Physical therapy clinical management recommendations for children with cerebral palsy - spastic diplegia: achieving functional mobility outcomes

Sports Activities in Children with Cerebral Palsy: A Narrative Review

Physical exercise is known to have beneficial effects on psychosocial well-being and cognitive performance. Children with cerebral palsy (CP) showed lower levels of physical activity (PA) than healthy children; this fact, in addition to the basic clinical condition, increased the sedentary habit with a psychological impact and motor impairment of these children. Furthermore, children and adolescents with CP are less committed to sports activities than typically developing children of the same age. The aim of the present narrative review was to increase the amount of knowledge regarding the effectiveness and importance of specific and individualized sports in children with CP. A comprehensive search of MED-LINE and EMBASE databases was performed, including specific search terms such as "cerebral palsy" combined with "sport", "physical activity", and the names of different sports. No publication date limits were set. We included studies with an age range of 0-18 years. The main results pointed out that most of the sports improved motor function, quality of life, and coordination in children and adolescents with CP. Physicians, therapists, and parents should become aware of the benefits of sports activities for this population of patients. Specific sports activities could be included as a usual indication in clinical practice in addition to rehabilitation treatment.

Enhancing Post-Operative Recovery in Spastic Diplegia through Physical Therapy Rehabilitation following Selective Dorsal Rhizotomy: A Case Report and Thorough Literature Analysis

Spasticity is a common issue among children, especially those with bilateral spastic cerebral palsy (CP). Selective dorsal rhizotomy (SDR) is a surgical procedure that is often used to decrease lower limb rigidity, alongside other treatment options such as intrathecal medication, peripheral nerve surgery, and deep brain stimulation (DBS). The objective of these therapies is to improve the standard of living for young individuals. This article intends to explain the motor deficits observed in spastic diplegia and a rehabilitation program using physical therapy after SDR. The information can help with counseling parents about the prognosis and developing a clinical treatment plan. The article presents a case study of a 12-year-old girl who recently underwent L3, L4, and L5 nerve root rhizotomy in the physical therapy department. It highlights the importance of long-term physical therapy follow-up and orthotic usage in the management of spastic diplegia.

Relationship-driven, family-centered care via TelePT: Reflections in the wake of COVID-19

In response to the throttling of children’s therapy programs precipitated by COVID-19 shutdowns, interest in the use of telehealth has increased among service providers at both the clinical and administrative levels. TelePT promises to be particularly appropriate in devising programs of on-going, therapeutic exercise interventions for children with neuromotor disorders. From the lay perspective, physical/physiotherapy (PT) which is seemingly characterized by the “hands-on,” and corrective approach to managing impairments, makes it a counter-intuitive candidate for delivery over telehealth. Over the past decades, however, PT as a discipline has increasingly adhered to a relationship-driven, family-centered model of intervention. This model is “hands-off,” figuratively if not always literally, and hence is not necessarily disconsonant with delivery mediated by telehealth technology. The current study explores in-depth the experiences and reflections of seven practicing therapists, on the impact of telehealth, telePT on the operationalization of relationship-based, family-centered methods into therapy. Interpretative phenomenological analysis was selected as the analytic method for understanding participants’ experience providing services using both distance and standard face-to-face practice modalities. Results identified eight principal themes emerging from participants’ descriptions of their experience of delivering therapy over telePT. Four of these themes correspond to the tenets of relationship-driven, family-centered care identified across four frameworks applied to pediatric rehabilitation. The remaining four themes focus on the particularities of the telePT modality and its viability in clinical practice. The ability telePT afforded to “see into the child’s environment” emerged arguably as the greatest value of the modality in patient care. It revealed to therapists so much that they did not know about their patients’ progress and, more strikingly, had not realized they did not know. TelePT provides a unique window into the child’s functioning in the hours he is not in therapy. Given its potential in parent–therapist relationship building, assuring the ecological validity of therapy programs, and the empowerment of families who seek it, telePT is likely to be part of the future of PT and one driver of its evolution as a profession. There is a compelling case to retain telePT modalities offering them alongside in-person formats for convenience, safety, and service quality enhancement.

