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Abstracts* of Poster Presentations at the 2014 Combined Sections Meeting

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doi: 10.1097/PEP.0000000000000020
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Abbruzzese LD, Quam A, Cooper S, Bornheimer R, Columbia University, New York, NY

PURPOSE/HYPOTHESIS: Cri du Chat Syndrome (CDCS) is a rare genetically based neurodevelopmental disorder caused by a deletion on chromosome 5. Gait and motor function research in individuals with CDCS is limited. Thus, the purpose of this study was to investigate the effects of three walking speeds and a manual dual task on gait parameters in individuals with CDCS.

NUMBER OF SUBJECTS: 11 individuals with CDCS (ages 4-23)

MATERIALS/METHODS: Participants walked under four task conditions: slow speed, comfortable speed, fast speed, and dual-task walking carrying an empty tray. Gait trial videos were analyzed using Dartfish analysis software in order to determine average velocity, stride length, and cadence. Coefficient of Variation (CV) was calculated for each measure. A repeated measures ANOVA was performed to test the equality of means for the four task conditions. Initial foot contact patterns were recorded for each subject.

RESULTS: There were significant task effects for average velocity (p < .001), average stride length (p < .001), and average cadence (p<.001). There were no effects for CV. Subjects walked at a higher velocity under the fast condition by increasing cadence. Cadence, stride length, and velocity were not significantly different in the slow condition as compared to the comfortable speed condition. Average stride length in the dual task condition was significantly smaller than each of the other single task conditions regardless of speed. Gait speed and cadence under the dual task condition only differed significantly from the fast walking condition and was not significantly different from the slow or comfortable walking conditions. Preliminary results indicate high variability of foot position during initial contact.

CONCLUSIONS: These findings suggest that individuals with CDCS may have difficulty modulating their walking velocity when slower speeds are required. Individuals with CDCS attempt to modulate gait via stride length when asked to perform a dual task, however ambulate at speeds similar to their slow/comfortable speed.

CLINICAL RELEVANCE: Knowledge of gait characteristics and how gait is affected by varying task demands will be beneficial when targeting interventions for this population. Further study is needed to explore interventions that address speed modulation and other strategies that may assist individuals with CDCS in adapting to differing environmental demands. Being able to adjust gait speed and perform dual tasks is essential to safe and successful community participation.


Anderson DK, Cech D, Midwestern University, Downers Grove, IL

PURPOSE/HYPOTHESIS: The Dynamic Gait Index (DGI) has been found to provide valid and reliable measurements of gait function and fall risk in adults. There is minimal evidence regarding the use of the DGI with children and no current published studies that look at developmental gait considerations related to balance and vestibular function which might impact a child's performance on the DGI. The dual purposes of this cross-sectional study were to (1) explore the relationship between three age groups of children (7-10 years, 11-14 years, 15-18 years) and performance on the DGI and (2) assess the inter-rater reliability of the DGI when used with children. This study was approved by the Institutional Review Board at Midwestern University.

NUMBER OF SUBJECTS: Sixty-two children, 24 male children and 38 female children participated in this study. Children were placed in three age groups: 7-10 years (n = 24), 11-14 years (n = 17), 15-18 years, (n = 21). Forty-eight children were rated by two raters who were experienced pediatric physical therapists.

MATERIALS/METHODS: Prior to completion of the DGI, participants were screened by parent/participant questionnaire. Participants completed the Movement Assessment Battery for Children – 2nd Edition (MABC-2) to further confirm typical motor performance, identified as scoring above the 5th percentile. One child was excluded from the analysis due to a low MABC-2 score. The DGI and MABC-2 were administered in random order to minimize potential effects of motor activity on DGI performance.

RESULTS: The Kruskal-Wallis test demonstrated a significant difference in mean DGI scores between the three age groups (Η(2) = 16.615, ρ<.05). The Mann-Whitney U test further identified significant differences in mean DGI scores between the 7-10 year-old group and the 15-18 year-old group (U = 91, Ζ = −3.638, ρ<.05); and between the 11-14 year-old group and the 15-18 year-old group (U = 72.5, Ζ = −3.125, ρ<.05). An ICC of .596 showed moderate inter-tester agreement of the total DGI score when used with children. In addition, there was a statistically significant difference between the raters on two DGI items: head turning (Ζ = −2.646, ρ<.05) and pivoting (Ζ = −2.434, ρ<.05) as identified by the Wilcoxon Signed Ranks Test.

CONCLUSIONS: Our preliminary analysis indicates that children of different ages perform differently on the DGI. For this reason, caution needs to be used when examining children of different ages or when the DGI is used to look at changes in gait function over time. In addition, two experienced raters demonstrated variability in interpretation of this tool when used with children. Future studies will explore developmental trends in performance of individual DGI items and factors related to gender and age.

CLINICAL RELEVANCE: Pediatric gait function and safety are important considerations for child participation in life roles. Identification of valid and reliable tools to examine pediatric gait function and safety is important to the pediatric physical therapist.


Aparicio JA, Ortiz A, Olson S, Texas Woman's University, Houston, TX; Wiggin MM, Texas Children's Hospital, Houston, TX

BACKGROUND & PURPOSE: Children with CP commonly have gait deviations that lead to loss of functional mobility as the patient ages and are often prescribed AFOs to aid in ambulation, with little objective evidence regarding the frequency and distribution of the abnormalities. The purpose of this case study was to use computerized gait analysis systems and EMG recordings to assess gait parameters objectively in a child with CP, with and without use of AFOs.

CASE DESCRIPTION: A 10-year-old Hispanic female diagnosed with CP, at a GMFCS Level II, participated in 12 walking trials, 6 with and 6 without her AFOs. Selected temporal and spatial data were recorded using the GAITRite Electronic Walkway. Kinematic 3-D data were recorded using a Vicon system. A Delsys Trigno wireless EMG system recorded muscle activity. All three systems were synced during data collection. Data were averaged for 6 trials without AFO (woAFO) and 6 trials with AFO (wAFO).

OUTCOMES: Differences were noted in self-selected walking speed woAFO (.74 m/s) compared to wAFO (.81 m/s.) and in stride velocity of the left and right foot woAFO (.73 m/s, .75 m/s, respectively) compared to wAFO (.82 m/s, .83 m/s). Observed kinematic changes included: greater hip flexion during swing for left and right legs wAFO (+44.3°, +49.1°, respectively) compared to woAFO (+39.9°, +43.6°); greater hip abduction during swing for left and right legs wAFO (+3.2°, +10.2°, respectively) compared to woAFO (+1.9°, +6.4°); greater knee external rotation in stance for both left and right legs wAFO (+16.3°, +12.23°, respectively) when compared to woAFO (+7.0°, +0.6°), and higher ankle dorsiflexion in stance for both left and right legs wAFO (+4.9°,+18.48°, respectively) compared to woAFO (+0.0°,+7.7°). EMG differences were observed in the gastrocnemius-soleus, with double the EMG activity on the right leg wAFO compared to woAFO and an abnormal amount of activity occurring late in the swing phase wAFO; and lower tibialis anterior activity on the right wAFO compared to woAFO, with a more normalized distribution of energy wAFO. Distribution of gluteus maximus activation within the gait cycle was greatly skewed with a significant increase of activity occurring early in stance wAFO when compared to woAFO.

DISCUSSION: These findings suggest AFOs have both positive and negative effects on gait biomechanics of a child with CP. Although self-selected walking velocity and stride velocity increased, the biomechanics, muscle activation, and distribution were greatly affected. Gains in one area came at the cost of another. Greater hip flexion during swing is thought to have contributed to the increase in stride velocity, subsequently increasing muscle activity of the gluteus maximi due to their role in hip stability during early stance. Other benefits observed were more normalized distribution of tibialis anterior activation during stance on the right wAFO, increasing ankle dorsiflexion during stance bilaterally and aiding in limb progression.


August D, Harper S, Perry L, Pollard K, Williams L, Chen Y, Physical Therapy, Georgia State University, Atlanta, GA

BACKGROUND & PURPOSE: Recently, virtual reality (VR) has been explored as a training device for improving reaching movement in children with spastic cerebral palsy (CP) and shows promising effects. However, the optimal practice schedule of using VR is still uncertain. Therefore, comparing VR practice schedules may yield further knowledge of the effectiveness of VR training for children with spastic Cerebral Palsy. The purpose of this study was to determine which practice schedule of VR would most improve reaching capabilities in children with spastic CP.

CASE DESCRIPTION: Participants were 4 males with Spastic Quadriplegic CP between 6 and 10 years old. Each child was randomly assigned to one of two practice schedules: Group 1: 5 sessions/week; Group 2: 3 sessions/week, for a total of 150 minutes per week for 8 weeks. Pre and Post testing measurements were taken using reaching kinematic video analysis and a standardized fine motor assessment tool (PDMS-2 Fine Motor Domain).

OUTCOMES: Both groups showed improvement in PDMS-2 score, but Group 1 showed a greater improvement in reaching time. Group 1 improved in 7 of 8 reaching categories, and improved overall reaching time by 38%. Group 2 improved in 2 of 8 reaching categories, but did not improve in overall reaching time.

DISCUSSION: This pilot study found that a more distributed practice schedule led to a larger improvement in reaching movements than a more massed practice schedule. When working with a child using VR therapy, a more distributed practice schedule appears to enhance VR intervention results.


Baratta-Ziska F, Hospital for Special Surgery, New York City, NY

BACKGROUND & PURPOSE: Spinal deformity is common in children with moderate to severe Type III osteogenesis imperfecta (OI). Progressive spinal curves > 30°are almost certain in children with Type III OI, as young as 7 years old. Thoracic scoliosis >60° in children with Type III OI leads to adverse pulmonary function. Bone fragility in children with Type III OI presents unique challenges for adequate spinal fixation, healing, early mobilization, and function due to scoliosis, immobilization and fracture risk. For this patient, posterior spinal fusion T2-L4 with instrumentation (PSF) and early physical therapy (PT) helped reduce these complications. The purpose of this case report is to highlight the role of PT and the interdisciplinary care for this patient pre and post-operatively to achieve a successful outcome. The Gross Motor Function Measure (GMFM), Children's Assessment of Participation and Enjoyment (CAPE), and the Gillette Functional Walking Scale (GWFS) were used to assess function and participation changes.

CASE DESCRIPTION: A 12 year old girl with Type III OI and 61° right thoracic, 13° left lumbar scoliosis underwent PSF with instrumentation. Preop the patient ambulated 300 feet/trial with a walker and used a manual wheelchair for community mobility. Following PSF, inpatient PT started post-op day 2. Via interdisciplinary efforts of PT and medical staff the patient received twice-daily graduated PT activities, including exercise, education regarding proper body mechanics, transfer and ambulation training, nutritional and social work counseling. The inpatient post-op course was complicated by fear of fracture, pain, fever, and poor appetite. The patient was discharged home with home PT, nursing, and weekly follow-up to the pediatric clinic. Post discharge the patient had poor appetite, fever, refused to cooperate with home PT and missed clinic appointments. The patient was readmitted upon suspicion of spinal infection, underwent incision and drainage, followed by a 12 week inpatient rehabilitation stay to ensure consistent medical follow-up and PT. The patient presently attends school and receives weekly outpatient PT.

OUTCOMES: Rather than face pulmonary and functional decline, the decision to undergo PSF with instrumentation to stabilize a progressive scoliosis was made despite the existing condition of Type III OI. At 8 months post spinal surgery, the patient has resumed most activities and participation. Patient has improved strength, function, walking ability, and participation as measured by the GMFM, GFWS, and CAPE.

DISCUSSION: Despite a diagnosis of Type III OI, progressive scoliosis, bone fragility, complicated post-op course, early mobility and functional improvements beyond baseline were attained as noted by outcome measures reliable for children with OI. In patients with Type III OI who undergo PSF with instrumentation, early and intensive PT and an interdisciplinary team helps prevent complications due to progressive scoliosis, immobility, and improve functional status.


Benedetto M, O'Neil MM, Drexel University, Philadelphia, PA; Ideishi R, University of the Sciences, Philadelphia, PA; Ideishi S, Cora Services, Philadelphia, PA

PURPOSE/HYPOTHESIS: Children aged 3-5 years in Head Start (HS) or Early Intervention (EI) pre-school programs often have or are at risk for delays in motor and social skills. Group yoga programs may benefit children by improving motor coordination and function while enhancing intellectual and social skills. The purpose of this study is to examine effectiveness of a yoga program for young children on motor and social skills.

NUMBER OF SUBJECTS: Children participated in a yoga program (n = 71). Only 38 children (21 males and 17 females) participated in pre and post measures (10 = EI and 28 = HS). Average age for children was 55 months (SD = 10.3 mos.).

MATERIALS/METHODS: Children participated in 30 minute group sessions twice a week for five weeks during regularly scheduled playtime. All sessions were facilitated by the staff OT and PT and OT students and faculty from partnering universities. The sessions included three series of 7-9 poses to promote motor and social skills. The series were “contextualized” in a story of a journey to major city landmarks to engage the children and for fun! Outcome measures included: Single Leg Stance; Timed Up and Go; Sit to Stand; Balance Beam Step-Overs and Shuttle Run. Pre-school teachers were interviewed on the Devereux Early Childhood Assessment to identify changes in social behaviors for some children (n = 13). A two-factor ANOVA (group x time) was conducted to examine outcomes with α = 0.05.

RESULTS: All children demonstrated significant improvement in these gross motor skills: Balance Beam Step-Overs (p = 0.014) and the Sit to Stand (p < .001). Significant group differences were found on Balance Beam Step-Overs (p < .001), Sit to Stand (p < .001) and Single Limb stance (p < .001), with better outcomes for HS group. Significant findings on the Devereux indicate emergence of attention skills (p < .001) and problems with emotional control (p = .047). Trends on the Devereux suggest improvement on initiation, attachment and decreased withdrawal behaviors.

CONCLUSIONS: Pre-school aged children demonstrated improvement in gross motor skills in balance, motor planning and transition after program participation. Some changes in social behaviors were observed. Results suggest that future yoga programs should consider an increase in duration and frequency. Also program content should include more social skill building activities.

CLINICAL RELEVANCE: Yoga programs in pre-school may be an effective intervention strategy to promote child development and to improve motor and social skills.


Benedetto M, O'Neil MM, Drexel University, Philadelphia, PA; Ideishi R, University of the Sciences, Philadelphia, PA; Ideishi S, Cora Services, Philadelphia, PA

PURPOSE/HYPOTHESIS: The purpose of this study was to explore the feasibility and effectiveness of a preschool Yoga program designed to promote motor and social skills for pre-school aged children.

NUMBER OF SUBJECTS: Participants included teachers and staff from 2 inclusive classrooms from a pre-school program (N = 5); 2 pre-school teachers, 2 pre-school teachers assistants and 1 speech therapist.

MATERIALS/METHODS: Classroom teachers and assistants and the staff occupational therapist participated in a 6 week summer yoga program along with two integrated classrooms (Early Intervention and Head Start). A focus group for a naturalistic inquiry with guiding questions was conducted at the end of the yoga program. Interview questions were developed under the supervision of faculty as part of a final project for two DPT students, and reviewed by an experienced qualitative researcher faculty member. The focus group was audio taped for transcription. Two experienced raters performed open coding of transcripts. Qualitative methods were used to define codes and identify themes. Reliability was established between both investigators to develop the coding scheme for transcript analysis (Kappa > 85%).

RESULTS: Six different themes emerged around the feasibility and effectiveness of the yoga program. Themes included: Benefits of the yoga program for the children; Value of the yoga program; Pragmatic challenges (equipment and scheduling); Implementation challenges (human resources and support); Future planning (human factors) and; Future planning (for next iteration regarding scheduling and equipment).

CONCLUSIONS: Teachers and staff OT identified benefits and challenges for present and future implementation of a yoga program for pre-school aged children. All participants believed the yoga program to be beneficial for the children and the staff. Although logistical challenges for future implementation were identified, all participants felt that it would be feasible to run the program in the future.

CLINICAL RELEVANCE: Group yoga programs for young children is seen by teachers and staff as an effective and feasible activity to promote motor activity and well being in the preschool setting.


Booth M, Yates CC, Lowe LM, University of Central Arkansas, Conway, AR; Shepard S, Children's Hospital of Philadelphia, Philadelphia, PA; Hall RW, Arkansas Children's Hospital, Little Rock, AR

PURPOSE/HYPOTHESIS: Preterm infants may require multiple diagnostic procedures (such as a Magnetic Resonance Imaging) and are typically given pharmacological interventions to induce sedation. Massage is a well−known and effective treatment for acute and chronic pain in adults and children, but limited literature is available to assess the use of massage to induce sleep. Massage has been shown in previous studies to improve weight gain in preterm infants, promote visual development, and improve sleep patterns. Massage therapy has been shown to be safe for medically fragile infants. This pilot study investigated if massage therapy can be used as an adjunct intervention to induce sleep in premature infants.

NUMBER OF SUBJECTS: Thirty infants with a minimum gestational age of 28 weeks at birth who were between 32 to 48 weeks adjusted gestational age, were randomly assigned to receive massage therapy on study day 1 or 2 with standard care provided on the alternate day. Infants with a history of severe birth asphyxia, major congenital anomalies, surgical procedures, or clinical instability were excluded from the study.

MATERIALS/METHODS: Infants were monitored continuously via pulse oximeter and cardiorespiratory monitor during the massage. The infant's temperature was taken prior to massage with a lower limit of 36.5 degrees Celsius for safety. The Motionlogger Micro Sleep Watch Actigraph was placed on the infant's ankle prior to the morning feed and recorded lower extremity activity until removal after the noon feeding. Massages occurred following the morning feeding when the infant was in a quiet alert state and were approximately 10 minutes in length. This study used a protocol adapted from a protocol published by Field et al with a modification to remove the Kinesthetic stimulation component.

RESULTS: The results of the sleep data revealed no significant difference between groups (non-massage versus massage day) for sleep efficiency (p = .13) for the time period evaluated. The groups were significantly different when comparing infants sleeping at the time that the massage ended to the same time on the non-massage day. Data was analyzed using a Pearson's Chi-squared test X-squared = 4.9802, df = 1, p-value = 0.026.

CONCLUSIONS: No adverse events for any subject were recorded during massage therapy administration, including temperature instability, or loss of medical lines. Massage therapy was discontinued for one infant who demonstrated an increased heart rate after having his clothes removed and who did not calm to the massage. Massage therapy did not result in the infant sleeping immediately after massage as compared to the non-massage day.

CLINICAL RELEVANCE: Massage was well tolerated in preterm infants. The results of this study suggest that preterm infants did not fall asleep faster after massage as compared to the non-massage day. Additional research would need to be conducted to determine whether infant massage facilitates depth of sleep to allow better tolerance for procedures with external stimulation/noise.


Brandsma BA, Paker KN, Embrey DG, MultiCare Good Samaritan Hospital, Puyallup, WA

PURPOSE: The goal of this presentation is to compare mean surface electromyography (SEMG) amplitude for a child with cerebral palsy (CP) to a child who is typically developing (TD). The purpose is to show how SEMG can be used as an evaluative tool to challenge or confirm current theoretical frameworks.

DESCRIPTION: SEMG data were collected in an outpatient pediatric therapy center for a 12 year-old with diplegic CP (GMFCS Level II) who presents with anteriorly tilted pelvis, tendency towards hip adduction and hip flexion, and lateral sway in gait. It was hypothesized that more consistent Gluteus Maximus (GMax) and External Abdominal Obliques (ExOb) coupling could help with pelvic alignment, and better Gluteus Medius (GMed) activation could decrease lateral sway. SEMG sensors were placed on the right side for the GMax, GMed, and ExOb. For comparison, SEMG data of the same muscles were also collected for a TD 9 year-old. Data were collected during free speed walking, walking backward, sidestepping, and walking up a rock path. Mean SEMG amplitudes were calculated and compared. Mean amplitude was calculated by the SEMG software as the average uV for stance and swing phase of each gait activity. The mean amplitude for each activity is calculated with a minimum of five strides.

SUMMARY OF USE: SEMG findings for the child with CP are not as expected. In general, the SEMG shows much higher mean amplitude (uV) for most muscles during all walking activities. The mean SEMG amplitude for the GMax shows ∼2-3 times higher amplitude than the TD child during all walking activities. The mean SEMG amplitude for the GMed is ∼3 times higher for free speed walking, but has measurements similar to the TD child in all other walking activities. The ExOb mean SEMG amplitudes for the child with CP are ∼40 times higher for free speed and walking backward activities. The mean SEMG amplitudes for the ExOb are ∼35 times higher for sidestepping and ∼10 times higher for walking up a rock path, compared to the TD child.

IMPORTANCE TO MEMBERS: These SEMG data are contrary to the belief that children with CP show decreased muscle activation around the pelvic stabilizers. Long held assumptions based on biomechanical visual analysis during gait were not validated by SEMG Data. These findings may require a revision in our theoretical frameworks. Replication and additional data are needed to validate these finding before any generalizations can be inferred.


Breton C, Fisler A, Ikuta K, Molin K, Ross B, Gosselin D, Covington KJ, Duke University, Durham, NC

PURPOSE: Little evidence exists on life span considerations and physical therapy interventions that allow for successful transitions from pediatric to adult care for patients with spina bifida. The purpose of this report is threefold: 1) To assess current practice in transition of care in patients with spina bifida 2) To identify gaps in the level of evidence regarding promotion of functional independence during the transition from pediatric to adult care in patients with spina bifida; 3) To recommend future research directions and suggestions for physical therapy practice to facilitate functional independence in this population.

DESCRIPTION: PubMed, CINAHL, Web of Science and ERIC databases were searched using the key words: spinal dysraphia, health transition, transition of care, and spina bifida. All studies that met the inclusion criteria were analyzed using a qualitative coding framework developed from the International Classification of Functioning, Disability and Health (ICF).

SUMMARY OF USE: Using the coding framework as a method for analysis, the following themes emerged: 1) Employment/secondary schooling, 2) Independent living, 3) Self-management, 4) Mobility, 5) Provision of health services. Individually, each of these 5 concepts has a positive or negative impact on functional independence necessary for transition. The analysis also indicate that relationships may exist across and among these themes which influence the outcomes of transitional care.

IMPORTANCE TO MEMBERS: In current practice, transition from pediatric to adult care is challenging on multiple levels, including the lack of multidisciplinary communication, moving from family-centered to patient-centered care, and changing parental and individual roles. For patients with spina bifida, these concerns are magnified in the presence of multi-system functional impairments and physical disability. These themes support the opportunity for physical therapy intervention to facilitate functional independence and reduce the influence of inhibitory factors at the impairment level. Future research directions should include, but are not limited to, physical therapy addressing functional mobility, independence with ADLs, skin care, community integration, and multidisciplinary care in patients with spina bifida.


Bush K, The Ohio State University, Columbus, OH; Christensen C, Nationwide Children's Hospital, Columbus, OH; Butler M, Buehner J, Basso MD, Heathcock J, The Ohio State University, Columbus, OH

BACKGROUND & PURPOSE: Step training on a treadmill is a common intervention for adult and pediatric patients with spinal cord injuries. With the exception of infants with Down syndrome, little research exists for treadmill training in infants and toddlers before the age of typical walking onset. This case report describes a step training intervention and locomotor behavior on a treadmill of an infant after surgical resection of a rare spinal tumor.

CASE DESCRIPTION: At birth, a large tumor was identified on the infant's spine (including the spinal cord, abdominal cavity and hip flexor musculature). Following surgical removal of the tumor a condition similar to an incomplete spinal cord injury at T11/T12 including loss of sensation in the lower extremities. Starting at 10-months of age the infant was seen for 1 hr, 3 x week for 20 months for manually-assisted stepping on a treadmill with body weight partially supported by a harness. Training also consisted of assisted over ground locomotion, backward walking, and transitions from/to sitting. The total dose was 120 hours of facilitated stepping intervention. Frame by frame video analysis examined the quantity and quality of steps taken without assistance in one-minute intervals 1 time per week for 20 months.

OUTCOMES: With training, step frequency increased bilaterally. For example, the average (right and left) stepping frequencies improved from 10 to 35 independent steps per minute. The pattern of steps improved markedly from 3% to over 95% alternating steps. Initially, no stepping occurred with the left lower extremity (LE) and only sporadic steps on the right LE. At the end of the 20-month intervention the participant was able to independently take several alternating steps with a reverse walker.

DISCUSSION: Continual improvements in the number of independent steps, pattern of steps, and symmetry were observed during treadmill training over 20-month period. We speculate that improvements in quality and quantity may suggest improvements in function at the spinal cord and behavioral levels. Improvement in treadmill stepping translated to over ground walking despite no evidence of sensation in the lower extremities. Infants with spinal cord injuries who have never ambulated may benefit from manually-assisted treadmill and over ground step training. The dose of stepping interventions may need to be high for infants with spinal cord injuries.


Cardinal RE, IU Health Neuroscience Center, Indianapolis, IN; Gleason S, Cappel M, Fuchs RK, Altenburger P, Indiana University, Indianapolis, IN

BACKGROUND & PURPOSE: Children with cerebral palsy (CP) often have impaired motor capacity resulting in inefficient walking patterns and decreased walking speeds. In order to improve motor capacity, interventions need to create lasting neurological change. Neuroplastic changes are fostered by interventions that are task specific, intensive and cognitively engaging. Over-ground gait training in children with CP is task specific but often lacks high intensity (repetitive stepping) and cognitive engagement (focused attention on walking). The purpose of this case study was to explore the impact of a high-intensity robot-assisted locomotor training (RALT) program emphasizing cognitive engagement on functional capacity in a child with CP.

CASE DESCRIPTION: The subject was a four-year-old female with a diagnosis of right hemi-paresis CP. Baseline testing revealed reduced activity levels assessed by an accelerometer and deficits in ambulation speed and distance. The subject completed 14-sessions, 2x/week, 45-60 min/session of the RALT program using the Hocoma Lokomat. RALT training focused on cognitive engagement using augmented feedback that simulates a virtual walking environment.

OUTCOMES: The subject wore an accelerometer for seven days prior to and following the intervention. Data revealed an increase in average steps/min (+0.64/min) and average total energy expenditure (TEE) (+0.02 kcal/min), while total activity count (TAC) decreased by 8.42 markers/min. C-PAQ post-report increased by 91 min of physical activity/day after 14 sessions. Additional outcome measures revealed changes in 10m comfortable walking speed (+0.02 m/sec), 10m running velocity (−0.35m/s), and 6-minute walk test total distance (+3 m). GMFM (Dimensions D and E) increased by 1 point pre-test to post.

DISCUSSION: Although the TAC indicates the subject engaged in fewer activities after the intervention, the subject took more steps (steps/min) and exerted more energy (TEE) when active. These findings, corroborated by the C-PAQ and parent report, indicate an improved level of activity following RALT. Throughout the training sessions the subject tolerated consistent increases in average gait speed (1.2 km/hr) average distance walked (+674 m), and average walking duration (+16:57 min/sec) which suggest the RALT program was of sufficient intensity (gait speed) and duration. Furthermore, the subject demonstrated a 90% increase in target acquisition through augmented feedback, with a concurrent 15% decrease in robotic assistance. This consistent level of cognitive engagement may have contributed to improvements in the subject's TEE. The benefit of augmented feedback may be particularly valuable for a young pediatric patient who is less likely to see comparable results during traditional treadmill training in which maintaining cognitive engagement is more difficult. Clinically, altering treatment programs to reflect an influence on maintaining cognitive focus could lead to greater control of motor capacity and improved musculoskeletal development.


Cesarz MC, Lee BS, Rowey ME, Swann BM, Waitsman LS, Woodward SL, Case LE, Duke University Medical Center, Durham, NC

PURPOSE/HYPOTHESIS: Our hypothesis is that sport specialization in childhood is leading to repetitive overuse causing injuries that are specific to a particular sport. The goal of our project was to review and evaluate the available and relevant literature on the risk factors contributing to upper extremity injuries affecting youth baseball players, with a focus on shoulder and elbow pathologies. A subsequent goal was to identify the risk factors that may be modifiable for potential control or prevention of injury. The purpose of this report is to share our findings and propose an algorithm to limit the amount and severity of upper extremity injuries being experienced by youth baseball players.

NUMBER OF SUBJECTS: 1,595 total subjects in 7 reviewed studies

MATERIALS/METHODS: A systematic literature search of 2 databases, PubMed and CINAHL, was examined for research on upper extremity youth baseball injuries over the period August 2012 to February 2013. Twelve studies met the inclusion criteria after title and abstract review and were included for full text review; of these 12, 4 were included in the study. After this, a hand search was conducted that resulted in 3 additional articles, for a total of 7 articles under review. These 7 articles studied healthy and injured pediatric pitchers under the age of 14. The articles were analyzed for factors including demographics of the participants and possible risk factors such as training methods implemented by coaches, pitch type and pitch count statistics, pitching mechanics, playing with arm fatigue, and self-satisfaction.

RESULTS: Across the 7 studies, risk factors that correlated with upper extremity injury included number of pitches, pitching more games, innings, and curveballs than non-injured pitchers, increased height and weight, lifting weights during season, decreased self-satisfaction, and pitching while experiencing arm fatigue.

CONCLUSIONS: Increased amounts of pitching and the use of certain pitch types were the most consistently reported risk factors for increased elbow and shoulder pain and injury in youth baseball players and should be considered in any guidelines and recommendations for injury prevention.

CLINICAL RELEVANCE: Using results from various studies, we have compiled recommendations regarding strength and conditioning options, limits to pitch counts, and playing time. These recommendations could be utilized by coaches, pediatricians, physical therapists, and other professionals working with pediatric baseball pitchers with goals of decreasing the rate of injury, the time spent on the sidelines due to pain rather than participating in the game, and preventing other injuries. Our goal is to contribute to the development of standards for safe play, while continuing to strengthen and develop higher level baseball skills.


Chau C, Albert L, Aufiero A, Mock L, Ward K, Nazareth College, Rochester, NY

PURPOSE/HYPOTHESIS: The purpose of this study is to compare the characteristics of spatiotemporal gait parameters in typically developing 4- and 5-year-old (yo) children while walking barefoot and with socks, at a self-selected regular and fast walking speed.

NUMBER OF SUBJECTS: Twenty children (10 male and 10 female) participated in this study.

MATERIALS/METHODS: All subjects walked on the GAITRite® (CIR System Inc. NJ), a portable carpeted walkway (3×14ft) embedded with electronic pressure sensors that record footprints. Each subject completed four trials of the four walking conditions (barefoot and with socks at regular speed and fast speed) in a randomized order. Spatiotemporal gait parameters were recorded and analyzed with the GAITRite® system which included velocity, cadence, step and stride length, cycle time, stance and swing phase duration, single and double support percentages. Paired t-tests were used to compare gait parameters while walking barefoot and with socks, for both regular and fast walking speeds.

RESULTS: The results showed that spatiotemporal gait parameters were comparable between walking barefoot and with socks at a regular speed, but different when walking at a fast speed. During fast walking with socks as compared to barefoot, there was 1) a statistically significant increase in cadence (+10.9 steps/min), and decrease in cycle time (−30ms); 2) a slight, but statistically insignificant, increase in velocity (+6.0 cm/sec), swing (+0.5%), and single support (+0.6%); and 3) a decrease in stride length (−2.1 cm), stance (−0.4%), and double support (−0.6%). The foot length and width are comparable between walking barefoot and with socks. Similar but slightly greater differences in cycle time (3.2 ms), step length (0.5 cm), stride length (0.6 cm), and cadence (3.1 steps/min) were observed in 5-yo children as compared to 4-yo children during fast walking with socks.

