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Abstracts of the Academy of Pediatric Physical Therapy Poster Presentations at the Combined Sections Meeting

doi: 10.1097/PEP.0000000000000357
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Ambekar A, Davis A, Young S. Doctor of Physical Therapy, Western Kentucky University, Bowling Green, Kentucky, United States

PURPOSE/HYPOTHESIS: A disruption in the development of this structure during gestation due to chromosomal errors or prenatal toxic exposures results in agenesis of the corpus callosum (ACC) which can cause motor deficits and delays. The purpose of the systematic review is to provide a comprehensive profile of the motor deficits associated with ACC.


MATERIALS/METHODS: A literature review was performed using the electronic databases CINAHL, PsycINFO and MEDLINE from January 1985 through January 2016 for randomized control trials, case-control studies, and cohort studies that met the inclusion criteria using pre-selected key terms. Inclusion criteria included: ACC diagnosed by MRI, motor deficits with standardized tests and/or outcome measures, and diagnosis of complete or partial ACC. Exclusion criteria included: subjects were diagnosed with hypoplasia ACC, case reports, case-series, systematic reviews, or expert opinion.

RESULTS: The search revealed 2834 studies with 6 meeting the criteria for analysis. All 6 studies were case-control studies, which classify as level III on the hierarchy of evidence. Motor deficits identified in these studies for this population included visuomotor integration, bimanual coordination, interhemispheric motor suppression during unilateral hand movements, and developmental milestone delay (specifically walking). Bimanual coordination was the most common motor deficit identified in the 6 studies that were analyzed.

CONCLUSIONS: A systematic review of the literature indicated that motor deficits exist in individuals with ACC. Development of bimanual coordination has been suggested to occur during callosal development. Additionally, the anterior portion of the corpus callosum has been associated with interhemispheric regulation of lower motor systems. Further, visual and motor integration has been seen to lateralize to the left hemisphere. An absence of callosal development, therefore, has been shown to delay development of these related motor skills. Limitations include a lack of higher level research studies in this area and low number of overall subjects in the studies that were analyzed.

CLINICAL RELEVANCE: By recognizing the motor deficits identified by the systematic review in individuals with ACC, health care providers can screen for and develop intervention plans that address these deficits. Further research is needed in the area of motor deficits associated with ACC.


Barkocy M. Physical Therapy, University of New Mexico, Albuquerque, New Mexico, United States

PURPOSE/HYPOTHESIS: Toe walking is defined by an absence of heel strike during initial contact of gait and the inability to obtain full foot contact during the stance phase of gait. Although toe walking is often associated with a variety of neurological and developmental disorders, toe walking can also occur without the presence of a known underlying pathology. Although some research exists which suggests a variety of possible underlying factors related to idiopathic toe walking, there remains a paucity of evidence linking impairments to treatments and outcomes. A better understanding of how to match interventions to identifiable impairments in order to maximize positive outcomes is necessary. The purpose of this study was to conduct a retrospective chart review at an outpatient pediatric clinic to investigate the relationship between identified impairments, interventions, and outcomes.

NUMBER OF SUBJECTS: Charts of children between the ages of 2-18 years old who were treated for toe walking at a private pediatric outpatient clinic between the years of 2008-2015 were reviewed.

MATERIALS/METHODS: An initial search using ICD-9 codes for toe walking, contracture of Achilles tendon, contracture of ankle/foot, and/or abnormality of gait identified possible subjects. If toe walking was mentioned in the evaluation, the chart was selected and given a coded identifier. Thirty-one charts were reviewed and data collected about each child's gender, age, length of treatment, number of visits, birth and medical history, impairments, interventions, and outcomes.

RESULTS: Subjects included 8 females and 23 males with an average age of 6 years, 4 months. Average length of treatment was 17 weeks and number of visits was 15. Average gestational age at birth was 36 weeks. At initial evaluation, patients spent an average of 76% of the time walking on toes compared with 17% at discharge. Overall, 70% of therapy goals were met or exceeded. Using a multiple regression model, preliminary data showed a moderate relationship between the percentage of time spent toe walking at discharge and the percentage of goals met; a weak relationship between the percentage of time spent toe walking at initial evaluation versus discharge; and the use of vestibular, visual, reflex integration, and orthotic interventions accounted for 85% of variance in outcomes and were associated with more favorable outcomes.

CONCLUSIONS: Based on these preliminary findings, toe walking evaluations should include an assessment of visual and vestibular systems, a screening for primitive reflexes, and an evaluation of the potential for orthoses use. Interventions should seek to specifically address impairments in these areas. Due to limitations in study size, lack of availability of data for all variables of interest, and narrow population, it is possible other variables played an important role in outcomes. More research is needed.

CLINICAL RELEVANCE: This study provides the foundation for physical therapists to track patient demographics, impairments, interventions, and outcomes for their pediatric patients who toe walk, both for clinical and research purposes.


Becnel M, Vo A, Salem Y, Liu H. Physical Therapy, University of North Texas Health Science Center, League City, Texas, United States

PURPOSE/HYPOTHESIS: The purpose of this systematic review was to analyze the current scope of literature regarding the effectiveness of aquatic therapy or aquatic exercises as an intervention for children with cerebral palsy (CP).

NUMBER OF SUBJECTS: The target population included children with CP of all five GMFCS classification levels and any type of spasticity, ages 0 to 21 years. A total of 280 children with cerebral palsy participated in these investigations. Sample size across the research studies varied from 1 to 46 children. The ages of the participants varied from 3 to 21 years old.

MATERIALS/METHODS: A literature search in 3 electronic databases - PubMed, CINAHL, and Academic Search Complete - was performed, using the following search terms: “cerebral palsy,” “children with disabilities,” “aquatics,” “aquatic therapy,” and “hydrotherapy.” Inclusion criteria for study selection included publication in the English language (or publication in any other language with available English translation); recruitment of participants with CP ages 0 to 21; and the use of aquatic therapy or aquatic exercises as the main experimental intervention. Studies were excluded if they were not written in English or had no easily accessible translation or if they recruited subjects older than age 21. The initial search resulted in 280 potential articles, which were screened for the stated inclusion and exclusion criteria as well as for duplicates.

RESULTS: Thirteen articles satisfied the inclusion criteria. There were two case reports, one case series, one pilot study, three cohort studies, five quasi-experimental studies, and one randomized controlled trial. Deficits in high quality studies as well as lack of standardization of participant characteristics, implementation of interventions, and outcome measure selection result in difficulties in drawing definitive conclusions regarding recommendations for implementation of aquatic exercises in the clinical setting.

CONCLUSIONS: The evidence suggests that aquatic therapy interventions and/or aquatic exercises are effective in the short term for improving gross movement and gait parameters as well as social function and self-esteem in children with CP ages 0-21, and that aquatic therapy or exercises are feasible, safe, and fun for this population. However, due to considerable heterogeneity in variables across studies, conclusions regarding specific successful interventions, optimal treatment duration and frequency, and impact on land-based performance continue to be inconclusive.

CLINICAL RELEVANCE: Cerebral palsy is the most common childhood physical disability resulting in a spectrum of motor impairments. More research should be conducted with larger sample sizes, higher quality study design, and more consistent outcome measures to determine effective exercise parameters and to further support the success of aquatic exercises as a physical therapy intervention for this population.


Beegle C, Rollins A, Tyra J, Chen Y, Garcia-Vergara S, Howard A. Physical Therapy, Georgia State University, Atlanta, Georgia, United States

PURPOSE/HYPOTHESIS: A new virtual reality game (Super Pop VRTM) was developed that uses a commercially available, low-cost, three dimensional (3D) depth camera (i.e., Kinect) to measure participants' reaching kinematics to increase the accessibility of a sensitive motion analysis system. The objective was to examine the test-retest, response stability, and minimal detectable change between two testing days in reaching kinematics in children with and without cerebral palsy (CP) who played the game.

NUMBER OF SUBJECTS: Twenty-nine children aged between 6 and 12 years participated in this study, including 9 children with CP (4 males; 9.64±1.93 years), and 20 children without CP (9 males; 10.10±1.66 years).

MATERIALS/METHODS: All participants underwent Super Pop VRTM assessments separated by 7 days. Testing involved reaching for and popping testing bubbles at a self-selected pace. On each assessment day, two games with ten sets of testing bubbles were collected for each hand. Reaching kinematics (path length, movement time (MT), number of movement units (MU), average speed, elbow range of motion, and shoulder range of motion) were computed using an automated kinematic assessment algorithm. Intraclass correlation (ICC), the standard error of measurement (SEM), and minimal detectable change (MDC) were computed.

RESULTS: Between-day ICC values for children without CP were good (0.75-0.80) except for elbow ROM and speed (0.26 and 0.22). ICC for the less-affected hand were also good for Path and MT (0.83 and 0.89), fair for MU and Speed (0.72 and 0.64), and poor for ROM (0.25 and 0.25). Response stability using SEM divided by mean values ranged from 11.30% -49.9% for children without CP, and 27.04% - 84.86% for less-affected hand in children with CP. The MDC for children without CP was 0.19 meters for path length, 0.34 seconds for movement time, 0.33 units for movement units and around 10.06 o for range of motion; whereas the MDC for less-affected hand was 0.42 meters for path length, 1.13 seconds for movement time, 0.89 units for movement units and around 28.23° for elbow range of motion and 35.96° for shoulder range of motion.

CONCLUSIONS: This study provides evidence of reliable performance of the Super Pop VRTM game as used to evaluate reaching kinematics in children. As expected, SEM and MDC were larger in children diagnosed with cerebral palsy.

CLINICAL RELEVANCE: Super Pop VRTM game may be able to use as an in-home evaluation tool to measure reaching kinematics in children with or without CP.


Bican R, Taranto A, McNally M, Alfano L, Lowes L, Heathcock J. Health and Rehabilitation Sciences, The Ohio State University, Columbus, Ohio, United States

PURPOSE/HYPOTHESIS: 3D motion capture provides a precise way of capturing spontaneous infant movements. Movement in the Z-axis, or anti-gravity direction, may be useful in determining a very young infant's strength and can be objectively measured to aide in clinical assessments. The direct relationship between spontaneous antigravity movements and motor milestone has not been measured, suggesting a gap in knowledge. The purpose of this study is to identify relationships between spontaneous movements, and gross and fine motor skill development in infants with typical and atypical development.


MATERIALS/METHODS: N=10 infants born full term; n=4 infants with Spinal Muscle Atrophy; and n=1 infant with Down syndrome were tested longitudinally 2-3 times from 2-6 months of age. Disparities in developmental diagnoses were part of the study design in order to include the necessary large range of motor skill development and spontaneous movement excursions of the limbs against gravity. Preliminary data analysis from n = 10 infants is reported here. Infants were placed in supine and the spontaneous movement of the upper and lower extremities were captured with VICON, a 10 camera motion capture system at 120 Hz for 3 × 30 second trials. The Bayley Scales of Infant and Toddler Development, a clinical tool to asses motor development, was used to assess gross (GM) and fine (FM) motor skills. Kinematic variables measured were excursion in the z-direction (mm), movements per minute (mm/min), movement length average (mm), first velocity average (mm/sec).

RESULTS: As expected, on average the infants with SMA had fewer movements per minute compared to TD infants (19.6 +/- 13.1 mm/min; 30.1 +/-19.0 for TD) and the infant with DS had lower GM and FM scores compared to TD infants (11.5 and 6; 15.5 and 8.9 for TD). The following Pearson correlations were observed: excursion in the z direction and Bayley GM strong (r=.52) suggesting that more movement and strength against gravity are related to better motor gross motor skills; mm/min and Bayley GM moderate (r=-0.284) suggesting fewer spontaneous movements are related to better gross motor skills; mm/sec and Bayley FM moderate (r=-0.325) suggesting fewer movements are related to better fine motor skills.

CONCLUSIONS: Spontaneous and antigravity movements may be positively related to GM and FM skills suggesting that a lack of antigravity movements may result in motor skill impairments. Although preliminary, to our knowledge this is the first study to specifically measure the relationship between antigravity movements and motor skills directly in young infants. This work joins other in suggesting that fewer spontaneous movements could be related to more mature GM and FM motor development.

CLINICAL RELEVANCE: Utilizing spontaneous infant movement as a clinical tool can provide important information regarding motor development without putting the infant through a standardized test; therefore 3D motion capture could be more feasible for both the infant and clinician.


Brandsma B, Webster A, Embrey D. Children's Therapy Unit, MultiCare, Puyallup, Washington, United States

PURPOSE/HYPOTHESIS: Physical therapists focus on improving gait and balance in children with hemiplegic cerebral palsy (HCP). Functional electrical stimulation (FES) has the potential to improve strength and functional gait for children with HCP. We hypothesized that a new FES system stimulating the dorsiflexor (DF) and plantarflexor (PF) muscles alternately at the correct time during gait, would lead to a significant improvement (p<.05) in foot contact, gait symmetry and balance, compared to 12 weeks of a healthy lifestyle program called 5210.6.

NUMBER OF SUBJECTS: This preliminary study includes the first seven subjects of a larger investigation. All subjects had a diagnosis of HCP and were GMFCS level 1. Subjects were 6-13 years old (mean = 9.6).

MATERIALS/METHODS: A baseline-intervention design compared 12 weeks of the 5210 program (eating 5 servings of fruits/veggies, limiting screentime to 2 hours, doing at least 1 hour of physical activity and drinking 0 sugary drinks each day) to 12 weeks of the FES program, with stimulation worn 3-4 hours/day with 1 hour of walking, 5-6 days/week for 12 weeks. Gait symmetry and foot contact were measured using freeze frame videography. Gait symmetry was calculated using custom software. Foot contact was ranked for 10 strides as 1, 2, or 3 to denote toe contact, foot flat, or heel strike, respectively. Balance was measured using a subtest of the Bruininks-Oseretsky Test of Motor Proficiency (BOT2). All measures were taken at baseline (T0), after 5210 (T1) and after FES (T2). Testing was completed without subjects wearing the FES system. Subjects completed daily logs and met weekly with a researcher to aid compliance and ensure FES settings were appropriate.

RESULTS: Preliminary data showed positive trends. At T0, one subject (14%) had symmetrical gait and at T1, two subjects (29%) were symmetrical. By T2, four subjects (57%) were symmetrical. This positive trend shows more even stance and swing time between involved and uninvolved legs. Paired t-test of asymmetry data approached, but did not reach significance (p=0.2) from T0-T2, and (p=0.1) from T1-T2. Four out of seven subjects showed a positive trend toward improved heel strike, although analysis was not significant. BOT2 balance scores did not show significant differences. Daily logs showed subjects adhered to 5210 and FES programs.

CONCLUSIONS: In a small sample size, this innovative FES system which stimulates the DF and PF muscles, showed positive trends for gait symmetry and foot contact for children with HCP compared to 5210 intervention. It should be noted that previous applications of FES for drop foot, assess walking improvement while the stimulation is applied. This study collected all measures without subjects wearing the FES system. The goal was to determine if the system would create motor learning effects. Our larger study will enroll additional children to determine if a larger N will yield significant findings.

CLINICAL RELEVANCE: An FES system which stimulates DF and PF muscles during gait will likely be a valuable tool for PTs who treat children with HCP.


Burman E, Finney M, Thompson V, Martin K, Looper J. Physical Therapy, University of Puget Sound, Tacoma, Washington, United States

PURPOSE/HYPOTHESIS: Down Syndrome (DS) is the most common genetic disorder in the United States, affecting 1 in every 691 live births. Orthotics (such as supramalleolar orthoses) are used to address common impairments such as hypotonia and ligamentous laxity, in order to promote postural stability and functional mobility. However, there is currently limited research investigating the effect of SMOs on stability in children with Down syndrome. The purpose of this study is to determine the effect of SMOs on single limb stance balance of children with Down Syndrome who have established walking patterns. We hypothesize that SMOs will increase single limb stance time in this population.

NUMBER OF SUBJECTS: 5 children with DS who had at least one year or walking experience and weighed less than 80 pounds have participated in this study.

MATERIALS/METHODS: This analysis was part of a larger study where children were followed for 8 weeks. During the first four weeks of the study the children did not wear orthoses. At week four, children received a pair or surestep SMOs and shoes. During the second four weeks each child wore a SureStep SMO and shoes for 8 hours per day. At the end of week 8 the childrens' single limb stance (SLS) time was measured both with and without SMOs. Researchers then compared both conditions, using a paired t-test, to determine whether SMOs improved single limb balance.

RESULTS: The average time that the children spent in SLS while wearing the SMOs and shoes was 1.48 (±.64) seconds. Without the SMOs, the average SLS time was 0.67 (± 0.51) seconds. The children stood on one leg significantly longer when they were wearing SMOs (p= 0.006, observed power= 0.992).

CONCLUSIONS: These findings are consistent with the hypothesis that SMOs significantly increase single limb stance balance in children with DS who have established walking patterns.

CLINICAL RELEVANCE: Single limb stance balance is considered an indicator of postural stability as well as a determinant of gait. Interventions, such as SMOs, that aim to increase foot and ankle stability may not only improve single limb stance balance but also lead to increased stability during other functional activities. Orthotics, including SMOs, are considered standard interventions for children with DS despite relatively limited research into their effectiveness for this population. This study provides additional evidence in support of the use of SMOs to increase stability in children with DS who have established walking patterns. In addition, the study serves as a foundation for further research concerning the effect of SMOs on postural stability and functional mobility in children with DS.


Chang H, Dusing S, Harbourne R, Lobo M, McCoy S. Department of Physical Therapy, Duquesne University, Pittsburgh, Pennsylvania, United States

PURPOSE: To describe the creation of an instrument to measure intervention fidelity, which can be used as a model for providing greater uniformity and improved evidence-based intervention in a clinic or research environment. Historically, early motor intervention is diverse and multi-faceted, which has presented challenges in evaluating effectiveness of differing approaches. This method will provide a template for measuring fidelity in any intervention.

DESCRIPTION: Understanding whether an intervention is delivered as intended is critical both in clinic practice and in clinical trials. Fidelity of implementation in intervention studies is a multidimensional construct and is commonly characterized along five dimensions: adherence, dosage, quality of intervention delivery, participant responsiveness, and program differentiation. This presentation will describe the process of identifying key ingredients of the intervention and establishing fidelity in a large multi-site randomized controlled trial, which was essential to guarantee uniform delivery of service across all sites. Agreement on the fidelity method was reached through multiple iterations of coding a variety of videotaped interventions. Videotapes of therapists providing intervention, the characteristics of that intervention, and coding samples will be presented. Examples of the characteristics for adherence measured from videos include: cognitive components, social opportunities, brainstorming with parents; dosage includes duration of intervention provided; quality of intervention delivery includes level of effectiveness of intervention activities to the child; and participant responsiveness includes parent interest and engagement with the therapist and with the child. Videos are coded globally as well as by using a minute-by-minute coding interval to capture all aspects of the intervention.

SUMMARY OF USE: Examples of the use of these factors to document successful intervention training prior to initiating a protocol, and maintenance of fidelity components during an intervention or clinical trial will be provided. In addition to establishing and maintaining the integrity of an intervention, the fidelity instrument is useful for providing feedback to interventionists, documenting change over time, and assuring that a specific intervention is done uniformly across therapists. Fidelity measures can establish that an intervention clearly is related to measured outcomes of the child or family.

IMPORTANCE TO MEMBERS: This information will challenge interventionists and researchers alike to clearly explain what their intervention is (or isn't), in order to better make clinical decisions and determine efficacy for intervention approaches.


Chapman D. Physical Therapy, St Catherine University, Minneapolis, Minnesota, United States

PURPOSE/HYPOTHESIS: Infants with SB present with a known central nervous system lesion that often results in neurologic and/or orthopedic impairments. They usually learn to walk later than typically developing (TD) infants. The delays they experience in learning to walk appear to be related to the fact that they spontaneously generate fewer leg movements and kicks than infants who are TD. To date, no one has described the effect(s) of placing infants with SB in a context in which they are be able to generate goal-directed leg movements (LMs) and kicks. The purpose of this study was to examine the impact conjugate reinforcement has on the frequency of leg movements (LMs) and kicks generated by infants with SB.

NUMBER OF SUBJECTS: Eight infants, 4 males and 4 females, with lumbar or sacral SB were recruited to participate in this cross-sectional study following IRB approval. They ranged in age from 16 to 42 weeks. Five had ventricular-peritoneal (VP) shunts and all but one presented with one or more musculoskeletal impairments commonly observed in infants with SB, e.g. club foot. None of the infants presented with a known visual or auditory impairment.

MATERIALS/METHODS: The infants' LMs were videotaped while they were supine in 3 conditions: Baseline (BL); Acquisition (tethered to a mobile) {ACQ}; and Extinction (EXT). The infants' LMs were video-taped for two minutes in each condition which captured their spontaneous and goal-directed LMs and kicks. The video-tape of each infant's LMs was then behavior coded via a frame by frame analysis to identify how often each baby moved his or her legs and kicked in each condition as well as how often they generated 9 types of kicks, e.g. single knee kicks, parallel leg kicks.

RESULTS: A significant Pearson correlation was observed between LMs and kicks (r= .976, p=0.00). These infants moved their tethered leg significantly more than their untethered leg (p=0.036) in the ACQ condition (p = 0.036) and generated more goal-directed LMs and kicks in the ACQ and EXT conditions compared to BL (p < .05). Single knee and leg kicks along with parallel knee and leg kicks were the most common types of kicks generated in each condition.

CONCLUSIONS: The present results suggest that the mobile paradigm creates an environment in which infants with lumbar or sacral SB generate more LMs and kicks than they spontaneously produce. As they move their legs and kick more often in response to the visual and auditory feedback provided by the mobile they have increased opportunities to strengthen their leg muscles as well as the neural pathways that support their LMs and kicks. These types of compensatory movement experiences may enhance their ability to move their legs and kick in the future.

CLINICAL RELEVANCE: The current results show that conjugate reinforcement implemented via an over-head infant mobile may be useful for increasing how often infants with lumbar or sacral SB move their legs and kick. Increased opportunities to move their legs and kick should help them move their legs and kick more often in the future which may influence when they learn to walk.


Christensen C, Haddad A, Maus E. Clinical Therapies, Nationwide Children's Hospital, Columbus, Ohio, United States

PURPOSE/HYPOTHESIS: No clinically feasible, objective outcome measure exists for children with idiopathic toe walking (ITW). Studies investigating ITW with objective outcome measures use equipment not available to most clinicians including shoe gait detectors, 3D gait analysis, the GAITRite, and accelerometers. Alternatively, clinical observation and parent report have been used. While these measures are clinically feasible, they are also subjective. The purpose of this study was to investigate the reliability and validity of the 50 foot walk test (FWT) which is a clinically feasible, objective outcome measure for children with ITW.


MATERIALS/METHODS: Thirty children, 11 females and 19 males, mean age 8.0 years (±2.1 SD) with a diagnosis of ITW were consecutively recruited from referrals to a physical therapy department. Each child was screened for a non-idiopathic origin of toe walking using the toe walking tool (TWT)7. If red flags were identified via the TWT, the child was excluded. Pedometers accurately count steps in children with ITW who are = 6 years of age but not in those = 5 years old8. Thus, only children = 6 years old were included in the study. The aim of the FWT is to determine a percentage of toe walking. The child ambulates 50 feet while wearing a pedometer and performing a cognitive task to achieve a more natural gait pattern. A clinician walks at least 6 feet behind the child to assess toe walking while not interfering with gait. The pedometer counts the total number of steps. The clinician counts the number of steps with initial contact on the toe. The number of toe walking steps counted by the clinician is divided by the total number of steps counted by the pedometer to get a percentage of toe walking. To assess inter-rater reliability, 2 clinicians, blinded to each other's result, simultaneously counted toe walking steps during the FWT. The results of the 2 clinicians were compared. To determine validity, the child ambulated over a GAITRite9 which assessed toe walking. Simultaneously and without knowledge of the GAITRite results, a clinician counted the number of toe walking steps observed. The number of toe walking steps recorded by the GaitRite and the clinician were compared.

RESULTS: Data was not normally distributed. The FWT inter-rater reliability was excellent (ICC=0.98, 95% CI .97-.99). A Wilcoxon signed-rank test found no significant difference in the GaitRite and clinician's results (W= 22.0, p=0.62) indicating the FWT is valid.

CONCLUSIONS: The FWT is a reliable and valid outcome measure for children ≥ 6 years old with ITW.

