Early Intervention for Children Aged 0 to 2 Years With or at High Risk of Cerebral Palsy: International Clinical Practice Guideline Based on Systematic Reviews.

Importance: Cerebral palsy (CP) is the most common childhood physical disability. Early intervention for children younger than 2 years with or at risk of CP is critical. Now that an evidence-based guideline for early accurate diagnosis of CP exists, there is a need to summarize effective, CP-specific early intervention and conduct new trials that harness plasticity to improve function and increase participation. Our recommendations apply primarily to children at high risk of CP or with a diagnosis of CP, aged 0 to 2 years. Objective: To systematically review the best available evidence about CP-specific early interventions across 9 domains promoting motor function, cognitive skills, communication, eating and drinking, vision, sleep, managing muscle tone, musculoskeletal health, and parental support. Evidence Review: The literature was systematically searched for the best available evidence for intervention for children aged 0 to 2 years at high risk of or with CP. Databases included CINAHL, Cochrane, Embase, MEDLINE, PsycInfo, and Scopus. Systematic reviews and randomized clinical trials (RCTs) were appraised by A Measurement Tool to Assess Systematic Reviews (AMSTAR) or Cochrane Risk of Bias tools. Recommendations were formed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework and reported according to the Appraisal of Guidelines, Research, and Evaluation (AGREE) II instrument. Findings: Sixteen systematic reviews and 27 RCTs met inclusion criteria. Quality varied. Three best-practice principles were supported for the 9 domains: (1) immediate referral for intervention after a diagnosis of high risk of CP, (2) building parental capacity for attachment, and (3) parental goal-setting at the commencement of intervention. Twenty-eight recommendations (24 for and 4 against) specific to the 9 domains are supported with key evidence: motor function (4 recommendations), cognitive skills (2), communication (7), eating and drinking (2), vision (4), sleep (7), tone (1), musculoskeletal health (2), and parent support (5). Conclusions and Relevance: When a child meets the criteria of high risk of CP, intervention should start as soon as possible. Parents want an early diagnosis and treatment and support implementation as soon as possible. Early intervention builds on a critical developmental time for plasticity of developing systems. Referrals for intervention across the 9 domains should be specific as per recommendations in this guideline.

Early, Accurate Diagnosis and Early Intervention in Cerebral Palsy: Advances in Diagnosis and Treatment.

Importance: Cerebral palsy describes the most common physical disability in childhood and occurs in 1 in 500 live births. Historically, the diagnosis has been made between age 12 and 24 months but now can be made before 6 months' corrected age. Objectives: To systematically review best available evidence for early, accurate diagnosis of cerebral palsy and to summarize best available evidence about cerebral palsy-specific early intervention that should follow early diagnosis to optimize neuroplasticity and function. Evidence Review: This study systematically searched the literature about early diagnosis of cerebral palsy in MEDLINE (1956-2016), EMBASE (1980-2016), CINAHL (1983-2016), and the Cochrane Library (1988-2016) and by hand searching. Search terms included cerebral palsy, diagnosis, detection, prediction, identification, predictive validity, accuracy, sensitivity, and specificity. The study included systematic reviews with or without meta-analyses, criteria of diagnostic accuracy, and evidence-based clinical guidelines. Findings are reported according to the PRISMA statement, and recommendations are reported according to the Appraisal of Guidelines, Research and Evaluation (AGREE) II instrument. Findings: Six systematic reviews and 2 evidence-based clinical guidelines met inclusion criteria. All included articles had high methodological Quality Assessment of Diagnostic Accuracy Studies (QUADAS) ratings. In infants, clinical signs and symptoms of cerebral palsy emerge and evolve before age 2 years; therefore, a combination of standardized tools should be used to predict risk in conjunction with clinical history. Before 5 months' corrected age, the most predictive tools for detecting risk are term-age magnetic resonance imaging (86%-89% sensitivity), the Prechtl Qualitative Assessment of General Movements (98% sensitivity), and the Hammersmith Infant Neurological Examination (90% sensitivity). After 5 months' corrected age, the most predictive tools for detecting risk are magnetic resonance imaging (86%-89% sensitivity) (where safe and feasible), the Hammersmith Infant Neurological Examination (90% sensitivity), and the Developmental Assessment of Young Children (83% C index). Topography and severity of cerebral palsy are more difficult to ascertain in infancy, and magnetic resonance imaging and the Hammersmith Infant Neurological Examination may be helpful in assisting clinical decisions. In high-income countries, 2 in 3 individuals with cerebral palsy will walk, 3 in 4 will talk, and 1 in 2 will have normal intelligence. Conclusions and Relevance: Early diagnosis begins with a medical history and involves using neuroimaging, standardized neurological, and standardized motor assessments that indicate congruent abnormal findings indicative of cerebral palsy. Clinicians should understand the importance of prompt referral to diagnostic-specific early intervention to optimize infant motor and cognitive plasticity, prevent secondary complications, and enhance caregiver well-being.

