Performance of physical activities by adolescents with cerebral palsy

Increasing participation in computer activities using eye-gaze assistive technology for children with complex needs

PURPOSE

Eye-gaze assistive technology offers children with severe motor and communication difficulties the opportunity to access and control a computer through eye movements. The aim of this study was to examine the impact of eye-gaze assistive technology intervention on participation in computer activities and technology usability among children with complex needs in Taiwan.

MATERIALS AND METHODS

This study involved a multiple baseline design across individuals. The participants were four children aged three to six years with severe motor and communication difficulties and low eye-control skills. The six-month intervention consisted of two collaborative team meetings and 12 individual supports to facilitate the use of eye-gaze assistive technology at home or in educational environments. Participation in computer activities (diversity, frequency, and duration) was repeatedly measured through a computer use diary. Other outcomes included assessments of goal achievements and parents/teachers' ratings on children's performance in computer activities.

RESULTS

The young children increased the diversity of their computer activities and their frequency and duration of computer use from baseline to the intervention phase. The children attained six of eight predefined goals related to play, communication, and school learning. Parents and teachers perceived the children's changes in performance as meaningful.

CONCLUSION

This study strengthens the evidence that eye-gaze assistive technology is useful in everyday contexts for children with complex needs in Taiwan. The findings add knowledge that children with weak eye-control skills increased participation in computer activities as a result of the eye-gaze assistive technology. Implications for RehabilitationEye-gaze assistive technology (EGAT) as an access method to control a computer can provide opportunities for children with severe motor and communication difficulties to participate in computer activities.Children with severe motor and communication difficulties and low eye-control skills with sufficient practice can learn to use EGAT for communication and learning, with support from stakeholders and collaborative service.EGAT could be introduced for children with complex needs at early ages as a means of using computers for play, communication, and school learning, which could be helpful for later education and learning.Stakeholders in educational environments could include EGAT in educational computer systems so that pupils with severe motor and communication difficulties could interact with a computer, thereby enhancing their engagement and learning.

Psychometric properties of the Spanish version of the Activities Scale for Kids (ASK): reliability, validity and the Rasch model

AIMS

To evaluate the psychometric properties of the Spanish version of the Activities Scale for Kids capability (ASKc) and ASK performance (ASKp) questionnaires.

DESIGN

It includes an analysis of different types of reliability (internal consistency, test-retest, inter-rater, Rasch model) and validity (convergent and discriminant) values.

SETTINGS

The sample was recruited in schools, associations and one hospital in Spain.

PARTICIPANTS

The main sample comprised 448 children (114 with disabilities); and 96 parents of the group of 114 children with disabilities, along with 2 therapists.

METHODS AND PROCEDURE

Children with physical disabilities completed questionnaires at two different time points; while healthy children only once. Both ASK questionnaires were also administered to parents. Therapists observed 69 children in 15 of the 30 activities listed in the ASKc.

PRIMARY AND SECONDARY OUTCOME MEASURES

ASKc and ASKp were used to measure physical disability among children. The Childhood Health Assessment Questionnaire (CHAQ), The Screening For and Promotion of Health-Related Quality of Life in Childrenand Adolescents - a European Public Health perspective (KIDSCREEN), Gross Motor Function Classification System (GMFCS), Manual Ability Classification System (MACS) and Functional Mobility Scale (FMS) were used to analyse convergent validity.

RESULTS

Excellent values were obtained for the reliability of the scale. Internal consistency was >0.95 (Cronbach's α) for both questionnaires. The intraclass correlation coefficient test-retest reliability was 0.94 (ASKc) and 0.93 (ASKp). Correlations between parents' and children's scores were 0.91(ASKc) and 0.90 (ASKp); and the correlation between therapists' and children's scores was 0.78. The Rasch analysis indicated that the Spanish version had a unidimensional structure. Furthermore, the results revealed adequate validity indices. Both ASK questionnaires correlated significantly with the CHAQ, three dimensions of the KIDSCREEN and the GMFCS, MACS and FMS. Finally, children without disabilities had higher ASKc and ASKp scores than children with disabilities (p=0.0001).

CONCLUSIONS

Both the ASKc and the ASKp versions are reliable and valid instruments that can be used to measure the capabilities of Spanish-speaking children, whose responses also demonstrate their own reliability as informants of the impact of disability on the activities of daily living.

Relationship of anthropometric measurements and percent body fat mass to cardiovascular disease risk factors in adults with cerebral palsy

INTRODUCTION

Adults with cerebral palsy (CP) face high morbidity from cardiovascular disease (CVD). Of concern, classic screening parameters are inconsistent in identifying CVD risk in this population. Dual-energy x-ray absorptiometry (DEXA), which provides direct measurements of fat mass (FM), may be an alternative screening method.

OBJECTIVE

To evaluate whether FM measurement with DEXA is feasible in screening adults with CP and compare FM and anthropometric measures to CVD risk factors.

DESIGN

Cross-sectional study.

SETTING

Outpatient rehabilitation hospital.

PARTICIPANTS

Forty-seven adults with CP.

MAIN OUTCOME MEASURES

Weight, height, waist circumference (WC), and hip circumference (HC) were measured; waist-to-hip ratio (WHR) and body mass index (BMI) were calculated. Blood pressure (BP), FM by DEXA, hemoglobin A1c (HbA1c), and lipid measurements were obtained. Logistic regression models investigated odds ratios (ORs) and 95% confidence intervals (CIs) between anthropometric measurements/FM and CVD risk factors; correlations were assessed using Pearson correlation coefficients.

RESULTS

Elevated BP or hypertension diagnosis was present in 47.8%; HbA1c ≥5.7% in 22.2%; and high-density lipoprotein (HDL) level below optimal for 33.3%. DEXA FM was obtained in 29 of 47 participants, as surgical metal and positioning limited many studies. Excess FM was noted in 75.9% versus 41.3% overweight/obese by BMI. WC correlated with HbA1c (r = 0.46, p = .002), HDL (r = -0.36, p = .018), and triglyceride (TG) levels (r = 0.30, p = .045); however at-risk WC values were associated only with odds of elevated HbA1c (OR 8.53, 95% CI 1.46-50.05; p = .018). HC correlated with HbA1c levels (r = 0.38, p = .011) and systolic BPs (r = 0.35, p = .019); similarly, ORs for elevated HC were weakly associated with elevated HbA1c and BPs (OR 1.08, 95% CI 1.01-1.16; p = .024 and OR 1.07, 95% CI 1.01-1.14; p = .024, respectively). WHR correlated with TGs; however few TG levels were elevated. FM measures were not associated with at-risk lab values or BPs.

CONCLUSIONS

DEXA FM measurements may not be feasible for CVD screening in many adults with CP. Although CVD risk factors are frequently present, anthropometric measurements commonly used for general population screening may not translate well to adults with CP.

Defining usual physiotherapy care in ambulant children with cerebral palsy in the United Kingdom: A mixed methods consensus study

BACKGROUND

Ambulant children with cerebral palsy (CP) undertake physiotherapy to improve balance and walking. However, there are no relevant clinical guidelines to standardize usual physiotherapy care in the United Kingdom. A consensus process can be used to define usual physiotherapy care for children with CP. The resulting usual care checklist can support the development of clinical guidelines and be used to measure fidelity to usual care in the control groups of trials for children with CP.

METHODS

Twelve expert physiotherapists were recruited. In Phase 1, statements on usual care were developed using a survey and two nominal groups. Phase 2 included a literature review to support usual physiotherapy interventions. Phase 3 used a confirmatory survey, which also captured changes to provision during the COVID-19 pandemic. Consensus was calculated by deriving the mean of the deviations from the median score (MDM). High consensus was deemed to be where MDM < 0.42.

RESULTS

Physiotherapists reached high consensus on five outcome measures (MDM range 0-0.375) and nine areas of assessment (MDM range 0-0.25). Physiotherapists reached moderate consensus on task-specific training (MDM = 0.75), delivered at weekly intensity for 4-6 weeks (MDM = 0.43). There was high consensus (MDM = 0) that children should participate in modified sport and fitness activities and that children with Gross Motor Function Classification System Level III should be monitored on long-term pathways (MDM = 0.29).

CONCLUSIONS

Physiotherapists reached consensus on two usual care interventions, and a checklist was developed to inform the control groups of future randomized controlled trials. Further consensus work is required to establish clinical guidelines to standardize usual physiotherapy care in the United Kingdom.

