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Abstracts* of Platform Presentations at the 2013 Combined Sections Meeting

doi: 10.1097/PEP.0b013e31827d589c

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

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K.F. Bjornson, C. Zhou, D. Christakis, Developmental Medicine, Seattle Children's Research Institute/University of Washington, Seattle, WA; R. Stevenson, Pediatrics, University of Virginia, Charlottesville, VA.

PURPOSE/HYPOTHESIS: Adolescents with cerebral palsy (CP) have been documented to have lower daily walking activity levels which limits participation in day to day life. Locomotor training strategies are often employed to facilitate walking activity and participation, yet there is limited knowledge of how to focus the intensity of this training in CP. The purpose of this project is to examine the relationship of walking activity patterns to participation in daily life in children with CP.

NUMBER OF SUBJECTS: A cross-sectional cohort of 128 children with CP (41% female) participated across Gross Motor Function Classification System (GMFCS) levels I-III, ages 2-9 yrs with 49% having hemiplegia and 72% spasticity.

MATERIALS/METHODS: Walking stride rate curves were developed from 5 days of StepWatch accelerometer (SW) data and categorized for high/moderate/low walking stride levels. Low, moderate, and high walking stride activity was defined as number of strides in the ranges of 1 to 30, 31 to 60 and >60 stride/min respectively. Participation was measured with parental report of the Assessment of Life Habits (Life-H) categories on a weighted 0-10 scale. We used regression analysis to estimate the association between walking activity and participation, controlling for age, lean body mass adjusted knee height and Gross Motor Function Classification (GMFCS) level.

RESULTS: The standardized number of strides at low stride activity was significantly associated with Personal Care (1.3, p = .01) and Mobility (1.4, p = .01), while moderate stride activity Mobility (1.3, p = .01) and Recreation (1.5, p = .01). High stride activity was significantly associated with the Nutrition (.99, p = .04), Personal Care (1.1, p = 02), Housing (.93, p = .03), Mobility (.99, p = .02), Education (1.3, p = .01), Recreation (1.6, p = .001) and Total (.96, p = .008) categories of the Life-H. Subgroup analysis within GMFCS level for high stride activity suggests an interaction effect with a negative relationship for GMFCS level III.

CONCLUSIONS: As expected, all three stride rate categories were significantly associated with mobility. Number of strides at high stride rates appears positively associated with seven of the 11 Life-H categories examined in children with CP while low and moderate stride rates were associated with two categories each. The relationship with high stride rates appears greatest for the life habits related to Education and Recreation. Thus, each 219 strides spent at a stride rate >60 stride/min, appears to positively predict approximately 1 to 1.6 points greater scores on the individual Life-H categories noted above. For example, a one point positive change in Life-H category scores may potentially represent a change from walking with no difficulty and an assistive device/adaptation to walking without an assistive device/adaptation.

CLINICAL RELEVANCE: This information has potential implications for interventions addressing both the activity and participation components of the International Classification of Functioning and Disability (ICF) framework. Walking activity treatment strategies at any stride rate have potential to increase life habits related to mobility. Interventions focusing on low stride rates may positively affect personal care habits while moderate rates appear to influence recreation. Training interventions which focus on enhancing skill and duration at stride rates >60 stride/min may enhance levels of accomplishment of overall life habits as well those related to nutrition, personal care, housing, mobility, education and recreation. Conversely, life experiences may act has facilitators of higher stride rates.

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C. Chen, J. Heathcock, S. Mrowzinski, Physical Therapy, The Ohio State University, Columbus, OH.

PURPOSE/HYPOTHESIS: Infants with neonatal stroke have focal brain injury and are at higher risk of hemiplegic cerebral palsy (CP). Children with hemiplegic CP use the unaffected side more than the affected side as a compensatory way to perform upper extremity tasks. As infants, adequate arm and hand movements develop over time as infants successfully learn to reach and grasp. It is unknown how the unaffected side compensates during early reaching development when one of the infant's arms is atypical. The purpose of this study is to use bilateral and unilateral experimental conditions to examine compensatory reaching in infants with and without neonatal stroke. We hypothesize that infants with neonatal stroke will demonstrate poorer compensatory ability than infants with typical development.

NUMBER OF SUBJECTS: 19 full term infants completed this project with typical development (n = 13) and neonatal stroke (n = 6).

MATERIALS/METHODS: In a longitudinal study design, infants were seen from 2-7 months of age. Reaching was tested every other week for a total of 190 visits. Infants sat in a chair and a toy was placed in front and midline. In the bilateral condition, infants could reach the toy with either the right arm or the left arm freely. In the unilateral condition, either of infants' arms was held, and thus infants could reach the toy with only with one arm. Infants' compensatory performance was calculated from the average number and duration of reaches by both arms in each condition.

RESULTS: A 2 (group) × 10 (visit) repeated measures ANOVA reveled a significant main effect of visit for both groups on unilateral (F = 7.004, p < 0.001 number; F = 7.292, p < 0.001 duration) and bilateral (F = 9.313, p < 0.001 number; F = 8.522, p < 0.001 duration) conditions, suggesting that both groups increase the number of reaches over time. In addition, there is a trend for main effect of group with the typical group demonstrating a higher reaching number and duration. A within group 2 (conditions) × 10 (visits) repeated measures ANOVA revealed a main effect of condition with a more reaches in the unilateral reaching condition (F = 14.839; p = 0.002) for the typical group. Importantly, the stroke group showed no difference between the conditions (F = 0.415, p = 0.548 number; F = 0.354, p = 0.578 duration), suggesting that typically developing infants show better compensation with both arms than infants with neonatal stroke.

