USE OF KNOWLEDGE TRANSLATION STRATEGIES TO INCREASE THE USE OF THE ALBERTA INFANT MOTOR SCALE IN PATIENTS WITH CONGENITAL MUSCULAR TORTICOLLIS IN THE PEDIATRIC OUTPATIENT HOSPITAL BASED SETTING
Adelstein L, Burke A, Smith S, Will B, Georgetti T. Connecticut Children's
BACKGROUND & PURPOSE: The Physical Therapy Management of Congenital Muscular Torticollis (CMT): A 2018 Evidence-Based Clinical Practice Guideline from the APTA Academy of Pediatric Physical Therapy supports the use of a standardized outcome measure (SOM) in the evaluation of a pediatric patient with CMT in order to remediate potential developmental delays. One of the recommended SOMs is the Alberta Infant Motor Scale (AIMS). Evidence shows there is limited use of SOMs across allied health professionals. This pediatric setting identified limited use of the AIMS in the evaluation of patients with CMT. Knowledge translation (KT) strategies have been identified as a method to promote practice change based on research. The purpose of this administrative case report was to increase use of the AIMS with patients with CMT utilizing KT strategies.
CASE DESCRIPTION: KT initiative was developed based in part on the knowledge-to-action framework. Knowledge of the AIMS via clinician self-report (via SurveyMonkey©) and utilization of the AIMS during CMT evaluations (via chart audits) were assessed at baseline. Per survey results, 78% of clinicians were familiar with the AIMS; however per chart audits, only 10% included the AIMS. Through survey questions, it was identified that length of appointment time, clinician knowledge, availability of test materials, and time to document were barriers to implementation. An action plan was created to address modifiable barriers, including use of in-services, peer-to-peer mentoring, and development of an electronic resource database. Testing materials were organized in order to improve efficiency of use. Documentation time was improved through creation of EPIC© smartphrases.
OUTCOMES: To determine if significant change was seen post implementation of KT strategies, clinician self-report of knowledge was reassessed after two years, where all clinicians reported familiarity with the AIMS. Additionally, percentage of CMT evaluations with completion of the AIMS were compared from baseline to 1.5 and 2.5 years post baseline via chi-square test of independence. All CMT evaluations were audited for AIMS completion, with exclusion of telehealth and those that included a different SOM. A significant increase was seen in 1.5 (44%) and 2.5 (77%) years from baseline (10%).
DISCUSSION: For this setting, KT strategies resulted in increased AIMS use during CMT evaluations. The COVID-19 pandemic may have impacted our ability to implement the KT strategies efficiently and time needed to observe the positive change. More research is needed to determine how these results affect clinical decision making. Use of KT strategies can be utilized to promote practice change based on research in this setting. Specific strategies such as implementation of a centralized research database, use of documentation templates, and peer-to-peer mentoring/education could be successful in translating evidence into practice.
ESTIMATING THE DIFFICULTY LEVEL OF MOTOR PRACTICE DURING PHYSICAL THERAPY IN YOUNG CHILDREN WITH CEREBRAL PALSY
Alcott M, Paremski A, Skorup J, Pierce S, Prosser L. The Children's Hospital of Philadelphia
PURPOSE/HYPOTHESIS: Infants with typical development continually challenge their motor skills by practicing more difficult movements and postures as their skills develop. Practicing challenging skills is presumably important for motor skill acquisition, but this has not been studied in children with cerebral palsy (CP). Our objective was to quantify the difficulty level of motor practice during physical therapy (PT) in young children with CP.
NUMBER OF SUBJECTS: Twenty toddlers with CP (12 boys, mean age 26.9 months, GMFCS level I-IV) were included. Children were enrolled in a clinical trial (NCT#02340026) and could not take independent steps.
MATERIALS/METHODS: Children were randomly assigned to conventional PT (dose-matched control group) or to an intervention designed to facilitate practice of skills beyond the participant's current level of function using dynamic weight support (experimental group). Participants were stratified by age and motor function to ensure equivalence at baseline. The Gross Motor Function Measure (GMFM-66) was scored by a blinded assessor at baseline and after 12 weeks. Difficulty level of motor practice during therapy was determined by estimating a GMFM score from manually coded videos of randomly selected PT sessions (116 videos total). Two coders simultaneously viewed each video to identify and score each gross motor activity that corresponded with a GMFM test item. All videos were 20% double coded for reliability by a third coder, and disagreements were reconciled for any that did not reach 85% reliability. An individualized difficulty level was measured as the difference between the estimated GMFM score and the actual GMFM score, essentially normalizing the raw difficulty level to the child's individual level of function. Positive values meant greater difficulty in therapy compared to current function. Difference between groups was assessed with an unpaired t-test and the relationship to baseline gross motor function was quantified by Pearson correlations.
RESULTS: Estimated difficulty level during PT exceeded participants' current level of function in both groups (experimental group mean 9.6; conventional group mean 3.4) and was significantly greater in the experimental group compared to the conventional group (p=0.0014). These observations suggest that the dynamic weight support harness allowed practice of harder motor skills and, more importantly, indicate that difficulty level can be manipulated during PT in young children with CP. Lower baseline motor function was significantly related to greater difficulty levels in both groups (experimental group −0.74, p=0.021; conventional group −0.61, p=0.046), meaning that children with more significant impairment practiced skills at a greater relative level of challenge.
CONCLUSIONS: PT can encourage motor practice at levels that are challenging for young children with CP, even those with significant functional impairment.
CLINICAL RELEVANCE: The degree of difficulty of motor practice can be manipulated in PT and may be important in the acquisition of motor skill. Future work should investigate the relationship between difficulty of motor practice and rehabilitation outcomes in children with CP.
EVALUATING THE BENEFITS OF WHEELCHAIR DELIVERY ON MOBILITY, SOCIOEMOTIONAL GROWTH, AND QUALITY OF LIFE ON UGANDAN CHILDREN WITH DISABILITIES
Andrews M, Dodds C. Medical University of South Carolina
PURPOSE/HYPOTHESIS: The World Health Organization estimates that in high resourced countries there are 30 wheelchairs for every 10,000 people; however, in low resource countries, the figure is reduced to 2-3 per 10,000. Uganda, a low resource country needs an average of 4,464 wheelchairs per district in each of its 127 districts. Ugandan Bureau of Statistics estimates that 7.1% of Ugandans (3.1 million) have disability and 31.4% are 17 years and younger. Twenty-five percent of these children have physical impairments with resultant mobility limitations, which interferes not only with mobility but also socioemotional development and quality of life (QOL). In collaboration with the Ugandan Disabled Persons Union, physical therapy faculty and students from Medical University of South Carolina (MUSC) operate the Ugandan Wheelchair Project in Masindi, Uganda for children and adults with disabilities. The purpose of this project was to evaluate the effect of delivering a wheelchair on the mobility, socioemotional growth, and QOL in Ugandan children with disabilities.
NUMBER OF SUBJECTS: Fourteen children with disabilities between the ages of 7-13 years were provided wheelchairs with data being collected on 10 children.
MATERIALS/METHODS: This study involved a sample convenience using a pre- and post- test design. Outcomes measured included the mobility domain of the Pediatric Evaluation of Disability Inventory (PEDI), the Facial Expression Survey, and specific questions within the Pediatric Quality of Life (PQOL) survey. Paired t-tests analyzed collected project data.
RESULTS: Significant improvements (p-values < 0.05) were documented in the mobility domain of the functional skills and caregiver assistance scales of the PEDI, Facial Expression Survey, and PQOL survey.
CONCLUSIONS: Our findings suggest that wheelchair delivery for children with disabilities improve mobility, decrease caregiver assistance, and promote socioemotional and QOL growth. Long term outcomes related to wheelchair delivery for Ugandan children with disabilities needs to be examined.
CLINICAL RELEVANCE: This study reinforces the immediate positive impact that wheelchair delivery and mobility can have on the development of children with disabilities. Pediatric physical therapists have the expertise and should be encouraged to advocate and influence global wheelchair delivery- children with disabilities around the globe should have the access to wheelchairs in order to live independently and participate fully in all aspects of life.
A CASE REPORT: PHYSICAL THERAPY MANAGEMENT OF AN INFANT WITH CONGENITAL MUSCULAR TORTICOLLIS AND CEREBRAL PALSY
Baratta-Ziska F, Oledzka M. Hospital for Special Surgery
BACKGROUND & PURPOSE: To present the outcome measures used to assess body structure and function, activity, and participation levels for this child with a referral for treatment of torticollis using the American Physical Therapy Association Clinical Practice Guideline for CMT (APTA CPG CMT). To present the clinical reasoning supporting the APTA CPG CMT action statements 4 to document infant history and 5 to screen infants for non-muscular causes of asymmetry and conditions associated with CMT. In support of APTA CPG CMT action statement 6, this child was referred from the physical therapist to a physician based on a PT assessment. To present the clinical decision-making rationale involved in managing this complex case. To present the PT plan of care as there is little to no information in the literature about PT for children with torticollis, seizures, and cerebral palsy (CP).
CASE DESCRIPITON: A 4-month-old infant boy was referred by the pediatrician for PT evaluation and treatment with the diagnosis of torticollis. He had an extensive past medical and surgical history including hospitalizations due to seizures, shunt placement, and shunt revisions. It was evident at the initial PT evaluation that along with the referring diagnosis of torticollis, he also presented with severe plagiocephaly and developmental delays in fine and gross motor skill sets. The clinical management of this infant included the application of the APTA CPG CMT, and assessment using the World Health Organization family and patient-centered framework for body structure and function, activity, and participation levels. The WHO-ICF was used as a guide for PT evaluation, therapeutic interventions, and outcome measures. Evaluation & therapeutic interventions were selected within a body, structure, developmental and functional context. The infant's outpatient PT episode of care was complicated by re-hospitalizations due to shunt failure, shunt revision, and seizures.
OUTCOMES: Despite a diagnosis of torticollis, seizures, and CP, body structure, developmental and functional improvements were attained as assessed by APTA CPG CMT and outcome measures that are valid for children with disabilities. This child who presents with a diagnosis of torticollis, seizures and cerebral palsy has achieved age-appropriate gross motor skills up to and including walking without assistance.
DISCUSSION: Physical therapy management in the complex case of a child with torticollis, seizures, and CP will necessitate modifications in applying the APTA CPG CMT. Outcome measures that are valid and address function, activity, and participation levels are necessary when working with complex presentations of infants with a primary diagnosis of torticollis. There is little to no information in the literature about PT management for children with torticollis, seizures, and cerebral palsy. This case presentation reports the clinical reasoning during the PT evaluation/reassessments, treatment interventions, and outcome measures used to assess the child as an infant, toddler, and young child.
ENHANCING YOUR BENCH STRENGTH-DEVELOPING CLINICAL COMPETENCIES FOR THE PEDIATRIC PHYSICAL THERAPIST
Baratta-Ziska F, Slevin C. Hospital for Special Surgery
PURPOSE: The purpose of this submission is to present the process of clinical competencies development and implementation in the pediatric section of the Rehabilitation Department of an elective orthopedic hospital. It will define what criteria need to be met for the pediatric physical therapist working with children from birth to 21 years of age to complete the competency requirements successfully. It will describe the didactic, clinical, and manual portions of this institution's pediatric clinical competency. It will review how completing the pediatric clinical competency by all the pediatric physical therapists at this institution has improved the pediatric section's clinical bench strength and knowledge and promotes this institution's culture and mission to strive to be better in delivering patient care research and education.
DESCRIPTION: Each pediatric physical therapist at this institution is eligible to complete the pediatric clinical competency after working in the pediatric section of the rehabilitation department. The therapist is paired with one of the clinical leads as their point person and mentor. A schedule is generated for the therapist, including inpatient and outpatient treatment slots, weekly co-treatment, 1:1 case review, manual labs, and blocked time for completing didactic e-learning modules. The manual labs and the e-learning modules were created and are led by experienced pediatric advanced clinicians and clinical leads at this institution and encompass advanced material related to specific topics relevant to the pediatric population. Some of the topics are an overview of electronic medical recording in EPIC, telehealth use, skeletal dysplasia, torticollis, young athlete, and limb lengthening, to name a few. Clinical competency is determined by the sections clinical leads and a combination of successful completion and demonstration of didactic, practical, and written assessments.
SUMMARY OF USE: Pediatric physical therapists can use information from this presentation in inpatient and outpatient pediatric physical therapy settings. The information will specifically outline the learning modules, topics, time allotment, and clinical expertise from successful completion of pediatric clinical competency and relevance for developing competencies in other similar pediatric physical therapy settings.
IMPORTANCE TO MEMBERS: This presentation demonstrates the clinical relevance that developing pediatric competencies in pediatric inpatient and outpatient settings to build expertise and a comprehensive knowledge base among the therapists that are in line with the American Physical Therapy Association and International Classification of Function, Disability and Health: Children and Youth (ICF: CY) for patient-centered care. Members practicing in inpatient and outpatient pediatric settings will be presented with the value benefits of developing pediatric clinical competencies and the department's overall bench strength in the therapist's clinical reasoning that is evidence-based, current, and involves collaboration with other health professionals and the patient.
PHYSICAL THERAPY POSTOPERATIVE GUIDELINE FOR THE CHILD FOLLOWING POSTERIOR SPINAL FUSION WITH INSTRUMENTATION
Baratta-Ziska F, Yang M. Hospital for Special Surgery
PURPOSE: This poster aims to present the pediatric physical therapy (PT) management of the child following posterior spinal fusion (PSF) with instrumentation at an urban-based elective orthopedic hospital. This poster will present the PT guideline established to manage the child following PSF with instrumentation including the acute postoperative phase, achieving the patient-centered PT goals before hospital discharge, followed by intensive outpatient PT.
DESCRIPTION: There are no established postoperative PSF with instrumentation guidelines for PTs to refer to when working with these children. Postoperative PSF with instrumentation PT guidelines was developed by the clinical staff of PTs and pediatric orthopedic surgeons at this institution. The postoperative PT management in this population is based on current literature, research, and clinical expertise and supports the World Health Organization International Classification of Function, Disability, and Health (WHO-ICF) framework for patient-centered care.
SUMMARY OF USE: The use of postoperative PT guidelines following PSF with instrumentation in the pediatric population will provide evidence-based evaluation and intervention recommendations for each postoperative phase will inform PTs on best practice standards and will assist with the acute and long-term postoperative management of this population. In addition, the establishment and use of postoperative PT guidelines in the management of children undergoing PSF with instrumentation will educate PTs and decrease the variation of PT management.
IMPORTANCE TO MEMBERS: The establishment and use of postoperative PT guidelines following PSF with instrumentation will standardize the PT management of children following spinal surgery, which may improve the quality of care and patient outcomes.
CARE COORDINATION IN PEDIATRIC PHYSICAL THERAPY: BARRIERS AND FACILITATORS
Blonien N, Wiegmann D. University of Wisconsin Madison
PURPOSE/HYPOTHESIS: Pediatric physical therapists play an integral role in care coordination for children with complex health needs. The purpose of this study is to conduct an in-depth exploration of the experiences and perceptions by expert pediatric physical therapists in performing care coordination activities.
NUMBER OF SUBJECTS: Ten pediatric physical therapists participated and primarily practice in Wisconsin and Illinois. They have between two and twenty-seven years of clinical experience. They represent a variety of settings including school-based, outpatient, acute care, and home therapy.
