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

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

Pediatric Physical Therapy 35(1):p 115-160, January 2023. | DOI: 10.1097/PEP.0000000000000991
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Abrams B, Nally MC, Cardella A, Heimes AM, Rodio NJ, Walton LM

PURPOSE/HYPOTHESIS: The purpose of this study was to analyze the impact of prenatal lead exposure on physical and cognitive health outcomes of infants and children across Bangladesh.

MATERIALS AND METHODS: A literature search of ProQuest, ScienceDirect, PubMed, and CINAHL was conducted using the search string: (“prenatal” OR “pregnant” OR “antenatal” OR “fetal”) AND (“children” OR “infants”) AND (“lead exposure” OR “lead toxicity”) AND “Bangladesh”. Search limits: peer-reviewed; research articles (ScienceDirect); articles (Springer Link); published from 2011-2022. Selection criteria: (1) Male and female infants, aged birth to 2 years, and children, aged 2-12, who were exposed to lead during fetal development in Bangladesh; (2) physical and/or health outcomes assessed during infancy or childhood; (3) prospective cohort studies. Studies were independently evaluated for methodological quality by two blinded reviewers using the Scottish Intercollegiate Guidelines Network (SIGN): Cohort Studies Tool.


RESULTS: A total of 450 (N=450) articles were screened for eligibility. Seven (N=7) met selection criteria. Levels of evidence were acceptable (+) to high quality (++). A total of 12,617 mothers and 8,874 infants/children were included. Two studies from Matlab, Bangladesh and five studies from Sirajdikhan and Pabna, Bangladesh were included. Mean age at time of health assessment was birth to age 5. Studies assessed child's fetal lead exposure via mother's urinary lead levels at delivery (N=1), infant/child fingerstick blood (N=4) and/or birth umbilical cord lead levels (N=4) with follow-up. Primary outcome measures were infant/child anthropometric and child cognitive data. One study found significant negative associations between blood lead concentrations and Bayley Scale of Infant Development (BSID) cognitive scores (β = − 2.10, SE = 0.71, p<=005). Another study found significant associations between stunting at 4.5 years of age and blood lead at 14 and 30 weeks gestation (rs=0.64, p<0.001). A 1-unit μg/dL increase in natural log cord blood lead in the presence of stunting was associated with a 2.10 decrease in cognitive scores. There was a significant inverse association between prenatal lead exposure in late gestation and kidney volume in females at preschool age (95% CI: 2.1, 0.049, p=0.041).

CONCLUSIONS: Acceptable to high quality evidence supports the associations between prenatal lead exposure and: (1) infantile/childhood stunting; (2) lower cognitive scores. Limitations included: (1) inconsistent lead exposure measurements and outcome measures; (2) recruitment from two primary cohorts. Further research is needed to identify any further impacts that lead exposure has on the body and the age at which lead exposure affects stunting and cognition the most.

CLINICAL RELEVANCE: PTs in Bangladesh should be aware of potential lead exposure and effects on a child's physical and cognitive abilities and provide community-based education on lead exposure and prevention during pregnancy. Additionally, PTs should screen children for stunting and cognitive delays at a young age to mitigate delays in achieving developmental milestones.


Alghamdi Z, Orlando JM, Cunha A, Lobo MA

PURPOSE/HYPOTHESIS: Infant containers (i.e., equipment that surrounds and contains infants) are a significant component of the infant's environment; most caregivers use them for hours each day (Gee et al., 2020; Carson et al., 2022). Beyond infants' homes, infant containers are used in infant classrooms in daycare centers (Hallam et al., 2018). The American Physical Therapy Association reports that prolonged container use can cause “Container Baby Syndrome” with head shape deformities, developmental delays, and obesity (Avruskin, 2021), despite limited scientific evidence about the effects of containers on infants' health (Jiang, de Armendi, and Smith 2016). This project aimed to systematically evaluate infant containers in terms of the movement and play opportunities they provide and constraints they impose.

MATERIALS AND METHODS: Each container was evaluated by trained researchers to code: 1) infant position in the container (supine/reclined, prone, or upright); 2) whether movement of the head, arms, trunk, or legs was restricted, possible, or encouraged by the design of the container; and 3) the presence and location of toys within the container (i.e., within or out of the infant's reach). Data were normalized to percentage of the total number of containers within each age group, and 25% of the data were recoded for reliability.

NUMBER OF SUBJECTS: Five hundred containers for infants 0-12 months of age were identified through a systematic online search on Amazon.com and other online retail stores including Target and buybuy BABY®.

RESULTS: Intra-rater reliability was 93.8%; inter-rater reliability was 92.1%. A total of 500 containers (e.g., exersaucers, play gyms, and floor seats) were evaluated. Based on the earliest recommended age of use, 57% of the containers were for 0-3 months, 32% for 4-6 months, 5% for 7-9 months, and 6% for 10-12 months. Most 0-3-month containers positioned infants in supine/reclined, most 4-12-month containers positioned infants upright, and few containers overall positioned infants prone. Trunk movement was often restricted due to the incorporation of harness systems; head, arm, and leg movement was typically possible but was not often encouraged. Most 0-12-month containers did not incorporate toys. When present, almost half of the toys in 0-3-month containers were beyond infants' reach; toys in 4-12-month containers were most often within reach.

CONCLUSIONS: Most containers position infants in supine/reclined or upright with few supporting prone positioning. Movement of the trunk is typically restricted by containers, and containers are not often designed in ways that explicitly encourage movement of the head, arms, or legs. Toys are not incorporated in most containers; when present, they are not typically placed to allow for manual interaction in 0-3-month containers.

CLINICAL RELEVANCE: Education about time outside of containers may be especially important for parents of 0-3-month-olds, since most containers target this age, and those containers are the most restrictive of movement and offer limited manual learning opportunities.


Almoadi N, Havens K, Kubo M, Wu TW, Sargent BA

PURPOSE/HYPOTHESIS: Impaired selective motor control is a primary feature of spastic cerebral palsy (CP) that results in lifelong walking limitations. Impaired selective leg joint control can be defined as the inability to move the hip, knee and ankle joints independently, resulting in excessive flexion/extension coupling across the joints. Recent advances in the early detection of CP provide an opportunity for earlier intervention and create a need to identify tasks that may promote selective motor control in early infancy. The objective of this study was to compare the selective leg joint control of spontaneous kicking and supported stepping on a treadmill of infants at high risk of CP monthly from 3 to 9 months of age. We hypothesized that infants at high risk of CP from 3 to 9 months would demonstrate more selective motor control during treadmill stepping compared to spontaneous kicking.

MATERIALS AND METHODS: Each month from 3 to 9 months of age, data from spontaneous kicking in supine and supported stepping on a treadmill (support at the trunk only, no one moved the infant's legs) were collected using inertial sensors and analyzed using three-dimensional kinematics. Kicks/steps were defined as a change of >11.5 degrees into hip flexion, followed by hip extension. Selective leg joint control was quantified for each kick/step using z-transformed Pearson correlation coefficients (ZCC) of hip, knee, and ankle joint angle pairs into flexion and extension. Mixed regression methods using repeated measures were used to analyze hip-knee ZCC, hip-ankle ZCC, and knee-ankle ZCC between tasks longitudinally. Alpha value was set at p=.007 to adjust for 7 comparisons. A less positive or negative ZCC was interpreted as more selective control, and a more positive ZCC was interpreted as less selective control.

NUMBER OF SUBJECTS: 15 infants at high risk of CP, identified by brain insults on neuroimaging, assessed longitudinally from 3 to 9 months of age, corrected for prematurity.

RESULTS: Each month, an average of 7 infants contributed spontaneous kicks and 6 infants contributed treadmill steps. The number of kicks/steps analyzed was 4,036. For each ZCC, a significant group*month interaction was found. The hip-knee ZCC was statistically significantly lower during treadmill stepping from 3 to 4 and 7 to 9 months (more selective control) and was similar between tasks at 5 and 6 months of age. The hip-ankle ZCC was statistically significantly lower during treadmill stepping at 4 to 6 and 8 to 9 months (more selective control) and was similar between tasks at 3 and 7 months of age. The knee-ankle ZCC was statistically significantly lower from 3 to 9 months of age for treadmill stepping compared to spontaneous kicking (more selective control).

CONCLUSIONS: Infants at high risk of CP from 3 to 9 months of age demonstrate increased selective leg joint control during treadmill stepping as compared to spontaneous kicking.

CLINICAL RELEVANCE: Further research is necessary to determine if impaired selective motor control can be remediated with early intervention focusing on tasks to promote selective motor control, such as treadmill stepping.


Ardolino EM, Flores MB, Manella KJ

PURPOSE: To discuss the evidence to support the use of commonly used assessments and interventions in the spina bifida population.

DESCRIPTION: Spina bifida is one of the most common congenital neuromuscular disorders for which children are referred for physical therapy. Yet there are no clear guidelines for the assessment and treatment of children with this diagnosis. Little is known about current trends in physical therapy practice for children with spina bifida. A recent nationwide survey of pediatric PTs asked them to identify impairments, activity limitations, participation restrictions, outcome measures, and treatment interventions for their pediatric patients with SB. The survey gathered qualitative data on current assessment tools and interventions used by pediatric PTs'. Out of a total of 33 assessment tools, 25.12% assessed body functions and structures, 73.49% assessed activities, and 10.7% assessed participation. The psychometric properties of the top 4 assessments has not been established for the SB population. Twenty-four impairments at the body functions and structures level of the ICF model were identified with decreased strength (17.92%), impaired balance (17.69%), and decreased range of motion (15.33%) as the most common. Out of 16 activity limitations, impaired ambulation (22.51%) was the most reported. There were 19 participation restrictions with limited socializing or playing with peers or siblings (22.59%) as the most common. Physical therapists identified 26 different interventions used in children with SB, with strength training (13.17%) and gait training (10.49%) as the most frequent. Four out of five of the most commonly used interventions focused on the activity domain, and only one focused on the impairment domain. When asked about interventions that are effective, but not used because of limited resources or special circumstances 2 themes emerged. First, PTs have knowledge about evidence-based treatment for children with SB but are limited in the treatment they can provide; and second, the most common barriers to implementing evidence-based treatments include access, cost, reimbursement, and caregiver burden. When asked about child, family, or service characteristics that impact the effectiveness of physical therapy interventions for children with SB, PTs overwhelmingly reported that consistent family compliance and carryover of a home program led to better outcomes.

SUMMARY OF USE: There is a large variety of assessment and intervention techniques used by PTs working with this population. More evidence is needed to support the common trends in the assessment and treatment of children with SB. The findings presented here may assist PTs in choosing the interventions that are supported by the strongest evidence. A clinical practice guideline on this topic may assist PTs in choosing the most appropriate outcome measures and interventions for children with SB.

IMPORTANCE TO MEMBERS: Understanding the evidence to support current trends in assessment and treatment in this population can assist PTs in developing the best treatment programs.


Arriaga JE, Lin CC, Gardas S, Surkar SM

PURPOSE/HYPOTHESIS: Children with UCP have difficulty in bimanual coordination that restricts their independence in daily activities.1 Early brain damage leads to deficits in cognitive, sensorimotor, and visual integration that may impair bimanual performance.2-5 While many studies have investigated the contribution of neuromuscular impairments, a knowledge gap persists in the understanding of bimanual coordination deficits at the cortical level. Hence, the goals of the study were to- 1) compare the cortical activation during a symmetric bimanual coordination task between children with UCP and typically developing (TD) children, 2) assess differences in bimanual performance between children with UCP and TD children.

MATERIALS AND METHODS: We used an ecologically valid, cup stacking task, as a symmetric bimanual coordination task with three patterns of varying complexity. Functional near-infrared spectroscopy ((fNIRS), NIRSport, NIRx, Germany)) was used to obtain the activation within the prefrontal cortex (PFC), primary motor cortex (M1), and supplementary motor area (SMA) while children performed the cup stacking task.6 There were total 9 trials of cup stacking. After one practice trial, participants were instructed to complete three trials of each pattern as fast and accurate as possible using both arms. Each trial started with 30 seconds of rest (baseline) followed by 30 seconds between each trial. Cortical activation was determined by changes in oxygenated/deoxygenated hemoglobin concentration. Bimanual performance was quantified as the average movement time across 9 trials. Additionally, children performed the Box and Blocks test (BBT) and Nine-Hole Peg test (NHPT) to assess manual dexterity and speed. Differences between groups for all outcomes were measured with independent t-tests.

NUMBER OF SUBJECTS: Total 24, 12 children with UCP (mean age= 11.8±3.5 yrs, MACS levels I-III) and 12 TD children (mean age= 11.6±3.2 yrs).

RESULTS: There was significantly greater (p<0.05) activation in the left SMA and left PFC in children with UCP, which suggests greater utilization of neural resources for planning and execution of the bimanual coordination task. There was significantly less (p= 0.01) activation in the left M1 in children with UCP compared to TD children, which suggests that children with UCP utilized less motor cortex resources to perform the bimanual coordination task. Children with UCP exhibited reduced bimanual performance as demonstrated by reduced stacking speed (stacking time: UCP= 33.34 ± 12.09, TD= 19.45 ± 4.91 sec, p=0.004), reduced affected hand dexterity (BBT: UCP= 23 ± 11, TD= 53 ± 8 blocks, p=0.001) and reduced hand speed (NHPT time: UCP= 158.73 ± 63.56, TD= 21.82 ± 3.51 sec, p=0.001).

CONCLUSIONS: The heightened activity in SMA and PFC and reduced activation in M1 in children with UCP are potentially due to greater utilization of neural resources for planning and execution of bimanual coordination task in view of motor deficits in children with UCP.

CLINICAL RELEVANCE: Along with task-specific motor interventions, therapeutic interventions should also include sensorimotor and cognitive components to enhance bimanual performance in children with UCP.


Assip BA, Oledzka MM, Sawade SA, Menino L, Janowski L

PURPOSE: Amplified musculoskeletal pain syndrome (AMPS) is an umbrella term for non-inflammatory musculoskeletal pain most commonly seen in childhood and adolescence, and most often affects pre-adolescent and adolescent girls. Assessment of pain related disability and consideration of psychosocial factors as contributors to progress are important components of the evaluation and treatment of pediatric pain. We aim to explore the utilization of objective measures as a means of tracking progress in an outpatient therapy setting in the pediatric population with AMPS.

DESCRIPTION: Characteristics of AMPS include increasing pain over time, disproportional physical disability, and the absence of other causes or structural changes. Primary goals of the multidisciplinary care team for the pediatric patient with AMPS are improving meaningful function in life and return to school and developing a child's skills to cope with pain. Pediatric patients with an AMPS diagnosis referred to our outpatient setting receive an intensive model treatment approach through physical and occupational therapy with a focus on function, pain science education, sensory desensitization, cognitive behavioral therapy, and caregiver education. These treatment approaches, effectively demonstrated through research and clinical experience, often in combination with cognitive behavioral therapy (CBT) create the best outcomes and are built on the foundation of active participation in functional tasks to “re-train” the body to respond to the input it is given with more integrated, functional responses. A variety of objective measures are utilized at the time of evaluation, throughout the treatment plan, and at the time of discharge in this population. We aim to review the objective measures utilized in this population in our setting from 2019-2022 to determine how well they track a patient's progress through the program and determine if a meaningful change in functional status has occurred.

SUMMARY OF USE: Functional patient reported outcome measures such as the Functional Disability Inventory (parent and child forms), Patient Specific Functional Scale, and Yellow Flag Risk Form are objective measures utilized at the time of evaluation, throughout treatment, and at the time of discharge to track progress and guide referrals, if indicated, during the episode of care. These objective measures are utilized to create meaningful functional goals and educate both patients and caregivers about progress/readiness for discharge.

IMPORTANCE TO MEMBERS: Children and their parents who seek treatment of AMPS have seen many specialists and no underlying musculoskeletal cause has been identified. Rheumatologists as well as physical and occupational therapists who have specific knowledge of AMPS and its specialized treatment approach are able to help patients make fairly quick improvements and get back to the activities they enjoyed prior to this diagnosis. In order to continue to understand the impact of pain-related disability in this population and create appropriate treatment plans, optimal assessment tools are imperative.


Boynewicz K, Chroust A, Campbell SK

PURPOSE/HYPOTHESIS: The purpose of this study was to examine the concurrent validity of the NICU Neonatal Network Scale (NNNS) and the Test of Infant Motor Performance (TIMP) scores within the first two weeks of life in infants with neonatal opiate withdrawal syndrome (NOWS).

MATERIALS AND METHODS: Infants were tested in the hospital on the Labor and Delivery floor or the NICU in the first two weeks of life. Atypicality cutoff scores for the TIMP were set at –0.5 SD below the mean. A receiver operating characteristic (ROC) curve and area under the curve (AUC) compared the true positive rate to the false positive rate to determine which NNNS subscales were significantly related to atypical TIMP scores. Optimal cutoff values (Kolmogorov-Smirnov; KS) for those NNNS subscales were used to calculate atypical performance on each respective NNNS subscale. A second ROC-AUC analysis was conducted to determine the total number of atypical NNNS subscales that best related to atypical TIMP scores.

NUMBER OF SUBJECTS: Seventy-one pairs of outcome measures were performed on full term infants (n=71), with (n=28) in the control group and (n=43) infants with NOWS.

RESULTS: 43 infants were categorized as atypical, and 28 infants were categorized as typical on the TIMP. The first ROC-AUC analysis indicated that eight NNNS subscales of attention, handling, self-regulation, arousal, excitability, hypertonicity, non-optimal reflexes, and stress had significantly areas under the curve (all p's < .003). The second ROC-AUC analysis indicated that infants with atypical scores on five or more of the eight NNNS subscales were the best fit for the TIMP data. 41 infants were categorized as atypical on the NNNS, and 30 infants were categorized as typical. Cross-tabulations between atypicality on the NNNS and TIMP indicated that the sensitivity, specificity, positive predictive value, and negative predictive values were 83.72%, 82.14%, 87.80%, and 76.67%, respectively.

CONCLUSIONS: Using the K-S cut-off scores provided by the ROC-AUC analysis for the NNNS subscales and a sum of atypical performance on 5 or more categories of the NNNS, the NNNS subscales were able to identify 84% of infants that were scoring –0.5 SD below the mean on the TIMP. These NNNS subscales include important aspects of infant neurobehavior including attention, self-regulation, arousal, excitability, hypertonicity, and stress cues.

CLINICAL RELEVANCE: Some neurobehaviors can capture the functional motor performance of infants with NOWS with high sensitivity (84%) and specificity (82%). If infants have difficulty with calming, fussiness, display numerous stress cues and struggle to engage with faces and voices, they may also have low TIMP scores. If infants are not having difficulty with those neurobehaviors, they are likely to have typical TIMP scores.


Bailes AF, Harpster K, Greve KR, Dudley J, Yuan W, Kurowski BG, Vargus-Adams J, Mitelpunkt A

BACKGROUND AND PURPOSE: Hemiplegia is the most common topology of cerebral palsy (CP) estimated to occur in approximately 39% of all cases. Diffusion tensor imaging (DTI) is a noninvasive objective tool to identify changes in white matter (WM) microstructure. The objective of this case series report was to explore the association between components of hand function, as measured by the Melbourne Assessment 2 (MA2), with DTI measures in children with hemiplegic CP.

CASE DESCRIPTION: Three children (ages 11, 9 and 6 years) participated. Two were female, one male; two right-sided and one left-sided hemiplegia; and two with the etiology of stroke, one with schizencephaly. All were Gross Motor Function Classification System (GMFCS) Level I and Manual Ability Classification System (MACS) Level II.

Diffusion Tensor Imaging (DTI) was acquired using a 1.5 Tesla Phillips Ingenia MR Scanner and was analyzed using the FSL toolkit (https://fsl.fmrib.ox.ac.uk/fsl). Components of hand function (range of motion, accuracy, dexterity and fluency) were assessed in each hand separately with the MA2. Both DTI and MA2 were completed on the same day. Fractional anisotropy (FA) values of twenty-one regions of interest (ROI) in each brain hemisphere were extracted. Pearson correlation coefficients were computed between the child's MA2 hand function component scores and the FA of each ROI in the contralateral hemisphere.

OUTCOMES: Twelve ROIs demonstrated correlations at or above 0.70 with components of the MA2. One ROI correlated with all four components of the MA2, six ROIs correlated with three components, three correlated with two components, and two correlated with one component. The fluency and range of motion components of the MA2 each correlated with 10 ROIs, accuracy and dexterity each with five. Accuracy was more highly correlated with tracts connecting to visual areas and basal ganglia, whereas dexterity was more highly correlated with regions of motor pathways such as corticospinal tract and posterior limb of internal capsule.

DISCUSSION: These findings suggest further work is warranted to explore relationships between structural connectivity and individual components of hand function as assessed by the Melbourne. The potential underlying association between microstructural integrity and motor function remains unclear but may be a method to quantify changes in components of hand function (dexterity, fluency. etc.) after intervention, as well as elucidating potential target regions for enhancement of brain plasticity.


Bellam P, Lopez C, Forbes SC, Willcocks RJ, Triplett W, Brandsema J, Finanger E, Rooney B, Wang DJ, Barnard AM, Lott DJ, Senesac CR, Walter GA, Sweeney L, Vandenborne KH

PURPOSE/HYPOTHESIS: Duchenne Muscular Dystrophy (DMD) is a progressive muscle-wasting disease predominantly in males. Both Magnetic Resonance Imaging and Spectroscopy (MRI/S) are noninvasive tools that have the potential to monitor biological disease progression in DMD. Both methodologies have the potential to measure fat infiltration in skeletal muscle, an important feature of disease progression in DMD. While MRS is considered the gold standard it is limited by voxel location and position, while Dixon imaging has the advantage that multiple muscles can be examined simultaneously with high spatial resolution.

The purpose of this study was to correlate MR Dixon imaging and MR spectroscopy measures of fat infiltration in biceps and deltoid with functional Performance of Upper Limb (PUL) measurements in DMD.

MATERIALS AND METHODS: Dixon imaging and a 1H-MRS single voxel stimulated echo acquisition mode (STEAM) spectroscopic data were evaluated from the biceps brachii and deltoid muscles at 3T (Philips or Siemens). Muscle function was evaluated using the Performance of Upper Limb test (PUL). The relationship between MRI and MRS fat fraction (FF) was analyzed using Pearson correlation and Bland-Altman assessments. Wilcoxon tests were used to examine longitudinal FF changes.

NUMBER OF SUBJECTS: MRI/S data was analyzed from a natural history study of 144 young boys with DMD (aged 12.47±3.07 years) with one-year follow up in 22 subjects.

RESULTS: Cross-sectional Analysis: The correlation between Dixon imaging and spectroscopic fat-fraction for both biceps and deltoids was significant (p<0.0001, r = 0.83 deltoids vs. r=0.80 biceps). The relationship between the two techniques, MRI and MRS, was supported by a Bland-Altman comparison, indicating that there is good agreement between the two methods. Both MRI/S of biceps and deltoids FF showed a strong (p<0.0001) negative correlation with PUL (r=-0.6 MRI, r=-0.8 MRS biceps and r=-0.7 MRI, r=-0.7 MRS deltoid). Longitudinal Analysis: A total of 22 subjects who took part in a follow-up visit were included in the longitudinal analysis. The annual increase in Dixon fat fraction was negligible in the early ambulatory stage of the disease (p=0.54) but significant in late ambulatory/non-ambulatory participants (p=0.02). Across all participants, PUL measurements decreased by 1.5 points per year.

CONCLUSIONS: Our findings support that MRI/S of the upper extremity muscles is a useful noninvasive technique for monitoring disease progression in DMD. MRS and Dixon are closely related in the upper extremity, and both are strongly correlated with upper extremity function. One possible advantage Dixon imaging has is the ability to image and measure fat-infiltration over entire muscle sections (slices) vs a limited voxel (volume) acquired by MRS.

CLINICAL RELEVANCE: Longitudinal analysis of muscle in DMD determines fat fraction increases slowly in the early ambulatory stage of the disease and more rapidly in the late ambulatory and nonambulatory stage. These MR measures maybe useful in future clinical trials to determine the efficacy of treatment options for children with neuromuscular diseases.


Brandon ZY, Mead CL, Cavallari Camargo ML, Hunt BE, Neeley DK

PURPOSE/HYPOTHESIS: Implementation of a tool that provides information about activity limitations in hospitalized pediatric patients is an important element in understanding the value of hospital care. Currently there are limited options for valid and reliable outcome measures in the pediatric acute care setting. The Activity Measure for Post-Acute Care (AM-PAC) “6-Clicks” Basic Mobility short form has been shown to be a reliable and valid measure in the pediatric physical therapy (PT) acute care setting.1 The AM-PAC form is utilized across the continuum of care for adults to assist with discharge disposition, fall risk, and determining utilization of therapy services & consults.2-4 The objective of this study is to describe the implementation and results of patient outcomes using the AM-PAC Basic Mobility form in a large nonprofit pediatric hospital.

NUMBER OF SUBJECTS: 658 patients (age 3-18) with baseline and discharge AM-PAC scores admitted to the Neurotrauma Unit or the Pediatric Intensive Care Unit within a single pediatric specialty hospital from 10/01/21-04/30/22.

MATERIALS AND METHODS: Training of all pediatric PTs in administration and collection of AM-PAC scores occurred in September of 2021. The AM-PAC was built into our Electronic Medical Record (EMR) and standardized scores on the T-score scale were calculated in the EMR from the raw scores. Daily compliance rate during the data collection timeframe was between 81-91% for children ≥3 years old for each therapy session. Data collected from this cohort included baseline (ADMIT) and discharge (DC) AM-PAC scale scores, scale score change (CHANGE), length of stay in the hospital in days (LOS), and number of therapy visits during the length of stay (NTV). The number of patients who met the Minimal Detectable Change (MDC) of 4.72 with 90% confidence level5 was also included in the analysis.

RESULTS: Data for the entire cohort (N=658) were 49% female, mean age of 11.5 years, ADMIT 35.3, DC 44.1, CHANGE 8.8, NTV 19.6, LOS 12.9, and 60% met MDC. Of note, patients who met the MDC were on average older (12.2 vs 10.6), had a greater NTV (24.1 vs 12.9), and a shorter LOS (12.9 vs 14.2). ADMIT scores were similar between those who met the MDC and those who did not (35.2 vs 35.4).

CONCLUSIONS: AM-PAC 6 clicks proved to be easy and quick to implement with a high compliance rate among pediatric PTs. Patients who met the MDC were older, had shorter lengths of stay, and had more therapy visits than those that did not meet the MDC. ADMIT score did not appear to impact the meeting of MDC. This study is limited by inability to compare groups due to heterogeneity of diagnoses of patients on these units. Further research is recommended for additional utilization of the outcome measure in this setting.

CLINICAL RELEVANCE: The AM-PAC 6 clicks allows for documentation of change in assist needed for functional mobility across an episode of care in the acute pediatric setting. This form can be utilized as a standardized outcome measure to assist with clinical decision making such as frequency of treatment, need for post-acute services, and documenting progress.


Bressler M, Thompson MC, Medley A, Simpkins SD, Poskey G

PURPOSE/HYPOTHESIS: Examine the perspectives of parents of children with disabilities on family-centered care (FCC), family empowerment, and satisfaction with care in north Texas outpatient clinics.

MATERIALS AND METHODS: We used an explanatory sequential mixed methods design consisting of collecting quantitative data first and then explaining the quantitative results with in-depth qualitative data collection and analyses. In the quantitative phase of the study, parents (a) rated the extent of FCC provided by their child's service provider using the 20-item Measures of Process of Care (MPOC-20) questionnaire, (b) completed the Family Empowerment Scale (FES) as a measure of their perceptions of their empowerment levels, and (c) assessed their overall satisfaction with services using the Client Satisfaction Questionnaire (CSQ-8). Three separate multiple regressions were used to examine if any of the five domains of the MPOC-20 predicted family empowerment at the family level, family empowerment at the service system level, and satisfaction with care. Using maximum variation purposeful sampling, a subset of the subjects was selected to participate in the qualitative phase of the study where semi-structured interviews were conducted to explore the specific behaviors of service providers that contribute to empowerment and satisfaction with care.

NUMBER OF SUBJECTS: Ninety-nine parents returned the survey instruments. Eight mothers (a subset of the 99 parents) participated in a one-on-one interview.

RESULTS: Survey response rate was 35.6%. Quantitative data analysis found that family-level empowerment is predicted by two factors: providing general and specific information. Similarly, service system level empowerment is predicted by providing general and specific information, with the addition of coordinated and comprehensive care. Satisfaction with care is predicted by two factors: providing specific information and respectful and supportive care. Qualitative interviews revealed that service providers offering knowledge, skills, resources, and emotional support to mothers appear to be a catalyst for the process of empowerment. Satisfaction with care is impacted by three factors relating to (a) child, (b) structure including the setting and environment, and (c) service provider (connection, communication, commitment).

CONCLUSIONS: Service providers offering mothers individualized knowledge of their children and activities, and providing emotional support were the common behaviors that led to both empowerment and satisfaction of care. Service providers need to effectively communicate individualized knowledge of the child and activities and have adequate interpersonal skills to create a supportive environment for mothers.

CLINICAL RELEVANCE: Service providers can maximize the benefit of their time with families by providing care that is not only family-centered, but additionally fosters empowerment, as families may find certain elements of FCC more empowering than others. Pediatric health care organizations can utilize this information to furtherance a family-centered environment by tackling any identified system level barriers to providing family-centered care.


Brewer AC, Kolobe TH, Jeffries LM, Fagg AH

PURPOSE/HYPOTHESIS: Task specific training is credited with enhancing motor skill acquisition in children but optimal dose for various training protocols remain unclear. Gannotti et al, stated an intervention must first be efficacious before beginning dosing studies.1 This study examined if increasing frequency of training on the Self-Initiated Prone Progressive Crawler (SIPPC), an assisted crawling robotic system, would result in faster skill acquisition and improve proficiency. We hypothesized that infants will learn to use the SIPPC earlier and become more proficient with higher (4x per week) than lower frequencies of training (3x, or 2x per week).

MATERIALS AND METHODS: We used a non-concurrent across individuals multiple baseline single subject design with three groups and a two-week baseline. Infants were assigned to one of three different training frequencies: Four times a week (Group A), 3x per week (Group B), or 2x per week (Group C). We administered the Bayley Scales of Infant and Toddler Development Third Edition (BSID-III) at the beginning and end of the study. The training protocol consisted of three 5-minute trials on the SIPPC for 16 weeks, or less if infants crawled independently before 16 weeks, for a total of 32 - 53 sessions.2 Training sessions occurred in the infants' homes. Baseline and training sessions were videotaped and coded using the Movement Observation Coding Scheme (MOCS). The SIPPC also gathered, in real time, distance travelled. We report descriptive statistics.

NUMBER OF SUBJECTS: Seven typically developing infants, ages 4-7 months.

RESULTS: Infants in group A completed the study in 13 weeks compared to 15 weeks for those in groups B and C. Group A had higher mean MOCS change scores (67.39) than Groups B and C (65.13; 64.94, respectively). The mean total distance travelled by Group A and B was larger (3.07; 3.00 meters, respectively) than Group C (1.01 meters). Group A showed increased BSID-III gross motor scale scores while Groups B and C scores did not change

CONCLUSIONS: Results of this study suggest that increasing task-specific practice opportunities may lead to faster skill acquisition of learning and improved proficiency of movement on the SIPPC. The results indicate that higher frequency SIPPC use is associated with accelerated attainment of postural control and crawling. Further investigation of intensity and motivation to move the SIPPC is needed to further describe the efficient dosing of SIPPC use. These findings, though encouraging, must be replicated with infants at high risk for CP and larger samples.

