A path model for evaluating dosing parameters for children with cerebral palsy

Health Promotion and Physical Wellness in Pediatric Physical Therapy

PURPOSE

A health promotion and physical wellness (HPPW) life course approach for pediatric physical therapy (PT) is recommended to improve children's health outcomes across the lifespan.

SUMMARY OF KEY POINTS

A life course approach describes how a child's individual responses to environmental factors influence health outcomes. Using HPPW strategies, pediatric physical therapists can identify health risks and promote positive outcomes. Outcome measures and intervention recommendations are outlined to assist therapists in integrating HPPW strategies to ensure a longitudinal plan of care and optimal health outcomes for children.

CONCLUSIONS AND RECOMMENDATIONS FOR CLINICAL PRACTICE

A child's health trajectory begins in the prenatal period and is influenced by individual and environmental factors. Pediatric PT uses child- and family-centered approaches and environmental assessments to design plans of care that address child and family HPPW goals. Incorporating HPPW strategies into pediatric PT facilitates positive health and physical wellness across a child's lifespan.See the video abstract for insights from the authors.

VIDEO ABSTRACT

Supplemental digital content available at https://www.dropbox.com/scl/fi/3g468hj1rpxrrivbeses0/HPPW-Video-Abstract_1080.mp4?rlkey=4p1i8z1gynroz064zpx3alijz&st=8u0gqemz&dl=0.

Defining paediatric neurorehabilitation: You cannot improve what you cannot characterize

Neurorehabilitation is the primary therapy for neurological impairment in children, yet its potential to achieve change remains incompletely understood and probably underestimated. Understanding 'the difference neurorehabilitation can make' against a background of neurological repair and recovery as well as ongoing neurological development is an enormous challenge, exacerbated to no small extent by the lack of a 'common currency' for the description and measurement of the neurorehabilitation services a child is receiving. This review addresses attempts to parse neurorehabilitation treatment content in theoretically and mechanistically valid ways that might help address this challenge.

Training intensity of robot-assisted gait training in children with cerebral palsy

AIM

We compared three different intensities of robot-assisted gait training (RAGT) for achieving favourable outcomes in children with cerebral palsy (CP).

METHOD

This study was conducted using a randomized controlled, single-blind design. Thirty children (19 males and 11 females; mean age 6 years 1 month, SD 2 years) with CP classified in Gross Motor Function Classification System levels II and III were assigned to three different RAGT intensity groups: high-intensity (fastest walking speed and lowest body weight support [BWS]), low-intensity (slowest speed and highest BWS), and comfortable intensity (intermediate speed and intermediate BWS). The RAGT intervention was performed three times a week for 6 weeks. Outcome measures included the 88-item Gross Motor Function Measure, stability index, spatiotemporal parameters of gait analysis, paediatric functional independence measure, and the Canadian Occupational Performance Measure.

RESULTS

The 88-item Gross Motor Function Measure was significantly improved after training in the high-intensity (D Δ8.3 ± 15.6; E Δ3.8 ± 4.1) and comfortable intensity (D Δ2.9 ± 3.1; E Δ1.2 ± 2.0) groups, whereas gait speed was improved in the comfortable intensity group, without statistically significant group differences. Only the low-intensity group showed improvement on the stability index (Δ -0.6 ± 0.9, p = 0.05). Everyday functional performance significantly improved in all three groups, with the comfortable intensity group showing the greatest improvement.

INTERPRETATION

Different training intensities produced improvement in different areas; individualized RAGT intensity adjustment is therefore needed based on the rehabilitation goal.

Neglect of Psychological Care for Children with Cerebral Palsy and Their Families and Its Impact on Their Occupational Engagement in Saudi Arabia

Background and Objectives: Many children with (CP) and their families in Saudi Arabia struggle emotionally. Unfortunately, there have not been many studies conducted on how to help them with these challenges. This research aims to bring attention to this gap and to explore how a lack of proper mental health care might affect these children's ability to participate in everyday activities. Materials and Methods: In this cross-sectional descriptive study, a survey was conducted between August and October 2023. A total of 300 parents of CP children from Saudi Arabia participated in the study. The impact of psychological care negligence on the occupational engagement of CP children and their families was assessed by designing a valid questionnaire. Results: A total of 300 parents of children with CP participated in this study. The majority of the sample, 71% of parents, said that their children did not receive any psychological care, and 59.7% of the participants said that their children did not even receive a referral to a psychologist. However, 60.3% of parents of children noticed a significant decline in the occupational performance of their children, and 65.7% predicted an improvement in their children's performance with future psychological care. Conclusions: It is clear that there is a lack of awareness about the importance of mental health care for children with CP in Saudi Arabia. This lack of care hinders these children and their families' occupational engagement and social participation.

Joystick-Operated Ride-On Toy Navigation Training for Children With Hemiplegic Cerebral Palsy: A Pilot Study

IMPORTANCE

Children with hemiplegic cerebral palsy (HCP) require intensive task-oriented training to make meaningful gains in affected upper extremity (UE) motor function.

OBJECTIVE

To evaluate the acceptability and utility of single joystick-operated ride-on toy (ROT) navigation training incorporated into a modified constraint-induced movement therapy (CIMT) camp for children with HCP.

DESIGN

Single group pretest-posttest design.

SETTING

Three-wk structured CIMT camp.

PARTICIPANTS

Eleven children with HCP between ages 3 and 14 yr.

INTERVENTION

Children received group-based CIMT for 6 hr/day, 5 days/wk, for 3 wk. As part of camp activities, children also received ROT navigation training for 20 to 30 min/day, 5 days/wk, for 3 wk.

OUTCOMES AND MEASURES

We assessed children's acceptance of ROT training by monitoring adherence and evaluating child engagement (affect and attention) during training sessions. The effects of ROT training combined with other camp activities on children's affected UE motor function were also assessed with the standardized Quality of Upper Extremity Skills Test (QUEST) and training-specific measures of ROT maneuvering accuracy.

RESULTS

Children demonstrated high levels of training adherence, positive affect, and task-appropriate attention across weeks. Positive engagement during ROT sessions was correlated with independent navigation. We also found medium- to large-sized improvements in QUEST scores and toy-maneuvering capabilities after the combined program.

CONCLUSIONS AND RELEVANCE

Our pilot data support the use of joystick-operated ROTs as child-friendly therapy adjuncts that can be incorporated into intensive UE training programs to improve adherence and motivation in therapy programs, boost treatment dosing, and promote affected UE motor function in children with HCP. Plain-Language Summary: This pilot study offers promising evidence that supports the use of modified single joystick-operated ride-on toys (ROTs) for children with hemiplegic cerebral palsy (HCP). The study used ROTs as one of several interventions that were part of a constraint-induced movement therapy (CIMT) camp program for children with HCP. The ROTs boosted children's motivation, their engagement with and adherence to training, and their practice in using their affected upper extremity (UE) for goal-directed activities in their natural settings. ROTs are accessible, age-appropriate, and easy-to-use devices for both occupational therapy clinicians and families to encourage children to use their affected UEs by challenging their perceptual, motor-planning, problem-solving, and movement-control skills in an enjoyable and engaging way. ROTs can be used within and outside conventional rehabilitation settings.