Pain burden in children with cerebral palsy (CPPain) survey: Study protocol

Pain is a significant health concern for children living with cerebral palsy (CP). There are no population‐level or large‐scale multi‐national datasets using common measures characterizing pain experience and interference (ie, pain burden) and management practices for children with CP. The aim of the CPPain survey is to generate a comprehensive understanding of pain burden and current management of pain to change clinical practice in CP. The CPPain survey is a comprehensive cross‐sectional study. Researchers plan to recruit approximately 1400 children with CP (primary participants) across several countries over 6‐12 months using multimodal recruitment strategies. Data will be collected from parents or guardians of children with CP (0‐17 years) and from children with CP (8‐17 years) who are able to self‐report. Siblings (12‐17 years) will be invited to participate as controls. The CPPain survey consists of previously validated and study‐specific questionnaires addressing demographic and diagnostic information, pain experience, pain management, pain interference, pain coping, activity and participation in everyday life, nutritional status, mental health, health‐related quality of life, and the effect of the COVID‐19 pandemic on pain and access to pain care. The survey will be distributed primarily online. Data will be analyzed using appropriate statistical methods for comparing groups. Stratification will be used to investigate subgroups, and analyses will be adjusted for appropriate sociodemographic variables. The Norwegian Regional Committee for Medical and Health Research Ethics and the Research Ethics Board at the University of Minnesota in USA have approved the study. Ethics approval in Canada, Sweden, and Finland is pending. In addition to dissemination through peer‐reviewed journals and conferences, findings will be communicated through the CPPain Web site (www.sthf.no/cppain), Web sites directed toward users or clinicians, social media, special interest groups, stakeholder engagement activities, articles in user organization journals, and presentations in public media.

Diet quality in adults with cerebral palsy: a modifiable risk factor for cardiovascular disease prevention

AIM

To assess diet quality and its relationship with cardiovascular health measures for adults with cerebral palsy (CP).

METHOD

A convenience sample of 45 adults with CP (26 females, 19 males; mean age 35y 10mo [SD 14y 9mo]). were recruited for this cross-sectional study. Demographic, medical, and Gross Motor Function Classification System (GMFCS) information were obtained through in-person visits. Participants completed two 24-hour dietary recalls using the Automated Self-Administered 24-hour Dietary Assessment Tool. Specific macronutrient intake was compared to 2015 to 2020 US Department of Agriculture (USDA) guidelines. Other data included body mass index (BMI), waist-to-hip ratio (WHR), blood pressure, and hemoglobin A1c (HgA1c;n=43).

RESULTS

Adults across GMFCS levels I to V were enrolled, 20 participants were in GMFCS levels IV or V. Mean calorie intake was 1777.91/day (SD 610.54), while sodium intake was 3261.75mg/day (SD 1484.92). Five participants met USDA vegetable and seven fruit guidelines. None met whole grain targets. Sixteen were overweight/obese by BMI. Sixteen participants without hypertension diagnoses had elevated blood pressure and nine had abnormal HgA1c without prediabetes/diabetes history. Percent calories from saturated fat was inversely associated with WHR in unadjusted and adjusted models (p=0.002 and p=0.003 respectively); all other dietary recommendations assessed (total calories, sodium, and sugar) were non-significant. Post hoc analyses were unchanged using 2020 to 2025 USDA guidelines.

INTERPRETATION

Assessment of nutrient intake and diet quality is feasible and warrants further study in adults with CP, as USDA guidelines are largely unmet. What this paper adds Adults with cerebral palsy (CP) do not meet US Department of Agriculture dietary quality recommendations. Prediabetes and hypertension may be common, but unrecognized, in adults with CP. Screening for nutrient intake and diet quality should be performed to facilitate nutritional counseling.

Effects of Ankle Continuous Passive Motion on Soleus Hypertonia in Individuals with Cerebral Palsy: A Case Series

Background

Continuous passive motion device (CPM) provides repetitive movement over extended periods of time for those who have low functional ability. The purpose of this research was to evaluate the effects of a four-week program of continuous passive motion of the ankle joint on the changes in soleus hypertonia in individuals with cerebral palsy who suffered from life-long hypertonia.

Methods

A single group, repeated-measures study was conducted. Eight individuals (7 males and 1 female with a mean age of 21.8 ± 8.5 years) with spastic cerebral palsy underwent bilateral ankle CPM for 1 h a day, 5 days a week, for 4 weeks. The outcome measures included the Modified Ashworth Scale (MAS) score, passive range of motion (PROM) of the ankle, the ratio of maximum H reflex to maximum soleus M-response (H/M ratio), and post-activation depression (PAD). All outcomes were measured before and after the intervention. A paired t-test was used to examine treatment effects pre-versus post-intervention.

Results

Paired t-tests showed that the CPM program significantly decreased the MAS score (p = 0.006), decreased the maximum H/M ratio (p=0.001), improved PAD (p = 0.003, p = 0.040, and p = 0.032 at 0.2 Hz, 1 Hz, and 2 Hz, respectively), and increased the passive ankle range of motion (p = 0.049).

Conclusion

Ankle CPM not only reduced soleus hypertonia but also improved the PROM in individuals with cerebral palsy. The results of this study show ankle CPM to be an effective intervention for individuals with cerebral palsy.

The utility of the fronto-temporal horn ratio on cranial ultrasound in premature newborns: a ventriculomegaly marker

BACKGROUND

The aims of this study were to find the normal value of fronto-temporal horn ratio (FTHR) as a marker of ventriculomegaly on cranial ultrasound (CUS) in premature newborns and the relation to white matter injury (WMI) and cerebral palsy (CP).

METHODS

This is a retrospective study of newborns admitted between 2011 and 2014. Inclusion criteria were: (1) gestation <29 weeks, (2) birth weight ≤1500 g, (3) referred within 7 days of life, (4) at least two CUS preformed, (5) brain magnetic resonance imaging (MRI) at term age-equivalent. Intraventricular hemorrhage (IVH) grade was identified and FTHR was measured on all CUS. WMI on MRI was evaluated through (1) injury score (Kidokoro 2013) and (2) fractional anisotropy (FA) on the MRI diffusion tensor imaging. CP was estimated using the gross motor function classification system (GMFCS).

RESULTS

One hundred neonates met the inclusion criteria: 37 with no IVH, 36 with IVH grade 1-2, and 27 with IVH grade 3-4. The FTHR cut-point of 0.51 had the highest sensitivity and specificity for moderate-to-severe WMI. In the IVH grade 3-4 group, the elevated FTHR correlated with lower FA and higher GMFCS.

CONCLUSIONS

FTHR is a useful quantitative biomarker of ventriculomegaly in preterm newborns. It may help standardize ventricular measurement and direct intervention.

IMPACT

The fronto-temporal horn ratio has the potential to become a standardized tool that can provide an actionable measure to direct intervention for post-hemorrhagic ventricular dilation. This current study will provide the basis of a future clinical trial to optimize intervention timing to decrease the risk of white matter injury in this vulnerable population.

Differences in Leisure Physical Activity Participation in Children with Typical Development and Cerebral Palsy

AIM

To compare participation in leisure physical activities in children with typical development (TD) and cerebral palsy (CP).

METHODS

A total of 170 children with TD (n = 101) and CP (n = 69) aged 8 to 18 years reported participation in 16 extracurricular physical activities. Non-parametric statistics examined differences between groups.

RESULTS

Children with TD participated more frequently in individual physical activities (p = .018), team sports (p = .026), and bicycling (p = .001), and less in horseback riding (p = .031) than children with CP in GMFCS II-V. The differences between children with TD and CP in GMFCS I and within the CP group were not statistically significant. We did not find differences between groups in enjoyment.

CONCLUSION

Children with CP in GMFCS II-V tend to participate less in leisure physical activities that require higher motor and perceptual skills. Support in the adaptation of physical recreation and sports may help improve participation.

Caregiver perception of hand function in infants with cerebral palsy: psychometric properties of the Infant Motor Activity Log

AIM

To evaluate the properties of the Infant Motor Activity Log (IMAL), a caregiver-report for frequency and quality of use of more affected upper extremity in infants with neurological and functional impairments.

METHOD

This was a prospective cohort study of 66 children (34 females, 32 males) aged 6 to 24 months (mean age [SD] 13.7mo [5.3]) with neurological and functional impairments and a confirmed cerebral palsy diagnoses after 2 years, and 51 age-matched typically developing children. The IMAL was administered at baseline and 4 weeks later. Typically developing infants were tested with randomly assigned 'more affected' upper extremity. Psychometric properties were evaluated using Spearman's correlation coefficient, Cronbach's alpha, and Jonckheere-Terpstra tests.