MATERIALS/METHODS: Individualized semi-structured interviews were conducted via Zoom. Methods of recruitment included electronic postings in the Academy of Pediatric Physical Therapy newsletter and snowball sampling. Interview questions were developed based on the integrative care model. Interviews were recorded, transcribed, and checked for accuracy. Deductive content analysis methods were employed in the data analysis.
RESULTS: Four groups emerged from the data: (1) patient/family, (2) individual therapist, (3) care team, and (4) health/education system. Themes of barriers and facilitators emerged for each group. Barriers identified for the patient/family group included negative social and behavioral factors, insufficient knowledge and resources, and high unmet needs. Individual therapist factors included insufficient information, lack of time, and difficulty in communicating with stakeholders. Care team factors included challenging interpersonal dynamics, inefficient documentation, and resistance to change in practice. Health and school systems factors included privacy concerns, restrictions for in person contact, productivity expectations, inaccuracies in the health/school record, poor adoption of technology, waitlist for therapy and lack of support in documentation and trainings. Facilitators identified for the patient/family group include developed self-efficacy skills, knowledge and access to resources, consistency of providers, and family involvement. Individual therapist factors included developed professionalism, effective communication skills, consistency of caseload, access to and adoption of technology. Care teams included positive personal relationships, established triage system for workflow, and professionalism. Health and education system factors included access and use of technology, work policies to allow for non-patient care time and documentation support.
CONCLUSIONS: This research illustrates the complexity of care coordination and identifies common themes for barriers and facilitators that apply across care settings. This understanding is necessary for successful adoption of strategies to improve patient care and outcomes.
CLINICAL RELEVANCE: Identification of barriers and facilitators for care coordination using a systems approach can be useful for clinicians to target interventions to improve quality of care.
PEDIATRIC SUNSHINE THERAPY SERVICE: CREATION OF AN INTERPROFESSIONAL INTEGRATED CLINICAL EDUCATION OPPORTUNITY
Bondurant A, Sammons A, Coker-Bolt P, Dodds C. Medical University of South Carolina
PURPOSE: In recognition of the evidence and educational benefits involving interprofessional (IP) experiences and Integrated Clinical Educational Experiences (ICEE), the purpose of our clinic is to intertwine these two themes. We have created an IP ICEE entitled MUSC Pediatric Sunshine Therapy Service (PSTS) – where MUSC stands for the Medical University of South Carolina. This service provided complementary physical and occupational therapy services for children on the waitlist of the MUSC Pediatric Out-patient Clinic, which often documents a waiting time of two to three months.
DESCRIPTION: The MUSC PSTS is an IP ICEE pediatric experience utilizing an in place pediatric outpatient therapy space. MUSC PSTS is addressing the gap in receiving therapy services rather than children who are uninsured or under-funded due to children being typically funded through governmental or private insurance companies. Children received short-term therapy (i.e., 4 weeks) from the MUSC PSTS before transitioning to an active care status or returning to the waitlist at MUSC Pediatric Out-patient Clinic. Through this project, educational aims will enhance 1) pediatric course learning objectives and clinical performance for PT and OT students, 2) MUSC PT Pediatric Resident's leadership and clinical instruction abilities, and 3) complement the care of children waiting for physical and occupational therapy by generating evaluative and treatment data for the MUSC Pediatric Out-patient Clinic. This project's aim used outcomes to measure feasibility of the MUSC PSTS. The MUSC PSTS was initially funded by MUSC Department of Rehabilitation Sciences 2021 Interdivisional/Interdepartmental/Intercollege Seed Grant Program.
SUMMARY OF USE: At the conclusion of this project's 16 weeks, all stakeholders deemed this project successful and valuable. Student feedback data included utilizing an app called “FlipGrid” which utilizes video to give a summary of their takeaways from their day in clinic. Survey data from clinicians and families that have participated were overwhelmingly positive. We have initiated the next steps to formally establish the MUSC PSTS, which may include a student board. The faculty from the MUSC Speech language pathology program have been formally invited.
IMPORTANCE TO MEMBERS: According to the American Council of Academic Physical Therapy (ACAPT), an ICEE is defined as “a curricular design model whereby clinical education experiences are purposively organized within a curriculum”.3 Findings indicate that following ICEE, students reported they have a better understanding of clinic operations and the roles of the IP team as well as improved confidence and communication.4 Utilizing these conclusions, implementing an IP clinic with support from clinical partners as well as in the pediatric realm is priceless to students' education and beginning to understand the innerworkings of communication with clinicians of different professions, families and fellow clinicians.
VISUAL STRESS CUES AND ATYPICAL EYE MOVEMENTS DURING A VISUAL TASK IN INFANTS WITH PRENATAL OPIOID EXPOSURE
Boynewicz K, Binns D, Burnett C, Bankston M, Patterson S, Chroust A, Konner S. East Tennessee State University
PURPOSE/HYPOTHESIS: The purpose of this study was to investigate atypical eye movements, visual stress cues, and state regulation during a visual task in infants with prenatal opiate exposure (POE). It is hypothesized that infants with POE will have increased nystagmus, strabismus and stress cues and decreased state regulation compared to infants without POE.
NUMBER OF SUBJECTS: 41 infants with prenatal opiate exposure, and 23 control infants were included.
MATERIALS/METHODS: During a social and non-social visual task, infants looked at faces, bodies, and shapes. Eye gaze was recorded using a video camera which captured the video for offline coding. Researchers created standardized definitions of infant behaviors including infant's eye movements, visual stress cues, state regulation, and response to handling. A coding checklist was initially developed by the primary researchers, coding five infants. All behaviors were discussed and revisions to the checklist were updated. Researchers then coded an additional four infants separately with inter-rater reliability accepted at .8. Differences in coding were discussed and agreements were reached. Two additional researchers attained reliability and sixty-four infants were coded. Data was placed into SPSS.
RESULTS: Preliminary analysis of maternal and infant characteristics indicated that there were significant group differences between infants without POE and infants with POE for infant birthweight, infant birth length, and maternal tobacco use. These characteristics were included as covariates in the following ANCOVAs. Infant abnormal eye movements (I.e., nystagmus, strabismus), behaviors (fussing, gaze aversion), state regulation (shutting down, remaining calms), and response to handling (rocking, pacifier, auditory stimulation) were used as outcome variables. The ANCOVAs indicated that even after statistically controlling for infant birthweight, birth length, and maternal tobacco use, rates of abnormal eye movements and visual stress signs were significantly different between the two groups of infants.
CONCLUSIONS: This study adds to the evidence of the impact of in-utero opioid and polysubstance exposure beyond the development of NOWS. The neonatal visual outcomes described here, including nystagmus, strabismus, gaze aversion, fussiness and growth deficits, suggest the possibility of longer-term health and developmental impacts. Findings reinforce the need for those working with families in the NICU or early intervention to identify infants with early delays to intervene early to mitigate neonatal effects of POE and polysubstance exposure.
CLINICAL RELEVANCE: Previous literature surrounding POE focuses on health outcomes and some speculate that the scope of adverse infant outcomes is not readily identified or apparent at birth. This research study provides evidence of differences between visual stress cues and abnormal eye movements of infants with POE and NOWS. Identification of early differences may aid in the early identification of developmental delays., justifying PT is an important member of the medical team whose expertise is critical in recognizing infant needs and intervening with infants and families with POE.
SPORTS MOVEMENT EVALUATION FOR THE ADOLESCENT ATHLETE
Brandsma B, Webster A, Winter M, Cyr A. Mary Bridge
PURPOSE: To describe what is involved in a sports movement evaluation at a clinical motion analysis laboratory. To inform and educate on the application of sports movement evaluation for adolescent injury rehabilitation and prevention.
DESCRIPTION: Adolescent participation in organized sports, along with sports specialization, has increased over time. Focus on injury rehabilitation and prevention is rising, as sports are the leading cause of injury in adolescents. Injuries can lead to decreased participation, increased risk for future pain, and movement dysfunction. Motion analysis laboratories are an ideal environment to perform sport movement evaluations. These evaluations utilize specialized equipment that provide more insight into movement than observation alone. Optical motion capture uses retro-reflective markers placed on anatomical landmarks to develop coordinate systems for each joint segment, and relationships to neighboring segments, to track relative motion (kinematics). These systems have been shown to have accuracies of 1 mm or less. For sport movement analyses, this is critical as significant functional changes in movement can occur at this scale. Force plates are used to measure the interaction between a person and the ground, recording linear and rotational components from 3 axes of measurement. Combined with motion capture, the forces are used to calculate internal loads at a joint (kinetics. These dynamic joint forces are an important metric for understanding healthy and impaired movement and cannot be measured observationally. Surface electromyography (SEMG) is the measurement of electrical signals generated from motor neuron activation. The SEMG sensors are placed on the skin over the muscle body alongside the motion capture markers, to gather data about muscle activation during joint movement. Together, all of these data provide detailed insight for the motions and loads experienced at the joint level, and the muscles contributing to those movements. This insight leads to better informed clinical decision making for injury prevention and treatment.
SUMMARY OF USE: This special interest poster presentation will demonstrate how data is collected in a clinical motion analysis laboratory. Data and images from de-identified adolescent normative research subjects will be used to show the activities performed during a 2-hour comprehensive sports movement evaluation. A detailed sports protocol is followed for all patients. Other activities specific to a patient's sport can also be performed and analyzed. Kinematic, kinetic, and SEMG findings will be explained as pertains to injury prevention, return to sport, and treatment recommendations.
IMPORTANCE TO MEMBERS: Sports movement evaluations are a growing area of assessment in motion analysis laboratories. The data provided by these evaluations are meaningful to therapists and patients because of increased sports participation and specialization among young athletes, and prevalence of chronic sports-related injuries in this population.
DEVELOPMENTAL POSITIONING IN THE NEONATAL INTENSIVE CARE UNIT AND ITS IMPACT ON HEAD SHAPE DEVELOPMENT IN A VERY PRETERM INFANT: A CASE REPORT
Bulliner E (Brooks Rehabilitation), Slate M (Medical University of South Carolina & Brooks Institute of Higher Learning), Ubben C (Brooks Rehabilitation)
BACKGROUND & PURPOSE: The intended goal of the Back to Sleep program in 1994 was to decrease the incidence of Sudden Infant Death Syndrome (SIDS), while this has been achieved, an unintended consequence has been an increase in the prevalence of atypical cranial molding and torticollis since that time. It is now necessary to address these impairments to determine how to best support infant's musculoskeletal development. Infants in neonatal intensive care units (NICUs) are very susceptible to these changes due to prematurity and environmental conditions. Current guidelines recommend that infants discharge home on the Back to Sleep program, however, the timeline of introduction during NICU stay is not well delineated. The purpose of this case report was to describe the developmental care plan utilized for a very preterm infant and to examine its effectiveness to promote typical head shape development.
CASE DESCRIPTION: The infant was born at 30 weeks and 2 days gestational age and physical therapy evaluation was performed on day-of-life four. A care plan focused on the use of current evidence regarding positioning for neonates under 32 weeks gestational age was implemented and infant head shape was monitored throughout the stay. Nurses and parents were provided education on physical therapy goals and the plan of care. Additional education focused on the importance of developmental care to prevent sequelae due to prematurity and NICU stays.
OUTCOMES: The infant was seen for 17 treatments throughout the 38-day NICU stay. The parents of the patient were educated on Back to Sleep and the importance of implementing it at home. However, while being closely monitored in the NICU, the patient was placed in a variety of positions under close supervision to promote appropriate cranial molding. Cranial Index and Cranial Vault Asymmetry Index indicated that the infant's head shape was within normal limits at all data collection points, including at discharge. The patient was discharged home at 35 weeks and 5 days gestational age.
DISCUSSION: Normal head measurements throughout this patient's NICU stay may indicate that consistent, intentional positioning prevented cranial deformation. Other factors could have impacted this case including multiple positive personal and environmental factors, minimal medical complications, and length of stay in the NICU. Since nurses often handle infants more than therapists, the importance of educating them on the positioning program and ensuring adequate skills to execute it cannot be understated. Furthermore, if the positioning program does not follow Back to Sleep, family education on the importance of implementing it when the child discharges home should begin early. Currently, no positioning protocol exists for infants older than 32 weeks. This case highlighted the use of a variety of positions for an infant up to 35 weeks gestational age with no adverse effects. It would be valuable to further study the implementation of a positioning protocol for infants older than 32 weeks to decrease the incidence of plagiocephaly and torticollis in infants with prolonged NICU stays.
FEASIBILITY OF IMPLEMENTING A SUSTAINABLE WHEELCHAIR SEATING AND MOBILITY CLINIC IN UGANDA, AFRICA
Burke K, Schroeder J, Dodds C. Medical University of South Carolina
PURPOSE: The purpose is to assess the feasibility of a sustainable wheelchair (WC) and mobility seating clinic for children and adults with disabilities in the low resourced country of Uganda. Findings from four feasibility components will be shared to support replication in other low resource countries.
DESCRITPTION: Feasibility testing is optimized when project acceptability, demand, implementation, practicality, adaptation, integration, and expansion are considered. This project, entitled the Ugandan Wheelchair Project, has focused on acceptability, demand, initial implementation, and practicality. Acceptability: Individuals served by Ugandan Disabled Persons Union desired access to WC seating and mobility clinic and were accepting of Medical University of South Carolina (MUSC) Physical Therapy Program's plan for implementing a clinic. Demand: Based on 2009 data, 750,000 Ugandans have mobility impairments. Other estimates suggest that Uganda needs 4,464 WCs per district in each of its 127 districts. The lack of access to a WC has a negative impact on physical health, functional independence, and quality of life. Implementation: In 2019, 6 WCs were delivered in a 2-day clinic at the Masindi Kitara Medical Center (MKMC). We then raised funds and shipped 60 WCs for a 5-day clinic. Individuals were scheduled by the Masindi district's Disabled People's Union of Uganda. Outcomes included: assembling, measuring, and delivering 40 WCs to 13 children and 27 adults with disabilities, training two Ugandans in assembly, and collecting data using the World Health Organization WC service materials, PEDI, and WC Skills Test. Practicality: The Disabled Persons Union was instrumental in identifying children and adults in need of WCs. Students were used in clinic and in training Ugandans in WC assembly. MKMC was a collaborative partner. Moving forward, we will need to promote adaptability, integrate the clinic into MKMC, and expand into other regions. Successful completion of these last components will better ensure sustainability of the project.
SUMMARY OF USE: Improvements were noted across all areas of data collection. Strong positive feedback from WC participants, WC assembly trainees, MKMC leadership, Disabled Person's Union, and students. Future steps include creating a budget for sustaining WC costs and services, training assemblers in maintenance, and training/mentoring a PT to conduct and manage the seating and mobility clinic.
IMPORTANCE TO MEMBERS: Expansion of WC mobility for individuals with disabilities is imperative to optimize participation in life. This is especially true for children in low resourced countries who need mobility to optimize development in order to participate in life. Findings from this project provide a blueprint to encourage international replication of WC clinics for children and adults with disabilities.
CAREGIVER AND CHILDREN'S PERCEPTIONS OF AN INTERDISCIPLINARY INTENSIVE THERAPY PROGRAM
Chole D (Children's Therapy Center/University of Missouri-Columbia), Hall J (University of Missouri)
PURPOSE & HYPOTHESIS: Pediatric intensive therapy models are increasing in popularity across the United States, with a variety of models described in the literature including suit therapy, constraint induced manual therapy and bimanual training, neurodevelopmental treatment, and programs emphasizing gait, power, and strength. However, few studies describe interdisciplinary intensive models or the perspectives of caregivers and children with intensive models. Therefore, the purpose of this study was to explore caregiver and children's experiences participating in a team-based, interdisciplinary, intensive therapy program.