CLINICAL RELEVANCE: A large body of evidence exists supporting the benefits of prone locomotion. There is a growing need for evidence supporting dosage of intervention to effectively and efficiently meet rehabilitative needs. Results of this study impact early intervention practice, in that they provide support for using higher frequency practice in improving earlier and more proficient motor skill attainment. This study's results highlight the importance of clinician use of task specific outcome measures to track skill attainment over time.


Brown SE, Inamdar K, Molinini R, Miller M, Salgaonkar A, Dusing SC

PURPOSE/HYPOTHESIS: Children with moderate to severe motor impairments are often require more time to generate their own motor experiences to explore and learn. Their parents often provide different opportunities compared to parents of peers who are typically developing. Parent-provided motor based problem-solving interventions, such as Sitting Together and Reaching to Play (START-Play) can effectively change developmental skills in very young children. The aims were to 1. determine if developmental skills improve during motor-based problem-solving intervention in a young child with cerebral palsy (CP), and 2. compare changes in developmental skills and retention of skills between therapist-delivered intervention (TDI) and parent-delivered (START-Play) intervention (PDI).

MATERIALS AND METHODS: A single subject experimental design using an A-B-C design with 5 assessments per phase. Bayley Scales of Infant and Toddler Development, third edition (BSID-III) raw scores were used to assess change in cognitive, language and motor skills. BSID-III was administered twice in Phase A and thrice in Phases B and C which were each 12 weeks. Additional outcome measures are not reported here. Phase A was a 5-week baseline. Phase B included TDI using START-Play principles. Phase C included PDI using principles learned in Phase B. The 2-standard deviation (SD) band and the Percent of Non-Overlapping Data (PND) methods were used to determine if there was an intervention effect (defined as a change in raw scores of each domain across phases and over time) and if the effect was sustained.

NUMBER OF SUBJECTS: A child with spastic bilateral CP, aged 30 months, classified at Gross Motor Functional Classification Systems level 4.

RESULTS: In TDI, 100% of cognitive and fine motor scores, and 67% of receptive language scores were greater than 2SD from baseline. In PDI, 67% of cognitive and fine motor, and 100% of receptive language scores were greater than 2SD from baseline. Only 1 of the 3 gross motor scores increased above 2SD in both TDI and PDI and no change in expressive language score was found. An intervention effect was further supported with the PND method demonstrating 100% of data points in cognition and fine motor, and 67% of points in receptive language being higher than baseline during TDI. Ongoing skill improvement during PDI was supported with 67% of points in cognitive and receptive language domains being above TDI. Rate of change was similar in TDI and PDI for cognition.

CONCLUSIONS: Cognitive, receptive language, and fine motor abilities of a 30-month-old child with spastic bilateral CP and GMFCS level 4 abilities can make statistically significant gains over time using motor-based problem-solving intervention with twice weekly visits for 12 weeks with a therapist and can potentially continue to gain with parent delivering intervention.

CLINICAL RELEVANCE: Using motor-based problem-solving intervention shows developmental skill improvement of a young child with spastic bilateral cerebral palsy with ability level of GMFCS 4.


Brummett MN, Isom A, Banik GM, Harris N

PURPOSE/HYPOTHESIS: The aim of this research report was to determine how common factors such as tummy time, screen time, and toy stimulation affect gross motor development in typically developing children, and identify opportunities for a physical therapist to educate caregivers on ways to encourage typical development in children five years and younger.

MATERIALS AND METHODS: A comprehensive literature search was conducted from February 2022 to May 2022 using PubMed, Scopus, CINAHL, and Cochrane databases. A total of 377 articles were found. To narrow the search, duplicate articles were eliminated, and abstracts were read to screen for any exclusion criteria. Once the first screen of articles occurred, the remaining articles were read in full to ensure they met the inclusion criteria and answered the research question. This process resulted in 22 relevant studies. Inclusion criteria included: research published within the past five years and in English, studies involving typically developing human subjects, and information regarding gross motor development. Exclusion criteria included: research involving children with intellectual or developmental disabilities, and children included in studies over the age of five years old.

NUMBER OF SUBJECTS: Typically developing children aged zero to five years old.

RESULTS: The three major modifiable factors within the home include the amount and quality of tummy time, limiting sedentary behavior with restraining devices and screen time, and meaningful playtime with exposure to toys.

CONCLUSIONS: The recommendation for tummy time in children under six months old is more than 30 minutes of supervised tummy time per day. Additionally, children under two years old should receive no screen time, and children two to three years old should receive fewer than 60 minutes of screen time per day with exposure only to education-based programs. Children three to five years old should receive fewer than 60 minutes of screen time per day with exposure only to education-based programs and fitness programs to increase daily physical activity. Lastly, children under five years old should have maternal interactions involving reading books, telling stories, singing songs, drawing, and counting. It is beneficial to create a play environment with access to toys of different textures, colors, sounds, and with different functions. A child will have a greater opportunity to develop gross motor skills with at least 73 minutes a day of free movement, 34 minutes per week of outside play, and 26 minutes of interaction with other children.1-7.

CLINICAL RELEVANCE: Overall, clinicians working with children ages 0-5, should discuss the role and influence that parents have with their child's gross motor development. Furthermore, healthcare professionals have valuable opportunities to educate the importance of the home environment and equip parents with strategies to implement the recommendations found in this literature review.


Burroughs CL, Dettor PN, Gardas S, Lysaght CR, Surkar SM

PURPOSE/HYPOTHESIS: Hand Arm Bimanual Intensive Therapy (HABIT) a well-established intervention to improve the affected upper extremity (UE) function and bimanual coordination in children with unilateral cerebral palsy (UCP).1 Traditionally, the improvements in UE function are assessed with standardized tests that measures UE capacity.2 However, there is conflicting evidence whether improvements in UE capacity translate to enhancing performance of the real-world bimanual activities in children with UCP.3,4 Furthermore, there is a substantial knowledge gap in understanding the long-term effects of HABIT in retaining the real-world bimanual performance. Accelerometry has emerged as a reliable and valid method to measure UE performance in daily life.5 Hence, the purpose of this study was to examine the effects of HABIT on the immediate gains and long-term retention of real-world bimanual performance using accelerometers in children with UCP.

MATERIALS AND METHODS: Children received 30 hours of HABIT (6 hrs/day for 5 days). In this longitudinal study, children wore GT9X Link accelerometers on bilateral wrists for 3 days pre-, post-, 3-month, and 6-month of HABIT protocol. We quantified bimanual performance using accelerometer variables– use ratio (UR), magnitude ratio (MR), bilateral magnitude (BM), and median acceleration (MA). UR and MR quantifies the contribution of the affected UE to bimanual activities and intensity of the affected UE movements, respectively.6 BM and MA quantify the intensity of bilateral UE and affected UE movements, respectively.6 We assessed change in UE capacity using Assisting Hand Assessment (AHA), box and block test (BBT), and 9-hole peg test (NHPT) pre- and post-HABIT using paired t-test. Immediate gains in bimanual performance were assessed with pre- and post-HABIT changes in UR, MR, BM, and MA using paired t-test. Long-term retention of bimanual performance was assessed by analyzing the differences in UR, MR, BM, and MA at pre-, post-, 3-month, and 6-month time points using mixed model ANOVA.

NUMBER OF SUBJECTS: 11 children with UCP (age= 12.2 ± 3.3 yrs; M=8, F=3), Manual Ability Classification System levels I-III.

RESULTS: There was a significance improvement (p<0.05) from pre- to post-HABIT in UR (pre=0.73±0.13, post=0.78±0.10), MR (pre= -1.94±2.1, post= -0.99±0.52), BM (pre=98.5±23.2, post=115.4±19.2) and MA (pre=18.81±13.1, post=28.30±13.8) indicating improvements in real-world bimanual performance immediately after HABIT. There was also a significant improvement (p<0.05) in UE capacity measures indicating enhanced UE bimanual coordination, speed, and dexterity. There was a significant main effect of time (p<0.05). Post-hoc analyses suggest progressive decrease in UR, MR, BM, and MA at 3 and 6 months compared to post-HABIT, which suggests decline in bimanual performance within 3 months and nearly reached baseline level at 6 months after HABIT.

CONCLUSIONS: HABIT has potential to improve the performance of real-world bimanual activities; however, the effects of HABIT start declining within 3 months.

CLINICAL RELEVANCE: Although HABIT improves bimanual performance, it needs to be repeated every 3-6 months to retain bimanual performance gains.


Byrnes J, Russo JE, Winterbottom L, De Martini N, Shatsky N, Spinner M, Bellissimo E, Kim H, Gannotti ME, O'Neil ME

BACKGROUND AND PURPOSE: Cerebral palsy (CP) is the most prevalent motor disability of childhood.1 Ambulatory adults with CP have high risk for gait deterioration, increased sedentary lifestyle and associated comorbidities.2-4 With aging, negative cycles of inactivity ensue which worsens the condition (e.g., contractures, pain, fatigue).2-7Adults with CP have limited access to physical therapy (PT) and health promotion services. A tele-rehabilitation program may provide tailored exercise to increase fitness and functional mobility. This study aims to describe and examine the feasibility and effectiveness of a telehealth rehabilitation home exercise program (TRHExP) to achieve individual goals on fitness and mobility for ambulatory adults with CP. Additional study objectives included assessing accessibility and adherence.

CASE DESCRIPTION: Six adults with CP enrolled in TRHExP (mean age: 27 yrs, SD: 6.9 yrs) with two adults in each of three GMFCS levels (I – III) and 66.67% female (n=4). Participants completed a 10-week TRHExP via Zoom™ (week 1: baseline session; weeks 2-8: exercise program with weekly virtual check-in; week 10: endpoint session). TRHExP components: tailored, goal specific interventions, weekly exercise coaching to progress interventions using activity logs for adherence and safety. Weekly questionnaires were administered for participants to elaborate on open-ended items and to identify themes on adherence, accessibility, and fitness. TRHExP required 150 mins/week of tailored exercise and physical activity based on participants' functional goals. The primary outcome measure was the modified Canadian Occupational Performance Measure (mCOPM) for tailored fitness and mobility goals.⁶ Secondary outcome measures: PROMIS surveys, motor performance measures and program evaluation.

OUTCOMES: Five participants completed the TRHExP (83.33% adherence). Participants identified 2-5 goals on the mCOPM (total =17). The mCOPM satisfaction change scores (min: 2.3 – max: 6) exceeded the MCD (2 points) for all participants; performance change scores (min: 1.4 – max: 5.7) exceeded the MCD for 94% of participants.⁶ PROMIS and motor performance outcomes showed no trends for significant change. Participants performed their tailored programs on average 5/7 days/week. 45.83% of participants achieved ≥150 min/week of TRHExP exercise and physical activity. Thematic analysis of open-ended items suggested that participants identified accessibility barriers (e.g: pain, fatigue, time, sickness and other life incidents) and facilitators (e.g: motivation, goal achievement). Participants reported increased fitness levels (e.g increased strength, stability, balance).

DISCUSSION: Participants reported that the TRHExP provided them with exercises specific to their goals and abilities. They rated their fitness levels as higher after the program despite little change in motor performance items. This discrepancy may be due to limited duration and dosing of the TRHExP to achieve change in performance. Participants reported that the TRHExP was accessible, feasible and effective. They indicated they would enroll again and invite friends to enroll.


Cardosi SM, Milner C, Smyles J, Yurick LE, Norquist NS, Krosschell KJ, Trenkle JM

PURPOSE/HYPOTHESIS: Children with spinal muscular atrophy (SMA) have limited opportunities for access to exercise that is fun and motivating. As the lifespan of children with SMA improves, there is a presumed need for them to have access to aerobic exercise, although additional research on potential benefits is warranted. Understanding aerobic exercise preferences, enjoyment and access may better facilitate participation. The purpose of this study was to examine attitudes toward exercise and exergaming in children with SMA and to gather their initial insights on an interactive arm ergometer prototype for a future study.

MATERIALS AND METHODS: Semi-structured interviews were conducted of parent-child dyads over Zoom by one interviewer. Discussions were centered on attitudes towards exercise, technology, gaming and participants' opinions on the arm ergometer prototype. Recordings were analyzed and coded for themes, and similarities and differences across individuals.

NUMBER OF SUBJECTS: 5 children between the ages of 8 and 15 with Type II SMA and their parents.

RESULTS: Interview participants were 40% female with a mean age of 11 (range 8-15). Themes emerged around exercise habits, design and media considerations, and prototype usability. Consistent positive aspects of exercise reported included feelings of freedom when provided with supports to increase activity and social participation. Negative aspects included the challenge of exercise and access to age-appropriate options and resources for success and enjoyment. Preference for mode of exergaming, types of games preferred and modifications for access varied, but all reported a likely increase in motivation for exercise if paired with technology. With the pairing, participants stated, “I think it'd make it a lot more fun and enjoyable. It'd probably take my mind off it too, like the hard part,” and “I'd probably do it more like, like more often.”

CONCLUSIONS: Community participants offered insight into their motivators and barriers for exercise as well as provided initial opinions on the arm ergometer prototype. Additionally, interviewee feedback was essential in determining the ideal number and ease of use of the controls of the ergometer. Overall, participants were interested in the ergometer and saw it as a feasible, accessible, and potentially enjoyable mode for exercise. Engaging consumers early in the design process and considering their feedback may enhance study feasibility, prototype design, and success.

CLINICAL RELEVANCE: Currently, there is limited information on the access to and participation in aerobic exercise for children with SMA. By interviewing children with SMA and their parents, we gained meaningful information about exercise, electronic gaming, and the ergometer prototype. This information, along with ongoing surveys regarding aerobic exercise in children and adults with SMA, will guide the development of an exergaming ergometer program for individuals with SMA in an upcoming study, with a goal to promote aerobic activity. This study also engaged with the targeted community to increase buy-in for the future study.


Castilla A, Gonzalez M, Kysh L, Sargent BA

PURPOSE/HYPOTHESIS: The purpose of this systematic review is to evaluate current evidence on the physical therapy (PT) assessment, intervention, and prognosis of congenital muscular torticollis (CMT) to inform the update to the 2018 CMT Clinical Practice Guideline (CPG).

MATERIALS AND METHODS: From January 2017 to June 2022, 6 databases were searched for studies that informed assessment, intervention, and prognosis for PT management of CMT. Risk of bias was assessed.

NUMBER OF SUBJECTS: Fourteen studies were included.

RESULTS: Fourteen studies were included: 4 informed assessment, 6 informed intervention, and 4 informed prognosis. Participants included 2,800 children aged 0 to 2 years with CMT. Results from assessment studies supported the reliability of Still Photography to measure habitual head tilt and the Muscle Function Scale (MFS) to measure cervical lateral flexion strength. In addition, the psychometrics of two new assessments were studied: the reliability of the Therapy Behavior Scale, version 2.2, to measure infant behavior and the content validity of the Functional Symmetry Observation Scale, version 2, to measure spontaneous posture and movement. Results from intervention studies supported that passive stretching was more effective than thermotherapy or active or active assist range of motion (ROM) for improving passive cervical rotation ROM, PT intervention may minimize asymmetrical mandibular height, and parents of children with mild and severe CMT have different concerns that need to be addressed. Results from low quality studies on supplemental interventions informed the efficacy of Traditional Chinese Massage compared to stretching and the feasibility of neural and visceral manipulation. Results from prognostic studies supported that treatment duration was correlated with age of initiation of PT and passive cervical lateral flexion ROM restriction; the first 3 grades of the CMT Severity Grading Scale were correlated with PT units billed, treatment duration, and total visits; infants with CMT who initiated PT but were lost to follow up, versus those who completed PT with discharge criteria met, had higher age at initial evaluation and more differences between sides in passive cervical ROM and MFS; infants with CMT who received supplemental interventions, compared to only first-choice interventions, were older at initial evaluation, had greater differences between sides in passive cervical ROM and MFS, and had a longer treatment duration; and more infants with CMT who were insured by Medicaid, versus private insurance, had unresolved habitual head tilt at discharge.

CONCLUSIONS: For children aged 0 to 2 years with CMT, this review provides new evidence on the psychometric properties of assessments, the feasibility and efficacy of first-choice and supplemental interventions, experiences of parents of infants with CMT, and prognostic factors associated with treatment duration, clinical outcomes, and use of supplemental interventions.

CLINICAL RELEVANCE: Revision of the 2018 CMT CPG may be needed to reflect new evidence on PT assessment, intervention, and prognosis of CMT.


Cheney M, Gosselin DJ

PURPOSE/HYPOTHESIS: Participation is “involvement in a life situation.” Real-life environments are often complex and multi-dimensional; however, most clinical assessment tools do not directly measure a person's performance in these types of environments. The primary purpose of this scoping review was to review the literature related to children with cerebral palsy, to identify clinical gait assessment tools that measure the International Classification of Functioning, Disability and Health (ICF) domain of participation. The secondary purpose was to determine if measures of participation have been increasingly used over time.

MATERIALS AND METHODS: JBI Reviewer's Manual guidelines were utilized. A web-based search, not limited by dates, of two databases (PubMed and SCOPUS) was conducted. The authors screened titles and abstracts applying the a priori selection criteria. All outcome measures used in included studies were extracted for data analysis where ICF domain was assigned.

NUMBER OF SUBJECTS: 501 studies were included in this scoping review. Inclusion criteria were observational cohort studies that reported the use of one or more clinical gait assessment tool(s) and included children (aged 0-21 years) who were ambulatory and had a formal diagnosis of cerebral palsy.

RESULTS: The database search yielded 2281 records of which 501 met the inclusion criteria. Over 80 unique clinical gait assessment tools were identified; however, very few (12%) assessments measured the ICF domain participation. The number of studies that utilized clinical gait assessment tools has increased historically. The first study to utilize a tool that measures participation was in 2003 and utilization of measures of participation has slowly increased over the past 20 years.

CONCLUSIONS: Many clinical gait assessment tools for children with cerebral palsy are available; however, the majority of those do not measure participation. This review demonstrated that there is a historical trend towards increasing utility of clinical gait assessment tools that have some measure of participation.

CLINICAL RELEVANCE: It is rare that assessment or intervention occurs in a real-life environment and there is a known discrepancy between how a child with cerebral palsy performs in a clinical environment compared to a real-life environment. One mechanism for bridging this discrepancy is having access to assessment tools that provide reliable data about how children perform in a real-life environment; however, these types of tools are uncommon. Development of additional assessment tools that measure participation will directly allow measurement of progress towards participation and may have the secondary benefit of providing important information to be considered in the development of the plan of care.


Chiarello LA, Shubaily R, Terhune HD, Ideishi R, McLarnon M

PURPOSE/HYPOTHESIS: The objectives of the study were to determine parents' perception of their children's engagement during pediatric rehabilitation therapy sessions and to examine the reliability and validity of the PRIME-PC measure.

MATERIALS AND METHODS: The PRIME-PC is a 4-item, parent-completed measure of a child's overall, affective, cognitive, and behavioral engagement during therapy sessions. Items are rated on a 4-point Likert scale. Parents completed the measure at the end of a therapy session and again after a second therapy session, 2-14 days later. Parents also completed the PRIME-P, a measure of parent engagement. A subset of providers completed the PRIME-SP, a service provider measure of client engagement. Both the PRIME-P and PRIME-SP were completed on the same occasions as the PRIME-PC. We estimated test-retest correlations using a robust complex sampling procedure to account for multiple clients being nested within service providers, which violates typical assumptions of independence. Pearson correlations were used to examine associations between parents' rating of children's engagement and parents' rating of their own engagement, parents' education, service providers' rating of child's engagement, service providers' years of experience, and child's age. A paired t-test was conducted to examine difference between parents' and service providers' ratings of child's engagement.

NUMBER OF SUBJECTS: 78 parents of children, 4 months to 17 years of age (M=4.9, SD=3.99) and 54 service providers (PTs, OTs, SLPs) across early intervention and outpatient settings in the U.S. and Canada participated.

RESULTS: Parents rated children with high engagement scores, (M=3.6, SD=0.51). Test-retest reliability indicated consistency, r=0.67, p<.001 (95% CI=.49–.85). Parents' rating of child's engagement had a moderate association with parents' rating of their own engagement (r=0.40, p<.01) and service providers' rating of child engagement (r=0.39, p<.01). There were no significant correlations between parents' ratings of children's engagement and parents' education, service providers' years of experience, and children's age. Parents' rating of child's engagement (M=3.5, SD=0.54) was significantly higher (p<.001) than service providers' rating of child's engagement (M=3.1, SD=.65).

CONCLUSIONS: Parents typically perceive their children as highly engaged during therapy sessions. The findings provide preliminary support for the PRIME-PC as a reliable and valid tool that can be used to gather parent feedback on children's engagement. Research is needed to further substantiate validity and the utility of the measure in practice.

CLINICAL RELEVANCE: Gathering parent's input on their child's engagement during therapy sessions is important for fostering a parent-professional partnership and collaborating on a meaningful service plan. Service providers can use the PRIME-PC to engage parents in discussions on their expectations, understanding, and insights regarding their children's involvement and investment in therapy services.


Crandall RG, Kobayashi K, Neeley DK, Minick K

PURPOSE/HYPOTHESIS: Patient reported outcome measures (PROMs) can provide insight into the value of physical therapy (PT) services and guide clinical decision making. Currently there are no validated PROMs specific to Congenital Muscular Torticollis (CMT). To address this gap in clinical practice, we began a quality improvement (QI) project to develop the Torticollis Specific Function Scale (TSFS). This PROM includes three questions, completed by proxy caregiver, on a scale of 0-10. Questions include perception of the child's ability to rotate neck, hold neck in midline, and perception of head shape. The lowest possible score on this survey is a 0 (poor perception of condition) and the highest possible score is a 30 (best perception of condition). This study is a retrospective review of TSFS data collected as part of a QI project and how it correlates to CMT severity classification as indicated by the American Physical Therapy Association (APTA) Clinical Practice Guideline (CPG).

MATERIALS AND METHODS: Patients were classified by PTs at initial visit as having mild (n=387), moderate (n=46), or severe (n=8) CMT using the APTA CPG criteria. The patient's caregiver completed the TSFS PROM at every visit throughout the episode of care. Discharge from episode of care was determined by PT based on CPG criteria or failure to return for follow up.

NUMBER OF SUBJECTS: 441 patients seen at 9 outpatient pediatric PT clinics within one pediatric hospital system over 27 months (08/2019-12/2021).

RESULTS: Initial TSFS scores differed for mild, moderate, and severe CMT patients at 16.94, 14.83 and 14.25 respectively. At final visit, TSFS scores were similar for mild, moderate and severe patients (22.43, 20.93, 22.13). Average percentage of patients who met all 5 standard discharge criteria (SDC) on final visit were 68%, 39%, and 50% respectively for mild, moderate and severe classification. A point-biserial correlation with TSFS score being a continuous variable and all SDC met yes/no (dichotomous variable) revealed a significant correlation at final visit for SDC met and TSFS score for patients classified as mild (r=0.30751, p=<.00001) and moderate (r=0.35621, p=.01511) but not severe (r=0.56145, p=.14759).

CONCLUSIONS: The TSFS score at final visit has a significant correlation to meeting discharge criteria for patients classified with mild or moderate CMT. This finding may help guide clinical decision-making regarding timing of discharge for patients being seen with CMT. Additional research is needed to determine psychometric properties of the TSFS and the strength of the correlation reported here.

CLINICAL RELEVANCE: TSFS scores may be a way for clinicians to monitor patient progress across an episode of care. Additionally, it may help guide clinical decision making related to timing of discharge for patients classified as mild or moderate severity CMT.


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

PURPOSE/HYPOTHESIS: The purpose of this study was to measure executive function (EF) skills at the age of 4 years (Mean=48.65 months, SD=3.02) in a sample of children with motor delays and relate these skills to children's early and concurrent cognitive, language, and motor skills. We expected that early global development might impact future EF skills.

MATERIALS AND METHODS: Participants were assessed by the Bayley-III at baseline, and 3-, 6-, 12-, and 36-months post-baseline, and the Minnesota Executive Function Scale (MEFS) at 36 months post-baseline. Scaled scores were used for the Bayley and MEFS. Hierarchical Linear Modeling (HLM) was conducted to relate longitudinal trajectories (baseline, and 3, 6, 12 months post-baseline) for Bayley scores (Cognitive, Receptive Language, Expressive Language, Fine Motor, and Gross Motor subscales) to MEFS at 36 months post-baseline; and Pearson correlation analyses to relate Bayley subscales at 36 months post-baseline to MEFS at 36 months post-baseline.

NUMBER OF SUBJECTS: Fifteen children enrolled in the START-Play randomized controlled trial participated in this study. Upon initial enrollment, they were between 7 to 16 months prematurity-corrected age at baseline (Mean=10.76, SD=2.55) and demonstrated motor delays (i.e., scoring >1 SD below the mean on the gross motor subscale of the Bayley Scales of Infant and Toddler Development, third edition, Bayley- III).

RESULTS: HLM showed that MEFS scores at 36 months post-baseline significantly related to the longitudinal trajectories for Bayley Cognitive scores (β=1.84, t(54)=3.00, SE=0.61, p=.004), Receptive Language scores (β=1.80, t(54)=2.56, SE=0.70, p=.013), Expressive Language scores (β=2.00, t(54)=2.74, SE=0.73, p=.008), and Fine Motor scores (β=1.76, t(54)=2.48, SE=0.71, p=.016), but not for Gross Motor scores (β=0.17, t(54)=0.20, SE=0.88, p=.841) – for all significant relations, across all visits, higher early Bayley scores were associated with higher MEFS scores at 36 months post-baseline. Concurrent relation of Bayley scores at 36 months post-baseline to MEFS scores at 36 months post-baseline showed significant correlations (using the Bonferroni corrected alpha=.01) for Cognitive scores (r(11)=.68, p=.011), Expressive Language scores (r(11)=.71, p=.006), and Fine Motor scores (r(11)=.70, p=.008), but not for Receptive Language scores (r(11)=.64, p=.019) or Gross Motor scores (r(11)=.36, p=.251).

CONCLUSIONS: These results suggest that early fine motor, cognitive, and expressive language skills may serve as important precursors for developing EF skills.

CLINICAL RELEVANCE: The evaluation of EF skills is especially challenging in young children with motor delays. The identification of precursors to emerging EF skills can support early identification and intervention practices to address EF impairments in at-risk populations.


Dempsey KL, Peavy SE, Scales MH, Vallabhajosula S, Collins N

PURPOSE/HYPOTHESIS: Idiopathic Toe Walking (ITW) is a condition where individuals exhibit a habitual forefoot-strike gait pattern without orthopedic or neurologic explanation. Literature suggests that ITW typically resolves by adolescence. However, anecdotally, some children with ITW continue to toe-walk into adulthood. The purpose of this study was to compare gait parameters from children with ITW and adults with a history of ITW to their respective age-matched Controls to determine if gait alterations in childhood persist into adulthood. Previously, children with ITW have been shown to have decreased dorsiflexion range of motion (ROM), spend less time in the double support phase of gait, and exhibit shorter center of pressure (COP) distance during single support phase compared to children without ITW. It is hypothesized that adults with a history of ITW will demonstrate similarly altered gait parameters compared to their age-matched Controls, suggesting that ITW may not resolve into adulthood, as literature currently suggests.

MATERIALS AND METHODS: Dorsiflexion ROM was assessed using a goniometer. Subjects walked six lengths of a 16-foot electronic walkway system at a typical pace. Average double support phase % and COP distance during the single stance phase were analyzed. Separate independent samples t-tests were performed to compare Controls to individuals with ITW for children and adults.

NUMBER OF SUBJECTS: 34 total children ages 2-8 years old (20 children with ITW, 5.9±1.7 years; 14 age-matched Controls, 6.1±1.9 years) and 14 total adults ages 20-34 years old (7 adults with history of ITW, 26.9±5.3 years; 7 age-matched Controls, 26.7±5.3 years) were recruited. They reported no neurological diagnoses, no current therapies, and no surgeries.

RESULTS: Dorsiflexion ROM was significantly decreased in both children (ITW: right, 9°±7.2 & left, 10.5°±9.1; Control: right, 21.3°±4 & left, 21.3°±5.3; both P<0.001) and adults (ITW: right, 8.9°±3.8 & left, 7°±4.5; Control: right, 17.4°±4.7, left, 17.6°±4.1; P<0.003) with ITW. Similarly, COP distance was significantly lesser in children (ITW: 9.2cm±2.7; Control: 11.7cm±2; P=0.01) and adults (ITW: 8.5cm±3.9; Control: 14.1cm±1; P<0.01) with ITW. Double support phase % was significantly decreased in children with ITW (ITW: 18.5%±2.2; Control 20.5%±2.5; P=0.03) but not in adults with ITW (ITW: 20.8%±1.6; Control 20.3%±2.8; P=0.7).

CONCLUSIONS: As children with ITW age into adulthood, they may adjust their kinematics to produce a more normalized gait pattern. However, adults with a history of ITW continue to exhibit decreased dorsiflexion ROM and the inability to achieve typical foot contact throughout their gait cycle.

CLINICAL RELEVANCE: ITW may not resolve in adolescence as previously reported in literature. Adults with a history of ITW may continue to have decreased ankle ROM and demonstrate an altered foot contact pattern during gait. This may suggest that continued physical therapy may be required as children with ITW age. PT checkups may be indicated for children with ITW as they age into adulthood.


Duijn AJV, Donald EK, Reyes J, Berris S

PURPOSE/HYPOTHESIS: Children with neuromuscular disabilities including cerebral palsy experience a variety of musculoskeletal impairments resulting in an abnormal gait pattern. The Therasuit Method™ is a treatment program that utilizes a system of elastic cords aiming to correct the patient's positioning and promote a more optimal gait pattern. The aim of this multiple single subject design study was to examine the immediate changes in pelvic and hip joint kinematics and changes in gait dynamic parameters when wearing the Therasuit™ compared to not wearing the suit.

MATERIALS AND METHODS: Three ambulation trials without the Therasuit™ and three trials wearing the Therasuit™ were performed. Hip and pelvic joint kinematics and dynamic parameters while walking were collected by the Qualisys Motion Capture System and processed using Visual3D. During the 3 trials, the average maximum joint angles and gait dynamic parameters, including gait speed, stride length, stride width, step length, step time, stance time, initial double limb support, and cadence were recorded. Data were analyzed using descriptive statistics and visual analysis.

NUMBER OF SUBJECTS: Eight children aged 2 to 10 y.o. with a diagnosed neuromuscular disorder were recruited from Johns Hopkins All Children's Therasuit Method™ program.

RESULTS: Significant changes in hip flexion and hip extension were observed during the gait cycle when wearing the Therasuit™ compared to out of the Therasuit™. Hip flexion decreased while wearing the Therasuit™ while hip extension increased. Decreases in pelvic obliquity, hip abduction, and hip external rotation angles were observed when wearing the Therasuit™ but these changes were not statistically significant. Visual analysis shows maximum pelvic and hip joint angles generally decrease and become closer to neutral. The variability of pelvic and hip kinematics when wearing the Therasuit™ compared to out of the Therasuit™ were also decreased. There were no significant differences or trends in the functional measures of gait speed, stride or step length, stance, step, initial double limb support time, or cadence.

