EASE OF CAREGIVING FOR CHILDREN: A MEASURE OF PHYSICAL CAREGIVING FOR PARENTS OF CHILDREN WITH CEREBRAL PALSY
Alghamdi M, Chiarello L, Palisano R (Physical Therapy and Rehabilitation Sciences, Drexel University), Avery L (Avery Information Systems, Orillia, Ontario)
PURPOSE/HYPOTHESIS: The Ease of Caregiving for Children has been validated to measure physical caregiving by parents of children with cerebral palsy (CP) aged 1.5-5 years. The purpose of this study was to re-validate psychometric properties for parents of children with CP up to 11 years of age.
NUMBER OF SUBJECTS: 611 parents of children with CP from two studies (Move and PLAY, n = 407; On Track, n = 204). Children were 1.5-11 years old and 56% were boys. Parents had a mean age of 36 (8.17) years and 90% were mothers.
MATERIALS/METHODS: Parents rated their physical caregiving using Ease of Caregiving for Children at the initial data collection point of both studies. Parents and therapists identified children's level of function using the Gross Motor Function (GMFCS), Manual Ability (MACS), and Communication Function (CFCS) classification systems. Partial Credit Model of the Rasch analysis was used to examine stability and hierarchal ordering of items, (n = 611). Intraclass correlation coefficient (ICC2,1) was used to examine test retest reliability, (n = 55). Three 2-way ANOVAs were used to establish known groups validity by examining effect of child's age, gross motor, manual and communication functions on ease of caregiving, (n = 204). Known groups were child's level of function in GMFCS, MACS, and CFCS (higher functioning: Levels I-II; lower functioning: Levels III-V) and child's age group (younger: 1.5-5.9; older: 6-11-).
RESULTS: Rasch analysis indicated a stable item calibration (ICC = 0.98) and hierarchical ordering by difficulty (logits varied from −0.88 to 0.78) and acceptable fit of items (infit values <2.0). The measure had moderate test retest reliability, ICC = 0.69. No significant interactions were found between child's age and manual or communication function on ease of caregiving, p > 0.05. A significant interaction was found between child's age and gross motor function level on ease of caregiving, p = 0.02. Analysis of simple main effects indicated that parents of older children with higher functions had higher ease of caregiving than parents of younger children with higher functions, p = 0.01. There were significant main effects for child's level of gross motor, manual and communication functions on ease of caregiving, p<0.001, parents of children with higher functioning had higher ease of caregiving scores compared to parents of children with lower functioning. No main effect was found for child's age on ease of caregiving, p > 0.05.
CONCLUSIONS: Findings support reliability and validity of the Ease of Caregiving for Children completed by parents of children with CP 1.5-11 years of age. Rasch analysis supported the unidimensionality of the measure, appropriateness of the rating scale, and logical ordering of items based on difficulty of the tasks.
CLINICAL RELEVANCE: Therapists are encouraged to have parents of children with CP complete the Ease of Caregiving for Children and engage parents in discussion to identity needs and concerns pertinent to physical caregiving, to develop individualized plans of care and to objectively document and monitor physical caregiving.
PROGRESSION OF OBJECT PERMANENCE IN RELATION TO SITTING DEVELOPMENT IN INFANTS WITH MOTOR DELAYS
An M, Harbourne R (Physical Therapy, Duquesne University), Hsu L (University of Washington), Stankus J (Department of Education, Duquesne University)
PURPOSE/HYPOTHESIS: Object permanence as a cognitive construct is thought to be grounded in infants' everyday perceptual-motor experience such as sitting, object interaction, self-mobility. Adequate postural control in sitting allows infants to process visual information and use their hands freely to manipulate objects, which links to understanding of object properties. However, it is not clear how sitting development relates to object permanence in infants with motor delays. The purpose of this study is to examine the progression of object permanence over 6 months as sitting skills advanced in infants with motor delays.
NUMBER OF SUBJECTS: Fifty-six infants with motor delays (mean age = 10.3 months, SD = 2.7) were involved in the study. Infants were recruited between 7-16 months of corrected age if they were able to sit propped on their arms for at least 3 seconds but unable to get in and out of sitting by him/herself.
MATERIALS/METHODS: The Object Permanence Scale (OPS) and the Gross Motor Function Measure-88 Sitting dimension (GMFM-SD) were administered 4 times over 6 months, at baseline, 1.5 months, 3 months and 6 months. The GMFM-88 is a reliable and valid outcome measure designed to evaluate changes in gross motor skills over time. The OPS was developed to measure object permanence from minimal to advanced skills, in which the child has an opportunity to earn a score from 0-10. Items were extracted from studies on the progression of object permanence. The correlations between OPS and GMFM-SD scores were calculated using the Spearman rho statistic. To examine the influence of sitting ability on object permanence progression, infants were divided into 2 groups based on GMFM-SD score at baseline and a mixed analysis of variance (ANOVA) was performed.
RESULTS: The results of Spearman rho statistic showed significant correlations between OPS and GMFM-SD scores with rranging from 0.584 to 0.715 (p < 0.001) at all 4 assessment visits. The results of mixed ANOVA indicated significant main effects of time (F(2.63, 118.50) = 7.23, p < 0.001) and sitting group (F(1, 45) = 22.90, p < 0.001), but no interaction between group and time (F(2.63, 118.50) = 0.38, p > 0.05). The results indicate that the OPS score increased over time in both sitting groups and infants with better sitting skill at baseline showed significantly higher object permanence scores across time.
CONCLUSIONS: Our findings suggest that object permanence of infants with motor delays develops with the improvement of sitting skill. This expands previous research showing the linkage between early motor skills and cognitive development. Infants with limited perceptual-motor experience such as sitting and object interaction are at risk for delays in aspects of cognitive development, including object permanence.
CLINICAL RELEVANCE: Pediatric physical therapists and other early intervention providers should consider the influence of sitting skills on development of object permanence and provide interventions that link motor and cognitive development.
INTERRATER RELIABILITY OF THE PEDIATRIC NEUROMUSCULAR RECOVERY SCALE IN CHILDREN WITH SPINA BIFIDA.
Ardolino E (Physical Therapy, University of St. Augustine for Health Sciences) Flores M (DPT, University of St. Augustine for Health Sciences), Ferreira G, Jeantete S (Doctor of Physical Therapy, University of St. Augustine), Manella K (DPT Program, University of St. Augustine for Health Sciences)
PURPOSE/HYPOTHESIS: There is a paucity of outcome measures to assess the quality of functional mobility in children with spina bifida. The Pediatric Neuromuscular Recovery Scale (Peds NRS) is a valid and reliable outcome measure that was developed to assess the motor capacity of children with spinal cord injury. The purpose of this study was to examine the interrater reliability of the Pediatric Neuromuscular Recovery Scale (Peds NRS) to classify motor capacity in children with myelomeningocele (MMC) form of spina bifida.
NUMBER OF SUBJECTS: Twenty-one children with MMC (1.4- 10 years of age; mean age of 5.3 years) were recruited from clinics and support groups within a 250-mile radius of Austin, TX. Four clinicians, two physical therapists (PTs) and two occupational therapists (OTs) served as the raters for the study. Raters had an average of 14 years of clinical practice and 11 years of pediatric practice.
MATERIALS/METHODS: Each child with MMC was scored on the Peds NRS three times: two live testing sessions and one video recorded session. Every child was scored by two PTs and one OT. Interrater reliability was analyzed using intraclass correlation coefficients (ICC) for individual items and the summary score.
RESULTS: The Peds NRS summary score demonstrated good reliability (ICC = 0.89; 95% CI, .80-.95). For the sixteen individual items, reliability was excellent for items forward reach and grasp (right and left), static stand, and walking (ICC = .919-.969), good for supine to sit, sit inside base of support, sit outside base of support, in-hand manipulation (right), overhead reach (right and left), sit to stand, dynamic stand, and step retraining (ICC = .765-.890) and moderate for in-hand manipulation (left), stand adaptability, step adaptability (.511-.745). None of the items had poor reliability. The summary score had consistent reliability across age categories and groups defined by modified Hoffer level. There was no difference in the summary scores among all raters at F(2,60) = .220, p = .804
CONCLUSIONS: Pediatric clinicians were able to reliably administer and score the Peds NRS on children with MMC, representing a wide range of ages and functional levels.
CLINICAL RELEVANCE: This is the first investigation of the use of the Peds NRS in children with MMC. This study adds to the literature regarding the psychometric properties of the Peds NRS and supports the use of this outcome measure as an instrument to assess motor capacity in children with MMC.
CONGENITAL MUSCULAR TORTICOLLIS AND MOTOR SPEECH DISORDERS: ARE WE RELATED?
Assip B, Passalacqua N (Pediatric Rehabilitation, Hospital for Special Surgery), Gerosa E (The Hospital For Special Surgery)
PURPOSE: The purpose of the project is to explore the relationship between speech motor planning and control deficits and Congenital Muscular Torticollis (CMT) in order to facilitate appropriate multidisciplinary identification and management of at-risk children.
DESCRIPTION: A retrospective case history analysis was performed on the January 2017-January 2018 speech and language caseload at Hospital for Special Surgery to assess the relationship between speech motor planning and control and CMT. Children determined to have speech motor planning deficits were then reviewed to determine if they had a current or past medical diagnosis of CMT for inclusion criterion for the purpose of this research.
SUMMARY OF USE: 20 case examples of children from the ages of 19 months to 6 years from the January 2017-January 2018 speech and language caseload at Hospital for Special Surgery (HSS) were gathered. This sample comprised the caseload at HSS who met the diagnostic criteria for a speech motor planning and control deficit. A retrospective review was conducted and determined the percentage of patients who have a current history or preexisting condition of CMT and age of referral to speech by parent/medical professional. Of those 20 patients, 8 patients had a medical history significant for CMT, based primarily on parent report and/or physical therapy referral. This indicates that 40% of the current caseload at HSS who present with deficits in speech motor planning and control had a diagnosis of CMT. Researchers are continually gathering data on the 2018 caseloads at HSS in order to further corroborate the relationship between motor speech disorders and history of CMT to solidify the necessity of educating physical therapists on appropriate speech motor milestones and potential risk factors for motor speech delays and impairments.
IMPORTANCE TO MEMBERS: The results of this retrospective review of children with speech motor planning and control and history of CMT at HSS promote the need for early speech and language referral and identification of at-risk children. The evidence for early physical therapy intervention for infants with CMT has been proven to have excellent outcomes, results in shorter episodes of care, prevention of secondary sequelae, and optimization on neuroplasticity. Implementing timely and appropriate speech/language intervention is fundamental to facilitate optimization of neural change and patient outcome. The aforementioned correlation renders the question of necessity, timing, and optimization of physical therapy referrals for speech and language evaluations and intervention within the CMT population. Furthermore, it indicates the need for appropriate education for physical therapists to determine appropriate speech motor milestones and potential risk factors for motor speech delays and impairments. The goal of this study is continual assessment of the 2018 caseload at HSS to determine the need for an appropriate screening protocol to identify at-risk children.
EFFECTS OF PLAYSKIN LIFTTM EXOSKELETAL GARMENT INTERVENTION ON REACHING AND OBJECT EXPLORATION OF INFANTS AT RISK
Babik I, Baraldi Cunha A, Lobo M (Physical Therapy, University of Delaware)
PURPOSE/HYPOTHESIS: Infants born preterm and/or with brain injury (PT/BI) often exhibit delays in the development of reaching and object exploration,1-3 increasing their risk of associated delays in cognitive development.4-6 This study evaluated assistive and rehabilitative effects of the novel PlaySkin LiftTM exoskeletal garment on reaching and object exploration in infants at risk.7 It was hypothesized the exoskeletal garment would improve infants' ability within a session when worn (assistive effects) and intervention with the exoskeletal garment would improve infants' independent ability across time (rehabilitative effects).
NUMBER OF SUBJECTS: 10
MATERIALS/METHODS: Ten infants (5 males; 25-40 weeks gestational age, Mean = 32.0, SD = 6.6) born preterm and/or with a brain injury (PT/BI; e.g., grade 4 IVH, encephalophathy, cerebral infarct). Age at the beginning of the study was 2.3 ± 1.3 months. Infants were followed using a longitudinal, multiple baseline, single-case design with a 1-2-month Baseline, 4-month Intervention, and 1-month Post-Intervention Phase. In Baseline and Post-Intervention, the exoskeletal garment was only used during assessments. During the Intervention Phase, parents provided infants with 40 minutes of daily, structured play activity using the PlaySkin LiftTM. Infants were tested biweekly throughout all phases with and without the exoskeleton (ON and OFF conditions) for their ability to reach for and explore toys presented at hip, chest, and eye level (60 sec/level). OpenSHAPA software was used for coding unimanual and bimanual object contacts, visual attention to objects, number of bouts of behavior, and combined/multimodal behaviors. Results were analyzed using multilevel modeling in SAS.
RESULTS: The Playskin LiftTM improved infants' reaching ability, hand orientation for grasp and object exploration, and multimodal object exploration when worn within sessions, especially during the Intervention Phase. The exoskeletal garment also improved independent reaching and object exploration across time during the Intervention Phase with retention of gains in the Post-Intervention Phase.
CONCLUSIONS: The PlaySkin LiftTM improved infants' reaching for objects, hand-eye coordination, and multimodal exploration of objects, which may allow for richer information gathering and enhanced learning outcomes. Positive assistive effects were observed within sessions while wearing the garment; rehabilitative effects were observed with improvements in independent function across time from daily intervention with the exoskeletal garment.
CLINICAL RELEVANCE: The Playskin LiftTM is a soft, easy-to-use, functional exoskeletal garment that may serve as an effective assistive and rehabilitative device to advance early reaching and object exploration for infants at risk for motor and cognitive delays. It may help promote early reaching and object exploration in the first half-year of life when these skills can be challenging for infants at risk but are critical for information gathering to facilitate cognitive development.
A GARMENT FOR FACILITATING USE OF THE AFFECTED HAND AND BIMANUAL HAND-USE IN CHILDREN WITH HEMIPLEGIA
Babik I, Baraldi Cunha A, Lobo M (Physical Therapy, University of Delaware)
PURPOSE/HYPOTHESIS: Unilateral paralysis/paresis may impede bilateral function and result in gross and fine motor impairments, affecting children's participation in daily activities and quality of life.1 The purpose of this exploratory study was to evaluate the effectiveness of the novel Playskin DuoTM (Duo) garment designed to encourage use of the affected hand and bimanual activity for children with hemiplegia. The Duo has the sleeve on the unaffected arm connected to the torso of the garment by elastic hook-and-loop bands, providing variable levels of shoulder and elbow constraint, without restricting manual activity of the preferred hand. Thus, the garment allows for modified constraint induced movement therapy (mCIMT),2-3 but, importantly, still permits bimanual exploration. Children's performance with the Duo was compared to unassisted performance and performance with a puppet (more traditional method of mCIMT). We hypothesized the Playskin DuoTM would: 1) encourage greater use of the affected hand and decrease, but not eliminate, use of the unaffected hand compared to unassisted performance; and 2) facilitate more equal use of both hands and bimanual reaching compared to the puppet.
NUMBER OF SUBJECTS: 2
MATERIALS/METHODS: Two children with hemiplegia due to stroke participated in this study: a 2-year old male with right-sided hemiplegia, and a 2-year old female with left-sided hemiplegia. Each child was tested every 2 weeks for 15 visits. Each visit assessed gross motor activity on the floor (5 min) and fine motor activity at a table (5 min) across three conditions: without a garment (OFF), with the Duo, and with a puppet on the unaffected hand. Hand use and time contacting and manipulating objects were coded using OpenShapa software. Simulation modeling analyses (SMA) were used to test the aforementioned study hypotheses.
RESULTS: Both the Duo and puppet dramatically decreased use of the unaffected hand and increased use of the affected hand during gross and fine motor activities. With the Duo, children shifted towards predominantly using the affected hand in gross motor activities and showed more equal engagement of both hands in fine motor activities. This more equal use of the hands was not observed with the puppet. With the Duo, bimanual reaching was not impeded in gross motor activities and was noticeably facilitated in fine motor activities. Only minimal amounts of bimanual reaching were observed in the puppet condition.
CONCLUSIONS: The Playskin DuoTM may encourage use of the affected hand, while still allowing functional reaching and object manipulation with the unaffected hand.
CLINICAL RELEVANCE: These data suggest that garments like the Playskin DuoTM may provide an affordable tool for rehabilitation for clients with hemiplegia/hemiparesis. They may encourage use of the affected arm as well as bimanual function. In contrast to more traditional methods of mCIMT,4-5 the Playskin DuoTM may provide an affordable means for intervention in the natural environment without impeding hand function.
PROMOTING PARTICIPATION THROUGH SCHOOL AND COMMUNITY COLLABORATIONS
Bader T, Kerfeld C (Special Education Department, Seattle Public Schools)
PURPOSE: Participation is an important outcome of school-based physical therapy practice. The International Classification of Functioning, Disability and Health defines participation as “involvement in life situations” and an essential aspect of child physical, emotional, and social well-being. Through participation in leisure, recreational, and sport activities, children learn to communicate and get along with others; build friendships; and develop skills and competencies they need to become successful in their home, school, and communities. The purpose of this special interest report is to describe a school and community collaboration that provides an opportunity for children with disabilities to participate in their school bike and pedestrian curriculum.
DESCRIPTION: The Let's Go program successfully promotes and supports participation in the Seattle Public Schools (SPS), in Seattle, Washington. Let's Go, part of the physical education (PE) elementary curriculum for 3rd–5th grade students, is a 3-week bike and pedestrian unit with comprehensive lessons on pedestrian and biking skills and safety. Through partnerships with Cascade Bicycle Club and Outdoors for All, SPS is providing an equitable PE program that is inclusive to all students, regardless of their previous experience, economic background, or abilities. The curriculum is limited to specific grades to stay consistent and use SPS capacity and resources appropriately. School-based physical therapists (PT) plan their service time to assist with implementing this program.
SUMMARY OF USE: The Let's Go program has shown tremendous growth in two years. During the inaugural years, 2016-2017, three schools implemented the curriculum. This past year, during a whole district role out, twenty-seven schools participated in the program. One hundred and nine students with disabilities participated with ninety-one needing adaptive bikes. Fourteen schools required direct support that included but was not limited to lesson support with the PE teacher and student, PT related services, and adaptive bike fittings. Thirteen schools did not require support. The teachers were confident and comfortable with their lesson teaching abilities with all students on standard and adaptive bikes. The school district adaptive PE instructor provided five trainings for PTs, PE teachers and other school supportive staff.
IMPORTANCE TO MEMBERS: Children with disabilities can be more restricted in their participation compared to children without disabilities. This special interest report provides a case example that models how collaborations between schools and community programs is key to promoting and supporting the participation of children with disabilities. The Let's Go program encourages children and their families, PTs, adaptive PE instructors, teachers and community programs to work collaboratively to develop strategies for optimizing the participation of children with disabilities with the goal of improving their overall health and well-being.
THE RELATIONSHIP BETWEEN REACHING FREQUENCY, MOTOR SKILL DEVELOPMENT, AND ACTIVITIES OF DAILY LIVING FOR INFANTS WITH MODERATE TO SEVERE CEREBRAL PALSY
Barbosa G, Bican R (Division of Physical Therapy, School of Health and Rehabilitation and Sciences, The Ohio State University), Heathcock J (The Ohio State University)
PURPOSE/HYPOTHESIS: Purpose/Hypothesis: Cerebral palsy (CP) is a common condition that can severely affect children physically, cognitively, and socially. Motor skills are compromised, making it difficult for the child to perform daily life activities. Reaching, a motor skill required for maximal interaction with the environment and object manipulation, is often affected. The purpose of this study was to describe frequency of reaching and investigate the relationship between reaching frequency, motor development, and ability to participate in and complete activities of daily living (ADLS) in infants with moderate to severe CP.
NUMBER OF SUBJECTS: 23
MATERIALS/METHODS: Infants with CP in GMFCS levels III, IV, V, aged 6-24 months corrected age, participated in this study. These infants were a cohort of a larger randomized control clinical trial. Infants were seated in a standard chair and presented with four different toys (ball, maraca, handle and glow wand) for 2 trials of 30 seconds. Each toy was presented in a random sequence at the infant's midline, shoulder height, and within arm's length. The sessions were video recorded. Behavioral reaching measures were coded using Datavyu, a behavioral coding software. Fine and gross motor skills were assessed using the Bayley Scales of Infant Developmental-III (Bayley III), fine (FM) and gross motor (GM) subtests. Functional capabilities and performance of ADLS were measures using the Pediatric Evaluation of Disability Inventory (PEDI), a parent-report outcome measure. The frequency of reaching was compared to motor development and functional capabilities, as measured by the clinical outcome assessment tools. Regression analysis was completed using IBM SPSS 24.
RESULTS: The average total number of reaches for infants in GMFCS level III was 41.4 ± 24; for level IV was 21.2 ± 22.3; and for level V was 3.7 ± 5.7. Reaching frequency had a significant, strong, and positive relationship with the Bayley combined FM and GM (r = .647, p = <.001, F = 17.5), the Bayley FM (r = .662, p = .001, F = 16.4), and Bayley GM (r = .621, p = .001, F = 13.9). Reaching frequency also had a significant, moderate, and positive relationship with the child's functional capabilities in ADLS (r = .502, p = .02, F = 6.73).
CONCLUSIONS: Conclusions: Infants who had more severe CP had lower reaching frequencies, lower motor scores, and decreased ability to participate in ADLS. In general, infants with higher GMFCS levels, or more severe CP, had less ability and opportunity to meaningfully interact with and explore their environment. This study shows frequency of reaching is a strong indicator of motor function and ADL participation, as measured by common clinical outcome measures.
CLINICAL RELEVANCE: Clinical Relevance: These results suggest an importance of therapeutic interventions that increase opportunities for purposeful reaching to promote motor skill development and maximize independence.
A 3D PRINTED INSERT FOR AN OFF-THE-SHELF BOOSTER SEAT ADDRESSES PARENTS' CONCERNS ABOUT CURRENT SEATING ISSUES
Barrett H, Fiscella M, Hensiek R, Illing M, Sadiq M, Trenkle J, Admani S, Krosschell K (Department of Physical Therapy and Human Movement Sciences and Department of Pediatrics, Northwestern University Feinberg School of Medicine)
PURPOSE/HYPOTHESIS: To describe the technique used to produce a 3D printed seating insert for an off-the-shelf child booster seat to supplement traditional and/or specialized seating for children with low muscle tone, and to explore parents' attitudes about impact on function and participation. Feasibility of production and customizability are described.
NUMBER OF SUBJECTS: 5 parents in focus group, 1 subject/parent dyad for testing prototype.
MATERIALS/METHODS: A CAD drawing was developed using a child with low muscle tone as a model to produce a 3D printed insert for an off-the-shelf child booster seat. This child used the prototype for 4 weeks. Parents completed a weekly survey. Two focus groups explored parents' attitudes toward their child's current seating, ideal seating, and the 3D printed prototype. Focus group transcripts were coded using Dedoose software. Cost and time to complete the insert were calculated to determine feasibility of production.
RESULTS: 3D printing of final insert took 6.2 days using an Ultimaker-2 printer, with estimated cost of $59. Analysis of focus groups comments revealed the most prevalent themes in regards to parent satisfaction. Current seating: multiple uses (88.9% pros, 11.1% cons), impact on participation (50% pros, 50% cons), portability (25% pros, 75% cons), postural alignment (19% pros, 81% cons), safety (15.4% pros, 84.6% cons), child preferences (11.8% pros, 88.2% cons), and ease of use (0% pros, 100% cons). 3D printed seating: impact on participation (100% pros, 0% cons), customizability (100% pros, 0% cons), cost (100% pros, 0% cons), time to delivery (100% pros, 0% cons), material (17% pros, 83% cons), aesthetics (0% pros, 100% cons), and safety (0% pros, 100% cons). During the 4-week individual user trial of the insert, parent reported it improved child participation in family activities, such as playing and eating at the table. Parent reported an average of 5 uses/week and 20.3 mins/use. Safety and aesthetic concerns were not reported.
CONCLUSIONS: Parents identified impact on participation, portability, ease of use, and time to delivery as unmet needs of current seating that could be addressed by the insert. While attitudes towards the 3D insert varied, most agreed that 3D printing could provide a customizable, portable option for their child's seating needs. The individual user tolerated the insert well for feeding and playing, which were previously identified as unmet needs of his current seating. Future research should include multiple users, longer trial periods, and larger focus groups to better determine feasibility of using this process in the clinical setting.
CLINICAL RELEVANCE: 3D printed seating for children with low muscle tone may be a cost-effective, portable, and customizable alternative to traditional seating. Time to delivery for the 3D printed insert is significantly less than most adaptive seating options. Print time and cost considerations are impacted by design, type of 3D printer, filament and other materials.
EARLY MOBILIZATION OF PEDIATRIC PATIENTS ON EXTRACORPOREAL MEMBRANE OXYGENATION (ECMO) IN A PEDIATRIC INTENSIVE CARE UNIT
Biagioni J, Griego B, Lowry K, Herbers-Sanger M, DeAlmeida M (Children's Healthcare of Atlanta)
BACKGROUND & PURPOSE: Early mobilization of critically ill patients has been shown in the literature to reduce intensive care unit (ICU) acquired weakness, decrease prevalence of delirium, improve functional outcomes at discharge, and decrease ICU and hospital length of stay. Mobilizing patients on ECMO involves an increased risk due to the fragile state of the patient and the tenuous position of the cannulas. There is very limited research on mobilizing pediatric ECMO patients specifically. The purpose of this case description is to highlight our experience in mobilizing critically ill pediatric patients on ECMO.
CASE DESCRIPTION: Between January 2014 and March 2018, 67 patients were cannulated for ECMO (VV or VA) in a 36 bed pediatric intensive care unit (PICU). Of these, 47 patients were evaluated by physical therapy (PT) while cannulated. All patients received at least passive range of motion and foot splints as needed. Thirteen patients were awake and able to participate in active assisted range of motion during PT sessions. Fourteen patients were deemed appropriate for further mobilization by the medical team. Of these, 8 patients were mobilized to the upright sitting positon by raising the head of the bed, 6 were assisted into long sitting in bed, 4 patients sat on the edge of the bed, and 1 patient stood up by the edge of the bed. Of the 6 patients mobilized to at least long sitting, 5 patients had an Avalon Bi-Caval Dual Lumen Cannula making mobilization more feasible. One patient with a conventional femoral cannula safely pedaled a supine bike. The internal jugular cannula was secured with Coban when needed and managed by the ECMO primer throughout the session. Team members present in the room during early mobility sessions included a physical therapist, occupational therapist, respiratory therapist, an ECMO technician and the ECMO primer. A pre-mobility checklist was utilized to ensure all team members understood their role and patient safety was prioritized. The type of mobility performed was individualized for every patient based on medical stability and their tolerance for activity.
OUTCOMES: There were no adverse events during early mobility sessions, defined by unplanned extubations, dislodgement of cannulas, disconnection of lines or tubes, or hemodynamic instability. All patients tolerated mobility well without a significant change in their vital signs or change in the flow of the ECMO circuit, as monitored by the ECMO technician throughout.
DISCUSSION: More research is needed to standardize practice for mobilizing pediatric ECMO patients but it should be considered, as it can be safe and feasible on the appropriate patient. A multidisciplinary team approach is needed to ensure the safety of the patient is prioritized.
THE RELATIONSHIP BETWEEN KINEMATICS OF THE UPPER EXTREMITY AND MOTOR DEVELOPMENT: AN EXPLORATORY STUDY
Bican R (The Ohio State University), McNally M (School of Health and Rehabilitation Sciences, Ohio State University), Heathcock J (Ohio State University), Lowes L, Alfano L (Nationwide Children's Hospital)
PURPOSE/HYPOTHESIS: Kinematic analysis is a commonly used method to study upper extremity movement in developing infants and children. This method of analysis provides insight on temporal (frequency, speed) and spatial (length) components of movement and how they may change over time. However to our knowledge, there have been no studies that investigate how these underlying movements influence the development of motor skills as measured through clinical outcome tools. The Bayley Scales of Infant and Motor Development, 3rd Edition (Bayley) and the Alberta Infant Motor Scale (AIMS) are commonly used outcome measures to evaluate motor development in the clinic. The purpose of this study was to investigate the relationship between upper extremity movement, as measured by kinematic analysis, and motor skill development, as measured by the Bayley and the AIMS.