RESULTS

In the children with impairments, the IMAL showed internal consistency (alpha≥0.88) for the How Well Scale (HWS) and How Often Scale (HOS). Test-retest reliability was 0.64 (HOS) and 0.70 (HWS), demonstrating stability over time. Correlation with Bayley Scales of Infant and Toddler Development, Third Edition more affected arm raw scores were 0.70 (HOS) and 0.72 (HWS) (p<0.001) demonstrating construct validity. Both scale scores decreased with increasing Gross Motor Function Classification System and Mini-Manual Ability Classification System (p<0.001) levels, supporting discriminative validity. Discrimination between typically developing infants and infants with impairments was high (HWS: area under the receiver operating characteristic curve [AUC] 0.96, 95% confidence interval [CI] 0.94-0.99 and HOS AUC=0.95, CI 0.92-0.99).

INTERPRETATION

The IMAL is a valid and reliable discriminative caregiver measure of upper limb performance and may complement measures of capacity in infants with neurological and functional impairments.

WHAT THIS PAPER ADDS

The Infant Motor Activity Log (IMAL) is a valid and reliable measure of caregiver perception of upper limb function. The IMAL fills a measurement gap for infant motor performance in children with impairments. The IMAL discriminates among motor function levels.

Can hippotherapy make a difference in the quality of life of children with cerebral palsy? A pragmatic study

Objective: To determine if the addition of 12 weekly therapy sessions, incorporating hippotherapy as the primary intervention to each child's usual therapy program, will improve balance, participation, and quality of life.Methods: Pragmatic, multi-center, randomized, controlled trial of 13 children with cerebral palsy (CP), ages 3 to 6 years. A treatment group received 12 weeks of weekly hippotherapy intervention in addition to their usual therapy. A control group continued with their usual therapy only. Assessments were completed for the treatment group pre-intervention (P0), post intervention (P1), and 12 weeks post no intervention (P2). Control group assessments occurred in the same timeframe: baseline, 12 weeks and 24 weeks.Results: The only significant difference between the groups, post intervention, was on the Pediatric Balance Scale (PBS). Within group analysis showed no significant changes for the control group between any pretest/posttest measures. The treatment group demonstrated significant improvement on the PBS (P0-P1, p = .02; P0-P2, p = .02) and Activities Scale for Kids (P0-P1, p = .02; P0-P2, p = .02) with delayed improvement on the 1 Minute Walk Test (P1-P2, p = .02) and Pediatric Quality of Life - CP Module (P0-P2, p = .03).Conclusions: Improvements in balance in children with CP may promote increased participation and quality of life when hippotherapy is added to their treatment plan.

Spasticity and pain in adults with cerebral palsy

AIM

To evaluate whether spasticity measures are related to pain in adults with cerebral palsy (CP).

METHOD

This cross-sectional study recruited individuals aged 16 to 89 years with a diagnosis of CP. Participants completed the Penn Spasm Frequency Scale (PSFS), Brief Pain Inventory (BPI), and PROMIS Pain Interference measures. The Modified Ashworth Scale (MAS) and Tardieu spasticity angles of six joints were rated and summed to composite MAS and Tardieu scores for each participant. Associations between spasticity and pain measures were evaluated.

RESULTS

Forty-seven participants (27 females, 20 males) with a mean age of 35 years 7 months (range 18-77y) spanning all Gross Motor Function Classification System (GMFCS) levels were included. Twenty-six participants reported their average pain level on BPI as greater than 0 over the past week (median pain level 4.0). Median PSFS was 1.0 (range 0.0-1.0) and this correlated with average BPI and Pain Interference T scores (median 40.7; ρ=0.33 and ρ=0.31 respectively [both p=0.01]). When adjusted for pain medication use and age, MAS correlated with BPI (ρ=0.30; p=0.04). Other pain and spasticity measures, or GMFCS level, were not significantly related with pain interference or BPI rating. Age was weakly associated with BPI (slope=0.10; p<0.01).

INTERPRETATION

PROMIS Pain Interference was lower than population-based norms. Patient-rated spasm frequency demonstrated better association with pain levels and interference than physician-rated MAS and Tardieu.

WHAT THIS PAPER ADDS

Pain was not associated with Gross Motor Function Classification System level. Pain increased with age, as anticipated. Self-reported spasm scores were associated with increased pain in contrast to clinical examination scales. Adjusted, summed spasticity on the Modified Ashworth Scale was associated with pain scores on the Brief Pain Inventory. Although pain is experienced by adults with cerebral palsy, pain did not interfere with activities.

Botulinum Toxin Type A Injections Impact Hamstring Muscles and Gait Parameters in Children with Flexed Knee Gait

The aim of this study was to determine if botulinum toxin type A (BoNT-A) injection into the medial hamstring can improve gait kinematics and muscle-tendon length in spastic cerebral palsy (CP) with a flexed knee gait (FKG). Twenty-nine children with spastic CP (Gross Motor Function Classification System I–III) with FKG were recruited for this prospective study. BoNT-A was injected into the semitendinosus and semimembranosus (SM) muscles under ultrasonography guidance. Assessments included Gross Motor Function Measure (GMFM), Modified Ashworth Scale (MAS), Modified Tardieu Scale (MTS), 3-dimensional computerized gait analysis, calculated SM muscle-tendon length and lengthening velocity during gait using musculoskeletal modeling at baseline, 4 and 16 weeks after the injection. Compared to baseline data, significant improvements in GMFM, MAS, and MTS were demonstrated at weeks 4 and 16, and also a significant increase in maximum knee extension during the stance phase was observed at week 4. In addition, the mean lengthening velocity during the swing phase was increased at week 16 without a change in the SM muscle length. Furthermore, there was a significant increase in anterior pelvic tilt at week 4, compared to baseline data. The significant decrease in hip internal rotation after injection was observed only in children with excessive hip internal rotation at initial contact before injection. BoNT-A injection into hamstrings leads to a significant increase in knee extension and anterior pelvic tilt with an increase in lengthening velocity of SM in spastic CP with FKG.

Suboptimal Nutrition and Low Physical Activity Are Observed Together with Reduced Plasma Brain-Derived Neurotrophic Factor (BDNF) Concentration in Children with Severe Cerebral Palsy (CP)

Brain-derived neurotrophic factor (BDNF) is a mediator of exercise and nutrition-induced neural plasticity. In children with cerebral palsy (CP), neuromuscular deficits and mobility impairment have a negative impact on their physical activity level and nutritional status, but whether these children have reduced BDNF concentrations is unknown. Therefore, the aim of the present study was to investigate the plasma BDNF concentration, nutritional status, and physical activity level in children with mild to severe CP. Blood sampling, dietary registration, and questionnaires were completed for children with mild CP (gross motor function classification system (GMFCS) I⁻II, n = 31, age 10.6 ± 0.6 years), severe CP (GMFCS IV⁻V, n = 14, age 10.9 ± 1.1 years) and typically developed (TD) children (n = 22, age 10.9 ± 0.6 years). Children with severe CP had ~40% lower plasma BDNF concentration than TD children (p < 0.05). Furthermore, children with severe CP had lower daily physical activity level than TD children (p < 0.01), and a daily intake of energy, n-3 fatty acids, and dietary fibers that was only ~50% of TD (p > 0.001). Reduced plasma BDNF concentrations were observed in children with severe CP. This may be of significance for optimal neural growth and plasticity. This was observed together with low physical activity levels and a suboptimal intake of energy, n-3 fatty acids, and dietary fibers.

The psychometric properties of the Childhood Health Assessment Questionnaire (CHAQ) in children with cerebral palsy

Background

The evaluation of children with cerebral palsy (CP) focuses on activity level measurement to examine the effect of health-care interventions on their physical functioning in the home, school, and community settings. This study aimed to identify the psychometric properties of the Korean version of the Childhood Health Assessment Questionnaire (CHAQ) by applying the Rasch model. The use of the Rasch model has an advantage in that item characteristic curve estimation is not affected by the characteristics of subject groups.

Methods

Data were collected from 65 children with CP aged 75–190 months using the Korean version of the CHAQ. Response data were analyzed according to the Rasch model, and item fitness and difficulty and the appropriateness and reliability of the rating scale were evaluated.

