The Quality Function Measure: reliability and discriminant validity of a new measure of quality of gross motor movement in ambulatory children with cerebral palsy

Are tactile function and body awareness of the foot related to motor outcomes in children with upper motor neuron lesions?

Introduction

Somatosensory function can be reduced in children with Upper Motor Neuron (UMN) lesions. Therefore, we investigated relationships between somatosensory functions of the foot and motor outcomes in children with UMN lesions.

Method

In this cross-sectional study, we assessed the Tactile Threshold (TT) with monofilaments and body awareness with Tactile Localisation Tasks for spatial-related action (TLTaction) and structural-related perception (TLTperception) body representation at the foot sole. Furthermore, we assessed four motor outcomes: the Selective Control Assessment of the Lower Extremity (SCALE), the modified Timed Up and Go test (mTUG), the Gillette Functional Assessment Questionnaire (FAQ), and the Functional Mobility Scale (FMS). Spearman's correlations (ρ) were applied to assess relationships between the somatosensory function of the foot sole and the applied motor outcomes.

Results

Thirty-five children with UMN lesions, on average 11.7 ± 3.4 years old, participated. TLTperception correlated significantly with all lower limb motor outcomes (|ρ|=0.36-0.57; p < 0.05), but TLTaction (|ρ|=0.00-0.27; p = 0.15-0.97, and TT did not (|ρ|=0.01-0.83; p = 0.73-0.94). TLTperception correlated strongly with the Gross Motor Function Classification System (|ρ|=0.62; p = 0.001) in children with cerebral palsy (n = 24).

Discussion

Assessing structural body representation of the foot sole should be considered when addressing lower limb motor impairments, including gait, in children with upper motor neuron lesions. Our results suggest that the assessment of tactile function and spatial body representation may be less related to lower limb motor function.

The novel Next Step test is a reliable measure of anticipatory postural adjustments made by children with cerebral palsy prior to taking a step

BACKGROUND

Children with cerebral palsy (CP) make smaller medio-lateral anticipatory postural adjustments (APAs) than typically developing peers when stepping forward to a medial target. They are also less accurate at reaching the stepping target. The Next Step test involves the biomechanical measurement of APAs and foot placement error. These may be useful outcome measures to evaluate dynamic balance in a clinical trial. The reliability of the measures must be assessed to establish their reliability as research tools.

RESEARCH QUESTION

What is the inter-rater and intra-rater reliability of stepping accuracy and measures of APAs made by children prior to taking a step?

METHODS

Typically developing (TD) (n = 14) or children with CP (n = 16) were recruited from local clinics. Children stepped to electro-luminescent targets placed medially and laterally to each foot. Stepping responses were measured using a force plate and 3D motion analysis of markers placed on the feet and pelvis. The APA was defined as the movement of the centre of pressure (COP) and the centre of mass (COM) estimated via pelvic markers, prior to lifting the lead leg. Stepping accuracy was defined as the absolute distance between the target and end foot position. Participants undertook two data collection sessions separated by at least one week. In session one, the test was measured by rater 1 who repeated this in session two, along with another data collection by a rater 2 or rater 3, after a rest period. Where data were normally distributed, they were assessed for inter-rater and intra-rater reliability using an intra-class correlation coefficient (ICC) and Bland-Altman plots. The standard error of measurement was calculated to determine the minimum difference needed to detect true change.

RESULTS

There was no between-group differences in group characteristics (age, weight, height) or in stepping velocity. We found good to excellent reliability when measuring the amplitude and velocity of medio-lateral APAs (ICC range 0.73-0.89). The reliability of antero-posterior APAs was more variable (ICC range 0.08-0.92). The minimum difference to detect a true change for peak medio-lateral motion of COP ranges from 23.7 mm to 29.6 mm and for peak velocity of medio-lateral COM estimate 41-61.9 mm. Stepping accuracy was not normally distributed.

SIGNIFICANCE

The Next Step test is a reliable measure of dynamic balance. The peak medio-lateral motion of the COP and medio-lateral velocity of the COM estimate are reliable when measured during a constrained stepping task in ambulant children with cerebral palsy.

