for use in a population of children aged 8–15 years with FASD and TD.

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G. Maldonado, T. Moran, P. Eberhart, D.P. Miller, University of Scranton, Scranton, PA, USA.

PURPOSE/HYPOTHESIS: The purpose of this systematic review was to examine various interventions for children diagnosed with developmental coordination disorder and conclude which interventions provided the best retention of motor performance for this population. The interventions reviewed included physical therapy, occupational therapy, education-based programming, psychological treatment, and dietary supplementation


MATERIALS/METHODS: CINAHL, PubMed, Science Direct, and ProQuest databases were searched with the following terms, “developmental coordination disorder” AND “Treat*”. Inclusion criteria for the literature included: peer-reviewed journals (2001–2011), children aged 5–12 years with DCD diagnosis (DSM-IV), and following-up testing at a minimum of two months post-intervention. Specific exclusion criteria included diagnoses in addition to DCD and those interventions with only pretest-posttest design. All interventions were considered, even those outside the physical therapy scope of practice, implying that the necessary referrals would be made for the benefit of the patient.

RESULTS: The literature search produced 110 titles, abstracts, and articles. Six articles met the stated criteria and were selected for inclusion in the systematic review. Two literature reviews specific to physical therapy suggested that cognition-based interventions demonstrated the best results for retention of motor performance. Success was attributed to the problem-solving aspect of the tasks. A cohort longitudinal study indicated that task-specific training from parents and teachers reinforced carry-over. An article from psychology literature stated that motor performance improved when addressed simultaneously with the child's self-concept. Another article disproved that dietary supplementation with fatty acids would provide positive results pertaining to motor skills. All research studies reviewed utilized the Movement ABC as the outcomes assessment tool. The PEDro scores ranged from 0/10 to 8/10 with an average score of 3.3/10.

CONCLUSIONS: The results of this systematic review suggest that physical therapy in combination with psychological interventions can improve retention of motor performance for children with DCD. Research to support a combination of physical therapy and psychological interventions for this disorder is limited and of low quality.

CLINICAL RELEVANCE: It appears that some type of intervention is better than none for these children with DCD. A combination of physical therapy and psychological approaches such as the enhancement of self-concept is recommended for the treatment of children with this diagnosis. These interventions should be focused on the developmental of motor performance.

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S. Mannell, HeartSpace Physical Therapy for Children, St. Catharines, ON, Canada; J.W. Wiebe, Interior Fitness, Lake Balboa, CA, USA; H.M. Larin, Ithaca College, Ithaca, NY, USA.

BACKGROUND & PURPOSE: Dynamic Core intervention, a systems approach linking inner and outer core musculature, targets core activation before movement, improved trunk alignment and stability during functional movement. Core stability is the ability to control alignment and motion of the trunk over the pelvis to allow for optimum force production and movement. The role of core musculature has been investigated in adults with musculoskeletal conditions and has provided some understanding of typical core function and dysfunction in the presence of injury. Several pediatric physical therapy approaches have suggested that trunk alignment and stability are important variables for postural stability and gross motor function. To date only one study has examined core function in children; the core muscles of boys with Developmental Coordination Disorder showed reduced amplitude and delayed recruitment to prepare for and stabilize the trunk during gross motor activities. A pediatric model for core intervention has not yet been reported. The purpose of this case report is to describe the use of the Dynamic Core intervention in the treatment of a child with Cerebral Palsy (CP) and present the outcomes obtained from this approach.

CASE DESCRIPTION: MD was a 12-year old boy with right spastic hemiparesis. Since age two, ongoing physical therapy (PT) and occupational therapy had concentrated on improving ROM, transitional movements and gross and fine motor skills. Secondary to growth and school demands, PT consistently addressed improvement in sitting and standing posture and balance. Dynamic Core concepts were introduced, first to promote seated and then standing postural stability. The program consisted of 2 consecutive 8-week blocks, delivered in weekly, one hour individual sessions. Each session focused on sequencing the activation of the inner core followed by the outer core musculature in precise alignment during strength and functional movement tasks.

OUTCOMES: At the conclusion of the 16-week period, MD improved in the targeted areas. Prior to treatment he sat in posterior pelvic tilt with and without the assistance of a wedge, stood in anterior pelvic tilt and could not stand still for more than 3 seconds. After the Dynamic Core intervention he was able to sit in neutral alignment for 20 minutes with a wedge and was able to transition from sitting to standing without using his arms. He maintained standing with increased neutral alignment of his pelvis and rib cage, and was able to stand still for up to 60 seconds. His parents noted decreased falls when playing outside with friends. No adverse effects were found.

DISCUSSION: Following the use of the Dynamic Core intervention, a child with CP demonstrated improvement in both postural stability and gross motor function. Dynamic Core intervention may be considered for children with orthopedic and neurological conditions. Investigation into this therapeutic approach is warranted.

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C. McSpadden, Rehabilitation Sciences, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA; S.W. McCoy, T. Jirikowic, Rehabilitation Medicine, University of Washington, Seattle, WA, USA.

PURPOSE/HYPOTHESIS: Pediatric physical therapists need standardized outcome measures that assess different components of balance including the sensory systems. The Pediatric Clinical Test of Sensory Interactions for Balance, 2nd edition (P-CTSIB2) is a clinical standardized test that measures a child's ability to maintain standing balance when sensory conditions are systematically altered. Purposes of this study were to examine test-retest reliability of the P-CTSIB2, concurrent validity of the P-CTSIB2 with the Sensory Organization Test (SOT), and construct validity of the P-CTSIB2 between groups of children with typical development (TD) and with Fetal Alcohol Spectrum Disorder (FASD). We hypothesized that there would be adequate test-retest reliability and validity of the P-CTSIB2.

NUMBER OF SUBJECTS: A convenience sample of 20 children between 8 and 15 years age, (10 with TD; 10 with FASD), participated in the validity study. Of these 20, 9 participated in the test-retest study (5 with TD; 4 with FASD).

MATERIALS/METHODS: Two pediatric physical therapists administered the P-CTSIB2 and an examiner familiar with SOT testing administered the SOT. Examiners were blind to the children's diagnosis and previous testing. Children in the validity study were given the P-CTSIB2 and SOT on the same day. Children in the test-retest study were given the P-CTSIB2 on two days, approximately one week apart.

RESULTS: Due to the small sample size and limited variability of the data, test and retest P-CTSIB2 total scores were compared for differences. The largest difference between test and retest score was 3 points (maximum score = 70). The P-CTSIB2 and the SOT total scores were moderately correlated (rs = 0.40), but did not reach statistically significance (p = 0.18). Further examination of each sensory condition score demonstrated higher correlations between more challenging conditions (Visual Inaccurate, Somatosensory Inaccurate and Vestibular, rs = 0.53 p = 0.06; rs = 0.62 p = 0.03; rs = 0.54 p = 0.06, respectively) and lower correlations with easier conditions. There was a statistically significant difference between the two groups on the P-CTSIB2 Somatosensory Inaccurate and Vestibular system scores (p < 0.05) and the total score neared statistical significance (p = 0.06).

CONCLUSIONS: Total scores on the P-CTSIB2 were similar test to retest, however, in every case except for one, the scores went up 1 to 3 points suggesting a small learning effect. Concurrent validity between the P-CTSIB2 and SOT total scores is suggested. Construct validity was demonstrated between the two groups of children on the most difficult sensory conditions. Children with FASD demonstrated subtle balance deficits therefore there was less data variability, which likely contributed to the low power to show statistical differences.

CLINICAL RELEVANCE: Clinicians should be cautious in using this test as a way to measure change across time until more study of test-retest reliability occurs. Validity of the P-CTSIB2 is suggested to test subtle differences in sensory systems used for postural control.

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R. Mercier, M. Beuttler, Chapman Doctor of Physical Therapy, Orange, CA, USA; M. Oropeza, von Ibsch D., South Coast Therapy, Inc., Cypress, CA, USA.

PURPOSE/HYPOTHESIS: Studies show that gastrocnemius-soleus muscle-tendon unit (MTU) length and extensibility may affect the range in which the muscle activates. Length changes to the MTU may occur as the muscle adapts to function required for gait. In children with developmental delay, changes in MTU length may not occur as they do in children with normal development. We aim to compare passive gastroc-soleus MTU measurements in normal developing children and children with neurological diagnoses to determine a) If gastroc-soleus MTU length and extensibility change during normal gait development in normal developing children, and b) if there is a difference in length and extensibility between normal developing children and children with various neurological diagnoses.

NUMBER OF SUBJECTS: 134 children (65 males, 69 females), aged 0–7 years, were divided into groups based on presence/absence of neurological diagnosis and level of tone, if diagnosis present. Groups were subdivided into three categories based on gait development: pre-walker (PW), immature walker (IW), and mature walkers (MW).

MATERIALS/METHODS: MTU length and extensibility were measured and compared across three gait development classes in normal children, and between normal children and children with diagnoses.

RESULTS: A0 (slack removed from MTU) shortened from PW to IW, then lengthened in MW. Amax (fully lengthened MTU) occurred in positions of greater dorsiflexion in PW when compared to IW and MW. There was significant increase in both A0 and Amax measurements in children with neurologic diagnoses and low tone compared to normal children. There was no significant difference in A0-Amax (muscle extensibility) when comparing gait development categories, or between normal children and children with diagnoses.

CONCLUSIONS: These results suggest that a shift in MTU length occurs during gait development in normal children, with both length measurements occurring in a more plantarflexed position. Similar MTU length changes also occur with tonal influences in children with medical diagnoses. While there is little or no change in the amount of extensibility in the MTU, the range where this extensibility occurs in active ankle motion does move based on function and in tone classification with neurological diagnosis.

CLINICAL RELEVANCE: Shortening of A0 may decrease degrees of freedom at the ankle when initially learning to walk. MTU length may assist pediatric physical therapists in identifying limitations in ankle function as their patients learn to walk.

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T.L. Millard, Physical Therapy, North Georgia College & State University, Dahlonega, GA, USA.

BACKGROUND & PURPOSE: Determining the most appropriate care path and use of family resouces for a child with cerebral palsy (CP) can be daunting for both parents and healh providers. This case study was developed to (1) determine the effectiveness of an TheraSuit Method intervention versus a conductive education program in meeting the family established goals of a young child spastic diplegia cerebral palsy; and (2) to assist family in making future choices for allocation of resources.

