VIDEO CODING OF POSTURE AND GROSS MOTOR BEHAVIOR VARIABILITY IN TYPICALLY DEVELOPING CHILDREN AND CHILDREN WITH AUTISM SPECTRUM DISORDER
Abbruzzese L, McGowan N, Thapa L (Department of Rehabilitation & Regenerative Medicine, Columbia University), Goldman S (Department of Neurology & G.H. Sergievsky Center, Divisions of Cognitive Neuroscience & Child Neurology), Fein D, Naigles L (Department of Psychological Sciences, University of Connecticut)
PURPOSE/HYPOTHESIS: Autism spectrum disorder (ASD) is a neurodevelopmental disorder characterized by impairments in social interactions and communication, restricted interests, and stereotyped or repetitive behaviors. While abnormal motor features are not considered as diagnostic criteria, they are observed in more than 85% of individuals with ASD and are the earliest reliable predictor of a later ASD diagnosis among high-risk siblings of children with ASD. Movement variability is critical for development and environmental exploration, impacting both social and language development. The purpose of this study was to investigate the frequency and variety of gross motor behaviors and postures explored by children with and without ASD during play. We hypothesized that compared to age-matched Typically Developing children (TD), children with ASD would either exhibit more static positions related to restricted interests or would present with a high frequency of postures and motor behaviors related to a hyperactivity co-morbidity.
NUMBER OF SUBJECTS: 40 [20 ASD (5 girls/15 boys) mean age 40 months; 20 TD (4 girls/16 boys) mean age 35 months].
MATERIALS/METHODS: Participants were videotaped during home-based play sessions with a caregiver as part of a longitudinal study to examine language development in children with ASD (University of Connecticut; PI. Naigles). Researchers blinded to ASD diagnoses independently coded the first five minutes of a 30-minute video using Datavyu software. Postures were categorized into “static” (sitting, lying, standing, kneeling) and “dynamic” (locomotor behaviors involving moving from one location to another). Each posture (e.g., standing, sitting) was expanded into more specific positions (e.g., half-kneel, W-sitting). Codes for supported postures and forced transition (when a child was physically moved by the parent) were also utilized. Inter-rater reliability for all codes ranged between 0.91 to 1.0 with a 95% confidence interval using Krippendorf's alpha. Video coding was used to quantify the frequency and variability in postures and gross motor behaviors observed during the 5-minute sample.
RESULTS: Compared to age-matched TD children, those with ASD exhibited similar frequency and distribution of sitting, lying, standing, kneeling, and locomotor behaviors during play. There was a significant difference between the two groups for the code “forced transition.”
CONCLUSIONS: These findings may have implications for understanding the role of caregivers in facilitating or inhibiting motor behaviors during play in children with ASD. Similar to language findings, these caregivers may tend to re-direct more postural changes to enhance exploration and social attention, or to control extraneous behaviors not directed at targeted play activities.
CLINICAL RELEVANCE: This study suggests that video coding may be useful as an objective method of assessing motor variability in young children with ASD. The longitudinal impact of caregiver influences on postural exploration and behaviors requires further investigation.
LONGITUDINAL CHANGES IN PHYSICAL CAREGIVING FOR PARENTS OF CHILDREN WITH CEREBRAL PALSY
Alghamdi M, Chiarello L, Palisano R, Orlin M, (Physical Therapy and Rehabilitation Sciences, Drexel University), McCoy S (Rehabilitation Medicine, University of Washington), E.M. Abd-Elkafy, (Physical Therapy, Umm Al-Qura University, Makkah, SAUDI ARABIA)
PURPOSE/HYPOTHESIS: To determine the change in physical caregiving for parents of children with cerebral palsy (CP) over a period of two years based on children's gross motor function and age.
NUMBER OF SUBJECTS: 153 parents of children with CP. Children had a mean age of 6.5 (2.7) years and 56% were boys. Parents had a mean age of 39.7 (7.13) years of age and 89% were mothers.
MATERIALS/METHODS: Parents rated their physical caregiving using the Ease of Caregiving for Children measure 3 times at approximately 12-month intervals. The average time interval between the first and last measurement was 23.1 (2.6) months. Parents and therapists classified children's gross motor function using Gross Motor Function Classification System (GMFCS). A mixed 3-way ANOVA was used to examine the interaction between children's gross motor function (GMFCS levels I, II-III, and IV-V), age group (1.7–5.9 and 6-11 years) and time (3 time points) on ease of caregiving. The alpha level was 0.05.
RESULTS: No significant 3-way interaction was found among children's GMFCS level, age group, and time on ease of caregiving, p=0.64. No significant 2-way interaction was found between age group and GMFCS level, p=0.41, or between age group and time, p=0.23, on ease of caregiving. There was no significant main effect of age on ease of caregiving, p=0.07. A significant 2-way interaction was found between children's GMFCS level and time on ease of caregiving, p<0.01. For the effect of children's GMFCS level, across all time points, parents of children in GMFCS level I reported the highest ease of caregiving followed by parents of children in GMFCS levels II-III, and by parents of children in GMFCS levels IV-V who reported the lowest ease of caregiving, p<0.001. For the effect of time, differences in ease of caregiving were found only for parents of children in GMFCS level I (2 years > baseline; 1 year > baseline) and parents of children in GMFCS levels II-III (1 year > baseline), p<0.01.
CONCLUSIONS: Over a period of two years, parents of children with higher gross motor function reported higher ease of caregiving compared to parents of children with lower gross motor function. Parents of children in GMFCS level I and levels II-III reported higher ease of caregiving over time but not parents of children in GMFCS levels IV-V. There was no difference in ease of caregiving between parents of children < 6 years and ≥ 6 years. Future research is warranted to examine longitudinal changes in parental ease of caregiving of children with CP at older ages and the effect of family and environmental factors on ease of caregiving.
CLINICAL RELEVANCE: Knowledge of longitudinal trajectories of parental physical caregiving for children with CP can help therapists address parents' needs and concerns, assist with future planning, and tailor interventions and supports to optimize their caregiving experience. Therapists are particularly encouraged to evaluate and address the needs of parents of children with significant motor limitations given that their ease of caregiving did not become easier over time.