Intensive Therapy of the Lower Limbs and the Trunk in Children with Bilateral Spastic Cerebral Palsy: Comparing a Qualitative Functional and a Functional Approach

Few studies have examined the effect of intensive therapy on gross motor function and trunk control in children with cerebral palsy (CP). This study evaluated the effects of an intensive burst of therapy on the lower limbs and trunk by comparing qualitative functional and functional approaches. This study was designed as a quasi-randomized, controlled, and evaluator-blinded trial. Thirty-six children with bilateral spastic CP (mean age = 8 y 9 mo; Gross Motor Function Classification II and III) were randomized into functional (n = 12) and qualitative functional (n = 24) groups. The main outcome measures were the Gross Motor Function Measure (GMFM), the Quality Function Measure (QFM), and the Trunk Control Measurement Scale (TCMS). The results revealed significant time-by-approach interaction effects for all QFM attributes and the GMFM's standing dimension and total score. Post hoc tests showed immediate post-intervention gains with the qualitative functional approach for all QFM attributes, the GMFM's standing and walking/running/jumping dimension and total score, and the total TCMS score. The qualitative functional approach shows promising results with improvements in movement quality and gross motor function.

A cross sectional study investigating dynamic balance when stepping to targets in children with cerebral palsy compared to typically developing children

BACKGROUND

Children with Cerebral Palsy (CP) have altered anticipatory postural adjustments (APAs) during gait initiation. These APAs may affect dynamic balance in tasks such as stepping.

RESEARCH QUESTIONS

How are APAs in children with CP affected during stepping to precise targets? How do children with CP modulate APAs when stepping to medial and lateral targets? What is the association between APAs and symptom severity, movement quality and impairment profile?

METHOD

Children undertook a stepping task to laterally and medially placed targets with either leg, in a randomised order. Movement of the centre of pressure (COP) and markers at the pelvis and foot were measured via a force plate and 3D motion analysis. Motion of the centre of mass (COM) was estimated via pelvic markers. APAs were assessed prior to leading leg lift-off in medio-lateral and antero-posterior directions. Stepping error was calculated. Baseline characteristics of children with CP included Gross Motor Function Measure (GMFM), Quality Function Measure (QFM), leg muscle hypertonia (Tardieu test) and strength (manual dynamometry).

RESULTS

Sixteen ambulant children with CP (12.2 years ± 2.2) and 14 typically developing (TD) children (11.6 years ± 2.9) were assessed. In children with CP, APAs in the medio-lateral direction were 20-30% smaller. Children with CP were less able to modulate their APAs with steps to medial and laterally placed targets, than TD children. Medio-lateral COP motion was associated with movement quality assessed by QFM subsections, GMFM (correlation coefficient r = 0.66-0.80) and hip abductor strength (r = 0.75). Antero-posterior APAs were significantly smaller when stepping with the non-paretic leg in children with CP. APA size was positively related to the length of the contralateral, paretic gastrocnemius (r = 0.77). Stepping error was higher in children with CP and inversely correlated to the size of the medio-lateral APA.

DISCUSSION

Children with CP show smaller medio-lateral APAs especially when stepping to medially placed targets. APA size may be limited by proximal muscle strength and gastrocnemius length.

Exercise Prescription Improve the Rehabilitation of a Child With Viral Encephalitis Sequelae: A Case Report

This study conducted a personalized exercise prescription intervention on a child with viral encephalitis sequelae (VES). The purpose was to observe the rehabilitation process from the aspects of brain activation, and the curative effects on balance function and gait. A further aim was to explore the possible nerve biomechanical mechanisms between the extent of brain activation and the improvement in balance function and gait. A 12-week exercise prescription was used as the treatment method, and functional near-infrared spectroscopy (fNIRS), balance function test system, plantar pressure distribution system, and 3D gait system were used to assess the effects of the rehabilitation process pre and post the intervention. Following the exercise prescription intervention: (1) fNIRS showed that brain activation in the S1-D1, S1-D2, S1-D3, S2-D1, S3-D2, S3-D3, S4-D3, S5-D5, S5-D6, S5-D7, S7-D6, S7-D7, S8-D7, and S8-D8 increased significantly (P < 0.05). (2) The balance test showed that the area of motion ellipse and movement length of the child with eyes open decreased significantly and area of motion ellipse, back and forth swing, left and right swing and movement length of the child with eyes closed all decreased significantly (P < 0.05). (3) The static plantar pressure distribution demonstrated that the pressure center of the left and right foot decreased significantly (P < 0.05) from 5.3° dislocation in a straight line in the sagittal plane to 1°; an increment of the pressure loading was found on the forefoot of both feet compared with what was recorded in the pre-test. (4) The testing results of the 3D gait system showed that she had a shortened time of unilateral support phase and prolonged swing phase on the affected leg (P < 0.05), compared to that of the non-affected leg. Furthermore, the dual support phase had also been prolonged (P < 0.05). Conclusion: 12 weeks' individualized exercise training can enhance the activation in the motor areas and improve balance function and gait in a child with VES.