Limitations to this study include small sample size, convenience sampling, and observational nature of the study.

CONCLUSIONS: This preliminary study may provide support that the Therasuit™ causes changes in pelvic and hip joint kinematics primarily by decreasing hip flexion and increasing hip extension. Hip adduction and hip internal rotation kinematics had minimal changes when wearing the Therasuit™ was compared to out of the Therasuit. Wearing the Therasuit™ also appears to reduce the variability of pelvic and hip kinematics and the range of joint movement when compared to joint movement out of the Therasuit™.

CLINICAL RELEVANCE: While joint kinematics improved with the use of the Therasuit™, there may be little sustained effect on gait dynamics that impact independent mobility. Further research with larger sample sizes, specific diagnoses, and observation over time is needed to fully understand the effects of wearing the Therasuit™ on gait of children with neuromuscular disorders.


Ettinger SL, Nair P, Perfect JH, Hill S, Smith AW

BACKGROUND AND PURPOSE: Internal hemipelvectomy with limb salvage is a procedure used to remove aggressive bone tumors in adults and children. While the primary goal of the surgery is to save lives, it is often associated with a decrease in the function in areas of mobility, balance, and activities of daily living. This may further impact children due to growth. The asymmetry in limb length and muscular weakness on the involved side can lead not only to impairments in walking but also disrupt spinal symmetry and balance leading to scoliosis. In a child with such a complex diagnosis, the task of parsing out impairments in movement stemming from the primary pathology to those observed from compensations and adaptations for maintaining walking ability is difficult through observation alone. The purpose of our case study was to utilize 3-D motion analysis to provide an objective and quantitative framework in understanding the causes and consequences of gait abnormalities stemming from hemipelvectomy. Specifically, we were interested in evaluating the role of trunk excursion during walking.

CASE DESCRIPTION: The case presented is a now 15-year-old subject who had a hemipelvectomy, type I/II/III resection at age 11 due to a chondroblastoma. The lumbosacral plexus and primarily the sciatic nerve was affected by the tumor which resulted in both sensory and neuromotor issues in the hip, knee and ankle. Additional sequalae include a leg length discrepancy that grew to 7 cm and acquired scoliosis that was progressing. Medical considerations included spinal fusion with and without hip reconstruction. Concerns that fusion may further impede the subject's walking led to performance of 3-D motion analysis with three walking conditions: barefoot walking, walking with ankle foot orthosis (AFO), and walking with AFO and forearm crutches.

OUTCOMES: Examination of trunk and lower extremity kinematics and kinetics, revealed increased sagittal and frontal plane excursion of the trunk which were essential to walking over an unstable lower extremity with or without assistive/orthotic device. Walking with AFO and forearm crutches was better than the other two conditions. Spinal fusion without hip reconstruction to provide stability may make walking more challenging.

DISCUSSION: There are limited resources available on the long-term musculoskeletal sequalae and in particular, the management of scoliosis for full internal hemipelvectomies in the pediatric population. In clinical practice, therapists rely on basic foundational knowledge of examinations tools such gait observation. However, for subjects with atypical anatomy, whether congenital or acquired, these tools may not be as accurate. 3D motion analysis systems have the ability to inform multi-disciplinary, clinical decision- making about how to address progressively worsening, associated conditions as the subject continues to grow.


Franjoine MR, Norton CP, Darr NS, Young B

PURPOSE/HYPOTHESIS: Ear infections are common in young children; According to the CDC, 5 of 6 children experience otitis media (OM) by age 3 years. Past research has addressed acute management of OM symptoms, hearing loss, and language acquisition; however, the potential effects of OM on balance are less well known. The purpose of this study was to examine the potential impact of OM on children's functional balance capabilities as measured by the Pediatric Balance Scale, 2nd edition (PBS-2). The presence of recent OM within the previous 12 months and a lifetime history of OM were examined based on children's age in terms of performance on the PBS-2.

MATERIALS AND METHODS: The PBS-2 was administered individually by trained raters. The PBS-2 is an expanded and revised version of the Pediatric Balance Scale containing 20 items of varying difficulty. It demonstrates excellent reliability (test-retest ICC=0.918, interrater ICC=0.946-0.997, intrarater ICC>0.99) and can differentiate children with mild balance dysfunction (BD) from peers with TD up through 8 years of age (p<.05). Effects of age in one-year increments and presence of recent OM, within the previous 12 months, were examined using descriptive statistics and a two-way ANOVA with Tukey HSD post hoc analyses. Lifetime history of OM based on age group was assessed in the same manner. PBS-2 total test scores (TTS), as well as, time and distance measures from 15 of the more challenging PBS-2 items were used for analyses.

NUMBER OF SUBJECTS: Retrospective data were derived from 381 children with typical development (TD), ages 3 to 13 years, who participated in PBS-2 validation studies from 2013 to 2021. All children were healthy at the time of testing. OM history was identified by parents using the study health history form.

RESULTS: History of OM was prevalent across all age groups. Parents reported a lifetime history of OM in 77.2% of children. Within each age group, at least 50% of children experienced 1 or more acute OM episodes within the previous 12 months. Age effect was significant (F10,21=73.74, p<.001), however, effects of OM during the previous 12 months (F1,21=2.642, p=.105) or over the child's lifetime (F1,21=0.700, p=.725) were not. Although not statistically significant, PBS-2 TTS for children with a recent or lifetime history of OM were lower when compared to those with no OM history in 6 age groups with similar PBS-2 TTS noted in the 12- and 13-year-old age groups. Children without OM outperformed children with a history of OM on most items.

CONCLUSIONS: Recent OM is highly prevalent among children ages 3 through 13 years. A history of OM may contribute to balance dysfunction in preschool and school-age children.

CLINICAL RELEVANCE: The results of this study support ongoing surveillance of balance in children with an OM history. The PBS-2 is a suitable measure of functional balance for children with a history of OM.


Gangwani R, Mark JI, Vaughn RM, Holland H, Thorpe DE, Alexander J, Surkar SM, Cassidy JM

PURPOSE/HYPOTHESIS: The heterogeneity of motor function in unilateral cerebral palsy (UCP) poses significant challenges in predicting outcomes and treatment response. Much of this variability arises from differences in neural reorganization during development following the initial injury. Neuroimaging, particularly measures of functional connectivity, may provide valuable insight to address variable motor function in children with UCP. Corticomuscular coherence (CMC) is a measure of functional connectivity between central and peripheral nervous systems acquired by simultaneous collection of brain and muscle signals via electroencephalography (EEG) and electromyography (EMG). Despite previous work in adults with UCP demonstrating abnormal coupling patterns between brain and muscle signals, CMC remains underutilized in the pediatric population. This study determined the feasibility of CMC measurement in children and adolescents with UCP.

MATERIALS AND METHODS: During CMC testing, brain signals were recorded using a 256-lead EEG net while simultaneously collecting muscle activity from bilateral biceps brachii, flexor and extensor digitorum, and first dorsal interossei. Participants performed an isometric squeezing task (2 blocks of 20 trials with a 1-minute break between blocks) at 20% of their average maximal voluntary force output using a visual target that provided real-time feedback. We assessed feasibility based on [1] the number of participants completing the above-described procedures and [2] the proportion of CMC trials retained across participants. We determined if the number of trials retained differed between the two blocks (indicative of fatigue). To determine the number of CMC trials necessary for a stable CMC measurement, we computed a running CMC average across retained trials for each participant for both extremities and determined the number of trials where the percent difference between the running and final average was two percent.

NUMBER OF SUBJECTS: 11 children and adolescents (6 females, 11.27 ± 2.37 years) with UCP (Manual Abilities Classification Scale levels I-III).

RESULTS: All participants enrolled completed CMC procedures. On average, 30 trials (75%) were retained from the affected extremity (n=9) and 27 trials (67.5%) from the less-affected extremity (n=10). The number of trials retained from bilateral extremities did not differ with respect to block, suggesting lack of fatigue. Stable CMC measurements for both affected and less affected extremities required approximately 28 trials/side.

CONCLUSIONS: These preliminary findings underscore the feasibility (> than 50% trials retained) of CMC measurement acquisition in children and adolescents with UCP and provide acquisition parameters that will guide future CMC testing methodology.

CLINICAL RELEVANCE: Neuroimaging-based biomarkers reflecting neural network connectivity with EEG have informed adult motor function and post-stroke motor recovery. Our findings are a first step towards the development of a similar biomarker for children and adolescents to provide novel insight to motor function in UCP.


Gannotti ME, Gross PH, Thorpe DE, Hurvitz EA, Noritz G, Krach LE

PURPOSE/HYPOTHESIS: To describe the development and initial findings of the Adult Surveys from the patient reported registry developed by the Cerebral Palsy Research Network. Adult Surveys describe experiences with functional changes, pain interference, and treatments among adults with cerebral palsy (CP) living in the community.

MATERIALS AND METHODS: An iterative process of consensus building identified registry purpose and items. Established purpose is to track functional changes and pain interference and treatments in longitudinal patient reported registry in efforts to inform research and practice. Functional Change Survey bundle included: age, gender, type of CP, gross motor, communication, and manual functional abilities (Gross Motor Functional Classification Scale, Communication Functional Classification Scale, Manual Ability Classification Scale, PROMIS Profile 29, Neurol-QOL Stigma Scale, race, level of education, and employment status. Chronic Pain Survey bundle included: Brief Pain Inventory; PROMIS Anxiety, Depression, Satisfaction with Social Roles, and Pain Interference scales, Current Opioid Misuse Measure and the Neuro-Qol Upper Extremity and Lower Extremity scales.

NUMBER OF SUBJECTS: A group of more than 50 clinicians, researchers, and consumers decided on survey purpose and items. To date, 263 respondents with CP (females n=200; 76%; Gross Motor Functional Classification levels I= 34%, II=46%, III=12%, IV=12%, V=10%; mean age of 42, 18-76 years) answered the Functional Change Survey; 149 respondents completed the Chronic Pain Survey.

RESULTS: Gross motor decline reported by 60% due to pain (54%), fatigue (49%) decreased strength (42%), or changes in spasticity/dystonia (39%). Declines reported by 29% in hand function, and 9% in communication. PROMIS 29 t-score means indicated poorer outcomes than peers without CP in Physical Function, Anxiety, Depression, Fatigue, Sleep, Satisfaction in Participation, Stigma, and Pain Interference. Chronic pain was reported by 78%. Chronic pain was reported on average in 8 locations, with moderate pain interference. Low back, neck, and legs were most frequently identified as most painful. Physical therapy, exercise, massage, and over the counter medication were most frequently reported as helpful.

CONCLUSIONS: Functional decline and chronic pain are experienced by adults with CP regardless of age group or functional ability. Functional improvements were also experienced by a small percentage of adults with CP. Increased numbers of respondents will allow for phenotyping functional decline and pain trajectories given clinical and personal characteristics.

CLINICAL RELEVANCE: A cross sectional and longitudinal patient reported outcome registry focused on function and pain has been created for adults with CP. Exercise, physical therapy, and massage were frequently reported as helpful in mitigating pain interference and functional decline, but adults with CP are underserved by rehabilitation therapies. Annual surveillance by physical therapy is warranted to monitor changes in strength and spasticity that may require additional medical or rehabilitation interventions to mitigate functional decline.


Gohrband CL

PURPOSE/HYPOTHESIS: The purpose of this study was to explore the experiences and perceived outcomes of adults with lifelong disabilities (LLDs) who have participated in physical and/or occupational therapy services along their lifespan. This study represents the third and final leg of a tripod of studies aimed at understanding the process of moving from pediatric to adult-oriented therapy services and settings from the view of individuals most significantly involved in this transition.

MATERIALS AND METHODS: This study used a qualitative descriptive approach to explore the experiences and perceived outcomes of adults with LLD. Data was provided through participant responses to semi-structured interview questions. This data was analyzed using both the Colaizzi and Stanley methods. Predetermined code areas for the preliminary units of meaning were identified with these codes corresponding to specific categories of self-determination; and then further organized into themes.

NUMBER OF SUBJECTS: 12 participants between the ages of 25-65 years with a lifelong disability (LLD) who demonstrated consent capacity were recruited for this study through a sample of convenience.

RESULTS: Four major themes emerged from this qualitative data that included Changes over Time; Thoughts about Therapy and Education Services; Transitions and Meeting Therapy Needs as an Adult; and; the Importance of Communication and Support. Concepts of Self-Determination, including autonomy, competence and relatedness were all well represented in the response data.

CONCLUSIONS: The participants discussed multiple changes over time in terms of their own development; changes in therapy and educational systems; and changes in technology over their lifetimes. The participants emphasized that the focus of their time in school should have been spent on academics. Many stated that they wished they had not spent so much time working on ambulation skills. Pediatric therapy services were provided, but in retrospect were thought not to have been helpful. These participants felt that their success was largely due to their own inner persistence and the support of critical persons in their lives. None of these participants engaged in any type of formal transition process to move toward receiving therapy services as adults in adult-oriented settings with adult-oriented providers. None of the participants seemed to understand the role of therapy services as an adult to enhance their function and participation.

CLINICAL RELEVANCE: This study illustrates the need for more education on the needs for therapy services for adults with LLD as they become adults. The need for more education and raised awareness should start in entry level therapy curriculums. Practicing pediatric and adult-oriented therapists would benefit from education in this area to meet the adult needs of individuals with LLDs. There is also a need for adolescents and adults with LLDs to have access to resources to gain information about expectations of aging as an adult and the value of physical and occupational therapy to enable them to maintain their abilities for function and to participate in their best life possible.


Gormley M, Dabrowski E, Delgado M, Tilton A, Christian A, Evans SH, Calvi-Gries F, Goldberg J

PURPOSE/HYPOTHESIS: In view of the wide range of presentations and patient needs, it is becoming increasingly recognized that the treatment of spasticity needs to be individualized, including the assessment of treatment goals. This prospective, observational, multicenter study assessed the longitudinal attainment of patient-centered, function-related goal attainment scale total (GAS T) score after repeated abobotulinumtoxinA (aboBoNT-A) injections for ≤30 months (≤10 cycles) in the US.

NUMBER OF SUBJECTS: A total of 210 eligible patients aged 2‒17 with PLLS were recruited from investigators' clinical practices.

MATERIALS AND METHODS: This Phase IV study was designed to collect real-world data on the clinical use of aboBoNT-A in patients with PLLS. Prescription decisions were independent of study enrollment. GAS T scores were assessed for each injection cycle and goals could be redefined at each injection visit; scores of ≥50 reflect goal achievement. Adverse events (AEs) were reported.

RESULTS: Of 210 patients, 77.6% (n=163) were previously treated with botulinum neurotoxin. The most common concomitant non-drug therapies reported were physiotherapy (63.8%), cast application (47.1%), and occupational therapy (42.4%). For patients where ambulation status was reported (n=195), one third of the patients (n=61) were non-ambulatory (Gross Motor Function Classification System level IV or V). Mean ± SD cumulated GAS T-score was 51.1 ± 9.3. Overall, 75.2% of patients achieved their primary goals. Across all cycles, the number of muscles injected ranged from 5.5 ± 2.9 to 7.0 ± 3.7, with gastrocnemius injections being most common (85.7%); the total number of injection points per session ranged from 8.1 ± 2.7 to 9.9 ± 5.7. Injection guidance techniques were used in >70% of patients in Cycles 1‒6; electrostimulation was most frequent (>50%). In the safety population (N=242), 102 patients (42.1%) reported 392 treatment-emergent AEs, which were mostly mild to moderate. Overall, a total of 35 AEs in 15 patients (6.2%) were deemed treatment related.

CONCLUSIONS: Overall, most patients treated with aboBoNT-A for spasticity in the lower limbs achieved their treatment goals as or better than expected. AboBoNT-A was well tolerated, with a low incidence of treatment-related AEs.

CLINICAL RELEVANCE: These results confirm aboBoNT-A as an effective treatment option, with a positive risk-benefit profile for patients with PLLS.


Gould JM

PURPOSE: It is well established that outcome measures can assist with guiding clinical decision making, interventions, and goal setting. However, it is not standard practice to incorporate these measures into the treatment of children with cerebral palsy (CP). This abstract describes the feasibility of implementing a battery of outcomes measures (OM) in a large rehabilitation hospital across multiple levels of care.

DESCRIPTION: A team of clinicians determined an appropriate selection of OM that target major impairment areas and are well-established, reliable, and validated in the CP population. These included 10 Meter Walk Test (10MWT), 6 Minute Walk Test (6MWT), Pediatric Balance Scale (PBS), Berg Balance Scale (BBS), Selective Control of Lower Extremity (SCALE), Tardieu, Gross Motor Function Measure (GMFM), CP child Quality of life assessment (CPCHILD) and Bruininks-Oserestsky Test of Motor Proficiency (BOT-II), with assignment by clinical appropriateness per the child's Gross Motor Function Classification level. Standardization of measures occurred through a series of in-person courses and integrated within the electronic medical record for ease of use. Small focus groups and a survey were utilized to identify barriers two years post implementation. Examples include adjusting frequency of administration for specific measures, increasing physician understanding and expectation of OM, and reviewed purpose and benefits of utilizing the battery through department meetings. Additional barriers include environmental constraints and continued need for ongoing education due to staffing changes.

SUMMARY OF USE: The utilization of all outcomes increased by 86% from prior to establishing the battery (May 2018) to present. Each individual outcome measure use increased significantly: 10MWT (91.4%); 6MWT (78.8%); BBS (81.8%); PBS (92.1%); BOT-II (85.7%); SCALE (97.8%), GMFM (79.8%); CPCHILD 100%; Tardieu 100%. Gait measures were the most frequently performed followed by the GMFM. Through the development of this battery, we have found that it is feasible to perform measures throughout levels of care in the CP population and established an institutional expectation that at least 1 measure is performed regularly throughout a plan of care. Future analysis seeks to understand how measures in the battery may help to inform clinical decision making such as appropriate length of stay and goal setting. With wider utilization of the battery into other hospital systems, it may facilitate clinical practice guideline development for improved rehabilitation management in children with CP.

IMPORTANCE TO MEMBERS: This protocol demonstrates it is possible to utilize standardized measures for all children with CP across multiple levels of care within a large hospital system. The implementation of this battery changed the standard of practice within pediatric teams, bringing an increased use.


Goyal C, Naqvi WM

PURPOSE/HYPOTHESIS: Virtual reality (VR) is an advanced technology that provides real-life like experience (1). Although, promising results have been obtained by its use in geriatrics (1) and in adults with stroke (2), there are limited studies on children with hemiplegic cerebral palsy (CP), specifically (3,4). During VR experience, audiovisual as well as haptic feedback (HF) enhance fine tuning of motor responses (5). Hemiplegic CP is one of the most common subtype of CP. It is characterised by weakness of one side of the body and usually upper extremity (UE) impairment is more than lower extremity (6). Aim of this study was to investigate the effect of VR and HF intervention on UE function and functional independence in children with hemiplegic CP.

MATERIALS AND METHODS: After the ethical approval, this interventional study was registered at Clinical Trial Registry – India. The protocol of the study was published in a PubMed/Medline and Scopus indexed journal (7). The study design is non-randomised, active controlled trial.

During 6 weeks of intervention, children in the experimental group received VR and HF based intervention for 30 minutes along with conventional physiotherapy for 30 minutes in each session. Children in the control group received 60 minutes of conventional physiotherapy only. There were 5 sessions per week. Nine-hole peg test (9HPT) and box and block test (BBT) were used as primary outcome measures to evaluate UE function. ABILHAND-Kids and functional independence measure for children (WeeFIM) were used as secondary outcome measures to evaluate functional independence. Statistical analysis was done by using descriptive and inferential statistics using Chi square test, Student's paired and unpaired t-test, Wilcoxon signed rank test and Mann Whitney U test. p< 0.05 was considered as level of significance.

NUMBER OF SUBJECTS: Inclusion criteria comprised diagnosis of hemiplegic CP, 6- 12 years of age, ability to understand commands, Gross Motor Function Classification System (GMFCS) level I-III and Manual Ability Classification System (MACS) level I-III. Exclusion criteria included epilepsy, history of BOTOX treatment in past 3 months, history of surgery in past 6 months and participation in another trial. Total 36 school-aged participants were divided into 2 groups, namely, experimental and control, with an allocation ratio of 1:1.

RESULTS: There was significant improvement in all outcome measures in both groups. However, the improvement in the UE function and functional independence was significantly more in the experimental group than in the control group.

CONCLUSIONS: VR and HF based intervention is feasible and effective in the management of children with hemiplegic CP for improving UE function and functional independence.

CLINICAL RELEVANCE: Children with hemiplegic CP are often ambulatory but UE function remains primary concern of parents as children tend to avoid the use of paretic extremity. Based on principles of motor-learning, VR and HF intervention must have tapped the neuroplastic potential by motivating the children to use both hands.


Grant-Beuttler M, Dizon D, Mandelbaum A, Soangra R, Beuttler R

PURPOSE/HYPOTHESIS: Idiopathic toe walking (ITW) is estimated to be present in 5% of 6-year-old children, making it a prevalent disability facing children today. Sensory processing has been an area of major focus in the literature on ITW and suggested by some to contribute to the development of ITW. Sensory integration and modulation is required to provide appropriate feedback for motor learning and successful motor control. This study aims to compare sensory processing during function in children with ITW and typical development.

MATERIALS AND METHODS: Parents/caregivers completed the Sensory Profile (SP), a 125-item caregiver questionnaire used to evaluate a child's sensory processing abilities in relation to their daily motor performance. Scores can be differentiated into typical, “probable” difference (+/-1 SD), or “definite” difference (+/-2 SD) when categorized into different sections, factors, and quadrants to assess a child's specific deficits or strengths in relation to sensory processing and integration. SP parent ratings were analyzed using a Fisher's Exact test in R Project to evaluate associations between the ITW and control groups.

NUMBER OF SUBJECTS: This study included a cohort of 42 children diagnosed with ITW between the ages of 4-14 years and an age and gender matched cohort of 36 typically developing children.

RESULTS: A significant difference was found between ITW and control group on 3 Sections; G (sensory processing related to tone and endurance) (p<0.001), H (modulation related to body position and movement) (p=0.005) and J (modulation of sensory input affecting emotional responses) (p=0.005). 27/42 (64%) of the ITW participants exhibit a “definite” difference (+2SD) in at least one of the 3 modulation sections (G,H,J) compared to 0/36 (0%) of the control group. When examining behavioral responses in the 4 quadrants (Q1: Registration, Q2: Seeking, Q3: Sensitivity, Q4: Avoiding), analysis revealed a significant difference between the two groups in Q1(p=0.05), Q2(p=0.03), Q3(p<0.001), Q4(p=0.01). Moreover, 20/42 ITW children (47%) scored a 2 in one or more quadrants, indicating “definite” difference compared to 2/36 (5%) of the control group.

CONCLUSIONS: Based on parent ratings, a significantly large proportion of our ITW participants demonstrate “definite” sensory processing issues compared to our typical participants. Specifically, sensory issues were observed in relation to endurance/tone, body position/movement, and emotional responses to input. In addition, regulation of sensory input varied based on ITW participants quadrant scores. These results do not reveal if these issues were the cause or a result of the toe-walking.

CLINICAL RELEVANCE: There is evidence in the pediatric literature demonstrating sensorimotor reorganization with improved motor performance and suggests sensory integration may develop in parallel with motor function. While this does study does not help clinicians understand the cause of the ITW, it does suggest specific sensory areas to evaluate and potential areas of sensory need along with motor function during rehabilitation of ITW.


Greve KR, Cook S

PURPOSE/HYPOTHESIS: Cerebral palsy (CP) is a lesion in the primary stages of brain development. Secondary impairments such as decreased muscle strength, muscle size and length, altered muscle tone and impaired selective motor control affect limb function. Neuromuscular electrical stimulation (NMES) is a promising intervention to address some of these deficits. The purpose of this study was to systematically review the effects of NMES on lower limb musculature in individuals with CP.

MATERIALS AND METHODS: A systematic review was conducted to search for publications relating to CP, NMES, and muscle physiology/pathology using Medline, Embase, Web of Science, CINAHL, and Cochrane. Studies were included when NMES was used as an intervention with or without a comparison intervention on lower extremity muscle groups to report muscle structure and architectural findings in individuals with CP. Articles were excluded if published before 2000, written in languages other than English, or printed as conference proceedings or case reports. The search was completed on November 5, 2021. Two authors screened titles and abstracts then critically appraised articles that met inclusion criteria.

NUMBER OF SUBJECTS: Ten articles from 2002 to 2017 were published using NMES and individuals with CP.

RESULTS: Using a PRISMA flow sheet, the search yielded 462 records with 29 duplicates resulting in 433 articles. A total of 415 articles were excluded, 18 were appraised, and 10 were included in the review. Four articles used ultrasound demonstrating improvement in cross-sectional area of the quadriceps (Quad) and tibialis anterior (TA), pennation angle of the TA and muscle length of the TA and gastrocnemius (Gastroc) following NMES. Two articles used MRI and found greater cross-sectional area of the Quad and an increase in muscle volume of the Gastroc. Electromyogram was used in one study and showed an increase in TA muscle contraction and activation. One article used a goniometer to measure range of motion with findings of increased active TA motion following NMES. To measure muscle strength, five articles used a dynamometer and one article used manual muscle testing demonstrating an increase in Quad, Gastroc, and TA strength following NMES. Two articles reported an increase in selective motor control following NMES in the TA muscle.

CONCLUSIONS: NMES has promising effects to improve muscle size and strength. There is insufficient evidence suggesting NMES has an effect on muscle architecture. Research is needed to evaluate the effects of NMES on muscle cross-sectional area, muscle length, pennation angle, and strength for individuals with CP.

CLINICAL RELEVANCE: A stimulation frequency of 30-50 Hz and a pulse width of 250 μs at least 30 minutes per day during an 8-week period appear to increase muscle size and strength of lower extremity muscles. Clinicians should consider NMES as an intervention for muscle strengthening in individuals with CP while acknowledging further research is needed to understand the effects on muscle architecture for individuals with CP.


Greve KR, Bailes AF, Long J, Aronow B, Zhang N, Mitelpunkt A

PURPOSE/HYPOTHESIS: Ambulatory children with cerebral palsy (CP) receive physical therapy (PT) after multilevel orthopedic surgery (MLS) to improve function. Past studies report limited details of PT dose (frequency, intensity, time, and type) after surgery. Visualization techniques provide a novel way to explore complex data across time. The aim of this case series was to examine PT dose after MLS and describe individual outcomes at 1 year.

MATERIALS AND METHODS: Data were extracted from the electronic record and preprocessed. Each dimension of PT dose was visualized across the first year after MLS to draw meaningful clinical insights. PT dose per week was described as frequency (# of visits), intensity (child's level of effort across sessions), time (minutes spent in focus areas), and type (intervention type). Time and type were classified based on the International Classification of Functioning, Disability and Health (ICF). Baseline and 1-year outcomes were described for Canadian Occupational Performance Measure (COPM), Pediatric Outcomes Data Collection Instrument (PODCI), and Gait Deviation Index (GDI).

NUMBER OF SUBJECTS: Four children (C1, C2, C3, C4) with CP, three female and White, between 8-15 years old, Gross Motor Function Classification System Levels I (C4), II (C2), and III (C1 and C3), received individualized PT after MLS at a large pediatric academic medical center from December 2017-June 2019. Surgical burden was low (soft tissue and/or single osteotomy) for C1, C3, and C4, and high (bilateral osteotomies) for C2.

RESULTS: C1 received PT the first 4 months after MLS with reduced Body Structure and Function (BSF) over time and no variation in intensity. C2 received PT for the full year after MLS with a high frequency episode in the first half of the year and an increasing intensity level that was maintained in the second half of the year. The majority of time and type were activity-based. C3 received PT for the first half of the year with a decrease in frequency and intensity during that time. There was a transition from BSF to activity focus in time and type. C4 received PT for the full year after MLS with at least weekly frequency in the first half of the year, however intensity increased in the second half. BSF in time and type were maintained over the year but more focus was spent on activity and participation intervention types in the second half of the year. All children had >2 point change on the COPM. C1, C3, and C4 demonstrated a minimal clinically important difference in the PODCI. No meaningful changes were found for the GDI.

CONCLUSIONS: Visualization of frequency, intensity, time, and type provided value to understanding PT dose across time and revealed differences across the year. COPM and PODCI scores improved with no change in gait.

CLINICAL RELEVANCE: This case series revealed variation in PT dose in four ambulatory children with CP after MLS. Patient reported outcomes and family goals were achieved. Visualization techniques may be useful in future studies to understand variation of physical therapy dose across time after MLS to move toward precision medicine for children with CP.


Håkstad RB, Øberg GK, Girolami GL, Dusing SC

PURPOSE/HYPOTHESIS: In pediatric physical therapy there is an ongoing debate about the use of hands-on treatment approaches and their potential effects on motor learning. In this study, we build on the concept “enactive therapeutic sensory-motor play” to support our view that therapeutic handling can be beneficial to motor learning, given that it is not disruptive to the child's self-driven movement initiatives. We investigate our research question: How does therapeutic handling in its various forms influence children's enactive sensory-motor play, performance and learning?

MATERIALS AND METHODS: This is a qualitative study based on video-observations of therapy sessions and interviews with physical therapist (PT)s treating children aged 0-3. In the analysis we connect to enactive perspectives on embodiment, experience, mutual incorporation and sense-of-agency; sensory-motor play and learning, and clinical reasoning in pediatric physical therapy.

NUMBER OF SUBJECTS: 15 pediatric physical therapists and 30 children receiving physical therapy treatment.

RESULTS: The characteristics and purposes of therapeutic handling are presented in two main themes: 1) Position and support, and 2) Directing movement. Position and support can increase play engagement and promote the child's discovery of new or improved motor actions. The children use new and additional support surfaces to self-initiate better posture and movement solutions and reach play goals. But positioning and support can also restrict children's movement initiatives and actions. In positions with too high postural demands, the PT's effort to align and support the child turns into an unfavorable struggle which in turn disables play. The PTs' ways of directing movements vary, with more strict governance of movement at one end of the scale, upon which the child usually reacts with objections and disconnect from play. Contrasting this, a more subtle guiding of movement awakes curiosity and invites the child to self-govern and explore new movement possibilities.

CONCLUSIONS: Bodily interaction and handling that is mutually incorporated between PT and child can enrich movement learning, by providing novelty and facilitating the child's sense-of-agency in the self-initiated exploration and refinement of movement possibilities. But bodily interaction and handling can also be of hindrance; therapeutic handling that restricts or aims at governing the child's movements diminishes the child's sense-of-agency and decreases the child's engagement in movement, play and learning.

CLINICAL RELEVANCE: The study's value lies in the ability to challenge the idea of therapeutic handling as either enriching or detrimental to motor learning, and the expansion and development of the theoretical underpinnings of pediatric physical therapy. The study is highly useful and relevant for pediatric PTs in clinical practice. Our aim is to initiate reflections and debate among clinicians. To ask them to reflect on their own bodily interactions and handling of children, with the hope of expanding their knowledge and contributing to their understanding of bodily interplay in pediatric physical therapy.


