CASE STUDY MULTIDISCIPLINARY APPROACH ADDRESSING PEDIATRIC PELVIC FLOOR DYSFUNCTION - PHYSICAL THERAPY WITH GASTROENTEROLOGY
Achhnani HD, Buxton RS
BACKGROUND AND PURPOSE: Pediatric patients with bowel incontinence are often referred to a motility clinic and seen solely by gastroenterology without consideration of the possibility of pelvic floor dysfunction. The purpose of this study was to demonstrate the importance of including physical therapy in the treatment planning of a pediatric patient with pelvic floor dysfunction in order to improve prognosis and quality of life.
CASE DESCRIPTION: One participant with a history of chronic fecal soiling of functional etiology and poor comprehension of squeeze maneuver likely leading to soiling and diagnosed with pelvic floor dysfunction referred for a physical therapy evaluation and treatment to improve pelvic floor continence function from the Gastroenterology department at a pediatric hospital in Los Angeles, California. RR is a 7 year old female who presents to Pelvic Floor Dysfunction Clinic with difficulty and poor comprehension of squeeze on command and rectal distension, poor ability to deferentially relax pelvic floor urination and stooling. On initial evaluation, RR had daytime and nocturnal urinary accidents daily and fecal soiling three to five times weekly. She was pharmacologically managed with 17 grams of Miralax every day. She had poor daily fiber intake and was drinking 15 ounces of water a day. RR required maximum cueing and multiple rest breaks for therapeutic neuroeducation exercises and had palpable abdominal fecal mass noted.
OUTCOMES: Pre-test measures included: frequency of bowel/bladder accidents, pharmacological intervention, detailed history of diet, and functional strength. RR and her mother received education regarding appropriate water and vegetable consumption according to RR height/weight, strengthening and neuroreducation exercises, abdominal massage and a calendar log to track progress and timed voiding schedule. Post-test measures taken over 6 sessions at varied frequency, pending compliance and progress. Within the first 3 sessions, RR had no urinary and fecal soiling accidents, including day and night contributing to an improved quality of life. She also decreased to 8 grams of Miralax every other day. RR was successful in maintaining a daily intake of fiber and drinking 30 ounces of water a day. RR was able to perform all therapeutic neuroeducation exercises with minimal verbal cueing for form and required no rest breaks. Upon palpation of abdomen, no notable fecal mass noted.
DISCUSSION: Frequency of bowel/bladder accidents, pharmacological intervention, detailed history of diet, and functional strength all improved after physical therapy was integrating in treatment planning for a pediatric patient with pelvic floor dysfunction. The outcomes of this case study suggest that physical therapy intervention may be a viable treatment option for patients with pelvic floor dysfunction who initially are primarily seen in gastroenterology.
COMPARING PEDIATRIC FACULTY AND CLINICAL INSTRUCTORS EXPECTATIONS FOR STUDENT PERFORMANCE IN TRANSFERS AND HANDLING TECHNIQUES
Anderson BS, Wolden MJ, Madsen J
PURPOSE/HYPOTHESIS: Safe physical management of pediatric patients requires skillful transfer and handling techniques. Doctor of Physical Therapy (DPT) students are typically trained on safe and effective transfer and handling techniques by practicing on adults. Practice on adults, cannot directly translate to pediatric patients due to the developmental differences between children and adults. There is limited information about the expectation of DPT students' knowledge and performance of pediatric transfer and handling techniques prior to their pediatric clinical experiences and upon graduation.
PURPOSE/HYPOTHESIS: The purpose of our study was to examine current DPT faculty and clinical instructors (CIs) expectations regarding pediatric transfer and handling techniques, specifically: 1. the perceived necessity of knowledge and performance of these techniques prior to a pediatric clinical and upon graduation and 2. the perceived self-efficacy of DPT faculty and CIs on performing and teaching the techniques to students. We hypothesized that there would be no difference between DPT faculty and CIs expectations regarding pediatric transfer and handling techniques.
NUMBER OF SUBJECTS: 106 DPT faculty and 47 CIs responded to our survey.
MATERIALS AND METHODS: As approved by the University of Jamestown institutional review board, DPT faculty who teach pediatric curricular content and pediatric CIs were invited to participate in our anonymous electronic survey. An independent t-test was performed to assess statistical differences (p<.05) between DPT faculty and CIs.
RESULTS: There were significant differences (p<.05) between DPT faculty and CIs perspectives regarding the necessity of students' knowledge and performance of pediatric transfer and handling techniques prior to a pediatric clinical and upon graduation. CIs rated the necessity of knowledge and performance of pediatric transfers and handling techniques upon graduation higher than DPT faculty. DPT faculty (μ=3.8, SD=1.1) rated the necessity of students' performance of pediatric handling techniques prior to a clinical experience significantly higher (p<.01) than CIs (μ=3.1, SD=1.0). There were no significant differences between DPT faculty and CIs perceived self-efficacy regarding self-performance and teaching of pediatric transfers and handling techniques to students.
CONCLUSIONS: The perceived necessity of student knowledge and performance of pediatric transfer and handling techniques prior to a pediatric clinical experience and upon graduation is significantly different between DPT faculty and CIs. DPT faculty rate the necessity of knowing and performing these techniques upon graduation significantly lower than CIs. In contrast, CIs rate the necessity of students' performance of pediatric handling techniques prior to a pediatric clinical experience significantly lower than DPT faculty. Our findings indicate that there is a need for improved transparency and communication between DPT faculty and CIs to allow for consistent expectations of students clinical performance.
CLINICAL RELEVANCE: To align with current clinical practice, DPT programs together with CIs should review current pediatric transfer and handling techniques taught in the classroom prior to a pediatric clinical experience and graduation. Transparency and communication of DPT student knowledge and expectations on the performance of pediatric transfer and handling techniques is needed between DPT faculty and CIs.
BIMANUAL INTENSIVE TRAINING FOR UPPER LIMB FUNCTION IN CHILDREN WITH CEREBRAL PALSY: A SYSTEMATIC REVIEW
Armstrong VM, D'Antonio EC, Duggan KL, Kuehner SJ, Conklin MN, Schwartz JJ
PURPOSE/HYPOTHESIS: The purpose of this study was to determine the effectiveness of bimanual intensive training (BIT) on upper limb (UL) function in children with cerebral palsy (CP).
NUMBER OF SUBJECTS: N/A
MATERIALS AND METHODS: A literature search of ProQuest Central, CINAHL, Cochrane, and PubMed was conducted using the terms: (Cerebral palsy OR CP) AND (children OR child OR adolescents OR youth OR teenager OR pediatric OR paediatric OR kids OR kid) AND (“HABIT” OR “hand-arm bimanual intensive training” OR “HABIT-ILE”) AND (“physical therapy” OR physiotherapy OR rehabilitation OR rehab OR “physical therapist” OR physiotherapist OR PT). Search limits: English, human subjects, peer reviewed, 2008-2019. Selection criteria: birth-18 years old, diagnosis of CP, use of BIT, and RCTs with UL function outcome measures. Two reviewers independently assessed each study for methodological quality and came to consensus based on PEDro guidelines.
RESULTS: A total of 200 articles were screened for eligibility. After detailed appraisals, 9 RCTs met the criteria. PEDro scores ranged from 5 to 8 (mean: 6.9/10). Sample size ranged from 12 to 63 subjects (270 total). Age ranged from 1.5 to 16 years old. Treatment parameters ranged from 60h to 96h total with 6 studies providing 90h. All 9 studies showed statistically significant UL function improvements with BIT using the following outcome measures: Assisting Hand Assessment (AHA; 5 studies), Canadian Occupational Performance Measure (COPM; 4 studies), Pediatric Evaluation of Disability Inventory (PEDI; 2 studies), Jebsen Taylor Test of Hand Function (JTTHF; 2 studies), Assessment of Life Habits (LIFE-H; 1 study), Quality of Upper Extremity Skills Test (QUEST; 2 studies), ABILHAND-Kids (2 studies), Goal Attainment Scale (GAS; 1 study). One study found greater improvements in children with more severe baseline impairments. Six studies compared BIT to constraint-induced movement therapy (CIMT) and found significant improvements in both groups, but no significant differences between groups. Greater carryover in functional tasks was reported with BIT groups compared to CIMT groups.
CONCLUSIONS: There is moderate to strong evidence to support the use of BIT to improve UL function in children with CP. Optimal treatment parameters cannot be concluded, but evidence supports at least 60h to show significant improvements in UL function. Limitations included small sample sizes, many outcome measures, and little follow-up. Future research should include long-term outcomes, optimal training parameters and age of subject.
CLINICAL RELEVANCE: Evidence supports BIT as an effective intervention for improving UL function in children with CP. Most functional activities require bimanual UL use so BIT is more task specific than CIMT and may be better tolerated due to the lack of restraint. BIT can be administered inexpensively in many settings such as home, school, camp, and outpatient, since it does not require special equipment. Clinicians should consider BIT for functional tasks when working with children with CP to improve UL function.
DELIVERY OF EVIDENCE-BASED INTERVENTION TO INDIVIDUALS WITH CEREBRAL PALSY IN THE OUTPATIENT MEDICAL SETTING
Bailes AF, Greve KR, Mitelpunkt A, Long J, Kurowski BG, Vargus-Adams J, Aronow B
PURPOSE/HYPOTHESIS: A systematic review of evidence-based interventions (EBI) for cerebral palsy (CP) has graded physical therapy interventions as green “definitely should do”, yellow “probably should do”, yellow “probably should not do”, and red “definitely should not do”. While delivery of EBI in ‘real world’ clinical settings are unknown, this information would be useful to support staff development and elucidate areas for future study. The purpose of this study was to describe physical therapist delivery of EBI in children with CP and examine variation by age, Gross Motor Function Classification System (GMFCS), race and insurance type.
NUMBER OF SUBJECTS: 618
MATERIALS AND METHODS: Using a standardized electronic medical record documentation form, therapists selected discrete fields for intervention type delivered during each session. Data from October 2017-2018 were extracted retrospectively and intervention type was categorized according to Novak's traffic light grades. Frequency and percentages were reported for all grades, and green and yellow ‘should do’ interventions were combined to create percentage of EBI for all sessions. Pairwise comparisons and Benjamini Hochberg (BH) adjustment for multiple comparisons were used to examine variation by age, GMFCS, race and insurance type. Results: Six hundred and eighteen children (357 male) were seen for outpatient physical therapy representing GMFCS Levels I-V (25.6%, 22.2%, 13.8%, 17.2%, and 12.9% respectively, under 2 years 8.4%). A total of 29,429 interventions were delivered over 4553 physical therapy sessions. Thirty seven percent were green, 28% yellow ‘should do’, 2% yellow ‘should not do’, 3% red, and 30% other. The most frequently delivered green interventions were goal directed training/functional training, home program/caregiver education, and home program/patient education. The most frequently delivered yellow ‘should do’ interventions were lower limb strengthening, assistive technology/equipment and orthotics. The only ‘should not do’ interventions were manual stretching/passive range of motion (yellow) and facilitation (red). Postural control, balance and skin check were the most frequently delivered other (ungraded) interventions. Significantly less EBI was delivered in sessions where the child was < 5 years old (62%), compared to other age groups (5 <12 years (71%), 12 <18 years (70%), and ≥18 years (70%)) p<0.01 and where the child was non ambulatory (GMFCS IV-V (65%)) versus ambulatory (GMFCS I-III (71%)) p<0.01. There were no significant differences in EBI delivered by gender, race or insurance type.
CONCLUSIONS: Physical therapist delivery of EBI varied by GMFCS and age but not by race, gender or insurance type. The majority of interventions (65%) delivered were EBI. Standardized documentation across institutions would support larger studies of EBI delivery and therapy dose.
CLINICAL RELEVANCE: The amount of home program/education intervention delivered suggests therapists are involving families and individuals in the rehabilitation process. Studies related to balance, postural control and skin checks would be useful. Future work should evaluate the relationship between receipt of EBI and outcomes in children with CP.
ASYMMETRICAL BEHAVIORS AND TOY PREFERENCE IN INFANTS WITH CEREBRAL PALSY
Barbosa GO, Rolf KE, Heathcock JC
PURPOSE/HYPOTHESIS: Cerebral Palsy (CP) is a neurodevelopmental disability leading to poor movement and coordination as a result of a brain lesion(s). Many infants with CP have difficulty contacting and grasping toys with one side more than the other. The purposes of this study were to 1) evaluate asymmetry of reach (contacts and grasps) between sides of the body and 2) identify toy preference for the more affected and less affected side in infants with CP GMFCS levels III-V.
NUMBER OF SUBJECTS: N=15 infants age 8-24 months corrected age with CP, GMFCS levels III-V. Mean corrected age = 15.04 ± 3.9 months; 53.3% female and 87% preterm (26.6 ± 3.7 gestational weeks at birth).
MATERIALS AND METHODS: Infants were seated in a standardized position and presented with four toys of different sizes at midline, shoulder height, and within 75% of arm's length for two thirty-second trials to elicit reach and grasp behaviors: a medium sized ball, the wide end of a maraca (maraca), the maraca handle (handle), and a glow wand (glow). Behaviors were recorded at two separate sessions that were one month apart. Interactions were videotaped and coded using Datavyu. Wilcoxon signed rank test was used to evaluate differences between sides using an asymmetry index (<1 means a strong asymmetrical preference and reduced behaviors of the more affected side of the body) and Friedman's test was used to compare conditions.
RESULTS: Infants showed asymmetry in contacts between sides, 67% of subjects showed an asymmetrical index <1. A month later, 80% had an asymmetrical index of <1. Wilcoxon signed rank test demonstrated a significant difference in contacts in the first session (Z=-4.2, p<0.01,) and one month later (Z=-5.0, p<0.01) with subjects preferentially using one side more frequently. Friedman two-way non-parametric ANOVA was used to compare upper limb sides and session. Significant differences for contacts with the less affected side were found in the initial session with the ball (X2 (1)=4.5, p=0.03), maraca (X2 (1)=6.2, p=0.01), and handle (X2 (1)=6.2, p=0.01) and one month later in the ball (X2 (1)=12, p<0.01) and glow (X2 (1)=12, p<0.01). Differences were found for grasps with the less affected side in the initial session for the maraca (X2 (1)= 4, p=0.04) and handle (X2 (1)=7.4, p<0.01), and one month later for the handle (X2 (1)=8.3, p<0.01). Glow wand differences for grasping (X2 (1)=5.4, p=0.02) were found from the initial session to one month later in the less affected arm.
CONCLUSIONS: Our results for session one and one month later show that individuals with GMFCS levels III-V had an unequal number of contacts between sides. Different toys facilitate more mature behaviors on the stronger side but not on the weaker side.
CLINICAL RELEVANCE: Our data may allow the selection of the most appropriate toys in early treatment in infants with asymmetric CP. Due to the behavioral neglect of the more affected side, it is important that we use appropriately stimulating toys for the infant to interact with their more impaired side. The most affected side needs to be further stimulated to minimize loss and improve function; such as treatments using constraint-induced movement therapy.
THE EFFECTS OF DANCE/CREATIVE MOVEMENT ON THE SOCIAL AND MOTOR SKILLS OF CHILDREN WITH AUTISM
Bhat AN, Peace I, Manders L, McGowan K, Tavino M, Lisa Levine, Su WC, Overby L
PURPOSE/HYPOTHESIS: To compare the effects of creative movement/dance or standard ABA-based seated play interventions on the social communication and motor skills of school-age children with Autism Spectrum Disorder (ASD).
NUMBER OF SUBJECTS: 25 children with ASD between 6 and 14 years of age participated in the study.
MATERIALS AND METHODS: All children completed pre- and post-testing using standardized social and motor performance measures. 13 children received the creative movement intervention protocol and another 12 children received the standard ABA-based seated play protocol. Both groups received 8 weeks of intervention, 2 days per week of expert sessions and another 2-3 days per week of parent provided sessions. Each session involved activities focused on learning dance concepts of flow/weight, energy/space, level, size/shape, pathways/directions, speed/rhythm, and look/balance. In terms of motor performance we will report on changes in bilateral coordination and balance using the Bruininks-Oseretsky Test as well as changes in task-specific and generalized imitation errors using praxis subtests of the Sensory Integration and Praxis Tests (SIPT). In terms of social performance, we will report on changes in socially directed affect and verbalization skills across Day 1, 8 and 16 over the intervention period to explain intervention-related changes in social interactions.
RESULTS: We found that children in the creative movement group showed improvements in bilateral coordination and balance; however, similar improvements were not seen in the standard seated play group. Task-specific improvements in imitation errors were seen in both groups. Generalized improvements in imitation performance were seen in the creative movement group but not the standard seated play group. There were more socially-directed smiles in the creative movement group; however, more compliant/interested affect was seen in the seated play group. We are still analyzing the verbalization changes across training and will report those within our presentation.
CONCLUSIONS: Children with ASD displayed improved motor performance as seen by improved whole body coordination and balance scores as well as improved imitation accuracy compared to the standard seated play group. Children in the creative movement group increased smiling whereas children in the standard seated play group showed more compliant/interested affect.
CLINICAL RELEVANCE: Learning creative movement concepts of flow, space, level, size/shape, pathways/directions, speed/rhythm, balance, etc. was highly engaging for children with ASD. Additionally, creative movement affords various types of partner-based synchronous activities such as mirroring, shadowing, front-to-front, back-to-back, sharing weight, etc. as well as creative pretend play activities involving functional skills training. Together, these principles are an interesting addition to a clinician's toolbox when working with special needs children with multi-system disorders impacting the motor, social communication, and cognitive-behavioral systems.
GEORGE: PREPARING FUTURE EARLY INTERVENTIONISTS IN THE NATURAL ENVIRONMENT
Birkmeier MC, Brady RA, Chimka J, Durie O, Long T
PURPOSE: The presentation will describe a unique program that prepares interprofessional graduate students to be competent and confident to provide evidence-based early intervention as new professionals.
DESCRIPTION: The Graduate Education of Related Service Providers at Georgetown and George Washington Universities in Early Intervention (GEORGE) Program is a 10-month interprofessional, inter-university program that provides enrolled physical therapy students and other graduate students in the related service professions and early childhood special education the knowledge, skills and abilities to be early interventionists upon graduation. To complement hybrid, didactic coursework, GEORGE incorporates a culminating team-based practicum in community-based inclusion programs for children and families eligible for early intervention (EI) services. Students are afforded experiential learning opportunities to implement evidenced-based EI practices; provide feedback to peers; and assess their own fidelity. Practicum development involved extensive planning, communication, and consideration to the unique aspects of each site. Primary site coordinators collaborated with GEORGE faculty to ensure the needs of the teachers, families and children were met while providing a learning experience that achieved course objectives and met student expectations.
SUMMARY OF USE: Results from the first cohort indicate students found GEORGE valuable to their future work. Students (N=9) completed pre and post surveys of their comfort with EI practices. They reported increased confidence across all categories after the practicum but particularly in the areas of family-centered care, assessment and collaboration. The largest changes in comfort with practices was in creating Individualized Family Service Plans. Additionally, students reported increased comfort in assessing the concerns, resources and priorities of families for program planning and summarizing and presenting assessment results jargon-free, in the context of the child or family strengths. They reported increased confidence in collaborating with professionals and families to support children's development and learning and cultivating partnerships that build family competence and confidence. There were differences in the extent of change in each of the areas between the two sites and within each student. Overall, the coursework and practicum increased participants' confidence in EI practices, and they will continue to be followed to see if they felt prepared and continue to feel confident once they are employed in an EI role.
IMPORTANCE TO MEMBERS: There is a significant need of EI providers across the nation but due to the specific knowledge, skills and abilities, new professionals are hesitant to work in EI. Additionally, employers seek EI providers with experience or advanced training. Programs designed to provide students with concentrated EI training that complement and occur in tandem with their professional programs can increase EI service providers while decreasing the educational debt on new providers.
RELATIONSHIP OF PAIN FREQUENCY, WALKING ACTIVITY, AND PARTICIPATION AMONG CHILDREN WITH SICKLE CELL DISEASE
Bush Tankersley J, Sweeney JK, Bjornson KF, Gibson R
PURPOSE/HYPOTHESIS: Disruptions of daily functioning can be varied and unpredictable for children with sickle cell disease (SCD). Current understanding of the complex dynamics contributing to a child's inability to participate fully in their daily life habits is limited. The purpose of this study was to examine the relationship between pain frequency, walking activity, and participation in life habits among children with SCD.
NUMBER OF SUBJECTS: 50
MATERIALS AND METHODS: For this cross-sectional descriptive study, 50 children with SCD consisting of 28 females and 22 males with a mean age of 9.36 years old (±2.28 SD) wore a wireless activity monitor to track step counts for four consecutive weeks while enrolled in school. Participants also completed pain diaries for those four weeks and were administered the Beery-Buktenica Developmental Test of Visual-Motor Integration (Beery VMI) and the Life Habits Assessment (LIFE-H).
RESULTS: After normal distribution of data was established, Pearson product-moment correlation coefficients were computed to assess the relationships between pain frequency, walking activity, Beery VMI standard scores, and participation in life habits. The negative relationship between pain frequency and participation was moderately correlated (r = -.332, p<.05). Increases in pain frequency were correlated with decreases in LIFE-H total scores with 9.7% of variance shared (r2 = .097). Pain frequency was also negatively correlated with the LIFE-H subgroup of fitness (r = -.311, p≤.05) with 11% of variance shared (r2 = .011). The LIFE-H subgroup of fitness was positively correlated with walking activity (r = .355, p≤.05). Increases in fitness were correlated with increases in walking activity with 12.6% of variance shared (r2 = .126). No significant relationship was found between pain frequency and walking activity (r =.016, p<.913). No correlation was found between Beery VMI standard scores and any other outcome measures.
CONCLUSIONS: Pain frequency and walking activity influence ability to participate in life habits for children with SCD. As pain frequency increases, overall participation decreases, with a greater effect on fitness. However, as walking activity increases, fitness increases regardless of pain frequency.
CLINICAL RELEVANCE: Developing effective pediatric physical therapy management protocols to address increased walking activity, fitness and overall participation while modulating pain control for children with SCD could help reduce the effects of the sequelae associated with vaso-occlusive events and improve quality of life.
A NOVEL RISK ASSESSMENT TOOL FOR EARLY MOBILIZATION AFTER PEDIATRIC TRACHEOSTOMY
Byrne EM, Freccero A
PURPOSE: To confirm the standard of care of postoperative mobilization practices following initial tracheostomy, establish face validity of novel early mobilization tools, and conduct a safety and feasibility pilot study. Due to the variability in patient comorbidities surrounding tracheostomy placement, this group of patients requires individualized care for optimal outcomes and rigid care protocols may ignore important clinical factors needed for assessing patient-specific risks following surgery. Despite the prevalence of tracheostomy in the United States, there is a lack of evidence-based protocols for mobilization of the pediatric population in the immediate postoperative period. As a result, the authors sought to create a patient-centered, multidisciplinary tool to be used by all specialty services involved in the care of pediatric patient post initial tracheostomy, with the goal of promoting early and safe mobilization and rehabilitation.
DESCRIPTION: This investigation was composed of 2 separate national surveys: 1) to assess post-tracheostomy mobility practices at other tertiary-care children's hospitals and 2) to establish face validity of the Pediatric Early Mobilization Pathway and Pediatric Mobility Risk Assessment Scoring Tool. Upon completion of the survey phase, a pilot study was conducted. To confirm the standard of care, we surveyed approximately 55 institutions and received a total of 26 survey responses (physicians (n=14), nurse practitioners (n=1), occupational therapists (n=2), physical therapists (n=8) and speech language pathologists (n=1)) from separate tertiary care children's hospitals. Of these responses, 20 institutions (77%) reported that they do not mobilize pediatric patients prior to the initial tracheostomy tube change,
further confirming that this is a widely accepted standard of care in this patient population. Twenty-five institutions (96%) expressed an interest in more information on a risk assessment tool, with 83% stating that they would consider changing their practice if they had access to an established tool to help guide clinical decisions. Of the 12 colleagues surveyed to establish face validity of the newly developed tools, 10 respondents (83%) agreed with the clinical factors and scoring structure outlined in the Pediatric Mobility Risk Assessment Scoring Tool. Regarding other elements of the tools, all 12 respondents agreed with the visual flow and readability of both the Pediatric Early Mobilization Pathway and Pediatric Mobility Risk Assessment Scoring Tool. The Pediatric Early Mobilization Pathway and Risk Assessment Scoring Tool were designed in collaboration with pediatric otolaryngology, pediatric and cardiovascular critical care, and rehabilitation services to promote early and safe edge of bed (EOB) and out of bed mobility (OOB) after initial tracheostomy placement in children. The pilot study included patients who underwent new tracheostomy tube placement after January 2017. Patient demographics, mobility status at discharge, complications associated with patient mobility using the protocol, and the ability to achieve early mobilization were extracted. Descriptive statistics were applied. The first 9 consecutive patients, median age 12 years (range 8-16y), 3 years of age or greater were included.
SUMMARY OF USE: The Pediatric Early Mobilization Pathway guides therapy after initial tracheostomy placement. In this pathway, the patient is on bedrest for the first 24 hours postoperatively. Following the initial bedrest phase, the patient then receives bed level therapeutic intervention until postoperative day two. On postoperative day 3, the Pediatric Mobility Risk Assessment Scoring Tool is implemented, and mobility is progressed as indicated by the tool. Each patient's mobility risk-assessment score is recorded daily and used by the treating rehabilitation therapist to assess the safety of EOB and/or OOB mobilization, until the first tracheostomy tube change. The Pediatric Mobility Risk Assessment Scoring Tool requires direct input from otolaryngology and the treating rehabilitation team, and includes recommendations from the pediatric critical care teams. The Pediatric Mobility Risk Assessment Scoring. Tool is subdivided into 5 categories encompassing complexity of airway anatomy, stoma or skin healing concerns, physiologic stability, patient's cognitive status, and patient's ability to participate in rehabilitation. Each category is subscored from 0-2, with higher numbers indicating a concerning clinical feature. The subscore of each category is summed on a daily basis until the first tracheostomy tube change for a total score between 0 and 10. Any patient with a very complex airway (subscore = 2) or physiologic instability (subscore =2) is deemed too high risk, and therefore EOB and OOB mobility are contraindicated, regardless of total score. A total score of 0 or 1 indicates that early EOB and/or OOB mobility is clinically indicated prior to the first tracheostomy change, with direct rehabilitation assessment. A score of 3 or 4 initiates a discussion between all services to further assess the risk of EOB and/or OOB mobility. If EOB and/or OOB mobility is deemed unsafe, bed level therapeutic exercises as outlined in the Pediatric Early Mobilization Pathway are continued. If EOB and/or OOB mobility is indicated, it requires the presence of a respiratory therapist and/or a physician. A score of 5 or greater is a contraindication for EOB and OOB mobilization, however bed level therapeutic exercises may still be considered. To date, a total of 9 pilot subjects with new tracheostomies were assessed using the Pediatric Early Mobilization Care Pathway and the Pediatric Mobility Risk Assessment Scoring Tool with no adverse events documented. The primary diagnoses associated with the patient's admission were variable, including trauma, neurologic injury following ruptured cerebral arteriovenous malformation, cerebral palsy with intractable epilepsy, and airway compression secondary to rhabdomyosarcoma. After being assessed with the Pediatric Mobility Risk Assessment Scoring Tool, early mobilization prior to the initial tracheostomy tube change was indicated in 6 of the 9 patients. The remaining 3 pilot subjects were assessed and both EOB and OOB mobility were contraindicated, due to their inability to follow commands or physiologic hemodynamic instability. These patients instead continued daily bed level exercises as indicated on the Pediatric Early Mobilization Pathway. In this pilot study, early mobilization did not result in accidental decannulation, stoma breakdown, hemodynamic or respiratory instability, or endotracheal ulceration.
IMPORTANCE TO MEMBERS: The Pediatric Early Mobilization Pathway and Mobility Risk Assessment Scoring Tool can facilitate and standardize communication between all services to help manage the safe progression of a pediatric patient after new tracheostomy placement prior to the first tracheostomy change. Our preliminary results suggest that when risk is properly assessed and mitigated, early mobilization of pediatric patients following tracheostomy is safe. In addition, the improved communication from this protocol enhanced safety by standardizing assessment, communication, and progression of the plan of care for each child. Although our sample size does not allow for meaningful outcomes analysis or widespread provider satisfaction assessment, the presented evidence suggests that this protocol is useful, safe, and feasible.
USE OF BRACING TO ADVANCE MOTOR CONTROL AND ALIGNMENT IN A 3 Y.O. WITH ACHONDROPLASIA
Chamberlain DA, Parent-Nichols JC
BACKGROUND AND PURPOSE: Children with Achondroplasia experience musculoskeletal impairments including hypotonicity and joint laxity/hypermobility. Gross motor development is delayed, and atypical patterns of movement are often used to compensate for short extremities. Over time, the malalignment and atypical movement patterns can lead to joint damage and pain. Bracing for children with hypotonia has had positive results but has not been explored in children with Achondroplasia. Soft bracing at the knee with hyperextension resistance may improve lower extremity alignment and movement efficiency for children with achondroplasia. The purpose of this study was to examine the effects of bracing on the movement patterns and functional control in a child with achondroplasia.
CASE DESCRIPTION: A 3 y.o. girl with Achondroplasia participated in a daily home exercise program (HEP) and trial of knee bracing in an A-B-A-B design. A neoprene brace with hyperextension resistance was used on the left lower extremity as there was significantly more hip and knee laxity compared to the right which was negatively affecting her movement. Consecutive measurements were taken over two months to establish a baseline. Study design included bracing for 12 weeks, no bracing for 4 weeks, and reintroduction of bracing for 6 weeks. The focus of HEP used was improvement of symmetry, alignment and control during transitional movements. Measures after each phase included passive range of motion (PROM), and postural and movement assessment through videography. Functional motor activities in the HEP included squat to stand, floor sit to stand, jumping, stair climbing, running, and ball skills.
OUTCOMES: The subject demonstrated improvement in alignment and control following 12 weeks of bracing. When the brace was withdrawn, significant regression in alignment and control was observed. When bracing was reintroduced for six additional weeks, gains in alignment, symmetry, and control were observed. At baseline, the patient demonstrated a 27% delay in gross motor skills and a 22% delay at final assessment. At the conclusion of the intervention, the use of knee hyperextension to transition from floor to stand was rarely seen and squatting was performed with bilateral full knee flexion. Substantial changes were noted in bilateral hip and knee PROM, with values to be closer to norms, with the differences between right and left lower extremities decreased. Both sitting and standing postures became more symmetrical and alignment was improved. These gains were maintained at a three month follow up where the brace was worn intermittently.
DISCUSSION: Use of a soft knee brace with hyperextension resistance combined with a HEP was helpful in improving joint alignment, symmetry, control in transitional movements and acquisition of age appropriate gross motor skills, in a 3-year-old with Achondroplasia. This intervention should be considered to promote motor control and protect against joint damage. When learning a new skill, children need sufficient amount of practice and intensity to have permanent motor learning to take place. This was evident when regression occurred during the middle 4 weeks without bracing.
REHABILITATION THERAPISTS' PERCEPTIONS OF FACILITATORS AND BARRIERS TO ENGAGEMENT OF CHILDREN AND PARENTS IN THERAPY
Chiarello LA, Ideishi R
PURPOSE/HYPOTHESIS: To identify outpatient rehabilitation therapists' perceptions of the facilitators and barriers to engage children and their parents in the therapy process.
