Contribution of stepping while standing to function and secondary conditions among children with cerebral palsy

Supported standing and stepping device use in young children with cerebral palsy, gross motor function classification system III, IV and V: A descriptive study

This study described and compared use of supported-standing and stepping devices by young children with cerebral palsy, Gross-Motor Function Classification System (GMFCS) levels III-V following power mobility introduction. Data was collected at two time-points, 5-6 months apart, for 42 participants, aged 18-80 months, using the Home Use of Technology for CHildren (HUTCH). Supported-standing and stepping device choice and time in each device remained stable over 6 months. Associations between device use and three functional classifications were examined. Children with more impaired motor, postural and manual abilities were more likely to use a supine stander rather than a prone/upright stander or no stander. Children at GMFCS V tended to use hands-free stepping devices, while support-arms stepping devices were more common for children at GMFCS IV. Only children at GMFCS III used convertible stepping devices. Using power mobility, standers and supported-stepping devices was feasible and 19/34 classified at GMFCS IV/V used all three devices over 6 months. A key finding was that introduction of power mobility did not reduce use of supported-stepping devices at any GMFCS level. Use of multiple upright positioning and mobility devices may assist children with limited mobility to be actively engaged and participate in daily life.

Supported Standing and Supported Stepping Devices for Children with Non-Ambulant Cerebral Palsy: An Interdependence and F-Words Focus

Children functioning at Gross Motor Function Classification System (GMFCS) levels IV-V cannot maintain an aligned standing position or take steps without support. Upright positioning and mobility devices have psycho-social significance for these children and their families, enhancing use of vision, communication, functioning and emotional well-being. Standers and supported stepping devices facilitate opportunities for biomechanical loading, potentially helping to build and maintain muscle and bone integrity, and they promote physical development. However, families are often required to choose between these two devices for their young child. This study aims to synthesize evidence for use and benefits of both supported standing and stepping devices through the lens of two contemporary theoretical frameworks to support clinical reasoning and implementation. The F-words for childhood development (functioning, family, fitness, fun, friends, future) and the interdependence-Human Activity Assistive Technology (iHAAT) models were combined to illustrate the complex interactions between the child, family, caregivers, peers and contextual factors when implementing standing and stepping devices with children at GMFCS levels IV and V. Supported standing and stepping devices provide complementary benefits, and both may be necessary starting at 9-15 months. We propose they both be included ON-Time, along with other age-appropriate positioning and mobility devices, to promote more equitable developmental opportunities for children with non-ambulant cerebral palsy.

Journey to 1 Million Steps: A Retrospective Case Series Analyzing the Implementation of Robotic-Assisted Gait Training Into an Outpatient Pediatric Clinic

PURPOSE

To describe the implementation of an exoskeleton program in a rehabilitation setting using a Design Thinking framework.

METHODS

This is a retrospective case series of 3 randomly selected children who participated in skilled physical therapy using a pediatric exoskeleton that occurred on our journey to walking 1 000 000 steps in the exoskeleton devices. Participants ranged in age from 3 to 5 years, and all had neurologic disorders.

RESULTS

All participants improved toward achieving their therapy goals, tolerated the exoskeleton well, and had an increased number of steps taken over time.

CONCLUSION

The implementation of new technology into pediatric care and an established outpatient therapy clinic is described. The Design Thinking process applies to health care professionals and improves clinical care. Exoskeletons are effective tools for use in pediatric physical therapy.

F-words e ingredientes das intervenções precoces para crianças com paralisia cerebral não deambuladoras: uma revisão de escopo

Cuidados centrados na família (incluindo coaching e intervenções fornecidas pelo cuidador) e treinamento parental formal são estratégias eficazes para crianças nos níveis IV e V do GMFCS. Os ingredientes de tecnologia assistiva podem promover várias F-words (funcionalidade, saúde, família, diversão, amigos e futuro). O menor nível de evidência foi encontrado para diversão, amigos e futuro. Outros fatores (prestação de serviços, treinamento profissional, dose de terapia, modificações ambientais) são relevantes para crianças pequenas nos níveis IV e V do GMFCS. Esta revisão de escopo identificou os ingredientes de intervenções precoces para crianças com paralisia cerebral em risco de não serem deambuladoras, e os mapeou-os de acordo com a estrutura das F-words. O treinamento formal dos pais e a tecnologia assistiva se destacaram como estratégias para abordar com várias F-words.