CLINICAL RELEVANCE: The FWT is the first accurate, objective, clinically feasible outcome measure for children with ITW. This test allows clinicians to objectively assess treatment outcomes of children 6 years and older with ITW. Further investigation is required into test-retest reliability of this outcome measure as children with ITW often have variable gait patterns10.


Christensen C, Haddad A, Maus E. Clinical Therapies, Nationwide Children's Hospital, Columbus, Ohio, United States

PURPOSE/HYPOTHESIS: Pedometers accurately count the steps of typically developing children, and children with physical disabilities. However, they may be inaccurate in those under 6 years old. No investigation into the use of pedometers with children with idiopathic toe walking (ITW) has occurred. Determining pedometer accuracy in children with ITW may be important to the development of health-related outcome measures. The purpose of this study was to determine the validity of pedometers used with children with ITW.


MATERIALS/METHODS: Seventy-five children were consecutively recruited from referrals to a physical therapy department. Inclusion criteria included children 2 to 18 years old with a diagnosis of ITW. Each child was screened for a non-idiopathic cause of the toe walking utilizing the toe walking tool (TWT). If red flags were identified via the TWT, the child was excluded from the study. Due to concerns for pedometer accuracy in young children, two groups were created: ≤ 5 years old (n=45) and ≥ 6 years old (n=30). A New-Lifestyles NL-1000 pedometer was placed posteriorly at midline. Children ambulated 50 feet while being video-taped from behind. A cognitive task was used as a distraction measure to achieve a natural gait pattern. The pedometer step count was recorded. A researcher blinded to the pedometer results viewed the video in slow motion and recorded the child's step count. The pedometer and video step counts were compared.

RESULTS: The data was not normally distributed. A two-tailed Wilcoxon signed-rank test found a significant difference in the pedometer and video step counts for children 2-5 years old (W= 72.0, p=0.000). No significant difference was found in the step counts of children 6 years old and older (W= 65.0, p=0.24).

CONCLUSIONS: A pedometer accurately counts the steps of children with ITW who are 6 years old or older but is inaccurate in children 5 and younger.

CLINICAL RELEVANCE: Pedometers are a valid method of measuring step count in children with ITW who are 6 years old or older. This may be important to researchers and clinicians interested in developing outcome measures for children with ITW.


Christy J, Rine R. Physical Therapy, The University of Alabama at Birmingham, Birmingham, Alabama, United States

PURPOSE/HYPOTHESIS: Development and function are disrupted if the vestibular system is not intact and functioning. The vestibular system includes two mechanisms: the vestibulo-ocular reflex (VOR), which enables clear vision (gaze stability), and 2) the vestibulospinal reactions (VSR), that enable control of posture. Increasing reports of peripheral and central vestibular problems or dysfunction in infants, children and adolescents warrant testing of vestibular function from infancy through adolescence. The purpose of this study was to develop the Questionnaire of Dizziness, Eye Movement and Balance (Q-DEB), as a screening tool for vestibular related problems in children from one through 21 years of age.

NUMBER OF SUBJECTS: Participants presented with typical development (TD) or varying diagnoses (DX): Infants 1-5 years: TD (n=2); DX (n=11); Children 6-12 yrs: TD (n=7); DX (n=8); adolescents 13-20 yrs: TD (n=4); DX (n=11). Diagnoses were categorized as peripheral vestibular or central vestibular.

MATERIALS/METHODS: The QDEB includes items known to be affected by poor vestibular health. It includes 5 questionnaires: Infancy and Early Childhood Parent (ages 1-5 yrs, 29 items), Childhood Parent (25 items) and Self (10 items) (ages 6-12 yrs), Adolescent Parent (15 items) and Self (13 items) (Ages 13-21 yrs). Items are scored from 0-4. Scores for all questions are summed and the total score is used to quantify vestibular system health. The total score is indicative of the likelihood and severity of poor health of the vestibular system (higher score indicates increased likelihood and severity). Repeated reviews by developers were performed to assure clarity of questions and format. For this data collection phase, we recruited participants from 2 pediatric clinics to complete the QDEB. Scores were totaled and graphed to determine whether the QDEB distinguished between TD and children with known diagnoses.

RESULTS: Participants reported that it took 5-10 minutes to complete the questionnaire and that questions were easy to understand. Many parents commented that no one had ever asked them such questions about their child (e.g. about motion sensitivity). The scores of infants and children with good vestibular health (TD) consistently achieved scores of < 20, while children with poor vestibular health achieved scores of >20. The children with confirmed peripheral vestibular hypofunction had a mean score of 34 (SD=10) and the children with central vestibular problems had a mean score of 43 (SD=6).

CONCLUSIONS: The QDEB shows promise to identify infants, children and adolescents in need of further vestibular assessment and intervention. A score of < 20 on the infant and child forms separated children with good vestibular health from those with peripheral and central vestibular dysfunction. Further research should continue to validate this clinical tool.

CLINICAL RELEVANCE: Early identification of vestibular related impairments will lead to early intervention so that motor delays, balance problems and gaze instability can be addressed.


Cross E. PT/OT-Rehab, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, United States

BACKGROUND/PURPOSE: Klippel-Trenauny (KT) syndrome is a rare, genetic condition characterized by port wine staining, soft tissue and bony hypertrophy, venous malformations and lymphatic abnormalities. KT syndrome has both a lymphatic and vascular component. Edema in KT syndrome can be limited to one limb, but may occur in multiple limbs, the head or trunk. KT syndrome is a life-long condition and requires multi-professional management including the reduction of the edema and shaping of the limb, prevention of infection, pain management and functional skill improvement. Similar to lymphedema, the chronic swelling in KT syndrome results from the buildup of the lymphatic fluid in the interstitial tissue space. Complete Decongestive Therapy (CDT) is the international gold standard for edema management. This case review will describe the use of a modified CDT intervention by both Physical and Occupational Therapists to treat edema associated with KT syndrome in 3 male toddlers.

CASE DESCRIPTION: Prior to evaluation by a Certified Lymphedema Therapist (CLT), all three patients had been treated with surgical and non-surgical interventions, which had not been effective in managing the edema in one extremity. All patients were referred to the lymphedema team for persistent edema in the affected limb. All three patients demonstrated decreased functional mobility and sensory tolerance of the affected limb which limited age appropriate activities. The patients with lower extremity edema had a history of wounds which were not healed at initial evaluation. Modified CDT was used to decrease limb edema, provide consistent, well-fitting compression and educate families for long term care of this chronic condition.

OUTCOMES: Edema reduction was achieved with use of compression bandaging and bandaging-alternative garments. Patients were fitted for custom garments for night and daytime wear that resulted in successful maintenance of limb volume. Volumetric measurements and serial photographs were taken to monitor differences in limb during course of therapy, in addtion to, changes in limb volumes and appearance following interventions. Volumetric differences between the affected and unaffected limbs were as follows: Patient 1 reduced from 97% to 71%, Patient 2 reduced from 151% to 107% and Patient 3 reduced from 29% to 17%. The draining wounds in the two males with lower extremity edema were healed and all three patients had improved sensory tolerance in the affected limb. Additionally, all three patients demonstrated improvements in functional age appropriate activities, which will be further described in this case review.

DISCUSSION: Modified CDT led to effective outcomes in achieving the goals of edema reduction, wound healing and improvement of functional limb use. These case reviews present success with conservative management using modified CDT as an intervention for pediatric patients with Klippel-Trenauny syndrome. This intervention lays the groundwork for guidelines for effective and appropriate treatment of edema in children with KT syndrome.


Del Rossi L, McGinnis P, Pawlowska M, Padden-Denmead M, Kientz M. Physical Therapy, Stockton University, Cinnaminson, New Jersey, United States

PURPOSE/HYPOTHESIS: Learning to work collaboratively as a team requires intentional practice. Interprofessional education (IPE) provides students an opportunity to learn “with, from and about each other to improve collaboration and quality of care.”(WHO) and is essential to in preparing future health care practitioners. Previously, foundational pediatric development was covered as discipline-specific content. The purpose of this research was to evaluate outcomes of an on campus interprofessional (IP) learning experience, Baby Lab. The goal of this experience was to understand the roles and experience of other team members, facilitate knowledge translation among disciplines and foster skills needed to work as a team.

NUMBER OF SUBJECTS: Student teams from four disciplines (DPT n=23; MSOT n=29; BSN n=33; MSCD n=32) interacted with infants/toddlers (n=20; age 4-30 months) and their parents.

MATERIALS/METHODS: Students teams collaborated to plan and interact with infants/toddlers and their parents to observe early child development. Quantitative outcomes: student and parent surveys assessed achievement of learning objectives from IPEC Core Competencies; select IP team interactions were rated by faculty observers and student teams with the Interprofessional Collaborator Assessment Rubric (ICAR) to assess performance on a 4-point scale (1=Minimal, 2=Developing, 3=Competent, 4=Mastery). Qualitative student reflections were analyzed.

RESULTS: Quantitative outcomes: survey responses supported achievement of IPEC core competency for Values & Ethics (students 95.7%, parents 95%) and IP communication (students 96.6%, parents 100%). The majority of observed behaviors were rated at 2 or 3 for all ICAR elements. Active Listening was rated highest with mean ICAR ratings (student 3.67, faulty observers 3.74). Qualitative themes emerged:a deeper appreciation of the variety and context of developmental milestones; the value of this experience in training future practitioners to work as a team; effective communication with parents and team members to optimize interactions with the infant/toddler.

CONCLUSIONS: Qualitative and quantitative data supported achievement of all learning outcomes. Students gained a holistic understanding of developmental milestones. Using an IP lens introduced students to the importance of communicating with team members and families, understanding the value of collaboration with other disciplines, and gaining confidence in these interactions. Demonstrating active listening and being respectful of different perspectives is an important aspect of IP collaboration. Students valued roles, experiences and the unique contribution of each team member in providing optimal care.

CLINICAL RELEVANCE: Common learning activities in pediatrics benefit from an IP learning approach. This model of turning a single discipline practice into an IP experience can be used to foster other IP experiences across the curriculum meeting, accreditation expectations for IPE. Developing these skills can help prepare students for clinical experiences with pediatric clients as a member of a healthcare team.


Denninger S. Kidnetics, Greenville Health System, Greer, South Carolina, United States

PURPOSE/HYPOTHESIS: Pectus excavatum is a common congenital deformity of the chest wall consisting of rib deformity and central depression of the sternum and thoracic cage. Surgical repair is generally undertaken when the defect is severe in order to improve cardiopulmonary function and to correct the anatomic disfigurement. It is well documented that there is significant postoperative pain and slow return of function are common in the postoperative period. The purpose of this study was to determine the effect of a goal directed pre-operative physical therapy program on the recovery of patients who had minimally invasive placement of a pectus bar to correct pectus excavatum.


MATERIALS/METHODS: A retrospective chart review of patients who had pectus bar placement was performed to compare those who underwent a regimented, goal directed pre-operative PT program with those who did not. PT intervention consisted of aerobic exercise, manual therapy, and strengthening and flexibility exercises, and post-operative education. Outcome measures used were postoperative length of stay, pain scores, and ability to transfer and ambulate without assistance.

RESULTS: This single institution, 16 year study had 83 patients in the PT program (group A) and 90 who did not have pre-operative PT (group B). Both groups were comparable with respect to patient age, gender, and Haller index. Patients in group A had shorter hospital length of stay (3.41 vs 5.72 days, p<0.001), and had more rapid return to activity based upon ability to ambulate without assistance (2.44 vs 4.35 days, p<0.001) and move from supine to sit without assistance (p<0.001). Patients in group A had no epidural catheters, but had lower pain scores when compared to group B who had epidural catheters (p<0.001).

CONCLUSIONS: A goal directed PT program for patients with pectus excavatum prior to surgery increases chest wall flexibility, facilitates surgical correction, results in less post-operative pain as compared to epidural catheter placement, decreases hospital stay, and hastens recovery.

CLINICAL RELEVANCE: Surgical correction for pectus excavatum continues to evolve and gain popularity as the procedure becomes safer, more readily available, and as research demonstrates the correction is imperative to improve cardiopulmonary function and decrease issues regarding long-term pain. Postoperative pain and slow return of function are common in the postoperative period, which are a burden to not only patients and families by imposing pain and disability but also add significantly to health care costs. This research demonstrates that pre-operative physical therapy significantly decreased post-operative pain and length of stay while improving the patient's level of functioning in the immediate post-operative period. Implementation of pre-operative physical therapy also contributed to illuminating the need to expensive and invasive epidural pain control treatment. This research supports an improved clinical pathway for patients looking to undergo surgical correction of pectus excavatum.


DiBiasio P, Osgood A, Vallabhajosula S. Elon University, Elon, North Carolina, United States

BACKGROUND/PURPOSE: Botulinum toxin (Botox) combined with physical therapy (PT) can be effective in individuals with Cerebral Palsy (CP). Outcomes include decreased hypertonicity, improved function, range of motion, gait, and energy expenditure. Treadmill training for individuals with CP can improve gait, balance, postural control and function. There is a lack of research examining treadmill training after Botox for individuals with CP. The goal of this case report is to share findings of this novel intervention.

CASE DESCRIPTION: The patient was a 14 year-old male, Gross Motor Function Classification System III who ambulated with loftstrand crutches and a crouched gait. He received Botox injections to bilateral hip adductors and hamstrings one day post initial PT exam. On examination he had decreased passive hip extension, knee extension and ankle dorsiflexion, increased tone in hip adductors, hamstrings, and gastroc-soleus, and bilateral lower extremity (LE) weakness. He required assistance with all activities of daily living (ADLs). PT was 2/week for 5 weeks. Sessions included treadmill training forward, backward and sidestepping at comfortable speeds (.5-.9mph), overground walking, and exercises for LE and core strengthening. The patient also walked on a treadmill at home. Goals included improving gait, riding a tricycle, and increased participation in ADLs.

OUTCOMES: Outcome measures that improved pre to post-intervention are as follows: seated functional reach (16.0”, 19.5”); timed up and go (TUG) (18.97s, 15.0s); 3-minute walk (328m, 395m); 10m gait speed (0.69 m/s, 0.9 m/s); PedsQL Family Impact Module (50, 59.7). Instrumented gait analysis revealed increased step length (left 25.7cm, 30.7cm; right 43.3cm, 48.1cm), stance/swing percentages approached typical values (pre 68.8/31.2; post 66.1/33.9), gait speed increased (0.5m/s, 0.62 m/s) and cadence increased (88.7 steps/min, 94.6 steps/min).

DISCUSSION: Improved functional reach indicated a decreased fall risk. Gait speed improved from limited community to full community ambulation. There is no minimally clinically important difference (MCID) for gait speed in CP however MCID for individuals with stroke is .14 m/s; this subject increased .21m/s. Cadence approached male adult norm of 110s/min. 10% improvement in quality of life had significant impact for the family. TUG MDIC for children with GMFCS III is 1.9 sec for a large effect; this patient improved by 3.97 secs. Improvements in TUG have been correlated to functional improvements. Within 2 weeks, the patient was able to sidestep on the treadmill at home which was previously unachievable. After 5 weeks, the patient reported for the first time he was able to sidestep to navigate a tight space in the kitchen and was independently swinging his legs in and out of the car. He was also able to ride his adapted tricycle 30 minutes in his neighborhood including the “hill” which was previously unattainable. PT focusing on treadmill training after Botox may be effective in improving gait, function, and quality of life.


Duong L, Flores M. University of St. Augustine for Health Sciences, Austin, Texas, United States

BACKGROUND/PURPOSE: Ehlers-Danlos syndrome (EDS) is a connective tissue disorder characterized by joint laxity, chronic pain, and joint instability. Often, children with EDS exhibit polyarthralgia and fatigue as their main symptoms. Although physical therapy is a mainstay of treatment for individuals with EDS, evidence is lacking for specific exercises or treatment strategies for management of pain. The purpose of this case report is to describe the effectiveness of closed kinetic chain and endurance exercises on reducing pain in a child with EDS.

CASE DESCRIPTION: The child was a 9 year old girl diagnosed with EDS hypermobility type, and a 3 week history of bilateral ankle pain. Her pain was worse when running and participating in sports (basketball and softball). She had long-standing polyarthralgia that occurred “all the time”, accompanied by fatigue during activities that had worsened over the past 3 weeks. The child wore ankle stabilizing orthotics at all times, and pain had caused her to discontinue playing sports. The child and her mother were seeking conservative treatment in an attempt to reduce her chronic pain and improve overall function.

OUTCOMES: Treatment focused on closed chain kinetic exercises. Initially, verbal feedback was given to obtain neutral range in weight-bearing joints in order to reduce microtrauma, facilitate proprioception, and recruit surrounding musculature for stability. After demonstrating proper form and reduced pain, the child was progressed to closed chain exercises within her full range of motion. The child's fatigue was addressed through the use of a Lower Body Positive Pressure Treadmill to reduce the forces applied from normal walking. The fact that she had a history of polyarthralgia suggested tailoring her treatment plan according to her functional capabilities and limitations, mainly hypermobility with reduced proprioception. After 6 weeks, the child reported decreased pain on the Faces Pain Scale from 7 out of 10 at initial evaluation to 2 out of 10 at discharge. Her Lower Extremity Function Scale, which identifies functional impairments, increased from 42/80 (52.5%) to 53/80 (66.3%). During the fourth week of her episode of care, she began wearing her Ankle Stabilizing Braces only during sports or when walking long distances. The child also reported less pain overall and was able to return to playing basketball, softball, and other extracurricular activities.

DISCUSSION: These results support interventions utilizing progressive closed kinetic chain exercises into full hyperextension range for children with EDS to help to achieve functional outcomes. Since EDS is a chronic condition, longitudinal studies could help increase the reliability of these exercise programs by investigating musculoskeletal influences over time. Further research should contribute to developing evidence-based treatment strategies for this condition.


Engel K, Norling J. Rehab Therapies, Gillette Children's Specialty Healthcare, Burnsville, Minnesota, United States

PURPOSE/HYPOTHESIS: There are many different types of pre-operative education offered to those undergoing surgeries. The majority of assessments of pre-operative education found in the literature are for adult joint replacement surgeries. Pediatric pre-operative classes are less common; with only one pre-operative interdisciplinary class identified. This pilot study consisted of an interdisciplinary team consisting of PT, social work, nursing, and child life specialists used life sized casting models, dolls, transfer videos, and real medical equipment to assist patients and families in feeling adequately prepared to cope while in the hospital, to develop expectations of therapy following surgery, and to prepare for care needs upon discharge.

NUMBER OF SUBJECTS: 150 patients.

MATERIALS/METHODS: This prospective study was designed to compare the effectiveness of an interdisciplinary preoperative class for caregivers with standard preparation for families of children undergoing SEMLS procedures. Patients were enrolled in one of two groups based on participation in the education class; attended (54) or not attended (83). Inclusion criteria for participants included having a bilateral SEMLS surgery, under the age of 18, and English as their first language. Patients undergoing SEMLS surgery were identified from the surgery schedule. Their caregivers were mailed an invitation for the education classes. They self-selected whether or not they would attend the class. Caregivers who chose not to attend the class were identified during the inpatient hospitalization.

RESULTS: The following data was analyzed: mean age at time of surgery, mean days from surgery to inpatient PT evaluation, mean inpatient PT sessions, mean hospital length of stay, mean PT sessions completed post-discharge, mean number of telehealth calls post-discharge, unplanned readmissions, major surgery complications, pain complaints, and diagnosis. Class attendees had statistically significant less inpatient PT sessions, more outpatient PT sessions post-operatively, and fewer surgical complications than those who did not attend the class. This group also trended towards having more telehealth calls. Unplanned readmissions, mean length of hospital stay and pain complaints were not significantly different in either of the groups tested.

CONCLUSIONS: Patients attending the pre-operative class were found to have less inpatient physical therapy sessions and less surgical complications. Further research needs to include the impact of the pre-operative education class on caregiver anxiety, as well as preparedness following the surgery. Education for families with English as a second language also needs to be further explored.

CLINICAL RELEVANCE: This study showed how pre-operative education classes, which are commonly used with adults, can benefit caregivers of children. Benefits were found in reducing the number of inpatient PT sessions needed, as well as decreasing post-surgical complications.


Fay D, Cardenas S, Koivuniemi-Berg T, Werkau S. Physical Therapy, ATSU, Mesa, Arizona, United States

PURPOSE/HYPOTHESIS: Bal-A-Vis-X (BAVX) is a program that uses balls and bags in a series of balance, auditory, and visual exercises. Although previous studies report positive changes in balance and coordination with interventions related to several components used in BAVX, the specific effect of a BAVX program on these skill areas has not been investigated. The purpose of this study was to explore the effect of a BAVX intervention on balance and coordination in school-aged children with typical development.

NUMBER OF SUBJECTS: Eight children with typical development between the ages of 4 and 12 years of age participated.

MATERIALS/METHODS: This was a quasi-experimental design with baseline assessments at weeks 1 and 10 and final assessment following intervention at 18 weeks. All children were tested with the Movement Assessment Battery for Children (MABC-2) and the Bilateral and Manual Coordination Composites of the Bruininks-Oseretsky Test of Motor Proficiency (BOT-2). During the baseline phase, children engaged in regular school and extracurricular activities. During the 7-week intervention phase, each child participated in a BAVX intervention class for 30-45 minutes bi-weekly. Skills were progressed based on performance and the BAVX protocol. Each participant completed an Activity Enjoyment Questionnaire (AEQ) during week 18, rating the intervention on a Likert scale of 1 to 5. Friedman's tests were used to compare scores across testing sessions with Wilcoxon Signed Rank tests used for post-hoc analysis (α = .05).

RESULTS: Overall, no significant changes were seen in the manual dexterity (p =.51), upper limb coordination (p =.67), and balance (p =.56) subtests of the BOT-2 or the manual dexterity (p =.67), aiming & catching (p =.91), and balance (p =.26) sections of the MABC-2. The bilateral coordination subtest of the BOT-2 was significant at p =.04, but post-hoc analysis revealed the difference occurred during baseline (p =.01). Median ratings on the AEQ indicated subjects liked the activity, thought it was “pretty easy,” and felt more coordinated after participating.

CONCLUSIONS: Although the subjects enjoyed the 7-week BAVX intervention, it did not result in significant changes in balance or coordination. These findings are not consistent with previous research on coordination interventions, but differences in duration and type of intervention may be relevant. Challenges experienced in delivery of the intervention may also explain the findings.

CLINICAL RELEVANCE: BAVX interventions have grown in popularity, with the belief they improve coordination of motor skills. The results of this study do not support this claim in typically developing children. Prior to concluding BAVX does not affect balance and coordination skills, the researchers suggest further studies be done, looking at shorter sessions offered more frequently (15 minute sessions, 3-5 times per week) over a longer period of time. Additionally, the effect of BAVX should be investigated in children with coordination impairments.


Font-Rivera A, Fernandez-Fernandez A. Physical Therapy, Nova Southeastern University, San Juan, Puerto Rico, United States

PURPOSE/HYPOTHESIS: Children with disabilities often do not meet the recommended levels of physical activity. For children with Down syndrome, the negative effects of a sedentary lifestyle are compounded with an inherent increased risk of developing chronic diseases early in life. The main purpose of the study is to explore the factors that parents in Puerto Rico identify as facilitators or barriers to a physically active lifestyle for their children with Down syndrome between 4 to 12 years of age.


MATERIALS/METHODS: This research used a phenomenological design. Seventeen parents (14 mothers; 3 fathers) from 5 different institutions providing health-related services to children with Down syndrome participated in the study. A self-administered questionnaire was designed to collect sociodemographic information and family's physical activity behaviors. A semi-structured interview was used to identify facilitators and barriers, and a thematic content analysis was performed to analyze this data. The ICF model was used as a framework to analyze how interactions between factors impact the adoption of a physically active lifestyle.

RESULTS: Puerto Rican parents identified physical activity facilitators as being related mostly to contextual factors. Examples included as extrinsic motivation from peers and family, as well as having professionals who are trained to work with children with disabilities and who can assist with integration in existing activities. Among barriers, they identified contextual factors such as parental time limitations, but also child-related factors such as child temperament and body/structure factors related to the diagnosis (hypotonia, joint instability). Even when families reported not engaging in physical activity, they recognized the importance of a healthy lifestyle, and would like for their children to be more active. Accessibility and transportation to facilities were not found to be a barrier.

CONCLUSIONS: Parents in Puerto Rico are aware of the benefits of a healthy lifestyle, but need more support for active participation. There is a need to train professionals who can specifically assist children with disabilities and help facilitate their participation in physical activity programs. Our results also show the importance of developing support systems for parents in order to allow more time for families to adopt an active life style.