Hedden KM, Quigley K, Darr NS, Fontana R, Newman K

PURPOSE/HYPOTHESIS: The Physical Abilities and Mobility Scale (PAMS) is a 20-item quantitative scale designed for serial measurement of functional change in children. The PAMS was intended for use and validated in the pediatric inpatient rehabilitation setting for patients ages 2 to 18 years. However, the PAMS has not been examined in a critical care setting. The purposes of this study were to examine the following in the acute care setting: 1) interrater reliability during PAMS administration and subsequently from video recordings, 2) intrarater reliability, 3) feasibility and accuracy of scoring the PAMS from video recordings and 4) ability of the PAMS to detect change during hospital stays.

MATERIALS AND METHODS: Seven raters (4 physical and 3 occupational therapists) were trained to administer the PAMS. Teams of two raters (1 OT and 1 PT) administered the PAMS to each child on 2 occasions, once after evaluation and a 2nd time prior to discharge. Each rater independently scored the PAMS to evaluate interrater reliability during live testing. All sessions were video recorded. One month after each testing session, the same 2 raters plus 5 additional raters rescored the PAMS from video to assess intrarater reliability and interrater reliability from video respectively. Scores obtained during live testing were compared to raters' scores from video to examine consistency between live and video scores. Children's initial and final scores were compared to examine change in PAMS scores over the course of hospital stay.

NUMBER OF SUBJECTS: Fifteen children (ages 2-18 years), who met the inclusion criteria for a hospital-based Early Mobility protocol, were recruited in the Pediatric Intensive Care unit (PICU) and followed to discharge.

RESULTS: The PAMS demonstrates excellent interrater reliability during live testing sessions (ICC2, 1=.981) and when scored from video (ICC2, 1=.997), as well as intrarater reliability (ICC3, 1= 0.841-1.00). Reliability was also excellent when scores from original two examiners were compared with 7 independent raters' scores from video, indicating accurate scoring can be obtained from video recordings (ICC2, 1=.978). A repeated measures ANOVA indicated that childrens' PAMS scores significantly improved during hospital stay (F=6.83, df=1, p=0.011).

CONCLUSIONS: The PAMS demonstrates excellent inter and intrarater reliability when administered in an acute care setting by trained raters. It can also be reliably and accurately scored from videos recorded in a consistent manner. Excellent reliability along with significant improvements in PAMS scores through the course of a hospitalization make the PAMS a promising tool for use in the acute care setting to track functional change with time.

CLINICAL RELEVANCE: Although originally validated in the inpatient rehabilitation setting, the PAMS demonstrates excellent reliability and may be used to identify functional change along the course of a hospitalization in the pediatric acute care setting. Ultimately the PAMS may be appropriate across the continuum of care as patients transition between rehabilitative settings.


Heschle AN

PURPOSE/HYPOTHESIS: Congenital muscular torticollis (CMT) affects approximately 3.9-16% of all newborns. Abnormal head posture (AHP) in infants accounts for 3.19% of visits in pediatric ophthalmology practice. Superior oblique palsy (SOP) is the primary cause of AHP in infants and presents as a head tilt toward the unaffected side, which can mimic CMT. There is currently a gap in guidelines for physical therapists to accurately screen for ocular co-morbidities associated with CMT. This case outlines an infant presenting with CMT, who developed strabismus on the ipsilateral side of head tilt, differing from what would be defined as an ocular AHP. It is hypothesized that using an eye patch over affected eye would lead the infant to engage more with ipsilateral visual field, thus strengthening contralateral sternocleidomastoid muscle, and improving overall head posture and cervical range of motion.

MATERIALS AND METHODS: Data were extracted from electronic medical record. Upon physical therapy examination, the infant was found to have left torticollis consistent with left head tilt and right cervical rotation preference. Treatment included range of motion, strengthening, and gross motor skill activities. The infant required a cranial remodeling orthosis to address cranial asymmetry. The infant was progressing gradually, but had continued resting head tilt and rotation between 5-10 degrees measured with arthrodial protractor. The infant also presented with adduction of left eye. Eye patching was used to screen for ocular AHP, and to improve attention to left visual field, thereby decreasing preference for head positioning in left tilt and right rotation. An eye patch was donned to the infant's left eye, and improvements in head tilt to less than 5 degrees from midline were observed in session.

NUMBER OF SUBJECTS: The case describes a 6 month old infant who initially reported to outpatient physical therapy referred from pediatrician for CMT and plagiocephaly at 3 months old. Initial resting head tilt was 15 degrees to the left.

RESULTS: After 1 week of home patching for 30 minutes daily, the patient returned for follow up with no noted strabismus and head tilt of less than 5 degrees. Due to co-occurring developmental delay, the patient continued to be seen on a weekly basis for skilled outpatient physical therapy, but maintained head tilt to less than 5 degrees, did not present with gross motor skill asymmetry, and had improved cervical passive and active range of motion to within 5 degrees bilaterally. The infant was referred for follow up from ophthalmology, who recommended monitoring.

CONCLUSIONS: Use of an eye patch in office and at home was an effective supplemental tool for investigating presence of ocular AHP in cases of CMT.

CLINICAL RELEVANCE: Cases of muscular changes associated with ocular AHP have been reported, but cases of ocular changes secondary to CMT have not been documented. Further research is required to confirm findings and further investigate clinical relevance.


Hill AN, Schlesinger R, Simermeyer J, Sullivan C, Bastian AJ, Keller J

PURPOSE: A primary focus of physical therapy for children with neurological impairments is postural control, the essential prerequisite to fluid use of the arms in an upright position. In typical development, postural control is gained as the nervous system integrates sensory inputs and motor outputs to learn to control the body. This process relies on experience of self-initiated balance perturbations and practice maintaining balance. Children with cerebral palsy or other neurological impairments do not experience the same frequency of balance challenges during regular free play as their typically developing peers and often receive therapy services to address deficits in postural control. Engaging young patients in therapy activities often presents a challenge due to age and attention span. The touch-interactive Aiding Distanced and Accessible Physical Therapy (ADAPT) system offers a solution to engage young patients in physical therapy. The ADAPT system uses customizable games for whole body movement and balance training. Previously, we have shown that the ADAPT Bubble Popper game engages young patients ages two to seven for similar durations of game play as older patients. However, it remains unknown how therapy with ADAPT compares to typical therapy approaches from the perspective of dosing. The purpose of this report is to describe a process of comparing typical therapy to therapy with immersive technology in order to improve our understanding of how different therapeutic approaches engage and challenge the nervous system.

DESCRIPTION: To explore the dynamic range of arm movement and weight shifts between different therapy delivery approaches, we have employed wearable sensors and a pressure mat. The three axis inertial measurement units placed on the wrists and trunk record angular velocities and linear accelerations at a high sampling rate and output activity counts in second to second epochs. The pressure mat tracks movement of the center of pressure and outputs limits of stability and the contribution of each foot to the total pressure. In the pilot study, participants completed at least two sessions, one with typical therapy activities and one with the ADAPT Bubble Popper game. The treatment position (ie sitting or standing) was kept consistent between session types. We demonstrate that movement data can be segmented into smaller epochs for specific comparisons of active versus rest time and overall quantity of movement in equal length segments of game play and a comparable therapy activity. For participants with hemiparesis, we demonstrate ability to compare movement initiated in the impaired and the non-impaired arms during each session type.

SUMMARY OF USE: Results from this pilot study highlight the feasibility of incorporating high resolution movement recording devices into therapy sessions.

IMPORTANCE TO MEMBERS: The data provided by additional measurements allows the therapist to track features of the patient's behavior during a session that are not as easily observed but provide insight into how the nervous system is being engaged during therapy.


Hoffman S

PURPOSE/HYPOTHESIS: 1.) To teach pediatric physical therapists behavior modification techniques to deal more effectively with children who exhibit disruptive behavior problems during PT sessions. 2.) To determine if PTs use of behavior modification skills during PT sessions with children who exhibit behavioral challenges will result in fewer behavior problems and improve participation during PT.

MATERIALS AND METHODS: A multiple baseline design was used across children and therapists. After baseline data for PT and child behavior were collected, PTs received training in behavior therapy. The intervention included 3 phases - didactic training and modeling videotape, interactive training during PT sessions, and verbal feedback. PT sessions were videotaped and coded for target behaviors of both the PT and the child.

NUMBER OF SUBJECTS: 2 PTs and 4 children in an inpatient setting + 2 PTs and 3 children in an outpatient setting.

RESULTS: Results indicated that physical therapists learned the behavior therapy techniques and incorporated these skills into their daily PT sessions. Specifically, across all therapists, the mean occurrence for the use of Direct Commands increased 21%, Ignoring negative child behavior increased 58%, and the use of Praise to appropriate child behavior increased from 1/min to 2.7/min. As a result, child compliance to PT requests increased 6%, Noncompliance to requests decreased 4%, and Inappropriate child behaviors that interfered with therapy decreased from 1.4/minute to 1/minute. The intervention was rated positive by all therapists.

CONCLUSIONS: Physical therapists can learn a psychologically informed intervention that incorporated a modeling videotape, individual interaction training, feedback and reinforcement. Integrating these newly acquired skills in PT sessions with children who exhibit challenging behaviors resulted in improved child behavior during PT sessions. Psychology has many skills that would benefit PTs in their expanding biopsychosocial approach to pt-centered care that will improve their effectiveness and outcomes in various settings and patient populations.

CLINICAL RELEVANCE: This study is an important contribution to both fields of physical therapy and psychology. It describes an effective training program for pediatric physical therapist to integrate into PT sessions with children who have challenging behaviors that interfere with effective PT. Psychologically informed physical therapy (PIPT) has continued to recieve a lot of attention since the PTJ published a special edition in 2011. The growth of PIPT has occurred almost singularly in one domain - chronic pain. There is a need for integrating PIPT into more areas of PT than just pain. This study demonstrates the use PIPT across the life span.


Jones SA, Gold AC, Jones M, Moyers WL

PURPOSE/HYPOTHESIS: Muscle performance has long been considered a contributor to the functional deficits seen among children with cerebral palsy (CP). Recent literature has focused more on progressive resistive strength training, specifically on power training and strengthening interventions to improve daily gait skills. The purpose of this review was to investigate the effective dosing of power training to improve gait parameters and gait function in children with CP.

MATERIALS AND METHODS: The American Academy of Cerebral Palsy and Developmental Medicine (AACPDM) methodology was used, relevant databases were searched in January 2022 using the following inclusion criteria: peer reviewed intervention studies, published in the last ten years, in English, subjects were children with CP who participated in power or plyometric training that measured functional outcomes related to gait.

NUMBER OF SUBJECTS: 133 children, age 4-16 with a diagnosis of CP, GMFCS level I-II.

RESULTS: Five articles met criteria, three were Sackett's level II randomized control trials, one was level III double-baseline design and one was level IV cohort study. Four were rated strong and one rated moderate in conduct. All studies included a power training component defined as a high velocity explosive activity, encompassing short stretch exercises and plyometrics. Dosing across studies ranged from 480 minutes delivered in 8 weeks to 2520 minutes delivered in 14 weeks. Outcome measures used in more than one study included gait speed, symmetry, muscle power sprint test, GMFM, and the shuttle run test. Power training produced greater gains in all outcome measures except the GMFM which had mixed results. Gains in gait parameters were shown in as little as 480 minutes of power training delivered in 8 weeks. Functional gait gains were reported with the higher dose of power training at 2160-2520 minutes delivered in 12-14 weeks.

CONCLUSIONS: Several other factors could have impacted outcomes, such as age and GMFCS level. Those could not be considered in this review as data in the included studies was not stratified based on these factors. Outcome measures were only assessed at baseline and the end of the intervention in four studies, making it difficult to determine when during the intervention period gains were achieved. Based on the findings of this review, physical therapists should include a minimum of 480 minutes of power training delivered over 8 weeks as part of their intervention to improve gait in children with CP. Future studies should include reassessment of outcome measures at least half way through the intervention period to better determine at what point during the intervention gains are achieved.

CLINICAL RELEVANCE: Providing quality care for children with cerebral palsy requires more than choosing evidence-based interventions. Those interventions must also be dosed appropriately to produce meaningful gains. Clinicians should consider reassessment of outcomes at regular intervals during the intervention period and follow up testing to better understand the impact of dosing on motor outcomes and long-term functional gains.


Jung Jeong H, Qashqai A, Muriello M, Basel D, Slavens B

PURPOSE/HYPOTHESIS: Children with joint hypermobility have altered motor control that influences their gait and movement patterns.1 A better understanding of inter-joint coupling variability of gait may help identify the movement dysfunction related to hypermobility,2 and ultimately improve clinical practice for treating children with joint hypermobility. Therefore, the purpose of this study was to investigate the variability of the lower extremity inter-joint coupling during gait in children with hypermobility spectrum disorder/hypermobile Ehlers-Danlos syndrome (HSD/hEDS) and compare to typically developing children. We hypothesized that children with HSD/hEDS will have a significantly different inter-joint coupling variability during gait as compared to typically developing children.

NUMBER OF SUBJECTS: Eighteen children diagnosed with HSD/hEDS [13 females, mean (SD), age: 14 (2.8) years height: 157 (16) cm, weight: 52 (13) kg, body mass index: 21.3 (5.4) kg/m2] and eighteen typically developing children [11 females, age: 13 (2.2) years, height: 155 (15) cm, weight: 49 (16) kg, body mass index: 20.1 (3.9) kg/m2].

MATERIALS AND METHODS: Three-dimensional (3-D) motion analysis (Vicon Motion Systems, Oxford, UK) was used to acquire sagittal plane joint kinematics of the ankle (foot with respect to shank), knee (shank with respect to thigh), and hip (thigh with respect to pelvis) during walking at a self-selected, comfortable speed. The gait cycle was time normalized from 0 to 100% and divided into seven periods: loading response (0-12%), mid-stance (13-31%), terminal stance (32-50%), pre-swing (51-62%), initial swing (63-75%), mid-swing (76-87%), and terminal swing (88-100%). A vector coding technique was used to calculate inter-joint coupling patterns of ankle-knee, ankle-hip, and knee-hip.3 Coupling angle and variability from each participant (10 gait cycles) and across participants were calculated using circular statistics (R statistical package: CircStats).4 Statistical parametric mapping and a Mann-Whitney U test were used to compare the coupling variability during the entire time series of gait cycles (0-100%)5 and in each of the seven periods between children with HSD/hEDS and typically developing children.

RESULTS: Children with HSD/hEDS had a significantly higher ankle-hip coupling variability [mean: 13.8 (4.0) deg] in terminal stance compared to that of typically developing children [mean: 11.3 (2.9) deg]. There were no differences in coupling variability during the time series of the entire gait cycle, and no differences in ankle-knee and knee-hip coupling variability in each of the gait periods.

CONCLUSIONS: A greater coupling variability was observed in children with HSD/hEDS. Changes of inter-joint coupling variability may reflect the movement adaptation of gait due to musculoskeletal pain, neuromuscular and proprioception deficits in children with HSD/hEDS.

CLINICAL RELEVANCE: The characteristics of the inter-joint coupling variability should be explored to better understand the gait abnormalities, which may lead to developing optimal rehabilitation strategies for children with HSD/hEDS.


Kenyon LK, Aldrich N, Marsman K, Lambert R, Vasseur M, Logan SW, Feldner HA

PURPOSE/HYPOTHESIS: For children with cerebral palsy (CP), both the Explorer Mini and a modified ride-on toy car (mROC) provide self-initiated mobility and exploration at ages similar to their peers without disabilities. This study explored potential differences in parental perceptions of their children's use of these 2 power mobility devices.

MATERIALS AND METHODS: Data were collected as part of a larger multi-site, randomized, counterbalanced AB crossover clinical trial wherein all participants randomly received both intervention A (Explorer Mini) and intervention B (mROC) across the 16-week study. Semi-structured interviews were conducted and recorded at 3 timepoints: baseline (T0), end of intervention 1 (T1), and end of intervention 2 (T2) for a total of 72 interviews. Interview questions provided insights into parental perceptions of their child's emerging agency and power mobility device use and included experiences regarding use of each device, and perceptions of self-efficacy and behavioral capacity. Interviews were transcribed verbatim and analyzed using the Linguistic Inquiry and Word Count (LIWC 2015) text-analysis program. LIWC was developed on the premise that the words people use reflect their physical and mental health and can be used to learn about their beliefs, thinking patterns, emotions, social relationships, and personalities. LIWC quantifies qualitative data by objectively evaluating a transcript against an internal dictionary and classifying words into 4 algorithmically derived summary variables (Analytical Thinking, Clout, Authenticity, Emotional Tone), and into categories such as biological, cognitive, and social processes and motivational drives.

NUMBER OF SUBJECTS: 24 parents of children with CP ages 12-36 months.

RESULTS: LIWC accounted for >92% of parents' word use (M = 1,146 words, SD = 779). Parents' language use indicated that they were highly positive (Emotional Tone) and confident (Clout), focused largely on the here-and-now (low Analytical Thinking), and displayed high levels of guarded speech (low Authenticity) at T0. Although there was no effect of intervention group, analyses revealed significant differences across timepoints. Parents' responses exhibited less confidence and included fewer references to social (talking, they) and biological (body, health) processes after intervention regardless of the device used (all ps = .000). Parents referred to motivational drives (success, benefit), especially for affiliation (social), as well as cognitive processes (think, cause) more often after intervention (all ps ≤ .03). In Emotional Tone, parental positivity increased from T0 after intervention, but only for those whose child used the Explorer Mini after the mROC (p = .03).

CONCLUSIONS: Findings indicate parental excitement and positivity towards the opportunities power mobility affords their child. LIWC revealed that regardless of device, parents were less likely to refer to body and health concerns and more likely to talk about social motivations and thoughts and reasoning after their child used power mobility.

CLINICAL RELEVANCE: For young children with CP, power mobility use may change parental perceptions of them and their capabilities.


Kerr L, Mason TL, Buckman AP, Howes HE, Meador MM

PURPOSE/HYPOTHESIS: Facilitating an inclusive recreation event for children of all abilities can experience limitations in participation levels. The understanding of facilitation techniques to improve participation levels at these events are limited. The purpose of our study was to obtain the parent/caregiver perception of participation experience and identify common themes in participation observations from the clinicians facilitating the events.

MATERIALS AND METHODS: All participants and caregivers completed a Trait Emotional Intelligence Questionnaire-Child short form and a Test for Quality of Peer-Relationships form. Participants were asked qualitative motivation questions about ‘why they chose to participate’ in camp each day they attended. The required participation included multiple days of recreations activities. Student physical therapist facilitated the physical activity and additional student therapist completed clinical observation forms on each of the participants. These collected observation were then reviewed and assessed for common themes regarding participation demonstrations.

NUMBER OF SUBJECTS: Number of Subjects: 28 total children attended the recreational events. 18 children had atypical physical or cognitive development and 10 children had typical physical and cognitive development. The age range of participants were 7-12 years old. All 28 caregivers participated in pre and post event questionnaires regarding quality of participation.

RESULTS: The quality of peer-relationship form indicated that Parents/Caregivers of atypically developing children had low expectations of relationship skills and overall level of quality participation. There was not a relationship between physical and cognitive ability and emotional intelligence scores. Common themes of observation emerged between the two categories of functional ability. Atypically developing children initiated more interaction with adults vs age matched peers, the initiation of any interaction required increased time. Typically developing peers engaged more with competitive motives vs atypically developing peers. Regardless of physical and cognitive levels participants with higher levels of emotional intelligence indicated motivation for participation beyond the activity requirements and focused on relationship with other participants.

CONCLUSIONS: Understanding the constructs associated with positive interaction will assist in the efficiency of activity design to facilitate opportunities for social learning to occur, increasing interaction across participants of all abilities. Parents/Caregivers educational requirements were also identified through a better understanding of parent/caregiver perception and definition of quality interactions.

CLINICAL RELEVANCE: The facilitation of more effective recreational opportunities for peer-to-peer engagement for children of all abilities is essential to improved socialization skills in children. A better understanding of these observed interactions and parent/caregiver perception will help to facilitate better environmental design allowing for efficient interactions.


King NE, Wiley MS, Rose A, Fergus AH

PURPOSE/HYPOTHESIS: School-based PTs (SBPTs) rapidly transitioned to telehealth during the COVID-19 pandemic. The benefits of telehealth PT have been well documented with reports of increased active patient engagement across practice settings. There is an anecdotal report of SBPTs expressing concerns about addressing educational goals through telehealth. The purpose of the present study was to examine perceptions and strategies utilized by physical therapists delivering services via telehealth in the school setting.

MATERIALS AND METHODS: Using a grounded theory qualitative design, semi-structured interviews were completed to explore perceptions surrounding the use of telehealth by SBPTs. All interviews were transcribed and theme coded by two independent researchers until saturation was achieved. A concept map was developed by consensus.


RESULTS: Seven interacting themes emerged from the data collected: supports and education, strategies promoting success of telehealth, challenges of telehealth, the learning curve, outcomes related to student and family, professionally related outcomes, and the sustained use of telehealth. Educational resources and school support impacted the ability to successfully deliver services via telehealth. All SBPTs reported a steep learning curve that occurred with the transition to telehealth. SBPTs had to overcome challenges inherent to this mode of delivery including those associated with technology, communication, space, equipment, and examination. Participants also reported several strategies that promoted their ability to deliver PT successfully including facilitating caregiver/family involvement in PT and the use of coaching techniques. With this steep learning curve, SBPTs reported professionally-related outcomes including improved communication with other team members, increased teacher involvement, improved efficiency and productivity and increased access to distant students. Student/family related outcomes were also reported including an appreciation of the context of the student, enhanced communication and relationships with families and enhanced family engagement. A final theme that emerged was the benefit of continuing to deliver PT through telehealth in a hybrid model utilizing in-person delivery and telehealth sessions.

CONCLUSIONS: SBPTs believed they were able to effectively deliver PT to students via telehealth when provided with school system support along with strategies to overcome challenges presented by telehealth provision. Several positive outcomes associated with the telehealth delivery of service were also reported.

CLINICAL RELEVANCE: While the COVID 19 pandemic forced a rapid transition to the telehealth delivery for SBPTs, many lessons were learned that can have a long lasting positive impact on school-based services. There are benefits to the use of telehealth that should be considered in the delivery of service in the school setting.


Kocabalkanli C, Fenton R, Gaetani SA, Aalamifar F, Linguraru MG, Seifabadi R

PURPOSE/HYPOTHESIS: Deformational plagiocephaly/brachycephaly (DPB) is manifested in 20% of newborns in the US (Fenton, et al) and can be effectively corrected by repositioning and/or physical therapy if detected and monitored before 4 months of age (Linz, et. al). The cranial index (CI), cranial vault asymmetry index (CVAI), and cranial vault asymmetry (CVA) are used for DPB diagnosis and monitoring (Foster, et al). There is no tool available to pediatricians, physical therapists or parents to quantitatively measure CI, CVAI, and CVA. We developed a smartphone app, called SoftSpot™, that measures CI, CVAI, and CVA at the point-of-care from photographs of a child's head to improve early detection and treatment of DPB (Seifabadi, et al). This prospective study evaluates the accuracy of smartphone-based measurements of CI, CVAI, CVA compared to those from calipers and 3D scanners in a clinical setting.

MATERIALS AND METHODS: A prospective study was done with patients aged 2-11 months (average 5 ± 1.5 months; 20 female, 51 male) with IRB approval and parental consent. For all infants, measurements of CI/CVAI/CVA were obtained by 3D scanner, caliper, and smartphone. For ground truth, 3D scans of the infant's head were captured using STARscanner (Orthoamerica, Orlando FL). Measurements of the diagonals, width, and length of the infant's head were obtained by a CRNP using calipers to calculate CI/CVAI/CVA. For smartphone, bird's eye-view photos of each infant's head were captured at a large multidisciplinary craniofacial center with SoftSpot (PediaMetrix Inc. Rockville, MD) using an iPhone X (Apple Inc., Cupertino, CA). Photos featured a reference sticker on the head to measure CVA in mm. Five images for each patient were chosen and digitally processed by an analyst, and for each, CI/CVAI/CVA were automatically measured by proprietary algorithms. For CVA, a regression model was trained and applied to increase accuracy, using an initial prediction from the reference sticker and the patient's sex and age (Kocabalkanli, et. al). Results for CI/CVAI/CVA were averaged for each patient. Smartphone and caliper measurements were compared against the ground truth using mean absolute error (MAE), standard deviation (SD) and Spearman Correlation Coefficient.


RESULTS: For CI, MAE and SD were 2.60 ± 1.96 for calipers and 1.63 ± 1.44 for smartphone. For CVAI, MAE and SD were 1.43 ± 1.22 for calipers and 1.45 ± 1.29 for smartphone. For CVA, MAE and SD were 2.00 ± 1.83 mm for calipers and 2.22 ± 1.70 mm for smartphone. Spearman coefficient for CI was 0.87 (p < 0.001) and 0.90 (p < 0.001), for CVAI was 0.93 (p < 0.001) and 0.94 (p < 0.001), and for CVA was 0.84 (p < 0.001) for and 0.85 (p < 0.001) for calipers and smartphone, respectively.

CONCLUSIONS: Our study demonstrates strong correlation for smartphone measurements of CI, CVAI, and CVA with respect to 3D-based ground truth, and that smartphone measurements of cranial shape indexes are similar to clinically used caliper measurements.

CLINICAL RELEVANCE: Smartphones can make cranial measurements more accessible at the point-of-care for infants, thus greatly assisting with the early detection and treatment of DPB.


Ladner H, Brockway KS, Henricksen JE

PURPOSE: This critically appraised topic (CAT) investigated, “Can simulated horse riding decrease barriers to hippotherapy while providing the same benefits as true horse riding for children with cerebral palsy?”

DESCRIPTION: A CAT is a short summary of the best evidence on a focused question. The clinical question and inclusion criteria for this CAT were developed using PICOT and include: cerebral palsy, simulated horse riding, true horse riding, postural control and balance, and studies from 2010 to present. PubMed, Web of Science, and LIRN were searched with the following MeSH terms: “Horse-riding Simulator” AND “Hippotherapy” AND “Equine-Assisted Therapy” AND “Cerebral Palsy” AND “Postural Control” AND “Balance”. The search yielded 144 articles. Titles and abstract review yielded three articles relevant to the clinical question: two randomized controlled trials (RCT) comparing true horse riding (THR) and simulated horse riding (SHR) and one quasi-experimental pilot study investigating virtual reality with SHR in children with cerebral palsy (CwCP). The PEDro scale was used to assess the quality of the RCTs, scoring good (6/10) and fair (4/10). The quasi-experimental study was assessed using the MINORS tool with a score of moderate (11/16). All three articles shared common internal validity threats increasing risk of bias such as no intention to treat analysis and no blinding of subjects or therapists. Threats to external and statistical validity included small sample sizes.

SUMMARY OF USE: With all therapy interventions, cost and insurance coverage are barriers, but for THR additional barriers further reduce its utility. Access to a riding clinic, weather conditions for an outdoor facility, extra staff required, animal maintenance, and behavioral limitations are some of the barriers to THR that are reduced with SHR. Lee et al reported SHR and THR as not significantly different in improving postural control (PC) and balance for CwCP, as SHR induced functional improvements in both areas on standardized outcome measures (OM). Temcharoensuk et al found THR to be more effective than SHR. However, they also found dynamic SHR to be more effective than static SHR and suggest that combining dynamic SHR with increased somatosensory stimulation would induce THR-like effects. Chang et al accomplishes this using SHR with a head-mounted display, 3D scene, and a pair of controllers to mimic THR. This study resulted in statistically significant improvements in functional OM and children and their parents reported enjoyment and interest.

IMPORTANCE TO MEMBERS: The moderate quality results of this CAT have significant clinical implications for improving access to hippotherapy. The findings of the three studies support SHR as an effective intervention to promote significant improvements in PC and balance in CwCP. SHR can reduce barriers to hippotherapy interventions by requiring lower resource utilization for provider and patient and still produce functional improvements. By reducing these barriers, SHR increases access to similar PC and balance improvements for CwCP.


Lin S, Pannell WC, Geno C, Wesson K, Edmonson A, Sollie R

PURPOSE/HYPOTHESIS: Cerebral palsy (CP) is the most common cause of chronic motor disability in childhood. Children with CP often demonstrate abnormal muscle tone, with spastic CP being the most common presentation. Spasticity and the resulting limitation in joint range of motion of lower extremities could lead to gait difficulties. Intramuscular injection of botulinum toxin (BTX) is a rather innovative way to control skeletal muscle spasticity. While a vast majority of previous studies have shown that BTX can decrease muscle spasticity and improve joint range of motion, it remains unclear whether BTX improves ambulation capacity in children with CP. Therefore, we conducted the current systematic review (SR) to evaluate the effects of BTX on gait capacity in children with spastic CP.

MATERIALS AND METHODS: PubMed and Embase were searched on November 18, 2021 for randomized controlled trials or quasi-experimental studies with control that investigated the effectiveness of single-dose BTX injection on gait in children with CP. The search strategy included a list of terms associated with the target population (children with spastic CP), intervention (BTX injection), and outcome (gait-related outcome measures). To provide the most up-to-date information, only studies published since 2011 were included in the current SR. Risk of bias of the included studies was assessed with PEDRO.

RESULTS: Seven studies with a total number of 367 individuals with spastic CP were included in this SR. The control group received conventional physical therapy (CPT), while the interventional group received single-dose BTX injection to one of the lower extremity muscle groups in addition to CPT. Our findings revealed that BTX decreased muscle spasticity and improved gait parameters (gait pattern, gait speed, endurance, balance, frequency of falls, and/or goal achievements) at 4-12 weeks following injection as compared to the control group (p<0.05) in 6 out of 7 studies. However, one study showed BTX did not add to the clinical effectiveness of rehabilitation as compared to control (p>0.05). Transient and mild adverse effects such as localized muscle weakness, pyrexia, and skin rash at the injection sites were reported in 5 out of 231 participants who received BTX injection. The average PEDro score is 7.7/10, indicating good quality of the included studies.

CONCLUSIONS: Single-dose BTX injection of lower extremity muscles could potentially improve ambulation capacity in children with CP.

CLINICAL RELEVANCE: The current SR demonstrated BTX injection not only reduced lower extremity spasticity in children with CP, but also improved their walking ability, which is one of the most meaningful goals for patients and their parents. Since management of CP requires multidisciplinary effort, we will continue to explore whether combining BTX and additional rehabilitation strategies such as orthotics or treadmill training further improves gait in this patient population.


Luppino VJ, McAdam AC

THEORY/BODY: Softball is a popular female sport involving a unique, dynamic, full-body movement- the windmill pitch.1 The overhead baseball pitch is well documented, and performance metrics to reduce risk of injury have been established in the literature.7 However, despite similarities in the overall structure of the game to baseball, there is little research that has examined the connection between windmill pitching mechanics and injury risk.

This model will review the biomechanics of the windmill pitch specific to range of motion, muscle activation, and sport-specific forces on the shoulder. It will address how these biomechanics change or develop from youth to the young adult, and the associated risk of common shoulder injuries with respect to age. This presentation will cover the rehabilitation examination unique to the female softball pitcher, and the impact of regional interdependence. Phased-based interventions will be provided to guide the plan of care from injury to return to sport. We aim to shine the spotlight on the female softball athlete, and to identify areas for further research to close the gap between softball and baseball pitching.