Protocol for The Toxin Study: Understanding clinical and patient reported response of children and young people with cerebral palsy to intramuscular lower limb Botulinum neurotoxin-A injections, exploring all domains of the ICF. A pragmatic longitudinal observational study using a prospective one-group repeated measures design

INTRODUCTION

Botulinum neurotoxin-A (BoNT-A) is an accepted treatment modality for the management of hypertonia in children and young people with cerebral palsy (CYPwCP). Nevertheless, there are concerns about the long-term effects of BoNT-A, with a lack of consensus regarding the most meaningful outcome measures to guide its use. Most evidence to date is based on short-term outcomes, related to changes at impairment level (restrictions of body functions and structures), rather than changes in adaptive skills (enabling both activity and participation). The proposed study aims to evaluate clinical and patient reported outcomes in ambulant CYPwCP receiving lower limb BoNT-A injections over a 12-month period within all domains of the WHO's International Classification of Functioning, Disability and Health and health-related quality of life (HRQoL).

METHODS AND ANALYSIS

This pragmatic prospective longitudinal observational study will use a one-group repeated measures design. Sixty CYPwCP, classified as Gross Motor Function Classification System (GMFCS) levels I-III, aged between 4 and 18 years, will be recruited from an established movement disorder service in London, UK. Standardised clinical and patient reported outcome measures within all ICF domains; body structures and function, activity (including quality of movement), goal attainment, participation and HRQoL, will be collected preinjection and at 6 weeks, 6 months and up to 12 months postinjection. A representative subgroup of children and carers will participate in a qualitative component of the study, exploring how their experience of BoNT-A treatment relates to clinical outcome measures.

ETHICS AND DISSEMINATION

Central London Research Ethics Committee has granted ethics approval (#IRAS 211617 #REC 17/LO/0579). Findings will be disseminated in peer-reviewed publications, conferences and via networks to participants and relevant stakeholders using a variety of accessible formats including social media.

Reliability of functional tests of the lower limbs and core stability in children and adolescents with cerebral palsy

BACKGROUND

Muscle weakness in children and adolescents with cerebral palsy (CP) can affect daily life activities, even more if functional capabilities are poor. Also core stability plays an important role in distal force generation.

AIM

The main purpose of this study was to investigate the reliability of functional tests of the lower limbs and the core stability in children and adolescents with bilateral spastic CP with Gross Motor Function Classification System (GMFCS) levels II and III. Secondary, associations within the functional tests and between the functional tests and gait capacity were analyzed.

DESIGN

Cross sectional study.

SETTING

CP reference center *blinded for reviewers*, pediatric physiotherapists and schools for children and adolescents with motor impairments.

POPULATION

Twenty-four children and adolescents with CP (11.4±2.5 yrs, GMFCS II/III:13/11) participated in this study.

METHODS

Functional tests of the lower limbs (GMFCS II: Sit-To-Stand (STS), Lateral Step-Up (LSU), bilateral heel rise (BHR), high jump (HJ), long jump (LJ); GMFCS III: STS, LSU) and core stability (bridging and Rolling Like a Ball (RLB)) were tested twice. On the second test occasion, gait capacity (1-Minute Walk Test (1MWT) and modified Timed Up and Go (mTUG)) were also assessed.

RESULTS

Relative reliability of the functional tests ranged from good to excellent (Intraclass Correlation Coefficients (ICC), 0.88 - 0.96). Absolute reliability showed large variability with acceptable results for the BHR, HJ, LJ and RLB (Minimal Detectable Change % (MDC %) < 40%). Strong associations were found of the RLB test and the mTUG with the BHR, HJ and LJ tests.