THE IMPACT OF PARENT DIRECTED MOVEMENT ON INFANT POSITIONS AND TRANSITIONS DURING A PARENT INFANT FREE PLAY SESSION
Dusing S, Greenberg K, Kane A, Marcinowski E (Physical Therapy, Virginia Commonwealth University)
PURPOSE/HYPOTHESIS: Both quality and quantity of dyadic play have a positive impact on cognitive and motor development. A lack of interaction and limited opportunities for motor exploration can negatively impact these same areas of development. The purpose of this study is to determine if the way a parent plays with their infant is related to an infant's choice of play positions or movement transitions in infants with motor delays. We investigated 2 hypotheses: (1) the frequency of parent directed movement will correlate negatively with infant play duration while independently sitting, and (2) parent directed movement will be related with higher frequency of parent-initiated transitions while infant directed movement will be associated with higher frequency of infant-initiated transitions.
NUMBER OF SUBJECTS: Preliminary analysis of 20 infants from the START-Play randomized clinical trial (n=90).
MATERIALS/METHODS: 20 infants, Mage of 11.8 months, were enrolled at sitting emergence and assessed across 5 visits over 12 months. Parents were asked to play with their infant as they typically would for 5 minutes. Coders quantified parent assistance during the interaction. Infant directed (ID) movement was coded when the parent encouraged or allowed the child to choose their movement pattern. Parent directed (PD) movement was coded when the child was directed to use a specific movement pattern or stopped from using a self-initiated movement. The session was considered to be PD if greater than 20% of the session was PD, otherwise it was ID. Dependent/independent sitting was coded if the parent was or was not providing support for the child sitting upright, respectively. The frequency of infant transitions was also coded. Spearman's correlation was used to compare the proportion of PD movements during dependent and independent sitting at each visit. A Mann Whitney U was used to compare the number of parent-/infant-initiated transitions at visits that were PD and ID.
RESULTS: Preliminary analyses revealed that the duration of PD movement positively correlated with dependent position duration at earlier visits (r=0.45, p=0.06), and negatively correlated with independent position duration after 6 months (r=−0.59, p=0.02). At baseline, the number of parent-initiated transitions was higher in infants whose PD movement compared to infants with ID movement (U=60.5, p=0.02). After 3 months, the number of infant-initiated transitions was higher in infants with ID rather than PD movement (U=8.00, p=0.03).
CONCLUSIONS: Preliminary results suggest that infants whose parents directed movement initiated fewer transitions and spent more time in dependent sitting, than infants who directed their own movement.
CLINICAL RELEVANCE: If these results are confirmed in the full START-Play sample, clinicians should include this as part of their coaching. By allowing infants to direct their own movement, parents can encourage infants' independence in positioning and mobility.
A MIXED METHOD APPROACH TO ANALYZING DATA THROUGH VIDEO ANALYSIS AND A VALIDATED MEASURE OF MOTOR FUNCTION IN CHILDREN WITH GIANT AXONAL NEUROPATHY: A PILOT STUDY
Elliott J, Mebrahtu A, Waite M, Robertson S, Jain M (Clinical Center/NIH, Rehabilitation Medicine Department), Fink M, Donkervoort S, Saade D, Foley A, Bharucha-Goebel D, Bonnemann C (National Institute of Neurological Disorders and Stroke, Neuromuscular and Neurogenetic Disorders of Childhood)
PURPOSE/HYPOTHESIS: Giant Axonal Neuropathy (GAN) is a rare genetic disorder caused by mutations in the GAN gene coding for the gigaxonin protein, resulting in progressive sensory and motor neuropathy with cerebral white matter changes. Children and young adults with GAN progressively have difficulty with walking, breathing, and activities of daily living, with mortality occurring in the 2nd or 3rd decade of life. Currently at the NIH/NINDS, there is an AAV9- mediated intrathecal gene therapy trial (#NCT02362438). Per protocol, children with GAN participating in the trial undergo motor function evaluations using standardized assessments to measure changes in functional skills. Physical therapists and family members of these children have reported observing qualitative improvements in the children's ability to complete motor tasks, while scores have remained stable. The purpose of this presentation is to propose the use of video analysis as part of standard motor assessments in order to measure qualitative and quantitative changes in the ability of children with GAN to perform functional activities.
NUMBER OF SUBJECTS: 6
MATERIALS/METHODS: Ten children with GAN participated in the NINDS protocol with video obtained on a subset of participants (N=6, 3 males) ranging in ages 6-12 years. The Motor Function Measure (MFM) is a 32-item scale that assesses functional capacity in individuals with neuromuscular disorders. The MFM has been validated in people 6-60 years of age. Video of the six subjects was captured at the 0 and 12 month clinical trial points. Video was recorded for the functional activities of: rolling supine to prone, bringing knee to chest, and dorsiflexion of the foot. Assessments were completed by a pediatric physical therapist and were videotaped by a research assistant. Mixed method analysis of the unedited videos was completed by a second independent pediatric physical therapist.
RESULTS: Preliminary analysis of the videos revealed two major themes: time to complete motor tasks and compensation strategies used. For the knee-to-chest maneuver, three subjects demonstrated faster times to complete the task by 27.43%, 46.25%, and 70.69% while their MFM scores for the item remained the same. Additionally, some subjects demonstrated a change in strategy for completing the knee-to-chest maneuver with some patients using their arms and others using both legs.
CONCLUSIONS: The results of this pilot study suggest that the qualitative analysis of video capturing motor function assessments in conjunction with a standardized motor assessment score may enrich motor evaluation results in children with rare neuromuscular diseases.
CLINICAL RELEVANCE: Adding qualitative perspectives to quantitative data may be useful in allowing clinical researchers to track effectiveness of clinical interventions in children with rare neurodegenerative disorders. Based on the results of this small pilot study, future research that validates the use of mixed-method analysis may contribute to improved patient-centered assessments.
