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

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

Pediatric Physical Therapy 35(1):p 108-114, January 2023. | DOI: 10.1097/PEP.0000000000000990
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Anthony CJ, Charles G, Golden EC, Kobiela L, Tracey MR, MacLennan B, Swiggum MS, Williams TE

PURPOSE/HYPOTHESIS: Research has focused on a gradual decline in physical functioning with age for individuals with cerebral palsy (CP) and the development of secondary complications such as sarcopenia, cardiovascular disease, and chronic pain. However, some individuals with CP are engaging in and enjoying challenging physical activities. The purpose of this qualitative study was to explore societal, familial, and individual factors that are related to the engagement in activities that push physical limits in adults with CP.

MATERIALS AND METHODS: Each participant was interviewed using a semi-structured interview that focused on physical activity, facilitators and barriers to participation, motivation, and psychological aspects of community integration. The interviews were performed over Zoom, recorded, transcribed, and checked by the participants for intended meaning and accuracy. Six of the researchers collaboratively coded the transcriptions and performed thematic analysis while two of the researchers reviewed the codes and themes and provided input for revisions. Final themes were then developed. Number of Subjects: Five adults (eighteen years and older) with CP agreed to participate. Primary mode of mobility varied from power wheelchair to independent ambulation Participants self-selected as a person who engages in physical activity. Participation in physical activity varied in mode and included strength training, marathon running, cross fit, aerobic exercise, team sports, etc.

RESULTS: Participants noted physiological changes as they aged that were often inadequately addressed by medical professionals. These changes had a significant impact on the participants' physical activity and patterns of participation. Themes that emerged from the data included: 1. Inclusion versus living up to expectations - meet me where I am. Families that included the participants in all activities regardless of the physical impairments positively influenced physical activity later in life; 2. Grit - the more difficult, the more rewarding. Participants were highly motivated to challenge their bodies. Each found a particular exercise that was intrinsically rewarding. They enjoyed working hard to achieve results; 3. Different bodies. Some found initiating exercise hard because their bodies did not move like other bodies and there were limited models available.4. Leaving a road map - advocacy. The lack of role models compelled the participants to be examples for other people with CP.

CONCLUSIONS: Previous studies regarding the determinants of exercise in adults with CP have identified caregiver aptitudes towards exercise as a positive determinant. This study found additional motivators and life experiences that encouraged the participants to push previous barriers and enjoy challenging activities. Adults with CP can reap numerous benefits from being included in sports and physical activities that are difficult and challenging.

CLINICAL RELEVANCE: Inclusion and participation in challenging physical activities in childhood can have a positive influence on later physical activity. Adults with CP need more role models, support, and opportunities to engage in challenging physical activity.


Bhat AN, Van Damme T

PURPOSE/HYPOTHESIS: Eighty-seven percent of children with Autism Spectrum Disorder (ASD) are at risk for motor impairment in the US.1,2 While 80% of this large sample was receiving speech and occupational therapy for their communication and fine motor/sensory processing problems, motor delays remained underdiagnosed (i.e., <15% held a co-diagnosis of Developmental Coordination Disorder (DCD) and only 13 to 31% of children with ASD received recreational or physical therapies, respectively.1 There is growing evidence for using the Developmental Coordination Disorder Questionnaire (DCD-Q) to screen for motor delays in school-age children with ASD.3 However, few studies have validated this tool against other standardized measures.4 The purpose of this presentation is to bring together data across two countries: US and Belgium to highlight the value of using the DCD-Q for motor screening in ASD and to validate it against other robust standardized measures to further confirm motor difficulties in children with ASD.

MATERIALS AND METHODS: Across both studies (SPARK and Leuven) parents reported their school-age children with ASD's (Age Range: 5-15 years) risk for motor impairment using the DCD-Q5 and another concurrent standardized measure. In the SPARK study, parents also reported motor delay using the Vineland Adaptive Behavior Scales, Second Edition (VABS-2)6 and in the Leuven study clinicians completed a motor assessment using the Movement – Assessment Battery for Children or M-ABC.7 The proportion of children with ASD who failed on the DCD-Q and the concurrent measure will be assessed. Various psychometric measures such as the positive predictive value, sensitivity, and accuracy of identifying a motor impairment using concurrent measures will be reported. Number of Subjects: Sample Size for SPARK study = 8,446 and Leuven study = 324

RESULTS: In the SPARK study, 87% children with ASD failed on the DCD-Q, 77.9% had moderate or more motor delays using the VABS-2. For children who completed both measures, 70.4% of children with ASD failed on both measures (i.e., a positive predictive value of 70.4%). In the Leuven study, 54% of children with ASD failed on the DCD-Q, 59% of children with ASD had borderline to definite motor problems on the Movement-ABC. For children who completed both measures, DCD-Q had a 78.5% positive predictive value and 79.5% sensitivity against the M-ABC.