CONCLUSIONS

The functional tests of the lower limbs and core stability were found reliable. To measure change over time, the BHR, the HJ and LJ can be used for children and adolescents with GMFCS level II. The RLB test can be used for both GMFCS levels. Associations between the BHR, HJ and LJ tests in particular showed strong associations with the RLB test and with the mTUG.

CLINICAL REHABILITATION IMPACT

this study highlighted the importance of developing functional tests for children and adolescents with lower motor function capacities and to integrate core stability tests in routine clinical assessments.

Potentiation of cord blood cell therapy with erythropoietin for children with CP: a 2 × 2 factorial randomized placebo-controlled trial

Background

Concomitant administration of allogeneic umbilical cord blood (UCB) infusion and erythropoietin (EPO) showed therapeutic efficacy in children with cerebral palsy (CP). However, no clinical studies have investigated the effects of UCB and EPO combination therapy using a 2 × 2 four-arm factorial blinded design with four arms. This randomized placebo-controlled trial aimed to identify the synergistic and individual efficacies of UCB cell and EPO for the treatment of CP.

Methods

Children diagnosed with CP were randomly segregated into four groups: (A) UCB+EPO, (B) UCB+placebo EPO, (C) placebo UCB+EPO, and (D) placebo UCB+placebo EPO. Based on the UCB unit selection criteria of matching for ≥ 4/6 of human leukocyte antigen (HLA)-A, -B, and DRB1 and total nucleated cell (TNC) number of ≥ 3 × 10⁷/kg, allogeneic UCB was intravenously infused and 500 IU/kg human recombinant EPO was administered six times. Functional measurements, brain imaging studies, and electroencephalography were performed from baseline until 12 months post-treatment. Furthermore, adverse events were closely monitored.

Results

Eighty-eight of 92 children enrolled (3.05 ± 1.22 years) completed the study. Change in gross motor performance measure (GMPM) was greater in group A than in group D at 1 month (△2.30 vs. △0.71, P = 0.025) and 12 months (△6.85 vs. △2.34, P = 0.018) post-treatment. GMPM change ratios were calculated to adjust motor function at the baseline. Group A showed a larger improvement in the GMPM change ratio at 1 month and 12 months post-treatment than group D. At 12 months post-treatment, the GMPM change ratios were in the order of groups A, B, C, and D. These results indicate synergistic effect of UCB and EPO combination better than each single therapy. In diffusion tensor imaging, the change ratio of fractional anisotropy at spinothalamic radiation was higher in group A than group D in subgroup of age ≥ 3 years. Additionally, higher TNC and more HLA-matched UCB units led to better gross motor outcomes in group A. Adverse events remained unchanged upon UCB or EPO administration.

Conclusions

These results indicate that the efficacy of allogeneic UCB cell could be potentiated by EPO for neurological recovery in children with CP without harmful effects.

Trial registration

ClinicalTrials.gov, NCT01991145, registered 25 November 2013.

Balance confidence and physical activity participation of independently ambulatory youth with cerebral palsy: an exploration of youths' and parents' perspectives

AIM

Youth with cerebral palsy generally participate in less physical activity than typically developing peers. In adults with physical disabilities, balance confidence is a strong predictor of participation and community re-integration. However, balance confidence has not been studied in youth with cerebral palsy.

METHOD

Qualitative descriptive methodology with interviews of eight youth with cerebral palsy (9-17 years old, three girls) in Gross Motor Function Classification System Levels I-III, and eight parents (five mothers) of youth with cerebral palsy (9-17 years old, two girls) in Levels I-III.

RESULTS

Three themes arose: (1) youth in Gross Motor Function Classification System Levels I-II are more concerned about losing their balance during physical activities than those in Level III; (2) when balance is lost, embarrassment and frustration are more common than fear, especially for those in Levels I-II; and (3) social factors can create a favorable participation environment when balance confidence is low, especially for youth in Levels I-II.