CASE DESCRIPTION: A 33 month old child with a diagnosis of spastic diplegia CP, GMFCS Level II, participated in two different intensive intervention programs: a 3 hour a day, two week TheraSuit Method program followed by enrollment in a 5 hour a day, six week conductive education program. Order of attendance was randomly determined. A two month interval of one hour a week physical therapy was spaced between the two interventions. All other therapies and activities were maintained at prestudy intensity levels. Family established goals were to promote ambulation as the main mode of the child's locomotion and to promote independent sitting with hands free. Using the ICF model and parent goals the Gross Motor Function Measure (GMFM-66), functional reach test and a 10-meter walk test were chosen as appropriate outcomes measures. Measurements were taken one day prior to the beginning of each intervention and the day following the end of each intervention.

OUTCOMES: After the TheraSuit Method intervention, time required to ambulate 10 meters decreased by 16 seconds; distance reached increased by 27 cm; GMFM score increased by 8.35 points. After the no intervention interval, continued improvements in time to walk 10 meters (23 seconds) and the GMFM score (.36 point) were observed. After six weeks of conductive education, time to walk 10 meters increased 2 seconds; functional reach decreased 2 cm; GMFM score did not change.

DISCUSSION: For this child the TheraSuit Method intervention appears to have assisted goal achievment better than the conductive education program. The order of attendance of interventions; type of intervention, and outcomes measures chosen may have all had an impact on the outcome of this case study. A difference between the two intervention programs could be described as practice versus activity. The TheraSuit Method incorporated both strength and endurance activities based specifically on achieving the established goals of the parents and promoted practice of these activities. The conductive education program focused primarily on practice of activities to improve performance in a school environment. This emphasizes the importance of choosing appropriate intervention techniques and outcomes measures to promote and measure goal achievment. The decline of skills not practiced highlights the amount of continued pracatice needed by a child with motor disabilities related to CP to sustain gains and promote continued improvement.

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A. Mitchell, Peiatrics, University of Arkansas for Medical Sciences, Little Rock, AR, USA; C.C. Yates, J. Womack, M. Webb, L. Lowe, Physical Therapy, University of Central Arkansas, Conway, AR, USA; Hall RW, Pediatrics, University of Arkansas for Medical Sciences, Little Rock, AR, USA.

PURPOSE/HYPOTHESIS: Kangaroo care (KC), skin-to-skin holding of an infant in an upright position on a parent's chest, is becoming more accepted as a method of care for preterm infants. While KC may reduce mortality and morbidity for some infants, little is known about the effects of KC on cardiorespiratory parameters of preterm infants. We sought to compare cardiorespiratory parameters of infants being held during KC vs. those same parameters while not being held.


MATERIALS/METHODS: Infants between 27 and 30 weeks gestation inclusive were randomly assigned to receive KC 2 hours daily, or standard care in an incubator between day of life 5 and day of life 10. Mothers of infants assigned to standard care agreed to hold the infant no more than 15 minutes daily for 5 days. All infants received respiratory assistance with a ventilator, continuous positive airway pressure (CPAP) or nasal cannula flow. Infants were monitored continuously via pulse oximeter and cardiorespiratory monitor for bradycardia (<80) and oxygen desaturation (<80%). Data was analyzed using the Wilcoxon signed rank test.

RESULTS: Preliminary data included 22 infants, 11 infants assigned to each group. There was a significant decrease in hourly bradycardia events within the KC group during holding compared with incubator time (p = 0.468). There was a trend toward fewer hourly desaturation events within the KC group during holding (p = 0.0625) compared with incubator time. It was also noted that infants in the KC group who experienced desaturation events at other times had no desaturation during skin-to-skin holding.

CONCLUSIONS: Preterm infants experienced fewer episodes of bradycardia and no desaturation events during KC. We speculate that upright positioning during KC helps to reduce cardiorespiratory events associated with airway obstruction in preterm infants.

CLINICAL RELEVANCE: No adverse events occurred at any time throughout the study in preterm infants between 27 and 30 weeks gestation who were receiving respiratory support. KC should be incorporated into the standard of care for stable preterm infants with or without respiratory support.

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V.A. Moerchen, K.L. Kolar, Human Movement Science, University of WI-Milwaukee, Milwaukee, WI, USA.

PURPOSE/HYPOTHESIS: The benefit of treadmill intervention with infants with gross motor delays is the engagement of the infant with a context that supports repetitions of rhythmic leg activity; a limitation of the treadmill intervention is that variability of leg activity is constrained. Combining different directions of infant stepping during treadmill intervention may provide relevant variability of stepping experience that would enhance the impact of this intervention context for infants with delays. One infant study has shown that infants with typical development are able to produce backward steps in response to the treadmill context, but the developmental trajectory of backward stepping during infant development that is necessary for empirical application of backward stepping as an intervention, has not been established. Thus, the goals of this longitudinal research were to characterize the developmental trajectory of changes in backward stepping frequency and step characteristics across the first year in infants with typical development.


MATERIALS/METHODS: Six, 30-sec trials of body weight supported forward and backward treadmill stepping were captured at 1800 Hz in infants at 4, 6, 8, 10, and 12 months of age. Dependent variables across ages included step types, step characteristics, and step frequencies. Analyses included RM-ANOVAs.

RESULTS: The proportion of backward steps to forward steps increased with age (p < 0.01), but the complexity of steps during backward stepping remained less than during forward stepping by 12 months of age (p < 0.05). The frequency of backward steps that terminated posterior to the hip increased with age (p < 0.05), but remained less than backward steps that terminated under the hip. Forward steps during backward stepping were more frequent in the younger ages (p < 0.05), but continued to occur even in new walkers tested at 12 months of age.

CONCLUSIONS: The unique contribution of this study is the description of developmental change in step location and step complexity for backward stepping in infants. The transition to consistent alternating stepping during backward stepping in infants occurs later than during forward stepping. Further, the variability in step types and step location during backward stepping suggest that infants are searching for and able to produce a step solution despite the biomechanical difficulty of moving their legs backward in response to forward translation of the treadmill belt.

CLINICAL RELEVANCE: Functional variability in the control of gait includes an ability to produce steps in all directions, thus supporting the incorporation of backward stepping during treadmill intervention. The results of this study suggest that backward stepping may be an option for intervention with infants. Examination of backward stepping in a clinical population is a necessary next step toward including directional variability as part of intervention in the treadmill context.

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J.G. Moore, A. Nunez, N.J. Kirk-Sanchez, Physical Therapy, University of Miami, Coral Gables, FL, USA.

PURPOSE/HYPOTHESIS: Several clinical measures of dynamic balance ability are available for use with children. A novel forward lean measure (FLM) using shoulder displacement measures has been shown to be reliable and valid in previous investigations with typical and atypical children. To perform the test, subjects stand with their feet flat and arms held parallel to the floor as they lean forward at their ankles. Shoulder displacement is measured in centimeters using a retractable tape measure held at the subject's shoulder height. The mean score of three trials is computed. This measure of dynamic balance ability has been shown to relate to walking ability (function, velocity, cadence and step length) previously in a small cohort of children diagnosed with cerebral palsy. The purpose of this investigation was to determine the relationship between a novel measure of dynamic balance (FLM) and gross motor function, walking ability, and strength in typically developing children.

NUMBER OF SUBJECTS: Sixty, typically developing children whose average age was 12 years old (10–14) were recruited from the Miami-Dade public school system participated in this investigation. Medical history and consent were obtained from each subject's parent prior to participation.

MATERIALS/METHODS: Anthropometric measures were taken for each subject: height, weight. Subjects then participated in a battery of tests including: the FLM, the short form of the Bruininks-Oseretsky Test of Motor Performance – 2 (BOT2), the six-minute walk test (6MW), the sit to stand test, the stair speed test, and gross measures of core strength (timed curl-ups and push-ups).

REULTS: The mean FLM for the group was 10.79 cm. (1.00–18.33). A significant relationship (p < .03) between the FLM and the standard score of the BOT-2 (r = 0.51), the 6MW (r = 0.27), the sit to stand test (r = 0.55), the stair speed test (r = 0.30), curl-ups (r = 0.42) and push-ups (r = 0.32) was demonstrated using the Pearson-Moment Product Correlation procedure.

CONCLUSIONS: Pediatric physical therapists often work on dynamic balance ability to improve motor function in children. This investigation supports the assumption that these constructs are related. However, further investigation specifically examining a dynamic balance intervention is necessary to determine its effectiveness in improving motor function.

CLINICAL RELEVANCE: The FLM is an easy to administer clinical measure of dynamic balance that can be used as part of an overall assessment of gross motor function in children.

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N.B. Muir, Physical Therapy, Children's Hospital of Philadelphia, Philadelphia, PA, USA; M.G. McBride, S. O'Malley, Cardiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA; H. Hanson, Physical Therapy, Children's Hospital of Philadelphia, Philadelphia, PA, USA; P. Stephens, S. Paridon, Cardiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA.

PURPOSE/HYPOTHESIS: Aerobic capacity in children and adolescents following the Fontan procedure for palliation of single ventricle anatomy has been shown to be decreased, as measured by maximal oxygen consumption (VO2 max). There is a subset of children whose VO2 max approaches normal, however no studies have examined variables that may contribute to their excellent exercise outcomes. The purposes of this study were to: 1) Describe exercise outcomes in a sample of children following Fontan surgery, 2) Identify variables contributing to exercise performance in this population, and 3) Identify variables that contribute to excellent (> 82% predicted VO2max) versus average (52–82% predicated VO2max) versus poor (< 52% predicted VO2max) exercise outcomes post-operatively.


MATERIALS/METHODS: Children and adolescents, ages 6 to 18, who underwent exercise testing between 2000 and 2010 were included. All subjects underwent exercise testing using breath-by-breath measures of oxygen consumption (VO2), carbon dioxide production, and minute ventilation. Subjects were excluded if they did not achieve a maximal exercise test, had a pacemaker at the time of testing, or had a chronic non-cardiac condition that precluded testing. Demographic, anatomic, and surgical variables were fitted and tested for their association with VO2max using independent t-tests and one-way analysis of variance, univariate correlations, and stepwise linear regression.