F-words and early intervention ingredients for non-ambulant children with cerebral palsy: A scoping review

AIM

To explore the ingredients of early interventions provided to young children with cerebral palsy (CP) who are classified in Gross Motor Function Classification System (GMFCS) levels IV and V, and to identify the 'F-words' addressed by the interventions.

METHOD

Searches were completed in four electronic databases. Inclusion criteria were the original experimental studies that fitted the following PCC components: population, young children (aged 0-5 years, at least 30% of the sample) with CP and significant motor impairment (GMFCS levels IV or V, at least 30% of the sample); concept, non-surgical and non-pharmacological early intervention services measuring outcomes from any of the International Classification of Functioning, Disability and Health domains; and context, studies published from 2001 to 2021, from all settings and not limited to any specific geographical location.

RESULTS

Eighty-seven papers were included for review, with qualitative (n = 3), mixed-methods (n = 4), quantitative descriptive (n = 22), quantitative non-randomized (n = 39), and quantitative randomized (n = 19) designs. Fitness (n = 59), family (n = 46), and functioning (n = 33) ingredients were addressed by most experimental studies, whereas studies on fun (n = 6), friends (n = 5), and future (n = 14) were scarce. Several other factors (n = 55) related to the environment, for example, service provision, professional training, therapy dose, and environmental modifications, were also relevant.

INTERPRETATION

Many studies positively supported formal parent training and use of assistive technology to promote several F-words. A menu of intervention ingredients was provided, with suggestions for future research, to incorporate them into a real context within the family and clinical practice.

WHAT THIS PAPER ADDS

Family-centred care (including coaching and caregiver-delivered interventions) and formal parental training are effective strategies for children in GMFCS levels IV and V. Assistive technology ingredients (power, mobility, supported, sitting, stepping, and standing) may promote several 'F-words' (functioning, fitness, family, fun, friends, and future). The lowest level of evidence was found for fun, friends, and future. Other factors (service provision, professional training, therapy dose, environmental modifications) are relevant for young children in GMFCS levels IV and V.

F-Wörter und Interventionsinhalte in der Frühförderung nicht gehfähiger Kinder mit Cerebralparese: eine umfangreiche Literaturübersicht

Ziel

Untersuchung der Inhalte von Frühfördermaßnahmen für Kleinkinder mit Cerebralparese (CP) mit Gross Motor Function Classification System (GMFCS) Level IV und V und die Identifikation von „F‐Wörtern“, die von den Maßnahmen adressiert werden.

Methode

Recherche in vier elektronischen Datenbanken. Einschlusskriterien: experimentelle Originalstudien, die die folgenden PCC‐Komponenten erfüllten: Population: Kleinkinder (im Alter von 0–5 Jahre, mindestens 30% der Stichprobe) mit CP und erheblicher motorischer Beeinträchtigung (GMFCS‐Levels IV oder V, mindestens 30% der Stichprobe); Konzept: nicht‐chirurgische und nicht‐pharmakologische Leistungen der Frühförderung, die Ergebnisse aus einem der Bereiche der Internationalen Klassifikation der Funktionsfähigkeit, Behinderung und Gesundheit (ICF) messen; und Kontext: Studien, die zwischen 2001 und 2021 veröffentlicht wurden, in allen Konstellationen und nicht auf einen bestimmten geografischen Ort beschränkt.

