Coupling Timing of Interventions With Dose to Optimize Plasticity and Participation in Pediatric Neurologic Populations

Developmental Skills and Neurorehabilitation for Children With Batten Disease: A Retrospective Chart Review of a Comprehensive Batten Clinic

BACKGROUND

Batten disease is a rare, progressive neurogenetic disorder composed of 13 genotypes that often presents in childhood. Children present with seizures, vision loss, and developmental regression. Neurorehabilitation services (i.e., physical therapy, occupational therapy, and speech-language therapy) can help improve the quality of life for children and their families. Owing to the rarity of Batten disease, there are no standardized clinical recommendations or outcome assessments. To describe developmental profiles, current dose of neurorehabilitation, and outcome assessments used clinically for children diagnosed with Batten disease.

METHODS

Electronic medical records of 70 children with Batten disease (subtypes n = 5 CLN1; n = 25 CLN2; n = 23 CLN3; n = 17 CLN6) were reviewed (7.0 ± 3.4 years). Descriptive statistics were used to describe clinical features, developmental skills, dose of neurorehabilitation, and outcome assessment use.

RESULTS

Across CLN subtypes, most children experienced vision impairments (61%) and seizures (68%). Most children demonstrated delays in fine motor (65%), gross motor (80%), cognitive (63%), and language skills (83%). The most common frequency of neurorehabilitation was weekly (42% to 43%). Two standardized outcome assessments were used to track developmental outcomes: Peabody Developmental Motor Scales, second edition (30% of children completed this assessment) and Preschool Language Scales, fifth edition (27.4% of children completed this assessment).

CONCLUSIONS

Neurorehabilitation professionals should understand the clinical features and prognosis for children with Batten disease. The child's clinical features and family preferences should guide the rehabilitation plan of care. Future work needs to be completed to define dosing parameters and validate outcome assessments for neurorehabilitation services.

Defining, quantifying, and reporting intensity, dose, and dosage of neurorehabilitative interventions focusing on motor outcomes

Introduction

Determining the minimal amount of therapy needed for positive neurorehabilitative outcomes is important for optimizing active treatment interventions to improve motor outcomes. However, there are various challenges when quantifying these relationships: first, several consensuses on the definition and usage of the terms intensity, dose, and dosage of motor interventions have been proposed, but there seems to be no agreement, and the terms are still used inconsistently. Second, randomized controlled trials frequently underreport items relevant to determining the intensity, dose, and dosage of the interventions. Third, there is no universal measure to quantify therapy intensity accurately. This "perspectives" paper aims to increase awareness of these topics among neurorehabilitation specialists.

Defining quantifying and reporting

We searched the literature for definitions of intensity, dose, and dosage and adapted the ones we considered the most appropriate to fit the needs of neurorehabilitative interventions. Furthermore, we suggest refining the template for intervention description and replication (TIDieR) to enhance the reporting of randomized controlled trials. Finally, we performed a systematic literature search to provide a list of intensity measures and complemented these with some novel candidate measures.

Discussion

The proposed definitions of intensity, dose, and dosage could improve the communication between neurorehabilitation specialists and the reporting of dose and dosage in interventional studies. Quantifying intensity is necessary to improve our understanding of the minimal intensity, dose, and dosage of therapy needed to improve motor outcomes in neurorehabilitation. We consider the lack of appropriate intensity measures a significant gap in knowledge requiring future research.

Clinical Outcomes of an Intensity Program for Children With Movement Challenges

PURPOSE

Physical therapists at an outpatient pediatric facility developed and implemented an Intensity Program for children with movement challenges. The program was initiated on the basis of best evidence, parent advocacy, and clinician expertise. The purpose of this investigation is to analyze outcome data gathered from the program since 2012 to determine the effect of the program along with any specific child characteristics that were more likely to lead to positive outcomes.

METHODS

A variety of outcome data were analyzed to compare preprogram performance with postprogram performance.

RESULTS

Program participants made statistically significant and clinically important improvement in most outcome measures. Parents were highly satisfied with the program, including 98% of respondents who indicated that they would like to repeat their participation in the program.

CONCLUSIONS

The results of this investigation suggest that many children with movement challenges are likely to benefit from participation in an Intensity Program.