NUMBER OF SUBJECTS: N = 188 total trials, 12 healthy infants (3-7 months) participated in this longitudinal, prospective study.
MATERIALS/METHODS: Participants were seen 2-4 study sessions. Passive markers were placed on the infant's hands and movement was recorded in supine with a 10-camera Vicon Nexus 3D motion capture at 120 Hz for 6 to 12, 30-second trials. Temporal variables included movements per minute, average movement speed, and peak velocity. Spatial variables included movement length, movement displacement, and arc length. The gross motor (GM) and fine motor (FM) subtests of the Bayley and the AIMS were completed.
RESULTS: Multiple linear regression analyses were performed to investigate the relationship between upper extremity kinematics and the Bayley and AIMS. Age was included as a covariate in all models. FM score: significantly predicted by all temporal variables (mov/min, p = .038; avg mov speed, p = .023; peak v, p = .035). GM score: significantly predicted by all spatial variables (mov disp, p = .036; mov length, p = .010; arc length, p = .048). Bayley Combined score: not significantly predicted by any variables. AIMS score: significantly predicted by the spatial variable arc length (p = .005).
CONCLUSIONS: This study provides insight on how spatiotemporal kinematics of the upper extremity relate to clinical assessment tools used to describe motor development. Improved GM score was significantly associated with smaller movement displacement, larger movement length, and smaller arc length. Improved FM score was significantly associated with decreased number of movements/minute, increased average movement speed, and decreased peak velocity.
CLINICAL RELEVANCE: The results of this study can be used to help target interventions designed to improve upper extremity function. Our study suggests that training could focus on temporal kinematics to improve FM skills and spatial kinematics to improve GM skills. Further testing of the effect of targeted training based on the results from this study may also be warranted. For example, assessing changes in FM skills following an intervention targeting speed and frequency of movement and changes in GM skills following an intervention targeting distance of movement.
DESCRIBING THE FUNCTIONAL RECOVERY OF AN ADOLESCENT FOLLOWING A CEREBELLAR ARTERIOVENOUS MALFORMATION (AVM) HEMORRHAGE USING THE INTERNATIONAL CLASSIFICATION OF FUNCTIONING, DISABILITY AND HEALTH (ICF) FRAMEWORK
Bloyer M, Brave M, Shannon M, Vitolo C (Physical Therapy, University of Miami)
BACKGROUND & PURPOSE: Cerebellar AVMs represent less than 15% of brain AVMs. Despite its rarity, the risk of hemorrhage with this lesion is particularly high. The significantly increased risk for hemorrhage results in greater neurological deficits before and after surgical intervention, necessitating more aggressive medical and rehabilitative management. Currently there is lack of literature describing outcomes following physical therapy treatment post-AVM rupture in adolescents. The purpose of this case report is to describe the functional recovery and outcomes of an adolescent female following physical therapy (PT) interventions post cerebellar AVM hemorrhage. The importance of the contextual factors (environmental and personal) of the ICF framework was a focus on enhancing her ability to participate in desired activities and return to her role as a college student.
CASE DESCRIPTION: A 19-year-old female, of Venezuelan origin, with a diagnosis of AVM of the left deep cerebellum, status post hemorrhage and repair with confounding vitreous hemorrhage (Terson Syndrome) of both eyes, was referred for outpatient physical therapy services. Interventions during therapies addressed impairments in balance, coordination, motor control and activities of daily living (ADLs). The patient's long-term goals were to ambulate independently without an assistive device, negotiate stairs, wear high-heeled shoes and return to college.
OUTCOMES: The patient was reexamined monthly for the first 6 months following the initial evaluation, and periodically afterwards. Data was collected from physical performance measures administered by her physical therapist during outpatient therapy visits. Outcome measures included: Berg Balance Scale (BBS), Timed Up and Go (TUG), Dynamic Gait Index (DGI), Mini-BESTest (shortened Balance Evaluation Systems Test), Functional Reach, and Modified Clinical Test of Sensory Interaction in Balance (mCTSIB). A reduction in dependence and assistance required was demonstrated by the patient's gradual transition to being able to perform all measures without an assistive device. Balance and mobility using the Sensory Organization Test (SOT) were examined and the 36-Item Short Form Survey (SF-36) questionnaire was completed at various time points throughout her recovery. Marked improvements were noted at discontinuation of outpatient physical therapy services and during follow up interview one year later after returning to college.
DISCUSSION: This case demonstrates the use of the ICF framework and the contextual factors that influenced this adolescent's ability to return to college and achieve pertinent goals as a young adolescent female. Contextual factors that contributed to her recovery include socioeconomic status, family support, motivation and age.
LONG-TERM FUNCTIONAL OUTCOMES IN PATIENTS WITH CEREBRAL PALSY POST SELECTIVE DORSAL RHIZOTOMY: A SYSTEMATIC REVIEW
Brumfield K, Anderson C, Cannon K, Slaughter J (Physical Therapy, University of Mississippi Medical Center)
PURPOSE/HYPOTHESIS: The long-term effects of Selective Dorsal Rhizotomy (SDR) remain unclear. The aim of this systematic review was to evaluate the long-term effects of SDR on functional outcomes in children with cerebral palsy.
NUMBER OF SUBJECTS: 235
MATERIALS/METHODS: PubMed and Embase databases were searched in November 2017 using terms associated with rhizotomy, cerebral palsy, and activities of daily living. Inclusion criteria consisted of all study designs containing participants diagnosed with CP who underwent SDR at lumbar or sacral levels on or before the age of 16 and the use of the Pediatric Evaluation of Disability Inventory (PEDI) as a functional outcome measure at least 12 months post-operatively. Articles were excluded if they were not available in full text. A stepwise selection procedure was used to identify the relevant research for inclusion. Risk of bias was assessed with the Joanna Briggs Institute checklist.
RESULTS: After performing the electronic search, six articles remained for review. In general, whole group scores after SDR in the self-care and mobility domains of the PEDI showed statistically significant improvement through 5 years postoperatively, compared to baseline values. PEDI scores were maintained in all GMFCS levels through 10 years. Changes in GMFCS levels from baseline were sparse. Functional improvements were most notably observed within the first 5 years in Levels I, II, and III and no trends toward functional decline in adolescence were noted. Four of the six studies also used the GMFM-66 and/or GMFM-88 to evaluate the change in gross motor function over time. GMFM total score changes were statistically significant from baseline through 10 years for GMFCS levels I-III and maintained through adolescence for GMFCS levels IV-V.
CONCLUSIONS: If SDR is performed on well-selected children before severe orthopedic deformities have developed, it has the potential to increase functional independence particularly in GMFCS levels I-III through 10 years post-operatively and protect against the functional decline in adolescence typically seen in GMFM levels III-V.
CLINICAL RELEVANCE: SDR has been shown to increase functional independence in GMFCS levels I-III and stabilze functional skills in levels III-V through 10 years post operatively. Additional studies with robust numbers of participants completing long term post operative follow up are needed to validate the data regarding functional outcomes.
PHYSICAL THERAPY INTERVENTIONS FOR AN ADOLESCENT AFTER PERIACETABULAR OSTEOTOMY AND LABRAL REPAIR SURGERY: A CASE REPORT
Buck K, Laslovich J, Edwards A (Physical Therapy, University of St. Augustine for Health Sciences)
BACKGROUND & PURPOSE: Periacetabular osteotomy (PAO) and labral repair are effective surgeries for adolescents with acquired hip dysplasia to improve the stability of the hip and reduce pain. PAO promotes hip preservation in skeletally mature adolescents with the hopes of delaying osteoarthritis and early total hip replacement (THR). The purpose of this case report was to investigate the importance and effectiveness of physical therapy (PT) in helping an adolescent return to participating in activities like horseback riding and marching band after PAO and labral repair surgeries.
CASE DESCRIPTION: The patient was a 17 year-old female senior in high school. She was diagnosed with bilateral acquired hip dysplasia and a right labral tear. She experienced pain for seven years which limited her participation in marching band and horseback riding for years prior to surgery. The patient underwent a right PAO and labral repair surgery and began PT at week six status post surgery. The patient completed a total of seven PT visits over the course of seven weeks. The plan of care and goals were designed to improve strength and motor control throughout the lower extremity (LE) and core musculature. Interventions were performed bilaterally to promote symmetry and reduce the risk of degenerative changes. Interventions included those to challenge static and dynamic balance as well as gait training with visual and verbal cuing to reduce compensation and improve pelvic rotation throughout swing phase.
OUTCOMES: The patient demonstrated improvement in all outcome measures at discharge. She rated pain 0/10 on the Numeric Rating Scale for Pain. Single Assessment Numerical Evaluation increased by 30%, 9.5% minimal clinically important difference (MCID)1 and Lower Extremity Functional Scale increased by 32 points, 9 points MCID2. Her quality of gait improved with good lumbopelvic dissociation and symmetrical step length. Single leg stance time on an unstable surface and dynamic balance also improved. Her improved balance and core strength allowed her to progress to marching on a grass field, but she was unable to carry the added weight of her bari saxophone during the activity. At the time of discharge, the patient was able to ride her horse due to restoration of hip mobility and improved LE strength in internal rotation and adduction, important for maintaining control of the horse.
DISCUSSION: Adolescents who undergo THR have a significantly high revision rate because the THR does not preserve the biological components of the hip. PAO provides an alternative treatment with hip preservation for patients with significant functional limitations due to hip pain and dysplasia; however patients often have a multitude of impairments post-operatively and may have contralateral dysplasia. Comprehensive PT post-operatively through restoration of prior level of function is critical in promoting stability and mobility throughout the kinetic chain to reduce the risk of early joint degeneration and delay THR in the adolescent population.
RECOVERY AFTER CARDIAC ARREST AND HYPOXIC BRAIN INJURY IN A PREVIOUSLY HEALTHY 15-YEAR-OLD MALE
Bulgarelli R (Physical Therapy, University of Chicago)
BACKGROUND & PURPOSE: Cardiac arrest is rare but lethal in adolescents: less than 10% of adolescents who undergo cardiac arrest will survive. Initial heart rhythm, first responder arrival time, age greater than 14, and on-scene intubation are associated with increased survival rate. Less is known, however, about recovery following cardiac arrest in the pediatric population. The purpose of this case is to describe recovery after cardiac arrest in a child with anoxic brain injury.
CASE DESCRIPTION: Patient was a 15-year-old male who collapsed while playing basketball and was diagnosed with myocarditis upon arrival at the hospital by EMS. Neurological evaluation demonstrated present pupillary light and vestibulo-ocular reflexes, no response to painful stimulus, and repetitive myoclonic movements necessitating pharmacological paralysis and sedation, with unremarkable head CT and MRI and EEG readings concerning for comatose state. Sedation wean began 7 days post-arrest, and withdrawal from painful stimulus was noted the next day. Physical therapy was initiated on day-12, and patient was noted to have decorticate posturing and scored a 6 on the Boston AMPAC Mobility sub-scale. 23 days post-arrest the patient was extubated. Frequency of physical therapy was increased to daily at this time due to his increased tolerance for activity. Interventions at this time focused on balance, transfers, mobility, and command following. After a 44-day hospital course, the patient was discharged to inpatient rehab.
OUTCOMES: Boston AMPAC, 5 times sit to stand, command following, and FIM scores were tracked throughout his hospital course. The patient followed simple commands day 24 post-arrest and followed multi-step commands on day 30. He stood with max assist on day 26 and walked for the first time on day 30 post-arrest. He walked with min assist 36 days post-arrest. On day 43 post-arrest, his Boston AMPAC Mobility score was 21. He walked and negotiated stairs with supervision, spoke in short phrases, and interacted with his family. The next day, he was discharged to inpatient rehab.
DISCUSSION: The child described in this case had a significant functional recovery following cardiac arrest and hypoxic injury. The indicators of prognosis were mixed, with positive signs including pupillary light and vestibulo-ocular reflexes and unremarkable MRI and CT. Negative indicators included lack of response to painful stimulus, persistent myoclonic activity, and EEG results. Sedation may have affected the ability of the medical team to evaluate and prognosticate. The patient's functional progress was significant and occurred in a short time span: after spending 23 days intubated with minimal signs of neurological recovery, he progressed from AMPAC score 6 to 21 in the 21 days following extubation. In conclusion, significant functional recovery is possible within weeks after cardiac arrest and hypoxic brain injury. Clinicians may consider medical and functional predictors when designing plans for those with brain injury.
CAN CLINICAL ASSESSMENT DATA IDENTIFY POSSIBLE EARLY SIGNS OF AUTISM IN HIGH-RISK NEONATES?
Carey H, Kelly N, Baldino M, Ratliff-Schaub K (The Nisonger Center, The Ohio State University), Tanner K (Nationwide Childrens Hospital)
PURPOSE/HYPOTHESIS: Routine developmental assessments for high-risk neonates may play a role in identifying children at risk for Autism Spectrum Disorder (ASD), especially considering suspected increased risk for ASD in preterm infants. While early identification of ASD is critical for early intervention, specific early behaviors predictive of a later diagnosis of ASD are not well documented. As monitoring of developmental skills over time is common practice for preterm infants, we aimed to assess if clinical data offered a means to identify early manifestations of ASD behavior by evaluating this data across multiple developmental domains for high-risk premature infants who were later diagnosed with ASD.
NUMBER OF SUBJECTS: This study included 144 infants (gestational age <37 weeks) identified through a neonatal follow-up clinic, 72 of which were later diagnosed with ASD and 72 sex- and gestational age-matched controls.
MATERIALS/METHODS: We completed a retrospective EMR chart review of clinical data from 2009 to 2016 to record scores from the Test of Infant Motor Performance (TIMP; 3-4 months) and Bayley Scales of Infant and Toddler Development, 3rd ed. (Bayley-3; 8-14 months and 20-26 months). Summary statistics were calculated, in addition to within- and between-group comparisons (ASD vs control) using two-sample t-tests, Fisher's exact test, and paired t-tests.
RESULTS: Between-group comparisons indicated no significant group difference in TIMP scores. The ASD group had significantly lower scaled and raw Bayley scores for most subscales at both time points (p<.05), however, mean scaled scores were within the average range for both groups at the first time point. Results of the within-group comparisons indicated that the ASD group had significantly lower Bayley-3 scaled scores at 20-26 months (as compared to 8-14 months) for all subscales (p<.05); scores were in the below average range for all subscales at this second time point. The control group also had significantly lower Bayley-3 scaled scores at 20-26 months (as compared to 8-14 months) for all subscales (p<.05), however, the decrease in some Bayley-3 scaled scores between time points was significantly larger for the ASD group (p<.05).
CONCLUSIONS: The results of this study indicate that, although there are similarities in early development between high-risk neonates who were later diagnosed with ASD and those who were not, there are clinically and statistically significant differences seen at 2 years. Infants who are later diagnosed with ASD may exhibit a more precipitous drop in Bayley-3 scaled scores in the first 2 years of life in comparison to those without ASD. Additionally, early gross motor delay was not associated with a later diagnosis of ASD.
CLINICAL RELEVANCE: This study highlights the importance of long-term, comprehensive developmental follow-up for high-risk neonates at risk of ASD, especially between 18-24 months of age. Further research is needed to develop early, comprehensive clinical screening tools for ASD.
MOVEMENT TIME AS AN ASSESSMENT OF DOSING DURING ROBOTIC REHABILITATION IN CHILDREN WITH HEMIPLEGIC CEREBRAL PALSY
Cardinal R (Department of Physical Therapy, Indiana University), Massie C (Occupational Therapy, Indiana University), Altenburger P (Physical Therapy, Indiana University)
PURPOSE/HYPOTHESIS: To maximize the impact of rehabilitation robotics (RR) on functional improvement, appropriately dosed interventions must be developed. The inherent characteristics of RR: intensive, repetitive training are a potentially powerful adjunct to traditional rehabilitation. RR research in pediatrics has shown promise; however, questions regarding repetitions, duration, frequency, and timing remain. In this study, we utilized kinematic data collected throughout training to identify the response of pediatric patients to RR. We sought to identify appropriate dosing by analyzing the response to RR across days and within single treatment days.
NUMBER OF SUBJECTS: 21
MATERIALS/METHODS: Children with a diagnosis of hemiplegic CP (age 4-11) completed 16 sessions of RR (2 x week; 8 weeks) with a total of 1,024 repetitions per session on the MIT-Manus Shoulder-Elbow robot. Training was divided into 3 treatment blocks of 320 repetitions and 4 assessments of 16 repetitions each; during which, planar reaching tasks were completed. In addition, subjects completed pre-, post-, and 6-month follow-up assessments. During each assessment and within each intervention, subjects completed “one-way records” which tracked performance on a planar task without robot assistance. Movement times from these records were extracted to assess performance. Average movement time over the course of sessions and the differences in movement time between individual days and blocks of treatment were calculated for comparison.
RESULTS: Overall, movement time decreased significantly for all participants from pre-test to post-test (-1.25s, p = .001) and from pre-test to follow-up (-.76s, p = .02). Significant movement time differences were found between the three blocks of intervention within individual days (p = .001). Specifically, significant differences were found between the last two one-way records each day which corresponded to the last block of treatment (p = .032) and the first one-way record and last one-way record of the previous day (p = .001). No main effect was found for changes in movement time over treatment days.
CONCLUSIONS: All children participating in RR improved their movement time indicating improved motor performance that was corroborated by the parents. Children's improved motor performance trended upward throughout the protocol despite the high number of repetitions and cognitive demand. This finding suggests previous studies may have been inadequately dosed to recognize the maximal benefits of RR; not only are children able to complete 1,024 repetitions, additional repetitions may have produced an increased motor response.
CLINICAL RELEVANCE: RR is becoming a more widely used approach within rehabilitation, including pediatrics. Children in this study benefitted from a high volume of repetitions as evident by their improved motor performance over the course of a single session. Even higher amounts of repetitions may be more beneficial, which further illustrates the need to continue to assess the amount of practice necessary to produce change in pediatric patients.
FUNCTIONAL MOBILITY THROUGH TREADMILL TRAINING AND OVERGROUND WALKING IN A CHILD WITH GMFCS LEVEL IV SPASTIC DIPLEGIC CEREBRAL PALSY: A CASE REPORT
Cates L, Messerschmidt E, DiBiasio P (Physical Therapy Education, Elon University)
BACKGROUND & PURPOSE: Children with cerebral palsy (CP) experience altered or delayed neuromotor development, depending on the severity of the condition, which often affects locomotion. Early gait training has been shown to enhance cognitive skill development as it increases the ability to explore one's environment. Treadmill training has been shown to be effective to improve parameters of gait in children with CP with GMFCS levels I-III. The purpose of this case report is to describe the effect of treadmill and overground ambulation training in a non-ambulatory 3.6 year old child with spastic diplegic CP GMFCS level IV. The hypothesis was that intensive physical therapy (PT) focused on ambulation and trunk control would result in improved parameters of gait and function, possibly reclassify the patient to GMFCS III.
CASE DESCRIPTION: The patient was a 3 years 8 months old boy who received outpatient physical and occupational therapy 1x/week. The patient presented with increased lower extremity and trunk extensor tone, weakness in bilateral lower extremities, and involvement of bilateral upper extremities. Prior to intensive PT he ambulated max assist up to 10 feet. He participated in intensive PT 2x/week for 5 weeks. Intervention focused on treadmill and over-ground ambulation, trunk strengthening, and postural control. Outcome measures included treadmill time, distance ambulated over-ground, Gross Motor Function Measure (GMFM-88) dimensions C and D, Pediatric Evaluation of Disability Inventory (PEDI), and Child Engagement in Daily Life (CEDL).
OUTCOMES: Total treadmill time improved from 2 to 5 minutes and distance ambulated over ground improved from 10 to 60 feet, with a reduction from max to moderate assistance with upper extremity support. GMFM-88: dimension C decreased from 47.6% to 42.86%, and dimension D remained at 7.7%. PEDI: mobility domain remained at 14, mobility caregiver assistance/modification remained at 6, and self-care caregiver assistance/modification increased from 13 to 14. CEDL: frequency of participation in family/recreational activities decreased from 60.9% to 56.6%, frequency of participation in self-care activities increased from 49.6% to 57.1%, and enjoyment of participation in family/recreational activities decreased from 87% to 78%.
DISCUSSION: Treadmill and over-ground training positively impacted functional mobility in this patient in regards to duration and distance ambulated. While no significant differences were noted in standardized tests, intervention over a longer period of time may have resulted in notable changes. Treadmill and over-ground gait training may be beneficial in improving functional mobility in children with spastic diplegic CP who are non-ambulatory and may promote in-home ambulation skills. Further research is needed to determine if a longer intervention period would result in functional improvements on the GMFM impacting GMFCS level.
VALIDITY AND USEFULNESS OF THE ECOLOGICAL ASSESSMENT OF PARTICIPATION
Chiarello L, Palisano R (Physical Therapy & Rehabilitation Sciences, Drexel University), Vanska N, Sipari S (Helsinki Metropolia University of Applied Sciences, Helsinki, FINLAND)
PURPOSE/HYPOTHESIS: The Ecological Assessment was developed based on the premise that achievement of child and family goals for participation is optimized through a collaborative process in which information is shared, solutions are identified, and interventions build on strengths of the child, family, and community. The purpose of this study was to evaluate construct validity, content validity, and usefulness of the Ecological Assessment of Participation.
NUMBER OF SUBJECTS: 35 therapists, 11 parents, and 10 children participated.
MATERIALS/METHODS: The Ecological Assessment of Participation is a tool to identify the strengths and needs of a child, family, and environment and to develop an action plan specific to a child's goal for participation. The tool consists of 8 attributes of the child, 6 of the family, and 4 of the environment along with sample questions to guide discussion of the determinants of the participation goal and action plan for achieving the goal. Two Nominal Group Consensus Processes were conducted. Following discussion, participants rated the importance of each Child, Family, and Environment attribute, clarity of wording, and the importance and usefulness of the assessment on a five-point ordinal scale. Ten therapists reviewed the tool for clarity. Ten parent/child/therapist triads completed the Ecological Assessment and parents and therapists provided written feedback. Feedback questionnaires were coded to identify meaning units.
RESULTS: Ratings for 93% (first group consensus) and 89% (second group consensus) of the statements met the criterion for consensus agreement, supporting construct and content validity. Parent and therapist feedback indicated that the assessment promotes engagement, goals are considered from many viewpoints, and there is a joint development of and commitment to the action plan. Limitations included the time needed to complete the assessment, the process was complex requiring preparation and guidance, and use of unfamiliar expressions.
CONCLUSIONS: The findings provide evidence of construct and content validity, and acceptability of the Ecological Assessment of Participation for use in examination, evaluation, and intervention planning to achieve child and family goals for family and community participation in leisure and recreational activities. Instructions, highlighting the adaptability and individualization of the assessment, have been expanded and a sample case added to provide further guidance in the process. Further research is needed to examine if these changes improve feasibility. Familiarity with collaborative, solution focused, participation interventions are considerations for use of the assessment in practice.
CLINICAL RELEVANCE: The Ecological Assessment is a novel tool to guide examination, evaluation, and intervention planning focused on a child's meaningful goal for participation in their daily life. The Assessment fosters a systematic, comprehensive, and collaborative approach enabling the building of a trusting relationship and involving children and families in the process.
HEAD SHAPE PROTECTION FOR INFANTS IN THE NEONATAL INTENSIVE CARE UNIT: AN EVIDENCE-BASED ALGORITHM
Elgren R, Wendland M (Doctor of Physical Therapy, Cleveland State University), A. McDonald (Therapy Services, Cleveland Clinic Childrens Hospital for Rehabilitation)
PURPOSE: The purpose of this poster is to present an evidence-based algorithm to minimize cranial molding deformities in the Neonatal Intensive Care Unity (NICU). Information included in the algorithm was derived from a literature review looking at the most effective interventions in preventing cranial molding deformities.
DESCRIPTION: The incidence of cranial molding deformities has been increasing in the preterm population while in the NICU, as recent research has shown that nearly three-quarters of preterm infants born <32 weeks postmenstrual age will exhibit cranial molding deformities. Understanding which patients may be at a high risk can help guide clinicians in developing a plan of care to prevent cranial molding deformities. Early recognition of cranial molding deformities can also prompt the initiation of targeted interventions to minimize the severity of cranial molding deformities and minimize the development of secondary impairments, including delays in motor skill acquisition.
SUMMARY OF USE: The intention of this evidence-based algorithm is to provide clinicians with current evidence to support clinical decision-making. The algorithm that was developed identifies: 1) bio-psycho-social characteristics that may place a neonate at greater risk for developing cranial molding deformities (e.g. birth weight, history of mechanical ventilation, and caregiver practices using positioning), 2) observational assessments and measurement techniques that can be utilized to assist with early recognition (e.g. cervical range of motion, cranial index, and cranial vault asymmetry index), 3) implementable interventions (e.g. positioning protocols, positional aids, staff/family education and referral to other practitioners), and 4) suggested frequency for therapist follow-up for neonates during a prolonged stay in the NICU and once discharged.
IMPORTANCE TO MEMBERS: Having this evidence-based algorithm provides a systematic perspective to assist with clinical decision making and allow for proactive adjustments to treatment techniques to help minimize cranial molding deformities during the neonate's stay in the NICU. It is important to understand which infants may be at risk as well as the most effective interventions that can be implemented while the infant is in the NICU in addition to the necessary follow-up procedures to ensure the infant is optimally reaching his/her developmental milestones.
ACT: A MULTI-SYSTEM ASSESSMENT CRITERIA TOOL FOR TOE WALKING
Falcone N, Harcsztark A (Institute for Child Development, Hackensack University Medical Center), Persaud L (Skiatook, Oklahoma), Kowalski J (Macomb Intermediate School District, Clinton Township, Michigan), Ashley K (Pediatric Outpatient Rehabilitation, San Juan Regional Medical Center)
PURPOSE: The purpose of this abstract is to introduce the Assessment Criteria Tool (ACT) to identify the multi-system factors that contribute to toe walking gait deviation in children, from an etiological approach, in order to effectively guide therapeutic intervention.
DESCRIPTION: Idiopathic toe walking (ITW) is a diagnosis of exclusion given when other medical causes are ruled out. While research suggests that ankle contractures are a common clinical finding in ITW, growing evidence supports that there is a higher incidence of sensory processing differences in toe walkers compared to non-toe walkers. These findings would suggest that the etiology of ITW is likely multifactorial. The musculoskeletal, neurological and sensory systems are key elements of gait. Therefore, dysfunction in one or more of these systems can contribute to the atypical movement pattern of toe walking. While diagnostic tools are available to therapists such as the Toe Walking Tool developed by Williams to address the identification of toe walking as a result of a medical condition, there are no tools that assess the often various clinical signs and symptoms over multiple domains within ITW population.
SUMMARY OF USE: An extensive literature search was conducted to identify contributory factors in toe walking. To better address the multifactorial etiology of ITW, the ACT proposes the classification of toe walking into three categories: Musculoskeletal, Neuromotor and Sensory. The ACT is a weighted checklist of contributory factors gathered by the clinician from patient history and clinical exam. Risk factors are weighted and a final score is tallied for each of the three categories. While the scores are not nominal or meaningful when taken individually, the three categories are ranked to determine the primary, secondary and tertiary etiology of TW. The ACT tool is designed to guide the therapist in identifying the underlying factors that contribute to TW in order to develop an individualized treatment plan to normalize gait. The ACT has been used successfully in Australia, New Zealand, Canada and the US.
IMPORTANCE TO MEMBERS: This approach recognizes the often multifactorial etiology of toe walking gait deviation in children in the absence of other medical conditions, and guides the therapist in the assessment of all contributing factors in order to effectively develop individualized intervention strategies to maximize outcomes. It also serves to indicate the need for referrals to services such as OT in the presence of significant sensory findings.