Ergebnisse

87 Studien wurden in dieser Literaturübersicht berücksichtigt, mit qualitativen (n = 3), Mixed Methods (n = 4), quantitativ deskriptiven (n = 22), quantitativ nicht‐randomisierten (n = 39) und quantitativ randomisierten (n = 19) Designs. Die meisten experimentellen Studien befassten sich mit Fitness (n = 59), Familie (n = 46) und Funktion (n = 33), während es nur wenige Studien zu den Bereichen Spaß (n = 6), Freunde (n = 5) und Zukunft (n = 14) gab. Verschiedene Umweltfaktoren (n = 55) waren ebenfalls bedeutsam, z. B. das Angebot an Dienstleistungen, Berufsausbildung, Therapiedosis und Umweltanpassungen.

Interpretation

Viele Studien unterstützen Elternschulungen und den Einsatz assistiver Technologien zur Förderung verschiedener F‐Wörter. Ein „Menü“ von Inhalten der Frühförderung wurden ermittelt, mit Vorschlägen für weitere Forschung, um diese in der klinischen Praxis mit Familien umzusetzen.

Was dieser Artikel beiträgt

Strategies used for childhood chronic functional constipation: the SUCCESS evidence synthesis

Background

Up to 30% of children have constipation at some stage in their life. Although often short-lived, in one-third of children it progresses to chronic functional constipation, potentially with overflow incontinence. Optimal management strategies remain unclear.

Objective

To determine the most effective interventions, and combinations and sequences of interventions, for childhood chronic functional constipation, and understand how they can best be implemented.

Methods

Key stakeholders, comprising two parents of children with chronic functional constipation, two adults who experienced childhood chronic functional constipation and four health professional/continence experts, contributed throughout the research. We conducted pragmatic mixed-method reviews. For all reviews, included studies focused on any interventions/strategies, delivered in any setting, to improve any outcomes in children (0-18 years) with a clinical diagnosis of chronic functional constipation (excluding studies of diagnosis/assessment) included. Dual reviewers applied inclusion criteria and assessed risk of bias. One reviewer extracted data, checked by a second reviewer. Scoping review: We systematically searched electronic databases (including Medical Literature Analysis and Retrieval System Online, Excerpta Medica Database, Cumulative Index to Nursing and Allied Health Literature) (January 2011 to March 2020) and grey literature, including studies (any design) reporting any intervention/strategy. Data were coded, tabulated and mapped. Research quality was not evaluated. Systematic reviews of the evidence of effectiveness: For each different intervention, we included existing systematic reviews judged to be low risk of bias (using the Risk of Bias Assessment Tool for Systematic Reviews), updating any meta-analyses with new randomised controlled trials. Where there was no existing low risk of bias systematic reviews, we included randomised controlled trials and other primary studies. The risk of bias was judged using design-specific tools. Evidence was synthesised narratively, and a process of considered judgement was used to judge certainty in the evidence as high, moderate, low, very low or insufficient evidence. Economic synthesis: Included studies (any design, English-language) detailed intervention-related costs. Studies were categorised as cost-consequence, cost-effectiveness, cost-utility or cost-benefit, and reporting quality evaluated using the consensus health economic criteria checklist. Systematic review of implementation factors: Included studies reported data relating to implementation barriers or facilitators. Using a best-fit framework synthesis approach, factors were synthesised around the consolidated framework for implementation research domains.

Results

Stakeholders prioritised outcomes, developed a model which informed evidence synthesis and identified evidence gaps.

Scoping review

651 studies, including 190 randomised controlled trials and 236 primary studies, conservatively reported 48 interventions/intervention combinations.

Effectiveness systematic reviews

studies explored service delivery models (n = 15); interventions delivered by families/carers (n = 32), wider children's workforce (n = 21), continence teams (n = 31) and specialist consultant-led teams (n = 42); complementary therapies (n = 15); and psychosocial interventions (n = 4). One intervention (probiotics) had moderate-quality evidence; all others had low to very-low-quality evidence. Thirty-one studies reported evidence relating to cost or resource use; data were insufficient to support generalisable conclusions. One hundred and six studies described implementation barriers and facilitators.

Conclusions

Management of childhood chronic functional constipation is complex. The available evidence remains limited, with small, poorly conducted and reported studies. Many evidence gaps were identified. Treatment recommendations within current clinical guidelines remain largely unchanged, but there is a need for research to move away from considering effectiveness of single interventions. Clinical care and future studies must consider the individual characteristics of children.