CLINICAL RELEVANCE: It is important to establish strategies that promote a physically active lifestyle in children with Down syndrome from an early age, in order to increase their overall level of health and well-being throughout the lifespan. Early identification and classification of barriers or facilitators, specific to the cultural environment and the needs of the participants, can be useful in the development of prevention and health promotion strategies to effectively engage children with disabilities in physical activity.


Funderburg S, Josephson H, Price A, Russo M, Case L. Duke University, Durham, North Carolina, United States

PURPOSE/HYPOTHESIS: The purpose of this study was to review the current literature and determine trends for interventions to improve gait in children with spinal cord impairments.

NUMBER OF SUBJECTS: In 27 studies, 303 children (age ≤= 21) with spinal cord impairments, including spinal cord injury and spina bifida received interventions for gait.

MATERIALS/METHODS: A scoping literature review was conducted to identify relevant citations from PubMed, Embase, and CINAHL. The inclusion criteria included articles written in English, human research, pediatric spinal cord impairment, and an intervention performed with gait as an outcome.

RESULTS: Studies of orthotic intervention showed that ankle foot orthoses (AFOs) are beneficial for improving walking velocity in children with low level lesions, while a variety of more supportive bracing options were used to improve ambulatory status for those with higher level lesions. Electrical stimulation studies showed an increase in gait velocity and distance ambulated, although level of independence did not necessarily improve. The use of treadmill training was found to be effective in increasing speed, distance, and community based activity; and allowed for the use of less restrictive assistive devices. Infant treadmill training was found to be effective for increasing leg activity and step rate. The majority of articles included (78%) were classified as Levels of Evidence III and IV. Most of the articles failed to report allocation assignments, blinding, and random sequence generation, which implied a risk of bias, supporting the need for additional research.

CONCLUSIONS: This review examines intervention for gait in individuals with pediatric spinal cord impairments, which, to our knowledge, has not been previously reported. Interventions studied included orthotic intervention, electric stimulation, and treadmill training, with benefits reported on various components of gait for each intervention. The review revealed that interventions tended to target specific outcomes, highlighting the importance of identifying individual patient characteristics and goals appropriate for each intervention to help guide clinical practice. The studies included were primarily low level evidence and only one article was a randomized controlled trial, which suggests the need for further research.

CLINICAL RELEVANCE: Determining the appropriate orthotic support for each child, as well as incorporating treadmill training and/or electrical stimulation is recommended. Infant stepping on a treadmill in the spina bifida population showed promising effects in increasing movement, however future research to determine long term effects on gait and mobility is still necessary. Individualized assessment is important in determining the optimal combination of interventions based on individual characteristics and response to intervention. All treatment decisions should consider each child's lesion level, current and previous level of function and ambulation goals, as well as considering physical, social and environmental factors.


Gaetani S, Fenton R. Physical Therapy and Occupational Therapy, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, Pennsylvania, United States

PURPOSE: There are many referrals of patients with deformational plagiocephaly (DP) to a large, well established cleft-craniofacial center. In 2007 the center initiated a nurse practitioner (NP) run DP clinic. Initially, the NP was seeing 20-30 patients per month. The NP evaluated the patients for DP and if diagnosed, provided information for DP and aggressive repositioning (AR). This patient population was generally 6 months or older allowing little time for AR. These patients were rarely previously evaluated or diagnosed with congenital muscular torticollis (CMT) or receiving physical therapy (PT). Most of these patients were considered to have severe DP and therefore, were candidates for helmet therapy. As the clinic grew and developed, it became apparent that the majority of these patients with DP also had CMT. Additionally, it is documented in the literature that there is approximately a 10% correlation of CMT and hip dysplasia. Due to the significant relationship of these orthopedic issues, the NP requested PT join the DP clinic to develop a more comprehensive evaluation and treatment approach. This request was granted with a PT who was very experienced with CMT.

DESCRIPTION: The team approach in evaluating these patients began in the fall of 2010. PT provides an evaluation of the neck, spine, hips, feet and gross motor skill screening. If the patients are diagnosed with CMT, PT provides education and teaches the caregivers home exercises. If the patients are identified to have hip or other medical concerns, the appropriate referrals are made.

Printed patient education materials were developed to include information regarding DP and AR, a tummy time brochure and exercises for CMT. Multiple in-services were provided to the community which included PCP's and PT's. A definite shift became noticeable in the referrals. After the educational sessions, patient referrals occurred when the patients were younger and when AR could make a significant impact on the DP. Many of the patient referrals are now already diagnosed with CMT and have started PT. Caregivers often identify that the CMT is already improving as is the DP when they present for evaluation. This early PT is associated with many of the patients not meeting the requirements for helmet therapy or receiving helmet therapy earlier (in the appropriate age range) and receiving greater improvement due to earlier intervention.

SUMMARY OF USE: This multi-disciplinary clinic benefits the patients and families greatly by providing simultaneous expertise from both disciplines to provide efficient care and resources as well as initiate treatment at the earliest possible time. The number of referrals to this team clinic has increased to the point where the center is now receiving approximately 100 patient referrals per month. The patient satisfaction surveys confirm that the families are very satisfied.

IMPORTANCE TO MEMBERS: Incidence of CMT and DP have increased dramatically; a multidisciplinary approach increases successful treatment outcomes.


Gaspari C, Jaccoud A. C, Vilela F. Physical Therapy, Instituto Estadual do Cérebro Paulo Niemeyer, Rio de Janeiro, RJ, Brazil

BACKGROUND & PURPOSE: Microcephaly (MC) is characterized by a smaller than normal head circumference. This can be caused by different mechanisms, including congenital acquired infections that damage the central nervous system. Motor alterations associated with MC could include: delayed motor development, tonus alterations and orthopedic malformations.

Since 2015, Brazil has reported a large number of cases of MC likely associated with the Zika virus (ZIKV) epidemic. The purpose of this study is to show the physical therapy (PT) findings of the first 30 infants with MC evaluated during the ZIKV epidemic in Rio de Janeiro.

CASE DESCRIPTION: This case report encompasses the findings of infants evaluated at triage program during the ZIKV epidemic in Brazil from March to April of 2016.

The program aimed to evaluate all recently notified cases of MC. The PT assessment included evaluation of primitive reflexes, tone, motor development and the observation of any orthopedic malformation.

OUTCOMES: The infants had an average age of 2.43 months (88±54) days. Most (73%) were born full-term (average gestational age: 37.4±1.9 weeks), with an average cephalic perimeter of 29.5±2.2 cm at birth.

There were 23 (76.7%) symptomatic cases of ZIKV and five (16.7%) asymptomatic cases during pregnancy. 2 infants had ZIKV excluded.

Out of the 28 infants likely exposed to the ZIKV:

25 (89.3%) had no primitive reflexes alteration (Moro, palmar and plantar grasp reflex, Babinski, suction, rooting reflex, asymmetrical tonic cervical reflex and Galant reflex).

24 infants (85.7%) had increased tone: 22 (91.7%) of the trunk, and 21 (87.5%) of the limbs.

4 infants (14.3%) had orthopedic malformation.

Motor development:

17 infants were < 3 months and 8 (47%) did not sustain head raising to 45 degrees.

11 infants were between 3-5 months and 8 (73%) did not sustain forearm support.

DISCUSSION: A causal link between ZIKV infection of the mother and MC in the child has yet to be confirmed, but there have been a growing number of case reports that aim to make that association.

Most infants had normal primitive reflexes and some of the infants had musculoskeletal anomalies.

Tone was evaluated by assessing the impact of spasticity on postural control and movement in prone and supine. The infants with increased spasticity presented with an active extensor pattern showing the ability to hold a prop-on-elbow position and sometimes even extend their elbows as early as one month of age. This extensor pattern was evident also in the supine when the infant was unable to hold the posture due to a high arching back and rolling to the side. When pulled-to-sit, they showed an abnormal extensor pattern as well. At times, the small size of the infant and their excessive irritability (60.7% of the cases) made any specific scale very difficult to be utilized.

To assess motor development delay, the guidelines established by the Brazilian government were used.

The impact of this early increased in tone in the development and function is still unknown.


George D, Allen V, Silone S, Slomski K, Summerhill E, Williams N. Physical Therapy, The University of Findlay, Tiffin, Ohio, United States

PURPOSE/HYPOTHESIS: Several organizations have recommended 150 minutes of weekly physical education, however, less than 20% of 3rd graders in United States were offered this activity during the 2007-2008 school year. Staggeringly, it is estimated that 31.8% of children are overweight and 16.9% are obese. If this trend continues, childhood obesity may decrease the lifespan 3 to 5 years by 2035. The purpose of this study was to describe the current means of promoting health and wellness practices of public schools within northwest Ohio region.

NUMBER OF SUBJECTS: Public schools within northwest Ohio (i.e., 419 area code) were selected as a sample of convenience. Three hundred and eighteen school principals were first contacted for participation; ultimately 16 schools participated.

MATERIALS/METHODS: Interview questions for the school systems were developed based on literature & expert review. The participants were interviewed about health and wellness regulations, the type of screening(s), and the intervention(s). The common themes found were analyzed with frequencies and percentages.

RESULTS: Of the 16 participating schools, 31.25% screened only elementary schools, 12.50% only middle schools, 43.75% both elementary and middle schools, and 12.50% did not indicate which grade levels were screened. Majority indicated that the screenings were financed through general school funds or the government. Others had volunteers, did not perform screenings, or did not know the financing mechanism. The interviews revealed that 56.25% assessed students' vision, 43.75% hearing, 25.00% scoliosis, but none assessed overall posture. Additionally, 12.50% did not perform any screenings, 6.25% assessed anthropometric measures, 6.25% assessed physical fitness, none assessed nutritional behaviors, and 6.25% did not respond. There was no consistency found with the frequency of screenings. If abnormal findings were found, 43% used an interdisciplinary approach to combat abnormal body mass index (BMI), 37.50% provided educational resources, and 37.50% didn't implement any intervention.

CONCLUSIONS: The results of this study showed the gaps that are present in the health and wellness screenings, as well as, the lack of health and wellness interventions provided with in our public elementary and middle schools. The shortcomings found through our research open the doors for the Physical Therapy community to step in and provide the schools with a standardized practice for health and wellness screenings and interventions. This standardization could include the types of screening, the tools used, and a predetermined frequency.

CLINICAL RELEVANCE: As professionals, we need to provide pro bono services to the community and this is a prime example of where our knowledge and expertise would be beneficial. In the future, Physical Therapists' may instruct the school nurse and/or other staff on how to appropriately continue the screening and referral process so that the promotion of health and wellness does not stop when the physical therapists are not present.


Gilbertson T, McCoy S, Bjornson K, Coombs A, Price R, Moritz C. Rehabilitation Medicine, University of Washington, Issaquah, Washington, United States

PURPOSE/HYPOTHESIS: Neural plasticity and motor-learning research suggest that task-specific practice should control intensity, repetition, timing, difficulty, and salience to have the largest effect (Kleim & Jones, 2008). Based on these principles, ‘NeuroGame’ Therapy (NGT) was designed and has shown promise in upper extremity rehabilitation in children with cerebral palsy (CP) (Rios et al, 2013). We explored the effects of task-specific practice using NGT for improving activation of ankle dorsiflexion muscles in children with CP. Our portable system provided biofeedback from ankle dorsiflexion (ADF) surface electromyography (sEMG). Successful ADF sEMG activation allowed children to control computer games.

NUMBER OF SUBJECTS: 9 children (3 boys) with bilateral lower extremity involvement and spasticity, Gross Motor Function Classification System level I-III, mean 12.15 years (SD 3.36 yrs) completed the study.

MATERIALS/METHODS: Our repeated measures case series design utilized 5 assessments, each occurring 3 weeks apart. Intervention occurred between the second to the fourth assessment as a home exercise program. Assessments spanned the ICF dimensions including: sEMG co-contraction, standing balance, muscle contraction force (MCF), spatiotemporal and kinematic motion analysis during active ROM and gait, ADF range of motion (ROM), Selective Control Assessment of the Lower Extremities (SCALE), falls, and the 6-minute walk test (6MWT). Intervention consisted of using NGT 3-5 times per week followed by a 5-minute walking session to practice ADF during gait. Walking adherence was documented via a FitBit activity monitor. Results were analyzed descriptively case by case.

RESULTS: All children used NGT multiple times per week and reported enjoyment of the game. Results were varied based on child, level of involvement, and amount of game play but all children showed improvement in at least two measures. Children who played the game the most showed the most change in sEMG co-contraction during AROM and walking. Positive changes were also seen in balance (6/9 participants) and MCF (4/9 participants). Two children showed improvements with gait variables (one dorsiflexion at initial contact and one in stride length). Two children had a slight increase with walking velocity. Only one child had changes in passive ROM. There were changes with the total SCALE scores in 6 of 9 children, and also changes seen with movement quality. Three children showed improvement with their 6MWT. One child had fewer falls.

CONCLUSIONS: NeuroGame therapy was feasible and enjoyable for these children with CP, and facilitated repetition and intensity of intervention. Results of NGT use seem to be highly correlated to the amount of time using this device. Participants improved their ADF muscle activity, which lead to some changes in ankle function.

CLINICAL RELEVANCE: NGT, which leverages neuroplasticity and motor learning principles, also appeared to increase participants' motivation to perform therapy at home.


Gillogly T, Koehl P, McLean T, Howman J. Division of Physical Therapy, Ohio University, Athens, Ohio, United States

PURPOSE/HYPOTHESIS: Intensive dosing of pediatric physical therapy (PT) interventions has been identified as evidence-based practice for some patients; however, in rural areas access to healthcare can be limited. Barriers to rural healthcare include travel distance, lack of public transportation, distrust of healthcare providers, financial concerns, and lack of understanding intervention benefits. Awareness of how these barriers impact intensive interventions is imperative for optimal pediatric service delivery in rural communities. The purpose of this study was to describe barriers to participating in intensive pediatric PT interventions in rural southeastern (SE) Ohio.


MATERIALS/METHODS: Ohio University Therapy Associate's pediatric PT staff developed a survey regarding barriers to accessing intensive interventions. Survey questions were divided into four categories: travel, schedule, cost, and value. Between March-June 2015, surveys were given to parents of children, currently on caseload, who were considered candidates for intensive interventions. Respondents were categorized according to three characteristics: (1) native to SE Ohio, (2) child's current age, and (3) prior experience with PT intensives. Descriptive statistics and frequency distributions were used to describe reported barriers in aggregate and across respondent characteristics.

RESULTS: Respondents were from 7 counties in SE Ohio, had children between 7 months-17 years of age, and were equally distributed between native and non-native status. Only 36% of respondents had past experience with intensive interventions. Overall, financial concerns were most frequently reported with insurance coverage (61%), cost of services (47.6%) and travel costs (40.5%) the top three identified barriers. The next most reported barrier was scheduling (30.8%). All other barriers were reported by less than 25% of respondents. When comparing results between age categories, parents of school-aged children reported lack of reliable transportation and scheduling barriers more frequently than parents of 0-5 year olds. While cost of intensives was of equal concern to native and non-native respondents; those native to SE Ohio were less likely to discontinue if insurance didn't pay. Parents with intensive experience reported less cost and scheduling barriers than their counterparts without experience.

CONCLUSIONS: This survey identified financial concerns as the most prevalent barrier, revealed that barriers can change as children mature and showed past experience with intensives reduced perceptions of barriers. Therefore, developing less expensive delivery models, providing alternative funding, varying structure depending on child's age and facilitating opportunities for experienced parents to share their insight may increase access to intensive interventions in rural communities.

CLINICAL RELEVANCE: Understanding barriers to accessing intensive pediatric PT services will assist clinicians in developing creative solutions so intensive dosing can be a viable option in rural areas.


Grinde K, Myhre J. Children's Minnesota, Plymouth, Minnesota, United States

PURPOSE/HYPOTHESIS: Pediatric constraint induced movement therapy (PCIMT) has been shown to be an effective treatment for improving unimanual and bimanual skills in children with hemiparesis. There is limited information on the effect of repeat episodes of PCIMT. This study investigates the outcomes of repeat episodes of hybrid PCIMT. We hypothesize that children will show significant gains in fine motor, gross motor and bimanual skills after each episode of hybrid PCIMT, and gains will be accompanied by improved participation in daily activities.


MATERIALS/METHODS: Nineteen children with asymmetrical upper extremity function, aged 14 months to 6 years participated in 2-4 repeat episodes of hybrid PCIMT in a pediatric outpatient rehabilitation clinic for a combined total of 49 episodes of care. Each episode consisted of 6 hours of treatment by the same physical therapist for 21 days over the course of 4 weeks. A long arm cast was worn 24 hours/day for 3 weeks, and removed daily in the 4th week for bimanual training. Casts were also removed and reapplied weekly to check skin. Treatment consisted of developmentally appropriate fine motor, gross motor and daily living activities using principles of shaping, repetition and motor learning. All children were evaluated on day 1 and day 21 using the Peabody Developmental Motor Skills-2 (PDMS-2), with the left and right hand scored separately for unimanual skills in the Grasp, Visual-Motor Integration and Object Manipulation subtests. The Assisting Hand Assessment (AHA) was added in 2010 (n=39 episodes), and the Canadian Occupational Performance Measure (COPM) was added in 2012 (n=17 episodes). A paired two sample t-test was used to analyze the difference in the means between the pre- and post-treatment scores.

RESULTS: The mean post-treatment score was statistically significantly higher than the mean pre-treatment score on all measures following treatment with p<0.001. The mean change in scores was 60.45 and 33.08 for the Total Raw Score of the assisting hand and dominant hand respectively on the PDMS-2, 17.36 for the AHA Scaled Score, 4.16 for the COPM Performance Score, and 4.97 for the COPM Satisfaction Score. Repeat episodes produced further increase in scores on the AHA and PDMS-2 for all children. Clinically significant gains were noted on the Scaled Score for the AHA for 39/39 episodes which were all greater than the smallest detectable difference. COPM Satisfaction and Performance Sores for 17/17 episodes were above the clinically meaningful threshold.

CONCLUSIONS: These findings support the hypothesis that children can make significant gains in fine motor, gross motor, bimanual and daily living skills after repeat episodes of hybrid PCIMT.

CLINICAL RELEVANCE: We expect large gains in total motor performance in children who participate in hybrid PCIMT. Repeat episodes provide further improvements and retention over time. This data provides further evidence for therapists to incorporate hybrid PCIMT into clinical practice in order to optimize outcomes for children with asymmetrical motor impairment.


Gutierrez M. Physical Therapy, TIRR Memorial Hermann, Houston, Texas, United States

BACKGROUND & PURPOSE: Dysautonomia, also known as postural orthostatic tachycardia syndrome (POTS) describes a condition characterized by a malfunction of a person's autonomic nervous system. Symptoms reported include fatigue, syncope, dizziness, headaches, poor concentration, gastrointestinal disturbance, and exercise intolerance. An exercise program focused on improving cardiovascular endurance and teaching physical maneuvers to avoid orthostatic hypotension has been proven to be beneficial for this group; however, patients frequently find exercising difficult and may even have symptom exacerbation related to exercise. This case study describes one individual's participation in a structured progressive exercise program of cardiovascular and strength training in progressively more upright positions.

CASE DESCRIPTION: AL, a 16 year old female, was referred to physical therapy with diagnosis of dysautonomia with chief complaints of fatigue and exercise intolerance. She had been diagnosed with dysautonomia 6 months prior to evaluation. AL was seen in physical therapy for 9 months. Once AL was stable enough to participate in more independent exercise, she was transitioned to a community group exercise program designed for patients with dysautonomia at the same clinic. Treatment included both land and aquatic-based therapy that focused on strengthening and endurance training in positions that avoided orthostatic stress. Throughout all sessions, AL's blood pressure, heart rate, and rate of perceived exertion (RPE) were closely monitored. Exercise intensity was capped at a RPE of 14.

OUTCOMES: The 6 minute walk test (6MWT) was used to measure endurance and tolerance to upright physical activity. No change in the 6MWT occurred after the physical therapy episode of care; however, AL demonstrated an improvement from 1590 to 1762 feet at a RPE of 13 after the community exercise program. The Patient Specific Functional Scale demonstrated an improvement in perception of functional ability in patient-selected activities after physical therapy and community exercise programs. Functionally, the individual was able to enroll in college and maintain a child care job.

DISCUSSION: Participation in supervised physical therapy, including exercise with skilled monitoring of vitals and patient education is an important component in the management of symptoms caused by dysautonomia. In addition to land-based cardiovascular exercise and strength training, aquatic exercise is beneficial in the management of dysautonomia. The hydrostatic pressure, which increases blood pressure and decreases heart rate, allows individuals to perform cardiovascular and strength training in an upright position with reduced orthostatic stress. Group exercise programs have the additional benefit of providing an informal support group for a population of individuals that experience social isolation secondary to disabling symptoms. This may lead to functional improvements and provides a support system.


Harbourne R, Kane A, Schriefer A. Physical Therapy, Duquesne University, Pittsburgh, Pennsylvania, United States

PURPOSE/HYPOTHESIS: This longitudinal study examined the ongoing interaction between the domains of cognitive and motor development in infants with neuromotor disability through the use of eye-tracking technology to quantify information processing skill via looking behavior. Look time and switch time of looking between targets have been shown to indicate cognitive processing skill in infants. We hypothesized that time to switch gaze would decrease as infants learned to sit, and that function would increase as switching gaze speed increased.

NUMBER OF SUBJECTS: Eight infants with developmental delays due to neuromotor disorders between the ages of 8 months and 17 months who were just beginning to sit (prop sit) were followed for 3 months as sitting emerged.

MATERIALS/METHODS: The Early Problem Solving Indicator test was used to score the number of explorations and functional movements during play with three standardized toys at baseline and at the final assessment. A Positive Science head mounted eye tracker was used to measure the movements and movement times that the child's eyes fixated on a salient feature of the presented toy, and the speed at which the child's eye fixation moved from one specified feature to another (switch time). Sitting skill advanced over time for all infants. Regression analysis using SPSS was performed using switch time to predict explorations of the toys at baseline; at 3 months a regression analysis was done using switch time to predict functional movements on the problem solving test. Pre and post comparisons of explorations, functions and switch time were done to note change over time.

RESULTS: Explorations increased from baseline to final assessment, but not significantly. Functional problem solving increased significantly from baseline to final assessment (P=0.042). Shift time of eye focusing also decreased from baseline to final assessment. Linear regression indicated that shift time contributed significantly to functional problem solving at final assessment (P=0.011), but not to exploration movements. However, shift time contributed significantly to exploration at baseline (P=0.032).

CONCLUSIONS: The ability of the eyes to shift quickly and foveate on features of importance in the visual field is a strong factor in developing cognition through exploration, functional movement, and problem solving. The developing skill of sitting contributes to changes in the ability of the eyes and head to dynamically orient to objects and pick up important information in the environment.

CLINICAL RELEVANCE: Physical therapists may contribute to infant learning and problem solving by supporting and advancing dynamic sitting skills through careful intervention. Awareness of infant looking and the ability to switch gaze is an important factor to incorporate into a comprehensive developmental intervention, in order to advance cognitive developmental skill.


Hoffman L, Harris N, Fuhr E, Way V, Foss L, Deslatte K, Tumenjargal N, Vong S, Lotfy M, Eigsti H. School of Physical Therapy, Regis University, Denver, Colorado, United States

PURPOSE/HYPOTHESIS: To examine the effect of carbon fiber (CF) and typically prescribed polypropylene (PP) ankle foot orthoses (AFOs) on balance, gait, and gross motor function in children with cerebral palsy (CP).


MATERIALS/METHODS: Two children with spastic diplegic CP and one child with spastic hemiplegic CP between 5-9 y.o; all classified with Gross Motor Functional Classification Scale I (GMFCS I) participated in this study. Orthotic prescription was made by consensus following an examination of flexibility, strength, tone and gait by three experienced pediatric physical therapists. Randomized cross-over design for 6 week on cycle of each AFO (CF or PP); followed by a 6 week on cycle of the self-selected AFO. Gross Motor Function Measure (GMFM), GAITrite (gait speed, step length, percent weight bearing), Edinborough Visual Gait Analysis (EVGS), Dynamic Motion Analysis (DMA), posture, and satisfaction questionnaire data were collected wearing CF, PP, and shoes (S) after each orthotic wear cycle.