Spreading Standardized Documentation of Pediatric Occupational and Physical Therapy Dose: A Quality Improvement Initiative

IMPORTANCE

Clinicians and researchers can leverage clinical documentation of therapy services for quality improvement and research purposes. However, documentation is often institution specific and may not adequately capture the dose of therapy delivered, thus limiting collaboration.

OBJECTIVE

To implement documentation of pediatric occupational and physical therapy dose from one institution to another institution. Dose documentation includes the frequency, intensity, time, and type of interventions delivered (FITT Epic® Flowsheet) at each session.

DESIGN

Prospective time-series quality improvement study.

SETTING

Two large urban pediatric hospitals.

PARTICIPANTS

Occupational and physical therapy staff members.

INTERVENTION

Staff training and feedback loops utilizing existing groups.

OUTCOMES AND MEASURES

The process measure (number of available staff trained and using the FITT Epic Flowsheet over time) and the outcome measure (percentage of FITT Epic Flowsheets used for treatment visits each month) were analyzed using a statistical process control chart. The balancing measure (percentage of notes closed before 7 p.m. on the same day as the encounter) was analyzed using mean per month across three time periods.

RESULTS

Fifty-seven staff members (68%) attended formal training. On average, clinicians documented 90% of sessions using the FITT Epic Flowsheet after implementation. There was no change observed in the balancing measure.

CONCLUSIONS AND RELEVANCE

Documentation of dose was spread from one institution to another. Shared documentation will facilitate future collaboration for quality improvement and research purposes. Occupational therapy practitioners and leaders should consider implementing documentation with common dose elements. Plain-Language Summary: Occupational therapy documentation is often institution specific and may not adequately capture the dose of therapy (frequency, intensity, time) or types of interventions that were delivered, thus limiting opportunities for collaboration between institutions. This article adds to the literature on administrative supports for clinical and quality improvement research by illustrating a specific example of how documentation of dose can be shared from one institution to another. The data show that clinicians at one institution started using a new style of documentation using the FITT Epic® Flowsheet and shared discrete dose elements with another institution, creating new opportunities for collaboration. Shared documentation can facilitate future collaboration for quality improvement and research purposes.

Selective Dorsal Rhizotomy: Patient Demographics and Postoperative Physical Therapy

BACKGROUND

Selective dorsal rhizotomy (SDR) is a surgical procedure that permanently alters lower extremity spasticity, common in children with spastic cerebral palsy (CP). Intensive postoperative physical therapy (PT) is recommended following SDR. The first purpose of this study is to describe and compare patient demographics between children who received SDR and the population of children with CP at one institution. The second purpose of this study is to compare the completed dose of postoperative PT with the clinically recommended dose for a subset of ambulatory children who underwent SDR.

METHODS

This retrospective, observational study included 60 children with spastic CP following SDR. A subset (n = 12 ambulatory children) was included to describe the dose of postoperative PT. Information gathered from electronic medical records included age at the time of SDR, sex, Gross Motor Function Classification System level, anatomic distribution, race, county-level habitancy, health insurance provider, timed current procedural terminology codes, and location for postoperative PT encounters within a single institution.

RESULTS

Black or African American children (P = 0.002), children living in large central metro areas (P = 0.033), and children with public insurance (P ≤ 0.001) were significantly less likely to receive SDR. Children undergoing SDR do not achieve the recommended dose of PT after hospital discharge.

CONCLUSION

SDR is not equally accessed by patient populations, and postoperative PT frequency is below current recommendations throughout the rehabilitation process. Future studies need to investigate why these disparities exist and what prevents children from meeting the clinically recommended dose of postoperative PT after SDR.

Implementing Parent Coaching in Hospital-Based Pediatric Occupational Therapy: A Multisite Quality Improvement Project

IMPORTANCE

Parent coaching (PC) is a best practice for young children with, or at high risk for, cerebral palsy (CP). Occupational therapy practitioners in outpatient settings encounter barriers to implementing PC.

OBJECTIVE

To increase the documented use of PC in outpatient occupational therapy visits for children younger than age 2 yr with, or at high risk for, CP from 0% to 80%.

DESIGN

Multicenter quality improvement (QI) initiative with a time-series design.

SETTING

Three pediatric tertiary-care institutions, each with multiple outpatient occupational therapy clinics.

PARTICIPANTS

Practitioners in the outpatient clinics and patients <2 yr old with, or at high risk for, cerebral palsy.

INTERVENTION

Plan-do-study-act cycles included interventions packaged as a toolkit: education sessions, quick references, electronic medical record (EMR) supports, and site-specific strategies.

OUTCOMES AND MEASURES

The primary outcome measure was the use of PC in outpatient sessions. Process measures included pre- and posteducation practitioner knowledge scores and an EMR checklist. Balancing measures (ensuring that changes do not cause problems in other areas) of parent satisfaction/experience and practitioner productivity were measured pre- and postintervention.

RESULTS

The primary outcome measure goal (80% documented use of PC in sessions) was attained in the seventh month of the study, sustained for 4 mo, and settled at 79.1% for the remaining 6 mo. Practitioner knowledge scores increased from 83.1% to 87.9% after initial education sessions, t[56] = 3.289, p = .001. Parent satisfaction/experience and practitioner productivity scores did not change.

CONCLUSIONS AND RELEVANCE

QI methodology can support PC implementation in pediatric outpatient practice. What This Article Adds: This multisite QI initiative shows that outpatient occupational therapy practitioners can implement PC as a best practice with the use of a toolkit. Results suggest that education alone does not result in changes to practitioner behavior and that QI methods can help when implementing best practices in a clinical setting.

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

Introduction

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

Defining quantifying and reporting

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

Discussion

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

A protocol for a single-arm interventional study assessing the effects of a home-based joystick-operated ride-on-toy navigation training programme to improve affected upper extremity function and spontaneous use in children with unilateral cerebral palsy (UCP)

INTRODUCTION

Children with unilateral cerebral palsy (UCP) face significant limitations in upper extremity (UE) function and require effective interventions that promote intensive goal-directed practice while maximising motivation and adherence with therapy. This study builds on our past work and will assess the effects of a 6-week researcher-caregiver codelivered, home-based ride-on-toy navigation training (RNT) programme in young children with UCP. We hypothesise that the RNT programme will be acceptable, feasible to implement, and lead to greater improvements in unimanual and bimanual function when combined with conventional therapy, compared with conventional therapy provided alone.