REULTS: Mean VO2max was 72.22 ± 15.15% predicted, with 27.2% of subjects achieving excellent exercise outcomes and 6.5% with poor exercise outcomes. Females achieved significantly higher VO2max than males (p = 0.001). In males, body mass index (BMI) and resting VO2/kilogram explained 36% of the variance in VO2max. In females, 47.9% of the variance in VO2max was explained by BMI and ventilatory equivalent ratio for carbon dioxide. Subjects who achieved excellent exercise outcomes were significantly shorter and had lower body surface area than subjects with poor exercise outcomes, and had significantly lower BMI than subjects with average exercise outcomes. BMI was moderately and negatively correlated with VO2 max for both males (r = −.606, p = .001) and females (r = −.466, p = .007). Ventricular morphology and perioperative variables had no association with exercise performance.

CONCLUSIONS: The subjects in this study demonstrated decreased VO2 max compared to healthy age and gender-matched peers. Exercise outcomes in this population are gender specific, and knowledge of anthropometric and ventilatory characteristics may be used to predict exercise outcomes.

CLINICAL RELEVANCE: Physical therapists can play an important role in maximizing exercise outcomes in this population. BMI should be monitored with the goal of maintaining BMI in the low-to-mid range of healthy values for age and gender, and children and their families should be educated about the importance of maintaining a healthy weight and regular participation in physical activity.

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A. Nunez-Gaunaurd, J. Haynes, J. Martinez, L. Montealegre, M. Nasralla, N. Solana, N.J. Kirk-Sanchez, Physical Therapy, University of Miami, Coral Gables, FL, USA.

PURPOSE/HYPOTHESIS: Children who are overweight and obese may have difficulty performing recommended levels of physical activity to maintain a healthy weight due to musculoskeletal impairments and mobility limitations brought on by high BMI and adiposity. The purpose of this research study was to examine differences in strength, balance, motor proficiency and endurance among minority healthy weight, overweight and obese children, and to examine relationships between body mass index for age percentile (BMItile) and impairment measures.

NUMBER OF SUBJECTS: Eighty-six middle school children were recruited to participate in a physical activity and fitness screening at their schools.

MATERIALS/METHODS: Height and weight measurements were taken to calculate BMItile scores as per CDC growth charts. Children were classified as healthy weight (BMItile between 5–85), overweight (85 ≤ BMItile < 95) or obese (BMItile ≥ 95). Impairment measures included: the Short Form Bruininks-Oseretsky Balance Test (BOT2) which includes timed pushups and curl-ups, 60 second Sit-to-Stand test(STS), Forward Lean Test (FLT), Timed Up and Down Stairs (TUDS) Test, and the Six-Minute Walk (6MW). Data were analyzed using ANOVA to examine differences among the three groups, and Pearson correlation to test the relationship between BMItile and physical performance measures in children who were overweight or obese.

RESULTS: Subjects were an average of 12 years old, 55% male, and 92% Hispanic. Fifty-four percent were classified as healthy weight, 23% overweight and 22% obese. For all impairment measures, healthy weight children performed better than overweight children who performed better than obese children. Compared to healthy weight children, overweight and obese children had significantly decreased curl-up repetitions (9.7 vs 9.3 vs. 5.4, p <.001), STS repetitions (27 vs 26 vs 23, p = .045), BOT2 percentile scores (33% vs 29% vs 17%, p = .005), FLT (.19 vs .16 vs .14, p = .021), 6MW distance (598m vs 568m vs 552m, p = .033). Push-ups and TUDS differences showed similar trends, but differences were not statistically significant. Among overweight and obese children, BMItile showed a fair negative correlation to the STS (r = −.36, p = .024), total curl-ups (r = −.33, p = .041), and a moderate negative correlation to the BOT2 percentile scores (r = −.47, p = .003).

CONCLUSIONS: Children who are overweight have impairments in strength, balance, motor proficiency and endurance compared to healthy weight children. Higher BMI was associated with lower scores in motor proficiency, lower extremity and trunk strength among overweight and obese children. These impairments may limit their ability to participate in the recommended levels of physical activity.

CLINICAL RELEVANCE: The findings of this study have important clinical relevance for physical therapists, who are uniquely qualified to assess the need for modifications in activity and exercise for children with musculoskeletal impairments and mobility limitations. Physical therapists may play an important role in the management of childhood obesity.

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M. O'Neil, Physical Therapy & Rehab Sciences, Drexel University, Philadelphia, PA, USA; M. Fragala-Pinkham, Research Center, Franciscan Hospital for Children, Brighton, MA, USA; J. Forman, Department of Rehabilitation Medicine, Franciscan Hospital for Children, Brighton, MA, USA; M. Cannella, Physical Therapy & Rehab Sciences, Drexel University, Philadelphia, PA, USA; S.G. Trost, Nutrition & Exercise Science, Oregon State University, Corvallis, OR, USA.

PURPOSE/HYPOTHESIS: To: 1) establish test-retest reliability of Actigraph accelerometers in measuring physical activity levels in children with cerebral palsy (CP); 2) establish validity of accelerometers in measuring physical activity intensity and 3) examine if activity and step count data can discriminate among different speeds (slow, comfortable, fast) for the six minute walk test (6MWT).

NUMBER OF SUBJECTS: A convenience sample of eight children (2 females, 6 males) with CP (GMFCS level I (n = 4), level II (n = 1), level III (n = 3)) participated. Children were 6–14 years old (mean = 10.67, SD = 2.78). Six children had healthy weight (BMI at 5th-85th percentile) and two were obese (BMI > 95th percentile).

MATERIALS/METHODS: Children participated in two measurement sessions at least one week apart. During each session, children completed three 6MWTs at different speeds while wearing an Actigraph accelerometer on each hip. Oxygen consumption (VO2) was measured at rest and during three 6MWTs using the Cosmed K4b2 Metabolic Portable Unit.

DATA ANALYSIS: Test-retest reliability was examined using intraclass correlation coefficients (ICCs) to compare count data between sessions and within sessions (comparing count data from left and right hips). ANOVA and post hoc pair wise comparisons were used to examine mean differences in count data across 6MWTs at different speeds. Pearson correlations were generated to examine concurrent validity of activity and step count data to VO2.

REULTS: Test-retest reliability was established between sessions for all 6MWT speeds for step counts (ICCs: 0.88–0.98, CIs95: .47-.99) and activity counts (ICCs: 0.75–0.95; CI95:. 02-.99) and within sessions (for left and right hips) for step counts (0.88–0.99, CI95: 0.54–1.00) and activity counts (ICCs: 0.92–0.99, CI95:0.68–1.00). ANOVA results were significant for activity counts (F: 11.95–31.98, p = .001) for all 6MWT walking speeds for both sessions. ANOVA results were significant for step counts (F: 4.41–29.78, p = .003-.054) for most 6MWT walking speeds for both sessions. Post hoc comparisons indicated some non-significant findings (mostly for step count data). Concurrent validity was established between VO2 and activity count data (r = 0.67, p < .0001) but not between VO2 and step count data (r = 0.16, p = 0.37).

CONCLUSIONS: These preliminary findings suggest that the Actigraph accelerometer may be a valid and reliable tool to measure physical activity (levels and intensity) for children with CP. Activity count data were more reliable and valid than step count data for measuring physical activity. Therefore, activity counts may be more appropriate to use when physical therapy goals include increasing physical activity levels and intensity (ie, increased fitness and endurance).

CLINICAL RELEVANCE: As pediatric physical therapy interventions integrate more health promotion, physical activity, and fitness strategies, it is important to identify and use best measures of physical activity (levels and intensity) to inform outcome effectiveness.

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M.N. Orlin, J. Williams, PT & Rehab Sciences, Philadelphia, PA, USA; A. Ramakrishnan, School of Biomedical Engineering and Health Systems, Drexel University, Philadelphia, PA, USA.

PURPOSE/HYPOTHESIS: The goal of this descriptive study was to examine the running coordination patterns of children with diplegic cerebral palsy (CP) compared to children with typical development (TD). We hypothesized that children with CP and TD would have different coordination patterns.


MATERIALS/METHODS: Children completed running trials at a self-selected speed until 3 representative gait cycles were captured. Kinematic and temporal spatial data were obtained using an 8-camera Vicon MX motion capture system at 120 Hz. A custom MatLab program was used to create representative plots from each motion capture file, using a complete stride. Sagittal phase plane trajectories for the joints were constructed by plotting joint angle vs joint angle velocity. Phase plane plots were created for the hip and knee and angle-angle plots were created for the knee vs hip for each child's left and right sides. Mean continuous relative phase (CRP) was calculated for stance, swing and stride. Data were compared between 1) younger and older, 2) children with TD and CP and 3) slower and faster runners. Data is presented from 12 participants between 7 – 14 years old with diplegic CP or TD who were part of a larger running study.

RESULTS: Smoother curves are present in older children both with and without CP. More variability in coordination is present during slow running than fast running in both children with CP and TD. Cusps, points of quick inflections in the phase-plane plots, indicate the presence of atypical movement reversals in children with CP at both slow and fast speeds. Mean CPR values were variable in both those with and without CP.

CONCLUSIONS: Coordination patterns are more variable in children who run more slowly. Younger children demonstrate more uncoordinated movement patterns than older children. This suggests that physical and neurological maturity and experience may play a role in running coordination. Some children with CP demonstrate atypical movement patterns while running regardless of age or speed. CRP can provide added insight into intralimb coordination patterns across the gait cycle.

CLINICAL RELEVANCE: The atypical coordination patterns observed in the children with CP may place them at an increased risk for running-related injury particularly if these patterns indicate limited adaptability. More research is needed to understand the impact of lower extremity coordination patterns during running in children with and without CP. There is potential for physical therapy to address these atypical movement patterns to improve lower extremity coordination and promote opportunities for lifelong running in individuals with CP.

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R. OShea, Physical Therapy, Governors State University, University Park, IL, USA; P. Pidcoe, Physical Therapy, VCU, Richmond, VA, USA; J. Vance, C. Oria, Physical Therapy, Governors State University, University Park, IL, USA.