CONCLUSION

Balance confidence may have greater influence on physical activity participation for youth in Gross Motor Function Classification System Levels I-II than those in Level III. Youth in Levels I-II may draw greater benefit from interventions targeting balance confidence when addressing physical activity goals.IMPLICATIONS FOR REHABILITATIONBalance confidence may have a greater influence on activity avoidance for youth with cerebral palsy in Gross Motor Function Classification System Levels I and II (who are independently ambulatory without walkers or cane(s)) than for those in Level II (who use walkers or cane(s) to ambulate).Youth who are independently ambulatory without walkers or cane(s) may benefit more from interventions directed at balance confidence (e.g., enactive mastery and verbal persuasion) to address their physical activity participation goals.For youth who are independently ambulatory without walkers or cane(s), addressing factors that could reduce the influence of balance confidence on physical activity participation, such as providing a positive and supportive social environment in which to participate, may be beneficial.

Reliability and Responsiveness of the Observable Movement Quality Scale for Children with Mild to Moderate Motor Impairments

AIM

The Observable Movement Quality (OMQ) scale measures generic movement quality and is used alongside standardized age-adequate motor performance tests. The scale consists of 15 items, each focusing on a different aspect; together, the entire construct of movement quality is assessed. This study aimed to determine interrater and intrarater reliability, and responsiveness of the OMQ scale.

METHODS

A prospective intervention study with pre-post design in pediatric physical therapy practices. For interrater reliability, 3 physical therapists observed video-recorded motor assessments of 30 children with mild to moderate motor impairments -aged 4 to 12 years-using the OMQ scale. One therapist scored baseline assessment a second time for intrarater reliability, and to calculate smallest detectable change (SDC). Responsiveness (n = 28) was tested by comparing outcomes before and after intervention.

RESULTS

Interrater reliability was moderate to good (ICC_2,1: 0.79); intrarater reliability was high (ICC_2,1: 0.97). Responsiveness results revealed an SDC of 2.4 and a minimal important change of 2.5; indicating sufficient validity in differentiating groups of children showing improved versus unchanged movement quality.

CONCLUSION

The OMQ scale is reliable and responsive to change when used to assess movement quality in clinical practice for children with mild to moderate motor impairments, aged 4-12 year.

Construct Validity of the Observable Movement Quality Scale in Pediatrics: Hypothesis Testing of a Formative Measurement Model

BACKGROUND

The Observable Movement Quality (OMQ) Scale measures generic movement quality. Each item of the OMQ Scale focuses on a different element; together, the 15 items assess the whole construct of movement quality.

OBJECTIVE

The aim of this study was to determine the construct validity of the OMQ Scale using 7 hypotheses defined to conform to the Consensus-Based Standards for the Selection of Health Measurement Instruments.

DESIGN

This was an exploratory validation study.

METHODS

A pediatric physical therapist assessed motor performance in 101 children using an age-specific motor test and the OMQ Scale. The direction, magnitude, and rationale for 7 hypotheses, which concerned relationships (n = 2), probability of low scores (n = 4), and difference between diagnosis subgroups (n = 1), were defined.

RESULTS

The results confirmed 6 of the 7 hypotheses, indicating sufficient construct validity. Significant positive relationships were found between OMQ Scale total scores and the severity of motor disabilities (r = 0.72) and z scores on motor tests (r = 0.60). Probabilities for low scores on OMQ Scale items-exceeding the chi-square critical value-were confirmed for children diagnosed with spasticity, psychomotor retardation, mitochondrial diseases, and ataxia; however, probabilities for low OMQ Scale item scores on strength regulation in children with ataxia were not confirmed. OMQ Scale total scores for children who were not ambulatory because of neurological conditions were significantly different from those for children who were not ambulatory because of fatigue (r = 0.66).

LIMITATIONS

The sample of children was based on theoretical assumptions about relevant variations in clinical representations; on the basis of the results, it appears that children with low strength regulation were underrepresented.

CONCLUSION

The confirmation of nearly all hypotheses supported the validity of the OMQ Scale for measuring movement quality in clinical practice in addition to standardized age-adequate motor performance tests.