NUMBER OF SUBJECTS: 13 caregivers and 10 children (6-13 years old, 9 males, 10 with cerebral palsy and 3 other diagnoses).
MATERIALS/METHODS: Children participated in an intensive program including physical, occupational and/or speech therapy for 3-6 hours/day for 4-5 days/week for 4 weeks. The team including the child and caregiver determined treatment frequencies, durations, and types based on the child/caregiver's functional goals and examination findings. Following the intensive 4-week period, caregivers and children participated in semi-structured interviews. Interviews were audio-recorded and transcribed verbatim. A research team consisting of 2 physical therapists (PT) and 2 PT students performed reflexive thematic analysis.
RESULTS: An overarching theme describing the intensive program as Immersive was generated. Other subthemes identified were Everybody's Empowered, Principles of Neuroplasticity, Progress Across the ICF, It Takes a Team, and Benefits Outweigh the Challenges. Caregivers described the immersive nature of the intensive program allowed them to focus on their child, prioritizing learning new strategies that could be implemented in the home and community. When describing perceived program benefits, caregivers intuitively described principles of neuroplasticity that made the intensive program unique and effective for their child. Overall, families acknowledged the challenges of the intensive program, but concluded it was worth it and described feeling empowered to maximize their child's potential, now and in the future. Overall, children described the intensive program as “fun” and would choose to repeat it.
CONCLUSIONS: Caregivers and children valued participation in the intensive program. Many families explained they preferred it to traditional models for their child and family. All caregivers planned to participate in another intensive episode of care in 6 to 12 months, as they felt it was beneficial for their child and family.
CLINICAL RELEVANCE: As part of family-centered care, it is vital to include child and caregiver's voices in service delivery model research. Not only was this model acceptable to caregivers, it was often preferred to traditional models. Future studies should consider the role of an interdisciplinary team in intensive models for children with neurodevelopmental diagnoses.
UTILIZING PHYSICAL ACTIVITY TO MANAGE INATTENTION AND HYPERACTIVITY IN THE CLASSROOM: WHAT TYPE OF EXERCISE IS BEST?
Connell E, Tremback-Ball A. Misericordia University
PURPOSE/HYPOTHESIS: Hyperactivity and attention deficits in school-aged children pose significant challenges to classroom functioning. In addition, children displaying these qualities are at risk for decreased academic performance and poor peer relationships. Pharmacological treatment of these symptoms is not always effective or feasible due to factors such as delayed diagnosis, financial burden, and side effects. Physical activity is a low-risk, low-cost alternative to medication that is gaining attention in the literature. Unfortunately, many studies do not provide specific guidance for implementing physical activity into classroom settings according to individual educational goals. A comprehensive understanding of how to do so is necessary to maximize the benefits. The purpose of this systematic review was to compare the effectiveness of different forms of physical activity on symptoms of inattention and hyperactivity in school-aged children. A second goal was to recommend specific types of activity based on classroom goals.
NUMBER OF SUBJECTS: Eighteen articles were included from the years 2001-2020.
MATERIALS/METHODS: Four databases were searched (PEDro, CINAHL, PubMed and Academic Search Ultimate) using exclusion criteria established by the researchers. Articles were divided into three general categories: mindful movement (n=7), general exercise (n=6), and aerobic exercise (n=6). One article discussed mindful movement and aerobic exercise and was counted twice.
RESULTS: Mindful movement interventions included Yoga and Tai Chi. The related outcome measures assessed symptoms of hyperactivity and inattention. General exercise interventions included physical education, sports and games. Aerobic exercise interventions included running, walking, swimming and jumping rope. Outcome measures in these categories assessed components of executive function including memory, concentration, inhibition and cognitive task performance.
CONCLUSIONS: The best type of physical activity to utilize for symptom management in classrooms will depend on the goal of intervention. Teachers should consider the activity level and cognitive demand of the students each day. Tasks requiring sustained attention benefit from mindful movement. On a more active day (i.e. a P.E. day), students will also benefit from mindful exercise. Tasks requiring increased executive function benefit from aerobic or game-based activity. Students will also benefit from aerobic or game-based exercise breaks on a more sedentary day.
CLINICAL RELEVANCE: In order to make informed decisions regarding use of physical activity as a classroom management strategy, educators must critically evaluate the needs of their students and what they are hoping to achieve. Many exercise programs that were studied exceeded 30 minutes in length. However, this may not be feasible in the school setting. Due to their expertise in exercise, physical therapists are uniquely positioned to play a role in educating teachers on how to modify these evidence-based movement programs to meet individual classroom needs.
MEASURING PHYSIOLOGICAL RESPONSES USING HEART RATE VARIABILITY ACROSS SENSORY SYSTEMS IN CHILDREN WITH MEDICAL COMPLEXITY
Dodds C, Mulrenin B. Medical University of South Carolina
PURPOSE/HYPOTHESIS: Heart rate variability (HRV) is a physiologic marker of autonomic nervous system (ANS) health. Children with medical complexity (CMC) display ANS impairment and subsequently reduced heart rate variability (HRV), which indicates a state of chronic sympathetic dominance (fight or flight) and physiological stress. It is also recognized that because of multiple body system impairments in CMC, assessing sensory motor responses is challenging; however, the measurement of HRV may provide insight. In order for HRV can be considered a potential physiological measure in CMC, preliminary descriptive values are needed. The purpose of this presentation is to report descriptive heart rate variability values for CMC at baseline and across five sensory domains (i.e., olfactory, visual, auditory, gustatory, tactile).
NUMBER OF SUBJECTS: Thirty-three CMC between the ages of 3-21 years were assessed within school-based settings. All children demonstrated severe brain impairments, functional limitations, high healthcare needs and utilization, and participatory restrictions in life. A subset of 19 children with cerebral palsy (GMFCS level IV and V) were identified within the study sample.
MATERIALS/METHODS: Heart rate variability was collected prior to and during administration of the newly developed Pediatric Assessment of Sensory Motor Awareness. Each child was assessed by the same assessor for five days within a 10-day period. Using FirstBeat Bodyguard 2 monitors, respiratory sinus arrhythmia (RSA) values were derived from HRV files using CardioBatch software. Descriptive and repeated measures statistics were used to analyze data.
RESULTS: Participant demographics and RSA values for baseline and across five sensory domains will be reported. Significant differences in RSA between sensory domains will be discussed. Comparisons between this study's larger CMC sample and its subset of children with cerebral palsy will be reported.
CONCLUSIONS: Study findings provide documentation of preliminary physiological responses in CMC including a subset of children with cerebral palsy. The measurement of HRV may provide a method to target and evaluate clinical decision making and interventions in CMC more accurately. Replication of these study findings will be necessary.
CLINICAL RELEVANCE: Findings from this study suggest that: 1) HRV is a simple and valid method by which to assess physiological stress in CMC and 2) certain sensory stimulation may reduce or intensify physiologic stress in CMC. Collectively, this information integrated into a physical therapy assessment and/or treatment may improve the ability to understand physiological stress in CMC and modify sensory stimulation to reduce chronic sympathetic dominance, enhancing patient outcomes and quality of life.
UNDERSTANDING CULTURAL VALUES TO SUPPORT PARENTS OF INFANTS & YOUNG CHILDREN IN EARLY INTERVENTION PHYSICAL THERAPY
Donaldson C. Russell Sage College
PURPOSE: This project was directed at community wellness of a specific cultural group, the Navajo American Indians. The purpose was to develop a culturally respectful, collaborative education model for Navajo American Indian parents and caregivers on activities to promote infant development with safe and appropriate use of commonly used baby equipment – specifically, traditional cradleboards and modern baby walkers. These types of equipment are commonly used by Navajo parents and have potential to impact infants' development, with potential concerns for plagiocephaly and developmental hip dysplasia from use of cradleboards and safety concerns from use of baby walkers, thus necessitating educational interventions by physical therapists working with Navajo infants. To develop this education model, objectives of this project were: 1) to develop an understanding of Navajo cultural and spiritual beliefs that influence infant caregiving practices related to use of baby equipment; 2) to collaborate with Navajo educators, providers, and family members to develop culturally sensitive and relevant education materials to address barriers to safe use of equipment and provide alternatives; and 3) to determine acceptability and effectiveness of education for Navajo families and providers to assist with increasing knowledge and changing practices.
DESCRIPTION: Through collaboration with Navajo members and interviews with families, researchers learned of traditional and spiritual beliefs associated with use of traditional cradleboards and modern baby walkers. This information was used to guide development of parent education materials that are culturally sensitive to Navajo parenting practices while providing information to guide safe use of equipment to enhance infant motor development. Although this project was initially aimed at parents of infants participating in a local early intervention program, the materials are relevant to the wellbeing and development of all Navajo infants.
SUMMARY OF USE: Physical therapists can use this information to assist them in how to best interact with and educate families of different cultural groups in order to impact change in caregiving practices. The methods used to respectfully learn of cultural parenting practices and use this knowledge in development of culturally relevant educational materials are applicable to therapists working with various unique cultural groups.
IMPORTANCE TO MEMBERS: As part of family-centered care, therapists need to educate parents and caregivers in activities to minimize risks and optimize outcomes. Because cultural identity influences caregiving practices, education needs to be culturally relevant to effect change. Therapy education materials that are culturally relevant have the greatest ability to motivate a change in caregiving practice to improve outcomes.
APPLICATION OF THE INTERNATIONAL CLASSIFICATION OF FUNCTIONING, DISABILITY, AND HEALTH (ICF) DURING PHYSICAL THERAPY MANAGEMENT OF A CHILD WITH IDIOPATHIC TOE WALKING, A CASE STUDY
Elhamadany M, Hoffman K. School of Medicine and Health Sciences - University of North Dakota
BACKGROUND & PURPOSE: The support for the conceptual application of the International Classification of Functioning, Disability, and Health (ICF) to clinical practice is evident from the literature, and yet, it challenges the practicability in clinical practice.
Idiopathic Toe Walking (ITW) is a diagnosis of exclusion characterized by a persistent toe–toe gait pattern after three years of age. It is often difficult to properly reach a clinical judgment on the mechanisms underlying ITW with many possible structural and functional involvements. Furthermore, the course of treatment for these patients can be challenging. The purpose of this case study is to describe a clinical decision-making process for PT management of a child with ITW using the ICF framework.
CASE DESCRIPTION: A 9-year-old female, with ITW, participated in this study. The child was born as an identical twin after an uneventful pregnancy with uncomplicated spontaneous delivery. No post-natal complications arose. There were no delays in attaining motor milestones, according to the caregiver. Toe walking was not better explained by neurological or musculoskeletal conditions. The parent interview and examination findings were classified into the ICF components. In the ICF component of body functions and structures, the child demonstrated reduced triceps surae and anterior tibialis strength, reduced ankle dorsiflexion ROM, increased lumbar lordosis, and impaired motor coordination and balance. Under the ICF component of activities and participation, the child scored 11/24 on the Pediatric Modified (DGI) displaying significant fall risk. The child also demonstrated limitations in walking long distances, stair climbing, ambulation on uneven surfaces, and running, jumping, and hoping skills, which clearly restricted the child's ability to keep up with peers. A plan of care to address impairments, activity limitations, and participation restrictions was developed.
OUTCOMES: Using the ICF framework was useful to organize the patient's examination information, interpret examination findings, identify problems, and guide the decisions needed for the PT management. as well as involve others who may be able to provide care for the patient from a different perspective. The relationships between the patient's most significant activity limitations, and impaired body functions and structures were evaluated to reach a clinical judgment on the mechanisms underlying the toe-toe gait pattern. The patient's results were encouraging, supporting the hypothesis that ITW can be managed through the conservative treatment
DISCUSSION: This case report illustrates the benefit of using ICF in the clinical decision-making process for PT management of a child with ITW. ICF can be applied in each of the five elements of the patient/client management model from examination to intervention. allowing for a comprehensive assessment, goal setting, and intervention planning. The Guide and the ICF are complementary. As such integration between both of them aids in the clinical decision-making process and at the same time helps in the identification of appropriate strategies for positive treatment outcomes.
MENTORSHIP IN PHYSICAL THERAPY
Fern-Buneo A. Phoenix Children's Hospital
PURPOSE/HYPOTHESIS: Physical therapists now have a greater emphasis on productivity with less understanding from administrators regarding the amount of time spent in non-billable tasks. Increased workloads lead to burnout, staff turnover, safety risks and poor quality of care. Mentoring has been shown to improve clinical decision making in novice clinicians in acute care, pediatric and inpatient rehab settings.
What is the importance of mentorship to job satisfaction in physical therapists? How does this differ by practice setting and years of experience?
What role does being a mentor play on job satisfaction/retention?
How does mentorship improve patient outcomes?
My hypothesis was that mentorship is critical for therapists at all stages and settings.
NUMBER OF SUBJECTS: 88 responses
MATERIALS/METHODS: IRB approved anonymous survey was sent to physical therapists in AZ and several national PT platforms. It was a snowball sampling. Survey included questions on-
- Qualities of a good mentor
- Facilitators/barriers to providing/receiving mentorship
- Benefits of having/being a mentor
- Relationship to job satisfaction, retention, productivity and patient outcomes
Descriptive statistics, qualitative and regression analyses. were reported, Stata17 (College Station, Texas). was used.
RESULTS: 88 responses:
- 89.9% female
- 47.5% 25-35 years old
- 76.5% large urban area
- 73.7% DPT
- 47.5% Hospital-based (32.3% OP, 5.2% IP)
- 64.6% Pediatrics
- 54.5% Staff level
- 30-100% Productivity standard, Meeting 39.3%
Significant findings were: Receiving mentorship is meaningful for
- Younger therapists impacting job retention p=.007
- Therapists with less experience p=.022
The value of receiving mentorship decreases with years of experience p=.010
Younger therapists benefit the most from receiving mentorship impacting patient outcomes. P=.022
The value of receiving mentorship decreases with years of experience p=.010
Providing mentorship valued at higher level positions p=.085
- Frustrations reported-lack of time/support, mentors with needed expertise and isolation
- Barriers to mentorship-poor fit, different goals/communi-cations styles
- Other findings include a focus on novice stage
CONCLUSIONS: Mentorship impacts many aspects of job functions for physical therapists across settings and stages of growth. Younger and less-experienced therapists value mentorship more, as do those in large urban areas, and hospital-based settings. Providing mentorship is more important for therapists at levels above staff positions.
CLINICAL RELEVANCE: Mentorship remains a valuable part of the professional development of physical therapists. Future directions for this research include determining the value of mentorship for mid and late career, in light of these findings. Improving infrastructure to support more opportunities to clinicians for providing mentorship through APTA would be beneficial. This is currently being done in The Academy of Pediatric Physical Therapy. Perhaps this section's mentoring program could serve as a prototype for the entire organization.
ARE YOU TRENDY? SURVEY OF PEDIATRIC PHYSICAL THERAPISTS ON CURRENT PRACTICE FOR CHILDREN WITH SPINA BIFIDA
Flores M (University of St. Augustine for Health Sciences), Ardolino E (Baylor University), Manella K (Nova Southeastern University-Tampa Bay FL
PURPOSE/HYPOTHESIS: The purpose of this study was to gain an understanding of contemporary physical therapist practice for children with spina bifida (SB).