Study registration

This study is registered as PROSPERO CRD42019159008.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 128470) and is published in full in Health Technology Assessment; Vol. 28, No. 5. See the NIHR Funding and Awards website for further award information.

F-words e ingredientes de las intervenciones tempranas dirigidas a niños no ambulantes con parálisis cerebral: Una revisión exploratoria

La atención centrada en la familia (incluyendo coaching e intervenciones realizadas por los cuidadores) y el entrenamiento formal de los padres son estrategias efectivas para los niños con niveles IV y V de la GMFCS. Los ingredientes de la tecnología de apoyo pueden promover varias "F-words" (funcionamiento, estado físico, familia, diversión, amigos y futuro). Se encontró el nivel más bajo de evidencia para diversión, amigos y futuro. Otros factores (provisión de servicios, formación profesional, dosis de terapia, modificaciones del entorno) son relevantes para los niños pequeños con niveles IV y V de la GMFCS. Ingredientes de la intervención y F-words en intervenciones tempranas dirigidas a niños no ambulantes con parálisis cerebral.

The Prevalence of Bladder and Bowel Dysfunction in Children with Cerebral Palsy and its Association with Motor, Cognitive, and Autonomic Function

PURPOSE

To describe the prevalence of bladder and bowel dysfunction (BBD) in 8-10-year-old children with cerebral palsy and its association with motor, cognitive, and autonomic dysfunction.

METHODS

A cross-sectional, random sample study of parents of 8-10-year-old children with cerebral palsy. Tools: The Enuresis/Urinary Incontinence Parental Questionnaire, the Functional Independence Measure children's version, the autonomic signs questionnaire, and the Gross Motor Function Classification System.

RESULTS

39 out of 59 parents consented to participate, whereas 25.64% reported complete continence. Of the 29 children with BBD, 21 (72.4%) had lower urinary tract symptoms and bowel problems. Only two of the children received conservative and noninvasive treatments. Lastly, motor, cognitive and autonomic impairments were associated with incontinence.

CONCLUSIONS

BBD is common in 8-10-year-old children with cerebral palsy at all levels of functioning. Most having both lower urinary tract symptoms and bowel problems.

Is Standing Function Improved After Orthopaedic Surgery in Children With Cerebral Palsy at GMFCS Levels III/IV?

BACKGROUND

Children with cerebral palsy (CP) at Gross Motor Function Classification System (GMFCS) levels III/IV are at risk for losses in standing function during adolescence and transition to adulthood. Multilevel surgery (MLS) is an effective treatment to improve gait, but its effects on standing function are not well documented. The objectives of our study were to describe standing function in children with CP classified as GMFCS levels III/IV and evaluate change after MLS.

METHODS

This retrospective study included children with CP (GMFCS III/IV) ages 6 to 20 years who underwent instrumented gait analysis. A subset who underwent MLS were evaluated for change. Primary outcome measures were Gross Motor Function Measure dimension D, gait velocity, functional mobility scale, and the Pediatric Outcomes Data Collection Instrument (PODCI). Additional impairment level measures included foot pressure, knee extension during stance phase of gait, and knee extension passive range of motion.

RESULTS

Four hundred thirty-seven instrumented gait analysis sessions from 321 children with CP (ages 13.7±4.8 y; GMFCS III-81%/IV-19%) were included. The GMFCS III group had higher Gross Motor Function Measure dimension D, gait velocity, PODCI scores, and better knee extension compared with the GMFCS IV group ( P <0.05); 94 MLS were evaluated for postoperative change 15.3±4.2 months after MLS. Children at GMFCS level III had improved PODCI scores ( P <0.05), better knee extension passive range of motion ( P <0.01), and improved coronal plane foot pressure ( P <0.05) post MLS. Maximum knee extension during stance and heel impulse improved significantly in both groups ( P <0.01).