Results

Among the 30 items of the Korean version of the CHAQ, two items (nail-cutting and opening a bottle cap that was already opened) were shown to be misfit items with low fitness. The analysis results for item difficulty indicated the requirement for modification of item difficulty, pointing out the need for the addition of question items with both higher and lower difficulty. The use of 4-point rating scale in the evaluation questionnaire was shown to be appropriate. With respect to analysis outcomes, the subjects’ separation reliability value and separation index were 0.97 and 5.92, respectively. In contrast, the separation reliability value and separation index for the question items were 0.95 and 4.51, respectively.

Conclusions

The results of this study suggest the need for the modification of item fitness and difficulty. The psychometric properties of the Korean version of the CHAQ were identified using the item response theory-based Rasch analysis.

Activity training on the ground in children with cerebral palsy: Systematic review and meta-analysis

Purpose: To systematically review the evidence about whether activity training on the ground is effective on activity or participation in children with cerebral palsy. Methods: Randomized controlled trials (RCTs) were searched in databases using relevant keywords. RCTs were included with children (≤18 years) with cerebral palsy who received activity training on the ground only or activity training on the ground combined with another type of physiotherapy. Outcome measures classified as measures of activity or participation according to the International Classification of Functioning, Disability, and Health were analyzed. Results: Nine RCTs (257 participants) were included in this review. Individual studies resulted in conflicting results when activity training on the ground was compared to no intervention. Based on meta-analysis, activity training on the ground was not more effective than no intervention (standardized mean difference [SMD]: 0.18; confidence interval [CI]: -1.49 to 1.86) or other therapies (SMD: -0.09; CI: -0.86 to 0.69) (I² > 75%) on improving activity or participation. Results from a single study demonstrated that activity training on the ground combined with other physiotherapy intervention was not more effective than no intervention (SMD: -0.18 CI: -0.89 to 0.54). Conclusions: The available evidence shows little effect of activity training on the ground on activity or participation in children with cerebral palsy, suggesting that rigorous trials with larger samples and larger "dosage" of activity training on the ground are needed in the future.

The use of clinical examination and cranial ultrasound in the diagnosis and management of post-hemorrhagic ventricular dilation in extremely premature infants

OBJECTIVES

The objective of this study is to describe clinical and ultrasound changes in a cohort of premature newborns with post-hemorrhagic ventricular dilation (PHVD), and to correlate these changes with outcome.

STUDY DESIGN

Premature newborns <29 weeks gestational age (GA) and ≤ 1,500 g birth weight with intraventricular hemorrhage were retrospectively reviewed. Clinical signs and cranial ultrasound (CUS) findings between time after birth and time before first cerebrospinal fluid temporizing intervention were compared with GA-equivalent newborns without interventions. White matter injury was assessed on brain magnetic resonance imaging.

RESULTS

Between 2011 and 2014, 64 newborns met inclusion criteria; 23% had PHVD. The growth rates of the ventricles on CUS and the head circumference (HC) were higher in newborns with PHVD (p < 0.01 and p = 0.04, respectively) and correlated inversely with white matter injury (p = 0.006 and p < 0.001, respectively).

CONCLUSION

Progression of PHVD in premature newborns as demonstrated by CUS and the HC correlated with outcome. Consistent measurement of these simple parameters will allow for much needed treatment comparisons, to define optimal protocols that decrease the risk of cerebral palsy in extremely preterm populations.

Self-efficacy of physical education teachers in including students with cerebral palsy in their classes

Children with cerebral palsy (CP) are often mainstreamed into the general education system, but are likely to be excluded from physical education (PE) classes. A questionnaire was constructed and utilized to measure PE teachers' self-efficacy (SE) toward inclusion of students with CP in each of three mobility categories (independent, using assistive devices, using wheelchair mobility) and the impact of experience and training on teachers' SE. Participants in the study were 121 PE teachers from different parts of Israel (mean age: 41.02±9.33 years; range: 25.00-59.00 years). Exploratory factor analysis was used to determine the structure of the sub-scales' factors' structure and Cronbach's Alpha reliability was satisfactory (range 0.872-0.941). Independent t-tests were calculated in order to compare the SE of teachers with and without adapted PE experience. Repeated Analysis of Variance was performed to measure within-group differences in SE. Results revealed that the PE teachers' SE in teaching students who use mobility assistive devices or wheelchairs was significantly lower compared to teaching those who walk and run unaided (F=19.11; p<0.001). The teachers' SE towards including CP children who independently ambulate was influenced (p<0.05; d=0.94) by the teacher's experience (elementary school practicum). SE in the mobility with assistive device group was also significantly influenced (p<0.05; d=0.1) by teaching experience (previous experience and having a specialization in adapted PE). Finally, SE when teaching the wheelchair mobility group was influenced by having an adapted PE specialization (p<0.05; d=0.82). Specialized training in this particular area should be enhanced to increase teachers' SE and enable greater participation of children with CP in general physical education classes.

Comparative Efficacy of Progressive Resistance Exercise and Biomechanical Ankle Platform System on Functional Indices of Children with Cerebral Palsy

Background

Progressive Resistance Exercise (PRE) and Biomechanical Ankle Platform System (BAPS) are two of the protocols available in managing children with Cerebral Palsy (CP). The comparative effects of these modalities on selected functional indices of ambulatory type CP were the focus of this study

Methods

Twenty-eight children with hemiplegic or diplegic CP receiving care at a tertiary health facility in Ibadan were consecutively recruited. They were systematically assigned into two intervention groups. Namely PRE, BAPS. Both groups received intervention twice weekly for 16 weeks. At baseline, 8 and 16 weeks of intervention balance and functional mobility were assessed using Berg Balance Scale (BBS) and modified timed-up-and-go test (TUG) respectively. Chi-square, Fisher's Exact tests, One way and repeated measures ANOVA were carried out. Level of significance (p) was set at 0.05.

Results

There were significant differences in the functional indices of participants in the BAPS group at the end of the intervention (p < 0.05). The two groups (BAPS and PRE) were not significantly different at baseline and 8 and 16 weeks (p > 0.05). All outcome measures increased in both groups from baseline to the end of the intervention period.

Conclusion

The two intervention protocols demonstrated improvements in the areas assessed. Comparatively, both PRE and BAPS could be used to promote function in CP.

Prevalence of secondary impairments of adults with cerebral palsy according to gross motor function classification system

[Purpose] This study aimed to investigate the prevalence of secondary impairments in adults with cerebral palsy. [Subjects and Methods] The study sample included 52 adults with cerebral palsy who attended a convalescent or rehabilitation center for disabled individuals or a special school for physical disabilities in South Korea. [Results] The univariate analysis showed that the Gross Motor Functional Classification System level was a significant predictor of spondylopathies, general pain, arthropathies, and motor ability loss. The prevalence of these impairments at Gross Motor Functional Classification System level I and II was low compared with the prevalence found at Gross Motor Functional Classification System level III–V. The prevalence of secondary impairments among adults with cerebral palsy at Gross Motor Functional Classification System level III–V was high: loss of motor ability, 42.3%; spondylopathies, 38.4%; general pain, 32.7%; and arthropathies, 28.8%. [Conclusion] In this study, adults with severe cerebral palsy showed a high prevalence of motor ability loss, spondylopathies, arthropathies, and pain. It is necessary to develop intervention programs to prevent secondary impairments in adults with cerebral palsy.

The Relationships Between Capacity and Performance in Youths With Cerebral Palsy Differ for GMFCS Levels

PURPOSE

To examine change in, and longitudinal relationships between motor capacity and activity performance across the Gross Motor Function Classification System (GMFCS).

METHODS

Ninety-two youths with cerebral palsy were examined at 2 time points, 1 year apart, using the Gross Motor Function Measure-66 (GMFM-66) for motor capacity, and the Chinese version of the Activities Scale for Kids-Performance Version (ASKp-C) for activity performance. The score changes and capacity-to-performance/performance-to-capacity pathways were explored across GMFCS levels.

RESULTS

The GMFM-66 scores declined over time in GMFCS levels IV-V while ASKp-C scores increased in GMFCS level I. The correlations for both pathways in GMFCS levels I, III, and IV-V were significant with a higher correlation for performance-to-capacity pathway in GMFCS levels IV-V.

CONCLUSIONS

Longitudinal changes in and relationships between capacity and performance differ between GMFCS levels. The opportunities to perform activities need to be emphasized in GMFCS levels IV-V.