CONCLUSIONS: Infants with typical development demonstrated partial compensation by increasing reaching number of one arm when only one arm was available (unilateral condition). Infants with neonatal stroke demonstrated no compensation. This may indicate that their affected arm failed to compensate for the limited movement of the unaffected arm, while the unaffected side also demonstrated poorer compensatory ability.

CLINICAL RELEVANCE: Impaired upper limb motor function and limited compensated ability during reaching in infants with neonatal stroke can be identified during early infancy. Clinicians can focus on active reaching movements with both arms in high risk infant populations.

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N.S. Darr, School of Physical Therapy, Belmont University, Nashville, TN; M. Franjoine, B. Young, Physical Therapy, Daemen College, Amherst, NY.

PURPOSE/HYPOTHESIS: The Pediatric Balance Scale (PBS) is a 14-item criterion-referenced measure of functional balance. It is able to differentiate performance of preschoolers with mild and moderate balance dysfunction from those developing typically and can identify school-age children with moderate balance impairments; however, the responsiveness of the PBS to functional balance changes is unknown. The overall aim of this study was to determine if the PBS can identify meaningful change in balance in children with cerebral palsy (CP). The specific purposes were to determine if PBS scores correlate with parent, child and physical therapist (PCT) perceptions of functional balance, changes in balance resulting from surgeries and other medical events (ME), and assistive devices (AD) used for mobility.

NUMBER OF SUBJECTS: Children with CP (n = 20), ages 5 to 15 years, participated in this study. All were able to stand 4 seconds unsupported and follow simple one-step directions.

MATERIALS/METHODS: The PBS was administered to each child as per protocol at 4-month intervals over a 3-year period. During each testing session the parent, child, and community physical therapist independently rated their perceptions of the child's functional balance using a 5 point Likert scale with “1” representing very poor balance (fearful of falling, limits physical activity) and “5” representing excellent balance (no fear of falling or activity limitations.) Type of AD used for mobility was also noted along with ME including recent or pending surgeries, seizures, illnesses, etc. Descriptive statistics were used to characterize changes in PBS scores, AD use and PCT perceptions of balance. Relationships between PBS scores and PCT perceptions of children's balance were analyzed with Spearman rank correlation coefficients. One-way ANOVAs with Bonferroni post hoc analyses were used to analyze the effect of ME and type of AD used for community mobility on PBS scores.

RESULTS: PBS scores varied from 5 to 55 (Max score = 56.) Changes in PBS scores over 3 years ranged from 2 to 34 points. Children, who ambulated without an AD at study onset and without any ME during the 3 years, demonstrated the smallest changes in PBS scores (1 to 5 points). Children who had a significant ME demonstrated changes in PBS scores up to 34 points. Correlations between PBS scores and PCT perceptions of children's functional balance were good to excellent in children who demonstrated >8 points of change on the PBS (rs = 0.78-0.97). PBS scores were significantly affected by AD usage for mobility (F = 208.19, p = 0.00) and by both major ME such as surgeries, seizures, and hospitalizations and less serious ME such as ear infections and viral illnesses (F = 47.97, p = 0.00).

CONCLUSIONS: PBS score changes in children with CP were consistent with PCT perceptions of functional balance, MEs, and AD usage.

CLINICAL RELEVANCE: The PBS is a useful tool for detecting change in functional balance in school-age children with CP who are able to stand unsupported and are ambulatory or have the potential to be ambulatory.

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S.C. Dusing, T. Izzo, L. Thacker, Virginia Commonwealth University, Richmond, VA.

PURPOSE/HYPOTHESIS: Variable postural control strategies are used by typically developing infants during supine and sitting postures. Infants born preterm and those with disabilities utilize more repetitive postural control strategies. Little is known about when these repetitive postural control strategies develop, how long they persist, and the impact on motor skills. The purpose of this study was to compare the development of postural control in infant born full term and preterm during the first months of life and during the development of 2 skills, head in midline and reaching.

NUMBER OF SUBJECTS: 22 full term and 18 preterm infants (mean gestational age 39.5 and 28.2, respectively) were assessed every 2 weeks from 35 weeks of post conceptual age (PCA) for preterm infants or 2 weeks of age for full term infant until 3 months of age adjusted for prematurity.

MATERIALS/METHODS: Center of Pressure (COP) movement variability was assessed using a pressure sensitive mat sampling at 5 Hz while the infant was in an active alert state and moving spontaneously in supine under 2 conditions. In the Toy Condition a toy was presented at midline within reach. In the No Toy Condition no visual stimulus was present. Approximate Entropy (ApEN) and Root Mean Squared Displacement (RMS) of the COP movement in the caudal cephalic (CC) and medial lateral (ML) direction were calculated to quantify the repeatability and variability. Behavioral coding was used to quantify head control and reaching. Developmental outcomes at 12 months of age are reported on the Bayley Scales of Infant Development. Preliminary Analysis of 22 full term and 12 preterm infants were completed using a one way analysis of variance (ANOVA) to compare the dependent variables in the No Toy Condition at 0.5, 2.5, and 3.0 months of adjusted age. Mixed Linear Models will be used in the full sample analysis to quantify longitudinal differences in postural control between the preterm and full term infants and under the 2 conditions.

RESULTS: There were no differences between the groups at 0.5 months of age. At 2.5 and 3.0 months of age there was no difference in RMScc. RMSml was no different at 2.5 months, but was greater in the preterm than full term infants at 3.0 months of age (p < 0.05). ApENml was lower in the preterm infants at both 2.5 and 3.0 months of age, and ApENcc was lower in preterm infants at 2.5 months of age (p < 0.05, figure 1). On average preterm infants kept their head in midline and reached at an older age than full term infants. Further analysis of the relationship between postural control and the motor behaviors is underway.

CONCLUSIONS: These preliminary findings provide evidence that preterm infant's utilize repetitive postural control strategy during early motor learning which may contribute to early motor control patterns. These early changes in postural control may alter motor pathways, experience, or perceptions.