NUMBER OF SUBJECTS: 217 physical therapists (PTs)
MATERIALS/METHODS: Over 600 pediatric PTs across the nation were sent an online survey. A survey link was posted in the APTA Pediatrics monthly newsletter for 6 months. PTs were asked to identify impairments, activity limitations, participation restrictions, outcome measures, treatment interventions and the characteristics that impact treatment effectiveness in pediatric clients with SB. Content analysis was used to examine PT answers to the survey questions. Two researchers performed independent open coding. To expand trustworthiness, a third researcher reviewed the codes and categories. All three researchers met regularly to discuss each question until strong consensus was reached. The International Classification of Functioning, Disability and Health (ICF) model was used as a framework for codes and categories.
RESULTS: Respondents were from 32 states and various practice settings. PT experience ranged from 1 to 48 years with 41 Board-Certified Clinical Specialists in Pediatric Physical Therapy. The primary area of practice was outpatient hospital or private practice (51.98%). Six categories were identified for the coded data: Assessments, Impairments, Activity limitations, Participation restrictions, Interventions, and Contextual Factors. PTs identified 33 assessment tools or outcome measures that assessed body functions and structures (25.12%), activities (73.49%), and participation (10.7%). Of the 24 impairments at the body functions and structures level, the most common were decreased strength (17.92%), impaired balance (17.69%), and decreased range of motion (15.33%). Out of 16 activity limitations, impaired ambulation (22.51%) was the most reported. For 19 participation restrictions, the most reported was limited socializing/playing with peers or siblings (22.59%). For 26 interventions documented, strength training (13.17%) and gait training (10.49%) were most frequent. One intervention theme emerged from open-ended questions: PTs have knowledge about evidence-based treatment for children with SB, but feel limited by barriers such as access, cost, reimbursement, and caregiver burden. Overwhelmingly, PTs reported better outcomes in their patients who had consistent family compliance and carryover of a home program.
CONCLUSIONS: A variety of assessment and intervention techniques for children with SB are used by PTs. The psychometric properties of the 4 most common assessments have not been established for the SB population. For the top 5 most common interventions, 4 focused on the activity domain. More evidence is needed to support PT trends in the assessment and treatment of children with SB. A clinical practice guideline may assist PTs in choosing the most appropriate outcome measures and interventions for children with SB.
CLINICAL RELEVANCE: This study provides PTs with an understanding of contemporary practice for children with SB, including the outcome measures and interventions currently used in this population.
OUTCOMES OF A MODIFIED INTENSIVE PHYSICAL THERAPY PROGRAM FOR A 4-YEAR OLD CHILD WITH CEREBRAL PALSY
Flowers M, Stamp B. Allied Therapy and Consulting Services
BACKGROUND & PURPOSE: A growing body of evidence supports the use of intensive physical therapy (PT) programs for improving body structure and function, activity, and participation in children with cerebral palsy (CP). The purpose of this case report is to assess the outcomes of a 6-week modified intensive PT program for a 4-year-old child with CP, Gross Motor Function Classification System (GMFCS) Level IV.
CASE DESCRIPTION: The focus of this case report is on a 4-year old boy with spastic quadriplegic CP, GMFCS Level IV. He is Twin A of a 29-week pregnancy and was diagnosed with a left Grade 3 IVH and a right Grade 4 IVH shortly after birth. He had been receiving direct PT for 90 minutes/week for the 12 months leading up the 6-week intensive. His family reported that they wanted the child to improve his ability to sit and move more independently and utilize his right hand for play and self-help activities. The child's age, diagnosis, current level of function, and clinical opinion of his treating physical therapist collectively informed the decision to utilize a 6-week, modified intensive model of PT to address these goal areas.
OUTCOMES: Upon completion of the 6-week PT intensive, the child's performance improved on 5 of the 6 outcome measures utilized to assess baseline function and response to intervention. He was able to maintain short-sitting for 46.4 seconds and tailor sit independently on the floor for 60.02 seconds. His ability to hold a modified quadruped position increased fourfold. He continued to need moderate assistance at his pelvis and trunk to transition from sit to stand, but his time to perform a modified Five Time Sit to Stand Test decreased. Utilizing his right hand, the child was able to grasp and pull out 3 pegs from a modified 9-Hole Peg Test. With his shoulder flexed to 90 degrees, he lacked only 5 degrees of elbow extension, indicating improvement in active range of motion and functional upper extremity use. The child's assisted walking ability did not improve.
DISCUSSION: A 4-year old boy with spastic quadriplegia CP, GMFCS Level IV, completed a 6-week PT intensive. He received 240 minutes of PT per week, and each treatment session incorporated balance, transition and gait training; standing; whole body vibration; and constraint-induced movement therapy. The increased PT treatment time per week and ample opportunities for practice and motor learning are thought to have contributed to the child's improvement in functional gross motor skills over a relatively short period of time. He demonstrated improvements in sitting, transition skills, reaching, and upper extremity range of motion following completion of the intensive. The results should be interpreted with caution, as the outcomes of a single-subject study have limited generalization to a larger population; however, the outcomes suggest that alterations in the frequency, intensity, time and type of the PT intervention contributed to positive changes. Exploring the effectiveness of a longer duration intensive would be beneficial to determine if greater improvements in body structure and function, activity, and participation could be gained.
BABYZOOM: AN EFFECTIVE WAY TO PROVIDE VIRTUAL EDUCATION REGARDING INFANT DEVELOPMENT TO MOMS LIVING IN POVERTY IN CENTRAL OHIO
Grisez L, Smith M, Young C. Nationwide Children's Hospital and The Ohio State University
PURPOSE: According to the CDC and Ohio Department of Health, Ohio has the 10th highest infant mortality rate in the country, with the leading causes being preterm birth and birth defects. BabyZoom is part of a larger initiative, Moms2B, at The Ohio State University that aims to improve these statistics and address maternal and fetal health disparities by working with mothers (“Moms”) living in poverty in central Ohio. BabyZoom aims to empower Moms to support their baby's development, identify concerns, and seek early evaluation and treatment for their baby when indicated. Pediatric physical therapists (PTs) play a crucial role as members of the transdisciplinary team supporting and educating Moms in BabyZoom.
DESCRIPTION: BabyZoom is a free, year-round, virtual community outreach program for Moms during their baby's first year of life. We chose a virtual format to improve ease of access and overcome barriers to in-person attendance. BabyZoom sessions are held weekly for one hour, consisting of a 30-minute music and movement class led by a Kindermusik teacher, a 10-minute presentation by a PT on infant development or local resources, and a 20-minute discussion for review of resources and questions. Moms receive a gift card for attending. Many presentations address gross motor development; however, applying a transdisciplinary theoretical framework, PTs also present on fine motor, speech, hearing, and safety. In collaboration with other members of the healthcare team, presentations were designed so that other disciplines could present the lessons in the future. To assess the effectiveness of the program for quality improvement purposes, a five-question poll was shared after each session from 10/27/21-3/6/22. Poll results and attendance trends were analyzed using Excel.
SUMMARY OF USE: A total of 233 poll responses were collected over 16 sessions. Average attendance at each session was 20 Moms, and an average of 72% responded to the poll. Of respondents across all sessions, 95% learned one new thing about their baby, 96% planned to try something new with their baby that week, 99% felt confident they can help their baby learn new things, and 96% knew where to access help for their baby. Moms identified “learning about development” (32%) and “playing with my baby” (28%) as their favorite parts of the sessions.
IMPORTANCE TO MEMBERS: Pediatric PTs regularly support infant development through direct patient care; however, they also have the tools to impact infant development beyond the clinic through participation in community outreach programs such as BabyZoom. Our project leveraged a transdisciplinary model of care to address maternal and infant health disparities in the local community by directly educating, empowering, and supporting Moms. The overall positive response to poll questions indicates that brief lessons on development presented by pediatric PTs may be an effective way to improve Moms' knowledge and self-efficacy. Virtual meetings may offer a feasible alternative to in-person meetings to expand outreach and overcome barriers such as transportation.
MOBILITY AND WHEELCHAIR USE ARE NOT ASSOCIATED WITH PARENT-APPRAISED POSITIVE PSYCHOSOCIAL FUNCTIONING IN OLDER CHILDREN WITH MOVEMENT LIMITATIONS
Jacobson R. George Fox University
PURPOSE/HYPOTHESIS: Mobility limitations in children with long-term physical disabilities can impact quality of life, but psychosocial factors might be independent of mobility when parents appraise their child's overall physical, mental and social functioning. The purpose of this study was to determine any association of mobility and wheelchair use with various psychosocial attributes, per parent proxy report.
NUMBER OF SUBJECTS: Thirty parents (96.7% mothers; mean age 46.3 ± 6.2 years) of children with physical disabilities (46.7% female; mean age 12.9 ± 3.0, 8 to 17 years; 70% Caucasian). Diagnoses included cerebral palsy (33.3%), developmental coordination disorder (16.7%), Down syndrome (13.3%), and spina bifida (10%), with 40% community wheelchair users.
MATERIALS/METHODS: Online anonymous surveys were completed from March through July 2021. Parent-proxy measures included Patient-Reported Outcomes Measurement Information System (PROMIS) Mobility, Peer Relationships (PR), Positive Affect (PA), and Meaning & Purpose (MP); and three items adapted from the Chronic Illness Acceptance Scale. PROMIS measures yield a T-score normed to the US average of 50, standard deviation (SD) of 10. Acceptance scores were summed (7 discrete answer choices per question) out of 21 possible points. Data analysis included Spearman rho coefficients to determine any associations between Mobility and the four psychosocial measures; and Mann-Whitney U tests to compare group mean scores between those who report any wheelchair use (wheelchair yes, vs. no). Bonferroni correction for repeated measures set significance level at p≤.01.
RESULTS: Overall mean scores were Mobility 31.0 (14.9-41.3), PR 35.8 (19.8-54.9), PA 43.7 (29.2-63.0), MP 39.4 (26.7-59.3), and Acceptance 16.2 (12-21). There were no significant correlations between Mobility and the other measures (with PR rho=.12; PA .10; MP .20; Acceptance .26). Interestingly, Acceptance was strongly associated with PR (rho=.70, p<.001) and MP (rho=.72, p<.001), and moderately with PA (rho=.51, p=.004), with no other significant correlations between psychosocial scores. Group mean score comparisons for wheelchair use yes (n=12) vs. no (n=18) were only significant for Mobility (yes 23.5±8.6 vs. no 36.1±4.8; p<.001); with PR 34.0±11.4 vs. 36.9±9.4; PA 44.2±8.5 vs. 43.4±8.8; MP 38.4±6.6 vs. 40.0±8.9; and Acceptance 15.7±2.3 vs. 16.5±2.7.
CONCLUSIONS: Psychosocial attributes were independent of mobility independence and wheelchair use in this population. Unexpectedly, acceptance of disability correlated well with multiple PROMIS psychosocial scores.
CLINICAL RELEVANCE: Measuring psychosocial attributes in pediatric practice might reveal a more complete picture as clinicians seek to understand the impact of mobility gains on overall functioning and quality of life. This analysis suggests that clinicians might integrate strategies to improve relationships, affect, sense of purpose, and acceptance of disability with mobility interventions in older children and adolescents with long-term physical disabilities.
USING A NEURODEVELOPMENTAL TREATMENT CERTIFICATION COURSE TO BOLSTER DATA COLLECTION OPPORTUNITIES
Kerrick S (Mary Bridge), Brandsma B (Mary Bridge), Pflugeisen C (MultiCare Institute for Research & Innovation)
BACKGROUND & PURPOSE: Neurodevelopmental Treatment (NDT) has been utilized as a practice model in neurorehabilitation for children for many years. The current NDT contemporary practice model (CPM) has evolved along with developments in neuroscience and neuroplasticity. For clinicians who use the NDT-CPM, there is a perception, based on anecdotal clinical experience, that this treatment practice approach is effective and helps facilitate improved function and participation for the children served. There is limited evidence to support the efficacy of NDT-CPM in the treatment of children with CP and other neuromuscular conditions. There are certification courses for clinicians through the Neuro-Developmental Treatment Association that are taught by certified Instructors. This case series served as a pilot study for using one such certification course, involving a 6-week practicum, to collect data to strengthen the evidence for the efficacy of NDT.
CASE DESCRIPTION: Data were collected for 14 children pre- and post- participation in the course practicum. They were between the ages of 1.9 and 7.4 years, 43% female, and 38% ambulatory. Subjects received between 7 and 23 NDT treatment sessions, with a mean of 11.5 sessions. The Canadian Occupational Performance Measure (COPM) and the Functional Independence Measure for children (WeeFIM) were administered pre- and post- practicum to assess impact. Assessors were not involved in treatment.
OUTCOMES: On the COPM, 21% (n=3) of children had a clinically meaningful change (MCID=2 points) in performance, while a different 21% (n=3) had a clinically meaningful change in satisfaction. For the bulk of the children, change in performance and satisfaction were < 1, though the group was too small to draw concrete conclusions. The children with meaningful change were as a group, older and had more total NDT sessions. WeeFIM scores did not show meaningful change.
DISCUSSION: This case series demonstrated some positive changes for 6 of 14 children who were part of a pilot study examining the efficacy of NDT. It was hypothesized that a certification course could be used as a platform to collect data to advance the assessment of NDT-CPM for children with CP. However, the minor impact on outcomes in this case series suggests the need for a different venue for data collection to help generate research on the efficacy of NDT. The treating clinicians were novices to NDT-CPM and were in early stages of motor learning in the application of this model. Utilizing certified NDT-CPM clinicians, a future study could be warranted for children above a certain age, who all have a similar diagnosis, and who receive a prespecified number of sessions. Qualitative research may also support the assessment of the benefits of NDT-CPM, as the families whose children were part of this case series expressed positive comments and impressions for the experience.
BENEFITS OF AND BARRIERS TO RECREATIONAL ACTIVITIES AND ALTERNATIVE THERAPIES FOR CHILDREN WITH SPECIAL NEEDS
King P, Carter K, Keen M, Leftrick H, McElroy E. Tennessee State University
PURPOSE: The purpose of this paper is to describe the benefits and barriers of non-traditional therapies and recreational activities for children with special needs. Secondarily, this paper proposes strategies that can be utilized by pediatric physical therapists to connect families of children with special needs to recreational activity programs and non-traditional therapies in their communities.
DESCRIPTION: Children with special needs present with varying developmental delays and learning disabilities that are not generally addressed with non-traditional treatments like recreational activities or alternative therapies, such as Special Olympics, sports, and adventure camps. Despite the knowledge of these specialized therapies, we hypothesize the frequency and consistency of their utilization to be limited. Results of a systematic review of the literature focused on the benefits of and barriers to non-traditional therapies was conducted. The review confirmed the benefits of non-traditional treatments influence progress not only in physical development but social and emotional as well. Barriers to participation include, but are not limited to, cost and parental involvement. An informational brochure was developed to provide recreational activities and non-traditional therapies available in our local community.
SUMMARY OF USE: Opportunities exist for pediatric physical therapists to facilitate the participation of children with special needs in recreational activities and non-traditional or alternative therapies through parental education and professional networking. The information in this poster will be used to encourage physical therapists to increase their efforts in identifying and partnering with other healthcare professionals and community experts to coordinate plans of care for children with special needs that include advancing engagement in physical activity through recreational and non-traditional/alternative therapies.
IMPORTANCE TO MEMBERS: Recreational and non-traditional/alternative therapies can influence progress not only in physical development but social and emotional growth, all of which are crucial to the health and wellness of a child with special needs (NCTRC, 2021). A physical therapist may be the only resource available to connect families to such programs. It is important to increase the knowledge and awareness of members and parents of programs available in communities and how they will benefit children with special needs. The benefits of these programs could provide life-long social skills and build the foundation for a long-term, easy-to-follow, health and wellness program. With the increased attention to the responsibility of physical therapists related to public health and individual health and wellness currently emerging in our profession, this topic is timely as well as relevant.