CONCLUSIONS: Together, these findings show the value of using the DCD-Q, a quick motor screening tool, to screen for motor problems to improve referrals for both physical and occupational therapy (PT and OT) for children with ASD in school settings.

CLINICAL RELEVANCE: While there is an under-diagnosis and undertreatment of gross motor issues in children with ASD within the US (Bhat, 2020), implementing DCD-Q regularly could improve motor screening for further PT and OT referrals. PTs in Belgium are the primary motor experts to conduct early motor screening and interventions for children with ASD and could provide valuable lessons on how to make access to PT services more equitable for children with ASD in the US.


Cooper S, Bergh C, Milligan HA, Branas AR

PURPOSE: Description of a mature pelvic health physical therapy practice in a pediatric hospital-based outpatient practice.

DESCRIPTION: Bowel and bladder management are essential components of childhood development. Dysfunctional voiding and pelvic health impairments can impact age-appropriate participation, social-emotional wellbeing, functional mobility, pain and quality of life. Pediatric physical therapists are uniquely qualified to assist in management of pediatric pelvic disorders. Management of pediatric disorders differs from management of adult pelvic disorders and must be addressed as such. Children have bowel and bladder dysfunctions that can and should be addressed by a pelvic health physical therapy (PT) to improve quality of life, increase participation and independence in social and educational settings, and decrease the burden of care. Children who have neurologic involvement can benefit from pelvic health physical therapy for assistance with positioning, motor control and learning, and strengthening exercises to improve bowel and bladder function. Children with cardiopulmonary involvement benefit from strengthening and respiratory exercises to improve control of the pelvic floor during necessary airway clearance techniques. Children with developmental delay benefit from preparation and support with toilet training.

SUMMARY OF USE: The pelvic health PT program at the Children's Hospital of Philadelphia has grown from one therapist in 2016 to six therapists in 2022 across five locations, with referrals increasing from three initially to 132 in 2021. The department receives pelvic health referrals from Urology, Gastroenterology, Primary care, Developmental pediatrics, and Adolescent Gynecology. Education by the pediatric pelvic health team is provided at department meetings, local and national parent conferences, and national professional conferences. Therapists are involved in the Center for Motility, Center for Voiding and Function, Inflammatory Bowel Disease Center, and the Multi Institutional Bladder Exstrophy Consortium. Therapists also provide expertise in multi-disciplinary clinics including Trisomy 21 clinic and neurogenetic clinics. Team focus includes implementation and use of patient reported outcome measures, standardized evaluation tools, E-stim and biofeedback, therapeutic exercises, positioning recommendations and home programs. In addition, therapists have assisted in the mentorship and development of several pelvic health programs at other institutions across the country. Future goals include involvement in Gender and Sexuality Development Program, integration of occupational therapists and development of screening questionnaires.

IMPORTANCE TO MEMBERS: The development of pediatric pelvic health programs is essential in supporting children's physical and emotional development. Children with a variety of diagnoses and conditions require therapeutic support for bladder and bowel health. Due to the modest size of the field of pediatric pelvic health, cross institutional collaboration, research and standardization of practice is essential for continued growth of the field.


Dao A, Nelson KS

PURPOSE/HYPOTHESIS: Children with Down Syndrome (DS) often begin therapies as infants and continue extended and repeated episodes of therapy services. Researchers aimed to explain the phenomenon of how children with DS and their family's perceived helpfulness and unhelpfulness in therapy service provision. This research purpose was intended to fill gaps in the literature regarding lived experiences of children with DS and their family members receiving rehabilitation therapy services. The results hope to inform rehabilitation therapists about providing the highest quality, most meaningful care possible for children with DS and their families. Researchers hypothesize that: (1) children with DS and their family members would identify more helpful components of rehabilitation therapy services as compared to unhelpful components; (2) children with DS and their family members to overall feel positively about rehabilitation therapy services; (3) helpful components will be related to therapist attributes.

MATERIALS AND METHODS: Participants were recruited via convenience sampling of children with DS and their associated family members. Data were collected through semi-structured interview with open-ended questions via videoconferencing or in person. Interviews were audio-recorded and later transcribed into text. Field notes of the principal investigator's observations were taken during and immediately following each interview to supplement the transcriptions. Data was analyzed using the framework of the analytic induction process described by Rubin and Rubin (2012). Researchers independently studied each interview and developed a coding and theming schema with representative quotes. Researchers then collaborated to create a final coding and theming document using a systematic consensus process, which set the stage for developing an illustration of the findings using a “good apples” and “bad apples” schematic. Narrative information from interviews was further triangulated with field notes taken after interviews. Number of Subjects: A total of 12 people from four families were interviewed. Participants included parents, siblings, and the child with DS.

RESULTS: The key terms associated is “helpful” attributes were: connection, supportive, fun, creative, meaningful, and inspirational. “Not helpful” key phrases included: lack of patient connection, lack of shared decision making, setting the bar, lack of direction, and logistics.