PURPOSE/HYPOTHESIS: Conductive Education (CE) increases participation and self actualization for children with CP. This research demonstrates improvement in childrens' functional skills while they were enrolled in a CE program.

NUMBER OF SUBJECTS: 14 children were involved in the experimental group of the study. The children all had cerebral palsy classified at the GMFCS level III or IV and ranged in age from 3 to 14 and were enrolled in a TCE program over the 24 month period. A control group of children with CP who did not receive CE were measured 3 times over the course of a year.

MATIERALS/METHODS: A 6 camera Vicon system was installed in the CE center. Prior to data collection, 26 small reflective markers were applied to each child in a manner consistent with the measurement of full-body kinematics. Children performed a sit-to-stand action, a hand-to-mouth action, and ambulated 20 feet. Kinematic data were collected in addition to synchronous video. These data were post-processed and used to compare performance metrics that included movement trajectory, velocity, and energy of both the extremities and center-of-mass (COM). Data collection coincided with the monthly on/off rotation of the CE intervention.

RESULTS: Kinematic metrics were compared for each activity: Sit-to-stand - Knee angle vs. time and COM movements were compared over time for 5 consecutive activities. There was a 47% improvement in time to full extension after 5 months of CE. COM excursion during the task decreased 43% in a left/right direction and 70% in an anterior/posterior direction demonstrating improved control. Hand-to-mouth–increase in focused time spent at the endpoints of each excursion and a marked decrease in cyclic trajectory deviation. Both suggest improved control. Further analysis will attempt to quantify these results. Ambulation – Sagittal plane hip and knee angle data were averaged over 5 trials. These data showed a 30% decrease in standard deviation over an 8 month time period. Correlative comparison (r2) to normal data showed improvements from 0.02 to 0.30 (hip) and 0.72 to 0.96 (knee) for the same time interval. Both results suggest a more ‘normal’ gait pattern.

CONCLUSIONS: Children enrolled in CE demonstrate normalization of movement patterns when ambulating. They also demonstrate increase speed and control when performing sit-to-stand and hand-to-mouth activities. The results suggest that CE provides an opportunity for the child to become more independent in specific functional activities. In addition, the kinematic improvements indicate that joint alignment and motion are more typical.

CLINICAL RELEVANCE: This proposal illustrates that intensive therapy with an intentional motor learning component coupled with rhythmic intention improve functional skills in children with Cp. These improved movement patterns may lead to decreased pain and joint destruction experienced by many adults with CP.

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N. Pathare, E.M. Haskvitz, M. Selleck, Physical Therapy, The Sage Colleges, Troy, NY, USA.

PURPOSE/HYPOTHESIS: More than 23 million children in the US are either overweight (OW) or obese, placing them at increased risk for serious health conditions. Most physical activities recommended for weight loss incorporate balance activities. Limited research exists on the effect of being OW on balance in young children (≤ 9 years). Therefore, the purpose of this study was to determine the differences in balance during bipedal, tandem and one leg stance (OLS) tasks in young children who are normal weight (NW) and OW.

NUMBER OF SUBJECTS: 42 children (5–9 yr) participated in this study. Participants were classified as NW (n = 27, age = 7.5 ± 0.2 yr, 18 females and 9 males) and OW (n = 15, age = 8.0 ± 0.3 yr, 7 females and 8 males), according to the international BMI cut-off points for children.

MATERIALS/METHODS: Postural stability was assessed using an AMTI (Advanced Mechanical Technology Inc., Watertown, MA) force platform to quantify centre of pressure (COP) dynamics. The testing included: (1) quiet bipedal stance with eyes open (EO) and eyes closed (EC), (2) tandem stance with EO and EC, and (3) OLS with EO and EC. Using the Balance Clinic software, the following COP parameters were calculated: excursion of the COP in medial-lateral (ML) and anterior-posterior (AP) directions, average velocity (Vavg) as well as the maximum velocity in ML (VML) and AP (VAP) directions, and sway area by fitting an ellipse to the data covering 95% of the COP displacement. Statistical analysis was conducted using a Mann-Whitney test (alpha level set at ≤0.05).

RESULTS: In both groups, postural stability was systematically decreased in conditions where vision and the base of support were challenged concurrently. Significant differences were noted between the 2 groups in the quiet bipedal EO condition for Vavg (NW: 10.2 ± 0.9 cm/s, OW: 6.3 ± 0.6 cm/s; p < 0.05), VML (NW: 18.8 ± 1.1 cm/s, OW: 13.3 ± 0.8 cm/s; p < 0.05) and VAP (NW: 18.3 ± 0.8 cm/s; OW:13.3 ± 0.7 cm/s; p < 0.05) and EC condition for Vavg (NW: 10.7 ± 0.9 cm/s, OW: 6.9 ± 0.6 cm/s; p < 0.05), VML (NW: 18.9 ± 1.12 cm/s; OW: 14.4 ± 0.7 cm/s; p < 0.05) and VAP (NW: 18.8 ± 0.82 cm/s, OW: 13.6 ± 0.9 cm/s; p < 0.05). Additionally, Vavg was significantly different between the 2 groups in the tandem stance, EO (NW: 13.0 ± 1.0 cm/s, OW: 9.0 ± 1.0 cm/s; p < 0.05) and EC conditions (NW: 14.3 ± 0.9 cm/s, OW: 9.5 ± 0.6 cm/s; p < 0.05). For the OLS condition, increased variability was observed in both the groups with no significant group differences.

CONCLUSIONS: Interestingly, preliminary analysis suggests that young children who are OW demonstrate decreased measures of velocity during postural balance when compared to their NW counterparts.

CLINICAL RELEVANCE: Future research is needed to determine if postural instability could be exacerbated in dynamic conditions and increase the risk of falling in young children who are OW. These data are critical to design optimal rehabilitation interventions. Given the health and economic burden of childhood obesity over an individual's lifetime, this is particularly relevant and important to physical therapist practice.

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G. Pinto-Zipp, J. Persico, R. Rooney, G. Rosequit, D. MacDonald, Graduate Programs in Health Sciences, Seton Hall University, South Orange, NJ, USA; S. Winning, Department of Physical Therapy, Children's Specialized Hospital, Toms River, NJ, USA.

PURPOSE/HYPOTHESIS: While CIMT studies have focused specifically on upper extremity effects of this approach, one question which has not been addressed in the literature is: “Does increasing the functional mobility of one's upper extremity further enhance the subjects' overall balance capabilities, quality of gait and overall mobility?” This question is plausible to ask given that the motor system functions as a dynamic system as proposed by the dynamic systems model of motor control and based upon the generally accepted theory that central pattern generators (CPG's) located in the spinal cord are involved in the coordination and control of limb and body segment movements used to produce stereotypic locomotor patterns associated with gait. Thus, it is hypothesized that improvements in upper extremity functioning resulting from CIMT would positively influence lower extremity functioning. This study reports the secondary effects of a constraint induced movement therapy (CIMT) protocol in children with cerebral palsy on overall functional mobility, balance and spatial temporal parameters of gait.

NUMBER OF SUBJECTS: 21 children between 4 and 12 years of age (M = 7.16, SD = 2.4) volunteered to participate in the study along with their parents consent. All 21 children completed both testing sessions. The project was approved by the University IRB.

MATERIALS/METHODS: Subjects participated in a 3 week CIMT program. Participants were tested on the first and last day of CIMT program on the Standardized Walking Obstacle Course (SWOC), the Pediatric Balance Scale (PBS) and spatial temporal parameters of gait.

REULTS: Pair t-Test was employed on all pre-post measures following determination that the difference scores were normally distributed. Only the spatial temporal parameter of cadence and mean normalized velocity were significant, displaying a faster cadence (number of steps or strides per unit of time) (p = .020) and a faster velocity (p = .03). Additionally, the mean PBS was found to be positive, that is, CIMT is effective in producing a better PBS, t(20) = 2.8, two-tailed p = .011 and the number of stumbles on the SWOC was found to decrease, t(20) = 2.7, two-tailed p = .013.

CONCLUSIONS: In this study, CIMT was found to be effective in promoting positive changes in two spatial temporal parameters of gait based upon GAITRite® values as well as decreasing the number of stumbles reported on the SWOC. Also, a positive change in the participants PBS was noted following CIMT. The lack of significant findings in other SWOC measures may be due to the SWOC requirement to ambulate around and over obstacles in addition to straight path walking which may require additional practice. These results raise important issues regarding the influence of CIMT on a child's gait pattern, balance and functional abilities.

CLINICAL RELEVANCE: By gaining a fuller understanding of the possible effects of CIMT on one's gait, balance and mobility, therapists may be better able to enhance a patient's overall functional independence.

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B. Pratt, D. Hall, K. Greif, M. Kosner, Department of Physical Therapy, Bradley University, Peoria, IL, USA.

BACKGROUND & PURPOSE: The adolescent with physical disability has many obstacles to meaningful interaction with their families, peers, and home, school, and community environments. Promotion of development through participation in important life situations is a focus of physical therapy for these individuals. The purpose of this qualitative case study was to discover the influence of service dog usage on the independence and social well-being of the adolescent with physical disability.

CASE DESCRIPTION: A 15-year-old male with Spinal Muscular Atrophy participated in the semi-structured interviews of this case study. The subject was a 10th grade student attending his neighborhood high school. He had limited range of motion and strength in all musculature, a stabilized scoliosis, and a tracheotomy. He was dependent in all activities of daily living and used a ventilator. Mobility required a power wheelchair. The subject had worked with his service dog for 13 months.

OUTCOMES: During semi-structured interviews, the subject discussed his life before and after receiving his service dog. While the subject considered himself to be ‘just a regular kid’, he felt that his physical disability was a barrier to others getting to know him before receiving his service dog. With the ‘service dog by his side’, the subject stated more individuals at school and in the community engaged in conversation with him. He felt that these individuals had the opportunity to realize that he was ‘just a regular kid’ through these conversations. Participation in classroom discussions and group projects increased after receiving the service dog according to the subject. Because of the physical disability, the subject required assistance with most physical tasks. Prior to receiving the service dog, people provided this assistance. When at home or in the community, a family member or home health nurse provided any needed physical assistance. At school, a teacher's aide, nurse, or peer provided the physical assistance. The subject reported often having to ‘wait on other people to help’ him. The physical assistance provided by the service dog included picking up objects, turning on and off lights, and opening doors. The subject reported greater independence and privacy with the assistance of his service dog.