METHODS AND ANALYSIS

15 children with UCP between 3 and 8 years will be recruited. During the 6-week control phase, participants will receive treatement-as-usual alone. During the subsequent 6-week intervention phase, in addition to conventional therapy, RNT will be provided 4-5 times/week (2 times by researchers, 2-3 times by caregivers), 30-45 min/session. We will assess UE function using standardised tests (Quality of Upper Extremity Skills Test and Shriner's Hospital Upper Extremity Evaluation), reaching kinematics, wrist-worn accelerometry, caregiver-rated ABILHAND-Kids questionnaire, and training-specific measures of movement control during RNT. Programme feasibility and acceptance will be assessed using device use metrics, child and caregiver exit questionnaires, training-specific measures of child engagement, and the Physical Activity Enjoyment Scale. All assessments will be conducted at pretest, following the control phase (midpoint), and after completion of the intervention phase (post-test).

ETHICS AND DISSEMINATION

The study is approved by the Institutional Review Board of the University of Connecticut (# H22-0059). Results from this study will be disseminated through peer-reviewed manuscripts in scientific journals in the field, through national and international conferences, and through presentations to parent advocacy groups and other support organisations associated with CP.

TRIAL REGISTRATION NUMBER

NCT05559320.

Exploring the Experiences and Perceptions of Pediatric Therapists who use Functional Electrical Stimulation in their Clinical Practice

Aim: This study aimed to 1) explore the experiences and perceptions of pediatric physical therapists (PTs) and occupational therapists (OTs) who use FES in their practice, and 2) provide recommendations for overcoming common barriers to FES implementation.Methods: Eight Canadian PTs (n = 6) and OTs (n = 2), who use FES in their pediatric practice, participated in semi-structured interviews. Open-ended questions queried the motivation, goals, perceived benefits and challenges, and facilitators and barriers of FES use. Interviews were audio recorded and transcribed verbatim. Interpretive description was used to analyze the transcripts.Results: One overarching theme emerged: FES is a useful adjunct to therapy for certain pediatric clients. Four sub-themes were identified: Participants described 1) motivation for incorporating FES into clinical practice, which led to 2) experiences with the implementation of FES in clinical practice, including strategies for overcoming implementation barriers. These experiences influenced 3) how FES is used in practice (e.g. for which populations and therapeutic goals), and informed 4) recommendations for pediatric FES practice (e.g. more educational opportunities, research, and access for families).Conclusions: Pediatric PTs and OTs who use FES in clinical practice view FES as a valuable adjunct, especially for motor training to improve functional skills.

Efficacy of Therapist Supported Interventions from the Neonatal Intensive Care Unit to Home: A Meta-Review of Systematic Reviews

Infants born preterm or with complicated medical conditions requiring care in the neonatal intensive care unit (NICU) are at high risk for long-term developmental disabilities. The transition from NICU to early intervention/outpatient settings results in a disruptive gap in a therapeutic intervention during a period of maximal neuroplasticity and development. This meta-review evaluated evidence from existing systematic reviews regarding therapeutic interventions that start in the NICU and continue at home with the goal of improving developmental outcomes for infants at high risk for cerebral palsy. We also evaluated the impact of these interventions on parents' mental health outcomes.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Effectiveness of Activity-Based Therapy for Individuals With Spinal Cord Injury in Promoting Static and Dynamic Sitting Balance: Is Olfactory Mucosa Autograft a Factor?

Background

Activity-based therapy (ABT) appears to improve outcomes for individuals with spinal cord injury (SCI); however, few studies have examined sitting static and dynamic balance. It was unknown whether individuals after SCI who elected to undergo an olfactory mucosa autograft (OMA) would respond differently to ABT.

Objectives

The first objective was to assess changes in sitting strength (static) and dynamic balance in a group of individuals with SCI undergoing intensive ABT. The second objective was to determine whether sitting balance changes would be different for those who had participated in ABT after the OMA versus those who had ABT alone.

Methods

A handheld dynamometer measured peak force (sitting strength) and the multi-directional reach test measured dynamic balance (n = 16).

Results

ABT (average dose: 7 hours per week over 4.6 months) appeared to promote improvements in sitting strength in four directions (0.6-0.8 kg per month) and dynamic balance in four of five directions (0.7-1.3 cm per month). Individuals who had undergone an OMA had similar, but not greater, improvements in static and dynamic balance when compared with those who had ABT alone. It is unknown whether balance improvements resulted from natural or other factors.

Conclusion

ABT may have contributed to balance changes in individuals with SCI. Although small improvements in sitting static and dynamic balance did occur, future research documenting therapy intervention details and ABT dose-response in larger groups of individuals with SCI must be performed to provide guidance as to the optimal, effective ABT dose required to generate clinically meaningful functional improvements.

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

PURPOSE

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

SUMMARY OF KEY POINTS

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

STATEMENT OF CONCLUSION AND RECOMMENDATIONS FOR CLINICAL PRACTICE

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

Describing the Delivery of Evidence-Based Physical Therapy Intervention to Individuals With Cerebral Palsy

PURPOSE

To characterize by evidence grades and examine variation in type of physical therapy intervention delivered in routine clinical care in individuals with cerebral palsy (CP).

METHODS

Retrospective data collection from the electronic record over 1 year at a tertiary care pediatric outpatient therapy division.

RESULTS

Four hundred sixty-five individuals with CP received 28 344 interventions during 4335 treatment visits. Sixty-six percent of interventions were evidence-based interventions (EBIs). Significant variation was demonstrated across Gross Motor Function Classification System levels, with children classified as level V receiving the least and level III the most. The most frequent EBIs delivered were caregiver education, motor control, functional strengthening, ankle-foot orthoses, treadmill training, and fit of adaptive equipment.

CONCLUSIONS

Further work is needed to determine whether amount of EBI is related to better outcomes. Combining this information with other aspects of dose (intensity, time, and frequency) may elucidate the contribution of each with outcomes.

Robotic lower extremity exoskeleton use in a non-ambulatory child with cerebral palsy: a case study

PURPOSE

With few treatment options available for non-ambulatory children with cerebral palsy (CP), a robotic lower extremity gait trainer may provide a non-invasive addition to conventional treatment options. This case study investigates the usage and impact of robotic lower extremity gait trainer use in a participant with CP over the initial 3 months of use.

MATERIALS AND METHODS

This prospective case study involves a 7-year old female (GMFCS V) with CP (registered clinical trial: NCT04251390). The participant used a Trexo Home robotic gait trainer (Trexo) in the community with assessments occurring in the home and school. Trexo usage and bowel movements (BMs) were tracked daily. Postural control and lower extremity range of motion (ROM) and spasticity were evaluated prior to Trexo use and weekly to biweekly thereafter.

RESULTS

The participant used the device an average of 46 min/week, over 3.3 d/week. BM frequency increased from 0.4/d at baseline, to 1.2 (±0.5)/d during Trexo use. There were no diffuse systematic changes in postural stability, ROM or muscle spasticity, but specifically head control and spasticity in the knee flexors had improvements.

CONCLUSIONS

Data and anecdotal reports suggest that regular use of the Trexo Home robotic gait trainer has positive outcomes on frequency and quality of BMs, and may improve head control, and knee flexor spasticity. Larger controlled studies are needed to evaluate the impacts of Trexo use in children with CP.Implications for RehabilitationNon-ambulatory children with CP can use and may experience benefits from using a robot-assisted gait trainer (RAGT).Constipation, aspects of balance and focal spasticity may improve.