CONCLUSIONS: Helpfulness was overwhelmingly focused on attributes of the therapist. Unfortunately, families had equally as many negative therapy experiences as compared to positive ones. Results show that the themes the families determined were “not helpful” were not simply the opposite of the “helpful” descriptions.

CLINICAL RELEVANCE: Early therapeutic experiences set the stage for families' expectations and influenced their behaviors and willingness to speak out or accept services. Families with early.


Domann J, Walz A, Barnes CK, Davies L, Scott KD, Little H

PURPOSE: To increase early mobilization of patients in a single center pediatric intensive care unit (PICU) using an early mobility protocol and quality improvement (QI) methodology. Specific aims include decreasing time to evaluation by physical and occupational therapy (PT/OT), and increasing PT/OT consults and number of mobilization sessions without increasing the unplanned extubation rate.

DESCRIPTION: All admitted PICU patients at a single center were reviewed over 3 distinct 3-month time periods as part of a retrospective & prospective QI initiative.

Key Terms:

  • Early Mobility (EM)–PT/OT evaluation within 72 hours of PICU admission.
  • Mobilization rate: The number of mobilization events relative to total PICU days in the studied time periods.
  • Unplanned extubation (UE)–unintentional dislodgement of an endotracheal tube. UE rate is defined as the number of UE's relative to ventilator days in a studied time period.

In January 2018 a multidisciplinary PICU team began educational initiatives to promote PT/OT involvement by day 3 of ICU admission in an effort to increase patient mobilization during critical illness. In September 2020, a formal EM protocol targeting all PICU patients with a length of stay >72 hours was implemented. Deidentified mobilization data were collected via medical records. Patient days, ventilator days, and UE data were collected via the Children's Hospitals' Solutions for Patient Safety Reporting Tool. We compared retrospectively collected data from March-May 2017 as a historical control and March-May 2019 after educational initiatives were introduced, to prospectively collected post EM protocol implementation data from March-May 2022.

SUMMARY OF USE: Over our 3 distinct 3-month time periods we saw a steady increase in the number of mobilization sessions with a corresponding increase in mobilization rate from 14.1 to 54.2 to 115.3 mobilizations/100 patient days across the three study periods. The mean time to PT/OT consult improved from an average of 2.2 days for PT and 3.1 days for OT in 2019 to 1.7 days and 1.9 days in 2022. During the study period the UE rate decreased from 0.85 to 0.75 UE/100 vent days, and no UE occurred during mobilization sessions.

IMPORTANCE TO MEMBERS: Critical illness often leads to reduced muscle strength and worsened physical function that can persist after PICU discharge.1-4 Mobilization can decrease these negative consequences and has been shown to be achievable and safe,2-6 with early mobility protocols suggested to be an important component of PICU care.7 This preliminary study describes how an EM protocol decreases time to PT/OT consult and increases frequency of patient mobilization without increasing UE, which is an adverse event commonly feared to occur with EM. Possible limitations include occasional interruption of data collection due to clinical circumstance and unknown individual patient characteristics or specific PT/OT interventions due to the retrospective nature of the data. These results support ongoing study of how EM can be used to support patient recovery.


Hsu LY, Dusing SC, Lobo MA, McCoy SW, Koziol NA, Jensen-Willett SL, Cunha A, Bovaird JA, Harbourne RT

PURPOSE/HYPOTHESIS: The Sitting Together and Reaching to Play (START-Play) early intervention study showed short- (3 months) and long-term (12 months) positive impacts on cognitive and motor outcomes for infants with significant motor delay. Longer-term effects (2 years), especially during the transition to preschool, were unknown. The study purpose was to evaluate the longer-term effects of START-Play intervention on cognitive and motor outcomes in young children with neuromotor disorders.

MATERIALS AND METHODS: In the original study, participants were assessed at baseline, 1.5, 3-, 6-, and 12-months post baseline. Participants randomly assigned to START-Play received START-Play intervention (twice-weekly home visits for 12 weeks provided by trained therapists) in addition to usual care. In this longer term follow-up, children were assessed at approximately 24 and 36 months post baseline. Due to the impact of COVID-19, 46% of the follow-up assessments were performed virtually rather than in person. Children were assessed via the Bayley-III (in person) or Developmental Assessment of Young Children 2nd Ed (DAYC-2) (virtually); the Gross Motor Function Measure (GMFM); and the Assessment of Problem Solving in Play (APSP). Regression was used to estimate long-term effects. For each outcome, a follow-up intervention effect was estimated that controlled for the child's baseline scores, baseline motor delay level, age at the follow-up assessment, time between the follow-up and baseline assessments, and recruitment site. Due to the limited sample, the analysis was done for the whole sample, but not separated by subcategories. Number of Subjects: Sixty of 112 children in the original START-Play study participated in long-term follow-up (25 usual care, 35 START-Play) across 5 sites. All children were 7-16-months corrected age at baseline, with a motor delay verified by the Bayley Scales of Infant and Toddler Development, 3rd Edition (Bayley-III) (motor scores >1 SD below the mean).