CONCLUSIONS: While it is possible that there is a difference in sensory feedback between walking barefoot and with socks, similarities in spatiotemporal gait parameters between the two conditions during regular walking speed was consistent with literature suggesting that cutaneous input exerts minimal effect on undemanding locomotion. Children walking at a fast speed with socks displayed a more unstable gait than when walking barefoot. It is possible that socks not only altered cutaneous input but also increased slippage especially during fast walking. Greater changes in 5-yo as compared to 4-yo children suggest that developmental maturation may play a role in the ability to adapt the locomotor pattern to different conditions.

CLINICAL RELEVANCE: This study will contribute to our understanding of how footwear may affect normal locomotion possibly through a combined change of cutaneous input and biomechanical factors. A better understanding of how cutaneous input affects locomotion may also allow us to manipulate cutaneous input to optimize pediatric gait rehabilitation.


Chen YP, Georgia State University, Atlanta, GA; Lee SY, Georgia State University, Atlanta, GA; Howard A, Georgia Institute of Technology, Atlanta, GA

PURPOSE/HYPOTHESIS: About 1 in 303 children in the US have Cerebral Palsy (CP) with 50% demonstrating with upper extremity (UE) dysfunction. Children with CP tend to show difficulty engaging in therapeutic interventions due to movement limitations, delayed adaptation of movements to meet different context, and poor motivation. Virtual reality (VR), which creates an interactive, motivating environment for children with CP, can be used as a therapeutic tool which the intensity of practice and positive visual feedback can be easily adjusted. The purpose of this systematic and meta-analytic review is to systematically examine the effect of VR on improving UE function in children with CP and assess the association between the VR effect and children's characteristics and intervention protocol.

NUMBER OF SUBJECTS: Eleven research articles reporting VR therapy, including 2 randomized controlled trials (RCTs) and 9 case series or single subject design were used to compute effect size.

MATERIALS/METHODS: A systematic literature search was conducted in Pubmed, CINAHL, Cochrane, and PsychInfo up to June 2012. Research using children with CP, using VR as the intervention method with a focus on UE function, and using UE measures were included in the review. Level of evidence from the Oxford Centre for Evidence-based Medicine as well as Kwakkel's quality scores were used to evaluate the quality of included articles.

RESULTS: Overall, VR provided a strong effect size (d = 1.13) when comparing between pre- and post-intervention. When further breaking down the effect size based on outcome variables classified by WHO's International Classification of Functioning, Disability, and Health levels, a strong effect (d = 1.92) was reported at Participation level, a small effect (d = 0.24) at Activity level, and a medium effect (d = 0.73) at Body Structure and Function level. For the subgroup analyses, children's age and intervention setting showed statistically significant differences: children at a younger age and receiving home-based VR had a better effect than children at an older age and receiving VR at clinics/laboratories.

CONCLUSIONS: VR seems to be a viable tool to improve UE function in children with CP. However, the majority of the published research using VR intervention used case series or single-subject design. The quality of the research was poor with high heterogeneity among studies and various intervention protocols. A larger-scale RCT with a more homogenous participant group of similar age and diagnosis is needed. Moreover, this large-scale RCT should use a home-based VR intervention with younger children with CP using the engineer-built system which would be expected to have the most benefits in improving the UE function in children with CP.

CLINICAL RELEVANCE: Virtual reality is a viable tool to improve upper-extremity function in children with CP. Implementing a home-based VR intervention program using the engineer-built VR system for young children with CP seems to yield the most improvement in their upper-extremity function.


Collins J, Donahue M, Eckstrom B, Kras A, Evans K, Wolf J, Nazareth College, Rochester, NY

PURPOSE/HYPOTHESIS: The purpose of this study was to examine the physical and psychosocial effects of a physical therapist (PT) designed wellness program using modified yoga-based exercises on young adults with DD.

NUMBER OF SUBJECTS: Seven participants (6 female, 1 male; mean age = 20.7) ambulatory, with a documented DD. Of the participants with Full Scale Intelligence Quotients (FSIQ), the reported range was 40-59, substantially below the 90-110 range considered to be average intelligence. Participants were recruited from a college-based inclusive educational program.

MATERIALS/METHODS: Participants attended 2, 45-minute sessions per week for 8 weeks, directed by PT students and faculty. Sessions included instruction in and performance of activities emphasizing yoga-based poses, proprioceptive awareness, and coordination of breathing with movement. Measures of physical performance included: L-test, Timed Rise Floor to Stand (TRFS), and PostureScreen Mobile (PSM) taken pre- and post-intervention. Field notes regarding responses were recorded and coded to identify themes related to psychosocial effects.

RESULTS: Mean times for TRFS showed a statistically significant decrease of 2.49 seconds (p = 0.028) using Wilcoxon Signed Rank Tests. Mean time for the L-test also showed a significantly significant decrease of 5.50 seconds (p = 0.028). Six of seven participants' head and/or hips improved toward neutral position in the sagittal plane, but this was not statistically significant. Review of field notes revealed the following themes as expressed by participants during the program: overall relaxation and a change in feelings of both the difficulty of the activities and the amount of “stress” from the beginning to the end of each session.

CONCLUSIONS: To date, there is a lack of evidence supporting yoga-based interventions for young adults with DD. Since the L Test has been used as a measure of functional mobility required for safe community integration, the statistically significant improvement in the L-test scores suggests the yoga based activities may have a positive effect on mobility in this population. Qualitative data revealed that while each participant reported individually unique responses to the program, there were also prevalent themes of relaxation, stress reduction, and ease of movement, similar to responses reported by people without physical and/or cognitive impairments. Results suggest that the use of yoga-based interventions in a young-adult DD population may improve functional mobility, posture, and body awareness.

CLINICAL RELEVANCE: The results of this study suggest that a PT designed program using yoga-based exercise has the potential to benefit young adults with DD. Future studies should consider the use of alternate measures to assess mobility, balance, and body awareness. Since this population is typically sedentary, it would also be important to investigate other types of regular physical activity to determine if there are similar improvements, or whether the yoga based approach is unique in these benefits.


Concilus KM, Rumbaugh JK, Gross RD, The Children's Institute, Pittsburgh, PA

PURPOSE/HYPOTHESIS: Historically, chronic pain in children has been managed using a variety of medications and physical and occupational therapy modalities with limited success. In 2000, David Sherry, MD introduced intense exercise as a treatment for pediatric chronic pain. He reported that following treatment, “roughly 80% of the children had no pain and are fully functional;” however objective methods were not used to assess functional gain. Our program has been using a similar intensive exercise program for the past 9 years to manage chronic pain in children diagnosed with reflex neurovascular dystrophy (RND). The purpose of this retrospective study was to objectively determine if pediatric patients with a diagnosis of RND who were treated with an intense exercise program reported improvement in daily function. We compared patient reported scores from the Functional Disability Inventory (FDI) that were taken before, and immediately after treatment. We hypothesized that patients who participated in the intense exercise program would demonstrate a statistically significant functional improvement when pre FDI scores were compared to post FDI scores.


MATERIALS/METHODS: After receiving IRB approval, we requested information from electronic medical records. Criteria for the medical record search included patients with physician diagnosed RND who underwent intensive exercise treatment during PT and/or OT between 2008 and 2012 and had recorded pre and post treatment FDI scores. Using these criteria, a total of 845 records were received. 685 were eliminated due to missing FDI data from electronic record. This resulted in 160 complete records available for analysis: 76 patients who received outpatient treatment only, 59 patients who received both inpatient and outpatient treatment, and 25 patients who received only inpatient treatment. Statistical analysis: To determine if there was a significant difference between the pre and post FDI scores within each group, the Wilcoxon signed rank test was used with a pre-set p value of 0.05. To examine for pre and post FDI score differences between the groups, a Kruskal-Wallis One Way Analysis of Variance on Ranks followed by Dunn's was conducted.

RESULTS: Post FDI scores were significantly lower than pre FDI scores in all groups, indicating functional improvement after treatment (p = <0.001). Post FDI scores of the outpatient only group were significantly lower than patients who received inpatient only treatment. (p = <.001) and both inpatient and outpatient treatment (p = <.001). There was not a significant difference in post FDI scores between the inpatient only group and patients who received both inpatient and outpatient treatment (p = >0.05).

CONCLUSIONS: Treatment of pediatric RND with intense exercise results in significant functional improvement. These findings support Dr. Sherry's claims.

CLINICAL RELEVANCE: Intense exercise for pediatric patients with RND seems to improve self report of function, and should be considered for patients with similar diagnoses.


Cunha AB, Federal University of Sao Carlos, São Carlos, São Paulo, Brazil; Lobo M, Kokkoni E, Galloway C, The University of Delaware, Newark, DE; Tudella E, Federal University of Sao Carlos, São Carlos, São Paulo, Brazil

PURPOSE/HYPOTHESIS: To verify the effect of short-duration training sessions on reaching behavior in infants. As a few minutes of experience can promote changes in motor behavior, we have hypothesized that three short-duration training sessions would facilitate immediate reaching behavior.

NUMBER OF SUBJECTS: Thirty healthy infants (M = 14.0 ±1.6 weeks of age) were randomly assigned after the first assessment to one of two groups: social training-control group (STG, n = 15) and reaching training group (RTG, n = 15).

MATERIALS/METHODS: Infants were trained and assessed in the reclined position (45°) up to 3 days after the onset of reaching. For the assessments, a flexible and attractive object was presented for 2 minutes to stimulate reaching movement. Infants were assessed by a blind examiner pre-training (start of Visit 1), immediately post-training (post-training assessment 1; end of Visit 1), and after a second training round on the following day (post-training assessment 2; end of Visit 2). For the training, both groups received three short-duration training sessions by a pediatric physical therapist. For the reaching training group, three reaching activities were provided to infants for 4 minutes in an alternating manner (i.e. ABC, ABC, ABC). Control infants remained in the therapist's lap for 4 minutes for social interaction without objects. Visits were recorded using three digital video camcorders and the number of reaches, hand orientation, and contact surface of the hand were coded from video recordings. A two-way repeated measures ANOVA was conducted to compare the groups and assessments (p < 0.05).

RESULTS: There was a difference in the number of reaches (F[2,28] = 4.576; p = 0.016), with more reaches in post-training 1 (p = 0.005) and post-training 2 (p = 0.001) for the reaching training group compared to the control group. There was also an increase in reaches within the reaching training group from pre-training to post-training 1 (p = 0.000) and post-training 2 (p = 0.000). Furthermore, there was a difference between groups (F[2,28] = 1.457; p = 0.02), with the reaching training infants reaching more with the hand ventral in post-training 1 (p = 0.002) and post-training 2 (p = 0.041) and with the hand vertical (F[2,28] = 8.324; p = 0.001) in post-training 2 (p = 0.01) compared to pre-training and to the control group.

CONCLUSIONS: Short-duration training sessions can impact reaching behavior resulting in a greater number of reaches and an increased proportion of reaches with the hand ventral and hand vertical in newly reaching infants. It seems that these infants changed their strategies to more mature behaviors in order to reach the toy.

CLINICAL RELEVANCE: This study provides new empirical knowledge on the fast changes in motor behavior that can be observed after one intervention session in infants and also provides information that can be applied to prevention and/or improvement of motor dysfunction in infants at risk for motor development.


Curbow-Wilcox KJ, Flowers M, Martin G, Patterson L, Ross LP, Thompson C, West M, University of Mississippi Medical Center, Jackson, MS

PURPOSE/HYPOTHESIS: Cerebral palsy (CP) describes a broad range of permanent, yet non-progressing, disorders of the brain caused by brain damage in utero or during birth. CP may result in a variety of deficits including balance, mobility, strength, and/or musculoskeletal tone. The modality of hippotherapy involves a patient riding a horse while a therapist controls the horse and guides the patient's posture and movement with the goals of improving gross motor functioning, cognitive abilities, and socialization skills while reducing energy expenditure during activities. Purpose: The purpose of this review was to determine if hippotherapy improves gait characteristics in children with CP.


MATERIALS/METHODS: The PubMed database was searched through February, 2013, for studies related to hippotherapy and changes in gait in individuals with CP. Specific search terms and combinations are presented. No electronic limitations were applied. Exclusion criteria included the use of a horse simulator and study populations that included diagnoses other than CP. Study quality was evaluated using both the PEDro and Center of Evidence Based Medicine (CEBM) scales. PEDro is a 10-point scale used to measure the internal validity of randomized controlled trials with higher scores implying higher internal validity. The CEBM is a scale that ranks the strength of study design and control of research bias. The CEBM scale is a 5-level scale; higher levels indicate better design and lower bias levels.

RESULTS: A total of seven studies were identified by the electronic search. Four articles that met all criteria remained after the title screen. After the abstract screen and application of inclusion/exclusion criteria, three articles remained for inclusion in the systematic review. The average PEDro score is 4 with the ranges between 6 and 3. Two studies have a CEBM score of IV and one study has a CEBM score of III.

CONCLUSIONS: Hippotherapy alone or hippotherapy in conjunction with conventional intervention shows a statistically significant increase in stride length, an increase in independence in running, jumping, and walking, a decrease in cadence, and a decrease in energy expenditure during gait. The available evidence is scored a C due to consistently weak studies based on the PEDro and CEBM scores.

CLINICAL RELEVANCE: Based on the results of this systematic review, hippotherapy with or without traditional therapy demonstrates improvement in selected gait characteristics. However, future studies with more robust data are needed to determine any additional benefits and the long term effects of hippotherapy related to gait characteristics in children with cerebral palsy.


Darr NS, Belmont University, Nashville, TN; Franjoine MR, Daemen College, Amherst, NY; Smith EV, Campbell S, University of Illinois at Chicago, Chicago, IL

PURPOSE/HYPOTHESIS: The Pediatric Balance Scale (PBS), a 14-item measure of functional balance for children, is hypothesized to assess 3 domains: Static balance, anticipatory control, and transitional movements. The PBS has demonstrated the ability to discriminate between preschool-age children developing typically and those with mild and moderate balance dysfunction. The purpose of this study was to further investigate the validity of inferences from PBS data using Rasch analysis to determine if PBS modifications are indicated.

NUMBER OF SUBJECTS: This study involved retrospective analysis of PBS performance data for 1,046 healthy children (540 boys, 506 girls), ages 2 through 14 years. Of these children, 908 were developing typically (DT) and 138 had known balance dysfunction (BD).

MATERIALS/METHODS: Data were analyzed with uni- and multi-dimensional Rasch partial credit models using Winsteps and Conquest. The hypothesized 3-domain model was compared to a unidimensional model for overall fit using Akaike's Information Criterion (AIC) and the Bayesian Information Criterion (BIC). Rasch analyses were also used to create item difficulty hierarchies. These item maps were analyzed to identify potential gaps and redundancies among the items. Item maps were also used to compare the item hierarchies for children with and without balance dysfunction. Scoring models for each item were evaluated by examining the functioning of the rating scale according to commonly used Rasch rating scale functioning criteria.

RESULTS: Although AIC suggested multidimensionality (123121.7 vs.12141.5), the PBS data best fit a unidimensional model based on BIC (12400.73 vs.12404.48) and strong correlations between the 3 proposed dimensions (r = 0.946-0.979). Infit and outfit statistics indicated only Item 14 (forward reach) potentially did not fit within the unidimensional construct (Zstd = 3.0); however, this item was retained because relatively few children (4.2%) contributed to misfit. Item maps indicated a ceiling effect, with 21.4% of all children scoring in the 99th percentile. Single limb stance, tandem stance and forward reach appear to be the most difficult items, and gaps were noted between these items. Two distinct item clusters indicate potential redundancies in less difficult items. Although the BD group was relatively small (n = 138), a one-way ANOVA revealed significant differences in performance between children with and without known balance dysfunction (F = 664.39, df = 1, p < 0.001). Item maps demonstrated slight differences in item difficulty hierarchies between children with and without balance dysfunction.

CONCLUSIONS: The PBS data support a unidimensional measure of functional balance. Item difficulty maps indicate a ceiling effect with item difficulty gaps between challenging items and redundancies in less difficult items. Item difficulty hierarchies may vary in children with BD.

CLINICAL RELEVANCE: The PBS is well suited for children ages 6 and under. Additional items and revisions may improve the utility of the PBS in older children. Further study of PBS performance in children with BD is warranted.


DeCarlo MB, Vidant Medical Center, Greenvile, NC; Edwards JL, Vidant Edgecombe Medical Center, Tarboro, NC; Willson JD, Gross McMillan A, East Carolina University, Greenville, NC

PURPOSE/HYPOTHESIS: Children and adolescents who are obese (OB, body mass index, BMI > 95th percentile for age/gender) or overweight (OW, BMI in 85th-94th percentile for age/gender) have an increased risk for injury, which may be partly explained by reported deficits in balance and coordination. A negative correlation has been reported between scores on the Balance subtest of the Bruininks-Oseretsky Test of Motor Proficiency – 2nd edition (BOT-2; Pearson, San Antonio, TX) and measures of adiposity in boys. The relationship between body mass and other clinical measures of balance in female adolescents has not been reported. The purpose of this study was to examine how body mass might affect balance measures in 12-17 year old girls. We hypothesized that adolescent girls with higher BMI would exhibit poorer balance on a variety of measures.

NUMBER OF SUBJECTS: Thirty-four girls (n = 25 HW, n = 9 OW/OB) age 12-17 years participated.

MATERIALS/METHODS: Measures included: anthropometric measurements (height, mass), BOT-2 Balance subtest (scaled score), Multidirectional Reach Test (MRT), Four Square Step Test (FSST), and Modified Balance Error Scoring System (BESS). All tests were administered and scored using standardized instructions. The MRT was performed on an AMTI force platform (Advanced Mechanical Technologies, Inc., Watertown, MA) to measure area and speed of center of pressure (COP) excursion during reach. Three trials were performed in each direction, and results were averaged across trials. Trials of the FSST were performed until two error-free trials were achieved. Time of fastest trial and number of errors (i.e., failed trials) were recorded. The Modified BESS included single limb and tandem stance with eyes open and closed, on foam and firm surfaces, and was scored by counting number of errors (defined by standard scoring instructions) on each surface (foam and firm).

RESULTS: Moderate to strong direct linear relationships were found between BMI Z score and BESS-Firm total (r = 0.50), FSST # of errors (r = 0.50), and FSST time (r = 0.42). A moderate inverse relationship was found between BMI Z score and BOT-2 Balance scaled score (r = −0.37). Weak relationships were seen between BMI Z score and all other variables measured. Correlations may have been low due in part to the relatively small sample size and relatively low number of OB/OW subjects in the sample.

CONCLUSIONS: Higher BMI was related to poorer balance performance on measures used in this study. Impaired balance likely contributes to increased falls and injuries, and to the wider step width and greater frontal plane motion often seen in this population.

CLINICAL RELEVANCE: Adolescent girls who are OW or OB are more likely to have difficulty with which may contribute to their inactivity as falling is embarrassing for them. Falls will certainly contribute to injury risk. With our in depth understanding of postural control, and gross motor development, PTs should be practitioners of choice to assess and intervene for balance issues in this population.


Dougher M, Bosch PR, Ganley K, Northern Arizona University, Phoenix, AZ

PURPOSE/HYPOTHESIS: The American Academy of Cerebral Palsy and Developmental Medicine describes cerebral palsy (CP) as impaired body movement and muscle coordination resultling from faulty development or damage to motor areas in the brain. Recent literature indicates that children with CP are likely to have sensory as well as motor impairments. Perception of vibratory threshold (PVT) is one tool for assessing sensation. Existing literature suggests that PVT may vary between children and adults and is sensitive to pre-clinical signs of diabetic neuropathies. PVT may be useful in the sensory evaluation of children with CP. Few instruments that quantify PVT are commercially available; of those, cost is generally prohibitive for use in small research and clinical settings. The Bio-thesiometer (Bio-Medical Instrument Company, Newbury, OH) is an accessible and somewhat affordable (<$1000) instrument designed to measure PVT. However, the source of the “normal values” provided with the instrument is dated 1937 and could not be located; further, these values do not match those from other insturments, nor could they be reproduced. The purpose of this project was to determine the reliability of the Bio-thesiometer in quantifying PVT and to compare data obtained from children and adults.

NUMBER OF SUBJECTS: 10 adults; 12 children

MATERIALS/METHODS: Participants were tested in supine on the dorsal surfaces of the 2nd metacarpal and 1st metatarsal phalangeal joints (MCP and MTP, respectively). The probe of the Bio-thesiometer rested on the test site, balanced by the tester. Intensity was incrementally increased from zero until the participant acknowledged awareness of the stimulus. Using a table provided in the company's user manual, intensity was converted to absolute amplitude in microns. The mean of 3 trials at each site was recorded as the PVT. Prior to the study, 3 adults (not in the study) participated in test-retest assessment of measurement reliability on 3 days. Intraclass correlation coefficient (ICC) was calculated using a two-way mixed effects model and type consistency. A two-way, between-subjects analysis of variance (ANOVA) was used to examine the effect of age and site on PVT.

RESULTS: The average measures ICC was .800. Children had lower PVT than adults (F = 4.549, p = 0.039); PVT was higher at MTP than MCP joints (F = 8.972, p = 0.005). The interaction between age and site was significant (F = 5.199, p = 0.028).

CONCLUSIONS: PVT can be reliably measured with the Bio-thesiometer. PVT was similar between groups at the hand, but higher in adults than in children at the foot. This pattern supports trends in the literature. Values resemble those reported in other studies that used the Bio-thesiometer, but are different from those reported by the manufacturer and those derived from other instrumentation.

CLINICAL RELEVANCE: PVT can be reliable measured with the Bio-thesiometer. It is sensitve to group/site differences and may be informative as a component of the sensory evaluation of children with CP. Values obtained with differing instrumentation may not be comparable.


Drennan RM, Wilson K, McElroy JJ, University of Missouri, Columbia, MO; Sohl K, University of Missouri, Columbia, MO

PURPOSE/HYPOTHESIS: Toe walking is one of the most prevalent gross motor function deficits found in children with autism spectrum disorders (ASD). Toe walking has been described as persistent walking on the balls of the feet that continues 3-6 months after independent walking begins (Ming 2007, Barrow 2011). Toe walking has been shown to be linked to early diagnosis and treatment of ASD with subsequent improved outcomes. It is important to better understand aspects surrounding identification of toe walking in individuals with ASD. The purpose of this study was to examine the relationships between toe walking and ASD for age of toe walking onset, age of ASD diagnosis, and individual who first observed toe walking.

NUMBER OF SUBJECTS: Seventy-three families completed the study surveys. Mean age for individuals with ASD at the time of the study was 12.9 years (range 3-38).

MATERIALS/METHODS: Data were collected using an anonymous survey which included questions about age of autism diagnosis, who first noted toe walking, and the age toe walking was noted. Surveys were distributed for a 3-month period to families attending autism clinics at a local autism center. Families completed surveys at the time of their clinic visit. Descriptive and inferential statistics were used to analyze the data.

RESULTS: The number of respondents who reported toe walking (TW) was 38 (52.1%): 17 were past toe walkers and 21 were current toe walkers. The difference between means for age of ASD diagnosis between the TW group and the non-toe walking (NTW) group was statistically significant (p = 0.0); TW group 4.2 years (range 1-10, SD 2.3), NTW group 8.3 years (range 2-33, SD 8.3). Toe walking was first identified by parents in 34 of 38 (89.5%) individuals. The mean age of identification of toe walking was 1.9 years (range 1-5, SD 1.2), while the mean age of ASD diagnosis for the same group was 4.2 years The difference between the means was statistically significant (p = 0.0, mean 2.1, 95% CI 1.3-2.9).

CONCLUSIONS: Data from this study are consistent with previous literature linking toe walking and early diagnosis of ASD. However, there remains a significant gap between the age at which toe walking is identified by parents and the age ASD is diagnosed. Reasons for the discrepancy are not clear. More research is needed to understand the delay mechanisms and effect system change for optimal utilization of toe walking as an early indicator of ASD.

CLINICAL RELEVANCE: Toe walking is one of the earliest indicators of ASD in children, producing opportunities for earlier intervention and more positive outcomes. It is important for healthcare providers to value and support parents' reports of toe walking in toddlers. Although all toddlers who toe walk do not have ASD, ASD is an important comorbid consideration for toe walking toddlers seen by physical therapists working in early intervention settings.


Duong TT, Childrens National Medical Center, Washington, DC; Birkmeier M, George Washington University, Washington, DC; Hu FN, Childrens National Medical Center, Washington, DC; Maring JR, George Washington University, Washington, DC; McDonald C, University of California-Davis, Sacramento, CA

PURPOSE/HYPOTHESIS: Duchenne muscular dystrophy (DMD), a progressive neuromuscular disease affecting males, leads to regression of fine and gross motor skills, loss of ambulation, contracture development and death in the late twenties. The purposes of this study were to describe current practices of conservative management of ankle contractures and to compare changes in scores on functional timed tests for boys classified according to level of contracture or loss of range of motion (ROM) of the Achilles tendon.

NUMBER OF SUBJECTS: Data, including contracture management history, was obtained from an ongoing 5-year natural history study by the Cooperative International Neuromuscular Research Group (CINRG) of DMD patients aged 2-28 years (n = 348).

MATERIALS/METHODS: Patients received annual clinical assessments of ankle dorsiflexion and timed test measurements (10 meter walk, 4 step climb, supine to stand) by a licensed physical therapist. Descriptive statistics were used to summarize data related to contracture management history. T-tests were used to compare differences in functional timed tests between baseline and 12 months for two groups categorized according to ankle ROM: group 1) dorsiflexion <−10; and group 2) dorsiflexion >−10).

RESULTS: 242 (70%) of participants implemented stretching at some point in their plan of care and of these 137 (57%) performed daily passive stretching and 207 (60%) wore night time splints at some point in their care. Fifty-six percent (n = 115) of nighttime splint users wore them consistently. In the entire cohort, 101 (29%) used a combined therapy of stretching and nighttime braces. There was a significant difference between groups in functional timed test score changes over one year; group 1 had a significantly greater decrease in functional time test scores compared to group 2.

CONCLUSIONS: Stretching is more commonly used for contracture management than nighttime splints. Daily use of splints exceeded 50% which is congruent with recommended standards of practice. Boys with contractures >−10 degrees had significantly more loss in one year in functional timed test scores compared to boys with contracture <−10 degrees.

CLINICAL RELEVANCE: Lack of evidence and expert consensus has led to inconsistent recommendations and standards of care in contracture management. Results from this study will greatly impact clinical decisions, insurance reimbursements, and will aid researchers' understanding of possible contributions of ankle contractures in important ambulation-based clinical trial endpoints.


Effgen SK, Univerisity of Kentucky, Lexington, KY; McCoy SW, University of Washington, Seattle, WA; Jeffries L, University of Oklahoma, Oklahoma City, OK; Chiarello LA, Drexel University, Philadelphia, PA; Smarr JM, Univ of Kentucky, Lexington, KY; Bush HM, Smith JT, University of Kentucky, Lexington, KY

PURPOSE/HYPOTHESIS: The purpose of this study was to examine intra-rater reliability of the School-Physical Therapy Interventions for Pediatrics (S-PTIP) data collection system. This manual and form were developed for use within clinical practice improvement design research for a national study of school-based physical therapy practice.

NUMBER OF SUBJECTS: Physical therapists were recruited from across the nation. After training and passing a competency test on the S-PTIP, 15 physical therapists recruited 25 students, ages 5 to 12 years of age, who receive school-based physical therapy.

MATERIALS/METHODS: After parent and school approval, the student was videotaped during a standard physical therapy intervention session with the therapist. Immediately after the session the therapist completed the S-PTIP form indicating what activities and interventions were performed with the student. Within one month, the therapists reviewed the videotaped intervention session and again completed the S-STIP form.

RESULTS: A total consistency was taken as the ratio of activities and interventions on first and second S-PTIP forms to the total number of recorded activities and interventions. A total of 489 activities and interventions were entered, and 51 of those activities and interventions only appeared on one form but not the other (29 total additions, 32 total omissions). 438 of the activities and interventions were consistent between forms. This gives a consistency of 90% between the two forms. Reporting of student participation/behavior ratings was highly consistent with Cronbach's alpha of 0.954.

CONCLUSIONS: The results of this study suggest that the S-PTIP data collection form is a reliable tool for reflecting the activities and interventions used by school-based pediatric physical therapists with children receiving therapy within school settings. Differences in activities and interventions provided to students that were listed on the second (video observed) iteration of the S-PTIP form but not the first (immediately following therapy) mainly concerned travel to and from locations which could be overlooked by the therapist as not a primary focus of the therapy session, but noted later upon video observation.

CLINICAL RELEVANCE: The S-PTIP data collection system has the potential to provide a wealth of information spanning research, clinical, and administrative contexts. Given the acceptable consistency of the S-PTIP, we have used it to collect descriptive data on activities and interventions and examine the associations of these with outcomes for students with disabilities that are receiving services in the school setting.


Ehrlich N, Hackett K, Grant-Beuttler M, Chapman University, La Crescenta, CA; Swan C, Hatten K, National Center for Equine Facilitated Therapy, San Francisco, CA

PURPOSE/HYPOTHESIS: Review current literature regarding the use of hippotherapy as an intervention strategy for treatment of children with neurological disorders. Hippotherapy is theorized to recreate normal 3 dimensional pelvic motion during gait, relax spastic musculature via heat and rhythmic motion, and promote dynamic postural musculature recruitment.

NUMBER OF SUBJECTS: 150 articles were reviewed for content. 12 articles fit the inclusion/exclusion criteria and were analyzed.

MATERIALS/METHODS: A internet based search of Web of Science, CINHAL and PubMed were used September of 2012 using key words “hippotherapy,” “cerebral palsy,” “pediatrics,” and “physical therapy.” From that search, one hundred and fifty articles were retrieved. To be included in the analysis, subjects had to meet the following criteria: receiving hippotherapy intervention, medical diagnosis of cerebral palsy (CP), ages 2-18, evaluation of gross motor skills, and published after 1998. Articles were excluded if they assessed cognitive/behavioral/lifestyle changes, and/or utilized of therapeutic riding as a treatment strategy.

RESULTS: Treatment dosages varied between each article. Effect sizes, Sackett scores, and quality scores were calculated for each outcome measure in each article. Effect sizes were large for improvements in balance, GMFM Dimension E, stride length, functional reach, and muscle synergy. Overall quality was 5-9/11 with Sackett scores level 2b and 3b.

CONCLUSIONS: Hipportherapy research shows improvements in scores on the GMFM Dimension E, gross motor function, balance demonstrated by Pediatric Balance Scale, gait characteristics such as velocity, energy expenditure, stride length and cadence, sitting posture, muscle activation and symmetry in trunk and lower extremities, anterior pelvic tilt in initial contact and terminal stance, and bilateral hip flexion/extension at initial contact. Based on this review, one time dosage showed smaller changes, however, lasting improvements were observed post 10-12 week interventions. Quality scores for articles included in the review ranged from 5/11 to 9/11 and clinical bottom line scores ranged from 2/5 to 4/5 indicating need for further improvement in research quality in this area of study.

CLINICAL RELEVANCE: Hippotherapy is a unique and motivating rehabilitation technique that shows clinical relevance for addressing postural, gait and balance deficiencies in children with neurologic disorders.


Fay D, Wilkinson T, Meduvsky E, Albrecht A, Manatt S, ATSU, Mesa, AZ

PURPOSE/HYPOTHESIS: Physical therapists often modify cues during assessment of children who have difficulty understanding standard instructions provided in the examiner's manual. The impact of these modifications can be concerning if normative values, collected under standardized conditions, are used for scoring. Previous research indicated modifications may have a significant impact on PDMS-2 scores, but the Locomotion subtest was not as susceptible to change. As not all items tested had the same form of modification, it was unclear if the lack of significant difference was related to the skills assessed or modifications made. The purpose of this study was to determine if Locomotion subtest scores would be altered with the use of modified verbal cueing or concrete tasks.