Upper limb weight-bearing effect on the body alignment of individuals with cerebral palsy who have spastic hemiparesis: a randomized clinical trial

Abstract Introduction: Cerebral Palsy (CP) patients who have spastic hemiparesis usually present asymmetrical weight shift between the affected and non-affected side. Objective: To assess the effects of upper limb (UL) weight-bearing exercises on trunk symmetry, weight shift to the affected side and possible secondary effects on gait (speed and quality). Method: eleven participants with CP were randomized into two groups: Intervention Group (IG) and Control Group (CG); IG (n = 6) performed stretching exercises of the major muscle groups of UL and lower limbs (LL) and UL weight-bearing exercises in prone and seated position for 12 weeks. The CG (n = 5) did not undergo any kind of motor therapy during the study period but received the same exercises that IG after the study. The variables analyzed were: Gross Motor Function Measure (GMFM-88); Pediatric Berg Scale; Trunk Impairment Scale (TIS); Six-minute walking test (6MWT); Ten meters walking test (10MWT); Timed Up & Go (TUG); Edinburgh Visual Gait Scale (EVGS); and ground reaction force. Results: The IG showed improvement on 6MWT, TUG, TIS and Pediatric Berg Scale (p < 0.01), and CG showed improvement on GMFM-88 (p < 0.04) only for the intragroup analysis. Conclusion: The exercises were effective to improve static and dynamic balance, increasing gait speed and identifying a trend of improvement on body alignment and weight shift to the affected side.

Interrater Reliability of the Observable Movement Quality Scale for Children

Purpose: The authors investigated the interrater reliability, the standard deviation of the random measurement error, and the limits of agreement (LoA) of the Observable Movement Quality (OMQ) scale in children. Movement quality is important in the recognition of motor problems, and the OMQ scale, a questionnaire used by paediatric physical therapists, has been developed for use with an age-specific motor test to observe movement quality and score relative to what is expected for a child's age. Method: Paediatric physical therapists (n=28; 2 men, 26 women) observed video-recorded assessments of age-related motor tests in children (n=9) aged 6 months to 6 years and filled in the OMQ scale (possible score range 15-75 points). For our analyses, we used linear mixed models without fixed effects. Results: The interrater reliability was moderate (intra-class correlation coefficient [ICC2,1]: 0.67, 95% CI: 0.47, 0.88); neither work setting nor work experience exerted any influence on it. The standard deviation of the random measurement error was 5.7, and the LoA was 31.5. Item agreement was good (proportion of observed agreement [Po] total 0.82-0.99). Conclusion: The OMQ scale showed moderate interrater reliability when being used by therapists who were unfamiliar with the questionnaire and who had received only 2 hours of training. Feedback from the participants suggested a need for more comprehensive training in using the OMQ scale in clinical practice.

The International Classification of Functioning (ICF) to evaluate deep brain stimulation neuromodulation in childhood dystonia-hyperkinesia informs future clinical & research priorities in a multidisciplinary model of care

The multidisciplinary team (MDT) approach illustrates how motor classification systems, assessments and outcome measures currently available have been applied to a national cohort of children and young people with dystonia and other hyperkinetic movement disorders (HMD) particularly with a focus on dyskinetic cerebral palsy (CP). The paper is divided in 3 sections. Firstly, we describe the service model adopted by the Complex Motor Disorders Service (CMDS) at Evelina London Children's Hospital and King's College Hospital (ELCH-KCH) for deep brain stimulation. We describe lessons learnt from available dystonia studies and discuss/propose ways to measure DBS and other dystonia-related intervention outcomes. We aim to report on current available functional outcome measures as well as some impairment-based assessments that can encourage and generate discussion among movement disorders specialists of different backgrounds regarding choice of the most important areas to be measured after DBS and other interventions for dystonia management. Finally, some recommendations for multi-centre collaboration in regards to functional clinical outcomes and research methodologies for dystonia-related interventions are proposed.

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.

Rater reliability and scoring duration of the Quality Function Measure in ambulant children with hyperkinetic movement disorders

AIM

To examine intra- and interrater reliability/agreement, and time taken to score, when the Quality Function Measure (QFM) is applied to children with hyperkinetic movement disorders (HMD; e.g. dystonia, chorea, athetosis, tremor, and myoclonus).

METHOD

Fifteen ambulant children with HMD participated (eight males, seven females; mean age 13y 7mo, SD 3y 7mo). Three trained raters (two physiotherapists, one occupational therapist) independently scored the QFM using videos of each child performing Gross Motor Function Measure (GMFM) Stand and Walk/Run/Jump dimensions. Reliability was evaluated using intraclass correlation coefficient (ICC) model 2.1, Standard Error of Measurement (SEM), and Bland-Altman methods.