Correlation between performance and quantity/variability of leg exploration in a contingency learning task during infancy

Quantity and quality of motor exploration are proposed to be fundamental for infant motor development. However, it is still not clear what types of motor exploration contribute to learning. To determine whether changes in quantity of leg movement and/or variability of leg acceleration are related to performance in a contingency learning task, twenty 6-8-month-old infants with typical development participated in a contingency learning task. During this task, a robot provided reinforcement when the infant's right leg peak acceleration was above an individualized threshold. The correlation coefficient between the infant's performance and the change in quantity of right leg movement, linear variability, and nonlinear variability of right leg movement acceleration from baseline were calculated. Simple linear regression and multiple linear regression were calculated to explain the contribution of each variable to the performance individually and collectively. We found significant correlation between the performance and the change in quantity of right leg movement (r = 0.86, p < 0.001), linear variability (r = 0.71, p < 0.001), and nonlinear variability (r = 0.62, p = 0.004) of right leg movement acceleration, respectively. However, multiple linear regression showed that only quantity and linear variability of leg movements were significant predicting factors for the performance ratio (p < 0.001, adjusted R² = 0.94). These results indicated that the quantity of exploration and variable exploratory strategies could be critical for the motor learning process during infancy.

Caregiver Perceptions of an Interdisciplinary Intensive Therapy Program: A Qualitative Study

PURPOSE

To explore perceptions of caregivers of children with neurodevelopmental conditions participating in an interdisciplinary intensive therapy program.

METHODS

Semi-structured interviews were completed with caregivers. The intensive program consisted of occupational, physical, and/or speech therapy 3 to 6.5 hours/day, 3 to 5 days/week, for 4 weeks. Team-based collaborative goal setting was used to determine each child's plan of care. Reflexive thematic analysis identified interview themes.

RESULTS

Thirteen caregivers participated. Children ranged in age from 6 to 13 years; diagnoses included cerebral palsy (n = 10), spina bifida (n = 1), ataxia (n = 1), and stroke (n = 1). An overarching theme of Immersive was identified; other themes included Everybody's Empowered, Principles of Neuroplasticity, Progress Across the ICF (International Classification of Functioning, Disability, and Health) Framework, It Takes a Team, and Benefits Outweigh the Challenges.

CONCLUSIONS

Caregivers valued interdisciplinary intensive therapy. For children with complex rehabilitation needs, an interdisciplinary, intensive therapy program may be a viable alternative to traditional therapy models for service delivery.

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.

Daily Outpatient Physical Therapy for a Toddler With a Neurodegenerative Disease: A Case Report

PURPOSE

This case report highlights the potential value of delivering a high-dose physical therapy (PT) intervention for a child with a neurodegenerative disease. We include developmental outcomes for a 23-month-old toddler with biallelic TBCD gene mutations following daily outpatient PT.

SUMMARY OF KEY POINTS

The child had clinical improvements in gross and fine motor, cognition, expressive and receptive language, socioemotional, and adaptive behavior function as determined through Goal Attainment Scaling, Gross Motor Function Measure, and Bayley Scales of Infant and Toddler Development following daily PT intervention.

STATEMENT OF CONCLUSION AND RECOMMENDATIONS FOR CLINICAL PRACTICE

High-dose outpatient PT may be beneficial for a child with a neurodegenerative disease at some time frames. In selected cases, if the neurodegenerative disease slowly progresses, high-dose PT may be a treatment option to promote motor change.

Changing the Paradigm of School-Based Physical Therapist Service Delivery: Using Evidence to Support Intensive Intervention

PURPOSE

The purpose of this article is to highlight the paradigm shift away from the typical model of direct service delivery of consistent frequency and duration in the school setting to accommodate an intensive progressive resistive exercise intervention. School-based physical therapists describe how they applied an evidence-based intensive intervention with multiple students in an urban public school district.

SUMMARY OF KEY POINTS

The school-based physical therapists had to modify the typical service delivery model and overcome other challenges to implement this intensive intervention approach. Substantial improvements in strength and functional activities were observed in multiple students and measured across several months.

CONCLUSIONS AND RECOMMENDATIONS FOR CLINICAL PRACTICE

An intensive intervention model appears effective and feasible in the school setting. Evidence-based intervention approaches should be considered when the student could benefit.

VIDEO ABSTRACT

For more insights from the authors, see Supplemental Digital Content 1, available at: http://links.lww.com/PPT/A339.

Exploring the Unmet Need for Technology to Promote Motor Ability in Children Younger Than 5 Years of Age: A Systematic Review

Objective

To (1) identify types of technology that promote motor ability in children younger than 5 years of age, (2) report on the type of support these devices provide, and (3) evaluate their potential for use in the community (outside of the laboratory or clinic).

Data Sources

A literature search of PubMed was conducted in February 2019 using specific terms, including child, rehabilitation, movement, and instrumentation.