GROSS MOTOR FUNCTION IN A PRESCHOOL AGED CHILD WITH SPINAL MUSCULAR ATROPHY TREATED WITH NUSINERSEN, A CASE REPORT
Lastra S. Hackensack University Medical Center
BACKGROUND & PURPOSE: Spinal muscular atrophy (SMA) is a genetic, neurodegenerative disease with motor neuron demise culminating in progressive weakness and functional decline. New pharmacological therapies are revolutionizing treatment of the disease prior to motor decline. The purpose of this case report is to provide a clinical example of gross motor (GM) function in a child with SMA who received intrathecal nusinersen intervention, and to provide prognostic insight for physical therapists to modernize their plan of care.
CASE DESCRIPTION: A four-year-old child with asymptomatic SMA with 3 copies of the SMN2 gene, treated with nusinersen since infancy, received two episodes of physical therapy (PT) over a 20-month span from ages 29-49 months. PT interventions were devised based on clinical findings after initial evaluation, parent concerns and goals, and adjusted over time relative to patient needs and progress. GM skill testing was performed at varying intervals using the Development Assessment for Young Children 2nd edition (DAYC-2) and/or the Hawaii Early Learning Profile (HELP).
OUTCOMES: During the treatment period the child displayed low muscle tone, mild weakness, and joint hypermobility. Initial GM assessment with the HELP indicated GM performance below age level; however successive HELP scores over the 20-month period demonstrated steady improvement in skill development with GM performance increasing to match and then surpass the child's age. During the second episode of PT care, gross motor testing using the DAYC-2 calculated the child's GM skill level in the “average” range between the 26th and 66th percentiles indicating typical performance. At the end of PT treatment, the child was capable of independent community level participation in school and recreation.
DISCUSSION: With the advent of new medical therapies, a child with presumed SMA type 2 treated with nusinersen may have potential for typical GM function and independent community level participation despite underlying issues of low muscle tone, weakness, and postural deviations inherent to SMA. For this new patient phenotype, the PT prognosis and plan of care need to evolve from a traditional maintenance focus to one which proactively pursues goals of timely acquisition of GM skills.
CASE SERIES: FEASIBILITY OF AN INTENSIVE PHYSICAL THERAPY INTERVENTION IN THE NEONATAL INTENSIVE CARE UNIT
Luck C, Lammers K, Hammond C. Women's Hospital, University of Missouri
BACKGROUND & PURPOSE: Physical therapy (PT) in the Neonatal Intensive Care Unit (NICU) is a well-established intervention to support behavioral state regulation, alignment and movement, developmental progression, and address atypical postures and muscle tone. Dosage of PT in the NICU typically averages two visits per week. Unlike many institutions in which infants well past term equivalent age (TEA) may transfer to pediatric intensive care, infants remain in our NICU throughout their stay. Intensive therapy, defined as 3-11 visits per week, is more commonly used in the outpatient setting. This report describes intensive therapy services (ITS) for three infants in the NICU.
CASE DESCRIPTION: Three infants with prolonged hospitalization past TEA, tracheostomy and ventilator dependence, abnormal findings on brain MRI, multiple comorbidities, and global developmental delays underwent ITS. Infant 1 is a full-term male with Central Congenital Hypoventilation Syndrome and Neonatal Encephalopathy. Infants 2 and 3 are preterm females with birth weight < 1000 grams. Adjusted ages of the infants ranged from 10 to 15 months when starting ITS. ITS initiation was based on sensitive periods when the infants demonstrated medical stability and readiness to learn new skills. Infants received an average of 218.8 minutes of PT per week over 3-4 weeks, in 14-16 sessions. PT intervention used developmentally appropriate positions and functional activities focused on improving postural control and transitional movements. All infants followed a daily routine that prioritized scheduled therapy sessions and naps. Families and nurses continued pre-existing play and positioning programs recommended by the infants' therapists.
OUTCOMES: All infants demonstrated increased scores on the Gross Motor Function Measure-88 (GMFM-88) from pre- to post-test. The mean change in GMFM-88 score was 6.29%. Goal Total Scores for Dimensions A (lying and rolling) and B (sitting) increased by an average of 14.85%. All infants completed the entire bout of intensive therapy without adverse effects.
DISCUSSION: Infants in the NICU experience a starkly different environment from the natural environment of most infants that affords far fewer opportunities for learning through natural exploration. Chronic, severe health conditions often limit their readiness to learn. Despite these challenges, infants experiencing prolonged hospitalization may show readiness for intensive interventions to improve developmental skills. Infants' GMFM-88 scores indicate improvement in skills related to supine, prone, and sitting positions, rolling, and dynamic postural control. Provision of ITS in a NICU setting is not well documented, and validity of the GMFM-88 for infants with ventilator dependence is not established. Despite these limitations, this case series illustrates that ITS is feasible in a NICU setting, and the GMFM-88 may be useful to document gains in gross motor function. Collecting two pre-ITS GMFM-88 scores to establish a baseline rate of progress would help elucidate the specific effects of ITS intervention.
FACTORS WHICH INFLUENCE PHYSICAL THERAPISTS' DECISION TO PRACTICE IN PEDIATRICS
Lundeen H. University Of Mary
PURPOSE/HYPOTHESIS: Pediatric physical therapy is a specialty area of practice, currently demonstrating a workforce shortage. Because this is a self-selected area of practice, it is important to understand what factors influence a physical therapist's (PT) decision to specialize in pediatric physical therapy. The purpose of this study was to investigate the factors (demographic, educational, clinical practice, mentorship, and personal/professional), perceptions and influences, associated with a PT's decision to practice in pediatrics.
NUMBER OF SUBJECTS: Participants included 245 pediatric PTs. A pediatric (PT) was defined as a PT whose caseload was >50% pediatric patients and/or a board-certified pediatric clinical specialist.
MATERIALS/METHODS: The study was a nonexperimental multi-methods design implementing cross-sectional survey methodology. Data was collected using a previously validated online questionnaire. The questionnaire consisted of 22 demographic questions, 2 open-ended questions and 2 questions with 22 individual items investigating factors associated with a PT's choice of pediatric physical therapy practice. The items were rated using a 5-point Likert scale. One set of items measured the participant's level of perception of pediatric physical therapy compared to other specialty areas of practice and the other set of items measured the influence of factors on the choice of pediatric specialty.
RESULTS: 80% of respondents chose their specialty prior to or during their professional education and participated in a full time pediatric clinical experience. All factors investigated positively (1=strongly negative, 5=strongly positive) influenced the participants' choice of the pediatric specialty. Mean scores of the factors were clinical patient care (4.2), mentorship (4.1), education (3.9), and personal/professional (3.4). The perception of pediatric physical therapy compared to other areas of practice was more positive (1=much less, 5=much more) in 3 of 4 factors. Mean scores of the factors, perceived as more positive, were clinical patient care (4.0), mentorship (3.6), and education (3.5). The mean score of the personal/professional factor (2.6) was perceived as more negative.
CONCLUSIONS: PTs who chose pediatric physical therapy as a specialty area were most likely to choose the specialty prior to or during their professional education. The choice to pursue pediatric physical therapy is most positively influenced by items representing clinical patient care, mentorship, and education. Items associated with clinical patient care were most influential and require engagement with children and families through intentional experiences.
CLINICAL RELEVANCE: Opportunities to expose pre- and professional physical therapy students and new professionals to engaging interactions with children and families is warranted. These critical interactions can occur in the classroom, during integrated or full-time clinical experiences both early and late in the curriculum, and as a component of clinical practice. The ultimate goal is to mitigate the shortage of pediatric PTs that is hindering access to care needed by children in our country.
INCLUSIVE SPORTS IN NOTH DAKOTA PUBLIC HIGH SCHOOLS: THE CURRENT LANDSCAPE INCLUDING BENEFITS AND BARRIERS
Lundeen H, Bass S, Chavez H, Kraft E, Krump E, Nihill J, Richter S, Spang T, Trom H. University Of Mary
PURPOSE/HYPOTHESIS: Inclusive sports, defined as athletic programs that combine students with and without disabilities to fully participate and compete on the same team for their school, have been shown to be beneficial for children/adolescents of all abilities in multiple domains of life. Children and adolescents with disabilities participate in sports significantly less often than their peers without disabilities. Inclusive sports provide an important opportunity for children and adolescents with disabilities to participate in sports. To increase access to inclusive sports opportunities the prevalence, benefits, and barriers must first be identified. The purpose of this study was to identify the prevalence, benefits, and barriers of the implementation of inclusive sports in high schools in the state of North Dakota (ND).
NUMBER OF SUBJECTS: Participants included an administrative representative from 36 ND public high schools representing 10 of 10 state public school regions.
MATERIALS/METHODS: The study was a nonexperimental multi-methods design implementing cross-sectional survey methodology. Data was collected using an online questionnaire. The questionnaire consisted of 20 demographic questions, 2 open-ended questions and 2 multiple-choice questions investigating the participants perceived benefits and barriers to offering inclusive sports at their respective schools.
RESULTS: Only 19% (n=7) of the participating schools offer at least one inclusive sport. Among all participants 8 different inclusive sports were identified as offered with baseball being the most prevalent (n=6, 17%) followed by basketball (n=4, 11%). The most frequent perceived benefit to inclusive sports was building relationships and promoting inclusion (n=30, 83%) followed by improving quality of life (n=23, 64%). The most frequent barriers reported were poor availability of coaches educated in inclusive sports (n=20, 56%) and lack of knowledge about inclusive sports (n=18, 50%). Qualitative data revealed that the prevailing theme of participants regarding why they offer inclusive sports was belonging to the community. The two themes emerging from participants who did not offer inclusive sports were lack of resources and lack of perceived interest.
CONCLUSIONS: There is an apparent lack of inclusive sports programs in ND public high schools. School administrators identify both benefits and barriers to providing inclusive sports. Based on the small percentage of schools (n=7, 19%) that offer inclusive sports in ND, it appears that currently the barriers such as limited resources and lack of knowledge/training outweigh the benefits of promoting inclusion and improving quality of life for the development and implementation of inclusive sports programs. Based on these findings of the local prevalence, benefits, and barriers, further research is needed to describe this issue regionally and nationally.
CLINICAL RELEVANCE: Physical therapists and others should further promote the development and implementation of inclusive sports to optimize the human experience. Advocacy efforts should aim to spread awareness of the benefits as well as work to overcome barriers of inclusive sports programs.
UPDATED RECOMMENDATIONS FOR ADOLESCENT IDIOPATHIC SCOLIOSIS (AIS) FOLLOWING POSTERIOR SPINAL FUSION (PSF)
Malczynski M, Park J, Benincasa J. The Children's Hospital of Philadelphia
PURPOSE: Over the years, surgical approaches and recovery pathways for patients with AIS who undergo PSF have evolved.1,2 As part of the patient's acute recovery, physical therapists serve an important role in educating patients and providing recommendations at the time of discharge. Unfortunately, as the medical aspects of a patient's care have changed, post-operative precautions and physical therapy (PT) recommendations have not always been concurrently updated in practice. This abstract describes the process of updating post-operative recommendations that include precautions and exercise programs at discharge. This abstract will also provide information regarding the collaboration process between therapists and physicians. The barriers identified and steps taken to complete this process will be reviewed.
DESCRIPTION: Representatives from the acute care PT team at an academic children's hospital identified a need to clarify and update post-operative precautions following PSF. Goals were to standardize practice and provide consistent recommendations for patients at time of discharge. Current patient educational handouts were reviewed and compared to a range of updated surgeon specific recommendations. The PT group came to consensus on updated exercises to be provided by each clinician as part of their typical practice. Information that required updates, including clarification of precautions and post operative recommendations, was presented to a group of orthopedic surgeons who regularly perform posterior spinal fusions at this institution. All confirmed updates were incorporated into a new patient and family educational handout. In addition, a standardized home exercise and activity program was developed and issued to patients prior to discharge.
SUMMARY OF USE: The updated patient and family education handouts and home exercise and activity program were submitted for review. Following review, all edits were completed and submitted for leadership approval. The completed handouts were presented by the PT group to the remainder of the leadership team. The full PT team was educated on the revisions made and how to incorporate the updated documents into patient care. The standardization of recommendations following surgery will result in positive changes in clinical practice and allow for better tracking of patient progress following discharge for future research opportunities.
IMPORTANCE TO MEMBERS: As surgical approaches and post operative precautions change, it is important for physical therapists to remain current with their post operative recommendations. With this review, it was determined that many of the recommendations that were being provided to patients following a PSF were more conservative than required. It is anticipated that the updated precautions and standardized PT recommendations will serve to minimize the patients' movement limitations and encourage mobility during recovery following PSF.
ART LESSONS IN PEDIATRIC WAITING ROOMS: FOSTERING WELL-BEING IN CHILDREN WITH DISABILITIES
Marra M (Medical University of South Carolina), Hund C (Medical University of South Carolina), Jenkins A (Medical University of South Carolina), Womack C (Medical University of South Carolina), Schroeder J (Medical University of South Carolina), Dodds C (Medical University of South Carolina), Walker J (Gibbes Museum of Art)
PURPOSE: Across the settings of home, school and community, participation is essential for children to develop skills and competencies, form friendships and relationships, explore self- identity, establish purpose in life, have fun, and achieve optimal quality of life. Children with disabilities (CWD) have decreased participatory levels and engagement including leisure activities yet participation in structured leisure activities such as art have significant cognitive benefits for children including developing intrinsic motivation, perceptions of freedom, concentration, and overcoming challenges. Current participation is often home-based, solitary, less physical or skilled-based, and commonly includes watching television, playing on the computer, listening to music, and talking on the phone; however, children with disabilities and parents have expressed a desire for participatory opportunities that are physically active, skill-based (e.g., art and music lessons, sports groups, swimming instruction), and social. The purpose of this South Carolina LEND pilot feasibility study was to examine if participation in art programming for CWD improved children's fine motor strength, anxiety, and happiness prior to healthcare visits.
DESCRIPTION: Using a sample of convenience, 18 children with illness or disability participated in art programming with an art teacher prior to a visit with a healthcare provider. Using Jamar pinch gauge, pinch strength was collected pre- and post- art class. Using the Smiley Faces Assessment Scale, parental report of children's anxiety was collected prior to art lessons with children reporting a happiness score after art lesson participation. Descriptive statistics were calculated and analyzed. Statistical significance was not tested secondary to small sample size.
SUMMARY OF USE: Following art lesson participation, small improvements in pinch strength were noted as well as reductions in anxiety with improvement in happiness scores. Based on parental stress scores, the use of art activities in the waiting room could also improve satisfaction/stress levels of parent experience in the clinic.
IMPORTANCE TO MEMBERS: Parents and children with disabilities desire participation in skill-based opportunities such as art lessons. Although this project was carried out in clinical waiting areas, findings can inform practice across all settings and environments. The implementation of art lessons may offer an opportunity for motor skill change, anxiety reduction, and promotion of overall well-being. The promotion of art lessons within the school, community, home, and clinical settings should be a priority for CWD and all working with this population.