Single-centre parental survey of paediatric rehabilitation services for children with cerebral palsy

Cerebral palsy (CP) is the most common childhood motor disability. The dose of usual care for rehabilitation therapies is unknown. The purpose of this study was to describe current dosage of rehabilitation services for children with CP recruited from a paediatric hospital system in the USA. 96 children with CP were included in this cross-sectional survey. Parents reported frequency, intensity, time and type of therapy services. Weekly frequency was the most common. Children with CP received 0.9-1.2 hours/month of each discipline in the educational setting and 1.5-2.0 hours/month in the clinical setting, lower than the recommendations for improvements in motor skills.

Protocol and Feasibility-Randomized Trial of Telehealth Delivery for a Multicomponent Upper Extremity Intervention in Infants With Asymmetric Cerebral Palsy

Background:

Past work showed that an in-person, therapist-guided, parent-implemented multicomponent intervention increased the motor functioning of the more affected upper extremity (UE) in infants with asymmetric cerebral palsy. The authors document treatment fidelity and provide initial testing of telehealth intervention delivery in a new subject sample.

Methods:

The authors adapted the intervention manual used in the previous trial for telehealth. Infants (6-24 months) were randomly assigned to intervention (n = 7) or waitlist (n = 6). The intervention prescribed soft-constraint wear on the less affected UE for 6 hours, 5 d/wk, and exercises. After an initial in-person training session, three 15- to 45-minute telehealth sessions were performed.

Results:

Median weekly constraint wear was 21 hours (interquartile range = 10.3-29.7); average parent-treatment fidelity was 95.7% (SD 11.2). A significant large (Cohen d = 0.92) between-group differences occurred on fine motor functioning of more affected UEs.

Conclusion:

The telehealth intervention was feasible and potentially effective, but a larger trial is needed to evaluate efficacy.

How does the intensity of physical therapy affect the Gross Motor Function Measure (GMFM-66) total score in children with cerebral palsy? A systematic review protocol

INTRODUCTION

Intensive physical therapy (PT) interventions administered to children with cerebral palsy (CP) have received a significant amount of attention in published literature. However, there is considerable variability in therapy intensity among studies and notable lack of information on optimal intervention dosing. This makes it difficult for clinicians to use evidence to inform practice. Many studies use the Gross Motor Function Measure (GMFM-66) to assess functional progress in children with CP. The purpose of this systematic review will be to identify the GMFM-66 change score reported in published studies, with outcomes based on intervention intensity. Whether the type of PT intervention, child's age, and Gross Motor Function Classification System level influence the GMFM-66 scores will be also assessed.

METHODS AND ANALYSIS

This systematic review protocol was developed based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols (PRISMA-P) 2015 checklist. In March 2018, nine databases (PubMed, Ovid MEDLINE, Cochrane Library, Embase, Scopus, Web of Science, CINAHL, ClinicalTrials.gov, and REHABDATA) were searched for controlled clinical trials and single-subject design studies of PT interventions of any kind and intensity that used the GMFM-66 as an outcome measure for children with CP, age up to 18 years. Two authors independently reviewed the titles and abstracts and arrived at consensus on paper selection for a full-text review. The same process was used for a full-text article screening based on further detailed inclusion criteria, with a final selection made for those suitable for data extraction. Prior to commencement of data extraction, all searches will be updated, and new results re-screened.

ETHICS AND DISSEMINATION

This study will involve a systematic review of published articles and no primary data collection. Therefore, no ethical approval will be necessary. Results will be disseminated in a peer-reviewed publication and presented at scientific conferences.

PROSPERO REGISTRATION NUMBER

CRD42020147669.

Methodological Considerations to Investigate Dosage Parameters of Intensive Upper Limb Rehabilitation in Children with Unilateral Spastic Cerebral Palsy: A Scoping Review of RCTs

PURPOSES

To identify and synthesize RCTs on the isolated effect of dosage parameters of upper limb Intensive Motor Rehabilitation Treatments (IMRT) of children with Unilateral Spastic Cerebral Palsy (USCP); to identify the most frequent methodological weaknesses.

METHODS

Searches were conducted until September 2018 in gray and published literature databases and supplemented by exploring the identified studies' references. Inclusion criteria applied: RCT; children aged 1.5 to 19 years with USCP; upper limb IMRT differing only from ≥1/4 dosage parameters between groups. Literature analyses conducted: qualitative and descriptive.

RESULTS

We identified 461 studies. Seventeen were included: three presented a rehabilitation dosage distinction between groups in Frequency-Time, four in Intensity-Progressivity, three in Intensity-Restraint, two in Intensity-Environment and five presented ≥3 distinctions above.

CONCLUSIONS

Inconsistencies were noted between USCP lifelong issues, and the short follow-ups and lack of participation assessments. Confounding factors and misstatements in Intent To Treat (ITT) analyses were identified. A meta-analysis was considered irrelevant.

ABBREVIATIONS

USCP, CP: Unilateral Spastic Cerebral Palsy, Cerebral Palsy; RCT: Randomized Controlled Trial; IMRT: Intensive Motor Rehabilitation Treatment.

Effects of auditovisual feedback on eye-hand coordination in children with cerebral palsy

BACKGROUND

Children with spastic hemiplegic cerebral palsy have deficits in eye-hand coordination. This limits manual actions performed with the affected hand, especially fine motor skills such as grasping and manipulation. Visual-motor integration, grasping skills, and visual perception are collectively involved in eye-hand coordination.

AIMS

We investigated the effects of augmented biofeedback training on eye-hand coordination in children with spastic hemiplegic cerebral palsy.

METHODS AND PROCEDURES

Forty-five spastic hemiplegic cerebral palsy children (5-8 years old) were included. Children were assigned randomly into three equal groups. One group received traditional physical therapy to facilitate visual-motor integration and grasping skills for 3 months. The second group received augmented biofeedback training. The third group received a combination of augmented biofeedback training and traditional physical therapy. Children were evaluated with the Peabody Developmental Motor Scale (2nd edition) (PDMS-2). Treatment sessions were conducted for 60 min, three times a week, for 3 consecutive months.

OUTCOMES AND RESULTS

Children that received augmented biofeedback training alongside traditional physical therapy had significantly improved scores in the Visual-Motor Integration and grasping subtests compared to children that received only one intervention.

CONCLUSIONS AND IMPLICATIONS

Augmented biofeedback training alongside physical therapy improved eye-hand coordination in children with spastic hemiplegic cerebral palsy.

Cerebral Palsy Research Network Clinical Registry: Methodology and Baseline Report

Objective

To apply practice-based evidence to clinical management of cerebral palsy (CP). The process of establishing purpose, structure, logistics, and elements of a multi-institutional registry and the baseline characteristics of initial enrollees are reported.