NUMBER OF SUBJECTS: A total of 37 typically developing preschool-aged children (mean age 50.6, range 30-67 months) participated.

MATERIALS/METHODS: Children were recruited at a daycare center and two groups were formed through modified randomization with age and gender matching. Each child was tested on the Locomotion subtest of the PDMS-2 twice, once with standardized instructions and once with modified cues, with the order of testing determined by group assignment. Modified cues included verbal prompts and the addition of concrete tasks. All sessions were videotaped for scoring by a researcher blinded to the study's purpose. A repeated measures ANCOVA was performed to test for differences and interactions between instruction type, age and testing order. As no significant findings or interactions were identified for age or order, a paired sample t-test with effect size was performed for instruction type.

RESULTS: A significant difference was found in Locomotion scores based on instruction type (p < .05, d = .41). A total of 36 of the 37 subjects had a change in raw score, with 22 subjects demonstrating a change in standard score/percentile rank. Of these 22 subjects, 17 had higher standard score/percentile rank with modified cues. Item analysis revealed twice as many items (13) showing higher scores with modified cues versus standard cues (6).

CONCLUSIONS: Modifying cues on the Locomotion subtest of the PDMS-2 significantly changed the scores of typically developing children when compared to standard testing, with most children having higher scores with modification. While more items responded favorably to modified cues, in some cases the increased complexity of the modifications resulted in higher scores under standard instructions.

CLINICAL RELEVANCE: The use of modified verbal cues and concrete tasks may change Locomotion scores on the PDMS-2. Since these modifications were not used during the establishment of the norms, use of them during assessment can inflate scores leading to inaccurate assessment of performance level. Further research is needed to establish how these modifications affect children with delay and if there is an ideal level and type of instruction to determine true motor ability.


Fergus A, Drogo B, Kania L, Duffy L, Stepien J, Shenandoah University, Winchester, VA

BACKGROUND & PURPOSE: The needs and opportunities for cross cultural pediatric PT are increasing tremendously. It remains unclear how to best treat patients from a cross cultural perspective and how to prepare future PT's to be equipped to do so. The purposes of this study were to: 1) describe the interventions and outcomes provided in the US for a child from a third world country and 2) discuss the cross cultural learning experiences of PT students through this case.

CASE DESCRIPTION: A 6-year-old girl from Haiti sustained a TBI in the 2010 earthquake in Haiti. The subject was brought to the US for rehabilitation including PT, OT and SLP. PT was provided by faculty and students of a DPT program two to three times per week during the subject's 42 day stay in the US. Each treatment session was recorded and videotaped and later analyzed by 2 blinded raters for each outcome measure. Interventions included facilitation of midline head control and pelvic control in various functional positions, facilitation of grasp and release to encourage spontaneous use and awareness of the upper extremities, equipment prescription appropriate for the third world environment, and caregiver education on home exercise plan which would be continued and progressed upon return home to Haiti. After the subject returned home, a focus group was conducted with students involved in the case. Common themes were identified and a concept map was developed. A follow up visit in Haiti occurred with the subject 217 days after leaving the US.

OUTCOMES: During the subject's time in the US, improvements were observed but more substantial gains were noted during the follow up visit in Haiti. The subject demonstrated an 11% increase in head control in sitting, a 77% increase in pelvic control in ring sit, and a 26.7% increase in success in upper extremity reaches while in the US. At the follow up, the subject demonstrated a 25% increase in head control in sitting, a 93% increase in pelvic control in ring sit, and only a 15.2% increase in success of reach attempts during the follow up in Haiti. While the percent change decreased in success of reach attempts after follow up in Haiti, the reaches appeared to be more intentional by the subject. The themes that emerged from the focus group were: 1) experiential learning enhances didactic learning, 2) strategies are developed when working with a patient of a different culture, and 3) one's therapeutic approach may be influenced by culture however, the overall goal of treatment will not change, 4) this model of cross cultural education was both effective and efficient.

DISCUSSION: This case presents a unique cross cultural experience in which the third world family was brought to the US but interventions were developed to be utilized in her natural environment. The substantial gains that were made in Haiti may reflect the efficacy of the home exercise program in the carefully considered natural environment. This case also supports the multidimensional enhancement of a cross cultural learning experience for PT students.


Ferrante RL, Hendershot S, Stuart K, Carey H, Nationwide Children's Hospital, Columbus, OH; Heathcock J, The Ohio State University, Columbus, OH

PURPOSE/HYPOTHESIS: The Gross Motor Functional Measure (GMFM) is the most common tool for children with cerebral palsy (CP). There are 2 versions, the GMFM-88 and a shorten version, the GMFM-66. The GMFM-66 is a concise and efficient assessment, and is used frequently to describe change in motor function following intervention, especially in research studies. The majority of items eliminated to form the GMFM-66 are from the lying, rolling and seated categories. Younger children and children with CP whose motor skills are most impaired may use lying and rolling the most, and as a result the GMFM-66 may under evaluate improvements following intervention programs. The purpose of this study is to compare changes on the GMFM-66 and the GMFM-88 in children with CP who demonstrate positive changes following an intense physical therapy program.

NUMBER OF SUBJECTS: 14 participants with CP with GMFCS levels I-V participated in this project. Participants had a mean age of 28 +/− 11 months.

MATERIALS/METHODS: Participants were seen for 2 hours a day, 5 days per week, for 1 month at an outpatient hospital. Based heavily on principles of motor learning our intensive and individualized physical therapy intervention focused on repetition and variable practice of motor skills. Outcome measures were performed at baseline (before intervention) and final (after intervention) time points.

RESULTS: All patients successfully completed an intensive physical therapy program at a children's hospital. Paired t-test with bonferroni correction reveled significantly higher GMFM-66 (t = −6.86, p < 0.001) and −88 (t = −5.07, p < 0.001) scores from baseline to final. Kendall's tau correlation statistic was used to assess the strength of the relationship between GMFCS levels and change scores on the GMFM-66 and −88. A nonparametric, correlation test by rank was chosen because the GMFCS levels are rank order. No relationship between GMFCS level and the GMFM-66 was observed, suggesting children at all GMFCS levels change similarly. A moderate positive relationship was revealed between GMFCS level and the GMFM-88 (r = .515, p = 0.023), suggesting that children at higher GMFCS levels demonstrated greater change on the GMFM-88.

CONCLUSIONS: The results of this study suggest that after a 1-month intensive physical therapy program, young children with CP demonstrate changes in both the GMFM-66 and −88. Interestingly, the GMFM-88 which includes more items at lower functional levels was related to GMFCS level. As such the GMFM-88 may be a better tool at detecting change in those children with more severe CP and lower function following high-intensity protocols.

CLINICAL RELEVANCE: Although the GMFM-66 offers a more concise and efficient assessment tool (and an interval score) to measure gross motor function in children with CP, the GMFM-88 may offer important information about functional change in children with more severe CP following high-intensity intervention. Positive changes in functional mobility are possible in children with higher GMFCS levels and this change could be underestimated on the GMFM-66.


Flynn TT, Prosen R, Thompson HR, Tonismae J, Case LE, White LE, Duke University Medical Center, Durham, NC

PURPOSE: The purpose of this review is to determine the state of the evidence in support of Treadmill Training (TT) to promote gait acquisition in infants with Spina Bifida (SB).

DESCRIPTION: A literature search of PubMed, CINAHL, Web of Science, and Google Scholar was conducted through April 23, 2013 to identify articles utilizing treadmill for infants with Spina Bifida (SB). The search produced 17 articles. Titles and abstracts were independently reviewed by two reviewers, and five articles were ultimately selected for inclusion. We reviewed all English-language, peer-reviewed, non-case study articles pertaining to treadmill stepping in individuals under three years old with Myelomeningocele (MMC) or SB. All studies were cross-sectional, observational treadmill trials for infants with MMC or SB; the initial study was also longitudinal. The longitudinal study assessed the emergence of stepping responses from 1-12 months of age on a moving and stationary treadmill, comparing typically developing infants to those with MMC. The subsequent studies assessed the effect of enhanced sensory input and manual facilitation on treadmill step parameters, and one study also took into account the effect of sensory input on motor output.

SUMMARY OF USE: Results from emerging treadmill studies show that step parameters of infants with SB can be influenced by sensory and mechanical input. Inputs that effected step parameters include visual flow, friction, vibration, loading, unloading, weights, Velcro, speed, and manual assistance. Longitudinal intervention studies have not yet been completed to explore the ability of TT to promote gait acquisition, earlier age of gait acquisition, carryover of altered step parameters, or long-term function in infants with SB. These studies support the need for additional research with larger sample sizes and longer intervention and follow-up periods to assess the potential benefits of TT in infants with SB.

IMPORTANCE TO MEMBERS: Due to the substantial neuromusculoskeletal plasticity present in infancy, prospective intervention at this stage can be critical in maximizing functional development, facilitating future gait acquisition, and preventing secondary musculoskeletal complications. Treadmill Training has been proven effective to promote gait acquisition in infants with Down Syndrome, positively impact the ambulation of ambulatory children with SB, and may also prove beneficial for infants with SB.


Gaetani SA, Department of Physical Therapy and Occupational Therapy, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA; Fenton RA, Rottgers AS, Grunwaldt L, MacIsaac Z, Kumar A, Department of Pediatric Plastic Surgery and Cleft-Craniofacial Surgery Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA

PURPOSE/HYPOTHESIS: Mandibular asymmetry (MA) associated with congenital muscular torticollis (CMT) has been associated with long-term facial asymmetry. We have identified a cohort of patients with CMT and deformational plagiocephaly (DP) presenting with MA in early infancy. Currently, no consensus exists regarding the timing and efficacy of physical therapy (PT) intervention to treat this condition. The purpose of this study is to evaluate the improvement of facial asymmetry, specifically MA, in patients with CMT treated with early PT.

NUMBER OF SUBJECTS: Ten patients diagnosed with CMT who were noted to have MA.

MATERIALS/METHODS: From July 2009 to July 2012, a retrospective study of patients with CMT, DP, and associated MA treated with early PT for a minimum of 6 months was performed in order to evaluate the outcome of PT intervention as measured by the degree of improvement in MA. All patients completed weekly skilled PT treatment sessions, which included stretching and strengthening exercises. Additionally, parents performed daily home exercise programs with the patients. Pre- and post-therapy CT scans were obtained to rule out craniosynostosis and evaluate the degree of ramal height asymmetry (calculated ratio:affected/unaffected). Patients were followed clinically and radiologically for evidence of improvement in MA.

RESULTS: Ten patients were identified who met inclusion criteria. The average age at presentation was 5.5 months (3-9 months). The average duration of PT was 6 months, and the average follow up was 7.5 months (5.5-9.6). Torticollis was left-side dominant in 60% and right-side dominant in 40%. MA, which was secondary to shortening of the vertical ramal height (CT-confirmed), correlated with the torticollis side (affected sternocleidomastoid (SCM)) in 100% of patients. The pre-therapy ramal height ratio (affected/unaffected) was 0.87 and improved to 0.93 post-therapy. One patient was diagnosed with late-onset right coronal synostosis on repeat CT scan. No complications occurred during therapy.

CONCLUSIONS: We have identified a unique cohort of infants with MA associated with CMT. These patients uniformly demonstrated decreased ramal height ipsilateral to the affected SCM muscle. PT initiated shortly after diagnosis improved ramal asymmetry as demonstrated by calculated ramal height ratios.

CLINICAL RELEVANCE: CMT can have many functional and structural implications including MA and facial asymmetry. Early initiation of PT for CMT is important for a multitude of reasons. Specifically, ramal height discrepancy greatly improved after 6 months of PT intervention. As seen in this study, early initiation of PT for CMT can improve MA.


Gilbertson TJ, Prange H, University of Washington, Seattle, WA; Orr O, University of Washington, Seattle, WA; Price R, Moritz C, McCoy SW, University of Washington, Seattle, WA

BACKGROUND & PURPOSE: Neural plasticity and motor-learning research suggests that task-specific practice should control the intensity, repetition, timing, difficulty, and salience to have the highest effect. Based on these principles, ‘NeuroGame' Therapy (NGT) was designed and has shown promise in upper extremity rehabilitation in children with cerebral palsy (CP) and adults after stroke and traumatic brain injury. We explored the effects of task-specific practice using NGT for rehabilitation of ankle dorsiflexion movements in children with spastic diplegic CP. Our portable system provided biofeedback using surface electromyography (sEMG) on the ankle dorsiflexion (ADF) that allowed the children to control computer games.

CASE DESCRIPTION: Two boys with spastic diplegic CP participated in the study. Child A (15 y/o) functioned at Gross Motor Function Classification System level I, and child B (14 y/o) at level II. Children were assessed twice before, midway through intervention, immediately after, and during a follow-up test one month later. Children practiced using voluntary activation of bilateral ankle dorsiflexors to control the movement of the cursor within a popular computer game for 8 weeks at home. Outcome measures included: agonist/antagonist independent control during active range of motion (ROM) and other functional activities, maximal voluntary contraction force, amount of active and passive ROM with ADF, single limb stance, Pediatric Balance Test, six minute walk test (6MWT), and a functional reach test (FRT). Outcome measures for each participant were compared among pre, mid, post, and follow-up tests.

OUTCOMES: Game play was reported to be enjoyable by the children and both played throughout the 8 weeks. Child B played the game four more times than Child A. Muscle independence with active ROM improved in both children with higher co-contraction ratios indicating more independent use of the tibialis anterior muscle when compared to the medial head of the gastrocnemius and soleus muscles. ADF contraction force was improved in one ankle of child B, but was not changed in child A. Both children showed improvements with active ROM and child B also showed improvements with passive ROM. Single limb stance improved in each leg of child A and one leg in child B. Differences were not observed on the Pediatric Balance Test, 6MWT, or FRT.

DISCUSSION: NeuroGame therapy was feasible and enjoyable for these children with CP, and facilitated repetition and intensity of intervention. Both participants improved their muscle coordination, which lead to notable changes in ankle function. Neurogame therapy, which leverages neuroplasticity and motor learning principles, also appeared to increase participants' motivation to perform therapy at home. Continued research using larger sample size is warranted.


Greenwood J, Boston Children's Hospital, Boston, MA; Wilmarth MA, Northeastern University, Boston, MA

PURPOSE: This poster will provide physical therapists information to help to 1) Identify a population of children who may benefit from a standing program 2) Identify the level of standing program needed to address specific impairments 3) Better understand the benefits and deterrents when implementing a standing program in a child's home or school.

DESCRIPTION: Children with neuromuscular conditions often rely on adaptive equipment to enhance function, prevent progression of musculoskeletal issues and increase overall independence. One device often recommended in children who are non ambulatory or present with limited ability to independently stand, transfer or execute active weight bearing through their legs is a stander. Physical therapists utilize standers as one part of a child's plan of care for interventions to improve weight bearing and provide a position of upright orientation. Therapists cite several reasons for use of standers and they can be divided into two categories: Reduction of Impairments & Improvements in Function. Pediatric standing and weight bearing programs are recommended in clinical practice based on many factors including clinician preference, patient tolerance, environmental limitations and with consideration of the literature and research utilized differently to either support or refute the medical necessity of standing. According to the Guide to Physical Therapist Practice, a physical therapist must utilize the evidence develop treatment interventions for the total care of their patients. While some of the evidence has low evidential weight due to small population sizes, there are a growing number of studies in support of use of standing programs for children with limited mobility. Research demonstrated that a standing program 30 minutes five days per week x 8 weeks improving distal femur and spinal bone mineral density. Research also indicates that children with cerebral palsy can mitigate tone following a session of standing. Standing is recommended 60 – 90 minutes daily to result in statistically significant changes in tone, lower extremity ROM and contracture management over time. Studies demonstrated straddled weight bearing for 1 hours daily benefited hip migration percentage and muscle length in children with cerebral palsy (GMFCS III to V).

SUMMARY OF USE: This poster will emphasize combining the clinical presentation of the child with the functionality of the standing device while providing the evidence for justification for both the biological benefits, psychological benefits and implementation strategies for the therapist.

IMPORTANCE TO MEMBERS: Therapists need to understand the benefits of the stander in order to determine the medical necessity of the standing device recommended for their client and the implementation strategies needed to ensure successful implementation as a treatment modality.


Gross McMillan A, Reinhard KE, East Carolina University, Greenville, NC; Scott W, Husson University, Bangor, ME; Williams DS, Virginia Commonwealth University, Richmond, VA

PURPOSE/HYPOTHESIS: Adolescents who are overweight and obese (OW/OB) exhibit movement characteristics suggesting lower extremity weakness. Little evidence exists as to strength deficits in this population. The purpose of this study was to compare the absolute strength and relative strength in adolescents who were OW/OB and their healthy weight (HW) peers.

NUMBER OF SUBJECTS: Fifty-four subjects (43 females and 11 males) participated in this study. Age ranged from 12 to 17 years old.

MATERIALS/METHODS: Subjects with a BMI for age/gender between the 5th and 90th percentiles were classified as HW (n = 24), while subjects with a BMI for age/gender greater than or equal to the 95th percentile were classified as OW/OB (n = 30). Strength data were collected using the HUMAC isokinetic dynamometer. Maximal voluntary isometric contractions were measured for plantarflexors and hip abductors bilaterally. The peak torque production was recorded as the absolute strength measurement. Relative strength was calculated as the average torque for each muscle group divided by body mass. Absolute and relative strength measurements were compared between OW/OB and HW groups using Student's t-tests.

RESULTS: Absolute strength was significantly greater in OW/OB group for both hip abduction (p = 0.006) and plantarflexion (p = 0.0001). Relative strength was significantly lower in OW/OB subjects for both hip abduction (p = 0.0001) and plantarflexion (p = 0.0001). Additionally, functional plantarflexion performance was found to be significantly different between groups with the OW group displaying a greater number of compensations than the HW group.

CONCLUSIONS: Adolescents who are OW/OB generated more absolute isometric torque but when adjusted for body mass they were relatively weaker than their HW peers in both hip abduction and plantarflexion.

CLINICAL RELEVANCE: Impaired muscle force production in weight bearing activities can lead to altered biomechanics and musculoskeletal dysfunction during functional activities such as ambulation. PTs must consider relative strength especially of lower extremity muscles when assessing and intervening with adolescents who are OW/OB.


Gross McMillan A, DeJesus KE, East Carolina University, Greenville, NC; Scott W, Husson University, Bangor, ME; Williams DS, Virginia Commonwealth University, Richmond, VA

PURPOSE/HYPOTHESIS: Adolescents who are overweight and obese (OW/OB) demonstrate differences in lower extremity mechanics during gait. While strength in this population appears to be compromised, these deficits have not been compared to gait abnormalities. We hypothesized that there would be a correlation between isometric strength and peak joint moments during gait in adolescents who were OW/OB.

NUMBER OF SUBJECTS: Twenty male and female subjects between the ages of 12 and 17 years participated in the study.

MATERIALS/METHODS: Subjects with a BMI for age/gender between the 5th and 90th percentiles were classified as HW (n = 10), while subjects with a BMI for age/gender greater than or equal to the 95th percentile were classified as OW/OB (n = 10). Isometric torque output of the plantarflexors was collected on the HUMAC isokinetic dynamometer. Three-dimensional gait analysis was performed using 8 digital cameras sampling at 120 Hz and two force platforms sampling at 960-Hz. Kinematic and kinetic data analysis was performed using commercial software. Ground reaction forces from the propulsion phase of gait were measured, and then normalized by each individual's body mass. Torque outputs from the dynamometer were averaged for each subject. This average was then normalized by each individual's weight to find their maximal potential for torque. Percent of torque output during propulsion was calculated. Student's t-tests were used to determine significant differences between the OW/OB and HW groups.

RESULTS: The HW group was significantly stronger when normalized by body weight. The HW group was able to exert a maximal force of 89.2 ± 27.1% of their body weight, while the OW/OB group was able to exert a force of 52.0 ± 16.6% of their body weight, (p < 0.01). The HW group also had significantly higher ground reaction forces during the propulsion phase of gait with 20.2 ± 3.83% compared to 17.9 ± 2.63% in the OW/OB group (p = 0.01). There was significant difference between the percent of maximum force used during gait between the HW and OW/OB groups. The HW group had a mean force of 24.0 ± 5.93% of their maximal capabilities used during their self-selected gait speed, whereas the OW/OB group had a mean force of 37.9 ± 15.2% (p < 0.01) of their maximal capabilities.

CONCLUSIONS: Based on these data, there is a correlation between gait impairments and strength in OW/OB and HW individuals. In general, OW/OB adolescents appear to be working harder than their HW peers during walking.

CLINICAL RELEVANCE: Physical therapists should assess effects of relative muscle strength in lower extremities, and effects of this strength on functional movements, when assessing and intervening with adolescents who are overweight and obese. These data may help guide pediatricians, families, and physical therapists in developing exercise programs specific to calf muscle strengthening that will help adolescents who are overweight ambulate with a more efficient gait pattern.


Guevara A, Senesac C, University of Florida, Gainesville, FL

BACKGROUND & PURPOSE: Patient was a two-year old female with type 1 and 2 Ehlers Danlos Syndrome. Ehlers Danlos syndrome is a genetic disorder that is categorized by various degrees of skin and joint hypermobility, collagen deficiency, and vascular components. The purpose of this case report is to determine if a progressive strengthening and balance program can increase gait speed, decrease falls, and improve balance as measured on the Pediatric Balance Scale during gait and functional activities in a 2-year old female with type 1 and 2 Ehlers Danlos Syndrome.

CASE DESCRIPTION: Patient was a two-year old female with type 1 and 2 Ehlers Danlos Syndrome. Ehlers Danlos syndrome is a genetic disorder that is categorized by various degrees of skin and joint hypermobility, collagen deficiency, and vascular components. This patient population can present with varying degrees of orthopedic, balance, and coordination problems. This young child had a history of increased falls, injury, and deficits in balance reactions with decreased response to perturbations.

OUTCOMES: Patient completed a 9 session progressive strengthening and balance program and was evaluated using the following tests and measures: Observed trips and falls, Pediatric Balance Scale, 5 time sit to stand, 18 foot walk (5.48 meters), single leg stance, and knee extension strength. Patient showed an overall increase in her strength and improvement in her balance as indicated by her decreased observed trips and falls, increased Pediatric Balance Scale Score, 5 time sit to stand, and 5.48 m walk test.

DISCUSSION: Although more research needs to be conducted on this topic, it appears that a progressive strengthening and balance program can increase gait speed, decrease falls, and improve balance in a child with hypermobile type Ehlers Danlos Syndrome.


Hedgecock JB, University of Colorado, Aurora, CO; Sutphin AR, Cindy Miles & Associates, Whitehall, PA; Rapport MJK, University of Colorado Anschutz Medical Campus, Aurora, CO

BACKGROUND & PURPOSE: Cerebral palsy (CP) negatively impacts selective motor control and gross motor development causing lifelong functional limitations and participation restrictions. Many children with CP have long-term physical therapy (PT) intervention, however, motor development often plateaus or remains relatively unchanged. Deficits of 50% or greater of expected strength in lower extremity musculature cause functional impairments in balance and gait due to insufficient lower extremity strength to counter typical ground reaction forces. The purpose of this case report was to describe the examination, intervention, and outcome of a 3-month episode of physical therapy intervention involving functional training and progressive resistance exercise (PRE) with an adolescent with spastic diplegic CP classified at GMFCS Level II.

CASE DESCRIPTION: The patient was an 18-year old male with spastic diplegic CP (GMFCS Level II), with a long history of physical therapy and medical/surgical interventions. He presented with strength impairments that limited functional and transitional movement, agility, and restricted peer-level participation in school and community activities. Examination included measures of spasticity (Modified Tardieu Scale), range of motion (ROM), functional strength (Sit-to-Stand Test, Lateral Step-Up Test, and 1/2-Kneel-to-Stand Test), agility (10×5 m Sprint Test and Timed-Up-and-Go Test), endurance (Six-Minute Walk Test), and anaerobic power generation (Muscle Power Sprint Test). Intervention centered on a short, intensive PRE regimen with targeted functional movement training, including body-weight supported treadmill training, and cardiovascular training.

OUTCOMES: Lower extremity ROM and spasticity were unchanged. Minimal strength improvements were measured with manual muscle testing (hamstrings: 4- to 4+; ankle dorsiflexors: 4- to 5-; gluteus maximus: 3+ to 4+; and gluteus medius: 4- to 4+). Clinically insignificant improvements in functional strength (+5 repetitions left and right pooled test results), agility (−1.43 sec.), endurance (+13.35 m) and anaerobic power generation (+7.9 W) were measured, along with variable success in achievement of treatment goals. Clinically significant improvements on the Sit-to-Stand Test (+5 repetitions) and Timed-Up-and-Go Test time (−2.0 sec.) were measured. The patient also demonstrated new abilities to complete an unassisted 1/2-kneel-to-stand transition and independence in negotiating curbs.

DISCUSSION: The patient outcomes described in this case report support the use of PRE and functional training to improve strength and functional mobility in an adolescent with CP, even after long-term PT intervention and plateaus in functional motor skills. Further study of this intervention approach and outcomes are necessary to better understand which patients are more likely to benefit.


Hendershot SR, Ferrante RL, Stuart K, Carey H, Nationwide Children's Hospital, Columbus, OH; Heathcock J, The Ohio State University, Columbus, OH

PURPOSE/HYPOTHESIS: Improvements in motor skills such as reaching and walking have been demonstrated in older children with cerebral palsy (CP) following high-dose protocols. The most common and well-studied intense protocols include constraint-induced movement therapy and locomotor training. Typically, these protocols are several hours each day over many weeks. Of the 1 in 303 children in the United States with CP, 33% are non-ambulatory. It is unknown how non-ambulatory children with CP will respond to a higher dose physical therapy treatment protocol. Therefore, the purpose of this study was to examine a high-dose physical therapy program for young children with CP, GMFCS III-V.

NUMBER OF SUBJECTS: 12 non-ambulatory young children with CP, GMFCS levels III-V, completed this project. Participants were 11.2 to 50.1 months with a mean of age of 25.8 months (+/− 11.4 months).

MATERIALS/METHODS: In this longitudinal design, participants were seen for 2 hours of treatment per day, 5 days per week, for 4 weeks (40 hours total). Participants completed at least 85% of the prescribed dose. Individualized treatment strategies were based on motor learning theory and each participant's treatment plan focused on two individualized goals. Changes in motor function and development were measured with the Gross Motor Function Measure-66 (GMFM-66) and the Bayley Scales of Infant and Toddler Development-III (BSID-III).

RESULTS: Paired t-test revealed a significant difference in GMFM-66 scores pre (31.91 −/+ 7.97), and post (36.67 −/+ 6.5, t = −5.55, p < .001), suggesting improvements in motor skills. Interestingly, age and change score for the GMFM had a moderate negative correlation (r = −.486, p = .016) suggesting that younger participants had a greater change in motor skills. On an individual level, 8/12 children demonstrated clinically meaningful differences on the GMFM-66. It is important to note that these changes were seen in just 1 month. A subset of six children received pre and post BSID-III testing. Paired t-test revealed a significant difference in Cognitive Raw Scores pre (33.3 −/+ 10.4), and post (39.3 −/+ 10.6, t = −3.56, p = 0.009), and a trend for Gross Motor Raw Scores pre (25.8 −/+ 5.5), and post (29 −/+ 4.3, t = −2.4, p = 0.053).

CONCLUSIONS: Participants in this high-dose program made significant improvements in gross motor skills. The total number of hours, forty, is similar to the total dose needed to see meaningful changes in protocols for older children with CP. This intervention may be implemented as early as 11 months of age.

CLINICAL RELEVANCE: Intensive physical therapy appears to be beneficial for non-ambulatory young children with CP. A younger age at the start of the program was associated with a greater improvement in gross motor skills suggesting that this protocol may be most beneficial when implemented at an early age. Interestingly, changes in both gross motor skills and cognitive skills were observed, suggesting improvements in multiple domains of development.


Hinkle JG, Freed SS, Coulter C, Children's Healthcare of Atlanta, Atlanta, GA

PURPOSE/HYPOTHESIS: The primary purpose of this study was to investigate the inter-rater reliability of cervical protractor measurements in young infants with and without congenital muscular torticollis (CMT). Another purpose was to determine if infants' pain behaviors were correlated with differences between the raters' measurements.


MATERIALS/METHODS: A randomized, repeated measures design was used with two blinded raters measuring the same motion toward left and right sides in the same infant within one session. Either cervical sidebending or cervical rotation was measured in 30 infants with CMT and 29 infants without CMT. Infants were 4-26 weeks old. A cervical protractor and a standardized measurement procedure developed at Children's Healthcare of Atlanta (CHOA) were used. The method studied required only one examiner. Measurements were in 5 degree increments. Total score on the Faces, Legs, Activity, Cry, and Consolability (FLACC) was recorded at the time of measurement.

RESULTS: Data was analyzed within each group of infants for left and right sidebending and rotation. The mean absolute differences between raters' measurements ranged from 4.62 to 11.18 degrees across all motions and groups. Interclass correlation coefficients (ICCs) for rotation in the CMT group were higher (left = 0.785, right = 0.626) than in the group without CMT (left = 0.126, right = 0.323). ICCs for sidebending were low in both groups and ranged from 0.043 to 0.304. The FLACC scale scores and the absolute differences in cervical motion measurements were not correlated for left sidebending and right rotation in the CMT group. Conflicting significant correlations were found between FLACC scale scores and the difference between raters for right sidebending (r = −0.494) and left rotation (r = 0.854) in the CMT group. No correlations were found between the FLACC scale scores and the absolute differences in cervical motion measurements for any motion in infants without CMT.

CONCLUSIONS: Small sample size limited the conclusions drawn from this study. Rotation measurements may have better inter-rater reliability than sidebending measurements in infants with CMT. Further research is needed to determine optimal procedures for examination of cervical motion in young infants.

CLINICAL RELEVANCE: Practical, reliable measurement tools are needed to measure outcomes of treatment in infants with CMT. The method used in this study required only one examiner. Inter-rater reliability is important when infants are examined by different clinicians across time. Caution is indicated when clinical decisions must be based upon cervical motion measurements obtained by two different raters.


Holdan W, Abramowicz S, Boston Children's Hospital, Waltham, MA

PURPOSE: The authors hypothesize that specific individualized PT interventions will lead to improvement in MPD in children.

DESCRIPTION:INTRODUCTION: Prevalence of myofascial pain (MPD) in healthy children ranges from 4-15%.1,2 There are multiple etiologies for MPD in pediatric population including parafunctional habits, anxiety and/or trauma. There is little information in the literature to guide physical therapists (PT) treating children with MPD.


MATERIALS/METHODS: This was a retrospective study of children with chief complaint of jaw pain who were evaluated by the Oral and Maxillofacial Surgery (OMFS) and Physical Therapy (PT) Services at Boston Children's Hospital from November 2011 to April 2013. Subjects were included if they were 21 years of age or younger at time of diagnosis, and were referred for jaw signs/symptoms (e.g. muscle and/or TMJ pain, difficulty chewing, decreased or painful mouth opening). Exclusion criteria included presence of congenital/acquired facial anomalies, history of facial fractures, previous intra-articular procedures, inability to verbalize or indicate pain/discomfort, and/or presence of major medical co-morbidities. Medical records were reviewed to document (1) PT interventions and (2) Efficacy of interventions. PT interventions consisted of intrinsic and extrinsic interventions. Intrinsic interventions consisted of: (1) jaw active range of motion (AROM), (2) condylar remodeling, (3) masseter massage, (4) physical modalities & agents (i.e. vibrating massager, ultrasound, moist hot pack, Kinesio Tape, (5) manual treatment (i.e. soft tissue massage, myofascial release, stretches), and (6) strengthening of jaw musculature (i.e. isometrics). Extrinsic interventions consisted of: (1) strengthening, (2) stretching, (3) posture education, (4) sleeping modifications, and (5) stress-relief strategies. Effectiveness of interventions was recorded via subjective (pain score via NRS/FACES) and objective (range of motion, deviation on opening) criteria.