RESULTS: No statistically significant long-term effects were observed. Effect sizes were .19 (cognition), -.11 (gross motor), and .05 (fine motor) for the Bayley-III/DAYC-2, .13 (GMFM-66), .08 (GMFM sitting), and -.21 (APSP).

CONCLUSIONS: START-Play showed positive short-term and long-term impacts on motor, cognitive and problem-solving skills for young infants with severe motor delay, but effects were not retained over multiple years in this sample of children. This may suggest that START-Play does not advance children's longer-term performance; however, results may reflect the relatively low dosage of START-Play, the long gap since START-Play intervention, the impact of other interventions or experiences after START-Play, or uncontrolled impact from the pandemic. Future research on efficacy and retention from a higher dosage or a longer intervention period of START-Play is warranted.

CLINICAL RELEVANCE: 12 weeks of START-Play intervention does not lead to significant retention over 2 years for children with neuromotor delays. Additional research is needed to evaluate the optimal dosage of START-Play intervention. Comparison of intervention studies in development need to incorporate longer-term planning.


Krosschell KJ, Young SD, Maczek E

PURPOSE/HYPOTHESIS: Newborn Screening (NBS) allows for early identification and treatment with disease modifying therapies (DMT) for those with spinal muscular atrophy (SMA) and has been associated with improved motor outcomes. Careful functional outcome selection will allow for effective characterization of motor progression as a newly unfolding phenotype emerges for these infants. The aim of this study was to explore the use of assessments currently utilized by physical therapists (PTs) who have evaluated infants with SMA who were treated early to better understand best practice outcomes for this population.

MATERIALS AND METHODS: International PT experts with knowledge and experience with infants with SMA identified presymptomatically or via NBS were recruited to complete a REDCap survey. Demographics, assessments selected across the 1st 5 years of life, and factors driving selection were collected. Assessment timing and facilitators and barriers to conducting assessments were determined. Data was analyzed using descriptive statistics and correlations (SPSS 23). Number of Subjects: 24

RESULTS: Twenty-four PT experts from the US, Italy and the UK were surveyed. The majority worked in inpatient or outpatient settings, with 58.3% affiliated with a MDA or neuromuscular center, and 37.5% with academia. All worked in clinical settings and 87.5% also affiliated with research settings. PTs had experience with children, adults, or both. Years of practice varied from 0-5 to greater than 21 years. All reported completing motor function assessments on infants diagnosed presymptomatically or via NBS in the last year. PT follow-up frequency varies and appears related to specific DMT. Most evaluations (64%) occur during routine clinic appointments, while some (36%) occur outside of routine clinic visits. PTs (68.8%) report evaluations completed are often limited by time during the clinic visits. Factors reported as driving assessments chosen (in order of priority) include: functional status, age at follow-up, presenting symptoms, age at diagnosis, insurance authorization, SMA type, DMT received, and SMN2 copy number. Both SMA specific and non-SMA specific assessments were utilized, with a blend of normative, categorical, criterion-referenced, timed-function and patient-reported measures.

CONCLUSIONS: Survey results described current assessment practice for infants with SMA diagnosed and treated early and identified barriers and limitations in the current assessment process. Results will inform development of a formal Delphi survey aimed at international clinicians managing infants with SMA to establish a consensus-derived recommendation of functional motor outcomes for this population. Future implementation will be evaluated for standard practice and facilitate data sharing across SMA clinics.

CLINICAL RELEVANCE: Tracking progress in infants with SMA who are diagnosed and treated early using appropriate motor outcomes is essential to assess development over time. As phenotypic expression evolves with DMTs it is imperative that we use the best set of consensus-derived outcomes to characterize the newly evolving phenotype with the least burden on the infant and their family.


Neeley DK

PURPOSE/HYPOTHESIS: The clinical practice guideline (CPG) for patients with congenital muscular torticollis (CMT) recommends physical therapists (PT) classify patients with CMT in 1 of 8 subgroups based on right (R) to left (L) differences in passive range of motion (PROM) and patient age, in months, at initial evaluation. Classification of patients in this way may improve communication and education with the family regarding patient prognosis and assist with future research. Another recommendation from this CPG is the use of standard discharge criteria (SDC), which includes PROM < 5° different R to L, cervical PROM lateral flexion <5° different R to L, cervical AROM rotation <5° different R to L, muscle function scale within 1 point R to L, and head in midline ≥90% of the time. The purpose of this study is to describe the clinical outcomes for a large cohort of patients with CMT based on severity classification.

MATERIALS AND METHODS: Electronic medical record documentation was compared between all 8 CMT classifications groups. Outcomes of interest included average number of SDC met at final visit (SDC-f), average percentage of patients who met all 5 SDC at final visit (SDC-%), average number of appointments (appts), and average length of stay (LoS) (number of days from evaluation to discharge). Number of Subjects: 1317 patients seen over >4 years (01/01/2018 – 06/01/2022) in 9 outpatient PT clinics across the Intermountain Healthcare system with documentation of classification, based on CPG criteria, at evaluation and number of SDC met at final visit.