Design

A consensus-building process among consumers, clinicians, and researchers used a participatory action process.

Setting

Community, hospitals, and universities.

Participants

More than 100 clinicians, researchers, and consumers and more than 1858 enrollees in the registry.

Main Outcome Measures

Not applicable.

Results

Consensus was that the purpose of registry was to (1) quantify practice variation, (2) facilitate quality improvement (QI), and (3) perform comparative effectiveness research (CER). Collecting data during routine clinical care using the electronic medical record was determined to be a sustainable plan for data acquisition and management. Clinicians from multiple disciplines defined salient characteristics of individuals and interventions for the registry elements. The registry was central to the clinical research network, and a leadership structure was created. A leading electronic health record platform adopted the registry elements. Twenty-four sites have initiated the data collection process and agreed to export data to the registry. Currently 12 are collecting data. Number of enrollees and characteristics were similar to other population registers.

Conclusions

This is the first multi-institutional CP registry that contains the patient and treatment characteristics needed for QI and CER. The Cerebral Palsy Research Network registry elements are implemented in a versatile electronic platform and minimize burden to clinicians. The resultant registry is available for any institution to participate and is growing rapidly.

Physical, occupational, and speech therapy for children with cerebral palsy

AIM

To explore the relationship between rehabilitation therapies and development in children with cerebral palsy (CP).

METHOD

We conducted a prospective, longitudinal study involving 656 children with CP (mean age [SD] 6y [2y 8mo] at study entry; 1y 6mo-11y 11mo; 287 females, 369 males), and their parents. Children were assessed two to five times over 2 years by therapists using standardized measures of balance and walking endurance. Parents completed questionnaires on demographics, rehabilitation therapies, and their children's performance in self-care and participation in recreation. Therapists and parents collaboratively classified children's Gross Motor Function Classification System (GMFCS) levels. We created longitudinal graphs for each GMFCS level, depicting change across time using centiles. Using multinomial models, we analyzed the relationship between therapies (amount, focus, family-centeredness, and the extent therapies met children's needs) and whether change in balance, walking endurance, and participation was 'more than' and 'less than' the reference of 'as expected'.

RESULTS

Children were more likely to progress 'more than expected' when participating in recreation when therapies were family-centered, met children's needs, and focused on structured play/recreation. A focus on health and well-being was positively associated with participation and self-care. The amount of therapy did not predict outcomes.

INTERPRETATION

Therapy services that are family-centered, consider the needs of the child, and focus on structured play/recreational activities and health/well-being may enhance the development of children with CP.

WHAT THIS PAPER ADDS

Family-centered rehabilitation therapies were positively associated with greater participation in family/recreation activities and walking endurance. Parental perception that rehabilitation therapies met children's needs was associated with greater participation in family/recreation activities. Structured play, recreational activities, and health/well-being are important for self-care and participation when planning rehabilitation therapy. The amount of rehabilitation therapy was not related to developmental outcomes.

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

PURPOSE

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

METHOD

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

RESULTS

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

CONCLUSION

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

Sistematização de instrumentos de avaliação para os dois primeiros anos de vida de bebês típicos ou em risco conforme o modelo da CIF

RESUMO O objetivo deste trabalho foi identificar instrumentos de avaliação do desenvolvimento neuropsicomotor (DNPM) de crianças de 0 a 2 anos, de baixo custo, que possam ser usados no contexto de creche e/ou ambiente clínico em programas de intervenção precoce, sistematizando esses instrumentos conforme o modelo biopsicossocial da Classificação Internacional de Funcionalidade, Incapacidade e Saúde (CIF). Foram selecionados instrumentos de avaliação do DNPM com tradução ou adaptação para o Brasil. Para isso os domínios da CIF foram escolhidos triangulando o checklist da própria CIF-CJ, core set de estimulação precoce e a última versão da CIF, para busca na literatura de instrumentos de avaliação. A sistematização das categorias selecionadas da CIF foi realizada por dois fisioterapeutas, e um terceiro para itens discordantes. As escalas que responderam aos critérios foram: Alberta Infant Motor Scale (AIMS), Teste de Triagem de Denver II, Inventário Pediátrico sobre Qualidade de Vida (PedSQl®), Affordance in the Home Environment for Motor Development-Infant Scale (AHEMD-IS) e vínculo mãe-bebê. Mesmo com essas escalas, verificou-se a necessidade de um questionário de anamnese complementar para o responsável, dados da Caderneta de Saúde da Criança e de um questionário socioeconômico da Associação Brasileira de Empresas de Pesquisa para o Brasil (ABEP). Essa sistematização está disponível no apêndice, e procura facilitar o olhar ampliado do fisioterapeuta ou profissional da educação com abrangência biopsicossocial dos bebês, além de possibilitar a identificação de riscos de forma precoce e subsidiar ações de promoção e intervenção em diferentes contextos.

How are children with cerebral palsy managed in public hospitals of KwaZulu-Natal, South Africa?

Background: Medical advances have resulted in the survival of infants who are born prematurely. This makes them at risk of developing neurological manifestations and increases the incidence of children diagnosed with cerebral palsy (CP). Physiotherapy plays an important role in the management of children with CP. However, in KwaZulu-Natal (KZN) there are challenges for rehabilitation of children presenting with CP due to limited equipment, assistive devices and shortage of health care professionals. The aim of this study was to determine the current physiotherapy management for children presenting with CP in public hospitals of KZNMethods: One hundred and fifty-two physiotherapists were recruited using convenience sampling from different levels of public hospitals in KZN. The design was a cross-sectional study using a survey with a self-designed questionnaire to review current physiotherapy management of CP. The data was analyzed and presented by means of descriptive statisticsResults: Seventy-two participants completed the study indicating a 47.4% response rate with an age range of 31 to 40 years. Thirty-five (48.6%) of participants treated one to ten children with CP each month. Twenty-five (34.7%) used outcome measures to evaluate their CP management. This study showed the most common treatment techniques used by physiotherapists were: postural stabilizing activities - 68 (94.4%); respiratory care - 67 (92.9%); and positioning - 67 (92.9%)Conclusion: Despite challenges by physiotherapists in KZN, the overall management of children with CP was holistic and favorable. The most common treatment approach was postural stabilizing activities with children with CP receiving treatment once a month for 30 minutes.

Documenting Physical Therapy Dose for Individuals With Cerebral Palsy: A Quality Improvement Initiative

PURPOSE

To describe the quality improvement (QI) activities used to improve treatment dose documentation for individuals with cerebral palsy (CP) and to discuss insights gained from this project.

METHODS

Global and smart aims were established and interventions were tested from January 2017 through February 2018 using Plan-Do-Study-Act cycles. Performance was tracked overtime using run and control charts.

RESULTS

The QI initiative resulted in a sustainable increase in percentage of dose elements present in the electronic medical record from 78% to 94%. Key drivers of improvement included (1) knowledge and awareness of dose, (2) clinician buy-in, (3) effective engagement of child and parent, (4) therapist knowledge of evidence-based treatments, (5) transparent and reliable documentation system, and (6) audit and clinician feedback.