CLINICAL RELEVANCE: Future discussion of the implications of repetitive postural control strategies on the development of early motor skills is forthcoming.

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D. Fay, T. Wilkinson, A. Anderson, C. Meador, K. Parker, K. Sterrenberg, J. Wong, Physical Therapy, A.T. Still University, Mesa, AZ.

PURPOSE/HYPOTHESIS: Administrating standardized tests, such as the PDMS-2, to children can be challenging, creating a desire to use clarifying and motivating cues. No previous research has investigated the effects of additional cues on scores of the PDMS-2 in typical children on whom the test was normed. The purpose of this study is to assess if clarifying and motivating cues alter gross motor scores on the PDMS-2.

NUMBER OF SUBJECTS: A total of thirty-eight typically developing preschool aged children, with a mean age of 44.1 (30-61) months participated in this study.

MATERIALS/METHODS: Children were recruited at a local daycare center and two groups were formed through initial randomization followed by age and gender matching. Each group consisted of 11 girls and 8 boys with mean ages of 43.9 and 44.2 months. Group 1 was administered the gross motor portion of the PDMS-2 using the standardized instructions first, followed by modified instructions, while Group 2 received assessment in the opposite order. Modified instructions added competition, pretend play, concrete tasks, or altered verbal prompts. All assessments were videotaped for scoring by a researcher blinded to the study's purpose. Data were analyzed using a repeated measures ANOVA and effect sizes were calculated using Cohen's f scores.

RESULTS: Overall gross motor quotient showed a significant effect for instruction type (p = 0.026), and significant interaction between instruction type and order (p = 0.018). Those who received the standard instructions first had large improvements in scores when given modified instructions during the second session, indicating the interaction favored modified instructions. Stationary scores also showed a significant effect for instruction type (p = 0.01) with a significant interaction between instruction type and age (p = 0.015). Children over 48 months obtained higher scores during standardized testing, whereas performance of younger children was positively influenced by modified instructions. Object Manipulation scores showed a significant interaction between instruction type and order only (p = 0.002) while Locomotion scores showed no significant changes (p = 0.253). All findings were supported with large effect sizes (f = .4 -.6).

CONCLUSIONS: Although there was variability in response to instruction type, overall findings support higher gross motor quotient scores with use of modified instructions. Changing verbal prompts and adding concrete tasks appeared to have the greatest influence.

CLINICAL RELEVANCE: This study supports that alterations may change gross motor scores on the PDMS-2, even with typically developing children. Therefore, comparison of scores to the norm should not be used if this test was administered with clarifying cues. Further research is warranted to determine optimal cues necessary to obtain the best representation of a child's true motor ability during standardized assessment.

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C.B. Footer, H. Eigsti, L. Hoffman, C. Anderson, B. Arvizo, C. Ellison, R. Gary, E. Graslie, M. Gray, R. Hancock, R. Hare, M. Kowitz, C. Leisen, K. O'Rourke, E. Payton, A. Pope, L. Proulx, M. Schaber, K. Vargas, I. Waasdorp, C. Wengrovius, Regis University, Evergreen, CO.

PURPOSE/HYPOTHESIS: Children with Down Syndrome (DS) acquire standing balance 18-24 months later than their peers. This is attributed to the inability to efficiently execute automatic postural control responses to a perturbation. Perturbation training delivered with a massed practice (MP) schedule improves standing balance among children with neurological disorders. The purpose of this preliminary analysis is to investigate whether MP perturbation training has a greater effect on gross motor function than a distributed practice (DP) schedule in children with DS.

NUMBER OF SUBJECTS: 16 children with DS

MATERIALS/METHODS: Subjects were assigned using a blocked assignment into either the MP (n = 8; mean age = 43m) or DP (n = 8; mean age = 45m) group based upon the order in which they were fully accepted into the study. Gross Motor Function Measure (GMFM-88) Dimensions D and E were administered 3 times during a 2 week baseline period, within 5 days following the intervention phase, and 1 month following the intervention phase. The Proprio 5000 Dynamic Motion Analysis (DMA) was performed immediately before, within 5 days following, and 1 month following the intervention phase. The MP training occurred over 5 consecutive days, while the DP training occurred 1 day per week for 5 consecutive weeks. The intervention consisted of 400-700 multiplanar perturbations/session at speeds between 24-126 degrees/second while the subject was standing with a safety harness on the Proprio 5000 perturbation platform. Baseline variables were compared between groups. The primary aim was examined with a 2×3 mixed model analysis of variance (ANOVA), with intervention group (MP versus DP) as the between Group variable and Time (baseline, 5 days post intervention, and 1 month post intervention) as the within subjects variable. Separate ANOVAs were performed for each dependent variable GMFM-88 D, E, and DMA score. Planned pair-wise comparisons were performed using an alpha level of 0.05.

RESULTS: Subject age and GMFM-88 D and E scores were similar between Groups (p > 0.05) at baseline. ANOVA GroupxTime interactions were not different for Dimensions D or E of the GMFM-88 nor the DMA score (p > 0.05). However, Dimensions D and E of the GMFM-88 were significant for Time (p < 0.05) with Tukey post hoc analyses significant for changes in both Dimensions D and E between baseline to 5 days post intervention (p < 0.05) and baseline to 1 month post intervention (p < 0.05). DMA scores were also significant for Time (p < 0.05) with Tukey post hoc analysis significant for changes between both baseline to 5 days post intervention (p < 0.05) and baseline to 1 month post intervention (p < 0.05).

CONCLUSIONS: The results suggest that children with DS can improve in gross motor function and postural control through perturbation training using either MP or DP training schedule since both schedules had a similar positive effect.