RESULTS: Grade1 (n=809): SDC-f 4.23, SDC-% 0.618, appts 3.33, LoS 50.87

Grade2 (n=104): SDC-f 3.43, SDC-% 0.365, appts 3.88, LoS 59.42

Grade3 (n=17): SDC-f 2.76, SDC-% 0.235, appts 4.35, LoS 77.21

Grade4 (n=235): SDC-f 4.35, SDC-% 0.668, appts 4.86, LoS 90.27

Grade5 (n=52): SDC-f 4.10, SDC-% 0.558, appts 6.60, LoS 134.26

Grade6 (n=43): SDC-f 3.58, SDC-% 0.372, appts 5.35, LoS 98.81

Grade7 (n=8): SDC-f 3.38, SDC-% 0.375, appts 10.00, LoS 185.87

Grade8 (n=36): SDC-f 4.06, SDC-% 0.528, appts 9.14, LoS 184.62

CONCLUSIONS: In this cohort, 79% of all patients were classified as grade 1 or 4. On average, these patients also met the highest number of SDC at final visit with 4.23 and 4.35, respectively. Patients classified as grade 2, 3, 6, or 7 did not average ≥ 4 SDC at final visit. Number of appointments and LoS appear to increase linearly with classifications except for grade 6 and grade 8, both of which were less than the previous grade.

CLINICAL RELEVANCE: This large cohort study describes clinical outcomes for patients with CMT based on CPG severity grade assigned at evaluation. In general, lower grades resulted in improved clinical outcomes but it appears there are some exceptions to this rule. Additional refinement of the CMT classification and/or SDC may be warranted to improve clinical relevance and adoption into routine clinical care.


Mattern-Baxter K, Talbott M

PURPOSE/HYPOTHESIS: Early assessment and intervention have been shown to improve developmental outcomes for infants at high likelihood for Autism Spectrum Disorder (ASD). Motor delays can negatively impact other areas of development including social-emotional, communication and cognitive development. Comprehensive interdisciplinary evaluations are available at large medical centers, leading to limited access to families in rural areas and during pandemic restrictions.

The purpose of this study was to 1) determine whether motor delays are present in infants ages 6-12 months, and 2) to assess motor skills longitudinally up to age 18 months via telehealth. We hypothesized that motor delays would be present as early as 6-12 months and persist up to 18 months.

MATERIALS AND METHODS: The Telehealth Evaluation of Development for Infants (TEDI) study is a play-based assessment of infant cognition, social communication and gross motor skills designed to be administered via telehealth. The infants were recorded during verbally guided floor play sessions led by a PhD level psychologist. The videos were randomly assigned to and scored by 2 physical therapists (PTs). Assessments were completed at the following time points: initial assessment and every 3 months until the child reached 18 months. The Alberta Infant Motor Scale (AIMS), which is validated for video administration, and clinical observations were completed at each timepoint. The intraclass correlation coefficient (ICC) was calculated for the total AIMS scores to determine interrater reliability for the first 20 videos and has been previously reported. Total AIMS scores were reported as percentages of children who scored ≤25th percentile. Qualitative reporting was based on clinical observations. Number of Subjects: 33 infants (20 males) with a mean (SD) age of 9.62 months (2.01) at increased likelihood for ASD, determined by previous screening concerns in the areas of social, communication or play skills.

RESULTS: The ICC for the total AIMS scores was 0.93, indicating excellent interrater reliability. 63.7% of infants received 3 or 4 assessment, and 27.3% received <3 assessments. 43.7% of infants scored ≤ 25th percentile on the AIMS at the initial assessment, 51.7%, 27.8% and 37.5% at assessment 2, 3, and 4, respectively. 52% of children had decreased tone.

CONCLUSIONS: Integrating the AIMS into an interdisciplinary telehealth evaluation can be completed with high interrater reliability. A high percentage of the infants demonstrated motor delays as early as 6-12 months that were largely consistent over time.

CLINICAL RELEVANCE: Preliminary data indicate that an assessment of gross motor skills using the AIMS can be reliably conducted via telehealth for infants with high likelihood of ASD, motor delays are present at an early age, and they largely persist over time. Motor delays may be an early red flag when assessing an infant for ASD. Motor assessments should be part of comprehensive interdisciplinary assessments and could facilitate early referral to appropriate services, with the potential for improving outcomes for infants living in remote areas and those who cannot access services due to other restrictions.


Molinini R, Choi T, Koziol NA, Stuyvenberg CL, Harbourne RT, Lobo MA, McCoy SW, Dusing SC

PURPOSE/HYPOTHESIS: Emotional Availability (EA) describes the capacity of a parent-child dyad to share an emotionally healthy relationship. START-Play utilizes a parent-therapist approach which may impact EA by enhancing emotional and physical communication between parents and children. The purpose of this analysis was to compare the short-term effect of START-Play vs. Business as Usual (BAU) on EA.