RESULTS: All three participants chose CF as their self-selected AFO for the last 6 week orthotic on cycle. All parents rated the CF AFO highest on the satisfaction questionnaire. Changes in gait speed, DMA and posture were highly variable across conditions and across subjects. All participants improved in their GMFM E scores with higher GMFM scores while wearing the CF compared to the PP AFO at the end of the study. Only one subject (8 year old with spastic diplegia, recurvatum gait) demonstrated improved gait speed in all conditions, and had the greatest velocity in the carbon fiber orthotic at the end of the study. The 8-year-old subject with spastic diplegia and the 9-year-old subject with spastic hemiplegia demonstrated improved balance in the carbon fiber and polypropelene AFO's at the end of the study compared to baseline, and all 3 subjects had better balance scores (DMA) in the CF compared to the PP AFO at the end of the study.

CONCLUSIONS: The three children and their parents preferred the Carbon Fiber AFO to the Polypropylene AFO. The limited number of participants precludes drawing conclusions about the efficacy of PP or CF AFOs in improving gait, balance and motor skills in children with cerebral palsy. Larger studies are warranted to determine the effectiveness of carbon fiber versus polypropylene AFO's.

CLINICAL RELEVANCE: Despite inconclusive findings to support efficacy of either CF or PP AFO's there were trends showing improved balance, gait speed and motor skills in carbon fiber versus polypropylene AFOs following 18 weeks of intervention. There was a subjective preference from participants and their parents for Carbon Fiber versus Polypropylene AFOs.


Holloway J, Biasini F. Physical Therapy, University of Alabama at Birmingham, Birmingham, Alabama, United States

BACKGROUND & PURPOSE: In addition to the social-communication difficulties that characterize Autism Spectrum Disorder (ASD), children with this diagnosis often demonstrate additional motor difficulties. Motor ability and social function are related in children who are typically developing, however, the extent to which motor deficits relate to social impairments in children with ASD is unknown. The purpose of this case series was to describe changes in peer acceptance and rejection in children with ASD following an 8-week inclusive, motor-based intervention program.

CASE DESCRIPTION: Eight participants (4 with ASD and 4 without ASD) ages of 4-5 years old were recruited from a local preschool to participate in the study during the afterschool program.

OUTCOMES: Motor skills were measured before and after the intervention using the Peabody Developmental Motor Scales 2nd Ed (PDMS-2). Pre- and post-intervention acceptance and rejection were measured using child and teacher ratings of preferred and non-preferred playmates. All participants took part in an 8-week motor-based intervention program consisting of gross motor games involving imitation, interaction, and turn-taking. Motor delays were present at pre-testing in 3 of the 4 children with ASD compared to 1 of the 4 children without ASD. All children improved gross motor skills after the intervention. Positive trends were seen for peer acceptance for 2 of the children with ASD when rated by other children and for 3 of the children when rated by the teacher. Social rejection trends were positive for 2 of the children with ASD when rated by peers and for 3 of the children when rated by the teacher. On average, children without ASD increased peer acceptance and decreased peer rejection.

DISCUSSION: Participation in a motor-based intervention program may produce social benefits for children with ASD. This study supports the literature that suggests many children with ASD demonstrate delays in motor skills and strengthens the perspective that this is an area of emerging opportunity for physical therapists. The study also offers preliminary evidence that children with ASD may benefit from participation in community-based programs that use movement to encourage social interactions.


Horbacewicz J, Bensinger-Brody Y, Barresi J, Bronchtain R, Genuth A, Gordon Y, Rosen E, Shmidman H. Touro College, New York, New York, United States

PURPOSE/HYPOTHESIS: Children with autism spectrum disorder (ASD) have deficits in attention, motor performance, and behavior which may impede ability to function in the classroom. The purpose of this study was to examine the effect of the Educate 2B yoga and mindfulness program incorporating two-minute yoga based sessions on social-emotional competence and motor performance in elementary school children with ASD.

NUMBER OF SUBJECTS: Twenty participants (18M, 2F) with ASD in grades 2-6 were recruited from 4 classrooms of students.

MATERIALS/METHODS: Two classrooms were assigned to the experimental group and 2 were the control with 10 children in each group. Teachers in the experimental group were trained in 15 different Educate2B Yoga and Mindfulness techniques. The experimental group partook in 2 minute yoga/mindfulness interventions 3 times a day for 11 weeks. Participants were assessed using the Devereux Student Strengths Assessment (DESSA) mini to assess social-emotional competence and the Motor Assessment Battery for Children (M-ABC-2). Data for all 20 participants was analyzed for the DESSA mini. Data for 18 participants was analyzed for the MABC-2 due to the inability of 2 participants to complete the testing.

RESULTS: The Mann Whitney U Test was used to determine group equivalence. For the MABC-2, there was no significant difference in pre-test scores between the control and experimental groups. However, there was a significant difference (p < 0.05) in the post-test MABC-2 scores between the control and experimental groups with the control group showing a decline and the experimental group showing no decline. For the DESSA-mini, there was no significant difference for both the pre- and post-scores between the control and experimental groups. The Wilcoxon Signed Rank Test was used to determine differences within groups. There was a significant difference (p < 0.05) in the DESSA mini scores of the experimental group with improvement of scores from pre test to post test. There was no significant difference (p > 0.05) in the MABC-2 scores of the experimental group from pre test to post test.

CONCLUSIONS: In this pilot study, children with ASD receiving the Educate 2B Yoga and Mindfulness Program demonstrated improvements in social-emotional competence as measured by the DESSA-mini, and maintained their motor functioning as measured by the MABC-2. Children in the control group showed no improvement in the DESSA-mini and had a reduction in MABC-2 scores. Suggestions for future studies include consideration of other measures for motor performance for this population and examining the association between level of severity of ASD and outcomes.

CLINICAL RELEVANCE: The Educate 2B Yoga and Mindfulness Program is a practical 2 minute intervention that can be incorporated into the school day more easily than formal yoga interventions requiring longer periods of time. Based on the findings of this pilot study it can be utilized as an effective method to improve behavior in the classroom and maintain motor function to optimize learning in the classroom.


Hsu L, Jirikowic T, Kartin D, McCoy S. Rehabilitation Medicine, University of Washington, Seattle, Washington, United States

PURPOSE/HYPOTHESIS: Postural control consists of sensory cueing of body orientation that results in appropriate muscle activation to maintain balance. The Multi-Modal Balance Entrainment and Response (MuMBER) system assesses sensory attention during standing balance. Our purpose was to compare sensory attention related to postural control via MuMBER in children with typical development (TD) in different age groups and healthy young adults. We expected younger children to attend more to visual/tactile than vestibular stimuli.

NUMBER OF SUBJECTS: Participants included 12 healthy adults aged 22-35 years and 28 children with TD in three age groups: 5-6 (n=6); 7-10 (n=13); and 11-16 year-olds (n=9). The Mini Balance Evaluation Systems Test (for adults) and the Movement Assessment Battery for Children, 2nd Ed were performed to verify that participants had no balance concerns.

MATERIALS/METHODS: During one session using MuMBER, sensory attention during standing balance was measured by determining the amplitude with which participants match their body-sway frequency to small frequency medial-lateral sensory inputs. Three sensory stimuli were provided in combinations of low and high frequencies for visual (dots on screen), somatosensory (touch pole), and vestibular (foam covered tilt board surface) inputs across 4 conditions. A Qualysis motion analysis system captured body sway movements by tracking markers on participants' sacrum. In each condition, one sensory stimuli was at high frequency (causing inattention to that stimuli) and the other two were at low frequencies (allowing choice of sensory attention). The outcome measurement was sensory attention index (SAI), a ratio that demonstrates the preference for sensory attention between the two sensory systems at low frequencies in each condition. One-way ANOVAs followed by Bonferroni comparison tests were used to compare among the different age groups.

RESULTS: Children age 5-6 years showed significantly lower attention to vestibular stimuli (p< 0.05) in both sensory conditions where visual or tactile stimuli were at high frequency. They had significantly higher attention to either tactile or visual stimuli compared to the older groups (11-16 year-olds and adults). Adults showed significantly higher vestibular attention compared to all three children groups among all sensory conditions (p< 0.001). There were no significant differences between 7-10 year-olds to either 5-6 or 11-16 year-olds.

CONCLUSIONS: Results supported differences in sensory attention indexes among different age groups. Children age 5-6 years did not show preference for vestibular stimuli when the visual or tactile stimuli was manipulated as compared to children age 11-16 years and adults, whereas adults tended to show more preference for vestibular stimuli during standing balance.

CLINICAL RELEVANCE: Younger children with typical development as compared to adults appear to show preference to visual and tactile stimuli instead of vestibular stimuli. Further study of children across more detailed age bands and children with disabilities is warranted.


Jeffries L, Neal G, Effgen S, McCoy S, Chiarello L. OUHSC, Oklahoma City, Oklahoma, United States

PURPOSE/HYPOTHESIS: Evidence shows students with Down syndrome (DS) require assistance on physical tasks, however there is little reliable data regarding the school-based physical therapy services provided. The purpose of this study was to identify the current physical therapy services, provided in school-based practice in the United States, for students with Down syndrome.

NUMBER OF SUBJECTS: Physical therapists (PTs) (N=109), within four regions of the US reported the school-based services provided to 296 children from their caseloads, age 5 to 12 years, 46 with Down syndrome.

MATERIALS/METHODS: PTs participated in training and passed reliability testing on the School-Physical Therapy Interventions for Pediatrics (S-PTIP) data collection system. For 20 weeks, during the 2012-2013 school year, PTs documented physical therapy services (time spent within activities, intervention techniques used, service delivery methods implemented, services on behalf of the student, and student participation). S-PTIP forms were sent to regional sites for data entry into an online database. Descriptive statistics were calculated.

RESULTS: PTs provide a mean of 24 minutes/week (SD=13.9) of service. The most frequent activities (minutes/week) were physical education/recreation (12.9, SD=10.6), mobility (5.2, SD=4.7), and sitting/standing/transitions (5.1, SD=7.3). The least frequently used activity was classroom activity (2.5, SD=1.1). The largest mean number of interventions received were neuromuscular (balance and motor learning techniques) (29.46, SD=17.7), mobility (primarily stair and door training) (16.7, SD=14.2), and musculoskeletal (primarily functional strengthening) (12.3, SD=6.6). The least number of interventions utilized was positioning (1.9, SD=1.5). More mean service minutes/week were delivered to the students individually (18.5, SD=14.6) than in a group (10.26, SD=11.1) and separate from a school activity (16.9, SD=11.6) than within a school activity (9.1, SD=12.4). Services on behalf of students occurred for a mean=11.6 minutes/week, SD=6.1. Most students received services within the school (87%) and students' mean participation on a 1 (no participation)-5 (excellent participation) scale was high (4.8, SD=0.89).

CONCLUSIONS: For students with Down syndrome the primary physical therapy services were recreation movement, mobility, and transitions during school-based services. PTs used balance, motor learning, mobility, and functional strengthening techniques. Services were provided individually to students and separate from school activities in the school environment. Given these data, studies of effectiveness of services for student outcomes can be designed.

CLINICAL RELEVANCE: The S-PTIP is a data collection system which allows PTs to examine the activities and interventions implemented with students. School-based services for students with DS should be considered especially related to methods of services.


Jones S, Blaser B, Toombs H, Wahl D. Physical Therapy, Southwest Baptist University, Bolivar, Missouri, United States

PURPOSE/HYPOTHESIS: According to the United States Center for Disease Control and Prevention childhood obesity is an epidemic and has more than doubled in children ages 6-11 from 1980-2012. It is understood that a multimodal approach is the best method to improve Body Mass Index (BMI). However, such approaches may not be feasible due to socioeconomic constraints and varied family participation. A systematic review was conducted to determine if a school-based physical activity program (PAP) alone, in addition to regular Physical Education (PE), can decrease BMI in school-aged children.

NUMBER OF SUBJECTS: Five studies 1,324 subjects.

MATERIALS/METHODS: The American Academy of Cerebral Palsy and Developmental Medicine (AACPDM) methodology was used to conduct this review. Five databases were searched using the following criteria: school aged children, school-based PAP provided in addition to PE, an outcome measure of BMI, and peer-reviewed studies published within the last 10 years. Four authors independently reviewed studies for eligibility, and the strength was rated using the AACPDM conduct of group design questions.

RESULTS: The initial search produced 376 articles. Following removal of duplicates and studies that did not meet inclusion criteria, five articles remained. Four of the five studies were Level II randomized controlled trials (RCT), and the fifth was a Level I RCT. All studies demonstrated moderate to high methodological strength. Reviewed studies included a total of 1,324 subjects.

The number of minutes of the PAP varied among the studies from 60-605 minutes per week and there was heterogenity in the types of activities provided between the different studies. Even with this limitation, each study showed an overall reduction in BMI for children who participated in a PAP with the greatest effect seen in obese and overweight children.

CONCLUSIONS: Even though a multimodal approach has shown to be most effective, the addition of a PAP alone is effective in improving BMI in 6-12 year old children, especially those who are already obese or overweight. Many schools may not have the resources to implement a multimodal approach, but may be able to provide a PAP in addition to their current PE curriculum. From this review, it appears that a minimum of 8 weeks of moderate to vigorous activity is indicated. Further research is needed to determine the optimal amount of physical activity needed to reduce BMI so that minimum activity requirements can be established.

CLINICAL RELEVANCE: Given the increasing incidence of childhood obesity in the United States, school based physical therapists could play a significant role in advocating for and establishing school-based PAPs to reduce BMI among children. Development of these intervention programs may not only impact children who are already overweight or obese, but could also improve the overall health and wellness of all school-aged children.


Kabiri L, Brewer W, Ortiz A, Mitchell K. School of Physical Therapy, Texas Woman's University, Houston, Texas, United States

PURPOSE/HYPOTHESIS: Motor skills are important to childhood health and have been linked to improved physical activity, body composition, academic performance, and both current and future levels of cardiorespiratory fitness. Public school children have the opportunity to develop motor skills through regular classroom activities and physical education. Roughly 1.8 million American children are schooled at home but no information is available on the level of motor skill attainment in this population. The purpose of this study was to evaluate motor skill proficiency among 5-8 year old homeschool children. It was hypothesized that motor skill development would be significantly different in homeschool children compared to established age/gender norms. This research was part of a larger study entitled Fitness Assessment in the Homeschooled: The FAITH Study.


MATERIALS/METHODS: Homeschool children grades K-5 were recruited using email, homeschool groups, and word of mouth. A subset of children aged 5-8 years was screened for overall motor skill development using the Bruininks-Oseretsky Test of Motor Proficiency, 2nd Edition – Short Form (BOT-2 SF). The BOT-2 SF is a reliable and valid screening tool in children. Scores were standardized using age/gender specific norms. BMI was assessed and parents filled out a demographic survey including sports participation. Descriptive statistics and subgroup differences from independent samples t-tests were calculated using IBM SPSS, v.23.

RESULTS: Seventy-three typically developing children (48% male, 52% female; mean age (yrs)=6.51, SD=1.01, Range [5-8]; 86% white, 14% other; median income=$100-$149K) completed the BOT-2 SF. Over half of the sample participated in organized sports (68.5%; mean average hrs/wk=2.77, SD=2.84, Range [0-10]). The entire sample demonstrated average overall motor skill proficiency (mean=53.49, SD=9.70, Range [31-76]). There were no significant differences in BOT-2 SF score between genders (t(71)=.96, p =.341, 95% CI=-2.35,6.72) or underweight/normal vs. overweight/obese BMI (t(71)=-.19, p=.850, 95% CI=-7.99,6.60). Subjects who participated in =2.5 hrs/wk of organized sports scored significantly higher with a medium effect size (t(71)=2.55, p=.013, 95%CI=1.22,9.95, d=.60).

CONCLUSIONS: Children schooled at home show average motor skill proficiency. This indicates no detrimental effect of homeschooling on motor skill development regardless of gender or BMI. Participating in 2.5 or more hrs/wk of organized sports significantly improves overall motor skill proficiency in homeschool children aged 5-8 years.

CLINICAL RELEVANCE: PTs and PTAs regularly screen and correct motor skill deficits. As health and wellness advocates for both typically and atypically developing children, PT professionals can reassure parents and other child healthcare providers that homeschooling has no detrimental effect on motor skills. Moreover, participating in 2.5 or more hrs/wk of organized sports can be recommended to improve motor skill proficiency in early elementary aged homeschool children.


Kasayama J, Turnquist P, Lazouras C, Myler A, Alvarenga W, Blydt-Hansen E, Lewthwaite R. Physical Therapy, Rancho Los Amigos National Rehabilitation Center, Los Alamitos, California, United States

PURPOSE/HYPOTHESIS: Cerebral hemispherectomy is an effective treatment option for children with medically intractable epilepsy. The majority of these children present with hemiparesis which remains unchanged following surgery. Most are able to walk without physical assistance, although many require the use of an assistive device (e.g. AFO). Research is limited in describing how well adolescents walk after surgery and how they compare with healthy, age-matched norms. This information can be used to guide the physical therapy community when treating patients with this diagnosis.


MATERIALS/METHODS: Baseline walking characteristics were collected for adolescents s/p cerebral hemispherectomy (time since surgery: mean = 6.7 years), with a mean age of 12 years (range: 10-15). Etiologies ranged from congenital to progressive. Measures included: GaitRite® analysis (gait velocity, cadence, stride length, step length, % stance, % swing) and 6-minute walk test (6MWT). Secondary measures included the Fugl-Meyer Assessment (FMA).

RESULTS: All participants walked without an assistive device, but some required use of an AFO. The majority of the participants were observed to walk with a hemiparetic gait pattern which was supported by increased stance time on the non-hemiparetic limb (mean: 67.9%). 6 of 13 participants demonstrated a normal self-selected gait velocity (+/- SD) compared with their age- and sex-matched norms. The mean gait velocity in our cohort was 81.8% N. If categorized to adult stroke norms, 10 participants would be classified as community ambulators (> .8 m/sec gait velocity) while 3 would be limited community ambulators (.4 - .8 m/sec). All participants scored below age-matched norms for distance covered in the 6MWT. The mean distance was 356 m in 6 minutes which is 52.7% N. The mean cadence was 92% of normal compared to age-matched norms; 7 of 13 scored within normal ranges (+/- SD). The mean stride length was 88% of normal compared to age-matched norms; 6 of 13 scored within normal ranges (+/- SD).

CONCLUSIONS: Comparison with healthy, normal age-matched adolescents indicates that our sample has the ability to walk at a similar gait speed as their peers and all of our participants would be classified as community ambulators based on gait velocity. However, their endurance is considerably limited. Those with the slowest gait speed covered the least distance on the 6MWT and had smaller stride lengths and a slower cadence. There does not appear to be a relationship between etiology, age at onset, time since surgery, or lower extremity motor control (FMA) on walking performance within this cohort.

CLINICAL RELEVANCE: Our data serve to describe the walking ability of adolescents after hemispherectomy. Physical therapists treating children at various time points after hemispherectomy may benefit from this report of gait characteristics in this understudied population. Treatment plans, which incorporate gait and endurance training, are recommended.


Kenyon L, Peterson C, Hostnik L, McElroy R, Farris J. Department of Physical Therapy, Grand Valley State University, Grand Rapids, Michigan, United States

PURPOSE/HYPOTHESIS: Power mobility is increasingly used to reduce the impact of severe mobility restrictions in children who have neurodevelopmental conditions. The purpose of this systematic review was to summarize and critically appraise the evidence related to power mobility training methods used with children 21 years of age and younger.

NUMBER OF SUBJECTS: The combined sample from included studies totaled 211 children, ages 5 months to 21 years.

MATERIALS/METHODS: A research librarian-assisted electronic literature search of 17 databases was conducted. Only primary source, peer-reviewed quantitative studies were included in the review. Mixed-method studies were included if the quantitative methods and data could be isolated. Inclusion criteria were: at least 1 subject ≤21 years of age, use of repeatable power mobility training methods, outcomes related to power mobility training or use, and published in English. Exclusion criteria were: power mobility outcomes indistinguishable from other technologies, outcomes not specifically attributed to children ≤21 years of age, and a focus on the development of technology or measurement tools. Screening, eligibility, and inclusion of studies were conducted in triplicate. Data extraction, determination of level of evidence, and evaluation of scientific rigor via a 10-criteria scale also occurred in triplicate. All disagreements were resolved through consensus with a fourth researcher.

RESULTS: A total of 15,337 unique citations were identified in the searches. Of these, 27 met the inclusion/exclusion criteria for this review. Scientific rigor scores ranged from 2-7.8 (mean=3.97; median=3.75). Levels of Evidence ranged from II to IV with a total of 20 studies at a Level IV. Two single-subject research designs were rated at Level V. Frequency of training ranged from daily to less than once a week while the duration of training sessions ranged from 10 to 60 minutes. Although none of the identified studies focused on the evaluation of specific power mobility training methods, commonly occurring concepts in the power mobility training methods used in the identified studies included a focus on play, a responsive partner approach, skills-focused training, use of virtual reality, and SMART wheelchair use. Identified outcomes of power mobility training included reported improvements in specific power mobility skills as well as improvements in personal-social skills, communication, mobility, and other developmental skills.

CONCLUSIONS: Evidence related to the use of specific power mobility training methods for children is in its infancy. Additional research is needed to investigate the use of specific power mobility training methods.

CLINICAL RELEVANCE: There is limited evidence to guide clinicians in the use of specific power mobility training methods for children.


Kolobe T, North E, Porter A, Rauh-Johnson L, Hughes E, Andrew K. Rehabilitation Sciences, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, United States

PURPOSE/HYPOTHESIS: Videotapes are commonly used in research to code desirable behaviors to quantify and analyze performance. Often the behaviors are predetermined. While appropriate for statistical analysis, predetermined behaviors often overlook potent interactions among motor, social, and cognitive behaviors that signal change during skill evolution. These hard-to-capture interactive threshold behaviors may signal the emergence of the next stage in the progression toward skill acquisition, therefore representing thresholds for change. We define threshold behaviors as new signals that indicate a change in performance (towards a targeted skill) that are sustained and are accompanied by increase in intensity of movements in other body parts. Capturing these behaviors is challenging, because whether or not they contribute to skill acquisition must be determined through repeated observations of performance over time rather than across performances. The purpose of this study was to use videography to capture threshold behaviors demonstrated by very young infants learning to crawl.

NUMBER OF SUBJECTS: 160 vignettes of 15 infants.

MATERIALS/METHODS: Infants, 4-5 months old, were videotaped twice weekly for 2-5 minutes while learning to crawl on or off the Self Initiated Prone Progression Crawler (SIPPC). Infants were enrolled in a larger 12 – 16 week prone locomotion study using the SIPPC. Parents interacted with and encouraged their infants to move using toys. We compiled the weekly videos for each infant; reviewed and identified segments in which the infants succeeded in moving by themselves, either on the floor or the SIPPC, and flagged behaviors that preceded the movement effort.

RESULTS: We identified five behaviors that met our definition for threshold behaviors: looking with intent, inflections in vocalizations during parent-child interaction, movement urgency accompanied by pounding (hands or feet), pleasurable fingering of objects/surfaces, and persistent reaching.

CONCLUSIONS: The threshold behaviors captured on the videotapes of infants learning to crawl have not been reported in the literature. Possible explanation is that because these behaviors emerge over time and do not represent a specific phase or hierarchy in skill acquisition, they are difficult to quantify and require repeated observation (videotaping) over time. Our results unveil the presence of specific motor and non-motor behaviors that signal infants' transition towards goal-directed movement.

CLINICAL RELEVANCE: While threshold behaviors may not be easily quantified, they can be used to:

a) guide progression of intervention approaches, b) provide parents a chronicled progression of their infant's learning styles; c) and provide visual aids during clinical education. The finding suggest that systematic and repeated video-graphy over time can, in and of itself, unveil behaviors that are hard to code, but that are important to skill acquisition and generating new movement learning hypotheses.


Lammers J, Elchert L. Physical Therapy, The University of Findlay, Findlay, Ohio, United States

PURPOSE/HYPOTHESIS: The purpose of this study is to investigate physical therapists implementation of fitness goals into their plan of care for different pediatric diagnoses.

NUMBER OF SUBJECTS: 125 physical therapists from 32 states completed the survey. The majority had a Bachelor's Degree (48%) and worked in the school system (38%) or outpatient (38%). 32% of respondents were Pediatric Certified Specialists.

MATERIALS/METHODS: This data is from a larger survey reporting on pediatric physical therapists' implementation of fitness, wellness and health promotion behaviors, which was based upon the data from the APTA Fact Sheet: The Role and Scope of Pediatric Physical Therapy in Fitness, Wellness, Health Promotion, and Prevention.