HINGED ANGLE-ADJUSTABLE ANKLE-FOOT ORTHOSES (AFOS) IN THE MANAGEMENT OF ANKLE PLANTAR FLEXION CONTRACTURES IN TOE WALKING
Falcone N, Ryan P, Lastra S (Institute for Child Development, Hackensack University Medical Center)
BACKGROUND & PURPOSE: The presence of ankle plantarflexion (PF) contractures is a common clinical finding and cause for physical therapy intervention in children with toe walking gait deviation. The use of serial casting to address PF contractures and conduct weight line training to improve gait has been demonstrated in the cerebral palsy population as well as in children with Autism (ASD) who toe walk. Serial casting requires advance training of the provider as well as a level of commitment from the child and family, which can limit accessibility for some candidates. The use of hinged angle-adjustable ankle-foot orthoses (AFO) with tuned footwear is proposed as a treatment alternative to the management of PF contractures in children when serial casting is not a viable option.
CASE DESCRIPTION: Hinged-adjustable AFOs were utilized in the treatment of ankle PF contractures of greater than R1 −10 degrees in the presence of 100% toe walking gait deviation in 2 children (with and without ASD) over a seven month period. The AFOs were designed with a hinged ankle and adjustable PF stop with check strap. The ankle angle was initially set in plantarflexion at the child's R1 (or R1A if present) ankle DF passive range of motion (PROM) with knee extended. A corresponding heel wedge was added to accommodate plantarflexed AFO to set the angle of tibial inclination (measured on the anterior aspect of the tibia) at 10-12 degrees when worn with a shoe. Depending on the height, the heel wedge was located on the AFOs with an extended toe plate, or added to shoes. Children wore the tuned AFOs daily. They participated in weekly or bi-weekly therapy for active stretching, strengthening and gait training activities. The child with ASD also received OT services. Ankle DF PROM assessments were conducted monthly, and orthotics were tuned accordingly. The 50 Foot Walk Test was utilized as an outcome measure to quantify the frequency of toe walking.
OUTCOMES: The use of hinged angle-adjustable tuned AFOs over time resulted in a decrease in ankle PF contractures by 8-16 degrees in both cases over a seven month period. Both children had ankle DF R1 or R1A measurements within 4 degrees of neutral that could be accommodated in a standard AFO design. The 50 foot walk test reflected a decrease in toe walking frequency for both children. In addition there were marked improvements in postural alignment in the sagittal plane.
DISCUSSION: Serial casting continues to be the gold standard for the management of ankle plantarflexion contractures. However, the use of hinged-adjustable AFOs with tuned footwear is an accessible and effective treatment intervention when serial casting is not a viable option. Similar to serial casting, the concept of prolonged stretch in shortened range in combination with weight-line training is achieved. Used in combination with a therapeutic exercise program, a hinged adjustable AFO with tuned footwear is an effective intervention to improve ankle DF range of motion and decrease toe walking gait.
MOBILITY IN PICTURES: A PHOTOVOICE NARRATIVE STUDY OF CHILD AND CAREGIVER EXPERIENCES DURING POWERED MOBILITY PROVISION AND EARLY USE
Feldner H (Rehabilitation Medicine, University of Washington), Logan S (Oregon State University), Galloway J (Physical Therapy, University of Delaware)
PURPOSE/HYPOTHESIS: Nearly 100,000 US children use powered mobility technology. Mobility experiences may be considered positive or negative depending on fit achieved between the child, the technology, and the environment yet very young children's own perspectives are unknown. This case study engaged children and families as co-researchers to document and understand perceptions and experiences of powered mobility provision and early use within two distinct provision models, via a powered wheelchair and a modified ride-on car.
NUMBER OF SUBJECTS: 4
MATERIALS/METHODS: Using a participatory action research framework, Photovoice method was used to capture visual images and associated narratives documenting meaningful provision and use processes experienced by two children and families pursuing powered mobility for the first time. Children were matched in age, diagnosis, and socioeconomic status; one family chose to pursue a modified ride-on car, and the other chose to pursue a powered wheelchair. Families were given a research camera and a list of guiding prompts but had the freedom to take photos of whatever they thought was important about the provision and early use process. Families then selected photos, narrated their meaning verbatim, and co-created themes with a researcher.
RESULTS: Four themes emerged from the data: 1) Dys/function of Mobility Technology addressing pros and cons of the devices and processes, and practical or abstract functions of the devices; 2) Daily Life, Play, and Participation addressing changing family and peer roles, barriers, and facilitators to activity; 3) Emerging Self/Advocacy addressing choice-making, setting a mobility agenda, and identity development; and 4) Complex Family/Industry Interplay addressing pros and cons of each provision model, and contrasting relationships between families and providers.
CONCLUSIONS: These themes reveal layers of complexity within powered mobility provision, especially in young children's own understanding of differences in mobility, technology, access, and environments. Similarities and differences in experiences, as well as pros and cons of each device, existed regardless of provision model. Participatory photographic methods are a valuable and accessible tool for capturing barriers, facilitators, and impacts of powered mobility technology design, provision, and use in very young children.
CLINICAL RELEVANCE: Given rapidly shifting social and professional perspectives about the benefits of early powered mobility for young children with disabilities as well as emerging alternative provision models, it is important to better understand the roles of accessible research methods for young children, generate new hypotheses and translational research questions to enhance clinical evidence for mobility technology and its role in shaping identity and clinical rehabilitation outcomes, and impact future innovation in technology design, provision models, and environmental accessibility.
PERCEIVED BENEFITS OF A COMMUNITY-BASED DANCE CLASS FOR CHILDREN WITH SPECIAL HEALTHCARE NEEDS AND THEIR FAMILIES: A QUALITATIVE ANALYSIS
Fletcher J, Sarah J, Harper E, Harris M, Roley T (Physical Therapy, University of South Alabama), Stribling K (Oregon Health and Science University)
PURPOSE/HYPOTHESIS: Decreased physical activity in children with special healthcare needs (CSHCN) has been linked to limited opportunities for participation in community-based programs, higher rates of obesity and decreased self-esteem. The goal of this study was to evaluate the perceived physical, social and behavioral benefits that Dance Without Limits (DWL), a studio-based dance program in Mobile, AL, provides for this population.
NUMBER OF SUBJECTS: 10
MATERIALS/METHODS: Focus groups were conducted with ten parents (7 females, 3 males) of children participating in DWL. Responses to open-ended questions were recorded, transcribed and analyzed using manual thematic analysis.
RESULTS: Three categories of perceived benefits emerged: physical, social and behavioral. Perceived social benefits included increased socialization opportunities, participation in an inclusive environment and enhanced social skills for children in DWL. Parents also reported the social benefit to caregivers of having a break during their day and a sense of community with other parents of CSHCN. Behavioral benefits reported by parents included improvements in the child's mood, increased self-esteem and enjoyment of the program. Perceived physical benefits included dance classes presenting a positive adjunct to traditional therapy, improved sensory integration and increased opportunities for physical activity.
CONCLUSIONS: Parent-reported benefits of participation in DWL were mostly social, but physical and behavioral benefits were also important to our participants. Community-based dance programs like DWL encourage CSHCN to be physically active in a fun and inclusive environment that acknowledges their social and behavioral development. The sample was limited to participants in the DWL studio in Mobile, AL and may only be generalized to this demographic.
CLINICAL RELEVANCE: Community-based recreational programs, such as dance classes, are valuable to parents because they provide enjoyable opportunities for CSHCN to participate in physical activity in a social setting. We as therapists have a role in advocating for inclusion of our patients/clients in community-based activities. This study presents valuable information for future research studies focusing on providing inclusive opportunities for CSHCN.
PHYSICAL ACTIVITY LEVELS OF CHILDREN WITH DOWN SYNDROME: A SYSTEMATIC REVIEW
Fox B, Moffett G, Kinnison C, Brooks G, Case L (Doctor of Physical Therapy, Duke University)
PURPOSE/HYPOTHESIS: Down syndrome (DS) is the most common chromosomal congenital disorder in the United States, affecting one out of every 790 infants. Children born with DS typically have delays in gross motor development and are at increased risk for numerous health conditions. Regular physical activity (PA) is important for promoting overall health and well-being across the lifespan; yet, the ability of a child with DS to engage and participate in PA may be decreased, increasing their risk for the progression or exacerbation of associated health conditions. This systematic review aimed to analyze the use of accelerometers to measure physical activity in pediatric populations with Down syndrome.
NUMBER OF SUBJECTS: 8 studies
MATERIALS/METHODS: A comprehensive search strategy was performed in accordance with PRISMA guidelines, using Downs and Black to assess methodological quality. Articles were included under the following criteria: 1) participants were ≤21 years old and diagnosed with Down syndrome; 2) activity monitors were used for data capture; and 3) physical activity was reported in terms of frequency, duration, or intensity.
RESULTS: The full search strategy identified 74 articles; of the 30 papers fully reviewed, 8 were included in the final review. The majority of studies had only “fair” methodological quality. Cut points for determining intensity of activity varied greatly across all studies, prohibiting the completion of a meta-analysis. Four studies used typically developing children as a comparator; six studies compared outcomes to PA guidelines of ≥60 minutes of moderate to vigorous PA per day; 1 study used a guideline of 30 minutes of moderate PA per day. The overarching results reveal children with DS are not meeting recommended PA guidelines, and PA, particularly more intense PA, tends to decrease with age while sedentary time tends to increase. In studies that included children with typical development, children with DS tended to engage in more light intensity PA than sedentary, moderate or vigorous PA compared to the controls.
CONCLUSIONS: The noted decline and lack of more vigorous physical activity as children with Down syndrome enter adolescence poses functional and general health risks for this population given their risk for health conditions for which PA can have a positive impact.
CLINICAL RELEVANCE: This review will be useful in educating PTs about the need for increased daily physical activity in children with Down syndrome; this is especially relevant for pediatric PTs, who are in a position to play a critical proactive role in optimizing care for these individuals. Targeting increased activity levels in children with Down syndrome and eliminating barriers to participation in PA will help foster physical activity as a lifestyle, decreasing the risk of compromised health and secondary musculoskeletal issues from inactivity as children get older.
IMPACT OF EARLY AGGRESSIVE REPOSITIONING AND PHYSICAL THERAPY FOR PATIENTS WITH DEFORMATIONAL PLAGIOCEPHALY AND CONGENITAL MUSCULAR TORTICOLLIS
Gaetani S (Physical Therapy and Occupational Therapy, Children's Hospital of Pittsburgh of UPMC), Fenton R (Pediatric Plastic Surgery Cleftcraniofacial, Children's Hospital of Pittsburgh of UPMC)
PURPOSE/HYPOTHESIS: Deformational plagiocephaly (DP) is highly associated with congenital muscular torticollis (CMT). We evaluate these patients (pts) with a team approach utilizing a nurse practitioner and a physical therapist. We have identified a small series of pts with DP and CMT who were referred early and physical therapy (PT) and aggressive repositioning techniques (AR) were initiated immediately. These pts demonstrated substantial improvement in their cranial index (CI) and oblique diagonal difference (ODD), negating the need for helmet therapy (HT). The 2016 Congress of Neurological Surgeons consensus statement states that AR and PT are helpful but that HT is more effective in addressing DP. We believe there is a significant role for AR and PT if initiated early. The aim of this study is to heighten awareness of the potential positive impact of implementing PT and AR early to reduce the severity of DP/CMT and decrease the volume of referrals for HT.
NUMBER OF SUBJECTS: 45
MATERIALS/METHODS: A small retrospective study from August 2016-October 2017 was performed with inclusion criteria consisting of pts 0-4 months, diagnosed with DP and CMT, and those who improved their CI and ODD enough to no longer qualify for HT. These pts' families were instructed as to AR and PT during their evaluation and underwent PT. CI and ODD measurements were obtained with a hand caliper by a single provider at both the initial evaluation and at their follow up at approximately 4.5 months of age.
RESULTS: We identified 45 pts who met inclusion criteria, 6 pts were born prior to 37 weeks gestation. Age at presentation ranged from 0-4 months. The average (avg) duration of AR and PT at the time of follow up visit was 1.5-2.5 months. 35 pts had right sided DP, 5 pts had left sided DP, and 5 pts had bilateral DP. 15 pts had right sided CMT, 30 pts had left sided CMT. CI range was 0.77-0.97. The range of improvement of CI was 0.00 to 0.09; avg improvement was 0.015. 29% of pts had a small increase in their CI with range of 0.01-0.07 with the avg of 0.007. ODD range was 2mm-12mm. The range of improvement of ODD was 0mm-8mm; avg improvement was 2.5mm.
CONCLUSIONS: We have identified a small cohort of pts with DP and CMT referred between 0-4 months of age who initiated AR and PT immediately. The CI and ODD improved enough to eliminate HT referral.
CLINICAL RELEVANCE: Although highly effective when indicated, a course of HT is time consuming for the family, expensive with potential lack of insurance coverage, parental loss of work and can be stigmatizing. Potential side effects include pts becoming over heated, pressure areas, wounds, contact dermatitis and exacerbation of skin issues. We rarely have pts referred this early, but we have found a substantial impact on their DP/CMT. The recent 2016 consensus statement states that AR and PT are important but that HT is more effective in reshaping the DP. We propose that AR and PT have the potential to be as effective as HT in addressing DP if initiated early enough and can result in substantial improvement.
SAFETY AND FEASIBILITY OF OUT OF BED MOBILIZATION FOR PEDIATRIC PATIENTS WITH EXTERNAL VENTRICULAR DRAIN IN A PEDIATRIC NEUROSURGICAL INTENSIVE CARE UNIT
Gaspari C, Correia R, Lafayette S, Badaró C, Garcia R, Jaccoud A,(Physical Therapy, Instituto Estadual do Cérebro Paulo Niemeyer, Rio de Janeiro, RJ, BRAZIL)
PURPOSE/HYPOTHESIS: The purpose of this study was to determine the safety and feasibility of mobilizing pediatric patients with an external ventricular drain in a pediatric neurointensive care unit.
NUMBER OF SUBJECTS: 12
MATERIALS/METHODS: This was a retrospective, observational study. The data were obtained from medical records of pediatrics patients who received physical therapy (PT) while an external ventricular drain (EVD) was in place from January to December 2017. Physical therapists followed a strict institutional protocol of fixating the catheter prior to getting the patient out of bed (OOB). Demographic data and adverse events were obtained from the PT notes from the medical records.
RESULTS: There were 22 subjects with EVDs who received PT while the EVD was in place. Ten patients were excluded from the analysis as they did not perform OOB activities during the sessions. The 12 remaining subjects (7 boys and 5 girls) had a total of 88 separate OOB PT sessions analyzed. Their average age was 6.5 years (+/- 4 years).
There were no loss of catheter events or EVD related mechanical complications during any of the OOB PT sessions. There were six adverse events (6.8%) that were considered minor in nature: nausea (1), headache (1), and dizziness (4). All of the symptoms returned to baseline within minutes. In a total of 88 PT sessions, there was one episode of seizure during the tilt-table which was considered a serious adverse event (1.1%).
CONCLUSIONS: Retrospective analysis of the data revealed that the patient who suffered a seizure on the tilt-table did not have proper dosage of anti-seizure medication on the day of the event. The adverse event cannot be directly correlated to the PT treatment.
The results from this study support that early OOB mobilization in patients with EVD is safe and feasible. Only 1.1% of encounters had significant events and the event did not cause significant harm to the patient. This study provides evidence that the presence of EVD catheters alone should not be a reason to limit progressive OOB mobility interventions during hospitalization.
CLINICAL RELEVANCE: Pediatric patients in a neurosurgical intensive care unit (ICU) face countless difficulties, including a high risk of death, severe physical and cognitive impairments.1,2 These patients are not typically mobilized OOB due to their illness alone or, at times, due to the complexity of the multiple lines and monitoring devices attached to them.1,3 There is limited evidence describing mobility interventions provided to pediatric patients with EVD, which is a common occurrence in any neurosurgical ICU.4,5 This study supports that early mobilization is safe and feasible for these patients.
EARLY INTERVENTION SERVICES PROVIDED BY PHYSICAL AND OCCUPATIONAL THERAPISTS FOR INFANTS WITH OR AT RISK FOR CEREBRAL PALSY
Gmmash A, Effgen S (Rehabilitation Sciences, University of Kentucky)
PURPOSE/HYPOTHESIS: The purpose of this study was to explore the frequency, intensity, and type of practices physical therapists (PT) and occupational therapists (OT) use currently in early intervention for infants with or at risk for cerebral palsy (CP) and to determine if the current practice matches the most recent evidence of best practices.
NUMBER OF SUBJECTS: A total of 359 participants accessed the survey link, 269 therapists (33% OTs and 67% PTs) from 42 states completed at least 50% of the survey items.
MATERIALS/METHODS: An online, 36 item survey was developed and disseminated using Qualtrics online software. An anonymous survey link was distributed to early intervention providers at scientific conferences, through a posting in the Academy of Pediatric Physical Therapy, Early Intervention Special Interest Group news, and by word of mouth.
RESULTS: A majority of providers (58%) begin therapy services for infants with or at high risk for CP between 0-5 months of age. Only 4% of therapists use the General Movement Assessment to predict CP and two providers (.7%) indicated using the Hammersmith Infant Neurological Examination to determine the motor severity of CP. The majority of the providers (57%) reported that infants at risk for CP receive therapy once a week and 58% of them think that these infants need additional therapy sessions. 89% consider parent education one of the most important goals followed by promoting engagement of the infant in daily routines. However, 73% of providers never or rarely use an outcome measure to identify and prioritize parents' goals, 31% provide parents with individualized home program, only 2% use formal instruments to assess enrichment of the home environment, and 61% of providers never include any strategies to promote environment enrichment.
CONCLUSIONS: Findings from this study suggest that therapists do not incorporate sufficient strategies for optimum environment enrichment, comprehensive parental education, and goal oriented interventions.
CLINICAL RELEVANCE: As recommended, PTs and OTs generally start serving infants with or at risk for CP in the first 5 months of life; however, they believe these infants need additional therapy. Therapists did not always report following best practices as reported in the literature. They are advised to: use more sensitive tools in the early detection of CP; use the best available evidence to promote parent engagement in the therapy process that includes using formal assessment tools for goal setting; provide parents with a written home program illustrated with photographs; incorporate in their intervention plan activities that facilitate activation of lower limb muscles using concentric and eccentric exercises; use modified constraint induced movement therapy and bimanual training when asymmetrical movement of the arm is present; use strategies to ensure environment enrichment; and provide parents with prognostic information to help them develop realistic expectations.
PHYSICAL THERAPY REEVALUATION OF CERVICAL RANGE OF MOTION AND STRENGTH IN INFANTS WITH CONGENITAL MUSCULAR TORTICOLLIS
Greve K (Division of Occupational Therapy and Physical Therapy, Cincinnati Children's Hospital Medical Center), Sweeney J (Pediatric Science, Rocky Mountain University of Health Professions), Bailes A (Division of OTPT, Cincinnati Children's Hospital), Van Sant A (Physical Therapy, Temple University)
PURPOSE/HYPOTHESIS: Congenital muscular torticollis (CMT) is a musculoskeletal condition diagnosed in infants. Infants present with a head tilt to one side and cervical rotation to the opposite side that may indicate range of motion (ROM) and strength deficits. Torticollis symptoms have been reported to resolve within 6 months with conservative physical therapy (PT). Physical therapy discharge criteria are established for infants with CMT. Residual cervical ROM limitations, muscle imbalance, and abnormal postures are not well described in infants with CMT who do not complete a full episode of PT. The purpose of this study was to compare cervical ROM and strength of infants with CMT when discharge criteria were met following direct physical therapy (DCM-PT) and when discharge criteria were unmet following direct PT (DCU-PT) or home program instruction (DCU-HP).
NUMBER OF SUBJECTS: 30
MATERIALS/METHODS: A prospective study was designed to measure baseline and follow-up passive lateral flexion and rotation, active rotation, and strength in 30 infants with CMT in DCM-PT, DCU-PT, and DCU-HP groups. Inclusion criteria for infants were 6 to 24 months of age, diagnosis of CMT, initial PT examination completed a minimum of 6 months before follow-up, and baseline ROM using an arthrodial protractor. Exclusion criteria were diagnosed neuromuscular conditions, congenital limb defects, nonmuscular torticollis, PT outside of the research hospital, baseline ROM using a goniometer, and baseline strength not recorded for infants greater than or equal to 4 months old. Follow-up assessments were completed by a clinical assessor blinded to groups.
RESULTS: Active rotation at baseline differed significantly between infants with CMT in DCM-PT, DCU-PT, and DCU-HP groups. At baseline and follow-up, no significant differences were found in passive ROM or strength between groups meeting or not meeting discharge criteria. Aside from groups, infants did not have remaining passive ROM deficits but 40% had ongoing strength deficits.
CONCLUSIONS: Infants with CMT may not have residual passive ROM deficits but ongoing strength deficits are observable despite meeting discharge criteria from PT services. Ongoing PT reevaluation is needed for infants with a history of CMT to identify strength deficits and resume treatment.
CLINICAL RELEVANCE: This study provides a foundation for reevaluation of all infants with CMT as stated in action statement 16 of the evidence-based clinical practice guideline for PT management of CMT. Future studies of time frames and age for completing a reevaluation of infants with CMT would be helpful to clinicians evaluating and treating this patient population.
CORRELATING THE KING-DEVICK (K-D) TEST WITH VESTIBULAR/OCULAR MOTOR SCREENING (VOMS) IN ADOLESCENT PATIENTS WITH CONCUSSION: A PILOT STUDY
Heitzman M, Russell-Giller S (RWJ Barnabas Health), Toto D (Mathew J Morahan III Health Assessment Center for Athletes)
PURPOSE/HYPOTHESIS: The purpose of this study is to explore the relationship between the King-Devick (K-D) test and the Vestibular/Ocular Motor Screening (VOMS) test in order to gain a better understanding of the underlying impairments affecting the K-D performance of concussed adolescents.
HYPOTHESIS: K-D test time of concussed adolescents at the initial clinical concussion visit will positively correlate with VOMS total scores.
NUMBER OF SUBJECTS: 71 patients; charts between October 1, 2016 and January 31, 2017
MATERIALS/METHODS: Patient charts were retrospectively analyzed (average age 14 +/- 2.1; average symptom score at initial visit 5.7 out of 22 +/- 5.7;) Included charts consisted of RWJBarnabas Health patients with a diagnosis of concussion who had completed K-D testing and VOMS assessment at initial physician visit. Univariate correlation between the K-D testing time and the 7 VOMS items was assessed with Pearson correlation coefficients.
RESULTS: K-D testing time strongly correlated with all 7 VOMS items (r(69) = .325-.585, p<.01). In a linear regression model that accounted for each VOMS item, the Convergence (near point) item and the Visual Motion Sensitivity item significantly predicted the K-D testing time, β = .387, t(63) = 2.81, p<.01, and β = .375, t(63) = 2.35, p = .02, respectively. Additionally, 37.5% of the 24 patients with worsening symptoms after the K-D testing freely reported increased visual problems.
CONCLUSIONS: This Pilot study suggests that prolonged K-D testing time in adolescents with concussion may be related to sub types of vestibular/ocular motor impairments that extend beyond saccadic abnormalities. The study further supports that prolonged K-D testing times in adolescents with concussion may be related to vestibular/ocular motor impairments. Further prospective research needs to be done using objective measures (such as quantitative eye tracking) to evaluate the effect of vestibular/ocular motor processing on K-D performance in adolescent patients with concussion.
CLINICAL RELEVANCE: Impaired KD testing performance of adolescents post concussion may indicate a range of vestibular/ocular motor deficits that need to be identified and addressed to maximize recovery. Additionally, while vestibular/ocular motor deficits may be a contributor to imaired K-D testing in concussed patients it is unkonwn whether attention and/or cogntive deficits play a role. Furthermore, if K-D test and VOMs deficits are consistently found in adolescents post concusssion, then is there a discussion for using K-D testing and/or VOMs in baseline assesments?
THE ASSOCIATION OF MOTOR DEVELOPMENT AND PARTICIPATION IN CHILDREN WITH AUTISM
Holloway J (School of Physical Therapy and Rehabilitation Sciences, University of South Florida), Long T (Center for Child and Human Development, Georgetown University), Biasini F (Psychology, University of Alabama at Birmingham)
PURPOSE/HYPOTHESIS: The hallmark features of autism spectrum disorder (ASD) include difficulties with social communication and interactions and patterns of repetitive or restrictive behaviors; however, many children with ASD also have difficulties with motor abilities. The goal of physical therapy for children with disabilities is to improve participation in daily routines and activities, but little is known about the role of motor abilities in participation for young children with ASD. The purpose of this study was to examine relationships between motor skill ability and components of participation in preschool-aged children with ASD.
NUMBER OF SUBJECTS: Twenty-two children between the ages of 4-5 years old (48-71 months) with ASD participated in the study.
MATERIALS/METHODS: Gross motor skills were measured using the gross motor subtests of the Peabody Developmental Motor Scales, Second Edition. Participation was measured using the Preschool Activity Card Sort (PACS), a parent-interview measure to assess children's participation in the areas of self-care, community mobility, high demand leisure (gross motor activities), low demand leisure (fine motor activities), social interaction, domestic, and education.
RESULTS: Overall gross motor score was positively associated with participation in self-care (r = .513), high demand leisure (r = .540), and social interaction (r = .652). The PACS also highlighted patterns of activities in which the children were often unable to participate, including playing games with children, playing a team sport, riding a bike, and playing with a pet.
CONCLUSIONS: This study demonstrates that motor development is related to overall participation, especially the social interaction component. It also identifies participation activities that may be difficult for preschoolers with ASD.
CLINICAL RELEVANCE: This study shows the relevance of motor skill ability to overall participation in children with ASD. Focusing on increasing participation within the context of a child's daily routines and activities, rather than on isolated gross motor skills, may define a more meaningful role of physical therapy in the lives of children with ASD.
THE EFFECT OF TRANSCRANIAL DIRECT CURRENT STIMULATION ON BALANCE AND MOBILITY IN CHILDREN WITH CEREBRAL PALSY: A SYSTEMATIC REVIEW
James C, Frank D, Ziegler K, Kosik S, Rodio N, Hakim R (Physical Therapy, University of Scranton)
PURPOSE/HYPOTHESIS: The purpose of this systematic review was to determine the effect of transcranial direct current stimulation (tDCS) on balance/mobility in children with cerebral palsy (CP).
NUMBER OF SUBJECTS: N/A
MATERIALS/METHODS: A literature search of CINAHL, PubMed, Cochrane, ProQuest, ScienceDirect was conducted using search terms: Pediatric AND (cerebral palsy OR perinatal stroke OR stroke) AND (direct current stimulation OR current stimulation OR transcranial OR stimulation OR microcurrent). Search limits: English, human subjects, pediatric (0-18 years), peer-reviewed. Selection Criteria: Children with CP, interventions included tDCS, outcome measures of balance and/or mobility, study design limited to RCTs. Two reviewers independently assessed each study for methodological quality and came to a consensus based on PEDro guidelines.
RESULTS: A total of 121 articles were screened for eligibility. Following detailed appraisals, 7 RCTs met criteria. PEDro scores ranged from 8 to 10 (avg = 9.14). Samples ranged from 6 to 24 participants (126 total; age range 4-12) with CP (GMFCS Levels I-III). Treatment parameters included 1mA of anodal tDCS placed over primary motor cortex in 6 studies or cerebellum in 1 study. Five studies applied tDCS during treatment for five 20-minute sessions for 2 weeks, while 2 studies applied a single session of tDCS for 20 minutes. tDCS was combined with virtual reality (VR) in 4 studies and with treadmill training (TT) in 3 studies. Outcome measures included temporal-distance (gait analysis, 6MWT), kinematic analysis (Gait Profile Score), functional performance (GMFM-88, PEDI, TUG), and balance (sway, PBS). 6 of 7 studies had statistically significant improvements in balance and/or mobility with tDCS co-interventions (3 with VR and 3 with TT) as compared to usual care. 5 of 7 studies reported sustained improvements at 1 month follow-up. 6 of 7 studies found significantly greater improvements with anodal tDCS combined with VR (3 studies) or TT (3 studies) when compared to a control group with no adverse events reported.