Effectiveness of motor interventions in infants with cerebral palsy: a systematic review.

AIM: To systematically review the evidence on the effectiveness of motor interventions for infants from birth to 2 years with a diagnosis of cerebral palsy or at high risk of it. METHOD: Relevant literature was identified by searching journal article databases (PubMed, Embase, CINAHL, Cochrane, Web of Knowledge, and PEDro). Selection criteria included infants between the ages of birth and 2 years diagnosed with, or at risk of, cerebral palsy who received early motor intervention. RESULTS: Thirty-four studies met the inclusion criteria, including 10 randomized controlled trials. Studies varied in quality, interventions, and participant inclusion criteria. Neurodevelopmental therapy was the most common intervention investigated either as the experimental or control assignment. The two interventions that had a moderate to large effect on motor outcomes (Cohen's effect size>0.7) had the common themes of child-initiated movement, environment modification/enrichment, and task-specific training. INTERPRETATION: The published evidence for early motor intervention is limited by the lack of high-quality trials. There is some promising evidence that early intervention incorporating child-initiated movement (based on motor-learning principles and task specificity), parental education, and environment modification have a positive effect on motor development. Further research is crucial.

Community fitness programs: what is available for children and youth with motor disabilities and what do parents want?

BACKGROUND: Physical activity is recognized as a rehabilitation approach for individuals with motor disabilities. OBJECTIVES: To determine whether community fitness programs were accommodating children and youth with motor disabilities, and to understand family perspectives on important outcomes related to fitness programs. DESIGN: Telephone survey and qualitative interviews. PARTICIPANTS AND SETTINGS: Representatives of 61 fitness programs/facilities and 13 parents of children with motor disabilities. METHODS: Telephone survey (facilities) and qualitative interviews (parents). RESULTS: 24.6% of programs reported lack of wheelchair accessibility. Only 9.8% of programs and facilities required their staff to have training to support individuals with disabilities. Parents discussed barriers, including lack of staff support and challenges with finding information about community programs. Parents focused on the social benefits of fitness programs. CONCLUSIONS/SIGNIFICANCE: Additional efforts toward reducing access barriers are needed. Parents' focus on social outcomes has direct implications on the design and evaluation of fitness programs.

Cross-sectional study to examine evidence-based practice skills and behaviors of physical therapy graduates: is there a knowledge-to-practice gap?

BACKGROUND: Curricula changes in physical therapist education programs in Canada emphasize evidence-based practice skills, including literature retrieval and evaluation. Do graduates use these skills in practice? OBJECTIVES: The aim of this study was to evaluate the use of research information in the clinical decision making of therapists with different years of experience and evidence-based practice preparation. Perceptions about evidence-based practice were explored qualitatively. DESIGN: A cross-sectional study with 4 graduating cohorts was conducted. METHODS: Eighty physical therapists representing 4 different graduating cohorts participated in interviews focused on 2 clinical scenarios. Participants had varying years of clinical experience (range=1-15 years) and academic knowledge of evidence-based practice skills. Therapists discussed the effectiveness of interventions related to the scenarios and identified the sources of information used to reach decisions. Participants also answered general questions related to evidence-based practice knowledge. RESULTS: Recent graduates demonstrated better knowledge of evidence-based practice skills compared with therapists with 6 to 15 years of clinical experience. However, all groups used clinical experience most frequently as their source of information for clinical decisions. Research evidence was infrequently included in decision making. LIMITATIONS: This study used a convenience sample of therapists who agreed to volunteer for the study. CONCLUSIONS: The results suggest a knowledge-to-practice gap; graduates are not using the new skills to inform their practice. Tailoring academic evidence-based activities more to the time constraints of clinical practice may help students to be more successful in applying evidence in practice. Academic programs need to do more to create and nurture environments in both academic and clinical settings to ensure students practice using evidence-based practice skills across settings.