RESULTS: For many diagnoses, PT's report implementing fitness goals into the POC routinely or often (GMFCS I, II, III 55%, DS 54%, Myelomengiocele 54%, DCD 65% Autism 64% and SPD 64%). For those same diagnoses, there are 36-46% of therapists occasionally or never implementing fitness goals. Fitness goals are less frequently included in the POC for children with DMD, and GMFCS level IV, and GMFCS Level V with 45%, 35% and 24% respectively reporting that they routinely or often implement fitness goals.

CONCLUSIONS: Implementation of fitness goals into the POC occurs routinely for 55-65% of the time for patients with many diagnoses, but occasionally or never for those same diagnoses. PTs are most frequently including fitness goals for children with DCD, Autism and SPD, myelomengiocele, and CP @ GMFCS levels I, II, III. More often, PTs report occasionally or never including fitness goals for children with DMD, and GMFCS levels IV and V. The recommendations from the Academy of Pediatric Physical Therapy includes recommendations for all of the above diagnoses.

CLINICAL RELEVANCE: Pediatric physical therapists have an important role in promoting fitness and wellness activities for persons with disabilities throughout the lifespan. The results of this survey indicate that the majority of pediatric physical therapists reported at least knowing about physical activity recommendations. The respondents also indicated that they often or routinely recommend all types of physical activity and incorporate fitness goals for many populations. However, there is limited use of objective fitness clinical measures.

Individual practitioners as well as clinical and academic educators, need to consider the impact of physical activity across the lifespan, and must begin discussing physical activity recommendations early in the lifespan with our patients. Aligning with this recommendation would be consistent assessment of PA and fitness as well as recommendations for PA and fitness for children with ALL diagnoses.

Future research should investigate child, parent and family perceptions of PT emphasis on health promotion activities, pediatric PT assessment of health and physical activity by diagnosis and practice settings, implementation of fitness activities in POC, as well as the impact on lifetime wellness.


Lehman S, Hickey S, Miros J, Scholtes S. Physical Therapy, Saint Louis University, Vernon Hills, Illinois, United States

PURPOSE/HYPOTHESIS: Children with cerebral palsy (CP) have lower physical activity levels, resulting in decreased cardiorespiratory fitness and increased prevalence of obesity. Since this sedentary lifestyle carries over to adulthood, there is a higher prevalence of health conditions that pose a significant risk for early mortality in individuals with CP. Children with CP, however, may not be able to participate in physical activity, thus not receiving the physiological benefits that activity provides. Therefore, an intensive day treatment program designed in an adapted sports camp format was created to allow children with CP to engage in physical activity. The purpose of this study was to examine heart rate (HR) during camp activities to determine activity level of participants. Since camp is designed to be intensive, we hypothesized campers would spend the majority of camp time above 60% of their maximum HR.

NUMBER OF SUBJECTS: 19 children with CP (7F, 12M; age 7-19 years; GMFCS range I-V) who attended the adapted sports camp participated.

MATERIAL METHODS: Subjects attended camp 7 hours a day, 5 days a week for 1-4 weeks. Camp was located at a recreational facility equipped with a gym, outdoor tennis courts and pools. Subjects participated in activities including tennis, martial arts, dance, swimming, soccer, basketball, yoga, cycling and baseball. The activities were adapted to each subject's ability level through the use of adaptive equipment and volunteers. Heart rate was measured during these activities using Scosche Rhythm HR monitors (Scosche Industry, Inc, Oxnard, CA) and Garmin Vivofit devices (Garmin International, Inc, Olathe, KS) that were worn on the subjects' dominant forearm. Each subject's maximum HR was calculated using the formula 206.9-(0.67xage), and the maximum HR was then used to calculate each subject's 5 HR zones: Resting HR Zone, Warm-Up Zone, Fat-Burning Zone, Training-Sensitive Zone, and Maximum-Effort Zone. The data were analyzed to determine the percent of time subjects spent in each HR zone.

RESULTS: Heart rate was collected for an average of 4 hours a day. Subject's spent an average of 76% of monitored camp time below 60% of their maximum HR, indicating that HR was in the Resting HR and Warm-Up Zones throughout camp activities performed during monitored time.

CONCLUSIONS: We hypothesized participants would spend the majority of time above 60% of their maximum HR due to the intensive design of the camp. However, participants spent the majority of time below 60% of their maximum HR.

CLINICAL RELEVANCE: Children with CP need to engage in physical activity to increase cardiorespiratory fitness and decrease the risk of early mortality. An intensive day treatment program designed in a sports camp format was created to allow children with CP to engage in activity. However, if participants are not achieving a high enough HR during camp activities, they may not be receiving the physiological benefits expected. Future research should examine methods to increase HR during camp activities to better understand HR during physical activity in children with CP.


Lott D, Cooke K, Park H, Black B, Forbes S, Byrne B, Walter G, Vandenborne K. Physical Therapy, University of Florida, Gainesville, Florida, United States

PURPOSE/HYPOTHESIS: Recent research in rodent models and milder forms of muscular dystrophy supports earlier studies that resistance exercise may be beneficial for maintenance of muscle mass in dystrophic muscle. However, careful and systematic investigation into the safety and feasibility of resistance exercise is needed to consider its implementation in boys with Duchenne muscular dystrophy (DMD). The overall objective was to examine the feasibility and response of a mild to moderate intensity resistance exercise in DMD.

NUMBER OF SUBJECTS: Six ambulatory boys (8.4±0.76yrs) with DMD who were receiving corticosteroids participated.

MATERIALS/METHODS: Safety measures were performed before and after exercise and included: T2 weighted magnetic resonance imaging (MRI) performed on a 3T whole-body scanner for the knee flexor/extensor muscles to monitor evidence of any muscle inflammation/damage, pain assessment, clinical examination, and serum creatine kinase (CK) levels. Isometric maximal voluntary contraction (MVC) was determined for the knee extensors and knee flexors at both 60 and 30 degrees of knee flexion. Participants were encouraged to perform isometric exercise for the knee extensors and flexors at a mild level of 30% MVC (n=4) or a moderate level of 50% MVC (n=2) for 4 sets of 6 reps per exercise on an isokinetic dynamometer. Safety measures were repeated 48hrs after exercise.

RESULTS: Subjects tolerated all testing very well and completed the exercise protocol without any complaints. The participants instructed to perform exercise at 30% MVC were able to complete the protocol at 29.3±0.05% of their MVC, and those encouraged to achieve 50% MVC exercised at 37.4±0.02% of their MVC. Across all eight thigh muscles analyzed, average T2 change only increased 1.2±2.6% (not significant). At 48hrs post-exercise there was no pain reported, and the CK values were not indicative of muscle injury.

CONCLUSIONS: Boys with DMD were able to complete mild to moderate intensity isometric exercise without any reported complaints, and the safety measures included in this pilot study did not indicate any acute muscle damage 48hrs post-exercise. Participants instructed to perform at a mild intensity level were able to achieve this goal. The subjects encouraged to exercise at a moderate intensity did exercise at a higher intensity than the mild intensity group but did not fully achieve the specified intensity level. Future work in this area may provide information of a proper dose/intensity of exercise that is safe and feasible for boys with DMD.

CLINICAL RELEVANCE: Despite knowing the clear benefits of exercise in healthy individuals it is unknown whether exercise has an overall beneficial effect in the DMD population. The literature contains insufficient evidence to support or refute the use of strengthening exercises in boys with DMD. Gaining a better understanding of how exercise can be safely prescribed in boys with DMD may lead to delaying the loss of ambulation and/or improving quality of life in these patients.


Martin K, Allen M, Gogel K, Kelzer H, Moffett L. Krannert School of Physical Therapy, University of Indianapolis, Indianapolis, Indiana, United States

PURPOSE/HYPOTHESIS: This descriptive study explored the type and amount of gross motor skill practice a child with Down syndrome (DS) accumulated in a play setting.

NUMBER OF SUBJECTS: Five (n=5) children with DS, age 22 to 33 months, who had been creeping for at least 6 months or walking independently for less than 6 months at the start of the study.

MATERIALS/METHODS: Participants were videotaped for up to 15 minutes playing freely in a small room (11' by 15') with developmentally appropriate toys and furniture. The videos were edited to the first usable 10 minutes for analysis. Four sessions, 4 to 6 weeks apart, occurred over a 6-8 month period. The researchers independently watched each video to code the following items: time in static standing, sitting or kneeling, and lying; time crawling, and walking/cruising; number of independent steps; number of transitions between postures; and number of falls. The mean from the researchers' individual data was used for final analysis. Each child was also categorized as having mild or moderate hypotonia.

RESULTS: Children with DS spent an average of 90.4% of time in static positions of sitting, laying, kneeling, and standing; and 7.7% of time in dynamic activities of cruising, walking, crawling, and creeping. The mean of 4 sessions for individual participants ranged from 79.1% to 95% of time in static positions and 3.2% to 19% of time in dynamic activities positions. The group mean for time on their feet was 38.5%, 47.1% for time in sitting or kneeling, and 12.5% for time in lying. Individual results for the mean of 4 sessions showed a range of 2.4% to 63.6% of time on their feet, 26.9% to 88.4% of time in sitting or kneeling, and 0.2% to 25.2% of time lying on the floor. The mean number of transitions for the group per session ranged from 12.2 to 37.4 and the mean number of falls for the group per session was 1.2 to 4.8. Independent steps taken ranged from 0 to 161.9 steps per 10-minute session. The one child with moderate hypotonia spent more time in static postures than did the 4 with mild hypotonia.

CONCLUSIONS: This study suggests that young children with DS spend much more time in static positions than in dynamic activities, and choose less-demanding postures to play. Degree of hypotonia may be a factor in these findings as the one child with moderate hypotonia spent the least amount time in dynamic activities, despite her status as an independent walker upon starting the study.

CLINICAL RELEVANCE: Children with DS have gross motor delays, but the role of motor skill practice in those delays has not been investigated. Four of the 5 participants were passive for >90% of the session, despite having developmentally-appropriate activities available. Comparisons to data for children who are developing typically suggest that children with DS are far less active in exploring their environment. Although this pilot study was not intended to identify why children with DS were less active, it may help physical therapists educate parents about the need to increase gross motor skill practice in the home environment.


Mattern-Baxter K. Physical Therapy, California State University, Sacramento, Sacramento, California, United States

BACKGROUND & PURPOSE: Children with myelomeningocele show delayed walking onset compared to children with typical development. Walking onset for children with low lumbar lesions usually occurs more than 2 years later than in children with typical development. This delay leads to significant decrease in bone mineralization and increased risk for fractures. In addition, children who walk later are less accomplished in their cognitive and social skills. In this case study, we evaluated whether an intensive, twice-weekly group-based treadmill program could accelerate walking onset and improve walking ability in a young child with myelomeningocele at L4/5.

CASE DESCRIPTION: The child was a 16-month old male who presented with myelomeningocele at L4/5 with Arnold Chiari malformation and ventriculoperitoneal shunt. He attended a group-based treadmill program for pre-ambulatory children with developmental delay, where he was encouraged to walk twice per week on a mini-treadmill for 30 minutes each session for 14 weeks/semester for 3 semesters. At program onset, he crept on hands and knees for his mobility needs. He was able to take a few steps with use of bilateral solid ankle-foot orthoses when held on hands or with help for steering in a reverse walker. Solid ankle foot orthoses were worn for all upright activities.

OUTCOMES: The toddler participated in the program for 22 sessions in fall of 2014, for 22 sessions in spring of 2015 and for 19 sessions in fall of 2015. Data was collected at beginning and end of each of the three 14-week semesters. Gross Motor Function Measure Dimension D and E (GMFM D/E) were used to assess gross motor skills, the timed 10 meter walk test (10MWT) to assess walking speed and the Functional Mobility Scale (FMS) to assess walking independence.

Walking speed and duration on the treadmill were recorded for each biweekly session. He walked an average of 30.05 minutes per session at an average speed of 0.23 meter/second (m/s) in fall 2014, progressing to 0.27 m/s by fall 2015. The boy improved GMFM D/E and FMS scores at each measurement and reached independent walking onset at 29 months. Overground walking speed improved from 0.21m/s with a reverse walker at program onset (16 months old) to 0.68 m/s independently at end of program (32 months old).

DISCUSSION: Bi-weekly, intensive group-based treadmill training program led to improved gross motor skills, improved walking speed and accelerated independent walking onset in a young boy with myelomeningocele at L4/5. The toddler achieved independent ambulation at 29 months, which is earlier than expected in children with low lumbar myelomeningocele. The boy had no fractures or adverse reactions during his participation in the treadmill program. Although bone mineral density was not measured, existing literature has shown increased bone mineralization after treadmill training in this population. Similar treadmill protocols might be beneficial for young children with this diagnosis.


Mazzarella J, Sundin E, McNally M, Schram M, Chaudhari A, Heathcock J. School of Health and Rehabilitation Sciences, The Ohio State University, Columbus, Ohio, United States

PURPOSE/HYPOTHESIS: Neonatal stroke (NS) is bleeding or interrupted blood flow in the brain that occurs between 28 weeks gestation and 1 month of life. NS is a leading cause of cerebral palsy (CP) in infants.. Brain damage from NS is often focal, resulting in hemiplegic CP, which affects the contralateral upper extremity. Currently, children are not diagnosed with CP until 18-24 months of age, when there are noticeable asymmetries in gross motor skills and tone. This study investigates differences in spontaneous upper extremity kinematics at 2 months of age between typically developing (TD) infants and infants with NS, as a potential early assessment for hemiplegic CP. We hypothesized that infants with NS would demonstrate poor coordination and asymmetry of spontaneous arms compared to their age-matched, TD counterparts.


MATERIALS/METHODS: Upper extremity kinematics were measured on ten TD infants and ten infants with NS at 2 months of age, using a object exploration paradigm to elicit movements of the upper extremities. The infants were placed in a chair with their upper extremities free, and markers were placed on both hands. A 10 camera VICON system was used to record 3D movement at 150Hz for 3 × 30 second trials. During each trial, a toy was held at midline shoulder height to encourage the infant to move. Variables measured, included movement length, speed, distance from toy, arc length, first movement unit length, peak velocity, first peak velocity and number of velocity peaks, all reliable measures of coordination in pediatric populations.

RESULTS: One-way ANOVA revealed a significant difference for arc length the total length of a single movement, between the left and right arms for infants with NS (F(1,18) = 6.411, p<.05) suggesting asymmetry may be measurable at 2 months of age. Importantly, this between hands difference was not present in the TD group. In addition there was a significant difference between groups for first peak velocity of right-handed movements (F(1,18)=5.6, p <.05) suggesting that TD infants show better coordination with their right hand than infants with NS. Trends between groups for peak velocity and average speed of movement, with TD infants moving at greater speeds than those with NS were also observed.

CONCLUSIONS: Results from this study revealed early laterality, as well as diminished speed of upper extremity movements as early as 2 months of age in infants with NS compared to age-matched TD infants. This is over a year before a CP diagnosis is typically made.

CLINICAL RELEVANCE: Kinematic evaluations may reveal atypical movement patterns and motor development as early as 2 months of age in infants at risk for CP. Using this as an early assessment option could allow therapists to provide targeted upper extremity interventions much earlier than current practice, to help prevent delay in reaching motor milestones in these infants.


McMillan A. G, Gower G, May L. Department of Physical Therapy, East Carolina University, Greenville, North Carolina, United States

PURPOSE/HYPOTHESIS: Moderate to vigorous aerobic exercise during pregnancy has been shown to contribute to improved cardiovascular health and higher infant heart rate variability in offspring. To date research has not investigated the effects of maternal exercise on infants' neurobehavioral status. The purpose of this study was to determine the effects of maternal exercise during pregnancy on the neuromotor development of offspring. We hypothesized that exercise during pregnancy would be associated with higher scores on the Peabody Developmental Motor Scales, 2nd edition (PDMS-2) and the Alberta Infant Motor Scales (AIMS) in infants at one month of age.

NUMBER OF SUBJECTS: Healthy, pregnant women between 18-35 years were recruited and randomly assigned to one of three exercise groups or to the control (CTRL), non-exercise group. Exercise groups performed aerobic exercise, resistance exercise, or circuit training three times per week under supervision, while those in CTRL group maintained usual activity. Data from n=38 offspring (n=9 CTRL, n=14 Aerobic, n=9 Resistance, n=6 Circuit) have been analyzed thus far.

MATERIALS/METHODS: Neurodevelopmental exams were performed on infants at one month of age using the PDMS-2 and AIMS. An AIMS score ratio (raw score:age), and the PDMS-2 subtest percentiles (%), subtest standard scores (SS), Gross Motor Quotient (GMQ), and GMQ percentile scores were analyzed using ANOVA to determine differences among groups.

RESULTS: Infants in CTRL group scored consistently lower than those in all exercise groups on all PDMS-2 variables, though only the scores for the Locomotion subtest were statistically significant (Locomotion %: F=4.18, p=0.01; Locomotion SS: F=4.04, p=0.01). Post hoc tests showed significant differences between each exercise group and CTRL, but not among different exercise groups. No differences were noted among groups on AIMS scores.

CONCLUSIONS: Infants' neuromotor skill development at one month appeared to benefit from maternal exercise during pregnancy. This suggests that the previously reported beneficial effect of maternal exercise is not specific to the autonomic nervous system, but may have a more global effect on neuromotor growth and development.

CLINICAL RELEVANCE: If effects of maternal exercise on infants persist beyond one month, infants might be set up to be “good movers” and more physically active in childhood, lessening their risk of becoming overweight or obese. Further study of the effects of maternal exercise on infants beyond one month of age is underway.


Miller D, Lolli J, McMahon C, Merino J, Nevers M. University of Scranton, Scranton, Pennsylvania, United States

PURPOSE/HYPOTHESIS: To evaluate outcomes, complications and postoperative considerations among surgical interventions for scoliosis in children with cerebral palsy (CP).


MATERIALS/METHODS: A literature search of Google Scholar, CINAHL, PubMed, and ProQuest was conducted using search terms: (children or pediatric) AND (cerebral palsy or CP) AND (scoliosis or spinal curvature) AND (surgery or surgical interventions). Search limits: English, human subjects, children under 18 years and selection criteria: scoliosis, surgical interventions, and outcome measures of Cobb and pelvic obliquity angles. Two reviewers independently assessed each study for methodological quality and came to a consensus based on MINORS scale.

RESULTS: A total of 3,849 titles were screened for eligibility. Following detailed appraisal, 6 retrospective cohorts met the criteria. MINORS scores ranged from 10-20/24 with a mean of 16.5/24. Sample sizes ranged from 27 to 157 subjects (396 total) with mean age of 13.7 years. The surgical procedures examined included anterior or posterior approach spinal fusions, using either custom rods, growing rods or Luque Galveston or Contrel Dubousset instrumentation. Outcomes measurements of Cobb and pelvic obliquity angles were taken pre-op, post-op, and at follow up (mean 4.68 years). The mean pre-op Cobb angle was 82.5° (70-100.84°), post-op the angle was 37.7° (31-59°) and the mean follow up was 34.1° (13-50°). The mean pre-op pelvic obliquity was 24° (15-23°), post-op mean was 20.88° (9-59°), and the mean at follow up was 11.2° (6-22°). Immediate post op results were not recorded in one study. In four studies, patients experienced infectious complications. In three studies, hardware was exchanged due to malformation. In three studies, patients experienced pulmonary complications. There was an overall blood loss mean of 1614 ml and mean hospital stay of 12.75 days.

CONCLUSIONS: There is moderate evidence in support of surgical interventions to improve Cobb and pelvic obliquity angles post-op and at follow up in pediatric patients with CP and scoliosis. The results suggest that parents and clinicians can expect a decrease in Cobb angle of 57.74% (36-86%) and pelvic obliquity decrease of 51.59% (18-89%) and a 12 day hospital stay. Limitations include lack of comparators for surgical procedures and lack of standardization with CP diagnoses. Future research is needed with specific CP diagnoses and better inclusion and exclusion criteria to determine effectiveness.

CLINICAL RELEVANCE: As medical advances occur, there are more options for treatment of scoliosis in children with CP. It is important for clinicians to understand the expected outcomes of scoliosis surgery including possible complications for children with CP and to educate parents and caregivers. Though quality of life was not directly assessed, the long term outcomes may improve physical well-being and cosmesis.


Mueller C, Stahl A, Zoeller A, Dunaway Young S, Montes J, Goldman S, Rao A. Rehabilitation & Regenerative Medicine (Physical Therapy), Columbia University, New York, New York, United States

PURPOSE/HYPOTHESIS: 16p11.2 and 1q21.1 deletions/duplications (proband) are genetic chromosomal mutations clinically characterized by poor coordination and Hypotonia [1]. These children show a higher prevalence, up to 24% of a comorbid diagnosis of Autism Spectrum Disorder (ASD)[1,2]. Quantitative spatio-temporal gait assessment in children with ASD shows increased variability in stride length [3,4], base of support [3,4] and decreased step length [5]. However, no studies have characterized gait and mobility of probands. The purpose of this study was to characterize these impairments in probands and their siblings, and to examine predictors of functional capacity.

NUMBER OF SUBJECTS: 23 probands, 15 unaffected siblings.

MATERIALS/METHODS: The GAITRite® Electronic Walkway measured variables including support base, percentage of time in double support, velocity and variability of step length and time. Mobility assessments included Timed Up and Go (TUG), 10 meter walk test (10MWT), and 6 minute walk test (6MWT). A caregiver-reported functional assessment, the Pediatric Evaluation of Disability Inventory-Computer Adaptive Tests (PEDI-CAT), was completed. Independent t-test were used for statistical comparisons between probands and sibling controls. Linear regression analysis was conducted to examine if with gait and mobility measures were independent predictors of PEDI-CAT score. Analyses were completed in IBM SPSS version 23 with significance value of 0.05.

RESULTS: The groups did not differ in age, height or weight (p= 0.971, p= 0.223). Probands had significantly longer TUG time (p=0.02), longer 10MWT time (p=0.015) and lower percent predicted 6MWT (p=0.00). Probands exhibited increased percent double support (p=0.046) and increased base of support (p=0.002). Linear regression indicated that percent predicted 6MWT was a significant predictor of mobility, daily activities, social/cognitive, and responsibility domains of the PEDI-CAT (p=0.00, p=0.00, p=0.002, p=0.012). Percent time in double support, base of support, TUG, and 10MWT were not predictive of PEDI-CAT scores.

CONCLUSIONS: Our results demonstrate that probands have impaired balance (increased base of support and percent double support), weakness (reduced percent predicted 6MWT), and overall impaired mobility (increased TUG and 10MWT) compared with controls. The 6MWT was a significant predictor of functional capacity.

CLINICAL RELEVANCE: This is the first characterization of gait and mobility impairments in a sample with 16p11.2 and 1q21.1 mutations. Quantitative gait analysis and clinical assessments (TUG, 10MWT, and 6MWT) are feasible evaluation tools for this population. The 6MWT, easily administered with minimal equipment, provides functionally relevant data. Our results suggest that balance and weakness are primary impairments interfering with functional capacity. Future research should examine if targeted exercises improve of functional capacity in probands.


Nunez-Gaunaurd A, Jaffe L, Gaunaurd I, Raya M. Research, iTrace Foundation, Inc, Miami, Florida, United States

PURPOSE/HYPOTHESIS: Few school-based physical education curriculums that emphasize the adoption/maintenance of physical activity (PA) programs by students, incorporate PA assessments and tracking. Expensive accelerometer-based PA monitors and student compliance are major barriers to objective PA assessment. Wireless Electronic Activity Monitors (EAM), manufactured by Fitbit and Jawbone are gaining popularity in both the consumer market and among PA researchers. However, validity studies on such devices for adolescents are few as newer device models and software are quickly introduced into the consumer market. A more recent EAM model from Fitbit® is the Flex, which is a wrist-worn tri-axial accelerometer. It is lower in cost and smaller in size than the research grade accelerometers, such as the StepWatch Activity Monitors (SAM). The preliminary phase of this study was conducted to determine the criterion validity of the Fitbit Flex as a measure of steps/day against the SAM with high school students.

NUMBER OF SUBJECTS: 20 high school adolescents, between the ages of 14-18.

MATERIALS/METHODS: The subjects were enrolled in an Enhanced Physical Education Curriculum in Broward County, FL, that integrated the Fitbit Flex as a measure of PA. Subject wore both the Flex and SAM simultaneously. BMI-for-age percentile and (zBMI) were calculated. Descriptive statistics were calculated for number of steps/hour for 1, 2 and 3 hours, total steps/day during the school day and total steps/day. Strength of association between monitors was assessed for normally and non-normally distributed step data using Pearson's and Spearman Correlations. Differences between the Flex and SAM were assessed by the paired samples t-test and Wilcoxan signed rank test.