CONCLUSIONS: There is strong evidence to support use of tDCS combined with VR or TT to improve balance/mobility in children with CP compared with usual care. Studies conducted over a 2-week period showed sustained performance of balance/mobility at 1 month follow-up. Both single session studies showed immediate improvements in gait and sway velocity for tDCS groups. Limitations included small sample sizes and wide range of motor levels (GMFCS I-III). Further research should focus on determining optimal training parameters of tDCS for this population to increase functional outcomes.
CLINICAL RELEVANCE: All studies concluded that tDCS is a safe and feasible intervention for patients with varying types of CP, though not currently approved by the FDA in clinical settings. Multiple 20-minute sessions (10 sessions over 2 weeks) of 1mA anodal tDCS should be considered by clinicians as a potential treatment option in conjunction with balance/mobility training for children with CP as availability permits.
THE ACUTE EFFECTS OF CARBON FIBER FOOTPLATE ORTHOSES ON JOINT ANGLES DURING IDIOPATHIC TOE-WALKING
Jerry L, Reisch P, Vice C, Vallabhajosula S, Scales M (Department of Physical Therapy Education, Elon University)
BACKGROUND & PURPOSE: Idiopathic toe-walking (ITW) is a pediatric condition hallmarked by a toe-to-toe gait pattern. Children with ITW walk with decreased dorsiflexion/increased plantarflexion. Carbon fiber footplate orthoses (CFOs) are a novel orthotic intervention being used with children with ITW. CFOs are rigid, thin orthoses placed under the insole of the shoes and mechanically prevent walking on the forefoot. They are cheaper, less restrictive, and may have improved wear adherence than other orthoses used with this population. There is minimal research on the effects of CFOs on ITW gait and none on joint angles. The purpose of this case study was to look at the changes to gait joint angles of a child with ITW both with and without CFOs applied.
CASE DESCRIPTION: Our subject was a 6-year-old girl with Type 3 ITW, the most severe on the ITW Severity Scale. Colored tape was placed on the following landmarks bilaterally for standardization of joint angle measurements: transverse midline of thorax, greater trochanter, lateral knee joint line, lateral malleolus, and base of the 5th metatarsal. The child walked at a normal pace for 10 trials on a marked surface under two conditions, first in shoes without CFOs and second with CFOs placed under the insole of the same shoes. Using a tablet leveled on a tripod, Dartfish Express gait analysis software was used to capture video of all trials. 2-D Joint angles were measured using landmarks listed above and averaged over 5 trials in both conditions for the following: hip extension and ankle plantarflexion during the pre-swing phase of gait, and hip flexion and knee flexion during the initial-swing phase of gait.
OUTCOMES: During pre-swing phase, the participant walked with reduced hip extension (2.62° ± 1.42°) and plantarflexion (50.12° ± 7.85°) with CFO compared to without CFO (hip extension: 5.12° ± 2.33° and plantarflexion: 68.64° ± 9.4°). During initial-swing phase, the participant walked with increased hip flexion (30.26° ± 3.32°) and knee flexion (54.72° ± 3.17°) with CFO compared to without CFO (hip flexion: 21.44° ± 3.70° and knee flexion: 44.32° ± 4.17°).
DISCUSSION: Compared to typically walking children, children with ITW walk with decreased dorsiflexion/increased plantarflexion as seen in our subject. CFOs helped our subject land with more typical foot contact and begin to develop increased hip extension and decreased plantarflexion that accompanies normal gait during the terminal stance. Dartfish Express, a convenient and accessible software is more reliable than observational gait analysis and allows clinicians to assess gait changes in a consistent manner before and after interventions. Research is currently ongoing to look at long term effects of CFOs on gait with a larger sample size; however, this case study shows that acute application of CFOs allowed our subject to walk with more similar gait kinematics compared to a typically walking child.
A HOME PARTICIPATION CHECKLIST FOR YOUTH WITH INTELLECTUAL AND DEVELOPMENTAL DISABILITIES
Johnson C (Physical and Occupational Therapy, Fairfax County Public Schools), Maring J, Cunningham R (Health, Human Function, and Rehabilitation Sciences, The George Washington University), Rose D, (PT, Alexandria, Virginia)
PURPOSE/HYPOTHESIS: Youth with intellectual and developmental disabilities (IDD) are less fit, have lower rates of employment, and are less prepared to meet vocational demands than peers without disability. Participation in home chores builds capacity to develop work skills. This study examined the construct validity of a Home Participation Checklist (HPC) measuring participation of youth with IDD in chores and fitness activities that are facilitators to employment. Specific objectives were to determine: 1) baseline data of participation in chores/physical fitness activities for youth with IDD; and, 2) if parents/caretakers found the HPC user-friendly and representative of the youth's engagement in chores/fitness-related activities.
NUMBER OF SUBJECTS: Responses were received from 45 parents/caretakers of youth ages 12-21 years old who were mostly male (87%) with a variety of health conditions associated with IDD.
MATERIALS/METHODS: The HPC was developed using an iterative process and expert panel review. The final tool included 27 home tasks. Following Institutional Review Board approval, parents/caretakers of youth with IDD were recruited to complete the HPC and respond to survey questions regarding the form. Responses were summarized using descriptive statistics.
RESULTS: Data showed highest frequency of engagement in: picking items up off the floor (47.7%), bringing items up/down stairs (42.2%), and making their bed (31.8%). Lowest frequency of engagement included dusting (52.3%), pulling weeds (51.1%), wiping kitchen counters/tables (52.3%), and sweeping (47.7%). The most frequently performed type of exercise was cardiovascular (33.3%). 31.1% reported exercising 2 or more hours/week and 42.2% reported no minutes/week of muscle resistance activity. Most frequently reported physical activity was sport activities (48.9%) and games involving walking/running (44.4%). 86.4% of Parents/caretakers reported the checklist was easy to complete, the range of survey frequencies were appropriate for tasks listed (71.4%) and the activity list was comprehensive for important activities/tasks (73.8%).
CONCLUSIONS: Findings of low participation in chores and physical activity is consistent with the literature for youth with IDD. Respondents found the survey easy to use and noted the tasks and frequencies were appropriate; supporting the HPC as a useful. Further work is needed to determine how the HPC may inform interventions and transition plans for youth with IDD.
CLINICAL RELEVANCE: The HPC accurately represents the range of chores and fitness activities for youth with IDD. Given the potential for chores and fitness to facilitate readiness for vocational opportunities, HPC has the potential to provide baseline information to guide subsequent interventions.
INTERPROFESSIONAL CARE AND INFANT MOTOR PERFORMANCE AND NEUROBEHAVIORAL OUTCOME MEASURES FOR TREATMENT OF AN INFANT WITH NEONATAL ABSTINENCE SYNDROME: A CASE REPORT
Jones J, Boynewicz K (Physical Therapy, East Tennessee State University), Speropulos K, Rary K (Physical Therapy, Niswonger Children's Hospital), Hollinger S (Medicine, East Tennessee State University)
BACKGROUND & PURPOSE: Infants with Neonatal Abstinence Syndrome (NAS) present with variable symptoms resulting from the withdrawal from opioid exposure. They often require lengthy hospital stays in the neonatal intensive care unit (NICU) and typically present with symptoms in the first 5 days of life. The purpose of this case was to examine an infant with a complex presentation of NAS, discuss the use of comprehensive interprofessional care (to include pharmacologic and physical therapy care) for the treatment of NAS, and investigate the use of neurobehavior and motor performance outcome measures for NAS.
CASE DESCRIPTION: The infant was a 38 week gestation male born via spontaneous vaginal delivery to a young mother with limited prenatal care and in utero exposure to subutex, cannabinoids, and nicotine. He was diagnosed and treated for NAS in the NICU at day of life 9, only after surgical treatment for Hirschsprung's disease. The Test of Infant Motor Performance was used am outcome measure for Motor Performance, the NICU Neonatal Network Scale (NNNS) was used for neurobehavior and the Finnegan Neonatal Abstinence Scoring Tool (FNAST) was used for withdrawl.
OUTCOMES: The infant was discharged to his mother at day of life 36 after weaning from morphine replacement therapy. Physical therapy was used effectively to assess for developmental delays, manage and reduce the infant's NAS symptoms, and educate the caregivers as such. The infant scored low average on the TIMP at 4 and 5 weeks of age, placing him between the 16th and 5th percentile. On the NNNS, the infant scored below the 10th percentile for quality of movement, self-regulation and attention/handling and above the 90th percentile for stress cues, arousal, excitability, hypotonia and non-optimal reflexes. The TIMP and NNNS supplemented the standardized use of the Finnegan Neonatal Abstinence Scoring Tool (FNAST), providing comprehensive assessment of motor performance and neurobehavior. Based on these results, odd posturing of the infant's legs was differentiated as a withdrawal symptom, the infant was referred for early intervention services, and the mother was educated on specific mild motor development concerns.
DISCUSSION: Matching current literature consensus, the infant in this case benefited from comprehensive, interprofessional care to include physical therapy for the management of his NAS withdrawal symptoms and NICU stay. The infant's course provides a unique delayed NAS presentation occurring after surgical treatment for Hirschsprung's disease. The use of the TIMP and the NNNS as outcome measures illustrate the value of comprehensive neurobehavior and motor performance measures to supplement other clinical instruments like the FNAST in the NICU.
EFFECTS OF BODY WEIGHT SUPPORT TREADMILL TRAINING ON FUNCTION AND PARTICIPATION IN CHILDREN WITH CEREBRAL PALSY
Jones S, Graves E, Richardson W, Schmidt L (Physical Therapy, Southwest Baptist University)
PURPOSE/HYPOTHESIS: To determine if body weight support treadmill training (BWSTT) improves both function and participation in children with cerebral palsy (CP).
NUMBER OF SUBJECTS: In total, 170 participants between the ages of 5 and 18 with a diagnosis of cerebral palsy, GMFCS levels I to V.
MATERIALS/METHODS: The American Academy of Cerebral Palsy and Developmental Medicine (AACPDM) methodology was used to complete this review. Six relevant databases were searched in January of 2018 using the following keywords: “physical therapy”, “cerebral palsy”, “body weight support”, “gait training”, “gross motor function” and “participation”. Inclusion criteria were peer-reviewed studies including children with CP under 18 years of age, published in the English language within the last ten years. Critical analysis was completed, and conduct rating was established using the AACPM's conduct questions.
RESULTS: Of the 240 titles initially identified, ten met criteria and were included in this review. Four studies were level II randomized control trials, three level IV studies, and three level V studies. Eight studies were rated moderate in strength, one was rated strong and one rated weak. Intervention frequency ranged from two to six days a week, length of BWSTT intervention ranged fifteen to thirty minutes per treatment session, and total duration of BWSTT ranged from six to twelve weeks. Of the studies that reported percentage of body weight used, treatment started at thirty percent and decreased incrementally. The impact of BWSTT on function was assessed in all studies based on various outcome measures and improvements were shown in eight of the ten studies. Improvements were seen at the body structure function level in gait kinematics and strength and at the activity level with improved gait function and higher-level gait skills. In three of the four studies that measured participation, improved levels were reported for the Pediatric Quality of Life Measure, the Pediatric Evaluation of Disability Inventory (PEDI or PEDI-CAT) or the School Function Assessment following BWSTT. Participation measures appeared to be more sensitive to change than other included functional outcome measures.
CONCLUSIONS: There is strong evidence that BWSTT improves functional mobility in children with CP. Less research is available regarding the impact of BWSTT on participation, in spite of the fact that valid and reliable participation measures are available. The results of this review indicate that participation measures may be more sensitive to change following BWSTT than functional measures, but they are not routinely used.
CLINICAL RELEVANCE: Although the immediate goal of physical therapy intervention for children with cerebral palsy is to improve functional mobility, the ultimate goal is to improve participation. Clinicians cannot assume that improved function correlates with improved participation, rather, assessment of participation must become a routine element of the physical therapy evaluation and plan of care.
IMPACT OF EARLY PROVISION OF MODIFIED RIDE-ON TOY CARS ON SOCIALIZATION IN YOUNG CHILDREN WITH MOBILITY DELAYS
Jones S, Knapp D, Dearing K, Sanders K (Physical Therapy, Southwest Baptist University)
PURPOSE/HYPOTHESIS: Independent mobility is foundational for global development, thus children who are dependent in mobility, often show delays in socialization. The modification of ride-on toy cars is being used as an intervention to allow children to actively explore their environment. Research shows that this self-initiated exploration improves mobility and participation. The purpose of this systematic review was to determine the affect of modified ride-on toy car use on socialization in young children with delayed mobility skills.
NUMBER OF SUBJECTS: 68 children between 6 months and 5 years of age
MATERIALS/METHODS: The American Academy for Cerebral Palsy and Developmental Medicine methodology was used to conduct this review. In February of 2018 five relevant databases were searched using key words such as: “ride on car”, “modified toy car”, mobility, socialization, cognition and children. Inclusion criteria consisted of children under age 5, peer-reviewed studies, published in the English language within the last ten years, the use of a modified toy car or adapted power mobility and measurement of socialization as an outcome. Eligibility was determined, and strength was rated using the AACPDM conduct questions. Data from included articles was then consolidated for qualitative analysis.
RESULTS: Of the initial 356 articles identified, seven studies and one follow up study from three authors were included in this review. Evidence ranged from Level III to Level IV and strength ratings ranged from moderate or strong for the group studies. Four of the five case studies were of moderate strength and one was weak. The interventions provided a variety of ride on car experiences, ranging from in-clinic therapist provided to at-home family monitored play sessions. Outcome measures varied among the studies with the most common being the Pediatric Evaluation of Disability Inventory (PEDI), which is both valid and reliable outcome tool for measuring social function, mobility, and self-care. All studies showed improvements in socialization, and the comparison studies showed greater gains among participants in the treatment group.
CONCLUSIONS: There is growing evidence that the use of modified ride-on toy cars is beneficial to young children with delayed mobility skills and promotes social development. A significant limitation in this area of research is that most ride-on cars are provided at a grassroots level, with inconsistent dosing and use of outcome measures, making large control trials difficult. Further research is needed to establish best practice recommendations and determine optimal dosing parameters.
CLINICAL RELEVANCE: The use of modified ride-on toy cars is a promising intervention for young children with motor delays. Clinicians should make every effort to consistently document setting, dosing, baseline and outcome measures that address various aspects of development in order to determine the global and long-term impact of this intervention.
DOES EARLY SPORT SPECIALIZATION INCREASE RISK OF INJURY AMONG ADOLESCENT ATHLETES?
Jones S, Paz J, Waggener C (Physical Therapy, Southwest Baptist University)
PURPOSE/HYPOTHESIS: The purpose of this study was to review the literature regarding the impact of early sports specialization on injury rates among adolescent athletes. New evidence on sports specialization has emerged since a similar 2015 review by Feeley et al. found the research inadequate to determine a correlation. This new evidence with larger sample sizes, stronger study designs and inclusion of a wider variety of sports prompted the current review.
NUMBER OF SUBJECTS: 6,950 subjects, ages ranged from 7-18 years (54.7% female and 45.3% male)
MATERIALS/METHODS: A systematic review was performed including qualitative analysis using the American Academy for Cerebral Palsy and Developmental Medicine (AACPDM) Methodology. In January of 2018 eight databases were searched using the following inclusion criteria: individuals between 7 and 18 years of age, peer-reviewed articles published within the last 10 years in the English language that analyzed the relationship between sport specialization and risk of injury. Exclusion criteria were: level of evidence IV and V, and upper extremity injuries.
RESULTS: Nine studies met criteria for inclusion. Of these studies, two were prospective cohort, one retrospective cohort, four cross-sectional and two case-control studies. Of the total, 56.3% individuals were considered single sport specialized and 43.7% participated in multiple sports. Only four studies used a 3-point scale to divide participants into 3 categories of sport specialization that were as follows: 39.3% low, 32.8% moderate and 27.8% high sport specialization. Four studies reported incidence of injury specific to the joint involved with ranges as follows: ankle: 17.5-34.4%; knee: 10-29.1%; upper extremity: 10-13.4%. Three studies reported incidence of type of injury with overuse reported in 20.5-67.4%. Data for acute injuries was not consistently reported and could not be consolidated. Based on these results, the lower extremity is the most susceptible body area to sustain an injury and incidence is higher among adolescent athletes that are highly specialized compared to those who participate in multiple sports.
CONCLUSIONS: The results of this systematic review suggest that early sport specialization, when compared to multiple sport participation, increases the risk of lower extremity injury in adolescents. However, the research supporting this statement needs to be strengthened through more objective methods of reporting injury, stronger research designs, uniform definitions of level of specialization, and larger databases that track athlete injuries.
CLINICAL RELEVANCE: It is important to examine the relationship between sport specialization and the risk of injury in adolescents so that health care providers can make appropriate recommendations to young athletes. Physical therapists possess a responsibility to advocate for injury prevention and secondary prevention of movement disorders by educating parents, coaches and athletes about the risks of early sports specialization.
POSTURAL ORTHOSTATIC TACHYCARDIA SYNDROME AND LATE DIAGNOSIS OF EHLERS-DANLOS: A CASE EXAMPLE
Kendall E, Collins S, Halsnes J, Pittman J, Enwright K (Plymouth State University)
BACKGROUND & PURPOSE: Ehlers-Danlos Syndrome (EDS), a group of connective tissue disorders, is characterized by joint hypermobility, skin hyper-extensibility, and tissue fragility. EDS contains 13 subtypes, each comprised of a specific set of qualifying criteria and caused by identified genetic defects. The hypermobility type (hEDS) is limited to joint laxity and other musculoskeletal complications. Other EDS types involve cardiopulmonary complications such as postural orthostatic tachycardia syndrome (POTS). POTS is characterized by an increase in heart rate of 30 bpm with prolonged standing. Change in position, low vascular resistance, and abnormal compensatory autonomic reaction cause an increase in heart rate. Clinical manifestations include lightheadedness, headaches, mental clouding, and exercise intolerance in addition to tachycardia.
CASE DESCRIPTION: A 20-year-old female was diagnosed with hEDS at 18 years, after a self-reported search for the cause of frequent dislocations, falls, clumsiness, pain, fatigue, irregular sleep patterns and “brain fog” throughout her childhood. Upon diagnosis, she received physical therapy for relief of symptoms of sacroiliac dysfunction and chronic pain. She initiated the current episode of care due to pain and ongoing movement deficits. Her current goals are to improve her general physical function and to avoid the need for opioids. She also complains of a sensation of her “heartbeat in her chest” which concerns her. Based on her report and history, it was determined there was a need for a comprehensive assessment of all systems that fall within the scope of practice of physical therapy.
OUTCOMES: She scored 9/9 in the Beighton scoring system, indicating a generalized joint hypermobility. All measures of active and passive range of motion demonstrated excessive motion. Measures of strength/muscle contractility indicated general asymmetrical weakness. Her score on the Functional Movement Screen was 10/21 (dysfunction that necessitates further evaluation). Her score of 20/24 on the Fear Avoidance Behavior Questionnaire-Physical Activity (FABQ-PA) indicates significant fear avoidance behaviors in physical activity. She received a score of 53/63 on the Fatigue Severity Scale (FSS), higher scores indicating more severe impact from fatigue. She tested positive for POTS with an increase in heart rate from 85 to 118 bpm (rest to stand).
DISCUSSION: EDS can have an impact of typical motor development. Pain and instability associated with hyper-extensibility can negatively impact motor skills and functional activity. Strength and functional exercise capacity are also affected. Both musculoskeletal and cardiopulmonary system deficits can impede development of motor function and should be considered during a thorough physical therapy evaluation. This case demonstrates the need for on-going assessment of cardiovascular function for patients with EDS regardless of the type distinction.
THE IMPACT OF POWER MOBILITY TRAINING ON CHILDREN WITH SEVERE CEREBRAL PALSY: A FEASIBILITY STUDY
Kenyon K, Walenta K, Chesser B (Department of Physical Therapy, Grand Valley State University), Farris J (Engineering, Grand Valley State University), Aldrich N (Psychology, Grand Valley State University), Virji-Babul N (University of British Columbia, Vancouver)
PURPOSE/HYPOTHESIS: Although the onset of self-mobility patterns (e.g., crawling, walking) substantially impacts a child's overall development, children with severe cerebral palsy (CP) are unable to reap the inherent benefits of self-mobility. Power mobility devices may minimize mobility limitations; however, power mobility is often not considered for children with severe CP. The purposes of this study were: (1) to determine if self-mobility in the form of power mobility training would result in neuroplastic changes in children with severe CP as indexed by quantitative electroencephalography (EEG) measures and (2) to assess the potential impact of power mobility training in these children.
NUMBER OF SUBJECTS: Three children with CP (Gross Motor Function Classification System [GMFCS] Level V, Manual Ability Classification System Level V, Communication Function Classification System Level V, and Eating and Drinking Classification System Level V) participated in study.
MATERIALS/METHODS: A non-concurrent, multiple baseline A-B single-subject research design was conducted with each subject randomly assigned to a Baseline (A) phase of a different duration. Inclusion criteria were as follows: 3-12 years of age and a diagnosis of CP (GMFCS Level V). Exclusion criteria involved power mobility training within the previous year. During the Baseline (A) phase, EEG data were collected twice weekly for 5 minutes under each of the following conditions: No Interaction 1 (child sitting in his/her own manual wheelchair [WC]), Passive Mobility (child pushed in WC), and No Interaction 2 (child sitting in WC). During the Intervention (B) phase, EEG data were also collected during power mobility training. The Canadian Occupational Performance Measure (COPM), the Assessment of Learning Powered mobility use (ALP), and the Wheelchair Skills Checklist (WSC) were used to assess the impact of power mobility training. In the 8-week Intervention (B) phase, power mobility training was provided 2 times/week for 45-60 minutes using evidenced-based training approaches within an engaging environment designed to target the emergence of specific power mobility skills.
RESULTS: Differences in EEG activity between baseline (A) and intervention (B) phases were identified for each subject. All subjects showed significant improvements in power mobility skills as measured by the COPM, the ALP, and the WSC. Improvements on the ALP indicated gains not only in power mobility skills, but also in attention, cause and effect skills, tool use, and interactions with people and the environment.
CONCLUSIONS: The results of this study suggest that power mobility training positively impacted all 3 subjects. Future studies involving use of EEG in children with severe CP should consider using accelerometers to quantify head movements that may contribute to motion artifact within the EEG data.
CLINICAL RELEVANCE: Children with severe CP may benefit from the experiences provided by power mobility training even though they may not become community power wheelchair users.
THE TEACHER – PHYSICAL THERAPIST RELATIONSHIP IN SCHOOL-BASED PRACTICE: PERSPECTIVES OF THE SPECIAL EDUCATION TEACHERS
Kerfeld C, Bryhan C (Special Education Department, Seattle Public Schools)
PURPOSE/HYPOTHESIS: School-based physical therapy is a related service under the Individuals with Disabilities Education Act. Physical therapy supports students with disabilities to help them access and benefit from their education program. The collaborative relationship between the special education teacher and physical therapist (PT) is a crucial indicator of successful physical therapy practice that can lead to improved outcomes for students. The purpose of this study is to examine the special education teacher perceptions toward teacher-PT relationship and school-based physical therapy practice.
NUMBER OF SUBJECTS: Participants were 163 special education teachers employed by the Seattle Public Schools in Seattle, Washington who currently work with a PT in a public school.
MATERIALS/METHODS: Data were collected via an anonymous online survey and analyzed using descriptive statistics and qualitative coding. An experienced PT team lead and mentor therapists developed the survey. The survey evaluated teachers' perception of the role of the PT and if the PT created a positive work environment with the teacher and her/his staff. Qualitative coding identified themes regarding improvements teachers would like to see with the delivery of physical therapy services.
RESULTS: Twenty-nine percent of the participants reported they understood the role of the school-based PT “very well”, 38% “well”, 26% “somewhat”, 6% “a little”, and 2% “not at all”. Fifty-three percent of the participants requested more information on the role of the PT in the school setting. Sixty-six percent of the participants perceived the PT they worked with created a positive work environment and developed positive working relationships with the teacher and her/his staff, 25% were not sure, and 9% did not perceive a positive working relationship. Three major “C” themes emerged regarding perceived needed improvements with delivery of physical therapy services: communication, collaboration, and consistency. For example, the teachers wanted increased team collaboration by incorporating the PT presence into the students' daily school activities. The PT presence also needed to be communicated well, planned to minimize distraction, and not directive. Many stated that it was important to have consistency with the PT they worked with and the PT's schedule.
CONCLUSIONS: Results indicate a majority of participants in the study perceive the PT as a valuable contributor to the educational team. An increase in communication, collaboration, and consistency is advised to improve the teacher-physical therapist relationship that will support the educational process and improved student outcomes.
CLINICAL RELEVANCE: Special education teachers are key components to the successful integration of physical therapy services that will support student success in the school context. Teachers report wanting to learn more about the role of the PT and ways to resolve the limitations of the educational system that challenge communication, collaboration, and consistency.
KEEP ON MOVIN': BUILDING A FAMILY-CENTERED RESEARCH PARTNERSHIP TO PROMOTE PARTICIPATION IN PHYSICAL ACTIVITY FOR CHILDREN WITH DISABILITIES
Kerfeld C (Special Education Department, Seattle Public Schools), Jirikowic T (Rehabilitation Department, University of Washington), Schreiber J (Family Stakeholder, Seattle, Washington), Williford J (Seattle Children's)
PURPOSE: We describe the Keep on Movin' partnership process for and lessons learned when engaging children and their families, community stakeholders, and researchers in research capacity building activities that formulated a comparative effectiveness research question around health-promoting physical activity (PA) participation for children with disabilities.
DESCRIPTION: All children benefit from health-promoting PA including those with disabilities. PA is especially important for children, since achieving an active lifestyle early improves their prospects for an active lifestyle during adulthood. Children with disabilities are more sedentary and restricted in their PA and have lower levels of health-related fitness than children without disabilities. This results in a significant health disparity. Improving the health outcomes of individuals with disabilities through participation in their communities is a national priority of Healthy People 2020.
Supported by the Patient-Centered Outcomes Research Institute's Pipeline to Proposal Program, the Keep on Movin' partnership, consisting of children with disabilities and their families, community stakeholders (healthcare professionals; community health, school, and social service providers; community organizations, and industry) and researchers was established.
SUMMARY OF USE: The Keep on Movin' advisory council, representing diverse stakeholders; recruited, engaged and established governance among a partnership team dedicated to developing stakeholder driven and informed patient centered outcomes research. Thirty-four children/families and community stakeholders participated in three research capacity building meetings across rural, suburban and urban geographic communities of Washington State. The critical need to understand what facilitates and supports access to and participation in health promoting PA for children with disabilities throughout their lifespan was validated.
This stakeholder-driven information laid vital groundwork to develop and implement a community symposium in which the advisory council and 30 additional children/families and community stakeholders identified and compared interventions to improve health promoting PA participation of children with disabilities. Stakeholder identified priorities included the need to address information access, built environment, and program availability and resources. This work culminated into a future research question that will examine the effects of two different enhanced information access interventions tailored to children with disabilities and their families.
IMPORTANCE TO MEMBERS: Physical therapists value family-centered care and interventions that promote health and well-being. This case example models how research partnerships can strengthen relationships between patients, stakeholders, and researchers, create the infrastructure, and build capacity for community partnerships to engage in research to identify meaningful child and family-driven research questions and outcomes.