CONCLUSIONS

QI methods provided the tools to improve workflow and increase dose documentation for individuals with CP.

Prescribing Physical, Occupational, and Speech Therapy Services for Children With Disabilities

Pediatric health care providers are frequently responsible for prescribing physical, occupational, and speech therapies and monitoring therapeutic progress for children with temporary or permanent disabilities in their practices. This clinical report will provide pediatricians and other pediatric health care providers with information about how best to manage the therapeutic needs of their patients in the medical home by reviewing the International Classification of Functioning, Disability and Health; describing the general goals of habilitative and rehabilitative therapies; delineating the types, locations, and benefits of therapy services; and detailing how to write a therapy prescription and include therapists in the medical home neighborhood.

Daily and Weekly Rehabilitation Delivery for Young Children With Gross Motor Delay: A Randomized Clinical Trial Protocol (the DRIVE Study)

PURPOSE

The proposed project tests the principle that frequency of rehabilitation is an important regulator of therapeutic response in infants.

METHODS

We will randomize 75 infants with cerebral palsy, 6 to 24 months of age and/or Gross Motor Function Classification System levels III to V (higher severity), to determine the short-term and long-term effects of 3 dosing protocols consisting of an identical number of 2-hour sessions of the same motor learning-based therapy applied over a different total number of calendar weeks.

RESULTS AND CONCLUSIONS

The results will inform clinicians, families, and scientists about dosing and will provide needed recommendations for frequency of rehabilitation to optimize motor function and development of young children with cerebral palsy.

Timing and Intensity of Early Intervention Service Use and Outcomes Among a Safety-Net Population of Children

IMPORTANCE

Federal per-child early intervention (EI) appropriations have declined, while accountability for improving children's development and function has increased. It is critical to understand high-value EI services and systems.

OBJECTIVE

To examine EI service timeliness and intensity, and the association between service intensity and outcomes.

DESIGN, SETTING, AND PARTICIPANTS

This secondary data analysis cohort study linked pediatric primary care electronic health records and EI program records from October 1, 2014, to September 30, 2016. Sample children from a large, urban safety-net health system and EI program who were younger than 35 months with a developmental disability or delay were examined. Data analysis was conducted from December 15, 2017, to May 15, 2018.

EXPOSURES

The study included measures of condition type and severity, race and ethnicity, family income, insurance type, sex, birth weight, and language.

MAIN OUTCOMES AND MEASURES

The timeliness of EI (days from referral to EI care plan), service intensity (hours per month) overall and for core EI services (physical, occupational, speech therapy, and developmental intervention), and change in function (measured on a 13-point scale). Adjusted quantile median regression estimated timeliness and intensity. Adjusted linear regression estimated change in function.

RESULTS

Of the 722 children who received an EI care plan (median [interquartile range] time to receive EI care plan, 56.0 [1.0-111.0] days) 457 (63.3%) were male, 447 (62.0%) were younger than 12 months, 207 (28.7%) were 12 to 24 months, and 68 (9.3%) were 25 to 35 months. A total of 663 children (91.8%) had a household income of less than $20 000 annually; 305 (43%) of the sample children received an EI care plan within the 45-day deadline. Median (interquartile range) for EI intensity was 2.7 (2.3-3.6) hours per month. Children living above the federal poverty threshold received greater occupational therapy intensity (b, 1.9; 95% CI, 0.9-3.0). Greater clinical severity was associated with more timely receipt of an EI care plan. Compared with infants, 2-year-old children received a care plan almost 2 months sooner (b, -52.0; 95% CI, -79.7 to -24.3). An additional hour per month of EI service was associated with a 3-point functional gain (b, 3.0; 95% CI, 1.5-5.9) among children with complete outcomes information (n = 448).

CONCLUSIONS AND RELEVANCE

In this study, greater EI service intensity was associated with better functional gains, yet most children in the study received delayed care and/or low service intensity. Clinical and EI record linkages could serve as a framework for improving EI processes.

Neuropsychomotor development assessment of children aged 0 to 5 in early childhood public education centers

ABSTRACT Purpose: to investigate the neuropsychomotor development, as well as nutritional and cognitive/emotional aspects of children aged 0 to 5, attending early childhood education centers, aiming at early identification and prevention of risks and delays in children’s development. Methods: the population studied was composed of 85 children attending two early childhood education centers. The children’s development approach was contextual, by means of ludic physical therapy assessment, by using the DENVER II scale; complementary assessments of their nutritional status were also performed, based on anthropometric measurements of weight and height, as well as evaluations of the cognitive/emotional development aspects through the Free Hand Drawing and Human Figure Drawing Tests. Results: neuropsychomotor development was found to be within normal range in 69.41% of the children and questionable in 30.58% of them. The significant variable affecting the result was found to be the class in which some children were inserted. In the scale utilized, the best performance was considered to be the gross motor skills (7.69%) and the most questionable performance occurred in the language skills (58.85%). As for nutritional data, it was discovered that 27.06% of the children had some nutritional risk, 22.35% had obesity risk and 4.71%, malnutrition risk. In the cognitive/emotional analysis, the result was that 34.37% of the children presented signs of difficulties related to adaptation and socialization or self-esteem. Conclusion: in the present study, about one-third of the children participating presented questionable neuropsychomotor development, especially in the field of language; in this regard, the class to which the children belong may constitute a barrier to their development. These children presented nutritional risks, with a tendency towards obesity, as well as the possible difficulties regarding adaptation and socialization or self-esteem.

Intensive Neuromotor Therapy improves motor skills of children with Cornelia de Lange Syndrome: case report

Abstract Introduction: The Cornelia de Lange Syndrome (CdLS) is a rare genetic syndrome. Children with CdLS usually require physical therapy, however the efficacy of physical therapy intervention in this population is lacking in the research literature. Objective: The aim of this study was to report the effect of Intensive Neuromotor Therapy (INMT) on gross motor function and participation of a child with CdLS using the International Classification of Functioning, Disabilities and Health (ICF) model. Method: A Brazilian child with CdLS was followed for over seven months while undergoing three modules of INMT. Results: The child demonstrated an evolution of gross motor function with gains of 11.28% in the first module, 9.22% in the second module, and 10.29% in the third module of INMT. Conclusion: INMT resulted in improvements in gross motor function and participation during daily activities in a child with CDLS. Further studies of larger cohorts are needed to investigate the efficacy of INMT in children with CdLS.

Social and Functional Characteristics of Receipt and Service Use Intensity of Core Early Intervention Services

OBJECTIVE

Describe children's diagnostic, social, and functional characteristics associated with the use of core early intervention (EI) services.

METHODS

The sample included infants and toddlers (N = 2045) discharged from an urban EI program (2014-2016). Adjusted logit models estimated the marginal effects and 95% confidence intervals (CIs) of receipt of any of the 4 core EI services, controlling for the child's developmental condition type, race and ethnicity, primary language, sex, insurance type, age at referral, and functional performance at EI entry. Adjusted median regression estimated EI core service intensity controlling for child characteristics.