NUMBER OF SUBJECTS: 9 physical therapists and 10 occupational therapists from U.S. and Canada participated in the study.
MATERIALS AND METHODS: Trained research assistants observed 19 outpatient pediatric therapy sessions and recorded field notes. After the therapy sessions, the research assistants conducted qualitative interviews with the therapists to explore their perceptions of the facilitators and barriers to engaging children and parents in the therapy process. The interviews were audio recorded and transcribed verbatim. The research team, consisting of 7 individuals with a background in physical therapy, occupational therapy, and social psychology, bracketed their assumptions, read the transcripts, and discussed initial impressions and coding strategy. Two researchers on the team, a physical therapist and an occupational therapist, reread and coded the transcripts, and through thematic analysis (a process of extracting, defining, organizing, and synthesizing important concepts) identified themes and representative participant quotes.
RESULTS: For facilitators of engagement, 8 themes emerged: fostering a caring relationship, preparing a facilitatory environment, being aware and responsive to the child and parent, demonstrating personalized and reciprocal communication with the child and parent, having parents attend sessions and using adult-learning approaches, giving child ownership of the therapy process, using child-focused intervention strategies, and balancing and framing interactions with child and parent. For barriers to engagement, 4 themes emerged: having limited awareness and responsiveness to child and parent, demonstrating poor communication, lacking balance of interactions with child and parent, and using long episodes of care. Therapists also identified characteristics of the child, parent, and service environment that contributed to facilitating or hindering engagement of children and parents in the therapy process.
CONCLUSIONS: Therapists' perceptions of the facilitators and barriers to engagement illuminated the importance of communication, collaboration, and responsiveness to the child and family. Engagement is an individualized, complex, and dynamic process. Engagement involves a relationship among the child, family, and therapists and is influenced by characteristics of the child, family, therapist, and system of care.
CLINICAL RELEVANCE: Engagement of children and their families in pediatric rehabilitation is an approach for implementing family-centered care and optimizing outcomes. Knowledge of the facilitators and barriers can inform the adoption of therapy strategies to support child and family engagement in the therapy process.
OUTPATIENT PHYSICAL THERAPY TO SUPPORT CHILDREN'S COMMUNITY RECREATIONAL PARTICIPATION: A PILOT STUDY
Chiarello LA, Palisano RJ
PURPOSE/HYPOTHESIS: To establish feasibility, acceptability, and preliminary evidence of effectiveness for a participation-based approach to physical therapy adapted for the outpatient setting.
NUMBER OF SUBJECTS: 5 children with disabilities (4-10 years of age), their mothers, physical therapists, and 3 community recreational program leaders participated in the study.
MATERIALS AND METHODS: Therapists collaborated with mothers and children on an ecological assessment and development of an intervention plan focused on attaining a community recreational goal. Children received outpatient therapy services over a period of 2-4 months. During therapy, parents, children, and therapists viewed videos taken by parents using a smartphone of the children participating in the community activity and collaboratively discussed and practiced strategies to optimize children's participation. Three therapists collaborated with the community leaders and visited the community program. Outcomes, measured pre- and post-intervention, were: 1) children's community participation (Participation and Environment Measure for Children and Youth [PEM- CY]), individualized goal achievement (Canadian Occupational Performance Measure [COPM], and Goal Attainment Scaling [GAS]), 2) children's self-determination (American Institute of Research Self-Determination Scale [AIRS]), and 3) parent capacity for enabling their children's community participation (researcher developed measure). Post intervention, children completed two questions on participation engagement and the family, therapists, and community leaders provided feedback on their experiences.
RESULTS: 4 children completed the study. Fidelity of the intervention protocol varied across the cases. Improvement in children's physical performance on the COPM varied from 2 to 9 points. Three children achieved a GAS score of +1 and one child a 0, indicating expected or higher than expected goal achievement. Children reported enjoying and learning “a lot” to “really a lot” from their community participation. Children's overall scores on the PEM-CY and AIRS did not change. Parents' capacity for enabling participation was high pre-and post-intervention. Therapists, mothers, and community leaders provided positive feedback on the therapy approach.
CONCLUSIONS: Participation-based physical therapy can be adapted for outpatient services and shows promise for positive outcomes in achieving community recreational goals. Smartphones enable therapists to observe children participating in community activities. This approach is valued by therapists, mothers, children, and community leaders. However, further study is needed to determine what supports are needed to enable therapists to fully implement the approach and engage parents and community leaders.
CLINICAL RELEVANCE: Knowledge about the feasibility, acceptability, and effects of outpatient therapy to support children's community participation will enable physical therapists to advocate for and partner with families and community leaders to provide participation-based services.
INVESTIGATING HIPPOTHERAPY FROM THE PERSPECTIVE OF PARENTS OF CHILDREN WITH PHYSICAL DISABILITIES: A QUALITATIVE STUDY
Collins ME, Brantingson LC, Yurko MP, Rinehimer MA
PURPOSE/HYPOTHESIS: Many existing therapies are utilized with the goal of effectively treating children with physical disabilities. One alternative form of therapy that has been increasing in popularity is hippotherapy. Current research on hippotherapy focuses on individuals with cerebral palsy. The purpose of this study was to broaden the scope of research to include the effects of hippotherapy on children with any physical disability as perceived by parents.
NUMBER OF SUBJECTS: 15 parents of 8 male and 7 female children participated in the study. The age range of the children was 2 to 16 years old and diagnoses included autism spectrum disorder, Down syndrome, hypotonia, cerebral palsy, Marfan syndrome, Lennox-Gastaut syndrome, and 15q duplication syndrome. All children were receiving hippotherapy once per week and the length of time receiving services ranged from 3 to 48 months.
MATERIALS AND METHODS: Convenience sampling was used to seek participants and qualitative data was obtained using a survey developed by the researchers that encompassed aspects of significance related to hippotherapy. The survey was available in both paper and online formats for convenience.
RESULTS: Data analysis focused on five themes: recommendation/referral, accessibility and affordability, effectiveness for children with various physical disabilities, differences in hippotherapy compared to other therapies, and parent opinions on the overall experience. 100% of subjects reported that their child enjoys hippotherapy more than other therapies. The beneficial effects identified by subjects that they directly correlated to hippotherapy included improved core and lower extremity strength, postural control, muscle endurance, motivation for and compliance to therapy, tolerance to length of therapy sessions, and longer lasting effects. 93% of subjects strongly agreed they would recommend hippotherapy to others.
CONCLUSIONS: Hippotherapy is perceived to result in positive physical and social changes in a wide array of physical disabilities. Regardless of the diagnosis, children have greater enjoyment with hippotherapy as they view it as a fun activity as opposed to “exercise,” which is leading to increased compliance. The recognized benefits of hippotherapy have the potential to carry over into other therapy services, including physical therapy. Therefore, there is an increased likelihood for achieving progression in the plan of care when hippotherapy services are appropriately utilized in conjunction with PT for children with physical disabilities.
CLINICAL RELEVANCE: This study is of particular interest to physical therapists because hippotherapy can be used in addition to PT to give children the utmost opportunity to improve their quality of life. Hippotherapy can encourage participation in patients who may not be cooperative with their PT services. This study can raise awareness to healthcare providers that the benefits of hippotherapy reach beyond cerebral palsy to numerous other diagnoses and it can have a profound impact on how parents perceive their child's progress.
BEST PRACTICE INTERVENTIONS TO MITIGATE PHYSICAL DECLINE IN DUCHENNE MUSCULAR DYSTROPHY: A SYSTEMATIC REVIEW
Conklin AB, Agudelo MF, Bauer-Rowe C, Garretson JC, Rothenberg C, Stopyra C
PURPOSE/HYPOTHESIS: Duchenne Muscular Dystrophy (DMD) is a progressive neuromuscular disease characterized by deterioration of proximal musculature resulting in gradual loss of lower extremity (LE) range of motion (ROM) and steady functional decline including loss of upright mobility. Physical therapy (PT) interventions for DMD include LE stretching and positioning and non-fatiguing therapeutic exercise. However, research supporting the effectiveness of such interventions is outdated and may not reflect current best practice. The purpose of this review was to explore the effectiveness of interventions implemented to mitigate physical decline in LE ROM and functional mobility in boys with DMD.
NUMBER OF SUBJECTS: N/A
MATERIALS AND METHODS: A search of CINAHL, PubMed, Scopus, and OVID Medline was conducted in November 2018, using keywords: “Duchenne Muscular Dystrophy/DMD” and “physical therapy”, “ambulation”, “walking”, “stretching”, “exercise”, “aquatics”, “aquatic physical therapy”, “kinesiotaping”, “orthotics/orthoses”, “serial casting”, “standers”, and “electrical stimulation”. Studies in English published within the past 10 years investigating PT interventions for boys with DMD ages 4-21 were included. Two reviewers critically appraised each study for quality and internal validity using the Joanna Briggs Institute critical appraisal checklist and the Centre for Evidence-Based Medicine (CEBM) Levels of evidence.
RESULTS: Ten studies ranging in quality from CEBM Level 1B to 4 met our inclusion criteria. Interventions compared in this review included assisted bicycle training, aquatic therapy (AT), distal LE serial casting, orthotics, and supported standing programs with heterogeneous outcome measures used. Although functional decline was observed across all studies, the rate of decline was significantly less in studies where boys received assisted bicycle training. Less compelling evidence suggested effectiveness of AT performed in a warm water pool. Significant improvements in LE ROM were obtained through application of LE serial casting, whereas the use of overnight orthotics best preserved LE ROM.
CONCLUSIONS: Results highlight assisted bicycle training as the most effective intervention for mitigating functional decline in boys with DMD with AT, LE serial casting, and overnight orthotics demonstrating some promising benefits. Future research assessing the long-term outcomes of similar interventions across all stages of disease progression and those comparing assisted bike training to AT with more clearly defined protocols, are needed to better determine best practice interventions to mitigate physical decline in boys with DMD.
CLINICAL RELEVANCE: Results suggest that assisted bicycle training, AT, distal LE serial casting, and overnight LE orthotic use should be considered when developing a PT plan of care for boys with DMD. Despite evidence suggesting efficacy of such interventions, implementation may be limited by clinical practicality and patient/parent adherence.
RELIABILITY OF THE PEDIATRIC BALANCE SCALE, SECOND EDITION (PBS-2)
Darr NS, Franjoine MR, Young B
PURPOSE/HYPOTHESIS: The Pediatric Balance Scale (PBS), a 14-item criterion referenced measure of functional balance, was developed to identify children with balance dysfunction (BD) and monitor change. The PBS has excellent psychometric properties, but demonstrates a ceiling effect limiting its ability to differentiate balance ability in children with typical development (TD) from those with mild BD over age 6 years. Based on Rasch analyses, the PBS was modified to create the second edition of the tool (PBS-2); six items were added to increase developmental challenge. Modifications were made to enhance item and rating scale functioning resulting in more complex administration and scoring. The PBS-2 has been pilot tested in over 700 children, ages 2 to 13 years; 20% of participants had health conditions resulting in BD. The purpose of this study was to examine PBS-2 reliability, as well as, feasibility of video based scoring.
NUMBER OF SUBJECTS: Forty-nine children (2 through 13 years), who could stand hands free for 4 seconds and follow simple one step directions, participated in this study.
MATERIALS AND METHODS: Nine PT students and 2 faculty mentors participated in data collection at 2 sites. Student raters received at least 20 hours of training by test authors. All testing was video recorded. During test sessions, each child's performance was scored by a test administrator and a videographer to examine interrater reliability during live testing. To assess test-retest reliability 16 of the children returned for a 2nd test session 2 weeks after initial testing. At least 2 weeks after the conclusion of all testing, 4 randomly selected videos were individually scored by 5 raters at site #1 and 22 videos were scored by 5 raters at site #2 to assess interrater reliability from video. Subsequently, 4 videos were rescored at least two weeks later to assess intrarater reliability. Raters' scores obtained from video recordings were also compared with the same raters' scores obtained during actual test administrations to examine consistency of scoring between video and live testing. Reliability was calculated using ICC 3,1 to determine intrarater and test-retest reliability and ICC 2,1 for interrater reliability.
RESULTS: The PBS-2 demonstrated excellent interrater reliability during live testing sessions (ICC=.946-.961) and when scored from video (Site #1 ICC=.997, Site #2 ICC=.998), as well as test-retest reliability (ICC=0.918) and intrarater reliability (ICC=0.931-1.00).
CONCLUSIONS: The PBS-2 demonstrates excellent interrater, intrarater, and test-retest reliability comparable to the original PBS despite the increased length and complexity. The PBS-II can also be reliably scored from video recordings using precise administration, scoring, and videography procedures.
CLINICAL RELEVANCE: Despite additional items and changes to rating scales to enhance PBS utility in children over age 6 years, the PBS-2 demonstrates excellent reliability.
DAILY HOME INTERVENTION PROGRAM TO ENCOURAGE LEG MOVEMENTS FOR INFANTS AT RISK OF DEVELOPMENTAL DISABILITY
Deng W, Rosales MR, Smith BA
PURPOSE/HYPOTHESIS: Early and intense therapy intervention is proposed to be more effective than standard care at promoting optimal neuromotor structure and function. However, we do not know what amount of movement experience is necessary and sufficient to have a positive effect on the development of infant neuromotor control. Intuitively, a higher frequency of movement would allow more opportunities to explore and find an optimal movement pattern. Our objective here is to compare leg movement rates in infants at risk for developmental disability pre and post intervention.
NUMBER OF SUBJECTS: 10
MATERIALS AND METHODS: Ten infants participated (7 males, 3 females) with median adjusted age 194 days old (min, max: 84, 214) at the first visit. We worked with families to determine a caregiver provided daily exercise program to encourage infant leg movement.1-3 On average, 2 to 3 exercises were prescribed, 3-5 times each day and 3-5 minutes for each exercise each time. We adjusted the exercise programs based on infant's and caregiver's responses during the monthly visit. All infants received 2 to 5 visits. To measure leg movement rate, infants wore a wearable sensor at each ankle from the morning until bedtime at each visit. Leg movement rate (average number of leg movements per hour of awake time) was calculated using a validated algorithm.4 We tested for a difference of leg movement rate between the first visit and last visit using paired samples T-test.
RESULTS: There was no significant difference of leg movement rate between the first visit (mean±sd: 1342±466) and last visit (1277±373) (p=0.50). For 4 infants who started with a leg movement rate smaller than 1200 movements/hour awake, median leg movement rates were 1003 (min:935, max:1070) at the first visit and 1230 (min:1102, max:1358) at the last visit (p=0.07). For 6 infants who started with a leg movement rate higher than 1200 movements/hour awake, median leg movement rate was 1682 (min:1613, max:1729) at the first visit and 1234 (min:998, max:1506) at the last visit (p=0.12).
CONCLUSIONS: We did not see a significant difference in leg movement rate pre and post caregiver-provided intervention in this preliminary analysis. This is a small pilot study with ongoing data collection, and infant leg movement rate has high variability.5 We will complete data collection and determine the effect size of what may be a leg movement rate increase for infants who started with a leg movement rate lower than 1200 movements/hour awake. We will also consider other variables (developmental status, quality of caregiver-infant interaction) that may be related to leg movement rate.
CLINICAL RELEVANCE: The results of this study will provide information about leg movement rates in infants at risk for developmental disability before and after a caregiver-provided intervention to promote movement. This is a first step toward determining what amount of movement experience is necessary and sufficient to have a positive effect on the development of infant neuromotor control.
PSYCHOMETRIC TESTING OF THE ACTIVITY MEASURE FOR POST-ACUTE CARE (AM-PAC) “6 CLICKS” IN PEDIATRIC ACUTE CARE
Denlinger K, Dent Resetar J
PURPOSE/HYPOTHESIS: The Activity Measure for Post-Acute Care (AM-PAC) was developed to assess functional limitations among adult patient populations, initially as a large set of items that has since been thoughtfully reduced to three domains of six questions each. The domains include basic mobility, daily activity, and applied cognition. The AM-PAC Inpatient “6-Clicks” Short Forms are scored by providers after direct observation of the task or how the provider thinks they would perform based on clinical judgment. Existing literature on the use of AM-PAC short forms among adult acute care populations has provided evidence that they have excellent reliability, content and construct validity. However, they have never been tested on a pediatric population. The objectives of this study were to determine the interrater reliability and construct validity of the AM-PAC “6-Clicks” Basic Mobility short form (BMSF) in the pediatric acute care setting among physical therapists (PTs). Hypothesis: The AM-PAC BMSF domain will demonstrate interrater reliability between PTs. When correlated to the Timed Up and Go (TUG) and Thirty Second Walk Test (30SWT), BMSF will demonstrate construct validity.
NUMBER OF SUBJECTS: 54 pediatric acute inpatients (ages 3-17 years old) of an academic medical center.
MATERIALS AND METHODS: To assess interrater reliability of the AMPAC “6-Clicks”, pairs of PTs rated BMSF during the patient's usual therapy session. One therapist in the pair would directly assess and the other would silently observe. Each rater was blinded to the scores of the other rater. To test validity, the treating PT scored an initial BMSF followed by instructing each patient to perform the TUG and 30SWT.
RESULTS: The interrater reliability values (intraclass correlation coefficients) were 0.91 (95% confidence interval [CI] = 0.84, 0.95) between PTs on the BMSF. Construct validity (Spearman correlations) was -0.53 between the TUG and BMSF (p=0.003) and 0.76 between the 30SWT and BMSF (p<0.001).
CONCLUSIONS: The AMPAC “6-Clicks” short form for Basic Mobility was found to have excellent interrater reliability between PTs. The correlation between the BMSF and 30SWT was strong, whereas the correlation between the BMSF and the TUG was moderate.
CLINICAL RELEVANCE: There is currently limited evidence pertaining to outcome measures that are reliable and valid in the pediatric acute care setting, limiting the ability of PTs to perform standardized assessments or measurable objective data. As the medical field continues to advance and patients continue to require longer hospital stays, the ability to have a standardized outcome measure for this population becomes crucial for measuring functional progress over time. The current findings suggest the AM-PAC “6-Clicks” Basic Mobility short form is a reliable and valid measure to be used by pediatric PTs in the acute care setting.
MANUAL THERAPY IN PEDIATRICS: A DELPHI INVESTIGATION OF UNITED STATES PHYSICAL THERAPIST
Dice JL, Dendy DW, Spelman Sizer P, Cook CE, Feuling SJ, Brismee JM
PURPOSE/HYPOTHESIS: (1) To build consensus amongst physical therapists holding advanced credentials in pediatrics, neurodevelopmental treatment and manual therapy regarding the appropriate Orthopaedic Manual Therapy (OMT) techniques used in the pediatric population; and (2) To identify barriers and factors which contribute to therapists' decision to use OMT techniques.
NUMBER OF SUBJECTS: A total of 33 United States physical therapists advanced credentialed in manual therapy (FAAOMPT), pediatrics (PCS) and neurodevelopmental treatment (C/NDT) from 23 states completed all three rounds of the Delphi investigation.
MATERIALS AND METHODS: Physical therapists participated in a three-round Delphi investigation. Data collection was performed via Qualtrics ® electronic platform. An initial survey identified musculoskeletal and neurological impairments in addition to manual techniques considered effective to treat musculoskeletal and neurological impairments. Responses from the first Round were used to create the second Round, during which respondents used a 4-point Likert scale to score each survey item. In the third Round, respondents again scored each item to establish consensus. Data were categorized per group: (1) FAAOMPT, and (2) PCS/NDT.
RESULTS: Composite scores were calculated for each manual technique by impairment as well as within and between group differences. Neuromuscular techniques were felt an effective treatment across all impairments. Consensus indicated joint mobilizations effective to treat joint and muscle/myofascial impairments. Visceral manipulation and craniosacral therapy were considered ineffective in treating most impairments. There was strong disagreement in the general utilization of grade 5 manipulation and dry needling. The most significant barriers for using OMT techniques in pediatric population were lack of knowledge and fear of harming patients or litigation.
CONCLUSIONS: This Delphi investigation demonstrated that therapists specializing in manual therapy (FAAOMPT group), neurodevelopmental treatment and pediatrics (PCS/NDT group) can agree that several techniques can be used to treat each impairment presented. Future investigations should address the amount of force produced with graded mobilizations and the possible effects on a developing musculoskeletal system. Additionally, investigation is necessary to identify how preventing joint dysfunction could enhance functional movement, improve pain and overall quality of life in children as they grow into adolescence and adulthood. Furthermore, review and development of manual therapy continuing education programs for the pediatric population are warranted to enhance physical therapists' knowledge, skills and confidence in the integration of neurological, developmental and orthopedic based treatment techniques.
CLINICAL RELEVANCE: This study is an initial step in creating manual therapy guidelines and developing education opportunities to enhance physical therapists' knowledge in treating children.
ADAPTED SPORTS AS AN ADJUNCT TO THERAPY- A CASE STUDY
Diermann JT, Scardino ME, Kamper AJ, Leonard AM, Cairer M, Treat H, Evers C, Friesen KA, Ludwig KM, Krug JB
BACKGROUND AND PURPOSE: Children with disabilities may have physical, cognitive and/or behavioral impairments. These increase the risk for secondary health issues due to inactivity and can result in decreased socialization and self- confidence and increased anxiety and depression.1-2 Skilled therapies and home programs are primary methods to address these issues. Adapted sports can serve as another way to facilitate improvement.3-5 Coaches take on the role of “therapist” and participants are the “patient”. The setting and activities provide sensory and perceptual input, and facilitation of gross motor, balance, coordination, strengthening, and flexibility/stretching.4- 5 This case example describes adapted sports' impact as an adjunct to therapy.
CASE DESCRIPTION: Adapted Gymnastics (AG) occurs through the MU PT Program. Students volunteer as coaches and provide assistance to children ages 3-18 with impairments to perform modified gymnastics (bars, beam, tumbling with neck precautions) and gross motor activities (parachute, Simon Says for motor skills, trampoline and foam pit). Adapted Triathlon (AT) includes student assistance with swimming, biking and walking/running. Case: “Riley” is an 8 y/o male with Down Syndrome. He has low muscle tone throughout, limited endurance, decreased strength and coordination and impairments with mobility and motor skills. Riley participated in 10-15 AG sessions/year over the course of 3 years and the annual AT for 2 years in addition to individualized therapies. AG activities were personalized for balance (beam, obstacle course), trunk and proximal stability (prone on ball, wheelbarrow and bear walking, handstands), strengthening (crawl in foam pit, swing on bars, parachute games) and motor skills (kicking ball, jumping on trampoline). AT activities addressed strength, stability and coordination.
OUTCOMES: Participant has progressed with gross motor and mobility skills per his parents and coaches. Parents comment that adapted sports, especially AG, played a significant role in his improvement. They note: 1) increased stability and balance with decreased falls, 2) improved motor skills, especially jumping, & 3) increased self confidence and independence. Coaches note an increased willingness to do gym activities and less need for assistance.
DISCUSSION: Riley has demonstrated progress with motor skills and mobility. He has participated off-and-on in individualized PT, OT & Speech therapies and these have likely facilitated progress. His parents express enthusiasm for the AG & AT programs citing Riley's excitement in participating and increased willingness to do physical activities in these settings. They also value his socialization with peers and feelings of success. While adapted sports' specific impact has not been measured, Riley's parents and helpers observe progress and cite his participation and effort as being increased. The adapted sports have provided a fun, positive and motivating setting with a variety of motor and sensory activities which address Riley's specific needs and act as an adjunct to traditional therapies.
ACUTE MYELOID LEUKEMIA PRESENTING AS A SPINAL CORD INJURY: A PEDIATRIC REHABILITATIVE APPROACH IN ACUTE CARE
Donenberg JG, Khalil NS, Barker K
BACKGROUND AND PURPOSE: Acute myeloid leukemia (AML) is a heterogeneous disease accounting for about 20% of all leukemias in children. Extramedullary (EM) AML is a rare condition consisting of immature myeloid cells occurring at EM sites. Spinal cord compression is a rare manifestation of this disease and has been reported in only a handful of cases. The purpose of this case report is to highlight the atypical medical and physical therapy (PT) course of an 11 year-old male with EM AML, presenting as an incomplete spinal cord injury (SCI). A secondary purpose is to demonstrate the feasibility of implementing functional based outcome measures in the inpatient acute care setting opposed to an inpatient rehabilitation facility, due to prolonged hospital admissions required for medical treatment.
CASE DESCRIPTION: A previously healthy 11 year-old male was admitted to the hospital for acute onset bilateral lower-extremity (LE) paraparesis, paresthesias, and imbalance. The patient underwent imaging and was found to have diffuse extradural intracranial and spinal masses, including a large intraspinous mass compressing the thecal sac at L2 and encasement of the right S1, S2 and S3 nerves. He was subsequently diagnosed with EM AML and placed on a treatment protocol requiring inpatient acute care hospitalizations for approximately six months. An immediate laminectomy was performed for cord decompression and mass resection at L2. The patient's initial ASIA score was consistent with a T12 ASIA D SCI. His postoperative course was complicated by neurogenic bowel and bladder (NBB), worsening bilateral LE weakness, paresthesias, and the inability to ambulate. On his initial evaluation, the patient required maximal assistance for all self-care, bed mobility, and transfers. He received inpatient acute care PT for 45-60 minutes per day, averaging five days per week, during all admissions. PT sessions initially involved parent and patient education, bed mobility including rolling and scooting, sitting tolerance with and without support, transfers, and LE active range of motion. With neurological return, therapies progressed to therapeutic exercises of the LE in supine, sitting, and standing, core strengthening including pelvic floor exercises to target his NBB, postural re-education with use of spinal mobility techniques, balance activities based on the pediatric balance scale (PBS), and locomotor training including over-ground ambulation and cycling activities.
OUTCOMES: Outcomes and progress over six months were assessed across all areas of the International Classification of Functioning, Disability and Health including impairment (ASIA scores, manual muscle testing), function (Six Minute Walk Test (6MWT), PBS, Timed Up and Go (TUG), Five Times Sit to Stand (5TSTS) and participation (patient and parent report). The patient improved in all outcomes assessed most notably in his LE strength, 5TSTS, and TUG. He no longer required assistance for functional mobility, most activities of daily living, or ambulation. He continues to be limited by LE weakness, movement inefficiency, and a NBB.
DISCUSSION: We report an extremely rare case of a patient diagnosed with EM AML, presenting with acute onset bilateral LE paraparesis due to a SCI. Complete remission was achieved and functional status improved across multiple health domains. This case study illustrates feasible implementation of an outcome-based SCI rehabilitation program, initiated in the acute care setting, and focused on the delivery of a comprehensive, and intensive PT program.
APPLICATION OF THE ICF DURING INTERDISCIPLINARY MANAGEMENT OF A CHILD WITH DOWN SYNDROME, CASE STUDY
BACKGROUND AND PURPOSE: The comprehensiveness of the ICF is its strength, and yet, it challenges the practicability in clinical practice and research. Thus, ICF generic sets and health condition-specific ICF Core Sets have been rigorously developed to enhance the utility of the ICF for clinical practice and research. A significant gap remains between the use of the ICF and documentation by clinicians. The purposes of this case report are: (1) to integrate the ICF generic sets into an interdisciplinary rehabilitation of a patient with Down Syndrome by using the ICF-based documentation tools and (2) to identify which ICF categories best represent the functional profile of patients with DS.
CASE DESCRIPTION: One 7-year-old male, with diagnoses of DS, participated in this study. An interface between ICF generic set and the Guide to PT Practice was used as the basis to guide the patient management. Examination started with parent interview then tests were performed to examine each ICF category. In the ICF component of body functions and body structures, the child demonstrated impaired balance and coordination, reduced muscle strength, low muscle tone and increased ROM. Under the ICF component of activities and participation, the child demonstrated limitations/restrictions in stair climbing/descending, ambulation on uneven surfaces, climbing onto and off various surface levels, jumping skills, propulsion of riding toys and ball skills.
OUTCOMES: 39 ICF categories were used to create the functional profile of 7-year-old child with DS with emphasis on the child's performance of everyday activities at home, school and in the community. Using ICF allowed the complete description of functional abilities and relevant contextual factors during the interdisciplinary management which starts from a comprehensive description of impairments, limitations, and restrictions using the ICF qualifiers to rate the patient's functioning state within the ICF categorical profile that served as the central information source for the rehabilitation team toward planning the intervention and discharge. Goals were established in terms of the components of the ICF in collaboration with the rehabilitation team and the parent. Based on the goal setting, intervention targets were selected from the list of ICF categories that were included in the ICF categorical profile.
DISCUSSION: This case report illustrates the benefit of using ICF categories and the Guide to facilitate the translation of the ICF into patient-oriented and comprehensive management. ICF categories provide the starting point for what to document and report; however, they do not prescribe how to measure the aspects of functioning selected. ICF-based patient evaluation goes beyond the “traditional” view of consequences of disease at the level of body functions and body structures. The Guide and the ICF are complementary. As such an integration between both of them aids in the clinical decision-making process and at the same time helps in the identification of appropriate strategies toward positive treatment outcomes.
EXPERIENTIAL LEARNING IN PEDIATRIC PT EDUCATION: A FACULTY SURVEY
Fiss AC, Wynarczuk KD, Rapport MJK, Gagnon KL, Kendall EA, Schreiber JM
PURPOSE/HYPOTHESIS: The purpose of this survey study was to describe the use of experiential learning (EL) with children as part of pediatric education in entry-level Doctor of Physical Therapy (DPT) programs. The study sought to explore barriers and facilitators to the use of EL with children as identified by pediatric PT educators and the perceived impacts of EL on student learning.
NUMBER OF SUBJECTS: Faculty teaching the pediatric physical therapy content in Commission on the Accreditation of Physical Therapy Education accredited DPT programs (n=249) were recruited to participate. Pediatric faculty were identified via program websites or by contacting the program Department Chair. Responses were received from 106 individuals (42.6% response rate).
MATERIALS AND METHODS: Faculty received an email invitation to participate in a research project on EL including a link to an online survey using Qualtrics software. The questionnaire included closed-ended questions regarding the respondent's: 1) clinical and academic experience, 2) current academic program characteristics, and 3) use of EL within their pediatric curriculum. The questionnaire also included open-ended questions related to perceived facilitators and barriers and impact of the use of EL with children. Descriptive statistics were used to analyze the survey responses. Responses to open-ended questions were analyzed by multiple researchers using thematic analysis.
RESULTS: The majority of respondents worked in full-time faculty positions (n=62, 58%), followed by adjunct (n=23, 22%), and part-time faculty positions (n= 18, 17%). 41% of respondents identified their institutional setting as urban, 28.3% as suburban, and 10.4% as rural. Average class size was identified as 50 students (SD= 17.7, range 24-100). Respondents reported including an average of 12.4 (SD 10.6, range 0-40) hours of EL with children, which included an average of 8.9 (SD = 9.1, range 0-38) hours of EL with children with participation restrictions in courses required for all DPT students in the program. Faculty satisfaction with the amount (mean = 2.67, SD=0.88) and quality (mean = 3.17, SD= .82) of EL with children in their academic programs varied with scores ranging from 1- not at all satisfied to 4- extremely satisfied for both questions. Several perceived barriers and facilitators to the use of EL with children were documented. 100% of faculty responding to the question regarding the impact of EL on student learning (n=72) stated they believed EL had a positive impact.
CONCLUSIONS: The use of EL with children in entry-level DPT education, as well as faculty satisfaction with current use of EL varies. Additional exploration of the rationale for why this variation exists and to determine whether this large variance in EL results in differences in educational outcomes is needed.