MATERIALS AND METHODS: Five-minute parent-child interactions were videotaped at baseline and 3-months post baseline immediately after START-Play intervention, with parents instructed to “interact with their child as they normally would”. The EA Scale quantified six dimensions of the parent-child relationship, including four adult (Sensitivity, Structuring, Non-Intrusiveness, and Non-Hostility) and two child (Responsiveness and Involvement) EA dimensions. The sum of the adult or child dimensions provided an Adult or Child EA score, respectively, and the combined Adult and Child EA scores provided a Total EA score. All dimensions have a potential score range of 7-29 with a higher score representing more optimal EA. A series of ordinary least square regression models were performed to examine if START-Play had an effect on EA dimensions from baseline to 3 months. Statistical significance was based on α=.05 and Hedges's g calculated standardized group mean differences with 0.20, 0.50, and 0.80 interpreted as small, medium, and large effects, respectively. Number of Subjects: Data were drawn from 81 parent-child dyads (START-Play=42; BAU=39) participating in a clinical trial evaluating the efficacy of a 24 visit, 3-month physical therapy intervention for children with motor delays. Children were enrolled between 7-16 months of age when they were learning to sit. Dyads were included in this analysis if English was spoken by the parent during the parent-child interaction and the same caregiver was present at included visits.

RESULTS: The groups did not differ in EA at baseline. Dyads in START-Play had significantly greater positive change from pre to post intervention in Total EA (Est.=9.56, p=.00, Hedges g=.44), Adult EA (Est.=7.59, p=.00, Hedges g=.53), Sensitivity (Est.=1.93, p=.00, Hedges g=.48), Structuring (Est.=2.55, p=.00, Hedges g=.61), and Non-intrusiveness (Est.=2.38, p=.01, Hedges g=.45). The START-Play group had significant and positive trajectories of Total EA (Est.=7.03, p=.00), Adult EA (Est.=4.63, p=.00), Sensitivity (Est.=1.3, p=.00) and Non-intrusiveness (Est.=1.94, p=.00) scores over time while BAU stayed stable (p's >.07). START-Play significantly increased their Structuring scores (Est.=1.35, p=.01) while BAU significantly decreased (Est.=-1.2, p=.02).

CONCLUSIONS: Adults in START-Play increased their EA scores with small to medium effects while adults in BAU stayed stable or decreased their scores. Child EA dimensions stayed stable, but as the scale is dyadic, an increase in Adult EA infers that the child was a responsive and involving partner during the interaction.

CLINICAL RELEVANCE: Early physical therapy interventions, such as START-Play, have the potential to foster a more physically and emotionally healthy relationship between parents and children.


Pontiff ME, Moreau NG

PURPOSE/HYPOTHESIS: Knee extensor muscle power in children with CP is reduced by 82% as compared to typically developing peers [1]. We recently developed and validated a novel lower extremity test of muscle power for youth with CP, the Power Leg Press (PLP) test. The purpose of this study was to examine the relationships between muscle power produced during the PLP test and muscle architecture in individuals with CP. Given than power is the product of force and velocity [2] and muscle size and fascicle length (FL) determine these respective components of power, we hypothesized that muscle size and FL would explain a significant portion of the variance in muscle power.

MATERIALS AND METHODS: Participants performed 5 inclined power leg presses at 40-50% of their 1-repetition maximum[3] with the concentric portion performed “as fast as possible”. A linear position transducer was attached to the weight bar, and the displacement, total load, and angle of the sled were used to calculate power in watts (W) for each trial. Peak Power (PP) was calculated as the highest power value across the five presses [4]. Muscle thickness (MT) and FL of the vastus lateralis (VL), medial gastrocnemius (MG), and rectus femoris (RF) muscles were obtained using 2-D B-mode ultrasound as well as RF and MG cross-sectional area (CSA). Simple linear and multiple regression were used to examine associations between architectural variables and muscle power and the variance explained (r-squared) (significance <0.05). Number of Subjects: Ambulatory individuals with CP (N = 26; age 19.3 ± 7.8 years; 8 male, 18 females; GMFCS level I/II/III: 4/19/3

RESULTS: PP was positively associated with all architectural variables (p<0.05) except for RF-FL (p=.058). The strongest single predictors of PP were RF-CSA, RF-MT, and MG-CSA which explained 46.4%, 50.8%, and 48.6% of the variance in PP, respectively. FL of the MG and VL explained 17% and 15.2% of the variance in PP. RF-CSA, age, and GMFCS level together explained 71.6% of the variance in PP (p<0.001). RF-CSA, MG-CSA, and RF-FL combined explained 68.8% of the variance in PP (p<0.001).