THE HAND MOTOR ACTIONS OF CHILDREN WITH CEREBRAL PALSY INVOLVE ATYPICAL SENSORIMOTOR CORTICAL OSCILLATIONS
Hoffman R (University of Nebraska Medical Center, Munroe-Meyer Institute), Wilson T (Center for Magnetoencephalography, University of Nebraska Medical Center), Kurz M (University of Nebraska Medical Center, Munroe-Meyer Institute)
PURPOSE/HYPOTHESIS: The neuroimaging literature on cerebral palsy (CP) has predominantly focused on identifying the structural aberrations within the white matter fiber tracts (e.g., corticospinal),1-3 with very few studies examining neural activity within the key networks that serve the production of the hand motor actions.4-6 The objective of the current investigation was to begin to fill this knowledge gap by quantifying the temporal changes in the sensorimotor cortical dynamics as children with CP performed a motor action with the hand. Our primary hypotheses were 1) that the children with CP would have uncharacteristic sensorimotor cortical activity relative to the typically developing (TD) group, 2) that the altered cortical activity seen in the children with CP would be linked with the deviations in the motor performance.
NUMBER OF SUBJECTS: 44; 18 children with CP (Age = 15.9 ± 4 yrs.; MACS levels I-IV) and 26 TD children (Age = 14.7 ± 3 yrs.)
MATERIALS/METHODS: Magnetoencephalographic brain imaging was used to quantifying the sensorimotor cortical oscillations as the children performed a button press response task with the second and third digits of the right hand when an arrow was displayed as pointing to the left or right. Advanced beamforming methods were used to image the oscillatory source power changes across the entire brain volume, and the peak activity (i.e., pseudo-t values) from these images were subsequently extracted and compared between the two groups.
RESULTS: Overall there was a beta (16–24 Hz) event-related desynchronization in the contralateral precentral and postcentral gyrus that started prior to the start of the button press, a gamma (68-82 Hz) event-related synchronization (ERS) at movement onset, and a prominent post-movement beta rebound (PBMR) after the hand motor action was completed (P < 0.001; corrected). The children with CP had weaker gamma ERS (P = 0.04) and PBMR (P = 0.016). In addition, the children with CP had slower reaction times (P < 0.001). Across both groups, the strength of the PMBR was negatively correlated with the reaction time (r = −0.343; P = 0.04) indicating that the children with weaker PMBR also tended to have slower reaction times.
CONCLUSIONS: These results are the first to show that sensorimotor cortical activity that is involved in the production of a hand motor action is aberrant in children with CP and related to their slower motor actions. These results are significant because they point to the neurophysiological nexus that may partly underlie the atypical hand motor actions seen in children with CP.
CLINICAL RELEVANCE: These results imply that the atypical hand motor actions seen in children with CP may be partly related to the execution of the intended motor action by the sensorimotor cortices and the cortical processing following movement termination. Alternations in the respective cortical oscillations may be a viable metric for gauging the success of the current task orientated physical therapy treatments that are directed at improving a child's execution of a hand motor action.
THE WIDE WORLD OF PEDIATRIC CLINICAL PRACTICE GUIDELINES
Kaplan S (Rehabilitation and Movement Sciences, Rutgers, The State University of New Jersey), Diaz C (Rutgers University)
PURPOSE/HYPOTHESIS: To describe the strategy and results of a scoping review of clinical practice guidelines (CPGs) related to pediatric physical therapy.
NUMBER OF SUBJECTS: 36 CPGs published since 2012.
MATERIALS/METHODS: A scoping review of freely available CPGs identified through database and website searches. CPG quality was analyzed against the Institute of Medicine's1 standards for trustworthy guidelines. CPG recommendations were categorized as ‘direct’ if there are specific recommendations for physical therapists (PTs) to implement; ‘referral’ if recommendations advise for referral to physical therapy, and ‘indirect’ if there is information that is relevant to practice but without specific actionable recommendations.
RESULTS: 36 CPGs represent 26 different conditions and 3 intervention approaches; 16 have direct recommendations for PTs, 10 advise for referrals to PT, and 10 have information that informs an understanding of a condition's management that would be useful to a PT. Sample topics include autism, pediatric fractures, scoliosis, hip dysplasia, asthma and end of life care.
CONCLUSIONS: There are many CPGs freely available to impact pediatric physical therapy practice. The Academy of Pediatric Physical Therapy, in consort with APTA, is promoting the development of 5 CPGs. While only 1 has been published to date, there are many others available that PTs should be aware of. The National Guideline Clearinghouse is closing in July, 2018 (https://guidelines.gov/) due to lack of funding, making it more difficult for physical therapists (PTs) to easily find relevant CPGs. PTs will benefit from understanding strategies for finding relevant CPGs and increased awareness of the breadth of topics and recommendation directedness.
CLINICAL RELEVANCE: CPGs have been shown to influence adoption of evidence based procedures2, 3 and improve clinical outcomes.4 Not all PTs know where to find CPGs or perceive having easy access to them.5 PTs should be aware of the availability and quality of CPGs relevant to pediatric conditions and interventions.
THERAPISTS' VIEWS ON AGE AND COGNITIVE SKILLS FOR POWER MOBILITY IN CHILDREN: A QUALITATIVE STUDY
Kenyon L (Department of Physical Therapy, Grand Valley State University), Gardner T (Mary Free Bed Rehabilitation Hospital), Jones M (Physical Therapy, Oklahoma City University), Breaux B (University of Colorado Anschutz Medical Campus), Tsotsoros J (University of Oklahoma Health Sciences Centre)
PURPOSE/HYPOTHESIS: Little is known about the factors that influence therapists' reasoning regarding power mobility for children with mobility limitations. The purpose of this study was to explore the views of pediatric physical therapists and occupational therapists in Canada and the United States related to the age at which power mobility was considered for a child and the cognitive skills that therapists contemplate when trialing power mobility.
NUMBER OF SUBJECTS: This study was part of a larger web-based survey study. Of the 1115 individuals who accessed the survey and met the inclusion/exclusion criteria, 651 responses were received for the question regarding age and 625 were received for the question regarding cognitive skills.