CONCLUSIONS

Standing function of children with CP at GMFCS IV was significantly more limited than at GMFCS III. After MLS, both groups (III/IV) showed improvement in impairment level outcomes (knee extension and foot position), whereas only those functioning at GMFCS III had improvement in activity/participation outcomes according to the PODCI. For children with CP at GMFCS levels IV, MLS may improve standing function, but appropriate goals related to assisted standing and measurement protocols sensitive to limited functional mobility should be adopted.

LEVEL OF EVIDENCE

Level III-retrospective comparative study.

Supported-standing interventions for children and young adults with non-ambulant cerebral palsy: A scoping review

AIM

To describe the evidence, outcomes, and lived experience of supported standing for children and young adults with cerebral palsy aged 25 years or younger, classified in Gross Motor Function Classification System levels IV and V.

METHOD

This scoping review included searches in eight electronic databases and manual searching from database inception to May 2020 and updated on 21st February 2022. Two of three reviewers independently screened titles and abstracts and extracted and appraised data. Methodological quality and risk of bias were appraised using tools appropriate to study type. Content analysis and frequency effect sizes were calculated for qualitative and descriptive evidence.

RESULTS

From 126 full-text references, 59 citations (one study was reported over two citations) were included: 16 systematic reviews, 17 intervention studies reporting over 18 citations, eight analytical cross-sectional studies, five descriptive cross-sectional/survey studies, five qualitative studies, and one mixed-methods study were identified, along with six clinical guidelines. Maintenance of bone mineral density and contracture prevention outcomes were supported by the most experimental studies and evidence syntheses, while evidence supporting other outcomes was primarily quasi-experimental or descriptive. Qualitative evidence suggests that programmes are influenced by attitudes, device, child, and environmental factors.

INTERPRETATION

Individualized assessment and prescription are essential to match personal and environmental needs. Although experimental evidence is limited due to many factors, lived-experience and cohort data suggest that successful integration of standing programmes into age-appropriate and meaningful activities may enhance function, participation, and overall health.

Benefits of a Low-Cost Walking Device in Children with Cerebral Palsy: A Qualitative Study

Children with Cerebral Palsy (CP) participate less regularly in physical and social activities. Support walkers allow mobility for infants who need aid. The aim of this study is to explore the benefits of a low-cost walking device in children with CP. A qualitative study using semi-structured, face-to-face interviews was conducted. Eight participants (two parents, two educational professionals, and four physical therapists) who live or work with children with CP that use a low-cost walking device were questioned to examine the benefits of the practice. Thematic analysis denoted three key factors about the benefits: emotional welfare, physical wellbeing, and social enjoyment. To conclude, the use of a support walker in children with CP makes them feel happier, improves their self-confidence and autonomy, and promotes participation.

Effect of the Hybrid Assistive Limb on the Gait Pattern for Cerebral Palsy

Background and objectives: Cerebral palsy (CP) is the most frequent childhood motor disability. Achieving ambulation or standing in children with CP has been a major goal of physical therapy. Recently, robot-assisted gait training using the Hybrid Assistive Limb^® (HAL) has been effective in improving walking ability in patients with CP. However, previous studies have not examined in detail the changes in gait pattern after HAL training for patients with spastic CP, including gait symmetry. This study aimed to evaluate the immediate effect of HAL training on the walking ability and the changes in gait pattern and gait symmetry in patients with spastic CP. Materials and Methods: We recruited 19 patients with spastic CP (13 male and six female; mean age, 15.7 years). Functional ambulation was assessed using the 10-Meter Walk Test and gait analysis in the sagittal plane before and after a single 20-min HAL intervention session. Results: The walking speed and stride length significantly increased after HAL intervention compared to the pre-intervention values. Two-dimensional gait analysis showed improvement in equinus gait, increase in the flexion angle of the swing phase in the knee and hip joints, and improvement in gait symmetry. Immediate improvements in the walking ability and gait pattern were noted after HAL training in patients with spastic CP. Conclusions: The symmetry of the joint angle of the lower limb, including the trunk, accounts for the improvement in walking ability after HAL therapy.