CLINICAL RELEVANCE: Information about the current use of EL as well as perceived barriers and facilitators to EL should help to inform decision making related to the use of EL in entry-level DPT education.
PSYCHOMETRIC PROPERTIES OF SEGMENTAL ASSESSMENT OF TRUNK CONTROL IN INFANTS AND TODDLERS WITH DOWN SYNDROME
Flores MB, Mitchell KE, Bickley CM, Pavelka Da Silva C
PURPOSE/HYPOTHESIS: The purpose of this study was to investigate infants and toddlers with Down Syndrome (DS) to determine: 1) interrater, intrarater, and live versus video reliability of the Segmental Assessment of Trunk Control (SATCo), 2) concurrent validity of the SATCo with the Gross Motor Function Measure (GMFM), and 3) whether a model of staggered entry with age and SATCo score predicts GMFM score.
NUMBER OF SUBJECTS: 18 children with DS between 6 to 23 months (mean = 13.67, SD = 5.31) participated.
MATERIALS AND METHODS: The SATCo is a dichotomous scale to assess 7 discrete levels of trunk control in children with neuromotor disabilities. At each level, the child is tested on static, active, and reactive trunk control for a possible total score of 20. The GMFM was developed to measure gross motor function in children with cerebral palsy and can be used for children with DS under 6 years old. The examiner scores a child's capabilities across 5 dimensions of functional movement, each consisting of several items (88 total) with a total possible score of 264. Experienced pediatric PTs were recruited as raters. Each child was tested (and video-recorded) on the SATCo by 2 PT raters at least 30 minutes apart. One PT rater also administered GMFM to all participants. After 2 weeks, the PT raters re-scored their video- recorded SATCo testing sessions. A third PT rater, who did not perform live testing sessions, also scored the SATCo videos.
RESULTS: Interrater reliability of the SATCo was moderate to good among all 3 raters (ICC (2,1) = 0.50 to 0.85, p ≤ 0.013). The SATCo had good to excellent intrarater reliability (ICC (2,1) = 0.77 to 0.94, p < 0.001). The interrater reliability between Rater 1 and Rater 2 reflected the lowest overall scores (ICC (2,1) ≤ 0.686, p ≤ 0.008). Highest scores were found in the intrarater reliability of Rater 1 (ICC (2,1) ≥ 0.806, p < 0.001). Spearman's rho correlations revealed good to excellent significant relationships (rs > 0.75, p < 0.001) for every category of the SATCo, SATCo total score, and SATCo level with GMFM Dimension B score (sitting ability) and GMFM total score. Regression showed that age accounted for 63% of the variation in GMFM total score and SATCo total score accounted for an additional 17%. There was a significant regression equation (F[2,15] = 30.45, p < 0.001) as follows: GMFM i = -53.22 + (6.40 x SATCo total score) + (3.61 x Age). Block entry of the single predictors of age (R = 0.82, R2 = 0.67, F[1,16] = 31.89, p < 0.001) and SATCo total score (R = 0.86, R2 = 0.74, F[1,16] = 46.599, p < 0.001) had a significant predictive effect on dimension B (sitting) of the GMFM.
CONCLUSIONS: Three PT raters who had no prior experience with the SATCo were able to administer and score this outcome measure in infants and toddlers with DS. Trunk control appears to play a central role in the gross motor function of infants and toddlers with DS. The SATCo was found to have good psychometric properties in infants and toddlers with DS.
CLINICAL RELEVANCE: This study contributes to the literature on the psychometric properties of the SATCo and supports its use to measure trunk control in infants and toddlers with DS.
EVALUATION OF A PEDIATRIC PRACTICE-BASED LEARNING EXPERIENCE: DEVELOPMENT OF PERCEIVED SELF-EFFICACY IN PHYSICAL THERAPY STUDENTS
Fragala-Pinkham MA, Hayward LM
PURPOSE: To describe a pediatric, practice-based, international service-learning (ISL) experience that included evaluation of 15 doctor of physical therapy (DPT) students' self-efficacy for administering standardized tests, communicating, and handling children with disabilities.
DESCRIPTION: DPT students are required to have entry-level pediatric physical therapy (PT) skills upon graduation1; however, only 2.5% of DPT programs require a pediatric clinical experience.2 Due to the wide variation nationwide in the time devoted to instruction in pediatrics in DPT curricula,5 competencies for new graduates were established by the Academy of Pediatric Physical Therapy. Educators are challenged to incorporate instructional approaches for DPT students that promote the five entry-level competencies in pediatric knowledge and handling skills.3 Practice-based learning models situate learners and teachers in authentic learning environments.4,5 The inclusion of experiential learning opportunities with children in a relevant setting with supervision by experienced therapists, can allow students to hone their skills and witness the direct application of developmental theory to practice.6-8 This ISL experience was a 9 day trip to Ecuador and part of a Capstone for DPT students. The overall goals were to improve the quality of PT services at an Ecuadorian orphanage and provide students with a meaningful practice-based learning experience.9 During the trip, the DPT students evaluated and provided PT interventions for children with disabilities including therapeutic exercise, gait training and fitting and adapting wheelchairs. They also administered a standardized assessment tool to evaluate motor development in infants. Evaluation of the experience was accomplished using the Pediatric Communication and Handling Self-Efficacy Scale (PCHSES), which has 18 communication items and 8 handling items, uses an 11-point scale and students rate their level of confidence with 0 representing “not at all confident” to 10 representing “extremely confident”.10 Four additional items were added to measure administration and interpretation of standardized tests. Students completed the scale a week pre and the week post travel. DPT students participated in one of two focus groups a week after the trip to provide additional information about their learning experiences.
SUMMARY OF USE: PCHSES data were analyzed using paired-samples t- test. Interview transcripts were analyzed using qualitative inductive techniques. Post scores on the PCHSES were significantly higher than the pre-trip scores (t=2.84, df=14, p=0.01), indicating higher confidence levels after the trip. Qualitative data revealed that students transferred knowledge from the classroom to the field, recognized the uncertainty of practice, benefitted from collaborating with experienced PTs and observing their decision making process.
IMPORTANCE TO MEMBERS: Appropriately structured, ISL experiences have the potential to address teaching 3 of the 5 core competencies: human development, age-appropriate client management, health promotion and safety.
DEVELOPMENT OF A SURVEY TO ASSESS PEDIATRIC PHYSICAL ACTIVITY WITHIN A BASNIAN REFUGEE COMMUNITY
Furgal K, Sabic F, Tarighi MM, Siu K, Stinnett B, Norris ES, LaRue Hoover D
PURPOSE/HYPOTHESIS: Political refugees are acknowledged to face many challenges in adapting to life in a new country. Yet, little research has addressed youth physical activity (YPA) among such populations who have resettled within the United States (US) in recent decades. The purpose of this study was to create a valid and reliable instrument to assess the attitudes and beliefs regarding YPA within a large refugee community that recently settled within the US.
NUMBER OF SUBJECTS: Subjects were recruited from a refugee population that had settled within a metro area within the US following the Yugoslavian civil war. Inclusion criteria consisted of adults who had 1) resettled in the US and 2) at least one child attend school in the local US community.
MATERIALS AND METHODS: Survey methods were used to assess attitudes and beliefs regarding sport and YPA. A 91-item survey instrument covering sport and YPA was constructed using a mixed-method format, consisting of Likert-scale and “fill in the blank” questions. All items were reviewed for face validity by 4 content experts. Twelve items within this instrument specifically addressed attitudes and beliefs regarding YPA. Other questions related to youth sport participation were not included in the present analysis. Participants were recruited through a local religious center during a period of high attendance, and the surveys were distributed to participants on 2 occasions. Measures of test-retest reliability via intra-class coefficients (ICC) with 95% confidence intervals (CI) and internal consistency via Chronbach Alpha were calculated on the measures gathered during this pilot study for the 12 items related to YPA.
RESULTS: Seventeen participants completed the survey, on two occasions. Test-retest reliability of the 12 items was fair to excellent (ICC = 0.571- 1.000; 95% CI 0.188 to 0.993), depending upon the respective item. Eight of 12 items in the survey had excellent reliability (ICC = 0.864 to 1.000). Four items had fair-to-good test-retest reliability with ICC of items 1, 2, 6 and 10 being 0.571, 0.651, 0.723, and 0.730, respectively. The internal consistency of responses to the 12 items related to YPA was high, with a Cronbach Alpha coefficient of 0.853.
CONCLUSIONS: While participation in YPA is a characteristic of all cultures, immersion into US culture presents challenges to refugee populations. The present findings suggest that the instrument used in this study possesses the characteristics necessary to accurately survey attitudes and beliefs regarding YPA within a unique refugee community. Future studies should expand this examination to other Balkan refugee communities that settled in North America in the aftermath of the Yugoslavian civil war.
CLINICAL RELEVANCE: These findings have particular relevance for clinicians working within healthcare settings that serve refugee communities from the former Yugoslavia. Physical therapists may administer the survey to refugees to increase their cultural sensitivity when promoting YPA and overall quality of life in given ethnic populations.
A COLLABORATIVE APPROACH TO TEACHING PEDIATRIC PT USING BLENDED LEARNING PEDAGOGIES
Gagnon KL, Catalino TA, Krogmann M, Denninger S, Footer CB
PURPOSE: The purpose of this session is to describe how two pediatric faculty teams collaborated to develop and implement pediatric physical therapy courses in two different accelerated, hybrid physical therapist education programs.
DESCRIPTION: Pediatric faculty teams from South College and Baylor University have collaborated since 2016 to create two unique stand-alone pediatric courses to prepare students for clinical practice. Each program leveraged the breadth and depth of the conjoined faculty team expertise to develop accelerated hybrid curriculum using shared materials for distance-based content delivery, assignments, written examinations, and ground-based lab activities.
SUMMARY OF USE: The faculty teams for each program consisted of pediatric physical therapists representing expertise across the continuum of care, including early intervention, acute care, outpatient, and school-based practice. Each team included 8-10 core and adjunct faculty, six of whom taught across both programs. Collaboration across programs allowed content to be built based on individual faculty strengths and expertise. For example, one faculty member with expertise in pediatric orthopedics was responsible for teaching those topics in both programs, including developing asynchronous content and leading synchronous online discussions and ground-based lab immersions. In this model, students received the full benefit of engaging with a breadth and depth of pediatric specialists.
IMPORTANCE TO MEMBERS: Hybrid physical therapist education challenges PT educators to explore what is possible when faculty and students are not tied to a geographic location or a traditional class schedule. For these two programs, hybrid education allowed for the creation of diverse faculty teams that collaborated to effectively and efficiently create and deliver content. These two faculty teams exposed students to the continuum of pediatric care, modeled professional discourse, and took collective responsibility for student learning. Given the relative shortage of qualified pediatric faculty, both hybrid and residential programs may benefit from exploring possibilities for faculty collaboration when delivering pediatric content. This not only eliminates duplicate effort, but may decrease feelings of isolation among faculty who may be the only pediatric instructor in their program. Diverse expertise among teaching teams may also strengthen the educational experience for students through exposure to the breadth and depth of pediatric practice. Pediatric faculty are encouraged to explore opportunities to develop and implement shared resources across individual programs and to discuss how faculty can share their expertise beyond their own program.
STRIDING THROUGH SUMMER: IMPROVEMENTS IN GAIT AND FUNCTION FOLLOWING A GAIT CAMP
Gilb M, Karakostas T
PURPOSE/HYPOTHESIS: It has been shown that there is a positive relationship between increased exercise intensity and enhanced physical function in both the adult and pediatric populations. (Kimberly et. al). This concept of increasing intensity can be utilized in the pediatric population through an intensive camp setting. It has been shown that intensive constraint induced movement therapy (CIMT) camps are effective in improving upper extremity function and participation (Wu et. al). Additional benefits have been reported for the lower extremity, documented in improved time-distance parameters (Coker et. al, Zipp et. al). Further evidence suggests that intensive therapy for patients who have suffered stroke results in benefits for balance, gait and mobility (Fritz et al.) Following the APTA's directive for evidenced- based practice, we pose the question of whether a gait-specific camp could be effective? Therefore, the purpose of this abstract is to present pilot data from such a camp.
NUMBER OF SUBJECTS: This is a pilot study testing the concept of a gait-specific camp through three case studies. Case 1: A 16 y/o male GMFCS I, neurofibromatosis type I, with three shunt placement/revisions, chemotherapy with resultant peripheral neuropathy, and posterior spinal fusion. Case 2: A 11 y/o male, GMFCS I, L hemiplegia secondary to Vein of Galen rupture, multiple LE muscle lengthenings and multiple shunt revisions Case 3: A 4 y/o male, GMFCS II, spastic triplegic CP secondary to premature birth who received botox but no hx of orthopedic surgeries.
MATERIALS AND METHODS: Therapy was delivered in a hospital and community camp setting for 32 hours total. Camp activities included strengthening, gait training, balance and postural control training, and various gross motor activities. Gait outcomes were measured by the GaitRite instrumented carpet and the 6-minute walk test. Participants were tested pre- and post-camp.
CONCLUSIONS: The results demonstrate clear improvements in lower extremity function and selected gait parameters following intensive physical therapy in the gait camp setting (Table 1). Velocity and cadence increased following the camp, while double limb support decreased suggesting improved balance. While the results are encouraging, our camp concept should be expanded to include more participants with various levels of physical ability. This would then facilitate assessing the efficacy and effectiveness of the camp concept in GMFCS levels I-IV.
CLINICAL RELEVANCE: Prescription of physical therapy in an intensive, camp-based setting appears to be effective. We know that children with chronic conditions and disabilities perform less physical activity and are less physically fit than their age matched peers (Kimberly et al). Children with cerebral palsy are 30% less active and twice as sedentary compared to the recommendations for a typically developing child (Carlon et. al). Shreurer et al. called for preventative interventions to empower children with disabilities. This camp setting answers this call by motivating and facilitating participation with peers while enjoying physical activity.
RELATIONSHIP BETWEEN RESPIRATORY MECHANICS AND CLINICAL MARKERS IN CHILDREN AND ADOLESCENTS WITH CYSTIC FIBROSIS
Godoy Bobbio T, Santos Schivinski CI, Castilho T, Gonçalves Wamosy RM, Santos BW, Sarmento de Figueiredo ICX, Rentz Keil PM
PURPOSE/HYPOTHESIS: Cystic fibrosis (CF) is a multisystem genetic disease. For this reason, it is important to monitor all patients' clinical markers. It is known that some spirometry parameters correlate with some of the CF clinical markers. However, it is unclear if respiratory mechanic parameters such as R5 and X5, both measured using impulse oscillometry (IOS), also correlate with CF clinical markers. Therefore, this study was designed to examine the relation respiratory mechanic parameters and CF clinical markers in children with CF. The primary questions were: (1) is there a relation between mechanical parameters and clinical markers? And, (2) if a relation exists, is there any difference in these clinical markers between CF children with altered IOS parameters and children with normal IOS parameters?
NUMBER OF SUBJECTS: 115
MATERIALS AND METHODS: This is a cross-sectional study approved by the Ethics Committee of the Santa Catarina State University. CF children were recruited from the CF clinic of the pneumology unit at Joana de Gusmao Children's Hospital - Brazil. Mean age was 9.8 years-old and mean BMI was 16.2 Kg/m 2. It was investigated anthropometric data, severity of the disease, pulmonary bacterial pathogens, genetic mutation, spirometry - FEV1 and FEF25-75 and IOS parameters. The relation between respiratory mechanic parameters and clinical markers was analyzed using Spearman correlation and Chi-square. Then children were divided into two groups - CF children with altered IOS (a) and CF children with normal IOS (n) for X5 (X5a and X5n) and R5 (R5a and R5n) parameters, and the Mann-Whitney test was used to verify the difference in clinical markers between the 2 groups.
RESULTS: For the whole group (n=115), a significant correlation was found between FEV 1 and X5, rho=-.82; p<0.001. Results showed an association between IOS parameters X5 and genetic mutation, p=.023 and p=; BMI, p=.005; and severity of the disease, p=.008. And, an association was also found between R5 and same clinical markers – genetic mutation, p=.014; BMI, p,.013; and severity of the disease, p<;.001. When analyzing the difference between the 2 ISO groups in all clinical markers, a significant difference was found between groups X5a and X5n; and between groups R5a and R5n in FEV1, P<.001; and FEF25-75, p<.001.
CONCLUSIONS: These findings are consistent with the hypothesis that there is a significant relationship between respiratory mechanic parameters and CF clinical markers. More precisely, a relationship between respiratory mechanic parameters and genetic mutation, BMI, and spirometry. Therefore, the IOS can be used in conjunction with spirometry to assess CF patient.
CLINICAL RELEVANCE: This study will help practitioners to use the IOS which is considered a fast, easy and safe tool as a complementary method to assess pulmonary function in CF children. In addition, the relation found between IOS and clinical markers could help in early detection of respiratory tract alterations and, consequently, early intervention.
HEALTHCARE TRANSITIONS FROM MULTIPLE PERSPECTIVES: A SYSTEMATIC REVIEW
Gohrband CL, Scherrer A, Bloemker O, Sticklen S
BACKGROUND AND PURPOSE: Medical advancements have increased the life expectancy of individuals with lifelong disabilities (LLDs), resulting in the need for effective health care transitions (HCTs) as adolescents seek adult-oriented health care services. Our primary aim is to present a systematic review of the multiple perspectives presented in the literature (therapists, physicians, nurses, caregivers/family supporters, and patients) for HCTs for children with LLDs. We aim to compare and contrast researchers' perspectives about what tools and suggestions exist for individuals with LLDs, caregivers, and healthcare providers.
CASE DESCRIPTION: Each member of the research team independently screened MEDLINE, ERIC, EBSCO, ProQuest, PubMed, and CINAHL databases between June 2018 and July 2019. Inclusion criteria consisted of healthcare-related or medical transitions in regards to individuals with LLD's that are development-based, affecting multiple body systems. For this review, LLDs were operationally defined to include diagnoses of cerebral palsy, Down syndrome, myelomeningocele, and intellectual disability. Searches were limited to publications written in English and published within the past 10 years. Exclusion criteria included LLDs that were rare in nature, populations focused on school systems, public policy, mental health, dental health, and medical home transitions.
OUTCOMES: Our research explores the various perspectives of individuals with LLDs, parents, caregivers, physicians, nurses, and therapists. From this analysis, current barriers for successful HCTs are summarized. This review also describes the available tools and resources that are currently accessible to the public regarding medical transitions. Gaps in the literature demonstrate that there is a critical need to enhance communication and collaboration between facilities, providers, and families. This review creates a case for future research in the area of HCTs. This review also promotes awareness of HCTs as this applies to physical therapy and the needs of patients with LLDs.
DISCUSSION: The results of this review demonstrate a need for improved awareness and more discussion regarding the challenges individuals with LLDs, families and healthcare professionals encounter throughout HCTs. Physical therapists should have an important role in the interprofessional team involved with the HCTs.
THE EFFECTS OF DESENSITIZATION AND GENERAL EXERCISE ON PEDIATRIC COMPLEX REGIONAL PAIN SYNDROME
Graham MC, Keith Purcell N, Chorley J
BACKGROUND AND PURPOSE: Pediatric Complex Regional Pain Syndrome (CRPS) is a condition of chronic peripheral pain characterized by intense pain with associated sensory, autonomic, and motor impairments. There are two types of CRPS, types I and II. CRPS type I typically develops after an inciting noxious event and has pain disproportionate to the injury. While an inciting injurious event may spur CRPS, psychological stressors and anxiety can also be a catalyst for the development of this disorder, especially amongst the pediatric population. Current treatment concepts of CRPS with physical therapy include gradually progressive aerobic exercise, mobilization, massage, and desensitization. This case study aims to highlight the effects of these concepts on the management of a pediatric patient with type I complex regional pain syndrome of the left distal lower extremity.
CASE DESCRIPTION: This case study outlines a 16 year-old high school female with insidious onset complex regional pain syndrome (CRPS) Type I of the left foot and leg. Of note, patient was enrolled at high achieving school with upcoming school testing which was causing increased stress. She presented to physical therapy with sensitivity to light touch, hyperalgesia, temperature changes in her foot and leg, and an unwillingness to bear weight on the extremity. Patient underwent both plain radiographs and MRI which were negative for musculoskeletal pathology. Patient was given CAM boot, axillary crutches, and referred to physical therapy for 2 times a week for 8 weeks. A few days after initiating physical therapy, patient was taken to the emergency room for hand and foot tremors which began while at school. Physical therapy initially focused on progressive desensitization, education regarding mechanisms of CRPS, general aerobic exercise, and progressive weight bearing on the affected limb.
OUTCOMES: Following 8 weeks of physical therapy patient had returned to her functional baseline. Her lower extremity functional scale (LEFS) score improved 2 points from 42/80 to 80/80. It took around 2 weeks for her allodynia and tremors to cease. Patient also was able to wean from both boot and crutches within 2 weeks. At discharge, the patient had taken her final exams successfully and made a full return to school without incident. Patient was referred for psychology services, but to my knowledge has never followed up with formal psychological treatment.
DISCUSSION: This case study investigated the effects of physical therapy on CRPS Type I in a female pediatric patient. While the exact etiology of this condition is unknown, early identification and referral to appropriate treatment sources can help to improve recovery rates and lessen disability in this population. Best treatment in the pediatric patient will include a multi-disciplinary approach that will include both physical therapy and cognitive behavioral therapy. The complex pathophysiology of CRPS continues to make it an elusive diagnosis, but with the expanding body of research and awareness regarding this condition we can hope to improve long-term outcomes.
OUTPATIENT SERVICES AND GUIDELINE ADHERENCE IN CHILDREN WITH CEREBRAL PALSY AFTER SINGLE EVENT MULTI- LEVEL SURGERY
Greve KR, Bailes AF, Mitelpunkt A, Long J, Kurowski BG, Vargus-Adams J, Aronow B
PURPOSE/HYPOTHESIS: Children with cerebral palsy (CP) often require single event multi-level orthopedic surgery (SEMLS) to improve musculoskeletal alignment and need frequent visits with medical professionals to return to baseline function post-surgery. A local practice guideline for physical therapy management of children undergoing SEMLS recommends orthotics, adaptive equipment and follow up assessment with the Gross Motor Function Measure (GMFM). The aim of this study was to characterize outpatient encounters within the medical center for children with CP 1 year post SEMLS, examine the frequency of physical therapy, and evaluate adherence to the guideline.
NUMBER OF SUBJECTS: Thirty-five children with CP underwent SEMLS at our institution between October 2017 and June 2018 (mean age of 10 years old (3.65 sd), 43% males, 66% White, 94% Non-Hispanic, and Gross Motor Function Classification System Levels I-V (8.5%, 20%, 23%, 40%, and 8.5% respectively).
MATERIALS AND METHODS: Data were extracted retrospectively from the electronic medical record and frequencies and percentages were reported for procedure type and outpatient encounters across the medical center in the year post-surgery. The number of physical therapy visits and guideline adherence number of children receiving adaptive equipment, orthotic intervention, and GMFM assessment (within 6 months and at 1 year post-surgery) were reported for children who received physical therapy at our institution.
RESULTS: The majority of surgeries were bilateral (83%) and both soft tissue and bony interventions (89%) with a mean number of 5 (2.28 sd) procedures. Thirty-five children had 1071 unique outpatient encounters in 1 year across the medical center. The most frequent encounters were therapy (52%), orthopedics (16%), radiology (12%), pediatric rehabilitation (4%), neurology (3%), lab draws (2%), complex care clinic (2%), and ophthalmology (1%). Post-surgery, 17/35 children were followed for physical therapy with a total number of 282 visits (mean 17, range 1-49) and the first visit an average of 112 days (sd 77) after surgery. Fifteen (88%) children received adaptive equipment and orthotics. Five out of 17 (29%) had a GMFM within 6 months post-surgery, and 1/17 (6%) had a GMFM at 1 year post-surgery.
CONCLUSIONS: Children with CP saw a variety of disciplines across the medical center in the first year post SEMLs with the majority of outpatient encounters for therapy. Frequency of physical therapy varied. Adherence to the local guideline was 88% for adaptive equipment and orthotics but only 29% and 6% for the GMFM at 6 months and 1 year, respectively.
CLINICAL RELEVANCE: Understanding utilization of outpatient encounters across the medical center for individuals with CP post SEMLS supports the need for coordinated and comprehensive care. Plans for quality improvement work to increase GMFM follow up are underway. Future research should examine physical therapy dose and outcomes for children with CP after SEMLS.
ATTITUDES OF PARENTS OF ADOLESCENTS WITH CEREBRAL PALSY TOWARDS INTENSIVE MODELS OF PHYSICAL THERAPY
Guerino AR, Kahn N, Manning A, Golden P, Moulton TS
PURPOSE/HYPOTHESIS: Research supports the use of intensive models physical therapy (PT) to foster accelerated physical and neurological gains for individuals with cerebral palsy (CP), leading to an overall shift towards intensive bouts of therapy. Although this new paradigm may be effective for clinical goal attainment, the perception of this approach among parents is not well understood. The objective of this study was to discuss families' perspectives of intensive PT, in the context of the Gross Motor Functional Classification System (GMFCS) level of their adolescent. We hypothesized that their responses would inform intensive PT recommendations across the continuum of gross motor function.
NUMBER OF SUBJECTS: 17
MATERIALS AND METHODS: Parents of adolescents with CP (12-20 years, 9 GMFCS I-III and 8 GMFCS IV-V) completed surveys prior to participating in video conference focus groups answering a series of semi-structured questions. The focus groups were recorded, transcribed, and coded by team members using the International Classification of Function for Children and Youth with CP (ICF-CY CP) framework to identify common themes. Saturation was achieved.
RESULTS: 42% of participants did not have prior experience with intensive PT, and 54% felt positively about the idea on the pre-survey. Common themes were found within complex and multifactorial responses during the focus groups. Most parents noted that transitioning from parental control to adolescent autonomy amplified the importance of adolescents' motivation in intervention decisions; therefore, the adolescents' commitment to intensive PT outweighed other practical considerations. Attitudes were also influenced by previous PT experiences, both positive and negative. Parent perceived plateau of their adolescent's functional ability led to skepticism. Common barriers to future intensive PT included finances and family schedule; facilitators included positive previous PT and setting attainable goals. Finally, a significant differential effect was identified across GMFCS levels regarding attitudes towards intensive PT, where parents of adolescents with level II were the most enthusiastic and level V were the most hesitant.
CONCLUSIONS: There are complex factors that influence the perspectives and attitudes of parents towards intensive PT, including GMFCS level. The support provided to and relationships developed with a patient and their family early in a child's life impact the opinions of future PT. Therefore, the discussion about therapy intensity decisions for an adolescent with CP begins years prior to adolescence.
CLINICAL RELEVANCE: When considering intensive PT, motivational interviewing should be utilized to identify adolescents' interests and help facilitate buy-in and adherence, while parents may require counseling on logistics such as transportation, finances, and scheduling. The adolescent's current level of function influences parental perception of attainable goals and willingness to participate in intensive PT. Parents value realistic goals that promote improvements in mobility and independence of their adolescent as they transition to adulthood.
DEVELOPMENT OF NORMATIVE DATA USING THE MINI-BESTEST ON CHILDREN AGES 7-17
Hajek J, Williams JA, Strausman RJ, Parmar N, Eschner KL, Phan NM, Pescitelli JR, Yang ML, Norton Southard V
PURPOSE/HYPOTHESIS: Balance normative values using the Mini-BESTest in children aged 7-17 remains unexplored. Factors such as age, gender, and anthropometric measures have been shown to influence balance in children and may alter the scores on the Mini-BESTest. Balance measures currently being used in the pediatric population do not comprehensively assess standing postural control and omit some key components of mobility and independence. The Mini-BESTest encompasses eight components of balance, only missing functional stability limits. This is more comprehensive than any of the balance assessments currently being utilized for pediatric patients. Additionally, the Mini-BESTest has high validity, intrarater reliability, and interrater reliability. Lastly, the Mini-BESTest may be the best balance assessment tool to utilize when analyzing balance in the pediatric population because of the reduced administration time and higher accuracy. The purpose of this study was to assess balance using the Mini-BESTest in developing children ages 7 – 17 years old in order to establish norms. We hypothesized that balance scores as assessed by the Mini-BESTest would increase with age and also reflect mature balance patterns as seen with adults. Our secondary objective is to assess the influence of anthropometric measures and gender on the Mini-BESTest scores.
NUMBER OF SUBJECTS: 101
MATERIALS AND METHODS: A sample of convenience was used in this IRB approved study. Participants were normally developing children assessed at camp or during sports matches, between the ages of 7-17. Age, gender, anthropometric measures, and activity levels were documented. Participants were assigned to groups by age; 7-10 years, 11-13, and 14-17. ANOVA was used to assess for differences within and between groups. Bonferroni corrections were used on significant results. Independent t tests were used to assess for differences with regard to BMI and gender. Item by item analysis was done to assess for the percentage of success.
RESULTS: There was an increase in mean scores for each age group as subjects increased in age. However, there was no significant difference found between groups for total mean score despite the increase; 23.84, 24.97, and 25.43 respectively (p= .342, .788). The data collected from our subjects was similar to scores published normative data in adults. There was a significant difference between total scores for subjects of normal weight vs. overweight/obese. The effects of gender were inconclusive. Lastly, 83.92% of subjects were unable to achieve a full score on item 14, the TUG with a cognitive component.
CONCLUSIONS: This is the first study to develop reference values for clinicians when applying the Mini-BESTest to the pediatric population. The Mini-BESTest is able to differentiate balance abilities between children who are classified as normal weight, obese, or overweight. Children scored similarly to adults on the Mini-BESTest supporting its use as an appropriate screening tool to assess balance for typically developing children aged 7-17.
CLINICAL RELEVANCE: Normative data that evolved from this study will enable clinicians working with balance impaired children to have a reference from which to assess score changes.
RELATIONSHIP AMONG POSTURAL CONTROL, VISUAL ATTENTION, MOTIVATION TO MOVE, AND COGNITION IN INFANTS
Hammontree JA, Kolobe TH, Jeffries LM, DeGrace B
PURPOSE/HYPOTHESIS: Study purposes: A) Investigate association among prone postural control (PC), visual attention (VA), motivation to move (MTM), motor and cognitive development in infants with and without risk for cerebral palsy (CP). B) Determine the predictive validity of these variables to later motor and cognitive development. We hypothesized that 1) PC, VA, MTM will be highly correlated with motor and cognition in infants with and without risk for CP; and 2) These factors would predict motor and cognitive development at 8-9 months of age old.
NUMBER OF SUBJECTS: 56
MATERIALS AND METHODS: We used a descriptive, cross-section design with two groups (low and high risk for CP). Infants (N=56) were part of a larger study using the Self-Initiated Prone Progression Crawler. Infants were placed in prone for two minutes and videotaped weekly while interacting with a caregiver for 16 – 20 weeks. We coded PC, VA, and MTM from the videos using the Movement Observation Coding System (MOCS), Visual Attention Scale (VAS), adapted Motivation to Move scale (MMTM), respectively. The Bayley Scales of Infant Development (Bayley) were used to measure cognition and motor development at 5 and 8-9 months of age. We used Pearson R to test the hypothesis of association and step wise multiple regression to test the prediction hypothesis.