PedBotHome: A Video Game-Based Robotic Ankle Device Created for Home Exercise in Children With Neurological Impairments

PURPOSE

This pilot study assesses the feasibility of using PedBotHome to promote adherence to a home exercise program, the ability of the device to withstand frequent use, and changes in participant ankle mobility.PedBotHome is a robotic ankle device with integrated video game software designed to improve ankle mobility in children with cerebral palsy.

METHODS

Eight participants enrolled in a 28-day trial of PedBotHome. Ankle strength, range of motion, and plantar flexor spasticity were measured pre- and posttrial. Performance was monitored remotely, and game settings were modified weekly by physical therapists.

RESULTS

Four participants met the study goal of 20 days of use. There were statistically significant improvements in ankle strength, spasticity, and range of motion.

CONCLUSIONS

PedBotHome is a feasible device to engage children with static neurological injuries in ankle home exercise. This pilot study expands the paradigm for future innovative home-based robotic rehabilitation.

Toward Evaluation of the Subjective Experience of a General Class of User-Controlled, Robot-Mediated Rehabilitation Technologies for Children with Neuromotor Disability

Technological advances in game-mediated robotics provide an opportunity to engage children with cerebral palsy (CP) and other neuromotor disabilities in more frequent and intensive therapy by making personalized, programmed interventions available 24/7 in children's homes. Though shown to be clinically effective and feasible to produce, little is known of the subjective factors impacting acceptance of what we term assistive/rehabilitative (A/R) gamebots by their target populations. This research describes the conceptualization phase of an effort to develop a valid and reliable instrument to guide the design of A/R gamebots. We conducted in-depth interviews with 8 children with CP and their families who had trialed an exemplar A/R gamebot, PedBotHome, for 28 days in their homes. The goal was to understand how existing theories and instruments were either appropriate or inappropriate for measuring the subjective experience of A/R gamebots. Key findings were the importance of differentiating the use case of therapy from that of assistance in rehabilitative technology assessment, the need to incorporate the differing perspectives of children with CP and those of their parents into A/R gamebot evaluation, and the potential conflict between the goals of preserving the quality of the experience of game play for the child while also optimizing the intensity and duration of therapy provided during play.

Physical Therapists' Use of Evaluation Measures to Inform the Prescription of Ankle-Foot Orthoses for Children with Cerebral Palsy

Aims: To examine how physical therapists (PTs) use evaluation measures to guide prescription and re-assessment of ankle-foot orthoses (AFOs) for children with CP. Methods: PTs in Canada who work with children with CP were invited to complete an online survey. Survey questions examined PT evaluation and interpretation of findings at initial AFO prescription and re-assessment. Closed-ended responses were analyzed using descriptive statistics, and a conventional content analysis examined responses to open-ended questions. Results: Sixty responses from ten provinces were analyzed. Three themes emerged from the open-ended responses, which were supported by closed-ended responses. (1) Focus on impairment-level measures. Although evaluation primarily involved observational, non-standardized measures of impairments and gait pattern, most respondents also considered participation-level constructs. (2) Lack of confidence/knowledge. Respondents reported a moderate level of confidence concerning decision-making about AFO type and characteristics. 3) Inconsistent practices between therapists, possibly reflecting the paucity of available evidence or individualization of the prescription. Conclusions: Non-standardized, observational assessment methods, and impairment-level constructs appear to guide AFO prescription decisions. Integrating current knowledge into practice, developing best practice guidelines, and developing standardized tools to assess the effects of AFOs on participation may promote confidence, consistency, and improved outcomes.

Reliability and Validity of Objective Measures of Physical Activity in Youth With Cerebral Palsy Who Are Ambulatory

BACKGROUND

Physical therapy for youth with cerebral palsy (CP) who are ambulatory includes interventions to increase functional mobility and participation in physical activity (PA). Thus, reliable and valid measures are needed to document PA in youth with CP.