A Preliminary Study to Assess Whether Spinal Fusion for Scoliosis Improves Carer-assessed Quality of Life for Children With GMFCS Level IV or V Cerebral Palsy

BACKGROUND

Scoliosis affects 50% of children with Gross Motor Function Classification System (GMFCS) level IV or V cerebral palsy (CP). In children with complex neurodisability following intervention, the WHO considers quality of life (QoL) should be assessed to aid decision-making and assess the effects. This study assesses whether scoliosis surgery improves carer-assessed QoL for children with severe CP.

METHODS

Retrospective review of 33 children (16 male:17 female) with GMFCS level IV/V CP and significant scoliosis. Fifteen underwent observational treatment during childhood, and 18 underwent surgery. Questionnaire and radiographic data were recorded over a 2-year period. The carer-completed Caregiver Priorities and Child Health Index of Life with Disabilities (CPCHILD) questionnaire was used to assess QoL.

RESULTS

In the observational group, Cobb angle and pelvic obliquity increased from 46 (40 to 60) and 8 degrees (0 to 28) to 62 (42 to 94) and 12 degrees (1 to 35). Mean CPCHILD score decreased from 50 (30 to 69) to 48 (27 to 69) (P<0.05). In the operative group, Cobb angle and pelvic obliquity decreased from 78 (52 to 125) and 14 degrees (1 to 35) to 44 (16 to 76) and 9 degrees (1 to 24). Mean CPCHILD score increased from 45 (20 to 60) to 58 (37 to 76) (P<0.05). Change in pain, and not presence of associated impairments, was the most significant factor affecting QoL changes for children in both groups. There was no difference in mobility, GMFCS level, feeding, or communication in either group before and after treatment.

CONCLUSIONS

Nonoperative treatment for children with GMFCS level IV/V CP and a significant scoliosis was associated with a small decrease in carer-assessed QoL over 2 years. Spinal fusion was associated with an increase in QoL. Change in pain was the most significant factor affecting QoL changes, and is therefore an important factor to consider when deciding upon surgery.

LEVEL OF EVIDENCE

Level III-therapeutic retrospective study.

Physical Activity Participation of Disabled Children: A Systematic Review of Conceptual and Methodological Approaches in Health Research

Physical activity (PA) participation is widely recognized as a critical component of health and development for disabled and non-disabled children. Emergent literature reflects a paradigm shift in the conceptualization of childhood PA as a multi-dimensional construct, encompassing aspects of physical performance, and self-perceived engagement. However, ambiguity remains around how participation as a health construct is integrated into PA research. The primary objective of the present mini-review is to critically examine current conceptual and methodological approaches to evaluating PA participation among disabled children. We conducted a systematic review of contemporary literature (published between 2000 and 2016). Seventeen articles met inclusion criteria, and their research approach was classified into guiding framework, definition of the key construct, and measurement used. The primary guiding framework was the international classification of functioning, disability and health. An explicit definition of PA participation was absent from all studies. Eight studies (47%) operationalized PA and participation as independent constructs. Measurements included traditional performance-based aspects of PA (frequency, duration, and intensity), and alternative participation measures (subjective perception of involvement, inclusion, or enjoyment). Approximately 64% of included articles were published in the past 2 years (2014-2016) indicating a rising interest in the topic of PA participation. Drawing from the broader discussion of participation in the literature, we offer a working definition of PA participation as it pertains to active, health-associated behaviors. Further description of alternative approaches to framing and measuring PA participation are offered to support effective assessment of health status among disabled children.

Correlates of physical activity in children and adolescents with physical disabilities: A systematic review

BACKGROUND

The benefits of physical activity (PA) for children with disabilities are well documented, and children with physical disabilities (PD) are often less active than peers with other disability types. Various correlates associated with PA in children with PD have been identified in separate studies, and a thorough analysis of these correlates could aid in understanding and designing interventions that promote children with PD to be more physically active. The purpose of this systematic review was to provide a comprehensive summary of the correlates of PA in children with PD.

METHOD

A systematic search using PubMed, CINAHL, Cochrane Library, PsychINFO, Eric, and EMbase was initiated in October 2014 to identify studies examining the correlates of PA in children with PD aged 6-18years. Two researchers independently screened studies, assessed their methodological quality, and extracted relevant data. The correlates were synthesized and further assessed semi-quantitatively.

RESULTS

A total of 45 articles were included in the detailed review. Several modifiable physical, psychological, and environmental correlates were consistently and positively associated with PA in children with PD. Some non-modifiable correlates (e.g., intellectual ability, parents' ethnicity) were found to be consistently and negatively associated with PA.

CONCLUSIONS

The correlates of PA in children with PD are multifaceted and along many dimensions. This review can have implications for future studies and these may confirm the consistency of variables related to PA. Insights derived from the outcomes may also foster the measurement of the magnitude of associations that could assist the development of future interventions.

Portuguese cultural adaptation and validation of the Activities Scale for Kids (ASK)

OBJECTIVES

The main purpose of the current study was to perform the cross cultural adaptation and validation of the Activities Scale for Kids (ASK) both in its capability and performance versions to the European Portuguese language so it can be used in Portugal by healthcare professionals in children from 5 to 15 years of age with functional disabilities related to specific health conditions.

METHODS

The cross-cultural adaptation of ASK followed the classic sequential methodology for linguistic equivalence. To test its validity, internal consistency, and reproducibility, the Portuguese version of ASK was administered together with the KINDL Questionnaire (KINDL) to 88 children (10±3 years of age) with functional limitations. The test-retest study was conducted two weeks apart.

RESULTS

After obtaining the semantic and content validity, the Portuguese version of ASK demonstrated good levels of reproducibility (performance: intraclass correlation coefficient [ICC]=0.99; capability: ICC=0.98) and internal consistency (performance: α=0.98; capability: α=0.97). The correlations between ASK and KINDL were positive and moderate.

CONCLUSIONS

The Portuguese version of ASK showed acceptable levels of validity, internal consistency, and reproducibility; the authors recommend its use in clinical settings.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

LIMITATIONS

This PA protocol consisted of controlled activity trials.

CONCLUSIONS

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

Does Spinal Fusion and Scoliosis Correction Improve Activity and Participation for Children With GMFCS level 4 and 5 Cerebral Palsy?

Spinal fusion is used to treat scoliosis in children with cerebral palsy (CP). Following intervention, the WHO considers activity and participation should be assessed to guide intervention and assess the effects. This study assesses whether spinal fusion for scoliosis improves activity and participation for children with severe CP.Retrospective cohort study of 70 children (39M:31F) with GMFCS level 4/5 CP and significant scoliosis. Thirty-six underwent observational and/or brace treatment as the sole treatment for their scoliosis, and 34 underwent surgery. Children in the operative group were older and had worse scoliosis than those in the observational group. Questionnaire and radiographic data were recorded over a 2-year period. The ASKp was used to measure activity and participation.In the observational group, Cobb angle and pelvic obliquity increased from 51 (40-90) and 10 (0-30) to 70 (43-111) and 14 (0-37). Mean ASKp decreased from 16.3 (1-38) to 14.2 (1-36). In the operative group, Cobb angle and pelvic obliquity decreased from 81 (50-131) and 14 (1-35) to 38 (10-76) and 9 (0-24). Mean ASKp increased from 10.5 (0-29) to 15.9 (3-38). Spinal-related pain correlated most with change in activity and participation in both groups. There was no difference in mobility, GMFCS level, feeding or communication in either group before and after treatment.In children with significant scoliosis and CP classified within GMFCS levels 4 and 5, spinal fusion was associated with an improvement in activity and participation, whereas nonoperative treatment was associated with a small reduction. Pain should be carefully assessed to guide intervention.

Physical Activity Among Adolescents with Cerebral Palsy: An Integrative Review

PROBLEM

Physical activity is necessary for optimum physical and psychosocial health in the general population. It is even more important for adolescents who struggle with impairments that limit motor function. Recommendations for best practice are needed as adolescents transition into adulthood.

PURPOSE

An integrative review was performed to determine the state of the science regarding 1) what factors impact physical activity in adolescents with cerebral palsy, and 2) how the needs of this population have been addressed regarding physical activity.

SEARCH STRATEGY

A literature search of MEDLINE, CINAHL, and PubMed was conducted using the terms cerebral palsy, mobility or activity, and adolescents. Exclusion criteria were surgical or pharmacological interventions.

RESULTS OF THE LITERATURE SEARCH

Descriptive and intervention studies were included and evaluated for purpose, design, and key findings.

SYNTHESIS OF EVIDENCE

Correcting the decline of physical activity in adolescents with CP may carry benefits over into adulthood. There are few studies that adapt physical activity to age and level of impairment. Several studies support approaching physical activity from a social model, focusing on participation of the person in the context of environment. There is a lack of research incorporating family-centered care. Many study designs are shallow and lack the proper instruments for assessing outcomes.