RESULTS: Results indicated a strong correlation between MOCS and VAS scores (r=.857), moderate association between MOCS scores and MMTM (r=.347), and MMTM and VAS (r=.390). When subjects were separated by risk the coefficients ranged from 0.733 to 0.282 for the low group and 0.905 to 0.453 for the high group, respectively, and were statistically significant. The high-risk group had stronger correlations. Multiple regression analyses revealed that combined MOCS, VAS, MMTM and risk-risk explained 28% and 51% of the variance in Bayley cognitive and motor scores at 9 months, respectively. MOCS and VAS scores combined explained 23 and 40% of Bayley cognitive and motor scores, respectively.
CONCLUSIONS: Our study supports inter-relationships among these domains during early development, and their contribution to predicting later development. The PC and VA have potential for identifying typical and atypical development. The novelty of this study is that the data was obtained from a 2-minute videotape at 5 months of age, making the approach feasible for implementation in practice.
CLINICAL RELEVANCE: Many professionals work with infants and can use this information to identify infants that may be at risk for developmental delays early, thus improving early referral rates. Therapists should include visual attention in their early detection assessments.
UNDERSERVED AND OVERBURDENED: REHAB CANDIDATES IN A STATE WITHOUT ACCESS TO PEDIATRIC INPATIENT REHABILITATION
PURPOSE/HYPOTHESIS: There is evidence that receiving inpatient rehabilitation (IPR) at pediatric-specific rehab facilities is associated with improved functional outcomes. Yet, there are still many places in the US where patients do not have access to pediatric IPR. In this study, we aimed to characterize IPR candidates discharged from pediatric acute care at a large academic medical center in a State where no pediatric-specific rehabilitation facilities exist.
NUMBER OF SUBJECTS: 69 patients
MATERIALS AND METHODS: This retrospective cohort study included IPR candidates aged 11 months-20 years discharged January 2017-June 2018. The Kruskal-Wallis H Test and Fisher's Exact Test were used to compare differences in characteristics between discharge groups. The Functional Status Scale (FSS) is a well-validated tool for measuring the functional status of hospitalized children. An increase by 3 points is a marker for morbidity, and an increase by 5 a marker for unfavorable functional outcomes. The FSS was scored from pre illness baseline status (i.e. prior to event that brought the child to the hospital) and later at hospital discharge retrospectively by two independent examiners, with disagreements resolved by consultation with a third reviewer.
RESULTS: There were 69 patients that met inclusion criteria and had complete record information on all characteristics of interest. Of them, 53.6% discharged to pediatric-specific IPR, 24.6% to home, and 21.7% to adult IPR. Sixty percent of discharges to home occurred due to medical and social barriers (e.g. need for local healthcare/services). Rehab candidates who discharged to pediatric IPR facilities were younger (p<0.0001), had more discharge-ready days waiting for rehab (p=0.02), traveled longer distances to get to IPR (p<0.0001), and had FSS score changes reflective of significant unfavorable functional outcomes (p=0.01). Statistically significant differences did not exist between groups in race or impairment type (diagnosis necessitating the rehab admission).
CONCLUSIONS: In a large academic hospital located in a State without pediatric IPR, significant disparities exist among rehab candidates. To the authors' knowledge, this is the first study characterizing hospitalized pediatric IPR candidates in a state without a pediatric specific rehab facility. Significant barriers exist that prevent nearly half from receiving age-appropriate post acute care. Many of these barriers reflect the distance required to travel to an appropriate facility. Children who do discharge to pediatric rehab facilities spend more discharge-ready days waiting for IRF and more functional decline from baseline than those who discharged to adult rehab. Future work should explore the relationship between discharge ready days and functional decline specific to this patient cohort further.
CLINICAL RELEVANCE: Further work needs to be established to advocate for the need for pediatric inpatient rehab access in all states. Greater advocacy is needed to streamline care for patients with complex continuing therapy after traumatic injuries.
CLOSING THE GAP: IMPLEMENTATION OF AN EBP TRAINING PROGRAM FOR A MULTIDISCIPLINARY PEDIATRIC REHABILITATION DEPARTMENT
Hedgecock JB, Ziegler KR, Muir NB, Mahnken HA, Judd DL
PURPOSE: There is a gap in knowledge and application of evidence-based practice (EBP) in physical (PT) and occupational therapy (OT) practice. There has been some effort focussed on reducing this gap in pediatric therapies, however, minimal progress has been made. EBP skills are taught as part of entry-level educational programs and clinicians value its use, but EBP is not routinely incorporated into clinical practice. Children's Hospital Colorado Rehabilitation Department (CHCO) partnered with the University of Colorado PT Program (CUPT) to develop a training program to improve practical EBP skills and successfully implement EBP into clinical practice.
DESCRIPTION: The initiative to close the gap between knowledge and application of EBP in practice began with the partnering of CHCO with CUPT. The preliminary state of the use of EBP at CHCO was assessed by measuring clinician confidence and competence in using EBP prior to program development. The results were used to create a pragmatic training program for clinicians consisting of six 3-hour sessions. The initial training cohort included department leaders and clinicians who were interested in EBP skill development. The Modified Fresno Test, the Evidence-Based Practice Confidence (EPIC) Scale, and the Modified Evidence Based Practice Knowledge/Attitudes/Behaviors Questionnaire (EBP-KABQ) were administered before and after the 6-week training. Qualitative feedback was gathered related to the practicality, feasibility, and applicability of the training program. Results of the questionnaires and qualitative responses are currently being analyzed to assess the effectiveness of the program and its impact on clinical practice, as well as to guide future program development.
SUMMARY OF USE: This program aimed to close the EBP knowledge-to-practice gap in pediatric rehabilitation practice by improving clinician competence and confidence in EBP skills through didactic learning experiences and skill practice. A total of 32 clinicians participated in this unique training program. Preliminary analysis of the results indicate a positive change in knowledge and confidence in using EBP, and strategies for sustainability are currently being explored. EPIC and Fresno scores significantly increased and the training program was positively received by participants. Further investigation into the program's long-term effect on clinical practice is still underway.
IMPORTANCE TO MEMBERS: Effective implementation of EBP in clinical care is challenging, and is integral to successful pediatric therapy practice. The creation of this training program demonstrates the success of a unique academic and clinical partnership that led to the development of a practical EBP training program to meet the needs of novice through expert pediatric therapists. Stepwise program development including status assessment, responsive program creation and implementation, and effectiveness analysis may serve as a model for other large, pediatric therapy systems.
RELIABILITY OF MANUAL BRAIN LESION SEGMENTATION AND ASSOCIATION WITH FUNCTION IN INDIVIDUALS WITH CEREBRAL PALSY
Helberg DS, Dougherty S, Gilray E, Sutter E, Van Beek N, Nemanich ST, Gillick BT
PURPOSE/HYPOTHESIS: The extent and location of brain lesions in children with hemiparetic cerebral palsy (HCP) may contribute to heterogenous functional phenotypes. Lesion segmentation provides quantification of lesion characteristics and can be used as an explanatory variable in research involving children with HCP. Furthermore, as our lab investigates non-invasive brain stimulation as an adjunct to rehabilitation, considering lesion characteristics may lead the field toward individualized applications of these methods. The purpose of this study was to assess the inter-rater reliability of manual brain lesion segmentation with (Approach 1) and without (Approach 2) the use of a standardized template, and to compare lesion volumes to upper extremity function in children with HCP due to perinatal stroke. Our hypotheses were: 1) inter-rater reliability will be higher when using a template, 2) lesion volume will correlate with upper-limb functional impairment.
NUMBER OF SUBJECTS: 20
MATERIALS AND METHODS: Lesions were manually segmented from T1-weighted magnetic resonance images by 2 of 5 total raters. For Approach 1 (n=7), raters performed segmentation in native image space (no template). For Approach 2 (n=20, including the sample from Approach 1), images were registered to a standard brain template before segmentation. Inter-rater reliability (intraclass correlation coefficient-ICC) of segmented lesion volume was assessed by comparing the 7 scans common to both Approaches. The spatial overlap of segmentations was examined with the Dice Similarity Coefficient (DSC). Upper-limb functional assessments (Assisting Hand Assessment - AHA) and grip strength dynamometry were compared to lesion volume using Pearson correlations.
RESULTS: 20 participants (ages 7-21, 11 female) with HCP due to perinatal stroke were included. For Approach 1 (with template), the ICC was 0.98 (95% CI=0.90-0.99, p<.0001) and the mean DSC was 79.8%. For Approach 2 (without template), the ICC (2,1) was 0.9883 (95% CI= 0.99-1.0, p<0.0001) and the mean DSC was 77.9%. DSCs were not significantly different between the two Approaches (paired t-test, p=0.786). Across all 20 participants, there were significant, moderate correlations between lesion volumes and the AHA (r= -0.476, p=0.033) and grip strength (r= -0.593, p=0.006).
CONCLUSIONS: Reliability was overall good to excellent. Using a template did not produce better segmentation consistency or reliability. Larger lesion volumes tended to correlate with lower upper extremity function. Future research should explore the functional impact of lesion location in addition to volume.
CLINICAL RELEVANCE: Brain lesion quantification can inform future research characterizing lesion burden and functional outcomes in a heterogeneous population like HCP. Furthermore, accurate lesion quantification is critical for determining dosing and safety of individualized non-invasive neuromodulatory techniques, which are influenced by brain anatomy and physiology. Safe and effective applications of neuromodulation may be used to augment physical therapy interventions.
EFFICACY OF THE START-PLAY PROGRAM FOR INFANTS WITH NEUROMOTOR DISORDERS: ADAPTIVE BEHAVIOR OUTCOME
Hsu LA, Paulson ML, Tambellini Harbourne R, Chapman Dusing S, Lobo MA, Westcott McCoy S
PURPOSE/HYPOTHESIS: Adaptive behavior (AB) is the ability to integrate conceptual, social, and practical skills to be effective in facing tasks in daily life. Previous research suggests AB is a significant predictor of gross motor and self care ability in young children with cerebral palsy. Physical therapists often consider influencing AB within intervention for children with neuromotor disorders, but do not routinely state goals to improve AB. The Sitting Together and Reaching To Play (START-Play) intervention utilizes physical therapists to deliver a perceptual-motor program centered on early cognitive constructs. The purpose of this study is to evaluate the efficacy of the START-Play intervention for improving AB for infants with neuromotor disorders.
NUMBER OF SUBJECTS: As part of the START-Play study, 20 infants (9 usual care, 11 START-Play; 7-16-months corrected age at baseline) with a motor delay verified by the Bayley Scales of Infant and Toddler Development, Third Edition (Bayley-III) participated. Participants' Bayley-III motor scores were at least 1 SD below the mean. Blocked random assignment to usual care or START-Play (plus usual) intervention was performed based on severity of neuromotor involvement.
MATERIALS AND METHODS: Assessments and interventions were performed in the community. Parents of all children completed the Bayley-III Adaptive Behavior Questionnaire for infant's AB at baseline and after intervention. START-Play infants received extra twice-weekly home intervention from trained physical therapists (with regular fidelity checks) for twelve weeks while usual care group received only their usual early intervention services. An independent-t test was used to evaluate change scores between the two groups, and paired-t test to compare pre to post scores for each group separately. The minimal detectable change (MDC) of Bayley-III general adaptive composite scores (GAC=8.58) was used as the cut-off to verify individual change from pre to post intervention.
RESULTS: There were no significant differences at baseline for age, gender, history of brain injury. While there was no significant group difference for the change of GAC, children in START-Play group showed significant increases in their GAC after training (p=0.04), whereas the usual care group showed little change (p=0.64). 54.5% of children in START-Play group showed improvements larger than the GAC MDC, while 44.4% in the usual care group showed improvements larger than the MDC.
CONCLUSIONS: Preliminary results indicated that usual EI across the USA and START-Play may both be effective at advancing AB ability for some infants, but START-Play results in greater changes. However, further research within larger sample sizes of infants with neuromotor disorders, and evaluation of a specific motor intervention protocol, which focuses on improving AB is warranted.
CLINICAL RELEVANCE: Both usual care and START-Play appear to affect AB in infants with neuromotor disorders. The START-Play intervention was found to be acceptable by infants and families and may have a greater effect on infants' AB function.
MEANINGFUL INTERVENTIONS IN DEVELOPMENTAL REHABILITATION – IT'S AS EASY AS RIDING A BIKE
Huijs L, Schwab SM, Garcia MC, Livecchi A, Schmit J
PURPOSE: The purpose of this presentation is to describe the program design and successful implementation of an adapted community-based bicycle program for children and young adults with developmental disabilities (DD). The presentation will outline (1) the evolution of the program protocol over a four-year period, (2) the assessment battery used to analyze constructs of meaningful motor performance, and (3) considerations for therapists seeking to implement a bicycle program.
DESCRIPTION: Children and young adults with DD exhibit lower levels of participation in sport and recreation compared to their peers of typical development (TD). Participation in sport and recreation has been identified as a highly prioritized area of function for individuals with DD and their families. Specifically, independent two-wheeled bicycle riding has been recognized as a valued motor activity; fewer children with DD independently ride a two-wheeled bicycle compared to children of TD. Fitness activities are becoming increasingly recognized as important complements to traditional physical therapy service models. Despite this, recent evidence indicates that less than 15% of physical therapy interventions focus on participation in leisure activity, and there is limited evidence regarding the clinical implementation of adapted bicycle programs in children and young adults with DD. Accordingly, there is a critical need to develop and evaluate the feasibility and efficacy of therapeutic programs designed to address meaningful motor activity, including two-wheeled bicycling.
SUMMARY OF USE: An adaptive community-based bicycle program (i.e., “Bike Camp”) was held for four years (2016-2019) and administered to 126 children and young adults (7-21 years) with a variety of developmental disabilities (e.g., cerebral palsy, autism spectrum disorder). Participants attended 75-minute training sessions each day of the 5- day camp week. In each session, participants utilized an adapted bicycle outfitted with proprietary “rolling pin” technology which permitted rear support with quick adjustments to alter the stability of the bicycle, promoting independent riding by the final day of camp. Riding was facilitated by a trained volunteer “spotter,” while overseen and directed by therapy staff. Over a four-year period, Bike Camp has been successful in the independent cycling of 98/126 (77.7%) children and young adults with DD. Results further suggest that participation in Bike Camp contributed to enhanced self-concept in prioritized areas of everyday motor performance for children and adolescents with DD.
IMPORTANCE TO MEMBERS: This presentation will provide therapists with important considerations for developing and implementing an adapted community-based cycling program. Independent bicycle riding is a functional, highly prioritized form of physical activity that should be considered as a useful complement to traditional therapy services which aim to promote meaningful, independent motor activity.
SITTING POSTURAL CONTROL INTERVENTIONS FOR CHILDREN WITH OR AT RISK FOR CEREBRAL PALSY: SYSTEMATIC REVIEW
Inamdar K, Molinini R, Panibatla ST, Chapman Dusing S
PURPOSE/HYPOTHESIS: Delayed sitting is common in children with or at risk for Cerebral Palsy (CP), however independent sitting skills are important for development of other milestones. Ability to sit independently before two years of age is predictive of independent walking and higher cognitive abilities in children with CP. While physical therapy commonly works to improve sitting, there is no consensus on the most effective intervention targeting sitting for children under 5 years. We aim to systematically identify and evaluate the quality of published literature on interventions targeting sitting control in young children with CP.
NUMBER OF SUBJECTS: Children with or at risk for cerebral palsy 5 years of age or under, in 14 papers.
MATERIALS AND METHODS: The review was performed using Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA) methodology. Inclusion criteria were defined as randomized control trials of interventions targeting sitting postural control, provided by a physical therapist and assessing functional or developmental outcomes in a sample including children with a mean age of 5 years or less, and at least 50 percent with a diagnosis of CP or high-risk of CP. Relevant studies were identified and included by searching the databases EMBASE, PubMed, Cochrane, CINAHL and Web of Science. Quality assessment was performed using the Cochrane Risk of Bias Assessment tool.
RESULTS: Fourteen studies were selected and grouped into three categories. Eight studies compared one physical therapy intervention with another. Of those, 2 studies reported that both interventions were equally effective, 2 reported one intervention as more effective than the other and in 4 studies neither group had improved functional outcomes. The second category included 5 studies that compared physical therapy with physical therapy plus an adjunct. Four of the five studies reported greater improvements in function in the groups with physical therapy plus an adjunct. Last, 1 study compared physical therapy with a non-treatment group; though neither group showed improvements. Due to heterogeneity of the outcomes a meta-analysis could not be completed. Interventions were deemed to be more effective than the comparator if the p-values for the group comparison were statistically significant for functional outcomes.
CONCLUSIONS: Majority of the studies that used comparative interventions and showed positive results on outcomes were based on an underlying theme of promoting active child-initiated movements, parental involvement and education, encouraging variability of practice and dynamic postural training. Quality assessment showed that 50% of these studies had a low risk of bias. However, the 4 studies that reported an improvement with the use of adjuncts had a 70% ‘Unclear’ risk of bias; indicating that the results should be interpreted with caution.
CLINICAL RELEVANCE: Early intervention practices targeting sitting postural control are highly variable. However, identifying components and dosages of effective interventions helps clinicians incorporate them in clinical practice.
OPERATIONALIZING THE EVIDENCE ON DEVELOPMENTAL COORDINATION DISORDER FOR PHYSICAL THERAPIST
PURPOSE: Describe the standardization of practice for evaluation and intervention for children with suspected Developmental Coordination Disorder.
DESCRIPTION: Physical therapists strive to transform patient care through the use of evidence-based recommendations in order to ensure best practice and optimal patient outcomes. This has become increasingly feasible using diagnosis-specific guidelines, though operationalizing the evidence continues to pose difficulties. The purpose is to describe the implementation of recommendations for diagnosis and treatment of DCD in a large institution.
SUMMARY OF USE: DCD is the persistently impaired acquisition and execution of motor skills without any identifiable medical or neurological condition that may explain the coordination difficulties.1 It affects approximately 5-6% of the population 2 and persists into adulthood. Beyond coordination difficulties, children with DCD have deficits that span many aspects of their lives including academic/school productivity, prevocational and vocational activities, leisure, and play. Children with DCD are less active than their peers, which presents risks for emotional, social, and physical problems.1 Despite the reported prevalence and lasting consequences, DCD remains poorly understood and highly under-diagnosed among practitioners. Standardization of care is imperative to improve patient outcomes though can be difficult to implement. A DCD team was developed to standardize care at a large pediatric hospital. Initially only three children with a diagnosis of DCD were found within the medical center and chart review revealed insufficient evidence that all DCD diagnostic criteria were met for these diagnoses. An initial goal of increasing awareness for therapists and primary care providers on presentation and DCD diagnostic criteria was created. The DCD team worked to provide a diagnostic pathway for therapists by implementing the use of the Developmental Coordination Disorder Questionnaire (DCD-Q). The DCD-Q is a screening tool to assess if coordination impairments impact multiple areas of a child's life.1,4 All outpatient staff was trained on the DCD-Q and supplementary documentation templates were created. Administration of the DCD-Q grew from zero assessments administered to 200+ over the course of 18 months. Over 80% revealed positive concern for DCD, leading therapists to provide task-based interventions. Task-based interventions are recommended for individuals with DCD.2,3,5 One form of task-based intervention is Cognitive Orientation to daily Occupational Performance (CO- OP).3 CO-OP training is provided to all staff allowing standardization of intervention. Efforts have improved physician awareness as more referrals requesting assessment for DCD and an increased number of DCD diagnosis has been seen. The DCD team will continue quality improvement work in an effort to enhance the patient, caregiver, and practitioner outcome for the DCD population.
IMPORTANCE TO MEMBERS: Provide standardization to the identification, assessment, and treatment of individuals with DCD.
SCHOOL-BASED PHYSICAL THERAPY: THE FACILITATORS AND BARRIERS TO PRACTICE
Jeffries LM, Dzul-Garcia CA, Jones M
PURPOSE/HYPOTHESIS: The purpose of this study was to identify facilitators and barriers physical therapist encounter when providing school-based services.
NUMBER OF SUBJECTS: 22 school-based physical therapists.
MATERIALS AND METHODS: Four focus groups, involving school-based physical therapists from across the United States, were held via Zoom, an online video conferencing application. Therapists expressed an interest in participating in a focus group following completion of an online survey regarding the use of evidence-based interventions in school-based settings. Each focus group was 1.5 to 2 hours in length. A moderator posed questions regarding what facilitators and barriers therapists encounter when implementing various evidence-based interventions. Recordings were transcribed verbatim and open coding and theme development was completed by two researchers and triangulated with a third researcher.
RESULTS: Five themes emerged as both facilitators and barriers related to physical therapists implementation of evidence-based interventions in school-based practice. The themes included: 1) administration, 2) resources, 3) communication, 4) teachers and 5) time. The determination of whether a theme was a facilitator or barrier depended on the school district. Other facilitator themes were proximity and teamwork. Other barrier themes were caregivers and policies.
CONCLUSIONS: Often a facilitator school-based physical therapists identify with regards to the implementation of evidence-based interventions can also be a barrier, depending on the school district. Variability exists across the country with regards to district policies, resources, and expectations of therapists. Future research, at the district level, is needed to identify how to shift barriers into facilitators.
CLINICAL RELEVANCE: These findings are relevant to clinical practice as the results provide insight into the barriers and facilitators therapists face when providing evidence-based interventions in schools. The results elude to the fact that facilitators and barriers can be similar depending on the lens used to make decisions regarding therapy services and professionals should seek ways to flip the lens to present a more positive and outcome to service.
EARLY MOTHER-INFANT SENSORIMOTOR PLAY INTERACTIONS IN INFANTS BORN PREMATURE: A MIXED METHODS APPROACH
Jensen-Willett SL, Bergwell HR
PURPOSE/HYPOTHESIS: Play is a known catalyst for all domains of infant development, including motor.1,2 Sensorimotor play, from the neonatal period onward, scaffolds infant exploration of the environment and understanding of sensory information.3 For infants born preterm and hospitalized in the Newborn Intensive Care Unit (NICU), fundamental differences in mother-infant interactions may influence early sensorimotor play opportunities and compound risk for developmental delays.4 The purpose of this mixed methods study is to explore and describe the sensorimotor constructs characterizing mother-infant play interactions in infants born preterm and at near term adjusted age.
NUMBER OF SUBJECTS: Seven mother infant dyads, purposefully sampled to include diverse sociodemographic backgrounds, participated. Infants were born between 28 - 36 weeks gestation, hospitalized in a Midwestern, urban NICU, near term adjusted age, and free of conditions that restricted movement. Mothers were older than 19 years, had no pre-existing mental illness or chemical dependency, and scored < 13 on the Edinburgh Depression Scale.
MATERIALS AND METHODS: Medical and sociodemographic variables were collected from the infant's EMR to ensure appropriate sampling and for mixed methods analysis. Two to three days prior to NICU discharge, a five-minute, maternally-defined play interaction, 2½ minutes without and 2½ minutes with a toy, was video-recorded. Using a five-step inductive coding procedure, 5 recordings were qualitatively analyzed for underlying movement and sensory themes. Themes were condensed based on maternal intent, weighted for infant sensory and motor challenge, and transformed into quantitative variables to explore trends and relationships between qualitatively defined (play) constructs and quantitative (maternal/infant sociodemographic) variables.
RESULTS: Four qualitative themes emerged: 1) maternal uncertainty about play, 2) maternal beliefs shaped interactions, 3) mothers emphasized optimal infant state/attention, and 4) motor experiences, though embedded, were not the focus. Associations were present between infant exploratory behaviors and maternal alerting frequency (rho = 0.778), average length of position change and no sensory stimulation (rho = .786), infant motor challenge and maternal soothing frequency (rho = -0.847), and average length of position change and multi-modal sensory stimulation (rho = -.964). Only maternal age correlated with two play variables: percent time of infant engagement (rho = 0.906) and awake/alert (rho = 0.936).
CONCLUSIONS: Despite uncertainty, mothers used both sensory and/or movement strategies to engage with infants born preterm. Overt maternal play behaviors revealed serendipitous infant motor opportunities.
CLINICAL RELEVANCE: Behavioral observation of naturalistic, sensorimotor play provides a mechanism for gaining nuanced understanding of early mother-infant developmental dynamics and potential risk for altered motor experience.
EFFECTIVE DOSING OF VIRTUAL REALITY GAMING TO IMPROVE POSTURAL CONTROL IN CHILDREN WITH CEREBRAL PALSY
Jones SA, Collins AM, Hanson M, Lawson CR, Sundermeyer HW
PURPOSE/HYPOTHESIS: Determine effective dosing parameters of virtual reality to produce postural control gains in children with cerebral palsy.
NUMBER OF SUBJECTS: 8 articles; 142 subjects 4 to 18 years of age
MATERIALS AND METHODS: The American Academy of Cerebral Palsy and Developmental Medicine Methodology (AACPDM) was used to complete this systematic review. Nine databases were searched in February of 2019 using the terms: cerebral palsy, postural control, virtual reality, and children. Inclusion criteria were peer-reviewed articles published within the last 10 years, in the English language, of subjects under the age of 21 with a diagnosis of Cerebral Palsy (CP) GMFCS levels I-III, and the use of a commercially-available virtual reality system as a treatment intervention. Critical analysis and conduct ratings were completed using the AACPDM conduct rating for group studies. Data was extracted and consolidated for review by all five authors.
RESULTS: The original search produced 224 articles, with 4 articles added from a Cochrane Database search. Eight studies met criteria and were included for qualitative analysis. Seven were level II and one was level IV, based on Sackett's levels. Four of the included studies were rated moderate in strength, and 4 were rated strong. With the exception of the Ferreira study, all used multiple outcome measures to assess changes in postural control. Three different forms of virtual reality were used: Nintendo Wii, Nintendo Wii with the Balance Board, or the Xbox 360 Kinect. Dosing varied across studies from 20-1200 total minutes delivered over the course of 1-12 weeks. Statistically significant improvements in postural control were reported using the TUG, PBS, FRT, BOT2 Balance subtest, or Gross Motor Quotient in seven of the included studies. Ferriera et al. included only one 20-minute treatment session and utilized the TUG alone to measure change. No significant changes were reported in this study, indicating that dosing of multiple sessions is required to produce changes in TUG scores. Data from this study was not consolidated with other studies when making dosing recommendations. Dosing in the remaining seven studies ranged from 30-50 minutes per session, 2-5 times per week over a duration of 2-12 weeks. Total sessions ranged from 10-25 for a range of total VR intervention of 420-1200 minutes.
CONCLUSIONS: VR dosing of 420-720 total minutes delivered over 5-12 weeks is effective in increasing postural control and functional balance in children with cerebral palsy. Further research is needed using larger groups of subjects and more consistent outcome measures to determine if smaller dosing delivered over shorter periods of time will produce similar gains in postural control. Adequate follow up periods should be included in to determine the extent to which postural control gains can be sustained over time.
CLINICAL RELEVANCE: Consideration of evidence-based dosing is essential when establishing an appropriate plan of care to improve postural control in children with cerebral palsy.
RELIABILITY OF THE NEURODEVELOPMENTAL INFANT SCREENING TOOL DURING THE FIRST YEAR OF LIFE
Katz J, Perenyi A
PURPOSE/HYPOTHESIS: The Neurodevelopmental Infant Screening Tool (NIST) was developed to be a measure of global central nervous system function in the first year of life and is intended to be used to screen infants at risk for neurodevelopmental delay. The tool is transdisciplinary, and covers nine streams of development, including social-emotional behavior, receptive language, expressive language, feeding, visual/fine motor-problem solving, sensory integration, extremity tone, axial alignment and function, and gross motor examination. It includes a whole repertoire of development, and assesses developmental delays as well as focusing on qualitative impairments, which may not be detected in other multidimensional tests. The intended use of the NIST will be to identify neurodevelopmental problems so that relevant services may be implemented in a timely fashion. The purpose of the current study was to determine the inter- and intra-rater reliability of the NIST with typically-developing (TD) infants. We hypothesized that a high, positive correlation exists between raters who are trained in the use of the NIST when testing TD infants.
NUMBER OF SUBJECTS: Twenty-eight TD infants, firm birth to 12 months of age, were recruited.
MATERIALS AND METHODS: The study was approved by the Institutional Review Board of Downstate Health Sciences University. Parents from the community and from our outpatient clinics were asked by one of the investigators if they would like to have their child participate in the study. After an informed consent form was read and signed, investigators ascertained if the infant was eligible for the study based on a completed health questionnaire by the parent. The NIST was then performed during the outpatient visit or in the infant's home. During the NIST administration, the infants were video recorded so that multiple raters who were trained in the use of the NIST could score the infants. Pearson Product-Moment Correlation Coefficients were calculated to determine inter- and intra-rater reliability of the total NIST score and individual scores on each stream of development on the NIST.
RESULTS: A total of 28 TD infants from 0.75 to 12 months of age participated in the study, with a mean age of 5 months. Inter- and intra-rater correlations were high, with r values ranging from 0.94 to 1.00.
CONCLUSIONS: The results show that the NIST has excellent inter- and intra-rater reliability for total NIST scores and for each subcategory score, which supports our hypothesis.
CLINICAL RELEVANCE: The NIST may be used as a reliable screening tool for infants to assess their neurodevelopment. This study is one step toward the validation of this tool. It is anticipated that the NIST will assist physical therapists to determine if early intervention is warranted. Screening tools that help us to determine an infant's need for physical therapy at a young age may help improve the child's neurodevelopmental outcome.
VESTIBULAR AND OCULOMOTOR DYSFUNCTION IN CHILDREN WITH IDIOPATHIC TOE WALKING
Kaufman E, Harris NM, Muir NB, Love Gray M
PURPOSE/HYPOTHESIS: Given the role of the oculomotor and vestibular systems in modulating gait and postural control, it was hypothesized that children with ITW may have impairments in these sensory systems. The purpose of this report is to explore the presence of vestibular and oculomotor dysfunction in a sample of children who presented to out-patient physical therapy (PT) with idiopathic toe walking (ITW).
NUMBER OF SUBJECTS: A total of 88 children were assessed for either oculomotor, vestibular and/or balance dysfunction.
MATERIALS AND METHODS: Physical therapists (PTs) at Children's Hospital Colorado (CHCO) assessed vestibular and oculomotor function in children referred for ITW. Saccades, smooth pursuit and convergence examinations were used to assess the oculomotor system. Abnormal result was recorded for smooth pursuit with presence of nystagmus, jerky or saccadic eye movements. Saccades were recorded as abnormal with over and/or undershooting the target, nystagmus, jerky eye movement and/or more than one eye correction. An abnormal result was recorded for convergence If the child was unable to adduct one or both eyes at the target or reported double vision more than 5 cm from the bridge of the nose. The Head Thrust Test was performed to assess the peripheral vestibular system and the presence of a corrective saccade was recorded as abnormal. The Modified Clinical Test of Sensory Interaction on Balance (m-CTSIB) was performed to assess balance and a total time of less than or equal to 110 seconds was recorded as positive. A value of Inconclusive was given for these exams if the subject had difficulty understanding instructions, paying attention or the examiner had inconsistent results. Examination findings were recorded in the child's electronic medical record. Statistical analysis included frequency statistics to determine the presence of balance, oculomotor and vestibular dysfunction in this sample of patients.
RESULTS: Of the children who were assessed for oculomotor dysfunction, 22/80 (27.5%) had abnormal smooth pursuits, 11/71 (15.5%) had abnormal saccades, and 21/76 (27.6%) had abnormal convergence. Vestibular dysfunction was present in 21/53 (39.6%) children based on the Head Thrust Test, and 9/14 (64.3%) children scored below the cut-off for the m-CTSIB.