Mazzarella JE, Heathcock JC

PURPOSE/HYPOTHESIS: Cerebral palsy (CP) and autism spectrum disorder (ASD) can both include impaired upper extremity function, which often results in decreased participation. Physical therapy (PT) using hippotherapy and the equine environment might be appropriate for increasing participation and improving upper extremity function in these children. This study aimed to evaluate the feasibility of a randomized controlled trial (RCT) protocol and fidelity of an upper extremity-targeted and participation-based PT intervention using hippotherapy and the equine environment for children with CP and ASD. We hypothesized that feasibility of the RCT would be demonstrated by >80% participant retention and attendance, and >85% outcome measure completion; intervention fidelity would be demonstrated by >50% of the session involving upper extremity and participation activities.

MATERIALS AND METHODS: The study was an RCT with waitlist control. Control participants completed a pre-baseline assessment, then a 4-week control period. All participants completed a baseline assessment, then received 16 hours (1 hour/4 days/week/4 weeks) of PT intervention using hippotherapy and the equine environment, then a follow-up assessment. Outcome measures included the Gross Motor Function Measure-88, a reach-to-drink kinematic measure, the Participation and Environment Measure for Children and Youth, the Child Assessment of Participation and Enjoyment/Preferences for Activities of Children, and the Vineland Adaptive Behavior Scales, 2nd Edition. Recruitment, screening, enrollment, attendance, and retention were tracked, as well as reasons for withdrawal or absences. Fidelity was measured by coding videos of the treatment sessions and recording the duration of all instances of functional upper extremity use and participation activities.

NUMBER OF SUBJECTS: 14 children ages 6-17 with CP and/or ASD with an upper extremity impairment.

RESULTS: There were 14/20 (70%) eligible participants enrolled, 12/14 (86%) attended their first assessment, 11/12 (92%) completed the treatment period, and 9/11 (82%) completed the follow-up assessment. Attendance for treatment sessions was 82%. Completion of the GMFM-88, PEM-CY, VABS-II, PRIME-O, and PRIME-SP was 100% for participants who attended the sessions. Completion of the CAPE/PAC was 81%, and of the reach-to-drink kinematic measure, 77%. Upper extremity and participation activities comprised an average of 73% and 77% of session time, respectively.

CONCLUSIONS: This study provides preliminary evidence of feasibility of an RCT protocol of PT using hippotherapy and the equine environment to target the upper extremities and participation in children with CP and ASD. Results from this study will inform design of a Phase II trial to continue to refine the intervention approach and RCT design for an eventual efficacy study.

CLINICAL RELEVANCE: Preliminary evidence from this study suggests that PT using hippotherapy and the equine environment can deliver a high dose of upper extremity and participation activities to children with CP and ASD. Further research is needed to confirm these results.


McCarthy E, Marchese VG, Gray VL

PURPOSE/HYPOTHESIS: Deficits in postural control are commonly reported as late effects from childhood cancer treatment. Jumping rope is a complex motor task that challenges balance while requiring bilateral coordination of the extremities in order to maintain an upright position. The purpose of this study is to determine the effects of a jumping rope intervention on postural control in a population of survivors of childhood acute lymphoblastic leukemia.

MATERIALS AND METHODS: Prior to participating in the intervention, participants were assessed using the balance and bilateral coordination subtests of the Bruininks-Oseretsky Test of Motor Proficiency (BOT-2) and center of pressure (COP) parameters including length of path, 95% confidence ellipse (area), and velocity as measured by adjacent force platforms during a countermovement jump. Participants then participated in a six-week jumping rope intervention. The participants completed training in-person with a physical therapist (5 sessions) as well as at home (13 sessions). Following the intervention participant's balance and postural control were reassessed using the BOT-2 and COP parameters. Group mean differences pre- and post- intervention and assessments of relationships between measures of COP and BOT-2 subtests were analyzed.

NUMBER OF SUBJECTS: 10 children who had completed medical treatment for ALL within the past five years were included.

RESULTS: Participants demonstrated significant improvements in balance (p<0.001) and bilateral coordination (p<.001) as measured by the BOT-2 following a six-week jumping rope intervention. There were no significant differences in COP parameters pre- and post-intervention. There were no significant correlations between subtests of the BOT-2 and measures of COP including length, area, and velocity.

CONCLUSIONS: A jump rope intervention significantly improved balance and coordination deficits in childhood cancer survivors. This type of intervention involves a complex motor task that sufficiently challenges balance and coordination. Our study highlights the need to comprehensively assess balance, coordination, and postural control as measures of center of pressure alone may not adequately capture balance or coordination deficits in a population of childhood cancer survivors.

CLINICAL RELEVANCE: Jumping rope is a complex motor task that can be used as an intervention to improve balance and coordination in a population of childhood cancer survivors. Clinical measures of balance such as the BOT-2 capture balance and coordination deficits that may otherwise be not picked up by posturography alone.


McKee DP, Wentzell EM

PURPOSE/HYPOTHESIS: Parental burnout has been defined as exhaustion, detachment, and feelings of inefficacy, which has been shown to have increased prevalence and risk for caregivers of children with disabilities. Parental personality traits, age, social support, and strength of partner relationships have been identified as risk factors for parental burnout. However, examining parent perceptions of routines to identify risk factors for parental burnout has scarcely been examined in the literature. The primary goal of the “Activity Matters” study was to examine physical activity and daily routines for ambulatory children with disabilities through a parental perspective. The goal of this secondary investigation is to examine possible risk factors that may be associated with burnout for parents of ambulatory children with a disability.

MATERIALS AND METHODS: Parents participated in a one-hour semi-structured virtual interview. The research team completed thematic analysis using the Consensual Qualitative Research (CQR) approach.

NUMBER OF SUBJECTS: This study utilized parental reports from 15 families of 16 ambulatory children aged 5-10 years old with a known disability, including Down syndrome, cerebral palsy, and autism spectrum disorder.

RESULTS: Possible risk factors for parental burnout were prevalent in this study including physical and emotional exhaustion, dissatisfaction, and lack of time which in part impacted participation. Families expressed dissatisfaction around multiple aspects of life such as level of physical activity, community participation, screen time, and COVID leading to feelings of stress and inadequacy. Parent emotional fatigue was identified as parents reported guilt for taking time for themselves and reporting that they felt exhausted after work with very little time outside of work and caring for their children. Additionally, families reported that numerous therapies made participation difficult as their children attended multiple therapy appointments most every day of the week.

CONCLUSIONS: Through this study we identified possible risk factors for parental burnout associated with physical and emotional exhaustion, dissatisfaction around various aspects of each day, and a lack of time due to busy therapy/work schedules. These possible risk factors for burnout may deepen the lack of participation for children and families. Therefore, consideration around the factors found through this research is essential to better recognize parental burnout and more effectively treat children with disabilities using a family-centered approach.

CLINICAL RELEVANCE: As physical therapists, we must understand both the rewards and demands of caring for a child with a disability to better serve our patients and families using family centered care. This will reduce the risk for burnout leading to greater community participation. We must also be vigilant in self-monitoring the demand that our therapies and home programs place on families and children. Through this self-reflection we can tailor our plan of care to meet families where they are to optimize outcomes and reduce the risk for burnout.


McKenzie C, Titzer M, Hutchinson A, Dodge C, Fergus AH

PURPOSE: The telehealth delivery of PT (TelPT) has increased exponentially but the literature in pediatrics is limited. TelPT promotes many of the cornerstone practices of pediatric PT including a family centered approach within the natural environment. The education of PTs in this area must therefore be considered. A novel entry-level collaborative clinical learning experience (CLE) involving pediatric TelPT was implemented. The feasibility, acceptability and potential efficacy of the model was examined.

DESCRIPTION: Twelve families, 55 entry-level second year DPT students, and 12 clinical instructors (CIs) including 4 DPT faculty participated in a collaborative TelPT CLE. Children 22 months to 19 years with a wide range of home situations and diagnoses received individualized PT for 4-5 one hour sessions over 4 weeks in their homes via telehealth. One CI and 3-4 DPT students participated via zoom conference calling with the caregivers and child using the chat and recording features. Documentation and video recordings of 11 of the children were analyzed by 2 independent researchers. Questionnaires were distributed to caregivers, CIs and students after the experience to explore perspectives.

SUMMARY OF USE: All children made subjective improvements and 73% made objective improvements toward their goals. Improvements were noted across many areas including milestone achievement, static and dynamic balance, gait, stairs, and fine motor skills. Family engagement increased across time in all cases. Forty-three percent of participants responded to the questionnaire (7 caregivers, 20 students, and 7 CIs). Prior to the experience, most students (95%) and CIs (85%) reported having little to no experience with telehealth. Student and CI interest in telehealth and student interest in pediatrics increased. Most students (95%) and CIs (100%) felt that it was a valuable and effective learning experience and benefited the child/family. Of the 15 relevant Clinical Performance Instrument domains, 100% of CI's believed students learned in all domains. This was consistent with student perception except for a few (5-20%) who did not feel they adequately learned screening, diagnosis, examination, assessment and evaluation skills. While all families felt the experience benefited their child and was a good student learning experience, 29% of caregivers felt that they were not able to build a connection with the students and CIs. Students, CI's and caregivers reported benefits of both TelPT and in-person PT and student learning.

IMPORTANCE TO MEMBERS: The delivery of pediatric PT via telehealth is feasible and has perceived benefits and efficacy for a wide range of children. This model provides a unique CLE for students in both pediatric PT and telehealth that appears to be effective across all domains based on the perceptions of CIs, students and families. This model provides a means of increasing access to pediatric PT that utilizes the natural environment and promotes family engagement. This model also provides a collaborative CLE for entry level students in pediatric PT and the telehealth delivery of services.


Medley ADH, Gatlin RR, Gilbert KK, Scutti NC, Armstrong DQ, Sadowksi L, Humphries E, Lenz N

PURPOSE/HYPOTHESIS: To investigate the developmental impacts and outcomes of Neonatal Abstinence Syndrome (NAS) and Substance Exposure (SE) on pediatric patients and determine if standardized pediatric assessment tools are being utilized in PT and OT and to survey therapists about their perceptions and challenges when treating this population.

MATERIALS AND METHODS: Pediatric subject charts were obtained from a rural pediatric therapy practice who met study inclusion and exclusion criteria. Child subject data of 15 subjects was accessed through electronic medical records search using de-identified data. Data was stored in a secure OneDrive file and analyzed for trends such as therapies received, identified functional limitations, impairments, and comorbidities, standardized assessment tools used, targeted interventions, and therapy goal attainment using both quantitative and qualitative analyses. Subjects (PT/OTs) from the same practice and region were anonymously surveyed who work with children diagnosed with NAS and/or SE to obtain information about their perceptions and experiences working with this patient population.

NUMBER OF SUBJECTS: 15 Children, 9 Therapists.

RESULTS: 11 subjects received OT and 7 received PT services. 8/15 evaluations included use of a pediatric standardized assessment tool (1/7 receiving PT and 8/11 receiving OT). The following limitations were noted: 93% sensory processing, 60% gross motor, 60% feeding, 46% self-regulation, and 40% fine motor. Of the 15 subjects, therapy specific goal attainment data included: 4 fully met all goals, 3 did not meet any goals, and 8 had partial mastery of goals.

SURVEY RESULTS: 100% of surveyed subjects agreed that this patient population would benefit from automatic multidisciplinary screening at diagnosis, 88% felt that clinical practice guideline need to be developed, 100% reported transportation & changing custody status as factors affecting patient outcomes. The greatest perceived barrier to therapeutic outcomes was caregiver noncompliance with lack of referral being second.

CONCLUSIONS: Children diagnosed with NAS and SE present with issues requiring the need for timely PT and OT intervention. This study revealed the most common impairments among subjects as difficulties in sensory processing, gross motor skills, feeding, self-regulation, and social skills and mixed goal attainment is noted. Based on therapists surveyed, the need for timely referrals and objective assessments is needed to provide optimal care and ongoing patient progress tracking. This study revealed OT to be the most referred discipline and the discipline performing the most standardized assessments. Currently there are no specific pediatric multi-disciplinary standardized assessment tool available that has been validated on this population. The study also suggests that there is a need for a timelier, streamlined referral process and practice guidelines to promote better patient outcomes.

CLINICAL RELEVANCE: The development of continuing education, standardized assessment tools, and clinical practice guidelines are needed to promote better patient outcomes and aid therapists working with this population.


Mischnick AK

PURPOSE: This report describes the process of accelerating frequency specific microcurrent (FSM) into clinical practice at a single pediatric academic hospital for the treatment of congenital muscular torticollis (CMT).

DESCRIPTION: Frequency specific microcurrent is a dual-channel, alternating electrical current applied superficially at an extremely low level not perceived by the patient. It has been found to treat nerve and muscle pain, reduce inflammation, relieve stiffness, and repair tissue. Microcurrent has been reported to treat infants with CMT outside of the United States (US), and only one case study has been reported within the US. Research indicates infants with CMT receiving FSM may have improved tolerance to therapy, quicker goal achievement, and faster recovery with fewer physical therapy visits. Despite FSM being identified as the strongest evidence for treating CMT using a supplement intervention by the American Physical Therapy Association, Academy of Pediatrics Clinical Practice Guideline for the Physical Therapy Management of CMT, FSM is not yet widely used in the US.

SUMMARY OF USE: To implement FSM at our facility, the CMT Translating Research and Clinical Knowledge into Practice (TRACK) leader attended the 2018 FSM CORE seminar at Cleveland Clinic Children's Hospital for Rehabilitation (CCCHR), the only known facility in the US using FSM to treat CMT during that time. TRACK team members shadowed FSM practitioners at CCCHR to identify techniques and protocols specific to pediatrics. The TRACK leader received further training at the 2020 FSM CORE seminar and acquired FSM units to implement this intervention for treatment of CMT symptoms. Per hospital safety requirements, Equipment and Standards approval was obtained for the devices before FSM trials began. Plan Do Study Act (PDSA) cycles were conducted by the leader utilizing FSM with 9 CMT patients over 53 sessions in 2020. Improvements were noted in infant tolerance to stretching during and following FSM sessions. The PDSA series focused on treatment technique modifications to increase tolerance, safety, and efficiency of FSM application. Findings guided creation of a departmental FSM competency, equipment instructions and a family education handout. Phrases were built to improve speed and consistency of documentation, and outcome measures were established corresponding with discharge criteria. With the equipment, process and documentation successfully operationalized with one practitioner, focus then turned to spreading use of FSM to all physical therapists who treat CMT utilizing the competency and a train-the-trainer model. An Institutional Review Board protocol was accepted to follow patients receiving FSM and facilitate further research for establishment of FSM as a supplemental modality for treating patients with CMT at our facility.

IMPORTANCE TO MEMBERS: Outlining steps to accelerate this innovative treatment technique into practice can facilitate propulsion of FSM into widespread clinical use and expand the use of FSM to additional facilities throughout the US.


Molinini Koziol NA, Rhee C, Salgaonkar A, Harbourne RT, Lobo MA, McCoy SW, Hsu LY, Burnsed J, Shall MS, Spence CM, Stevenson R, Dusing SC

PURPOSE/HYPOTHESIS: Clinicians needs affordable tools that can be administered quickly and repeatedly to track problem-solving in young children with or at high risk for neuromotor delays. The Assessment of Problem-Solving in Play (APSP) is one such valid tool; however, the scoring process is lengthy. The purpose of this analysis was to validate a modified scoring procedure for the APSP (referred to as the APSP-4) against the Bayley Scales of Infant and Toddler Development-III (Bayley).

MATERIALS AND METHODS: Participants were assessed with the APSP-4 and Bayley at each visit. The APSP-4 is a videotaped 6-minute assessment in which children are given three standardized toys each for two minutes. Each 2-minute period was divided into 30, 4 second intervals using Datavyu open access software. Each interval was viewed once in real time and the highest-level problem-solving skill observed was marked. The frequency of each skill was entered into a weighted equation and divided by assessment length to derive a single APSP-4 weighted score. Each 6-minute assessment was typically scored in 12-20 minutes. All sections of the Bayley were performed but only the cognitive raw scores were used in this analysis. Multivariate linear mixed modeling compared correlations of APSP-4 and Bayley cognitive raw scores and trajectories by time, age and baseline motor delay. Statistical significance was set at α = .05.

NUMBER OF SUBJECTS: Data were drawn from 95 children evaluated in two clinical trials. Infants (N=28) born extremely preterm were stratified into mild vs severe motor delay based on baseline Test of Infant Motor Performance Z-scores (mild >0.50 and <1.0 SD below the mean; severe ≥1 SD below the mean) at 35-42 weeks of gestation and assessed up to 4 times (15 weeks, 30 weeks, 12 months, and 24 months post baseline). Children (N=67) with motor delay, were enrolled between 7-16 months of age, stratified into mild vs severe motor delay based on baseline Bayley motor composite scores (mild <2.5 SDs below the mean; severe ≥2.5 SDs below the mean), and assessed up to 7 times (baseline, 3-, 6-, 12-, 24-, and 36-months post baseline, or up to 54 months of age).

RESULTS: Correlations of APSP-4 and Bayley cognitive raw scores at ages 3-54 months were significant (p's<.05), with large magnitude correlations for ages 6-54 months (r's>.56) and moderate at 3 months (r=.36). APSP-4 and Bayley linear growth trajectories were highly correlated (r=.81) with both demonstrating a deceleration in change as children got older. Children with mild or severe baseline motor delay performed similar on the APSP-4 and Bayley (p's>.21) and children with mild motor delay demonstrated greater average growth on the APSP-4 and Bayley than children with severe motor delay. APSP-4 had strong inter- (ICC=.96) and intra-rater (ICC=.95) reliability.

CONCLUSIONS: The APSP-4 performed similar to Bayley cognitive raw scores across time, age, and motor delay.

CLINICAL RELEVANCE: The APSP-4 may be a tool that clinicians can use to track problem-solving in children with or at high-risk for neuromotor delays aged 3 months to 4 years. Future research is needed to examine the feasibility of clinical implementation.


Miller KL, Castillo A, Duenas N

PURPOSE/HYPOTHESIS: To determine the impact of childhood trauma, specifically ACEs on psychosocial and physical childhood development.

MATERIALS AND METHODS: A literature review was conducted concerning the impact of adverse childhood experiences on childhood development. The search of studies was performed from February to April 2022 on the following databases: Scopus, CINAHL Complete, and Medline Complete. Inclusion criteria: (1) published into an academic journal, (2) study participants were aged 0-18 years old, (3) inclusion of impact of adverse childhood experiences, and (4) inclusion of a domain of child development. The exclusion criteria: (1) articles in which full text was not available, (2) data analysis was on adult study participants, and (3) review articles. Search terms included: adverse childhood experience(s), Alberta Infant Motor Scale(AIMS), motor, milestone, and developmental delay.

NUMBER OF SUBJECTS: Children aged 0-18 years old who have experienced ACEs.

RESULTS: 513 articles were identified, of which 36 articles met criteria to be included in the review. Exposure to ACEs demonstrated decreased motor development compared to children who had not experienced ACEs. Additionally, children exposed to ACEs demonstrated decreased cognitive development when compared to children who had not experienced ACEs. Also, children exposed to 3 or more ACEs were at a greater risk of developing socioemotional delays compared to children who had not experienced ACEs. Three of the studies found that with the increasing number of ACEs, the rate of socioemotional or behavioral problems increased as well. Information on the impact of trauma on language development was limited with the three articles identified containing conflicted findings. Three of the studies analyzed the differences between high and low amounts of ACEs and developmental delay with two finding a negative association and one not finding any statistically significant findings. The remaining two studies analyzed specific ACEs and their associations with developmental delay indicating further that the type of maltreatment plays a role in developmental delay.

CONCLUSIONS: This literature review found that adverse childhood experiences can negatively impact childhood development. The number of ACEs and type of ACE were important factors in how the domains were impacted. Parental ACEs can have an impact on their children's development as well on top of the child's own ACEs. Further research needs to be done as there were very limited studies focusing on childhood ACEs impact on development and an even more scarce amount on the specific development domains of motor, cognition, and language. Understanding ACEs is vital to providing trauma informed care in any healthcare profession and beneficial for understanding our patients better to provide them with the best care.

CLINICAL RELEVANCE: Overall, the clinical relevance of ACEs is profound in a healthcare worker's ability to properly screen and treat patients exposed to ACEs while implementing appropriate trauma-informed care and collaborative care.


Munecas T, Thomas A

PURPOSE: According to the Academy of Pediatric Physical Therapy, models, standards, and competencies are available but lack the prescriptive delivery and specific competencies for clinical development. With that being said, how can we compare student's clinical success to pediatric curricula within the DPT program? A variety of studies suggest small examples of curricula, but the results are lacking in the respective examples. The aim of this study was to see if the knowledge translation of the advanced pediatric course improved scores on the clinical performance instrument after pediatric rotations. Utilization of the Clinical Performance Instrument (CPI) is a common tool used to analyze a student's clinical competence and understand the relevance in relation to the curriculum.

DESCRIPTION: Our advanced pediatric curriculum consists of a unique opportunity that allowed students to experience firsthand exposure of pediatric physical therapy practice with the course being hosted off-campus at a children's hospital outpatient clinical setting. This allowed the students to experience the use of knowledge translation into a clinical setting. Students spent class time observing and participating in initial pediatric examinations, evaluations, and interventions of pediatric patients with orthopedic and neurological impairments. Course content was presented during lectures and labs that were reinforced through live case demonstrations, clinical research articles, and the sharing of professor clinical experience. The innovative course format provided students with opportunities to enhance their critical thinking and clinical decision-making with pediatric patient care.

SUMMARY OF USE: Clinical Performance Instrument data for 20 students from 2 cohorts were successful in achieving “advanced intermediate and above” in 6 areas on the clinical performance instrument by their final CPI report. The six areas of focus were professional behavior, clinical reasoning, examination, plan of care and procedural interventions. The average rating was “between entry-level or beyond entry-level” rating for both cohorts in all 6 area items.

IMPORTANCE TO MEMBERS: Implementing clinical reasoning with application towards pediatric patients while teaching courses in a clinical setting engages a student to think at a higher order level. There is a distinct separation between the didactic portion of the curriculum and clinical education provided during clinical experiences. The course aimed to bridge the gap by providing students with live patient demonstrations that linked evidence-based practice with clinical decision making and application. The unique learning experience provided students with a comprehensive understanding of how to examine, assess, evaluate, and treat the pediatric patient from infancy through adolescence.


Neeley DK, Minick K, Norton BE

PURPOSE/HYPOTHESIS: The clinical practice guideline (CPG) for patients with congenital muscular torticollis (CMT) recommends physical therapists (PT) determine CMT severity based on differences (diff) in passive range of motion (PROM) from left to right at initial evaluation. Severity categories are mild (< 15° PROM diff), moderate (15-30° PROM diff), and severe (> 30° PROM diff). Additionally, the CPG recommends PTs use standard discharge criteria (SDC) which includes diff in PROM < 5°, diff in cervical PROM lateral flexion < 5°, diff in cervical AROM rotation < 5°, muscle function scale within 1 point left to right, and head in midline ≥ 90% of the time. The purpose of this study is to describe outcomes for patients with CMT based on severity and patient age at evaluation.

MATERIALS AND METHODS: Two analyses were performed using documentation data. The primary analysis compared groups based on severity. The second analysis compared the largest group (mild severity) stratified by age. Outcomes of interest included averages of number of SDC met at final visit (SDC-f), percentage of patients meeting all 5 SDC at final visit (SDC-%), number of appointments (appts), and length of stay in days (LoS).

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 CMT severity at evaluation and number of SDC met at final visit.

RESULTS: Primary analysis comparing CMT severity:

  • Mild (n=1118), SDC-f 4.25, SDC-% 0.625, appts 3.87, LoS 64.84
  • Moderate (n=170), SDC-f 3.47, SDC-% 0.359, appts 5.06, LoS 85.24
  • Severe (n=29), SDC-f 3.03, SDC-% 0.310, appts 8.41, LoS 148.67.

Chi-square analysis between severity groups for patients who met 5 SDC on final visit vs ≤ 4, was statistically significant (54.0961, p<0.00001)

Secondary analysis, mild severity patients, stratified by age:

  • 0-3mo (n=141), SDC-f 3.63, SDC-% 0.383, appts 2.53, LoS 27.93
  • 4-5mo (n=484), SDC-f 4.33, SDC-% 0.655, appts 3.31, LoS 51.52
  • 6-8mo (n=378), SDC-f 4.41, SDC-% 0.683, appts 4.35, LoS 76.91
  • 9-11mo (n=80), SDC-f 4.18, SDC-% 0.613, appts 6.23, LoS 121.20
  • > 12mo (n=35), SDC-f 4.17, SDC-% 0.600, appts 6.37, LoS 138.83.

Chi-square analysis within this cohort for patients who met 5 SDC vs ≤ 4, was statistically significant (41.4857, p<0.00001)

CONCLUSIONS: In our cohort, mild severity accounted for 85% of the CMT population, of which 77% were 4-8mo. Worsening severity was associated with a decrease in percentage of patients who met all SDC, an increase in number of appointments, and an increase in LoS. Within the mild severity cohort, all age groups met SDC ≥ 60% of the time except 0-3mo, and number of appointments and LoS increased with age.

CLINICAL RELEVANCE: This study highlights two clinically relevant findings. 1) PT interventions for CMT are most effective for patients classified with mild severity. 2) Patients 0-3mo with mild severity CMT do not meet SDC criteria as often as other age groups of the same severity.


Nies K, Baldwin JS, Kaur M

PURPOSE/HYPOTHESIS: Autism Spectrum Disorder (ASD) is a highly prevalent (1 in every 44 children) neurodevelopmental disorder usually diagnosed after 2nd year of life.1,2 Currently, there is a significant push towards early diagnosis of ASD as it allows access to intervention and opportunities for optimal future outcomes.3,4 Although, majority of early detection studies have focused on characteristic atypicalities of ASD (i.e. social communication delays),5 there is growing interest in identifying the early motor delays of ASD.6,7 Therefore, the primary aim of this scoping review was to summarize the current literature on ASD-specific motor delays during the first 2 years of life.

MATERIALS AND METHODS: Four electronic databases were searched (Pubmed, PsycINFO, CINAHL, ERIC) for terms associated with “motor” and “autism”. Studies were eligible if they a) were peer-reviewed and published in English, b) examined motor skills of participants during the first 2 years of life, and c) included infants at risk for ASD or children diagnosed with ASD. The data from the eligible studies was extracted to code for sample and study characteristics, assessment measures, dependent variables, and study results.


RESULTS: 19 studies met the eligibility criteria; 16 prospective studies included infants at risk due to an older sibling with ASD and 3 retrospective studies included children with ASD. Majority of the studies reported on motor performance during the first 6 months of life (n =12). Overall, infants at risk or later diagnosed with ASD a) perform poorly on standardized assessments such as Mullen Scale of Early Learning and Alberta Infant Motor Development (n =9), b) show delayed acquisition and poor maturity of gross motor postures such as lying, sitting, and standing (n =5), c) have motor anticipation deficits and delayed initiation of movement during experimental tasks such as an approaching ball (n =4), and, d) produce fewer functional actions and facilitating grasps during spoon feeding (n =1). All prospective studies followed up infants at a later age (18-36 months) to confirm ASD diagnosis; however, only 7 of these compared motor performance across infants who were diagnosed with ASD vs those who were not, and none were able to identify ASD-specific early motor delays. Lastly, 6 studies highlighted an association of early motor delays with later ASD outcomes such as autism severity (n =2), language (n =3), and social skills (n =1).

CONCLUSIONS: Motor delays could be identified using standardized or non-standardized measures as early as 3-6 months of age in infants at risk for ASD. However, it is still unclear whether early motor delays in ASD during the first 2 years of life are specific to ASD or are a consequence of general developmental disorder.


Oriel KN, Campagna J, Czyszczon KN, Little JM, Selby CM, Wick LE, Ferreira D, Kanupka J

PURPOSE/HYPOTHESIS: Children with disabilities have fewer opportunities for participation in community-based fitness programs. This may negatively impact their overall health and wellness. The purpose of this study was to examine the impact of a school-based running program on physiological cost index and quality of life in children with physical and cognitive disabilities.

NUMBER OF SUBJECTS: Participants included 22 children (16 males and 6 females) with a mean age of 12.4 years. Participants were all ambulatory without an assistive device with diagnosed disabilities including intellectual disability, Autism Spectrum Disorder, and Down syndrome among others.

MATERIALS AND METHODS: Three classrooms from a local middle school were recruited to participate in a school-based running program. The program was designed to be implemented 2X/week for 6 weeks by classroom teachers/aides. Physical therapy faculty and students developed the program and assisted with implementation. The program was 30 minutes in length consisting of a warm-up/cool-down, relay races, games, and timed runs. Pre/post test measures included physiological cost index (PCI) (working heart rate-resting heart rate/walking speed), and PedsQL™ Pediatric Quality of Life Inventory Version 4.0. Participants engaged in walking/running for a prescribed distance with working and resting heart rate (HR) and time recorded to establish PCI. The PedsQL™ was read to each participant with responses recorded by classroom teachers.

RESULTS: Pre and post test data were compared using the Related-Samples Wilcoxon Signed Ranks Test. Statistically significant improvements were observed for both the PCI (p=0.028), and the PedsQL™ (p=0.003).

CONCLUSIONS: Results of this study suggest that participation in a 6-week school-based running program may improve energy efficiency and quality of life. Teachers were able to easily incorporate the program into the school day. Informal feedback from parents of participants indicated additional benefits may exist including improved sleep habits.

CLINICAL RELEVANCE: Pediatric physical therapists, in collaboration with classroom teachers, should consider developing and implementing school-based fitness programs given the limited opportunities for children with disabilities in community settings. Such programs may allow children to not only improve their fitness levels, but also improve their overall quality of life.


Panzarino J

BACKGROUND AND PURPOSE: Noonan syndrome is an autosomal dominant genetic disorder with a high incidence of congenital heart defects. Heart transplantation is rare in children, but is often a treatment for end stage pediatric heart disease. Following heart transplantation, studies have shown positive outcomes in adult patients who participate in cardiac rehab. Supervised exercise in cardiac rehab programs in the adult population following heart transplant have been shown to improve peak VO2 and skeletal muscle strength, decrease stroke risk, decrease hospitalization for acute rejection or heart failure, and decrease risk of death. However, there is limited guidance regarding implementation of a physical therapy program in pediatric heart transplant recipients. The purpose of this case series is to assess the benefits of outpatient physical therapy on activity, participation, and quality of life for children with Noonan syndrome status post heart transplantation.

CASE DESCRIPTION: A 10-year-old female and 8 year old male who underwent heart transplantation with a premorbid diagnosis of Noonan syndrome presented to outpatient physical therapy 4 weeks post-transplant. Adult cardiac rehab guidelines were used as a model when developing a plan of care which included 2-3 sessions per week for 12 weeks and consisted of aerobic, resistance, and flexibility training with warm up and cool down periods. Tests and measures were assessed at initial evaluation and at 12 weeks. These tests include: (1) Six-Minute Walk Test (6MWT), (2) 30 Second Sit to Stand (30CST), (3) 2 Minute Step Test (2MST), and (4) PedsQL: Cardiac Module (Parent Report).