USING EXPLORATORY LEARNING TO ENCOURAGE SELECTIVE HIP-KNEE MOVEMENT IN INFANTS BORN FULL-TERM AND PRETERM
Kim J (Division of Biokinesiology and Physical Therapy, USC), Sargent B (Division of Biokinesiology and Physical Therapy, University of Southern California), Fetters L, Biokinesiology & Physical Therapy, University of Southern Californina)
PURPOSE/HYPOTHESIS: Infants born preterm (PT, <37 weeks gestation) are at high risk for brain damage, which may result in cerebral palsy. A primary impairment in cerebral palsy is impaired selective joint movement. Selective joint movement is the ability to isolate the movement of one joint from the movement of the other joints within the limb. Previous research shows that infants born full-term (FT), but not PT, will generate more selective leg movement when playing with an infant kicking-activated mobile. To encourage infants born PT to exhibit more selective leg movement, we scaffolded the kicking-activated mobile task by requiring the infants to lift their feet higher. The aims of this study are to determine 1) if infants born FT and PT learn the association between their leg movement and the mobile movement, and 2) if infants who learn the association generate more selective hip-knee movement during the Scaffolded Mobile Task.
NUMBER OF SUBJECTS: 6 infants born FT and 6 infants born PT (<32 weeks gestation) at 4 months, corrected age for prematurity.
MATERIALS/METHODS: Each infant participated in a 10-min Scaffolded Mobile Task for 2 or 3 consecutive days. Day 1 consisted of a 2-min Baseline “spontaneous kicking” during which the mobile did not move, followed by an 8-min Mobile condition, during which the musical mobile rotated when the infant lifted either foot over an individually determined threshold. Day 2 and 3 consisted of a 10-min Mobile condition, during which the threshold height was systematically increased. Learning was quantified as mobile active time (MAT) ratio, the ratio of time that the infant performed leg movements that activated the mobile during the Mobile condition on their last participation day, compared to the time that the infant performed leg movements that would have activated the mobile during the Baseline on Day 1. Selective hip-knee movement was quantified as the hip and knee joint angle correlation coefficient (Hip-Knee CC) of each leg movement. Mixed regression models using repeated measures were used to test differences of MAT ratios and Hip-Knee CCs between groups.
RESULTS: Learning: Both the FT and PT groups demonstrated learning based on a significant increase in MAT ratio (p = .01, p = .04, respectively). Using individualized learning criteria, each infant was then classified as a Learner or Non-Learner. Selective hip-knee movement: the Learner group (5 FT, 4 PT), but not the Non-Learner group (1 FT, 2 PT), demonstrated more selective movement based on a significant decrease in the Hip-Knee CC during the Mobile condition on their last participation day than their Baseline on Day 1 (p = .002, p = .12, respectively).
CONCLUSIONS: These findings are consistent with our hypotheses that infants born FT and PT can learn the task, and that infants who learn the task generate more selective movement.
CLINICAL RELEVANCE: Our data informs the capability of infants born PT to generate selective hip-knee movement when participating in a learning task. It provides foundational knowledge for developing early, child-active therapeutic interventions.
EARLY MOBILITY IN A CHILD WITH AUTISM AND RESPIRATORY FAILURE
Kovelman S, Klein J, Williamson K (Childrens National Medical Center)
BACKGROUND & PURPOSE: Children with austism specturm disoder (ASD) have a higher prevalence of hospital admissions and emergency room visits compared to the general population. With the rise of the prevalence of children with ASD, the medical community will need to adapt to support the specialized needs of this population. Research supports early mobility with intubated patients as an effective approach to reduce length of stay. There is a gap in the research to show effective strategies when mobilizing patients with ASD in the ICU. The ASECRET clinical reasoning model is used to address communication delays and behavioral barriers with children with ASD, analyze the environment, and adapt tasks to create individualized plans of care. Through the use of this framework, the patient participated in therapy sessions with the application of patient-specific sensory-behavioral strategies.
CASE DESCRIPTION: A 6 year old boy with non-verbal Autism Spectrum Disorder (ASD) and diagnosis of tuberous sclerosis and epilepsy was admitted to the ICU for respiratory distress due to pneumonia, and was subsequently intubated. He remained in the ICU for 16 days prior to inital Physical Therapy (PT) consult. Prior to PT evaluation, patient was in 4 point restraints and sedated. PT was consulted with concern for range of motion loss. At request of the PT, Occupational Therapy (OT) was consulted to assist with self regulation, environmental modification, and implementation of communcation and behavioral strategies. PT and OT collaborated to begin early mobility and advocate for an appropriate sensory environment.
OUTCOMES: PT and OT saw the patient two times a day with respiratory therapy for one week until he was extubated. Therapy sessions focused on supported sitting, pulmonary toileting, performing transfers to a chair where he could interact with his mother and familiar activities. Therapists also advocated for and implemented an appropriate sensory environment which included decreased sedation, eliminating mechanical restraints, decreased auditory stimulation, and normalizaiton of day/night schedule. Patient was then seen once a day each by PT and OT after extubation with the emphasis on progressing functional mobility independence. At the time of discharge, the patient was weaned to room air and ambulating small distances with moderate assistance. He was transferred to an outside hospital for inpatient rehabilitation.
DISCUSSION: This patient with non-verbal ASD was safely mobilized while intubated to address strength, respiratroy efficiency, and promote functional independence through meaningful activity. Using the ASECRET model and co-treating with OT to identify sensory needs and environmental modifications, established a safe envrionment for optimal participation and mobility in the ICU. This collaborative model led to discontinuation of mechanical and chemical restraints and ultimately improved quality of care. Using a team approach and applying the concepts from this model could assist with safely treating and mobilizing patients with sensory and communication needs in the future.
USE OF A NOVEL COMMUNITY-BASED PARTICIPATORY RESEARCH APPROACH TO TRANSLATE EARLY INTERVENTION RECOMMENDATIONS INTO CULTURALLY APPROPRIATE MESSAGING FOR CAREGIVERS
Magnusson D, Murphy N (Physical Therapy Program, University of Colorado Anschutz Medical Campus), Pena-Jackson G (2040 Partners for Health, Aurora, Colorado)
PURPOSE: The overall purpose of this platform is to introduce clinicians and researchers to Boot Camp Translation (BCT), a novel community-based participatory research (CBPR) approach that engages community members in the translation of evidence-based medical guidelines into culturally-meaningful messaging.1,2
DESCRIPTION: Use of the term CBPR in the health field has grown over the last 20 years. Like many other participatory research methods, CBPR emerged during the 1960s as the result of strained relationships between researchers and communities.3 The goal was to use knowledge as a means of promoting a more equitable society; transforming research from a process in which community members were objects of study to one in which they were participants, contributing to the design, implementation, and dissemination of research across the translational spectrum. Research that meaningfully engages the community in discussions about health beliefs and behaviors enhances the capacity of communities to reflect on their beliefs and make health-promoting choices.3 BCT is a robust CBPR approach that translates evidence-based medical guidelines into culturally-appropriate messaging.1 The goal of BCT is to foster better understanding of health conditions and behaviors among community members, and to co-develop messaging that promotes discussions of the condition with clinicians and engagement in shared decision-making. Participants of BCT strive to answer three questions: What do we want our message to say? Who needs to hear our message? How do we disseminate that message to our community? The end result is culturally-meaningful messaging that integrates evidence-based medical guidelines with community beliefs and expertise.
SUMMARY OF USE: Significant racial, ethnic, and socioeconomic disparities exist in the early identification of children with developmental delay (DD) and in their use of early intervention (EI) services.4-7 While the mechanisms underlying these disparities are numerous and complex, there is mounting evidence that parental health beliefs play an important role in influencing the help-seeking pathway for children with DD. Developmental screening guidelines and EI service recommendations, presented during the well-child visit, do not always resonate with parents or align with their beliefs. As a result, many parents forego EI services and other developmentally appropriate supports.8,9 During this platform, we will present the process of BCT, share our community's decision aid and their messaging around development, developmental delay, and early intervention, and present data regarding the decision aid's acceptability and feasibility in pediatric primary care settings.
IMPORTANCE TO MEMBERS: This platform is intended to introduce clinicians and researchers to Boot Camp Translation as a means of translating evidence-based medical guidelines into culturally-meaningful messaging, with the ultimate goal of reducing service-related disparities.
THE ROLE OF PHYSICAL THERAPISTS IN CREATING INCLUSIVE WELLNESS PROGRAMS FOR CHILDREN WITH AND WITHOUT DISABILITIES: PERCEIVED BARRIERS AND FACILITATORS
Martino S (Physical Therapy, Stony Brook University), Mei W (Biology, Stony Brook University), Block P (Disability Studies, Stony Brook University)
PURPOSE/HYPOTHESIS: Physical therapists play an important role in health promotion and wellness and are integral healthcare professionals in linking wellness opportunities to individuals and populations with special health needs. Children who are overweight/obese lead sedentary lifestyles with lower physical activity (PA) levels and imbalanced energy consumption. Children with disabilities engage in less PA compared to their typically developing peers, and many children with medical conditions or disabilities that affect their activity levels or food intake are at heightened risk for overweight and obesity. Childhood obesity prevention/management programs may not consider adapting programs to make them inclusive and relevant for children with disabilities. These concerns have led to calls for more collaboration between various experts to address this disparity through inclusion team science. This study documents the inclusion team science model as applied in an interdisciplinary fitness program (Fit Kids for Life [FKFL]) developed and implemented for diverse groups of children with and without disabilities.
NUMBER OF SUBJECTS: 40
MATERIALS/METHODS: Qualitative methods (interviews, focus groups, and participant observation) were used for data collection. Four focus groups (n = 40), consisting of 7 children with BMI > 85th% and disability (autism spectrum, n = 4; Lowe syndrome, n = 1, Intellectual disability, n = 1, and Ewings Sarcoma/Hemipelvectomy, n = 1) 10 children with BMI > 85th% and without disability, 12 parents and 11 student volunteers, were conducted to explore factors perceived as barriers and facilitators to participation in the FKFL program for children with disability. Data were analyzed thematically by two researchers.
RESULTS: Four themes were identified: 1) inclusive team approach may have lowered obesity stigma, 2) children with and without disabilities formed bonds and demonstrated increased socialization, 3) parents play important, yet different roles, and 4) communication is needed to facilitate student volunteers.
CONCLUSIONS: Improved social skills between the disabled and nondisabled group members as well as the integral role of families and volunteers in supporting these children influenced PA participation. Parents reported that children with disability face additional barriers to PA participation compared to children with typical development including a lack of local opportunities, lack of inclusive sites, lack of instructor skills and negative societal attitudes towards disability. Reports of increased PA, better nutritional choices and reduced obesity stigma are indicative of success of the inclusive approach of the FKFL program.
CLINICAL RELEVANCE: The perspectives gathered in this study are relevant to physical therapists as we begin to engage in pediatric wellness models. An inclusive, collaborative team approach appears to be both feasible and appropriate for this population.
SPATIAL AND TEMPORAL CHARACTERISTICS OF SPONTANEOUS UPPER EXTREMITY MOVEMENTS IN INFANTS WITH NEONATAL STROKE
Mazzarella J, Heathcock J, Chaudhari A (Physical Therapy, The Ohio State University), Schram M (College of Public Health, The Ohio State University), McNally M (School of Health and Rehabilitation Sciences, College of Medicine, The Ohio State University), Ott B (College of Biomedical Sciences, The Ohio State University)
PURPOSE/HYPOTHESIS: Neonatal stroke (NS) occurs around the time of birth, and is the leading cause of hemiplegic cerebral palsy (CP). Motor asymmetries are not clinically apparent in this population before 6-9 months of age. Studies on infant reach development often utilize kinematic measurement for detailed analysis of movement. Spatial variables like movement length, and length of the hand path, and temporal variables like movement speed, and number of velocity peaks are often measured in these studies. To identify early differences in movement quality between infants with NS and typically developing (TD) infants, we measured these variables in spontaneous upper extremity (UE) movements of the infants at 8 weeks old. We hypothesized that infants with NS would demonstrate shorter movements with larger hand paths, creating a larger straightness ratio (SR), and slower movements with more velocity peaks, in their involved side compared to their uninvolved side, as well as in comparison to TD infants.
NUMBER OF SUBJECTS: 22 8-week-old, full-term infants, 11 TD and 11 with NS, confirmed with MRI by a radiologist.
MATERIALS/METHODS: The infants were secured in a custom chair, 30° from vertical, with a strap around the trunk that allowed free arm movement. Reflective markers were placed on both hands, and movement was recorded at 120 Hz for 3, 30-second trials, using a 10-camera VICON system. In each trial, a toy was presented to the infants at midline shoulder height to stimulate UE movements. Dependent variables included SR (path length/movement length), movement speed, and number of velocity peaks; all reliable measures of UE coordination in pediatric populations.
RESULTS: Independent samples Kruskal Wallis tests revealed no asymmetries between the left (L) and right (R) UE for TD infants (p > .05), confirming a valid control. Additionally, no asymmetries were present between the involved (I) and uninvolved (U) UE for infants with NS (p > .05): SR χ2(1) = .056, mean ranks: U = 32.94 I = 34.06; movement speed χ2(1) = .364, mean ranks: U = 34.39 I = 31.56; number of velocity peaks χ2(1) = .969, mean ranks: NS = 35.34 TD = 30.73. Additionally, there were no group mean differences (p > .05): SR χ2(1) = .752, mean ranks: NS = 37.23 TD = 41.77; movement speed χ2(1) = .419, mean ranks: NS = 40.32 TD = 36.93; number of velocity peaks χ2(1) = .519, mean ranks: NS = 37.53 TD = 41.30.
CONCLUSIONS: Contrary to our hypothesis, objective measurement with 3D motion capture revealed no difference in spontaneous UE movement between infants with NS and TD infants, nor asymmetries between the involved and uninvolved UE of infants with NS at 8 weeks of age. Future research could track these infants longitudinally, to identify the earliest age at which these differences are detectable.
CLINICAL RELEVANCE: These findings support the clinically observed period of asymptomatology in infants at risk for CP. This population would benefit from close monitoring throughout early development, in order to provide early intervention for those infants who do develop gross motor asymmetries.
PRESENTATION OF GAIT PARAMETERS AND MOTOR FUNCTION IN CHILDREN WITH GIANT AXONAL NEUROPATHY
Mebrahtu A, Matsubara J, Waite M, Stanley C, Zampieri C, Alter K, Jain M (Clinical Center/NIH, Rehabilitation Medicine Department), Norato G (National Institute of Neurological Disorders and Stroke, Clinical Trials Unit), 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 Section)
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 and severe sensorimotor neuropathy with associated cerebral and cerebellar white matter changes. Children and young adults with GAN demonstrate progressive difficulty with walking, breathing, and activities of daily living, with mortality occurring in the 2nd or 3rd decade of life. The objective of this study was to describe spatiotemporal gait parameters and investigate associations between these parameters and performance on the Motor Function Measure (MFM) in a group of children with GAN. We hypothesize that gait parameters are going to be altered and significantly associated with components of the MFM in our cohort.
NUMBER OF SUBJECTS: 14
MATERIALS/METHODS: 33 children with GAN seen under an NINDS natural history study protocol, and of them, 11 were non-ambulatory and 8 used assistive devices. Our analysis included the fourteen independently ambulatory subjects (8 males) with a mean age of 8.6 years. Gait assessment was performed with the GAITRite instrumented walkway system. Motor Function Measure (MFM) was used to quantify functional capabilities within 3 domains using an ordinal scoring system. The 3 domains are D1: standing and transfers, D2: axial and proximal motor function and D3: distal motor function.
RESULTS: We compared spatiotemporal gait parameters measured in our group against reported normative data for age and gender matched subjects ranging from 3-19 years. Results are reported as group means in % height (standard deviation): velocity = 77.5 (15.62), cadence = 106.67 (25.8), step length = 42.34 (11.29), step width = 12.48 (4.4) and double support % of gait cycle = 32.31% (7.4). We found significant differences between groups, showing that double support time was greater, velocity was slower and step width was wider among our cohort of children with GAN. Total MFM percent scores were 79.6 (11.06) while domains were 58.33 (23.53), 98.71 (1.9), 85.88 (10.30) for D1, D2, D3 respectively. Spearman's correlation between MFM scores and gait parameters showed significant relationships between MFM D1 and step width (r = −.756, p < .002), D2 and velocity (r = .642, p < .01) and MFM Total with step width (r = −.664, p < .01).
CONCLUSIONS: These results further support that children with GAN have impaired walking ability and reduced motor function. Correlation results indicated that subjects with wider step width and slower gait velocity perform worse on activities such as transferring, standing, walking, and running.
CLINICAL RELEVANCE: As there is an active intrathecal AAV9 mediated gene therapy trial (NCT02362438) at the NIH, it is critical to identify and understand additional measures describing disease progression to assess the effectiveness of these therapies.
MUSCULOSKELETAL PAIN IN TEENS AND ADULTS WITH AUTISM SPECTRUM DISORDER
Miller C, Powell G, Lakie A, McElroy J (University of Missouri)
PURPOSE/HYPOTHESIS: The purpose of this study was to examine the prevalence of musculoskeletal low back (BMP) and lower extremity pain (LEMP) in individuals older than 12 years (yrs) with a diagnosis of Autism Spectrum Disorder (ASD). The secondary purpose was to examine the relationship between toe walking and pain, hypothesizing there would be a significant positive correlation.
NUMBER OF SUBJECTS: 98
MATERIALS/METHODS: A 100 question survey was emailed to 740 individuals with a diagnosis of ASD. Survey questions addressed BMP and LEMP, pain duration, and toe walking. Descriptive statistics were used to analyze pain frequencies. Correlations between pain and toe walking were examined using Pearson's chi-squared tests.
RESULTS: There were 98 completed surveys, 26 females and 72 males (median age 17 yr, range 13-52 yrs). Eighty-four percent of the surveys were completed by caregivers. Fifty-five percent of participants reported musculoskeletal pain, and males and females reported pain at similar rates. Pain was most often reported in the low back (32%), followed by foot (22%), knee (21%), ankle (19%), and hip (9%). Chronic pain (lasting 3 months or longer) comprised 80% of the reported pain. Chronic LEMP was present in 27% of the teens surveyed (13-18 yrs) and 46% of the adults surveyed (19-29 yrs). Teens reported chronic pain less frequently than adults in the back (27% vs 39%), hip (5% vs 15%), and ankle/foot (19% vs 30%). Thirty-nine percent of participants toe walked as a child and 18% continued to toe walk as teens or adults. Among participants who toe walked, 61% reported BMP and/or LEMP. There was a statistically significant correlation between chronic foot pain and participants who continued toe walking as a teen or adult (X2 [1, n = 74] = 12.856, p = .001).
CONCLUSIONS: Teens and adults with a diagnosis of ASD report rates of musculoskeletal pain similar to rates reported in the general population. Compared specifically to published prevalence rates of non-traumatic chronic LEMP, teens with ASD reported chronic pain rates double that of teens in the general population. Ankle/foot prevalence was also twice as high, while hip and knee prevalences were similar to the general population. Pain report rates were similar between genders, in contrast to higher rates reported by females in previous general population studies. Back, hip, and ankle/foot pain rates were higher in the adult group compared to the teen group. Prolonged toe walking was significantly associated with chronic foot pain, supporting the study hypothesis.
CLINICAL RELEVANCE: Physical therapists need to be aware of the musculoskeletal back and lower extremity pain associated with ASD. Pain prevention should be included in early therapeutic interventions and adult clinics should be prepared to interact and treat these individuals by understanding the implications of ASD. Further research is needed to determine the etiologies of musculoskeletal pain in ASD given the differences in movement and gait, with special attention given to toe walking in this population.
TOTAL CONTACT CASTING FOR A CHRONIC FOOT WOUND IN AN 11-YEAR-OLD MALE PATIENT
Mikolaj K (Physical Therapy, Children's Hospital Colorado), Circle A, Devick K, Khechoyan D (Plastic Surgery, Children's Hospital Colorado)
BACKGROUND & PURPOSE: To utilize total contact casting (TCC) and gait analysis to heal a chronic foot wound in a pediatric patient. This case study demonstrates the efficacy of TCC and the use of a partial gait lab study to heal a chronic foot wound while allowing participation in normal activity and activities of daily living.
CASE DESCRIPTION: The patient presented to the wound clinic with a chronic pressure injury to the plantar lateral aspect of his right foot along his 5th metatarsal. The wound, a multi-year recurring issue, was created when the patient rubbed his foot along the bottom of a swimming pool and became exacerbated by orthotic use. The patient has a complex medical history including spina bifida and right club foot, both of which have been surgically repaired. He uses a left knee-ankle-foot orthotic and a right ankle-foot-orthotic for ambulation.
Our wound clinic utilizes a multidisciplinary team approach and adjusted their treatment plan from a soft dressing to a dressing in combination with TCC. TCC was used as it is considered the ‘gold standard’ treatment in the adult population to offload plantar neuropathic ulcers. Our patient was actively treated with wound care and the TCC technique for nine weeks, in which time the wound fully healed. Unfortunately, he returned to the wound clinic two months later as the wound re-opened related to right ankle-foot-orthotic use. This led to an additional seven weeks of TCC to reclose the wound. As the pressure wound was related to his orthotic use, we referred him to the Center for Gait and Movement Analysis. They performed a partial gait lab study to address the pressure areas of his current orthotic. After analyzing the results of the gait study, the orthotist fabricated a new ankle-foot-orthotic that mirrored the offloading effects of a cast. After his wound healed, he was fit for a new ankle-foot-orthotic and has not had issues with re-formation of an open wound.
OUTCOMES: The patient's wound healed following multiple weeks of TCC in combination with gait analysis to mirror the offloading effects of a cast. The utilization of weekly TCC is effective in treating chronic foot wounds and allowed for the preservation of the patient's active lifestyle. Without the use of this casting technique, restricting the patient's ability to ambulate would have led to decreased endurance, circulation, social interactions and overall quality of life.
DISCUSSION: A multidisciplinary team approach leads to efficient and quality patient care. TCC is effective in reducing plantar pressure when treating chronic foot wounds in pediatric patients. Immobilization of the ankle joint reduces pressure in the forefoot and plantar regions from walking. The elimination of sheer forces on the wound bed while in the cast also promotes wound healing. Strength and mobility should be assessed with each cast change and following treatment. The PT's knowledge of anatomy, wounds, application of dressings, and positioning of the foot within the cast are critical components that support optimal outcomes and success of this technique.
PARTICIPATION IN SCHOOL TRIPS FOR STUDENTS WITH DISABILITIES: IDENTIFICATION OF BARRIERS AND STRATEGIES BY SCHOOL TRIP SITES
Monaco N, Burns D, Giri M, Wynarczuk K, (Kean Unviersity)
PURPOSE/HYPOTHESIS: School trips are a very important aspect of the education of all students. Students with disabilities frequently encounter accessibility issues with school trips, especially related to physical mobility, sensory, health, or behavioral needs. To fully participate in a school trip, special accommodations may be needed for students with disabilities. School trip destination sites may be instrumental to help school teams plan school trips. The purpose of this study was to gain the perspectives of school trip site personnel on 1) barriers faced by students with disabilities during school trips and 2) strategies to accommodate students with disabilities.
NUMBER OF SUBJECTS: Ten participants including administrative staff, tour guides, and group sales employees from six school trip destination sites. Sites included history-, science-, recreation-, arts-, and environmental-related school trip destinations.
MATERIALS/METHODS: Participants were recruited from a list of school trip destination sites created by the researchers. Researchers completed structured in-depth interviews with participants from each site (via phone or in-person) to discuss school trip barriers and accommodations for students with disabilities.
RESULTS: The major barrier to school trip participation from the perspective of site personnel is lack of communication and planning prior to a trip. Sites currently primarily focus on and provide accommodations for physical disabilities, including specialized wheelchairs to access outdoor terrain, specialized seating, and the use of technology to increase accessibility to locations that are not ADA compliant. Sites identified and discussed a need to accommodate sensory-, health-, and behavior-related concerns. Sites expressed a need for a structured way to facilitate communicate with schools regarding needed and available accommodations.
CONCLUSIONS: Students with disabilities face barriers to participation when attending a school trip. School trip destination staff are motivated to improve their ability to accommodate all students by developing strategies to address site-specific barriers. A commonly discussed barrier in the interviews was lack of communication, which indicates a need for a site-specific tool to organize the accommodations information sites wish to disseminate.
CLINICAL RELEVANCE: School trips are a critical part of learning for students and a key component of educational programs throughout many levels of education. The active learning opportunities provided by school trips provide multi-experiential learning, contribute to the perception of being a part of the class, increase academic understanding, and expand students' awareness of their community. This study provides valuable information to identify planning and accommodations for students with disabilities. Such information may facilitate planning and ensuring inclusion and full participation of every student on school trips.
SCHOOL TRIP SITE PERSONNEL FEEDBACK ON THE SCHOOL TRIP ACCOMMODATIONS TOOL FOR STUDENTS WITH DISABILITIES
Monaco N, Burns D, Giri M, Wynarczuk K, (Kean Unviersity)
PURPOSE/HYPOTHESIS: The School Trip Accommodations Tool – Student Form and Site Form (STAT) was developed to assist school teams plan trips for students with disabilities. Utilizing a standardized tool to identify needed accommodations ahead of a school trip is expected to allow trips to run more smoothly for both school and destination site personnel. Previous research investigated the validity and utility of the STAT from the perspectives of school personnel. The purpose of this study was to investigate the face validity and perceived utility of the STAT-Site Form from the perspective of school trip site personnel.
NUMBER OF SUBJECTS: Ten participants, including administrative staff, tour guides, and group sales employees from six school trip sites. Sites included history-, science-, recreation-, arts-, and environmental-related school trip destinations.
MATERIALS/METHODS: Participants were recruited from a list of school trip sites. During structured meetings, researchers reviewed the STAT with each participant and provided training on the intended use of the tool. After reviewing the STAT, researchers facilitated discussion to elicit initial verbal feedback on the tool. After the meeting, participants completed a questionnaire to assess face validity and perceived utility of the STAT-Site Form. Each questionnaire included open-ended questions and guiding statements with Likert scale responses. A four-point Likert scale was used; the lower two responses were considered “do not agree” and the upper two responses were considered “agree.” A response of “agree” by at least 80% of participants indicated consensus on agreement of each guiding statement. Participants mailed completed questionnaires back to researchers.
RESULTS: All participants agreed that the mobility, terrain, and sensory sections of the STAT-Site Form adequately reflected barriers that might impact a student's ability to access and participate in a school trip. However, the food/cafeteria section did not reach consensus of being adequate. All participants agreed that the STAT-Site Form is understandable, that it adequately considers major barriers encountered by students with disabilities, that it would be helpful in planning, and that it would decrease the chance of an unexpected barrier during a school trip. Participants reported that they would like a site-specific tool to disseminate information about their site.
CONCLUSIONS: Participants' responses indicate that the STAT-Site Form is received positively by school trip site personnel, with initial indicators of face validity and perceived utility. However, sites would like an easily accessible and distributable site-specific tool to initiate communication with schools about needed accommodations.
CLINICAL RELEVANCE: School trips are a key component of educational programs. The STAT-Site Form was well received by school trip destination site personnel. Use of the STAT-Site Form may facilitate communication between schools and school trip sites and may aid in achieving maximal participation of students with disabilities on school trips.
LOWER EXTREMITY FUNCTIONAL TRAINING (LIFT) IN YOUNG CHILDREN WITH UNILATERAL SPASTIC CEREBRAL PALSY: IMMEDIATE AND LONG TERM OUTCOMES
Moreau N (Louisiana State University Health Sciences Center), Surana B, Gordon A (Biobehavioral Sciences, Columbia University), Dew A (Rehab Services, Ochsner Health System), Ferre C (Burke-Cornell Medical Research Institute), Brandao M (Universidade Federal de Minas Gerais, Belo Horizonte, MG, BRAZIL)
PURPOSE/HYPOTHESIS: Children with unilateral spastic cerebral palsy (USCP) have strength, coordination, and balance deficits affecting gross motor skills, such as walking, running, and jumping. However, there is a paucity of evidence for effective treatments for lower extremity function in children with USCP. The purpose of this randomized controlled trial was to determine the effectiveness of Lower Extremity Intensive Functional Training (LIFT) compared to an attention control group receiving upper extremity bimanual training (H-HABIT). A unique design of the study was delivery in a home-based setting.