CLINICAL RELEVANCE: This study suggests that clinicians should consider using perturbation training to improve gross motor function and postural control in children with DS.

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H. Hanson, A. Tokay Harrington, The Children's Hospital of Philadelphia, Philadelphia, PA.

PURPOSE/HYPOTHESIS: Monitor feasibility and efficacy of treatment frequency guidelines (TFG) to guide episodes of care in medically-based pediatric outpatient (OP) physical therapy (PT).


MATERIALS/METHODS: Previously developed TFG were modified for use in our pediatric OP PT department using the following frequencies: intensive, weekly, bimonthly, periodic, and consultative. Two datasets were analyzed, each consisting of chart reviews of 10 consecutive initial evaluations per OP therapist. First, we measured therapists' adherence to the established standard (discussing and documenting TFG), then evaluated accuracy using TFG to predict frequency and duration, and finally examined factors that may impact therapist use of TFG.

RESULTS: Initially, 225 charts were reviewed. Analysis revealed 31% of therapists adhered to the established standard. This analysis led us to provide further comprehensive education on TFG via in-person sessions with therapists. After re-education sessions, a second set of charts were reviewed (n = 197), demonstrating 90% adherence. Comparisons were made between datasets 1 and 2 by examining courses of therapy that were completed with goals met (n = 118 and n = 60, respectively). Accuracy in predicting the course of therapy was defined as predicting the total weeks or total number of sessions of therapy within a 25% window of error. Although there were only minor increases in accuracy of predicting total number of weeks of therapy following re-education (36.4% vs. 40%), there was a significant decrease in the number of courses of therapy where the actual duration exceeded the predicted duration by more than 25% (42% of cases vs. 23%; p = 0.001). Likewise, accuracy in predicting total number of sessions for a given plan of care increased from 40.7% to 43% following re-education, while the number of courses of therapy where the number of sessions provided exceeded the number of sessions predicted by more than 25% decreased (23% of cases vs. 5%; p = 0.19). Analysis of factors contributing to accuracy of predicting treatment frequency and duration demonstrated a significant correlation between years of practice and accuracy of predicting number of weeks of therapy in dataset 1 (p = 0.01), but was not significant in dataset 2 (p = 0.26). There were no significant correlations between factors examined and accuracy in predicting total number of sessions.

CONCLUSIONS: The use of TFG represents a shift in philosophy for pediatric OP PT toward episodic care. Treatment frequency guidelines may improve therapists' ability to predict duration of care. Comprehensive education via in-person meetings may also improve adherence among staff. Years of practice appears to impact accuracy predicting total length of treatment in the absence of comprehensive education on use of TFG.

CLINICAL RELEVANCE: The use of TFG is feasible in pediatric OP PT. Future work will examine the effect of TFG on patient attendance, therapy outcomes, and reimbursement for PT services.

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R. Hawe, J.P. Dewald, Physical Therapy and Human Movement Sciences, Northwestern University, Chicago, IL.

PURPOSE/HYPOTHESIS: While the corpus callosum is not directly impacted by unilateral brain injuries, losses of integrity of callosal fibers have been previously reported. The purpose of this study is to examine whether the corpus callosum is impacted differently when the brain injury occurs early in life before the callosal fibers have fully developed compared to in adulthood. We hypothesized that there will be greater losses in integrity in earlier injuries, which may contribute to differences in clinical presentation between pediatric and adult hemiplegia.

NUMBER OF SUBJECTS: 43 total subjects (13 pediatric hemiplegia; 10 pediatric control; 10 adult-onset stroke; 10 adult control)

MATERIALS/METHODS: All participants underwent diffusion tensor imaging on a 3T scanner. An echo-planar based diffusion imaging sequence was used with diffusion weighting of 1000 s/mm2 in 60 different directions, as well as a total of 8 scans without diffusion weighting. Images were processed using the FMRIB Software Library. Masks were hand drawn on the corpus callosum at the midsagittal slice using a directional color map as a guide. The corpus callosum was then further sectioned anteriorly to posteriorly into five regions corresponding with the location of the cortical projections (I: prefrontal; II: pre-motor and supplementary motor areas; III: primary motor cortex; IV: primary sensory cortex; and V: parietal, occipital, and temporal regions). For each region, the average fractional anisotropy was calculated as a measure of white matter integrity. Fractional anisotropy for each region was compared between groups using one-way ANOVAs with LSD post-hoc t-tests when indicated.

RESULTS: Significant differences in fractional anisotropy between groups were found for all regions of the corpus callosum except for the prefrontal region. Post-hoc tests revealed significant differences between pediatric control subjects and pediatric hemiplegia subjects for all regions and between pediatric and adult hemiplegia for both the motor and parietal/temporal/occipital regions. Adult hemiplegia was not found to be different than adult control subjects in any region.

CONCLUSIONS: Based on our results, the corpus callosum appears to be affected to a greater extent by unilateral injuries occurring early in life compared to with adult-onset stroke. This is most likely due to the fact that the corpus callosum is not fully developed at the time of the early injury, affecting its subsequent maturation.

CLINICAL RELEVANCE: By understanding how unilateral brain injuries impact callosal pathways differently depending on the maturational stage of the brain, we can better understand the differences in presentation between patients with injuries obtained at different time points. Losses in transcallosal motor pathways can contribute to difficulties with bimanual coordination, as well as complex motor tasks associated with activation of bilateral motor areas.

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E.T. Kennedy, H. Swingle, S.J. Anderson, Univ of South AL, Mobile, AL.

BACKGROUND & PURPOSE: The Autism Spectrum Disorders (ASDs) diagnostic process involves an interdisciplinary healthcare team. Family centered care (FCC) permits the development of collaborative relationships between parents and professionals empowering families to make educated decisions about their children. This case report documents the administrative process implemented by staff at an autism diagnostic clinic to evaluate FCC processes, to guide improvement of services provided by the clinic, and to evaluate the effectiveness of a standardized tool for on-going program evaluation.