SUMMARY OF USE: There were 13 patients (11 female, 2 male) with average age of 13 years (range 6.8 to 20.5 years) who met inclusion criteria. Patients had average of 7.15 visits during study period. On average, each patient had 3.92 intrinsic and 3.23 extrinsic interventions. At discharge, pain score was 0.18/10 (NRS/FACES) (range 0-2) with average decrease of 6.36/10 (range 0-10) from time of initial evaluation. Jaw opening was 39.3 mm at discharge (range 29-50mm) with average improvement of 5.33 mm. All but one patient had resolution of jaw deviation. An individualized pediatric PT plan consisting of these interventions helps to improve pain, mouth opening and jaw function.

IMPORTANCE TO MEMBERS: This investigation serves pediatric physical therapists treating TMD by providing suggestions for intrinsic and extrinsic interventions specifically for children.


Housel NR, Jones T, Starks D, Physical Therapy, Tennessee State University, Nashville, TN

PURPOSE/HYPOTHESIS: According to the U.S. Department of Health and Human Services, the number of overweight adolescents in the United States has tripled since the year 1980. Physical therapists are part of the pediatric medical team, responsible for helping to encourage children and adolescents to exercise for improved overall health. The purpose of this research was to see if weight loss could be encouraged through the use of a competitive pedometer study.

NUMBER OF SUBJECTS: Ninety-Three students in a health sciences curriculum at an area high school were asked to wear pedometers and to compete with a group of doctoral physical therapy students for the number of steps taken and the amount of weight lost over period of 6 weeks.

MATERIALS/METHODS: Participants were asked to sign consent forms and Tennessee State University (TSU) IRB board approval was granted. Thirty-Five TSU DPT students went to the school to distribute pedometers and take measurements of weight, height, BMI, and body composition for all participants. The high school students were informed that the TSU DPT students would also be wearing the pedometers. The challenge was to see if the high school students could would lose weight while trying to out-perform the TSU DPT students in the number of steps taken per day over a 6 week period.

RESULTS: Of the 93 high school participants, only 63 students actually wore the pedometers, and competed with the TSU DPT students. The remaining 30 students were present for both pre and post measurements but did not wear the pedometers. Paired t-testing to compare pre-and post weight and body fat was, therefore, done for the 63 students separately from the 30 non-participating students. There was no difference in weight when comparing the pre and post measurements of the participating 63 students (p = .248), and there was also no difference in weight for the 30 non-participating students (p = .524). There was, however a statistically significant decrease in percent body fat for the 63 participants (p = .019), but not for the 30 non-participating students, who actually had a slight but insignificant (p = .544) increase in percent body fat.

CONCLUSIONS: The literature suggests that increased inclusion of exercise during the typical day can improve overall health in the adolescent population. The addition of the competitive element might have helped to motivate certain students to actively participate during this project, possibly resulting in decreased percent body fat for those who participated.

CLINICAL RELEVANCE: Walking can help to keep high school students in shape. The addition of a competitive element might have helped to motivate some of the students in this study. One student stated, “I hope I took more steps than those TSU students! I even went hiking twice a week!” This student lost 6 pounds, and 1.2% body fat. If a study helps only one student, it's appears to these researchers to be worth doing. The results of this study, however, imply that more than one student was affected. The researchers on this project plan to continue this program on a yearly basis for further analysis.


Hsu LY, Jirikowic T, Price R, University of Washington, Seattle, WA; Dellon B, Boston Dynamics, Boston, MA; Kartin D, McCoy SW, University of Washington, Seattle, WA

PURPOSE/HYPOTHESIS: Sensorimotor Training to Affect Balance, Engagement and Learning (STABEL) is a novel virtual reality (VR) system designed to train the ability to use specific sensory information during balance. Visual background and support surface are controlled to distort sensory input during standing balance perturbations. We examined the effects of STABEL in children with Fetal Alcohol Spectrum Disorder (FASD), hypothesizing that STABEL would improve use of vestibular information during standing balance.

NUMBER OF SUBJECTS: A sample of convenience of 9 children with FASD and motor coordination concerns, age 8-16 years, participated. Six received STABEL and 3 children received no intervention.

MATERIALS/METHODS: All children were tested twice (pre/post STABEL or control session) with the Movement Assessment Battery for Children (M-ABC) and the Multi-Modal Balance Entrainment and Response (MuMBER) system. The MuMBER measured the ability to weight sensory input during standing by determining the amplitude with which children match their body sway frequency to small frequency visual, tactile, and support surface oscillations. We captured body sway movements by tracking markers on children's head, neck, sacrum and heels using a Qualysis motion analysis system. The STABEL group received 5 sessions of training in three weeks. Within a STABEL session, children wore VR goggles and moved their bodies to drive a virtual plane through hoops while the visual background and compliance of the surface were manipulated. Outcome measurements included M-ABC balance standard scores, gains and ratios of the magnitude of body sway oscillations at the frequency of visual, tactile and support surface stimuli over the sum of the peak frequencies of body sway movement related to the three sensory stimulations. The ratios represent children's weighting of the sensory stimuli. Paired t tests were used to compare pre to post sessions for MuMBER and M-ABC scores for STABEL and control groups separately.

RESULTS: Sensory weighting patterns were different from pre to post testing for several sensory conditions within the STABEL group. Children significantly increased the vestibular gain in the sensory condition in which tactile input was eliminated (p = .01). Children significantly improved their balance performance after STABEL training on the M-ABC (p = .04). No changes in MuMBER or M-ABC were found in the control group.

CONCLUSIONS: The results support that STABEL can improve children's balance skill. It may also change the patterns of sensory weighting. Further research using a larger dose of STABEL within a larger sample is warranted.

CLINICAL RELEVANCE: The STABEL intervention was found to be acceptable and fun by children and appears to affect balance and sensory integration during standing.


Keller CS, Huber SB, Becker D, Kennedy Krieger Institute, Baltimore, MD

BACKGROUND & PURPOSE: Acute Disseminated Encephalomyelitis (ADEM) is an auto-immune mediated demyelinating and inflammatory condition that affects the central nervous system (CNS). There is a good prognosis for the majority of children; however, some children continue to have long-term neurological sequelae. Studies suggest that those children with an initially severe presentation may continue to demonstrate long-term deficits. There is limited research on rehabilitation for those patients. Activity-based restorative therapy (ABRT) is an approach that can be utilized for patients with an insult to the CNS. ABRT is based upon the plasticity of the CNS, and utilizes activation of the nervous system above and below the level of injury to optimize the nervous system for recovery and reduce chronic complications associated with paralysis. This single case design describes the interventions and outcomes of a pediatric patient with a severe presentation of ADEM.

CASE DESCRIPTION: We present a 16-year-old female with symptoms of ADEM, including encephalopathy, altered vision, respiratory failure requiring mechanical ventilation, right upper extremity (UE) and bilateral lower extremity (LE) paralysis, and neurogenic bowel/bladder. At admission to inpatient rehabilitation, she presented with absent deep anal pressure and contraction, absent deep tendon reflexes in bilateral LEs, and 0/5 strength in bilateral LEs and right UE except 1/5 strength in right elbow flexion. Left UE strength remained 4-5/5. She was dependent for all functional mobility and ADLs, except feeding. She completed 12 weeks of inpatient rehabilitation, 20 weeks of outpatient PT, and 9 weeks of outpatient OT. ABRT was the primary focus during therapies. She participated in FES paired with functional activities and exercise, FES UE and LE cycling, aquatic therapy, locomotor and gait training, ADL and functional mobility training.

OUTCOMES: At discharge, LE strength improved to 3-4/5 and she was an independent community ambulator. Right and left UE strength improved to 5/5 and she was independent with all ADLs. The Walking Index for Spinal Cord Injury II (WISCI II) score increased from 0/20 to 20/20. Spinal Cord Independence Measure, version III (SCIM) score increased from 17/100 to 93/100. Scores on the Capabilities of the Upper Extremity Questionnaire (CUE) improved from 130/224 to 224/224. She continued to present with LE weakness, gait deficits, and neurogenic bowel and bladder.

DISCUSSION: Here we describe significant improvements in strength, function and mobility, despite severe initial presentation of ADEM. The intensity and interventions included in the ABRT program may have contributed to her substantial progress. More research is needed regarding rehabilitation for individuals after severe presentation of ADEM.


Kenyon LK, Grand Valley State University, Grand Rapids, MI; Ripmaster C, Lincoln Developmental Center, Grand Rapids, MI; Farris J, Grand Valley State University, Grand Rapids, MI; Hannum N, Proctor K, Roberts K, Briggs L, Cain B, King E, VandenBerg A, Peck J, Grand Valley State University, Grand Rapids, MI

BACKGROUND & PURPOSE: Children with severe motor, cognitive, and communication deficits are limited in their ability to use self-initiated movement to explore and learn from the world around them. Such children are often dismissed as candidates for power wheelchairs and are denied access to power mobility. Our Power Wheelchair Trainer (Trainer) provides an opportunity for these children to safely explore power mobility. This case series describes the use of the Trainer to provide these children with the opportunity to explore their environment and improve prerequisite skills for power mobility.

CASE DESCRIPTION: The Trainer is a motorized platform that allows a manual wheelchair to be temporarily converted to a power wheelchair, thereby permitting children to practice using power mobility while positioned in their own seating system. The control panel on the Trainer interfaces with both a traditional joystick and switches that adapt the power access system to meet the needs of each child. Three children with cerebral palsy at Gross Motor Function Classification System levels IV or V participated in this case series. Examination procedures included the Caregiver Priorities & Child Health Index of Life with Disabilities (CPCHILD), the Power Mobility Screen, the Pediatric Evaluation of Disability Inventory Computer Adaptive Test, and assessment of power access options using switches or a joystick. Individualized interventions focused on operating the Trainer were designed based on the needs of each child and included structured repetition of mobility tasks in the Trainer as well as opportunities for self-directed mobility exploration. Intervention frequency and duration were determined based on the setting (school versus outpatient) and ranged from 30-60 minutes, 2-3 times per week over a period of up to 12 weeks.

OUTCOMES: In each case, beginning intervention sessions were characterized by accidental switch or joystick activation. As each child became more familiar with the Trainer, independent purposeful activation of the Trainer increased and movement exploration in the Trainer emerged. Increases in purposeful stops and obstacle avoidance were observed in each case. All cases demonstrated improvements on the Power Mobility Screen and 2 had improvements on the CPCHILD. Parents of all 3 children reported incidental benefits such as increased contentment and increased engagement. The one child who was able to communicate often remarked that he enjoyed driving and that it was “awesome” to be able to move by himself.

DISCUSSION: When provided with consistent, repetitive practice in the Trainer, the children participating in this case series demonstrated improvements in active exploration of their environment while simultaneously improving their prerequisite skills for power mobility. Future research objectives include the development of child-centered instructional methods and valid assessment instruments to optimize use of the Trainer in promoting self-directed mobility for this unique population.


Koch KM, Physical Medicine and Rehabilitation, Mayo Clinic, Rochester, MN

BACKGROUND & PURPOSE: Functional mobility has significantly changed in young children undergoing aggressive cancer treatment. When a child has a life threatening medical condition impairing their judgment, mobility and cognition, a caregiver needs to provide answers to allow health care providers to establish a baseline for care. There are outcome measures often used in physical therapy examinations to track various functional changes following therapy interventions. The focus of this case report was to measure functional mobility before and after physical therapy interventions using an established outcome measure typically used for orthopedic pediatric patients, the Pediatric Outcomes Data Collection Instrument (PODCI). This outcome measure was utilized as it was economical, easy to access as a clinician and easy to follow as a parent questionnaire. It has not been used or reported on by other clinicians in the research for pediatric patients who are deconditioned or undergoing cancer treatment to this author's knowledge.

CASE DESCRIPTION: A seven year old female with a brain stem tumor was seen for seven outpatient sessions of physical therapy interventions while undergoing radiation therapy. The PODCI and modified Functional Independence Measure (FIM - for functional transfer items only) were completed before and after outpatient physical therapy treatment. Basic measures for body structure and function also included in the examination were manual muscle testing, posture assessment, basic balance assessment, coordination and distance able to ambulate.

OUTCOMES: By discharge, the patient made improvements in functional mobility and active participation. The caregiver was able to report change subjectively and through the use of the PODCI. Improvements were noted in upper extremity and physical function, transfer and basic mobility, sports functioning, treatment expectations and global functioning scales included in the PODCI. The patient also demonstrated improvement in her modified FIM scores with less transfer assistance. As function improved, activity tolerance, strength, posture, and coordination also improved demonstrating improvement in body structure, function and participation by the patient.

DISCUSSION: In this case report, the PODCI was used to assess functional change with physical therapy intervention for a medically complex and deconditioned pediatric patient undergoing cancer treatment. The PODCI was effective at representing progress in function for the patient. The use of the PODCI needs to be further explored in the research for patients outside of the orthopedic pediatric subgroup. It was a financially and clinically feasible outcome tool to measure functional progress in this patient.


Kokkoni E, University of Delaware, Newark, DE; Cunha AB, Federal University of São Carlos, São Carlos, Brazil; Rahman T, A.I. DuPont Hospital for Children, Wilmington, DE; Galloway C, Lobo MA, University of Delaware, Newark, DE

BACKGROUND & PURPOSE: Upper extremity function is fundamental for promoting early exploration and learning. Infants born with movement impairments that limit their exploratory abilities often have associated perceptual-motor, cognitive, language, and social delays. The goal of this study was to assess the impact of a novel assistive device, the enhanced pediatric Wilmington Robotic Exoskeleton (pWREX+), on improving reaching and play ability. Specifically, we examined the potential of pWREX+ as an assistive tool by measuring performance with and without the device within each session and as a rehabilitation tool by measuring performance with and without the device across time.

CASE DESCRIPTION: An 8-month old diagnosed with arthrogryposis multiplex congenita (AMC) was followed bi-weekly for 5 months. The study consisted of a 1-month baseline, 3-month intervention and 1-month post-intervention phase. At each assessment, motion analysis and behavioral coding were used to evaluate the arm movement and function with and without pWREX+ during standardized reaching and object play tasks. During baseline, the infant used pWREX+ only for the assessments. During the intervention, the infant used pWREX+ for home reaching and object play interventions. During post-intervention, the infant wore the device but was not required to perform the intervention activities.

OUTCOMES: pWREX+ was successful as an assistive device evidenced by improved ability to interact with objects within each session. The infant held hands closer to objects, had more bimanual activity, and greater time contacting and manipulating objects within a larger play space. Data suggest pWREX+ may also be a successful rehabilitative device for infants with upper extremity impairments. Across time, the infant not only improved his ability to interact with objects using one or both hands while wearing the device, but he evolved from not being able to reach for objects with either hand to demonstrating some successful reaching even when not wearing the device.

DISCUSSION: The results reveal the exciting possibilities of using devices like pWREX+ to improve early upper extremity movement and function. Such tools can serve as assistive devices to allow infants to immediately participate, play, explore, and learn despite their perceptual-motor impairments. They can concurrently serve as rehabilitative devices to improve future ability without the device by encouraging functional and participatory play that addresses the infants' underlying impairments. Devices like pWREX+ may change the way we provide early intervention for children with a variety of diagnoses, including brachial plexus palsy, neonatal brain injury, and hemiplegic cerebral palsy.


Kondratek M, Oakland University, Rochester, MI

PURPOSE/HYPOTHESIS: Functional performance of individuals with Cerebral Palsy (CP) is frequently compromised by muscle contractures and abnormal muscle tone. Historically open surgical muscle/tendon lengthenings have been used to address contractures. More than 4 months may be needed to achieve optimal function post-lengthening. Patients and families are seeking less invasive methods with improved outcomes. Selective percutaneous myofascial lengthening (SPML), a minimally invasive surgical lengthening of the muscle/tendon unit, is growing in popularity. Tiny incisions/no stitches, minimal blood loss, same day ambulation, and rapid return to function contributes to the appeal of SPML. One published SPML study was located; functional improvements were favorable. The purpose of this study is to describe the functional outcomes in the first year following SPML.

NUMBER OF SUBJECTS: 29 individuals; 6-26 years; 12 females; 17 males; Gross Motor Function Classification System (GMFCS) levels: I (n = 6); II (n = 12); III (n = 5); IV (n = 6); CP types: hemiplegia (n = 5); diplegia (n = 13); quadriplegia (n = 11).

MATERIALS/METHODS:: Inclusion criteria were: scheduled for SPML; diagnosis of CP; and GMFCS levels I-IV. Exclusion criteria were: concurrent boney or open muscle surgeries; diagnosis not CP; and GMFCS Level V. One surgeon identified the lower extremity muscles to be lengthened and performed SPML. Evaluation was carried out prior to, and at 3, 6, and 12 months post-SPML using the Gross Motor Function Measure (GMFM)-88, Activity Scale for Kids (ASK)p38, and 6 Minute Walk (6MWT). Post-op management included: soft knee immobilizer (24 hours/day x 3 days; during sleep x 3-4 months) for hamstrings/adductors; walking cast (4 weeks) for calf muscles; ambulation on the day of surgery; and individually designed PT intervention.

RESULTS: Clinically significant changes in one or more outcome measures were achieved by 27 of 29 subjects. GMFM-88: The mean change between visits 1 and 4 was +14 (range: 2 – 36.4). The 6 subjects with the smallest changes had the highest pre-op scores (92-99%). The GMFM Minimal Clinical Important Difference (MCID) was achieved by 25 of 29 subjects. ASKp38: The mean change in subject perception of abilities between visits 1 and 4 was +5.8 (range: −3.69 − 53.39). The ASKp38 MCID was achieved by 14 of 25 subjects. 6MWT distance: A clinically significant increase was achieved between visits 1 and 4 for 15 of 26 subjects. GMFCS: Eight subjects improved by 1 level.

CONCLUSIONS: Significant functional changes were reported in 27 of 29 subjects. The largest improvements occurred in those with diplegia or quadriplegia; GMFCS level II and III, and/or pre-SPML GMFM-88 scores of < 70. Qualitative individual reports include improved self-care and endurance, and increased freedom and spontaneity of movement.

CLINICAL RELEVANCE: The results of this study provide preliminary evidence of positive functional outcomes following SPML. Further investigation is warranted.


Kordick L, Fisher S, Fontaine K, Peck J, Kenyon LK, Shoemaker M, Grand Valley State University, Grand Rapids, MI

PURPOSE/HYPOTHESIS: Adolescents with cerebral palsy (CP) are less physically active and often participate in less structured and lower intensity activities than their typically developing peers. The purpose of this study was to examine the intensity of functional and recreational activities of younger ambulatory children with CP, as well as their manual dexterity and communication skills, and to relate the findings to typically developing children.

NUMBER OF SUBJECTS: 3 male participants with a medical diagnosis of CP, ages 9-11.

MATERIALS/METHODS: A RT3 triaxial accelerometer was worn for 2 school and 2 weekend days. The child and parent(s) completed an activity log and the CAPE/PAC participation/enjoyment measure. Each child was classified using the Gross Motor Function Classification System-Expanded & Revised (GMFCS), the Manual Ability Classification System (MACS), and the Communication Function Classification System (CFCS).

RESULTS: The classification results on GMFCS, MACS and CFCS were respectively: Child One – II, I, I; Child Two – I, I, II; Child Three – I, II, I. Child 1-3 reported high enjoyment for most of their activities and the majority of activities were performed with family and at home. All 3 reported the highest diversity, intensity and preference for recreational activities. The 3 children reported the lowest intensity for the physical activity category and the highest enjoyment for physical activity or skill-based activity. Participation in informal activities was more frequent than formal activities, and with a higher intensity. Child 1-3 demonstrated contrasting levels of weekday vs. weekend activity, yet all demonstrated total activity counts in school higher than after school. The 4 day total of hard/vigorous activity was 2 minutes for Child 1, 22 minutes for Child 2 and 59 minutes for Child 3.

CONCLUSIONS: All children reported lower intensity for physical activity in comparison to recreation, social, skill-based, and self-improvement activities. As expected, the child with more impairment (Child 1, GMFCS Level II) demonstrated a lower occurrence of hard/vigorous activity than Child 2 and 3 (GMFCS Level I). While all three children identified several preferred activities, many barriers prevented the children from actually completing these activities (e.g., season, community availability, feasibility and cost). Child 1 and 2 experienced higher activity counts during gym class, and Child 3 during a walking field trip, which identifies the benefit of scheduled, organized physical activity.

CLINICAL RELEVANCE: In comparison to typically-developing, age-matched peers, all three children demonstrated a much lower amount of time per day spent in hard or vigorous activity. If clinicians were provided with CAPE/PAC results which identified the child's preferences, home exercise programs that included the child's preferences may increase the child's amount and intensity of physical activity.


Kreger A, Fazio S, Wheeling Jesuit University, Wheeling, WV

BACKGROUND & PURPOSE: Interactive gaming has become increasingly popular through the years, especially with school age children. One such system is the Nintendo Wii. Taking an interest in a child's like for gaming can this be used as motivation to increase participation in physical activities for children with disabilities to help improve their health. Nintendo Wii EA Sports 2 was chosen as the intervention because of its versatility and ability to target the desired body systems of this study. This is a case study following an 8-year-old boy with a medical diagnosis of Neurofibromatosis (NF2) Type II and COPD.

CASE DESCRIPTION: The subject was an 8 year-old boy with NF2, COPD, and scoliosis. The Nintendo Wii system was used with the ES Sports 2 program with customized exercises to improve pulmonary function, strength and endurance in a setting in which his vitals could be monitored. The subject was instructed to perform the 20-30 minutes of activity 5 times per week. (Which was an increase in activity due to his not participating in regular gym class in school at this time.) Selected activities included: boxing, jogging/walking intervals, basketball drills of shooting/passing, bicycling, squatting, jump roping, and upper extremity isotonic exercises. A log book was created that that subject's grandmother and nurse were educated on/instructed to record daily game play, including length of time played, heart rate activity, and physical response to the activity. Prior to beginning the intervention, pulmonary function, resting heart rate (HRr), and upper extremity strength were taken and the 6-minute walk test (6MWT) administered to obtain baseline measurements. At the end of 12 weeks, the same measurements were taken again.

OUTCOMES: Endurance increased with the 6-minute walk test. No increases were seen in either FVC or FEV following 12 weeks of playing Nintendo Wii. (FVC/FEV readings may not have been sensitive to subject's pulmonary values due to air leakage around tracheotomy site causing false spirometry readings).) A decrease in HR was seen. Of the 28 muscle groups tested (14 on the left and 14 on the right), increases were seen in 18 muscle groups.

DISCUSSION: While many factors could have contributed to the outcomes of this study, the results support the use of the Wii as a possible alternative to physical activity in children with physical limitations. Given the variety of games available, a physical therapist, or a parent, can tailor game play to target the child's specific needs while considering his or her needs, whether it be strength, endurance, or balance, and provide a controlled environment in which amount and intensity of activity can be monitored. While all children can benefit from interactive video game activity, this is especially true for children with illnesses and disorders that prevent them from participating in other forms of activity. Gaming can be an age appropriate activity that enables a child to be a child, use his imagination and receive health benefits at the same time.


Lee S, Lee H, Sahmyook University, Seoul, Republic of Korea

PURPOSE/HYPOTHESIS: Attention-deficit hyperactivity disorder (ADHD) is one of the most common neuropsychiatric disorder of childhood. It is characterized by three core symptoms; developmentally/age inappropriate level of inattention, hyperactivity and impulsivity. Furthermore, ADHD have generally reported to have an excess slow wave activity (delta, theta) and decreased fast wave activity (alpha, beta) in electroencephalogram (EEG). A number of animal models have been suggested for ADHD. The Spontaneously Hypertensive rat (SHR), bred from the normotensive Wistar Kyoto rat, display behavioral characteristics of ADHD children (over-activity, motor impulsivity and poorly sistained attention). Stimulant medications, specifically, methylphenidate (MPH) has been used to manage ADHD symptoms. However, there are concerns about the long-term consequences of this drug, especially on the developing brain of children. Thus, there is currently substantial interest in developing alternative ADHD treatment, and also non-pharmacological approaches such as environmental enrichment (EE), etc.


MATERIALS/METHODS: The present study investigated the effects of EE, on alleviating ADHD-like behaviors in SHR as well as EEG waves. SHR were reared in EE or standard environment (SE) for four (4) weeks starting from post-natal 21 days (P21) to adolescent (P49) and then behavioral assessment (open-field test, object recognition test, Y-maze test) and EEG measurement followed.

RESULTS: A decreased distance moved and movement duration on the open-field test was observed in EE reared rats. Moreover, EE rats demonstrated improvement in object recognition (novel object recognition task) and spatial working memory (y-maze task) as compared to SE rats. Furthermore, EEG recording in the rat's frontal cortex indicated increase in beta and decreased delta frequency, in percentage of total power of EEG, which might indicate EE induced improvement in attention and memory.

CONCLUSIONS: Therefore, these results suggest that EE, during growth and development alleviate on the general hyperactivity, low cognitive performance and may also enhance dysfunctional brain activity in individuals with ADHD.

CLINICAL RELEVANCE: This study suggests that EE during the early stages of the neurodevelopment might be a possible physically therapeutic management for ADHD.


Lennon N, George A, Nemours AI duPont Hospital for Children, Wilmington, DE; Fragala-Pinkham MA, Franciscan Hospital for Children, Boston, MA; O' Neil M, Drexel University, Philadelphia, PA

PURPOSE/HYPOTHESIS: This study examined oxygen consumption (VO2), heart rate (HR) and metabolic equivalents (METs) in youth with cerebral palsy (CP) during daily activities. The purpose of the study was to identify aerobic capacity and demands of these activities for the participants and to examine the relationship among measures.

NUMBER OF SUBJECTS: Twenty-four youth with CP (average age = 12.04 years; SD = 2.7) participated in the study. Most youth were boys (58%); most (50%) had spastic diplegia; and most (50%) were at GMFCS level I (50%).

MATERIALS/METHODS: Youth participated in a 2.5 hour data collection session in the Gait Lab of a large Children's Hospital. Youth participated in a physical activity protocol consisting of nine activities at light intensity (resting and writing); moderate intensity (household chores; wiping counters and folding laundry); and moderate to vigorous intensity (two active video games and three 6 minute walk tests (6MWT) at comfortable/slow, brisk and fast speeds). During the activities the youth wore HR monitors and a portable indirect calorimetry unit.

RESULTS: Trends on all measures (HR, VO2, METS) suggest that aerobic demands increased across activities which validates the classification for activity intensity across the protocol. There were significant association between VO2 and METs for nearly all activities (r = 0.042 to 0.99; p = 0.041 to < .001). Significant associations between VO2 and HR were found for light to moderate intensity activities for VO2 and moderate activities for HR (r = 0.422 to 0.744, p = 0.04 to < 0.001). Significant associations between METS and HR were found for moderate intensity activities (r = 0.420 to 0.733, p = 0.041 to < 0.001).

CONCLUSIONS: Findings suggest that youth with CP have relatively high aerobic demands in moderate to vigorous activities and HR may be a good clinical measure to examine aerobic capacity and activity intensity.

CLINICAL RELEVANCE: Measuring intensity of daily activities in youth with CP helps to understand aerobic capacity and informs dosing PT interventions.


Lima-Alvarez CD, Tudella E, University Federal of São Carlos, São Carlos, SP, Brazil

PURPOSE/HYPOTHESIS: There is a lacuna in the literature about the development of kinematical parameters of head movement during the acquisition of head control in full term infants in the first months. This study aims to describe age-related changes head movements organization (structured) in time and space. We hypothesized that larger head movements will develop with age. Also, we predicted concomitant changes in movement organization.

NUMBER OF SUBJECTS: Eighteen healthy full-term infants (39±1.0 weeks gestational age), birth weight of 3,235 g (± 492.62) and Apgar scores of 9/10 in the 1/5 minute, were assessed monthly (newborn: 13 ± 3; 1-month: 32 ± 3; 2-months: 61 ± 3; 3-months 88 ± 2; 4-months: 121 ± 3 days). Local institution Human Research Ethics Committee approved this study, and parents gave written informed consent.

MATERIALS/METHODS: The infant was lying supine on a comfortable padded table with adjustable supports to straighten the infant's trunk. The infant was presented with a black and white card showing a happy face (10×10 cm) at eye level at a distance of 25 to 40 cm, that was manually moved in a sideways direction to elicit head movements, during 2 minutes. Three digital video cameras (60 Hz) recorded infants' head movements (two at 1.5m distance at 120° to the sides of the infant; one directly behind and above − 2.20m height). Three passive markers were attached to the infant's head (right and left zygomatic arches and at the superior parietal bone). The variables observed were rotation of head movement, number and duration of movement units and speed. The RM-ANOVA was applied, with an alpha level of .05.

RESULTS: An increase in rotation F(4, 48) = 10.5; P < 0.001, ηp2 = 0.84, and speed F(4, 48) = 10.0, P < 0.001, ηp2 = 0.76, of the head movement was observed between 2 and 3 months. Kinematic analysis also showed that head movements were organized in movement units that increased in number until three months of age, F(4, 48) = 7.45, P < 0.001, ηp2 = 0.80, but significantly decreased afterwards. This went together with an increase in the duration of the movement units, F(4, 48) = 5.25, P < 0.005, ηp2 = 0.88.

CONCLUSIONS: After two months head movements become larger and faster. In addition, it was shown that infants' head movements are organized into a basic structure - movement units. The decrease in the number of movement units together with an increase in their duration pointed to the head movements becoming more fluent or better controlled after 3 months of age. Finally, the most dramatic changes clearly occurred between 2 and 3 months of age, suggesting that this age represents an important milestone in the development of head control.

CLINICAL RELEVANCE: Based on the results of this study, is possible to orient the early interventions in at risk infants, aiming the acquisition of head to ages, to be developed at 2 and 3 months, once at this age was observed a rapid change in the kinematical parameters, representing a milestone in head control development.


Lowe LM, Ferguson JO, Yates, Charlotte C, University of Central Arkansas, Conway, AR

PURPOSE/HYPOTHESIS: Body weight supported treadmill training (BWSTT) is a task-specific method of retraining or, in children, developing gait. This method has been shown to be efficacious in the development of gait, improvements in strength, and improvements in gross motor function in children with Down Syndrome, Cerebral Palsy, and spinal cord injury but there are no studies investigating the use of BWSTT in children with a primary diagnosis of developmental delay (DD). This study examines the effect of a high intensity program of BWSTT on gait, postural control, and gross motor skill development in ambulating children with DD.

NUMBER OF SUBJECTS: Three independently ambulating children (one male and two females) age two to five years old with a diagnosis of DD and currently receiving direct physical therapy completed the pilot study. The children were excluded from participation if they were under consultation with a geneticist or neurologist, had a known metabolic disorder, or had a different primary diagnosis resulting in developmental delay.

MATERIALS/METHODS: In addition to their typical physical therapy protocol, the subjects received up to three, 15 minute BWSTT sessions per week. Over the course of 10 weeks, the speed, inclination, and time on the treadmill was increased gradually as each patient tolerated while the body weight support was gradually decreased to 0%. Also, manual, passive facilitation was gradually decreased and replaced with active subject movement with verbal cueing and cognitive demands. The subjects were tested using the 10 Meter Walk Test and Gross Motor Function Measure (GMFM) Sections D and E at baseline and following four, six, and ten weeks of BWSTT. Subjects had follow-up testing four weeks after cessation of training.