MATERIALS/METHODS: This study analyzed responses to 2 open-ended survey questions pertaining to the rationales for the age at which power mobility was considered and the cognitive skills contemplated when trialing power mobility. Data were analyzed using the constant comparative method. Units of information within the data were independently coded by each author and then discussed to develop an initial coding guide. Each author individually re-coded the data using this guide. Discrepancies were resolved through discussion until consensus was reached and a final codebook created. Codes were amalgamated into themes through a consensus process. NVivo® 11 Pro was used to organize, store, and visualize data. Trustworthiness was addressed through identification of each authors' biases, an inquiry audit, and a peer debriefing.
RESULTS: The following themes were identified across both survey questions: (1) Child Requirements For Power Mobility; (2) Non-child Requirements For Power Mobility; and (3) Power Mobility Trials, Use, and Options Are Dependent on Age and Goals. Child Requirements included cognitive and non-cognitive requirements. Non-child Requirements included family readiness, therapist experience, and issues related to equipment availability and funding/insurance. Additional themes related to rationale for the age at which power mobility was considered included: (1) Developmental Impact Of Mobility; (2) Benefits Of Power Mobility; and (3) Power Mobility Should Be Introduced At A Specific Age Or Stage. Although data revealed that respondents contemplated a wide variety of cognitive skills when deciding to trial power mobility, some respondents expressed the opposing view that cognitive skills should not be a consideration when trialing power mobility.
CONCLUSIONS: Numerous respondents reported introducing power mobility at a specific age or stage; however, this varied greatly amongst respondents. Multiple responses reflected misconceptions about power mobility use in children that were not supported by existing evidence.
CLINICAL RELEVANCE: Data gathered in this study indicated wide variability in respondents' views related to the provision of power mobility. Additional research is needed to explore both therapists' reasoning regarding power mobility use for children and how to best facilitate knowledge translation in this area of practice.
METABOLIC RESPONSE OF INDIVIDUALS WITH CEREBRAL PALSY TO SEQUENTIAL ‘SIX MINUTE WALK TESTS’: A PILOT STUDY
Kondratek M, Brandt L (Physical Therapy, Oakland University, Rochester)
PURPOSE/HYPOTHESIS: The functional ability of individuals with cerebral palsy (CP) may be described using the 5-level Gross Motor Function Classification System (GMFCS). The most variable motor performances occur within the GMFCS-3 level. A correlation between high gait energy cost (EC) and lower functional levels of individuals with CP has been reported. It is common for those who function at GMFCS-3 to use more than one assistive device, select devices based upon situational demands, and expend large amounts of energy to walk. The purpose of this study was to explore the impact of three ‘Six Minute Walk Tests’ (6MWT) performed 30 minutes apart on six minute walk distance (6MWD) and EC by four individuals functioning at GMFCS-3. The potential change in these variables across three trials and difference in these variables between subjects has not been previously reported for GMFCS-3. We hypothesized: 1) within subject differences across trials, and 2) higher EC in subjects with a greater number and/or severity of impairments.
NUMBER OF SUBJECTS: Four
MATERIALS/METHODS: Each subject completed three - 6MWT performed 30 minutes apart. Oxygen consumed (quantified by portable metabolic device), weight (kilograms) and 6MWD (meters) were used to calculate EC (milliliters of oxygen/kilogram/meter) using Excel. Fifteen second averages of oxygen consumed during the last four minutes of rest, one minute transition to standing, 6MWT, and 10 minutes of rest for each of three 6MWT were graphed for visual comparison within and across subjects.
RESULTS: Four subjects participated: two 13 years old (yo) and two 19 yo; one male and one female of each age; and CP type - one spastic triplegia and three spastic diplegia. Individual characteristics, such as tone, surgical and medical history, varied. Subject rationale for choosing reverse walkers (RW) (2 subjects) was the support provided; and forearm crutches (2 subjects) was the maneuverability afforded. 6MWD increased and EC decreased from trial one to three in three subjects. The most consistent performance and lowest EC was by a 19yo with the lowest number and severity of impairments who chose an RW. 6MWD decreased, EC increased and pre-6MWT baselines increased from trial one to three for the 13yo subject with spastic triplegia and pulmonary stenosis. Energy expended was highest for the subject whose gait pattern was crouched. All subjects returned to baseline EC within the 30 minute rest period.
CONCLUSIONS: The individual characteristics and resulting performance of these four subjects illustrates a potential relationship between the number and severity of impairments, and the variations in gait performance within GMFCS-3 level. Further investigation is warranted.
CLINICAL RELEVANCE: Individuals who function at GMFCS-3 may expend large amounts of energy to walk. When selecting a mobility device, the combination of number and severity of impairments may be a relevant consideration. It is recommended that the energy cost to walk with a given assistive device be considered during the device selection process.
LOW-INTENSITY VERSUS HIGH-INTENSITY HOME-BASED TREADMILL TRAINING AND WALKING ATTAINMENT IN YOUNG CHILDREN WITH CEREBRAL PALSY
Mattern-Baxter K (California State University), Looper J (University of Puget Sound), Bjornson K (Seattle Childrens Research Institute/University of Washington)
PURPOSE/HYPOTHESIS: Home-based treadmill training (TT) on small treadmills can be successfully carried out by parents of children with cerebral palsy (CP). In small studies, intensive TT has been shown to accelerate walking acquisition in pre-ambulatory children with various types of CP compared to no TT. However, the optimal dosing of home-based TT protocols remains unknown.
The purpose of this study was to determine optimal parameters for dosing home-based TT by comparing the effects of a low-intensity (LI) to a high-intensity (HI) protocol on walking skills and walking performance in children with spastic diplegic CP.
NUMBER OF SUBJECTS: 19 children with spastic diplegic CP, Gross Motor Function Classification System (GMFCS) Level I and II, ages 14-32 months (male n=8).
MATERIALS/METHODS: The children were randomly assigned to LI and HI groups at 3 geographical sites. The LI group received TT 2 days/week, once/day for 10-20 minutes for 6 weeks and the HI group received TT 5 days/week, twice/day for 10-20 min for 6 weeks in their homes. Children were assessed at study onset, post intervention, and 1 and 4 months post intervention. The Gross Motor Function Measure Dimension D/E (GMFM-D/E), average strides/day and percentage of time spent walking were primary outcome measures. The Peabody Developmental Motor Scales-2 (PDMS-2), Pediatric Evaluation of Disability Index Mobility Scale (PEDI), 10-meter and 1-minute walk test, and Functional Mobility Scale were used as secondary outcome measures. GMFM-D/E and PDMS-2 were scored via blinded assessor from videotapes. Linear mixed effects regression models were applied to all outcomes. The main hypothesis was addressed by testing the time-by-group interaction using likelihood ratio tests.