CASE DESCRIPTION: The setting is a university-based autism diagnostic clinic in the US Gulf Coast region. Interdisciplinary services include medical evaluation, standardized testing, and additional consultation/evaluations by affiliated specialists including physical therapy. Initiated in 2008, the Measure of Processes of Care: Questionnaire for families (MPOC-20) and questionnaire for service providers (MPOC-SP) were used to evaluate FCC. A purposeful sample of parents completed the MPOC-20 (n = 31) with primary staff completing the MPOC-SP (n = 6). Scores were compared (t-test). Additional information was gathered with a focus group with staff, in-depth interview with parent, and follow-up interviews with staff. Strategies to ensure accuracy and appropriate interpretation of the data included analysis of interview transcripts, analysis of clinic archival data, and participant observations at the clinic. Utilization of constant comparison analysis allowed for categorization of the data into themes and generation of conclusions.

OUTCOMES: Parents expressed overall satisfaction with the diagnostic process. Parents expressed need for increased access to support after diagnosis. Parents appeared to need interaction with other families. Parents expressed need for multiple sources of information. Parents rated clinical services higher than staff. Staff understood importance of individualization and placed a high value on providing emotional support. Staff demonstrated a discomfort with inability to meet all families' expectations. Changes were initiated with regards to educational and resources needs as indicated from evaluative process. Policies are currently being developed for on-going assessment of FCC processes at the clinic.

DISCUSSION: The evaluation process appears to be useful as a strategy for self-evaluation of FCC practices in this clinic. The MPOC questionnaire for families and professionals is a reliable, validated, inexpensive, and easy to administer standardized tool for the clinic setting. The MPOC also appears to be a useful tool for self-evaluation for staff and trainees of FCC behaviors. The information gained in this study will assist with on-going improvement of FCC practices. Future efforts to gain additional family perspective will be explored, such as telephone interviews. Routine staff focus groups are also seen as important to the on-going evaluation process.

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T.H. Kolobe, Rehabilitation Sciences, University of Oklahoma Health Sciences Center, Oklahoma City, OK; P. Pidcoe, Physical Therapy, Virginia Commonwealth University, Richmond, VA; M. Warner, University of Oklahoma Health Sciences Center.

PURPOSE/HYPOTHESIS: Prone locomotion, the earliest functional mobility during infancy, is not only compromised in children with cerebral palsy (CP), but has also shown little responsiveness to interventions. Infants with CP show paucity of self-initiated movements critical for prone locomotion and these movements diminish over time. We examined whether infants with or at risk for CP can learn to independently propel themselves using a motorized and computerized self-initiated prone progression crawler (SIPPC); determined the responsiveness of the SIPPC control algorithms to the infants' efforts to move; and examined the learning strategies used. The SIPPC represents integration of robotic and sensor technologies designed to influence movement effort.

NUMBER OF SUBJECTS: Data based on 114 training sessions from 14 infants 4.5-7 months old (4 with and 10 without risk for CP (TD)). This sample size offers 80% power to detect a difference of .20 in the proportion of participants who can travel 6 feet. MATERIALS/METHODS: We used the Test of Infant Motor Performance at 3-4 months to determine risk for CP. The intervention protocol comprised of 20 minutes of in-home videotaped training on the SIPPC, twice a week, for 12 weeks. Positional data collected from the SIPPC included velocity, direction, distance, areas explored, amount of assistance needed. A camcorder provided qualitative movement and infant behavior. These were coded using Movement Observation Checklist (MOCS). We used graphs, ANOVA for repeated measures, and Pearson r to analyze the data.

RESULTS: Means for distance, peak velocity, and area explored were significantly different across time and between groups (p values range = .03-.001). No infants with CP propelled the SIPPC for more than 3 feet. On average the infants with TD attained the 6 ft mark by 6 months but did so specifically during the last 3 weeks of training, suggesting that the SIPPC-based sensor input was responsive to later but not early movement efforts. The average movement index was 71.2 for infants with CP and 12.7 for the TD group (p = .001), indicating high movement effort by infants with CP that did not result in high distance. MOCS data correlated with SIPPC data.

CONCLUSIONS: The findings suggest that infants with CP need additional input from their arm/leg movements to the SIPPC to capture their efforts. The control algorithms worked well when children first learned to rock forwards/backwards, but not with early kicking. Early in their efforts to move young infants and infants with CP rarely generated a ground reaction to trigger the SIPPC assist function, resulting in higher movement index.

CLINICAL RELEVANCE: Prone locomotion is integrated with other systems and its development coincides with a highly active brain synaptic formation period. Failure to develop early mobility by children with CP has far-reaching adverse consequences on later developmental outcomes. The SIPPC is unique and innovative in that it is not only an intervention device, but can also be used to gather comprehensive information about infants' learning and mobility patterns.

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P. Lin, H. Lien, Wong, Department of physical medicine and rehabilitation, Taoyuan Chang Gung Memorial Hospital, Taiwan, Tao-Yuan, TAIWAN; W. Liu, Department of Physical Therapy and Graduate Institute of Rehabilitation Science, Chang Gung University, Taiwan, Tao-Yuan, TAIWAN; H. Wang, Department of Pediatric Neurology, Chang Gung Memorial Hospital Linkou Branch, Taiwan, Tao-Yuan, TAIWAN; F. Tang, Department of physical medicine and rehabilitation, Chang Gung Memorial Hospital Linkou Branch, Taiwan, Tao-Yuan, TAIWAN.