CONCLUSIONS: This preliminary investigation shows that children with ITW may present with vestibular and/or oculomotor system dysfunction.
CLINICAL RELEVANCE: ITW is a complex diagnosis with multiple impairments related to both musculoskeletal and neurological systems. Because of the multi-system involvement that may be present in children with ITW, the CHCO PT department has begun specifically assessing vestibular and oculomotor systems in this population in addition to a standard ITW assessment. Given the role of the oculomotor and vestibular systems in the development of mature postural control and gait, these may be important systems for pediatric PTs to assess and treat in children with ITW and future research is warranted.
OBJECT PLAY IN CHILDREN WITH AND WITHOUT DOWN SYNDROME
Kaur M, Needham A
PURPOSE/HYPOTHESIS: Object play is an integral part of early development with current evidence suggesting positive implications of active exploration on the motor, cognitive, and social development of children.1,2,3 In contrast, infants and children with Down syndrome (DS) explore objects less actively than TD infants, e.g. 4- to 6-months-old infants with DS showed less grasping and greater looking at objects compared to TD infants.4,5 Similarly, school-aged children with DS showed limited demonstration of novel functional actions while playing with a random set of toys compared to TD children.6 In the current study, we explored the spontaneous play with objects in school-aged children with DS, along with the child's ability to improve their play when engaged in a social imitative play with the experimenter.
NUMBER OF SUBJECTS: 20
MATERIALS AND METHODS: Ten children with DS between 6 and 14 years (mean age = 10.63 ± 1.01) and ten mental-age matched TD children between 3 and 5 years (mean age = 4.44 ± 0.38) participated in the study. The task included playing with a set of tea party toys (e.g. cup, saucer, teapot) during a solo and a social condition. During the solo condition, children spontaneously played with the toys for 60 seconds while the experimenter pretended to finish her paperwork. During the social condition, the experimenter demonstrated an easy (4-step sequence) and difficult action sequence (8-step sequence) using the toys and asked the child to copy her actions. Solo play was evaluated by coding the total number of actions, functional (e.g. pouring tea into cup) and non-functional actions (e.g. banging spoon on the table) demonstrated by the child. Social play was evaluated by the number of errors (e.g. omitting/adding an action from the sequence) performed by the child while copying the easy and difficult sequence.
RESULTS: During the solo play, children with DS showed fewer functional actions while playing with the toys compared to TD children (DS = 4.75 ± 0.60; TD = 9.50 ± 1.61; p = 0.02); with no differences for the number of total actions (p = 0.48) and non-functional actions (p = 0.21). During the social play, both the DS and the TD group produced similar numbers of errors for the easy (p = 0.21) and difficult action sequence (p = 0.62).
CONCLUSIONS: As expected, children with DS showed reduced age-appropriate, meaningful exploration of objects during the solo play. However, during the social play, children with DS improved their play by accurately copying the actions of the experimenter. This could be attributed to the fact that children with DS are socially responsive and show positive affect and attention towards social partners,7 which could have motivated children to closely attend to the actions of the experimenter.
CLINICAL RELEVANCE: Our results suggest that socially engaging games could be a valuable context for teaching new motor skills and action sequences to children with DS. However, due to the preliminary nature of the study, we recommend clinicians and researchers to use caution while generalizing the study results.
HANDHELD DYNAMOMETRY AND SEATED REACH TESTING IN CHILDREN WITH DUCHENNE MUSCULAR DYSTROPHY
Kern R, Tissier Carvell K
PURPOSE/HYPOTHESIS: The purpose of this study is to determine the relationship between trunk strength, sitting balance, and level of disability. The hypothesis is that there will be a positive relationship between functional independence, as measured by the Pediatric Evaluation of Disability Index (PEDI), and trunk strength, as measured by hand-held dynamometry (HHD), and sitting balance, as measured by seated reach test, making these meaningful measures to utilize with children who have DMD.
NUMBER OF SUBJECTS: 18
MATERIALS AND METHODS: Eighteen male participants, 11 ambulatory and 7 non-ambulatory, with a mean age of 10 (± 3.78 SD), had their trunk strength measured using HHD while in a seated position resisting anterior, posterior, and lateral movements. The HHD was placed on the sternum, thoracic spine, and bilateral acromion, respectively. After an initial verbal explanation and practice movement, each direction was tested twice and the average was recorded. Each participant had their sitting balance measured using the seated reach test, which measures the distance each child was able to lean forward in a sitting position in centimeters. There were two trials and the average was recorded. The PEDI was used to measure functional independence as reported by caregiver proxy. This is a cross-sectional observational study where each participant was recruited from a transdisciplinary clinic setting and measured during their scheduled appointment time.
RESULTS: Higher trunk strength scores in all directions are positively correlated with higher functional independence as reported on the PEDI. Trunk strength in the flexion direction is significantly correlated (P=0.03) with the PEDI, indicating for every 1 unit increase of trunk flexion strength there is a 1.68 unit increase in the PEDI functional skills section when controlling for age. No significance was noted when adjusted for weight alone. Higher independence was also correlated (p=0.07) to a greater seated reach score on a one to one ratio.
CONCLUSIONS: These findings are consistent with the hypothesis that there is a positive correlation between objective seated strength and balance measures and independence in ambulatory and non-ambulatory children with DMD as measured by the PEDI. There is a significant positive correlation between trunk flexion strength and independence.
CLINICAL RELEVANCE: The use of these valid and reliable measures is meaningful for children with DMD. These same measures can be used from initial diagnosis through loss of ambulation as important tools to aid in determining functional prognosis. These measures may also be used to guide best practice interventions that could have the potential for greatest impact on a patient's quality of life. This study shows that objective measures of strength and balance can be utilized throughout the continuum of this condition to provide information to patients and families. In addition, this study prepares the foundation for future clinical studies focusing on interventions to best influence independence for individuals with DMD.
DYNAMIC ABDOMINAL STRENGTHENING THROUGH SPORTS PARTICIPATION TO IMPROVE GAIT EFFICIENCY IN CHILDREN WITH CEREBRAL PALSY
Kerr LO, Seewer EC, Wiseman TM
BACKGROUND AND PURPOSE: Individuals with cerebral palsy demonstrate excessive co-activation of agonist and antagonist musculature impeding task-specific postural adaptations resulting in compensatory strategies for all functional activities. In order to increase community participation and peer-to-peer interactions, a child needs to be able to appropriately respond to postural adaptations when navigating environments such as school hallways or stairs. Typically developing children establish and advance postural control strategies through sport participation. The dynamic task of swing a bat for the purpose of hitting a ball requires the sequenced control of musculature activation for both the trunk and extremities. Engaging in this novel task provides opportunities for participants to develop and experience postural adaptation strategies associated with dynamic rotation that children with cerebral palsy often lack during their gross-motor developmental experience. The purpose of this study is to examine the efficiency of gait and transfers in children with Cerebral Palsy after a dynamic abdominal strengthening program through sports participation.
CASE DESCRIPTION: A single-subject design (A-B with follow-up) was used in implementing a 8 week hitting protocol. Consisting of 1- week baseline testing, 8-week intervention, 1-week post-intervention testing, and follow-up at 6 weeks. Each child received 2 sessions of softball hitting lessons for a total of 2 to 3 hours of treatment per week. The softball swinging protocol included swinging a bat in four different developmental positions (tall-kneeling, right and left half-kneeling, and standing) with decreased levels of postural support and increased swinging resistance as the intervention progressed. The two children participating were both diagnosed with spastic cerebral palsy with a mean age of 9.5 years, and GMFCS level III.
OUTCOMES: The outcome measures included the Timed Up and Go (TUG), Five-repetition sit-to-stand, 6 Minute Walk Test (6MWT), Gross Motor Function Measure–88 (GMFM), and gait analysis via a 2-D motion capture system. Both children demonstrated improvements in the TUG (15.6% change), five-repetition sit-to-stand (29.7% change), and the 6MWT (10% change). The gait kinematic improvements demonstrated from the intervention such as velocity and stride length continued to show improvements at the 6 week follow-up testing session.
DISCUSSION: An 8-week dynamic abdominal strengthening program accomplished through sports participation appeared to have a positive effect on the efficiency of gait and transfers in both children. Our results support the idea that: task- oriented strengthening targeting the abdominal muscles, can serve as a means of improving trunk control and stability during ambulation. By increasing abdominal strength, a more symmetrical upright posture is encouraged which allows for greater maximization of energy during ambulatory and dynamic postural control tasks.
INFANTS BORN FULL-TERM AND PRETERM ADAPT NEW TASK DEMANDS
Kim J, Fetters L, Sargent BA
PURPOSE/HYPOTHESIS: Infants born preterm (PT) are at high risk for impairments in motor control. This impairment in motor control has been reported in the mobile paradigm, where the vertical leg movements of infants are reinforced with sound and movement of an overhead infant mobile. Previous research supports that infants born PT, compared to full-term (FT), have difficulty adapting their leg movements to the task demands of the mobile paradigm. Environmental supports may assist infants born PT to learn to independently adapt their movements to meet progressively more challenging task demands. We scaffolded the mobile paradigm using three different heights of threshold by requiring the infants to lift their feet higher to activate the mobile. The aim of this study was to assess if infants born FT and PT could produce higher kicks. We hypothesized that both groups of infants would significantly increase their kick heights during the highest threshold of mobile reinforcement on their last day of participation, compared to their spontaneous kicking actions on the first day.
NUMBER OF SUBJECTS: 16 infants born FT, 16 infants born PT (<32 weeks gestation) at 4 months of age, corrected for prematurity.
MATERIALS AND METHODS: Infants participated in the scaffolded mobile task for 2 to 3 consecutive days. Day 1 consisted of a 2-min baseline spontaneous kicking condition, followed by an 8-min mobile condition during which the mobile activated when the infant lifted either foot vertically over an individualized threshold. The threshold was computed as the mean height of the foot IREDs plus one standard deviation (sd). Days 2 and 3 consisted of a 10-min mobile condition, during which the threshold height was systematically increased. For the first 2-min, the threshold was consistent with the mobile condition on Day 1 (mean+1sd). For the following 4-min, it was increased to a threshold height of mean plus 1.5sd. For the last 4-min, it was increased to the height of mean plus 2sd. Kick height was quantified as peak foot height, the vertical distance from the testing table to the highest foot marker position for each kick. Mixed regression models using repeated measures were used to test differences of the peak foot heights between the baseline condition on Day 1 and the highest threshold condition (mean+2sd) on the last day of participation.
RESULTS: Both FT and PT groups increased the foot kick heights during the Last Day highest threshold condition compared to the Day 1 baseline condition (<.05).
CONCLUSIONS: These findings are consistent with our hypothesis that infants born FT and infants born PT would adapt to the task demands of the scaffolded mobile paradigm by increasing their kick heights.
CLINICAL RELEVANCE: Our data informs the capability of infants born PT to adapt to task demands and generate higher kicks when participating in a scaffolded task. Scaffolded environments during child-active therapeutic interventions may help infant born PT to develop more age appropriate movements.
MULTIDISCIPLINARY APPROACH TO THE MANAGEMENT OF FUNCTIONAL NEUROLOGICAL SYMPTOMS WITH CO-MORBID CONCUSSIONS AND HYPERMOBILITY SYNDROME
Kogut M, Laux J, Tunney M, Vassilopoulous A
BACKGROUND AND PURPOSE: Functional neurological symptom disorder (FNSD) refers to the presence of altered voluntary motor or sensory function found to be incompatible with recognized neurological or medical conditions. Children and adolescents with FNSD may present with diverse symptoms including, but not limited to, motor weakness or paralysis, abnormal movements, non-epileptic seizures, altered sensation, and diminished consciousness. The purpose of this case report is to describe the unique presentation of an adolescent girl with symptoms of FNSD and the successful multidisciplinary approach to her treatment.
CASE DESCRIPTION: A 15-year-old girl with symptoms of FNSD, history of three concussions in four years, and comorbidities of hypermobility syndrome, dysautonomia and chronic pain syndrome. She presented to physical therapy (PT) with pain and non-epileptic seizures that prevented her from participating in school and preferred social activities. The patient required a skilled multidisciplinary approach to her care in order to facilitate return to her prior level of function and participation.
OUTCOMES: The following outcome measures were assessed pre and post multidisciplinary rehabilitation: Energy Expenditure Index (EEI), Timed Up and Down Stairs (TUDS), 5 Time Sit to Stand (5TSTS), 6 Minute Walk Test (6MWT) and Functional Disability Index (FDI). In addition, the patient's impairments, activity limitations and participation restrictions were assessed before, during and after treatment using the International Classification of Functioning, Disability and Health (ICF) model. All outcome measures demonstrated improvement pre and post treatment, indicating an improvement in the patient's function and participation in daily activities. Her EEI decreased from .44 to .18 and her 6MWT improved from 1342 feet to 1425 feet, indicating an improvement in aerobic capacity. Her 5TSTS decreased from 13.37 seconds to 9.28 seconds and her TUDS decreased from 13.55 seconds to 8.10 seconds, indicating an improvement in speed and quality of functional mobility. Most notably, her FDI score decreased from 34/60 to 0/60, indicating an improvement in the patient's subjective perception of functional limitations.
DISCUSSION: In this case report, the patient was predisposed to the symptoms of FNSD by her history of multiple concussions, family stressors and conflicting demands from different areas of her life. Her course was further complicated by her comorbidities of anxiety, hypermobility syndrome and dysautonomia. After multidisciplinary treatment lasting almost a year, the patient demonstrated improvements in all domains of the ICF model. Traditional PT alone would not have been adequate to improve the patient's function and quality of life. Skilled communication and collaboration between PT, pediatric psychology, the patient and her family was essential to the successful management of this patient's complex presentation.
THE EFFECT OF HIPPOTHERAPY ACROSS THE ICF IN CHILDREN WITH CEREBRAL PALSY: A SYSTEMATIC REVIEW
Kruse C, Mummey M, Penland C, Swiec A, Waller RM, Case LE
PURPOSE/HYPOTHESIS: Research has shown that hippotherapy is beneficial in children with cerebral palsy. However, previous systematic reviews were limited to certain outcome categories and included studies that involved both hippotherapy and therapeutic horseback riding. The purpose of this systematic review was to determine the various effects of hippotherapy on specific areas of status and function across all International Classification of Function (ICF) domains in children with cerebral palsy.
NUMBER OF SUBJECTS: 24 studies
MATERIALS AND METHODS: A comprehensive search strategy was performed in accordance with PRISMA guidelines. The following electronic databases were searched for relevant articles: PubMed/MEDLINE, Embase, CINAHL, Web of Science, and Scopus. Resulting studies were included under the following criteria: 1) participants were younger than 22 years old; 2) had a diagnosis of cerebral palsy; 3) intervention was hippotherapy rather than therapeutic riding or robotic simulation. Risk of bias and level of evidence were assessed through the Modified Downs and Black Checklist and Oxford Level of Evidence, respectively.
RESULTS: The full search strategy identified 256 articles, and after comparison to inclusion/exclusion criteria, 24 articles were included in the qualitative analysis. Risk of bias of the studies ranged from fair to excellent, with the majority being fair. The levels of evidence of the studies were Level 2 (n=7), Level 3 (n=13), and Level 4 (n=4). Outcome measures utilized were across all ICF domains with 13 in Body Structure/Function, 9 in Activity, 4 in Participation, and 7 in Personal/Environmental Factors. Improvements with intervention were found in each of the domains with statistically significant findings reported in the areas of spasticity, passive ranges of motion, endurance, balance, muscle activation patterns, gross motor skills, functional strength, quality of life, overall participation, desire to master tasks, perceived competence, and social acceptance.
CONCLUSIONS: Hippotherapy is a beneficial intervention for children with cerebral palsy with effects found across ICF domains, especially in the areas of gross motor function, posture, and balance. Further research is needed to confirm the effects of hippotherapy, especially in the domains of participation and in relation to personal/environmental factors. Variability in outcome measures highlights the need for outcome standardization.
CLINICAL RELEVANCE: This review reinforces the beneficial effects of hippotherapy while highlighting gaps in this area of study. Although current research on hippotherapy is limited overall, there are more studies reporting evidence in the body structure/function and activity domains than studies reporting evidence in the participation and personal/environmental factor domains. Further research is needed in order to fully understand the extent of hippotherapy benefits across the ICF, especially on domains directly related to quality of life.
REHABILITATION OF A 15-YEAR-OLD MALE WITH PERIPHERAL NERVE DAMAGE AFTER CARDIAC TRANSPLANT
Leipe GB, Nelson CM
BACKGROUND AND PURPOSE: Extra Corporeal Membrane Oxygenation (ECMO) and Left Ventricular Assist Devices (LVAD) are used as life support for patients following respiratory failure or cardiac arrest. Damage to the femoral nerve is a known possible complication of ECMO implantation; decreased blood flow to the lower extremities is a known risk of both ECMO and LVAD. Ischemia can cause peripheral nerve damage which can contribute to disabling symptoms including pain, loss of sensation, and strength. These symptoms limit participation in activities of daily life (ADL), school, and recreation. The purpose of this case report is to describe the effectiveness of various physical therapy interventions at reducing neuropathy/sensitivity symptoms in the lower limb of a 15-year-old male status-post cardiac transplant, in order to improve his ability to participate in ADL's and return to hobbies.
CASE DESCRIPTION: The patient is a previously healthy, active teenage male with peripheral nerve damage/right lower limb neuropathy following cardiac transplant. At a routine physical he was diagnosed with ventricular tachycardia and subsequently underwent corrective ablation. The patient went into cardiac arrest during the procedure and ECMO cannulation was performed; he eventually transitioned to an LVAD. The patient began to develop ischemia and pain in the right lower limb. Successful heart transplantation occurred four months later; following transplant, he reported loss of sensation and increasing pain in the right foot/ankle.
OUTCOMES: The patient was seen twice per week for 11 weeks, for 22 visits in an outpatient rehabilitation setting. He presented with altered sensation and pain of the right ankle/foot, impaired balance, antalgic gait, and decreased range of motion and strength of the right lower limb. Physical therapy management included stretching, joint mobilization, desensitization, TENS, strengthening, and balance/gait training. Outcome measures included range of motion (ROM), manual muscle testing (MMT), balance assessment (single limb/tandem stance time), Lower Extremity Functional Scale (LEFS), gait analysis, and subjective report of sensation. After multi-modal treatment, right active and weight-bearing dorsiflexion, active great toe flexion and passive great toe extension ROM increased. R hip flexion, abduction, and knee flexion MMT scores improved. Single limb stance and tandem stance times on the right improved with and without shoes. LEFS score was slightly improved. Following intervention, the patient was better able to navigate the school environment and independently perform ADL's.
DISCUSSION: Neuropathic pain has been shown to negatively impact quality of life, therefore more research is needed to determine the best course of non-surgical rehabilitation. Most published research on peripheral nerve injury is focused in neuroscience with little clinical or functional implications noted. There is no documentation of rehabilitation of a peripheral nerve injury following pediatric cardiac transplant, therefore this case presents a novel treatment course.
THE PHYSICAL THERAPIST'S ROLE IN PREVENTION: A PRENATAL EDUCATION MODEL FOR INFANT WELLNESS
PURPOSE: The purpose of this report is to emphasize the role and effectiveness of the pediatric physical therapist in proactive prevention efforts for infants and parents through a prenatal education model.
DESCRIPTION: No formal prevention education curriculum exists that addresses daily infant positional needs within expectant parent education. Caregivers report confusion with educational resources that lack specific and clear recommendations regarding infant awake prone activities(1,2) Physical therapists traditionally provide infant care interventions once referrals are received from primary care providers, our skills and expertise are underutilized within education/prevention. A prenatal education model that incorporates definitions of awake prone activities, positional variety, and strategies for caregivers is needed.(1,2-7) A sample of convenience included 61 participants in prenatal education classes at a local hospital. A physical therapist presented information to expectant parents that included a definition of infant positional variety, a review of Safe to Sleep (STS) recommendations, potential negative outcomes for infants having limited daily positional changes, and ways to facilitate variety of infant positions during daily routines.(2-7,8)
SUMMARY OF USE: Participant responses to pre-post survey questions were used to measure their understanding of infant positional variety recommendations and the impact of education on their understanding of these recommendations using a repeated measure design. It appeared expectant parents were informed on infant sleeping recommendations, but reported confusion about purposeful infant handling/positioning activities including prone play.(1-10) Statistically significant change was found in participant self-rated knowledge of infant positional variety needs throughout daily routines after participating in the 60-minute educational presentation.
IMPORTANCE TO MEMBERS: Timely education to caregivers could decrease infant risk factors for positional preference, cranial deformities, and delayed acquisition of early motor development. The literature supports prenatal and postnatal education for caregivers/expectant parents to facilitate overall infant wellness.(2-5) Pediatric physical therapists are underutilized within the area of infant wellness. Pediatric physical therapists can promote infant wellness and skull deformity/torticollis prevention by collaborating with other health care professionals in local prenatal programs and birthing centers.
VALIDITY AND RELIABILITY OF A DEVELOPED 2D SMARTPHONE APPLICATION TO MEASURE PLAGIOCEPHALY IN INFANTS
Mao DP, Jacobs KD, McRae K, Larson BM, Lundeen HM
PURPOSE/HYPOTHESIS: The purpose of this study was to develop and establish the reliability and validity of a 2D smartphone app using the Cranial Vault Asymmetry Index (CVAI) to determine the severity of plagiocephaly in infants using the 3D STARscanner™ as the gold standard. We hypothesized the 2D smartphone app will provide physical therapists (PTs) with a valid, reliable, easy to use, accessible, and cost-effective measurement tool in the evaluation and treatment of infants with plagiocephaly.
NUMBER OF SUBJECTS: Twenty infants, 10 with typical (CVAI < 3.5) and 10 with atypical head-shape (CVAI < 3.5) (mean age ± SD, 217± 79.22).
MATERIALS AND METHODS: A 2D photographic capture analysis application was created utilizing Apple's Integrated Development Environment™ to calculate an infant's CVAI following a bird's eye view picture taken of the infant's head. Each infant participated in one session consisting of two non-consecutive 2D smartphone app measurements by 1 pediatric PT and 3 PT students (8 total measurements) and 1 3D STARscanner™ (gold standard) measurement by an experienced orthotist all calculating CVAI. All testers were blinded to the results during testing. The 2D smartphone app and 3D measurements were collected to determine the reliability and validity of the newly developed app.
RESULTS: The CVAI difference for typical, atypical, and combined between the 3D and 2D measurements was 0.84, 2.80, and 1.8, respectively. There was a strong, positive correlation between 3D gold standard and 2D measurements (r = 0.923, P < .001) for the 20 participants. A significant association (X2 = 13.33, P < .001) indicating concurrent validity was observed between the measurements of the 2D and 3D gold standard measurements for the frequency of children identified with typical or atypical head-shape measurements. Based on this association, the specificity and sensitivity of the 2D measurements were determined to be 100% and 80%, respectively. Paired t-tests revealed a significant difference between 3D gold standard and 2D measurements for the atypical head-shapes (P =.002) but not the typical (P>0.05). Strong intrarater and interrater reliability was determined with an Intraclass Correlation Coefficient (ICC) exceeding 0.85 and 0.96, respectively.
CONCLUSIONS: The developed 2D smartphone app demonstrated concurrent validity and a strong degree of intra- and inter-rater reliability among testers with variable experience. Results indicate the app is valid in determining typical or atypical head shape, however, at this time accuracy for determining the level of severity of atypical could not be established, thus signifying its clinical utility as a screening tool.
CLINICAL RELEVANCE: The 2D smartphone app is a promising measurement tool for use among experienced and inexperienced clinicians as a reliable and valid screening for plagiocephaly in infants. The app takes quick and accurate measurements that are cost-effective, accessible, easy to use, and non-invasive. It can assist the PT in determining the need for intervention and/or referral to a cranial orthotist.
THERAPEUTIC INTERVENTION FOR A 3-YEAR-OLD GIRL WITH CASK-GENETIC DISORDER: A CASE REPORT
McCandless C, Mattern-Baxter K
BACKGROUND AND PURPOSE: With the advancement of genetic testing, infants with genetic disorders that affect central nervous system development are increasingly classified with specific conditions rather than categorized under the umbrella term of cerebral palsy (CP). Calcium/calmodulin-dependent serine protein kinase (CASK) with microcephaly and pontine/cerebellar hypoplasia (MICPCH) is such a genetic disorder, which results in interruptions of brain growth. To date, there are 53 known cases worldwide. There is a paucity of research on the efficacy of physical therapy interventions for children with CASK mutation. In this case report, we evaluated how an 8-week, twice weekly functional stretching and strengthening program with task-specific interventions, including intensive treadmill and overground training, would affect functional mobility in a preschooler with CASK and MICPCH.
CASE DESCRIPTION: The child was a 38-month old girl who presented with generalized hypotonia and global developmental delay. She had additional diagnoses of autism spectrum disorder, poor weight gain and sleep disorder. Her clinical presentation mirrored that of a child with hypotonic CP in Gross Motor Function Classification System (GMFCS) level III. At the initial encounter, she presented with decreased hamstring length measured by bilateral popliteal angles of 45[Combining Ring Above], decreased standing and walking ability measured by a Gross Motor Function Measure-66 (GMFM) score of 45.6%, and the need for moderate assist to propel her gait trainer. The family's goal for the child was to improve gross motor function and independent walking in her gait trainer so that she could participate in walks in the park with her family. Main interventions used were positioning on a wedge in long-sitting for hamstring stretching, intensive and progressive treadmill training with incline and ankle weights, high-volume over-ground gait training, and task- specific strengthening via high repetitions of sit-to stand.
OUTCOMES: The child received 16 sessions of intervention over 8 weeks. Data were collected at the beginning and end of the episode of care. By discharge, she achieved bilateral popliteal angles of 0[Combining Ring Above] and was able to walk independently in her gait trainer for short distances at the park. She improved her total GMFM score from 45.6 to 48.3%, exceeded the minimally clinically important difference in total GMFM and Dimension D and E scores, and moved from 35th to 50th percentile for GMFCS level III.
DISCUSSION: For this 38-month old girl, a family-centered program of positional stretching combined with task-specific training, intensive treadmill training and overground walking, led to increased functional mobility and walking independence with an assistive device. The child gained weight in spite of the intensive intervention, but did not improve her sleep patterns. There is a paucity of literature for physical therapy interventions for children with CASK mutation and MICPCH. To our knowledge, this is the first description of a plan of care for a child with this rare condition. Other children may benefit from a similar plan of care.
MAXIMIZING INTENSITY! INTERVAL TREADMILL TRAINING TO OPTIMIZE RECOVERY IN A PEDIATRIC SPINAL CORD INJURY CASE
McCole L, DeValerio K, Quartano J
BACKGROUND AND PURPOSE: Persistent gait impairments in pediatric patients with chronic incomplete spinal cord injury can impact their ability to participate with peers which in turn impacts their quality of life. Locomotor training is widely supported in spinal cord injury literature to promote motor activity below the level of the lesion with improvements in walking independence, gait speed, and distance of ambulation. Increasing the intensity of gait training through increased treadmill speeds has been found to elicit even greater changes in gait kinematics, gait speed, and endurance across neurological diagnoses. Adults with chronic spinal cord injury have reported greater enjoyment during higher intensity upper extremity ergometer training vs prolonged moderate intensity training. However, high intensity interval training has not been applied to gait training within the spinal cord injury literature. Therefore, the purpose of this case report is to determine if a fast-paced interval treadmill training protocol can improve gait kinematics, gait speed, and endurance in a pediatric patient within the early chronic phase of an incomplete spinal cord injury.
CASE DESCRIPTION: An 11-year-old male, 9 months status post traumatic incomplete spinal cord injury at the level of L3 continues to present with significant gait abnormalities resulting in decreased gait velocity and limited participation with peers.
OUTCOMES: At the conclusion of the intervention period consisting of 11 sessions of fast paced interval treadmill training over the course of 6 weeks, clinically significant improvements were seen in preferred gait speed (1.06 m/s to 1.34 m/s), fast gait speed (1.45 m/s to 1.68 m/s), and 6-minute-walk test distance (412.7 m to 467.26 m). The patient also demonstrated improvements in bilateral lower extremity strength, gait kinematics, and reported improved participation with peers.
DISCUSSION: Based on this case, interval treadmill training is a feasible way to increase the intensity of intervention in a pediatric, independent ambulator who is in the chronic phase of recovery from an incomplete SCI. This intervention demonstrates the potential to elicit patient improvements across the ICF model, but further research is needed to further examine and generalize its efficacy.
EXISTING OUTCOME MEASURES MAY BE USEFUL IN UNDERSTANDING LIFTING CAPABILITIES IN YOUNG ADULTS WITH DISABILITIES
McInerney S, McGee MC, Stamp B, Flowers M, DiGangi A
PURPOSE/HYPOTHESIS: Young adults with mental or physical disabilities are only half as likely to participate in employment than their peers without a disability.1 Researchers suggest that young adults with disabling health conditions may benefit from supported employment to foster entry into the labor market.1,2 Vocational training programs exist to provide work-related training, job-specific mentorship, and health and rehabilitation care.1 Healthcare clinicians working in these vocational training programs aim to identify key physical skills required for successful employment.3 One method to do this is through the use of objective outcome measures.4,5 Many objective outcome measures currently exist that determine the mobility status of an individual with or without disability.6,7,8 However, current research does not indicate if these tests can also determine an individual's ability to perform physical work tasks, such as lifting or carrying of an external load. The purpose of this study is to determine if the results of the 5x Sit to Stand Test (5xSST), Timed Up and Go (TUG), and 4 Meter Walk Test (4MWT) correlate with the results of those same tests when performed with an external load.
NUMBER OF SUBJECTS: 29
MATERIALS AND METHODS: Participants were recruited from an existing group of young adults who participate in a vocational training program for those with intellectual and physical disabilities. Each participant performed 3 objective outcome measures under two conditions: in the traditional format and in a weighted condition. The weighted condition was defined as carrying an external load of 10% of the individual's body weight. 9 Individuals performed the tests in a random order and were randomly assigned to perform the traditional or weighted test condition first. Due to the nature of the study, participants and researchers were not blinded for which condition they were performing. All testing was performed in one session.
RESULTS: Statistically significant mean differences (p < .004) were found between performance times on traditional and weighted tests. The results of Pearson product-moment correlations found strong, positive correlations between the weighted and unweighted version of each test (5xSST: r = .940, p = .000; TUG: r = .980, p = .000; 4MWT: r = .825, p = .000).
CONCLUSIONS: The results of this study suggest that currently existing objective outcome measures may predict the capacity of an individual with a disability to perform the same outcome measures while carrying 10% of his or her body weight. Therefore, the 5xSST, TUG, and 4MWT may be utilized in understanding lifting and carrying capabilities in this population. The results also suggest that an external load of 10% of body weight was sufficient to significantly decrease speed of movement on the outcome measures. Additional research is needed to establish reference data for outcome measures in adults with disabilities and to identify whether correlations exist between weighted and unweighted tests using heavier loads.
CLINICAL RELEVANCE: Clinicians working with young adults with disabilities can use the 5xSST, TUG, and 4MWT as a component of a physical therapy evaluation to determine the individual's ability to perform light lifting and carrying activities, which may be necessary for employment.