Muscle activation and energy-requirements for varying postures in children and adolescents with cerebral palsy.

OBJECTIVE: To determine energy expenditure and muscle activity among children and adolescents with cerebral palsy (CP), across several conditions that approximate sedentary behavior, and standing. STUDY DESIGN: Subjects with spastic CP (n = 19; 4-20 years of age; Gross Motor Function Classification System Expanded and Revised [GMFCS-E&R] levels I-V) participated in this cohort study. Energy-expenditure and muscle activity were measured during lying supine, sitting with support, sitting without support, and standing. Energy-expenditure was measured using indirect calorimetry and expressed in metabolic equivalents (METs). Muscle activation was recorded using surface electromyography. The recorded values were calculated for every child and then averaged per posture. RESULTS: Mean energy expenditure was >1.5 METs during standing for all GMFCS-E&R levels. There was a nonsignificant trend for greater muscle activation for all postures with less support. Only for children classified at GMFCS-E&R level III did standing result in significantly greater muscle activation (P < .05) compared with rest. CONCLUSIONS: Across all GMFCS-E&R levels, children and adolescents with CP had elevated energy expenditure during standing that exceeded the sedentary threshold of 1.5 METs. Our findings suggest that changing a child's position to standing may contribute to the accumulation of light activity and reduction of long intervals of sedentary behavior.

Emerging therapy approaches: an emphasis on function.

Children and youth with cerebral palsy receive ongoing physical and occupational therapy services to improve their functional performance and participation in activities at home, school, and in the community. Over the past 2 decades, rehabilitation interventions have become more functional and goal oriented. In this article, we discuss factors that have influenced emerging intervention approaches. These factors include greater involvement of families in decision making, changing conceptual frameworks and theories underlying skill development and improved outcome measures. New research findings indicate that rehabilitation interventions embracing family-centered services and focusing on functional improvement can be more effective in promoting participation. This knowledge can serve as the platform for further examination of the most effective rehabilitation interventions for children and youth with cerebral palsy.

Have infant gross motor abilities changed in 20 years? A re-evaluation of the Alberta Infant Motor Scale normative values.

AIM: To compare the original normative data of the Alberta Infant Motor Scale (AIMS) (n=2202) collected 20 years ago with a contemporary sample of Canadian infants. METHOD: This was a cross-sectional cohort study of 650 Canadian infants (338 males, 312 females; mean age 30.9 wks [SD 15.5], range 2 wks-18 mo) assessed once on the AIMS. Assessments were stratified by age, and infants proportionally represented the ethnic diversity of Canada. Logistic regression was used to place AIMS items on an age scale representing the age at which 50% of the infants passed an item on the contemporary data set and the original data set. Forty-three items met the criterion for stable regression results in both data sets. RESULTS: The correlation coefficient between the age locations of items on the original and contemporary data sets was 0.99. The mean age difference between item locations was 0.7 weeks. Age values from the original data set when converted to the contemporary scale differed by less than 1 week. INTERPRETATION: The sequence and age at emergence of AIMS items has remained similar over 20 years and current normative values remain valid. Concern that the 'back to sleep' campaign has influenced the age at emergence of gross motor abilities is not supported.

Stability of serial range-of-motion measurements of the lower extremities in children with cerebral palsy: can we do better?