RESULTS

The median per-child EI service intensity was less than 3 h/mo (median, 2.7; interquartile range, 2.1-3.5). Children whose primary language was English were 6% more likely to receive occupational therapy (marginal effect = 0.063; 95% CI, 0.010-0.115). Compared to infants, 1- to 2-year-old children were less likely to receive physical therapy and occupational therapy but more likely to receive speech therapy. Compared to infants, 1-year-olds received more intensive speech therapy (β = 0.42; 95% CI, 0.10-0.70), and 2-year-olds received less intensive occupational therapy (β = -0.70; 95% CI, -1.35 to -0.10). Children's functional performance at EI entry was significantly associated with the receipt and intensity of EI services.

CONCLUSIONS

Many EI-enrolled children received low-intensity services, a result that was associated with the primary language of the caregiver and the child's age and functional status. Results suggest the need for interventions to improve service delivery for vulnerable EI subgroups.

Feasibility of an intensive outpatient Perception-Action Approach intervention for children with cerebral palsy: a pilot study

PURPOSE

The purpose of this pilot study was (1) to evaluate feasibility of attendance and parent satisfaction with an intensive outpatient physical and occupational therapy program for young children with spastic cerebral palsy (CP) and (2) to examine changes in motor function. Methods: Sixteen children with CP, age range 18-36 months (mean 24.3 ± 6.3 months), received physical and occupational therapy sessions (30 minutes each) 5 days per week for 12 weeks. Attendance rates and parent satisfaction were assessed. Change in motor function using a one-group pre-post design was evaluated using the Gross Motor Function Measure-66 (GMFM-66), Quality of Upper Extremity Skills Test, and Pediatric Evaluation of Disability Inventory. GMFM-66 outcomes were also compared with expected outcomes using previously published normative developmental trajectories of children receiving standard therapies. Results: An average of 82% of scheduled outpatient physical and occupational therapies for 16 children were completed and the 11 parents who completed the Hills and Kitchen's Physiotherapy Outpatient Satisfaction Questionnaire were satisfied with the therapies and with their child's progress. Participants showed notable, statistically significant improvement across all activity-related measures. Conclusion: An intensive protocol of outpatient therapies utilizing Perception-Action Approach was feasible for most families of young children with spastic CP to attend at the outpatient clinic location. As this was not an experimental study, no reliable conclusions related to efficacy can be made, but the promising results suggest that further research into the effectiveness of intensive protocols is worthwhile.

Stepping Up to Rethink the Future of Rehabilitation: IV STEP Considerations and Inspirations

BACKGROUND AND PURPOSE

The IV STEP conference challenged presenters and participants to consider the state of science in rehabilitation, highlighting key area of progress since the previous STEP conference related to prediction, prevention, plasticity, and participation in rehabilitation.

KEY POINTS

Emerging from the thought-provoking discussions was recognition of the progress we have made as a profession and a call for future growth. In this summary article, we present a recap of the key points and call for action. We review the information presented and the field at large as it relates to the 4 Ps: prediction, prevention, plasticity, and participation.

RECOMMENDATIONS FOR PRACTICE

Given that personalized medicine is an increasingly important approach that was clearly woven throughout the IV STEP presentations, we took the liberty of adding a fifth "P," Personalized, in our discussion of the future direction of the profession.

Shared meanings of success, happiness, and health among adults with cerebral palsy and physiotherapists: implications for practice and research

PURPOSE

To describe shared meanings of success, happiness, and health of adults with cerebral palsy and physiotherapists.

MATERIALS AND METHODS

Ethnography employed open ended/semi-structured interviews and structured questionnaires (Satisfaction with Life Scale, Beck Depression Inventory-II^®, Oxford Happiness Questionnaire, Life Habits Questionnaire, Medical Outcomes Study-Social Support Survey, and PROMIS^® Pain Interference Scale). Content analysis of qualitative data and principal components analysis of questionnaire responses identified shared meanings.

RESULTS

Fourteen adults with cerebral palsy and 15 physiotherapists (median age 46) had similar levels of education. For both groups, social achievements, personal goals, employment, and supporting a family defined success. Adults with cerebral palsy more frequently identified tenacity and persistence as important for success. Both groups described happiness as spending time with loved ones, recreational activities, and having purpose in life. Adults with cerebral palsy identified the importance of self-acceptance for happiness. For both, health included self-care of mind/spirit, cardiovascular and musculoskeletal wellness, and physical fitness (the ability to perform physical tasks). Analysis of questionnaire responses identified shared meanings (eigenvalue 41, 95% explained variance).

CONCLUSIONS

Adults with cerebral palsy and physiotherapists share similar experiences, behaviors, and feelings about success, happiness, and health. This knowledge may improve communication, enhance evidence-based practice, and foster services to support wellbeing. Implications for rehabilitation Cerebral palsy is a life-long condition, but we know little about social and physical outcomes for adults with cerebral palsy. Lack of understanding about meanings of success, happiness, and health may be a barrier for consumers accessing and for providers delivering evidence-based services. Physiotherapists and adults with cerebral palsy share similar meanings (feelings, experiences, beliefs, behaviors) of success, happiness, and health- or wellbeing. Knowledge of this common ground may result in improved communication between providers and consumers, and foster more relevant and meaningful services to support the wellbeing of adults with cerebral palsy.

Effects of Aquatic Intervention on Gross Motor Skills in Children with Cerebral Palsy: A Systematic Review

AIMS

To review the literature on the effects of aquatic intervention on gross motor skills for children with cerebral palsy (CP).

DATA SOURCES

Six databases were searched from inception to January 2016.

REVIEW METHODS

Aquatic studies for children aged 1-21 years with any type or CP classification and at least one outcome measuring gross motor skills were included. Information was extracted on study design, outcomes, and aquatic program type, frequency, duration, and intensity. Quality was rated using the Centre of Evidence-Based Medicine: Levels of Evidence and the PEDro scale.

RESULTS

Of the 11 studies which met inclusion criteria, only two used randomized control trial design, and the results were mixed. Quality of evidence was rated as moderate to high for only one study. Most studies used quasi-experimental designs and reported improvements in gross motor skills for within group analyses after aquatic programs were held for two to three times per week and lasting for 6-16 weeks. Participants were classified according to the Gross Motor Function Classification System (GMFCS) levels I-V, and were aged 3-21 years. Mild to no adverse reactions were reported.

CONCLUSIONS

Evidence on aquatic interventions for ambulatory children with CP is limited. Aquatic exercise is feasible and adverse effects are minimal; however, dosing parameters are unclear. Further research is needed to determine aquatic intervention effectiveness and exercise dosing across age categories and GMFCS levels.

Creative Dance Practice Improves Postural Control in a Child With Cerebral Palsy

PURPOSE

To investigate the effect of creative dance instruction on postural control and balance in an 11-year-old with spastic triplegic cerebral palsy, Gross Motor Function Classification Scale level II.