Study Selection

The search yielded 451 peer-reviewed articles, which were screened by multiple reviewers. Articles that described the use of devices for the purpose of motor rehabilitation and/or assistance (regardless of device type or body part targeted) in the age range of 0-5 years were eligible for inclusion.

Data Extraction

In conformity with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, final stage data extraction consisted of full text readings where each article was reviewed twice by 3 independent reviewers.

Data Synthesis

About half of the devices available (46%) for children younger than 5 years of age are orthotics and corrective casting devices. There are more facilitative (ie, power mobility devices) than inhibitive (ie, casting) technologies being used. Approximately 60% of the devices are designed for use by a single body part. Walking is the most common motor skill addressed. Although most of the devices were used to some degree outside of the laboratory or clinic, most of the devices available are considered investigative and are not available for commercial purchase.

Conclusions

Many types of pediatric devices to assist movement exist, but the current scope of employed devices is limited. There is a need for developing technology that allows for, if not supports, high-dosage, early, and variable motor practice that can take place in community settings.

GEARing smart environments for pediatric motor rehabilitation

BACKGROUND

There is a lack of early (infant) mobility rehabilitation approaches that incorporate natural and complex environments and have the potential to concurrently advance motor, cognitive, and social development. The Grounded Early Adaptive Rehabilitation (GEAR) system is a pediatric learning environment designed to provide motor interventions that are grounded in social theory and can be applied in early life. Within a perceptively complex and behaviorally natural setting, GEAR utilizes novel body-weight support technology and socially-assistive robots to both ease and encourage mobility in young children through play-based, child-robot interaction. This methodology article reports on the development and integration of the different system components and presents preliminary evidence on the feasibility of the system.

METHODS

GEAR consists of the physical and cyber components. The physical component includes the playground equipment to enrich the environment, an open-area body weight support (BWS) device to assist children by partially counter-acting gravity, two mobile robots to engage children into motor activity through social interaction, and a synchronized camera network to monitor the sessions. The cyber component consists of the interface to collect human movement and video data, the algorithms to identify the children's actions from the video stream, and the behavioral models for the child-robot interaction that suggest the most appropriate robot action in support of given motor training goals for the child. The feasibility of both components was assessed via preliminary testing. Three very young children (with and without Down syndrome) used the system in eight sessions within a 4-week period.

RESULTS

All subjects completed the 8-session protocol, participated in all tasks involving the selected objects of the enriched environment, used the BWS device and interacted with the robots in all eight sessions. Action classification algorithms to identify early child behaviors in a complex naturalistic setting were tested and validated using the video data. Decision making algorithms specific to the type of interactions seen in the GEAR system were developed to be used for robot automation.

CONCLUSIONS

Preliminary results from this study support the feasibility of both the physical and cyber components of the GEAR system and demonstrate its potential for use in future studies to assess the effects on the co-development of the motor, cognitive, and social systems of very young children with mobility challenges.

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.

User-centred assistive technology assessment of a portable open-area body weight support system for in-home use

PURPOSE

Current paediatric technology lacks mobility devices that support early, high-dose and variable movement that can be managed by professionals and parents outside of the lab or clinic. Parent acceptability of the technology is a critical piece to the continued use of devices by their infants. The purpose of this study was to determine the level of feasibility of an in-home application of a novel portable body weight support system (PBWSS), designed for community use.

METHOD

Sixteen typically and atypically developing infants used the system for four sessions at the home and lab. Parents assisted with the in-home system setup and completed a questionnaire on their: (a) infant's behavioural change, (b) infant's enjoyment, (c) own satisfaction, need and predicted use of the device, and (d) recommendations for future modifications.

RESULTS

Parents and their infants successfully used the device during a wide range of activities. Parents noted positive changes in their infants' behaviour including their infants initiating certain behaviours for the first time. Parents quickly learned to setup and use the device and were satisfied with its current structure. Future modifications included increasing the wearable harness comfort.

CONCLUSION

Infant performance and parent perceptions support the development of devices that place body-weight supported activity in real-world environments to promote high-dose, enriched experiences for young infants with mobility challenges.Implications for rehabilitationAssistive technology that can support multiple aspects of mobility in developing infants is limited.The in-home application of open-area body weight support systems has the potential to support early, enriched, high-dose mobility.Users of this technology, infants and their parents, were meaningfully involved throughout the assessment process.Preliminary findings support that: (1) this device was successfully implemented in these homes, (2) parents and infants enjoyed using the device, (3) parents noted positive changes in their infant's behavior, and (4) parents perceived the device to be safe and easy to use.Future studies can now determine the optimal use of this device with a range of pediatric populations.