The use and perception of support walkers for children with disabilities: a United Kingdom survey

BACKGROUND

Support walkers are a type of assistive device that may enable non-ambulant children with disabilities to walk independently and promote improvements in bowel function, bone mineral density (BMD), mobility, independence, participation and social function. However, there is little evidence to support these benefits and there is a lack of research describing the use of support walkers in clinical practice. This study aimed to examine the use of support walkers for children with disabilities in clinical practice.

METHOD

A survey was distributed via professional organisations, charities and schools associated with paediatric disabilities in the UK. Participants were recruited between January and March 2018. Populations of interest were those who prescribe support walkers to children with disabilities and those who work with children who use them.

RESULTS

In total, 125 people were included in the analysis; 107 responders prescribed support walkers and 18 responders worked with children who used support walkers. The population of children who use support walkers ranged from 6 months to 18 years and included children with cerebral palsy, chromosomal abnormalities and other medical conditions. Use of these devices was also reported in schools, at home and in the community for varying lengths of time. Numerous perceived benefits were noted, most frequent of which were increases in physical activity and enjoyment. By comparison, fewer perceived problems were identified but centred on lack of space and difficulty with transfers.

CONCLUSIONS

This study provides insight into the use of support walkers in the UK, particularly surrounding current practices, which may help to improve consistency in clinical settings. Perceived benefits and problems may provide a basis for identification of appropriate outcome measures to monitor effectiveness. These results should also provide a basis for designing future studies to examine effectiveness of support walkers for paediatric disabilities.

Comparison of a robotic-assisted gait training program with a program of functional gait training for children with cerebral palsy: design and methods of a two group randomized controlled cross-over trial

Background

Enhancement of functional ambulation is a key goal of rehabilitation for children with cerebral palsy (CP) who experience gross motor impairment. Physiotherapy (PT) approaches often involve overground and treadmill-based gait training to promote motor learning, typically as free walking or with body-weight support. Robotic-assisted gait training (RAGT), using a device such as the Lokomat^®Pro, may permit longer training duration, faster and more variable gait speeds, and support walking pattern guidance more than overground/treadmill training to further capitalize on motor learning principles. Single group pre-/post-test studies have demonstrated an association between RAGT and moderate to large improvements in gross motor skills, gait velocity and endurance. A single published randomized controlled trial (RCT) comparing RAGT to a PT-only intervention showed no difference in gait kinematics. However, gross motor function and walking endurance were not evaluated and conclusions were limited by a large PT group drop-out rate.

Methods/design

In this two-group cross-over RCT, children are randomly allocated to the RAGT or PT arm (each with twice weekly sessions for eight weeks), with cross-over to the other intervention arm following a six-week break. Both interventions are grounded in motor learning principles with incorporation of individualized mobility-based goals. Sessions are fully operationalized through manualized, menu-based protocols and post-session documentation to enhance internal and external validity. Assessments occur pre/post each intervention arm (four time points total) by an independent assessor. The co-primary outcomes are gross motor functional ability (Gross Motor Function Measure (GMFM-66) and 6-minute walk test), with secondary outcome measures assessing: (a) individualized goals; (b) gait variables and daily walking amounts; and (c) functional abilities, participation and quality of life. Investigators and statisticians are blinded to study group allocation in the analyses, and assessors are blinded to treatment group. The primary analysis will be the pre- to post-test differences (change scores) of the GMFM-66 and 6MWT between RAGT and PT groups.

Discussion

This study is the first RCT comparing RAGT to an active gait-related PT intervention in paediatric CP that addresses gait-related gross motor, participation and individualized outcomes, and as such, is expected to provide comprehensive information as to the potential role of RAGT in clinical practice.

Trial registration ClinicalTrials.gov NCT02196298

Electronic supplementary material

The online version of this article (doi:10.1186/s40064-016-3535-0) contains supplementary material, which is available to authorized users.