IMPLICATIONS FOR PRACTICE

Home and community based interventions need to be developed that are individualized. More studies are needed with stronger research designs and better instruments in order to generalize results for practice.

An examination of motor unit number index in adults with cerebral palsy

Spinal motor neuron loss may be a factor contributing to weakness in central disorders. The aim of this study was to assess whether motor unit numbers are reduced in the hand musculature of adults with cerebral palsy (CP) using the motor unit number index (MUNIX) technique. In this prospective, case-control study, 10 adults with CP were matched with healthy controls. MUNIX was computed using area and power of voluntary surface hypothenar electromyographic (EMG) signals and the compound muscle action potential (CMAP) recorded with ulnar nerve stimulation. The motor unit size index (MUSIX) was calculated based on maximum CMAP amplitude and MUNIX value. Gross Motor Function Classification Scale (GMFCS) and Manual Abilities Classification Scale (MACS) levels were rated for CP subjects. MUNIX was significantly lower for CP participants (Mean 167.8 vs. 214.4, p=.022). MUNIX values did not correlate with GMFCS or MACS. MUSIX values were higher, though not significantly, for CP subjects (p=.11). MUSIX increased with increasing MACS levels (r(2)=.4017, p=.049). Thus, motor unit numbers in ulnar hand muscles may be decreased with CP. MUSIX values are associated with greater hand impairment. Therefore, peripheral motor unit loss as a component of the weakness found with CP deserves further evaluation.

Use of the Child Engagement in Daily Life and Ease of Caregiving for Children to Evaluate Change in Young Children with Cerebral Palsy

ABSTRACT Aims: Participation in family and recreational activities, self-care, and parent ease of caregiving are important outcomes for young children with cerebral palsy (CP). The aim of this study was to examine use of the Child Engagement in Daily Life and the Ease of Caregiving for Children to measure change over time. Methods: A convenience sample of 387 parents of young children with CP (18 months to 5 years of age) completed the measures twice, a mean of 12.7 months apart. Results: For the Child Engagement in Daily Life, parents of children in Gross Motor Function Classification System level I and levels II-III reported more change for the Self-care domain (medium effect) than the Family and Recreational Activities domain (small effect) and the Ease of Caregiving for Children (small effect). The change reported by parents of children in levels IV-V on all three measures was less than the criterion for a small effect. Minimal detectable change for each measure varied from 12.1 to 14.1, out of a total possible score of 100. Conclusion: Further research is recommended to determine responsiveness to change following intervention.

The continuum of care for individuals with lifelong disabilities: role of the physical therapist

Many individuals with lifelong disabilities (LLDs) of childhood onset are living longer, participating in adult roles, and seeking comprehensive health care services, including physical therapy, with greater frequency than in the past. Individuals with LLDs have the same goals of health and wellness as those without disabilities. Aging with a chronic LLD is not yet well understood; however, impairments such as pain, fatigue, and osteoporosis often present earlier than in adults who are aging typically. People with LLDs, especially those living with developmental disabilities such as cerebral palsy, myelomeningocele, Down syndrome, and intellectual disabilities, frequently have complex and multiple body system impairments and functional limitations that can: (1) be the cause of numerous and varied secondary conditions, (2) limit overall earning power, (3) diminish insurance coverage, and (4) create unique challenges for accessing health care. Collaboration between adult and pediatric practitioners is encouraged to facilitate smooth transitions to health practitioners, including physical therapists. A collaborative client-centered emphasis to support the transition to adult-oriented facilities and promote strategies to increase accessibility should become standard parts of examination, goal setting, and intervention. This perspective article identifies barriers individuals with selected LLDs experience in accessing health care, including physical therapy. Strategies are suggested, including establishment of niche practices, physical accessibility improvement, and inclusion of more specific curriculum content in professional (entry-level) doctorate physical therapy schools.

Duration and patterns of habitual physical activity in adolescents and young adults with cerebral palsy

AIM

Adolescents and young adults with cerebral palsy (CP) show reduced motor function and gait efficiency, and lower levels of habitual physical activity (HPA), than adolescents with typical development and children with CP. This study examined activity duration and patterns in this population in the Middle East through long-term monitoring of a large sample using accelerometers.

METHOD

Adolescents and young adults with bilateral CP at Gross Motor Function Classification System (GMFCS) levels II, III, and IV, were monitored in their habitual environment for four consecutive days with ActivPAL3 monitors. Time spent in sedentary, standing, and walking activities, and frequency of walking steps and transitions, were analysed for each GMFCS level.

RESULTS

Measurements were made on 222 participants (132 males, 90 females; mean age 16 y 9 mo SD 2y, range 13 y 4 mo-22 y). The Mann-Whitney U test demonstrated significant differences (p<0.05) between GMFCS levels, showing reduced walking and standing activity and increased sedentary duration at higher GMFCS levels (p<0.001), except for increased standing time between GMFCS levels II and III (p=0.07). Participants in educational facilities exhibited less sedentary behaviour than those who were homebound (p<0.05).

INTERPRETATION

These descriptions of duration and frequency of active and sedentary behaviours may serve as a basis for recommendations to minimize inactivity in this population. Adolescents and young adults with CP in the Middle East demonstrate similar patterns of HPA to their peers in other regions.

Developmental trajectories of daily activities in children and adolescents with cerebral palsy

OBJECTIVES

To describe the developmental trajectories of mobility performance and daily activities in children and young adults with cerebral palsy (CP). To explore the influence of gross motor function and intellectual disability on these trajectories.

METHODS

Four hundred and twenty-four Dutch participants with CP (aged 1-20 years at study onset) were followed yearly over a period of 2 to 4 years. Developmental trajectories (from ages 1-16 years) were described for mobility performance and performance of daily activities, assessed by using the Vineland Adaptive Behavior Scale for gross motor function (classified by the Gross Motor Function Classification System) and intellectual disability (by IQ or school type). A subanalysis was done for performance of daily activities in a subgroup of participants without intellectual disability (aged 1-24 years).

RESULTS

The developmental trajectories of mobility performance differed according to levels of gross motor function but not levels of intellectual disability. Intellectual disability affected the performance of daily activities, with lower overall trajectory levels for participants with intellectual disabilities. For participants without intellectual disability, high-level developmental trajectories were found, with values similar to those of typically developing children despite differences in gross motor function level.

CONCLUSIONS

Mobility performance is determined mainly by levels of gross motor function. For performance of daily activities, intellectual disability was a more important determinant. Participants without intellectual disability showed developmental trajectories approaching values for typically developing participants. These estimated trajectories can guide rehabilitation interventions and future expectations for children and young adults with CP.

Psychosocial effects of reverse-integrated basketball activity compared to separate and no physical activity in young people with physical disability

The purpose of this study was to examine the impact of participation in different sport modalities on quality of life (QOL) and perceived social competence (PSC) in young people with physical disability. Ninety participants (33 females and 57 males) were monitored across four conditions: competitive separate physical activity (COSPA), recreational separate physical activity (RESPA), reverse-integrated basketball activity (RIBA), and no physical activity (NOPA). QOL and PSC questionnaires were administered at the beginning and the end of the study's duration of six months. ANCOVA corrected for functional independence and gender revealed significant group effects for pre to post change values of QOL and PSC, with greater positive change in the RIBA compared to all other groups. In addition, one-way ANOVA on pre to post change values with LSD post hoc revealed significant differences. RIBA change values for QOL with 8.77%, and for PSC with 9.98% change were significantly higher (p<.001) than in all other groups (ranges -0.18 through 1.36% for QOL, and -2.31 through 2.34% for PSC). These outcomes demonstrate a favorable outcome of the RIBA on participants. Low functional ability did not constrain the effects of sport participation.

Amount and focus of physical therapy and occupational therapy for young children with cerebral palsy

The aims of this study were to describe physical therapy (PT) and occupational therapy (OT) services for a cohort of 399 children with cerebral palsy (CP), 2-6 years old, residing in the United States and Canada. Parents completed a services questionnaire by telephone interview. Therapists classified children's Gross Motor Function Classification System (GMFCS) level. Mean minutes per month of PT and OT were greater for children receiving services in both an educational and clinic setting. Mean minutes per month of PT and OT were greater for children in levels IV-V than children in level I and greater for children in the United States than children in Canada. Parents reported that interventions focused a moderate to great extent on primary impairments, secondary impairments, activity, and structured play activities, a moderate extent on environmental modifications and equipment; and a moderate to small extent on self-care routines. The results support the importance of coordination of PT and OT services.