RESULTS: No significant between-group differences were found in any outcome measure at the different time points, except for the PEDI at the 4-month follow-up in the HI group (p=0.01). Children in both the LI and HI group made significant within-group improvements at each assessment with p-values ranging from 0.00 to 0.01, but strides/day and walking activity did not reach significance until the 4-month follow-up. Children in the HI group did not show significant improvement immediately following the intervention in GMFM-E regardless of GMFCS level, while children in the LI group did.
CONCLUSIONS: A twice-weekly home-based TT program showed similar outcomes compared to a 10x/week TT program in pre-ambulatory children with spastic diplegic CP in GMFCS level I/II. Children in both groups made significant improvements at each time point. Children in the HI group had less skill attainment for walking outcomes compared to children in the LI group immediately following the intervention.
CLINICAL RELEVANCE: TT is an effective intervention for children with spastic diplegic CP who are not yet ambulatory. A twice-weekly dosage was equally effective in improving skills related to walking compared to a high-dosage protocol and can be more readily implemented into clinical practice. Larger studies are needed to confirm these results.
RELATIONSHIP OF REHABILITATION SERVICES TO CHILDREN WITH CEREBRAL PALSY'S DEVELOPMENT
McCoy S (Rehabilitation Medicine, University of Washington), Avery L (Avery Information Services Ltd, Orillia, Ontario, CANADA), Palisano R (Physical Therapy & Rehabilitation Sciences, Drexel University), Chiarello L (Drexel University), LaForme Fiss A (Mercer University), Jeffries L (OUHSC, Oklahoma City), Hanna S (McMaster University, Hamilton, Ontario, CANADA)
PURPOSE/HYPOTHESIS: The On Track study determined children with cerebral palsy's (CP) progress in body functions and participation via creation of developmental percentile graphs. A second purpose explored the relations of rehabilitation services to children's development in balance, endurance, self-care and participation in family/recreational activities. We expected that children developing most optimally would receive family-centered services with more focus on task-specific practice and environmental modifications and parents would report their children's needs were met to a greater extent as compared to those developing less optimally.
NUMBER OF SUBJECTS: 708 children with CP, 1.5-11.9 years-old, from all Gross Motor Function Classification System (GMFCS) levels and their parents from the US and Canada.
MATERIALS/METHODS: Using a prospective cohort design, trained therapists measured children 2-5 times over 2 years on balance (Early Clinical Assessment of Balance) and endurance (6-minute walk test). Parents completed questionnaires on children's health, participation in family/recreation activities and performance of self-care (Child Engagement in Daily Life), and rehabilitation services. Therapists and parents collaboratively classified children on the GMFCS. Outcomes were analyzed by linear and nonlinear mixed-effects modeling to create developmental percentiles by GMFCS levels. Service amount, focus, family-centeredness, and the extent children's needs were met by services were explored using multinomial models followed by likelihood ratio tests to determine relationships to outcome percentile categories of progressing “more than” (>90th %) and “less than” (<10th %) to the reference of “as expected” (20-80th %).
RESULTS: Family-centered services were related to endurance (OR=0.57, 95% CI 0.38, 0.88, corresponding to a relative risk (RR) of 0.2), and participation in family/recreation (OR=1.46, 95% CI 1.06, 2.02, RR=3.9). The extent parents perceived children's needs were being met by services (OR=1.48, 95% CI 1.07, 2.03, RR=4.1), a focus on structured play and recreation (OR=1.03, 95% CI 1.07, 1.58, RR=2.5) and a focus on health (OR=0.81, CI 0.67, 0.99, RR=0.6) also related to participation in family/recreation activities. A focus on health (OR=1.36, 95% CI 1.11, 1.65, RR=2.9) was related to self-care performance. Amount of services did not significantly relate to any outcomes.
CONCLUSIONS: Services that are family-centered, employ joint decision making, consider children's needs, and focus on structured play/recreational activities, health and well-being may enhance development of children with CP. Generalization should be cautious as the study was designed to create developmental percentiles versus services effects and services were parent-reported.
CLINICAL RELEVANCE: Rehabilitation service providers should recognize the complexity of development and service provision for children with CP and consider developing expertise in provision of family-centered care with reimbursable time for collaborative service provision discussions to better support children and their families.
TRANSCUTANEOUS SPINAL CORD STIMULATION GENERATES RECIPROCAL LOWER EXTREMITY MOVEMENT IN PEDIATRIC PATIENTS WITH MOTOR COMPLETE SPINAL CORD INJURY
Meyer B, Martin R (International Center for Spinal Cord Injury, Kennedy Krieger Institute)
PURPOSE: The purpose of this report is to demonstrate that a single application of transcutaneous spinal cord stimulation (TSCS) generates reciprocal, step-like movement of the lower extremities (LE) in children with motor complete spinal cord injury (SCI). It will also describe the ability of one subject to translate involuntary movement produced by TSCS into voluntary effort during functional activities. Finally, it will demonstrate that this application is safe and feasible in children.
DESCRIPTION: TSCS was applied to three pediatric patients (ages 2, 4 and 10) with motor complete SCI. One 2 × 2 inch square electrode was placed over the skin at the T11-T12 intervertebral space as a cathode, and one 3 × 5 inch rectangular electrode was placed over the abdomen as an anode. A symmetrical biphasic rectangular waveform was used to apply stimulation at 50 Hz and 1 millisecond, at amplitudes to each patient's tolerance. Video was utilized to capture the resultant reciprocal, step-like movement. All patients tolerated TSCS well with no adverse effects. All subjects were unable to produce LE movement without TSCS, then demonstrated reciprocal LE movement in response to TSCS. Subject three had the most exaggerated response to TSCS, demonstrating a rapid and cyclical reciprocal pattern in bilateral LEs, with angular displacement ranging from 12–80 degrees at bilateral knees and from 28-50 degrees at bilateral hips.