NUMBER OF SUBJECTS: 24 subjects provided 80% power to detect group differences
MATERIALS/METHODS: Children with USCP between the ages of 2 and 13 were randomized to receive 90 hours of LIFT (5.8(2.3) years) or an equivalent dosage of H-HABIT (5.1(2.6) years) delivered 2 hours/day, 5 days/week for 9 weeks. Caregivers were trained to administer the intervention in the home setting. Progress and skill progression were monitored, and supervision was provided weekly via telerehabilitation. Primary outcome was the 1-minute walk test (1MWT). Secondary outcomes included self-selected and fast walking speeds, ABILOCO, 30-s chair rise test, and single leg stance. Outcomes were assessed at baseline, immediately post-training, and at 6 months post-training. Intent-to-treat analysis was performed. Linear mixed models were used to compare changes over time.
RESULTS: The groups were similar at baseline for all demographic variables and outcomes. The LIFT group demonstrated greater improvement than controls for the 1MWT (group x session; p = 0.017) at post and 6 month follow-up. Overall locomotion ability (ABILOCO) improved in LIFT as compared to controls (group x session; p = 0.008). Fast gait speed approached significance in favor of LIFT (p = 0.06). The other secondary outcomes were not different between groups.
CONCLUSIONS: To our knowledge, this was the first randomized trial to examine the effectiveness of intensive lower extremity training in children with USCP provided by caregivers in the home setting using telerehabilitation. As compared to an intervention of equal intensity and duration that also controlled for the increased social interaction and attention between caregiver and child, LIFT resulted in improvements in ambulation distance and overall walking ability that were maintained at 6 months.
CLINICAL RELEVANCE: The administration of lower extremity intensive interventions in the home setting by caregivers was shown to be an effective and novel mode of delivery that can be monitored via telerehabilitation. The LIFT dosage was modeled off of bimanual training studies for children with USCP, which have been extensively reported in the literature. However, the appropriate dosage for lower extremity training in USCP has not been determined. Future dosing studies are needed to determine whether reduced training hours or an altered practice schedule would produce similar or greater improvements to those reported in the present study.
MOTOR COMPETENCY AND PHYSICAL ACTIVITY IN YOUNG AMBASSADORS OF PHYSICAL EDUCATION
Norman C, Geer W, Looper J (University of Puget Sound)
PURPOSE/HYPOTHESIS: The Young Ambassadors of Physical Education (YA) is a program designed to promote physical activity in school age children. YA focuses on non-sport based physical activities, which are different from the skills often tested in norm-refenced tests; including the Test of Gross Motor Development (TGMD-2). Despite the children in YA being highly motor competent, these tests may fail to accurately assess their motor skills. The purpose of this study it to determine whether the TGMD-2 can identify the children in YA as competent in their motor skills, and determine if there is a link between the overall physical activity level of the children in YA and their motor competency scores. It was hypothesized that the TGMD-2 would misclassify YA participants as having average motor competence, and that children with higher levels of physical activity would score higher on the TGMD-2.
NUMBER OF SUBJECTS: 12
MATERIALS/METHODS: Participants for this study were recruited from the 2017 YA program, part of Tacoma Public Schools. Two researchers trained in the administration of the TGMD-2 completed all the testing as described in the test manual. Each researcher administered the same portion of the test every session. Testing was completed in an elementary school gymnasium directly following YA practice in groups three to five over a period of 3 weeks. Following completion of the TGMD-2, each participant was fitted at the waist with an Actigraph activity monitor, which was worn for the next five consecutive days. Participants were also provided a journal to record each time the Actigraph was removed or put back on. Guardian signatures were required for each journal entry to ensure that Actigraphs were being properly used.
RESULTS: Descriptive scores on the TGMD-2 range from below average to above average, representing scores from the 25th percentile for children of the same age and gender to the 95th percentile. There was no significant difference between locomotor and object control scores (p = 0.898). No correlation was found between physical activity levels and TGMD-2 locomotor scores (R = 0.09, p = 0.767) or object control score (R = 0.09, p = 0.781). Participants spent an average of 177.9 ± 35.3 min in MVPA during the weekday and 185.9 ± 79.2 min in MVPA on the weekend.
CONCLUSIONS: It was expected that the children in YA would demonstrate above average scores on the TGMD-2 due to their proficiency in complex motor skills and high activity levels. However, this study demonstrates that these factors do not correlate with average or above average scores on the test. The TGMD-2 may not be the best tool for measuring motor proficiency in specific populations of children that practice non-traditional motor skills in their activities.
CLINICAL RELEVANCE: Due to the widespread use of the TGMD-2 to identify fundamental motor skills in children, understanding the limitations of the test is an important area of research. For children that are highly active, but utilize non-traditional motor skills, clinicians should carefully select an outcome measure that accurately assess the child's motor proficiency.
PROGRESSION OF GAIT TRAINING FROM BODY WEIGHT SUPPORTED TREADMILL THERAPY (BWSTT) TO OVER GROUND GAIT TRAINING (GT) WITH AN ASSISTIVE DEVICE (AD) IN A CHILD WITH CEREBRAL PALSY: A CASE REPORT
Ngan-Monzon J (California Children's Services, Monrovia, California)
BACKGROUND & PURPOSE: The pt showed meaningful functional changes after targeted over ground GT with an AD compared to the initial BWSTT. This may due to BWSTT did not provide sufficient task specificity to meet the unique needs of children at GMFCS Levels IV and III, who used ADs for mobility. BWSTT provided a safe and structured environment for children to practice symmetrical and efficient stepping with high repetitions. Targeted over ground GT provided task specific learning opportunities for children to work on balance and problem solving using an AD. The transition from BWSTT to targeted over ground GT is a logical progression when working with children who are learning to walk using an AD.
CASE DESCRIPTION: Pt was a 5 year 4 month old boy with tetraplegia CP, GMFCS Level IV. He scored 49.6 on the GMFM-66 and functioned at 90th percentile per Motor Growth Chart. Pt walked with mod A using a gait trainer. Mother would like him to walk using a walker at home per Canadian Occupational Performance Measures (COPM).
Per training protocol of Kurz et al., pt was recommended to receive PT 2x/week for 12 weeks, with 20 min of BWSTT. He completed PT 3x/week for 12 weeks; 30min on the treadmill every session. Attempts to integrate over ground GT with each BWSTT session were unsuccessful due to pt's reported fatigue.
After completion of BWSTT, pt participated in targeted over ground GT using a reverse walker for 36 additional weeks at 2x/week. The 6 min walk test (6MWT) was completed every 12 weeks to monitor his progress. Parents also practiced standing and walking with the pt everyday using a gait trainer without trunk supports at home.
OUTCOMES: After 12 weeks of BWSTT, pt's GMFM-66 score improved to 51.6 (a 4% improvement) and 6MWT increased 13% from 189ft to 214ft. He continued to function at GMFCS Level IV requiring mod A for ambulation using a gait trainer. Mother reported no change in performance per COPM.
After 36 weeks of targeted over ground GT, pt walked with supervision using a reverse walker. His GMFM-66 score remained at 51.6 but he showed improved performance in areas of standing and walking. The pt was classified as GMFCS Level III and functioned at 45th percentile per Motor Growth Curve. He ambulated 326ft during 6MWT, a 72% improvement when compared to his status prior to BWSTT. Mother reported 80% improvements of his ambulation status and her satisfaction as 90% per COPM.
DISCUSSION: Family participation was vital for the pt to practice negotiating environments at home and in the community. Combining BWSTT and over ground GT within a treatment session was determined to be non-feasible with young children due to fatigue. In this case study, family commitment to practice along with 48 weeks of BWSTT and targeted over ground GT led to this pt's improvement from GMFCS IV to III. Other children with CP, GMFCS level IV may benefit from a similar plan of care because meaningful functional changes are possible with PT and family participation.
INFLUENCE OF DIFFERENT TOYS ON THE FREQUENCY OF REACHING IN INFANTS WITH GMFCS LEVELS III-V
Nyktas D, Oliveira Barbosa G, Sigmon K (School of Health and Rehabilitation Sciences, Division of Physical Therapy), Bican R (The Ohio State University), Heathcock J (Ohio State University)
PURPOSE/HYPOTHESIS: Cerebral palsy is a neurological disorder caused by a brain injury. This injury disrupts the development of motor control and posture effecting gross and fine motor function like reaching. Successful reaching allows an infant to gather information and learn through object exploration. Physical properties of a toy can shape the motor actions of reaching behaviors in infants with typical development. The purpose of this study is to describe the influence of different toys on characteristics of reaching in infants with CP GMFCS level III-V.
NUMBER OF SUBJECTS: N = 15 (N = 5 in each GMFCS level III, IV, and V) age 15.2 ± 7.4 months.
MATERIALS/METHODS: Participants were seated in a chair and presented with four toys (ball, maraca, maraca handle and glow wand). Each toy was presented for 2 × 30 second trials at the child's midline, shoulder height, and within arm's length. Hand-toy contacts were coded using Datavyu, a behavioral coding software program. The frequency of reaching statistical analysis was completed using the Mann-Whitney U Test.
RESULTS: Participants in GMFCS III reached a total of 458 times. They reached for the ball 30.7%, maraca 25.1%, maraca handle 15.4%, and glow wand 28.7%. GMFCS IV completed 596 reaches. They reached for the ball 36.2%, maraca 24.3%, maraca handle 20%, and glow wand 19.5%. GMFCS V completed 8 reaches. They reached for the ball 36.2%, maraca 24.3%, maraca handle 20%, and glow wand 19.5%. GMFCS III and IV had the most success with the ball and GMFCS V had the most success with the maraca and maraca handle. Results indicated a significant difference in reaches between participants in GMFCS III and V and levels IV and V, p = 0.01208 with infants in GMFCS V reaching only 1.7% of the total reaches of the infants in GMFCS III.
CONCLUSIONS: Our study suggests successful reaching is dependent upon toy characteristics and varies by motor function. GMFCS III, were most engaged by the ball and glow wand, toys that are larger and visually stimulating. GMFCS IV, showed a preference for the larger toy, the ball, a toy easy to engage with due to its size. GMFCS V, demonstrated an ease of reaching for the maraca and maraca handle, possibly due to the auditory feedback the child receives when they touch it. GMFCS levels III and IV demonstrate similar ability to reach. GMFCS V show a significantly decreased ability to reach compared to the infants in GMFCS III and IV demonstrating a disproportionately lower amount of time infants in GMFCS V can actively engage with and learn from toys.
CLINICAL RELEVANCE: Reaching behaviors are applicable to clinicians and families as they present differently in high risk infants. Therefore, they can influence learning and development and offer opportunities to clinicians and families for targeted intervention strategies. These differences can also lead to different preferences for toys based on their gross motor function abilities. By measuring and learning these toy preferences, clinicians can tailor their play-based interventions, increase engagement and repetition during therapy and home, and possibly improve outcomes.
THE RECOMMENDED TREADMILL TRAINING PARAMETERS FOR CEREBRAL PALSY PATIENTS: A SYSTEMATIC REVIEW
Obaidat S (Physical Therapy and Rehabilitation Science, KUMC), Sasse L, Clayton S, Oligbo M (Physical Therapy and Rehabilitation Science, University of Kansas Medical Center), Liu W (Physical Therapy & Rehabilitation Science, University of Knasas Medical Center)
PURPOSE/HYPOTHESIS: Improving walking and function in children with cerebral palsy (CP) has long been a primary concern of physical therapy. Treadmill training (TMT) has been utilized frequently in CP rehabilitation. So far, TMT protocols are widely variable. Up To the best of our knowledge, no previous study had compared settings of TMT protocols in CP population. In this review, we examined variations in current TMT protocols reported and their possible association to specific outcomes.
NUMBER OF SUBJECTS: NA
MATERIALS/METHODS: Systematic Review. The databases CINAHL, PubMed, Cochrane, and PEDro were searched from February 2017 to January 2018 using specific selective criteria.
We reviewed randomized clinical trials in patients with CP diagnosis, in which TMT constituted at least 50% of their rehabilitation intervention. Functional outcomes included Gross Motor Function Measure (GMFM), walking speed, and walking endurance measured by the 6 Minute Walk Test (6MWT). We extracted the data about participants' functional level; protocol length, session duration and intensity. The quality of each reviewed trial study was evaluated according to PEDro quality scale (0-11 score, where 0 is lowest quality).
RESULTS: Twelve articles met selective criteria and were included in this review. The sample size ranged from 15 to 36 (Total n = 305), with mean ages between 3 to 19 years. The length of ranged from 6-12 weeks, with 20-40 minutes per session at a frequency of 2-5 sessions per week. Four studies used individualized TMT speed for 2x/week over 6-7 weeks and reported positive results in GMFM; while 5 studies reported positive findings in over ground walking speed by using the individualized TMT speed for > 30 minutes and > 7 weeks. Only 1 trial showed improvement in 6MWT with TMT 2x/week for 6 weeks, while 2 trials showed improvements in 6MWT using training duration > 7 weeks for 3x/week.
CONCLUSIONS: TMT training using individualized tolerated speed with high frequency and long training period may lead to improvements in multiple outcomes. With less aggressive intensity, TMT may still improve gross motor function in children with CP
CLINICAL RELEVANCE: This review showed high variability in TMT training protocols and a trend in favor of higher frequency and longer duration in TMT training. This review may help clinicians to develop training guidelines based on functional objectives.
VALIDITY OF THE CONGENITAL MUSCULAR TORTICOLLIS SEVERITY CLASSIFICATION SYSTEM
Oledzka M (Pediatric Rehabilitation, Hospital for Special Surgery), Kaplan S (Rehabilitation and Movement Sciences, Rutgers, The State University of New Jersey), Sweeney S (Pediatric Science, Rocky Mountain University of Health Professions), Evans-Rogers D (Rocky Mountain University), Coulter C (Orthotics and Prosthetics, Children's Healthcare of Atlanta)
PURPOSE/HYPOTHESIS: The 2013 congenital muscular torticollis (CMT) clinical practice guideline (CPG) proposed a 7-grade CMT severity classification system (CMT-SCS). The purpose of this study is to evaluate outcomes for 352 consecutive patients with CMT who were seen at the PI's institution from 2010-2013 and to examine the relationship between grades of severity and length of treatment. We hypothesized that there will be a positive relationship between the increasing severity of grades within age groups and length of treatment.
NUMBER OF SUBJECTS: 331
MATERIALS/METHODS: Data for this study was derived from the PI's institution's CMT database containing data from initial evaluations and discharge summaries of all clients with CMT treated between 2010 and 2013. Descriptive analysis of all 331 cases assessed natural grades' distribution. One-way ANOVA was used to compare the continuous variables, while chi-square tests were used to compare the discrete variables for the “early” group. Mann-Whitney U tests were used to compare the continuous variables and Chi-square tests were used to compare the categorical variables in the “late” group. ANCOVA was used to analyze if lateral flexion limitation has an effect on treatment duration.
RESULTS: Out of 331 patients who initiated therapy, 164 completed full treatment. Grade distribution among the 331 cases was as follows: the “early” group included 80% of children: Grade 1: 159 (48%), Grade 2: 70 (21%), and Grade 3: 41 (11%). The “Late” group included 18% of children: Grade 4: 38 (11%), Grade 5: 9 (3%), Grade 6: 5 (2%), and Grade 7: 3 cases (1%). There was no corresponding grade for 6 cases (2%). Only one child required surgical intervention (.33%). Mean age of initial assessment in the “early” group was 2.9 months (SD = 1.43) and in the “late” group was 8.35 months (SD = 1.78).
The “early” group had a statistically significant difference between groups and treatment duration (p = 0.039) with longer treatment duration with increase in an severity grade. There was no difference in treatment duration in the “late” group.
For severity grades 1-3, there was no effect of lateral flexion on the relationship between severity grade and treatment duration (p = 0.984). For grades 4-7 even after adjusting for lateral flexion, there was no difference in treatment duration between severity grades (p = 0.533).
CONCLUSIONS: There is a positive relationship between severity grades and treatment duration within the “early” group; however there is no difference in treatment duration between severity grades in the “older” group. Lateral flexion limitations in cervical range of motion had no effect on treatment duration.
CLINICAL RELEVANCE: Understanding of the natural grade distribution among infants and the relationship between grades and treatment duration will strengthen future research and inform future revisions of the CPG and CMT-SCS. Validation of the CMT classification scheme for infants younger than 7 months supports use of the CMT-SCS in clinical documentation and communication among professionals treating CMT by providing standardized language and decision pathways.
MEASURING PHYSICAL ACTIVITY INTENSITY IN YOUTH WITH CEREBRAL PALSY WHO ARE AMBULATORY: CONSIDERATIONS FOR ‘DOSING’ PHYSICAL THERAPY INTERVENTIONS
O'Neil M, Dagan M, Jurcik D, Brody M, Betta J (Physical Therapy & Rehabilitation Sciences, Drexel University), Chopski S (Biomedical Engineering, Drexel University), Mayer A, Lint S, Goetschius C (Rehabilitation Services, St. Christopher's Hospital for Children), Kondrad M, Feehan K, Turchi R (Center for CYSHCN, St. Christopher's Hospital for Children)
PURPOSE/HYPOTHESIS: Ambulatory youth with cerebral palsy (CP) may benefit from physical therapy (PT) interventions that ‘dose’ physical activity (PA) intensity to promote fitness, functional mobility and participation in activities of daily living (ADLs). The purpose of this study was to measure PA intensity during an ADL protocol to determine aerobic demands.
NUMBER OF SUBJECTS: Twenty ambulatory youth with CP participated (mean age: 13.10 years, SD = 0.72; boys, n = 12, 60%). Youth were GMFCS Levels I (n = 1, 5%), II (n = 14, 70%) and III (n = 5, 25%).
MATERIALS/METHODS: Parents and youth completed Consent and Assent Forms and Health Questionnaires. Youth participated in an ADL protocol consisting of six activity trials (six minutes each). The protocol included ADLs across a range of PA intensities (i.e, sedentary, light, and moderate). Youth were randomly assigned to Protocol A or B with variety on 2 activity trials. Activities included supine resting, writing at a desk or wiping a counter, playing active video games (AVGs) or stair climbing, walking at comfortable and fast self-selected speeds, and negotiating obstacles. Youth at GMFCS III did AVG instead of stairclimbing. PA intensity was measured during the ADL protocol. Youth wore: 1) a Cosmed® indirect calorimeter to measure oxygen consumption (VO2) and 2) a Polar® heart rate (HR) monitor. MET values were calculated using VO2 and resting metabolic rate. Descriptive data analyses were generated to identify youth perceptions and ratings on PA experiences and to identify the PA intensity for activity trials. Correlations were calculated to examine relationships among the exercise variables (VO2, METs, and HR).
RESULTS: On average, youth reported that: 1) they participate in 5 days of moderate to vigorous PA per week; 2) pain is a barrier to PA ‘once in a while’; 3) fatigue is a barrier to PA ‘50% of the time’; and 4) they enjoy PA ‘very much’. PA intensity was measured by: 1) average HR (range: 82 – 126 bpm; average VO2 (range: 5.70 – 19.68 ml/kg/min; and average MET values (range: 1.25 – 5.21).
MET values across trials suggest that: 1) supine rest is a very light activity (1.25 METS); 2) writing and cleaning a counter are very light to moderate activities (1.44 and 3.31 METS); 3) AVG play and stair climbing are moderate activities (3.00 and 5.21 METS); 4) walking at a comfortable pace is a moderate activity (3.83 METS); 5) walking at a fast pace is a moderate activity (4.53 METS) and 6) navigating a short obstacle course is a light activity (2.23 METS).
Spearman correlations are significant for: HR and VO2 (r = 0.87, p = 0.02); HR and METs (r = 0.87, p = 0.02); and VO2 and METS (r = 1.00, p = .01)
CONCLUSIONS: Findings show wide variability in PA intensity across activity trials in the ADL protocol. Findings suggest that HR may be a good clinical proxy measure for PA intensity.
CLINICAL RELEVANCE: It is important to consider dosing PA intensity in PT interventions to achieve child and family goals and promote fitness, mobility and participation in ADLs.
THE IMPACT OF A ROCK CLIMBING PROGRAM ON CHILDREN WITH ATTENTION DEFICIT HYPERACTIVITY DISORDER
Oriel K, Price J, Angelini E, Cook K, Drawbaugh R, Payung K, Weidemoyer G (Physical Therapy, Lebanon Valley College)
PURPOSE/HYPOTHESIS: Children with Attention Deficit Hyperactivity Disorder (ADHD) demonstrate decreased attention and planning that has adverse effects on behavior and success in the classroom, home, and with peers in community-based settings. Preliminary evidence suggests that rock climbing may improve attention, problem solving, and the ability to learn from mistakes. The use of rock climbing in children with ADHD has largely been unexplored. The purpose of this study was to explore the effects of rock climbing on attention in children with ADHD.
NUMBER OF SUBJECTS: Participants included five children (4 males, 1 female) with a medical diagnosis of ADHD between the ages of 8-13 years (mean age = 10 years).
MATERIALS/METHODS: Participants with ADHD were recruited to participate in a rock climbing program which was held 1X/week for 8 weeks. Before and after every session, participants completed a trail making test to quantify attention. Resting and working heart rates were also measured each week to allow for exercise intensity to be calculated. Following the last climbing session, parents were asked to complete the Intervention Rating Profile (IRP-15) to determine the social validity of the intervention.
RESULTS: Pre and post intervention means of the trail making test were compared using the Wilcoxon Signed Ranks Test. Statistically significant improvements were demonstrated (p = 0.43). Regarding exercise intensity, two participants worked at a moderate intensity, while three worked at a light intensity. All IRP-15 scores were above the 52.5 cut score, indicating that the intervention was socially valid. All families indicated that they would be willing to participate in rock climbing again.
CONCLUSIONS: Participation in a rock climbing program at a light to moderate intensity appeared to have a positive impact on attention in children with ADHD. Rock climbing was also found to be a socially valid activity.
CLINICAL RELEVANCE: Rock climbing should be considered and recommended by pediatric physical therapists for patients who have difficulty with attention and focus. Additionally, rock climbing can be adapted in a variety of ways for many patient populations, and is ideal for children who have difficulty with team sports.
UTILIZATION OF EXERCISE IN SCHOOL-BASED SETTINGS FOR CHILDREN WITH AUTISM SPECTRUM DISORDER
Oriel K, Reed T, Saufley R, Wetzel E, Wilt C (Physical Therapy, Lebanon Valley College)
PURPOSE/HYPOTHESIS: Evidence suggests that exercise improves a variety of problem behaviors in children with Autism Spectrum Disorder (ASD). It has also been shown to positively impact academic success by improving correct responding and on-task time. As such, it is critical for ASD support teachers to implement an exercise routine in their classroom, although the degree to which exercise is being utilized is unclear. The purpose of this study was to determine the extent to which exercise is being incorporated into the school day for children with ASD.
NUMBER OF SUBJECTS: Forty-six teachers participated in the study. The majority were between the ages of 25-44 (69%) with a Master's degree (77%).
MATERIALS/METHODS: A survey was sent to ASD support teachers through the Council for Exceptional Children via email. The survey was developed to determine how, and the extent to which, exercise was being utilized by ASD support teachers. Descriptive statistics were used to describe quantitative data, while qualitative responses were read and re-read to identify themes among responses.
RESULTS: Results indicated that 97% of participants either agreed or strongly agreed that exercise is beneficial for children with ASD, while 83% indicated that they utilize exercise either every day or most of the time. Exercise occurred most often through classroom activities (varying types) multiple times per day. Twenty percent of teachers indicated that only some/not many of the children in their classroom participate in designed activities, while 80% indicated that all or most participate. Participants indicated (82.5%) that the children with ASD engaged at a moderate level (defined as participating at least half of the time and/or showing effort), versus high exertion which was described as face flushed, sweating, elevated breathing. The majority (72%) indicated that it is difficult to engage children with ASD in physical activity. Participants were also asked to describe the benefits and barriers to exercise in children with ASD. Emerging themes identified as benefits included improved focus, an opportunity for socialization, decreased problem behaviors, and improved self-regulation. Barriers included physical limitations, sensory issues, lack of staff, and varying interest levels.
CONCLUSIONS: Results suggested that ASD support teachers recognize the importance of allowing time for exercise in their classrooms, and are attempting to integrate exercise into the school day. While exercise appears to be being utilized, the activities utilized may not be at an intensity where the greatest benefits can be observed. It was also clear that teachers find engaging children with ASD a challenge, with several barriers limiting participation.
CLINICAL RELEVANCE: Pediatric physical therapists must play a key role in school-based settings in providing recommendations for exercise for children with ASD, as it has been shown to improve a variety of problem behaviors. Teachers appear to be attempting to incorporate exercise into daily routines, but may need guidance on how to utilize exercise most effectively.
PROMOTING CAPACITIES FOR FUTURE ADULT ROLES AND HEALTHY ADULT LIVING: A LLFECOURSE HEALTH DEVELOPMENT APPROACH
Palisano R (Physical Therapy & Rehabilitation Sciences, Drexel University), Di Rezze B, Stewart D, Freeman M (Rehabilitation Sciences, McMaster University, Hamilton, Ontario, CANADA), Hlyva O, Wolfe L (CanChild Centre, McMaster University), Rosenbaum P, Gorter J (Pediatrics, McMaster University)
PURPOSE/HYPOTHESIS: Children with cerebral palsy (CP) as they develop and make the transition to adulthood face challenges in the areas of health and wellness, socialization, education, community living, and employment. The objective was to describe how young adults with CP experience lifecourse health development (LCHD) and create key messages to promote children's capacities for future adult roles and healthy adult living.
NUMBER OF SUBJECTS: Participants were a purposive sample of 23 young adults with CP, 25 to 33 years of age (mean = 28.2, SD = 2.4) (10 females) who varied in functional abilities, education, living, and work situations. Eight had a bachelorr's or master's degree, 11 lived by themselves or with a partner, and 9 worked independently.
MATERIALS/METHODS: An interpretive description qualltatlve design was used. Three experienced Interviewers conducted 23 Interviews each lasting 50-60 minutes. Seventeen Interviews were with a young adult only, three with a young adult and parent, and three with a parent proxy of a young adult. Questions included: “What does healthy living or being healthy mean to you?” “What do you currently do to promote healthy living?” “Throughout your childhood and adolescence, what experiences influenced your development and interests in managing your health?” and “Looking back, is there anything that would have helped your development of abilities in managing health?” Transcripts of the interviews were analyzed to identify themes. Subsequently, a one-day meeting was held with an advisory group that included 3 young adults with CP, 2 parents of young adults with CP, 2 service providers, and 1 researcher. Input from the advisory group Informed our Interpretive description of key messages that are meanlngful and applicable to pediatric rehabllftation service providers.
RESULTS: Four themes emerged from the interviews: i) Personal lifecourse (dynamic nature of a person who is constantly changing throughout their life), ii) Contextual lifecourse (ongoing. mutual, interdependent relationships among a person and their life contexts), iii) Everyday experiences (develop capacities for current and future healthy living), and iv) Adaptive process (healthy living as a continual process of adaptations of individuals and their contexts). Key messages for pediatric rehabllltatlon service providers include: a) Address healthy living across the llfecourse, b) Focus on contexts of healthy living, c) Focus on everyday experiences and experlentlal learning, and d) Pay attention to the timing of opportunities and experiences. Action-oriented recommendations are provided to facilitate moving the key messages into practice.
CONCLUSIONS: The findings provide conceptual and practical support for a LCHD approach for individuals with CP through early adulthood that can be applied to pediatric rehabilitation.
CLINICAL RELEVANCE: Coordination and continuity of health care services between pediatric and adult systems and services and supports for desired soclal participation and achievement of personal goals are important considerations for healthy living.