OBJECTIVE

The purpose of this study was to evaluate the inter-instrument reliability and concurrent validity of 3 accelerometer-based motion sensors with indirect calorimetry as the criterion for measuring PA intensity in youth with CP.

METHODS

Fifty-seven youth with CP (mean age=12.5 years, SD=3.3; 51% female; 49.1% with spastic hemiplegia) participated. Inclusion criteria were: aged 6 to 20 years, ambulatory, Gross Motor Function Classification System (GMFCS) levels I through III, able to follow directions, and able to complete the full PA protocol. Protocol activities included standardized activity trials with increasing PA intensity (resting, writing, household chores, active video games, and walking at 3 self-selected speeds), as measured by weight-relative oxygen uptake (in mL/kg/min). During each trial, participants wore bilateral accelerometers on the upper arms, waist/hip, and ankle and a portable indirect calorimeter. Intraclass coefficient correlations (ICCs) were calculated to evaluate inter-instrument reliability (left-to-right accelerometer placement). Spearman correlations were used to examine concurrent validity between accelerometer output (activity and step counts) and indirect calorimetry. Friedman analyses of variance with post hoc pair-wise analyses were conducted to examine the validity of accelerometers to discriminate PA intensity across activity trials.

RESULTS

All accelerometers exhibited excellent inter-instrument reliability (ICC=.94-.99) and good concurrent validity (rho=.70-.85). All accelerometers discriminated PA intensity across most activity trials.

LIMITATIONS

This PA protocol consisted of controlled activity trials.

CONCLUSIONS

Accelerometers provide valid and reliable measures of PA intensity among youth with CP.

Feasibility of using a large amplitude movement therapy to improve ambulatory function in children with cerebral palsy

Cerebral palsy (CP) is the most common cause of motor disability among children. Limited evidence exists regarding the efficacy of traditional rehabilitation strategies on improving ambulatory function in this population. The purpose of the study was to investigate the feasibility and short-term effects of a novel large amplitude movement therapy on ambulatory functions in children with CP. Temporal-spatial gait characteristics were examined before and after a single intervention session, replicated over five children. Five children with CP (7.0 ± 1.0 years); Gross Motor Function Classification System Levels I-II, participated. Baseline gait parameters were obtained as the participant walked across an instrumented walkway at self-selected and fast speeds. Children then participated in a 20-30 min intervention focused on making body and limb movements as large as possible with gait assessment repeated immediately. All children tolerated testing and therapy with no adverse effects. Outcomes after one intervention included: significantly greater stride velocity; reduced double support time; and greater stride length after training for three of the five participants. Results for this pilot study suggested that the large amplitude movement therapy was feasible for children with CP. There is a need for a larger scale study to determine if the protocol can be effective at an appropriate clinical dose.

A therapeutic skating intervention for children with autism spectrum disorder

PURPOSE

The purpose of this study was to evaluate the effects of a highly structured therapeutic skating intervention on motor outcomes and functional capacity in 2 boys with autism spectrum disorder aged 7 and 10 years.

METHODS

This multiple-baseline, single-subject study assigned participants to three 1-hour skating sessions per week for 12 weeks focusing on skill and motor development. Multiple data points assessed (a) fidelity to the intervention and (b) outcomes measures including the Pediatric Balance Scale, Timed Up and Go, floor to stand, Six-Minute Walk Test, goal attainment, and weekly on-ice testing.

RESULTS

Improvements were found in balance, motor behavior, and functional capacity by posttest with gains remaining above pretest levels at follow-up.

CONCLUSIONS

Therapeutic skating may produce physical benefits for children with autism spectrum disorder and offer a viable, inexpensive community-based alternative to other forms of physical activity.