RESULTS: The mean age was 14.8 (range 14-18 yo), (n=8 boys/12 girls) with 81% reporting of Black/African-American race and 50% of Hispanic ethnicity. Thirty-five percent were overweight/obese. The Fitbit Flex measured significantly less steps/day than the SAM during the school day and all day monitor wear (6146 vs 5699 p<.001) and (11533.17 vs.10826.10, p=.03) The total number of steps/hour for 2,3 hours, and total steps per day as provided by the Fitbit Flex correlated strongly (r>.83, p<.05,) and total number of steps/hour for 1 hour, and total steps/day during the school day correlated moderately (r>.75, p <.05) with the SAM.

CONCLUSIONS: Our study shows that the consumer grade Fitbit Flex reasonably estimates steps counts when compared to a research grade activity monitor (SAM) during free-living activities as encountered by high school adolescents.

CLINICAL RELEVANCE: The findings suggest that among this population of minority youth, a commercially available accelerometer such as the Fitbit Flex may provide a more attractive and low cost alternative to accessing free-living physical activity data. The Fitbit Flex may be an accurate tool for clinicians and school-based physical therapists to track the adoption/maintenance of a physical activity program.


Oledzka M. Pediatric Rehabilitation, Hospital for Special Surgery, New York City, New York, United States

PURPOSE/HYPOTHESIS: Congenital muscular torticollis (CMT) is a musculoskeletal deformity observed at birth or in infancy characterized by unilateral contracture of the sternocleidomastoid muscle (SCM). Clinical presentation consists of persistent head tilt toward the involved side with the chin rotated toward the contralateral shoulder. Historically, infants with CMT have been classified based on several taxonomies based on variety of clinical factors. In 2013, a Clinical Practice Guideline (CPG) by Kaplan et al. proposed a new classification grading system for CMT based on age of presentation, age at the time of referral, and type of CMT. Seven grades of severity were proposed. The system has not been subjected to reliability testing. The purpose of this study was to establish intra- and inter-rater reliability for determining severity levels. We hypothesized that the severity scale has good inter- and intra-rater reliability.

NUMBER OF SUBJECTS: Phase 1:144; Phase 2: 90.

MATERIALS/METHODS: Clinicians across the United States and abroad assigned CMT severity grades to 24 cases representing all seven severity grades chosen from the actual data records. All raters were provided with the CMT severity grading handout and the decision tree from the CPG. For intra-rater reliability, the raters then repeated the classification rating at least two weeks after the first round of ratings (Phase 2). They were provided with the same 24 cases but the order of the cases was varied. An analysis of inter-rater reliability used data from each respective phase. The intra-rater reliability compared data from both phases. The inter-rater and intra-rater reliability was calculated with intraclass correlation coefficient ICC-model.

RESULTS: The inter-rater reliability for Phase 1 and Phase 2 demonstrated almost perfect reliability with intraclass correlation coefficient (ICC) values of 0.90 or greater. For responders who answered the survey for both Phase 1 and 2, their intra-rater reliability for the 24 cases assessed ranged from slight to near perfect.

CONCLUSIONS: This study demonstrates that the CMT severity classification scale can be used by clinicians treating this population with confidence in its high inter-rater reliability. The intra-rater reliability statistical analysis was affected by an unusual statistical occurrence in the data. Further iteration of the analysis will be performed prior to the presentation.

CLINICAL RELEVANCE: The high inter-rater reliability of the classification scheme found in this study indicates that clinicians treating children with CMT can assign severity grades upon evaluation with adequate reliability. The CMT classification system provides clinicians with a standardized language, common taxonomy of CMT severity, and decision pathways. As a result, communication among professionals, clinical documentation, and decision making regarding most appropriate intervention will be improved. In addition, universal use of the severity classification system will guide and strengthen future research on CMT.


Oriel K, Kanupka J, Burger K, Dierwechter B, Dooley A, Lala A, Robenolt E. Physical Therapy, Lebanon Valley College, Annville, Pennsylvania, United States

PURPOSE: Promoting physical activity in young children of all abilities is essential, as it has the potential to improve friendships, self-identity, creativity, as well as overall health and wellness. Young children with disabilities have limited opportunities for participation with peers in physical activities in community-based settings, due to environmental, cost, societal, and attitudinal barriers. While many benefits of inclusive environments have been identified in the literature, few studies have explored the impact of early inclusive experiences. As such, few community-based inclusive programs exist. The purpose of this project was to develop and implement an early inclusive experience for young children with disabilities enrolled in traditional Early Intervention.

DESCRIPTION: Young children with disabilities enrolled in Early Intervention were recruited for participation in an inclusive aquatic exercise program. An age matched peer was recruited for each child with a disability through local play groups. A total of 12 children enrolled (6 children with disabilities and 6 age matched peers). The aquatic exercise program was held 1X/week for 6 weeks, and included individualized instruction, games, songs, and free play. The individualized instruction was developed based on the results of the Canadian Occupation Performance Measure (COPM) that was completed for each child with a disability. The typically developing participants served as peer models during the individualized instruction portion of the program. A physical therapy or education student was paired with each participant in the pool. A parent focus group was held at the completion of the program.

SUMMARY OF USE: The program described provided young children with disabilities an opportunity to participate with their peers in an age appropriate physical activity in a community-based setting. The program served to supplement the existing Early Intervention services provided in the home environment. Results of the parent focus group indicated that all children benefited from participating in the aquatic exercise program and gained confidence in the pool. The majority of parents that participated in the focus group indicated their children also gained additional levels of comfort separating from their parent and interacting with other children.

IMPORTANCE TO MEMBERS: Pediatric physical therapists should consider recommending early inclusive experiences for their patients/clients in the community. Such experiences provide an important socialization opportunity for children with disabilities, as well as their peers without disabilities.


Oriel K, Kanupka J, Fuehrer A, Klumpp K, Stoltz K, Willey D, Decavalcante M. Physical Therapy, Lebanon Valley College, Annville, Pennsylvania, United States

PURPOSE/HYPOTHESIS: It is often a challenge for adolescents with Autism Spectrum Disorder (ASD), as it is for many individuals with disabilities, to participate in community activities with their typically developing peers. As such, activities that do not require high skill levels and team environments have been recommended for individuals with ASD. Rock climbing allows individuals of all abilities and skill levels to participate. The purpose of this pilot study was to: 1) explore the impact of a community-based rock climbing intervention on adolescents with ASD, and 2) examine the social validity of rock climbing as a community-based activity for adolescents with ASD.

NUMBER OF SUBJECTS: Ten adolescents with ASD, including 9 males and 1 female, participated in the study (range 10-19 years; mean age: 13.6 years).

MATERIALS/METHODS: Individuals with ASD were recruited through local support groups and schools for participation in a rock climbing program. The program was held 1X/week for 4 weeks. During each session the following were recorded: 1) a task analysis, 2) resting and working heart rates, and 3) pre/post cancellation test to assess attention. After the 4th climbing session, parents participated in a focus group and completed a social validity scale (IRP-15). Demographic and IRP-15 data were analyzed using descriptive statistics, exercise intensity was established for each participant using American College of Sports Medicine guidelines, and pre/post-test cancellation test scores were compared using a Wilcoxon Signed Ranks Test. The focus group session was transcribed, and reviewed to identify themes.

RESULTS: Results indicated that 6/10 participants were working at moderate aerobic capacity, 1/10 at light capacity, and 3/10 at very light capacity. No statistically significant differences were observed in attention test scores, although visual analysis revealed that 6/10 participants decreased the time it took to complete the attention test from pre to post test. According to the IRP-15, 100% of parents strongly agreed/agreed that rock climbing was a good activity to address their child's participation needs, and all strongly agreed that they would be willing to use the activity again. Themes identified following the focus group related to the impact of the rock climbing program included improved confidence, and an opportunity for participation in a challenging physical activity.

CONCLUSIONS: Results of this study suggested that rock climbing is a feasible community-based activity for adolescents with ASD that required the majority of participants to work at a moderate aerobic capacity. IRP-15 data, along with parent focus group results, indicated that rock climbing is a socially valid intervention to improve participation in adolescents with ASD.

CLINICAL RELEVANCE: Rock climbing gives adolescents with ASD an opportunity to participate in a community-based physical activity. Rock climbing should be considered as an effective intervention to improve participation in adolescents with ASD.


Paleg G, Livingstone R. Physical Therapy, MCITP, Silver Spring, Maryland, United States

PURPOSE/HYPOTHESIS: The purpose of this review is to summarize the clinical measurement tools available to assess outcomes relevant to children with cerebral palsy (CP) who are using gait trainers; to critically appraise the psychometric properties of these tools and to identify which International Classification of Functioning, Disability and Health (ICF) (World Health Organization, 2001), (World Health Organization, 2007) domains they address.

NUMBER OF SUBJECTS: 16 Outcome Measures.

MATERIALS/METHODS: We built on the search that was completed for the systematic review (Paleg & Livingstone 2015) and updated it in January 2016. Databases included CINAHL; Medline; EMBASE; and EBM Reviews. Outcome measures that require specialized equipment and are not able to be completed in a typical clinical environment were excluded e.g. x-ray, bone mineral density scans, specialized gait analysis etc. We also excluded studies that did not provide detail on the clinical measurement tools or information on their psychometric properties.

RESULTS: Eleven of the original 17 articles identified in the previous systematic review of gait trainer outcomes (Paleg & Livingstone 2015) were included in this new review specific to outcome measurement (Barnes, Eisenberg, Farrell, Lancioni 2005, 2007a, b, 2013, Van der Putten 2005a, Willoughby, Wright 1999, Wright 2006). These articles described 12 different clinical measurement tools and provided information on their psychometric properties and clinical utility. The tools include the 10 meter walk test (Evans 1997; Watson 2002; Van Loo 2004), 10 minute walk test (Pirpiris 2003), Directional Mobility Assessment (Wright 1999, 2006), Gross Motor Function Measure (GMFM)(Russell, 1989), Pediatric Evaluation of Disability Inventory (PEDI)(Haley 1992), Physical Abilities and Mobility Scale (PAMS) (Suskauer, 2006; Trovato 2013), School Function Assessment (SFA) – Travel subscale (Coster 1998), Step/leg movement count (Lancioni 2007a), Step length and velocity footprint analysis (Wright 1999,2006), Top Down Motor Milestone Test (Van der Puten 2005b), Videoing indices of happiness (Lancioni 2005, 2007b, 2013) and the Functional Independence Measure for children (Wee FIM) (Chen 2005, Uniform Data 1998).

In the expanded search, two additional tools used with children who use gait trainers, the Observational Gait Scale (OGS) (Boyd, 1999; Mackey 2003)) and Support Walker Ambulation Scale (SWAPS) (Malouin 1997) were identified in studies that did not meet inclusion criteria for the systematic review (Kurtz, 2013; Low 2004; Low 2011b; Malouin 1997).

CONCLUSIONS: We identified 16 valid and reliable measures that could be used to assess outcomes for children with CP who use gait trainers.

CLINICAL RELEVANCE: There is a paucity of studies on children who use gait trainers that use valid and reliable outcome measures. We hope this work assists clinicians and researchers in using appropriate measurement tools.


Peyton C, Vogel C, Schreiber M. University of Chicago Medicine, Chicago, Illinois, United States

PURPOSE/HYPOTHESIS: Unilateral cerebral palsy has been notoriously difficult to diagnosis in the young infant. However, differences in spontaneous movement can be detected in the upper extremity at 2 months of age. This protracted development of asymmetric upper extremity movement mirrors the structural changes seen in the developing corticospinal tract. The trajectories of upper extremity movements, from spontaneous to purposeful, are not well described in infants who subsequently develop unilateral cerebral palsy. The purpose of our study was to describe the upper extremity movements from term age to onset of reaching in infants who subsequently developed unilateral cerebral palsy.

NUMBER OF SUBJECTS: Four subjects diagnosed with unilateral cerebral palsy, with serial video recordings in infancy, were recruited at a university medical center.

MATERIALS/METHODS: Video recordings of spontaneous infant upper extremity movements were collected at three time points: term age, 12 weeks post-term age, and onset of initial reaching (14-16 weeks post-term age). Videos were edited to 2 minutes length. Right and left extremities were coded separately for amount of wrist rotation, pronation, supination, and global hand opening and closing.

RESULTS: Spontaneous forearm supination of the involved extremity was noted in 67% of infants (2/3) at term age, 50% of infants (2/4) at 12 weeks post-term age, and 0% of infants at onset of early reaching (14-16 weeks post-term age). Forearm supination was the only spontaneous behavior that was absent in the involved extremity at onset of reaching in all subjects.

CONCLUSIONS: In our small sample, a loss of spontaneous forearm supination was noted in the involved extremity at onset of reaching in infants who eventually developed hemiplegic cerebral palsy. Further investigation with a larger sample size is needed.

CLINICAL RELEVANCE: The eventual loss of spontaneous forearm supination in infants with unilateral cerebral palsy may be an important clinical predictor of structural damage and outcome. Clinicians working with infants at high-risk for cerebral palsy may be able to use this marker to assist in activity-dependent early intervention at the time of greatest motor plasticity.


Pogemiller K, Õunpuu S, Pierz K. Center for Motion Analysis, Connecticut Children's Medical Center, Farmington, Connecticut, United States

PURPOSE/HYPOTHESIS: Charcot Marie Tooth (CMT) is the most commonly inherited peripheral neuropathy with clinical presentations of foot and ankle impairments which impact gait. Treatment interventions can vary from conservative to surgical options; however decisions are often based on clinical examinations with or without motion analysis assessment of gait function. It is understood that discrepancies exists between static clinical joint measures and dynamic joint range of motion in other neuromuscular disorders but the research to understand this relationship in the CMT population is lacking. Our purpose was to determine if clinical exam ankle dorsiflexion was consistent with dorsiflexion in gait and if not, to identify contributing factors to this discrepancy.


MATERIALS/METHODS: Retrospective review of 48 subjects (96 sides; 23 male, 25 female), mean age 13.9 years (±11.5 SD) with CMT who completed 3D gait analysis during barefoot walking. Subjects were sub-grouped on whether peak stance ankle dorsiflexion during gait (GD) was greater than (Group 1, n=80), equal to (Group 2, n=16) or less than (n=0) measured clinical ankle dorsiflexion (CD). Outcome variables included passive ankle dorsiflexion in supine, ankle plantar flexor strength and presence of cavus foot deformity. Dynamic peak stance ankle dorsiflexion angle was extracted using custom software. Comparisons of group means were analyzed using pearson correlation coefficient and chi square analysis with p value significance set at <0.05.

RESULTS: As expected a significant difference was present between the two groups in mean CD and GD with a weak correlation of GD compared to CD in Group 1 (r=0.44) and strong correlation in Group 2 (r=0.95). However, there was no significant difference between groups in age, body mass index or the frequency of cavus deformity. Interestingly while there was no difference between the median plantar flexor strength there was a significant difference between groups in frequency of good plantar flexor strength (MMT ≥4/5) with p value of 0.016.

CONCLUSIONS: Majority (83%) of subjects with CMT had CD that underestimated the GD. This discrepancy can alter treatment recommendations in the absence of motion analysis. Findings support that in subjects with plantar flexor weakness (<4/5) CD poorly correlated with GD. One reason is CD was non-weight bearing which limits impact of body weight during stance, so further research is needed. The presence of increased cavus was not significantly different between groups despite its potential impact on ankle dorsiflexion measurement. An objective cavus assessment should be examined.

CLINICAL RELEVANCE: This study supports that clinical dorsiflexion will often underestimate the ankle dorsiflexion during gait more so in subjects with plantar flexor weakness. It is important to obtain objective motion assessment in this population for optimal treatment decisions. Further investigation of this predictive relationship should be pursured given the natural progression of distal ankle weakness in CMT.


Pratt B, Peters R, Ali A, Peterson M. Department of Physical Therapy, Bradley University, Peoria, Illinois, United States

BACKGROUND & PURPOSE: Coaching is a cognitive treatment strategy used to facilitate client knowledge, advocacy skills, and problem-solving strategies to overcome barriers to participation. Studies have examined the influence of coaching parents of children with developmental delays or youth with physical disability. Little is published on the use of coaching with children with spina bifida. This case report describes the use and outcomes of using coaching strategies with a child with spina bifida.

CASE DESCRIPTION: A 7.5 year old male with non-ambulatory spina bifida attending general education classes without special education academic support received physical therapy services twice a week (60 minutes each) for 11 weeks. Goals were determined using parent and child input using the Canadian Occupational Performance Measure (COPM). Additional outcome measures were the Dimensions of Motivation Questionnaire (DMQ) and the Pediatric Evaluation of Disability Inventory (PEDI). Measurements were completed at baseline and post-intervention. Child-directed coaching was used to facilitate the child's problem-solving abilities, solutions, re-evaluation of success to complete tasks and overcome barriers to desired home and community participation goals. The majority of sessions occurred in community settings with the remainder in simulated tasks in a clinic.

OUTCOMES: The parent and child rating of performance on the COPM increased from 2.8 to 9 and 2.8 to 5.8 respectively. The COPM satisfaction ratings increased from 3.4 to 9.4 and 5.8 to 6.2 respectively. The total motivation score for the DMQ parent and child ratings changed from 4.69/5 to 4.59/5 and 4.18/5 to 4.18/5 respectively. The ratings on the Negative Reactions to Failure scale of the DMQ changed from 4.40/5 to 2.20/5 and 3.00/5 to 2.00/5 respectively. The PEDI raw scores remained the same in all functional and caregiver assistance domains except for self-care (62 increased to 66) and social (65 decreased to 64) function.

DISCUSSION: Coaching appeared beneficial to improvement on goals determined for this episode of care. The parent rating of performance and satisfaction and the child rating of performance improved more than the 2 points consider clinically important for the COPM. All total motivation scores of the DMQ rate the child as above the average typically developing child. The post-intervention parent rating decrease may have been due to the observation of their child's performance during sessions. The lower rating on Negative Reaction scale corresponds to the negative expression being less typical for the child. The improvement in the self-care domain of the PEDI was the result of improved awareness and autonomy in bowel and bladder management. Coaching and/or the use of real community tasks/settings appeared to improve the child's confidence and ability to develop solutions to participation barriers as evidenced by the decrease in Negative Reaction scores (parent/child) on the DMQ and the need for ‘less’ coaching during later sessions.


Ross S, Neuner C, Essenpreis A, Wengert A, Glover A, Reis A. Physical Therapy, Maryville University, Chesterfield, Missouri, United States

PURPOSE/HYPOTHESIS: All infants are born with physiological flat feet, and the formation of plantar arches is a part of normal development throughout the first decade of life. Valmassy suggests using the formula 7 degrees minus the child's age to determine the acceptable degree of standing rearfoot pronation. The purpose of this study was twofold: first to determine the relationship between age and standing rearfoot pronation and how it relates to gait and footprints in typically developing children ages 3 to 7 years old, and secondly to determine the inter-rater reliability of standing rearfoot pronation measurement.

NUMBER OF SUBJECTS: A convenience sample of typically developing children aged 3 to 7 years was recruited from a private grade school in St Louis, MO (N=22, boys=10, girls=12, mean age=5.1 ± 1.2 years).

MATERIALS/METHODS: Data was collected in a single session. Rearfoot pronation in standing was measured by two blinded investigators using a standard goniometer (avg of 3 measures). Freely chosen and fast walking speeds were recorded using the GAITRite System (a pressure sensitive mat) to determine gait speed (cm/s), stride length (cm), and toe-in/out (°). The Berkemann Footprint Impression System, an ink and paper footprint, was used to measure midfoot width at the navicular (cm) and foot length. The Beighton Hypermobility Scale, body mass index (BMI) (kg/m2), and a questionnaire were used to collect demographic data.

DATA ANALYSIS: Data was normally distributed and no significant difference was found for right and left feet so averages were used. Pearson correlations were used to determine relationships between variables. Inter-rater reliability between two blinded testers was determined using an ICC.

RESULTS: Children demonstrated a mean rearfoot pronation angle of 7.74°. A moderate negative correlation was found between age and rearfoot pronation (r= -.52). No significant correlation was found between rearfoot pronation and other demographics, dynamic and static width to length ratios, or any gait variables. The inter-rater reliability for rearfoot pronation was high (ICC=.85).

CONCLUSIONS: Rearfoot pronation negatively correlates with age (r= -.52), indicating as children age the amount of rearfoot pronation decreases. This is in agreement with previous researchers' findings. According to Valmassy, all of our participants are considered to have excessive rearfoot pronation for their age. Children had more pronation than expected based on the accepted formula of 7 degrees minus 5 years (mean age) = 2 degrees and we found almost 8 degrees of pronation. We also found the midfoot width to total foot length ratio did not correlate with rearfoot pronation.

CLINICAL RELEVANCE: From these findings, we suggest clinicians consider implementing methods for assessing the midfoot in children, such as the Feiss line or the navicular drop test, in addition to examining the rearfoot. We need to fully understand the normal amount of flatfoot that occurs with development when making decisions about orthotics for children.


Sampras J, Volkl R. Physical Therapy, University of Illinois at Chicago, Chicago, Illinois, United States

PURPOSE: The purpose is two-fold: First, to provide parents and caregivers with video resources for in-home gross motor activities with infants and toddlers with Down Syndrome; second, to assess the impact on parents who participated in developing exercise videos.

DESCRIPTION: This project involved 8 parent-child dyads. All children had a diagnosis of Down Syndrome (DS). Parents and children were invited to serve as models for filming video clips which spanned positioning and activities in prone, carrying, rolling and activities to enhance sitting, crawling, standing and walking.

SUMMARY OF USE: Children with DS typically have physical impairments (incl. muscular hypotonia and hyperflexibility) which delay motor function and development. These impairments impact the development of skills which require increased postural control including sitting, standing, and walking. These delays require early intervention through physical therapy; however, medical conditions associated with DS have the potential to delay the initiation of therapy for 12-16 months after birth. This is especially troubling because there is a positive correlation between early service initiation and motor development outcomes. As a field, we know the role that family knowledge, resources and parental advocacy play in early initiation of therapy but research on parental involvement during and outside of therapy is less developed. Parents play an important role outside of therapy offering support during solitary exploratory play and skill acquisition; and parental involvement impacts the amount, duration and complexity of play, contributing to motor skill development.

With this project, we aimed to provide parents with video resources encouraging skill development and better understand how parent involvement in developing skill videos enhances confidence outside therapy. Parents were taught various motor skills to perform with their children while being videotaped. Parents reported that before participating, they lacked appropriate “videos about DS made by children with DS which is more relatable for me and my child's experience”. One parent even resorted to “pinteresting stimulation exercises and therapy techniques”

Parents additionally reported involvement in making videos which would “be useful while doing therapy techniques at home” increased their confidence outside therapy, reassured them about their child's progress and lowered stress. They also reported better understanding the role of parent involvement on motor development.

IMPORTANCE TO MEMBERS: This project partnered student PTs with parents to develop a series of home program videos. Parents reported that making these videos enhanced their understanding of the importance of exercising with their child. This project has demonstrated the potential of incorporating parents in order to improve parent confidence, parent-infant bonding and motor skill development in infants with DS.


Schlosser R, Walrath J, Goldberg J, Elias B, Cabrerra A, Dreyer W, Price J, Denfield S, Adachi I, Jeewa A. Physical Medicine and Rehabilitation, Texas Children's Hospital, Houston, Texas, United States

INTRODUCTION: Minimal data exist regarding functional improvement in children with heart failure after left ventricular assist device (LVAD) placement. Six-minute walk distance (6MWD) is a useful and valid assessment of functional mobility in pediatric patients with various medical conditions and provides important information about cardiac rehabilitation.

HYPOTHESIS: Among children who participate in physical therapy services after LVAD placement, functional mobility, as measured by 6MWD, improves over time.


MATERIALS/METHODS: We reviewed the medical records of all patients who underwent continuous flow LVAD placement at our institution. Physical therapy services were initiated as soon as patients were medically stable after LVAD implantation. 6MWD was collected within 90 days before implantation and while each child remained on support. 6MWD was recorded as a proportion of the predicted value for sex, age, and height. Wilcoxon signed rank test was used to evaluate the change between the best 6MWD before and after implantation. Mixed effects linear modeling was used to evaluate correlation between increasing duration of support and 6MWD.