INTENSIVE PHYSICAL THERAPY MANAGEMENT OF AN INFANT WITH CEREBRAL PALSY - A CASE REPORT
Miller KE, Guthrie JL, Hedgecock JB
BACKGROUND AND PURPOSE: Cerebral palsy (CP) is the most common cause of physical disability in children.1,2 Early diagnosis and timely initiation of appropriately dosed and diagnosis-specific physical therapy (PT) intervention capitalizes on periods of highest neuroplastic capability to facilitate optimum long-term function and caregiver well-being.1,2,3 High intensity intervention based on motor learning principles including repetitious infant initiated training has demonstrated positive functional gains, however clinical trials for these interventions have been completed in natural settings.4,5,6,7 Coaching of caregivers to promote participation and empower continued reinforcement via home programming has additionally demonstrated improved motor outcomes.3,4,7 Unfortunately many infants in Early Intervention programs receive delayed services that are unable to replicate dosing recommendations, and there is a lack of published research describing outcomes of similar clinic based interventions for at-risk infants.8,9 The purpose of this case report is to describe the translation of clinical research detailing intensive PT programming in the infant's natural environment to the outpatient setting for an infant with right hemiplegic CP.
CASE DESCRIPTION: The patient was a 10-month old female with right hemiplegia secondary to perinatal left middle cerebral artery stroke who presented to a hospital-based outpatient clinic. Intensive programming (completed twice a week for 4 weeks) was focused on repetitive task-specific training and caregiver coaching. Encouragement of daily reinforcement of 1-2 emerging motor skills in the home setting was a focus. At evaluation, outcome measures were performed as prioritized by the International Clinical Practice Guideline for Early Detection and Diagnosis of Cerebral Palsy and “High Risk for Cerebral Palsy”. The Hammersmith Infant Neurological Examination, Alberta Infant Motor Scale (AIMS), and Developmental Assessment of Young Children-2 were used for diagnostic confirmation. Standardized measures including the AIMS, Peabody Developmental Motor Scales-2 (PDMS-2), Gross Motor Function Measure-66 (GMFM-66), and Goal Attainment Scale (GAS) were used to establish baseline functional mobility levels, monitor progress, and direct plan of care.
OUTCOMES: Increased raw scores were noted in the AIMS, PDMS-2 (Stationary and Locomotion subscales), and GMFM-66. Clinically significant improvements were noted in parent-driven GAS goals including transitioning from sitting to supine and rolling independently (t-score change=24.8).
DISCUSSION: Improvements in raw scores of standardized developmental assessments, clinically significant improvements in GAS scores, and achievement of parent identified functional goals resulted from a brief and distinct episode of care using intensive clinical programming with a focus on parent education. This case report demonstrates successful and feasible translation of clinical research about developmentally responsive PT intervention using dosing recommendations from the best available evidence for an at-risk infant with an early CP diagnosis. This case also illustrates the possibility that emerging evidence regarding early, intensive PT intervention for at-risk infants can be integrated into hospital-based outpatient settings and may serve as a model for altering practice patterns, including clinical use of standardized and patient/family specific outcome measurement and developmental surveillance.
CLINICAL CHARACTERISTICS OF INFANTS WITH TORTICOLLIS WHO CHANGE PRESENTATION DURING AN EPISODE OF PHYSICAL THERAPY
Mischnick AK, Perry R, Greve KR
PURPOSE/HYPOTHESIS: Congenital muscular torticollis (CMT) is a musculoskeletal condition in infants. Typical CMT presentation is head tilt to one side and cervical rotation to the opposite side. Atypical CMT presentation is head tilt and cervical rotation to the same side. Infants who change tilt or rotation presentation during an episode of physical therapy have not been investigated. The purpose of this study was to describe infants with CMT who changed presentation during a course of physical therapy.
NUMBER OF SUBJECTS: From 2015-2018, 89 infants with CMT were identified with a change in presentation.
MATERIALS AND METHODS: Demographic and clinical characteristics were extracted retrospectively from electronic medical records. Variables included gender, ethnicity, race, age at CMT detection, age at physical therapy examination, birth history, positioning, presentation, type, CMT Classification Grade, cervical range of motion (ROM) and strength, head shape and physical therapy dose. Percentages were generated based on variable type.
RESULTS: Infants were 56% male, 96% non-Hispanic and 80% White. Birth history included 30% premature, 16% twin births, 33% Cesarean delivery, 9% Breech, 29% with reflux and 11% with constipation. Positioning equipment was used >6 hours per day (14%) and for daytime sleeping (49%). Torticollis was first noticed at 0-3 months (90%) in most infants. Age at examination included 0-3 months (59%), 4-6 months (35%) and >9-12 months (6%). Presentation at examination was Left (L) CMT (34%), Right (R) CMT (30%), R Atypical CMT (20%) and L Atypical CMT (16%). CMT Classification Grade included 1 (77%), 2 (13%), and >3 (10%). Baseline passive cervical ROM was limited by 0-5° (36%), 5-15° (47%), 15-30° (14%), and >30° (3%) with subgroups determined by cervical LF limitation in 34% of infants. Active cervical rotation was limited by a mean of 19°. Lateral flexion strength was asymmetrical in 64% of the infants, while 33% were symmetrical and 5% not assessed. Sixty-six percent had abnormal head shape. Physical therapists recommended weekly visits for 72% of infants with an average number of 7 (range 2-42) visits completed. Physical therapy included stretching, strengthening and symmetrical development (91%), kinesiotaping (6%) and myofascial release (3%). Seventy-three percent completed a physical therapy episode, and 27% were lost to follow up.
CONCLUSIONS: Three percent of infants with CMT change presentation during physical therapy and have 22% more atypical presentations and 5° less passive cervical ROM deficits than previously described in this physical therapy registry. Birth history, positioning and head shape may be factors. Infants with CMT who change presentation resolve symptoms with an episode of physical therapy.
CLINICAL RELEVANCE: Clinicians should be aware that infants with CMT can change presentation during physical therapy. Premature or twin births, reflux, constipation, positioning, CMT presentation and head shape are important at a physical therapy examination. Infants with CMT who change presentation should receive physical therapy.
VALIDATION OF A MEASURE OF CHANGE IN PROBLEM-SOLVING SKILLS IN INFANTS WITH MOTOR DELAYS
Molinini R, Inamdar K, Russell D, Tambellini Harbourne R, Westcott McCoy S, Koziol NA, Bovaird JA, Chapman Dusing S
PURPOSE/HYPOTHESIS: The purpose of this abstract is to validate The Assessment and Behavioral Coding of Early Problem-Solving (ABC-EPS) to identify change over time in infant motor-based problem-solving skills on a sample of children with mild, moderate and severe motor delays.
NUMBER OF SUBJECTS: 124 infants enrolled in the ongoing START-Play clinical trial with more than one ABC-EPS were included in this analysis (mild N=64, moderate N=32, and severe N=28). Participants were 7-16 months of age at baseline and had a motor delay of 1 or more SD below the mean on the Bayley. 113 subjects completed baseline and 3 month assessments and 66 completed the 12 month assessment.
MATERIALS AND METHODS: At each visit, the infant was videotaped interacting with 3 standardized toys for two minutes each in supported sitting. Using behavioral coding (Datavyu) we quantified the frequency count (FC) of each of 5 behaviors, including, from lowest to highest difficulty level: Look (gazes at toy), Simple Explore (manipulates toy to gather information about object properties), Complex Explore (manipulation related to the function of the toy), Function (completes one step of the toy's function), and Solution (solves the toy's function). Four-second interval (FI4) coding documented the highest-level behavior that occurred within every 4 second interval of the assessment. The scoring rubric allocated a weighting multiplier to each behavior based on its level of difficulty. Trajectory of the ABC_EPS from baseline to 12 mo was calculated using linear mixed modeling, first controlling for baseline age and severity, and then stratifying by severity.
RESULTS: FI4 standardized response means (SRM; ratio of mean change score and standard deviation) for the full sample analysis from baseline to 3 and 12 mo were 0.63 and 1.60, respectively. FI4 SRM at 3 and 12 mo per severity group were: mild=0.58 and 1.40, moderate=0.69 and 1.00, and severe=0.46 and 0.41. There was a significant quadratic trajectory for ABC_EPS FI4 scores over time (p=0.0266) such that the rate of increase in scores decreased over time. ABC_EPS FC scores demonstrated a positive linear trajectory over time (p<0.0001). ABC_EPS FC and FI4 scores had significant change over time in mild and moderate groups at 3 and 12 mo (<0.0001). FC yielded significant change for the severe group at 3 mo (p=0.02) and 12 mo (p=0.02). FI4 change over time was not significant for the severe group at 3 mo (p=0.12) or 12 mo (p=0.10).
CONCLUSIONS: The results of this validation study support the use of the ABC_EPS with the proposed weighting system to quantify change over time in children with motor impairment ages 7-17 months at baseline. Change was detected in the severe group with detailed frequency count coding rather than the frequency interval method of coding. However, the small sample combined with the slower rate of change in the severe group may have limited the detection of change over time in this subsample.
CLINICAL RELEVANCE: The ABC-EPS is a sensitive measure of change in motor-based problem solving in infants with motor delays or disabilities.
ANALYSIS OF PERCEIVED SOCIAL-EMOTIONAL BEHAVIORS IN TODDLERS WITH GASTROINTESTINAL DYSFUNCTION AND THEIR PARENT'S ANXIETY
Nelson HM, DeGrace B, Arnold SH, Kolobe TH
PURPOSE/HYPOTHESIS: Children with gastrointestinal disorders (GID) often display impaired social-emotional development and behaviors by the time they enter school. While social-emotional behaviors are formed based on relationships and interactions between infants/toddlers and caregivers, little is known about how early these behaviors are formed. The purpose of the study was to determine the social-emotional development (SE) of toddlers with GID and their relation to parent's anxiety levels. We hypothesized that: a) SE maladaptive behaviors form early during development b) Toddlers with gastrointestinal disorders will score lower than typically developing toddlers and have an increased likelihood of scoring below the 10 th percentile on the Infant Toddler Social Emotional Assessment (ITSEA), and c) Parents' anxiety level will be positively correlated with their toddlers' perceived social-emotional behaviors.
NUMBER OF SUBJECTS: 120 parents of toddlers, 12 to 35 months of age.
MATERIALS AND METHODS: A descriptive survey design was used with two groups: half of the toddlers were diagnosed with gastrointestinal disorders, and half were healthy. Parents completed two surveys, the ITSEA, to assess the child's social-emotional behaviors and the State-Trait Anxiety Inventory (STAI) to assess the parents' current and potential levels of anxiety. Both tools were completed at a single point in time, using hard copies or electronically. We used a t-test to determine differences between the groups, and Pearson r to examine the correlation between the parents and toddler scores.
RESULTS: Toddlers with gastrointestinal disorders scored lower than toddlers with typical development on three of the four domains of the ITSEA (Externalizing domain t=-1.364, p=0.175; Internalizing domain t=-21.042, p=0.000; Dysregulation domain t=-19.094, p=0.000; Competence domain t=4.503; p=0.000) and were more likely to score below the 10 th percentile (Externalizing domain chi-square=9.259, p=0.002; Internalizing domain chi-square = 105.00, p=0.000; Dysregulation domain chi-square=97.634, p=0.000; Competence domain chi-square=97.634, p=0.000). The correlations coefficients of anxiety scores of parents of typically developing toddlers and their child's perceived social-emotional development were low and not statistically significant (Externalizing domain r=1.22, p=0.353; Internalizing domain r=0.085, p=0.518; Dysregulation domain r=-0.118, p=0.369; Competence domain r=-0.050, p=0.703).
CONCLUSIONS: Toddlers with gastrointestinal disorders are perceived by their parents to display social emotional problems. Our findings suggest that the maladaptive behaviors are already formed by the toddlerhood stage. The low correlation between the parents' anxiety levels and their children's behavior is inconsistent with previous findings with older children and may suggest that parents are more accommodating of their young children's maladaptive behaviors at this age.
CLINICAL RELEVANCE: These findings underscore the need for therapists to screen for GID in children referred for maladaptive behaviors and developmental delays and make appropriate referrals. Previous studies have shown that GID in children have a negative impact on the development, including malnutrition and growth delays. These children may present to therapists with developmental delays.
CONGENITAL MUSCULAR TORTICOLLIS: PARENT EXPERIENCES WITH DIAGNOSIS AND INTERVENTION
Oledzka MM, Sweeney JK, Evans-Rogers DL, Kaplan SL, Coulter CP
PURPOSE/HYPOTHESIS: The primary purpose of this study was to investigate, analyze and describe the experiences of parents of infants diagnosed with congenital muscular torticollis (CMT). A secondary purpose was to compare the experiences of parents of infants with mild grades versus severe grades of involvement based on the CMT severity classification system (CMT-SCS)
NUMBER OF SUBJECTS: 12
MATERIALS AND METHODS: Through semi-structured interviews, a qualitative phenomenological approach of inquiry was used to investigate the lived experiences of the parents. Twelve parents of infants with CMT participated; six parents of infants with mild CMT and six parents of infants with severe CMT.
RESULTS: Eight themes common to both groups of parents were identified. Findings indicated having an infant with CMT has a significant impact on the parents and other caregivers. Three themes were unique to parents of the infants with severe CMT
CONCLUSIONS: As parents face the excitement and challenges of welcoming an infant to the family, they are faced with a diagnosis that requires regular therapy visits and an addition of a daily home activity program into routine caregiving. Physical therapists play an essential role in shaping the parents' experiences. Parents highly value therapists' professionalism, expertise, and ongoing support.
CLINICAL RELEVANCE: The findings from this investigation provide insight into the parental experience of having a child with CMT. Parents of infants diagnosed with CMT experience additional stress from the diagnosis and ongoing physical therapy treatment in addition to the usual stressors experienced by parents of healthy infants. Pediatric physical therapists provide expert guidance for the family while they are dealing with the diagnosis and treatment of CMT.
FEASIBILITY AND EFFECTIVENESS OF A HOME STRENGTHENING PROGRAM WITH NMES TO IMPROVE GAIT EFFICIENCY
Oreel Kerr L, Mueth LJ, Sweetland AE, Thiede NL, Morrison DE, Jahnke CR, Wiseman TM
BACKGROUND AND PURPOSE: The purpose of this study was to incorporate a home exercise program for strengthening with the use of a wireless bluetooth app for neuromuscular electrical stimulation (NMES) in order to improve functional movements and quality of life for individuals with cerebral palsy. The utilization of NMES to enhance a strengthening program is well documented throughout the literature across multiple medical diagnosis. However, there is limited research on the benefits, compliance and feasibility of a home program utilizing a wireless device for NMES.
CASE DESCRIPTION: In this comparative case study the participants were a 10-year-old female, GMFCS level II and 12-year-old male, GMFCS level III. Both diagnosed with spastic cerebral palsy. Participants were asked to complete a NMES home exercise program 6 days per week x 6 weeks using a bewell connect wireless unit and app program. The app program provide detail instruction for electrode placement, and documented total usage time. Each participant came to the clinic for a interventions session 1 time per week. During the physical therapy sessions participants completed 30 minutes of retrowalking on treadmill, and demonstrated their home exercises. (hamstring curls, glute squeezes, and sit to stands with NMES)
OUTCOMES: Outcome measures included both objective and subjective assessments. Objective assessment tools were administered pre and post intervention. The objective assessments include: the Gross Motor Function Measure (GMFM)-88, 6-minute walk test(6MWT), 5 times sit to stand(5xSTS), and Timed Up and Go (TUG). Subjective data was collected from the caregivers involved in the study. They documented reflections daily on compliance and feasibility of the home program and completed an exit interview with the primary investigator.
DISCUSSION: The 10-year-old participant had improvements in her GMFM (increased score 2.84%), TUG (decreased time by 13.4%). She able to perform the 6MWT with a single cane as opposed to the original testing with bilateral canes, however her overall score on the 6MWT decreased by 59.2 ft. She did not improve on her overall 5xSTS (increased time by 7.7%). Her caregiver reported a “88% compliance rate with the home program”. She also stated “it was easy to use however her child had little motivation to become independent with her exercises at home and it became time consuming to complete”. The 12-year-old participant showed improvements in his 6MWT (226 ft greater distance), TUG (by 6.5%), and GMFM (4.52%). He did not improve in the 5xSTS (increased time by 7.93 sec), however he was able to complete sit to stand without upper extremity support and improved quality of movement post the intervention. His caregiver reported a “100% compliance rate and noted an increase in independence with the home program.” The participant stated “he could feel himself getting stronger and asked to continue the home program after the study had concluded”. These findings indicate that involving a home exercise plan focusing on the use of a wireless NMES unit is both effective and feasible in children with spastic cerebral palsy. The convenience of the wireless NMES unit and app allowed the caregiver to provide a quality treatment at an intensity and frequency level to resulted in improvements in multiple objective measures indicating an overall progression in strength and endurance with functional movements.
THE IMPACT OF BEING OVERWEIGHT AND OBESE ON POSTURAL CONTROL IN CHILDREN: A SYSTEMATIC REVIEW
Pathare N, Barnes E, Kiak S, Lafiandra A
PURPOSE/HYPOTHESIS: Childhood obesity continues to be a global health concern with astounding health care costs. Given the impact of obesity on postural control in children, a detailed synthesis of the current literature is important. Our purpose was to comprehensively review literature on postural control and balance in children that are overweight (OW) and obese (OB). We hypothesized that there will be impaired postural control and balance in children who are OB/OW when compared to their healthy weight (HW) peers.
NUMBER OF SUBJECTS: In total, data was extracted from 1,207 participants (mean age: 10.8 y; BMI range: 16.0 ± 1.2 to 28.8 ± 4.9 kg/m2).
MATERIALS AND METHODS: To conduct this systematic review, Medline and CINAHL databases were screened for articles in July 2018 using PRISMA guidelines. 2 The search phrases utilized were: (“pediatric obesity” or “childhood obesity”) or (“child” AND “overweight or obese”)) AND (“postur*” or “balance”). Inclusion criteria were: 5-15 y, English language, published after 2007, anthropometric measurements, postural control or balance outcome measures, and inclusion of a HW group. Articles were evaluated for eligibility by 4 independent reviewers and were further assessed using a Physiotherapy Evidence Database (PEDro) score.
RESULTS: Ten articles (out of 810 articles) were deemed eligible. Appraised articles ranged from poor to fair in quality (PEDro scores: 3/10 – 5/10). Study designs included in the review were: cross-sectional designs (n = 7), quasi-experimental (n = 2) and randomized controlled trials (n = 1). Significant differences in postural control and balance, when comparing OB/OW groups to HW group, were noted (n = 7). Alteration of visual input and sensory conditions revealed greater differences in BMI groups (n = 3). Out of the five studies that solely used motor tests, 4 studies reported significant differences in BMI groups. Associations with age (n = 2) and gender (n = 3) attributed to variations in findings across the BMI groups.
CONCLUSIONS: This review suggests that children (5-15 y) who are OW and OB may have impaired postural control and balance when compared to children who are HW. Differences in postural control and balance between the BMI groups can be attributed to alterations in base of support, postural control strategies, lower extremity strength, eccentric control, lower extremity joint stiffness, and flattened medial-lateral arches.3-6 Specifically, a greater dependency on visual and sensory inputs was noted in children who are OW/OB compared to their HW peers.7 Limitations included a wide age range, low PEDro scores, varied outcome measures and lack of comparisons between OW and OB groups. More research with rigorous research designs and consistent outcome measures is needed.
CLINICAL RELEVANCE: The current review provides physical therapists with valuable information that can help guide treatment plans and patient education for children who are OW/OB.
CHANGES IN FUNCTIONAL MOBILITY IN CHILDREN AFTER A SELECTIVE DORSAL RHIZOTOMY: A SYSTEMATIC REVIEW
Patton M, Gosselin DJ, Chandler LE
PURPOSE/HYPOTHESIS: The purpose of this study is to systematically review the current literature that evaluates the efficacy of selective dorsal rhizotomy (SDR) on long term functional changes in children with spastic cerebral palsy (CP).
NUMBER OF SUBJECTS: Primary research studies, conducted after 1995, investigating the effects of SDR on GMFM scores, as a primary outcome measure, in children formally diagnosed with spastic CP. Children included in the studies were between 2-18 years old with GMFCS levels ranging from 1-5. 13 studies total were included in this systematic review.
MATERIALS AND METHODS: A systematic review was carried out using the following databases: PUBMED, SCOPUS, and CINAHL. Two independent reviewers determined whether studies met the established inclusion criteria. The inclusion criteria were as follows 1) the study was primary research directly investigating the efficacy of SDR as an intervention and using the GMFM as an outcome measure; 2) the study evaluated GMFM scores at least 12 months post-SDR with baseline scores taken before the SDR 3) the article used a participant group diagnosed with spastic cerebral palsy; and 4) the study utilized GMFM score and GMFCS level in their outcomes assessment.
RESULTS: When comparing post-procedure GMFM scores over time to expected changes from natural history within a 12 month period the SDR widely fell within a non-effect of improving functional outcomes. Furthermore, five-years post-SDR a non-effect of GMFM improvements is seen with an SDR as compared to natural history.
CONCLUSIONS: The published treatment effects of an SDR procedure has a non-effect on functional mobility in children diagnosed with spastic cerebral palsy when compared to expected natural history in both the short term and in the long-termfollow-up.
CLINICAL RELEVANCE: Valid and reliable analysis of the published effects of an SDR on functional mobility determined by GMFM scores and the comparison of changes seen with intervention to expected natural history. This paper also highlights the gaps in current research regarding SDR efficacy as an intervention in children with spastic CP.
ADAPTIVE BEHAVIOR IN INFANTS WITH NEUROMOTOR DELAY
Paulson ML, Hsu LY, Harbourne RT, Dusing SC, Lobo MA, McCoy SW
PURPOSE/HYPOTHESIS: Adaptive behavior (AB) is a “collection of conceptual, social, and practical skills that are learned and performed by people in their everyday lives”. AB encompasses the ability to be persistent in a task, have preferences for a difficult task, and have motivation in free play, all of which are decreased for children with disabilities. AB has been shown to be predictive of gross motor, self-care, and participation in recreation and leisure activities in young children with cerebral palsy. There is limited research describing AB in young children and infants, specifically those with neuromotor delays. Our purposes were to describe AB in infants with neuromotor delays and to examine the relationship between AB and motor function.
NUMBER OF SUBJECTS: As a part of a study entitled “START-Play”, 25 infants with neuromotor delay (corrected age 7- 16 months), who were at least 1.0 SD below the mean on the Bayley Scale of Infant Development-III (Bayley-III) motor scale and their parents.
MATERIALS AND METHODS: Parents of all children completed the Bayley-III Adaptive Behavior Questionnaire for infants' adaptive behavior. The Bayley-III was used to examine infant's gross and fine motor function. The Bayley-III Adaptive Behavior questionnaire contains domains of communication (Com), community use (CU), functional pre-academics (FA), home living (HL), health and safety (HS), leisure (LS), self-care (SC), self-direction (SD), social (SoC), motor (MO) and general adaptive composite scores (GAC). Lower scores represent more problematic behaviors in the testing domain. Infant's AB scores were compared with normative data from test developers. Spearman Correlation was used to determine if there was a correlation between Bayley-III Adaptive Behavior questionnaire GAC and Bayley-III motor scores.
RESULTS: Compared to normative data, infants with neuromotor delay showed more problematic behaviors (>+1 SD) in HL, SC, and MO, and in overall scores (mean: HL=6.50; SC=5.04; MO=4.60; total score=70.20). Examination of results within the infants showed that more than 50% of children had some problems in FA(60%), HL(80%), HS(52%), SC(84%), SoC(56%), MO(84%) and GAC(76%). The relationship between Bayley-III GAC scores and Bayley-III motor scale scores was moderate (r=-0.48, p=0.05).
CONCLUSIONS: Results suggest that infants with neuromotor delay showed some limitations with adaptive behavior, especially with home living, self-care, and motor domains. More than 50% had some difficulties with health and safety, self-care, and motor domains of AB. Infants who had more difficulties in motor function also in general had more problems in adaptive behavior.
CLINICAL RELEVANCE: The Bayley-III Adaptive Behavior Questionnaire can provide valuable information about AB in infants. It can be helpful for identification of AB limitations that affect young children's participation in daily life. Based on the study results, therapists should examine AB abilities in infants with neuromotor delays in order to incorporate interventions focused on AB and potentially decrease the gap seen with peers who are typically developing.
PRACTICING PHYSICAL THERAPIST INTERVENTION RECOMMENDATIONS COMPARED TO STANDARD OF CARE GUIDELINES FOR SPINAL MUSCULAR ATROPHY
Peterson A, Roback K, Brugman J, Trenkle JM, Krosschell KJ
PURPOSE/HYPOTHESIS: Spinal Muscular Atrophy (SMA) is an autosomal recessive genetic disorder that results in weakness and decreased function and presents with phenotypic variation impacting prognosis. Medical care for those with SMA has changed significantly as disease-modifying therapies (DMT) have impacted prognosis and functional outcomes. Therefore, identifying current physical therapist (PT) practice patterns to optimize education of peer professionals and best care for patients is critical. This survey examined current PT practice alignment with standard of care (SOC) guidelines, and barriers and facilitators to care. We hypothesized that practice recommendations would vary from SOC guidelines and would also vary based on familiarity with SOC and after DMT.
NUMBER OF SUBJECTS: 153
MATERIALS AND METHODS: A REDCap cross-sectional survey was distributed to pediatric PTs by e-blast and public posting on PT and SMA related websites to recruit pediatric PTs working with patients with SMA. Demographics, knowledge of SOC, implementation of interventions, and barriers and facilitators to successful application were captured. Practicing PT recommendations for strengthening, aerobic exercise, stretching, standing, and balance were compared to SOC guidelines. Completed survey data was analyzed using descriptive analysis, chi-square, binomial tests and correlations (SPSS 20) to examine factors associated with therapy provision and facilitators and barriers associated with implementation.
RESULTS: Of 356 respondents, 190 completed surveys, with 156 reporting direct care of those with SMA. State of practice, years in practice, education, and practice setting varied, with more PT's working in the Midwest and treating children in outpatient settings. More than half were familiar with SOC guidelines and familiarity was associated with change in practice (p=.001), with 98% reporting an influence on their practice choices. The majority of PTs recommend interventions across 5 categories (strengthening, aerobic exercise, stretching, standing, and balance) discussed in the SOC, with some variation in intervention parameters as compared to SOC. With DMT, more PTs report changing strengthening, aerobic, standing and balance parameters with less describing changes in stretching. Key barriers and facilitators to SOC implementation were identified.
CONCLUSIONS: Common PT recommendations for the 5 interventions are generally in line with SOC guidelines, but more education is needed on specific parameters. Familiarity with SOC significantly influences plan of care and DMT impacts PT practice recommendations. The most common barrier and facilitator to PT progress are medical status and caregiver support, respectively.
CLINICAL RELEVANCE: This data provides a rich resource on how PTs implement the 5 discussed interventions into their plan of care and how these parameters match or vary from SOC guidelines. With improved prognosis due to DMT, understanding barriers and facilitators to PT progress is crucial. This information can guide educational initiatives for therapists as well as further inform SOC and best-practice rehabilitation management.
PARENT PERCEPTIONS AND EXPERIENCES REGARDING THEIR CHILD'S USE OF MODIFIED RIDE-ON CARS
Pfaff JP, Jeffries LM
PURPOSE/HYPOTHESIS: Children's self-directed mobility allows for advancements in cognition, socialization, emotional development, and language skills. Therapists frequently recommend modified ride-on car's (MROC) to promote self-directed mobility and exploration for infants and toddlers with mobility limitations. The purpose of this study was to describe the parents' experiences and perceptions regarding their child's use of a MROC to better understand what factors influence the use of MROCs.
NUMBER OF SUBJECTS: Ten parents of children with limited mobility.
MATERIALS AND METHODS: This study implemented a qualitative phenomenological approach using structured interview questions. Three parents participated in an in-person focus group and seven other parents participated in individual interviews via phone. Following verbatim transcription, researchers coded transcripts, meeting to create codes, followed by categories, and finally themes. To provide credibility and support trustworthiness, two parents reviewed their interview transcription for accuracy and clarity. Researchers triangulated data through the convergence of information from different sources to validate the study.
RESULTS: While the experiences of each parent was unique, three themes emerged that appeared to influence the experiences of all of the parents. The identified themes were: (a) environment, (b) challenges, (c) impact. The environment theme included inside space, outside space, and weather which all affected their child's use of the MROC. The challenges theme focused on the families struggles related to the physical components, modifications, and transportation of the MROCs. The impact theme described how the MROCs allowed families the opportunity to see their child's enjoyment and their children's ability to experience greater opportunities for participation in the home and community.
CONCLUSIONS: This study illuminates that families whose children use MROCs often have shared experiences related to environment, challenges, and opportunities. The stories families shared illustrate that the MROCs are enjoyable and provide an outlet for children and families to experience movement opportunities while also presenting some modifiable and non-modifiable challenges.
CLINICAL RELEVANCE: MROCs provide children the opportunity for self-propelled mobility. However, before therapists provide a car, they should consider the family's living environment, including physical home design, neighborhood, and city in which the family resides and the families means of transporting the MROC. Using this information, therapists can offer suggestions and ideas for places in the local community where families can take the MROC. Therapists should also carefully consider the steering mechanism during the MROC build and potentially the MROC speed. Once the family has a MROC, therapists should continue to be involved by asking questions, providing resources, and connecting families together who have MROCs to ensure the family experiences success and enjoyment with their children's use of a MROC.
RECOGNIZING AND COMMUNICATING THE ATYPICAL IN PEDIATRIC PHYSICAL THERAPY: A CASE STUDY
Phipps AJ, Tzagournis Wendland M
BACKGROUND AND PURPOSE: Pediatric physical therapists have a unique role and opportunity to witness growth and development in their patients. While physicians complete medical examinations, which may only last 15 minutes every 3-6 months, therapists tend to have more frequent and in-depth encounters allowing for time to explore and attend to all underlying concerns (including those of the parents). As there is an inherent variation in typical development due to biological, environmental and social factors, being able to use an evidence-based approach to discern movement abnormalities as a red flag is of paramount importance. The purpose of this case study is to demonstrate the importance of early identification of movement abnormalities and how crucial it is to communicate these concerns to the physician, which for this infant, led to diagnosis and treatment of Opsoclonus-Myoclonus and associated neuroblastoma.
CASE DESCRIPTION: 17 month old male (corrected age 15 months) referred by pediatric neurology to outpatient PT with developmental delay, ataxia, spasmodic torticollis and nystagmus. Parent reported primary concern as frequent loss of balance which they thought to be progressive. Prior to outpatient PT, patient had received brain MRI which suggested mild periventricular leukomalacia (PVL). Therapist concerned about ataxia and nystagmus at evaluation as not typically noted in patients with PVL or infants with prematurity.
OUTCOMES: The pediatric physical therapist communicated initial concerns to pediatrician and neurologist. One month after initiation of therapy, therapist noted continued progressive ataxia with posterior loss of balance in “W” sitting position. Therapist sent an urgent message to neurologist and pediatrician, which resulted in an inpatient hospital stay and diagnostic testing. Patient diagnosed with Opsoclonus-Myoclonus and associated Neuroblastoma. Due to continued physical therapy and fast action by the healthcare team to initiate proper treatment to address the tumor, the patient is currently in remission and was ambulating independently with minimal ataxia at 21 months of age.