PURPOSE/HYPOTHESIS: Tourette syndrome (TS) is a childhood-onset neurodevelopmental disorder. The pathophysiology of TS is not fully understood, but several studies have revealed structural abnormalities in basal ganglia and cerebellum. These structures are essential for gait control. However, gait performances in children with TS were rarely reported. Dual task and fastest walking conditions were frequently used in assessing gait performances in patients with neurological impairments to reveal subtle defects in gait. The purpose of this study was to compare the temporal-spatial and kinematic gait characteristics between the children with TS and the healthy control (HC) children under preferred, dual tasking and the fastest walking conditions.

NUMBER OF SUBJECTS: Fifteen children with TS (6-12y/o; 13 boys and 2 girls), and 15 age-gender-matched HC children participated in this study.

MATERIALS/METHODS: Gait parameters were quantified in three conditions: walk with preferred speed, walk with fastest speed, and dual task walking. Three sets of kinematics (Vicon, Oxford Metrics Group, Oxford, UK) and temporal-spatial gait data were collected for each condition. Two by three ANOVA with repeated measures were used for data analysis.

RESULTS: The velocity (p = 0.02) and stride length (p = 0.02) were differed significantly between groups. Post hoc analysis showed children with TS walked slower than HC children in the preferred (p = 0.03) and fastest (p = 0.02) speed walking condition with shorter stride length (p = 0.02 and 0.01 for preferred and fastest condition respectively). The difference between groups in the dual condition was diminished (p = 0.39 and 0.06 for velocity and stride length). Differences between left and right step length were statistically significant between two groups (p = 0.01). Compared to the HC children, the peak ankle plantar flexion in the preferred legs (p = 0.004) and peak hip extension in the non-preferred legs (p = 0.04) were postponed significantly for children with TS.

CONCLUSIONS: Children with TS regulate their cadence in the similar ways as the HC children. However, children with TS demonstrated poorer control in spatial parameters of gait, such as stride length, step length, symmetry of step length and composite parameter, such as velocity, compared to HC children. The delay in generating peak joint angles at ankle or hip specifically on preferred or non-preferred leg may partly account for the discrepancies. In dual task walking, change in walking speed or external focusing on the second task may help children with TS to improve their gait performances.

CLINICAL RELEVANCE: To recognize gait characteristics in children with TS in clinical observation. Further studies should explore the kinetic, electromyography and underlying neural mechanism effect on gait in children with TS.

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J.J. McElroy, University of Missouri, Columbia, MO; C.B. Heriza, J.K. Sweeney, Rocky Mountain University of Health Professions, Provo, UT; T.H. Kolobe, University of Oklahoma, Oklahoma City, OK.

PURPOSE/HYPOTHESIS: Identification of very young infants with motor dysfunction is inadequate due to a lack of tools that are easily administered and highly prognostic for infants under 3 months of age. Assessment of spontaneous movements is a promising tool for this population. Though spontaneous movements of hip, knee, and ankle flexion and extension have been investigated, foot movements outside the sagittal plane were not addressed in the literature. Expanded descriptions of spontaneous foot movements may improve clinical identification of movement dysfunction in very young infants. The purpose of this study was to describe forefoot eversion/inversion and abduction/adduction during spontaneous lower extremity movement in newborn (NB) and 3 month (3M) old infants. Movements were examined for spatial and temporal coordination of hip, knee, ankle, and forefoot. Comparisons were made between the 2 ages to examine developmental changes.

NUMBER OF SUBJECTS: Ten infants born between 38 and 41 weeks gestational age.

MATERIALS/METHODS: Infants were video-recorded for 5 minutes during supine spontaneous lower extremity movement at 5-6 days and again at 3M. Kinematic analysis was performed on three 10-second segments from each video producing 3D joint angles for hip and knee flexion/extension, ankle dorsiflexion/plantarflexion, forefoot eversion/inversion, and forefoot abduction/adduction. Correlation coefficients and phase lags between joint pairs were calculated to determine joint coordination and temporal approximation of movement initiation respectively.

RESULTS: Joint correlation coefficients of forefoot eversion/inversion and abduction/adduction when paired with hip, knee, or ankle movements were low for all joint pairs never exceeding rs = .22 at 5-6 days of age and at 3M. Within foot joint correlation coefficients were stronger, rs = .46 in NB period and rs = .52 at 3M. Temporal sequencing of foot movements in relation to proximal joint movements was highly variable. No statistically significant differences were found between the NB and 3 M testing periods for either joint correlation coefficients or phase lags.

CONCLUSIONS: Independent movements of forefoot eversion/inversion and abduction/adduction during supine spontaneous lower extremity movements are typical in infants born full term. Unlike proximal joint pairings which demonstrate tight coupling and close synchronization which decrease over time, forefoot to proximal joint pairings demonstrate loose coupling with highly variable synchronization which does not change as infants age from NB period to 3M.

CLINICAL RELEVANCE: Variability of foot movements promotes lower extremity interaction with the environment and adaptability needed for motor development. Outcomes from the kinematic analyses in this study provide a basis for clinical examination of foot movements in relation to hip, knee, and ankle movements in very young infants.

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

PURPOSE/HYPOTHESIS: Childhood obesity is a serious global health threat. Research on the effect of being overweight (OW) in young children (=9 years) is limited. The primary objective of this study was to determine the differences in gait, balance and muscle strength in young children (5-9 yr) classified as normal weight (NW) or OW.

NUMBER OF SUBJECTS: 70 children (5-9 yr) participated in this cross sectional design study. Based on body mass index (BMI) percentiles, participants were classified into 2 groups: OW (= 85th BMI percentile, n = 29, age = 7.3 ± 1.9 yr) and NW (<85th BMI percentile, n = 41, age = 7.2 ± 1.2 yr).