SUMMARY OF USE: Subject three is highlighted to describe functional applications of TSCS as a supplement to activity-based PT interventions, including body-weight supported (BWS) standing and stepping. Voluntary muscle activity during BWS standing was absent without application of TSCS, but was increased by 37 microvolts in right quadriceps and by 317 microvolts in right plantarflexors with application of TSCS, as measured by sEMG. During BWS robotic gait training, increased force through footplates was noted with application of TSCS, as compared to no TSCS. During locomotor training over treadmill, patient was unable to assist with standing or stepping without TSCS. With TSCS applied, patient demonstrated the ability to engage LE extension during standing and LE flexion during stepping. Following locomotor training paired with TSCS, the patient demonstrated carry-over within the single session, demonstrating the ability to voluntarily engage hip and knee extension to assist with BWS standing, without use of TSCS.
IMPORTANCE TO MEMBERS: This report demonstrates that TSCS generates a reflexive, reciprocal step-like movement in children with motor complete SCI. One subject was able to translate this to voluntary movement with and without TSCS applied, within a single session. TSCS is a non-invasive approach, which appears to be a safe and feasible treatment for children. As demonstrated in adult SCI, TSCS may augment voluntary muscle activation through excitation of spinal cord circuitry, representing a promising adjunct to currently available therapies for children with SCI.
OUTCOMES OF CONSERVATIVE INTERVENTIONS FOR CHILDREN WITH IDIOPATHIC TOE WALKING: A RETROSPECTIVE CHART REVIEW
Migliore S, Andrew E, Balla N, Hadeed G, Ondeck C, Wescoe E (Doctor of Physical Therapy Program, DeSales University)
PURPOSE/HYPOTHESIS: Toe walking is a typical component of a child's developing gait cycle. By two years of age, a child is expected to adopt a heel-toe gait pattern and any continued toe walking warrants further investigation due to the possibility of an underlying neurologic condition. Patients diagnosed with idiopathic toe walking (ITW) typically have limited dorsiflexion (DF) range of motion (ROM) due to prolonged walking in a fully plantarflexed position. Interventions for ITW range from conservative, such as triceps surae stretching, ankle-foot orthoses (AFO), serial casting, and botulinum toxin injections, to invasive procedures such as surgery. With the abundance of interventions, it is difficult to state which is initially most effective. The purpose of this study was to determine the effects of implementing serial casting within the first two months of ITW treatment in comparison to casting after two months, or not casting at all, on DF ROM and cessation of toe walking.
NUMBER OF SUBJECTS: 58 medical records
MATERIALS/METHODS: A retrospective chart review was performed on 821 medical records extracting DF ROM measurements, percentage of the child's day spent toe walking, physical therapy (PT) interventions, billing costs, and number of PT visits. Children that had a diagnosis of ITW, absent heel strike, limited ankle DF ROM, ages 2-12, and who received outpatient PT within a regional children's hospital network were included. Data were stored in Research Electronic Data Capture (REDCap). REDCap and IBM™ SPSS Statistics 23 were used for data analysis.
RESULTS: Medical records were divided into two groups casted (C) (n=14) and non-casted (NC) (n=44). There were not enough medical records with late casting to include that group in the analysis. Variables statistically analyzed, using Levene's test for equal variance prior to an independent t-test, included age at time of treatment, number of PT sessions, sum of PT charges, and change in DF ROM bilaterally. There were no significant differences between the C and NC groups in age at time of treatment, number of PT sessions, and sum of PT charges (p >.05). Statistical significance was found for mean DF gained. Mean DF ROM gained on the left: C group was 15.93°, NC 7.30° (p=.001). Mean DF ROM gained on the right: C group was 15.29°, NC group 7.20°(p=.007).
CONCLUSIONS: Significant differences were found in the amount of DF ROM gained bilaterally between C and NC groups. This study confirmed the effects of serial casting for patients with limited DF ROM. Children who received serial casting gained more DF ROM in approximately the same amount of treatment sessions, with similar costs as those not casted.
CLINICAL RELEVANCE: Since ITW is common in the pediatric population it is important to select effective interventions. Children who received serial casting showed greater gains in DF ROM in the same amount of treatment sessions in comparison to only using other conservative interventions. Pediatric physical therapists should consider early serial casting for children who lack more than seven degrees of DF ROM.
EFFECT OF LOW-INTENSITY LASER THERAPY IN REDUCING KNEE PAINFUL LIMITATION AND GAIT DEVIATIONS IN CHILDREN WITH JUVENILE IDIOPATHIC ARTHRITIS: A RANDOMIZED CONTROLLED TRIAL
Salem Y (Physical Therapy, University of North Texas Health Science Center), Elhamadany M (Brooklyn Clinic, United Cerebral Palsy of NYC)
PURPOSE/HYPOTHESIS: Previous studies have demonstrated beneficial effects of Low-Intensity Laser Therapy (LILT) in reducing pain and improving quality of life in patients with rheumatoid arthritis. As the major emphasis of treatment for JIA is to help the child lead a life that is as normal as possible by controlling JIA signs and symptoms, this study aimed at investigating the effect of LILT on knee pain and swelling, gait parameters and disease activity in children with Juvenile Idiopathic Arthritis (JIA).
NUMBER OF SUBJECTS: Thirty children, 22 girls and 8 boys with polyarticular JIA aged between 7 and 13 years, voluntarily participated in this study. Participants were diagnosed according to the International League of Associations for Rheumatology criteria, and present with knee joint pain, swelling and gait deviations. Participants were randomly assigned into two groups: trial group (n =15) and control group (n = 15).