A randomized, single-blind cross-over design evaluating the effectiveness of an individually defined, targeted physical therapy approach in treatment of children with cerebral palsy

Objective:

A pilot study to compare the effectiveness of an individual therapy program with the effects of a general physical therapy program.

Design:

A randomized, single-blind cross-over design.

Participants:

Ten ambulant children with bilateral spastic cerebral palsy, age four to nine years.

Intervention:

Participants were randomly assigned into a ten-week individually defined, targeted or a general program, followed by a cross-over.

Main outcome measures:

Evaluation was performed using the Gross Motor Function Measure-88 and three-dimensional gait analysis. General outcome parameters were Gross Motor Function Measure-88 scores, time and distance parameters, gait profile score and movement analysis profiles. Individual goal achievement was evaluated using z-scores for gait parameters and Goal Attainment Scale for gross motor function.

Results:

No significant changes were observed regarding gross motor function. Only after individualized therapy, step- and stride-length increased significantly ( p = 0.022; p = 0.017). Change in step-length was higher after the individualized program ( p = 0.045). Within-group effects were found for the pelvis in transversal plane after the individualized program ( p = 0.047) and in coronal plane after the general program ( p = 0.047). Between-program differences were found for changes in the knee in sagittal plane, in the advantage of the individual program ( p = 0.047). A median difference in z-score of 0.279 and 0.419 was measured after the general and individualized program, respectively. Functional goal attainment was higher after the individual therapy program compared with the general program (48 to 43.5).

Conclusion:

The results indicate slightly favorable effects towards the individualized program. To detect clinically significant changes, future studies require a minimal sample size of 72 to 90 participants.

Clinical tools to assess balance in children and adults with cerebral palsy: a systematic review

We aimed to review tools used to assess balance in clinical practice in children and adults with cerebral palsy (CP), to describe their content and measurement properties and to evaluate the quality of the studies that have examined these properties. CINAHL, Embase, and PubMed/MEDLINE were searched. The COnsensus-based Standards for selection of health Measurement INstruments (COSMIN) was used to assess the 'quality of studies' and the Terwee criteria were used to assess the 'result of studies'. Twenty-two clinical balance tools were identified from 35 papers. The content and focus of the tools varied significantly. There was moderate or limited levels of evidence for most of the measurement properties of the tools; the strongest level of evidence was found for the Trunk Control Measurement Scale and the Level of Sitting Scale, in the category 'maintain balance', the Timed Up and Go and the Segmental Assessment of Trunk Control in the categories 'achieve balance' and 'restore balance' respectively. Information on responsiveness was scarce. Further studies providing better evidence for reliability and responsiveness for clinical balance tools are needed. In the meantime, results of studies evaluating effects of treatment of balance in individuals with CP should be interpreted with caution.

Training to enhance walking in children with cerebral palsy: are we missing the window of opportunity?

The objective of this paper is to (1) identify from the literature a potential critical period for the maturation of the corticospinal tract (CST) and (2) report pilot data on an intensive, activity-based therapy applied during this period, in children with lesions to the CST. The best estimate of the CST critical period for the legs is when the child is younger than 2 years of age. Previous interventions for walking in children with CST damage were mainly applied after this age. Our preliminary results with training children younger than 2 years showed improvements in walking that exceeded all previous reports. Further, we refined techniques for measuring motor and sensory pathways to and from the legs, so that changes can be measured at this young age. Previous activity-based therapies may have been applied too late in development. A randomized controlled trial is now underway to determine if intensive leg therapy improves the outcome of children with early stroke.

Continued ambulation gains through high school in a student with cerebral palsy: a case report

PURPOSE

The purpose of this case report is to describe school-based physical therapy services received throughout high school by a student with diplegic cerebral palsy and to share her functional gains.

KEY POINTS

This previously discharged 15-year-old freshman was re-referred due to a perceived walking regression using long-leg braces/reverse rolling walker and her desire to again try crutches. She subsequently resumed walking, typically 4 days per week at school and progressed to axillary crutches on level surfaces and stairs. Gross Motor Function Measure scores increased from 66.4% freshman year to 78.8% senior year, with the greatest dimension changes in standing (35.9%-69.2%) and walking, running, and jumping (8.3%-25.0%).