Comparison of the inertial properties and forces required to initiate movement for three gait trainers

The purpose of this study was to evaluate the inertial properties and forces required to initiate movement on two different surfaces in a sample of three commonly prescribed gait trainers. Tests were conducted in a laboratory setting to compare the Prime Engineering KidWalk, Rifton Pacer, and Snug Seat Mustang with and without a weighted anthropometric test dummy configured to the weight and proportions of a 4-year-old child. The Pacer was the lightest and the KidWalk the heaviest while footprints of the three gait trainers were similar. Weight was borne fairly evenly on the four casters of the Pacer and Mustang while 85% of the weight was borne on the large wheels of the mid-wheel drive KidWalk. These differences in frame style, wheel, and caster style and overall mass impact inertial properties and forces required to initiate movement. Test results suggest that initiation forces on tile were equivalent for the Pacer and KidWalk while the Mustang had the highest initiation force. Initiation forces on carpet were lowest for the KidWalk and highest for the Mustang. This initial study of inertia and movement initiation forces may provide added information for clinicians to consider when selecting a gait trainer for their clients.

Outcomes of gait trainer use in home and school settings for children with motor impairments: a systematic review

OBJECTIVE

To summarize and critically appraise evidence regarding use of gait trainers (walkers providing trunk and pelvic support) at home or school with children who are unable to walk independently or with hand-held walkers.

DATA SOURCES

Searches were performed in seven electronic databases including EBM Reviews, CINAHL, Medline and EMBASE for publications in English from database inception to November 2014.

REVIEW METHODS

Included studies involved at least one child with a mobility limitation and measured an outcome related to gait trainer use. Articles were appraised using American Academy of Cerebral Palsy and Developmental Medicine criteria for group and single-subject designs and quality ratings completed for studies rated levels I-III. The PRISMA statement was followed with inclusion criteria set a priori. Two reviewers independently screened titles, abstracts and full-text articles.

RESULTS

Seventeen studies involving 182 children were included. Evidence from one small randomized controlled trial suggests a non-significant trend toward increased walking distance while the other evidence level II study (concurrent multiple baseline design) reports increased number of steps. Two level III studies (non-randomized two-group studies) report statistically significant impact on mobility level with one finding significant impact on bowel function and an association between increased intervention time and bone mineral density. Remaining descriptive level evidence provides support for positive impact on a range of activity outcomes, with some studies reporting impact on affect, motivation and participation with others.

CONCLUSIONS

Evidence supporting outcomes for children using gait trainers is primarily descriptive and, while mainly positive, is insufficient to draw firm conclusions.

Effectiveness of standing frame on constipation in children with cerebral palsy: a single-subject study

Children with cerebral palsy (CP) and quadriplegia or severe diplegia suffer from highly reduced mobility and consequent constipation. Clinicians recommend standing frames to exercise the support reaction in this population, sharing the opinion that the upright position may facilitate intestinal transit, although no evidence supports this assumption. We conducted this study to determine the effects of the standing frame on spontaneous evacuation in children with CP. Moreover, we studied its effects on the frequency of induction of evacuation, the characteristics of the stool and the pain suffered by the child due to constipation and/or evacuation. We implemented a single-subject research design in one chronically constipated child with CP and quadriplegia, Gross Motor Function Classification System Level V. To monitor the effects of the standing frame, we measured the outcome of interest throughout the study using a daily diary and the Bristol Stool Scale. This study was approved by the local Ethics Committee. This study has several limitation; primarily, the use of a single-subject research design only makes possible the visual analysis of data obtained from a unique patient. So, by themselves, data obtained do not allow us any generalization for the target population. Future research should verify our results collecting more data and also investigating the effect of the standing-frame on respiratory functions. Although the standing frame did not affect the frequency of evacuations or the characteristics of the stool, its employment reduced the inductions of evacuation and the related pain suffered by the child. However, this study has several limitations, such as the lack of generalization due to the fact that we studied a unique patient and the overall brevity of the study due to external circumstances. Therefore, we suggest future research to verify our results, also investigating the effect of the standing frame on respiratory functions. Relevance to clinical practice. The standing frame may positively influence the management of constipation of these children, possibly improving their quality of life.

Orthopedic surgery and mobility goals for children with cerebral palsy GMFCS level IV: what are we setting out to achieve?