MATERIALS/METHODS: This study is a parallel-group designed, randomized controlled trial. Children in the trial group received Ga- Al-As diode laser, on the knee joints, with continuous wave, wavelength = 830nm, mean power = 30mW and energy density = 0.1 joules/cm2 with total time = 13.3 minutes per session for 12 successive sessions over a four week period (3/week). Instead, children in the control group were treated using sham laser probe. Kinematic gait parameters were measured using a 10-meter walkway and freeze frame videography. Parameters (such as knee flexion/extension, step length, and cadence) were calculated using custom software. Joint pain was determined by 15-cm Visual Analogue Scales (VAS), joint swelling was determined by the change in the knee joint circumference and disease activity was measured by the erythrocyte sedimentation range (ESR). Baseline and post-intervention values were compared between trail and control group using Student t-test and nonparametric Mann Whitney U test with the continuous data. Chi-square test was used with the categorical data. Yates correction was used instead when the frequency is less than 10. A probability value (p-value) less than 0.05 was considered significant.
RESULTS: children in trial group demonstrated a significant decrease in the knee pain and swelling and in the painful limitation with knee joint movement during midstance, as a result, these increased knee extension and step length and reduced cadence compared with those in control group with a non-significant difference between the two groups in disease activity.
CONCLUSIONS: As a result of its effect reducing knee pain and swelling, LILT enhances knee joint movement during gait and improves the gait parameters in children with JIA.
CLINICAL RELEVANCE: This study provides a degree of certainty for physical therapists to use LILT as a useful adjunct treatment to control joint pain and swelling and to improve gait in children with JIA.
THE EFFECTS OF CARBON FIBER FOOTPLATE ORTHOSES ON 2-D GAIT KINEMATICS OF CHILDREN THAT IDIOPATHICALLY TOE-WALK COMPARED TO TYPICALLY WALKING CHILDREN
Shelton L (Physical Therapy, Elon University), Cunningham H (Physical Therapy, Elon University), Vallabhajosula S (Physical Therapy Education, Elon University), Scales M (Department of Physical Therapy Education, Elon University)
PURPOSE/HYPOTHESIS: Idiopathic toe-walking is a difficult pediatric condition to treat with foot and ankle pain and bony abnormalities being common impairments treated. Orthotic interventions include: serial casting, ankle foot orthoses and more recently though minimally studied, carbon fiber footplate orthotics (CFO). The purpose of this pilot study is to analyze and compare how CFOs alter the temporospatial kinematics of gait in children who idiopathically toe-walk compared to children who walk with a typical gait pattern.
NUMBER OF SUBJECTS: 18; 12 in the typically walking group (TYP) and 6 in the idiopathic toe-walking group (ITW). Participant mean ± SD of ages: TYP 5.8±1.7 years; ITW 5±1.9 years.
MATERIALS/METHODS: Participants completed a minimum of 5 trials on a 16'x4' pressure-sensor-based electronic walkway for 2 conditions, without and with CFOs. A 2-way mixed ANOVA was applied to assess group and condition effects on gait kinematics including: foot contact area (FCA), stride width (SW), stride time (ST), stance %, stride length (SL), and velocity.
RESULTS: FCA was significantly greater for the TYP group compared to the ITW group (TYP: 148.6±8.9 cm2, ITW: 107.9±12.6 cm2; p=.018) across conditions. None of the other measures tested showed significant changes. Significant condition main effects were seen for FCA (No CFO: 122.9±8.3 cm2, CFO: 133.6±8.0 cm2; p=.044), SW (No CFO: 7.7±0.9 cm, CFO: 10.3±0.9 cm; p=.006), ST (No CFO: 0.9±0.03 s, CFO: 0.9±0.04 s; p=.044), Stance % (No CFO: 59.5±0.4, CFO: 60.8±0.4; p=.001). No significant differences were seen for SL (No CFO: 99.2±4.2 cm, CFO: 98.3±4.4 cm; p=.737, and velocity (No CFO: 117.2±4.7 cm/sec, CFO:111.0±5.0 cm/sec; p=.192). There were no significant interactions between groups and conditions.
CONCLUSIONS: Immediate effects of the CFOs resulted in significant increase of FCA, SW, ST, and stance % for both groups. The non-significant differences in the remaining temporospatial kinematics could be due to the application of CFOs for only one session. Irrespective of whether CFOs were applied or not, FCA is significantly decreased in the ITW group. It is noted that FCA for the ITW group increased with CFO use, though no significance was found to indicate that the ITW group with CFOs were more similar to TYP without CFOs.
CLINICAL RELEVANCE: The findings of this pilot study support further research into the effects of CFOs as an alternate treatment option for ITW. CFOs are low-cost, more aesthetically pleasing, and available over-the-counter. This research looks specifically at how this orthotic intervention affects gait kinematics acutely. More research is needed to look at long term wear. Additionally, this study seems to suggest that application of CFOs increase FCA in children with ITW to potentially address foot and ankle pain and mimic a similar gait pattern of typically walking children.
INFLUENCE OF A DUAL-TASK ON PREFRONTAL CORTICAL ACTIVATION IN CHILDREN WITH HEMIPLEGIC CEREBRAL PALSY
Surkar S (Physical Therapy, MMI, University of Nebraska Medical Center), Hoffman R, Kurz M (Physcial Therapy, University of Nebraska Medical Center, Munroe-Meyer Institute), Harbourne R (Physical Therapy, Duquesne University)
PURPOSE/HYPOTHESIS: Dual-task (DT) is defined as simultaneously performing a cognitive and motor task.1 It is known that the competing cognitive-motor resources in DT deteriorates the task performance.2,3 Our prior studies suggest that the reduced task performance in children with hemiplegic cerebral palsy (HCP) is partially related to greater cognitive load imposed for controlling motor actions of the affected arm.4,5 Moreover, such cognitive load is reflected in greater activation in the prefrontal cortex (PFC) during the motor action.4 It is currently unknown how additional challenges of DT burdens the PFC and affects performance of motor task in children with HCP. Therefore, the purpose of this study was to investigate differences in PFC activation while performing a goal-directed motor action on a stable vs. an unstable surface between typically developing (TD) and children with HCP.
NUMBER OF SUBJECTS: 21; 12 TD children (Age=6.0± 1.1 yrs.) and 9 children with HCP (Age=7.2±3.1 yrs., MACS Levels I-III).