DISCUSSION: The themes identified during data analysis relate to the psychosocial development of adolescence. This development includes establishing an identity and autonomy, developing life goals, developing intimacy, and becoming comfortable with personal sexuality. For this individual, the use of a service dog appeared to be facilitating four of the five psychosocial areas. Increased social engagement with family members and peers may enhance the development of personal identity and intimacy. The increase in independence may support the development of autonomy and life goals. Given the benefits for this individual, service dog usage may be a supplemental service to traditional assistive devices and rehabilitation services.

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L.A. Prosser, L. Ohlrich, L. Curatalo, K. Alter, D. Damiano, Rehabilitation Medicine Department, National Institutes of Health, Bethesda, MD, USA.

PURPOSE/HYPOTHESIS: The purpose of this pilot study was to test the feasibility and effects of a functional mobility training program using overground dynamic body weight support on the motor ability of young children with cerebral palsy (CP).


MATERIALS/METHODS: A single-subject research design with repeated measures during baseline and intervention phases was used. Participants ranged from 12–27 months of age, had a minimum motor delay of 4 months, and were able to pull to stand but could not walk independently. Biweekly assessments of gross motor function (GMFM-66), walking ability (if applicable), and parent rating of performance and satisfaction on parent-identified goals (COPM) were performed throughout a 6-week baseline phase and a 6-week intervention phase, and after a 6-week withdraw phase. The mobility training program included facilitation of age appropriate gross motor skills using the ZeroG track system with dynamic body weight support. The focus of therapy was upright motor function and parent-identified goals. Unlike traditional body weight support systems, the dynamic system used here allowed the toddlers to move in a manner that mimics the typical development of walking and upright motor skills, by allowing transitions and falls. Pediatric physical therapists provided therapy 3 times per week for 30 minutes. Activities while using the dynamic weight support included standing, walking, squatting, and climbing stairs, with frequent transitions between the floor, sitting, and upright positions.

RESULTS: All children tolerated therapy using the dynamic weight support system. Data collection is ongoing with anticipated completion in August 2011. Two participants have completed the intervention phase, and three others are currently in the intervention phase. Gains of 3–8 points on the GMFM-66 have been observed with 2–6 weeks of therapy to date (average gains of 7–9 points represent increasing one level on the GMFCS at the age of 2 years, Rosenbaum 2002). Of the two participants who were walking with a walker at the initial assessment, one has started to walk without the walker, and the other increased walking speed beyond gains observed in the baseline phase. Parent ratings of performance and satisfaction increased more than during the baseline phase in the participants who have completed the intervention phase (range of −5–3 baseline change vs. 6–13 intervention change).

CONCLUSIONS: Gains in motor ability that exceeded the expected rate have been observed after treatment. It is hypothesized that the postural training and freedom of movement allowed by the dynamic weight support system, combined with the functional practice, facilitates the development of postural control, thereby improving motor ability. A larger, controlled clinical trial with longer treatment duration is planned to test this hypothesis.

CLINICAL RELEVANCE: Motor and postural control training that mimics typical toddler movement, delivered during the emergence of upright mobility in children with CP, may facilitate the development of more functional movement patterns.

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M. Rahlin, L. Fasshauer, J. Linden, K. Morris, K. O'Donnell, Physical Therapy, Rosalind Franklin University of Medicine and Science, North Chicago, IL, USA.

PURPOSE/HYPOTHESIS: The Therapy Behavior Scale (TBS) is a standardized instrument that evaluates therapy-related behaviors in infants and toddlers regardless of their developmental level or level of disability. The reliability of the TBS and the amount of training required for its use have not been examined. The purpose of this pilot study was to determine interrater reliability of the TBS Version 1.1 with novice raters assessing therapy-related behaviors of infants and toddlers after viewing DVD recordings of physical therapy (PT) sessions.

NUMBER OF SUBJECTS: DVD recordings of 10 PT sessions conducted with 5 infants and toddlers were used in this research.

MATERIALS/METHODS: Five infants and toddlers, ages 5–25 months, receiving Early Intervention services were recruited from a private, home-based pediatric PT practice. Four novice raters (first year Doctor of Physical Therapy (DPT) students) and one experienced rater (a pediatric physical therapist and the scale author) viewed 10 DVD recordings of PT sessions and assessed the subjects' behavior using the TBS Version 1.1. Novice raters underwent 4 hours of TBS training prior to scoring the DVDs. Subsequently, they viewed each recorded session individually, filled out a TBS Version 1.1 Record Form, and completed an Experience Form to assess the ease of the scale use and comment on each item. Data were analyzed using the Intraclass Correlation Coefficients (ICC) to assess interrater reliability for 4 novice TBS raters and for each novice rater with the experienced therapist.

RESULTS: ICC(2,1) for 4 novice raters was 0.75; ICC(2,1) for each novice rater with the experienced therapist varied from 0.68 to 0.86. It took novice raters 5 minutes on average to complete the TBS Version 1.1 record form. They stated that it was easier to score patient behavior on the TBS 1) after using the scale several times; 2) when the child displayed good behavior; and 3) when observed behavior fit well with the item description. They reported some difficulty in using the TBS related to the lack of knowledge of development and specific medical conditions that had not yet been covered in the DPT curriculum. Several scale issues revealed by this research were related to 1) the record form instructions for the scoring procedure; 2) the child's age or diagnosis possibly affecting the highest score he/she could receive in several instances; and 3) some of the score descriptions not fully fitting the behavior of a younger infant.

CONCLUSIONS: Results indicate moderate to good reliability of TBS scores assigned by novice raters. Scale modifications are suggested. Further research is needed to develop the TBS Version 2.0 and to determine the quantity and nature of training required for novice raters and experienced clinicians to successfully use the TBS.

CLINICAL RELEVANCE: Results of this pilot study suggest that novice raters may be reliable in using the TBS with infants and toddlers given appropriate amount of training.

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C. Rainey, S. Swetter, J. Putnam, D.P. Miller, University of Scranton, Scranton, PA, USA.

PURPOSE/HYPOTHESIS: The purpose of this study was to systematically review the effectiveness of physical therapy interventions for children with decreased exercise performance and tolerance related to hypoplastic left heart syndrome (HLHS) and similar congenital heart defects (CHD).


MATERIALS/METHODS: Literature searches were conducted across 3 electronic databases (CINAHL, MEDLINE, COCHRANE) for physical therapy and exercise for HLHS conditions. Studies that met the following inclusion criteria were accepted into the review: published in English, human subjects, exercise measures, developmental outcomes, patients under 19 years of age, physical therapy and HLHS characteristics.

RESULTS: The search produced 338 titles and abstracts. Twenty articles were selected for further evaluation following the review of full articles. After a thorough assessment, six articles fulfilled the inclusion/exclusion criteria and were included in the review. The PEDro quality assessment scores ranged from 3/10 to 8/10 with an average of 4.5/10. Sample sizes of the studies reviewed ranged from a single-subject case study to 158 in a random controlled trial. Three studies indicated decreased exercise performance in children with HLHS as demonstrated through the use of bicycle ergonomic testing and treadmill protocols. Two studies examined postoperative physical therapy for children with HLHS using various aerobic, resistance, and interval training. One study investigated the developmental and neurological status of children with cardiac pathology similar to HLHS. These subjects demonstrated decreased motor function as determined by the Peabody Developmental Motor Scales.

CONCLUSIONS: There is limited research available related to physical therapy for children with HLHS and similar CHD. The results of this systematic review suggest that exercise interventions and physical therapy are indicated and beneficial for patients in this population. The studies indicated a decreased exercise tolerance in patients with HLHS; however, research to support the use of exercise and physical therapy is limited.

CLINICAL RELEVANCE: As more children with HLHS are surviving into adolescence and adulthood it is necessary to enhance their quality of life through improved patient-specific physical therapy exercise interventions. It is recommended that more research on duration, intensity, and frequency of therapeutic interventions be pursued.

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S. Rosenberg, B.J. Bour, C. Senesac, Physical Therapy, University of Florida, Gainesville, FL, USA.

BACKGROUND & PURPOSE: Children with athetoid cerebral palsy (CP) demonstrate fluctuations in muscle tone and persistent pathological reflexes resulting in asymmetries. Variable tone leads to impairments with head stability, midline orientation, and verbalization. Traditionally, these children have used augmented communication devices such as communication boards or touch screens that require fine motor capabilities. The ECOTM2 is an augmentative communication device that allows for touch screen and eye-gaze control.

CASE DESCRIPTION: A 6 year-old-boy with athetoid CP demonstrated limitations in postural stability and head control exhibiting mass movement patterns for mobility skills. He required assistance for all daily activities. Daily communication was performed through head nods in response to yes/no questions. He had recently received an ECOTM2 but use of the device was limited to practice sessions in speech therapy. Outside of speech therapy, the device was only used during infrequent practice sessions at home. This was mainly due to frustration for both the child and parent when using the device.

OUTCOMES: The subject participated a 6-week intervention to increase postural stability and head control with emphasis on gaze stabilization and peripheral tracking. He was classified using the Gross Motor Functional Classification System (GMFCS) and his father, the primary caregiver, completed the functional skills section of the Pediatric Evaluation of Disability Inventory (PEDI) at the outset of the study and 12 weeks post intervention. Functional measures included time to maintain a neutral upright head posture, peripheral tracking at eye level, and the recoded time to trigger a key on the ECOTM2. Functional measures were completed at the beginning and end of treatment, and weeks 4,8, and 12-post intervention. Improvement was shown in all functional measures with significant improvement (MDC95) in the social function domain of the PEDI. No change was seen in the GMFCS or the other domains of the PEDI.

DISCUSSION: Over the course of this case study, use of the ECOTM2 expanded to functional use in school and at home. It served as a tool for socially appropriate communication. Outcomes were limited by the availability of standardized, valid, and reliable measures to detect changes in head control and the impact of head control on visual performance. Future research will require more sensitive measures to detect change in postural stability and functional vision to provide substantial conclusions.

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J.K. Sansom, B. Ulrich, School of Kinesiology, University of Michigan, Ann Arbor, MI, USA.