Description of the Pediasuit ProtocolTM

INTRODUCTION: PediaSuit ProtocolTM is an intensive therapy with a holistic approach to the treatment of individuals with neurological disorders like cerebral palsy (CP), developmental delays, traumatic brain injuries, autism and other conditions which affect a child's motor and/or cognitive functions. OBJECTIVE: The aim of the present work is to describe the PediaSuit ProtocolTM. METHODS: The authors team remained two months observing the care provided in a clinic with physical therapists trained by the PediaSuit ProtocolTM team (USA). RESULTS: The PediaSuitTM is a therapeutic protocol which uses a suit combined with intensive physical therapy and consists of up to four hours of therapy a day, five days a week, during three or four weeks. The PediaSuit ProtocolTM is customized to fit the needs of each child, with specific functional goals, and usually involves an intensive rehabilitation program. It combines the best elements of various techniques and methods, and has a sound rationale based on exercise physiology. CONCLUSION: This protocol anticipates results obtained only with long periods of conventional physical therapy.

Fundamental movement skills and physical activity among children with and without cerebral palsy

Fundamental movement skills (FMS) proficiency is believed to influence children's physical activity (PA), with those more proficient tending to be more active. Children with cerebral palsy (CP), who represent the largest diagnostic group treated in pediatric rehabilitation, have been found to be less active than typically developing children. This study examined the association of FMS proficiency with PA in a group of children with CP, and compared the data with a group of typically developing children. Five FMS (run, jump, kick, throw, catch) were tested using process- and product-oriented measures, and accelerometers were used to monitor PA over a 7-day period. The results showed that children with CP spent less time in moderate to vigorous physical activity (MVPA), but more time in sedentary behavior than typically developing children. FMS proficiency was negatively associated with sedentary time and positively associated with time spent in MVPA in both groups of children. Process-oriented FMS measures (movement patterns) were found to have a stronger influence on PA in children with CP than in typically developing children. The findings provide evidence that FMS proficiency facilitates activity accrual among children with CP, suggesting that rehabilitation and physical education programs that support FMS development may contribute to PA-related health benefits.

Hippotherapy--an intervention to habilitate balance deficits in children with movement disorders: a clinical trial

BACKGROUND

Clinical observations have suggested that hippotherapy may be an effective strategy for habilitating balance deficits in children with movement disorders. However, there is limited research to support this notion.

OBJECTIVE

The purposes of this study were to assess the effectiveness of hippotherapy for the management of postural instability in children with mild to moderate balance problems and to determine whether there is a correlation between balance and function.

DESIGN

A repeated-measures design for a cohort of children with documented balance deficits was used.

METHODS

Sixteen children (9 boys and 7 girls) who were 5 to 16 years of age and had documented balance problems participated in this study. Intervention consisted of 45-minute hippotherapy sessions twice per week for 6 weeks. Two baseline assessments and 1 postintervention assessment of balance, as measured with the Pediatric Balance Scale (PBS), and of function, as measured with the Activities Scale for Kids-Performance (ASKp), were performed.

RESULTS

With the Friedman analysis of variance, the PBS and the ASKp were found to be statistically significant across all measurements (P<.0001 for both measures). Post hoc analysis revealed a statistical difference between baseline and postintervention measures (P≤.017). This degree of difference resulted in large effect sizes for PBS (d=1.59) and ASKp (d=1.51) scores after hippotherapy. A Spearman rho correlation of .700 indicated a statistical association between PBS and ASKp postintervention scores (P=.003). There was no correlation between the change in PBS scores and the change in ASKp scores (r(s)=.13, P>.05).

LIMITATIONS

Lack of a control group and the short duration between baseline assessments are study limitations.

CONCLUSIONS

The findings suggest that hippotherapy may be a viable strategy for reducing balance deficits and improving the performance of daily life skills in children with mild to moderate balance problems.

Fundamental movement skills testing in children with cerebral palsy

PURPOSE

To examine the inter-rater reliability and comparative validity of product-oriented and process-oriented measures of fundamental movement skills among children with cerebral palsy (CP).

METHOD

In total, 30 children with CP aged 6 to 14 years (Mean = 9.83, SD = 2.5) and classified in Gross Motor Function Classification System (GMFCS) levels I-III performed tasks of catching, throwing, kicking, horizontal jumping and running. Process-oriented assessment was undertaken using a number of components of the Test of Gross Motor Development (TGMD-2), while product-oriented assessment included measures of time taken, distance covered and number of successful task completions. Cohen's kappa, Spearman's rank correlation coefficient and tests to compare correlated correlation coefficients were performed.

RESULTS

Very good inter-rater reliability was found. Process-oriented measures for running and jumping had significant associations with GMFCS, as did seven product-oriented measures for catching, throwing, kicking, running and jumping. Product-oriented measures of catching, kicking and running had stronger associations with GMFCS than the corresponding process-oriented measures.

CONCLUSION

Findings support the validity of process-oriented measures for running and jumping and of product-oriented measures of catching, throwing, kicking, running and jumping. However, product-oriented measures for catching, kicking and running appear to have stronger associations with functional abilities of children with CP, and are thus recommended for use in rehabilitation processes.

Factor- and item-level analyses of the 38-item activities scale for kids-performance

AIM

Children and adolescents highly value their ability to participate in relevant daily life and recreational activities. The Activities Scale for Kids-performance (ASKp) instrument measures the frequency of performance of 30 common childhood activities, and has been shown to be valid and reliable. A revised and expanded 38-item ASKp (ASKp38) version has been reported in recent literature and is currently used in clinical research. The aim of this paper is to assess the factor structure and item-level statistics of the ASKp38.

METHOD

Our study used factor analyses and Rasch analyses to determine the item-set dimensionality and to calculate item-level statistics respectively, for existing ASKp38 data from 200 children (104 males; 96 females; mean age 12y 7mo; SD 2y 8mo; range 6-20y) with physical disabilities. The children had a variety of physical impairments including cerebral palsy (n = 105; range 8-13 y), limb salvage (n = 18; range 11-20y), arthrogryposis (n = 13; 6-17y), and other, including individuals with spina bifida and spinal cord injury (n = 64; 8-19 y).

RESULTS

A two-factor model, with components of activities of daily living and play, most optimally fit the data. Item-fit statistics based on this two-factor model demonstrated adequate fit and content coverage.

INTERPRETATION

The ASKp38 appears to consist of two factors, defined as (1) activities of daily living and (2) play, and may be used to measure the frequency of activity performance on two corresponding subscales.

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

PURPOSE

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

KEY POINTS

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

CONCLUSION

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

ASKing the kids: how children view their abilities after perinatal stroke

A total of 19 children with a history of perinatal stroke were asked how they saw their own motor abilities and disabilities using the Activities Scale for Kids (ASK) performance and capability questionnaires. The median ASK performance score was significantly lower (86.7) than the median ASK capability score (93.4; P = .03), suggesting children felt they were not doing everything they were capable of doing. Performance and capability total scores were not associated with gender or stroke type; lower performance and capability scores were associated with cerebral palsy. Within groups, performance scores were significantly lower than capability scores in girls (P = .02), children with presumed perinatal stroke (P = .02), children with unilateral stroke (P = .02), and children with large versus small branch unilateral middle cerebral artery stroke (P = .03). Further work is needed to understand why these children's performance does not match perceived capability.

Muscle architecture predicts maximum strength and is related to activity levels in cerebral palsy

BACKGROUND

Muscle architecture is known to be predictive of muscle function. However, it is unknown whether this relationship is similar in children and adolescents with and without cerebral palsy (CP).

OBJECTIVE

The objective of this study was to determine whether the architecture of the rectus femoris (RF) and vastus lateralis (VL) muscles was predictive of maximum voluntary knee extensor torque in children and adolescents with and without CP and whether these measures were related to activity and participation levels.

DESIGN

A case-control design was used.

METHODS

Eighteen participants with CP (mean age=12.0 years, SD=3.2) at Gross Motor Function Classification System (GMFCS) levels I through IV and 12 age-matched peers with typical development (mean age=12.3 years, SD=3.9) were evaluated. Muscle thickness, fascicle length, and fascicle angle of the RF and VL muscles were measured with 2-dimensional, B-mode ultrasound imaging. The activity and participation measures used for participants with CP were the Pediatric

OUTCOMES

Data Collection Instrument (PODCI) and the Activities Scale for Kids, Performance Version (ASKp).