RESULTS: The subjects showed statistically significant improvements in self-selected walking speed as measured by the 10 Meter Walk Test {F (3.6) = 7.183, p < 0.05, multivariate partial eta squared = .782 with an observed power of 80.4%}. The subjects also showed statistically significant improvements in gross motor function as measured by GMFM-E {F (3.6) = 12.654, p < 0.05, multivariate partial eta squared = .864 with an observed power of 96.5%}. Pair-wise comparisons revealed an effect approaching statistical significance, p = .073, between Baseline and Four weeks BWSTT with a plateau for Six weeks BWSTT and Ten weeks BWSTT for GMFM-D.

CONCLUSIONS: The significant improvements in walking velocity and functional gains occurred at four or six weeks of training. All subjects demonstrated maintenance of gains in all areas at follow-up testing.

CLINICAL RELEVANCE: Body weight supported treadmill training is a safe, time-efficient, and clinically practical intervention. This study suggests that in conjunction with typical physical therapy treatment, BWSTT may assist children with DD in increasing their walking speed and functional skills. Additional research is needed to examine the use of BWSTT for ambulatory children with DD. Support: 5P20RR020146-09 and 8 P20 GM103425-09 from NIH.


Lowes LP, Alfano L, Batterson, Nancy, Mayhan M, Orr T, Tonneman J, Nationwide Children's Hospital, Columbus, OH; Case-Smith J, The Ohio State University, Columbus, OH

PURPOSE/HYPOTHESIS: Motor skills develop rapidly in the first 2 years of life, and through motor experience, infants develop a map of their body. Infants with hemiparetic CP may develop an incomplete or faulty map during this early period, and begin to demonstrate a disregard of the affected upper extremity. Early intervention has the potential to prevent unilateral disregard, improve movement in the affected upper extremity, improve the infant's development across domains, and long-term, increase his or her potential for independence in life skills. The evidence for Constraint Induced Movement Therapy (CIMT) effectiveness for infants and toddlers with unilateral cerebral palsy is minimal. This study evaluated the efficacy and safety of CIMT in infants ages 7-18 months of age.


MATERIALS/METHODS: A multiple baseline design was used with the subjects serving as their own controls. Following baseline assessments the subjects received 1 x/week therapy for one month. This was followed by one month of CIMT in which the infants received 2 hours of therapy and 1 hour of parent-implemented home program 5 days/week. The infants were casted for the first 23 days and bimanual therapy was provided for the last 3 days. For the final month, the infants returned to 1x/week therapy.

RESULTS: Mean fine motor scores for the more involved arm improved 2.2 +/− 1.8 points during usual care therapy and 4.2 +/− 1.8 points during CIMT. The constraint phase produced a statistically significant increase on the BSID Fine Motor Scale for the affected arm raw score (n = 5; t = −5.25; p = 0.006), indicating that the infants improved significantly more in CIMT intervention than usual care therapy. The Gross Motor Scale raw scores increased 1.0 +/− 1.7 points during “usual care” therapy and increased to 3.2 +/− 1.9 during the CIMT phase. This increased rate of acquisition was maintained during the follow-up month (3.0 +/− 1.9). The improvement for the Gross Motor Scale was significant for the CIMT phase (t = −3.0; p = 0.04) and the retention phase (t = −3.59; p = 0.023). The less involved arm did not decline in abilities.

CONCLUSIONS: This pilot study provides initial evidence that CIMT is feasible for infants with unilateral cerebral palsy and presents preliminary data for the efficacy of CIMT on fine and gross motor performance. The uninvolved arm continued to follow a normal developmental progression suggesting that casting an infants arm for one month is not detrimental to development.

CLINICAL RELEVANCE: Constraint induced movement therapy should be considered as a possible intervention for infants with hemiplegia.


Mathai A, Senesac C, University of Florida, Gainesville, FL

BACKGROUND & PURPOSE: The Berlin Heart is a mechanically driven pump that provides biventricular support for a pediatric patient. This ventricular assistive device (VAD) provides the opportunity for the patient to participate in mobility, ambulation and physical therapy. Implementing a multidisciplinary team approach, including physical therapy, may improve a patient's functional status pre-transplant and recovery post-transplant. The purpose of this case study is to describe the therapeutic intervention, including functional strength training and ambulation, utilized to improve endurance and mobility in a 14 year-old male following the placement of a Berlin Heart secondary to myocarditis.

CASE DESCRIPTION: The patient was a 14 year-old obese male presenting with acute viral myocarditis. A Berlin Heart VAD was implanted in response to severe heart failure. He later developed lower extremity compartment syndrome, foot drop and allodynia. Upon initial assessment, the patient was sedentary and unable to stand. Treatment included functional mobility and ambulation over the course of 5 weeks.

OUTCOMES: Pain, quality of life, quadriceps muscle strength, functional independence measure, and walking distance were assessed and used as outcome measures. Following physical therapy intervention, improvements were found in muscle strength, FIM score and walking distance. The patient reported 0/10 pain and began ambulating with stand by assistance and a rolling walker. The patient walked long distances following 4 weeks of treatment and we found that there was a clinically meaningful difference in quadriceps strength.

DISCUSSION: Future research should focus on establishing a more specific physical therapy protocol for the pediatric patient following placement of a Berlin Heart. Early activity and mobilization are key components in promoting postoperative heart transplant recovery. Outcome measures and parameters need to be established and defined in the hopes of providing patients with a better recovery following transplantation.


Mattern-Baxter K, California State University, Sacramento, Sacramento, CA

PURPOSE/HYPOTHESIS: Treadmill training (TT) has been shown to accelerate walking onset in young children with cerebral palsy (CP) with Gross Motor Function Classification System (GMFCS) I and II, however its effect is less clear in children with GMFCS level III. Furthermore, there is a lack of research on the coupled effect of botulinum toxin-A injections (BTX) in combination with intensive TT in this population. The purpose of this single subject research study was to examine the effects of an intensive TT protocol prior to and after BTX injections in a young child with spastic CP.

NUMBER OF SUBJECTS: A 31-month old boy with spastic quadriplegic CP, GMFCS level III, resulting from premature birth at 28 weeks complicated by periventricular leukomalacia. The child required maximal support for propulsion of a gait trainer at study onset, but was able to take steps when held on hands.

MATERIALS/METHODS: The child received 6 weeks of intensive home-based TT, where he engaged in TT twice/day, 5 days/week, for 6 weeks. After a wash-out period of 4 months, the subject received BTX in bilateral hamstring, hip adductor and gastrocnemius muscles, followed by a second trial of TT with the same 6-week protocol. Assessments were performed for each TT trial at pre-test, 6-week post-intervention and 1-month post-intervention. Outcome measures were the Gross Motor Function Measure (GMFM) Dimension D and E (blinded assessor), the 10-meter walk test (10MWT), cadence (number of steps in 10 seconds) and Pediatric Evaluation of Disability Inventory Mobility Domain (PEDI).

RESULTS: The child made most improvements in GMFM Dim D and E after the first trial of TT, improving by 13% and 9% respectively, but scores remained largely unchanged at each subsequent assessment. The child achieved independent walking in his gait trainer after the first trial of TT, and made continuous improvement in 10MWT and cadence during all subsequent assessments. However, walking speed and cadence accelerated after the second trial of TT compared to the first trial. The subject showed a 10-point improvement on the PEDI after the first TT trial, and showed a 4-point improvement after the second trial.

CONCLUSIONS: The results of this single subject study indicate that a young child with spastic quadriplegic CP with GMFCS III can benefit from intensive, home-based TT. Initial TT led to the ability to engage in meaningful walking with a gait trainer, but the effects of TT in combination with BTX led to accelerated changes in walking speed and cadence even in the absence of measurable changes on the GMFM in gross motor skills related to standing and walking.

CLINICAL RELEVANCE: Intensive home-based TT in combination with BTX injections maximized previously acquired walking ability in a young child with spastic CP with GMFCS III. Larger studies should be conducted to systematically examine intensive TT protocols and their effects on walking after BTX-A injection in the lower extremities in young children with CP.


McCoy SW, Fritz A, University of Washington, Seattle, WA; Chiarello L, Drexel University, Philadelphia, PA

PURPOSE/HYPOTHESIS: Physical therapists and families often place emphasis on improving ability to sit and reach in children with cerebral palsy (CP) as this should improve children's ability to explore and learn important cognitive and social skills. The relationship of these movement abilities to playfulness, participation and adaptive behavior in young children with CP, however, has not been examined. Our purpose was to examine this relationship. We hypothesized that higher sitting and reaching ability would be significantly related to greater playfulness, more participation, and more effective adaptive behavior.

NUMBER OF SUBJECTS: A sample of convenience of 64 children with CP, 18-24 months (mean = 20.4, SD = 1.9) across all Gross Motor Function Classification System (GMFCS) levels (I:16, II:15, III:8, IV:13, V:12), was evaluated. This was a secondary analysis of data collected for a larger study of the determinants of gross motor, self-care, and play in children with CP, entitled Move and PLAY.

MATERIALS/METHODS: As a part of the Move & PLAY study, trained physical and occupational therapists collected data on children within their homes or clinics and parents completed questionnaires. Therapists classified the children on the GMFCS and completed a battery of tests of impairments and gross motor ability. For this analysis we utilized therapists' results from the Test of Playfulness and the Gross Motor Function Measure (GMFM Basal and Ceiling method) and total scores from the parent-completed questionnaires, Early Coping Inventory and Child Engagement in Daily Life – Participation Section. Through examination of GMFM items, children were given a reaching and a floor sitting score based on the sum of the GMFM item scores related to reaching (3 items) and sitting (5 items). Spearman correlation coefficients were calculated between the reaching and sitting GMFM scores and overall playfulness, participation and adaptive behavior scores.

RESULTS: Reaching and sitting scores (rs = 0.83, p < .001) and playfulness and adaptive behavior scores (rs = 0.61, p < .001) were highly related. Participation was moderately related to adaptive behavior and playfulness (rs = 0.49, p < .001 and rs = 0.40, p = .001). Reaching and sitting were moderately related to playfulness (rs = 0.45, p < .001 and 0.50, p < .001, respectively) and adaptive behavior (rs = 0.42, p < .001 and 0.37, p = 003, respectively). Reaching and sitting showed small relationships to participation scores (rs = 0.24, p = .06 and 0.27, p = .03, respectively).

CONCLUSIONS: Reaching and sitting ability account for a significant but small amount of the variance in playfulness (r2 = .20 and .25) and adaptive behavior (r2 = .18 and .14) in young children with CP. Participation is a complex construct which is not as related to ability to sit or reach in this sample (r2 = .06 and .07).

CLINICAL RELEVANCE: Improving reaching and sitting ability should assist with increasing a young child with CP's playfulness and adaptive behavior. Improvements in participation will require focus on aspects other than just improvements in motor ability.


McWhorter WJ, Rocky Mountain University of Health Professions, Provo, UT; Hickman R, School of Allied Health Sciences, University of Nevada Las Vegas, Las Vegas, NV; Walker MC, Rocky Mountain University of Health Professions, Provo, UT

PURPOSE/HYPOTHESIS: The purpose of this study was to examine relationships and differences between motor proficiency, activity level, and parental activity level in children who are at a healthy weight and children who are overweight or obese.

NUMBER OF SUBJECTS: 44 children, 36 parents

MATERIALS/METHODS: Forty-four children (26 children at a healthy weight and 18 children who were overweight or obese) between the ages of 8-16 (BMI: 14.3-43.6 kg/m2) and 36 parents (BMI: 18.1-44.7) participated in this study. Children and parents wore StepWatch activity monitors (SAM) to measure activity levels over a 72-hour period. Several tests reflecting determinants of motor performance were also administered to all children including: 60 second half sit up test, Timed Up and Go (TUG) test, and 30 second sit to stand (STS) test.

RESULTS: Data analyses demonstrate several significant correlations between the SAM data of fathers to daughters and mothers to sons. A statistically significant difference was found between children at a healthy weight and children who are overweight or obese for percent time spent in high activity. Statistically significant differences were found between all three motor performance tests between children at a healthy weight and children who are overweight or obese.

CONCLUSIONS: Relationships between activity levels of parents and children suggest that children pattern their activity levels after their parents. More specifically, children and parents of opposite genders demonstrate stronger relationships in their activity levels than children and parents of the same gender. Differences were also found for all motor performance tests between children at a healthy weight and children who were overweight or obese, indicating that children at a healthy weight may be more motor proficient.

CLINICAL RELEVANCE: It is important for therapists to include parents, particularly those whose gender is opposite to the child's, when educating pediatric clients about increasing their activity levels. Training that focuses on improving motor performance may increase skill level, equipping and empowering overweight children to exercise at higher intensities to improve fitness.


Miles C, Cindy Miles & Associates, Whitehall, PA; Sweeney JK, Rocky Mountain University of Health Professions, Provo, UT; Ganley K, Northern Arizona University, Phoenix, AZ; Rauh MJ, Doctor of Physical Therapy Program, San Diego State University, San Diego, CA

PURPOSE/HYPOTHESIS: To investigate potential relationships between the diagnosis of torticollis and 1) time spent in positional devices, and 2) exposure to prone positioning.

NUMBER OF SUBJECTS: 300 children (birth to 24 months).

MATERIALS/METHODS: A case-control design was used with a convenience sample of 100 children with torticollis and 200 children without torticollis. Data collected included average time an infant slept, time spent in supine (sleep and non-sleep) or supine sitting devices, and non-sleeping time spent in prone. Using multiple logistic regression, adjusted odds ratio (AOR) estimates and 95% confidence intervals (CIs) were determined to examine the relationship between the diagnosis of torticollis and positional factors.

RESULTS: Eighty seven percent of all infants slept in supine. Infants with torticollis were approximately 5 times more likely (AOR: 4.48, 95% CI: 2.30-8.70) to sleep 10 or more hours and three times more likely to sleep 8-9.5 hours on average (AOR: 3.23, 95% CI: 1.69-6.19) than infants without torticollis. Compared to infants without torticollis, infants with torticollis were almost twice as likely (OR: 2.14,95% CI: 1.55-2.94) to have spent greater than 30 minutes per day in an infant carrier seat; greater than 30 minutes per day in an infant swing (AOR: 1.80, 95% CI: 1.28-2.53); greater than 120 minutes per day in an infant sitting device (AOR: 2.88, 95% CI: 1.35-6.15); greater than 180 minutes per day in supine non-sleep (AOR: 8.39, 95% CI: 3.86-18.25) and less than 15 minutes per day in prone (AOR: 2.09, 95% CI: 1.12–3.89). Parents of infants with torticollis were significantly more likely than parents of infants without torticollis to have reported they did not receive instructions from pediatricians to place the infant in prone position during non-sleep time (OR: 1.56, 95% CI: 1.12-2.16).

CONCLUSIONS: A significant association was found between factors related to infant positioning and the diagnosis of torticollis. Increased time in supine and/or supine sitting devices and decreased time in prone were associated with torticollis. Further research is necessary to: 1) explore cause and effect relationships between positioning and torticollis; and 2) determine the effects of education and intervention on the risk and management of torticollis.

CLINICAL RELEVANCE: Limiting time spent in supine and supine sitting devices and increasing time in prone may be critical strategies for preventing or managing torticollis. Pediatric health professionals should consider increasing emphasis on the importance of awake prone positioning while continuing to promote the safe sleep campaign.


Millard TL, Mehlferber J, Brady Brittany, University of North Georgia, Dahlonega, GA

BACKGROUND & PURPOSE: Quality of life and self-esteem are enhanced when children with severe disabilities are able to participate in age appropriate play activities alongside of typically developing peers. Riding tricycles is one way to enhance participation. While many models of commercially adapted tricycles are available, they are expensive and do not adequately accommodate children with severe motor issues. 3D printing allows the creation of a three-dimensional object that translates a virtual 3D computer model into a usable product. The process allows individualization of adaptive components quickly, easily and inexpensively providing an opportunity to meet the needs of a child with limited motor abilities.

CASE DESCRIPTION: An 11-year-old male, with spastic quadriparesis cerebral palsy, participated in this study. He was receiving physical therapy with goals for tricycle riding. He displayed decerebrate posturing at rest, communicated through eye blinks and was able to initiate random movement of all extremities. The long-term goal of the child's family was to promote participation in leisure activities. Limiting motor control problems included lack of trunk and head control; inability to grasp the handlebars; inability to sustain foot placement on the pedals and inability to maintain appropriate alignment of the lower extremities to pedal the tricycle. The adaptations available on the commercially adapted tricycle did not support the child and maximal assistance was required to cycle. A PT and an artist collaborated to create tricycle adaptations. An IPad camera was used to record the body parts.123 Catch software was used to process the collected photographs into a digital image. Blender 3D modeling software was used to create a polygon mesh to define the shape of a virtual 3D object. The naturalistic 3D scans were combined with geometric 3D modeling to create assistive devices that became an interface between the human body and the tricycle. A MakerBot Replicator 2 printer printed stereo lithography files. Several versions of each assistive device were printed and tested. Refinements to the designs were made to improve fit and function.

OUTCOMES: The final versions of the printed devices, two hand holds and two pedal boots, allowed the child to maintain a neutral hand position and appropriate foot and lower leg alignment. A 5 gallon bucket was fitted to provide trunk and head support. Total cost of the tricycle adaptations was less than $20. By locking the front fork to limit need for steering, once positioned the child was able to pedal his tricycle without assistance for 50 feet.

DISCUSSION: Results demonstrate that 3D printing can be used successfully to inexpensively customize tricycle adaptations for children with severe motor disability, enhancing participation in leisure activities. As new technology becomes available, physical therapists should explore and consider collaborative efforts with nontraditional venues to enhance the quality of life of individuals with disabilities.


Millard TL, Brown J, Cambron CM, Frey SA, Gardner MC, Lowe SW, Sherman AE, University of North Georgia, Dahlonega, GA

BACKGROUND & PURPOSE: The Bruininks-Oseretsky Test of Motor Proficiency, second ed. (BOT2), designed to assess fine and gross motor skills of children ages 4 to 21, is used to screen children for motor impairment, to assist in making placement or program adjustments and to evaluate the effect of motor interventions. The test evaluates fine manual control, manual coordination, body coordination, and strength and agility by scoring items such as running, hopping on one leg, balance activities, catching and throwing a ball and jumping in place. The items scored on the BOT2 reflect motor skills demonstrated by athletic young soccer players. The BOT2 was chosen to classify the impact of a training program to enhance the gross motor skills of a young soccer player because it is a good indicator of motor function and has a reported test-retest reliability of .80 in children between the ages of 8 to 12.

CASE DESCRIPTION: A ten-year-old typically developing male with pes planus participated in this study. The goals of parent and child were to improve soccer performance. The client received one session each of low-Dye taping, WBV, and taping with WBV. Outcome measurements included lower extremity ROM, strength, posture grid, BOT2 and Navicular Drop Test. Baseline measurements were established before the first intervention and before each intervention. Posttest measurements were taken immediately after each intervention. All measurements, including the BOT2, were completed 22 times in a seven-week period.

OUTCOMES: While results of the investigated intervention were statistically not significant, continual improvement in BOT2 scores was noted over the seven-week period, particularly in the running speed/agility and balance subsections. Improvement in soccer skills during game play was reported at study end by the child's parents.

DISCUSSION: The positive trend of BOT2 scores may demonstrate a learning effect and/or training effect of repeated test administration. Literature demonstrating test-retest reliability was based on two test administrations between 7 and 14 days apart. This is the first time that the BOT2 has been repeated 3 times a week for 7 weeks, effectively becoming an intervention to enhance soccer skills. Further investigation is required to determine the appropriate use of the BOT2 as a research tool to demonstrate improvement in gross motor skills and effectiveness of therapeutic interventions. An appropriate interval between testing sessions should be established.


Morsy MM, New York City Department of Education, Brooklyn, NY; Salem Y, Cairo University, Cairo, Egypt

PURPOSE/HYPOTHESIS: The use of whole body vibration (WBV) as a form of training has become increasingly popular over the last decade. Research examining the effects of WBV has suggested benefits related to a variety of outcomes; however, there is no review that synthesized research findings for children with cerebral palsy (CP). The purpose of this review was to examine the evidence concerning the effectiveness of WBV for improving bone mineral density in children with CP. Safety concerns, potential benefits and practical application are discussed.

NUMBER OF SUBJECTS: This is a systematic review of literature. We identified six studies for a total of 196 subjects.

MATERIALS/METHODS: Electronic databases and hand searches were undertaken to locate studies published in English. The databases searched included PubMed, PEDro, PMC, PsycBITE, and ProQuest. The key words searched were cerebral palsy, vibration therapy and bone density. The initial search resulted in a retrieval of a total of 362 potential articles. We screened those articles for duplicate and Inclusion and exclusion criteria.

RESULTS: After review, only six studies were identified that met the predetermined inclusion and exclusion criteria. Across all studies, a total of 196 children with CP were investigated. The sample size for each study ranged from 4 to 78 participants. Of the six studies, four studies were randomized controlled studies, one study was a retrospective study and one was case series. Five of the six studies (83%) reported that WBV resulted in significant improvements in bone mineral density. Studies showed improved bone density in the hip and tibia but not in the lumbar spine. Based on those studies, there was moderate evidence that WBV resulted in improvements in bone mineral density in children with CP.

CONCLUSIONS: The result of this review suggests positive effects of WBV on bone mineral density in children with CP. This result should be interpreted with caution given that the number of studies that examined the effects of WBV in children with CP is low. Moreover, study protocols have used widely variable WBV parameters. The optimal delivery and dose (intensity, duration and frequency) of WBV were not clear.

CLINICAL RELEVANCE: To our knowledge this is the first systematic review to examine the effects of WBV on bone mineral density in children with CP. Given the lack of mobility and weight bearing activities in children with CP, the use of WBV to prevent reduction and improve bone mineral density in children with CP is promising. The results of this review suggest positive effects of WBV on bone mineral density in children with CP. Regardless to the strength of evidence, most of the studies reviewed reported that WBV resulted in improvements in bone mineral density. Despite these improvements, the number of studies was limited. There is a need for more studies with a longer-term follow-up to determine if any gains are retained for long term. Additional studies are needed to determine safe and effective parameters for WBV in children with CP.


Murphy DA, Hillier A, University of Massachusetts Lowell, Lowell, MA

PURPOSE/HYPOTHESIS: Individuals with Autism Spectrum Disorders (ASD) typically present with social challenges and decreased motor function, and communication (Petrus et al., 2008). Evidence supports that individuals with ASD have a relatively inactive lifestyle compared to their peers, but can benefit significantly from physical activity (Sowa et al., 2012). The aim of the study was to examine the effect of physical activity on overall fitness in adolescents and young adults with ASD after a 9-week exercise program using qualitative and quantitative measures.

NUMBER OF SUBJECTS: 18 participants with an autism spectrum disorder completed the intervention program with an age range of 13-27 years. The average age was 17 years old. 16 participants were Caucasian, one Hispanic and one Asian.

MATERIALS/METHODS: The intervention program, “Fit and Fun”, consisted of nine weekly group exercise sessions. Pre and post fitness measures were taken on week one and week nine of the nine-week program. Measures assessing weight, BMI, strength, cardiovascular fitness, muscular endurance, and flexibility were used to evaluate the impact of the intervention. A focus group conducted with parents was held at the end of the intervention.

RESULTS: Pre and post fitness scores were statistically significant (p < 0.05) for positive changes in 3 of the 8 fitness measures. Focus groups with parents were analyzed for major themes using NVivo software. Parents noted the positive growth in social interaction as one of the most important outcomes of the program.

CONCLUSIONS: This study demonstrated that a short-term exercise intervention program can have significantly positive outcomes on levels of fitness on a range of fitness measures including strength and flexibility. Given the lack of opportunities for those with ASD to participate in community based programs, these findings have important implications for improving the health and well-being of those with ASD.

CLINICAL RELEVANCE: Additional research is indicated to evaluate the most effective mode and frequency for an exercise regimen for individuals with ASD. There is a need to compare the physical and psychological benefits of exercise for individuals with ASD as compared to the general population.


Murphy K, Bour B, University of Florida, Gainesville, FL

BACKGROUND & PURPOSE: Juvenile dermatomyositis (JDM) and juvenile idiopathic arthritis (JIA) are rare autoimmune disorders that cause aerobic deconditioning, decreased muscle strength and diminished quality of life. Literature demonstrates the benefits that children with each diagnosis receive from participating in structured exercise programs. Various protocols have been implemented in treating these diseases in isolation. Currently, no studies address the use of circuit training in a patient diagnosed with JDM and JIA in the context of overlap syndrome and mixed connective tissue disease (MCTD). The purpose of this case study is to compare the outcomes when utilizing standard physical therapy versus an endurance-based circuit training program in the treatment of a child diagnosed with overlapping JDM and JIA.

CASE DESCRIPTION: A 10 year-old female with previous diagnoses of polyarticular JIA, JDM, and MCTD presented to physical therapy with significant impairments in cardiovascular and musculoskeletal endurance. Six sessions of standard physical therapy (SPT) and 5 sessions of circuit training physical therapy (CTPT) were implemented over 6 weeks. Outcomes were assessed before SPT, after SPT/before CTPT and after CTPT. Outcome measures included: the BOT-2 Strength Subset, lower extremity flexibility SLR test, Childhood Myositis Assessment Scale (CMAS), Ten-Meter Walk Test (10mWT) and PedsQL 3.0 Rheumatology Module Scales.

OUTCOMES: The total CMAS score exhibited a clinically meaningful 1.5 to 3 point improvement following SPT. Clinically meaningful improvements were not observed in the remaining outcome measures for SPT or CTPT. However, greater improvements in lower extremity flexibility occurred following CTPT. Additionally, the patient increased CTPT duration with each respective session.

DISCUSSION: The results of this case study demonstrate the potential benefits of utilizing CTPT to treat patients with JDM and JIA. The subject participated in longer sessions of CTPT with fewer rest breaks required. This finding could translate to increased bouts of playtime for the child. Prior rehabilitation in the SPT mode, a school break and scheduled infusions may have affected the patient's CTPT performance. A case series comparing SPT to CTPT with more rigorous criteria for exercise selection and progression would be beneficial in future research.


Neumann CE, Parikh R, Patel J, Sammons E, Allen A, Lema Y, Morales M, Zintl C, Physical Therapy, Touro College, Bay Shore, NY

PURPOSE/HYPOTHESIS: Little data exists regarding Clinical Instructors' (CIs) views about their roles in students' affiliations. The purpose of this qualitative retrospective study is to examine pediatric school-based CIs' perspectives and how these views are translated into action. The hypotheses were that, through analysis of interviews, common themes would be identified, that the themes would be influenced by the specific practice setting and that they would parallel APTA documents.

NUMBER OF SUBJECTS: Eight female CIs in school-based pediatric sites

MATERIALS/METHODS: In-person, tape-recorded, semi-structured interviews were conducted by a team with each CI. There were nine open-ended questions and one close-ended question encompassing five major categories. The questions stemmed from the culminating question, based on reflection upon previous answers: “What are your most important roles as a CI?” The typed, de-identified transcripts were thematically analyzed by another team, using operational definitions established in previous phases of the study in different practice settings. In order to increase reliability of the coding process, a separate team of investigators re-analyzed each transcript to confirm consensus of thematic codes assigned. A Demographic Form completed by each CI was quantitatively analyzed.

RESULTS: These researchers concurred with themes assigned previously. Using the established Operational Definitions, five key themes emerged based on the high frequency of response, as well as being discussed by all CIs. The most common themes were Clinical Competence (28%), Instruction/Supervision (15%), Intrapersonal Skills/Attributes (14%), Communication/Interpersonal Skills (11%) and Patient Characteristics & Response (9%). Additionally, a new theme, Resourcefulness, emerged, reflecting the need for intuitive flexibility in this setting. Six of the 8 CIs believed that their setting (pediatric school-based) influenced how they answered the interview questions. Three of eight CIs were APTA members; 4:8 were CI credentialed.

CONCLUSIONS: The leading theme addressed by CIs in the school-based setting is clinical competence, operationally defined as ‘the ability to apply one's knowledge efficiently and effectively and to consistently convey the desire to expand one's knowledge'. The top five themes that emerged in the study stressed team communication throughout a wide variety of school settings, and understanding the many perspectives of interacting with children and families. The key themes were consistent with all Core Values, notably ‘Excellence' and ‘Accountability' and correlated to 4 of the 5 of the CPI's Red Flag criteria; Safety was not a key theme. In addition, the CPI criteria of “Professional Development' was frequently addressed.

CLINICAL RELEVANCE: The study highlights the need for academic and clinical collaboration in delineating performance objectives for a specific setting. Students entering pediatrics and CIs new to their role can benefit by evaluating the study's CIs' perspectives and expectations.


Nunez-Gaunaurd A, Miami Dade County Public Schools, Miami, FL; Roach KE, Kirk-Sanchez NJ, Moore JG, Physical Therapy, University of Miami, Miami, FL

PURPOSE/HYPOTHESIS: Self-efficacy is an important correlate of physical activity. It has also been found to be associated with motor proficiency scores among children. Overweight children tend to demonstrate lower actual and perceived physical competence when compared to non-overweight children. Although BMI is currently the recommended clinical screening tool to assess body composition in youth, it has apparent limitations, especially among groups of different ethnicities. As an alternative, Waist to Height Ratio (WHtR) has gained significant acceptance as a routine screening and assessment tool for overweight and obese children. The aim of this study was to determine the utility of the waist/height ratio WHtR in the assessment of physical activity self-efficacy and motor proficiency in middle school students.


MATERIALS/METHODS: A convenience sample of 54% healthy-weight, 23% overweight and 22% obese middle school students were enrolled. Students participated in an after-school fitness and physical activity screening. BMI percentiles were calculated based on age and gender specific criteria. The BMI percentile categories (normal, overweight, and obese) were further stratified for comparison on the basis of WHtR (<0.5, no central obesity versus ≥ 0.5, central obesity). Motor Proficiency and Physical Activity Self-Efficacy was assessed using the Short Form Bruininks-Oseretsky Balance Test (BOT2) and the Children's Self-Perception of Adequacy in and Predilection for Physical Activity Scale (CSAPPA). An independent T-test was applied to examine differences in BOT2 performance and CSAPPA responses between students with and without central obesity. Pearson product-moment correlations were computed to examine relationships between WHtR, motor proficiency and self-efficacy.

RESULTS: Students were an average of 12 years old, 55% male, and 92% Hispanic, and 53% had central obesity. Students who were overweight/obese with central obesity demonstrated lower BOT2 standard scores and self-efficacy total scores when compared to their peers without central obesity, (40.93 vs 45.25, p = .033 and 63.24 vs 72.13, p < .001). Among students with central obesity, WHtR was significantly associated with increased deficiencies in motor proficiency and self-efficacy, (r = −.77, p < .001) and (r = −.63, p < .0001).

CONCLUSIONS: Middle-school youth who classify as overweight/obese and have central obesity may be at a greater risk for motor proficiency deficiency and decreased self-efficacy. In youth with central obesity, WHtR is moderately correlated with motor proficiency and physical activity self-efficacy.

CLINICAL RELEVANCE: The results suggest that a supplemental measure such as WHtR may assist in identifying youth at risk for impaired motor proficiency and lower physical activity self-efficacy. Clinicians should consider including WHtR as routine screening and assessment of overweight and obese children.