MATERIALS/METHODS: Balance was measured using the 1-leg stance test (OLST) in the eyes open condition. Gait data were collected at a self-selected walking speed using the GAITRite system. Hand grip strength was determined with a handgrip dynamometer. Leg strength/power was assessed with vertical jump (VJ) height using a Just Jump mat. Each child's physical activity (PA) and parent/guardian's socioeconomic status were assessed using self-reported questionnaires completed by a parent/guardian. An independent t test, Mann Whitney test, ANCOVA and logistic regression analysis were used to compare groups and determine relationships (P < 0.05).

RESULTS: The NW and OW groups did not show significant differences in their racial makeup or in other measures of socioeconomic status. Being OW resulted in poorer performance on OLST (NW: 14.0 ± 7.2 s vs. OW: 8.3 ± 4.2 s; P < 0.05) and VJ height (NW: 30.1 ± 4.5 cm vs. OW: 25.4 ± 6.5 cm; P < 0.01). Gait data revealed that children who were OW had increased base of support (NW: 7.4 ± 2.5 cm vs. OW: 8.7 ± 2.2 cm; P < 0.05) and stride length (NW: 107.4 ± 13.6 cm vs. OW: 116.1 ± 10.7 cm; P < 0.05) compared to children who were NW. Further analysis with an ANCOVA revealed no significant differences in stride length when leg length was controlled. Significant differences were noted between the 2 groups for time spent watching video games or on the computer each day (P < 0.05). Children who were OW spent 4.2 times (95% CI:1.06-16.27; P < 0.05) more time playing video games or on a computer compared to children who were NW.

CONCLUSIONS: These findings suggest that young children who are OW have decreased leg strength, reduced balance, walk with an increased base of support and spend greater time playing video games and computer related activity each day compared to children who are NW. This study provides new useful data for clinical practice and adds to the limited research on physical performance in young children who are OW residing in the US.

CLINICAL RELEVANCE: This information is important for physical therapists to consider when designing exercises that are appropriate for children's physical abilities to allow safe and successful participation in those activities.

ACKNOWLEDGEMENTS: This work was funded by grants from the Sage Research Institute and the New York Physical Therapy Association.

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S.A. Ross, K. Winking, C. Rosentreter, M. Meehan, M. Althoff, A. Hill, Physical Therapy Program, Maryville University, St. Louis, MO; A. Pagano, S. Grau, United Services Early Childhood Center, St. Louis, MO.

PURPOSE/HYPOTHESIS: Typically developing toddlers have flat feet (pronation) and develop arches as they age and walk with a more adult gait pattern. Children with hypotonia (low tone) have increased ligament laxity and excessive pronation. According to the literature, a child normally exhibits calcaneal valgus in relaxed standing of no more than 10° through the age of three. By the age of five, a child should present with calcaneal valgus of less than 6° and by age seven a child should demonstrate relaxed calcaneal stance much like that of an adult (2° valgus). Although typically developing children have more pronation when they are younger, and children with low tone have more pronation in general, it is unclear what degree of pronation should be braced and if the degree of pronation is related to the child's functional ability. The purpose of this study was to determine the difference between degrees of pronation, plantarflexion (pf) strength, balance, stride length and gait speed in children with low tone and typical development and explore the relationship between these variables.

NUMBER OF SUBJECTS: Participants included 44 preschool children: 29 (13 girls, 16 boys) in the typically developing (TD) group [mean age 4.3 years (±5.1 months)] and 15 (4 girls, 11 boys) in the low tone (LT) group [mean age 4.3 (±6.8 months)].

MATERIALS/METHODS: Outcome measures included gait speed and stride length (GAITRite), pf strength (hand-held dynamometer), static hindfoot pronation (goniometer) and balance (subtests of the Pediatric Balance Scale). All data were normally distributed. Right to left differences were found for static hindfoot pronation and pf strength; all other variables were averaged. Between group differences were compared using a MANOVA. Correlations were completed using Pearson's Correlation Coefficient (p < .05).

RESULTS: A significant difference was found between the TD and LT groups for all outcome variables (p = .001). Mean static pronation for the TD group (10° ± 3.7) was significantly less than the LT group (16° ± 5.6). For the TD group no significant correlations were found between the variables tested except gait speed and stride length (r = .71). For the LT group hindfoot pronation was not correlated to function however, there was a moderate correlation between balance and the following variables; gait speed, stride length and strength.

CONCLUSIONS: The majority of typically developing children (55%) in this study exhibited greater pronation than would be clinically acceptable. Additional research needs to determine if typically developing children and those with hypotonia who display greater degrees of pronation require orthotics. Hindfoot pronation was not correlated to function in either the TD or LT groups.

CLINICAL RELEVANCE: Surprisingly typically developing preschool children displayed greater degrees of pronation than expected based on the literature. It is unclear when or if we should order orthotics for children with low tone who display standing pronation similar to those in the typically developing group.

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D. Thorpe, B. Henderson, Division of Physical Therapy, The University of North Carolina at Chapel Hill, Chapel Hill, NC; H. Kecskemethy, Nemours Biomedical Research, A.I. Dupont Hospital for Children, Wilmington, DE; R. Grossberg, Medicine, Hattie Larlham Center for Children with Disabilities, Mantua, OH; K. Sheridan, Adult and Pediatric Endocrinology, Gillette Children's Specialty Healthcare, St. Paul, MN; R. Stevenson, Pediatrics, University of Virginia, Charlottesville, VA; S. Hidalgo, Biostatistics, The University of North Carolina at Chapel Hill, Chapel Hill, NC; B. Nikolova, T. Bonau, Research, Gillette Children's Specialty Healthcare, St. Paul, MN; R. Henderson, Department of Orthopaedics and Pediatrics, The University of North Carolina at Chapel Hill, Chapel Hill, NC.