CONCLUSION

School-based physical therapists are uniquely positioned to work with students in natural environments to optimize activity and participation. This report shows that continued ambulation gains in individuals with cerebral palsy are possible throughout adolescence.

Predictors of Standardized Walking Obstacle Course outcome measures in children with and without developmental disabilities

PURPOSE

This study was designed to determine which characteristics of children predict measures on the Standardized Walking Obstacle Course (SWOC).

METHODS

SWOC testing was performed under 3 conditions: (1) walk, (2) walk with a tray, and (3) walk wearing shaded glasses. Trials consisted of standing up, walking the course in 1 direction, and sitting down. Children (n = 440) completed 2 trials per condition. Trial measures included time, and numbers of steps, stumbles, and steps off the path. Relationships were evaluated using Chi-square analyses and significant predictors were determined by multiple logistic regression analyses. Sensitivity and specificity were calculated to determine the accuracy of disability as a predictor.

RESULTS

Age, weight, and disability were the strongest predictors (P < .05). Increased age and weight predicted shorter time and fewest steps. Disability predicts longer time and most steps.

CONCLUSION

The SWOC is appropriate to screen children for disabilities in functional ambulation.

Pediatric physical therapists' use of support walkers for children with disabilities: a nationwide survey

PURPOSE

This study investigated pediatric physical therapists' use of support walkers (SWs) for children with disabilities.

METHODS

An 8-page survey was mailed to 2500 randomly selected members of the Section on Pediatrics of the American Physical Therapy Association. Respondents to the survey included 513 pediatric physical therapists who were users of SWs. Descriptive statistics were calculated and themes were analyzed.

RESULTS

Several SWs were reported as used most often to improve gait, mobility, participation at school, and interaction with peers. Use commonly included a month trial before purchase and 9 sessions of physical therapy to train a child for use in school. Reasons given for the use of SWs were improving impairments, functional limitations, and participation with peers.

CONCLUSIONS

Pediatric physical therapists use SWs to increase postural control, mobility, and children's participation in school.

The application of motor learning strategies within functionally based interventions for children with neuromotor conditions

PURPOSE

To identify and describe the application of 3 motor learning strategies (verbal instructions, practice, and verbal feedback) within 4 intervention approaches (cognitive orientation to daily occupational performance, neuromotor task training, family-centered functional therapy, and activity-focused motor interventions).

METHODS

A scoping review of the literature was conducted. Two themes characterizing the application of motor learning strategies within the approaches are identified and described.

RESULTS

Application of a motor learning strategy can be a defining component of the intervention or a means of enhancing generalization and transfer of learning beyond the intervention. Often, insufficient information limits full understanding of strategy application within the approach.

CONCLUSIONS

A greater understanding of the application, and perceived nonapplication, of motor learning strategies within intervention approaches has important clinical and research implications.

Use of the Guide to Physical Therapist Practice by pediatric physical therapists

PURPOSE

Physical therapists are encouraged to use the Guide to Physical Therapist Practice (Guide) in their practice. The purpose of this study was to determine whether and how pediatric physical therapists (PTs) use the Guide.

SUBJECTS AND METHODS

A nationwide electronic survey was sent to pediatric physical therapists. Four hundred seventy-five members returned the survey yielding a 9.6% response rate.

RESULTS

Respondents reported that they practice consistently with the Guide's patient/client management model but that they do not find the Guide useful. Respondents made recommendations for a future edition of the Guide.

CONCLUSIONS

Pediatric PTs value the Guide as a reference, resource, and teaching tool. When the Guide is revised, the following should be considered: pediatric content, format, and utility of the Guide; educational needs of pediatric PTs about the Guide; and how stakeholders and PTs with other specialties view and use the Guide.