BACKGROUND

Multilevel orthopedic surgery is considered to be the gold standard treatment for ambulatory children with cerebral palsy (CP), classified at levels I, II, or III according to the Gross Motor Function Classification System (GMFCS). Hip enlocation and stability are the main goals of orthopedic intervention in the GMFCS level IV subgroup and are well researched; however, there is no evidence to date to support or challenge the effectiveness of orthopedic treatment to preserve functional mobility in this patient group. The aim of this study was to evaluate the results of orthopedic surgery to maintain or restore standing transfers and supported walking in children with CP at GMFCS level IV.

METHODS

Twenty-two children with CP GMFCS level IV who underwent orthopedic surgery to improve mobility between the years 2004 and 2008 were included in this study. A retrospective chart review was performed and a satisfaction questionnaire sent to all patients. The primary outcome measure was the attainment and maintenance of mobility goals 2 years post-surgery. The secondary outcome measures were family/patient satisfaction, Functional Mobility Scale (FMS), and complications.

RESULTS

The two goals identified by the patients and carers were standing transfers and supported walking. At the 2-year post-surgery assessment, 14 children (63.6 %) did not reach their pre-determined goals. In the questionnaire, 21.4 % of the families reported that surgery was not beneficial. The FMS score remained unchanged in 95.4 % of the patients. Fourteen patients (63.6 %) had at least one complication that prolonged their post-operative rehabilitation (e.g., neuropraxia).

CONCLUSION

This study suggests that orthopedic surgery in children with CP at GMFCS level IV is unlikely to maintain or restore mobility. Furthermore, it carries a significant risk of complications.

LEVEL OF EVIDENCE

Case series, Level IV.

Informing evidence-based clinical practice guidelines for children with cerebral palsy at risk of osteoporosis: a systematic review

AIM

The aim of this systematic review was to inform evidence-based clinical practice guidelines for children with cerebral palsy (CP) and low bone mineral density (BMD).

METHOD

A computer-assisted literature search was focused on low BMD in children with CP, and was limited to the following interventions: weight-bearing activities, bisphosphonate use, and vitamin D or calcium supplementation. Articles were classified according to American Academy of Neurology guidelines and recommendation classifications were given based on the evidence for the intervention increasing BMD and decreasing fragility fractures. Studies were included if they were English-language full-text studies, focused on children with CP, and included at least 10 participants receiving the studied interventions.

RESULTS

Twenty-one articles underwent full-text review and data abstraction, including seven studies of weight-bearing activities, five studies of vitamin D or calcium supplementation, and nine studies of bisphosphonates administration. Overall, the evidence that bisphosphonates administration increases BMD was assessed as level B (probable) while the evidence that vitamin D or calcium supplementation does so was assessed as level C (possible); there was insufficient evidence to suggest that weight-bearing activities are an effective intervention to improve BMD. The evidence that bisphosphonates help to prevent fragility fractures was assessed as level C (possible); there was inadequate evidence to support the use of weight-bearing activities or vitamin D or calcium supplementation to decrease fragility fractures.

INTERPRETATION

Evidence-based clinical practice guidelines were created outlining the suggested role of weight-bearing activities, vitamin D and calcium supplementation, and bisphosphonate use for children with CP with low BMD at risk of fragility fractures.

Item bank development for a revised pediatric evaluation of disability inventory (PEDI)

The Pediatric Evaluation of Disability Inventory (PEDI) is a useful clinical and research assessment, but it has limitations in content, age range, and efficiency. The purpose of this article is to describe the development of the item bank for a new computer adaptive testing version of the PEDI (PEDI-CAT). An expanded item set and response options were reviewed by clinician experts and examined at parent and clinician focus groups. Eleven parents participated in 32 cognitive interviews to examine content, format, and comprehension of items and responses. A set of 76 self-care, 78 mobility, and 64 social function items with pictures and a four-point "Difficulty" scale were developed. The PEDI's Caregiver Assistance scale was replaced by a "Responsibility Scale" with 53 items. Content validity was established incorporating input from clinicians and parents. The new item bank covers a broad range of functional activities for children of all ages and abilities.