CONCLUSIONS: Muscle power was significantly associated with lower extremity muscle architecture in individuals with CP with RF-MT alone explaining 50.8% of PP produced during a PLP test. Adjusting RF-CSA for age and GMFCS level resulted in 71.6% of the variance explained in PP. As hypothesized, FL and size of the lower extremity combined explained 68.8% of PP produced during the PLP test.

CLINICAL RELEVANCE: Although muscle architecture is one of the primary determinants of muscle function [5], associations between lower extremity muscle power and muscle architecture have not been explored in CP. The results of the study suggest that muscle architecture contributes significantly to motor dysfunction in individuals with CP as 68.8% of PP is explained by RF-CSA, MG-CSA and RF-FL combined. These relationships should guide resistance training interventions for individuals with CP as improving lower extremity power generation may lead to plastic changes in muscle architecture that could positively impact activity and participation.


Sansare AA, Arcodia M, HReimann H, Jeka JJ, Lee SCK

PURPOSE/HYPOTHESIS: Individuals with cerebral palsy (CP) compensate for deficits in somatosensory and proprioceptive processing1,2 by relying on visual input over proprioception for balance control.3,4 Higher visual reliance is associated with poor balance and development in individuals with CP.5-6 Upweighting, i.e., increasing reliance, on proprioception helps free up vision for high-level use like navigation and obstacle avoidance. It is not known, if children with CP will be able to upweight proprioception and reduce visual reliance if their proprioception is improved. A promising technique to improve proprioception is the use of Stochastic Resonance (SR) stimulation, which uses random, sub-sensory, electrical current to make weak proprioception more detectable.7 The aim of this study is to investigate if SR stimulation improved proprioception and reduced reliance on vision during visually perturbed walking in individuals with CP.

MATERIALS AND METHODS: Fourteen ambulatory individuals (age 16.3 ± 4.3, 8 males) with spastic diplegic or hemiplegic CP with Gross Motor Function Classification System levels I-II and fourteen age-and sex-matched typically developing individuals (TD, age 16.1 ± 4.2) were recruited. SR stimulation was applied to the muscles and ligaments of ankle and hip joint via a constant current stimulator controlled by custom software. An optimal SR intensity during walking was determined for each subject. Subjects walked on a self-paced treadmill in a virtual reality environment that induced a visual fall stimulus in the frontal plane once every 10-12 steps. Subjects completed three trials of two minutes each of SR stimulation (SR) and no stimulation (noSR) in a randomized order. We performed two-way mixed ANOVAs, with group (CP, TD) as between-subject and condition (noSR, SR) as within-subject factors. Our primary outcome measure was medial-lateral center of mass (COM ML) excursion. We hypothesized that COM ML excursion in response to the visual perturbations would be smaller in trials with SR stimulation compared to the noSR trials. Number of Subjects: 28

RESULTS: Our results showed a significant group by condition interaction (p=0.008). Post-hoc tests revealed that there was a significant improvement in the COM response for CP group with SR compared to noSR condition (p<0.001). No significant differences were found for the TD group between noSR and SR conditions (p=0.883). Also, there was a significant difference between CP and TD at baseline i.e., between noSR CP vs noSR TD (p=0.031); and no significant difference with SR stimulation i.e., between SR CP and SR TD (p=0.569), implying that after receiving SR stimulation, the CP group response became more typical of their age.

CONCLUSIONS: Individuals with CP showed reduced response to visual perturbations with SR stimulation, implying that they relied less on visual input for walking balance when their proprioception was augmented via SR.

CLINICAL RELEVANCE: Adding sensory-centric therapies targeted towards improving proprioception to the current standard of care for CP may help in reducing excessive reliance on vision and in turn, translate to enhanced balance and reduced fall risk during walking.


Scott KS, Sakzewski L, Ziviani J, Hyer M, Heathcock JC, Boyd R

PURPOSE/HYPOTHESIS: Diagnosis of unilateral cerebral palsy (UCP) is possible in infancy. Early intervention aimed at improving upper extremity function may optimize participation across the lifespan. The efficacy of UCP-specific interventions in infancy (infant-friendly constraint-induced movement therapy, Baby-CIMT; or bimanual therapy, Baby-BIM) is unknown. Baby-CIMT and Baby-BIM are complex interventions with multiple components. Measuring fidelity of delivery, the extent that interventions are delivered by therapists as intended, is critical to attribute outcomes to key intervention components. Rehabilitation EArly for Congenital Hemiplegia (REACH) was a randomized trial comparing equal doses of Baby-CIMT and Baby-BIM for infants with UCP. REACH interventions were home-based and parent-directed with coaching from a trained therapist. The purpose of this study was to quantify fidelity of delivery and to determine factors impacting fidelity for REACH.