RESULTS

Rater reliability was excellent for all five QFM attributes: intrarater ICCs ≥0.98 (95% confidence interval [CI] 0.83-1.00), and interrater ICCs ≥0.96 (95% CI 0.91-1.00). SEM varied from 2.07% to 4.72% points for intra- and interrater scores across QFM attributes. Bland-Altman tests demonstrated close agreement between ratings, with absolute mean differences varying from 0.34% to 3.23% (intrarater) to 1.67% to 3.82% (interrater). Median scoring duration time was 83 minutes (range 56-144min, SD 16.02).

INTERPRETATION

Low measurement error attributable to rater effects suggests the QFM has potential as an evaluative measure in research studies involving children with HMD, though its lengthy scoring requirements are an important consideration for clinical practice. Evaluation of test-retest reliability and responsiveness is required.

Evaluation of the effectiveness of robotic gait training and gait-focused physical therapy programs for children and youth with cerebral palsy: a mixed methods RCT

Background

Robot assisted gait training (RAGT) is considered to be a promising approach for improving gait-related gross motor function of children and youth with cerebral palsy. However, RAGT has yet to be empirically demonstrated to be effective. This knowledge gap is particularly salient given the strong interest in this intensive therapy, the high cost of the technology, and the requirement for specialized rehabilitation centre resources.

Methods

This is a research protocol describing a prospective, multi-centre, concurrent mixed methods study comprised of a randomized controlled trial (RCT) and an interpretive descriptive qualitative design. It is a mixed methods study designed to determine the relative effectiveness of three physical therapy treatment conditions (i.e., RAGT, a functional physical therapy program conducted over-ground (fPT), and RAGT + fPT) on gait related motor skills of ambulatory children with cerebral palsy. Children with cerebral palsy aged 5–18 years who are ambulatory (Gross Motor Function Classification System Levels II and III) will be randomly allocated to one of four treatment conditions: 1) RAGT, 2) fPT, 3) RAGT and fPT combined, or 4) a maintenance therapy only control group. The qualitative component will explicate child and parent experiences with the interventions, provide insight into the values that underlie their therapy goals, and assist with interpretation of the results of the RCT.

Discussion

n/a.

Trial Registration

NCT02391324 Registered March 12, 2015.

Patient-specific determinants of responsiveness to robot-enhanced treadmill therapy in children and adolescents with cerebral palsy

AIM

The aim of the study was to evaluate patient-specific determinants of responsiveness to robot-enhanced repetitive treadmill therapy (ROBERT) in patients with early-developed movement disorders.

METHOD

Patients were treated over 12 sessions during a 3-week period. Gross Motor Function Measure-66 (GMFM-66) scores 1 day before ROBERT were compared with scores recorded 1 day after ROBERT. The association of GMFM-66 baseline score, age, sex, aetiology, and add-on botulinum toxin therapy to response to treatment was assessed.

RESULTS

Eighty-three patients aged between 4 and 18 years (48 males, 35 females; mean age 10y 8mo, SD 6y 1mo; Gross Motor Function Classification System level I [n=12], II [n=21], III [n=35], IV [n=10], and V [n=1]) were each treated for a total of 7.2 (SD 1.9) treadmill walking hours. Aetiology was bilateral spastic cerebral palsy (BS-CP; n=69), unilateral CP (n=3), ataxic CP (n=3), hereditary spastic paraparesis (n=6), and genetic syndrome including spasticity (n=2). Meaningful improvements were observed in GMFM-66 (+2.5; 95% CI 2.0-3.0), GMFM-D (+5.2; 95% CI 3.6-6.8), and GMFM-E (+4.0; 95% CI 2.8-5.3). There was a high inter-individual variability in treatment response. After multivariable adjustment, the improvements in GMFM-66 and GMFM-E scores were positively associated with the GMFM-66 baseline score. The effect on GMFM-D improvement was inversely associated with age.

INTERPRETATION

Gross motor abilities at baseline and age were identified as relevant determinants for the high degree of interpersonal variability in response to ROBERT.