UTILIZATION OF AUDITORY CUEING TO IMPROVE FUNCTIONAL MOBILITY IN A CHILD BORN WITH ANOPHTHALMOS AND MICROPHTHALMOS: A CASE STUDY
Moxley S (Brooks Rehabilitation), Slate M (Medical University of South Carolina & Brooks Institute of Higher Learning), Ubben C (Brooks Rehabilitation)
BACKGROUND AND PURPOSE: Anophthalmos is a diagnostic term that describes the absence of an eyeball, while Microphthalmos describes the presence of a small eyeball. In children born with Anopthalmos, there is a significant delay in gross motor skills due to visual impairments. Research has found that in children who are born blind, perceptual development can be enhanced with naturally associated auditory feedback to body movement. In this study, the researcher looks at the use of multiple surfaces to provide auditory and proprioceptive input and allow for further sensory processing. The learned responses to auditory and proprioceptive cueing were then incorporated to over ground gait training to improve functional mobility and gross motor skills. The purpose of this case report was to describe the use of auditory and proprioceptive input for mobility training in a child born with Anophthalmos and Microphthalmos.
CASE DESCRIPTION: The participant of this study is a 4-year-old girl presenting to Physical Therapy evaluation with concerns of gross motor delay. She was born with Anophthalmos of the left eye and Microphthalmos of the right eye. She had recently begun pre-school and was receiving all services in the school setting. According to her mother, she was unable to independently ambulate in her school or community setting, and would only take small steps in her home. During evaluation, the therapist and the patient's mother worked together to create functional goals. It was determined that the primary goal for the child was for her to be able to walk in and out of a community or school building with handheld assist and verbal cues instead of needing to be carried.
OUTCOMES: At the completion of ten weeks, the patient demonstrated improvements in functional mobility evidenced by ability to navigate the entire obstacle course without handheld assist or falls. Each week, verbal and auditory cueing decreased, and the number of times she was able to complete the course successfully in a session increased. The patient was able to navigate a 10-inch step independently at week 10, and she navigated 5 obstacles independently without a loss of balance.
DISCUSSION: This case study served to demonstrate how the use of auditory and proprioceptive feedback facilitated spatial compensation. This compensatory strategy promoted functional ambulation and improved her confidence and skills needed for community mobility. Overall, research for mobility adaptations in children with visual impairments is limited. The theory of early intervention in promoting compensatory skills exists across multiple diagnoses that are known to cause visual impairment, but the practice would benefit from further research regarding effective interventions for promoting safe and independent mobility.
FEASIBILITY OF PHYSICAL THEARPY IN A CHILD TO ADULT PRIMARY CARE TRANSITIONAL CLINIC
Parish A, Kim A, Koshy B, Myrick L. UAB
PURPOSE/HYPOTHESIS: Transitioning young adults with complex medical needs from child to adult based medical services is challenging due to the multifaceted management of the patient. Challenges include communication among unfamiliar medical providers, equipment stipulations, insurance coverage and available resources. As a result, transition can lead to increased caregiver burden, frequent hospital readmissions, and poor quality of life. Recently, an interdisciplinary transitional clinic that includes physical therapy (PT) as part of the primary care team was implemented at UAB. The goal of the clinic is to create a bridge to facilitate effective interdisciplinary care, decrease barriers for both caregivers and young adults with chronic medical conditions, as well as hospital admission rates. PT impacts these goals by performing functional screens, providing education, facilitating outpatient services, and referring for equipment needs. The purpose of this study is to assess the feasibility and impact of PT as part of the primary care team during the first year of a transitional clinic for young adults with complex medical needs.
NUMBER OF SUBJECTS: 112
MATERIALS & METHODS: A feasibility study was conducted over the first year of a transitional clinical for medically complex young adults to assess the impact of PT in a primary care setting. A prospective cohort design was used to track number of patients seen, referrals, referral areas, changes in caregiver burden scores, as well as clinical outcomes. Findings and recommendations are discussed with the team to facilitate interdisciplinary care. Reassessments are performed at follow-up appointments to evaluate changes and adherence.
RESULTS: 210 patients were referred to clinic and of those, 112 (53.33%) were seen by PT. Of the 112 patients screened, 22 (19.64%) were referred to outpatient-based PT services. 32 (28.57%) referrals were made to wheelchair seating clinics. 11 (0.10%) referrals were made for equipment. 34 (30.4%) patients were referred to community-based resources local to Birmingham. Patients additionally received education on home exercise and positioning programs, pain relief, caregiver education, as well as other strategies to improve the patient's quality of life. Data from caregiver burden scores and adherence to referrals are currently being collected as patients return for follow-up.
CONCLUSIONS: PT in a primary care transitional clinic for young adults with complex medical needs is feasible and allows for screening that can provide education, refer for needed therapy services, equipment, improve quality of life and potentially decrease caregiver burden. This is particularly important as many young adults have not had therapy services since childhood or have missed school services due to the pandemic.
CLINICAL RELEVANCE: Clinics that focus on transition of young adults with chronic complex medical needs from child to adult based services are rare with only three established clinics in the United States. PT can have an important role in primary care clinics to improve functional outcomes from a physical and affective perspective.
SELF-INITIATED MOVEMENT DURING PHYSICAL THERAPY IN YOUNG CHILDREN WITH CEREBRAL PALSY
Prosser L, Skorup J, Paremski A, Alcott M, Pierce S. The Children's Hospital of Philadelphia
PURPOSE/HYPOTHESIS: Gross motor practice in infants with typical development is overwhelmingly self-initiated. Young children with cerebral palsy (CP) have more difficulty moving independently, but the frequency of their initiation of movement has not been studied. Physical therapists often balance competing priorities of facilitating practice of challenging motor activities with facilitating child-directed motor play and exploration. Our objectives were to quantify self-initiated movement in young children with CP during physical therapy (PT), and to determine if there was a relationship between movement initiation and gross motor function.
NUMBER OF SUBJECTS: Thirty-seven toddlers with CP (20 boys, mean age 26.3 months, GMFCS I-IV) were included. Children were enrolled in a clinical trial (NCT#02340026) and could not take independent steps.
MATERIALS/METHODS: Participants were randomly allocated to conventional PT (dose-matched control group) or to an intervention that encouraged (among other things) child-directed movement by using dynamic body weight support (experimental group). Participants were stratified by age and gross motor function to ensure equivalence at baseline. Videos of randomly selected biweekly therapy sessions (271 total) were coded for two types of movement initiation – initiation of a new movement/posture and selection of the motor pattern. Videos had been previously coded for movement/posture (i.e. sit, crawl, transition, etc). For each of the pre-coded gross motor activities, the initiation coder selected ‘therapist’ or ‘child’ for who initiated the motor activity (had the idea) and who selected the motor pattern (assigned to therapist if physical or verbal cues were given). Videos were 20% double coded for reliability, and disagreements were reconciled for any video that didn't reach 85% reliability. Group differences were assessed with unpaired t-tests and the relationship to motor function (GMFM-66) was quantified by Pearson correlation.
RESUTLS: Reliability exceeded 85% for 143 videos (53.7%) for movement initiation and 170 videos (62.7%) for motor pattern selection. Consensus on disagreements was reached for the remaining 128 and 101 videos, respectively. Movement initiation was significantly greater (p=0.004) in the experimental (80.4%, SD 13.2%) compared to the conventional (67.9%, SD 11.7%) group. Similarly, selection of motor pattern was greater (p=0.005) in the experimental (90.6%, SD 9.0%) compared to the conventional (77.6%, SD 15.1%) group, indicating that child-initiation of motor practice can be manipulated in PT. As expected, greater movement initiation was related to higher gross motor function in both groups (experimental group r=0.73, p=0.0005; control group r=0.75, p=0.0003).
CONCLUSIONS: Young children with CP initiate motor activity less often than their peers with typical development, with greater motor impairment related to fewer child-initiated activities.
CLINICAL RELEVANCE: Child-initiation of motor practice can be manipulated in PT for young children with CP, even those with significant motor impairment. Future work should explore the relationship between self-initiation of movement and rehabilitation outcomes.
TYPE AND DISTRIBUTION OF GROSS MOTOR ACTIVITY DURING PHYSICAL THERAPY IN YOUNG CHILDREN WITH CEREBRAL PALSY
Prosser L, Paremski A, Alcott M, Skorup J. The Children's Hospital of Philadelphia
PURPOSE/HYPOTHESIS: Infants learn to move through thousands of repetitions and hours of variable practice each day. New walkers locomote 32% of the time during free play but the majority of walking bouts last less than 6 seconds. The amount and distribution of gross motor activity in toddlers with cerebral palsy (CP) has not been reported. Our purpose was to characterize the type, amount and timing of gross motor experience during physical therapy sessions in young children with CP.
NUMBER OF SUBJECTS: Thirty-seven toddlers with CP (20 boys, mean age 26.3 months) were included. All children could initiate pulling to stand (score of at least 1 on the Gross Motor Function Measure item 52) but were not able to take independent steps. Participants were enrolled in a clinical trial (NCT#02340026) at a pediatric academic medical center in a large US city and were randomly allocated to one of two dose-matched physical therapy programs.
MATERIALS/METHODS: Videos of randomly selected biweekly therapy sessions were continuously coded for gross motor activity (422 videos total). The ten gross motor activity codes included lying, sitting, four point, crawling, kneeling, knee walking, standing, walking, transitions between floor postures and transitions to/from an upright posture. All videos were 20% double coded for reliability, and disagreements were reconciled for any video that didn't reach 90% reliability. Total time per session, number of bouts, and median time per bout were calculated for each gross motor activity and for two aggregate measures – movement time and upright time. Movement time included dynamic activities (walking, crawling, knee walking, transitions). Upright time included activities in standing or kneeling postures. Observations were interpreted in the context of existing data from infants with typical development.
RESULTS: Reliability for 266 videos (63%) exceeded 90% and consensus on disagreements was reached for the remaining 156 videos. There were few differences between groups and therefore results were combined for the full sample. Participants spent more than half of their therapy time in sitting (23.7%) and standing (31.5%) combined. Transitions occurred more frequently than any other gross motor activity (mean=49.7 bouts per session, SD=20.0). Movement time averaged 18.2% of the session (SD=8.3%) and occurred over an average of 66.4 (SD=32.5) bouts per session. Upright time averaged 58.0% of the session (SD=17.0%) and occurred over an average of 78.5 (SD=42.5) bouts per session. Sixty percent of walking bouts were longer than 6 seconds in duration.
CONCLUSIONS: During individualized physical therapy sessions, toddlers with CP spent approximately half as much time moving and motor practice was half as variable (moving from one gross motor activity to another nearly half as frequently) as their typically developing peers.
CLINICAL RELEVANCE: Like their typically developing peers, the accumulation of gross motor practice may be an important factor in the acquisition of motor skill in young children with CP. Future work should explore the relationships between amount and type of motor practice and rehabilitation outcomes.
INDEPENDENT MOTOR PRACTICE TIME DURING PHYSICAL THERAPY IN YOUNG CHILDREN WITH CEREBRAL PALSY
Prosser L, Paremski A, Skorup J, Alcott M, Pierce S. The Children's Hospital of Philadelphia
PURPOSE/HYPOTHESIS: An immense amount of independent motor practice provides the basis for motor skill learning in infants. Children with cerebral palsy (CP) are less able to move independently than their peers with typical development. Physical therapists often balance competing priorities of facilitating opportunities for independent practice with facilitating functional success by giving hands-on assistance. Independent practice and assisted time during therapy have not previously been measured. Our objectives were to quantify the amounts of independent motor practice and assisted time that young children with CP experienced during physical therapy, and to determine if there was a relationship between independent practice and gross motor function.
NUMBER OF SUBJECTS: Thirty-seven non-ambulatory toddlers with CP (20 boys, mean age 26.3 months, GMFCS I-IV) were included. Participants were enrolled in a clinical trial (NCT#02340026) at a pediatric academic medical center.
MATERIALS/METHODS: Children were randomly allocated to conventional physical therapy (dose-matched control group) or to an intervention that encouraged (among other things) independent practice through the use of a dynamic body weight support system (experimental group). Children were stratified by age and gross motor function to ensure equivalence at baseline. Videos of randomly selected biweekly therapy sessions were coded for therapist contact (421 videos total). The 3 contact codes were: therapist assistance, touch contact only, and no contact. All videos were 20% double coded for reliability, and disagreements were reconciled for any video that didn't reach 85% reliability. Independent practice time was the sum of no contact and touch only time. The remainder of the time was assisted time. Group difference was assessed with a Mann Whitney test and the relationship to baseline gross motor function was quantified by Spearman correlation.
RESULTS: Reliability for 312 videos (74.1%) exceeded 85% and consensus on disagreements was reached for the remaining 109 videos. Independent practice time during therapy was significantly greater (p< 0.0001) in the experimental group (73.6%, SD 18.7%) compared to the conventional therapy group (26.7%, SD 14.3%), indicating that independent motor practice time can be manipulated in physical therapy. Assisted time was 26.4% in the experimental therapy group, compared to 73.3% in the conventional group. As expected, greater independent practice was related to higher gross motor function in both groups (experimental group r=0.80, p< 0.0001; control group r=0.54, p=0.020).
CONCLUSIONS: Unlike their typically developing peers, young children with CP spend much of their motor practice time being assisted rather than moving independently, with greater motor impairment related to less independent practice time.
CLINICAL RELEVANCE: We demonstrated that independent and assisted motor practice time can be manipulated in physical therapy for young children with CP, even for children with significant motor impairment. Future work should explore how best to manipulate the tradeoffs between independent and assisted practice time to optimize rehabilitation outcomes.
PARTNERING WITH PEDIATRICIANS: EARLY IDENTIFICATION OF DEVELOPMENTAL DELAY IN HIGH-RISK INFANTS
Queralt A. College of St. Scholastica
PURPOSE: The population of high-risk infants is increasing due to biological and environmental factors. Despite the corresponding greater need for early identification of developmental delay, pediatricians find themselves limited in the time and resources necessary to complete the recommended screenings and surveillance. Additionally, the subtle qualitative movement challenges often are difficult to identify. As a result, identification of developmental delay is hindered, leading to delayed referrals to therapy, poor school readiness, and long-term sequela of motor delay. Beyond identification, navigating early intervention (EI) eligibility, educating families about EI, and monitoring therapy services received are additional burdens on already time-restricted pediatricians. Physical therapists (PTs) can be critical players in primary pediatric care due to their expertise in movement and function. This special interest project presents a timely, innovative collaboration between PTs and pediatricians in a primary care setting.
DESCRIPTION: PTs and pediatricians would partner to create a multidisciplinary medical home for the patient and family in this program. In this presentation, I will discuss (1) current practices of pediatricians regarding developmental surveillance and screening, (2) PTs' role in pediatric primary care, (3) the importance of early intervention (EI) services for school readiness (3) barriers of EI services (4) screenings recommended for identification or prediction of developmental delay and measurement of movement quality for ages 0-3 and (5) multidisciplinary models of care.
SUMMARY OF USE: This program aims to identify and address subtle movement challenges and developmental delays early via an innovative family-centered collaborative care program focusing on high-risk infants in the primary pediatric care setting. PTs can decrease therapy needs during school years and improve school readiness through this program while empowering families with education. The result would be:
- Identifying subtle development delays and poor movement quality earlier than nine months of age.
- Increasing parent knowledge and participation in the therapeutic care of their child through education in handling, play, and anticipated developmental milestones.
- Improving school readiness and decreasing therapy needs during school-age for high-risk infants.
IMPORTANCE TO MEMBERS: Pediatric physical therapists can play an essential role in primary pediatric care through screening and education, decreasing the need for long-term therapy services, and preventing long-term sequela from delayed therapy services.