MATERIALS AND METHODS: This prospective correlational study was a secondary analysis of the REACH trial. Home intervention sessions with infants, parents, and therapists were video recorded. The Therapist Fidelity Checklist (TFC) was an intervention-specific checklist of key intervention components developed for REACH. The first delivery of Baby-CIMT and Baby-BIM for each therapist (n=22 videos) and a random sample of 10% of remaining intervention recordings (n=50) were scored using the TFC. The a priori threshold for high fidelity of delivery was >80% (TFC score of ≥13 out of 16). Descriptive statistics were calculated for scored sessions. Spearman's rho was calculated for TFC versus infant age at the start of intervention, manual ability (based on Hand Assessment for Infants), and parent engagement (based on PRIME-G). Number of Subjects: N=95 infants with UCP, aged 3-9 months at the start of intervention, were enrolled in REACH from 5 sites and randomized to Baby-CIMT (n=46) or Baby-BIM (n=49). Study therapists (n=12) completed standardized training for delivering REACH interventions to parents during monthly home sessions.

RESULTS: Fidelity of delivery was high (>80%) for 88.9% of sessions scored. Scores for 8 (11.1%) sessions were classified as moderate fidelity of delivery (56.3-75%). Sessions scored <80% all occurred with infants receiving Baby-BIM and primarily occurred at the intervention midpoint or later. Checklist items related to parent coaching and intervention-specific skills were most often scored lower when fidelity of delivery was <80%. No significant relationships were found for TFC scores versus infant age (p=.054), manual ability (p=.205), or parent engagement (p=.377).

CONCLUSIONS: Fidelity of delivery was high for the REACH trial in most home intervention sessions. Results indicate that some interventions (i.e., Baby-BIM) may be more challenging to deliver as designed over time.

CLINICAL RELEVANCE: Standardized therapist training can result in high fidelity of delivery for complex interventions, such as Baby-CIMT and Baby-BIM. Ongoing monitoring and additional training as needed are important to ensure consistency in delivery over time.


Surkar SM, Gardas S, Willson JD, Lin CC, Bjornson KF

PURPOSE/HYPOTHESIS: Cerebral palsy (CP) is a leading cause of childhood disability that limits the child's walking performance and mobility.1 Despite years of study on identifying muscle weakness and loss of motor control as key factors resulting in gait impairment, this knowledge has not led to innovative and effective interventions for improving walking performance.2 Ischemic conditioning is an endogenous phenomenon to protect an organ against ischemia by exposing the organ to a controlled, short-term, local, sublethal ischemia.3 Remote ischemic conditioning (RIC) is a clinically feasible way of performing ischemic conditioning where alternating, brief ischemia and reperfusion is delivered with cyclic inflation and deflation of a blood pressure cuff on the arm or leg.4 Previously, we demonstrated that when paired with strength training, RIC improves muscle strength in young adults.5 RIC also improves walking speed in stroke population.6 Hence, the purpose of this study was to assess the effects of RIC combined with strength and treadmill training on strength gain and walking performance in children with CP.

MATERIALS AND METHODS: RIC was performed via blood pressure (BP) cuff inflation on the more affected thigh with a pressure of 200 mmHg and sham conditioning with 25 mmHg. RIC/Sham conditioning consisted of a standard dose of 5 cycles of alternating 5 min of inflation and 5 min of deflation. Each participant underwent the RIC or sham conditioning plus bilateral as well as single leg muscle strength and treadmill training for 4 weeks (3 times/week). Strength training consisted of progressive lower extremity training with a training load of 70-80% of 1 RM (6 sets, 6 repetitions/set each session) and with 10% increase in training load from previous visit for the subsequent visits. Treadmill training consisted of 15 minutes of walking with overhead harness with progressive increase in gait speed. Pre- and post-training assessments included 1 repetition maximum (1RM) and 1-minute walk test with self-selected and fast walking speeds. Number of Subjects: This ongoing randomized controlled trial consists of data from 10 children with CP (RIC=6, Sham=4), age=11.94±3.19 yrs, GMFCS levels: I-III

RESULTS: We anticipate to complete 20 children by December 2022. Our preliminary findings suggest that both groups were trained at similar workload over 4 weeks (p=0.97). While both groups gained strength over time (P = 0.01), RIC group showed greater gains in strength (pre- to post-training change in 1 RM= 129.66 ± 20.6 lbs) compared to Sham group (change in 1 RM= 77.5 ± 24.2 lbs). RIC group also showed greater increase in self-selected (pre- to post-training change in walking speed: RIC= 0.27 ± 0.05 m/s vs. Sham= 0.23 ± 0.03 m/s, p=0.049) and fast walking speed (pre- to post-training change in walking speed: RIC= 0.36 ± 0.09 vs. Sham= 0.24 ± 0.07 m/s, p=0.031) as compared to sham group.

CONCLUSIONS: When paired with training, RIC has potential to enhance strength and walking performance in children with CP.

CLINICAL RELEVANCE: RIC is a safe, inexpensive, and clinically feasible method. Hence, it may serve as an effective adjunct to enhance rehabilitation effects in children with CP.

© 2023 Academy of Pediatric Physical Therapy of the American Physical Therapy Association