A MULTI-YEAR, MIXED METHODS ASSESSMENT OF STUDENT COMPETENCY WITHIN A PEDIATRIC INTERPROFESSIONAL EDUCATION EXPERIENCE
Pawlowska M (Communication Disorders, Stockton University), Padden-Denmead M (Nursing, Stockton University), Kientz M (Occupational Therapy, Stockton University), Del Rossi L, Li Z, McGinnis P (Physical Therapy, Stockton University)
PURPOSE/HYPOTHESIS: Interprofessional education (IPE) provides students an opportunity to learn “about, with and from each other to improve the quality of care” (WHO). In the delivery of collaborative, family-centered pediatric care, parents are a team member. Learning to work as a team requires intentional practice. For students to practice working as a team, we created an immersion IPE experience called Baby Lab (BL) matching parents and infants/toddlers (dyad) with student teams from physical (PT), occupational (OT), speech therapy (SLP) and nursing (BSN).
This study was designed to measure student performance on objectives based on the IPEC core competencies over 3 years of BL. We hypothesized that BL would be a beneficial learning experience for all students regardless of discipline.
NUMBER OF SUBJECTS: 349 students participated (PT = 79, OT = 89, SLP = 93, BSN = 88).
MATERIALS/METHODS: Student performance was evaluated using instruments that recorded: 1) parent perceptions of student performance: the parent survey measured students' skills on a scale from 1-4 (none of the time-all the time) in the variables such as respect of parental values, provision of information, effective communication and trust. 2) faculty assessment and 3) student assessment utilizing a proficiency rubric: faculty and students rated observed student behaviors on 14 dimensions of the Interprofessional Collaborator Assessment Rubric (ICAR)using a scale of 1-4 (minimal-mastery). 4) student self-rated achievement of objectives: students rated self-efficacy on evaluation form objectives on a scale of 1-5 (n/a-excellent). 5) student written reflections: utilized guiding questions to identify new learning.
All students completed the same assignments, with a subset of student groups randomly selected for student/faculty observation with the ICAR. IRB approval was obtained for use of all data.
RESULTS: Parent responses were overwhelmingly positive on all eight variables. Students demonstrated developing, competent or mastery performance for all dimensions in faculty ICAR ratings. Active Listening was rated the highest (mean = 3.33 ± 0.62) and Information Sharing with Patient/Client was rated the lowest (mean = 2.73 ± 0.81). Student ICAR results were higher than faculty assessments across all dimensions. Student self-evaluation responses were rated at the level of good to excellent and students' perceptions did not differ based on discipline. Student reflections support these quantitative results highlighting experience strengths as well as strategies to enhance student learning.
CONCLUSIONS: This immersion learning experience was effective in meeting behavioral objectives based on the IPEC core competencies. Statistical analysis revealed that faculty, parents, and students perceived competency via direct and indirect measures. These outcomes close the feedback loop on the BL experience and guide future offerings.
CLINICAL RELEVANCE: IPE experiences can be integrated into many types of curricula with populations beyond pediatrics. Suggestions and guidelines for implementation will be discussed.
INNOVATIVE TREATMENT FOR CHILDREN WITH SMA TYPE 1 RECEIVING SPINRAZA: A CASE SERIES
Pillsbury L, Bagwell J (Creighton University), McHugh V (PT, Key Complete Therapies), Furze J (Department of Physical Therapy, Creighton University)
BACKGROUND & PURPOSE: Children with SMA1 receiving new medical managements now have an improved prognosis of attaining gross motor skills and surviving long beyond infancy. The purpose of this case series is to describe the developmental progression of achieved motor skills in patients with SMA1 receiving SPINRAZA and physical therapy treatment, and to describe the physical therapist's plan of care, innovative treatment strategies, and clinical reasoning process when treating this unique population.
CASE DESCRIPTION: Four children (1 male, 3 female) with SMA1 (age 8 mo – 5yo) were observed over a period of 12-20 weeks. Each child was receiving SPINRAZA injection maintenance dosing at the onset of observation, and had been receiving physical therapy services 1-2 times per week in land and aquatic settings. Interventions included unique manual facilitation strategies for gross motor skills and strengthening, positioning, whole body vibration, bracing/orthoses, and taping/strapping. Gross motor skills were assessed using the Children's Hospital of Philadelphia Test of Neuromuscular Disorders (INTEND), and three participants were additionally assessed with the Revised Hammersmith Scale for SMA (RHS). Initial INTEND mean score was 39 (± 3.5). Initial RHS mean score was 7(± 3.3). Video footage of each child's motor assessment and individualized unique interventions was obtained.
OUTCOMES: All participants improved in their INTEND scores, with final mean score of 45(± 5.6). All participants that were appropriate for assessment using the RHS improved their scores, with a final mean score of 12(± 2.4). Participants all improved in their attainment of gross motor milestones, including 3 children attaining independent sitting, and one child achieving unsupported prone neck extension. One child attained the ability to stand with upper extremity support and KAFOs. Scoliosis management did not appear to improve structural deformity during the observation period.
DISCUSSION: New disease-modifying therapies have shown initial success in improving functional outcomes for these children and directly impacts the current standard of care for children with SMA1. PTs will inevitably treat patients with SMA1 receiving these medical interventions and should be aware of the unique clinical presentation when compared to children that have not received this medication. Although these children improved, they continued to present with complex neurological involvement that seemed variable across similar cases, with atypical and unpredictable patterns of neurodevelopment that appears to affect their typical progression of motor milestones, particularly involving head and trunk control. The novelty of new drug therapies changes what pediatric PTs need to know about children with SMA1, creating a gap in the literature regarding clinical presentation, interventions, and expected functional outcomes. These kinds of complex clinical cases require clinicians to demonstrate adaptive expertise and the ability to learn and innovate in response to practice challenges.
PHYSICAL THERAPY EXAMINATION AND INTERVENTION IN PATIENTS WITH THORACIC INSUFFICIENCY SYNDROME
Platenecky D, Vicencio J (Physical Therapy, Children's Hospital of Philadelphia)
PURPOSE: To propose recommendations for the role of physical therapy (PT) in the management of Thoracic Insufficiency Syndrome.
DESCRIPTION: Thoracic Insufficiency Syndrome (TIS) is a condition in which the thorax, primarily the spine and/or ribs, can no longer support the needs of the respiratory system. Mayer and colleagues proposed that this is due to one of the following: “deformity of the spine causing distortion of the rib cage with both volume and function loss, primary thoracic dysplasia which can compromise chest volume and rib cage function, or neuromuscular dysfunction causing secondary spine and chest deformities”. Patients with TIS typically present with a small, stiff, and/or asymmetrical thorax and poor lung growth which subsequently leads to poor pulmonary function. There is limited literature on proper PT evaluation and intervention for patients with TIS and a need to further educate the PT profession on the importance of involvement in this patient population.
EXAMINATION: A comprehensive PT examination should include range of motion, strength, muscle tone, posture, and developmental and functional assessments. Additionally, careful examination and evaluation of chest wall mobility and chest wall mechanics as they relate to pulmonary function is vital to analyzing and treating this population. This includes chest wall excursion measurements during quiet breathing and maximal inhalation at the levels of the third rib, xiphoid process, and midway between the xiphoid and umbilicus. It is also important to qualitatively examine the flexibility of the trunk in the frontal plane in order to further identify areas that may be contributing to pulmonary and/or musculoskeletal impairments. Examinations should be completed serially as thoracic wall and vertebral deformities can progress during periods of rapid growth. They should also be completed before and after any surgical intervention to establish a baseline and to track changes over time.
INTERVENTION: The need for PT intervention may be missed without the sufficient examination described above. PT treatment should focus on maximizing chest wall mobility and mechanics including vertebral and thoracic cage mobility, respiratory muscle training, and neuromotor re-education. These intervention approaches can optimize pulmonary endurance, normalize posture, and improve the quality of movement patterns. Additional interventions that have been found to improve outcomes in this population include extensive caregiver education, flexibility management, and focused mobility training.
SUMMARY OF USE: In this platform, recommended examination and intervention techniques for patients with TIS will be described and applied to cases from patients followed at our institution. It is recommended that standardized measures and respective interventions are performed by physical therapists for all patients with TIS to maximize outcomes and track changes over time.
IMPORTANCE TO MEMBERS: This approach is applicable to clinicians working across all therapy settings who are treating patients with TIS.
CHANGES IN MUSCLE STRUCTURE AND FUNCTION WITH AGING IN INDIVIDUALS WITH CEREBRAL PALSY COMPARED TO THOSE WHO ARE TYPICALLY DEVELOPING
Pontiff M, Robertson M, Connick B, Rabalais T, Moreau N (Physical Therapy, Louisiana State University Health Sciences Center)
PURPOSE/HYPOTHESIS: Muscle size and strength are decreased in children and adolescents with cerebral palsy (CP). However, the trajectory of muscle size and strength deficits with aging is unknown. Therefore, the purpose of this study was to examine the rate of change in muscle size and strength of the knee extensors with age in individuals with CP compared to typically developing (TD). We hypothesized that the rate of change in both muscle size and strength with aging in those with CP would be lower than in TD individuals.
NUMBER OF SUBJECTS: Fifty-three individuals with CP, GMFCS levels I-V (14. 6 ± 4. 48 years; range 6-25) and 33 TD individuals (16. 2 ± 5. 47 years, range 7-25).
MATERIALS/METHODS: A retrospective analysis was performed on a combined dataset from TD individuals and those with CP. Muscle volume of the rectus femoris (RF) and vastus lateralis (VL) was calculated from muscle thickness and thigh length. Muscle strength was defined as isokinetic peak torque at 60 degrees/second. Linear regression was used to examine relationships between variables separately for those with and without CP. ANCOVA was used to determine differences in slopes of regression lines for TD individuals and those with CP.
RESULTS: Muscle volume of the VL and RF increased significantly with age in both TD (VL: R2 = .48, p = .003; RF: R2 = .56, p = .001) and those with CP (VL: R2 = .36, p<.001; RF: R2 = .27, p<.001). However, no differences were found between the slopes of the regression lines for the two groups (VL: p = .058; RF: p = .325). Thigh length increased with age similarly in both groups (TD: R2 = .72, p = .003; RF: R2 = .66, p = .001). Isokinetic strength significantly increased with age in both TD (R2 = .66, p<.001) and those with CP (R2 = .10, p = .024). However, the slope of the regression line was steeper in TD compared to CP (p<.001). When individuals with CP were analyzed by GMFCS level, VL and RF muscle volume increased at significantly different rates with age (VL: p = .034, RF: p = .017).
CONCLUSIONS: Although muscle volume and bone length growth rates were similar in TD individuals and those with CP, muscle strength increased at a slower rate with age in CP. Central contributions to strength deficits, such as decreased voluntary activation and co-contraction, may have contributed to the discrepancy between these results. Furthermore, muscle volume includes contractile and non-contractile tissues, such as collagen accumulation and fatty infiltration into muscle, especially in lower functioning individuals. When analyzed by GMFCS level, different muscle growth rates were observed for the VL and RF, with GMFCS levels IV-V demonstrating a lesser rate of change in muscle volume with age compared to GMFCS levels I-II.
CLINICAL RELEVANCE: These findings demonstrate the impact of aging on skeletal muscle volume and strength as well as the negative effects of mobility level on muscle growth in individuals with CP. Future work should examine changes in muscle size and strength and its relationship to activity and participation throughout the lifespan.
EFFECTS OF CLASSROOM BASED YOGA ON BALACE IN PRESCHOOL AGED CHILDREN WITH AUTISM SPECTRUM DISORDER: A CASE SERIES REPORT
Priore J (Daemen College, Clarence Center, New York)
BACKGROUND & PURPOSE: Autism Spectrum Disorder (ASD) is a complex neurodevelopmental disorder effecting 1 in 68 children in the United States. ASD impacts development in domains such as communication, behavior, social, and motor skills. Treatment of ASD requires a variety of therapies, such as Physical Therapy, to address the wide range of limitations and restrictions. Many individuals and families often seek adjunct interventions, such as yoga, to supplement traditional therapy approaches. Yoga has benefits in pediatric populations in mental, emotional, physical, and behavioral health. Research in pediatric populations with typical development has shown yoga has benefits in self-regulatory behavior to manage anxiety, and improved fitness and cardiopulmonary health. Limited research has been conducted in pediatric populations with ASD. Improvement has been noted in self-regulation, stereotypic behaviors, eye contact, and body awareness, however varied methodologies were used with limited examination on motor-related impairments of balance. The purpose of this case series was to examine the effect of a classroom based yoga program on balance in children with ASD.
CASE DESCRIPTION: Four participants, age range 4.2 to 4.8 years, with ASD, were recruited from a sample of convenience from Buffalo Hearing and Speech Centers, Buffalo, NY. Children participated in a classroom based yoga program, once weekly for 30 minutes over 10 weeks, in addition to their typical Physical Therapy. Yoga was taught by a licensed Physical Therapist and registered pediatric yoga teacher. Gross motor skills were assessed by the same therapist using the Movement Assessment Battery for Children second edition (MABC-2), just prior to the initiation of the yoga program, and immediately after 10 weeks of yoga. The MABC-2 is a standardized norm referenced tool with domains of manual dexterity, aiming and catching, and balance.
OUTCOMES: Comparisons between MABC-2 pre and post-test scores were made for each child. All children demonstrated improvement in the balance domain of the MABC-2 between pre and post-test, with an average increase of 7.25 points. This is a substantial improvement in scores, as the Minimal Detectable Change (MDC) and Minimally Clinically Important Difference (MCID) for the MABC-2 is greater than or equal to 2.0 points of the total score.
DISCUSSION: The outcomes of this case series suggest that a once weekly yoga program for 10 weeks, in addition to current therapies, may improve balance in children with ASD. Improved balance in these children have the potential to positively impact these children's ability to participate to across environments. Physical Therapists are in a unique position to be able to integrate yoga based interventions into their current programs. Future research with larger cohorts needs to be conducted to either support or refute these initial findings. Research using control groups of children with ASD who do not currently receive Physical Therapy may also aide in future programming for these children.
THE EFFICACY OF MOTOR INTERVENTION TO IMPROVE MOTOR SKILLS OF CHILDREN WITH AUTISM SPECTRUM DISORDER: A SYSTEMATIC REVIEW
Ruggeri A, Marrone A (Children's Hospital of Los Angeles), Sargent B (Division of Biokinesiology and Physical Therapy, University of Southern California)
PURPOSE/HYPOTHESIS: Approximately 80% of children with Autism Spectrum Disorder (ASD) demonstrate difficulty performing age-appropriate motor skills. Motor intervention has potential to improve motor skills of children with ASD and specific motor learning strategies may result in improved outcomes. The primary objective of this systematic review was to evaluate the evidence on the efficacy of motor intervention to improve motor skills of children with ASD. The secondary objective was to identify motor learning strategies reported within the studies and assess relationship to outcome.
NUMBER OF SUBJECTS: N/A
MATERIALS/METHODS: Six databases were searched from 2000 to 2017 for literature that studied the motor outcomes of motor intervention for groups of children with ASD. Level of evidence and strength of the research report were assessed.
RESULTS: Thirty studies were included: 9 randomized clinical trials, 12 non-randomized clinical trials, 8 prospective cohorts, and 1 retrospective cohort. Research report strength was strong for 1 study, adequate for 5 studies, and weak for 24 studies. A total of 962 participants with ASD ranging from 3 to 19 years of age participated in the studies. Interventions included: hippotherapy, equine-assisted, or simulated horse-riding interventions, aquatic interventions, motor skill interventions (e.g. throwing, running), motor activity interventions (e.g. soccer, table tennis), exergaming interventions, and physical education interventions. In addition, 3 studies investigated the effects of a motor learning variable on motor skill acquisition. Overall results demonstrated improvements in: (1) participation outcomes after aquatic and physical education interventions; (2) activity outcomes after aquatic, motor skill, physical education, and equine-assisted or simulated horse-riding interventions; and (3) body structure and function outcomes after motor skill, motor activity, exergaming, and hippotherapy or simulated horse-riding interventions. Twenty-four studies used strategies to support participants with ASD to more fully participate in the interventions, including: predictable routine, pictorial support, behavioral support, sensory considerations, and activities to support social and expressive communication. Twenty-eight studies used motor learning strategies, including: task modification, repetitive practice, contextual practice, observational learning, augmented feedback, verbal guidance, physical guidance, and strategies to increase motivation. Variability and poor reporting of motor learning strategies limited assessment of relationship to outcome.
CONCLUSIONS: This review found low quality evidence for the efficacy of motor intervention to improve motor skills of children with ASD. Further high-quality research is needed.
CLINICAL RELEVANCE: This review summarizes the evidence for the efficacy of motor intervention on motor outcomes for children with ASD. It additionally summarizes motor learning and autism specific strategies that have been used to support outcomes.
EFFECT OF BALANCE BIKE TRAINING ON BALANCE IN CHILDREN WITH INTELLECTUAL AND DEVELOPMENTAL DISABILITIES
Schwalje G (PT, Center of LifeLong Learning, Highland Park), Anderson E (Rehabilitation & Movement Sciences, Rutgers, The State University of New Jersey)
PURPOSE/HYPOTHESIS: Children with intellectual (ID) and developmental disabilities (DD) have impaired balance compared to typically developing children and are slower to achieve gross motor milestones. They especially have difficulty when task complexity increases, resulting in a majority of persons with ID/DD not able to ride a two-wheel bike.
Delays in developing dynamic balance contribute to the inability of persons with ID/DD to learn to ride a two-wheel bike. Balance bikes have emerged as an effective tool for teaching young children to ride without using training wheels. Once balancing on a bike is achieved, pedaling is quickly achieved. For children with ID/DD, improvement in balance alone can be important for daily life skills such as navigating a school bus and uneven surfaces. Balance bike training (BBT) may therefore be effective for 1) teaching children to ride a two-wheel bike, and 2) improving balance in children with ID/DD. Achievements realized through BBT may also influence attitudes and expectations of parents/guardians of children with ID/DD.
Compared to a control group, children with ID/DD will demonstrate improved balance on the Pediatric Balance Scale (PBS) after 8-weeks of BBT. Parents/guardians of children who receive BBT will have improved perceptions of their child's abilities, as measured by a pre- and post-BBT survey.
NUMBER OF SUBJECTS: Twenty-four children with ID/DD, ages 5-9 years old (16 males and 8 females)
MATERIALS/METHODS: Participants were fitted with a balance bike and helmet. A pediatric physical therapist (PT) experienced in balance bikes led the BBT sessions, which were done in two rounds. Each round included a BBT group and a control group. Children in the BBT group attended one 45-mintute BBT session per week and were encouraged to practice balance bike skills at home. Children in the wait-list control group received BBT after 8 weeks of no intervention. An experienced pediatric PT blinded to group assignment conducted the PBS at baseline and at all time points for all groups. At each time point, parents/guardians completed a survey about attitudes and their child's balance. Both rounds followed the same procedures.
RESULTS: Pre-test- post-test analysis indicates that children with ID/DD who received 8 weeks of BBT demonstrated significant balance gains on the PBS. Between group analysis demonstrates that compared to a wait-list control group, BBT can positively impact balance in children with ID/DD. There was also an increase in parent/guardian perceptions of their child's balance capabilities across the BBT groups.
CONCLUSIONS: Despite the study's limitations, the results suggest that BBT is able to play a role in helping children with ID/DD improve their balance. Also, BBT appears to influence parents' perception of their child's balance skills and abilities.
CLINICAL RELEVANCE: Therapists, parents and recreation professionals may be able to use BBT as way to improve balance in children with ID/DD. This may also lead to the promotion of physical activity and opportunities for socialization.
VALIDATION OF APDM OPAL INERTIAL SENSORS FOR BALANCE ANALYSIS IN THE PEDIATRIC POPULATION
Shieh V, Sansare A, Jain M, Bulea T, Zampieri C (Rehabilitation Medicine Department, National Institutes of Health), Mancini M (Oregon Health and Sciences University)
PURPOSE/HYPOTHESIS: Clinical evaluation of balance has relied on force-plate systems, such as the NeuroCom Smart EquiTest (Natus, Inc.), as the gold standard for postural sway measures. Recently, systems based on wireless inertial sensors (MobilityLab and Opals, APDM, Inc.) have been explored as an alternative in the clinical setting given their practicality and lower cost. Previous studies have validated the sensors for balance assessment in adults, but no investigations have included children. Our goal is to validate the MobilityLab measures of balance against the NeuroCom ones in a group of typically developing children during tests of quiet stance. We hypothesize significant and strong correlations will be observed between measures from the two devices.
NUMBER OF SUBJECTS: 9
MATERIALS/METHODS: Nine participants (5 males) 7 to 17 years old performed a quiet stance test inside the Smart EquiTest booth while wearing the APDM Opals, which wirelessly streamed inertial-based balance data through the MobilityLab program. Three 30 second trials of barefoot, quiet stance were performed under 5 conditions: firm surface with eyes open and closed, foam surface with eyes open and closed, and tandem stance with eyes open. Data from both devices were time-synchronized and the following measures were calculated independently: sway area, path length, sway root mean square (RMS), and sway velocity. Variables were represented in the sagittal, coronal and bidimensional planes, except for sway area (bidimensional only), adding up to 10 measures per condition for a total of 50 comparisons. Pearson correlations were calculated for normally distributed data and Spearman for data that was not normally distributed.
RESULTS: Our results indicate 31 significant (25 good-to-excellent correlation strength: r > 0.75, and 6 moderate-to-good: 0.50 < r < 0.75) and 19 non-significant correlations. Variables found to be significant were represented across all conditions, except for the foam eyes closed condition, which only showed 2 significant correlations out of 10 comparisons. Overall, total path length and coronal RMS sway were the only variables consistently showing significance under all conditions.
CONCLUSIONS: This pilot study shows preliminary data to support the validity of the MobilityLab system in measuring quiet stance under various conditions in typically developing children 7 to 17 years of age. The lack of associations for most variables under eyes closed on the foam condition may be a result of a multi-segmental body strategy used for that condition, therefore a sensor at the center of mass level would detect strictly the center of mass excursion, while a force plate would detect the resultant forces under the feet.
CLINICAL RELEVANCE: If these findings are confirmed with a larger sample size, this potentially supports using the Opals in place of force-plates. It would be easier and more accessible to measure postural stability in children with balance challenges. In addition, the measures we obtained with the sensors can serve as normative data for other studies or clinical reference.
REACHING AND TOY PREFERENCE BETWEEN PRETERM AND TERM INFANTS WITH CEREBRAL PALSY: A PRELIMINARY STUDY
Sigmon K, Barbosa G, Nyktas D, Bican R, Heathcock J (The Ohio State University)
PURPOSE/HYPOTHESIS: Children born preterm or full term with a brain injury, are at a higher risk for cerebral palsy (CP). Reaching is commonly used to assess upper extremity dysfunction in children with CP. The purpose of this study is to identify potential differences in reaching and toy preference between preterm and term infants with CP, in order to expand our understanding of the contribution of neonatal history on upper extremity motor performance. If there are differences in preterm vs. full term birth history in a cohort of infants with CP, then targeted interventions may be necessary.
NUMBER OF SUBJECTS: 8 infants with CP (GMFCS level III), N = 5 infants born preterm (<29 weeks GA) and N = 3 infants born full term (> 37 weeks GA).
MATERIALS/METHODS: Participants were part of a larger clinical trial on motor skill development in infants with lower functional levels and CP. All infants have CP, and were identified as a GMFCS level III. The infants were seated in a chair in a supported upright position. Each were provided with 4 toys (ball, maraca, maraca handle, and glow wand) for 2 × 30 second trials. All toys were offered at the child's midline, at shoulder height, and within reach. Datavyu, a behavioral coding software program, was used to measure frequency of reaching and toy preference.
RESULTS: Infants born preterm had 11.5 ± 6.0 reaches per trial, while infants born at term had 12.0 ± 5.1 reaches per trial. In the preterm group, the total number of reaches on the right and left sides were 68.7 %, and 62.0% respectively. The preterm group demonstrated the highest percentage of reaches to the ball at 30.9%, followed by 28.8% for the glow wand, 24.9% for the maraca, and 15.5% for the handle. The term group performed 67.4% of reaches on the right, with 56.7% of reaches observed on the left. The term group also demonstrated the highest percentage of reaching for the ball at 32.6%, followed by 29.2% for the maraca, 19.9% for the glow wand, and 18.2% for the maraca handle.
CONCLUSIONS: Infants born preterm may have demonstrated a fewer number of reaches. Preterm and term infants demonstrated a preference for the ball with the highest percentage of reaching observed. Similarly, both the preterm and term groups exhibited an asymmetry in reaching with a higher percentage of reaches observed on the right.
CLINICAL RELEVANCE: Preliminary results suggest that larger toys produce more reaches than smaller toys in infants with CP, and that similar intervention strategies, including the type of toy, could be utilized to improve reaching. In addition, most infants demonstrated asymmetrical reaching performance (more reaches with one hand verses the other) at an age when reaching performances should be similar on both sides. These results suggest that overall, preterm infants may reach less than full term infants (note all infants have CP). Since these are preliminary data with a small sample per group, this result should be confirmed.
PRACTICAL CLINICAL MEASURES FOR DETERMINING CARDIORESPIRATORY FITNESS AND ADIPOSITY IN OBESE CHILDREN
Singh B, Goulart J, Niino M (Physical Therapy, California State University), Hammons A (Child and Family Science, California State University)
PURPOSE/HYPOTHESIS: Childhood obesity rate continue to increase, and physical therapists treat a lot of obese children in the clinics. The purpose is to explore relationships between different clinical measures when assessing cardiorespiratory fitness and adiposity in obese children.
NUMBER OF SUBJECTS: Twenty-eight subjects aged 8-11 years
MATERIALS/METHODS: Twenty-eight subjects (13 females, 15 males) aged 9.8 ± 0.9 years old with BMI measures above the 85th percentile for their age completed the study. The Nemeth submaximal treadmill walking protocol asked subjects to walk on a treadmill for four minutes at 0% grade and four minutes at 5% grade. Walking speed, heart rate (HR) pre-Nemeth, and HR post-Nemeth were documented to predict VO2max. In comparsion, the 20-meter Progressive Aerobic Cardiovascular Endurance Run (PACER) protocol was implemented by having the subjects run back and forth with maximal effort until they missed two consecutive laps or if self-perceived fatigue was reached. The number of laps, age, gender, and HR following the PACER protocol were documented to calculate VO2max.
Adiposity was measured by air displacement plethysmography (Bod Pod). Subjects wore a tightly fitting bathing suit inside the Bod Pod. A breathing protocol was implemented using a mouth tube. Adiposity was estimated based on measured thoracic volume using Lohmann equations. In comparsion, adiposity was also assessed with skinfold measurements taken at the right triceps and gastrocnemius. Subject's skin was pinched and pulled away from the underlying muscle with skinfold calipers to measure adiposity. Data was graphically displayed, and regression analysis was performed using general linear models to establish relationships between the different measures. SPSS version 23 was used for analysis.
RESULTS: The mean aerobic fitness was 36.15 ± 7.1 mL/min/kg using the Nemeth equation and the PACER quadratic equation calculated mean aerobic fitness to be 34.13 ± 6.0 mL/min/kg. A strong relationship was seen (R2 of 0.65) between estimated VO2max by Nemeth and VO2max by PACER protocol.
The mean adiposity for the subjects using the Bod Pod was estimated at 32.32 ± 7.7%, while as the skinfold measurements determined the mean adiposity was 31.55 ± 8.1%. R2 of 0.59 was seen between both measures.
CONCLUSIONS: This study demonstrates a strong association between the Nemeth and PACER protocols in estimating cardiorespiratory fitness levels in children. Similarly, the Bod Pod and skinfold measurements indicate a strong association in determining adiposity in children.
CLINICAL RELEVANCE: Although there are a variety of ways to measure cardiorespiratory fitness and adiposity in children, not every clinic has expensive equipment to collect clinical measures. This study shows that Nemeth and PACER protocols, and the Bod Pod and skinfold measurements have a strong correlation and can be effective in clinical setting. Weighing the pros and cons of both techniques should be implemented in the clinic as cardiorespiratory fitness and adiposity have important implications on a child's overall health.