MATERIALS/METHODS: We assessed the PFC activation of the participants using functional near infrared spectroscopy (fNIRS) brain imaging. The children performed a sequential-shape matching task in a block paradigm (30 s task and 30 s rest) while sitting on a stable (single task condition) and unstable surface (DT condition). Children with HCP performed the task with their affected hand, while TD children performed the task with their non-dominant hand. The task was repeated four times and the average change in the oxygenated hemoglobin (HbO) was assessed. A larger concentration of HbO indicates greater neural activity. Outcome variables were HbO, total number of shapes matched, and reaction time (RT). Data was analyzed using mixed ANOVA (Group x Single/DT).
RESULTS: There was a significant group by condition interaction for HbO (P=0.001). Post-hoc tests indicated that the children with HCP exhibited greater PFC activation during the single (HPC: 0.24±0.021; TD: 0.04±0.018 μmol; P=0.001) and DT conditions (HCP: 0.53±0.021; TD: 0.11±0.018 μmol; P=0.001). There was a significant group by condition interaction for number of shapes matched (P=0.01). Post-hoc tests indicated reduced task performance in children with HCP for the single (HPC: 48±3; TD: 88±6 shapes; P=0.01) and DT conditions (HCP: 23±3; TD: 61±5 shapes; P=0.01). Moreover, significant group by condition interaction was found for RT (P=0.01). Post-hoc tests indicated a longer RT in children with HCP for the single (HPC: 2.56±0.3; TD: 0.9±0.1 s; P=0.01) and DT conditions (HCP: 3.69±0.5; TD: 1.2±0.1 s; P=0.001).
CONCLUSIONS: Children with HCP had greater PFC neural activity during single and DT conditions compared to TD children. Greater PFC activation was coupled with reduced task performance and slower RT.
CLINICAL RELEVANCE: Children with HCP appear to have a greater cognitive demand while performing DT. This demand potentially further deteriorates the task performance. Clinical assessments and therapeutic interventions should consider the interaction between the cognitive and motor components of children with HCP.
MIXED-METHOD DEVELOPMENT OF THE PROMIS® PEDIATRIC PHYSICAL ACTIVITY ITEM BANKS, CHILD-REPORT AND PARENT-PROXY EDITIONS
Tucker C (Physical Therapy, Temple University), Forrest C (Childrens Hospital of Philadelphia), Bevans K (Rehabilitation Sciences, Temple University)
PURPOSE/HYPOTHESIS: The purpose of this study was to develop the NIH Patient Reported Outcomes Measurement Information System (PROMIS®) Pediatric Physical Activity item banks, child-report and parent-proxy editions.
NUMBER OF SUBJECTS: Item bank calibration was based on national samples totaling 3,033 children 8-17 years old, and 2,336 parents of children 5-17 years old.
MATERIALS/METHODS: We applied the NIH PROMIS mixed-method instrument development process to create child- and parent-proxy physical activity instruments from a previously developed, content valid pool of physical activity item concepts. Each item used a 7-day recall period and had 5 response options. Quantitative analyses included reliability assessments, factor analyses, item response theory (IRT) calibration, differential item functioning, and construct validation.
RESULTS: A final item bank comprised 10 items selected based on content and psychometric properties. The item bank was unidimensional, free from differential item functioning, showed excellent internal consistency and test-retest reliability, and a high degree of precision across the latent variable. Child-report and parent-proxy 4- and 8-item fixed-length instruments were specified. The instruments showed moderate correlation with existing self-report measures of physical activity.
CONCLUSIONS: The PROMIS Pediatric Physical Activity instruments provide precise and valid measurement of children's lived experiences of physical activity.
CLINICAL RELEVANCE: The PROMIS Pediatric Physical Activity instruments are ready for use in clinical practice and research.
ASSESSMENT OF REACTIVE SEATED POSTURAL CONTROL IN CHILDREN WITH TORTICOLLIS: A FEASIBILITY STUDY
Ubben C (Pediatrics, Brooks Rehabilitation), Fernandez J (Brooks Institute of Higher Learning), Walczak S (Brooks Rehabilitation), Lundy M, Aceros J (University of North Florida), Osborne R (Research, Brooks Rehabilitation)
PURPOSE/HYPOTHESIS: Congenital muscular torticollis (CMT) is a musculoskeletal (MSK) deformity, characterized by an ipsilateral head tilt with contralateral rotation, resulting in a muscular imbalance. The Clinical Practice Guidelines (CPG) for torticollis discuss first time interventions, specifically including the development of symmetrical movement, though never specifically discusses postural control development. The purpose of this study is to assess the correlation of the side of torticollis impairment with reactive seated postural control and propose the need for postural control assessment and training in patient with a current or past diagnosis of torticollis.
NUMBER OF SUBJECTS: Four children with torticollis, between the ages of 4 months and 2 years, were enrolled in this study. One typically developing 2-year-old was enrolled as the control, specifically for graph analysis purposes.
MATERIALS/METHODS: Children were seated on a Tekscan pressure mat atop an adapted ride on car. Perturbations in the lateral direction, left and right, were provided on the dynamic surface and center of pressure mapping was recorded for each subject in one trial for each direction. Graph analysis for quantitative measures of displacement was performed. MANOVA and paired samples T-test were performed for data analysis.
RESULTS: A statistically significant difference was found between the side of torticollis and the difference in recovery time between the left and right lateral perturbation. For the two patients with a loss of balance (LOB) during displacement, the side of displacement was the same as the side of torticollis. No correlation was found between side of torticollis and quantitative measurements of reactive postural control.
CONCLUSIONS: Postural control development may be influenced by abnormal proprioceptive input of the neck or abnormal visual and vestibular input from head position, in association with torticollis. It is hypothesized that recovery time, not displacement measurements, may provide the most information on reactive postural control impairments in children with torticollis. Limitations in sample size prevent generalizability of results.
CLINICAL RELEVANCE: This study captures reactive seated postural control impairments in four children with torticollis. This research supports that a correlation may exist between the side of torticollis and recovery time differences between the side of perturbation. The effects of torticollis on postural control has not been assessed in the literature and needs to be assessed for future inclusion in first line interventions of the CPG. The data from this study supports doing more research, necessitating a larger study to assess postural control impairments related to torticollis.