Oebser AB, Hussey EE, University of Wisconsin - La Crosse, La Crosse, WI; Waerzeggers E, St. Vincent Hospital, Green Bay, WI

BACKGROUND & PURPOSE: Persistent toe walking behavior can interfere with motor development. To address idiopathic toe walking with spasticity or contractures, Botulinum toxin (Botox) injections followed by serial casting has been successfully used to improve joint range-of-motion (ROM) and support improved balance and gait. Typically, serial casts are non-removable, a factor that prevents skin cleaning and assessment until the cast is removed. At this clinic, therapists have adopted the use of a removable soft serial casting that allows for skin inspection while retaining the desired casting position. The purpose of this report was to assess the potential benefit of using removable soft serial casting as an alternative to non-removable serial casting.

CASE DESCRIPTION: Two children with toe walking behavior were referred for serial casting 6-7 days after receiving Botox injections. Each child was evaluated for appropriateness of casting before initial application and repeated measures of passive ankle ROM and spasticity on the Modified Tardieu Scale (MTS) were completed before each weekly recasting. Casts were fabricated using 2 layers of Soft Cast with Primacast dorsally between layers, then bisected anteriorly to provide the removability and wrapped with Coflex to maintain closure during use. Prescribed dosage was to wear the casts for 23 hours per day with removal only for skin assessment, cleaning, and special activity.

OUTCOMES: Outcomes included compliance to dosage, parent satisfaction, passive ROM and MTS, and assessment of balance and gait. Nine casts were fabricated for the 2 children over 27 days. In both children, passive dorsiflexion end-ROM (R2) increased by > 15 degrees and there was a reduced spastic catch (R1). Parents reported excellent compliance with the prescribed dosage, with only one 2-hour exception for a special event. The rating of satisfaction was “very good” to “excellent.” One minor skin issue was documented and resolved with padding without incurring any change in dosage. After casting, both children achieved heel contact during gait and demonstrated an ability to perform single leg stance bilaterally with heel contact.

DISCUSSION: Removable soft serial casting may be a feasible alternative to non-removable casts, showing comparable benefit in ROM gains and spasticity reduction, a low risk of complications that could be easily detected and addressed, high dosage compliance and satisfaction ratings. The children made functional gains in balance and gait, but some of this may reflect developmental progress and the use of more quantitative pre-post measures could improve this functional assessment. Removable soft serial casting may be as effective as non-removable serial casting methods and may be superior in allowing for skin inspection and improved satisfaction ratings. Additional research is needed to compare efficacy as well as to address the cost-benefit analysis.


O'Grady MG, Dusing, SC, Virginia Commonwealth University, Richmond, VA

BACKGROUND & PURPOSE: Problem-solving behaviors change as infants learn new motor skills. Previous research has suggested the importance of assessing changes in problem-solving as a result of motor interventions. Some problem-solving assessments allow use of a variety of assessment positions. The purpose of this study was to quantify problem-solving abilities in a child with motor delays in two positions: lying on the floor and sitting with manual support. It is hypothesized that position will influence the validity of a problem-solving assessment for this child.

CASE DESCRIPTION: The subject was an 18 month-old female who was unable to sit independently. She was hypotonic in the trunk and hypertonic in all extremities. Her motor skills were consistent with Gross Motor Function Classification System level IV. Her Gross Motor Function Measure score was 27.3.

OUTCOMES: The Early Problem-Solving Indicator (EPSI) section of the Individual Growth and Development Indicators was used to quantify problem-solving during two visits completed one week apart. During each visit, problem-solving was assessed in two positions. The first position was lying on the floor for 2 minutes in supine and 4 minutes in prone. The second position was sitting for 6 minutes with the minimum manual support necessary to enable her to maintain sitting while interacting with the toys. For each testing occasion, the EPSI was administered using a standard toy set and testing protocol with consistent ordering of subtests. The frequency of problem-solving behaviors defined in the EPSI (look, explore, function, solution) was scored from video by a reliable researcher. The total EPSI score was compared between lying on the floor and sitting. This child demonstrated more problem-solving behaviors in sitting (41 and 42) than on the floor (31 and 29) on each of the testing days – an increase of 32% on day one and 45% on day two. Qualitatively, the subject's arms and hands were freed to reach, her visual attention to the toys improved, and she was more active and motivated to explore the toys in sitting.

DISCUSSION: Supported sitting was a more valid indicator of problem-solving than lying on the floor for this child. In supported sitting, her perception changed, and she had fewer biomechanical constraints which enabled her to demonstrate her problem-solving more fully. A secondary comparison of problem-solving behavior frequencies for this child in prone and supine is also discussed. Therapists who plan to assess changes in problem-solving over time should utilize the same positions for each assessment because position alone may be an important determinant of problem-solving behaviors in a child with motor delays. Further research is needed to determine if sitting consistently allows a larger sample of children to display more problem-solving behaviors than lying on the floor. Additional studies will help to determine how problem-solving changes coincide with position changes in children with motor delays.


O'Loughlin A, Lauer R, Temple University, Philadelphia, PA

PURPOSE/HYPOTHESIS: To outline possible treatment strategies for improving gait in child with Cerebral Palsy (CP). This Critical Appraised Topic (CAT) examines the best evidence based intervention to improve gait in children with Cerebral Palsy. There has been growing research in support of vibration therapy to improve gait parameters in other populations. There has also been moderate evidence to support the use of hippotherapy in improving gait parameters in children with CP. Because vibration therapy and hippotherapy work by a similar mechanism the purpose of this research was to examine the effectiveness of each intervention and to determine if gait improvements could be elicited by more cost effective and practical option of vibration therapy.

NUMBER OF SUBJECTS: The six articles included in this study have 158 subjects age 5 or older with various forms of CP.

MATERIALS/METHODS: A literature search was conducted using PubMed, CINAHL, and PEDro. Articles that were included had subjects with spastic cerebral palsy, used vibration therapy or hippotherapy as an intervention, included objective gait outcome measures, and was published within the past 10 years. Articles were excluded if they reported surgical intervention, pharmaceutical intervention, botulinum toxin injection, only examined effects on upper extremities, or included subjects with additional neurological disorders. Six articles were included in this CAT.

RESULTS: The vibration studies showed improvements in gait parameters in 2 out of the 3 articles included, however there were no significant differences in GMFM scores. In the hippo therapy studies 2 out of 3 demonstrated improvements in gait parameters and GMFM scores, specifically dimension D and E.

CONCLUSIONS: Hippotherapy and Vibration Therapy were studied in conjunction with conventional physical therapy therefore improvements are not mutually exclusive. It cannot be determined that vibration therapy is superior to hippotherapy in improving gait parameters, however vibration therapy studies are preliminary and promising. Hippotherapy does not show immediate improvements after a single session, but 5 to 12 weeks of hippotherapy intervention elicits statistically significant improvements.

CLINICAL RELEVANCE: There is currently no clear consensus in prescription or effectiveness of intervention, thus future research is needed. Intervention should be based on best clinical judgment, patient preference, & availability of resources to determine best treatment.


Ollendick KM, Wilfley L, Noonan C, Scales MH, Scow S, Brown L, Carolina Institute for Developmental Disabilities and Division of Physical Therapy, University of North Carolina at Chapel Hill, Chapel Hill, NC

PURPOSE: Medical advances have greatly improved the life expectancy of individuals with intellectual and developmental disabilities (IDD). As a result of this increase in lifespan longevity, there has been an unprecedented expansion in the population of aging individuals with IDD. The aging process of an individual with IDD presents with similar clinical challenges to that of the general elderly population with injurious falls being a serious issue of concern in both populations. The purpose of this special interest report is to investigate the incidence, risk factors, and causes of falls among the aging population of individuals with IDD to assist in determining the most appropriate physical therapy based interventions for this population.

DESCRIPTION: A local private, non-profit organization that provides living and vocational options as well as an array of related supports to people of all ages with IDD identified a need for a falls assessment and reduction program for their residents. Currently this organization serves a population of over 120 adults and children in 16 residences and a retirement community. As an initial step in creating a falls prevention program for older adults with IDD, a thorough retrospective analysis was deemed necessary. This retrospective information gathering will be completed via review of medical charts as well as caregiver, medical team, and client interview. The information gathered will be used to document the incidence of falls among clients, identify the causes of falls among clients, identify and categorize clients' falls risk factors into medical, physical, and cognitive domains, and identify common themes in falls histories of individuals with IDD.

SUMMARY OF USE: Based upon the findings from this retrospective analysis of falls incidence, risk factors, and causes of falls among the aging population of individuals with IDD future steps will be determined for the creation of the most appropriate falls assessment protocol and falls prevention program for individuals with IDD.

IMPORTANCE TO MEMBERS: As the lifespan of individuals with IDD continues to increase, completion of standardized falls assessments and implementation of successful falls prevention programs will be essential. Identification of falls incidence, risk factors, and causes is the first step in the successful development and implementation of appropriate physical therapy based intervention programs.


Olzenak DL, University of Rochester, Rochester, NY; Nolan K, Ithaca College, Rochester, NY; Hyman S, Fernandez D, van Wijngaarden E, University of Rochester, Rochester, NY

PURPOSE: The World Health Organization defines participation as involvement in life situations resulting from interactions within an individual's social and physical environments. In children, participation is an essential component of development that influences long term mental and physical health. Autism spectrum disorder (ASD) profoundly affects an individual's ability to relate and reciprocally interact with peers within their environment and therefore children with ASD are at considerable risk for limited participation in everyday activities. Although ASD is not considered a syndrome with obvious motor deficits, emerging evidence supports the presence of motor impairments; coordination and motor planning deficits are regularly recognized clinically in children with ASD. Fundamental motor and active play skills are practiced through peer interaction. Gross motor skills become progressively more complex during school age requiring a higher level of coordination, planning, and body awareness. In addition to impaired social skills, motor deficits may be an important contributor to poor motivation for activities involving peer interaction, decreased participation, and increased inactivity. Few studies have investigated the extent to which impaired motor proficiency in ASD may impact physical activity, participation and well-being. A comprehensive theoretical framework that can be utilized in research and clinical practice is lacking.

DESCRIPTION AND SUMMARY OF USE: To address this gap, we propose a theoretical model to determine the role motor proficiency plays in physical activity and overall participation, and its relationship to health. The model is adapted from the International Classification of Functioning, Disability and Health, and is expanded to examine the relationship of motor ability in physical activity and overall participation in children with ASD. Specifically, our model provides a testable mechanism by which motor proficiency may impact participation, and describes the potential long term health consequences associated with impaired motor proficiency and lack of participation. Furthermore, the model takes into consideration primary clinical features of ASD that are universally recognized and may impact participation. It also accounts for the family, social and health care characteristics that are important for the identification and management of ASD. Finally, we propose specific validated assessment tools and statistical approaches to further refine this framework and demonstrate its application.

IMPORTANCE TO MEMBERS: Participation is a multi-faceted phenomenon, and the role of motor proficiency is often overlooked in ASD. The proposed model will assist research and clinical practice in describing the relationships between motor proficiency, participation, and overall health in children with ASD. Knowledge of these relationships may prioritize motor assessment in this population, provide insight into appropriate interventions, and improve the long-term health outcomes for children with ASD.


Oriel KN, Lebanon Valley College, Annville, PA; Kanupka JW, Lebanon Valley College, Annville, PA; Himmelberger B, Janke B, Repoley M, Lebanon Valley College, Annville, PA

PURPOSE/HYPOTHESIS: The purpose of this study was to explore the impact of participation in an aquatic exercise program on behavior in children with Autism Spectrum Disorder (ASD).

NUMBER OF SUBJECTS: Participants included 11 children diagnosed with ASD, including 7 males and 4 females (mean age: 6.6 years).

MATERIALS/METHODS: This study used a mixed methods design. Quantitative data was collected using the Pervasive Developmental Disorder Behavior Inventory (PDDBI) at pre and post test, while qualitative data was collected through a parent focus group discussion at the completion of the aquatics program. The aquatic exercise program was held 2X/week for four weeks, and consisted of a variety of age appropriate exercises.

RESULTS: Statistically significant improvements (p < 0.05) were observed in behavior following exercise using paired t-tests in 6 of 10 subtests on the PDDBI, including: sensory/perceptual approach behaviors, ritualisms/resistance to change, semantic/pragmatic problems, arousal regulation problems, specific fears, and aggressiveness. Statistically significant improvements (p < 0.05) were also observed in 3 of 5 composite scores including: repetitive, ritualistic, and pragmatic problem behaviors composite, approach/withdrawal problems composite, and Autism composite. Results of the parent focus group discussion substantiated the improvements observed on the PDDBI, with parents specifically reporting improved sleep, improved transitions between tasks, decreased stereotypical behaviors, and an improved ability to follow directions following aquatic exercise.

CONCLUSIONS: The results of this study suggest that participation in an aquatic exercise program may lead to improved behavior in children with ASD.

CLINICAL RELEVANCE: Aquatic exercise should be considered as an intervention by physical therapists working with children with ASD, as it may provide a safe and effective means to improve behavior.


Oriel KN, Lebanon Valley College, Annville, PA; Kanupka JW, George C, Lebanon Valley College, Annville, PA; Dunkes B, MacDonald M, Scola J, Sherman K, Lebanon Valley College, Annville, PA

PURPOSE: Girls with physical disabilities have fewer opportunities for participation in community-based exercise programs than their peers without disabilities. The purpose of this project was to provide girls with physical disabilities an opportunity to participate in fitness activities in an age-appropriate, non-threatening environment.

DESCRIPTION: A community-based exercise program for girls with physical disabilities was developed and implemented jointly by faculty and students in the department of physical therapy and teacher education at a small liberal arts college. The exercise program consisted of walking/jogging on an indoor track, a group activity (alternating between Zumba, yoga, line dancing, and swiss ball activities), and strengthening in a fitness center. The program was held 1X/week for 8week, with each session lasting one hour. The participants in the exercise program included 4 girls with physical disabilities, with a mean age of 16 years. The girls were recruited through teachers and related services providers in local schools. The impact of the program on quality of life, self-concept, and participation and enjoyment were measured at pre and post-testing using the PedsQL, Piers-Harris 2 Self-Concept Scale, and The Children's Assessment of Participation and Enjoyment (CAPE).

SUMMARY OF USE: This project provided an opportunity for community-based participation for girls with physical disabilities. The participants were able to engage in age-appropriate exercises that were individually modified as necessary. The exercise modifications made for each participant allowed for individual success with each program activity. In addition to providing the participants with an opportunity for community-based exercise, they were also able to socialize with their peers in a setting outside of the school environment.

IMPORTANCE TO MEMBERS: Pediatric physical therapists have the expertise to design and implement community-based programs for individuals with disabilities who often have few existing opportunities for such participation. By specifically targeting girls with physical disabilities, we have the potential to empower an at risk group of individuals.


Paleg G, Physical Therapy, Montgomery County Public Schools, Silver Spring, MD; Glickman LB, Physical Therapy and Rehabilitation Science, University of Maryland, Baltimore, MD; Smith BA, Neurology, Oregon Health & Science University, Portland, OR

PURPOSE: The purpose of this presentation is to use case examples of two children with cerebral palsy to illustrate evidence-based clinical decision making for the dosing of supported standing programs.

DESCRIPTION: Supported standing programs have been implemented for decades in a variety of settings and for multiple purposes, yet there is limited information on effective dosing at a practical level. To determine the basis for various programs, we extracted evidence from a systemic review of the literature between 1954 and 2012, with categorization according to the ICF framework (Child and Youth version). Within the limited evidence, the greatest impact from supported standing programs was on bone mineral density, hip stability, and range of motion. We then created clinical guidelines based on existing evidence and expert clinician opinion (Paleg, Smith and Glickman, Pediatric Physical Therapy, in press). Here, using a case-based approach, we will describe the clinical decision making process for the dosing of supported standing programs for two children with cerebral palsy. We will then discuss several programmatic considerations, including the mode, frequency, duration, and intensity of supported standing programs in relation to goals and desired outcomes.

SUMMARY OF USE: The use of supported standing programs appears universal; however, lack of formal guidelines contributes to considerable variability and inconsistencies. We will discuss the application of evidence-based clinical guidelines to determine the dosing of supported standing programs within the context of professional clinical judgment and client/caregiver goals and preferences.

IMPORTANCE TO MEMBERS: This topic is important to members because the evidence for supported standing programs is somewhat limited and variable in strength. Information from this platform, both process-related (clinical decision making) and from the practical side (case example details) will have direct application to therapists working in a variety of pediatric settings including the home and recreational environments. It is a unique and innovative topic because we take a practical approach and provide concrete examples for the cases with guidelines for applying the principles to other cases.


Peyton C, Conrath E, University of Chicago Medical Center, Chicago, IL; Adde L, Department of Laboratory Medicine, Women and Children's Health, Norwegian University of Science and Technology, Trondheim, Norway; Fjørtoft T, Clinical Services, Physiotherapy Section, St Olaf University Hospital, Trondheim, Norway; Støen R, Department of Laboratory Medicine, Women and Children's Health, Norwegian University of Science and Technology, Trondheim, Norway; Schreiber MD, Msall ME, University of Chicago Medical Center, Chicago, IL

PURPOSE/HYPOTHESIS: Early identification of neuromotor impairments, including cerebral palsy, in high-risk infants during the first year of life is notoriously difficult but essential for supporting families and accessing supports. Our purpose was to track early motor developmental performance of high-risk preterm infants using Prechtl's Generalized Movement Assessment (GMA), the Alberta Infant Motor Scale (AIMS), and the Test of Infant Motor Performance (TIMP).

NUMBER OF SUBJECTS: Subjects: 27 infants born at <32 weeks gestational age (GA) with a birthweight <1500 g were recruited from a regional university hospital neonatal intensive care unit that serves a perinatal network of 20,000 births per year.

MATERIALS/METHODS: At 10 to 15 weeks post term age, infants were tested with the TIMP and video recordings were obtained and classified based on absent (FM-) or present (FM+)FMs using Prechtl's approach At 12 months adjusted age, motor development of each infant was assessed with the AIMS. All testing was administered by experienced testers.

RESULTS: Only 3 of 27 infants had abnormal findings on the GMA, the TIMP and the AIMS. 9 infants demonstrated absent FM-. 5 infants scored in the abnormal range on the TIMP (1-2 SD below mean); 6 of 27 infants had abnormal AIMS scores (<5th percentile).

CONCLUSIONS: Early motor trajectories are quite dynamic and require sequential assessments.

CLINICAL RELEVANCE: FMs and TIMP may provide valuable early developmental biomarkers for understanding difficulties in both early motor skills as well as their adaptive correlates. Further longitudinal investigations examining biological risk, CNS structural and functional connectivity, fidgety movements, neuromotor performance, and long term gross, fine, and oral motor control, and adaptive competencies are required.


Pratt B, Crone C, Waxman L, Department of Physical Therapy, Bradley University, Peoria, IL

PURPOSE/HYPOTHESIS: To describe the physical activity patterns of ambulatory children with disability during discrete segments of the school day.

NUMBER OF SUBJECTS: Four children with disabilities, aged 4 to 10 years, who ambulated without an assistive device. Diagnoses represented were cerebral palsy (2 participants), spina bifida, and encephalopathy/seizure disorder.

MATERIALS/METHODS: Using a cross sectional design, each participant wore a StepWatch monitor for 5 school days to document their step activity patterns including daily total step count, percentage of time inactive, and percentage of time in low, medium, and high activity levels. The attributes of the school day that influence physical activity was documented using behavioral mapping, an observation method of collecting data on target behaviors and their environments simultaneously. Descriptive statistics were used for data analysis.

RESULTS: Means for step activity patterns during the school day were 5,287 steps/day, 85.1% time inactive, 11.8% time in low activity, 3.12% time in medium activity, and 0.85% time in high activity. For participants educated in more inclusive settings, physical activity was lowest during classroom desk time and highest during physical therapy, transitions between classrooms, and recess. For participants educated in segregated settings, physical activity was lowest during lunch/nap time and highest during free time or adaptive physical education.

CONCLUSIONS: The participants in this study accrued between 34 and 55% of the recommended steps per day guidelines for their gender and age. The majority of their physical activity was in the low activity range (0-15 steps/minute). When examining the results as the interaction between each participant's health characteristics, personal factors and the environment, information emerged that may guide future clinical practice and research.

CLINICAL RELEVANCE: Pediatric physical therapists, especially those in school settings, are in a unique position to support and develop the physical activity behaviors of children with disabilities. Daily physical activity patterns should be a part of the assessment and intervention of children with disabilities because of the importance of regular physical activity for health.


Qualls KK, Student Support Services, Department of Physical Therapy, Matanuska-Susitna Borough School District, Palmer, AK; Arnold S, McEwen IR, Jeffries L, Department of Rehabilitation Sciences, The University of Oklahoma Health Sciences Center, Oklahoma City, OK

BACKGROUND & PURPOSE: Children who are unable to participate in outdoor physical activity, such as those with primary Raynaud's disease (PRD), must find alternative exercise solutions to minimize their risk for obesity. However, climate conditions may restrict opportunities for outdoor physical activity; contributing to reduced fitness, decreased health related quality of life (HRQL) and associated health conditions, which may include obesity. Development of physically active video games such as the Nintendo® Wii Fit and Wii Fit Plus (Kyoto, Japan) may encourage children to be physically active indoors. The purpose of this case report is to describe the use of the Nintendo® Wii Fit Plus as an alternative exercise for a child with PRD and obesity who was not involved in organized sports and had limited outdoor physical activity.

CASE DESCRIPTION: The child was a 12-year-old female, living in Alaska, and diagnosed with PRD at birth. She stayed indoors when the temperature dropped below 25°F to reduce the risk of frostbite. The child was eager to try the Wii Fit Plus and her goals were to lose weight, strengthen her legs, and to find an indoor exercise she enjoyed. Using the Wii Fit Plus, she began with yoga stretches (5 min.), followed by strengthening (15 min.), balance games (15 min.), and aerobic exercise (20 min.). She concluded with yoga cool down stretches (5 min.). The total minutes were gradually increased until she reached 60 minutes per session, 5 sessions per week for 24 weeks.

OUTCOMES: During the 24-week Wii Fit Plus exercise program, the child grew 3 cm and her final BMI was 27.9, greater than the 97th percentile. Her time to complete the one-mile Rockport Fitness Walking Test (RFWT), developed by Kline et al. (1987), decreased 12.4% to 14 min 53 s and her estimated relative VO2 max increased to 44.0 ml/kg/min. At 24 weeks and out of 100 points possible, the child's total score on the PedsQL™ 4.0 (Varni, Seid, & Kurtin, 2001) was 94.6, physical health summary score was 100, and psychosocial health summary score was 91.7. At 24 weeks and out of 100 points possible, the child reported, on the PedsQL™ Multidimensional Fatigue Scale (PedsQL™ MFS) (Varni, Limbers, Bryant, & Wilson, 2010), a total fatigue score of 98.6, a general fatigue score of 100.0, a sleep/rest fatigue score of 100.0 and a cognitive fatigue score of 95.8. She exercised 88.3% of the recommended five days per week and described 71.7% sessions as moderate intensity and 22.6% sessions as maximum intensity exercise.

DISCUSSION: Physical therapists who provide services to children who are obese and have health conditions that limit physical activity often need to find creative solutions for children to engage in age-appropriate exercise. The Wii Fit Plus gaming system provided the child an indoor exercise program that she could complete throughout the winter months. The findings from this case report suggest that the Wii Fit Plus may have been an effective exercise strategy for this child to decrease her BMI, increase her cardiorespiratory fitness and increase her HRQL.


Rieber C, Dalebout M, Campbell K, Kahn C, Looper J, University of Puget Sound, Tacoma, WA

PURPOSE/HYPOTHESIS: The ability to coordinate limb movements is essential for infants to develop movement patterns and sets the foundation for meeting motor milestones. Research indicates typically developing (TD) infants learn to control and coordinate their legs in space through spontaneous supine kicking (Thelen & Smith, 1994). Supine kicking in infants mimics the joint kinematics seen in walking and with repetition infants can build neuromuscular connections to strengthen these patterns (Jeng, 2004). For infants with Down syndrome (DS), motor and cognitive development is considerably delayed in comparison to children with TD. Children with DS walk 1 year later in comparison to infants with TD and exhibits significantly diminished motor skills, including supine kicking (Ulrich & Ulrich, 1995). A previous anti-gravity kicking study using the Fisher-Price® Kick and Drive Gym found significant increases in supine kicking in infants with DS compared to infants who did not use the toy (Lloyd & Ulrich, 2006). The Kick and Drive Gym provided visual and auditory feedback to promote kicking however it was discontinued. Therefore, this study used the Fisher-Price® Discover ‘n Grow Kick and Play Piano Gym which facilitates kicking by providing auditory reinforcement. The purpose of this study was to determine if an 8 week supine kicking intervention for infants with DS using the new kicking toy would yield similar results. We hypothesized that the replacement toy would be as effective at increasing spontaneous kicks as the previous toy.

NUMBER OF SUBJECTS: Six infants with DS, between the ages of 4 and 10 months entered the study.

MATERIALS/METHODS: Participating families received a kick toy to use at home. Parents were instructed to place the infants under the toy for 10 minutes per day, 5 days per week, for 8 weeks. At entry and every 2 weeks for a total of 5 visits, the infant's spontaneous supine kicking was videotaped for 5 minutes in our lab. Researchers analyzed the kicking activity to determine whether the kick toy was effective in increasing the amount of spontaneous anti-gravity kicks.

RESULTS: The mean number of spontaneous kicks at pretest was 13(SD 7) and 14(SD 13) at visit 5. One-way repeated measures ANOVA compared the quantity of spontaneous kicks over the 5 visits. There was no significant change over time (p = 0.27).

CONCLUSIONS: Results indicate that this 8 week kicking intervention using the Fisher-Price® Discover ‘n Grow Kick and Play Piano Gym is not effective at increasing supine spontaneous kicks in infants with DS.

CLINICAL RELEVANCE: A previous study indicated that a kicking toy, which elicited auditory and visual feedback, effectively increases anti-gravity leg movements. That toy was discontinued. This study shows that its replacement, which offers only auditory feedback, is not effective at increasing spontaneous kicking in infants with DS. All kick toys do not lead to increased kicking. Therapists who want to use an at-home intervention to increase kicking in their patients with DS should consider the toy carefully.


Rivera M, Physical Therapy Department, Samuel Merritt University, Oakland, CA; Theis R, Wilson M, Graduate Program in Physical Therapy, University of California San Francisco/San Francisco State University, San Francisco, CA

PURPOSE/HYPOTHESIS: Crawling is a complex task involving leg and arm strength, body posture and limb control. Currently clinicians lack measurable and observable facets such as crawling velocity, head posture, rests or pauses and limb coordination to categorize crawling behaviors. Furthermore, there have been no studies systematically investigating crawling characteristics in atypical motor development. The purpose of this study is to characterize prone mobility features in typically developing (TD) infants and infants with myelomeningocele (MMC), and to compare the effect of crawling experience in these two groups.

NUMBER OF SUBJECTS: The subjects included 88 TD infants with a mean age of 8.9 months and five infants with MMC with a mean age of 15 months.

MATERIALS/METHODS: Infants were videotaped crawling on a 2.4-meter mat leading to the caregiver. The caregiver was instructed to encourage the infant to crawl using physical gestures and verbal cues. Caregiver diaries helped determine developmental history and extent of crawling experience. Each infant was analyzed using the Xilisoft Movie Maker 6 program at 10 frames per second. Velocity was assessed using NERO 11 program at 29.97 frames per second. Two video coders independently coded for crawling velocity, initiation time, body posture, limb mode, head posture, and number of pauses in each trial.

RESULTS: The TD infants demonstrated variability in velocity with a range of 0.0129 meters per second to 0.4689 meters per second. Age and crawling velocity displayed a moderate positive correlation (r = 0.36) and crawling velocity and crawling experience showed a strong positive correlation (r = 0.434). The influence of body posture on velocity was evident with belly crawlers exhibiting a mean of 0.0949 meters/second and hands and knees crawlers demonstrating 0.1881 meters/second. Limb coordination also influenced velocity with single limb advancement displaying 0.1231 meters/second and a reciprocal limb pattern demonstrating 0.2369 meters/second. The infants with MMC showed slower mean velocity with belly crawling showing 0.045 meters/sec and the reciprocal limb pattern revealing 0.1650 meters/sec. Infants with increased crawling experience showed a reduction in the amount of pauses/rests while crawling across the mat.

CONCLUSIONS: Age and crawling experience demonstrated a positive correlation with crawling velocity. Velocity increases were observed as limb coordination progressed from belly crawling to single limb support to a reciprocal pattern. Infants with SB demonstrated increased pauses during crawling trials, indicating potential differences in crawling capability and/or attentional deficits.

CLINICAL RELEVANCE: This study provides preliminary information on crawling characteristics in TD infants and infants with MMC. This information can guide physical therapists when providing therapeutic programs for infants with motor disability.


Ronan S, Butler S, Kirkup C, Morello E, Physical Therapy, New York Medical College, Valhalla, NY; Manente N, Physical Therapy, Mount Sinai Medical Center, New York, NY; Ramirez J, Physical Therapy, White Plains Hospital, White Plains, NY; Sproviero N, Physical Therapy, Elizabeth Seton Pediatric Center, Yonkers, NY

PURPOSE/HYPOTHESIS: The purpose of this study was to measure the functional balance and clinical vestibular responses of children with Autism Spectrum Disorder (ASD) stratifying by a scale that measures autism severity.

NUMBER OF SUBJECTS: 10 male subjects 9 to 20 years of age (mean age 15.1 years) participated in testing.

MATERIALS/METHODS: Subjects were recruited from an educational setting for school age individuals with ASD excluding individuals with confounding diagnoses or the presence of a seizure disorder. The primary teacher for each subject completed the Gillian Autism Rating Scale-2 (GARS-2) for autism severity using the three subscales of stereotyped behaviors (SB), social interaction and communication. Balance testing was conducted using the Pediatric Balance Scale (PBS) and clinical vestibular testing using the Pediatric Clinical Test for Sensory Interaction of Balance (P-CTSIB).

RESULTS: 10 subjects, 9 to 20 years of age (mean age 15.1 years) participated in testing. GARS index scores ranged from 15 (less severe) to 122 (more severe) with a mean of 80.5. Clinical vestibular testing had the greatest variability in the subjects' ability to comply with instructions to close their eyes, or maintain their head in a desired test position. All subjects were able to participate and complete the PBS. Total PBS scores ranged from 31 to 56 with a mean of 45. GARS-2 and PBS total and item scores were analyzed using Pearson correlations. Findings indicate that children with higher stereotyped behavior (SB) scores had decreased scores on the PBS (p = .001). There were no correlations with communication or social interaction and the PBS. Single leg stance correlated with overall PBS score (p = .016). Children with higher PBS scores were able to participate in a greater number of vestibular testing. Children with a higher GARS score were unable to participate in the forward reach component of the test.

CONCLUSIONS: The results of this pilot study suggest that children with ASD who score higher in stereotyped behaviors had worse balance as measured using the PBS. Children with ASD may have more success in complying with functional standardized balance testing. Vestibular and balance testing requiring eye closure and or manual placement of the head in space may be difficult for the child to tolerate or perform. Standing on one leg, (SLS) may be an indication of overall performance on the PBS.

CLINICAL RELEVANCE: This is the first study to examine the relationship between stereotyped behaviors and balance issues in children with ASD using clinical measurements of balance. The results of the pilot data suggest that children with ASD who present with more frequent and severe stereotyped behavior may have impairments in balance. Additionally, children with ASD may be able to complete and cooperate with balance and vestibular testing that is functional, such as the PBS. Clinicians may find value in using standing on one leg as an indication of the child's overall balance.