DISCUSSION: There is a paucity of research discussing therapist-physician communication with regards to early diagnosis and treatment of cancer and other progressive disorders. And while there has been a recent shift where physical therapists are receiving a greater amount of early referrals for infants with motor abnormalities, physical therapists have a duty to refer back or seek out consultation when the identified problems do not align with the referring diagnosis. It is imperative that therapists are educated not only in pathophysiology but also taught how to professionally and effectively communicate with doctors and other health care professionals.
PARENT PERCEPTIONS OF AN EARLY PARTICIPATION EXPERIENCE IN YOUNG CHILDREN WITH DISABILITIES: AQUATIC VS LAND
Price JL, Oriel KN, Burns DM, Fiedler KG, Kelley AL, Roca KA
PURPOSE/HYPOTHESIS: Early participation in community-based activities provides young children with disabilities an opportunity for both physical activity and social interaction. Given the many demands of raising a child with a disability, parents must make choices regarding community-based participation. While aquatic exercise is often encouraged in young children with disabilities, parent perceptions of such programs have not been studied. Additionally, there are no studies that have explored the differences between aquatic verses general land-based physical activity programs in young children with disabilities. The purpose of this study was to analyze parent perceptions of the impact of an aquatic and land activity program as an early participation opportunity in young children with physical disabilities.
NUMBER OF SUBJECTS: 10 participants, aged 15 months to 4 years, who were receiving early intervention therapy services, participated in the student-led community based program.
MATERIALS AND METHODS: Participants enrolled in Early Intervention were recruited for participation in a 1x/week exercise program for 8 weeks. The first four weeks were held in a pool, followed by four weeks on land. Both the aquatic and land-based program were designed to encourage physical activity and social interaction. Parent perceptions were measured through the use of semi-structured interviews prior to the beginning of the program, following the aquatics portion, and following the land based portion. The IRP-15 was also utilized following the aquatics portion, and following the land based portion to objectively measure social validity.
RESULTS: All 10 participants completed the first 4 weeks of aquatic exercise, while 7 completed the land-based program. The majority of parents identified improvement of motor skills as their primary goal of participation. Following both the aquatics portion of the program and the land-based portion, the majority of parents identified improved social skills as the area where they saw the most improvement in their child. The parents of children with greater physical involvement did note improved gross motor skills as well, especially those children who were new walkers. While parents identified areas of improvement following both portions of the program, the majority preferred the aquatics portion and desired a longer time frame for pool activities. Only one parent preferred the land-based program because they found the skills to be more functional. Scores of the IRP-15 were above the cut-score for an acceptable intervention for both the aquatic and land-based portion of the program.
CONCLUSIONS: Overall, parents found both aquatic and land-based exercise to be beneficial, not just for their own child's development, but also as a means to connect to other parents who are facing the same challenges with their child.
CLINICAL RELEVANCE: The results of this study suggest that parents of children with disabilities prefer aquatic exercise to traditional land-based activity. This should be considered as pediatric physical therapists develop community-based programs, and when they recommend programs to families.
SACRAL OSTEOMYELITIS IN A HIGH SCHOOL RUNNER PRESENTING AS LOW BACK PAIN WITH SCIATICA
Purcell NK, Saloom AD, Chorley J
BACKGROUND AND PURPOSE: Low back pain is one of the most common musculoskeletal complaints in adolescents participating in sports. As physical therapists it is within our scope to rule out systemic pathology in order to ensure patients are appropriate for treatment. This case study presents an unusual cause of low back pain with sciatica that was ultimately diagnosed as hematogenous sacral osteomyelitis with successful resolution of the infection and return to sport.
CASE DESCRIPTION: A 15-year-old female experienced sudden onset of left sided low back and buttock pain after completing track practice on a Monday. She participates in track and basketball regularly and denies any specific mechanism of injury that caused her symptoms. Her pain did not improve with manipulation and stretching from the school athletic trainer and she was referred to a sports MD for evaluation three days after onset of pain. She presented with 9/10 pain during prolonged sitting in the car, walking, and bending. Fever, night sweats, weight change, and excess fatigue were not present at the time of evaluation by the sports MD.
OUTCOMES: Evaluation revealed tenderness to palpation at left sacral base, PSIS, and piriformis muscle. Hip passive range of motion was normal bilaterally. Lumbar active range of motion was painful at 30° of flexion, 15° of extension, 10° of rotation, and 20° of side bending bilaterally. Myotomes, dermatomes, reflexes, and lumbar/pelvis radiographs were normal and she was referred to physical therapy. Following a PT evaluation, she was prescribed a walker due to severe pain with walking and then scheduled for follow-up one week later. Shortly after the initial PT evaluation the patient's pain worsened significantly and she developed a fever resulting in an emergency room visit and admission to the hospital. MRI revealed osteomyelitis of left sacrum with edema surrounding left sciatic nerve and lab values indicating bacteremia. She received IV antibiotics and was monitored in the hospital for eight days. Following hospital discharge, she reported to outpatient PT with poor single leg stability due to severe left sided weakness of glute and hamstring. PT consisted of neural flossing and lumbar exercises to reduce nerve pain with progressive strengthening exercises to address left lower extremity weakness. The patient attended outpatient sports physical therapy twice a week over six weeks to return to running and basketball.
DISCUSSION: Osteomyelitis is a rare but serious condition that should be considered by physical therapists. As more PTs are working in a primary care role for musculoskeletal pain it is important to rule out serious pathology that is outside our scope of practice and refer when necessary. The physical therapy evaluation must contain specific questions to rule out systemic causes of pain along with vital signs such as body temperature and blood pressure. This case demonstrates the progression of osteomyelitis in an adolescent athlete and will help physical therapists better understand the signs, symptoms, treatment, and return to sport progression for this serious condition.
IMPACT OF CYBERCYCLING BREAKS FOR CHILDREN WITH AUTISM SPECTRUM DISORDER ON HEALTH AND CLASSROOM BEHAVIORS
Reelfs HK, Saxton T, Eckstein A, Cox J, Kupzyk S, Kupzyk K
PURPOSE/HYPOTHESIS: Children with Autism Spectrum Disorder (ASD) are less likely to engage in physical activity and are at higher risk for obesity than children without a developmental disability.1 Exercise has been associated with decreased stereotypy and increased on-task behaviors in children with ASD.2 Students with behavioral health disorders participating in a cybercycling program at a therapeutic school had better self-regulation and spent less time out of class.3 The purpose of this study was to examine the effects of a cybercycling program on health and behavioral outcomes for students with ASD in a typical school setting. We hypothesized that students with ASD would be more academically engaged and show less stereotypy following cycling and have improved health outcomes.
NUMBER OF SUBJECTS: 13
MATERIALS AND METHODS: Students, ages 9-14 years, with a diagnosis or educational verification of ASD at three elementary and one middle school were enrolled. Students completed a 15-minute training protocol on a stationary bicycle with gaming functions three times per week for six weeks. Teachers and researchers completed 30-minutes of direct classroom observations immediately after cycling. Health measures included: cycling data (time, power, distance, heart rate), perceived rate of exertion (PRE), and pre-post Progressive Aerobic Cardiovascular Endurance Run (PACER). Students completed the Child Intervention Rating Profile (CIRP).
RESULTS: Nonparametric Wilcoxon Signed Rank Test showed no significant differences between ride and non-ride days for academic engagement or stereotypy. However, teacher ratings of academic engagement were approaching significance (p=0.062), indicating higher engagement on ride days. The remaining mean differences were in the expected direction, (higher engagement and lower stereotypy on ride days). Six of 11 students increased the laps run at the PACER post-test. Students rode for an average of 14:33 min. Power, cadence, and distance showed little change over the intervention period. Correlation between PRE and heart rate was low (0.2). Heart rates were within their target zones. The CIRP average score was 4.6 out of 5.
CONCLUSIONS: Change in mean for engagement and stereotypy were in the expected directions for researcher and teacher observations. All students scored below the expected minimum level of fitness on the PACER, suggesting the need for increased physical activity in students with ASD. Cybercycling appears to an acceptable intervention based on survey results. Students used most of the ride time available; there were no adverse effects. Heart rate monitoring for activity intensity was useful as students were poor reporters of PRE.
CLINICAL RELEVANCE: This study explored the feasibility of incorporating sustained aerobic exercise within a typical school day to improve classroom behaviors and health outcomes. Cybercycling for breaks in place of sedentary activities can be considered as it is generally enjoyed by students and provides opportunity for physical activity. Longer intervention periods may lead to greater health outcomes.
RELIABILITY OF ARCH HEIGHT INDEX AS A FOOT MEASURE IN CHILDREN AGES 1-7 YEARS
Renner TA, Donahoe-Fillmore BK, White JR, Durisek KM, Rushing AE
PURPOSE/HYPOTHESIS: An objective assessment of an abnormally flat foot in the young pediatric population is needed. Current literature includes a single study investigating the reliability of the Arch Height Index (AHI) in children ages 6-12. We aim to determine the reliability of the AHI in toddler, preschool and early school aged children when many children are conservatively treated with bracing and orthotics off of subjective examination. Further, we hypothesize the AHI to have good inter-rater and test re-test reliability in preschool aged children.
NUMBER OF SUBJECTS: 30 ambulatory participants (n= 60 feet) ages 1-7 years recruited from a local daycare, preschool and school. An a priori power analysis determined a sample size for α = 0.05 and β ≤ 0.2 to be n = 60 feet. 15 children ages 1-3 years and 15 children ages 4-7 years were included.
MATERIALS AND METHODS: Subjects were screened for foot pain, foot surgeries, gross motor delay, and use of orthotics or assistive device through a parent questionnaire. Height and weight measurements were taken. The Observational Gait Scale was utilized and resting calcaneal stance position (RCSP) and forefoot to rearfoot position (FF-RF) were noted. Two investigators independently measured total foot length, truncated foot length, and the height of the dorsum of the foot at 50% of total foot length with subjects seated with back support and hips, knees and ankles flexed to 90 degrees resting in the AHI tool. The tool was reset and all measurements were repeated with the subject standing. A second trial was completed by each investigator. The arch height index was calculated by dividing the height of the dorsum of the foot at 50% of foot length by truncated foot length.
RESULTS: Descriptive statistics including AHI mean and standard deviation for seated and standing were separated by age and BMI. A two-way random effect model was utilized to determine the ICC with absolute agreement. The intra-rater and inter-rater reliability had an ICC ≥0.76 in the 4-7 age range. Data from the participant questionnaire found no trends secondary to pain, foot surgery, or gross motor delay within our data.
CONCLUSIONS: We found the AHI to have good inter-rater and test re-test reliability in the children ages 4-7. Preschool and school age children were cooperative for the data collection. The time required to take the measurements was difficult for the daycare children. No trends were identified in the sample related to foot pain, surgery or gross motor delay; all of which have not been previously reported. More research is needed to understand how the AHI can be applied to various involved populations.
CLINICAL RELEVANCE: The AHI tool may be clinically useful and reliable in younger children. We need objective and reliable measurements to track longitudinal changes in the young child's foot as it develops and for prompt intervention if there is a need. More research is needed to determine the role of the AHI as a clinical tool to measure foot structure in young children.
EFFECTS OF ACHILLES KIDS' RUN TO LEARN SCHOOL BASED PROGRAM ON CHILDREN WITH AUTISM
Ronan SL, Probish Dolot J
PURPOSE/HYPOTHESIS: To examine the effect of participation in the Achilles' Kids school-based Run to Learn program on fitness and social behaviors for children with autism.
NUMBER OF SUBJECTS: 94 students with autism, aged 5-14 years, attending public schools in New York City.
MATERIALS AND METHODS: The Achilles Kids Run to Learn program is a school-based program where children run, walk or roll during two physical education classes per week during the school year. The goal of the program is for students to complete a “virtual marathon” over the course of the school year. The physical education (PE) or adaptive PE teacher records the distances. After obtaining New York City Department of Education institutional review board approval, schools were approached for participation in the study. Students with autism were recruited from schools that were using the Run to Learn program in their physical education classes. Autism severity was measured with the Gilliam Autism Rating Scale-3 (GARS-3)). Outcome measures included autism behaviors (Social Responsiveness Scale-2 (SRS-2)), and fitness markers (6-minute walk test (6MWT), energy expenditure index (EEI)). Comparisons were made at baseline and after four months of program participation.
RESULTS: 94 students (80 males (85.1%), 14 females) from four schools participated in the program and provided data points at baseline and four months. 39.4% of the sample identified as Hispanic, 29.6% as African-American, 22.5% as Asian, and 8.4% as other. Not all students provided all data points, resulting in variable sample sizes for each outcome variable. 29 students provided GARS-2 data. The GARS-2 data indicated that 86.2% of students required at least moderate support at school due to autism symptoms. 6MWT scores improved significantly at four months (n=40) and met the criteria for minimally clinically important difference. EEI scores (n=10) did not change significantly at four months. Total and sub-scale SRS-2 scores improved significantly (n=18) at four months.
CONCLUSIONS: The findings are consistent with previous literature examining the benefits of fitness programs for persons with autism and offer initial support of the effectiveness of the school-based Achilles Kids' Run to Learn program for children with autism attending public school in an urban environment. Limitations include an inability to account for the effects of concurrent therapies and medications, and that not all participants provided data for all measures at each time point. This is not uncommon for projects investigating the effects of exercise programs on children with autism.
CLINICAL RELEVANCE: This study provides initial support for the use of school-based running and walking to improve fitness, communication and social skills for children with autism. Access to community-based fitness programs can be challenging for students. The Achilles Run to Learn school-based walking/running program may be effective at providing activity in an urban school setting that results in improved social/communication and fitness for students with autism.
ASSOCIATION BETWEEN THE QUALITY OF CAREGIVER-INFANT INTERACTION AND THE ADHERENCE TO A CAREGIVER PROVIDED INTERVENTION
Rosales MR, Deng W, Smith BA
PURPOSE/HYPOTHESIS: Early and intense intervention for infants at risk of developmental disabilities is proposed to be more effective at producing optimal neuromotor structure and function compared to standard care. One strategy for implementing these early interventions is to have the caregiver of the infant provide the intervention. Therefore, an important and understudied variable that could impact the effectiveness of a caregiver provided intervention is the quality of the interaction between a caregiver and their infant. Here we test the hypothesis that there is a positive correlation between the quality of caregiver-infant interaction and the adherence to a caregiver provided intervention.
NUMBER OF SUBJECTS: 6
MATERIALS AND METHODS: Six infants at risk of developmental delays (4 male, median adjusted age at first visit: 194 days) and their caregivers were assessed once a month. At each visit, quality of caregiver-infant interaction was measured using the NCAST-Teaching assessment. Next, a physical therapist worked with caregivers to determine a daily exercise program based on the principles of the GAME protocol. The caregiver and physical therapist decided each month on 2 exercises, 3-5 times each day, 3-5 minutes each exercise. Caregivers kept track of adherence in logbooks. Adherence of the prescribed intervention was quantified using a percentage, calculated by dividing the amount of time the participant completed by the amount of time prescribed. Spearman correlations were used to assess the association between average quality of interaction and the average adherence.
RESULTS: Results showed all of the caregivers and infants scored within the normal ranges for caregiver-child interaction according to the NCAST norms (Range of caregiver-infant sub-scale total: 45-53). Additionally, adherence to the intervention was 127% on average (Range: 53-267%). Lastly, results from the spearman correlations showed that there was no statistically significant association between the quality of caregiver-child interaction and adherence to the intervention (r=0.086, p=0.872).
CONCLUSIONS: In summary, there was no significant association between quality of caregiver-infant interaction and adherence to the caregiver implemented intervention in this preliminary analysis of a small sample from an ongoing study. Further, descriptive statistics of our sample showed that the caregivers and infants had a fairly narrow range of quality of interaction scores in the typical range. Further studies should explore whether an association exists between quality of interaction and adherence in a larger, more diverse sample.
CLINICAL RELEVANCE: Results showed that dyads with average quality of interaction adhere to a caregiver provided intervention similarly. Whether or not caregiver-infant dyads with poor quality interaction adhere similarly remains unknown.
A PROSPECTIVE, ONE-YEAR, COHORT STUDY OF MOTOR FUNCTION IN INDIVIDUALS WITH HNRNPH2-RELATED DISORDERS
Salazar R, Beenders SM, LaMarca NM, Bain J
PURPOSE/HYPOTHESIS: Heterogeneous Nuclear Ribonucleoprotein H2 (HNRNPH2) belongs to a group of RNA binding proteins that work as a shuttle between the nucleus and cytoplasm. The HNRNPH2 gene is located on the X chromosome and female probands with a variant in this gene present with neurodevelopmental features including developmental delay, intellectual disability and autism spectrum disorder.1 The purpose of this study is to describe the one-year natural history of gross motor skill development and function2,3 in participants with HNRNPH2-related disorder using the Gross Motor Function Measure-88 (GMFM-88) total score4 and the Pediatric Evaluation of Disability Inventory-Computer Adaptive Test (PEDI-CAT)5 mobility domain score. Although some individuals with HNRNPH2 report a developmental regression in infancy, our hypothesis is that children and adults with HNRNPH2 will demonstrate an overall maintenance of gross motor function after one year.
NUMBER OF SUBJECTS: Ten female participants with HNRNPH2-related disorders, mean age 12.5 years, range 3.3 –37.1 years at baseline, participated in this one year follow up study.
MATERIALS AND METHODS: The GMFM-88, a commonly used standardized observational outcome measure in neurodevelopmental disorders, 4,6 was performed at baseline and at one year follow up. A caregiver of the participant completed the PEDI-CAT, an instrument for evaluating functional performance. 5 Yearly inter-rater reliability between the physical therapist and student physical therapist performing the GMFM-88 was established using intraclass correlation coefficients (ICC), ICC = 0.94 (90% CI: 0.80, 1.00). Descriptive statistics and mean changes over 1-year will be performed for GMFM-88 and PEDI-CAT. The 12-month change in the GMFM-88 values will be compared using T-tests and analysis of variance.
RESULTS: Of the 10 participants, 90% sat independently, 70% stood independently, 60% walked 10 steps independently and 40% were able to negotiate stairs. At baseline the mean GMFM-88 total score was 128.6 points (range: 58 to 239 points), the mean PEDI-CAT mobility domain score was 57.5 points (range: 49 – 63) and the mean PEDI-CAT mobility domain T-score was < 10. Convergent validity was established between the GMFM-88 total score and the PEDI-CAT mobility domain score (n = 10, r = 0.814, p = 0.004). One year follow up data will be analyzed.
CONCLUSIONS: Delays in gross motor function were exhibited in all participants with HNRNPH2-related disorders. The GMFM-88 and PEDI-CAT are useful measures to quantify gross motor function in these individuals. Further research is required to develop a valid disease specific outcome measure and to establish minimal clinically important differences across ages in a larger cohort.
CLINICAL RELEVANCE: Understanding the trajectory of disease progression is helpful in tailoring the functional goals and expectations of patients, families and clinicians. Appreciation of the natural course of the disorder provides the necessary framework to interpret the effects of future treatments and interventions.
PHYSICAL LITERACY IN ELEMENTARY PHYSICAL EDUCATION: A SURVEY OF FUNDAMENTAL MOVEMENT SKILL PRACTICE PATTERNS
Schlacht Butler L, Gupta A, DeVerna A, Moore JG, Latz K, Foley Davelaar C, Sugimoto D
PURPOSE/HYPOTHESIS: Pediatric physical inactivity is a major public health concern. According to the 2017 State of Play report, only 24% of youth meet the recommended physical activity (PA) dosage. Previous studies identified fundamental movement skill (FMS) proficiency as a predictor of physical literacy and PA. Mastery of FMS requires direct instruction and practice; however, it is unknown how well FMS are implemented in physical education (PE). The purpose of this study is to describe FMS practice patterns in the elementary PE curriculum. We had two hypotheses: 1) Fewer PE teachers provide comprehensive FMS instruction in later curriculum (grades 4-6) compared to early curriculum (grades 1-3) and 2) Fewer PE teachers teach FMS with direct instruction methods in later curriculum compared to early curriculum.
NUMBER OF SUBJECTS: 87
MATERIALS AND METHODS: A cross sectional survey design was used. PE teachers (grades 1-6) were recruited via electronic mail from various U.S. regions from January 2018 to March 2019. An electronic questionnaire was developed to ask about timing of FMS teaching and method of instruction. Additional questions were asked about the methods used to evaluate FMS proficiency, including the use of a standardized assessment of gross motor development, referrals and remediation recommended for children who appeared to be falling behind, and perceived barriers to FMS instruction. Chi-square tests (p<0.05) were employed.
RESULTS: We collected 87 responses with approximately 9% from West, 42% from Midwest, and 49% from South regions. Among all responses, 54% of PE teachers taught all FMS and 40% taught all FMS with direct instruction. Approximately, 66% taught all FMS for grades 1-3 compared to 42% for grades 4-6 (p<0.0001). Regarding instruction methods, 47% of teachers for grades 1-3 utilized direct instruction to teach all FMS compared to 27% for grades 4-6 (p=0.0007). Only 3.7% of teachers used a standardized assessment of gross motor development to evaluate FMS proficiency. For children who appeared to be falling behind, 6.7% of teachers reported accepting the child's “best effort” in participation. Only 7.3% reported referring to an exercise program and no PE teacher sought a healthcare referral. Time was reported as the greatest barrier to improving a child's FMS competency in 52.4% of responses.
CONCLUSIONS: Results suggests that fewer PE teachers teach all FMS in late elementary PE curriculum compared to early curriculum. Additionally, fewer teachers utilize direct instruction methods to teach skills in late elementary curriculum.
CLINICAL RELEVANCE: The findings indicate that a decline in FMS instruction may occur in late elementary PE curriculums. Given the current trend for youth physical inactivity, more comprehensive FMS instruction may be needed throughout the elementary PE curriculum. With time reported as the greatest barrier, a more efficient screening tool to evaluate FMS competency may also be needed.
LOCOMOTOR ASSISTED THERAPY'S INFLUENCE ON MUSCLE ACTIVATION PATTERNS IN CHILDREN WITH CEREBRAL PALSY
Seeger Scheidler C, Altenburger PA
PURPOSE/HYPOTHESIS: Ambulation is critical to a child's participation, development of self-concept, and quality of life. Children with cerebral palsy (CP) frequently exhibit limitations in walking proficiency which has been identified as the primary physical disability. Driven gait orthosis (DGO) training is a novel approach focusing on motor learning principles that foster cortical neural plasticity.
NUMBER OF SUBJECTS: Twenty subjects were recruited, 10 with CP and 10 age-matched typically developing (TD), ranging in age from 4 to 11 years. Inclusion criteria for the children with CP were diagnosis of CP, ability to ambulate barefoot with or without an assistive device for at least 20 feet and ability to follow one step verbal directions. Exclusion criteria included Botox to the lower extremity in the past 3 months, history of tendon transfer and presence of a severe deficit in visual acuity and/or visual field.
MATERIALS AND METHODS: Muscle activity patterns of the rectus femoris, semitendinosus, gluteus maximus and gluteus medius were recorded in over ground (OG) and DGO walking conditions for both groups. The gait cycles were identified, and the data was averaged to produce final average gait cycle time normalized values.
RESULTS: Within group variability of the muscle activation patterns revealed significantly lower muscle activation variability in CP DGO walking when compared to CP OG. Between group muscle activation pattern analysis revealed consistent differences (p < .05) in terminal stance, pre-swing and initial swing phases of gait during DGO walking. Both CP and TD experienced consistently greater muscle unit recruitment.
CONCLUSIONS: The results indicate that walking in the DGO provided the ability to practice with measurably repetitive movement as evidenced by decreased variability. Consistent elevated recruitment was noted in muscle activation patterns in the terminal stance, pre-swing and initial swing phases of gait in DGO walking for both groups. The alteration in ground reaction force within the DGO environment may play a role in this variance. Evidence shows that guidance force, body weight support and speed can negatively affect ground reaction force. With the goal of normalizing gait, it is important that the effect of these parameters on ground reaction forces be considered when using DGO rehabilitation.
CLINICAL RELEVANCE: The results of this study indicate under training conditions that the DGO provides consistent, repetitive recruitment of the muscles. Elevated muscle recruitment during portions of the gait cycle suggest the need for therapist management of DGO settings. Normal levels of recruitment might be achieved with lower guidance force, higher speed, and lower body weight support. Further study would be necessary to determine the optimal initial DGO parameters and their progression, DGO dosage, and co-treatment with OG walking.
IMPROVING GAIT MECHANICS IN CHILDREN WITH CEREBRAL PALSY WITH CIRCUIT TRAINING AND REVERSE WALKING
Seewer EC, Wiseman TM, Klem EM, Ridley CM, Kerr LO
BACKGROUND AND PURPOSE: The purpose of this study is to examine the efficiency of gait and transfers in children with cerebral palsy after completing retrowalking and progressive circuit training protocol for 8 weeks. Energy consumption while walking is six times higher in children with cerebral palsy, resulting in an increased rate of fatigue. To decrease the body's fatigue response to ambulation a cardiovascular exercise component needs to be part of a daily routine. Improved postural control and balance during ambulation will also impact the fatigue rate of children with cerebral palsy. Strengthening exercises that target the muscles of the lower extremity and lower abdominal are effective in increasing upright posture, improving balance and motor control during gait. Completing a cardiovascular session prior to strengthening interventions serves as a central nervous system “primer” to enhance functional gains. However, limited research has been completed combining retrowalking and resistance circuit training with in the cerebral palsy population.
CASE DESCRIPTION: Two children diagnosed with spastic cerebral palsy, GMFCS level III, ages 10 and 11 participated in a single-subject design (A-B-A-B with follow-up). Participants completed 1-week baseline testing, 8-week intervention, 1-week post- intervention testing, and follow-up testing at 6 weeks. Each participant received 2 sessions per week, consisting of 30 minutes of retrowalking followed by a resistance training program. The resistance training program alternated between two circuits of three exercise activities focusing on strengthening of the lower extremities, lower abdominals, and back extensors. Participants completed 3 sets of 8 repetitions per exercise.
OUTCOMES: Outcome measures consisting of: Timed Up and Go (TUG), 5 Times Sit to Stand, 6 Minute Walk Test (6MWT), GMFM-88, and gait kinematics using a 2-D motion capture system were captured at three points in time; before and after the intervention and at a 6 week follow-up.
DISCUSSION: The results showed significant improvements in the participant's TUG and 6MWT which indicates increases in gait efficiency, reduction in fatigue rate, and increased endurance. These results constitute the finding that high intensity circuit training with retrowalking locomotor treadmill training improve gait mechanics in these two children with spastic cerebral palsy.
PARENT-PROVIDER PARTNERSHIPS IN CEREBRAL PALSY CLINICAL MANAGEMENT: IDENTIFYING PHASES OF GRIEF TO PROMOTE INFORMATION SHARING
Selber P, Gannott MEi, Frumberg D, Liquori B, Jezuquel J, Eileen M
PURPOSE: Family-centered care (FCC) delivered by an interprofessional team is critical in the clinical management of cerebral palsy (CP).1 FCC tenets state that families of children with disabilities must be partners in decision making and be satisfied with service delivery.2 FCC is associated with improved child and family health and well-being, communication and collaborative care.2 Parents and families experience a myriad of emotions (love, grief, stress, coping, resiliency, hope, joy, adaptation, acceptance) in raising a child with CP.3,4 The purpose of this Special Interest Report is to present a framework developed by an orthopedic surgeon on our team to tailor communication, information sharing and support for parents and families, especially in times of difficult health care decisions.5
DESCRIPTION: Dr. Selber designed the ‘Four Phases of Grief In View of the Child with Limited Abilities’ (Phases of Grief) based on his clinical experiences and observations of families with children with CP.5 These Phases share similarities to previous work by Kubler-Ross and Kessler.6 The rationale for the Phases of Grief is to assist clinicians to tailor communication and align FCC approaches to parents' readiness to accept or act on the information. In Phase One, parents receive the diagnosis of CP for their child. Often they are in shock and overwhelmed with feelings of loss.3,7 In Phase Two, parents are in denial and have questions about their child's prognosis. They may seek a second opinion to cope with this new, life changing situation.4,8 Parents may seem antagonistic as they come to terms with the impact of CP on their child and family.4 In Phase Three parents often seek ‘curative treatments’ from healthcare providers and others (e.g., support groups, websites).8,9 Many ‘curative treatments’ are offered by alternative and complementary medicine9 or by providers who do not consider potential long term harms.10 Seeking ineffective curative interventions may result in financial loss or harm to families and individuals with CP. Conversely, evidence-based, preventive interventions may be perceived as ineffective by families. In Phase Three, parents may benefit more from care management support rather than clinical interventions. In Phase Four, parents move towards acceptance and are open to clinicians recommendations with less interest in seeking curative interventions with no known effectiveness.4,8
SUMMARY OF USE: Being sensitive to the Phases of Grief will allow clinicians to provide information when families are ready and able to hear it and will promote satisfaction with outcomes.8 Using the Phases of Grief to conceptualize families readiness to accept evidence based interventions is useful for information sharing and clinical management of CP.
IMPORTANCE TO MEMBERS: Having a tool that allows the interdisciplinary team to identify the family's Phase will facilitate FCC and may allow clinicians to identify families who seek curative interventions at high financial, social, and physical costs. We propose additional investigation to validate a checklist for the Phases of Grief in an effort to promote FCC.
CLINICAL UTILITY OF THE FITKIDS TREADMILL TEST IN YOUTH WITH CHRONIC PAIN DISORDERS
Shulman JM, Smith A, Kenney AM, Damice BDM, Jervis K, Sethna NF
PURPOSE/HYPOTHESIS: Aerobic exercise is central to physical therapy management of children with chronic pain treated within intensive interdisciplinary pain treatment (IIPT) programs, however measurement of improvements in exercise tolerance and aerobic capacity following treatment using aerobic exercise is lacking in children. The overall objective of this study is to explore the feasibility and validity of the Fitkids Treadmill Test (FTT) as an outcome assessment among youth with chronic pain undergoing intensive interdisciplinary pain treatment (IIPT). In such, this study has three aims: 1) determine if youth with chronic pain demonstrate significant improvement in cardiovascular endurance (as measured by the FTT) after participation in IIPT, 2) evaluate convergent validity of the FTT among youth with chronic pain undergoing IIPT by examining baseline and change correlations with other physical functioning variables known to improve with the intervention, and 3) explore biopsychosocial factors associated with FTT performance by evaluating baseline and change correlations of patient characteristics known to influence pain-related disability. We hypothesized that youth with chronic pain will demonstrate significant improvements on the FTT between IIPT admission and discharge. We also hypothesized that FTT performance would correlate with related physical and psychological constructs at baseline, and that improvements in FTT performance will correlate with improvements in psychological and physical variables.
NUMBER OF SUBJECTS: Youth with chronic pain disorders (n = 55; ages 9-18y; 89% female)
MATERIALS AND METHODS: The FTT is a norm-referenced submaximal graded exercise test performed on a treadmill. Primary outcomes of the FTT include the total time to exhaustion (minutes) and the child's self-reported reason for stopping the test (dichotomized into pain-related – yes or no). Eligible participants completed the Fitkids Treadmill Test (FTT) at admission and discharge from IIPT. Participants also completed measures of physical functioning (Bruininks Oseretsky Test of Motor Proficiency-2) self-report functional measures (Lower Extremity Functional Scale; Functional Disability Inventory) and self-report psychosocial measures (Fear of Pain Questionnaire, Chronic Pain Acceptance Questionnaire; Children's Somatization Inventory) at admission and discharge. Pain intensity on the numeric rating scale was also recorded. Data was extracted from an IRB-approved data registry. Retrospective data analysis was performed across the two time points. Descriptive statistics were used to describe participant characteristics and aerobic capacity relative to established normative values for total time to exhaustion on the FTT. Paired student t-tests and Wilcoxon signed rank tests were used to compare scores on all continuous and ordinal variables, respectively, over time. Pearson's r and Spearman's rho were used to correlate baseline and change scores of function and psychosocial variables with FTT performance.