DECREASING GAPS IN SERVICE AND INCREASING COLLABORION FOR CHILDREN IN OUT-OF-HOME-CARE
Quinn E. Solace Pediatric Home Healthcare
PURPOSE: The purpose of this study, originally part of a capstone project for the APTA Centennial Scholars Program, was to build foundational knowledge regarding out-of-home care (which includes, foster care, kinship care, and emergency placement), learn how PTs/PTAs are currently serving this population, and gain preliminary data on where service gaps exist for this population as it relates to pediatric physical therapy.
DESCRIPTION: This project included the creation of a resource of key terms and definitions related to children in out-of-home care and a survey to gain data on current care and gaps in care. Using snowball methodology, an eight-question survey was sent out via email, social medial postings in physical therapy groups and by word of mouth. The survey was open for one month in May to June 2021 Spring to early Summer of 2021.
SUMMARY OF USE: The results included 132 responses from 40 states from clinicians of all settings, with outpatient/outpatient private practice, EI, and school-based having the most responses. The majority (75.8%) of respondents reported working with children in out-of-home care on their caseloads, with 28% of respondents working with this population 76-100% of the time. In terms of racial makeup, respondents reported working with children in this population of all races, with White, African American/Black, and Hispanic/Latinx being the most prevalent. Majority of skills worked on were developmental skills and caregiver education, with limited care in transitional life skills (0.8%). Collaboration with other healthcare professionals was mostly with OT and SLP, 100% and 96.1% respectively s, 53.4% with social work, 50.5% with physicians, and 30.1% collaborating with mental health providers. Trends for barriers to care for this population include difficulty with carryover of care between caregivers, difficulty navigating the healthcare system, decreased communication with care team (including case managers), and frequent transitions.
IMPORTANCE TO MEMBERS: Limited literature exists in relation to this topic and population, with very little data found in relation to PT care in a literature search. Furthermore, trends from initial survey show majority of clinicians work with this population. However, initial survey results also indicate decreasing care for this population as the children age, with most care being in the developmental years. Initial data also demonstrates limited collaboration outside of other rehabilitation professions. The current gaps in service found through this project, allow for opportunities for growth in the profession and where care can be improved to better serve this population.
PAIN AND SELF-PRESSURE RELIEF IN ADOLESCENTS WITH CEREBRAL PALSY
Ridilla S (University of Oklahoma), Wang H (University of Florida), Sylvester L (University of Oklahoma), Arnold S (University of Oklahoma)
BACKGROUND & PURPOSE: Background: Adolescents with cerebral palsy classified as Gross Motor Functional Classification System Level V, who use wheelchairs as their primary form of mobility, often attend school for up to eight hours per day and lack independent movement with limited ability to self-reposition. Despite the high levels of reported pain within this population, there is a lack of knowledge of perceived pain associated with pressure in sitting, and of self-pressure relief during prolonged sitting. Purpose: The purposes of this study were to determine perceived pain during prolonged sitting with a standard pressure relief protocol, the feasibility of using SensiMATTM technology to detect adolescent pressure relief movements during standard classroom sitting, and to identify any associations of perceived or expressed pain measurements with SensiMATTM pressure readings and pressure relief movements.
CASE DESCRIPTION: Methods: A case series design was used. A convenience sample of six adolescent students (13-18 years) with CP classified as GMFCS V were recruited. The SensiMATTM was placed on the students' wheelchair cushion and pain assessments were taken every 30 minutes during a five-hour period of one typical school day. Self-relief assessments using the SensiMATTM were recorded continuously, except during the one-hour repositioning when students were out of their chairs.
OUTCOMES: Results: Two of the six students independently reported pain. Proxy pain assessments of three students showed increased movement in either their legs or head and trunk positioning after a period of prolonged sitting. All students had unrelieved pressure or did not self-relieve pressure for at least 1.5 consecutive hours during the five-hour study. Four students increased their self-pressure relief movements after a prolonged period of 3.5 hours.
DISCUSSION: Conclusions: Students demonstrated independent pressure relief movements and increased unrelieved pressure, with and without increased pain suggesting that students may be experiencing pain during periods of prolonged classroom sitting, or that students are independently relieving pressure to prevent or reduce pain. Relevance to Allied Health: The SensiMATTM is a feasible piece of technology to measure independent pressure relief movements for individuals with CP with the most severe disabilities. With future adaptations, the SensiMATTM may be a useful piece of technology for school physical therapists to develop positioning protocols, specifically tailored to students in special education. Pressure relief activities can be associated with discomfort or pain, which need be further investigated.
ACCESS TO INCLUSION: INCORPORATING FAMILY-CENTERED BELIEFS IN THE COMMUNITY
Rolf K, Brinkman D, A Ehrenschwender, Matthews C, Scott M, Smith J, Ayers K. Cincinnati Children's Hospital Medical Center
PURPOSE: Though public venues are required to meet accessibility standards under the Americans with Disabilities Act, families and individuals with developmental disabilities (DD) still struggle with accessibility and inclusion concerns in community spaces. To promote a culture of inclusion, environmental barriers to access and inclusion need to be identified as well as using universal design to make environments accessible and inclusive for all individuals. The Cincinnati Leadership Education in Neurodevelopmental and related Disabilities (LEND) Training Program is part of a national network promoting education and leadership in order to improve the health of infants, children, and adults with or at risk of having DD. A previous LEND group orchestrated a scorecard for local communities to self-assess their levels of accessibility and inclusion and generate future plans for full inclusion in their spaces based on opinions from healthcare professionals. However, there is a need for stakeholders' input to determine key areas of focus for optimal improvement. Our LEND research group found it imperative to further include both individuals with DD and their family's input to drive continued advancement in this area. The aim of this project was to develop a survey about accessibility and inclusion and use the stakeholder data to inform, previously created, community scorecards for local businesses.
DESCRIPTION: Our Vision. Our Vision is to transform our Greater Cincinnati area into the most accessible and inclusive region in the country for individuals with developmental disabilities and their families. We want to serve as a national model for accessibility and inclusion in community settings. Family-Centered Focus. To guide the development of the survey, the project's goals and questions about accessibility and inclusion within the community were presented to a local family advisory council (FAC). By incorporating their feedback and counsel in our research and creation of our survey, we were able to better advocate with a family-centered perspective for improved accessibility in the community. Survey Development. Qualitative and quantitative survey questions about inclusion in various community settings were developed based on the feedback from families of children with DD at the FAC.
Data Collection. Surveys will be sent to families of children with DD as well adults with DD and the data will be analyzed in the Fall of 2022.
SUMMARY OF USE: LEND trainees gained experience in developing a family and person-centered survey to measure physical accessibility and inclusion within the Greater Area of the Cincinnati community. The resulting data may allow for us to improve accessibility and inclusion for all families in the Greater Cincinnati area.
IMPORTANCE TO MEMBERS: Our survey development and vision may guide future advocacy efforts and assist pediatric physical therapists in helping to make our communities more accessible and inclusive. Gaining feedback from families in the community will further foster our profession's values of family centered care.
‘PEDS CLASS’ IS NOT ENOUGH! LEVERAGING PEDIATRIC CLINICAL SPECIALISTS AND COMMUNITY INFANT/CAREGIVER GROUPS TO AUGMENT PEDIATRIC PHYSICAL THERAPY EDUCATION
Sander R, Porter K, Benjamin D, Jacobson R. George Fox University
PURPOSE: To describe a novel 8-week experiential-based learning (EBL) seminar provided to Doctor of Physical Therapy (DPT) students following completion of their 3-credit pediatric physical therapy course.
DESCRIPTION: This university-sponsored seminar combined didactic learning with hands-on practice in the context of a community-recruited infant/caregiver group hosted by the DPT program. The purposes were: 1) to provide DPT students further training in infant development, movement assessment, and psychosocially sensitive interaction; and 2) to offer local families of typically-developing infants a rich educational and collaborative developmental learning group.
SUMMARY OF USE: Twelve DPT students voluntarily participated in the seminar which was offered at no-charge to all second-year DPT students regardless of pediatric interest. Commitment entailed one hour per week of didactic curriculum and one hour per week of mentored interaction with 12 infant/caregiver pairs in a community group. Curriculum was developed and delivered by an ABPTS Board Certified Pediatric Specialist (PCS) who is also a full-time pediatric teaching assistant, in consultation with the pediatric PT faculty. Learning objectives reflected content beyond that offered in the required pediatric PT course, focusing on infant development, appraisal of movement and overall development, and psychosocially sensitive interaction with infants and families. Weekly didactic learning included video movement analysis, case discussion, preparation for infant/caregiver interaction, and guided self-reflection. The goal of each EBL session was collaborative learning alongside an infant/caregiver pair. This hour followed a framework of “Discuss/Watch/Assess/Teach”—for example, discuss emotional regulation observations and strengths, watch the infant play in prone, assess movement and exploration, and teach caregivers how to set up the environment to promote crawling. Formal debriefing after each community group session was an essential component for student clinician development. In addition to the rich EBL experience for students, the weekly group offered caregivers tailored developmental education and positive interaction with other local families of infants from 2 to 11 months of age.
IMPORTANCE TO MEMBERS: Preparing new DPT graduates for pediatric practice with infants is challenging within the pediatric PT curriculum. The 8-week EBL experience described here is novel in that it: 1) dives deeply into infant movement development within in a family-centered collaborative learning environment; 2) allows students to follow the same infants across two months of development; 3) targets students more likely to go into pediatric practice, yielding high return-on-investment for our pediatric specialty; and 4) simultaneously offers local families of infants a supportive, collaborative learning group. Specialty training and close familiarity with the required pediatric PT course content means PCS teaching assistants are well-positioned to provide focused, integrative learning opportunities to better prepare new DPT graduates for independent practice with infants and families.
CREATING NEONATAL INTENSIVE CARE UNIT CAREGIVER MODULES
Schroeder J, Zwolski M. Medical University of South Carolina
PURPOSE: Evidence indicates that caregiver education has the potential to improve outcomes for newborns with prematurity and low birth weight as well as parents.1 Knowing this, March of Dimes consultants at the Medical University of South Carolina approached South Carolina Leadership and Education in Neurodevelopmental and Related Disabilities (SCLEND) trainees to create educational video content for parents of infants in the Neonatal Intensive Care Unit (NICU). This contributes to the goal of improving competence and confidence in parents of infants in the NICU.
DESCRIPTION: Using a literature review and interviews with the March of Dime consultants, the following eight educational topics were chosen: tummy time6, infant massage6, breastfeeding6, mental health for NICU parents and caretakers4,6, car seat safety6, developmental milestones2,6, developmental concerns2,6, and medical concerns and medications2,3,6. These specific topics address a majority caregivers' top reported stressors in the neonatal intensive care unit 6. The interprofessional coverage of these topics introduced caregivers to the comprehensive network of providers that would make up the family's healthcare team.
SUMMARY OF USE: Collectively, two hours of recorded educational content was produced within six video recordings. The MUSC March of Dimes coordinators completed 5-point Likert scale surveys addressing the content and instructional quality of the videos. The scale addressed familiarity, relevancy, and comprehensibility of the topics covered, caregiver stress-levels, and caregiver skill improvement levels. Scoring and narrative feedback from these collaborators was satisfactory. Although feedback from the March of Dimes consultants was positive, parent learning outcomes and feedback could not be assessed because Covid restrictions prevented in-person presentations. Future collaborators should be encouraged to collect these learning outcomes. In addition, the literature review identified other learning topics of interest. In the future these video recordings could be created and expand the existing video library. Lastly, a more diverse group of parents could be targeted if the video recording library was translated into Spanish and other languages.
IMPORTANCE TO MEMBERS: The educational videos provide a method to empower parents to ideally and safely care for their infants. By educating parents to recognize the medical, environmental, and therapeutic needs of their infants, prevention of additional risks and impairments may occur. Additionally, the mental health educational module teaches parents to consider their own needs and permits them to examine their emotional responses and health. These educational modules may improve the overall health outcomes for NICU graduates as caregivers may be better positioned to foster proper medication administration, manage equipment, and execute therapeutic home programs.
EXPLORING THE IMPACT OF INCLUDING TOTAL-BODY VIBRATION IN PHYSICAL THERAPY INTERVENTION ON ACTIVATION OF THE KEY MUSCLES OF GAIT IN YOUNG CHILDREN WITH DEVELOPMENTAL DISABILITIES
Schlueter K, Janowitz E, Broussard R, Kuo Y, Wentz E. SUNY Upstate Medical University
BACKGROUND & PURPOSE: To determine if adding total-body vibration (Hypervibe) to physical therapy interventions would increase the activation of key ambulatory muscles [the rectus femoris (RF), semitendinosus (ST), and medial gastrocnemius (MG)] to improve participation in gait-oriented tasks in pediatric patients with developmental disabilities.
CASE DESCRIPTION: This case series followed six children between 20 months and 6 years old with varying levels of physical challenge. Three children were diagnosed with cerebral palsy (GMFCS levels I (P05), II (P03), and V (P06)), one with Tuba1A (P04), one with mutation of the CACNA1A gene (P02), and one with SMC1A (P01). All six participants had goals related to gait. The six participants were tested pre-intervention using the Modified Ashworth (MA), surface EMG (sEMG), and Gross Motor Function Measure-88 (GMFM-88).2,3,4,5 Muscle activation of bilateral RF, ST, and MG muscles was measured with sEMG during ambulation. The MA assessed spasticity in these muscles. Two GMFM-88 dimensions were assessed based on each participants' level of function and goals. Participants completed a 12-week intervention that included an activity on the Hypervibe as well as gait related activities.6,7 At 12 weeks, participants were re-tested using the MA, sEMG, and GMFM-88.
OUTCOMES: P01 demonstrated a 2% and 5% increase in GMFM-88 dimensions A and B. P02 demonstrated a 12.8% increase in dimension D. P03 demonstrated a 23.1% and 36.1% increase in dimensions D and E. P04 demonstrated a 2.6% and 1.4% increase in dimensions D and E. P05 demonstrated a 7.8% and 13.9% increase in dimensions D and E. P06 demonstrated a 2.6% increase in dimension D. No changes were noted in MA. Muscle activation (calculated as the root mean square value) increased in five to six target muscles in all participants (range of group means: 36.5%-59.9%, median: 43.6%) after receiving the intervention. Additionally, sEMG data showed more physically involved participants demonstrated more muscle activation percent change.
DISCUSSION: The GMFM-88 was utilized due to its ability to detect changes in gross motor function in physically involved children.4,5 All participants demonstrated functional improvements as measured by the GMFM-88, with greater gains noted in participants with less physical involvement. P02, P03 and P05 demonstrated significant improvements while P01, P04 and P06 demonstrated mild improvements in measured dimensions.4,5 Increased muscle activation in the lower extremity at the pathophysiologic level was evident in all participants especially those with more severe motor impairments. Improved muscle activation is a precursor to functional change; and functional change is often harder to elicit in more physically involved children. Findings suggest promise for adding total-body vibration to interventions to prompt meaningful change in function for children with varying physical challenges.
MEASURING MOTOR ERROR DURING PHYSICAL THERAPY IN YOUNG CHILDREN WITH CEREBRAL PALSY
Skorup J, Paremski A, Alcott M, Pierce S, Prosser L. The Children's Hospital of Philadelphia
PURPOSE/HYPOTHESIS: Typical toddler movement is characterized by a high degree of error, with 17 falls per hour when learning to walk. Young children with cerebral palsy (CP) may not experience motor error as frequently as their peers with typical development because of lower physical activity levels or a limited ability to produce movements that challenge their balance - but this has not been quantified. Our objectives were to measure the type and amount of postural error during physical therapy in young children with CP and to determine if there was a relationship between error experience and gross motor function.