Rushing C, Luker L, Alford A, Swank C, Texas Women's University, Dallas, TX

BACKGROUND & PURPOSE: Lissencephaly is a rare brain formation disorder caused by defective neuronal migration during the 12th-14th weeks of gestation and results in the cerebral cortex lacking gyri and sulci. Symptoms of the disorder may include unusual facial appearance, difficulty swallowing, failure to thrive, muscle spasms, seizures, and severe psychomotor retardation. Due to rare nature of this disorder, there is a lack of evidence related to physical therapy intervention for patients with lissencephaly. This single case design investigates the effectiveness of early physical therapy intervention for a pediatric patient with lissencephaly.

CASE DESCRIPTION: AA is a 14-month old male with a diagnosis of lissencephaly who presented with decreased trunk and lower extremity strength, hypotonia, hypermobility, decreased reflexes, delayed gross motor skills, and decreased visual attention to the environment. Additionally, AA was medically managed with Onfi which is an anticonvulsant medication to control seizures to prevent further regression in functional abilities. Outpatient physical therapy services were initiated at 9 months of age at a frequency of 2x/week for 45 minute sessions. Therapy sessions included therapeutic activity, neuromuscular re-education, and family/caregiver education. Specific treatment focused on postural stability using Neurodevelopmental Technique (NDT). As AA progressed, adaptive equipment, including a stander and supportive pediatric wheelchair, were introduced to improve impairment in the body/structural, function, and participation domains of the International Classification of Functioning (ICF).

OUTCOMES: Initial Peabody Developmental Motor Scale-II (PDMS-II) age equivalents at 9 months of age for both the stationary and locomotion categories were 3 months. Upon re-examination at 17 months of age, PDMS-II age equivalents for the stationary and locomotion categories were 6 months and 5 months, respectively. More specifically, AA was able to improve his function by being able to roll independently in multiple directions, sit independently for >1 minute, and beginning to maintain quadruped positions. He was also able increase his participation by standing in the standing frame for >30 minutes while reaching and interacting with the environment.

DISCUSSION: Fifty percent of children with lissencephaly have a lifespan of 10 years with a motor developmental equivalent to 3 to 5 months of age. In this case, AA's functional gains surpassed these prognostic indicators. These findings suggest that early physical therapy intervention may be beneficial to improve functional abilities, as well as quality of life for a pediatric patient with lissencephaly. However, more research should be done to further investigate the potential benefits of physical therapy intervention in this population.


Sabovich S, Wong L, Grant-Beuttler M, Physical Therapy, Chapman University, Orange, CA

PURPOSE/HYPOTHESIS: Between 4-6 years of age, children learn to integrate somatosensory input into their vision reliant approach for standing balance. With increased reliance on the somatosensory system, it is important to understand the role the ankle joint plays in postural control. The purpose of this study is to examine balance skills using the three sensory systems (vision, somatosensory, and vestibular) in normally developing 5-year-old children.

NUMBER OF SUBJECTS: 114 5-year-old subjects (53 boys; 61 girls), with mean age 5.1 years, mean height 44.6 inches, and mean weight 45.1 pounds.

MATERIALS/METHODS: Each subject had their muscle tendon unit measured and performed three 10- second trials of the mCTSIB on the Balance Master System. Sway velocity and center of gravity alignment during the three trials were recorded. Muscle tendon unit measurements of A0 and AMax were obtained using a goniometer and passively dorsiflexing the subject's ankle. A0 represents the measure of a taut gastrocnemius/soleus tendon and relaxed muscle belly. AMax represents the measure of a maximally stretched muscle tendon and belly. Muscle extensibility was calculated as A0- AMax. Sensory system sway velocity ratios were calculated using the best performance in each mCTSIB condition. The visual system is represented by the ratio of foam eyes open/firm eyes open, when the somatosensory system is inaccurate. The somatosensory system is represented by the ratio of firm eyes closed/firm eyes open, when vision is removed. The vestibular system is represented by the ratio of foam eyes closed/firm eyes open, when the visual and somatosensory systems are both inaccurate. Handedness data was also recorded for 73 subjects (9 left handed; 64 right handed). Descriptive statistics and Pearson correlations were calculated using SPSS.

RESULTS: Of the sensory system sway velocity ratios, the somatosensory system was the lowest (1.218 degrees/sec ±1.704) and the vestibular system was the greatest (2.763 degrees/sec ±1.006). Significant correlations were found for subjects who sway more when relying on vision with A0 (r = −.270, p = .046) and A0-AMax (r = .284, p = .036). Significant correlations were also found for hand used to throw/write and COG alignment in vision dependent mCTSIB conditions.

CONCLUSIONS: A smaller A0 and greater muscle extensibility correlate with children who sway more when the somatosensory system is inaccurate. These children may seek sensory information from the muscle tendon unit for balance control. A relationship was observed between hand use and balance control when somatosensory is inaccurate and vision is predominantly used. Further research is needed to confirm and explain this relationship between balance and hand dominance.

CLINICAL RELEVANCE: Clinicians should consider including A0 as a standard objective measure for 5-year-olds. Understanding factors affecting balance will help clinicians determine areas for early treatment intervention. Sensory system sway velocity ratio norms can be used for early detection of sensory system dysfunction in children 5 years of age.


Scala MT, NEU College of Professional Studies, Northeastern University, Boston, MA; Paez A, LEND Fellow in Neurodevelopmental Disabilities, Adjunct Professor, Northeastern University, Boston, MA

BACKGROUND & PURPOSE: Parents of children with cerebral palsy (CP) often pursue single event, multilevel orthopedic surgeries in order to correct impairments of body structure and function (BS&F) hoping to improve activity and participation (A&P). Strength training (ST) has been shown to improve motor activity in children with CP. The purpose of this case study is to: describe the effects of a short term, intensive lower extremity ST program on assistive device use with ambulation and demonstrate improvements at the BS&F level can be detected as A&P improvements using pediatric assessment tools available to clinicians with limited resources.

CASE DESCRIPTION: A male student with CP, pre-surgically at Gross Motor Function Classification System (GMFCS) level II, underwent bilateral femoral derotation osteotomies and hamstring lengthening procedure at age six. He received school based physical therapy (SBPT) services prior to the surgery, focused on acquisition of gross motor skill and independent function. Six months after surgery he functioned at GMFCS level III, and FMS level 2 at all distances: 5, 50 and 500 yards, requiring use of a posterior rolling walker. The student attends a school with expertise serving children with special needs, with a goal of moving to a regular education setting the next school year. Six months after his operation his SBPT program increased to include 3 hours/week of progressive, resistance strengthening exercises (PREs) over a 12-week period. His lower extremity PREs utilized the Therasuit program universal exercise unit equipment: pulleys and sandbag weights.

OUTCOMES: Hand held dynamometry for muscle force was the primary outcome measurement at the BS&F level of the International Classification of Functioning, Disability and Health (ICF) model. The School Function Assessment (SFA) was the primary participation-level outcome measure and the Functional Mobility Scale (FMS), Distance Walk Test-line leader (DWT), and Timed up and Go (TUG) served as secondary outcome measures at the A&P levels. The Pediatric Quality of Life Inventory (PedsQL) survey of both child and parent was used to support participation changes through self assessment. The student's GMFCS level was determined pre-surgically, before, and after the 12 week physical therapy strengthening program. At the conclusion of the program, the student demonstrated gains in muscle strength (p = 0.000), and progress to GMFCS level 1, FMS level 6.

DISCUSSION: This case report describes the use of practice patterns to develop a PT diagnosis in the school based setting. We further explore the improvements experienced at the BS&F level. We describe how they influence the student's subsequent improvements in A&P, detecting them using easily accessible tools commonly found in SBPT settings.


Selby-Silverstein L, Mitchell KL, Hanley S, Marchincin RL, Medley-Keith M, Physical Therapy, Neumann University, Aston, PA

BACKGROUND & PURPOSE: Custom foot orthoses (CFOs) have been shown to affect gait in young children with bilateral flat feet (Leung et al, 1998), heel alignment and gait in children with Down Syndrome (DS) (Selby-Silverstein et al, 2001) and function in a child with hydrocephalus (George et al, 2007). SureStep supramalleolar orthoses (SMOs) improved gross motor function in ambulatory children with DS (Martin et al, 2004), but in prewalking infants with DS Looper et al, 2010, found that DAFO SMOs slowed gross motor development with a trend toward faster gait acquisition. In 2012, Looper et al reported decreased cadence and greater cycle time in children with DS wearing DAFO SMOs compared with barefoot (p = .04), and greater cycle time (worsening gait) while wearing SMOs compared to wearing DAFO foot orthoses (FOs) (p = .05). Also, DAFO FOs decreased (improved) cycle time compared to DAFO SMOs (p = .05). Taminga and Martin (2012) compared SureStep SMOs to DAFO 4 SMOs for 2 children with DS. Gross motor function was better wearing SureStep SMOs in both, and wearing DAFO 4 SMOs in one child. Effects of CFOs have not been compared to prefabricated FOs. The purpose of this case study was to compare CFOs to two prefabricated FOs (DAFO Fast Fit Chipmunk and Crickett®).

CASE DESCRIPTION: A 35 month old ambulatory male child with heel eversion posture and gross motor delay was referred for FOs. Heel bisection lines were photographed through a machined Plexiglas grid barefoot, and wearing the three pairs of FOs. Data were collected using the Parotec inshoe plantar pressure measurement system. The Peabody Developmental Motor Scales 2 (PDMS2) locomotor section and Gaitrite data were collected in shoes alone and in CFOs at baseline. Four months later, Gaitrite and PDMS2 data were collected in the CFOs again.

OUTCOMES: The DAFO Cricketts® were not tolerated. DAFO Chipmunks improved heel alignment more than CFOs. Higher medial than lateral heel pressure was seen standing in sneakers alone. Heel pressure was lateral on the left and medial on the right in Chipmunk FOs. Heel pressure was equal or higher laterally than medially in CFOs. Medial heel pressure was higher walking in sneakers alone. Heel pressure was higher medially than laterally and toe walking was induced in Chipmunk FOs. Heel pressure was equal medially and laterally or higher laterally walking in CFOs with maintained heel contact time, so, CFOs were dispensed. In CFOs, immediate narrowing of base of support but detrimental effects of other temporal spatial gait parameters was seen. After 5 months, all gait data improved over baseline. PDMS2 scores were the same at baseline and after 5 months, representing a lack of progression.

DISCUSSION: Long term gait findings were better than initial findings in CFOs. Since this is only one subject, and there were a number of intervening variables, (i.e. inadvertent therapy stoppage when starting FOs), it is unclear if the PDMS2 finding was the result of FOs. These questions warrant study in a long term group design.


Simpson D, Rehabilitation Services, Good Samaritan Hospital, Cincinnati, OH; Morress C, Department of Occupational Therapy, Xavier University, Cincinnati, OH

PURPOSE/HYPOTHESIS: Approximately 12% of infants in the United States are born preterm each year. With continuous improvements in mechanical ventilation and the limit of viability continuously being pushed, the long-term motor development of these infants who often require prolonged mechanical ventilation must be studied. The results of these studies will help to determine best therapy practices both in the hospital and post-discharge. The purpose of this study is to examine the relationship between the time a former premature infant spends on mechanical ventilation after birth and motor development at five to seven months and fourteen to sixteen months adjusted age.

NUMBER OF SUBJECTS: The study aims to enroll 150-200 subjects. The results presented here are based on a midway data analysis of 83 children to examine trends in the data.

MATERIALS/METHODS: Participants are recruited to participate in the study while undergoing a routine developmental evaluation at either five to seven months or 14-16 months adjusted age. Following consent, a retrospective chart review is completed to determine length of mechanical ventilation and to record other birth history information. Children are then further subdivided into groups based on the total length of mechanical ventilation. The Peabody Developmental Motor Scales-2nd Edition (PDMS-2) is then used to assess fine and gross motor development, as well as, determine a standard score for overall motor development.

RESULTS: Preliminary results of the data analysis show that Total Motor Quotient (p = .023) and Gross Motor Quotient (p = .023) is significantly different between infants who require less than 7 days of mechanical ventilation and those who require more than 14 days of ventilation. Fine Motor Quotient and length of time of mechanical ventilation was not significant at this midway analysis. The fine motor, gross motor, and total motor development of those infants who spent between 7 and 13 days on mechanical ventilation were not found to be correlated with the length of ventilation. Data analysis was not completed on the 14-16 month adjusted age group at this time, as there are only 9 infants in this group.

CONCLUSIONS: The preliminary results of this study indicate that infants who require mechanical ventilation for longer periods of time have lower standard scores in the Total Motor Quotient and Gross Motor Quotient of the PDMS-2 at five to seven months adjusted age. The lack of significance in the Fine Motor Quotient may be related to the overall lack of fine motor skill development that is expected at this age.

CLINICAL RELEVANCE: The preliminary results of this study support the need for therapy services in the Neonatal Intensive Care unit, enrollment in Early Intervention services and frequent physical therapy assessments for former preterm infants who required extended periods of mechanical ventilation.


Singh B, California State University, Fresno, CA; Yack J, Physical Therapy and Rehabilitation Sciences, University of Iowa, Iowa City, IA; Janz K, Francis S, Health and Sports Studies, University of Iowa, Iowa City, IA

PURPOSE/HYPOTHESIS: The purpose of this study is to determine how cardiorespiratory fitness and fatigue influence gait biomechanics in obese children (aged 8-11 years). The unique aspect of this project is the examination of cardiorespiratory fitness (an attribute) and cardiorespiratory fatigue (a temporary state), in obese children and the association with physical performance (gait biomechanics). It was hypothesized that gait biomechanics, as measured by hip and knee moments, will be inversely related to cardiorespiratory fitness in obese children, in a non-fatigued state. Secondly, introduction of cardiorespiratory fatigue will be associated with an increase in gait biomechanical measures compared to the non-fatigued condition.

NUMBER OF SUBJECTS: 30 obese children.

MATERIALS/METHODS: Thirty children aged 8-11 years (9.8+/− 0.9) with BMI above 95th percentile (96.1+/− 4.1) volunteered for the study. Infra-red emitting markers were applied to the lower limbs, pelvis, and trunk segments. Anatomical bony landmarks were digitized to generate subject specific link based biomechanical models. Gait evaluations were conducted along an 8 m walkway using a 3D motion analysis system (Optotrak, NDI) and force plates (Kistler Instruments). Cardio-respiratory fitness was assessed using an 8-minute submaximal Nemeth treadmill protocol. A 15 m PACER protocol was used to fatigue subjects. Walking biomechanics was assessed prior to and immediately following the fatigue activity.

Visual 3D software (C-Motion) was used to obtain, right side, peak hip and knee moments normalized to body weight for five walking gait cycles, pre/post fatigue. Paired t-tests (p < 0.05) were performed to determine differences in peak hip and knee moments. Regression analysis was performed to determine association between fitness and moments.

RESULTS: Cardiorespiratory fitness assessed as V02 max by Nemeth protocol was 35.3 +/− 6.5 (range 24.13 to 49.1)mL/min/kg. During the PACER fatigue protocol subjects completed an average of 17.5+/− 8.5 (range 4-45) laps. The peak hip and knee adduction moments showed moderate associations with fitness levels (r = 0.52 and 0.54 respectively). Hip and knee extensor moments showed weak relationship with fitness level (r = 0.22 and 0.18 respectively). Following fatigue there was a significant increase in the knee adduction moments (p = 0.01), knee extensor moments (p = 0.02) and hip extensor moments (p = 0.01).

CONCLUSIONS: The results showed a weak to moderate inverse relationship between cardiorespiratory fitness and gait biomechanics, as measured by hip and knee moments. Furthermore, the hip and knee extensor and knee adduction moments increased after fatigue. This may have implications for participation in physical activities and long-term effects on the musculoskeletal system.

CLINICAL RELEVANCE: This study provides information on how the level of fitness and fatigue might affect the response during clinical evaluations in obese children. This might have implications in clinics, where deviant or injury prone gait patterns may not be present when obese children are briefly examined during an unfatigued state.


Smith B, Horak FB, Oregon Health and Science University, Portland, OR

PURPOSE/HYPOTHESIS: Our overall goal is to use full-day monitoring with small movement sensors to determine quantity, type and quality of infants' leg movements and differentiate typical, delayed and impaired developmental trajectories. Our specific goal here is to establish a typical developmental trajectory for quantity of infants' leg movements from birth through walking onset.

MATERIALS/METHODS: We collected a full day (ranging from 8-13 hours) of leg movement activity from 12 typically-developing infants, ages 1 to 12 months. Infants were measured 3 times each, with 2 months between measurements. Gyroscope data (rate of rotation) were collected at 20 Hz from sensors attached to the front of the right and left ankles. We low-pass filtered the data at 4 Hz and defined a kick as a leg movement of 30 degrees/s of total rotation sustained for 0.4 s.

RESULTS: Preliminary analysis shows that the overall kicking rate increases with age, from approximately 215 kicks/h at 1 month of age to 430 at 5 months and 500 at 8 months. When adjusted for percent of awake time, preliminary analysis still shows increased kicking activity with age; infants produce approximately 250 kicks per hour of awake time at 1 month of age, 500 at 5 months, and 700 at 8 months. Infants show a preference for moving one leg more often than the other; average percent difference in quantity of kicks between the legs ranges from 1% to 12%, with 10/12 infants preferring to move their right leg more often than their left.

CONCLUSIONS: It is feasible to collect full-day movement monitoring with small gyroscope sensors attached to infants' legs across the first year of life. Preliminary analysis shows that we are able to detect age differences in kicking quantity, as well as potential early limb preferences. We will continue to validate the sensor-obtained data, relate leg movement trajectories to developmental milestones, and expand to assess infants with or at risk for neurodevelopmental disorders.

CLINICAL RELEVANCE: Very early identification of impaired infant neuromotor control is necessary for initiating and targeting early therapeutic intervention to promote optimal development. Full-day assessment is desirable due to high inherent variability in infant performance and temperament.


Smith CR, Roberts A, Physical Therapy, University of Tennessee at Chattanooga, Chattanooga, TN

PURPOSE: The purpose of this review was to compare the effectiveness of conservative treatments to correct. nonsynostotic cranial deformities in infants.

DESCRIPTION: PubMed, CINAL, APTA, PEDro, and ERIC databases were searched. Articles were restricted to the English language. Search terms included positional, deformational, occipital, nonsynostotic, plagiocephaly, flat head syndrome, orthotic, positioning, repositioning, therapeutic, helmet, conservative, nonsurgical, treatment, intervention, outcome and result. Citation tracking was also conducted to identify additional studies regarding conservative treatment of cranial deformities. Duplicate titles were omitted from the final search. Two independent reviewers selected articles to be reviewed based on predetermined inclusion and exclusion criteria. Critique strength of research design was determined using the Methodological Items for Non-Randomized Studies (MINORS) assessment tool. Of the 108 articles originally identified, nine articles were selected for inclusion in this review.

SUMMARY OF USE: Four of the articles compared repositioning to helmets, two assessed helmets alone, two studied the effectiveness of positioning devices, and one assessed the effect of physical therapy. The majority of research supports the implementation of repositioning and/or physical therapy as soon as a cranial vault deformity is identified in a young infant. Helmet use is supported for infants of at least 6 months of age, regardless of severity. For younger infants, repositioning is reserved for mild cases and helmets for moderate to severe cases.

IMPORTANCE TO MEMBERS: An increase in prevalence of nonsynostotic cranial deformities has been noted in recent years. However, no official recommendations or guidelines are available regarding when treatment is warranted, the gold standard of treatment, or the appropriate sequencing of available treatment. This systematic review identified age and severity as the two primary confounding factors influencing choice of treatment and the ensuing success of the intervention in correcting cranial deformities. When considering severity, repositioning and/or Physical Therapy intervention is supported to treat mild cases of nonsynostotic cranial deformity, while orthotic treatment is reserved for moderate to severe cases. When considering age, most of the studies assessing the use of helmets supported the implementation of orthotic intervention if the presenting infant is five to six months old or older.


Smith CR, Breter M, Hemmingsen M, Sinquefield A, Physical Therapy, University of Tennessee at Chattanooga, Chattanooga, TN

PURPOSE/HYPOTHESIS: To compare the reliability of three non-invasive clinical instruments in quantifying head shape variability in young infants.


MATERIALS/METHODS: Three trained examiners used the following instruments to measure head shape variability in infants less than 12 months post conceptual age (PCA): a) craniometer caliper, b) “Head's Up” (trademark) band, c) flexicurve ruler. Examiners were blinded to the measurements obtained from the calipers to reduce bias. Reliability for all instruments was assessed. Parents of the infants recruited to participate completed a brief questionnaire to obtain demographics, prone positioning experience, nursery orientation and birth history.

RESULTS: Intraclass correlation coefficient calculations (SPSSv18) confirmed excellent inter-rater reliability between examiners when using the craniometer calipers (>0.80) and strong reliability when using the flexicurve (0.70 − 0.80). However, the examiners felt the Flexicurve ruler demonstrated potential for error when removing the ruler from the infant's head to photograph the marker band. A Pearson r was calculated to examine correlation of the cranial index measurement for the craniometer caliper and heads Up instruments. Excellent correlation was demonstrated between these two instruments for all measures except the left diagonal which showed only moderate agreement in reliability within all three measurement tools (0.5 − 0.69).

CONCLUSIONS: The data generated by the Head's Up software provided multiple calculations that could be used to compare head shape differences in young infants. However, the placement of the marker band was difficult to ensure the marker tabs could be fully visualized by the software program. The craniometer calipers revealed excellent inter-rater reliability, and proved clinically quicker and easier to use than the other two assessment tools being compared.

CLINICAL RELEVANCE: Objectively documenting head shape variability in young infants can both identify positional deformities as well as record change over time in response to interventions provided. The three clinical measurement tools examined in this study are low-cost and time efficient to use. Of the three instruments examined, the craniometer caliper had the highest inter-rater reliability for each of the four single variables as well as for the calculated cranial index and cranial vault asymmetry measures (CI ICC = .993; CVA ICC = 9.60).


Soares DD, Cunha AB, Department of Physical Therapy, Federal University of Sao Carlos, Sao Carlos, Sao Paulo, Brazil; Guimarães EL, Department of Applied Physical Therapy, Federal University of Triângulo Mineiro, Uberaba, Minas Gerais, Brazil; Tudella E, Department of Physical Therapy, Federal University of Sao Carlos, Sao Carlos, Sao Paulo, Brazil

PURPOSE/HYPOTHESIS: This study aimed at comparing the effect of short-duration practice on the reaching behavior of late preterm and full-term infants at the onset of goal-directed reaching. As late prematurity is related to reaching alterations in infancy, we hypothesized that late preterm infants differ from full-term infants regarding their earliest goal-directed reaches and that a short bout of guided reaching practice can lessen such differences.

NUMBER OF SUBJECTS: Participants were 12 late preterm infants (16.2 ± 2.3 weeks, chronological age; birth weight of 2.5 ± 0.3 kg) and 12 full-term infants (14.2±1.7 weeks, chronological age; birth weight of 3.0±0.3 kg).

MATERIALS/METHODS: From 2 weeks before the infants' 3-month birthday, the examiner made home visits twice a week in order to establish the infants' period of onset of goal-directed reaching. Preterm and full-term infants were assessed in the laboratory respectively 3.3 ± 1.4 days and 2.6 ± 1.0 days after the onset of goal-directed reaching. All infants were similar in their motor development according to the Alberta Infant Motor Scale. The infants were assessed twice in a single day: immediately before practice (pre-training) and immediately after practice (post-training). During the assessments, the infants were placed in a baby chair and a rubber toy was presented at their midline within reaching distance for 2 minutes. Between assessments, the infants received practice of toy-oriented reaching in 3 activities repeated for approximately 4 minutes. The activities were elicited in a pre-established serial sequence and were applied by a physical therapist. The number of reaches and the proportions of reaches according to hand opening behaviors and grasps were computed from video recordings.

RESULTS: Both preterm (p = 0.001) and full-term (p = 0.002) groups increased the number of reaches from pre- to post-training (intra-group analyses). Inter-group analyses showed no differences between groups in the number of reaches at pre- (p = 0.137) and post-training (p = 0.385). At pre-training, the preterm infants performed more reaches with semi-open (p = 0.025) hand, less reaches with open hand (p = 0.005) and less grasps (p = 0.023) than the full-term infants. At post-training, there were no differences between groups (p > 0.109).

CONCLUSIONS: Late preterm infants open less their hands, which may result in less grasps than full-term infants at the onset of goal-directed reaching. However, a short bout of guided reaching practice can nullify such differences at least immediately after the practice. Future work should assess whether these changes are retained as well as other reaching variables.

CLINICAL RELEVANCE: This study provides new empirical knowledge on the changes in the motor behavior of late preterm infants that are commonly experienced by physical therapists just few minutes after toy stimulation in early intervention sessions. The practice protocol adopted in this study can be easily applied by pediatric physical therapists in early intervention sessions for late preterm infants.


Stolzman SC, Lemley K, Hoffmeister K, Coate M, Department of Physical Therapy, Marquette University, Milwaukee, WI; Drendel A, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI; Hoeger-Bement M, Marquette University, Milwaukee, WI

PURPOSE/HYPOTHESIS: The decrease in pain with exercise is known as exercise-induced hypoalgesia (EIH). The optimal prescription for pain relief is unclear and the underlying mechanisms are not clear. One potential mechanism is conditioned pain modulation (CPM); pain in one part of the body produces a general analgesia elsewhere (pain inhibits pain). Pain with exercise may activate CPM resulting in a subsequent decrease in pain. CPM and EIH are underinvestigated in adolescents. In particular, obese adolescents often experience pain and the impact of body composition on these phenomena is unknown. The purpose of this study was to evaluate EIH and CPM in adolescents including the role of body mass index (BMI) and percentage of body fat.

NUMBER OF SUBJECTS: 14 adolescents (6 male, 8 female; 14.5 + 1.9 years).

MATERIALS/METHODS: Subjects completed three sessions: one familiarization and two counterbalanced experimental (treadmill and CPM). The treadmill session involved measurement of pressure pain thresholds (PPTs) before and after a maximal aerobic capacity treadmill test (i.e., VO2Max test). Subjects were asked to rate their pain during the treadmill test using a numerical rating scale (0-10). The CPM session measured PPTs with the foot placed in a cool water bath and again with the foot placed in an ice water bath. PPTs were measured with a computerized pressure algometer at two sites for the CPM session (nailbed and lateral deltoid muscle) and three sites for the treadmill session (nailbed, lateral deltoid muscle, and quadriceps muscle). Pressure (kPa) was gradually increased until the subjects pushed a timing device when they first felt pain. BMI was calculated from height and weight measurements and plotted on the gender specific CDC BMI-for-age growth charts to obtain a percentile ranking. A DEXA scan was completed to determine total body fat percentage during the CPM session.

RESULTS: PPTs increased during the ice water bath for both the nailbed (p = .004) and deltoid (p = .009) with no differences for BMI. PPTs did not change following the maximal aerobic capacity test at any of the sites (p > 0.05). VO2Max peak pain reports (5.8 ± 3.6) were inversely correlated to BMI (22.4 ± 2.8 kg/m2, r = −.646, p = .023). VO2Max values (50.1 ± 13.8 ml/kg/min) were inversely correlated with total body fat percentage (26.1 ± 11.4%, r = −.624, p = .03).

CONCLUSIONS: Adolescents experience CPM independent of BMI, indicating activation of descending inhibitory pain pathways. EIH was not apparent with a maximal aerobic capacity test in this small population but there was a trend towards EIH in the quadriceps muscle. Adolescents with higher BMI report less pain during maximal aerobic capacity testing and achieve lower VO2max values. The mechanisms responsible for the lower pain ratings are unclear.

CLINICAL RELEVANCE: PT interventions that utilize CPM to relieve pain may be beneficial in adolescents. Aerobic exercise prescription should be individualized to take into account differences in exercise capacity and pain reports that may accompany increasing BMI.


Stuart K, Ferrante R, Hendershot S, Carey H, Clinical Therapies, Nationwide Children's Hospital, Columbus, OH; Heathcock J, Physical Therapy, The Ohio State University, Columbus, OH

BACKGROUND & PURPOSE: Young children with quadriplegic cerebral palsy (CP) account for 25% of the spastic CP population. These children typically have more severe CP, are classified at higher GMFCS levels, and are infrequently included in intervention studies, especially those with high intensity protocols. Intensive physical therapy (PT) programs have demonstrated motor and cognitive improvements over programs of lower intensity. For children who are more severely involved it is unknown if daily intervention can improve outcomes and be tolerated by families and children. The purpose of this case-series is to describe a novel daily and individualized PT program delivered in an outpatient hospital setting.

CASE DESCRIPTION: Two children, ages 19 and 23 months, with quadriplegic CP (GMFCS level V) received daily intervention for 1 month. Motor, speech and cognitive assessments were completed at 2 time points, before and after intervention. Participants received PT treatment for 2 hours a day, 5 days a week for 4 weeks, for a total of 40 hours. Daily sessions focused on 2 specific gross motor goals. Interventions included therapeutic exercise, postural control, and neuromuscular re-education. The daily program was designed to enhance gross motor skills through repetition and variable practice at an intensive frequency at an age when most children with CP receive less frequent intervention.

OUTCOMES: Daily intervention in an outpatient hospital setting was feasible and well tolerated by participants and families. The participants completed at least 90% of the program. For the 2 subjects ages 19 and 23 months, the GMFM-66 scores improved by 6.06 and 9.3 points respectively. These values are above established clinically meaningful differences for the GMFM-66. BSID-III motor improved by 5 and 7 points, fine motor skills by 0 and 3 points, language skills by 3 and 2 points, and cognitive skills by 0 and 5 points respectively. In addition, both participants met their established gross motor goals which included independent sitting, improved mobility, and improved head control. Interestingly, parents of both subjects reported observable improvements in global development including cognitive, language, and fine motor skills observed by emergence of visual preference, response to name being called, attention to play routines, improved visual tracking, and preference for novel objects or pictures.

DISCUSSION: Children with quadriplegic CP GMFCS level V can participate in an outpatient-delivered daily PT program. The intervention program presented is novel as it focuses on two skills meaningful to both the therapist and family and was at a much higher intensity than reported for this population. We speculate that daily treatment protocols may be effective in promoting motor and cognitive development for younger and more severe children with CP. Furthermore, we anticipate that this type of services delivery may be used in several bursts throughout the child's lifetime.


Talley SA, Galen S, Physical Therapy Program, Wayne State University, Detroit, MI

PURPOSE/HYPOTHESIS: Activity limitations and participation restrictions have been observed in children with LE muscle weakness. There is little research which examines the relationship between LE muscle force production, body mass and balance in young children. Understanding the relationship between these factors may help physical therapists develop interventions to improve function in children with strength and balance impairments. The purpose of this study was to examine the relationship between LE muscle force production, body mass and postural sway in 6 and 8 year old (YO) children.

NUMBER OF SUBJECTS: 40 typically developing children from a suburban public school; 20 (50% female) were 6 YO (76.8 +/− 2.78 mos) and 20 (50% female) were 8 YO (100.8 mos +/− 3.12 mos).

MATERIALS/METHODS: Height, weight and dominant leg were recorded. The strength of 8 LE muscle groups were measured in the preferred leg using a Lafayette hand-held dynamometer using a “make” test. Mean force(kg) of 3 trials each of ankle dorsiflexion, plantarflexion, inversion, eversion, knee extension and flexion, hip abduction and adduction were recorded. Force was normalized (mean force/height). Postural sway was measured on a force platform under 4 conditions: bipedal stance (eyes open and eyes closed) and tandem stance (eyes open and eyes closed). Center of pressure displacement was measured during three 10-second trials in each position and the mean was recorded (degrees/s). The participants were divided into 4 groups (n = 10) based on weight quartiles. Descriptive statistics were used as well as Independent t-tests, Mann Whitney U and ANOVA with post hoc Bonferroni corrections to compare groups. Pearson's correlation was used to examine the relationship between strength and postural sway. Alpha = 0.05.