RESULTS: In this sample, participants were significantly deconditioned compared to normative values; 53/55 participants scored well below the 50th percentile for their age on the FTT at admission. Consistent with our hypothesis, TTE on the FTT significantly improved from 7.85 minutes at admission to 9.37 minutes at discharge from IIPT (p< 0.001). Additionally, baseline FTT performance was correlated with another physical performance-based test, the Strength & Agility subscale of the Bruininks-Oseretsky Test of Motor Proficiency – 2. Contrary to our hypotheses, FTT baseline and change scores were not correlated with subjective functional or psychosocial outcomes.
CONCLUSIONS: This study provides evidence for cardiovascular deconditioning in youth with chronic pain. Unlike patient-report measures of functioning (e.g., lower extremity functional scale, functional disability inventory), performance on the FTT was not correlated with psychosocial factors. Use of the FTT as an objective outcome of aerobic capacity in youth with chronic pain was supported. Further research into the reliability and sensitivity of the FTT in youth with chronic pain is warranted.
CLINICAL RELEVANCE: Results of this study inform clinical practice by providing evidence for the clinical utility of the FTT in measuring cardiovascular endurance in youth with chronic pain. Additionally, these findings provide insight into cardiovascular fitness in youth with chronic pain before and after IIPT, with consideration to how biopsychosocial factors may or may not influence aerobic capacity.
LEVEL OF AGREEMENT OF 36-MONTH ASQ-3 BETWEEN PARENTS, CHILD CARE PROVIDERS, AND HEALTH CARE PROFESSIONALS
Simunds E, Hill V, Nichols E, Sohre J, Swain M, Zenker KA
PURPOSE/HYPOTHESIS: Developmental delay is present in approximately 15% of children in the United States, but less than one-fifth of those children receive intervention before age three. 1 Only 52% of pediatricians routinely utilize screening tools for children 36 months and younger. 2 Key members in the child's early life may be ideally situated to recognize delay through employment of standardized developmental screening tools, such as the Ages and Stages Questionnaire, 3rd ed. (ASQ-3). This study investigated the level of agreement in the 36-month ASQ-3 between parents, child care providers (CCPs), and other health care professionals, represented by student physical therapists (SPTs).
NUMBER OF SUBJECTS: Three groups with vested interest in early child development - parents, CCPs, and health care professionals - used the ASQ-3 to assess 10 children (median age 3.2) attending an early learning center.
MATERIALS AND METHODS: The ASQ-3, a valid and reliable measure, assesses pediatric development across five domains: communication, gross motor, fine motor, problem-solving, and personal-social. Parents scored their child's performance based on experience, followed by CCPs and SPTs administering the full 36 month ASQ-3 in a joint session within two weeks. The agreement between the three dyads of raters was assessed for each domain using Spearman's Rho.
RESULTS: Based on preliminary analysis of raw data, agreement that is likely to be significant across the three dyads is as follows:
- Communication: Excellent agreement between all three dyads
- Gross Motor: Good agreement between all three dyads
- Fine Motor: Excellent agreement between parents and CCPs
- Problem Solving & Personal-Social: Good agreement between SPTs and CCPs
Statistical analysis will be finalized by October 2019.
CONCLUSIONS: Based on the preliminary results of this study, parents and CCPs are valuable assets in the screening process for the detection of developmental delay.
CLINICAL RELEVANCE: Parental concerns should be considered throughout the process, particularly with regard to communication skills and gross motor performance.
INSTRUMENTED GAIT ANALYSIS FOR THE CLINICAL MANAGEMENT OF CHILDREN WITH CEREBRAL PALSY: A SCOPING REVIEW
States RA, Godwin EM, Hoffecker L, Krzak JJ, McMulkin M, Salem Y, Winter Bodkin A
PURPOSE/HYPOTHESIS: The aim of this scoping review was to identify, classify and analyze the literature about instrumented (3D) gait analysis (IGA) as used in the management of children with cerebral palsy (CP) who have a gait dysfunction. This review was undertaken in preparation for development of a clinical practice guideline (CPG) on this topic.
NUMBER OF SUBJECTS: 1296 citations were identified for review through a search of Medline.
MATERIALS AND METHODS: A health sciences librarian developed the search strategy with 4 key inclusion criteria: a) original peer-reviewed research study; b) population included children with CP; c) used IGA to investigate gait; and d) available in English. Each citation and abstract was reviewed by 1 or 2 authors, after establishing reliability across the 6 reviewing authors. Studies were classified into eight categories derived from Wren et al.'s 2011 systematic review about IGA: psychometric validation; description of clinical patterns; intervention study testing IGA as evaluation tool; intervention study testing IGA as a key part of treatment; cost-effectiveness of IGA; IGA used as outcome measure; did not meet inclusion criteria; insufficient information available. Study purposes and designs were also documented.
RESULTS: 1296 citations were reviewed. Of the 599 included studies, 315 (53%) validated IGA-specific measures or used IGA to describe kinematic patterns that could be useful for clinical management. Another 298 (50%) studies used IGA as an outcome measure to assess some intervention. A small number (29 or 5%) directly tested the effectiveness of an intervention or evaluation process that incorporated IGA as a critical feature to assist in clinical decision-making. Dual purposes were recorded for 43 studies resulting in total percentages greater than 100%. Analysis of study purposes and designs showed a wide range of prospective and retrospective designs analyzing myriad clinically important features of gait.
CONCLUSIONS: This scoping review describes the spectrum of existing literature on IGA for children with gait dysfunction related to CP. A substantial body of peer-reviewed research has been identified, classified and analyzed and can form the basis for development of a CPG on the topic. Additional steps such as stakeholder surveys, development of precise PICO(T) questions for the CPG and quality assessment of the literature are progressing under sponsorship of the Academy of Pediatric Physical Therapy.
CLINICAL RELEVANCE: As a key technology for documenting gait dysfunction, IGA provides the basis for a wide range of approaches to the examination, evaluation, and measurement of outcomes for gait dysfunction, as well as forming a crucial step in clinical decision making for treatment for children with CP related gait dysfunction. This review provides an overview of the peer-reviewed research available and can form the basis to begin developing a CPG about the use of IGA for the clinical management of children with CP related gait dysfunction.
AN ACUTE INTENSIVE NEUROSENSORY REHABILITATION PROGRAM FOR CHILDREN WITH DISORDERS OF CONSCIOUSNESS: A CASE SERIES
Stoddard C, Conners K, Gatling S, Threadgill E, Wang-Price SS
BACKGROUND AND PURPOSE: Disorders of Consciousness (DOC) including coma, vegetative state, and minimally conscious state, can occur following brain injury. Applying a structured sensory stimulation program has been shown to facilitate the recovery process in head injured comatose adults. However, little is known about the impact of providing similar interventions to a pediatric population. The purpose of this case series was to describe the effect of a formalized acute neurosensory program for children with DOC.
CASE DESCRIPTION: Nine children (age:11.4 ± 3.9 years) who had a traumatic or acquired brain injury, were admitted to the investigators' affiliated hospital for acute rehabilitation services. The diagnoses of these patients included anoxic brain injury, acute disseminated encephalomyelitis, arteriovenous malformation, diffuse axonal injury, central nervous system vasculitis, hypoxic ischemic Injury, subarachnoid and subdural hemorrhage, and ruptured aneurysm. Due to the severity of the brain injury and low functional level in these patients, the 5-state Rappaport Coma Near Coma Scale (CNC) was used as an outcome measure to assess clinical changes. On the initial evaluation, 1 patient was in an extreme coma state, 2 in a marked coma state, 4 in a moderate coma state, and 2 in a near coma state. Each patient received 2-4 therapy sessions daily, lasting 10-30 minutes each session with an additional session provided by caregivers. Each session included structured stimulation of sensory systems, including visual, auditory, tactile/proprioceptive, olfactory, and gustatory, followed by a mandatory 30-45 minutes of non-stimulation rest time. Sensory stimulation was individualized for each patient based on their clinical presentation, consciousness level, and caregiver's feedback.
OUTCOMES: These patients received structured sensory stimulation for 21-71 days during their hospital stays. Upon discharge, 6 patients progressed 1-3 levels on the CNC from various coma states, 2 patients had no change and remained in a near coma or moderate coma state, and 1 patient regressed one level to a marked coma state. In addition, 8 patients were discharged from the hospital to an inpatient rehabilitation facility. Four of the 8 patients were in a no-coma state upon discharge from the hospital and the remaining 4 progressed to a no-coma state while they were in the inpatient rehabilitation facility, including the one who had regressed during hospitalization. One patient remained in the hospital and in a near coma state.
DISCUSSION: Implementation of an early intensive sensory stimulation program for children with DOC in the acute setting may be beneficial for progression to a conscious state and may improve functional outcomes. Without a control group, it is not certain to what extent the intensive neurosensory stimulation contributed to the patients' improved coma states and functional levels. Nevertheless, results of this case series suggest that structured stimulation followed by non-stimulation rest breaks may have the greatest effects on conscious states for this population.
PERCEPTIONS OF THE CAREGIVER PEDIATRIC PHYSICAL THERAPIST RELATIONSHIP
PURPOSE/HYPOTHESIS: Collaboration between physical therapists and caregivers of children who receive physical therapy is integral to the functional outcomes of the child and wellbeing of the caregiver. Successful collaboration is dependent upon the therapeutic relationship built within the caregiver-therapist dyad. However, the nature of these relationships is not well understood. The purpose of this study was to explore the caregiver-physical therapist relationship from the perspective of the caregiver and physical therapist.
NUMBER OF SUBJECTS: 10
MATERIALS AND METHODS: A qualitative case study methodology was used in which a caregiver and pediatric physical therapist represented a bounded case. Each caregiver and therapist within a dyad engaged in separate, semi-structured, in-depth interviews.
RESULTS: Through within- and cross-case coding, three major themes were identified: physical therapist as a guide, social and emotional connection, and professional qualities and performance.
CONCLUSIONS: These themes help to provide a rich understanding of the therapeutic relationships that can occur between therapists and caregivers.
CLINICAL RELEVANCE: Therapists can use these findings to help examine the relationships with their patients and families.
MEASUREMENT PROPERTIES OF THE DIZZINESS HANDICAP INVENTORY-CHILDREN AND ADOLESCENTS (DHI-CA) IN CHILDREN AND ADOLESCENTS POST-CONCUSSION
Tiwari D, Yorke AM, Goldberg A, Marchetti GF, Alsalaheen B
PURPOSE/HYPOTHESIS: Up to 80% of individuals report having dizziness post-concussion. Among children and adolescents, dizziness has been identified as a predictor of prolonged recovery post-concussion, and significantly impacts their activities and participation. Dizziness Handicap Inventory – children and adolescents version (DHI-CA) was recently adapted from the original DHI to evaluate the impact of dizziness on activity and participation in children and adolescents with dizziness. Purpose. The purpose of this study was to examine and report the psychometric properties of the DHI-CA in post-concussion children and adolescents.
NUMBER OF SUBJECTS: 132
MATERIALS AND METHODS: A retrospective chart review from electronic medical records was conducted for 132 consecutive children and adolescents who received vestibular physical therapy at a tertiary center specializing in comprehensive interdisciplinary management of patients with concussion. Data was extracted on various outcome measures including DHI-CA, sports concussion assessment tool -III (SCAT III), vestibulo-ocular motor screen (VOMS) and patient-reported percent of recovery. The DHI-CA was examined for validity, factor structure, responsiveness and internal consistency.
RESULTS: The DHI-CA demonstrated convergent validity with the SCAT-III symptoms related to dizziness (r s = 0.30-0.40). However, it failed to demonstrate discriminant validity and showed limited diagnostic ability to discriminate between individuals who did or did not show clinically meaningful improvements. Factor analysis revealed that the items on DHI-CA demonstrated cross loading with an overall poor model fit (RMSEA = 0.105) indicating structural inconsistencies.
CONCLUSIONS: Despite demonstrating convergent validity, DHI-CA demonstrated limited discriminant validity and responsiveness along with significant structural limitations in the factor structure. Caution is recommended while making clinical decisions based on the DHI-CA results. There is a need to revise the DHI-CA and reevaluate the psychometric properties in post-concussion children and adolescents before it can be utilized in clinical settings to evaluate the impact of dizziness post-concussion.
CLINICAL RELEVANCE: This study highlights the need to revise the DHI-CA and reevaluate the psychometric properties in post-concussion children and adolescents before it can be utilized in clinical settings to evaluate the impact of dizziness following a concussion in this population.
IMPACT OF AN INTEGRATIONAL PHYSICAL ACTIVITY PROGRAM ON CHILDREN 6 TO 12 YEARS OLD
Tucker JE, Bhat S, LaMaster KM, Webster HK, Dawson NT
PURPOSE/HYPOTHESIS: Intergenerational (IG) programs have been used in different disciplines to bridge the gap between two generations. The purpose of the study was to investigate the impact of an intergenerational physical activity program on children focusing specifically on physical activity, attitudes, and perceptions of aging and participation.
NUMBER OF SUBJECTS: 9 children between 6 and 12 years old
MATERIALS AND METHODS: A pilot study was conducted using a pretest posttest research design. Nine children between the ages 6 and 12 years old were recruited from the Central Florida community. Pre-testing was completed one week prior to the start of the program. Grow and Play, an intergenerational physical activity program was implemented over a period of 8 weeks for a total of 16 sessions lasting approximately 60-90 minutes each. Children interacted with six older adults over the age of 65. Post testing was performed the week after the program concluded. Testing included the following assessments, the Children's Attitudes Toward Physical Activity (CAPTA), the Children's Perception of Aging and Elderly (CPAE), and the Semantic Differential Scale (SDS) which were used to measure perception of aging and physical activity in the children. Physical activity was measured using the Actigraph GT9X.
RESULTS: Data was analyzed using SPSS version 25. Results revealed an improvement in the children's attitudes towards physical activity (α = 0.093). These positive changes were specifically seen in the impact of physical activity on social life (α = 0.029), overall health and wellness (α = 0.104), and enjoyment with more graceful movements (α = 0.081). Other factors such as physical activity levels using an accelerometer were not found to be significant.
CONCLUSIONS: Social life, health and wellness, and enjoyment of graceful movements all improved in children following participation in an intergenerational physical activity program. The intervention had a positive impact on the children's views towards physical activity. Additional research with larger sample size is warranted.
CLINICAL RELEVANCE: Intergeneration physical activity programs offer a novel approach for promoting physical activity in children 6 to 12 years of age.
THE RELATIONSHIP BETWEEN CONGENITAL MUSCULAR TORTICOLLIS AND PELVIC ROTATION ASYMMETRIES IN INFANTS
Unanue Rose RA, Lagemann AP, Uhrich TM, Byrd K, Johnston J, King RL
PURPOSE/HYPOTHESIS: There has been an increase in the incidence of Congenital Muscular Torticollis (CMT) over the past two decades. Although CMT affects the head and neck, it should be investigated how abnormal alignment of the head affects the pelvis due to the interconnectedness of the two. The purpose of this study was to identify if a relationship exists between CMT and pelvic rotation asymmetries in infants. It was hypothesized that infants with CMT will have a pelvic rotation asymmetry in the direction opposite of the cervical rotation component of their CMT.
NUMBER OF SUBJECTS: Forty-four infants participated in this observational study. Infants were included if they were between the ages of 1 and 10 months with a diagnosis of CMT and were receiving physical therapy at a local outpatient facility.
MATERIALS AND METHODS: Resting head position and bilateral cervical lateral flexion and rotation passive range of motion (PROM) measurements were taken with an arthrodial protractor. Resting pelvic position and right and left pelvic rotation PROM measurements were obtained using an adapted scapulometer. All infants were classified on the torticollis severity scale. One participant was excluded from data analysis for differing from the mean by more than 2 standard deviations for all measurements collected. Pearson correlations were used to determine if a relationship exists between the absolute value of the difference in pelvic rotation PROM right to left and the absolute values of the difference in cervical lateral flexion PROM right to left, cervical rotation PROM right to left, and combined limitation based on traditional SCM motions. The correlation for combined limitation was performed on 35 participants, due to 8 participants having an atypical presentation of CMT. Pearson correlations were also utilized to determine if severity was related to asymmetrical pelvic rotation on a subgroup of participants who could be classified on the torticollis severity scale. Chi squared tests were used to determine if a relationship between the direction of static pelvic position and static cervical lateral flexion and rotation position existed.
RESULTS: No relationship exists between cervical lateral flexion asymmetries and pelvic rotation asymmetries (r=-.144) (p=.357). In addition, no significant relationship was found between cervical rotation asymmetry and asymmetrical rotation of the pelvis (r=-.181) (p=.298). Severity of torticollis was not significantly correlated with rotation asymmetries at the pelvis. Infants classified by severity displayed no significant correlation between cervical rotation and pelvic rotation (r=.322) (p=.598). In addition, the infants classified by severity also showed no significant correlation between cervical lateral flexion and pelvic rotation (r=.555) (p=.333).
CONCLUSIONS: Overall, our study was unable to confirm the hypothesis that a relationship exists between CMT and asymmetrical pelvic rotation, regardless of side involved. Given the lack of association, it can be stated that infants with torticollis do not demonstrate statistically significant pelvic rotation asymmetries. Without this association, position of the pelvis cannot be predicted based on PROM at the cervical spine.
CLINICAL RELEVANCE: Clinically, 50% of infants in this study presented with a pelvic rotation asymmetry of 5 degrees or more with 20.5% of infants presenting with a pelvic asymmetry of 10 degrees or greater. Therefore, it is recommended that therapists evaluating infants with CMT screen and consider treatment for pelvic rotation asymmetries accordingly.
POSTURAL STABILITY DIFFERENCES AMONG PRESCHOOL-AGED CHILDREN USING SWAY BALANCE MOBILE APPLICATION
Wengrovius C, Rowe HA, Bauer SC, Robinson LE
PURPOSE/HYPOTHESIS: The primary aim of this study was to determine age and gender differences in postural stability among preschool-aged children. A secondary aim was to investigate the validity of the SWAY Balance Mobile Application (SBMA) compared to the Pediatric Balance Scale (PBS). This was a secondary analysis of baseline data collected for a yoga intervention pilot study that examined preschool children's balance, classroom behaviors, and sleep habits. Considering previous SBMA normative data in school-aged children, we hypothesized that there would be age and gender differences in postural stability for a younger age group. We also hypothesized that SBMA scores would directly correlate with PBS scores.
NUMBER OF SUBJECTS: 134
MATERIALS AND METHODS: This study was a retrospective analysis of baseline balance measurements of preschool children. Nine preschool classrooms across two locations participated in the study. The SBMA and PBS assessments were completed in the school setting using the appropriate administration and scoring protocols. The SBMA uses the built-in triaxial accelerometer in common mobile devices to quantify postural sway. An Apple iPod Touch was secured on a vest in front of the child's sternum before conducting the SBMA CDC-4 protocol (i.e., feet together [FT], semi-tandem [ST], tandem [TA], single leg stance [SL]). A multivariate analysis of variance was used to examine age and gender differences on postural stability and Pearson's r correlations were used to determine the association between the SBMA and PBS scores.
RESULTS: 134 preschoolers (46% female, Mage = 4.2 years) were evaluated on their postural sway and functional balance. SBMA scores improved with age, F(1, 131) = 15.08, p < .001, ηp2 = .103. Older preschool children performed better than younger preschool children for FT (Mo = 92.6, M y = 82.8), ST (MO = 91.6, My = 77.5), TA (Mo = 42.1, My = 30.2), and SL (Mo = 15.8, My = 9.6). There was a significant gender difference in postural sway, F(1, 131) = 7.33, p = .008, ηp2 = .053. Females demonstrated greater postural stability for FT (Mf = 92.4, Mm = 86.0), ST (Mf = 89.8 Mm = 83.3), TA (Mf = 42.3, Mm = 33.6) and SL (Mf = 17.7, Mm = 10.2). The SBMA and PBS scores were significantly related and demonstrated a moderate, positive correlation, r(129) = 0.54, p < .001.
CONCLUSIONS: Similar to research findings in older children, preschoolers demonstrate differences in postural stability across age and gender. The SBMA can be used with the preschool-age population as a valid postural stability measure. Further research is needed with larger sample sizes in order to establish normative values for this young age group.
CLINICAL RELEVANCE: Postural stability is frequently assessed in pediatric physical therapy and time- and cost-effective measures are important when evaluating young children. For clinicians to use the SBMA as a balance screen or outcome measure, typical performance across demographic variables needs to be established. The SBMA may be a practical and valid measure to use with preschool-aged children.
DOES SUPERVISED EXERCISE EXTEND THE BENEFITS OF EPISODIC PHYSICAL THERAPY FOR ADULTS WITH CEREBRAL PALSY?
Withers CM, Dusing SC, Marcinowski E
PURPOSE/HYPOTHESIS: The lifespan of the patient with cerebral palsy is approaching that of the general population. Adults with cerebral palsy frequently present with secondary impairments (pain, fatigue, and progressive orthopedic problems) and activity limitations (decreased mobility) that have the potential to decrease physical activity levels as they age. Adults with developmental disabilities are more likely to lead sedentary lifestyles and are at greater risk of chronic health conditions than adults without CP. The health benefits of physical fitness have been demonstrated in multiple research studies for able-bodied individuals, but less so for adults with cerebral palsy. The purpose of this study is to compare the effectiveness of 2 community intervention approaches to maintain community mobility and walking speed in adults with CP who have previously completed an 8 week course of physical therapy.
NUMBER OF SUBJECTS: Thirteen adults with cerebral palsy, Gross Motor Function Classification System (GMFCS) level I, II, or III participated in this study. Eligible criteria including participation in an episode of physical therapy within one month prior to the baseline assessment, living within the community in their own home or group housing, and be 18 years of age or older. Exclusion Criteria include GMFCS level IV or V or unable to follow 2 step directions.
MATERIALS AND METHODS: All participants were assessed on the same schedule at baseline, 4 weeks, 8 weeks, and 12 weeks of intervention. The Pediatric Evaluation of Disability Inventory Computer Adaptive Test, Timed up and Go and the Six Minute Walk Test were completed at each assessment visit by a reliable examiner blinded to group assignment. Following enrollment and the baseline assessment, participants were randomly assigned to either the home program or fitness membership groups. Both groups participated in their assigned group for 12 weeks and their programs were designed to meet the evidence based exercise recommendations including cardiovascular and strengthening exercises.
RESULTS: The mean number of sessions completed in the gym was 24, while the mean number of days of home program was 18. This represents 66% and 50% respectively per group of the recommended sessions following discharge. The results of this study showed that neither group demonstrated significant change in the PEDICAT (ps > 0.18), TUG (p = 0.37), or 6 minute walk test (p = 0.32), from baseline to the end of intervention.
CONCLUSIONS: Adults with CP who have recently completed a PT episode of care did not regress when participating in a home based fitness program or a fitness membership. The similar findings between the groups suggests that either may support the maintenance of any skills. However, this pilot study was underpowered.
CLINICAL RELEVANCE: As children with cerebral palsy grow up to be adults, good health is essential to prevent secondary impairments and decrease overall healthcare costs. Community home programs and fitness facilities may both be effective ways to gain strength.
PARTICIPATION OF STUDENTS WITH DISABILITIES IN SCHOOL TRIPS: PARENTS' EXPERIENCES AND PERSPECTIVES
Wynarczuk KD, Schaefer A, Bongiovanni JD, Monaco N, Kellar BL
PURPOSE/HYPOTHESIS: Successful school trip planning for students with disabilities requires a comprehensive and planned approach to identify and accommodate potential barriers to participation. However, schools are often not equipped with standardized strategies to plan such trips and thus frequently have difficulty accommodating every student. The purpose of this research was to identify barriers and strategies to the successful participation of students with disabilities on school trips, from the perspectives of parents of children with disabilities.
NUMBER OF SUBJECTS: 849 parents of children with disabilities participated in this study. Parents were from the United States (n = 823; 46 states) and seven additional countries (n = 26). The mean age of children represented in this study was 11.2 years (included ages were 6 to 21 years). Autism spectrum disorder was the most frequently identified primary diagnosis (n = 261), followed by cerebral palsy (n = 65), and Down syndrome (n = 43).
MATERIALS AND METHODS: Parents of children with disabilities were recruited via Facebook groups to complete an online questionnaire between March and June 2019. This questionnaire included multiple-choice, Likert scale, and open-ended questions. Quantitative data were analyzed using SPSS; responses to open-ended questions were analyzed by multiple researchers using thematic analysis.
RESULTS: Nearly a third of the parents (n = 271; 32%) reported that their child has been excluded from school trips because of their disability. A quarter of parents (n = 231; 27%) disagreed or strongly disagreed that the school ensures their child's needs are met during school trips. One fifth of parents (n = 180; 21%) reported that their child's physical abilities limit their participation in school trips quite a bit or a tremendous amount. There was a statistically significant association between the destination site's ability to meet the student's needs and the extent to which the student's physical abilities limit their participation in school trips. Four themes regarding barriers and strategies to promote participation during school trips emerged during qualitative analysis: 1) Culture regarding acceptance and inclusion; 2) Student experience surrounding the trip; 3) Communication and planning; and 4) Support provided by adults.
CONCLUSIONS: Advanced planning and coordinated support provided by parents and school and destination site staff are viewed as helpful strategies to support meaningful participating in school trips. Parents value destination sites and activities that are accessible, staff who are educated in meeting the needs of children with disabilities, and cultures that value inclusion and acceptance.
CLINICAL RELEVANCE: This research identifies many barriers and strategies to meaningful participation of students with disabilities during school trips. Physical therapists who work with students with disabilities may collaborate with other members of the educational team and destination site personnel to address these challenges and foster meaningful participation during school trips.
CANWARRIORS: FEASIBILITY OF A SPECIALIZED PEDIATRIC ONCOLOGY WELLNESS PROGRAM WITHIN AN URBAN MEDICAL CENTER
Yoon LH, Bombacie M, Ladas E, Stark E, Zacharoulis S, Garvin J, Wong CK
PURPOSE: The overall five-year survival rate in pediatric cancer was 84% in the United States. The Childhood Cancer Survivor Study indicated that adult survivors of pediatric cancers experience long term physiological and psychological consequences, which impact mortality, overall health, and quality of life. The positive benefits of physical activity and exercise in reducing symptoms and deficits within the context of a community wellness program have been documented in mixed pediatric cancer groups. The purpose of this pilot was to describe the feasibility and process to establishing a wellness program in a pediatric outpatient oncology clinic of a large urban medical center in partnership with an academic physical therapy program.
DESCRIPTION: Integrative health practitioners including nutrition and acupuncture from the outpatient clinic linked the cancer care team with faculty and students from the Program in Physical Therapy. The integrative health practitioners recruited and obtained medical clearance for potential participants and referred them to the CanWarriors team. A CanWarriors team member then provided an explanation of the program and obtained consent/assent. Two one- hour weekly group and/or individual sessions were provided over 12 months. Activities included in the session were arranged by themes (aerobic, muscle strengthening, flexibility and balance), and carried out with each participant based on information: gathered in the medical clearance, provided by the oncology team, and/or identified by the participants or families. Individualized tailoring of activities, and suggestions for physical activity or exercise were discussed with participants and families, and relevant information from the session relayed to the medical team. Feasibility was assessed by recruitment, retention of participants, and safety and tolerability of the intervention.
SUMMARY OF USE: Over 12 months, 51 children, adolescents and young adults participated in this program, and a total of 117 sessions were delivered. Data collected from participants included age, and diagnosis. 51% of patients came to the group more than once, demonstrating a high interest in the program. Thirty-one first, second and third-year DPT students participated in delivering this program with an academic faculty specialist in pediatric physical therapy responsible for designing, and supervising the program.
IMPORTANCE TO MEMBERS: Pediatric physical therapists have specialized expertise as movement specialists, and can contribute as key team members in creating and adapting a wellness program provided within the context of a patient's treatment day. The objective was to utilize the ICF to tailor activities based on participant and family priorities and interests, with a focus on function, and an eye to encouraging healthy habits early. This pilot described a feasible wellness program utilizing existing resources and staffing that provided a unique academic, clinical and research partnership that was valued by participants, families, faculty, students and the oncology team.
LOWER LIMB ALLODYNIA FOLLOWING STROKE IN A 15 YEAR OLD TEENAGER
BACKGROUND AND PURPOSE: Neuropathic pain, specifically allodynia, can be a very disabling symptom that affects mobility and overall quality of life 1. Allodynia is much less frequently encountered in pediatrics compared to adults, but typically results from complex regional pain syndrome (CRPS) or another neurological injury 2. Stroke is rare in children, but can cause sensorimotor, cognitive, and communicative impairments 3. The goal of this poster is to highlight treatment interventions utilized on a pediatric patient who presented with lower limb allodynia after stroke.
CASE DESCRIPTION: A 15 year old male with no past medical history sustained a left intraparenchymal hemorrhage and subdural hematoma from a temporal arteriovenous malformation (AVM). He underwent emergent decompressive craniotomy and embolization of the AVM. His primary impairments included allodynia localized to the dorsum of his right foot and distal shin with associated pain perseveration, mild right-sided weakness with trace extensor digitorum and absent extensor hallucis longus movement. He received only gabapentin for pharmacological management of pain.
OUTCOMES: Gross functional assessment via the Wee-Functional Independence Measure (Wee-FIM), static balance via the Pediatric Balance Scale (PBS), dynamic balance via the Dynamic Gait Index (DGI). Pain Catastrophization Scale (PCS) was used as a subjective questionnaire to assess the patient's thoughts about pain. Admission: Wee-FIM 4 for bed mobility/transfers, 0 for ambulation and stairs; PBS 0/56; DGI 0/24; PCS 22/52. Discharge: Wee-FIM 7 for bed mobility/transfers, 7 for ambulation, 6 for stairs; PBS 55/56; DGI 19/24; PCS 8/52.
DISCUSSION: The focal allodynia in this patient's lower limb was a surprising finding, as this is uncommon in stroke and with children. There were concerns about the potential for CRPS, however there were no autonomic changes or other signs or symptoms supporting this. Treatment for his pain became a priority, as he was unable to stand or ambulate initially due to severe pain. Despite there being limited literature in treating allodynia after stroke in adult and pediatric populations, interventions commonly utilized for CRPS were subsequently incorporated 4. This included graded exposure to functional training, desensitization, virtual reality, diaphragmatic breathing, and incorporating his interest in soccer into therapy 5, 6. Pain science education was also provided, emphasizing the importance of reducing thoughts about pain, focusing on the positives of recovery, and hypersensitivity of the nervous system. Over time, his pain intensity and perseveration decreased, allowing for greater progress. Clinicians who encounter pediatric patients with allodynia after stroke may benefit from providing interventions focused on function and reducing hypersensitivity of the nervous system. This includes commonly utilized treatments for CPRS including pain science education, distraction based therapies, and desensitization. Initiating treatment early on may also help prevent symptoms from progressing to the subacute and chronic phases.