PURPOSE/HYPOTHESIS: Myelomeningocele (MMC) is the most common and severe form of spina bifida, a neural tube defect affecting the integrity of sensorimotor nerves in the lower body, typically resulting in gait impairments. If children w/MMC learn to walk, they generally require an assistive device (AD). Nevertheless, ∼50% transition to wheelchair use in adolescence and young adulthood due to increasing metabolic demands during walking (Desouza and Carroll, 1976; Thomas et al., 2001). Our goal was to determine if walking poles will increase energy efficiency compared to walking w/walkers or crutches.

NUMBER OF SUBJECTS: 8, 5–12 y/o children w/MMC. Four children wore ankle foot orthoses (AFOs) (Community Minus = C−) while walking in the community; 4 did not (Community Plus = C+).

MATERIALS/METHODS: Children performed 1 trial/condition, 4 conditions, randomized: Independent (I), Walker (W), Crutches (C), Walking Poles (P). Trials consisted of 3, 5-minute phases: rest, walk, recovery. Children walked at their preferred pace wearing a portable oxygen uptake unit (COSMED K4b2).

RESULTS: Our results show C+ ambulators had lower average M(SD) net energy consumption (ECSnet) when walking I = 141.79(70.78) than w/ADs (C = 232.159(52.59); P = 209.37(36.32); W = 297.28(17.46)). The C− group had an ECSnet when walking I = 217.24(66.15) that was higher than w/ADs (C = 198.41(81.48); P = 204.96(79.30); W = 224.027)). The C+ group had higher variability (%) when walking I = 49.92 than w/ADs (C = 22.65; P = 17.33; W = 5.87). Conversely, C− ambulators had less variability walking I = 30.45, but more when walking w/any AD (C = 41.07; P = 38.69; W = 45.94). C+ ambulators had lower energy cost (EC) when walking I = 2.86(1.81) than w/ADs (C = 7.49(3.79); P = 5.43(3.29); W = 9.02(5.22). C-ambulators, had higher overall EC, but EC was lowest when walking I = 6.57(3.89) and w/P = 7.16(3.98) than when walking w/C = 7.32(4.01) or W = 8.82(5.22). The C+ group had higher variability when walking I = 63.36 and w/P = 60.62 than children in the C− group (I = 59.15; P = 55.50). However, children in the C+ group had lower variability when walking w/W = 57.92 and C = 50.60 than the C− group (W = 59.19; C = 54.80).

CONCLUSIONS: Our results show that children w/MMC w/gait impairments like C-ambulators consumed more energy when walking w/ADs than walking independently. Use of poles resulted in a slight increase in energy cost over walking independently, but less than walking w/walkers or crutches. Our results may indicate that walking poles provided ‘just enough’ stability for these children whereas the benefits of increased stability provided by walkers or crutches were outweighed by the amount of energy required to use them.

CLINICAL RELEVANCE: Children who require AFOs for community walking may remain ambulators beyond adolescence w/use of walking poles as their AD because walking poles appear to improve energy efficiency.

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C. Senesac, D. Lott, Physical Therapy, University of Florida, Gainesville, FL, USA; S. Mathur, Physical Therapy, University of Toronto, Toronto, ON, Canada; S. Germain, Gastroenterology, University of Florida, Gainesville, FL, USA; J. Deol, I. Arpan, E. Senesac, S. Forbes, Physical Therapy, University of Florida, Gainesville, FL, USA; G.A. Walter, Physiology & Functional Genomics, University of Florida, Gainesville, FL, USA; K. Vandenborne, Physical Therapy, University of Florida, Gainesville, FL, USA.

BACKGROUND & PURPOSE: Duchenne muscular dystrophy (DMD) is the most common and severe form of muscular dystrophy affecting boys. Absence of the large sarcolemmal protein dystrophin leads to an increased susceptibility to contraction induced muscle damage. Magnetic resonance imaging and spectroscopy (MRI and MRS) provide a unique way to examine characteristics of skeletal muscle that may be indicative of disease progression in DMD. The purpose of this study was to examine changes in muscle size, mean T2 values by MRI indicating markers of muscle inflammation and damage, and muscle lipid composition by MRS. In conjunction, quantitative strength and functional measures were reported in four boys with varying degrees of disease progression with DMD, over a period of 2 years. Comparisons were made of these characteristics to aged-matched non-affected controls for the initial baseline measures.

CASE DESCRIPTION: Four boys with DMD paired in two age matched groups (2 younger and 2 older) were tested at four- five repeated time-points over a 2 year period (0, 2, 6, 12, and 24 months). Age matched controls were tested once (baseline) for comparison purposes. Testing included MRI/MRS followed by isometric strength on the Biodex and timed functional testing. Descriptive cross sectional and longitudinal comparisons were made across all measures.

OUTCOMES: Cross sectional analysis of the outcome measures revealed boys with DMD demonstrated a 2.6 fold increase in maximum muscle CSA of the plantarflexors (soleus, medial and lateral gastrocnemius) compared to controls. Increased T2 values indicative of muscle damage were noted in the boys with DMD when compared to their age matched controls. Lipid to water ratio by spectroscopy in boys with DMD was elevated 3.6 times higher than the mean of the controls. Isometric strength revealed the inability of the boys with DMD to improve strength across time points at the rate of increase compared to controls. Functional measures indicate that across time points the boys actually show an increase in the amount of time to complete these tests. Individually the results highlight the heterogeneity and variability of disease progression across subjects. When comparing the younger and older group of boys with DMD it is noted that the observed progression of the disease varies greatly among boys regardless of age.

DISCUSSION: Although, the disease progression is variable across the population the use of MRI/MRS documents objectively and non-invasively the extent of muscle injury and biochemical makeup of the muscles within a compartment. These outcome measures in combination with timed functional tests, strength, and clinical observations give a more complete picture of this disease and are promising for future studies. Further investigation is necessary to expand our understanding of the progression of this disease and the application of MRI/MRS and their ability as outcome measures to document healthy and injured tissue as interventions for this disease come to the forefront.

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J. Stout, R. James, Gage Center for Gait and Motion Analysis, Gillette Children's Specialty Healthcare, St. Paul, MN, USA; G. Gorton, Motion Analysis Laboratory, Shriners Hospitals for Children, Springfield, MA, USA; R.C. Tervo, Department of Pediatrics, Gillette Children's Specialty Healthcare, St. Paul, MN, USA; T.F. Novacheck, R. James, Gage Center for Gait and Motion Analysis, Gillette Children's Specialty Healthcare, St. Paul, MN, USA.

PURPOSE/HYPOTHESIS: Understanding differences in typically developing children (TDC) on outcome measures used for children with disabilities is important to accurate interpretation. The item-level properties of the 22 item skill-set of the Gillette Functional Assessment Questionnaire (FAQ) in children with gait impairment (GIC) and in TDC have previously been described. Whether it is valid to compare the two is controversial. Understanding whether skills represent a similar level of difficulty for TDC and GIC is important. The purpose of this study is to compare the order of skill difficulty for typically developing children to those with gait impairment on the 22-item skill set and walking level of the FAQ.

NUMBER OF SUBJECTS: 810 typically decveloping children (TDC) 485 children with gait impairment (GIC)

MATERIALS/METHODS: A retrospective review of data was conducted. TDC data were obtained from 25 child-care, hospital, or home-school settings. Children with gait impairment had undergone first time gait analysis in a tertiary specialty care setting; 289 GIC had a diagnosis of cerebral palsy; 196 had other neuromusculoskeletal diagnoses. All data were obtained by proxy report.

Factor and Rasch analyses were used to characterize the dimensionality, and item level characteristics of each dataset (TDC and GIC) separately, and as a combined dataset. Differential item functioning (DIF) was assessed by calculating item difficulty differences based on sex in the combined dataset. Differences based on age and diagnosis were also calculated in the GIC dataset. The differences between mean person-ability scores of groups by FAQ-WL were tested using ANOVA.

RESULTS: Model fit statistics indicate improved fit when the datasets are analyzed separately vs. a combined dataset. The combined dataset indicated DIF based on group (TDC vs. GIC) in 13 of the 22 skills. When analyzed separately there were no differences based on sex in the TDC dataset and only for the “jump rope” item in the GIC dataset. Four items in the GIC dataset were more difficult than predicted by the model for children with a diagnosis of cerebral palsy than children for other diagnoses.

The Rasch-based item difficulty rank order (easiest to hardest) was different between the TDC and GIC datasets. Two of the three easiest items were the same across the two datasets and the five most difficult skills were the same, but in a slightly different order. The most discrepant skills were “runs”, “runs with control”, “walks up/down stairs with a railing”, “steps up/down curb”, and “ride a 3-wheel bike”.

CONCLUSIONS: The differential item functioning and the rank order differences indicate direct comparison between TDC and GIC groups based on skill difficulty should be avoided. The rank order of difficulty did match developmental sequences for TDC.

CLINICAL RELEVANCE: The standard reference for appropriate function in GIC on the FAQ should not be TDC. Standard references based on walking level or other classifications systems should be more thoroughly explored.

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S.A. Talley, A. Ostrowski, A. Konja, S. Pilon, S. Valicevic, C.L. Carlson, Physical Therapy, Wayne State University, Detroit, MI, USA.

PURPOSE/HYPOTHESIS: Gait speed has been shown to influence temporal and spatial parameters of gait, primarily in adults. The purpose of this study was to collect normative data on the temporal and spatial gait parameters of 3, 5 and 7 year old children walking at slow (SL), self-selected (SS), and fast (FW) speeds and to examine differences in gait patterns indicative of gait maturation. Gait characteristics previously associated with gait maturity were collected, specifically gait velocity, step length, single limb support, double support, cadence, and stance duration.

NUMBER OF SUBJECTS: Fifty-six healthy young children were recruited from 3 urban schools. Eleven participants were between the age of 3 and 3.5 years (3YOs) (38.6 + 2.0 mos; 72.7% female), 24 were between 5 and 5.5 years (5YOs) (61.8 + 1.2 mos; 58.3% female) and 21 were between 7 and 7.5 years (7YOs) (87 + 1.4 mos; 47.6% female).