RESULTS: 11 patients had both pre- and post-implant 6MWD data available. After implantation, 9 of 11 patients showed improvement in 6MWD with a mean increase in 6MWD of 24% (± 21%) of predicted distance (Z = -2.353, p = 0.019). The mean highest 6MWD while on support remained 30% (± 17%) below predicted norms. 18 patients had serial measurements of 6MWD after LVAD implantation. All of these patients showed improvement from first 6MWD after LVAD implantation to best 6MWD after LVAD implantation, with a mean improvement of 25% (± 19%) of predicted distance (p < 0.01). Longer duration of time post LVAD was correlated with an improvement in 6MWD (p = 0.002). There was a statistically significant increase in 6MWD within the first 90 days (p = 0.004), without a significant increase after 90 days (p = 0.639). Physical therapy services were initiated with these 18 patients as early as medically stable 29.4% initiated day 2 post implantation, 29.4% initiated day 3 post implantation, 11.8% initiated day 4 post implantation, 17.6% initiated days 5-10 post implantation and 11.7% initiated days 10-20 post implantation.

CONCLUSIONS: Among our pediatric cohort, 6MWD improved with physical therapy after LVAD implantation, with the most significant improvement occurring in the first 90 days. Routine use of 6MWD among children with a LVAD can play a vital role in the assessment of rehabilitation.

CLINICAL RELEVANCE: As LVADS become more common in the pediatric population, the need for objective functional improvement measures to justify therapy services has become increasingly important. In this retrospective study the 6MWT shows significant functional improvement with physical therapy services within the first 90 days after implantation.


Seider J, Martin A, Sullivan B, Fitzgibbon C, Bility M, Ekeji N, Barton S, Bettger J. Physical Therapy, Duke University, Durham, North Carolina, United States

PURPOSE: To advocate for improved care coordination in low-income countries supporting children and adolescents living with a disability, especially following an acute illness or injury. We examined the comparative burden of disease and disability, acute hospitalizations, public and private health care and community services, and related international policies promoting physical rehabilitation for children and adolescents in the United States and Uganda.

DESCRIPTION: The most vulnerable population of people living with disability is those who suffer acutely from loss of function. Children with new disability are even further at-risk due to the long-term consequences of stigma and discrimination as well as acquired impairments. Limited availability of resources may negatively affect potential for productive contributions to society and achievement of greatest quality of life. However, improving the coordination of care between acute, post-acute, and community-based rehabilitation in low-income settings will promote access to patient-centered care and increased quality of life. The Global Alliance on Disability and Healthcare Innovation - Children and Adolescents (GANDHI-CA) was created to promote the optimal functional independence and community reintegration for children and adolescents with new disability after an acute hospitalization.

SUMMARY OF USE: We conducted a systematic mapping review to compare data from the U.S. and Uganda for several socio-ecological levels (child, family, health care, school, community and society). Comparisons were made for disease and disability burden, reasons for acute hospitalization, public and private health care and community-based services for children and adolescents transitioning home from the hospital, and related national policies. Unlike the provision of physical therapy and rehabilitation in acute, post-acute, and community-based centers in the U.S., acute physical therapy and rehabilitative services in Uganda are limited primarily to the two national referral hospitals. A more developed foundation of post-acute and community-based rehabilitation is available in Uganda, but use is dependent on provider referral. Additionally, access is challenged by inadequate national health insurance, the need for out of pocket payment, and the burden of travel. The geographic distribution of rehabilitative services in Uganda is distant from both the regional and national referral hospitals and from the children and families in need.

IMPORTANCE TO MEMBERS: APTA membership could play an important role in translating knowledge of acute and community-based rehabilitation effectiveness and benefits of care coordination to address physical disability among children and adolescents after acute illness and injury in low-income countries like Uganda. As a key stakeholder, physical therapists could help promote coordination of existing rehabilitation services, increase capacity and access of services, and develop new models of care.


Selby-Silverstein L, Atkins T, Leibrand A, Russen C. Physical Therapy, Neumann University, Aston, Pennsylvania, United States

PURPOSE/HYPOTHESIS: To test reliability and validity of a clinical test battery for infants with plagiocephaly; To identify variables most predictive of head shape after 3 months of physical therapy (PT).

NUMBER OF SUBJECTS: 14 infants < 6 months old with plagiocephaly measured monthly, by at least 2 raters.

MATERIALS/METHODS: The Skull Cap Test uses the Palpation Meter (PALM)1 to measure head breath along 2 diagonal lines at 40 degree angles from the sagittal head bisection and calculates an oblique cranial length ratio (OCLR PALM) by dividing the larger value by the smaller. The OCLR PALM measures were compared to OCLR, OCLR at 40 degrees of midline (OCLR40), and Cephalic Index (CI) calculated by the HeadsUp™ program2. The relationships between these head variables and resting sitting and supine head posture, neck PROM (lateral flexion and rotation), strength using Muscle Function Scale (MFS), and gross motor development on Alberta Infant Motor Scale (AIMS) were also explored. Forward stepwise regression identified best predictors of head shape at discharge.

RESULTS: Interrater reliability for OCLR PALM was good, ICC(2,1)=.86, and excellent for all other measures ICCs(2,1)>.9, except for neck rotation, ICC(2,1)=.78, and MFS, ICC(2,1)=.7. Head measure validity findings were that HeadsUp™ OCLR baseline was strongly related to OCLR40 at baseline (r=.98). OCLR at discharge was moderately related to OCLR PALM at discharge (r=.61); and was strongly associated with OCLR40 at discharge (r=.96). OCLR40 at discharge was moderately related to OCLR PALM at discharge (r=.58), supine resting head tilt at baseline (r=.64), and sitting resting head tilt at baseline (r=.55). OCLR at baseline was strongly related to supine resting head tilt at baseline (r=.92). OCLR40 at baseline was strongly related to supine resting head tilt at baseline (r=.89), and moderately related to OCLR40 at discharge (r=0.6); Age of the infant at baseline was positively related to OCLR at discharge (r=0.7), OCLR40 at discharge (0.6), and OCLR PALM at discharge (r=0.55); the older the infant started PT, the worse their discharge head asymmetry. OCLR40 was the only head shape measure to show significant change over time. Forward stepwise regression of baseline variables to predict OCLR40 at discharge found HeadsUp™ OCLR and OCLR40 were the strongest predictors (R =.894 and R2 =.798, p=.000). When the baseline HeadsUp™ variables were removed, supine resting head tilt and age at the start of PT were the strongest predictors of OCLR40 at discharge; R=.817 and R2 =.67, p=.004.

CONCLUSIONS: This battery of tests was reliable and useful for infants with plagiocephaly.

CLINICAL RELEVANCE: The Skull Cap Test is a clinical alternative for quantifying head shape, but may not be as reliable or responsive as the HeadsUp™ variables. The younger the infants and smaller their supine resting head tilt at baseline, the better their head shape at discharge.


Selthafner M, Hong K. Physical Therapy, Children's Hospital of Wisconsin, New Berlin, Wisconsin, United States

BACKGROUND & PURPOSE: There is a paucity of published research investigating the role of Physical Therapy interventions for treatment of Adolescent Idiopathic Scoliosis (AIS). Physical Therapists have historically utilized therapeutic exercise as a foundation of their treatment approach for this population. Spine stabilization exercises have been considered a potentially effective treatment option to prevent curve progression, pain and improving respiratory function. However, only a few clinical studies investigate how these same exercises also affect aesthetics, including shoulder and pelvic asymmetry, and rib hump.

CASE DESCRIPTION: The subject was a 13 year old female recently diagnosed with Adolescent Idiopathic Scoliosis, Risser Stage 3. She was seen for 8 visits and issued a set of spine stabilization exercises to be performed at least 1x/day. Once the subject was able to demonstrate proper mechanics at 4 weeks, scoliosis specific postures/exercises were implemented. At the completion of 8 weeks, she was instructed to continue her HEP at least 5 times a week until she reached spine maturity, Risser Stage 5.

OUTCOMES: 3-D Topography was used to measure shoulder height (POTSI score index), rib hump or axial rotation (Suzuki sum index), and pelvic obliquity (measured in degrees). Her POTSI score index improved by 50%, the Suzuki sum index decreased from 12 to 9 (normal range is 0-10), and her initial 3.5 degrees of pelvic obliquity resolved.

DISCUSSION: Improvements in shoulder and pelvic symmetry were observed in this patient who received spine and scoliosis specific exercises over a ten week course. A Boston Brace was also prescribed, but the family deferred this option due to limitations associated with pre-morbid conditions. It is unclear if concomitant brace wear would have made a significant difference in the coronal plane and overall curve management.

This case study highlights the importance of aesthetics in addition to curve management for this age group. A physical therapy exercise protocol to improve shoulder, rib cage, and pelvic asymmetry should be designed and validated in the future.


Shepherd R, Gunner M, Haller M, Lowe C, Nagy M, Roscoe E, Case L. Duke University, Durham, North Carolina, United States

PURPOSE/HYPOTHESIS: The purpose of this scoping review was to compare quality of life of individuals following rotationplasty to that of healthy, matched controls and following other surgical options including alternative limb salvage procedures.

NUMBER OF SUBJECTS: The population included 81 individuals who underwent rotationplasty at an average age of equal to or less than 21 years as a result of either proximal femoral focal deficiency (PFFD) or osteosarcoma. Participants were assessed a minimum of two years post-rotationplasty with a maximum average follow up of 25.1 years.

MATERIALS/METHODS: Three databases (PubMed, Embase, CINAHL) were searched for articles that assessed outcome measures of rotationplasty amongst pediatric patients using the Musculoskeletal Tumor Society Rating Scale (MSTS) and/or the Short Form 36 (SF-36) outcome measures.

RESULTS: Individuals who underwent rotationplasty scored slightly lower on the SF-36 in the physical functioning subscore, but consistently scored higher on a number of other subscores, including vitality, social functioning, mental health, and general health when compared to the healthy, general public. There was no significant difference in SF-36 scores when rotationplasty was compared to alternative surgery options including other limb salvage procedures. Two articles reported MSTS scores, which range from 0 to 100 with higher scores indicating better function. One article reported rotationplasty patients scoring higher on the MSTS (27.5±1.9) than individuals who underwent above the knee amputation (AKA) (19.6±4.7) or limb-sparing femur surgery (21.8±4.6). The other article reported an average MSTS score of 64±12% in rotationplasty patients; however, this result was not compared with an alternative group.

CONCLUSIONS: Overall, the articles reviewed in this paper concluded that those who had undergone the rotationplasty procedure exhibited generally positive scores on quality of life measures reported, with higher scores in all SF-36 subscores except physical functioning when compared to the general population, and with comparable scores when compared to other procedures.

CLINICAL RELEVANCE: This scoping review is clinically relevant as it provides evidence that rotationplasty is a viable and satisfactory treatment option for appropriately selected patients, with higher scores in many of the quality of life subscores when compared to the general population and with comparable scores compared to other treatment options. It is important to educate potential candidates for this surgery about the benefits and challenges of rotationplasty when compared with other limb salvage procedures. Informing patients and their families about the increase in overall scores in the MSTS compared to AKA and limb sparing surgeries allows them to make an educated choice in their treatment. The psychosocial benefits and increased quality of life that patients experience after rotationplasty may outweigh the unconventional cosmetic appearance.


Simoes S, Tovin M, Lyke G, Morales M, Alban G. Physical Therapy, Nova Southeastern University, Miami Shores, Florida, United States

BACKGROUND & PURPOSE: Individuals with autism spectrum disorder (ASD) typically have difficulties in social interaction, verbal and nonverbal communication, and behavior. They may also present with intellectual disability, difficulties in motor coordination, attention deficit disorder, sensory processing disorder and seizure disorder. These impairments result in difficulty participating in recreational physical activity with peers. Moreover, obesity has a higher prevalence within this population, particularly teens and young adults, for whom opportunities for physical activity in a social context is diminished. Engagement in physical activity has been shown to improve motor function and exercise capacity, social and communication skills, attention, motivation, self-esteem, and desire to participate in community peer activities. There is limited research on the benefits of recreational physical activity as perceived by family members of individuals with autism. The purpose of this qualitative case study was to understand the impact of a community-based Special Olympics running team on physical, social and emotional wellness in young adults with ASD from the perspective of family members.

CASE DESCRIPTION: Seven young adults with ASD ages 18-24 years took part in a Special Olympics track team. Team training activities, run by physical therapy faculty and students, were designed to improve the participants' level of physical fitness, understanding of physical activity and healthy lifestyle, social/peer interaction, and self-esteem. Training occurred once a week, and consisted of pre- and post-season fitness testing, fitness training, peer-modeling, team membership, competitions, and social events. Following program completion, family members were invited to participate in interviews to share their experience and perspectives on the impact of the training program on their adult children's physical, social and emotional wellness.

OUTCOMES: Interviews with 7 family members were audiotaped and transcribed. Data were analyzed using the constant comparison method to identify common themes that represent the family members' perspectives. Common themes included: A Safe Place (acceptance), Support (for team members and parents), Engagement (socialization and friendship), Something to Look Forward To (enjoyment), Pride, and Physical Activity (motivation and carryover).

DISCUSSION: Family members noted improved physical fitness and motivation for physical activity that extended beyond the training program. Furthermore, they expressed surprise and excitement at the social and emotional benefits of the program that enabled participation with peers in ways not previously observed in their children. Many participants formed lasting friendships. Findings support development of similar programs to promote participation and wellness for young adults with ASD. Further research on the impact of community-based physical activity programs is warranted.


Steenbergen K, Furgal K, Krimple E, Perkins B. Physical Therapy, Western Kentucky University, Bowling Green, Kentucky, United States

PURPOSE/HYPOTHESIS: Participation in mobility activity begins in early childhood and is a driving force in development. Barriers to participation encountered by pediatric wheelchair (PWC) users may relate to inadequate mobility options that can limit access to important developmental social or educational encounters. Procurement of PWCs is complex, with many junctures throughout the process when delays may occur. Growth spurts that occur while awaiting delivery may impact PWC initial fit and duration of usability. The purpose of this study was to determine trends and perceptions in PWC delivery times. We also sought to identify causative factors for any perceived lengthy delivery times for future mitigation, particularly in light of current changes in the healthcare system.

NUMBER OF SUBJECTS: Participants were 463 members of the Rehabilitation and Assistive Technology Society of North America Wheeled Mobility Special Interest Group (RESNA-SIG), with a response rate of 11.2% (n=52).

MATERIALS/METHODS: A survey developed with input from 2 clinicians experienced with PWC use, was sent via email to RESNA-SIG members. Responses collected in Qualtrics were statistically analyzed using SPSS. Responses that considered PWCs paid by third party payers in the U.S. were included.

RESULTS: In this survey, 73.1% (n=38) of respondents perceived that PWCs are not delivered in a reasonable amount of time. 92.3% (n=48) reported lengthy delivery times for both power and manual PWCs. PWC delivery times taking longer than 10 months were reported in 59.6% (n=31) for power and 44.2% (n=23) for manual PWCs. Top contributing factors were reported as follows: third-party-payer (TPP)(92.3%, n=48), wheelchair vendor (WV)(50%, n=26), and prescribing physician (PP)(50%, n=26). Of the TPP group, requesting more documentation (84.6%, n=44) and denying a component (82.7%, n=43) were the top contributing factors. WV issues were scheduling conflict (30.8%, n=16), initial delivery delay (28.8%, n=15), and change in client insurance (28.8%, n=15). PP-related responses included either delayed submission of the letter of medical necessity (LMN)(48.1%, n=25), or incomplete information provided in the LMN (46.2%, n=24). Other factors were related to the patient (34.6%, n=18), manufacturer (13.5%, n=7) and clinic (13.5%, n=7).

CONCLUSIONS: The results of this research suggest that the time between PWC prescription and delivery is perceived to be lengthy by U.S. seating and mobility professionals. The identified causes of lengthy delivery times appear to be multi-factorial, with the top 3 being TPP, WV and PP factors.

CLINICAL RELEVANCE: Findings of this survey justify future studies addressing patient/parent perceptions of PWC delivery times, as well as to determine the extent to which lengthy delivery times are related to secondary impairments in PWC users. Raising awareness of potential causes can further improve the system by helping focus efforts to streamline the procurement process. Improving delivery times may be important to extend the usable life of a PWC in light of anthropometric changes that can occur while awaiting delivery.


Stewart M, Ward K. Physical Therapy, University of the Sciences, Philadelphia, Pennsylvania, United States

PURPOSE/HYPOTHESIS: Previous studies have found that children diagnosed with autism-spectrum disorder (ASD) frequently do not meet recommended levels of physical activity and are at an increased risk for being overweight or obese. Families with children with ASD experience facilitators and barriers that influence participation in physical activity. By understanding participation in physical activity, healthcare providers may identify opportunities for intervention to promote physical activity, health, and wellness. The purpose of this qualitative study was to gain insight on the lived experiences of parents, siblings, and children with ASD, particularly related to physical activity. This was part of a larger qualitative study of the lived experiences of families with children with ASD.

NUMBER OF SUBJECTS: Twelve parents with at least one child with ASD (4 – 18 years old) participated in this study.

MATERIALS/METHODS: Participants were recruited from a convenience sample of children enrolled at Camp Inspire, a camp for children with ASD in Southern Maryland. Parents filled out a demographic questionnaire and the Pediatric Evaluation of Disability Inventory-Computer Adaptive Test (PEDI-CAT) based on their child with ASD. Each parent then participated in a semi-structured interview. Parents were asked about facilitators and barriers to physical activity for their family. A researcher transcribed each interview verbatim. Two researchers collaboratively conducted qualitative analysis of the interview transcripts using thematic analysis.

RESULTS: Barriers of physical activity for children with ASD include social, physical, environmental, cognitive, and personal barriers. Facilitators of physical activity for children with ASD include social, physical, personal, and environmental characteristics. Parents indicated that their children with ASD most frequently participate in physical activity that is mandated by the school system (i.e. physical education class) or physical activity that they set as a requirement for their children. Barriers of physical activity for typically developing siblings include physical and personal factors and incentives were not necessary in order to motivate children to participate in physical activity. Parents expressed a need for physical therapy services for their children with ASD to help improve coordination, tone, and skilled motor acquisition for participation in organized sports.

CONCLUSIONS: Families with children with ASD experience multiple facilitators and barriers to participation in physical activity. Interventions to address modifiable barriers should be further examined to help increase participation in physical activity for children with ASD.

CLINICAL RELEVANCE: This qualitative study identifies facilitators and barriers to participation in physical activity for families of children with ASD. This may help service providers 1) discuss participation in physical activity amongst families with children with ASD and 2) identify strategies to address barriers to participation in physical activity for children with ASD.


Sugimoto D, Loiacono A, Blenis A, Meehan W. Boston Children's Hospital/The Micheli Center for Sports Injury Prevention, Waltham, Massachusetts, United States

PURPOSE/HYPOTHESIS: Purpose/Hypothesis: Approximately 270 million people participate in soccer worldwide. [1] A history of previous injury is risk factor for future musculoskeletal injury among soccer players. [2-4] Other risk factors, however, are not well-established, especially among younger players. The purpose of this study was to find additional risk factors for musculoskeletal injuries among elite, adolescent male soccer players. We hypothesized that 1) limited range of motion (ROM), 2) increased joint laxity, 3) reduced lower extremity strength, 4) decreased functional performances, and 5) history of previous injury would be associated with risk of injury.

NUMBER OF SUBJECTS: Number of Participants: 56.

MATERIALS/METHODS: We conducted a prospective cohort study of adolescent male soccer players who belong to a youth soccer academy. Prior to the start of the season we measured 1) ROM at the ankle, knee, and hip, 2) joint laxity using a Marshall test, 3) strength of quadriceps and hamstring muscle groups, 4) functional measures including triple hop distance, Y-balance test, and functional movement screen (FMS), and 5) self-reported history of previous ankle, knee, hip, low back, hamstring, groin, and head injuries. The incidence of sport-related injuries was recorded throughout the season, including both practices and games. A multivariate logistic regression model was used to determine the independent association between each risk factor and incidence of injury.

RESULTS: Those who sustained musculoskeletal injuries (N=21) were taller (176.3±7.7 vs. 171.1±9.4 cm, p=0.002), heavier (68.3±7.5 vs. 59.6±11.3 kg, p=0.028), and showed higher body fat (22.0±2.1 vs. 20.2±1.9%, p=0.026) than players who did not sustain injuries (N=35). Injured players also demonstrated limited ankle dorsiflexion ROM bilaterally (Right: 6.6°±5.8°vs: 11.1°±5.6° p=0.005; Left: 6.6°±6.0°vs: 10.5°±5.4° p=0.015). A higher proportion of injured players had sustained previous hip and low back injuries (p=0.006). In addition, injured players were older (p=0.119), had decreased left hip external rotation ROM (p=0.109) and higher FMS scores (p=0.069). After adjusting for covariates in a multivariate logistic regression model, greater weight (p=0.003) and height (p=0.021), decreased ankle dorsiflexion ROMs (Right: p=0.006; Left p=0.029), higher FMS scores (p=0.013), and presence of previous hip and low back injury (p=0.018) were independently associated with incidence of injury.

CONCLUSIONS: There are several potentially modifiable risk factors for soccer-related injuries. These represent potential targets for injury prevention among male soccer players.

CLINICAL RELEVANCE: Since ankle dorsiflexion ROM can be improved by stretching and manual therapy, [5-7] such an intervention might reduce soccer related injuries. Soccer players with bigger physical statures and higher FMS scores also had a higher incidence of injury, but this may be due to greater athletic-exposures.


Sukal-Moulton T, Cameron E, Byrne E, Murphy S, Robertson A, Warner K, Krosschell K. Department of Physical Therapy and Human Movement Sciences, Northwestern University Feinberg School of Medicine, Chicago, Illinois, United States

PURPOSE/HYPOTHESIS: The Test of Arm Selective Control (TASC) was developed to evaluate selective voluntary motor control (SVMC) in the upper extremity (UE) of individuals with cerebral palsy (CP). It is objective, reliable, has similarities to tools clinicians are already familiar with for the lower extremities, and quantifies SVMC in a way that can be used to facilitate intervention planning and evaluation. Observation of movement control, coordination, fluency, mirroring, and speed are considered in determining SVMC at each joint, and a larger sample size was used in this study to determine the tool's validity with the CP population. We hypothesized that TASC scores would correlate with validated measures of upper extremity manual ability [Manual Ability Classification System (MACS)] and performance [Abilihand-Kids (AH-Kids)].

NUMBER OF SUBJECTS: 57 participants with spastic CP (age range=3.4-18.9y, μ=11.5y±3.8y; 25m, 32f) and Gross Motor Classification System (GMFCS) levels I-IV, were recruited from the CP Research Registry and local pediatric PTs.

MATERIALS/METHODS: All TASC Raters (2 PTs, 1 OT, and 5 SPTs) participated in a 2-hour training session on administering and scoring the TASC that included video examples of scores (0=no SVMC; 1=impaired SVMC; 2=intact SVMC). Blinded raters not involved in TASC scoring recorded Gross Motor Function Classification (GMFCS) and MACS scores. Parents completed the AH-Kids. Time to administer was recorded for 53 subjects. Additional video analysis was conducted to determine if variability of select components (child's visual gaze and rate of cueing) of TASC administration affected scores.

RESULTS: There was a moderate correlation between TASC and MACS (r=-0.584, p< 0.001), TASC and AH-Kids (r=0.612, p<0.001) and TASC and affected extremities (r=-0.432, p=0.001). There was a weak correlation between the TASC and GMFCS (r=-0.363, p=0.006) and no correlation between the TASC and CP diagnosis (p=0.631) or age (p=0.81). Rate of cueing appears to affect performance (r=-0.199, p=0.038), while no correlation was found between TASC and direction of visual gaze (p=0.637). Average time to administer was 16.3 minutes (range: 5-30 minutes).

CONCLUSIONS: The TASC was shown to be a time-efficient and valid measure that correlates with functional ability. Within the ICF, TASC (body structure and function), MACS (activity), and AH-Kids (activity and participation) describe movement and use of the UE. The TASC identifies contributing impairments not assessed by the MACS and AH-Kids. TASC score was not impacted by age, suggesting that it can be used with a child with CP of any age. Improved consistency of cue rate could improve test standardization, as rate of cueing appears to affect TASC score.

CLINICAL RELEVANCE: Clinicians should consider using the TASC to identify underlying impairments (SVMC) contributing to functional ability during evaluation and treatment of children with CP. The TASC can be administered quickly, requires minimal administrator training, and is applicable and feasible in a broad range of children with regards to severity, CP classification and age.