DESCRIPTIONS

We conducted 1-hour dance interventions twice weekly for 8 weeks, with a focus on somatosensory awareness and movement in all planes of motion. Computerized dynamic posturography using the SMART Balance Master/EquiTest (NeuroCom) was used to assess postural control and balance reactions before the first class and following the final class.

OUTCOMES

Gains in standing stability, balance recovery, directional control, and endpoint excursion of movement were found. Participation in creative dance lessons appears to improve somatosensory effectiveness and postural control in a child with cerebral palsy.

WHAT THIS CASE ADDS

Dance is a fun way to improve balance and coordination. These interventions could be easily implemented into programs for children with cerebral palsy.

The effects of dosage time and frequency on motor outcomes in children with cerebral palsy: A systematic review

PURPOSE

Provide an updated review regarding treatment dosage for children with cerebral palsy (CP) by examining the variables of type, time, frequency, and intensity.

METHODS

A systematic review was performed with 30 articles meeting the inclusion criteria. Two authors independently extracted data including information about risk of bias. Ten articles were included in the review.

RESULTS

Eight studies manipulated time, two studies manipulated frequency, and three studies manipulated both variables. No studies investigated intensity. Findings suggest that manipulating time and/or frequency may result in better motor function for higher total dosing; however, benefits were not consistent across studies and few showed clinically significant improvements.

CONCLUSION

This most current evidence regarding the effect of dosage on motor function for children with CP suggests that there is insufficient evidence to support implementing high-dosage therapy. Further research is needed to clarify the relationship between dosage variables on motor function for children with CP.

A Progressive Running Program for an Adolescent With Cerebral Palsy

PURPOSE

To describe the physical therapy intervention and outcomes for a 20-week progressive running program.

SUMMARY OF KEY POINTS

A 12-year-old boy with spastic diplegic cerebral palsy, Gross Motor Function Classification System level II, participated in a 20-week running program. The 6-minute walk test and the 88-item and 66-item versions of the Gross Motor Function Measure (GMFM) were administered at baseline and program completion. After completion of the program, the participant exceeded thresholds for minimally clinically important differences on the GMFM-66 total score and GMFM-88 Dimension D and E scores. He improved gait speed and distance walked during the 6-minute walk test.

CONCLUSIONS AND RECOMMENDATIONS FOR CLINICAL PRACTICE

Participation in a progressive running program is a feasible intervention to promote improvements in walking speed and gross motor function in some adolescents with spastic diplegic cerebral palsy in Gross Motor Function Classification System level II.

Stepping Up to Rethink the Future of Rehabilitation: IV STEP Considerations and Inspirations

BACKGROUND AND PURPOSE

The IV STEP conference challenged presenters and participants to consider the state of science in rehabilitation, highlighting key area of progress since the previous STEP conference related to prediction, prevention, plasticity, and participation in rehabilitation.

KEY POINTS

Emerging from the thought-provoking discussions was recognition of the progress we have made as a profession and a call for future growth. In this summary article, we present a recap of the key points and call for action. We review the information presented and the field at large as it relates to the 4 Ps: prediction, prevention, plasticity, and participation.

RECOMMENDATIONS FOR PRACTICE

Given that personalized medicine is an increasingly important approach that was clearly woven throughout the IV STEP presentations, we took the liberty of adding a fifth "P," Personalized, in our discussion of the future direction of the profession.

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

PURPOSE

The purpose of this article is to propose that coupling of timing of interventions with dosing of interventions optimizes plasticity and participation in pediatric neurologic conditions, specifically cerebral palsy. Dosing includes frequency, intensity, time per session, and type of intervention. Interventions focus on body structures and function and activity and participation, and both are explored. Known parameters for promoting bone, muscle, and brain plasticity and evidence supporting critical periods of growth during development are reviewed. Although parameters for dosing participation are not yet established, emerging evidence suggests that participation at high intensities has the potential for change. Participation interventions may provide an additional avenue to promote change through the life span. Recommendations for research and clinical practice are presented to stimulate discussions and innovations in research and practice.

Pediatric Rehabilitation Services for Children With Cerebral Palsy: What Can Existing Data Sources Tell Us?

Knowledge about associated service utilization patterns and positive outcomes in children with cerebral palsy (CP) of varying levels of severity is a national priority. Families, clinicians, program directors, and policy makers need this information for clinical decision-making and service planning. Existing data sources in the United States that contain information about children with CP, their health, function, well being, and utilization of health services may add to our existing knowledge. We provide a summary of fourteen national, state, and local sources' data: where the data come from, challenges and/or specific considerations when using or accessing information, and specific data elements included. Currently available sources of data can provide meaningful information for policy, practice, and program development. We propose questions for future inquiry and suggest elements that may be useful for when developing data sources specific to physical therapy and individuals with CP. A physical therapy specific registry is warranted.

Standing activity intervention and motor function in a young child with cerebral palsy: A case report

PURPOSE

There is limited evidence to fully justify the use of standing interventions for children with cerebral palsy (CP). This case report describes the impact of an 8-week standing program on motor function in a child with severe CP living in western Africa.

METHODS

The subject was diagnosed with ischemic - hypoxic encephalopathy shortly after birth and with CP at 12 months of age. Gross Motor Function Classification of CP was level IV. Early attempts at physical therapy were interrupted by limited access to medical services. At 18 months, a standing program using a locally constructed standing frame was initiated. The standing intervention was completed at home 5 times a week for 8 weeks. Motor skills were assessed at baseline and post-intervention using the Gross Motor Function Measure (GMFM-66).

RESULTS

Scores on the GMFM-66 increased from 28 at baseline to 37.4 in 8 weeks. Improvements in motor function included improved head control, improved upper extremity function, and increased sitting ability.

CONCLUSIONS

Implementation of a home-based standing program may have contributed to improved motor skills for this child. Further research is needed to determine the effect of standing interventions on functional motor development for children with severe CP.

Physical Therapy Dosing: Frequency and Type of Intervention in Pediatric Postacute Hospital Care

PURPOSE

To examine differences in physical therapy dosing frequency recommendations based on children's characteristics and to describe types of intervention recommended at postacute hospital admission.

METHODS

Demographic and clinical information, recommended physical therapy intervention frequency, and intervention types were collected for all admissions from April 1, 2015, to March 1, 2016. Differences across 2 groups, children with recommendations for "less" (≤3x/wk) or "more" (≥4x/wk) frequent therapy, were examined. Types of interventions recommended were described and the measure of association between frequency and type was determined.

RESULTS

Older children, those with higher admission functional scores, and children with less dependence on medical technology were recommended for "more." Therapeutic exercise was the most common intervention recommended. Greater physical therapy frequency was associated with Functional Training and Motor Function Training.

CONCLUSION

Children's age, functional level, and technology dependence influence dosing recommendations. Interventions focused on function are associated with greater physical therapy frequency.