OUTCOMES: After 12 weeks, both patients improved their scores in all objective measures. The 10 year old patient improved their 6MWT score from 60m to 120m, their 30CST score from 9 to 13, and their 2MST score from 0 to 53. The 8 year old patient improved their 6MWT score from 96m to 216m, 30CST score from 5 to 12, and their 2MST score from 24 to 39. The 8 year old patient's PedsQL score changed from 53% to 72% improved quality of life, while the 10 year old patient's scores remained the same. No adverse effects were reported by the patients following treatment sessions.

DISCUSSION: This case series describes the successful implementation of a physical therapy program for two pediatric patients with Noonan syndrome status post heart transplantation. Some limitations included transportation issues to get to the clinic, conflicting medical appointments, and hospitalizations that took place during the intervention period. There is research supporting the efficacy of adult based cardiac rehab, but limited guidelines have been established for treating the pediatric patient post heart transplant. Outpatient physical therapy can be both effective and safe in promoting function and improving endurance in pediatric heart transplant recipients with Noonan syndrome. Further research is required to establish specific clinical practice guidelines on treating the pediatric patient post heart transplant.


Pontiff ME, Moreau NG

PURPOSE/HYPOTHESIS: 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 investigate the relationship between lower extremity power produced during the PLP test and activity and participation in those with CP. We hypothesized that muscle power will be positively related to tests of walking capacity as well as self-reported activity and participation.

MATERIALS AND METHODS: Participants performed 5 inclined power leg presses at 40-50% of their 1-repetition maximum “as fast as possible” [1]. A linear position transducer was attached to the weight bar, and the displacement, total load, and angle of the sled were used to calculate peak power in watts (W) for each trial [2]. Peak Power (PP) was calculated as the highest power value across the five presses. Walking capacity was measured using the Timed-Up and Go (TUG), 10-meter walk test(10mWT)- fast and self-selected (SS) speeds, and the 1-minute walk test (1MWT) [3-5]. Self-reported activity and participation were measured using the performance version of the Activities Scale for Kids (ASKp), Patient-Reported Outcomes Measurement Information System (PROMISÒ)-Pediatric Profile-49 v2.0, and the Gait Outcomes Assessment List (GOAL) [6]. Pearson's correlation coefficients were used to determine relationships between PP and both walking ability and self-report activity and participation (significance level <0.05).

NUMBER OF SUBJECTS: Ambulatory individuals with CP (n=26; age 19.3 ± 7.8 years; 8 male, 18 females; range 10-37 years; GMFCS level I/II/III: 4/19/3).

RESULTS: PP was moderately correlated to the TUG (r = -.47), 10mWT- Fast (r= .46), and 1MWT(r=.54) (p<0.05). There was no significant relationship between PP and SS gait speed (r= .32, p >0.05). PP was significantly related to composite scores on the ASKp (r=.62) and GOAL (r=.71) and to 4 components of the PROMIS: physical function (r=.73), fatigue (r= -.58), peer relationships (r=.61), and pain intensity (r= -.44). The play subscale of the ASKp (r= .81), Activities of Daily Living (ADL) (r= .76) and physical activity and sport (r= .76) components of the GOAL had the strongest relationships to PP produced during the PLP test (p<0.05).

CONCLUSIONS: The higher velocity of the PLP test may explain the moderate association of PP with the 1MWT and fast gait speed. Self-reported activity and participation showed moderate to strong relationships to lower extremity muscle power. In particular, associations with PP were strong for subscales which focused on rapid movements (sports and play) as well as ADLs.

CLINICAL RELEVANCE: Lower extremity power produced during the PLP test significantly influences walking ability, activity, and participation in ambulatory individuals with CP. Those who produced more power had greater walking ability and higher levels of self-report activity and participation in everyday activities. These results may guide selection of resistance interventions for ambulatory individuals with CP as increasing muscle power generation may translate into improvements in walking ability, activity and participation.


Powell ML, Atkins K

PURPOSE/HYPOTHESIS: The CDC's recently released “Evidence-Informed Milestones” omitted crawling from the motor milestone section of its checklist for developmental surveillance. This has led to a renewed interest in the importance of crawling to human infant development. The purpose of this review was to examine the existing evidence related to human infant crawling.

MATERIALS AND METHODS: The authors undertook a scoping review of current evidence to achieve the following objectives: 1) determine a standardized vocabulary to describe the different crawling variations and other pre-walking locomotion strategies, 2) identify the percentage of infants across studies who omitted the crawling milestone, 3) determine if there are any differences in musculoskeletal, neuromuscular, cognitive function, or learning outcomes when comparing infants who crawled to those who omitted crawling, and 4) determine if there is any predictive value in the method and age of onset of pre-walking locomotion strategies. Studies included in this review were identified using a systematic search of PubMed, CINAHL, PsychInfo, and Pedro databases. Full methodology including search terms and inclusion/exclusion criteria will be described in further detail.

NUMBER OF SUBJECTS: 3209 articles identified, 19 included in review.

RESULTS: As to the objectives: 1) There is inconsistent nomenclature overall, although the most recent evidence is more consistent in its use of “hands-and-knees crawling” as the terminology to describe what most practitioners describe as “typical crawling.” Descriptions of different variations as well as different terms used interchangeably with “hands-and-knees crawling” will be explained in further detail. 2) The most recent study with the largest cohort reported that 95.7% of infants demonstrated hands-and-knees crawling of some duration; older studies and those with smaller sample sizes report a lower percentage of hands and knees crawlers (85-88%). 3 and 4) Lower-level studies support correlation between a skipped or shortened crawling period and a relative decrease in hip and shoulder stability, correlation between delayed crawling onset and future motor delay, correlation between a skipped crawling milestone and lower scoring on the upper extremity portions of the Miller Assessment of Preschoolers, and correlation between later crawling onset and different measures of infant overweight/obesity.

CONCLUSIONS: Although there are multiple studies that suggest relationships between delayed or omitted crawling and future musculoskeletal, gross motor, and upper extremity coordination issues, there is a lack of high-level, current evidence that specifically looks at the infant crawling milestone and its predictive use in human development. This review does provide a basis from which we can target future research.

CLINICAL RELEVANCE: As physical therapists have demonstrated renewed interest in the importance of the crawling milestone in light of the updated CDC milestone guidance, it is important to know what evidence currently exists regarding crawling as well as the quality of that evidence. This scoping review lays the basis for future research endeavors.


Proffitt JL

BACKGROUND AND PURPOSE: Pediatric vaso-occlusive crisis' increase in frequency and intensity as the child ages. These recurrent acute painful events lead to lower self-efficacy, impaired mobility, depression, anxiety, decreased school attendance, and sleep disorders ultimately leading to a reduced quality of life. Once admitted in the hospital, these children typically are treated with pharmacologic interventions, have limited out of bed mobility secondary to side effects of pain medications, pain at rest and with activity, and fear of movement which can lead to physical and emotional changes. Current research is limited regarding benefits of inpatient physical therapy for these patients. This case series aims to see how physical therapy intervention combined with pharmacologic treatment can improve self-efficacy and mobility while a patient is hospitalized with a vaso-occlusive crisis (VOC).

CASE DESCRIPTION:Patient A 17-year-old F with SCD and presents with acute chest syndrome with hx of 1 hospitalization/year; consulted for PT Day 1. Pt with complaints of RUE and chest pain. LOS 9 days, 4 PT sessions total; max 1L LFNC. Ambulatory- WBAT BLE. Reports fear and helplessness when having pain and/or VOC; unable to participate in PE class/sports at school due to fear of VOC.

Patient B 15-year-old M with hx of Sickle Cell disease, presented as a level 2 trauma for a fall from roof and ingestion of bleach with bilateral ankle fractures and L5 compression fracture. S/p external fixator application to bilateral ankles Day 1 and bilateral ankle ORIF on Day 12. Non-ambulatory: NWB BLE. VOC dx Day 4. LOS 20 days, 12 PT sessions total. Reports he used to swim but is afraid of VOC onset.

OUTCOMES: Both patients demonstrate improvements in self-efficacy, pain, and mobility by the end of their hospital stay. Physical Therapy interventions showed immediate improvements in baseline heart rate and pain levels at rest for both patients in 1 session.

DISCUSSION: Physical therapy intervention initiated during a vaso-occlusive crisis in adolescents both male and female could possibly lead to improved self-efficacy and mobility along with immediate improvements in baseline heart rate and pain levels at rest. Furthermore, both patients have significant differences in hospital course due to psychosocial components and traumatic injury demonstrating physical therapy intervention can be used for a wide variety of adolescents diagnosed with a vaso-occlusive crisis. Currently, research is limited in terms of acute physical therapy intervention benefits in this population especially looking at long term outcomes. Further research is warranted regarding the role of acute physical therapy for these patients for both short- and long-term outcomes.


Price JL, Miller TY, Orlando CM, Swank CR, Lausch ML, Baum LD, Alyssa Marie Raughley AM, Robert Creath R,

PURPOSE/HYPOTHESIS: Summer camps are a modality that addresses barriers to social interaction. While there is a growing amount of evidence supporting camps for individuals with chronic illness, there is no known research on camp experiences for those who require ventilatory support. The purpose of this study was to examine the perceptions of attending camp on self-esteem, social functioning, emotional functioning, and physical functioning for individuals who require ventilatory support.

MATERIALS AND METHODS: Participants completed the Pediatric Camp Outcome Measure (PCOM) via online survey or a mailed paper survey. The PCOM examines the psychosocial functioning and quality of life of camp attendees. The PCOM is a 27-item instrument, answered of a 5-point Likert scale, used to assess perceptions of the pediatric camp experience. The total combined score, which consists of 4 subscale scores, reflects an overall perception of the camp experience. 4 subscale scores reflect: 1) self-esteem; 2) emotional functioning; 3) social functioning; 4) physical functioning.

NUMBER OF SUBJECTS: Eleven campers responded to the survey for this study. The mean age of the campers was 18 years and the mean years participating in camp was eight years with 72% attending eight or more years.

RESULTS: This study found positive correlations between the number of years an individual attended the camp and their overall PCOM score, as well as social functioning and physical functioning subscales. This study found positive correlations with questions in all subscales with the number of years attending camp. Of the 27 PCOM questions, 8 demonstrated strong correlation to years participating in camp. Of specific interest to this study, 5 of the social functioning subscale question had strong correlation. Four of the questions had weak correlations to years participating in camp. Examining these findings at the participant level showed that all participants positively answered these questions regardless of years participating in camp. Findings show that 82% of the participants reported feeling like themselves almost always while at camp, 73% were very happy at camp, and 91% were almost never lonely at camp.

CONCLUSIONS: In conclusion, understanding the connection between quality of life and participation in summer camp for individuals who require ventilatory support provides useful insight into the role of summer camps and its impact on overall development. When working with individuals who require ventilatory support as physical therapists it is important to consider supporting these types of activities with families who may express hesitancy in providing camp opportunities.

CLINICAL RELEVANCE: This study highlights the important role of adaptive camps in the quality of life for medically complex pediatric patients.


Purcell NK, Mitchell KE, Saloom, Melfi N, McKay S

PURPOSE/HYPOTHESIS: Lateral patellar dislocations (LPD) are a common injury in adolescents accounting for 3% of all knee injuries. Current treatment typically involves knee immobilization (KI) followed by physical therapy (PT). However, there is limited literature on whether KI as compared to early ROM (ER), followed by PT, after a first-time LPD affects the likelihood of recurrence. The purpose of this study was two-fold: 1) to determine if there are differences between those who experience a LPD recurrence in the 6 months following PT, and 2) can a recurrent LPD be predicted by variables such as pain, range of motion (ROM), isokinetic strength, self-reported and performance measures.

MATERIALS AND METHODS: This prospective study included 21 (17 females, 4 males) participants (ER N = 11, KI N = 10). Participants were 11-17 years of age (mean age = 14.09 ER, 12.90 KI) diagnosed with LPD (<10 days). Inclusion criteria included: acute LPD, effusion, and (+) apprehension. All participants participated in PT and were assessed at 2, 4, 8, and 12 weeks for pain, knee ROM, isokinetic strength, Kujala, Pedi-IKDC, and Y-balance composite (YBC) scores. At 24 weeks, participants were contacted by phone to determine if they had experienced a recurrent LPD since discharge. Descriptive statistics, Chi-square, binomial logistic regression, t-tests, and Mann-Whitney U tests were used to analyze the data at an alpha level of .05.


RESULTS: There were no differences in those who reported LPD recurrence when comparing KI vs ER groups at Χ2=.403, p=.525. However, 18% of the ER group had a recurrence compared to 30% of the KI group. Those who reported a recurrent LPD (RG) had the following characteristics: slightly younger (average age 13.00 vs 13.69), less initial knee flexion PROM (61.8 vs 76.75), higher initial Kujala scores (31.6 vs 21.88), and all were female. There was a significant difference in passive knee flexion at 8 weeks at p=.022 (RG average: 149.5° vs 135.3°). There was a significant difference in the affected limb's YBC scores at 8 weeks at p=.033 (RG average: 97.20 vs 83.00). YBC scores on the affected side was a significant predictor of recurrence (exp(B)= 2.13, p=.010). Therefore, with every one unit increase in YBC, the odds of a recurrent episode was 2x higher.

CONCLUSIONS: Despite the small N, we believe this is a valuable first step in investigating factors associated with LPD recurrence. These results suggest that there was no relationship between KI or ER on LPD recurrence. Also, the participants with recurrence tended to have more ROM into flexion at 8 weeks and better YBC scores. This may be due to these patients having less pain later in PT or more confidence which later translated to riskier behaviors leading to recurrence.

CLINICAL RELEVANCE: Prior to this study, no research has been conducted on a group of adolescents to compare KI to ER following LPD. The use of a knee immobilizer raises the cost of treatment, leads to muscle atrophy, and has little evidence to show beneficial effects. Immobilization after LPD may not reduce recurrence and it may be beneficial for our patients to perform early ROM of the limb.


Pyi S, Shin G, Yang D, Kim H, Choi B

PURPOSE/HYPOTHESIS: To investigate whether children's self-report ratings are different from their parents' ratings on the Korean version of the KIDSCREEN-10 instrument following a school-based wellness program. Due to children's cognitive immaturity, parents' proxy reports may be considered a primary role in viewing their children's judgment on the health-related quality of life (HRQoL). However, in general, children's views on their HRQoL status still can be taken into consideration rather than being inferred from parents' views.

MATERIALS AND METHODS: Children and parent versions of the KIDSCREEN-10 were administered to two focus groups upon completion of the wellness program. The program includes a screening session performed by a physical therapist for 1) potential postural imbalances, 2) health examinations on ideal postures to prevent postural scoliosis, and 3) followed by implementation of home exercise programs when indicated. Scores were analyzed with the Winsteps software program for the Rasch rating scale model.

NUMBER OF SUBJECTS: A total of 22 subjects for two focus groups, 11 parents and 11 children.

RESULTS: Internal consistency reliability as determined by the intraclass correlation coefficient between two reports ranged from 0.011 to 0.905 (i.e., high on items 7, 9, and 10). All items, except four items of parent proxy report (i.e., psychosocial well-being, mood/emotion, self-conception, and parent relation) and three items of child's self-report (i.e., psychosocial well-being, autonomy, and home life) exhibited acceptably or slightly out of range in fit statistics (i.e., 0.6≤MnSq≤1.4). The order of item difficulty based on children's responses was somewhat similar to that of parents' responses except for two items (physical well-being, and psychological well-being items). For differential item functioning (DIF) analysis of the KIDSCREEN-10 instrument, a scatterplot of item difficulty estimates between two reports also detected two items as problematic items at 95% confidence intervals.

CONCLUSIONS: High or low fit statistics, four items of children's reports, and three items of parents' reports indicate an erratic pattern of responses. In other words, the children and parents may have more of a tendency to view those items as being more or less challenging. The hierarchical order of most item difficulty showed a similar tendency except for two items. That is, parents tended to rate the “psychosocial well-being” item as more challenging than children did, while children tended to rate the “physical well-being” item as more challenging than their parents did. Finally, the DIF analysis also detected the two items as problematic items. This indicates that two responses between children and parents were differently responded.

CLINICAL RELEVANCE: Clinicians should aware that the discrepancy between children and their parents may occur on “physical well-being” and “Psychosocial well-being” items within the KIDSCREEN-10 instrument when evaluating children's HRQoL. Due to children's cognitive immaturity, it may be necessary for clinicians to carefully consider the two items when parents' proxy reports of their children's HRQoL are available.


Rienstra R, O'Donovan C, Peyton C, Sukal-Moulton T

PURPOSE/HYPOTHESIS: Limitations in independent joint control is a hallmark of spastic cerebral palsy (CP) in children and adults, although there is limited information about when this sign emerges. We created a systematic approach for infants to observe independent joint movements called Observational Selective Control AppRaisal (babyOSCAR). We evaluated initial psychometric properties of the tool and the relationship between an infant's spontaneous joint movement and future gross motor function.

MATERIALS AND METHODS: One-minute video recordings of the spontaneous movements of 30 infants, aged 10-16 weeks, were used to observe joint movements. A rating scale (babyOSCAR) was created with 18 items for the upper extremities (UE) and 14 items for the lower extremities (LE). One point is scored for each isolated spontaneous movement about a joint. All included infants had known 2-year outcomes blinded to the raters (15 typical development, 15 spastic CP with GMFCS I-V). Of the 15 infants with spastic CP, 5 infants had unilateral CP. In a subset of 12 infants, 2 different one-minute clips were scored. SPSS Version 28 was used for statistical analysis.


RESULTS: When comparing babyOSCAR scores at 3 months to 2 year GMFCS levels, predictive validity was excellent for total and LE (CCTotal=-0.868, CCLE=-0.842) and good for UE (CC=-0.737) with all p<0.001. Interrater reliability was excellent for total score and LE (ICCtotal=0.876, ICCLE=0.876, p<0.001) and good for UE (ICC=0.545, p=0.019). Test-retest reliability was excellent for total and LE (ICCtotal=0.786, p=0.006 and ICCLE=0.939, p<0.001) and poor for UE (ICC=0.444, p=0.164). Construct validity was evaluated using t-tests between children with and without CP (UE t=5.04, LE t=6.87, Total t=7.39; p<0.001) and test internal validity (Cronbach's alpha=0.912).

CONCLUSIONS: In our sample, total and LE babyOSCAR scores were excellent predictors of future gross motor function in infants with spastic CP. BabyOSCAR was shown to be reliable and valid.

CLINICAL RELEVANCE: The babyOSCAR is a promising tool that can be used as an adjunct to concurrent video assessments to enhance planning for future motor function.


Riordan KD, Fragomeni A, Humbert A, Logan S, Kenyon LK, Feldner HA

PURPOSE/HYPOTHESIS: Mobility is an inherently socio-cognitive experience embedded in the contexts of everyday life. Powered Mobility (PM) can enhance this experience for children with Cerebral Palsy (CP) that have movement delays. Research has demonstrated the benefits of PM across developmental and psychosocial domains. However, evidence is lacking regarding the short and long-term cognitive benefits of early exposure to PM in children with CP, especially under 3 years old. This study examined the qualitative and quantitative short-term cognitive impacts of early short-term exposure to PM.

MATERIALS AND METHODS: This study is part of an overarching, multi-site, mixed methods, randomized clinical trial funded by the National Pediatric Rehabilitation Resource Center and the American Academy for Cerebral Palsy and Developmental Medicine. Children aged 1-3 years with a diagnosis of CP or at risk for CP were provided 8-week trials of two powered mobility devices in randomized order: the Permobil Explorer Mini and a modified ride-on toy car. Assessments were completed at baseline, 8 weeks, and 16 weeks, including all domains of the Bayley Scales of Infant and Toddler Development (BSID-IV) and semi-structured caregiver interviews. This study focuses on a subset of eight participants from the University of Washington site (GMFCS III-IV). Qualitative data were coded using constant comparison until themes emerged. Raw scores on the BSID-IV cognitive domain were statistically analyzed using R.


RESULTS: Though mean raw scores on the BSID-IV increased over time, this change was not statistically significant. However, qualitative analysis revealed several positive impacts of PM use on caregiver perceptions of their child's cognition and learning. Three themes emerged from the data: 1) Extrinsic Motivation: Early Mobility leads to Learning and New Social Perspectives, 2) Intrinsic Motivation: Learning to Move, Moving to Learn, and 3) Promising Connections: Emerging Understanding of Self-Initiated and Exploratory Mobility.

CONCLUSIONS: Caregiver perceptions on the importance of early PM use were positive in terms of cognitive development, despite non-significant quantitative results on the BSID-IV. However, norm-referenced measures may lack sensitivity in evaluating cognitive changes in children with significant disabilities, thus a mixed-methods approach may be advantageous to capture nuanced results. Caregivers valued access to PM for cognitive development and saw promise in their child's growth and response, including greater interaction with siblings and peers. Future work must evaluate cognitive effects of longer trials with prescribed dosages of PM intervention.

CLINICAL RELEVANCE: All active mobility opportunities, regardless of form, are learning opportunities for young children with disabilities. Development of cognition is grounded in exposure to multi-modal, social experiences, and clinicians can play a crucial role in facilitating these experiences by incorporating PM trials within early intervention, whether temporary or as a precursor to other mobility technologies.


Rivera MJ

PURPOSE/HYPOTHESIS: Although crawling is the initial form of infant mobility, there are few studies documenting the changes in limb kinematics over time. The purpose of this study is to document the progression of limb kinematics in belly and in hands and knees crawling and to determine the significant correlations between crawling velocity and various kinematic parameters.

MATERIALS AND METHODS: This longitudinal study consisted of 2 assessment periods, 4 weeks apart. The Alberta Infant Motor Scale was performed at each session to determine crawling status: immature crawling (IC), mature crawling (MC) and belly crawling (BC). Infants were categorized into 2 groups by crawling status: BC to IC and IC to MC. Crawling kinematics were assessed on the Zeno Walkway, a 4' X 20' sensor embedded mat. Sagittal video recordings (60 frames per second), set at 10 feet were taken to document diagonal limb time sequences. Investigators placed the infant in the prone position on the Zeno mat with caregivers positioned 6 feet away. The trial was considered successful when the infant crawled 5 feet.

Upper and lower limbs were identified through to data analysis by Photokinetic software. Parameters analyzed were stride length (StrL), step length (StepL), crawling velocity (CV), stance duration (StaD), cadence (Cd), swing velocity (SwV), and swing duration (SwD.) Analysis of means and standard deviations were compiled for each parameter. Pearson Product Correlations were performed between CV and the following parameters: StrL, Cd, SwV and StaD. Diagonal interlimb time sequence was coded using Mangold Interaction software.

NUMBER OF SUBJECTS: 9 typically developing infants. 6-10 months. 3 Females, 6 Males.

RESULTS: Cadence progression from IC to MC showed a 16.3% increase (119.05± 52.75 to 143.23 ± 47.46 steps/min) and from BC to IC: (47.87± 49.08 to 87.33± 29.92 steps/min) documenting a 45% increase. CV changes increased 31.03% in IC to MC (29.07± 15.16 to 39.17±13.16 cm/sec) and in BC to IC an increase of 22% was recorded (14.7± 9.21 to 19.01 ± 4.81 cm/sec). Reductions in time were noted in StaD, showing a 30.7% reduction in IC to MC (0.744± 0.61 to 0.503± 0.29 sec) and in BC to IC (4.2 ± 4.1 to 0.91± 0.5 sec) a 300% decrease. Positive correlations were documented between CV and Cd, r= 0.92 and between CV and StrL, r= 0.89. A negative correlation was found between CV and StaD, r=-0.57. Diagonal time differences between upper and lower limbs in IC was 0.2 ± .04 sec compared to .057 ± 0.039 sec in MC.

CONCLUSIONS: Infants demonstrated consistent kinematic changes from BC, IC to MC. There were notable advances in VC and Cd with time reductions in StD. Strong positive correlations were identified between CV and Cd and CV and StrL. Limb diagonal timing became more synchronous. However, the upper limb consistently initiated the crawling cycle.

CLINICAL RELEVANCE: TD infants showed consistent progression in all the parameters and will provide the basis for crawling kinematics. Further studies will compare these findings to infants with atypical motor development to better identify major crawling deficits.


Franjoine MR, Norton CP, Darr NS, Young B

PURPOSE/HYPOTHESIS: Ear infections are common in young children; According to the CDC, 5 of 6 children experience otitis media (OM) by age 3 years. Past research has addressed acute management of OM symptoms, hearing loss, and language acquisition; however, the potential effects of OM on balance are less well known. The purpose of this study was to examine the potential impact of OM on children's functional balance capabilities as measured by the Pediatric Balance Scale, 2nd edition (PBS-2). The presence of recent OM within the previous 12 months and a lifetime history of OM were examined based on children's age in terms of performance on the PBS-2.

MATERIALS AND METHODS: The PBS-2 was administered individually by trained raters. The PBS-2 is an expanded and revised version of the Pediatric Balance Scale containing 20 items of varying difficulty. It demonstrates excellent reliability (test-retest ICC=0.918, interrater ICC=0.946-0.997, intrarater ICC>0.99) and can differentiate children with mild balance dysfunction (BD) from peers with TD up through 8 years of age (p<.05). Effects of age in one-year increments and presence of recent OM, within the previous 12 months, were examined using descriptive statistics and a two-way ANOVA with Tukey HSD post hoc analyses. Lifetime history of OM based on age group was assessed in the same manner. PBS-2 total test scores (TTS), as well as, time and distance measures from 15 of the more challenging PBS-2 items were used for analyses.

NUMBER OF SUBJECTS: Retrospective data were derived from 381 children with typical development (TD), ages 3 to 13 years, who participated in PBS-2 validation studies from 2013 to 2021. All children were healthy at the time of testing. OM history was identified by parents using the study health history form.

RESULTS: History of OM was prevalent across all age groups. Parents reported a lifetime history of OM in 77.2% of children. Within each age group, at least 50% of children experienced 1 or more acute OM episodes within the previous 12 months. Age effect was significant (F10,21=73.74, p<.001), however, effects of OM during the previous 12 months (F1,21=2.642, p=.105) or over the child's lifetime (F1,21=0.700, p=.725) were not. Although not statistically significant, PBS-2 TTS for children with a recent or lifetime history of OM were lower when compared to those with no OM history in 6 age groups with similar PBS-2 TTS noted in the 12- and 13-year-old age groups. Children without OM outperformed children with a history of OM on most items.

CONCLUSIONS: Recent OM is highly prevalent among children ages 3 through 13 years. A history of OM may contribute to balance dysfunction in preschool and school-age children.

CLINICAL RELEVANCE: The results of this study support ongoing surveillance of balance in children with an OM history. The PBS-2 is a suitable measure of functional balance for children with a history of OM.


Rose RA, Derstine K, Barnes KL, Fonner CB, Williams KE, Welker E

PURPOSE/HYPOTHESIS: Trunk rotation is a fundamental component of infant motor development needed for reaching developmental milestones and allowing exploration of the environment. A standardized method to assess infant trunk passive range of motion (PROM) has not been determined. Therefore, the purpose of this study was to determine the reliability of a method to measure passive trunk rotation in full-term, healthy infants. Another purpose of this study was to determine the normal value of passive trunk rotation in infants. The hypothesis for this study predicts that excellent intra and inter-rater reliability of the method will be found to examine trunk rotation PROM in infants. Additionally, a normative value of passive trunk rotation in full-term, healthy infants will be established within our sample.

MATERIALS AND METHODS: Left and right passive trunk rotation were measured utilizing a modified inclinometer. Eighteen participants were measured by Tester A to determine a normative value. A sub-sample of six participants were measured a second time by Tester A to determine intra-rater reliability. Additionally, a different sub-sample of eight participants were measured by Tester B to determine inter-rater reliability. A Shapiro-Wilk Test of Normality was utilized to determine normality. An Intraclass Correlation Coefficient (ICC) was used to assess intra and inter-rater reliability.

NUMBER OF SUBJECTS: Eighteen full-term, healthy infants were recruited for this study. The inclusion criteria consisted of: 1) born after 37 weeks of gestation; 2) 1-12 months of age. The exclusion criteria included: 1) physical impairments that could result in restricted or excessive spinal biomechanics; 2) born before 37 weeks of gestation.

RESULTS: Excellent inter-rater agreement (ICC >0.90) for left trunk rotation was found (ICC = 0.946; p-value <0.001). A moderate inter-rater agreement (ICC = 0.50-0.75) for right trunk rotation was found (ICC = 0.520; p-value = 0.136). A moderate intra-rater agreement (ICC = 0.50-0.75) for left trunk rotation was found (ICC = 0.616; p-value = 0.178). A poor intra-rater agreement (ICC < 0.50) for right trunk rotation was found (ICC = 0.265; p-value= 0.581). A normative value of passive trunk rotation in infants (n=18) 2-12 months of age was found (42.1°± 2.70).

CONCLUSIONS: This pilot study provides a preliminary method to determine a normative value of passive trunk rotation in infants. However, the normative value of 42.1° ± 2.70 remains unconfirmed due to inconsistent reliabilities within our method.

CLINICAL RELEVANCE: This study provides a mean value of infant passive trunk rotation that can be used as a foundation for future research.


Rosen J, Rizzolo R, Lefkowitz J, Mueller I, Nicholas JA, Reda C, Bennett M, Chheda A, Feiner S, O'Neil ME

BACKGROUND AND PURPOSE: Youth with cerebral palsy (CP) have decreased fitness and engage in limited physical activity (PA) due to the impairments associated with this diagnosis (e.g., spasticity, weakness, decreased motor control).1 They have increased sedentary behaviors (SBs) resulting in high risk of comorbidities (e.g., prehypertension, metabolic syndrome).2 Youth with CP report decreased motivation for exercise and PA due to fatigue, pain, and boredom.3 Virtual reality (VR) in the form of active video games (AVGs) is an effective solution to promote fitness and PA in youth with CP.4,5 No studies have used immersive VR, which may be effective by providing a three-dimensional environment for youth to perform PA and functional tasks.4 The purpose of this study is to determine if youth with CP tolerate custom immersive VR games, if they increase fitness and PA during game play, and if they enjoy playing VR games.

CASE DESCRIPTION: Ten ambulatory youth with CP (mean age: 11.5 yrs, SD: 2.84 yrs; 90% male; GMFCS I (n=1), II (n=6), III (n=3)) participated in a custom VR gaming protocol consisting of: pre-game measures; four VR games (total of 20-minutes); and post-game measures. Games were played in sitting and standing and required different upper (UE) and lower extremity (LE) movements. During game play, youth wore a heart rate (HR) monitor to measure PA intensity; accelerometers for PA counts; and motion sensors for PA reach and kick patterns. Youth completed the Pediatric Simulator Sickness Questionnaire (PSSQ)6 and the Pediatric Motivation Scale (PMOT).7

OUTCOMES: Nine of 10 youth (90%) completed the game session with one youth stopping due to simulator sickness. ANOVA results were non-significant on PSSQ scores suggesting youth tolerated the games. ANOVA results on PA intensity (HR) were significant (p<0.05) with standing games showing highest intensity. PA intensity approximated moderate levels in sitting (56.47% max HR) and standing (59.36% max HR). PA counts were significantly higher (p<0.001) for wrist accelerometers for all games. PA counts for hip and ankle accelerometers were similar with ankle counts slightly higher than hip. Motion sensor data from VR trackers were used to examine reach and kick excursion patterns. Average PMOT ratings on the enjoyment/interest subscale were 95% (4.75/5) indicating high levels of enjoyment.