Sumida C. Rehabilitation, Rusk Rehabilitation NYU Langone Medical Center, Maplewood, New Jersey, United States

BACKGROUND & PURPOSE: Positioning is commonly used as an intervention in neonates for promoting improved oxygenation, breathing patterns, feeding, gastric residuals, sleep, behavior states and musculoskeletal alignment1-11. Individually designed supine and prone wedge positioners with customized straps are used as an adjunct to managing body alignment in infants with myelomeningocele (MM) and gastroesophageal reflux (GER). The purpose of this case series was to describe physiologic tolerance of two infants in custom, foam positioners on the initial day of use. Hip flexion range of motion changes were analyzed in the infant with MM over 7 days.

CASE DESCRIPTION: Two infants using custom positioners were recruited from the Infant Therapy Team caseload at Seattle Children's Hospital, Seattle, WA. Case 1 (term infant, 7 days old, used 30-degree elevated supine wedge) had gastroschisis with turban closure and GER. Case 2 (term infant at 2 days or weeks of age, used prone positioner) had MM with L1/2 functional level and shunted hydrocephalus.

OUTCOMES: Case 1 (gastroschisis) had increased heart rate (HR)(34.2%), respiratory rate (RR)(6.7%) in the first 2 minutes, and crying behavioral state of 2 minutes placement on positioner with stress signs of lower extremity extension and redness. Case 2 had increased HR (4.4%), RR (25.0%), and transition from sleeping to drowsy state at 2 minutes after being placed prone on the positioner. Oxygen saturation remained stable with no stress signs exhibited. Hip extension range of motion increased from -90 degrees prior to intervention to -40 degrees on day 7. This infant spent approximately 33.3% of the day prone on the positioner with the remaining time held by his mother, breastfeeding or in sidelying on the positioner.

DISCUSSION: Case 1 was appropriate for a 30-degree supine wedge seat positioner due to emesis prior to initiation of oral feeding and diagnosis of GER. Between the 4 – 6 minute interval after initiating use of the positioner, heart rate trended downward as the infant became drowsy. Case 2 was also an appropriate candidate for a prone positioner due to wound healing needs and hip flexion contracture management. This infant had negligible change in heart rate except during placement on the positioner. Once awake, this infant remained in a quiet alert state during the monitoring period.

Customized supine and prone wedge positioners individually designed and constructed by pediatric therapists, provide a valuable method for promoting musculoskeletal alignment and wound healing in infants with MM or GER. After initial adaptation of 2 minutes with temporary HR and behavioral changes, both infants showed excellent tolerance to wedge positioning. Improved hip extension range occurred on the prone wedge over 7 days. These data may guide neonatal and pediatric professionals in developing and monitoring positioning options for infants in hospital and discharge settings.


Tobias L, Lennon A, Duhart C, Borstad A. The Ohio State University, Columbus, Ohio, United States

BACKGROUND & PURPOSE: Manual facilitation of gait for children with Cerebral palsy is physically demanding for caregivers. Access to equipment such as harness systems is not practical in many developing countries such as Mexico. Children with cerebral palsy benefit from partial body weight supported gait training as demonstrated by improved GMFM scores in walk and standing categories. High intensity gait training has been shown to be effective to improve walking skills and decrease the amount of support needed. Here we provide an example of design and fabrication of a low-cost gait trainer and it's application in an environment with limited resources.

CASE DESCRIPTION: A 40-month-old boy with hypotonic cerebral palsy with delayed independent mobility who resides in a government supported home for children in Merida, Yucatan, Mexico was observed for this case. He was able to roll, sit without support and pull to stand but was unable to transition from supine or prone to sitting and was not yet cruising. Stepping could be facilitated with trunk support for upright position and weight shifting. His caregivers desired an easier and ergonomically healthy method of facilitating his walking. They lacked assistive devices for his developmental level and body size. Our DPT program's short-term international service-learning group visited the residential facility for 6 days in March of 2016, which necessitated a quick and sustainable solution that would enable his caregivers to increase his walking intensity. The steps in the process of designing the system were 1. Brainstorming gait trainer styles 2. Simplifying the design for ease of use 3. Identifying local materials 4. Taking measurements 5. Fitting 6. Sewing 7. Testing. Our materials and resources were limited to what could be purchased locally at an upholstery store. Our final design was created over two days for and estimated cost of less than $30 USD.

OUTCOMES: Caregivers: Improved posture during gait facilitation allowed for increased intensity of gait training and integration to play activities. Movement throughout the multi-level facility was improved as he could be carried up and down stairs without removing the device. Child: Free hands enabled a more natural gait pattern and participation with peers during group activities. An increased intensity of walking was desired to accelerate his mobility development. Twelve weeks after initiating this intervention caregivers reported he was taking some steps without support and had begun creeping on hands and knees.

DISCUSSION: This easy to use device facilitated stepping at a low cost and allowed face to face interaction with peers. Caregivers believed the device increased the intensity of stepping while reducing caregiver burden. After 12 weeks of use the Velcro waistband had worn out from use and required replacement. Not unlike equinotherapy the cadence of the caregivers stepping provided facilitation for weight shifting and stepping.


Trenkle J, Griffin M, Szewerniak D. Arlington Pediatric Therapy, Arlington Heights, Illinois, United States

BACKGROUND & PURPOSE: Children with Arthrogryposis Multiplex Congenita (AMC) demonstrate difficulty participating in activities of daily living due to limited range of motion and musculoskeletal anomalies. The Wilmington Robotic Exoskeleton (WREX) has been developed at Nemours/Alfred I. DuPont Hospital for Children in Delaware in order to increase independence and strength in children with this diagnosis. The purpose of this case study is three-fold:

1) To gain an understanding of the WREX and how it can be used with a child with AMC.

2) To understand how to implement specific activities during intensive sessions with children wearing the WREX in order to increase independence and strength.

3) To demonstrate how to develop functional home activities that target the same muscles/skills that were focused on during clinic sessions.

CASE DESCRIPTION: A case study was performed on a 5 year old girl with a diagnosis of AMC which documented her manual muscle testing (MMT) and Canadian Occupational Performance Measure (COPM) scores pre- and post- use of the WREX during two separate intensive periods. The child participated in 2x/week occupational therapy (OT) sessions for which she wore the WREX, and in addition wore the WREX outside of her OT sessions for a minimum of 1 hour/day for 4 days out of the week. Specific activities were performed during OT sessions and at home in order to gain muscle strength and independence in desired areas.

OUTCOMES: Pre- and post-test activity and participation was measured using the COPM. Muscle strength was measured using MMT. In terms of muscle strength, the greatest improvement was seen in the following muscle groups: shoulder flexors, elbow extensors, wrist flexors, wrist extensors and grip strength. In terms of her ability to perform activities of daily living that were deemed most important by the client and her family, the child made the greatest improvements in the following: ability to bring utensil to mouth for eating, ability to hold onto walker for gait; ability to participate in craft activities that included cutting with scissors, gluing and removing/applying stickers.

DISCUSSION: The results from the COPM show that the child's performance and the mother's satisfaction in her performance in several tasks improved following the intensive sessions using the WREX. The scores obtained are rated on performance without wearing the WREX. MMT results show that the activities performed while wearing the WREX were successful in strengthening the specific muscle groups that were targeted.


Tucker J, Rogal S, Miley M, Hess J. Health Professions, University of Central Florida, Orlando, Florida, United States

PURPOSE/HYPOTHESIS: The purpose of this study was to investigate the influence of a school based physical activity program on fitness measures in children with and without developmental disabilities, in grades K-3.

NUMBER OF SUBJECTS: 41 subjects.

MATERIALS/METHODS: A pre-and post-test intervention study was used to investigate the influence of a school based physical activity for 41 children, grades K-3, with and without developmental disabilities. Assessments took place at UCP of Central Florida Bailes Charter School. Fitness measures included height, weight, BMI, pedometer readings during 30 minutes of walking, 6 Minute Walk Test, and V Sit and Reach Test. The intervention involved a teacher-supervised, daily walking program for 30 minutes over 12 weeks.

RESULTS: Data was analyzed using SPSS version 22. The sample of 41 children had an average age of 6.33 years old with a mean BMI of 16.78 (SD 2.07), which is categorized as within normal healthy weight for this age group. The effect of the intervention was evaluated via paired sample t-test, with a significant improvement identified in performance on the Six-Minute Walk Test (t=-9.91, p<.001). This lead to an increase in children “meeting normative values” on the Six-Minute Walk Test, with only 2.4% (n=1) meeting the normative criteria at baseline to 46.3% at final (n=19). Additionally, a significant decline was noted in V Sit and Reach Test (t=-5.65, p<.001).

CONCLUSIONS: There were positive effects of the intervention on aerobic capacity and endurance. Surprisingly, there was a decline in lumbopelvic flexibility noted with V-sit and reach values. This is possibly due to normal childhood growth and development, increase in physical activity or time spent sitting in the classroom. Further research is needed based on the results of this study to conclude the influence of a school based physical activity program on fitness measures in children grades K-3.

CLINICAL RELEVANCE: Physical therapists play an integral role in health promotion and wellness programs for children with and without disabilities. Understanding the impact of physical activity programs is important when selecting programs to support and recommend to the community.


Twum-Ampofo N. S, Kolobe T, Porter A, Rauh-Johnson L, Fagg A. Rehabilitation Sciences, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, United States

PURPOSE/HYPOTHESIS: Children with or at risk for cerebral palsy (CP), unlike typically developing children, are often unable to achieve prone locomotion. A major underlying problem is postural instability and movement incoordination. The purpose of the study was to compare two new intervention approaches by determining whether the Self-Initiated Prone Progression Crawler (SIPPC), with a sensor suit (SA) promoted postural control and motor coordination during prone locomotion better than the SIPPC alone (NSA) when used with infants with and without risk for CP. The SIPPC is a motorized wheeled platform that uses robotic and sensor technology to assist movement effort and postural control during prone locomotion. The sensor suit, used with the SIPPC also measures and indirectly assist spontaneous arm and leg movement effort and may be more effective.


MATERIALS/METHODS: At 4 months of age, the infants were randomly assigned to three groups; typically developing (TD); high risk with SA (HR1), and high risk with NSA (HR2). Infants were videotaped while learning to use the SIPPC twice a week for 12 weeks. We used the Movement Observation Coding System (MOCS) to code the videotapes and to assess infants' postural control and overall movement proficiency. Weekly MOCS scores were averaged in 4 time intervals corresponding with the infants' ages 5, 6, 7 and 8 months. We used ANOVA with repeated measures to analyze the data.

RESULTS: Mean postural control and movement proficiency scores for the TD group was higher than that of the HR1 and HR2 groups at all time intervals. The differences occurred as early as 6 months of age (p = .006 & p=.016, respectively). Mean postural control and movement proficiency scores for the HR1 was higher than the HR2 group at 7 months (p = .002) and 8 months (p = .016), respectively. Group/time interaction between the HR1 and HR2 at 8 months (p = .026) and the TD and HR2 at 6, 7, and 8 months was statistically significant (p = .041, p = .014 and p <0.0005, respectively).

CONCLUSIONS: Infants in the TD group, as expected, developed postural control and movement proficiency earlier than those in the high risk groups. However infants receiving additional assistance from the sensor suit, HR1achieved earlier and better motor proficiency as indicated by the significant interaction between HR1 and HR2. These findings suggests that the sensor suit facilitated movement learning and coordination than the SIPPC alone.

CLINICAL RELEVANCE: Success with prone locomotion in infants with CP affects functional independence and other domains of learning. Typical development of this skill, also coincides with a period of highly active synaptic connections in the brain. Any effective intervention targeting this skill for infants with developmental problems will ultimately benefit learning in other domains as well.


Unanue Rose R, Pietzman K, Anderson C, Kruse S, Maynez J, Strauser C. Physical Therapy, Maryville University, St. Louis, Missouri, United States

PURPOSE/HYPOTHESIS: The purpose of our study was to examine the correlation between standing pronation, plantar flexor strength, and vertical jump height in typically developing children ages 3 to 7. The secondary purpose of our study was to identify any correlation between pronation and contributing factors such as BMI, gender, age and hypermobility.

NUMBER OF SUBJECTS: Participants included 22 typically developing children (11 boys, 11 girls), ages 3 to 7 years, from one area independent school.

MATERIALS/METHODS: Each child's height (cm) and weight (lbs) were obtained at check-in. Measurements of standing pronation, plantar flexor strength, and jump height were recorded. Pronation was measured in standing using a universal goniometer. Bilateral plantar flexor strength was assessed in long sitting utilizing a handheld dynamometer. Vertical jump height was measured in standing with the right arm overhead from the tip of the third finger to the highest jump height achieved out of three attempts. Hypermobility was measured using the Beighton Scale. Information regarding demographics, family history, sports participation, active play, history of foot pathology, and inactivity was obtained from a questionnaire completed by the child's parents. A Pearson correlation coefficient was used to determine the relationship between standing pronation, plantar flexor strength, and vertical jump height. Means were calculated to analyze any trends between pronation and variables such as age, sports participation, active play, and hypermobility.

RESULTS: Bilateral plantar flexor strength and vertical jump height demonstrated a positive correlation (left r = 0.760, right r = 0.659). Age and average pronation were inversely related, r = -0.438. However, bilateral plantar flexor strength and average pronation were not correlated (left r = 0.016, right r = 0.166, p = 0.01). No correlation was found between jump height and average pronation with an r-value of -0.038. No trends were noted between pronation and age, sports participation, active play, and hypermobility.

CONCLUSIONS: Results of this study show as a child ages, the amount of pronation decreases and the natural arch begins to develop supporting previous research. Those with stronger plantar flexors jumped higher. However, the influence of plantar flexor strength and vertical jump height on standing pronation was insignificant. Factors such as active play, sports participation, and hypermobility did not demonstrate a trend or show a significant relationship to pronation. Limitations of this study included sample size and diversity of participants.

CLINICAL RELEVANCE: Clinicians should understand normal arch development in order to appreciate children's flat feet in their early years of growth. These results reveal the need for further research with a larger, more diverse sample in order to identify specific influences on the prevalence of flat feet and arch development.


Vandenberg Z, Stolzman S, Hoeger Bement M. Department of Physical Therapy, Marquette University, Milwaukee, Wisconsin, United States

BACKGROUND & PURPOSE: Physical therapists (PTs) screen patients for wellness including risk for cardiovascular disease (CVD) and type 2 diabetes (T2DM). A screening option for these metabolic related diseases is to determine a patient's level of Metabolic Syndrome (MetS). MetS is a diagnosis based on a group of biometric factors which quantify risk in the categories of obesity, glycemic homeostasis, arterial pressure, and dyslipidemia. The leading categorical guidelines for MetS in the adolescent population come from the World Health Organization (WHO) and the International Diabetes Foundation (IDF). Recently, a continuous model which equates a severity z-score for a patient's risk of MetS has been proposed by M. J. Gurka et al., 2012.

CASE DESCRIPTION: This case study aims to compare use of these three guidelines for MetS (WHO, IDF, and Gurka) in a single female adolescent and the impact of weight loss on the MetS diagnosis. This case study was part of a larger study investigating adolescent obesity, pain, and inflammation. The following biometrics were collected at baseline and at 12 months (after a 50 lb weight loss): height, weight, waist circumference (WC), resting systolic/diastolic blood pressure (SBP/DBP), and fasting blood sample.

OUTCOMES: At baseline, a 13.3 year old female was classified as obese (BMI z score 2.05, 98%) with a blood pressure of 124/88 (SBP z score 1.3, 90.3%), glucose 83.5 mg/dL, HDL 27.0 mg/dL, insulin 21.94 μU/mL, triglycerides (TG) 79 mg/dL, and WC 87.5 cm (>90%). She did not meet the MetS criteria for WHO (obese & 1/3 categories) or IDF (2/4 categories). Using the Gurka model, her severity z-score was 1.41; she was more likely than 92% of girls her same age and race to develop CVD or T2DM.

One year later, she was classified as normal weight (BMI z score 0.63, 74%) with a blood pressure of 106/68 (SBP z score -0.6, 27.4%), glucose 78.0 mg/dL, HDL 42.0 mg/dL, no insulin result, TG 57.0 mg/dL, and WC 66.5 cm (<50%). The IDF model could not be used due to lack of insulin result. She did not meet the MetS criteria for WHO (not obese & 0/3 categories). Using the Gurka model, her severity z-score was -0.16. This new score indicates that she was now only 44% more likely than girls her same age and race to develop CVD or T2DM.

DISCUSSION: This case study suggests that categorical models may not capture the complexity of MetS. The Gurka model allows PTs to discuss MetS on a risk continuum. This model is clinically accessible as it requires common biometrics that a PT could assess in the clinic or review via medical record. Using the Gurka model, PTs could identify adolescents at risk for metabolic related diseases and track progress with PT interventions.


Visser A, Westman M, Otieno S, Kenyon L. Physical Therapy, Mary Free Bed Rehabilitation Hospital, Grand Rapids, Michigan, United States

PURPOSE/HYPOTHESIS: Children with cerebral palsy (CP) may have lower levels of cardiorespiratory endurance and fitness than their typically developing peers. Such children, however, may have difficulties sustaining movement at the intensity and duration necessary to improve cardiorespiratory endurance and may be unable to reap the innate health benefits of uninterrupted activity. The purpose of this pilot study was to explore the impact of a home-based body weight supported treadmill training (BWSTT) program on cardiorespiratory endurance and functional mobility in children with CP.

NUMBER OF SUBJECTS: Ten children with CP between the ages of 6 and 16 years old (Mean age = 11.4 years) participated in the study.

MATERIALS/METHODS: This study used a within-subjects, repeated measures design. Inclusion criteria were as follows: a diagnosis CP - Gross Motor Function Classification System (GMFCS) Levels II-III, access to a treadmill, the ability to take unassisted steps on a treadmill when supported by a harness, and the ability to follow simple instructions. Exclusion criteria included: medical restrictions on physical activity, any surgical intervention within 3 months, orthopedic or neurosurgery within 6 months, and any acute injury impacting ambulation. A 12-week home-based BWSTT program was conducted 3-4 times per week by a parent/caregiver. The following measures of functional mobility and cardiorespiratory endurance were administered pre and post-intervention: Six-Minute Walk Test (6MWT), Physiological Cost Index (PCI), Functional Mobility Scale (FMS), Mobility Domain of the Pediatric Evaluation of Disability Inventory - Computer Adaptive Test (PEDI-CAT), Gillette Functional Assessment Questionnaire (FAQ), and the Canadian Occupational Performance Measure (COPM). Statistical Analysis: The Wilcoxon signed-rank test or Sign Test were used to determine statistical significance (p<0.05). Effect size was determined via the Spearman Correlation Coefficient.

RESULTS: Both the 6MWT and the PCI showed significant improvements following the 12-week intervention program (p = 0.001/r=.84; p=0.001/r=.79, respectively). Significant improvements were also seen in the COPM for both performance and satisfaction (p=0.001/r=.47; p=0.001/r=.06, respectively), the FMS at a distance of 50m (p=0.016/r=.81), and the FAQ (p=0.016/r=.42).

CONCLUSIONS: Additional research is warranted to further investigate the effects of a home-based BWSTT program on cardiorespiratory endurance and functional mobility in children with CP.

CLINICAL RELEVANCE: As a group, subjects demonstrated significant improvements in cardiorespiratory endurance and functional mobility at the completion the 12-week intervention program. This suggests that a 12-week home-based BWSTT program may be beneficial for children with CP (GMFCS Levels II-III).


Zarkou A, Lee S, Prosser L, Hwang S, Jeka J. University of Delaware, Newark, Delaware, United States

PURPOSE/HYPOTHESIS: Stochastic Resonance Stimulation (SRS) has been used to enhance balance in populations with sensory deficits by improving the detection and transmission of afferent information. SR is a phenomenon in which a random subsensory noise ameliorates a nonlinear system's (i.e. somatosensory) sensitivity to differentiate a weak afferent signal, and thereby potentially enhances essential sensory information processing for self-orientation and equilibrium control of upright stance. Despite the potential promise of SRS in improving postural control, its use in individuals with cerebral palsy (CP) is novel. The objective of this study was to investigate the immediate effects of electrical SRS when applied in the ankle muscles and ligaments on postural stability in children with CP

NUMBER OF SUBJECTS: Ten children with spastic diplegia.

MATERIALS/METHODS: The sensory SRS thresholds were determined for each individual. The control condition and four stimulation intensities (25%, 50%, 75%, 90% of the sensory SRS threshold), randomly ordered, were tested while each participant stood motionless on top of 2 force plates for 25s with their eyes open and closed. The differences between the resultant center of pressure velocity (COPVr) of the 4 SRS conditions over the control condition were calculated. The intensity that produced the greatest balance improvements (i.e. reduction in COPVr) was defined as the optimal SRS intensity level for each individual and was subsequently used for the analysis for each visual feedback condition. Then, the COPV in the anteroposterior (A/P) and medial-lateral (M/L) directions, 95% COP Confidence ellipse area (COPA), and root mean square (RMS) A/P and M/L distance of COP displacement for the optimal and control SRS conditions were computed and compared.

RESULTS: Applying SRS resulted in improved balance performance in all participants but one. The optimal SRS intensity significantly decreased COPVr, and to a greater extent, than the rest of the applied intensities for both eyes open and eyes closed conditions (p<.05). SRS significantly enhanced stability as measured by the reduction in COPV measures compared to the control for visual feedback condition (p< .05). In the absence of visual information, SR significantly decreased COPV only in A/P direction. Mean COPA, RMS A/P and M/L values decreased, but changes were not statistically significant.

CONCLUSIONS: SRS can be potentially used as a therapeutic tool to improve balance performance by up-regulating somatosensory information in individuals with CP. Applying subject-specific SRS intensities is recommended to maximize balance improvements.

CLINICAL RELEVANCE: Rehabilitation interventions in CP have thus far focused on improving motor performance but with limited consideration of somatosensory impairments whose deficits can affect motor behavior. Since sensory information is a key component of postural control, more effective interventions should potentially include sensory facilitation, like SRS, as part of the everyday treatment procedure.


Ziegltrum A, Hsu L, Jirikowic T, McCoy S. Rehabilitation Medicine, University of Washington, Seattle, Washington, United States

PURPOSE/HYPOTHESIS: Measuring sensory integration of balance in children is critical in guiding treatment decisions with the goal of increasing children's safety and involvement in daily activities and participation both at school and in their homes. The Pediatric Clinical Test of Sensory Interactions for Balance 2nd Ed (P-CTSIB2) provides information on balance under systematic sensory conditions that manipulate vestibular, visual, or somatosensory information. Duration of standing balance and degrees of sway are recorded for each condition. There is limited research validating the P-CTSIB2. The purposes of this study are to determine the validity of using four conditions on the P-CTSIB2, eliminating conditions requiring use of the visual conflict dome, and determine the validity of the P-CTSIB2 compared to the balance composite of the Movement Assessment Battery for Children 2nd Ed (MABC-2).

NUMBER OF SUBJECTS: Seventy children, age 5 to 16 years, participated in this study, including children with typical development (TD) (n=6), children with developmental coordination disorder (n=19), and children with fetal alcohol spectrum disorder (n=45).

MATERIALS/METHODS: All children were examined using the P-CTSIB2 and the balance composite of the MABC-2. Pearson correlations were used to compare the four (conditions 1, 2, 4, and 5) to the six condition set of the P-CTSIB2, and to compare the P-CTSIB2 total ordinal score to the MABC-2 balance composite score.

RESULTS: For the four compared to the six-condition set, a high Pearson correlation of 0.95 (p<0.001) was found. For the MABC-2 compared to the P-CTSIB 2, a moderate Pearson correlation of 0.52 (p< 0.001) was found.

CONCLUSIONS: The results suggest that using the four items of the P-CTSIB2 could supply similar results from using the six-condition set of P-CTSIB2. Therefore, the visual conflict dome items may not be necessary for children with TD and children with minor motor limitations. Second, the P-CTSIB2 is not assessing the same thing as MABC-2. Compared to the MABC-2, which focuses more in general balance performance, the P-CTSIB2 measures sensory related balance control more specifically.

CLINICAL RELEVANCE: We recommend using the four-condition set on the P-CTSIB2, which will take less time to implement and children will tolerate the test better without the dome component. Also, since the P-CTSIB2 focuses on sensory integration for balance, it should be used to help distinguish between vestibular, somatosensory, and visual balance issues and should be used alone or in addition to the MABC-2 with children with minor motor limitations.

© 2017 Wolters Kluwer Health, Inc. and Academy of Pediatric Physical Therapy of the American Physical Therapy Association