NUMBER OF SUBJECTS: Fifteen toddlers with CP (6 boys, mean age 26.7 months, GMFCS I-IV) were included. Children were enrolled in a clinical trial (NCT#02340026) and could not take independent steps.
MATERIALS/METHODS: Participants were randomly allocated to “conventional” physical therapy (dose-matched control group) that prevented falls or to an intervention that encouraged (among other things) more error experience by not preventing falls and encouraging upright activities (experimental group). Participants were stratified by age and gross motor function to ensure equivalence at baseline. Videos of randomly selected biweekly 30-minute therapy sessions were manually coded to count losses of balance (118 videos total). All losses of balance were further coded as falls (child contacted the floor), rescues (fall prevented by therapist) or saves (child recovered their balance on their own). All videos were 20% double coded for reliability, and disagreements were reconciled for any video that didn't reach 80% reliability. Differences between groups were assessed with Mann Whitney tests and the relationship to baseline level of gross motor function was quantified by Spearman correlation.
RESULTS: Reliability for 78 videos (66%) exceeded 80% and consensus on disagreements was reached for the remaining 40 videos. Total losses of balance per session averaged 13.2 (SD 5.6) per session in the experimental group compared to 8.5 (SD 7.8) in the conventional therapy group. As intended, falls were significantly greater (p=0.038) in the experimental group (7.6, SD 4.1) compared to the conventional therapy group (1.6, SD 0.8). Neither rescues (experimental 4.7; conventional 6.8; p=0.27) nor saves, which were infrequent (experimental 0.9; conventional 0.2; p=0.19), differed between groups. In the whole sample combined, baseline gross motor function was related to the frequency of saves (r=0.58, p=0.032), but not falls (r=0.10, p=0.73) or rescues (r= −0.18, p=0.54).
CONCLUSIONS: Postural error experience resulting in falls may conventionally be lower in young children with CP than their peers with typical development but can be manipulated during physical therapy to approximate typical levels, even in children with significant motor impairment.
CLINICAL RELEVANCE: Error experience through losses of balance may be an important ingredient in the acquisition of motor skill by promoting problem solving and introducing greater movement variability in young children with CP. Future work should investigate the relationship between error experience and rehabilitation outcomes.
MOTIVATION TO MOVE IN YOUNG CHILDREN WITH CEREBRAL PALSY
Skorup J (The Children's Hospital of Philadelphia), Paremski A (The Children's Hospital of Philadelphia), Wu T (Washington University in St. Louis), Ruwaih N (The Children's Hospital of Philadelphia), Alcott M (The Children's Hospital of Philadelphia), Pierce S (The Children's Hospital of Philadelphia), Prosser L (The Children's Hospital of Philadelphia)
PURPOSE/HYPOTHESIS: In children with neuromotor disabilities, the degree of functional limitation is influenced not only by the severity of physical impairment but also by non-physical factors, such as cognition and motivation to move. Motivation to move has been measured in infants with typical development but has not been well studied in infants with physical disabilities. Our objective was to report motivation to move in young children with CP and to determine if there was a relationship between motivation to move and motor function.
NUMBER OF SUBJECTS: Thirty-seven toddlers with CP (20 boys, mean age 26.3 months) were included. All children could initiate pulling to stand (score of at least 1 on the Gross Motor Function Measure item 52) but were not able to take independent steps. Participants were enrolled in a clinical trial (NCT#02340026) at a pediatric academic medical center in a large US city and were randomly allocated to one of two dose-matched physical therapy programs.
MATERIALS/METHODS: Videos of randomly selected biweekly 30-minute physical therapy sessions (420 total) were coded for motivation to move per Atun-Einy and colleagues (2013). The 5-point ordinal scale considers the child's behavior on five factors (persistence to move, frequency of position changes, time in motion, strength of stimulus to elicit movement and energy level), with 5 being highly motivated to move and 1 being weakly motivated to move. One researcher coded all videos in five 6-minute sections. The median value was used as the overall score for analysis. A second researcher double coded 20% of 128 videos for reliability, with a maximum difference of 1 considered reliable. The Gross Motor Function Measure (GMFM-66) was scored by a blinded assessor at baseline. Descriptive statistics are reported and Spearman correlation was used to evaluate the relationship between motivation to move and gross motor function.
RESULTS: All videos in the double-coded dataset reached reliability. There were no differences between groups and therefore results were combined for the full sample. Median motivation to move was 3.0 (range for total video scores 1.0-3.0; range for video section scores 1.0-4.0) which is similar to that reported in 7-month old infants with typical development and lower than reported in 12-month old infants. Higher motivation to move was related to greater gross motor function (r=0.62, p< 0.0001), but not age (r=0.16, p=0.35).
CONCLUSIONS: Young children with CP demonstrate a range in motivation to move, with children who have greater gross motor function generally demonstrating higher motivation to move.
CLINICAL RELEVANCE: Apart from their physical impairment, motivation to move may influence response to rehabilitation therapies in children with CP. Future work should explore the trajectory of motivation to move over the developmental years and the relationship between motivation to move and rehabilitation outcomes in children with CP.
THE USE OF THE EMOTIONAL AVAILABILITY SCALES IN NEONATAL INTENSIVE CARE UNITS: A FEASIBILITY STUDY
Stuyvenberg C (University of Minnesota), Molinini R (Virginia Commonwealth University), Dusing S (University of Southern California)
PURPOSE/HYPOTHESIS: The Emotional Availability Scale (EAS) is a well-established instrument measuring affective qualities of parent-child relationships. Adult dimensions of the EAS include Sensitivity, Structuring, Non-Intrusiveness, and Non-Hostility. Child dimensions include Responsiveness and Involvement. Despite preterm birth impacting parent mental health, infant development, and parent-infant relationships, the EAS has not been used to quantify parent-preterm infant relationships in the neonatal intensive care unit (NICU). We aimed to determine the feasibility and inter- and intra-rater reliability of the EAS when administered within a NICU setting.
NUMBER OF SUBJECTS: Subjects were nine infants with a mean gestational age of 27.1 weeks (SD=4.3) at birth and their parents.
MATERIALS/METHODS: Parent-infant dyads were retrospectively assessed at two timepoints. The first timepoint was between 36-40 weeks gestation, as soon as the infant was stable (defined as off of ventilator support, independent with thermoregulation, and cleared by the medical team). The second timepoint took place three weeks later. The EAS was scored using 5-minute videos of parent-infant interactions, collected as part of a larger study. Scoring was deemed feasible if a composite, direct score was attained on the four parent scales and one of the two infant scales of the EAS. Percent agreements were calculated by dividing the number of codes within +/- one point by the total number of codes. Percent agreement between a primary and secondary coder was determined by scoring 15% of the videos for intra-rater reliability after a one-week waiting period and 40% of the videos for inter-rater reliability without discussion with a minimum threshold set at > 85% agreement.
RESULTS: All 18 videos of parent-infant interactions in the NICU were feasibly scored. Intra-rater agreement for the primary and secondary coders were both 100%. Inter-rater agreement was 99.04%.
CONCLUSIONS: We have identified the EAS as a feasible and reliable instrument for quantifying the affective qualities of parent-infant relationships at a critical time for both infant development and for the establishment of parent-infant relationships.
CLINICAL RELEVANCE: The EAS is an instrument that may provide NICU and early intervention physical therapists with a measure of the security and health of parent-infant relationships. We hope to next explore the potential of parent-infant relationship qualities to impact a parent's ability to sensitively deliver recommended physical therapy interventions and an infant's potential to benefit from the intervention.
INTERDISCIPLINARY DISCHARGE PLANNING IN PEDIATRIC PATIENTS WITH SPINAL CORD INJURY SECONDARY TO FIREARM VIOLENCE
Warwick-Arndt L, Farrell E. Kennedy Krieger Institute
PURPOSE: To describe the physical and psychosocial barriers to discharge planning for pediatric victims of firearm violence resulting in spinal cord injury following acute inpatient rehabilitation in an urban setting. This poster will highlight the roles of each interdisciplinary team member in discharge planning, identify opportunities for collaboration, combating compassion fatigue, and vicarious trauma experienced by healthcare professionals.
DESCRIPTION: Approximately 5,800 children in the United States are treated for gunshot wounds (GSW) each year.4 Firearm violence is currently the second most common overall cause of injury in children in the United States.4 These pediatric patients present with an increased burden of care, especially those with medically complex injuries. Pediatric victims of firearm violence may face unique challenges for discharge planning following spinal cord injury; these may include physical, emotional, psychological, behavioral, and psychosocial barriers to discharge. In our urban setting, patients discharging home following gun violence may continue to experience poverty, racism, food insecurity, violence, cultural expectations, decreased access to education, distrust in medical establishment, lack of accessible housing, and challenges with law enforcement. For many medical professionals, entry level training has not prepared them to navigate these barriers to discharge planning. It is paramount for the health care professional working in an urban setting with victims of firearm violence to work with team members to support one another Opportunities for team collaboration with this patient population may include home assessments for accessibility, legal challenges, and child custodial placements. Each of these team members provide assistance to the patient and family to guide them towards a successful discharge, yet support one another through the emotional challenges experienced in working closely with pediatric victims. Healthcare professionals working with children following firearm violence are susceptible to experiencing compassion fatigue. Symptoms of compassion fatigue can include bottled up emotions, isolation from others, feeling physically or emotionally tired, sadness, and difficulty concentrating. It is important that healthcare workers identify compassion fatigue so that they can utilize techniques to combat burnout in order to best care for their patients and themselves.
SUMMARY OF USE: When healthcare professionals have a greater understanding of the challenges surrounding discharge planning in pediatric victims of firearm violence, they may improve the likelihood of a successful discharge for the patient.
IMPORTANCE TO MEMBERS: Due to the high rate of pediatric victims of firearm violence, it is important for pediatric physical therapists to have an understanding of the challenging physical, emotional, psychological, and behavioral aspects of this population. Identify the personal impact on yourself, be aware of compassion fatigue in colleagues, and learn ways to combat compassion fatigue. Understanding the unique barriers to discharge may improve discharge outcomes in the future.
THE USE OF PAIN NEUROSCIENCE EDUCATION IN THE REHABILITATION OF A PEDIATRIC PATIENT WITH AMPLIFIED MUSCULOSKELETAL PAIN SYNDROME THROUGH VIRTUAL TELEMEDICINE: A CASE REPORT
Will B, Georgetti T. Connecticut Children's
BACKGROUND & PURPOSE: Amplified musculoskeletal pain syndrome (AMPS) “is a term that encompasses the spectrum of manifestations of chronic pediatric musculoskeletal pain.” Treatment for AMPS includes cognitive-behavioral therapy, rehabilitation, and medication. Pain neuroscience education (PNE) is an educational model utilizing stories, metaphors, and images to teach patients about pain biology and physiology and has been found effective in the treatment of adults. There is limited published research on PNE outside of the adult population, particularly when combined with traditional physical therapy (PT) in a virtual telemedicine (VT) format for pediatrics. The purpose of this case report is to describe the benefits of PNE in the treatment of a pediatric patient with AMPS through VT.
CASE DESCRIPTION: The patient was a young adolescent female diagnosed with AMPS and referred for PT in order to improve function, school participation, and address pain complaints. Treatment included traditional PT combined with PNE through VT, at a frequency of 1×/wk for 11 weeks. At baseline, the patient reported constant pain ranging from 2-9 on the numeric pain rating scale (NPRS). The patient's level of physical function and disability was determined utilizing the functional disability inventory (FDI), to which she scored 16/60 (moderate disability). The patient was also attending school virtually secondary to her pain. PNE intervention consisted of the use of images displayed via screen sharing, in combination with metaphors and stories told by the therapist to aid in patient understanding of her pain.
OUTCOMES: At completion of intervention, the patient's average post-treatment pain ranged from 0-2 on the NPRS scale. An improvement in function was noted by reports of completion of 4,000 steps without an increase in pain and a decrease in FDI score to 3/60 (no/minimal disability). The patient's decrease in pain allowed for in person school participation. Patient with noted proficient understanding of PNE concepts through self-reports of listening to her body, resting when needed, and staying active. She reported PNE to be the most beneficial aspect of PT, specifically understanding the cause of her pain through PNE metaphors.
DISCUSSION: This case report describes effective use of PNE with traditional PT in pediatrics through VT. Where VT platforms lack in ability for hands on treatment it allowed for excellent transfer of PNE knowledge. For this patient, PNE provided through VT allowed for increased pain knowledge, ability to identify pain triggers, and improved self-management techniques that would likely be lacking in traditional PT approaches. Clinicians should consider use of PNE with pediatric patients with AMPS. More research regarding the use of PNE in the pediatric population would be beneficial to more thoroughly note the effects on pain, function, and disability.
SERIAL CASTING AND ORTHOTIC MANAGEMENT FOR TOE WALKING IN A CHILD ON THE AUTISM SPECTRUM: A CASE REPORT
Wirth A. NYU Langone Orthopedic Hospital
BACKGROUND & PURPOSE: This case study report will discuss the implementation of serial casting in conjunction with orthotic management to improve gait kinematics for a child with a diagnosis of autism spectrum disorder (ASD) and idiopathic toe walking (ITW). Literature review revealed serial casting and orthotic usage as a potential treatment strategy to improve gait kinematics for patients with ASD and ITW.
CASE DESCRIPTION: The patient is a four-year-old boy with a medical history of ASD and ITW. The family was referred for a physical therapy (PT) evaluation with primary complaints of ankle stiffness and toe walking. Family was referred for a PT evaluation by their orthopedic surgeon with primary complaints of ankle stiffness and toe walking. The patient had never received PT services prior. Research by Barkocy et al shows improvements in ankle kinematics and functional ankle dorsiflexion (DF) in children with a history of ASD and ITW.
OUTCOMES: The following outcome measures were administered prior to initiation of serial casting: ankle DF range of motion (ROM) knee extended and flexed, hamstring length test, observational gait scale and 50 foot toe walking test. Patient received 7 applications of bilateral serial casts utilizing soft cast with fiberglass reinforcement roughly one time per week over a 10 week period. Missed PT sessions were due to coverage difficulties and a transportation issue. Following serial casting, he was immediately placed into bilateral posterior leaf spring orthotics for carryover. Improvement in ankle DF knee extended ROM by 32 degrees on the right ankle (increasing to +6 degrees) and 26 degrees on the left ankle (increasing to +2 degrees). Pre-casting, he ambulated on tip-toes 100% of the time as per the 50 foot toe walking test. Post serial casting, he ambulates with 100% flat-foot and/or initial contact with use of his orthotics as per the 50 foot toe walking test. Heel rise improved from fixed equinus to slightly early and improved base of support from narrow to neutral as per the observational gait scale.
DISCUSSION: In conclusion, the child demonstrated improvement in bilateral ankle DF ROM knee extended and knee flexed, improvement in 50 foot toe walking test, and improvement in observational gait scale following a 10 week program of serial casting and orthotic management. The patient will continue with outpatient physical therapy receiving conservative treatment with emphasis on strengthening his proximal musculature, continue to improve range of motion, and develop a home exercise program for home carryover. Family has been instructed to utilize his orthotics daily with the plan to follow up in 6 months or sooner as needed. The combination of serial casting and orthotic management may be appropriate to consider when working with a child with ASD and ITW.