MATERIALS/METHODS: The GAITRite® electronic walkway system was used to collect temporal and spatial gait parameters using a portable 5.5m by .9m portable carpet, embedded with pressure sensitive switches for 4.9m. Participants were asked to walk the length of the mat, plus 2 m at either end to account for acceleration/deceleration. One practice and 3 walks at each speed were completed. Based on pilot trials, SS speed was always tested last. The order of the FW and SL speed trials were alternated in blocks to minimize an ordering effect. Scripted instructions were used for all children. Alpha was set at .05.

RESULTS: There was a significant difference in gait speed between all age groups at the FW speed and between the 3YO group as compared to both the 5YO and 7YO groups. Gait speed increased with age. There was no significant difference in gait speed at the SL speed. Cadence was significantly slower in the 7YOs compared to the 3YOs for SS and SL speeds. There was no significant difference in cadence at the FW speed. Step length was significantly different between all groups at the SS and FW speeds, increasing with age, and between the 3YOs compared to both the 5YOs and 7YOs during SL walk. Single leg support was significantly longer for 7YOs compared to 3YOs at both SS and SL speeds. Stance time was significantly longer for 7YOs compared to 3YOs only during the SL walks.

CONCLUSIONS: Gait velocity was most impacted by age at the FW speed. At SL speed there was no difference in gait velocity between groups yet there were changes in other parameters, primarily between the 3YOs and 7YOs. Step length differentiated between all three groups at FW and SS speeds. The data suggests that control of single limb support, cadence and stance time may contribute to 7YO's increasing gait maturity.

CLINICAL RELEVANCE: Objective measurement of gait is often necessary in physical therapy to make informed clinical decisions and to demonstrate efficacy of interventions. Normative data is necessary for reference in the evaluation process, particularly for parameters critical to maturation of gait.

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S.A. Talley, A. Ostrowski, A. Konja, S. Valicevic, S. Pilon, C.L. Carlson, Physical Therapy Program, Wayne State University, Detroit, MI, USA; A. Goldberg, Physical Therapy Program, Mobility Research Laboratory and Institute of Gerontology, Wayne State University, Detroit, MI, USA.

PURPOSE/HYPOTHESIS: The objective of this study was to estimate the absolute and relative reliability and minimal detectable change (MDC95) of gait velocity in 3, 5 and 7 year old children walking at free, slow and fast gait speeds. Relative reliability was calculated using Intraclass Correlation Coefficients (ICC 3,1) and absolute reliability was estimated using the standard error of measurement(SEM) and normalized SEM(SEM%).

NUMBER OF SUBJECTS: Fifty-six healthy young children were recruited from 3 urban schools. Eleven participants were between 3 and 3.5 years (3YOs) (38.6 + 2.0 mos; 72.7% female), 24 were between 5 and 5.5 years (5YOs) (61.8 + 1.2 mos; 58.3% female) and 21 were between 7 and 7.5 years (7YOs) (87 + 1.4 mos; 47.6% female).

MATERIALS/METHODS: The GAITRite® electronic walkway system was used to collect gait velocity using a portable 5.5m by .9m portable carpet, embedded with pressure sensitive switches for 4.9m. Participants were asked to walk the length of the mat, plus 2 m at either end to account for acceleration/deceleration. One practice and 3 walks at each speed were completed. Based on pilot trials, SS speed was always tested last. The order of the FW and SL speed trials were alternated in blocks to minimize an ordering effect. Scripted instructions were used for all children. Relative reliability for intra-trial tests of gait speed was computed using the ICC(3,1). SEM and the SEM% were used to quantify measurement error/absolute reliability. MDC was computed at the 95% confidence level.

RESULTS: ICC values ranged from .304 to .824 across age groups and speeds with excellent reliability (≥.750) for 3 conditions (SS speed for 5YOs and 7YOs) and poor for 7YO SL speed. Absolute reliability may be best expressed as SEM% (SEM/mean*100) and ranged from 6.13–14.88% (9.18–17.12% using a more conservative approach). MDC95 ranged from 18.63–35.54cm/sec (22.98–55.27cm/sec more conservatively). MDC95 was greatest for FW speed for all age groups and smallest for 5YOs and 7YOs when walking at SS speed.

CONCLUSIONS: The ICC for 7 YO SL speed gait velocity was poor, reflecting large variability across trials although their gait speed was not significantly different than the 3YO or 5YO groups. In general absolute reliability and relative reliability were better and MDC95 smaller for SS gait speed. SS gait speed may be preferable to SL and FW speeds when using gait speed to assess efficacy of interventions or change in performance.

CLINICAL RELEVANCE: Minimal detectable change (MDC) is clinically useful to differentiate real change in performance greater than that attributable to measurement or random error. No studies have reported the MDC of gait speed in young children at self-selected (SS), slow (SL) and fast (FW) gait speeds. The relative reliability (ICC), absolute reliability (SEM, SEM%), and MDC and MDC% values reported in this study can assist physical therapists in interpreting changes in gait velocity in young children in clinical and research settings.

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H. Tamhane, E. Townsend, K.D. Gross, Physical Therapy, MGH Institute of Health Professions, Boston, MA, USA.

PURPOSE/HYPOTHESIS: Although lower extremity bracing for supported ambulation in the later stages of progressive muscular dystrophy has been described, the effects of DR-AFO bracing in earlier disease stages to address functional limitations and limited walking endurance have not been described or evaluated. The DR-AFO is a lightweight, carbon, anterior shell, floor reaction AFO designed to provide dynamic assistance at toe-off, while allowing natural ankle movements in stance. The aim of this pilot study was to provide a descriptive analysis of the effects of DR-AFO bracing on functional performance, endurance and gait in ambulatory boys with DMD. The study hypothesis was that with DR-AFO use, ambulatory boys with DMD would show improved ambulation speed and walking endurance.

NUMBER OF SUBJECTS: Three ambulatory boys aged 5–11 years with varied steroid dosing regimes.

MATERIALS/METHODS: Employing a crossover design, boys were randomly assigned to either the DR-AFO bracing condition followed by the placebo bracing condition (elastic sleeves) or the reverse sequence of conditions. Intervention phases were two weeks in length and separated by a 1-week washout phase. Outcome measures evaluated at the beginning and end of each phase included those of functional performance (10-meter walk test, time to rise from floor, 4-stair climb), walking endurance (modified 6MWT for children) and gait parameters (step width, stride length, cadence and velocity) using an instrumented walkway system.

RESULTS: All boys tolerated daily brace wear. With DR-AFO bracing, time to walk 10 meters increased in all boys (Mean = 21%; SD = 17) and distance walked in the 6MWT decreased in 2 of 3 boys (Mean = 6%; SD = 9). Time to rise from floor increased in 2 of 3 boys (Mean = 29%; SD = 34) and time to climb 4 stairs increased in all three boys (Mean = 50%; SD = 13) with DR-AFO bracing. Step width at self selected walking speeds did not change appreciably, but step width at fast pace walking speeds increased in 2 of 3 boys (Mean = 30%; SD = 44).

CONCLUSIONS: The results of this pilot study do not provide evidence to support the use of DR-AFO bracing for improved functional performance and endurance in ambulatory boys with DMD. Walking speed slowed, walking endurance did not improve and times to rise from the floor and climb stairs were slower with DR-AFOs. Corticosteroid dosing schedules may impact functional performance and endurance in boys with DMD. Future studies should control for the effects of steroid dosing to avoid potential confounds.

CLNICAL RELEVANCE: Although continued study is warranted, preliminary findings suggest that clinicians should exercise caution in recommending DR-AFOs to improve functional performance and walking endurance in ambulatory boys with DMD.

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L. Timmerman, A. Copp, M. Lillyblad, L. Scott, K.J. Krosschell, Department of Physical Therapy and Human Movement Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.

PURPOSE/HYPOTHESIS: Spinal Muscular Atrophy (SMA) is a neuromuscular disorder which leads to muscle weakness and impaired motor function. This can adversely affect a child's ability to participate in their environment. Therapists can potentially address factors that limit participation and assist in fostering abilities and opportunities for enhanced participation. A better understanding of patterns of participation is primary to this process. The purpose of this study was to determine how dimensions of participation (Diversity, Frequency, and Intensity) and participation in different activity types (Play, Skill Development, Active Physical, and Social) varied by SMA type, age, household, and community variables. For children with SMA we hypothesized that: 1. Patterns of participation would be dependent on type, age, and gender. 2. Those with less severity of impairment (Type 3) would have greater participation for all activity types.3. Community type and family income would affect dimensions of participation.

NUMBER OF SUBJECTS: Fifty-eight children with SMA (29 males, 29 females, mean age 3.74 y, SD 1.2 y, range 1.87 y–5.98 y) and their primary caregivers participated. Of the participants, 22.4% had Type 1, 55.2% had Type 2, and 22.4% had Type 3 SMA.

MATERIALS/METHODS: Caregivers, as proxies for their child, completed a demographics questionnaire and a standardized measure of participation (The Assessment of Preschool Children's Participation). One and Two-Way ANOVA and t-tests were used to determine effects of SMA type and other demographic variables on participation (dimensions and types) using SPSS 19.0.

RESULTS: Key findings (p ≤ .05): There were significant differences between children by age (≥4, <4) for play, skill, active physical, and social diversity and intensity. Children ≥ 4 were participating in a wider variety of activities and doing skill development, active physical, and social activities more often. There were significant differences between SMA types for play diversity and frequency, and skill diversity. Children with Type 3 participated in a wider variety of play and skill development activities than those with other types; those with Type 1 participated more frequently in the play activities they actually did. There were differences in social and active physical diversity and intensity based on household income. Children who lived in a household with an income level <$29,999 participated in fewer active physical and social activities less often. There were no differences in participation by gender or community type, and there was no interaction between age and SMA type for any variables of interest.

CONCLUSIONS: Results suggest that participation patterns vary by age, SMA type and household income. The number of participants in this study was limited; therefore a larger study to confirm results is warranted.

CLINICAL RELEVANCE: This study enhances our understanding of participation patterns in children with SMA and has implications for services, interventions, and supports that optimize participation.

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J.E. Tucker, K. Crosby, K. Fowke, L. Westervelt, Health Professions - Program in Physical Therapy, University of Central Florida, Orlando, FL, USA.