PURPOSE/HYPOTHESIS: The principal aim of this retrospective, cross-sectional, study was to describe bone health in adults with CP, ages 18>, across Gross Motor Function Classification System (GMFCS) Levels.

NUMBER OF SUBJECTS: Two hundred sixty-three adults with cerebral palsy who had not received bisphosphonate therapy prior to Dual X-ray Absorptiometry (DXA) participated.

MATERIALS/METHODS: Retrospective DXA scans of left and right distal femurs (n = 488; R = 238, L = 250) using Hologic QDR 4500W densitometers were analyzed using Hologic v8.25 software. Technicians divided distal femurs into three regions (R1, R2, and R3). Multiple regression analysis determined associations between bone mineral density (BMD) and GMFCS Level, age, gender, body mass index (BMI), and fracture history using GMFCS Level V as the reference.

RESULTS: Participants were aged 18-71 years, mean age (SD) 27.12 (10.54) years who received their medical care from one of five institutions across the USA. Participants were 55% male, 83.5% Caucasian, 10.2% Black, 2.4% Hispanic Nonwhite 2.4% Asian/Pacific Islander, .4% American Indian, and 1.2% Other. They classified into GMFSC Levels I (13%), II (11%), III (9%), IV (23%), and V (44%). Participants' BMIs ranged from 13.8kg/mm2 to 48.9 kg/m2 with a mean BMI of 23.6 kg/m2. Participants in GMFCS Level III had the highest mean BMI at 23.7 (8.4) kg/m2 and those in GMFCS Level V had the lowest mean BMI at 20.7 (4.2) kg/m2. Thirty-two percent of the participants had a history of fracture and of those 62% were GMFCS Levels IV and V. In Region 1, age, GMFCS Level, weight, and prior fracture history explained 58% of the variance in BMD. In Region 2, age, GMFCS Level, and weight explained 58% of the variance in BMD. In Region 3, age, GMFCS Level, and weight explained 61% of the variance in BMD.

CONCLUSIONS: Results suggest that adults with CP that have better weight bearing status (i.e. GMFCS Levels I-III) and higher BMIs, have better bone health. Future studies should address longitudinal reporting of bone health in persons with CP to better determine specific variables which predict bone health and fracture risk over time.

CLINICAL RELEVANCE: There is substantial evidence on bone health and fracture history in children and adolescents with CP however, little evidence exists related to bone health in adults with CP. Pulling adult bone health data from multiple centers and using uniform analysis has provided a clinical picture of bone health across GMFCS Levels. This information can be used to design future longitudinal studies, from which predictive models of bone health by GMFCS Level can be developed to guide interventions to reduce fracture risk and improve health-related quality of life in persons with cerebral palsy.

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C. Yates, A. Drinkwitz, E. Everson, R. Smith, Physical Therapy, University of Central Arkansas, Conway, AR; A. Mitchell, Center for Translational Neuroscience, University of Arkansas for Medical Science, Little Rock, AR; R.W. Hall, Department of Pediatrics, College of Medicine, University of Arkansas for Medical Science, Little Rock, AR.

PURPOSE/HYPOTHESIS: Kangaroo Care (KC) is a technique used with infants by maintaining skin to skin contact between the infant and caregiver. KC has been used in term infants and shown positive benefits. The safety and efficacy of KC has not been documented in preterm infants (GA 27-30 weeks) who are receiving respiratory support. The purpose of this study was to determine if KC is safe and effective in reducing pain and stress in preterm infants who are also receiving respiratory support.

NUMBER OF SUBJECTS: Preterm infants between 27 and 30 weeks GA, who were considered medically stable, were randomly assigned to either the KC (holding time of minimum of 2 hours daily) or Standard Care (SC) group (maximum holding of 15 minutes daily) during days of life 5-10. A total of 38 subjects were included in the study.

MATERIALS/METHODS: Infants were monitored continuously via pulse oximeter and cardiorespiratory monitor for bradycardia (<80bpm) and oxygen desaturation (<80%). Episodes of cardiorespiratory events were analyzed for 3 groups: KC group during holding, KC group in the incubator, and SC group. Analysis was based on hourly means using ANOVA with Tukey post hoc analysis. Salivary cortisol samples were obtained from all infants on DOL 5 and 10. Differences were analyzed using repeated measures ANOVA and t tests. Pain during suctioning was assessed using the Premature Infant Pain Profile (PIPP). The Parental Stress Index (PSI) was completed following the study.

RESULTS: The KC group had significantly fewer bradycardia events (p < 0.048) and oxygen desaturation events (p = 0.01) during holding than in the incubator and significantly fewer desaturation events than the SC group (p = 0.02).

The results of the salivary cortisol data revealed there was no main effect of group (p = 0.49), but there was a significant main effect of age with salivary cortisol levels decreasing in both groups from DOL 5 to 10 (p = 0.02).

Pain scores for both groups indicated mild to moderate pain during suctioning, however, no significant difference in pain scores between the two groups (p = 0.59).

CONCLUSIONS: No adverse events were recorded for any infants during KC administration. There were no significant differences in salivary cortisol levels between the KC and SC groups. However, both groups indicated decreased stress levels or dampened response to stress from DOL 5 to 10. Infants in the KC group did not have lower mean PIPP scores immediately after suctioning, but infants were not being held during the painful procedure. Previous literature reveals that KC is beneficial if the infant is held at the time of the painful stimulus.

CLINICAL RELEVANCE: KC was well tolerated and safe in preterm infants who were a minimum of 27 weeks GA and receiving respiratory support. KC is now the standard of care for stable preterm infants at the UAMS NICU. This study demonstrated KC reduced bradycardia and oxygen desaturation events in preterm infants during holding time. Additional research needs to be done to determine specific mechanisms of KC to lower cardiorespiratory events.

© 2013 Lippincott Williams & Wilkins, Inc.