RESULTS: The 8 YO group was significantly taller and heavier than the 6 YO group. Weight was not normally distributed in the 6 YO group resulting in overlap between the groups. When divided into quartiles by weight the lightest group had the most significant correlations between normalized force production and postural sway (r = −.66-.79). The majority of the correlations in this group were positive, i.e. as normalized force production increased postural sway increased. The middle two weight groups had more negative fair to good correlations (r = −.74–.47), i.e. postural sway decreased as normalized force production increased. In the heaviest group, there was a return to more positive correlations in the fair to good range (r = .46 –.74).

CONCLUSIONS: Control of postural sway was poorer in the lightest and heaviest groups as normalized muscle force increased. This may indicate that muscle force production relative to weight is a factor in balance control in addition to maturation of motor control.

CLINICAL RELEVANCE: Postural sway is negatively correlated with muscle force production in children with the lightest and heaviest body weight. Physical therapists may need to develop interventions which help children with balance impairments to modulate LE muscle force production in order to improve balance.


Taylor MJ, Brown N, McNellie K, Lam K, Maine K, Physical Therapy Department, Gannon University, Erie, PA

PURPOSE/HYPOTHESIS: To determine the effect of an 8 week group fitness and nutrition program on body morphology, fitness, and nutrition/exercise behaviors in high school females(HSF).

NUMBER OF SUBJECTS: Forty-seven HSF predominantly classified as overweight or obese based on elevated body mass index (BMI).

MATERIALS/METHODS: Twenty HSF were recruited to join an afterschool fitness and nutrition club which met for 8 consecutive weeks. An additional 27 girls participated in a daily physical education class and served as controls. Data were collected from both groups before and after intervention and included: BMI, waist and hip circumference, heart rate (HR), blood pressure (BP), Presidential Physical Fitness Challenge (sit-ups and push-ups in one minute, timed plank hold, shuttle run, timed mile, and sit & reach test), and Palo Alto Teen Poll for Nutrition and Fitness. Descriptive statistics were calculated. Between group differences were determined using an independent t test of within group pretest - post test gain scores. Differences were considered statistically significant when p < 0.05.

RESULTS: No significant difference (p >.05) in pretest values between groups was noted for dependent variables. Ninety-five percent of females in the intervention maintained or decreased BMI by more than one point compared to 67% of the controls. Only 5% [95%CI .8, 23] of the intervention sample increased BMI by one point or more compared to 33% [95%CI 19, 52] of the control group resulting in a relative risk reduction in weight gain of 85% for intervention participants. Significant improvements were achieved in the intervention group compared to the control for: BMI (p = .02), waist and hip girth (p < .0001), sit-ups and push-ups in 1 minute, timed shuttle run and mile (p < .0001 for fitness measures). Statistically significant behavioral changes included an increase in vegetable (p = .01), whole grain (p = .03), and water consumption (p = .007) with a subsequent decrease in soda consumption (p = .02) in the intervention group when compared to controls. Exercise frequency (p = .01) and duration (p = .02) also increased significantly in the intervention group compared to controls. No between group differences calculated for remaining variables.

CONCLUSIONS: An 8 week afterschool program was effective in improving body morphology, fitness, and nutrition/exercise behaviors in HS females. Further study is recommended to assess if benefits are sustained and effect of changes on other life style behaviors.

CLINICAL RELEVANCE: In the US, approximately 35% of teenage girls are overweight or obese. An estimated 60% are likely to become overweight or obese adults for whom the incidence of related health complications is significantly increased. Physical therapists are well positioned to develop, conduct, and monitor efficacy of community based weight management programs in the hopes of improving health and quality of life for participants, preventing long term complications associated with increased body mass, and reducing significant obesity related costs for the individual and society.


Taylor MJ, Adams M, Darling T, Gnesda K, Marmol K, Physical Therapy Department, Gannon University, Erie, PA

PURPOSE/HYPOTHESIS: To examine discrepancies in Body Mass Index (BMI) and perceptions of body morphology using a figure rating scale in female adolescents (FA).

NUMBER OF SUBJECTS: 100 adolescent females separated into norm-referenced BMI classifications which included: underweight(n = 14), healthy weight(n = 43), overweight(n = 27), and obese(n = 16).

MATERIALS/METHODS: Description: BMI classification was compared to participant self-selection on a figure rating scale with previously established BMI classification correlations. Perception score (PSc) was considered accurate if the selected figure matched actual BMI classification. PSc was characterized as negative if a leaner figure was chosen compared to actual BMI classification and positive, if a heavier figure was chosen.

RESULTS: Summary of Use: Overall, 42% of FA demonstrated an accurate perception, 38% perceived themselves as leaner than their BMI classification, and 20% rated themselves as heavier. When BMI classification was considered, 50% of those classified as underweight demonstrated a positive PSc whereas, 33% of those who were overweight and 94% of those who were obese perceived themselves as leaner than their BMI classification. PSc was separated into a dichotomous variable (accurate vs. inaccurate) and a Chi-Square was performed. A significant difference in PSc was detected between groups (p = .001) with the group classified as obese (standard residual = −2.2) demonstrating greater inaccuracies than expected by chance. With respect to ethnicities, Caucasian FA were the most accurate (50%, n = 14) and African Americans were the least accurate (63%, n = 32) with 56% perceiving themselves as leaner than classified by BMI. Finally PSc was compared among participants who registered for a fitness-nutrition program and controls utilizing a Chi-square. No significant difference was detected(p = .161).

CONCLUSIONS: Health literacy in FA as it pertains to accurate perception of their body mass may be deficient especially in those who are obese and/or African American. For these adolescents, opportunities to improve health and prevent long term consequences associated with obesity may be compromised.

CLINICAL RELEVANCE: IMPORTANCE TO MEMBERS: Nearly 32% of adolescents 12-18 years of age are overweight or obese in the US with even greater percentages reported in female adolescents who are minorities or living in economically disadvantaged homes. Further, many may not recognize that they are overweight or obese reducing the likelihood that they will see necessity for behavior change as personally relevant in improving their health. Health illiteracy is an important issue for physical therapists to consider as they develop, implement, and monitor efficacy of weight management programming. Physical therapists are well positioned to screen adolescents for potential obesity related risk factors, educate adolescents about findings from clinical measures and potential consequences of less than optimal values, and propose evidence based intervention strategies to promote better health and lifestyle behaviors.


Tozzi M, Van Zant RS, Physical Therapy, University of Findlay, Findlay, OH

PURPOSE/HYPOTHESIS: There is limited research available regarding the comprehensive rehabilitation of conjoined twins. This case report describes the inpatient rehabilitation of two year-old twins prior to and following surgical separation.

NUMBER OF SUBJECTS: The patients were a set of 14 month-old African-American female ischiopagus tripus twins that received inpatient rehabilitation prior to and post separation surgery.

MATERIALS/METHODS: At 14 months of age the patients received inpatient rehabilitation prior to separation surgery to prepare them for living at home while awaiting surgery. The course of treatment the twins received occurred over a three month period which included increasing strength and endurance, assessing the need for adaptive equipment, and educating the caregivers regarding the plan of care. The twins were discharged home prior to surgery, and then returned for a four month inpatient rehabilitation admission following successful separation surgery performed at two years of age. The post-surgical treatment plan focused on each twin's individual needs, and in general addressed strength, endurance, gait training, orthotics, adaptive equipment, and caregiver education. The patients' progress was monitored using the WeeFIM and updated goals by all treating disciplines. Admission WeeFIM physical therapy scores both pre and post-surgical separation were total assist (WeeFIM = 3/21) for each twin. Across all disciplines, the overall WeeFIM score for twin A was 18/126 and twin B 19/126 at pre surgical separation admission and was 28/126 for each twin following post-surgical admission. Functionally the patients were able to sit for increased amounts of time, tolerate developmental positions such as prone, tall kneeling, and standing, and perform supine to sit transfers with supervision prior to separation surgery.

RESULTS: Following separation surgery each twin was able to sit independently, perform bed mobility independently, and tolerate developmental positions. Twin B was able to perform wheelchair mobility and supported standing at anterior surface with assistance. At discharge from inpatient rehabilitation the physical therapy WeeFIM score was 7/21 and overall score was 42/126 for both twins. Functionally twin A was able to perform dynamic sitting with single upper extremity support, floor mobility by scooting, standing at an anterior surface with maximum assistance, and propelling a manual wheelchair indoors with minimal assistance. Twin B was able to functionally perform floor mobility by scooting, standing at anterior surface with minimal assistance, propelling manual wheelchair indoors and outdoors with supervision.

CONCLUSIONS: This case describes the continuum of care required for the inpatient rehabilitation of conjoined twins prior to and following separation surgery. Comprehensive rehabilitation care maximized function of the conjoined twins in preparation for and following separation surgery.

CLINICAL RELEVANCE: Maximizing pre-surgical functional status, and treating the unique needs of each twin post separation are integral in the successful treatment of these unique patients.


Ulrich DA, Hauck JL, Wentz EE, Movement Sciences, University of Michigan, Ann Arbor, MI

BACKGROUND & PURPOSE: Research over the past 20 or more years focusing on the development of locomotor functioning in the Down syndrome population consistently demonstrates significant delays. In general, these delays have not diminished meaningfully, although a few more recent intervention strategies (e.g. treadmill training) have demonstrated meaningful reductions in the age of onset of walking and improved walking gait. It has been strongly recommended that the frequency and intensity of intervention must be increased. Therapists must be creative in teaching parents how to stimulate their infant to spontaneously move their arms, legs, and trunk. The purpose of this presentation is to present the components of a model of early intervention beginning by 2 months of age designed to maximize physical activity exposures in an effort to increase physical activity, health and functioning of the infant with Down syndrome. Each component of the model has been subjected to empirical research with positive results for the child, but the model as a whole has not been tested.

DESCRIPTION: The research evidence for each component of the model will be briefly summarized. The primary components of the early intervention model include (1) practicing new born stepping daily until it can no longer be elicited, (2) daily supervised tummy time once the infant has gained head control while in the prone posture, (3) daily conjugate reinforced kicking while in a supine posture, (4) body weight supported treadmill training once the infant is willing and able to take a few self-generated treadmill steps, and (5) encouraging parents to minimize the amount of time their infant's arms and legs are constrained in a day (e.g., car seat, stroller, sling). All of these components can be used to supplement the regular pediatric therapy activities.

IMPORTANCE TO MEMBERS: Given the economic reality of health care costs including physical therapy, most parents cannot afford to pay for more than one therapy session in a given week or two. Most insurance does not cover an appropriate frequency and intensity of early intervention delivered by physical therapists that would meaningfully increase the rate of development in the locomotor domain. It is critical that therapists explore innovative strategies, based on research evidence, to help parents supplement their physical therapy program at home based on maximizing frequency and intensity of physical activity exposures. This model should generate research questions for PT students and faculty.


Vaughan B, Sabo S, Hill K, Howman J, Division of Physical Therapy, Ohio University, Athens, OH

BACKGROUND & PURPOSE: Agenesis of the corpus callosum (ACC) is a congenital brain anomaly that affects 4 in 1000 births and involves the complete or partial absence of the corpus callosum. Persons with callosal disorders may share common physical, communication, social, behavioral and cognitive features such as vision impairments, hypotonia, poor motor coordination, motor milestone delay, and low pain perception. However, individual differences exist, ranging from subtle developmental and cognitive deficits to severe disability. Given the limited availability of evidence related to physical therapy (PT) for children with ACC, the purpose of this retrospective case study is to describe PT interventions including body weight support treadmill training (BWSTT) and associated outcomes of one child with a diagnosis of partial ACC.

CASE DESCRIPTION: This child received PT services 1-2 times/week from 5 to 34 months of age. BWSTT was used in conjunction with traditional PT interventions from 18 to 24 months of age for a total of 20 sessions. Traditional interventions included task-specific activities, handling and adaptive equipment to facilitate strengthening and acquisition of motor milestones and functional skills. BWSTT included treadmill ambulation up to 30 minutes per session at a tolerable speed with assist to achieve appropriate lower extremity kinematics. Overground ambulation included using push toys, gait trainer and manually assisted gait. The child's functional abilities and developmental milestones were monitored using observational analysis, the Alberta Infant Motor Scales (AIMS) and the Pediatric Evaluation of Disability Inventory (PEDI).

OUTCOMES: Repeat AIMS scores between 5 and 9 months of age showed motor development below the 5th percentile. At initiation of BWSTT at 18 months, the child used rolling and crawling for mobility and PEDI normative standard scores for functional skills (FS) and caregiver assistance (CA) mobility domains were below the 10th percentile. Following cessation of BWSTT at 24 months, FS and CA mobility scores were still below the 10th percentile but the child progressed to creeping, cruising and walking with hand held assist for mobility. Between 18 and 24 months, change scores on PEDI scaled scores in both mobility domains (12.4 and 20.2) demonstrated minimal clinically important differences (MCID). By 27 months, the child ambulated with a posterior walker for community mobility. At 29 months, FS and CA mobility scores increased to the 15th and 24th percentiles respectively and the CA mobility change score (13.9) showed MCID. By 34 months, she ambulated independently for limited distances within her home.

DISCUSSION: This retrospective case analysis supports the use of multiple PT interventions to promote development of motor milestones and functional mobility in a child with partial ACC and significant motor delay. BWSTT appeared to be a useful adjunct to traditional interventions for facilitating emergence of functional ambulation.


Viazzo-Trussell D, Univ of Utah School of Medicine, Salt Lake City, UT; Krosschell KJJ, Northwestern Univ Feinberg School of Medicine, Chicago, IL; Gappmaier E, Marcus RL, Univ of Utah College of Health; Xue M, Univ of Utah; Stoddard G, Weng C, Univ of Utah; White A, Univ of Utah College of Health; Swoboda K, Univ of Utah School of Medicine; Lewelt A, Children's Hospital Central California, Madera, CA

PURPOSE/HYPOTHESIS: Historically, individuals with neuromuscular disease (NMD) have been advised to avoid exercise. However, spinal muscular atrophy (SMA) mouse model and adult NMD studies suggest exercise is safe and effective. In spite of this, exercise has not been studied in children with SMA, where it has the most potential to make a difference early in the disease course. The objective of this pilot study was to assess the feasibility, safety, and preliminary outcomes of progressive resistance training (PRT) exercise in children with SMA.

NUMBER OF SUBJECTS: Nine children with SMA, age 10.4 ± 3.8 (7.2-18.7) years old completed the PRT study intervention (5 female, 6 non-ambulatory).

MATERIALS/METHODS: The study was a non-blinded, intervention-only pilot. Study participant inclusion criteria were age 5-21 years, SMA types II or III, cooperation with physical therapist, residence within 60-miles of study institution. Exclusion criteria were planned surgery during intervention period, other neurological diagnosis. The study intervention was a 12-week, 3 days/week supervised, home-based PRT program. Exercised muscles included bilateral flexors and extensors of the shoulder, elbow, hip and knee. Outcome measures included: enrollment rate, adherence to study protocol, pain, adverse events, and mean change in strength [quantitative muscle analysis (QMA)] and motor function [Modified Hammersmith Functional Motor Scale-Extend(MHFMS-Extend)] over 12 weeks.

RESULTS: Nine of 16 previously identified potential local participants enrolled in and completed the study. Of 323 scheduled PRT visits, 290(90%) occurred per protocol. No study related adverse events occurred. Using the Children's OMNI-Resistance Exercise Scale of perceived exertion, participants reached at least 6/10 (somewhat hard) 76% of the time. On average, resistance lifted increased by 0.5-1.5 pounds from study week 3 to 12 in arm muscles (p < 0.02), and by 2.1-2.5 pounds in leg muscles tested (NS). Wong-Baker FACES Pain Rating = 0 was reported in 99.8% visits during PRT sessions, and in 98.0% two days after PRT sessions. Mean change in strength using QMA showed a positive non-significant trend in all 14 muscles exercised. Five subjects, 4 non-ambulatory and 1 ambulatory, showed specific improvements in MHFMS-Extend scores. The MHFMS-Extend average change over 12 weeks was 2.45+/−0.89 (p = 0.03).

CONCLUSIONS: A 12-week, supervised, home-based, 3 days/week PRT strengthening program was feasible and safe. This pilot study was not powered to address efficacy of PRT; however, preliminary trends were in the direction of increased strength, and there was a statistically significant increase in motor function using the MHFMS-Extend.

CLINICAL RELEVANCE: This study is the first to provide preliminary data on exercise as a potential intervention in children with SMA. Larger scale trials addressing efficacy of PRT are warranted.


Ward KD, Citrino K, Cleaver A, Weber C, Physical Therapy, University of the Sciences, Philadelphia, PA

PURPOSE/HYPOTHESIS: The purpose of this study was to assess the content validity and perceived utility of the School Trip Accommodations Checklist using 1) nominal group meeting and 2) online educational staff survey.

NUMBER OF SUBJECTS: 10 participants total: 4 participated in the nominal group meeting and 6 completed the online survey. Participants were from 4 different states and included 6 physical therapists, 3 occupational therapists, and 1 teacher.

MATERIALS/METHODS: Researchers previously developed a planning tool, the School Trip Accommodations Checklist, which considers mobility, transportation, sensory, health, and behavioral factors when planning a school trip with students with disabilities. The tool consists of two separate forms: the Student Form that identifies individual student needs and the Site Form that describes features and activities at the school trip destination, which may impact participation. The current study used a nominal group meeting and online survey of school professionals. Professionals were recruited for the nominal group through the Bucks County Intermediate Unit. After reviewing each component of the School Trip Accommodations Checklist, participants rated each section of the checklists using guiding statements with modified Likert scale responses. Researchers then facilitated discussion to elicit further comments. For the online educational staff survey, the School Trip Accommodations Checklist and feedback survey were distributed via email to 30 school professionals. The online survey consisted of the same guiding statements and modified Likert scale used in the nominal group meeting.

RESULTS: Results are based on both the nominal group and the online participants. An 80% response rate to “strongly agree” and “adequately agree” on the Likert scale indicated consensus on agreement of the guiding statements. The School Trip Accommodations Checklist as a whole was accepted by 100% of participants to adequately reflect the barriers that may impact a student's ability to access and participate in a school trip. Individual sections of the checklist were all accepted by at least 80% of participants, indicating adequate content validity and perceived utility. Participants also provided narrative feedback that was used to refine the checklists.

CONCLUSIONS: Based on participants' responses, the School Trip Accommodations Checklist demonstrates adequate content validity and adequate perceived utility for participation in school trips for students with disabilities.

CLINICAL RELEVANCE: Many students with disabilities encounter barriers that impede participation in school trips. Educational teams may benefit from strategies to identify potential barriers and plan school trips that support full participation of all students. The School Trip Accommodations Checklist may help interdisciplinary teams consider multiple factors to ensure maximum participation of students with disabilities on school trips.


Weaver PA, Bradley University, Peoria, IL; Kennedy J, Cothran D, Dickinson S, Frey G, Indiana University, Bloomington, IN

PURPOSE/HYPOTHESIS: The demand for accountability of health care professionals by stakeholders within the health care system has led to the promotion of continued competence by health professions to improve practice standards and advance professional development. The updated early intervention (EI) competencies by Chiarello and Effgen are intended to guide the professional development of physical therapists (PTs) in EI; however, it is uncertain if the competencies accurately reflect the knowledge and skills that are valued by clinicians in practice today. The purpose of this study was (1) to investigate the importance of the EI competencies to the practice of PTs who work with children from 0-3 years of age; and (2) to examine the influence of years of experience working in EI, primary work environment, highest level of education, membership in the APTA, or being a Pediatric Certified Specialist regarding importance of the early intervention competencies.

NUMBER OF SUBJECTS: Pediatric PTs were recruited through a mass dissemination of emails, resulting in 288 surveys meeting the criteria for analysis.

MATERIALS/METHODS: An online survey framed by the EI competencies was developed and piloted by the researchers. The respondents used a 5-point Likert-type scale to rate the level of importance of the competencies in relation to their own practice in EI. Data analysis consisted of descriptive statistics, parametric and nonparametric testing, and post-hoc tests for significant findings.

RESULTS: The PTs perceived the competencies, on average, as ‘Extremely Important' or ‘Very Important' (86%) and ‘Slightly Important' (14%) to their practice. The statistically significant findings between therapists revealed areas for further education relating to care coordination, administration issues, leadership abilities, and research in early intervention.

CONCLUSIONS: The clustering of the responses on the positive end of the scale suggests that the EI competencies are an integral part of current practice. This consensus supports the potential for their use for continued competence to advance professional development of PT EI providers.

CLINICAL RELEVANCE: The similar perception by pediatric PTs on the importance of the competencies signifies their value; not only in practice, but also to support the potential for their use for continued competence to meet the demands for safe and quality services for children and families in the program. Additionally, the results yield support for professional and post-professional education programming to be derived from the competencies to reflect topics relevant to practitioners today.


Whalen CN, Health and Rehabilitation Sciences, The Ohio State University, Columbus, OH; Worthen-Chaudhari L, Center for Personalized Health Care, Motion Analysis and Recovery Laboratory, Physical Medicine and Rehabilitation, The Ohio State University, Columbus, OH

PURPOSE: Approximately 200 children and adults with physical or cognitive disabilities attend the Ubumwe Community Center (UCC) in Gisenyi, Rwanda annually to receive an education, learn basic life skills, and learn marketable trades. One of the top priority health concerns for the UCC identified by the directors is the physical limitations and movement disorders of a majority of the students. Currently, these students have no access to rehabilitation service. An innovative, sustainable school-based rehabilitation model to improve function and quality of life without physiotherapist supervision is needed at the UCC. Therefore, the purpose of this special interest report is to assess the feasibility and cultural relevance of an interactive, creative technology at the UCC for children with disabilities.

DESCRIPTION: Embedded Arts is an interactive, creative software that uses motion-sensing technology to provide real-time feedback, in the form of graphic art. Evidence is emerging to suggest the rehabilitation benefits of interactive technologies in patients in the chronic stages of neurologic conditions. However, the feasibility and cultural relevance of implementing this type of technology in developing nations in children with neuromuscular disorders is unknown.

SUMMARY OF USE: Embedded Arts was made available to children at the UCC for one session during an interdisciplinary international service trip. The directors of the UCC identified 2 children as appropriate for Embedded Arts use. Child 1 was a female between 6-20 years with a diagnosis of cerebral palsy (GMFCS level IV). Child 2 was a female between 7-8 years with an unknown diagnosis that presented with contractures, musculoskeletal deformity, muscular weakness, and dynamic balance deficits. Each child was seated in front of the computer screen during use. The sensor (gyroscope) was placed on various body parts via CoBand during trials (hand, trunk, head, or leg). Minimal direction was provided during Embedded Arts use. Time to set up Embedded Arts ranged from 30 seconds to 2 min 51 seconds. Child 1 remained engaged in movement activities for 12 minutes 59 seconds and Child 2 remained engaged for 4 minutes 53 seconds. Embedded Arts graphic art artifacts were saved for each “drawing” created. Each child was videotaped to observe movement patterns used to create the graphic art.

IMPORTANCE TO MEMBERS: Both children indicated enjoyment from using Embedded Arts. Directors of the UCC reported satisfaction with Embedded Arts and noted that children were motivated to move in new ways. The directors also reported that this technology is meaningful to students at the UCC as a way for those with severe physical impairments to create art that can be sold and to increase participation in school life. This special interest report demonstrates that implementing an interactive, creative technology is feasible and culturally relevant in children with neuromuscular disorders at a community center in Rwanda.


Wilkinson T, Fay D, Kurash J, Suddock B, Zimmerman A, Physical Therapy, A.T. Still University, Mesa, AZ

PURPOSE/HYPOTHESIS: Previous research has supported that environmental setting may impact motor ability and overall assessment of motor skills. In addition, natural environments have been shown to influence a child's responsiveness and motivation for motor tasks. However, little is known on the effects of environment on the performance of ball skills in typically developing children. The PDMS-2 is a commonly used assessment tool for preschool aged children and does not specify a testing environment for administration, rather directs the clinician to use a room, hallway, or outdoor space. The purpose of this study was to determine if the testing environment alters motor performance of ball skills in typically developing preschool children.

NUMBER OF SUBJECTS: A total of thirty-seven typically developing preschool aged children, with a mean age of 50.6 (30-67) months participated in this study.

MATERIALS/METHODS: Children were recruited at a local daycare center and two groups were formed through modified randomization with age and gender matching. Group 1 consisted of 18 children (8 girls and 10 boys, mean age 52.5) and Group 2 contained a total of 19 children (8 girls 11 boys, mean age 49.3). Group 1 was administered the Object Manipulation subtest of the PDMS-2 in the indoor environment first followed by the outdoor environment while Group 2 tested in the opposite order. All assessments were videotaped for scoring by a researcher blinded to the study's purpose. Data were analyzed using a repeated measures ANCOVA and effect sizes were calculated using Cohen's f scores.

RESULTS: No statistically significant differences in Object Manipulation scores on the PDMS-2 were determined between the groups based on setting alone (p = 0.096). A total of 33 of the 37 children demonstrated a change in score between the two settings, but raw score differences did not favor one setting over another. A setting and age interaction was determined (p = 0.05) with a medium to large effect size of Cohen's f = .34. When higher raw scores were obtained in the outdoor setting, older children were more likely to have a higher average point increase (mean 6.2, range 1-11), compared to younger children (mean = 2.8, range 1-5). For children 61 months and older (N = 8) a greater number of children scored higher in the outdoor setting with an average point increase of 7.7 (range 5-11).

CONCLUSIONS: Environment appears to frequently effect children's performance on the PDMS-2 Object Manipulation subtest; however, there is a not a clear bias in scores toward one environment over the other. Older children were most affected by the environmental change and more often demonstrated improved performance in the outdoor environment, but more research is needed to examine this relationship further.

CLINICAL RELEVANCE: Clinicians should be cognizant of the potential setting influence when assessing ball skills and repeat assessments should be conducted in the same setting, particularly for older children.


Womack JM, Department of Physical and Occupational Therapy, Pediatric Division, Duke University Health System, Durham, NC; Horne J, Department of Physical Therapy, George Regents University, Augusta, GA

BACKGROUND & PURPOSE: Pediatric patients waiting for a heart transplant may be placed on a Berlin Heart as a bridge to heart transplantation. The Berlin Heart is a new left ventricle assist device (LVAD) technology that affords children longer wait times for heart transplants. Physical therapy is consulted to maintain mobility while managing sternal precautions. The device can be uncomfortable as the cannula sites are sutured near the sternum. Patients may use compensatory postural patterns to minimize discomfort. This case design investigated the effects of postural re-education after placement of a Berlin Heart while maintaining sternal precautions.

CASE DESCRIPTION: The patient presented to an outside hospital at 9 years of age with shortness of breath. Echocardiogram revealed left ventricle global dysfunction and dilation consistent with cardiomyopathy. Upon transfer to Duke Hospital, physicians recommended a left ventricular assist device as a bridge to heart transplant and the patient received surgical implantation of the Berlin Heart Excor LVAD. She was referred to PT for mobility. Due to the uncomfortable nature of the pulsating device hanging anterior to the trunk and lower pelvis, she developed kyphotic thoracic posture and tight hip external rotators and flexors. PT intervention then focused on postural correction in addition to endurance and strengthening. For 6 weeks, the patient was limited by restriction of shoulder abduction beyond neutral as part of her sternal precautions.

OUTCOMES: Initially the patient spent most of her time in flexed positions such as reclined in bed or sitting in a chair. She was unable to tolerate supine without intense discomfort. Thoracic spine interventions included isometric rhomboid strengthening, manual pectoralis stretching, and kinesiotaping as well as stretching over a towel roll with prolonged supine positioning. Squats and lunges for hip and knee strengthening were utilized for muscle re-education with progression from moderate assistance to stand by assistance. Postural changes included thoracic extension with shoulder retraction and hip and knee extension in standing. The patient progressed to tolerating supine for thirty minutes.

DISCUSSION: The patient was unable to tolerate thoracic extension due to the pull of the Berlin Heart cannulas following placement. Her lower extremity posture was affected by the pulsing sensation of the device. This patient waited for her heart transplant three months and two days after placement of her Berlin Heart. Without intervention, the patient's posture may have been difficult to correct following heart transplantation. PTs should be aware of the postural changes that can occur following placement of the Berlin Heart as well as the benefits of physical therapy intervention within the limits of sternal precautions. Continued research is needed to identify the best treatment interventions and the average length of postural deviations following Berlin Heart placement.


Yates, CC, Lowe, LM, University of Central Arkansas, Conway, AR; Mitchell, AJ, Center for Translational Neuroscience, University of Arkansas for Medical Sciences, Little Rock, AR; Garza N, University of Central Arkansas, Conway, AR; Hall RW, Center for Translational Neuroscience, University of Arkansas for Medical Sciences, Little Rock, AR

PURPOSE/HYPOTHESIS: Hospitalized infants may undergo frequent painful procedures with inadequate pain relief. Alternative pain relief interventions are needed. This study was an open label trial to assess the safety of the Empi Select Transcutaneous Electrical Stimulation (TENS) unit and Empi StimCare electrodes (1.25 inches) in healthy term infants at acupuncture sites in 30 infants receiving a routine heel stick.

NUMBER OF SUBJECTS: Thirty infants were recruited from a newborn nursery. Infants were eligible for the study is they were estimated to be 37-42 weeks gestational age, less than three days old, and demonstrated a normal neurologic assessment.

MATERIALS/METHODS: Non-invasive acupuncture was applied using four self-adhesive electrodes to the baby's lower extremities at four acupuncture points The TENS unit was turned on and the infant received NESAP for 10 minutes prior to the heel stick, the duration of the heelstick and for 5 minutes afterwards. The first 6 infants received TENS unit stimulation at 1.0 mA, 2Hz. The second 6 infants received TENS unit stimulation at 2.0 mA, 10 Hz. The last 18 infants received TENS unit stimulation at 3.5 mA, 10 Hz. Outcome measurements included: 1) skin assessment to evaluate any injury to the skin of the infant at electrode sites, 2) evaluation of any changes in heart and rhythm, oxygen saturation levels, and blood pressure, 3) assessment of pain using the Premature Infant Pain Profile (PIPP) scale and 4) analysis of whether electrical activity from the TENS unit interferes with the heart monitor and oxygen saturation recording.

RESULTS: There were no significant changes in vital signs before versus after TENS stimulation. In the first 12 infants, there were no changes in Premature Infant Pain Profile (PIPP) scores before and after initiating the TENS unit. In the last 18 infants, some infants moved their legs for a few seconds, indicating that they probably felt the stimulation. The mean baseline PIPP score in these 18 infants was 2.65 before the TENS unit and 3.5 after initiating the TENS unit. Increases in PIPP scores lasted from 30-90 seconds and then infants returned to baseline or went to sleep.

CONCLUSIONS: There were no adverse events including color changes, skin abnormalities, feeding difficulties, or alterations in urine output either at the time of testing or at the 1 week follow-up. NESAP is safe for infants.

CLINICAL RELEVANCE: These results are consistent with pediatric studies in older children documenting the safety of this device. Further research is needed to determine the effectiveness of the TENS unit to relieve pain in neonates during routine heel sticks, as well as the ideal setting required. In addition, future research investigating the effectiveness of NESAP in infants may lead to a novel therapeutic approach for infants requiring surgical interventions, infants developing opioid tolerance and/or withdrawal and infants suffering from any highly painful condition.

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