DISCUSSION: Ambulatory youth with CP tolerated and enjoyed custom VR games in this feasibility study. Youth achieved moderate intensity PA levels to promote fitness and increased activity counts to promote PA. The four VR games and two game conditions (sit vs stand) posed different demands on PA intensity and activity and provided choices for youth with CP to promote fitness, PA, and enjoyment. Integration of motion sensor data with clinical measures may provide more detailed information on quality and amount of movement produced in VR games.


Sabir O, Johnson EG

PURPOSE/HYPOTHESIS: Ear infections in children often cause abnormal postural stability. However, the long-term effects of recurrent ear infections on postural stability have not been investigated. The purpose of this study was to examine the long-term effects of multiple ear infections on pediatric postural stability.

MATERIALS AND METHODS: Forty children aged 10-12 years were divided into two groups (18 participants with history of tympanostomy tubes and/or 3 or more ear infections prior to age five and 22 participants without history of tympanostomy tubes and/or 0-2 ear infections prior to age five). Computerized Stability Evaluation Test (SET) and non-computerized postural stability was measured for all participants.


RESULTS: A significant difference was found in median postural stability scores in the SET during tandem stance on unstable surface between the two groups (median (minimum, maximum) of 9.1 (1.4, 11.4) versus 5.8 (1.7, 12.8), p= 0.04). In addition, there was a significant difference in median Pediatric Balance Scale scores between participants with versus without ear infection (54 (47, 56) versus 56 (55, 56), p=0.001).

CONCLUSIONS: Results suggest that children ages 10-12 with history of tympanostomy tubes and/or 3 or more ear infections prior to age five have decreased postural stability.

CLINICAL RELEVANCE: Our results suggest that pediatric ear infections can lead to reduced postural stability in children as they age. Physician referral of post-ear infection pediatric patients to physical therapy could promote healthier development of sensory integration systems through vestibular and balance exercise programs. Further investigation is needed to measure the effects of vestibular and balance interventions on pediatric patients with reduced postural stability.


Salgaonkar A, Molinini R, Rhee C, Inamdar K, Brown S, Burnsed J, Stevenson R, Harper AD, Dusing SC, Shall MS

PURPOSE/HYPOTHESIS: The COVID-19 pandemic required pediatric research outcome measures to be administered via telehealth to avoid halting research protocols and loss of data. We administered the Assessment of Problem-Solving Skills in Play (APSP) to measure problem-solving in preterm infants as a part of an ongoing clinical trial. The purpose of this study was to evaluate the feasibility of parent-guided completion of APSP via telehealth in 3- to 24-month-old infants in their home environment.

MATERIALS AND METHODS: A set of three standardized toys namely popup, cups, and gumball were sanitized, and delivered to the infant's house to standardize conducting teleassessment. During the telehealth assessment, caregivers were asked to setup the camera, position APSP toys in front of the child without demonstrating the function of the toy, limit prompts, and avoid distraction for the child. Caregivers were instructed to provide minimal assistance needed by their child in sitting to ensure the child could use their arms to interact with each toy for 2 mins. Behaviors quantified include Looks (scored when child gazes at the toy), Simple and Complex Explores (when the child manipulates the toy in a specific manner), Functions (scored when child uses toy as intended), and Solutions (scored when child completes a series of functions) were coded from the video using the Datavyu software. A metric to assess the feasibility of the problem-solving measure via telehealth was derived from earlier feasibility metrics. A feasibility metric quantified completion and challenges including family and sibling involvement in demonstrating APSP, camera angles and set up, scoring, and toy safety which were then grouped into domains. The metric was divided into 3 domains namely family measures, instrumentation and setup, scoring, and application. The proportion of visits in which each metric could be quantified was reported as a measure of feasibility. Based on our previous experience in APSP, a threshold of 80% was set to represent feasibility.

NUMBER OF SUBJECTS: Eighteen very preterm (<29 weeks of gestation) infants were a part of a clinical trial (NCT03518736) and were assessed for APSP by telehealth between 3 and 24 months of age.

RESULTS: APSP was completed on a total of 17 out of 18 participants who consented to participate in a telehealth visit. 87% of family measures, 98.5% of instrumentation & setup, and 100% of scoring & application domains were above the threshold. All the subdomains under instrumentation and set up as well as scoring, and application showed good compatibility with APSP via telehealth.

CONCLUSIONS: Telehealth is a feasible method of conducting parent-guided problem solving infants between 3 to 24 months of age. Barriers to conducting telehealth sessions included parents and siblings demonstrating the tasks, and poor postural support to the infant, which were specific to the domain of family measures. While the ASPS in person is highly reliable and valid, future research is needed to evaluate the reliability and validity of APSP via telehealth.

CLINICAL RELEVANCE: APSP via telehealth shows promise but is not yet validated for a use.


Sanjiv M, Bloyer MH, Gimenez CW, Moore JG

BACKGROUND AND PURPOSE: Cerebral palsy (CP) is a non-progressive motor disorder due to a central nervous system insult during the perinatal period. Clinical presentation may include: spasticity and decreased strength, range of motion, postural control, walking speed, and endurance. High intensity gait training (HIGT) is a method of task-specific training requiring walking/stepping at a fast enough speed to keep heart rate (HR) at 60-80% of maximum heart rate (HRmax). Research assessing the use of HIGT and its effect on gait and endurance in children with CP is sparse. The purpose of this case series was to describe the feasibility and effects of participation in a HIGT intervention on (1) gait speed and endurance as measured by the 10-meter walk test (10MWT), 6-minute walk test (6MWT), and 7.5-meter shuttle run test (SRT) and (2) functional gait mobility as measured by the GMFM dimension E in three children diagnosed with CP Gross Motor Function Classification System (GMFCS) level III.

CASE DESCRIPTION: Three children with CP GMFCS level III participated in this HIGT protocol 2-3 times per week for 5 weeks in lieu of their routine physical therapy treatment. Participant 1 (P1), a 12-year-old girl, ambulates using a Kaye posterior walker but can ambulate household distances with close supervision without her walker. Participant 2 (P2), a 6-year-old boy, ambulates using a Crocodile gait trainer and has been working on ambulating short distances without his walker. Participant 3 (P3), a 7-year-old girl, ambulates using a Kaye posterior walker and is unable to ambulate without it. Outcome measures were collected at baseline (week 0) and post-intervention (week 6). Sessions consisted of treadmill training starting at 0.2 miles per hour (mph) and progressing by 0.1 mph every 30-60 seconds while monitoring HR to achieve 70-80% of HRmax or 6-8/10 perceived exertion on the OMNI scale. After achieving 15 minutes total on the treadmill including the gradual progression to the high intensity level, participants transitioned to overground ambulation for an additional 15 minutes at an adequate speed to maintain 70-80% of HRmax or 6-8/10 perceived exertion.

OUTCOMES: Post-intervention, P1-P3 demonstrated clinically significant improvement for 10MWT speed (seconds) with their assistive device (2.82, 2.62, and 11.4, respectively) and 6MWT total distance (feet) (76.29, 105.37, and 61.25, respectively) based on the minimal clinically important difference (MCID) for each measure. P1 and P2 exhibited clinically significant improvements based on MCID in 7.5-meter SRT level (3.5 and 2, respectively) and GMFM dimension E scores (6.9% and 15.3%, respectively).

DISCUSSION: In this case series, 3 children with CP GMFCS level III demonstrated improvements in functional gait (including gait speed), gross motor function, and endurance following participation in a HIGT. Further research is needed with a larger, diverse sample size to determine the most effective parameters and long-term effects of HIGT in this population.


Sargent BA, Havens KL, Kubo M, Wu TW

PURPOSE/HYPOTHESIS: Individuals with spastic cerebral palsy (CP) experience lifelong walking limitations due in part to impaired selective leg joint control. Impaired selective leg joint control can be defined as the inability to move the hip, knee and ankle joints independently of one another, resulting in excessive flexion/extension coupling across the three joints. Effective early detection of infants with CP using selective motor control has been elusive because selective control emerges during early infancy and the time course for selective motor control in infants at high risk of CP is unclear. The objective of this study is to compare selective leg joint control of spontaneous kicking between infants at high risk of CP and infants with typical development (TD) monthly from 1 to 9 months of age. We hypothesized that infants at high risk of CP, compared to infants with TD, would demonstrate decreased selective leg joint control from 1 to 9 months of age.

MATERIALS AND METHODS: Each month from 1 to 9 months of age, data from spontaneous kicking actions were collected using inertial sensors and analyzed using three-dimensional kinematics. Kicks were defined as a change in hip joint angle of >11.5 degrees into flexion, followed by hip extension. Selective leg joint control was quantified for each kick using z-transformed Pearson correlation coefficients (ZCC) of hip, knee, and ankle joint angle pairs into flexion and extension. Mixed regression methods using repeated measures were used to analyze hip-knee ZCC, knee-ankle ZCC, and hip-ankle ZCC between groups longitudinally. Alpha value was set at p=.0056 to adjust for 9 comparisons. A less positive or negative ZCC was interpreted as more selective control, and a more positive ZCC was interpreted as less selective control.

NUMBER OF SUBJECTS: 15 infants at high risk of CP, identified by brain insults on neuroimaging, and 18 infants with TD assessed longitudinally from 1 to 9 months of age, corrected for prematurity.

RESULTS: Each month, an average of 7 infants at high risk of CP and 10 infants with TD contributed kicks. The number of kicks analyzed was 5,662. For each ZCC, a significant group*month interaction was found. The hip-knee ZCC was statistically significantly higher for the infants at high risk of CP at 3 to 5 and 7 to 9 months (less selective control) and was similar between groups at 1, 2, and 6 months of age. The knee-ankle ZCC was statistically significantly higher at 3, 4 and 9 months (less selective control) and was similar between groups at the other ages. The hip-ankle ZCC was statistically significantly lower at 1 month (more selective control) and higher at 2 to 6 and 8 to 9 months (less selective control) for the infants at high risk of CP and was similar between groups at 7 months of age.

CONCLUSIONS: Infants at high risk of CP demonstrate decreased selective leg joint control as early as 2 to 3 months of age when compared to infants with TD.

CLINICAL RELEVANCE: Further research is needed to determine if selective motor control can be used to support the early detection of infants with CP and if impaired selective motor control can be remediated with early intervention.


Scott KS, Heathcock JC, Sakzewski L, Boyd R

PURPOSE/HYPOTHESIS: Unilateral cerebral palsy (UCP) is the most common subtype of CP. The efficacy of UCP-specific interventions in infancy is unknown. Enactment, the extent individuals carry out intervention in daily life, is one dimension of intervention fidelity often not measured or not reported. Intervention outcomes cannot be accurately attributed to intervention dose when enactment is not measured. Rehabilitation EArly for Congenital Hemiplegia (REACH) was a randomized comparative efficacy trial comparing infant-friendly constraint-induced movement therapy (Baby-CIMT) and bimanual therapy (Baby-BIM) for infants with UCP. REACH interventions were home-based and parent-directed with coaching from a therapist. Home-based intervention presents a challenge for measuring enactment because intervention occurs in the absence of a provider. The purposes of this study were to describe parent-reported enactment and to explore methods to quantify enactment for REACH.

MATERIALS AND METHODS: This pilot study was a secondary analysis of the REACH trial. Parent-reported enactment was recorded using Parent Diaries. Parents submitted video-recorded home intervention sessions (n=12) with their infant. Sessions were analyzed using continuous duration (proportion of time), 1-minute partial-interval time sampling, and an intervention-specific checklist. Videos were coded for goal-related and unrelated activities and for key intervention components.

NUMBER OF SUBJECTS: N=12 infants with UCP, aged 3-9 months, enrolled in REACH from a single intervention site.

RESULTS: Differences between parent-reported monthly intervention hours from diaries and expected monthly hours based on the intervention protocol ranged from −7.30 to 0.75 hours. 34.24% of Parent Diary data were unreported. All parents spent time providing opportunities for REACH goal-related activities (median of 60.1% of time based on continuous duration; 93.3% of session minutes based on partial-interval time sampling). Parents spent an average of 29.5% of session time performing supportive or care tasks for the infant (e.g., comforting). Intervention-specific checklist scores were higher where opportunities for goal-related activities were more frequent and activities unrelated to goals were fewer.

CONCLUSIONS: Parent Diaries may be a variable and incomplete measure of enactment. Continuous duration and partial-interval time sampling may provide an objective measure of types of activities performed and proportion of sessions focused on goal-related activities. Partial-interval time sampling is a more efficient method but may over-estimate goal-related opportunities. Activities unrelated to goals (i.e., care tasks) may be necessary when providing intervention with infants. A checklist may provide a means to quantify intervention-specific components, such as intensity of activities.

CLINICAL RELEVANCE: Accurate measures of enactment are essential to relate intervention dose (time, intensity, and type) to clinical outcomes. Methodologies explored here may enable clinicians to better quantify intervention dose enacted by individuals in daily life.


Schlessman AM, Barreca JA

PURPOSE: The American Occupational Therapy Association, American Physical Therapy Association, and American Speech-Language-Hearing Association are committed to and encourage interprofessional collaboration to maximize outcomes for clients across the lifespan. In school-based practice, one element of this is the development of collaborative student-centered goals where interprofessional skills and knowledge are integrated to facilitate the student's access to and participation in their educational program. The purpose of the Individuals with Disabilities Education Act (IDEA) is “to ensure all students with disabilities have available to them a free appropriate public education (FAPE) that emphasizes special education and related services designed to meet their unique needs and prepare them for further education, employment, and independent living” (IDEA, 2004). Collaboration is a key component of IDEA, particularly in the development of a student's individualized education program (IEP), which must be developed by a team. To achieve the standard of FAPE, parents/guardians, students, educators, related service providers, and other stakeholders must work together.

DESCRIPTION: Central to the IEP team's work is the development of student-centered IEP goals and determination of how IEP team members will help the student achieve those goals. Working together, the IEP team sets the tone for collaboration throughout the implementation of the IEP. Collaboration is a process in which team members share their unique knowledge, expertise, and skills to identify and address the needs of students. Interprofessional collaboration in education and practice leads to greater understanding of others' roles and enhances outcomes. Collaborative goals can be defined as IEP goals written by IEP team members working together to engage in mutual problem solving and decision making to identify and prioritize student needs. This document highlights a process for IEP team members to collaborate to develop IEP goals to support students with disabilities in participation in school life.

SUMMARY OF USE: The foundation for collaborative goal writing is a strong educational team where members articulate their scope of practice clearly, demonstrate their value, and understand the contribution of others. Establishing a process for implementing collaborative goals takes an investment of time; therefore, teams will need to identify strategies for joint planning and for building team skills. Initial steps include sharing information with educational teams and parents, identifying times/strategies for planning, and creating a timeline to begin the process.

IMPORTANCE TO MEMBERS: Interprofessional practice: (1) facilitates collaborative goal development by encouraging team ownership of goals, (2) promotes the connection between the contributions of team members and academic and functional goals, and (3) fosters skill generalization through development of skills in goals across environments and with a variety of professionals.


Shelton H, Zapata KA, McLaughlin K, Reyes F

PURPOSE/HYPOTHESIS: Treatment options for equinus include therapeutic exercises, serial casting, botulinum toxin (BTX) injections, and surgery. Physical therapists routinely perform serial casting for equinus in children with Charcot-Marie-Tooth disease (CMT) and cerebral palsy (CP), occasionally in conjunction with BTX injections for spasticity management in children with CP. Limited information exists regarding the safety and efficacy of serial casting in children with neuromuscular conditions. This clinical quality improvement (QI) initiative assesses adherence to our serial casting guidelines expanded from idiopathic toe walking to neuromuscular conditions.

MATERIALS AND METHODS: The QI project included 43 patients (21 boys, 22 girls) with CMT and CP reviewed retrospectively from June 2017 to March 2022 whose average age was 5.4 years (range: 1-10 years). This institution's clinical guidelines include weekly serial casting for 4 to 6 weeks to achieve 10° ankle dorsiflexion (ADF) passive range of motion (PROM) with the knees extended or, with significant contractures (>10° equinus), a braceable foot. The Foot Posture Index (FPI) and Single leg stance (SLS) are also measured pre- and post-casting.

NUMBER OF SUBJECTS: 43: 4 with CMT, 39 with CP (26 with a recent history of BTX injections the previous 6 months, 13 without BTX injections).

RESULTS: Serial casting averaged 4.2 weeks (5.2 weeks for CMT, 4.1 weeks for CP). Skin injury occurred in 18 patients (4 CMT, 14 CP) which impacted the length of casting in 3 patients (1 CMT, 2 CP). At baseline, ADF PROM averaged −5.9° knees flexed (−18.8° CMT, −4.6° CP) and −11.7° knees extended (−26.9° CMT, −10.0° CP). Post-cast, ADF PROM improved 14.1° knees flexed (13.8° CMT, 14.9° CP) and 15.6° knees extended (19.4° CMT, 14.9° CP) to an average of ADF PROM 8.2° knees flexed (−5.0° CMT, 9.6° CP) and 3.9° knees extended (−7.5° CMT, 5.1° CP). In the 26 patients with CP with BTX injections, casting was initiated on average 16.2 days post injection (range: 0- 55 days). ADF PROM at baseline, changes, and post-cast did not differ in children with CP with BTX injections compared to children with CP without BTX injections. The FPI was measured in 15 patients both at baseline and post-cast, changing an average of 2.1 points (from 0.6 to 2.7), indicating a more pronated foot. The SLS was only measured in 8 patients since many patients could not stand on one leg. All patients wore ankle foot orthoses (AFO's) post-casting; 16 patients received physical therapy post-casting.

CONCLUSIONS: Serial casting guidelines for patients with neuromuscular conditions should consider safety concerns such as skin injury and functional limitations. Despite skin injury, especially in patients with CMT, serial casting does not commonly impact the length of casting.

CLINICAL RELEVANCE: Patients with CMT and CP demonstrate good tolerance to serial casting and gains in ADF PROM to allow for AFO wear. The QI team is establishing messaging triggers to the referring team to improve communication processes when the plan of care is altered due to skin injury.


Sherman J

BACKGROUND AND PURPOSE: In the United States, 5/100 children have a moderate to profound hearing loss.1 3.9-16% of newborns have Congenital Muscular Torticollis (CMT).2 The American Physical Therapy Association's (APTA) clinical practice guideline (CPG) has no current recommendations for treatment of CMT in infants with a concurrent diagnosis of hearing loss.2 The purpose of this case report is to outline the special considerations that complicated treatment and outcomes of a patient with hearing loss and CMT.

CASE DESCRIPTION: The patient presented to physical therapy at 3 months with diagnoses of right CMT, plagiocephaly and brachycephaly. He had a concurrent diagnosis of bilateral profound hearing loss from cochlear nerve deficiency; MRI confirmed normal anatomy of the vestibule and semi-circular canals. Initial cervical range of motion (ROM) showed a 10 degree asymmetry in passive and active side bending and rotation. Resting posture was 15 degrees right tilted and 75 degrees left rotated. Head control was poor. The patient was classified as a Grade 1 or “Early Mild” CMT as he had <15 degrees difference in muscle tightness in passive cervical rotation.2,3 Treatment initially followed the CPG including passive stretching, active rotation, environmental adaptations, parent education, and head righting; however, the patient had atypical progression. He inconsistently responded to head righting exercises. Delays in gross motor milestones included: sitting at 8M, standing at 10M, crawling at 11M. Concurrent with persistent right lateral tilt of 10 degrees. At 10M, a Tubular Orthosis for Torticollis (TOT) collar was introduced - parents noted immediate improvement in posture. At 11M, he underwent bilateral Cochlear Implant surgery. TOT collar was gradually weaned at 13M with continued tactile cues and core strengthening for posture. Discharge occurred at 14M of age after 18 visits, over >11 months, of intervention.

OUTCOMES: The patient required an extended episode of care in physical therapy to meet all CMT discharge criteria including full and symmetrical passive cervical rotation and side bending, full and symmetrical active cervical rotation, symmetrical side bending strength, and upright posture within 5 degrees of midline.

DISCUSSION: Despite most Grade 1 torticollis seeing full resolution within 2-3 months,2,4,5 this patient continued to have a persistent tilt and did not meet discharge criteria >11 months. Regardless of no anatomical differences in his vestibular system, the patient did not respond consistently to head righting. When treating infants with concurrent diagnoses of hearing loss and CMT, clinicians should consider the following clinical quandaries: duration of plan of care, timing of introduction of TOT collar, and use of individualized manual cues and developmental positioning in respect to impaired auditory and vestibular processing. More evidence is needed to understand the impact different types of hearing loss can have on treatment of CMT.


Silveira JA, Trudelle-Jackson E, Thomas JL, Poskey G

PURPOSE/HYPOTHESIS: The purposes of this study were to 1) determine if there are differences in physical activity, gross motor development, and segmental trunk control between preterm and full-term infants; 2) determine if term group (full-term versus preterm), segmental trunk control and physical activity predict gross motor development in infants.

MATERIALS AND METHODS: Physical activity was measured by the Daily Activities of Infants Scale (DAIS) and achievement of the World Health Organization's Physical Activity Guidelines (WHO-PAG). WHO-PAG for infants includes >30 minutes of wakeful prone positioning each day, being physically active several times each day, and spending no more than 1 hour at a time restrained in any baby equipment (e.g. car seat, high chair, etc.). Gross motor ability was measured by the Alberta Infant Motor Scale (AIMS) and segmental trunk control was measured using the Segmental Assessment of Trunk Control (SATCo). A pediatric physical therapist administered the AIMS and SATCo during the initial in-person session. The legal guardian or caregiver then completed the DAIS for 24 hours and a physical activity log for 3 days. Independent t-tests were completed to compare the means of DAIS, AIMS, and SATCo between full-term and preterm infants. Pearson's χ2 test was used to determine if there was a significant difference in the achievement of WHO-PAG between preterm and full-term infants. Prediction of gross motor function was investigated using multiple regression.

NUMBER OF SUBJECTS: 24 full-term infants [Chronological Age (months): M=7.39, SD=2.37] and 16 preterm infants [Adjusted Age (months): M=6.63, SD=1.68] participated in the study.

RESULTS: A significant difference in the mean AIMS total test score was found between preterm and full-term infants, with preterm infants scoring a mean difference of 6.96 points lower than full-term infants (p=.044). No significant differences in DAIS, SATCo, and WHO-PAG achievement were found between preterm and full-term infants. The overall regression was statistically significant, accounting for 52.8% of the variance in gross motor ability. When looking at individual predictors, only the SATCo score significantly predicted gross motor ability. Term group, DAIS score, and WHO-PAG were not significant predictors of gross motor ability.

CONCLUSIONS: The results of this study further confirm that preterm infants demonstrate significantly lower gross motor ability than full-term infants. This study also found that segmental trunk control is an important predictor of gross motor ability.

CLINICAL RELEVANCE: This study provides insight into the physical activity of infants and the relationships between physical activity, segmental trunk control, and gross motor ability. This study found that segmental trunk control is a significant predictor of gross motor ability, suggesting that addressing segmental trunk control is important in promoting motor development in preterm and full-term infants. In addition, this study finds that most preterm and full-term infants are not meeting WHO-PAG, which is especially problematic for preterm infants who are already at risk for developmental delay.


Slaughter JP, Swahlan LM, Killen BS, Olsen AL, Curbow-Wilcox KJ, Pannell WC, Lin S, Dear RK

PURPOSE/HYPOTHESIS: Pediatric obesity affects approximately 18% of children in the United States. Childhood obesity contributes to several health-related issues including diabetes, hypertension, decreased quality of life (QOL), and adult morbidity. Programs tailored toward educating children and parents on healthy lifestyle choices, exercise, and nutrition have been shown to improve health-related outcomes for this population. The purpose of this study was to retrospectively investigate the effects of an 8-week community pediatric health program on Body Mass Index (BMI), fitness measures, and QOL in overweight children and adolescents.

MATERIALS AND METHODS: Subjects aged 8-16 years were recruited from a hospital-based weight management clinic to participate in an 8-week weight loss program. Subjects attended weekly one-hour sessions consisting of education on health and wellness, exercise instruction, home program development, and practical goal-setting. Seven children participated in the program and completed all outcome measures. Outcome measures included BMI, functional strength (jumping jacks, wall sits, push-ups, and sit-ups), balance (single-limb stance, SLS), flexibility (straight leg raise, SLR), endurance (6-minute walk test, 6MWT), and QOL assessment (Pediatric Quality of Life Inventory, PQOL). Outcomes were assessed at baseline and week eight.

NUMBER OF SUBJECTS: 7 participants from two sessions of the Iron Kids 8-week program.

RESULTS: Although the BMI did not show clinically significant improvement, three functional strength measures (wall sit ES 1.19, p=0.026; push-ups ES 1.12, p=0.010; sit-ups ES 1.18, p=0.003), endurance (6MWT ES 1.69, p=0.026) and flexibility (SLR L, R ES 0.68, 0.7, p=0.011, 0.046) showed statistically significant improvement at week 8. Jumping jacks and the Pediatric Quality of Life showed a tendency of improvement without reaching statistical significance (p>0.05). No improvement in SLS was noted (p>0.05).

CONCLUSIONS: The findings indicate a community-based pediatric health and wellness program resulted in significant improvement in the fitness of overweight children. Further research is needed to determine the long-term effects of this program.

CLINICAL RELEVANCE: Other studies have shown comparable evidence in programs lasting between 12-16 weeks up to 1 year. Our study demonstrated that similar changes may be found with a shorter duration of 8 weeks. This type of program could be a valuable adjunct to physical therapy interventions for overweight and obese pediatric patients.


Sumrall KL, Litwin SJ, Alkuino RJ, Pieroni CL, Kuebler J

PURPOSE/HYPOTHESIS: Sedentation rates in students have been rising due to the introduction of new technology that keeps young students primarily stationary instead of being physically active. Since students are in a school setting for at least half of the time that they are awake, the classroom would be an efficient and effective place to introduce a sit-to-stand desk to promote healthy behavior at an early age. The objective of this research was to assess the overall benefits of sit-to-stand desks implemented in classrooms.

MATERIALS AND METHODS: To be included in this study, studies included students who have availability to a sit-to stand desk or participate in active standing in the classroom. Pregnant women and non-students were excluded from this review as well as those using sit-to-stand desks prior to this study. Participants who were unable to sit/stand for half a day were also excluded. Individualized computer-based searches within PubMed and Embase databases were developed. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) was utilized as a well structured guide and tool to organize the findings in the research. The Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies were used to assign each article a quality rating with each article scoring either “fair” or “good”.

NUMBER OF SUBJECTS: 8 studies with 1,388 participants total with 6 different classroom settings were included.

RESULTS: This systematic review looked at 8 total articles that integrated sit-to-stand desks or standing breaks in the classroom. A total of 1,388 participants in 6 different classroom settings ranging from 3rd grade to undergraduate students were used in this study. Each article had an intervention group with sit-to-stand desks or standing breaks incorporated into the classroom as well as a control group to compare results to. Articles looked at attentiveness and fidgeting, cardiometabolic health, overall sitting time vs standing time, light and moderate physical activity, physical/mental/cognitive condition, musculoskeletal discomfort, energy expenditure, waist circumference, and BMI following the intervention of sit-to-stand desks or standing breaks.

These studies collectively showed that the implementation of sit-to-stand desks or standing breaks improved attentiveness, cardiometabolic health, and activity levels in the students while decreasing sedentary time and sitting durations as compared to the control group.

CONCLUSIONS: The implementation of the standing desks in the classroom had numerous benefits with little to no adverse effects. Most articles concluded that additional research needed to be done, but this is a place to start. With increases in sedentation rates among our youth, the use of sit-to-stand desks is one way that schools could combat this issue. The hope is that the use of these desks in classrooms will carry over to result in a decrease in sedentary behavior and promote a more active lifestyle both in and outside of the classroom that will progress throughout adulthood.

CLINICAL RELEVANCE: The use of sit-to-stand desks in the classroom can help support an increase in activity to promote healthy behavior.


Sutter EN, Xenopoulos-Oddsson A, Galli M, Gillick BT

PURPOSE/HYPOTHESIS: Transcranial Magnetic Stimulation (TMS) has many applications in pediatric rehabilitation, both as a non-invasive assessment of brain excitability and as a neuromodulatory intervention. In infancy, TMS assessment can identify atypical motor system connectivity that may be associated with high risk of cerebral palsy (CP). Understanding the potential influence of TMS through computational modeling promotes safe and effective TMS implementation and analysis, and broadens knowledge of underlying mechanisms. Modeling may thus be a valuable preparatory step to using TMS with infants. Models of TMS have not been reported in infants, potentially limiting further clinical translation of this tool for exploring development after early brain injury.

MATERIALS AND METHODS: Magnetic resonance imaging (MRI) and TMS assessments were performed at age 4 months and at age 2 years. We created head models and simulated single-pulse TMS assessments using SimNIBS software. The infant's T1 and T2 anatomical images were incorporated into tissue type segmentation, using both manual and automated tools due to errors in initial automated output: 1) initial automated segmentation with headreco with manual correction in ITK-SNAP (skin, bone, eyes, air cavities) 2) the infant Brain Extraction and Analysis Toolbox (iBEAT) (CSF, white matter, gray matter), and 3) manual lesion segmentation in ITK-SNAP. Segmentations were transformed into a 3D head model with appropriate tissue-type conductivities. Single pulse TMS was modeled over the region of the motor cortex with the coil pointed 45 degrees to the nasal-inion line.

NUMBER OF SUBJECTS: One infant with a left frontal intraparenchymal hemorrhage with interventricular extension.

RESULTS: Realistic head models were successfully created for the infant at both ages. iBEAT resulted in high-quality gray and white matter segmentations compared to automated tools designed for adults. Compared to an adult brain (Minjoli et al. 2017), the electric field spread over a greater percentage of brain area and reached a higher maximum field strength with simulated pulses. At 100% of Maximum Stimulator Output, the peak electric field strength in the infant was approximately 120% of that observed in an adult brain at the same intensity. Additional analyses will systematically investigate various coil positions around the motor cortex and evaluate electric field spread.

CONCLUSIONS: The modeled TMS-induced peak electric field was stronger in an infant than in an adult brain at the same stimulator intensity, with differences in the spatial extent of the induced field. Modeling TMS in infants is time- and labor-intensive due to the extent of manual editing required but may inform protocol development and analysis.

CLINICAL RELEVANCE: Computational modeling of TMS can support interpretation of neurophysiological assessments, contribute to safety analyses, and inform individualization of TMS protocols for infants. Using TMS to non-invasively assess infant brain circuitry after early injury may provide information about recovery and development relevant for early detection of cerebral palsy and subsequent intervention.