RESULTS

When age and GMFCS level were controlled for, VL muscle thickness was the best predictor of knee extensor isometric torque in the group with CP (R(2)=.85). This prediction was similar to the prediction from VL muscle thickness and age in participants with typical development (R(2)=.91). Rectus femoris muscle fascicle length was significantly correlated with the Sports and Physical Functioning Scale of the PODCI (ρ=.49), and VL muscle fascicle angle was correlated with the Transfers and Basic Mobility Scale of the PODCI (r=.47) and with ASKp Locomotion subdomain (r=.50).

LIMITATIONS

A limitation of this study was the small sample size.

CONCLUSIONS

Ultrasound measures of VL muscle thickness, adjusted for age and GMFCS level, were highly predictive of maximum torque and have the potential to serve as surrogate measures of voluntary strength (force-generating capacity) in children and adolescents with and without CP.

Physical activity measurement instruments for children with cerebral palsy: a systematic review

AIM

this paper is a systematic review of physical activity measurement instruments for field-based studies involving children with cerebral palsy (CP).

METHOD

database searches using PubMed Central, MEDLINE, CINAHL Plus, PsycINFO, EMBASE, Cochrane Library, and PEDro located 12 research papers, identifying seven instruments that met the inclusion criteria of (1) having been developed for children aged 0 to 18 years, (2) having been used to evaluate a physical activity dimension, and (3) having been used in a field-based study involving children with CP. The instruments reviewed were the Activities Scale for Kids - Performance version (ASKp), the Canada Fitness Survey, the Children's Assessment of Participation and Enjoyment/Preferences for Activities of Children (CAPE/PAC), the Compendium of Physical Activities, the Physical Activity Questionnaire - Adolescents (PAQ-A), StepWatch, and the Uptimer. Second-round searches yielded 11 more papers, providing reliability and validity evidence for the instruments.

RESULTS

the instruments measure physical activity frequency, mode, domain, and duration. Although most instruments demonstrated adequate reliability and validity, only the ASKp and CAPE/PAC have established reliability and validity for children with physical disabilities; the Uptimer has established concurrent validity. No instrument measuring intensity in free-living has been validated or found reliable for children with CP.

INTERPRETATION

the findings suggest that further studies are needed to examine the methodological properties of physical activity measurement in children with CP. Combining subjective and objective instruments is recommended to achieve better understanding of physical activity participation.

Effectiveness of motor learning coaching in children with cerebral palsy: a randomized controlled trial

Objective: To evaluate effectiveness of motor learning coaching on retention and transfer of gross motor function in children with cerebral palsy.

Design: Block randomized trial, matched for age and gross motor function.

Setting: Coordinated, multinational study (Israel, Jordan and Palestinian Authority) in schools and rehabilitation centers.

Subjects: 78 children with spastic cerebral palsy, gross motor functional levels II and III, aged 66 to 146 months.

Interventions: 1 hr/day, 3 days/week for 3 months treatment with motor learning coaching or neurodevelopmental treatment: two groups.

Main measures: Gross motor function Measure (GMFM-66), stair-climbing mechanical efficiency (ME) and parent questionnaire rating their child’s mobility. Immediate treatment effects were assessed after 3 months and retention determined from follow-up measurements 6 months after treatment.

Results: GMFM-66, ME and parent questionnaires were obtained from 65, 31 and 64 subjects, respectively. Although both groups increased GMFM-66 score over 3 months, measurements 6 months later indicated retention was significantly superior by 2.7 in the motor learning coaching children of level-II. Similar retention trend was evident for ME, increasing 6 months after motor learning coaching by 1.1% and declining 0.3% after neurodevelopmental treatment. Mobility performance in the outdoors and community environment increased 13% from 3 to 9 months after motor learning coaching and decreased 12% after neurodevelopmental treatment. Minor group differences occurred in children of level-III.

Conclusions: In higher functioning children with cerebral palsy, the motor learning coaching treatment resulted in significantly greater retention of gross motor function and transfer of mobility performance to unstructured environments than neurodevelopmental treatment.

Participation in home, extracurricular, and community activities among children and young people with cerebral palsy

AIM

Participation in home, extracurricular, and community activities is a desired outcome of rehabilitation services for children and young people with cerebral palsy (CP). The purpose of this study was to investigate the effect of age and gross motor function on participation among children and young people with CP.

METHOD

Five hundred participants (277 males, 223 females) were grouped by age and Gross Motor Function Classification System (GMFCS) level. There were 291 children aged 6 to 12 years and 209 young people aged 13 to 21 years. There were 128 participants in GMFCS level I, 220 in levels II/III, and 152 in levels IV/V. Participants completed the Children's Assessment of Participation and Enjoyment to measure number of activities (diversity) and how often they were performed (intensity) in the past 4 months.

RESULTS

Children had higher overall participation diversity and intensity than young people (p<0.001). Children and young people in GMFCS level I had the highest overall participation, followed by children and young people in levels II/III and IV/V. Children had higher participation in recreational (p<0.001) but not formal (such as team sports or clubs) or physical activities. Children (p<0.01) and young people (p<0.001) in level I had the highest participation in physical activities; diversity and intensity were generally low.

INTERPRETATION

The findings provide evidence of the effect of age and gross motor function on participation of children and young people with CP. Low participation in physical activities may have implications for fitness and health, especially for children and young people in GMFCS levels IV and V.

Family needs of parents of children and youth with cerebral palsy

BACKGROUND

Understanding the needs of families of children and youth with cerebral palsy (CP) is important for family-centred services. The aims of this study were to identify: (1) differences in the number and types of family needs expressed by parents based on the age and gross motor function level of their children with CP; (2) the most frequent family needs; and (3) needs that differ on gross motor function level.

METHODS

A total of 501 parents (77.6% mothers) of children and youth with CP completed a modified version of a Family Needs Survey and a demographic questionnaire. Children's gross motor function level was classified using the Gross Motor Function Classification System.

RESULTS

Total number of family needs differed based on gross motor function level (P < 0.001) but not age. Parents of children/youth who use wheeled mobility expressed the highest number of family needs, while parents of children/youth who walk without restrictions expressed the fewest needs. Family needs for Information (P= 0.001), Support (P= 0.001), Community Services (P < 0.001) and Finances (P < 0.001) differed based on children's gross motor function level. Over 50% of parents expressed family needs for information on current and future services, planning for the future, help in locating community activities and more personal time. Parents of children and youth who use wheeled mobility were more likely to express the need for help in paying for home modifications, equipment, services and locating sitters, respite care providers and community activities.

CONCLUSIONS

The gross motor function of children/youth with CP has implications for collaboration with families to identify needs and co-ordinate services. Health professionals have a role to assist families with information needs and locating community services and leisure activities. Family needs for future planning suggest that health professionals should assist families to prepare for key periods in the lives of their children with CP.

Social and community participation of children and youth with cerebral palsy is associated with age and gross motor function classification

BACKGROUND

Through social and community participation, children and youth with cerebral palsy (CP) form friendships, gain knowledge, learn skills, express creativity, and determine meaning and purpose in life.

OBJECTIVE

The purposes of this study were: (1) to determine whether social and community participation of children and youth with CP differ based on age, sex, and gross motor function, and (2) to identify the types of activities in which social and community participation are highest.

DESIGN AND METHODS

A prospective cross-sectional analytic design was used. The participants were a sample of convenience of 291 children (6-12 years of age) and 209 youth (13-21 years of age) with CP (55.4% males, 44.6% females) receiving services from 7 children's hospitals. Participants completed the Children's Assessment of Participation and Enjoyment (CAPE) by structured interview. Gross Motor Function Classification System (GMFCS) level was determined by the researchers.

RESULTS

Youth did a higher percentage of activities with friends and others and outside the home than children. Children and youth in level I did a higher percentage of activities with friends and others compared with children and youth in levels II and III and in levels IV and V. Children and youth in level I and in levels IV and V did a higher percentage of activities outside the home than children and youth in levels II and III. Differences were not found between females and males. The percentage of activities done with friends and others and outside the home was highest for physical and skill-based activities.

LIMITATIONS

Findings cannot be attributed only to GMFCS level.

CONCLUSIONS

The ability to walk without restrictions is desirable for social and community participation. For children and youth with CP who have limitations in mobility, physical therapists have roles as consultants for accessibility, activity accommodations, and assistive technology and as advocates for inclusive environments.