PURPOSE/HYPOTHESIS: The purposes of this study were to: 1) determine the current understanding of physical activity (PA) recommendations in caregivers of children with Sickle Cell Disease (SCD) 2) identify amounts of PA of children with SCD 3) identify potential barriers to PA experienced by children with SCD.


MATERIALS/METHODS: Design: An internet survey utilizing snowball sampling.

METHODS: An investigator developed survey was created and using snowball sampling was distributed to SCD support groups via email lists, websites, and social networking including Face book. The survey include 20 items addressing demographics, painful crisis, PA, and barriers to participation in PA. Respondents were adults over 18 years of age who were legal guardians of at least one child with SCD ages 2–21 years. The data was analyzed using descriptive statistics.

RESULTS: Twenty-one caregivers completed the survey, including 17 mothers, 3 fathers and 1 grandmother. The majority of children were of Black/African American descent (85.7%). Children with SCD were physically active as 85.8% reported 30 min or more of PA per day. PA occurred at both home and school in slightly more than half of the children (52.3%). Over half of the children (52.4%) did not participate in physical education (PE) at school. The identified barriers to PA included: pain/fatigue (84.2%), environmental reasons (68.4%), lack of time (26.3%), lack of interest (15.8%), financial reasons (10.5%), asthma (4.8%), and avascular necrosis (4.8%). Many caregivers (47.6%) believed that PA could be harmful for their child, 28.6% did not think PA could be harmful, and 23.8% did not know. Painful crisis occurred frequently with 47.6% reporting monthly occurences. The crisis were attributed to exercise (30%), extreme temperatures (70%), not drinking enough water (60%), and emotional stress (55%). Pain management strategies included medication (78.9%), rest (63.2%), massage (52.6%), spirituality (63.2%), and other treatments(9.6%). Formal education on SCD was reported by 80% of caregivers; however, only 47.4% correctly reported the recommended amount of daily PA. Physical therapy (PT) for SCD was received by only 20% of caregivers.

LIMITATIONS: The small sample size and sampling method.

CONCLUSIONS: Children with SCD are physically active; however, the level of PA and participation in PE varies. Painful crisis occur frequently potentially reducing a child's PA. Many caregivers had received formal education; however, it was unknown if PA guidelines were incorporated. Interestingly, many respondents had not received PT for SCD. Further research is needed to explore PA in larger numbers of children with SCD as well as the role of PT in the medical management of SCD.

CLINICAL RELEVANCE: Children with SCD and their families need accurate information on safe PA. They may benefit from PT for education and exercise program development. At the conclusion of this study, an education pamphlet was created addressing PA recommendations and guidelines for safety.

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M. Urban, Rehabilitation Services, Shriners Hospitals for Children, Chicago, IL, USA; I. Moss, Rush University Health Center, Chicago, IL, USA; S. Hassani, K. Hammerberg, Rehabilitation Services, Shriners Hospitals for Children, Chicago, IL, USA; S. Mardjetko, Illinois Bone & Joint Instititue, Morton Grove, IL, USA; P. Sturm, Cincinnati Children's Hospital Medical Center, Chicago, IL, USA.

PURPOSE/HYPOTHESIS: Scoliosis is a frequent complication for children with neuromuscular disorders. Pelvic obliquity often occurs as a result of large rigid curves, asymmetric hip dislocations, and asymmetric hip contractures. Severe deformities can have a negative impact on a patient's sitting balance often leading to skin breakdown and other complications from abnormally distributed sitting pressures over prolonged periods of time. Long spinal fusion to the pelvis addresses both sagittal and coronal balance thereby correcting the scoliotic curve and pelvic obliquity. No studies have prospectively looked at the relationship of spinal correction on seated pressure distribution. We hypothesized that surgical correction of the scoliosis will improve sitting contact area and reduce areas of peak pressure.

NUMBER OF SUBJECTS: 13 patients with neuromuscular scoliosis (average age 15.3 years, Cobb angle > 50 degrees).

MATERIALS/METHODS: Data was prospectively collected at a preoperative and at a one month postoperative visit. The major curve Cobb angle and pelvic obliquity were measured from radiographs. Total contact area and peak pressure were measured using the XSENSOR® X3 pressure mapping system (The Roho Group, Belleville, IL) while the patient was seated in their own wheelchair with their seating system. Preoperative and postoperative means were compared using a paired T-test.

RESULTS: Surgery resulted in statistically significant reductions in both radiographic parameters with mean major curve Cobb angles reduced from 82 degrees to 27 degrees (p < 0.001) and mean pelvic obliquity reduced from 18 degrees to 7 degrees (p = .001). Surgery did not result in a significant reduction in mean peak pressure. However, total contact area did significantly increase from 155.6 cm squared to 171.6 cm squared (p = 0.02).

CONCLUSIONS: Instrumented spinal fusion to the pelvis reliably improves significant pelvic obliquity in children with neuromuscular scoliosis in the early postoperative period. While the peak pressure generated while sitting in a wheelchair is unchanged, the total contact area is significantly increased. This likely leads to a more even distribution of forces and may ultimately reduce the skin complications of prolonged wheelchair use.

CLINICAL RELEVANCE: These findings reinforce the concept that significant pelvic obliquity must be addressed during surgical correction of neuromuscular scoliosis.

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R.S. Vohra, D. Lott, Physical Therapy, University of Florida, Gainesville, FL, USA; S. Mathur, Physical Therapy, University of Toronto, Toronto, ON, Canada; S. Germain, C. Senesac, J. Deol, Physical Therapy, University of Florida, Gainesville, FL, USA; G.A. Walter, Physiology and Functional Genomics, University of Florida, Gainesville, FL, USA; K. Vandenborne, Physical Therapy, University of Florida, Gainesville, FL, USA.

PURPOSE/HYPOTHESIS: Duchenne muscular dystrophy (DMD) is an X-linked recessive disease that is characterized by the replacement of contractile tissue with non-contractile tissue (fat and fibrosis) with disease progression. This pathology leads to substantial weakness, disability, and eventual death (generally by the third decade of life). While numerous interventions are being developed to cure and/or alleviate this disease, there are few non-invasive measures to monitor disease progression and/or changes from therapies. Having a means to quantify the muscle pathology that is correlated to the patients' functional ability would be of great utility in the treatment of people with DMD. The purpose of this study was to 1) non-invasively quantify contractile and non-contractile contents in the calf muscles of boys with DMD and healthy controls and 2) determine the relationship between contractile and non-contractile contents and functional abilities in boys with DMD.

NUMBER OF SUBJECTS: Ten boys with DMD and 5 healthy control boys (5–14 years old) participated in the study.

MATERIALS/METHODS: Trans-axial magnetic resonance imaging (MRI) of the right lower extremity was acquired from all subjects at 3.0T with the following parameters: repetition time = 24 ms, echo time = 1.8 ms, flip angle = 20 degrees, optimized field of view = 12–14 cm2. Medical Image Processing, Analysis and Visualization software was used to analyze the images. Five different muscles were analyzed for contractile and non-contractile content: tibialis anterior (TA), peroneals (Per), lateral-gastrocnemius (LG), medial-gastrocnemius (MG) and soleus (SOL). Isometric peak torque of the plantar flexors and dorsiflexors was measured using a Biodex dynamometer. Subjects performed different timed functional tasks, including time to walk 30 feet, time to rise from the floor, rise from a chair, pediatric timed up and go, and time to ascend 4 stairs. The study was approved by the Institutional Review Board at the University of Florida.

RESULTS: Non-contractile content of Per, LG, MG and SOL was significantly different from control subjects (p < 0.05). Among timed functional tests, time to walk 30 feet was significantly correlated to LG (r = .76), MG (r = .89) and SOL (r = .69) non-contractile content.

CONCLUSIONS: Non-contractile content in patients with DMD was significantly greater than in the controls, and this measure demonstrated a strong correlation to functional ability. Time to walk 30 feet appears to be a good indicator of non-contractile content of the calf muscles for clinical assessment.

CLINICAL RELEVANCE: MRI can be utilized to assess non-contractile content in different muscles, and this measure is associated with functional ability. Non-contractile content may be a useful measure to evaluate the efficacy of novel treatments in boys with DMD.

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D.M. Wrisley, M.S. Swiggum, Physical Therapy, Lynchburg College, Lynchburg, VA, USA.

PURPOSE/HYPOTHESIS: Children with Asperger's Syndrome often demonstrate sensory integration dysfunction, yet it is not known whether they have primary dysfunction in their sensory systems (visual, vestibular, somatosensory). The purpose of this pilot study is to compare sensory function between children with and without Asperger's syndrome to determine if children with Asperger's syndrome demonstrate primary sensory deficits that may contribute to problems with sensory integration.

NUMBER OF SUBJECTS: Ten children, ages 5–12, were recruited from local schools and through personal contacts. Five had a diagnosis of Asperger's syndrome provided by a local healthcare provider and five were typically developing children.

MATERIALS/METHODS: Caregivers completed the Asperger's Syndrome Diagnostic Scale (ASDS) to verify the diagnosis of Asperger's syndrome and the Short Sensory Profile (SSP) to quantify sensory involvement. The following clinical tests were performed: visual acuity using a Standard 20′′ Snellen Eye Chart, visual contrast sensitivity using the FACT test, tactile sensory thresholds using Seemes-Weinstein monofilaments, vibration using 128 and 256 Hz tuning form, and the clinical test of sensory interaction on balance with normal and single limb stance. The Mann-Whitney U test was used to determine whether there were statistical differences between the 2 groups in the clinical tests.

RESULTS: The children diagnosed with Asperger's Syndrome rated likely to have Asperger's Syndrome on the ASDS, and displayed abnormal scores on the SSP. Significant differences were found between the children with Asperger's syndrome and the typically developing children but only in visual contrast sensitivity and single limb stance on firm surface eyes open and foam surface eyes closed.

CONCLUSIONS: Children with Asperger's syndrome appear to have intact primary sensation – visual acuity, somatosensation and vestibular but demonstrate impairments in tasks that require integration of senses such as visual contrast sensitivity and higher level balance activities.

CLINICAL RELEVANCE: Intervention for children with Asperger's syndrome should focus on sensory integration as the primary senses appear intact in these children.

© 2012 Lippincott Williams & Wilkins, Inc.