ANTIGRAVITY TREADMILL TRAINING FOR CHILDREN WITH CEREBRAL PALSY: SUMMARY OF EVIDENCE AND CLINICAL RECOMMENDATIONS
Steffen J, Nemann M, Walker S, Dunning K (Department of Rehabilitation, Exercise, and Nutrition Sciences, University of Cincinnati)
PURPOSE: An increasing number of clinics have antigravity treadmill devices (e.g. Alter G) but there are no systematic reviews or clinical practice guidelines specific to children with cerebral palsy (CP). The purpose of this project was to summarize the evidence and provide clinical recommendations.
DESCRIPTION: A literature search was conducted using keywords including Alter G, treadmill training, cerebral palsy, antigravity treadmill, pressure controlled treadmill, reduced body weight conditions, lower body positive pressure. Eligible articles involved antigravity treadmill training for pediatric CP and excluded body weight support and robotic devices. Evidence by outcome measure was rated as follows: Level 1a - at least 2 randomized control trials (RCT) with PEDro at least 4; Level 1b - 1 RCT with PEDro at least 4; Level 2 - at least 1 quasi-experimental study.
SUMMARY OF USE: A total of 8 articles were found that involved antigravity treadmill training for children ages 4-18 years old with spastic hemiplegia and diplegia. Study designs included 3 RCTs 1-3 published 2015-2017 (PEDro range 4-8) and 5 quasi-experimental studies 4-8 published 2011-2017 (pre/post intervention cohort, case series). The 3 RCTs involved 95 participants and compared traditional therapy plus antigravity treadmill training to traditional therapy alone. The 5 quasi experimental studies involved 22 participants. Treatment durations ranged from 20-45 minutes per session, 2-3 times per week for 6 weeks-3 months. Evidence suggested level 1a effectiveness for improving postural sway (Biodex Stability System) and level 1b effectiveness for fall risk (Biodex Balance System), gait speed, percent of time in double limb support, step and stride length and cadence. There was level 1b evidence suggesting antigravity treadmill training does not improve Timed Up and Go. There was Level 2 evidence for effectiveness to improve fractional ansiotrophy (cerebellar white matter and brain stem), BESTest score, lower extremity strength, stride time, step width and maximum voluntary contraction. Exclusions in these studies that need to be considered for clinical translation include: fixed deformities that interfere with lower extremity function, cardiac or respiratory conditions that are affected by exercise, seizures, lower extremity orthopedic surgery in past 12 months, botulinum toxin injections in past 6 months, hearing defects, limiting cognitive or visual impairments.
IMPORTANCE TO MEMBERS: This evidence summary suggests antigravity treadmill training may be a promising adjunct to traditional therapy for children with CP to improve balance and gait. Based on the literature, clinical recommendations include: frequency and duration 3 times per week, 20-minute treatment sessions for 3 months; treadmill speed 75-90% of client's comfortable gait speed over ground; start treatment with 40-50% body weight support; progress treatment by decreasing body weight support and increasing speed as client tolerates.
COMBINATION OF TECHNOLOGY AND ASSOCIATIVE LEARNING TO ASSESS INFANT PRONE MOTOR LEARNING
Tripathi T, Dusing S, Khurana S, Syed G, Greenberg K, Brennan K, Libiran L (Virginia Commonwealth University)
PURPOSE/HYPOTHESIS: Associative learning is the ability to discover a relationship between two or more events. Prone play provides natural opportunities to develop head control, reaching, sitting and prone mobility skills. Prone mobility expands opportunities for infants to explore and learn. However, the dynamics of prone mobility are complex and require constant adaptation in infants' prone motor control. We combined principles of associative learning with technology and developed a paradigm to assess if infants can adapt their prone motor control to discover the activation of a toy early in development. Purpose: Determine if 3-6 months old infants can demonstrate: 1) short term learning of an association between their upper body movements in prone and activation of a toy; and 2) retention of association learned on day 1, 24 hours later.
NUMBER OF SUBJECTS: Twenty eight typically developing infants born at term participated at 3-6 months of age.
MATERIALS/METHODS: Infants were assessed for associative learning and retention in prone using the Prone Play Activity Center (PPAC). The PPAC has sensors that locates position of infant's head in space and records the head's distance from the floor. The microcontroller in the PPAC compares the infant's head height to a preset parameter and activates the toy if conditions are met. Infants were tested in the PPAC for 2 consecutive days. Both days of testing had a baseline and up to 4 acquisition phases (2 minutes each). During the acquisition phase the toy activated when the infant's head height matched with the preset parameter. The toy turned off after 10 seconds or when the infant's head was below the preset parameter, whichever came first. Infants were categorized as short term learners if the frequency of toy reactivations (FTR) or total duration of toy on (DTO) during acquisition was 1.5 times baseline frequencies. All learners were categorized as retainers of the association learned on day 1, if FTR or DTO on day 2 acquisition was 1.5 times day 1 baseline value.
RESULTS: Of 28 infants, data of 22 infants was included for analysis. Fourteen infants (63.6%) met the criteria for short term learners. On 2nd day we had an analyzable sample of 9 short term learners. Three of the 9 short term learners (33.3%) demonstrated retention on day 2.
CONCLUSIONS: Our findings are similar to prior research done using different associative learning protocols. The majority of infants learned the association of their movement with the activation of the toy but retention of the association was not found on day 2.
CLINICAL RELEVANCE: With this study we are providing two avenues for physical therapists to contemplate in their practice: 1) The PPAC and an associative learning paradigm that may have the potential to detect early motor learning delays in infants and 2) The ability to measure learning using this prone associative learning paradigm may lead to the development of associative learning-based intervention to train infants to modify their motor control in prone. Additional research is needed before either of these ideas can be implemented into practice.
CHANGES IN CANADIAN OCCUPATIONAL PERFORMANCE MEASURE (COPM) AND TIMED WALK TEST (TWT) IN PEDIATRIC PATIENTS WITH DIAGNOSIS OF EHLERS DANLOS SYNDROME (EDS) FOLLOWING AN INTENSIVE REHABILITATION PROGRAM FOR CHRONIC PAIN
Turlington P, Naber E, Billups K, Reidy T, Whiston N, Trovato M (Kennedy Krieger Institute)
PURPOSE/HYPOTHESIS: Physical therapists are uniquely qualified to address the effects of chronic pain on patients' function and participation. The impact of chronic pain is widespread in the life of a child or teen, and psychosocial stressors may exacerbate their pain. It can negatively impact functional mobility, participation [1, 2, 3], social interaction, school attendance  and sleep . In addition, it affects the child's family and caregivers. In a study examining health care costs and lost wages of families with children with chronic pain Evans and colleagues  reported that prior to admission to an intensive pain program on average health care costs were $61,988 and $14, 189 in the year post treatment. Lost wages by family in the year prior to admission went from $12,229 to $1,189 .
There is a small but growing body of evidence that supports intensive inpatient and outpatient interdisciplinary programs to address pediatric chronic pain [6, 2]. A systematic review of inpatient and outpatient interdisciplinary models found, despite the large variation in program models and outcomes, large positive changes in disability status and small to moderate changes in perceived pain after treatment that were maintained at follow-up . Intensive inpatient rehabilitation has demonstrated positive effects on sleep, school attendance, functional ability and physical mobility 
NUMBER OF SUBJECTS: 11
MATERIALS/METHODS: Eleven participants (mean age 15.9 years) with the diagnosis of EDS (6 females), participated in an intensive interdisciplinary outpatient rehabilitation program. One subject was excluded secondary to early unscheduled discharge from the program limiting data collection. Subjects participated in a 5 day per week program that included physical therapy, occupational therapy, psychology, nursing and educational services with the goal of reintegration to school and community. Mean length of stay was 18 days. Two patients withdrew early, one due to medical admission to acute hospital and another due to family request (hardship to travel to program each day). The patients completed TWT (3 or 6 minute) as well as the COPM on admission and discharge.
RESULTS: Nine patients improved on their TWT. All showed increases in the performance and satisfaction scores on the COPM. Seven patients had clinically significant increase in their performance scores on the COPM. Eight patients had clinically significant changes in their satisfaction scores on the COPM.
CONCLUSIONS: These findings demonstrate that participation in an intensive rehabilitation program for chronic pain for patients with a diagnosis of EDS improves their function as well as satisfaction on self-identified goals.
CLINICAL RELEVANCE: With the current opioid addiction crisis non-pharmaceutical management of chronic pain conditions in children and teens is a growing area of practice among rehabilitation professionals.
DEVELOPMENT OF A JUMPING ASSESSMENT AND PROGRAM FOR THE PEDIATRIC PATIENT WITH OI
Ubben C (Pediatrics, Brooks Rehabilitation), Fernandez J (Brooks Institute of Higher Learning)
BACKGROUND & PURPOSE: Osteogenesis imperfecta (OI) is an inherited connective tissue disorder that is caused by mutations affecting collagen type I, with a prevalence of 1 in 15,000 to 20,000. The presentation of OI includes decreased bone mineral density, bone deformity, Blue sclerae, vascular fragility, dentinogenesisimperfecta, and hearing loss, with the cardinal symptome being the pathologic fracture. Common clinical practice with this diagnosis is centered around avoiding passive range of motion, protection and prevention of deformity, safe positioning and facilitation of strengthening and safe achievement of motor milestones. Children and adolescents with OI type I have, on average, a significant force deficit in the lower limb as measured by dynamic force tests and muscle force and strength is lower in children and adolescents with OI type I than in healthy age and gender-matched controls. This case looked at creation of a jumping protocol to promote strengthening and typical motor development in a child with OI.
CASE DESCRIPTION: A 7 year old with a diganosis or Treacher Collins Syndrome and a mild form of OI presented with goals of the child being able to jump on the trampoline. A five exercise jumping program was desgined for a child with OI by combining previous jumping interventions developed for pediatric or osteoporosis patients. The goal of the intervention was to maintain safety while incorporating jumping into a home program. Exercises included squat jumps, trampoline jumps, skipping, forward and lateral jumps, which were performed for a month between assessments. Muscle strength and endurance was assessed through hop testing and gross motor function was assessed through the BOT-2.
OUTCOMES: The child improved in all hop testing with the greatest improvements being seen in her single leg hopping for both her left and right foot, where she improved by over 14 inches for each. She presented with 2 standard deviation (SD) improvements in balance and strength, 1 SD improvements in bilateral coordination and no change in running speed and agility, as noted with BOT-2 testing. This complimented Mom's reports at initial evaluation that “she would be happy if strength and balance improved. This was her biggest goal for therapy”.
DISCUSSION: With this patient, we demonstrated that jumping can be safely prescribed, and it lead to improvements in gross motor function, activity and participation. Jumping lead to improvements in gross motor function in this patient with OI, most notably strength and balance and the jumping assessments helped to capture this child's improvements in function. Limitation in this study include no DEXA scan or force plate data being collected.
YOGA FOR CHILDREN AND ADULTS WITH STROKE AND MULTIPLE SCLEROSIS: WHAT DOES THE LITERATURE SAY?
Veneri D (Department of Physical Therapy and Human Movement Sciences, Sacred Heart University), Gannotti M, Fournier S (Department of Rehabilitation Sciences, University of Hartford), Bertucco M (University of Verona, Verona, Verona, ITALY)
PURPOSE/HYPOTHESIS: Research pertaining to yoga and children with cerebral palsy (CP) is negligible. The primary purpose of this study was to determine the domains of the ICF model and levels of evidence for yoga and adults with stroke and multiple sclerosis (MS), and children. A secondary purpose was to determine if any inferences could be made for children with CP.
NUMBER OF SUBJECTS: 2,000
MATERIALS/METHODS: A search of yoga and said populations across 27 databases was conducted from September 2015 through May 2016. Outcome measures (OM) were categorized according to the ICF model domains of body structures & function, activity, and quality life. Effect sizes (ES) were calculated using Cohen's d and a meta-analysis was performed. Since there were few commonalities among OM and reporting of outcomes within and among diagnostic groups, direct comparisons of effect sizes was difficult. Hence, we chose to evaluate the impact of yoga as compared to the control group or other physical exercise using a General Linear Mixed Model.
RESULTS: There were five studies with stroke, fifteen with MS, and twelve with children. Studies with children used OM related to body structure and function, whereas those with stroke and MS used OM across all three domains of the ICF. Effect sizes varied from negligible to medium for stroke, negligible to large for MS and children. Of the studies with stroke, four were randomized control trials (RCTs) and one a case series. The highest ES among the RCTs for stroke was evident for depression with a dose of 50 minutes, 6x/wk for 6 wks and included a combination of Hatha yoga, Satyananda yoga nidra, and progressive poses. Of the studies with MS, twelve were RCTs and three were case series. The highest ESs among the RCTs were with doses of 60-90 minutes of Hatha yoga 3x/wk or more for 12 wks. Of the studies with children, there were five RCTs, three cohort, two case control, two case series, and one case study. The highest rated RCT yielded large positive ES for 1.5 hrs of yoga 4x/wk for 12 wks with healthy children.
CONCLUSIONS: The findings of this meta-analysis indicate that yoga is no better or worse than other exercise modalities as a treatment intervention for adults with stroke and MS, and children. Yoga practices have demonstrated improvement in self-efficacy, confidence, mood, personal resilience and positive outlook of people with neurologic conditions. Research on yoga, particularly in children and adults with CP, would yield valuable information for creating safe and effective programs.
CLINICAL RELEVANCE: Yoga teaches participants to practice self-awareness, celebrating one's own progress while relinquishing comparison to others. Mental imagery can be incorporated when physical practice is challenged by ability, space, or time. Therapists can re-conceptualize treatment approaches of individuals with CP, with emphasis on the individual as a whole- a novel approach to treating one of the most challenging, yet prolific of physical disabilities.
FEASIBILITY OF WALKING ACCELEROMETRY AND GLOBAL POSITIONING SYSTEM MEASUREMENTS IN AMBULATORY CHILDREN WITH CEREBRAL PALSY: A PILOT STUDY
Villarosa C, Hurvitz P (University of Washington), Bjornson K (Seattle Children's Research Institute)
PURPOSE/HYPOTHESIS: Children with cerebral palsy (CP) experience walking activity limitations that negatively influence their participation in the community [1,2]. The Global Positioning System (GPS) is a satellite-based system that provides geolocation and timing services. StepWatch (SW) is an accelerometer-based device that is currently considered the most reliable pedometer for measuring strides in daily life [3,4]. Due to the limited research on the use of GPS and accelerometry in this population, this pilot study describes the feasibility of synchronizing GPS and stride accelerometry data as an outcome measure for walking activity in the community for ambulatory children with CP.
NUMBER OF SUBJECTS: 5
MATERIALS/METHODS: Three children with diplegia and 2 children with hemiplegia (Gross Motor Classification [GMFCS] level I = 1, II = 4) age 6-10 years participated. Children wore the SW on the left ankle and the GPS on the right during all waking hours throughout the proposed capture of 14 days. Strides (step of one leg) were collected by the SW and were synchronized with corresponding GPS records. Each child's home and community locations were identified with geographic information systems (GIS) software using GPS locations that were time-synchronized with activity data from SW . Home was identified for each child using their address of residence and all other locations were considered in the community.
RESULTS: Participants wore SW and GPS for an average of 8 days. A total of 42 days and 197,106 steps were captured. On average, the children walked 1,634 strides/day at home (range = 897-2,250) and 3,059 strides/day (range = 1,549-5,359) in the community. At home, daily strides were on average less for children with diplegia (1,465 strides/day, SD = 702) compared to children with hemiplegia (1,860 strides/day, SD = 42). Conversely, daily strides in the community averaged more for children with diplegia (3,262 strides/day, SD = 1,934) compared to children with hemiplegia (2,467 strides/day, SD = 81).
CONCLUSIONS: Children with diplegic CP may be less active at home, but more active in the community compared to children with hemiplegia. In order to reliably capture walking behavior in children 6-14 years of age with CP, a minimum of 5 and 6 days is suggested for GMFCS levels II and I, respectively . These recommendations are made for SW monitoring alone and do not consider GPS. Variables that may influence walking activity by location include personal and environmental factors, such as school and walking opportunities. The optimal number of days needed to adequately capture habitual stride patterns using synchronized SW and GPS data warrants further investigation.
CLINICAL RELEVANCE: Stride accelerometry and GPS measures have potential to describe walking activity behavior by geographical location in ambulatory children with CP. Further work is necessary to validate the synchronization of stride accelerometry and GPS data.
USING THE PEDI-CAT TO HIGHLIGHT IMPROVEMENTS IN FUNCTIONAL PERFORMANCE FOLLOWING 6 MONTHS OF HIPPOTHERAPY
Wands C, Grant-Beuttler M (Physical Therapy, Chapman University), Conroy S, Evans T, Butler-Moburg D, Robinson J (J.F. Shea Therapeutic Riding Center, San Juan Capistrano, California), Beuttler R (Independent Data Scientist, Orange, California)
PURPOSE/HYPOTHESIS: Hippotherapy (HPOT) harnesses equine movement, providing repetitive and rhythmic motion, to work on therapeutic goals. A cadence of 100 steps per minute provides up to 5000 postural challenges during a 45 minute therapy session. The use of the horse and barn provide environments and tasks which facilitate a variety of opportunities for functional motor activities, behavioral, and cognitive experiences. While evidence suggests HPOT results in improvements in gait and balance, there is limited data on changes in functional task performance and responsibility. The Pedi-CAT, a norm referenced participation measure, may be a useful tool to document improvements following HPOT in daily activities, mobility, social cognitive performance, and responsibility. The purpose of this study is to investigate use of the Pedi-CAT in a hippotherapy center.
NUMBER OF SUBJECTS: Forty-five subjects, 23 male and 22 female, age 1.9-11.75 years (mean = 4.74 years) were included in this analysis. Subjects had a variety of diagnoses, including Autism (27%), Cerebral Palsy (20%), Developmental Delay (11%), Genetic Syndromes (13%), and other diagnoses at a rate of 4% or less. Subjects were included in this analysis if they participated in 45 minute therapy sessions one time per week for approximately 6 months. Subjects were excluded for excessive absences or if they did not complete two Pedi-CAT assessments.
MATERIALS/METHODS: Subjects participated in a weekly 45 minute therapy session (PT, OT or SLP) session with a minimum of 30 minutes spent using equine movement followed by activities off of the horse. Parents or caregivers completed the Pedi-CAT on an iPad during a treatment session (T1). Pedi-CAT was used for reassessment (T2) 6 months following initial administration. A linear mixed effects model was used to analyze significant changes in the scaled score between 1st and 2nd assessments. Cohen's d effect sizes was used to examine the magnitude of improvements.
RESULTS: Linear models revealed significant improvements on scaled scores between T1 and T2 for, mobility (p<.001, mean T1 = 59.9, T2 = 61.4, d = .24), social cognitive (p<.001, mean T1 = 59.3, T2 = 60.6, d = .25), daily activities (p = .002, mean T1 = 50.9, T2 = 52.0, d = .23) and responsibility (p = .02, mean T1 = 39.3, T2 = 40.7, d = .20).
CONCLUSIONS: Analysis of T1 and T2 Pedi-CAT standard scores suggests a significant improvement in all four areas of functional performance reported by parents with small effect sizes. Improvements in standard scores suggest that these subjects moved closer to the norms for their age. Additional analyses are needed to examine improvements over diagnosis, age, and initial limitation level.
CLINICAL RELEVANCE: Use of the Pedi-CAT may assist clinicians in determining which children, diagnoses, and participation level issues are best addressed using HPOT. In addition, clinicians may use this assessment to guide decision making in order to address specific functional goals.
A COMPARISON OF HORIZONTAL AND VERTICAL REACHING AND GRASPING IN INFANTS WITH HEMIPARETIC CEREBRAL PALSY
Weller S, Torbet P, Heathcock J (Physical Therapy, The Ohio State University), Schram M, Darragh A (Occupational Therapy, The Ohio State University), Ramey S, DeLuca S (Virginia Tech Carilion Research Institute, Virginia Tech)
PURPOSE/HYPOTHESIS: Hemiparetic cerebral palsy (CP) results in asymmetric function of the upper extremity (UE) and lower extremity. Infants with CP often neglect the affected UE, leading to disuse and decreased motor function compared to typically developing peers. There is limited research measuring the frequency of reaching and grasping in infants with CP before 2 years of age. The purpose of this study is to quantify and compare the characteristics of reaching and grasping in horizontal and vertical planes in infants with CP as a way to guide early treatment for UE function.
NUMBER OF SUBJECTS: N = 11, participants were 6-24 months old with hemiparetic CP. Subjects were part of a larger study examining UE function in infants with hemiparetic CP.
MATERIALS/METHODS: Participants were seated in a standardized position and presented with a toy in a vertical or horizontal orientation at midline within 75% of their reach. 54 trials of 30 seconds were completed. Sessions were videotaped and coded for reaching and grasping with Datavyu. Data was analyzed unilaterally and bilaterally with paired t-tests and included the following variables: reaching frequency, reaching duration, hand position, and grasp type.
RESULTS: Horizontal plane – Subjects reached for the toy significantly more with the unaffected UE (5.12 ± 3.35) compared to the affected UE (0.50 ± 1.24, p = .001). Reaching with the affected UE was identified in 27.3% of subjects. The toy was grasped significantly more with the unaffected UE (3.00 ± 2.46) compared to the affected UE (0.35 ± 1.17, p = .01). 18.2% of subjects grasped with the affected UE.
Vertical plane – There were significantly more reaches with the unaffected UE (3.12 ± 2.45) compared to the affected UE (1.58 ± 2.34, p = .02). 54.5% of subjects reached with the affected UE. Grasping occurred significantly more with the unaffected UE (1.98 ± 1.49) than with the affected UE (0.73 ± 1.07, p = .008). Grasping with the affected UE was identified in 45.5% of subjects.
Comparison – There was no significant difference in reaching (p = .13) or grasping (p = .34) frequency with the affected UE when comparing the horizontal and vertical planes. A trend was observed for a higher number of infants who successfully reached for (p = .08) and grasped (p = .08) the toy with the affected UE in the vertical plane.
CONCLUSIONS: As expected, infants with CP reach and grasp more frequently with their unaffected UE in both planes. Some of these infants lacked the ability to spontaneously use the affected UE. A trend suggests they are more successful reaching and grasping in the vertical plane. Therapy needs to first facilitate the development of spontaneously using the affected UE and then work towards more symmetrical function.
CLINICAL RELEVANCE: Therapeutic techniques that encourage the use of the affected UE, such as constraint-induced movement therapy or bilateral training, may be utilized to reduce neglect of the affected UE. Therapists may consider presenting the toy more often in the vertical plane because this study suggests a trend of more success with the affected UE in this orientation.
WALK THIS WAY: THE USE OF RHYTHMIC AUDITORY STIMULATION AND TREADMILL TRAINING TO IMPROVE GAIT KINEMATICS FOR A CHILD POST UNILATERAL BELOW-KNEE AMPUTATION
Wirth A, Savvides E (Outpatient Pediatrics, NYU Rusk Rehabilitation)
BACKGROUND & PURPOSE: This case study report will discuss the implementation of rhythmic auditory stimulation (RAS) in conjunction with treadmill training to improve gait kinematics for a toddler with a unilateral below-knee prosthetic limb. Literature review revealed RAS as a potential treatment strategy to improve gait for patients with unilateral lower extremity deficits. RAS is “based on an entrainment model in which rhythmic auditory cues synchronize motor responses” 7 and therefore has the capability to resolve gait deficits in certain populations. This technique, while primarily used for patients with neurological deficits, has been rarely explored for those with orthopedic impairment. Research shows improved stance time and symmetry with gait in hemiparetic adults after stroke 4 and supports RAS as an “effective therapeutic method to improve gait velocity, stride length, cadence and standing balance in hemiplegic stroke patients.” 8 The purpose of this case study is to report the results of an RAS and treadmill training program for a pediatric orthopedic patient.
CASE DESCRIPTION: The patient is a two-year-old boy with congenital right tibial hemimelia, whose family opted for below-knee amputation of the right lower extremity due to significant lower extremity asymmetry and functional mobility limitations. The child participated in outpatient physical therapy after receiving a prosthetic with the goal of independent gait. Once he was able to ambulate without an assistive device, he presented with significant gait asymmetries due to neglect of the right residual limb and prosthetic. He participated in treadmill training for task-specific, repetitive practice of gait paired with exercises emphasizing forced use of his right lower extremity. Over time he continued to present with gait asymmetry and difficulty keeping up with peers. A physical therapist and music therapist implemented RAS with treadmill training over a ten-week period one time per week.
OUTCOMES: The following outcome measures were administered pre and post-treatment sessions: two minute walk test, ten meter walk test, number of steps taken during ten meter walk test, velocity, cadence, and clinical observation. After RAS with treadmill training, the child presented with improved right arm swing, improved stance time of the right leg, and a more narrow base of support. The child was taking eighteen less steps in ten meters, his speed increased by 80%, and he was able to cover 50% more distance in one lap.
DISCUSSION: In conclusion, the child demonstrated improvement in gait speed, symmetry, and stride length after participating in a ten-week program of RAS and treadmill training with a physical and music therapist. These interventions may be appropriate to consider when working with children who present with lower extremity asymmetry. Limitations in this case study include time constraints, ability to attend sessions only once per week, and interfering behaviors of the child.
IMPACT OF UPPER EXTREMITY STRENGTH ON FUNCTION IN TYPE II SPINAL MUSCULAR ATROPHY
Young S, Salazar R, Cornett K (Neurology, Columbia University), Zreibe K, Montes J (Department of Rehabilitation and Regenerative Medicine, Program in Physical Therapy, Columbia University Medical Center), Estilow T (Children's Hospital of Philadelphia)
PURPOSE/HYPOTHESIS: Spinal muscular atrophy (SMA) is a neuromuscular disease caused by degeneration of spinal motor neurons resulting in proximal muscle weakness. The intermediate form, Type II (SMA II) is characterized by symptom onset at 6-18 months of age, achieving the ability to sit independently, but unable to walk.1,2 The few studies that have examined the association between upper extremity (UE) strength and function in SMA have reported variable results on the impact of strength on function and independence warranting further research.3-6 Quantitative measures of strength and function are required to formally assess their relationship. The purpose of this study is to investigate the association between UE strength and range of motion (ROM) with function in participants with SMA II. We hypothesize that UE strength and ROM will be positively associated with function.
NUMBER OF SUBJECTS: Ten participants with SMA II (15.3 years ± 5.6) were recruited prospectively during their clinic visit.
MATERIALS/METHODS: Outcome measures included UE strength of shoulder abduction, elbow flexion and extension, wrist extension and gross grasp using handheld dynamometry (HHD). ROM was measured using standard goniometry for shoulder flexion, elbow extension, forearm supination, wrist extension and radial deviation, composite wrist/digit extension and composite thumb extension. UE function was assessed using the Revised Upper Limb Module (RULM), a disease-specific scale.7 The dominant hand was used for analysis. Associations between measures were evaluated using Pearson correlation coefficients.
RESULTS: UE strength (shoulder abduction, elbow extension, wrist extension, gross grasp) and ROM (elbow extension, wrist extension) both had a positive association (r > 0.6; p<0.05) with RULM scores (mean = 13.9 ± 9.0 out of a total of 37). UE strength was impaired in all patients and ROM limitations greater than 10 degrees exist in shoulder flexion, elbow extension and forearm supination.
CONCLUSIONS: SMA II participants had decreased UE strength and ROM which is associated with impaired function. Nearly half of the participants were unable to produce any force with some muscle groups, highlighting the severity of their weakness. Understanding the most vulnerable UE muscle groups and their associated functional limitations may help direct therapeutic interventions.
CLINICAL RELEVANCE: UE function is critically important for SMA II patients to navigate their environment and maximize functional independence. The observations described in this study will help physical therapists design individualized rehabilitation programs to emphasize improving UE strength, maintaining ROM, and develop compensatory strategies to perform functional tasks. Future studies are needed to evaluate the effectiveness of UE strengthening programs in SMA II.