Sutter EN, Gissler L, Koziol H, Schiller JR, Mak V, Gillick BT

PURPOSE: The foundation for evidence-based clinical practice is sound research, requiring successful recruitment of research participants. In pediatric research, family recruitment is a unique aspect of successfully running a research study. Study participants, and families of the children participating, prefer active engagement with their research team, as evidenced in open communication models where the participants and researcher acknowledge and appreciate the other's expertise and experiences. The Pediatric Neuromodulation Lab (PNL) is currently conducting a pediatric longitudinal observational study to investigate the impact of perinatal brain injury on motor development and risk for cerebral palsy (CP) (NIH 1R01HD098202). Caregivers may feel complex emotions about their young child's medical journey and participation in research, as their child has likely experienced multiple medical procedures and has been identified as at risk for CP. In an effort to prioritize open communication, facilitate recruitment, and provide an educational opportunity for the families of the infants during the two-year study commitment, we developed a ‘Travel Passport’ to guide families through each of five timepoints of the research journey.

DESCRIPTION: The PNL Travel Passport is an interactive, innovative approach to inform families about what to expect when joining our study and throughout the years of participation. To convey the goals and purpose of the study, plain language and informative images are used. Each study component: MRI, transcranial magnetic stimulation (TMS), and behavioral assessments are described in detail, with information about the child's unique progress in participation. This aims to create an inclusive environment for the primary readers, the families, and ensures they feel knowledgeable about their experience. The Travel Passport aims to directly involve families throughout the study process and facilitate communication and involvement.

SUMMARY OF USE: The travel passport serves as an accessible, approachable way for the research team to communicate with families throughout the course of the study. Every family is provided with a personalized Travel Passport at the first study visit. Each section is updated with individualized information at the end of every participation session, allowing study coordinators to provide consistent updates throughout. To evaluate the effectiveness of the Travel Passport, we will gather feedback from families via a brief open-ended survey of caregivers that will assess perceived benefits and potential improvements to this participant engagement tool. Summative feedback from the caregiver surveys will be shared in the poster and a recruitment, enrollment and retention manuscript developed to discuss this novel approach for this pediatric longitudinal study.

IMPORTANCE TO MEMBERS: We will present an innovative tool to support family enrollment and engagement in pediatric longitudinal clinical studies. Engagement and education of families in research is critical for evidence-based pediatric practice.


Tiffany NN, Stevens EM, Burris EK, Hall JB

PURPOSE/HYPOTHESIS: PICO question: What interventions are used to improve balance in patients with CP GMFCS Levels III-V across the lifespan?

MATERIALS AND METHODS: PRISMA and Joanna Briggs Institute guidelines for systematic reviews were used. Inclusion criteria included studies of individuals with a diagnosis of CP, GMFCS levels III-V, and any age. Exclusion criteria included interventions provided following surgery or other medical interventions. 3 researchers were involved throughout the process. Databases searched were PubMed, Scopus, Web of Science complete collection, and CINAHL. After duplicates were removed, the remaining articles were assessed first by title, then abstract, and finally full text. Levels of evidence of included articles ranged from 2-5. Due to the heterogeneity of participant demographics, interventions, and outcome measures, meta-analysis was not completed. This review was registered through PROSPERO ID # 343766.

NUMBER OF SUBJECTS: n=49 articles from 2007 through 2022. 24 articles lacked a control group, 16 articles compared outcomes of an intervention versus standard care, and 10 articles compared outcomes of two different interventions. 35 studies included patients with GMFCS level III, 30 included GMFCS level IV, and 13 included GMFCS level V. All articles included participants under 18-years-old, only two articles included participants above 18. Most commonly reported type of CP was spastic diplegia (n=21) and least reported was athetosis (n=1).

RESULTS: Sample sizes ranged from 1 to 146. 21 unique balance interventions were included. The most commonly reported were orthoses/adaptive equipment (n=8) and hippotherapy (n=8); the least reported were (n=1) seating equipment, BWSTT, strength training, ice skating, bungee trampolining, task specific training, and a sling exercise tool. Across studies, balance was assessed using 35 different outcome measures. The most common outcome measures were Gross Motor Function Measure (GMFM) dimensions D (n=16) & E (n=14) and the Pediatric Balance Scale (PBS) (n=11). 21 studies reported statistically significant results, 15 reported improvements from baseline, and 3 reported clinical significance. 6 studies performed long-term follow-up, the longest being 3 months post intervention. 11 studies addressed intervention effects on participation. No studies reported lasting adverse effects.

CONCLUSIONS: In the literature surrounding balance in CP, few studies included individuals with higher GMFCS levels. Study limitations included lack of control group, follow-up, evaluation in natural environments, and measures addressing participation. Studies also varied in levels of evidence.

CLINICAL RELEVANCE: Findings suggest physical therapy interventions may improve balance in individuals with CP GMFCS levels III-V. However, more rigorous studies are needed in order to better understand which interventions are most effective and feasible to implement in the clinic.


Tiwari D, Gochyyev P

PURPOSE/HYPOTHESIS: The purpose of this study was to develop a revised version of the Dizziness Handicap Inventory Children and Adolescents (DHI-CA) and examine the measurement properties using item response theory methods.

MATERIALS AND METHODS: A cross-sectional retrospective chart review was conducted, and de-identified data on age, gender, and DHI-CA was extracted. Exploratory factor analysis with quartimin rotation was performed to examine the factor structure of the DHI-CA. Confirmatory factor analysis was performed to obtain measures of model fit, including root mean square of approximation (RMSEA) and Tucker Lewis Index. A multidimensional ordinal Rasch modeling approach to fit a 4 -dimensional partial credit model was used due to its ability to handle categorical items with more than two scoring levels. The estimation of the model was done using the marginal maximum likelihood method. Wright Maps were obtained to explore the mapping between respondent abilities and item difficulties and to evaluate the distribution of person abilities and item parameters.

NUMBER OF SUBJECTS: 132 patients (8-18 years) from a tertiary center specializing in comprehensive multidisciplinary post-concussion management.

RESULTS: Factor analysis of the original scale revealed that 12 out of 25 items did not fit in the subscale these were originally described under. Items were reorganized into subscales based on item fit. Corrected item-rest correlations for the physical, emotional, walking/mobility, and community participation subscales on the revised DHI-CA ranged from 0.44-0.66, 0.27-0.61, 0.54-0.57, and 0.32-0.69, respectively. Item 9 (“because of the dizziness, are you afraid to leave the house?”) demonstrated the lowest difficulty level whereas item 11 (“do fast movements of the head worsen your dizziness?”) demonstrated highest difficulty. Fifty percent of the items pooled in the lower difficulty level as observed from the Wright Maps, indicating a potential ceiling effect. Further exploration of the revised DHI-CA revealed presence of several double-barreled items and items with negative formulation in the measure.

CONCLUSIONS: Although revised DHI-CA demonstrated better internal consistency than the original DHI-CA, Rasch analysis indicated several structural limitations. Presence of double barrel items and a potential ceiling effect for post-concussion population necessitate caution while interpreting the results of the DHI-CA in post-concussion population.

CLINICAL RELEVANCE: To accurately document the effectiveness of rehabilitation interventions it is required that the measures must be created and tested using robust research methods. Clinicians are encouraged to interpret the results from the DHI-CA based on the item-response theory to get a better estimate of patient's functional limitations. The DHI-CA can be cautiously utilized in association with performance-based measures to assess dizziness in children until more robust measures are developed.


Tovin MM, Flores MB, Gill SV, Iverson MJ

PURPOSE/HYPOTHESIS: This scoping review project arose during the Academy of Pediatric Physical Therapy Research Summit V amid consensus building on the development interdisciplinary research on physical activity as a gateway to participation across the lifespan. This study aimed to examine developmental and rehabilitation literature to identify 1) whether improving opportunities for movement in transitional periods enhances participation across the lifespan; 2) whether improving movement quality enhances participation across the lifespan; and 3) gaps in knowledge of how movement affects participation across the lifespan.

MATERIALS AND METHODS: Arksey & O'Malley's scoping review (ScR) protocol was used to canvas studies that examined the impact of movement opportunities on participation. The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines were used to ensure rigor and standard reporting requirements. The protocol was pre-registered with OSF. Initial search terms were tested and modified until the search string aligned with the study aim. Only material published in English between 2000 and 2021 was included. Six scientific databases were utilized: PubMed, CINAHL Plus, Ovid MEDLINE, PsychINFO, ProQuest Dissertations & Theses Global, Embase via Ovid. Consistent with ScR method, published journal articles as well as material considered gray area (e.g., conference presentations, abstracts, theses, dissertations) were included that met the following criteria: involved infants through transition aged adults 0-25 years with neuromotor or developmental disabilities; provided a movement opportunity or motor intervention; and reported a measure(s) of social participation as a study outcome linked with movement opportunity. Data were extracted and summarized across studies based on specific characteristics identified as relevant to the research question. Consensus of overall results, including participant characteristics, movement opportunities, and participation was achieved through on-going discussion by the authors.

NUMBER OF SUBJECTS: Initial search yielded 7,524 research articles. After rigorous screening, 37 were included in final review (11 systematic reviews, 9 RCTs, 17 other), with a total of 1,442 subjects.

RESULTS: No studies adequately addressed the impact of movement opportunities on key points of age-related transitions. Movement opportunities focused primarily on the ICF framework activities domain with participation as a secondary measure. Findings revealed a lack of consistency in how participation was defined and measured.

CONCLUSIONS: Findings suggest additional research is necessary given the small number of studies that investigated specific movement opportunities as interventions to facilitate participation. Future studies should explore movement opportunity to support participation during key points of transition through the lifespan.

CLINICAL RELEVANCE: As movement specialists, pediatric physical therapists strive to optimize movement and participation across the lifespan. This study highlights the lack of evidence for movement interventions during critical transition periods and provides a framework for future research.


Treat H, Konieczny J, Pierce J, Jameson ATW, Gehringer J

BACKGROUND AND PURPOSE: Cerebral palsy (CP) is the most common cause of childhood-onset lifelong physical disability.1 Hand arm bimanual intensive training (HABIT) is a successful therapy technique. However, HABIT traditionally requires time and labor-intensive efforts from the family and therapist, as well as a high volume of repetitive activities.2 Virtual reality (VR) has been established as an effective and motivating method for improving motor function in CP.3 This study explored at-home HABIT-VR as a method to increase access to treatment and maximize therapeutic outcomes.

CASE DESCRIPTION: The subject was an 11-year-old male with hemiplegic cerebral palsy, provided with a portable VR system loaded with a single HABIT-VR game and followed pre- and post-intervention. This immersive VR game was designed to incorporate HABIT into a motivating, accessible, at-home program. Intervention consisted of 28 30-minute game sessions over 2 weeks. Outcome measures included Canadian Occupational Performance Measure; Box and Blocks Test; 9-hole Peg Test; Pediatric Functional Reach Test; range of motion; manual muscle testing; qualitative participant interviews, accelerometer data, and task performance data.

OUTCOMES: Clinically relevant improvements were seen in 3 of 5 goals in performance and satisfaction ratings. Gross motor and fine motor function did not change after intervention. Weekly interviews reveal themes including ease of set-up, independence with game-play, and protocol compliance. Data analysis revealed significant increase in task accuracy, significant decrease in upper extremity acceleration, and significant changes in path length. A reduction in the overall path length was pronounced in the more affected side, and the overall time to complete the shooting task was reduced from 2.60s to 1.4s.

DISCUSSION: It is feasible that HABIT-VR in the home environment could increase access to treatment and maintain upper-extremity function as measured by clinical tests. HABIT-VR offers a virtual platform for access of therapeutic interventions in rural areas and provides families flexibility in scheduling therapeutic interventions. This could lead to more continuous treatment, which has shown to improve outcomes of HABIT.5 Task-specific improvements in accuracy, acceleration, and path length indicate improved efficiency and demonstrate motor learning. Peak movement accelerations are associated with performance on other clinical measures in children with CP,4 however, this connection has not been explored after an intervention. Study limitations include: single subject design with limited number of data collections; specificity of the game's motor task potentially minimized generalization of functional gains; subject's high baseline abilities may have experienced a ceiling effect for selected outcome measures; dosage was only 14 hours of HABIT-VR, which is considered the minimum needed to see motor learning.6 Future research should explore greater sample size, increase game variety and features, and investigate the effect of dosage.


Ubben CL, Brown S

PURPOSE/HYPOTHESIS: Children with special needs attend occupational (OT), physical (PT), and/or speech (ST) therapy to improve their ability to participate in meaningful activities. During therapy, children participate in standardized testing to measure performance. Therapists and parents often report improvements in a child's ability, however these assessments do not always demonstrate measurable functional changes as a child progresses through therapy. The Pediatric Quality of Life Inventory (PedsQL) was implemented across an outpatient rehabilitation system to reduce redundancy and potentially streamline the process by including an assessment that can provide vital information regarding a child's true performance changes across all disciplines involved in the child's care. However, acceptability by the clinicians is a component to successfully implementing the PedsQL into the outpatient rehabilitation clinics.

MATERIALS AND METHODS: This was an exploratory mixed-methods study to probe implementation of the Pediatric Quality of Life Inventory (PedsQL) as a centralized measure to support standardized assessments within pediatric rehabilitation. A brief survey guided by the Usage Rating Profile-Assessment ([URP-A], Chafouleas, et al., 2012) was administered to probe the therapists' perceptions of the PedsQL. Semi-structured interviews were also conducted to attempt to gain additional insight across the therapeutic team. Quantitative data were analyzed using the Mann-Whitney U test to explore differences across OT, PT, and ST in six areas of the URP-A: system support, feasibility, understanding, collaboration, system climate, and acceptability. Qualitative data were analyzed descriptively.

NUMBER OF SUBJECTS: Twenty-four therapists were recruited from three clinics, with fourteen OTs, PTs, and STs completing the survey. Three clinicians participated in interviews.

RESULTS: All three disciplines reported agreement with understanding of the PedsQL and the need for parent collaboration. Statistically significant differences were noted between OT and PT when compared to ST in the areas of acceptability (p<.01), additional support needed (p<.05), feasibility (p<.01), and clinic climate (p<.01). ST reported that the administration of the PedsQL was burdensome and their work environment was not conducive to administration. During the interviews, all therapists expressed a need for additional time to implement the PedsQL however also noted the need for inclusion of a quality of life measure.

CONCLUSIONS: OT and PT demonstrated overall support of the PedsQL while ST reported that the administration of was burdensome.

CLINICAL RELEVANCE: This study probed the inclusion of a centralized quality of life measure across disciplines in pediatric rehabilitation, however revealed the need for further exploration as to why this tool was not accepted across the therapy team.


Wentzell EM, McKee DP

PURPOSE/HYPOTHESIS: Childhood is critical for developing healthy routines prioritizing physical activity (PA) over sedentary behavior (SB) and promoting good sleep habits. The 24-hour movement guideline is a framework that has age-level recommendations for activity across the entire day. Research has found that children who adhere to the 24-hour movement guidelines have lower adiposity, better fitness, and better health. In previous studies, children with disabilities have higher rates of non-communicable diseases, lower self-reported quality of life, and less adherence to recommended activity levels. Establishing active routines may produce health benefits across the lifespan. The Activity Matters study aimed to understand parents' perceptions and knowledge related to PA, SB, and sleep.

MATERIALS AND METHODS: Parents participated in a one-hour semi-structured virtual interview. The research team completed thematic analysis using the Consensual Qualitative Research (CQR) approach.

NUMBER OF SUBJECTS: The Activity Matters study utilized parental reports of 15 families with ambulatory children age 5-10 years old with a known disability, including Down syndrome, cerebral palsy, and autism spectrum disorder.

RESULTS: Parents were unfamiliar with the 24-hour movement guideline and were unaware of recommendations for PA in children. Children were noted to be active in a way that matched their parent's definition of PA. In a majority of the children, fatigue was the most significant limiting factor for participation in all forms of activity. Lack of opportunity, speech delays, and available time due to frequent therapy appointments were also cited as barriers. Playing outdoors, playgrounds, music, peers, and family routines helped facilitate PA. Increased amounts of SB, including screen time, was a source of parental frustration. Poor sleep was an issue for some children, and this negatively impacted behavior, activity level, and participation.

CONCLUSIONS: In this qualitative focus group study, parental knowledge, the family's capacity, and access to opportunities impacted the child's activity level. Many parents were not pleased with their child's PA and SB and noted barriers to participation. However, parents who reported satisfaction with PA levels also noted a family culture of activity and established routines that built in activity throughout the day. Parental perceptions of activity provide potential avenues for intervention to move toward healthy habits.

CLINICAL RELEVANCE: As physical therapists (PT), we must ensure families the knowledge and the capacity to create healthy routines. Instilling healthy habits early in life may help prevent adverse health outcomes. The 24-hour movement guideline provides a robust framework for holistic health. PTs are well positioned to screen for sleep issues, address poor endurance, promote PA opportunities, create structures to limit SB, and increase overall activity throughout the day.


Wiley MS, Chiarello LA, Effgen SK, Gracely EJ

PURPOSE/HYPOTHESIS: School-based physical therapists (SBPTs) recognize the value of inclusive services, but many indicate they do not provide these services in practice. This study examined associations of the characteristics of SBPTs and students, with inclusive services to gain an understanding of facilitators and barriers to their use.

MATERIALS AND METHODS: A secondary data analysis of PT COUNTS was performed examining SBPTs' expertise, years of school-based experience, level of education, professional association membership, continuing education hours, and number of journal articles read annually; student age, level of inclusive classroom placement, and GMFCS level; and services provided with other students present, within the context of school activities, and through knowledge sharing activities with education team members.

NUMBER OF SUBJECTS: 106 SBPTs and 106 students.

RESULTS: Three variables correlated (p ≤ 0.015) with the proportion of service time provided within the context of school activities and were included in a multiple regression analysis: APTA membership (r=0.15, p=0.149), level of student inclusive classroom placement (r=-0.35, p<0.001), such that less inclusive classroom placement of students was correlated with a higher proportion of service time delivered within the context of school activities, and GMFCS level (r = 0.20, p=0.03), indicating a higher proportion of service time delivered within the context of school activities for students who have greater functional limitations.

There were no significant correlations of the PT and student characteristics with the proportion of service time spent with other students present, or the proportion of service time spent in knowledge sharing with education team members; therefore, these variables were not further analyzed. The multiple regression analysis found APTA membership, level of student inclusive classroom placement, and student GMFCS level explained 14% of the variance of service time provided to students within the context of school activities (p<0.001). Only the level of student inclusive classroom placement uniquely contributed to the variance (p=0.001). Students who spent the majority of the day in a regular classroom received a lower proportion of service time in the context of school activities.

CONCLUSIONS: The results substantiate the influence of student classroom placement on providing services within the context of school activities. SBPTs should consider creative strategies to extend interventions in the context of school activities outside of the students' classrooms. Decision-making about service delivery and inclusive practices in the school-based setting appears multifaceted, requiring future prospective research.

CLINICAL RELEVANCE: Providing services within the context of school activities requires a creative and flexible approach to addressing student goals. SBPTs should consider their beliefs about serving students in their classroom and explore novel ways to provide services during naturally occurring school routines to promote the carryover of targeted skills.


Williams KL, Menner MK, Meyer DJ, Bailes AF

BACKGROUND AND PURPOSE: Individuals with spinal cord injury (SCI) often experience spasticity as a secondary complication that can cause pain, contractures, and reduce mobility and quality of life. Effective management can include conservative treatment, oral medicine, injections, or surgery. Most of the literature focuses on adults with SCI. Little is known about the combined use of functional electrical stimulation (FES) cycling, oral medication (baclofen) and injections (botulinum neurotoxin (BoNT)) to manage spasticity in children with SCI. The purpose of this case study was to examine the effects of FES cycling combined with oral baclofen and BoNT injections on spasticity and occupational performance in a child with T1 SCI.

CASE DESCRIPTION: The child was a 6 y.o. male in 2015 when he sustained a T1 complete SCI. He received 2 months of comprehensive inpatient rehabilitation before transitioning to outpatient services. Outpatient physical therapy services included multiple episodes of traditional therapy for transfer training, equipment, bracing, and strengthening, as well as intensive body weight supported locomotor training. Medical management included Magnetic Expansion Control rod placement to manage neuromuscular scoliosis and oral baclofen + dantrium + periodic BoNT injections to manage lower extremity (LE) spasticity. Four years post injury, LE spasticity was not well controlled and the child underwent a trial of FES cycling to assist in management. Spasticity initially limited tolerance, but he was eventually able to participate in an intensive episode of FES cycling 2-4x/week for a total of 32 visits. The child received BoNT injections, once during the episode, to the right hip adductors, quadriceps, and hamstrings. Spasticity angles (Modified Tardieu scale-MTS) and performance and satisfaction with family centered goals (Canadian Occupational Performance Measure-COPM) were monitored pre and post intervention.

OUTCOMES: Upon completion of 32 visits of FES cycling, there was a 7 point improvement in average COPM performance score, and a 7.6 point improvement in satisfaction score. The child demonstrated a 10 degree reduction in the left knee and ankle spasticity angles, and a 30 degree reduction in the right knee and ankle spasticity angles. Family reported a reduction in the number of daily bladder accidents from 2/day to 0/day, and a reduction in bowel program time from 60 min to 22 min. Six months after completion of the FES intensive episode, family was able to wean patient off baclofen without significant self-reported change in spasticity.

DISCUSSION: While this is only one case, our findings are consistent with a recent systematic review in the adult literature reporting FES cycling is effective in managing spasticity and at least 20 intervention sessions of FES cycling are required to obtain a decrease in spasticity. This child and caregiver goals were specific to spasticity; however, FES cycling may also impact goals in other areas. Further research examining the role of FES cycling in combination with other interventions is warranted in children after SCI.


Williams ME, Campbell ME, Leporati BL, Lockyer CR, Wendland MT, Bellows DM

BACKGROUND AND PURPOSE: Pediatric physical therapists (PTs) and assistants (PTAs) need ready access to the best available synthesized evidence to inform practice. The Academy of Pediatric Physical Therapy (APTA Pediatrics) has supported dissemination of fact sheets since 2006 as a tailored intervention to meet this need, but the program has never been evaluated. This administrative case report describes the assessment of, utilization, usability, and usefulness of APTA Pediatrics fact sheets.

CASE DESCRIPTION: APTA Pediatrics Fact Sheet Committee, established in April 2020, has an overarching vision to maintain a repository of up-to-date fact sheets on relevant topics to enhance awareness and knowledge of the best available evidence. Committee members assist authors with fact sheet production and recommend dissemination strategies to APTA Pediatrics leaders. To inform this work a 32-item survey was distributed from February to April 2021 through APTA Pediatrics website and social media accounts using a snowball sampling technique. Anonymous responses about fact sheet content, access, usability, and usefulness were collected via Likert scale, ranking, and open response items. One hundred ninety-six pediatric PTs representing a variety of practice settings completed the survey. No PTAs participated. Quantitative data were analyzed using descriptive statistics and open responses were analyzed using content analysis.

OUTCOMES: Overall, PTs described fact sheets as a useful, informative, succinct resource they would seek out in the future. The most common reasons for accessing fact sheets were to share knowledge about pediatric conditions and as a starting point for evidence-informed patient care. Important characteristics included brief evidence synthesis, visual presentation of information, algorithms or decision aids, and references. Challenges with searching for topics, lack of translation into other languages, timeliness of revision, variable organization of information, and limited caregiver fact sheets were identified as areas for improvement.

DISCUSSION: Clinical practice guidelines (CPGs) are the gold standard for knowledge translation, but they take years to develop and not all relevant pediatric topics have adequate evidence for this or other types of synthesis. For these topics, individual PTs must access, analyze, and synthesize evidence. Some PTs possess this skill and others do not. Our results agree with research suggesting brief evidence summaries such as fact sheets can help PTs and other healthcare practitioners keep up with emerging evidence about pediatric conditions, associated interventions, and practice trends. Improvements in how fact sheets are formatted and disseminated may increase utilization. Evaluation of the reach, effectiveness, and impact on intention to change practice for APTA Pediatrics fact sheets is warranted.

CLINICAL RELEVANCE: Dissemination strategies must be tailored for an intended audience. Results of this study will inform quality improvement efforts to optimize the creation and dissemination of fact sheets to support best practice.


Wirth A

PURPOSE: Idiopathic toe walking (ITW) is persistent toe-walking in a patient in the absence of medical condition and is often seen in patients with autism spectrum disorder (ASD) and sensory processing disorder (SPD). Recent literature suggests that children with ITW have SPD that results in decreased proprioceptive processing, vestibular impairments, and tactile defensiveness.1 There is evidence to support physical therapy (PT) intervention with successful short term resolution of ITW consisting of AFOs, casting, and home exercise programs2 and in 2021, Barkocy et al found improvements in gait kinematics and ankle dorsiflexion (DF) range of motion (ROM) following serial casting and orthotic management in children with ITW and ASD.3 Gaps in the literature do not account for long term follow up of these patients, nor is there literature to support the effectiveness of both PT intervention and sensory-based occupational therapy (OT) treatment in the treatment of the ITW patient who presents with SPD.

DESCRIPTION: Therapists at NYU Rusk Rehabilitation outpatient pediatric clinic found inconsistency in referrals for patients with ITW. Most patients with ITW were referred directly to PT only to address the gait abnormality. Patients with severe SPD and ASD diagnoses with a symptom of ITW were referred to OT only. These inconsistencies highlighted the need for standardization in referrals to PT and OT for ITW. The model addresses the importance of PT intervention to address the physical impairments of ITW in addition to OT sensory based treatments to address the underlying SPD and enhance long term outcomes.

SUMMARY OF USE: In this model, PT intervention prioritizes improving ankle DF ROM, improving soft tissue mobility and orthotic management as well as prescribed exercises to address muscular weakness, improve/maintain ROM, monitor orthotic wear, and posterior weight line and gait training exercises. Patients attending PT for ITW with sensory impairments as identified by administration of the Sensory Processing Measure (SPM) were referred to OT to participate in their “Stomp It Out” program, a sensory-based treatment protocol for ITW that is utilized to address the underlying SPD related to ITW. PT outcome measures including goniometric measurements, 50 foot toe walking test, observational gait scale, and gross motor assessments as well as OT outcome measures including the SPM and Goal Attainment Scale (GAS) were taken at evaluation and discharge.

IMPORTANCE TO MEMBERS: The collaboration of PT and OT play a vital role in the treatment of ITW with underlying sensory dysfunction. Collaboration between doctors, families, and therapy providers is important when treating this population. This pilot program has shown improvements in gait kinematics as per the observational gait scale, ankle DF ROM, and decreased amount of tip-toe steps taken as per 50 foot toe walking test. Red flags identified by administration of the SPM will justify referral for OT in conjunction with PT. It is theorized that a combination of PT and OT evaluation and treatment will improve long term outcomes in order to keep patients with ITW off their toes.


Wynarczuk KD, Harkins M, Kelly P, Macfarlane A, Weslosky A, Curley B

PURPOSE/HYPOTHESIS: School trips enhance didactic learning and provide opportunities for experiential learning and social engagement. However, school trips may present unique challenges for students with cerebral palsy. The purpose of this study was to describe school trip experiences from the perspective of parents of children with cerebral palsy and to explore the relationship between children's physical and manual abilities and their participation during school trips.

MATERIALS AND METHODS: The survey included questions on the child's Gross Motor Function Classification System (GMFCS) and Manual Abilities Classification System (MACS) levels and Likert scale and open-ended questions regarding school trip experiences. Response frequencies and Kendall's Tau correlation coefficients were calculated using SPSS. Responses to open-ended questions were analyzed using thematic analysis.

NUMBER OF SUBJECTS: This poster presents secondary data analysis of a subgroup of respondents from a previously conducted Qualtrics survey for parents of children with disabilities. Responses from 67 parents of children with cerebral palsy (ages 6 to 21) were included in the secondary data analysis. Parents lived in the United States and one lived in Canada. The mean age of children was 12.9 years (SD 3.9). Most attended public school (89.6%) and received at least some special education services (83.6%).

RESULTS: Almost all parents of children with cerebral palsy reported that their child requires accommodations to participate in school trips (92.5%). Participation in school trips was limited a tremendous amount or quite a bit by the child's physical (71.6%), health (28.4%), or sensory (25.4%) needs. Most agreed that schools meet their child's needs on school trips (64.2%), however only 39% agreed that the destination sites meet their child's needs. Thirty-eight percent of parents reported that their child had been excluded from school trips because of their disability. Parents of children classified as GMFCS IV and V or MACS IV and V were more likely (p<.05) to report that their child needed accommodations to participate in school trips and that their child's disability, physical abilities, sensory needs or health needs limit their participation in school trips. Responses to open-ended questions revealed three themes related to school trip success for students with cerebral palsy: Advocating for social inclusion, Identifying and preparing accommodations for success, and Recognizing and resolving occupational injustices.

CONCLUSIONS: Although many parents report that their child's school meets their needs during school trips, many experience barriers which inhibit or exclude their child's participation in school trips. These findings indicate that additional strategies are needed to support the meaningful participation of students with cerebral palsy on school trips.

CLINICAL RELEVANCE: As members of the interprofessional education team, school-based physical therapists may be instrumental in identifying potential barriers and developing individualized accommodations for students with cerebral palsy on school trips.


Wyker C, Harstook K, Heyl NA, Lewis T, Fergus AH

PURPOSE/HYPOTHESIS: The family-centered care framework of Early Intervention (EI) has shifted the focus toward caregiver engagement. Coaching can build caregiver confidence and engagement but the underlying processes that build this are unknown. Therapeutic alliance has been shown to improve outcomes in adult populations. The purposes of this study were to examine the extent of therapeutic alliance (caregiver buy-in) and investigate factors perceived to influence caregiver buy-in, confidence and engagement in EI.

MATERIALS AND METHODS: A mixed methods approach using quantitative questionnaires and qualitative semi-structured interviews was utilized. Questionnaires were developed and distributed to caregivers and PTs practicing in EI to determine the perceived caregiver buy-in, factors associated with and strategies used to develop buy-in. Semi-structured interviews were completed to further explore the factors associated with the development of buy-in in EI. Interviews were transcribed and theme coded until saturation was achieved. A concept map was developed by consensus.

NUMBER OF SUBJECTS: Quantitative phase: 23 caregivers and PTs. Qualitative phase: 4 caregivers, 4 PTs.

RESULTS: The questionnaire data revealed that 100% of the caregivers believed that their children benefited from EI, that they were empowered and confident in caring for their children, and their quality of life improved. Factors reported to influence their buy-in included noticing improvement, reaching milestones and attaining goals. Therapists believed that the family awareness and acceptance of the diagnosis, caregiver confidence, caregiver level of concern, and the therapist/caregiver relationship influenced buy-in. Strategies believed to build this included communication and caregiver education. The qualitative phase of the study supported and expanded these data with the emergence of the following themes: therapist relationship and rapport, communication, the coaching approach, caregiver education, caregiver comfort level and confidence and family involvement. The data suggest that clear and flexible communication including education on diagnosis, interventions and the reasoning behind them as well as active listening and responsiveness help to build the relationship and rapport between the caregiver and the PT. This caregiver/PT relationship fosters caregiver confidence and comfort performing interventions. The foundation for the development of buy-in was believed to be a combination of this relationship and the PT/caregiver noting improvements in the child.

CONCLUSIONS: Communication and building the caregiver/PT relationship appear to be the cornerstone for developing buy-in in EI. Flexibility and active listening along with thorough caregiver education are PT-implemented strategies that build caregiver comfort, confidence and buy-in.

CLINICAL RELEVANCE: Improved understanding of the factors influencing the development of buy-in will provide a framework for the clinician to enhance caregiver buy-in. Enhanced buy-in may promote parental engagement and improved outcomes for the child and family.

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