BACKGROUND: Serial joint range-of-motion (ROM) measurements are an important component of assessments for children with cerebral palsy. Most research has studied ROM stability using group data. Examination of longitudinal intraindividual measures may provide more clinically relevant information about measurement variability. OBJECTIVE: The aim of this study was to examine the stability of intraindividual longitudinal measurements of hip abduction (ABD), popliteal angle (POP), and ankle dorsiflexion (ADF) ROM measures of children with cerebral palsy. DESIGN: Secondary data analyses were performed. METHODS: The stability patterns of individual serial measurements of ABD, POP, and ADF from 85 children (mean age=3.8 years, SD=1.4) collected at baseline (T1), 3 months (T2), 6 months (T3), and 9 months (T4) were examined using T1 as the anchor and bandwidths of ±15 degrees (ABD and POP) and ±10 degrees (ADF) as acceptable variability. Frequencies of stability categories (0°-5°, 5.1°-10°, 10.1°-15°, and >15°) were calculated. Patterns of stability across the 4 time periods also were examined. Group means (T1-T4) were compared using repeated-measures analysis of variance. RESULTS: No significant differences in group means were found except for ABD. Stability patterns revealed that 43.3% to 69.5% of joint measurements were stable with T1 measurements across all 3 subsequent measurements. Stability category frequencies showed that many measurements (ABD=17%, POP=29.9%, and ADF=37.1%) went outside the variability bandwidths even though 39% or more of joint measurements had a change of 5 degrees or less over time. LIMITATIONS: Measurement error and true measurement variability cannot be disentangled. The results cannot be extrapolated to other joint ROMs. CONCLUSIONS: Individual ROM serial measurement exhibits more variability than group data. Range-of-motion data must be interpreted with caution clinically and efforts made to ensure standardization of data collection methods.

Change in parent-identified goals in young children with cerebral palsy receiving a context-focused intervention: associations with child, goal and intervention factors.

The purpose of this study was to examine the relationship between goal achievement measured by the Canadian Occupational Performance Measure (COPM) and child, goal, and intervention factors. Participants were 41 preschool children with cerebral palsy (CP) who were in the context-focused therapy arm of a randomized controlled trial. Factors including child age, Gross Motor Function Classification System (GMFCS) level, type and complexity of goals, and intervention strategies were analyzed. Children made large, positive mean changes on the COPM over 6 months (Performance = 3.8, SD = 1.9; Satisfaction = 4.3, SD 4.3) with younger children showing greater change. The COPM scores had low to moderate correlations with change on the Pediatric Evaluation of Disability Inventory and the Gross Motor Function Measure (GMFM-66). Regression analysis indicated that age, but not GMFCS level influenced COPM change scores. Goal complexity and intervention strategies were not significantly related to COPM change scores. The results provide support for using the COPM as an individualized measure of change in young children with CP receiving intervention.

Stability of parent report on Mobility and Self-Care item scores of the Pediatric Evaluation of Disability Inventory.

Secondary analysis using data from a clinical trial was performed to evaluate the stability of individual items of the Mobility and Self-Care functional skills scales of the Pediatric Evaluation of Disability Inventory (PEDI). Parents of 113 children aged 1-6 years old with cerebral palsy completed the PEDI twice by questionnaire 6 months apart. An item was classified "unstable" if the score changed from capable to unable. The number of children with more than five unstable items and the number of items with more than five children having unstable scoring patterns were calculated. Nineteen children (17%) and 13 items had unstable scoring patterns. The majority of PEDI items demonstrated stability of parent scoring. Examination of unstable items suggests that parents may need assistance in understanding the difference between "usual" and "best" performance, interpreting descriptors such as "thoroughly," and maintaining the same context reference for outdoor mobility items.

Health-enhancing physical activity in children with cerebral palsy: more of the same is not enough.

Physical activity is important for young people's health. The emphasis over the last 2 decades has been on moderate to vigorous exercise when designing activity and exercise programs for children and adolescents with cerebral palsy (CP). Emerging evidence suggests that sedentary behavior is distinctly different from a lack of moderate to vigorous physical activity and has independent and different physiological mechanisms. The concept of concurrently increasing moderate to vigorous physical activity and replacing sedentary behavior with light physical activity may be beneficial for children and adolescents with CP. This article is a summary of the evidence for what works and what does not work for improving the physical activity of children and adolescents with CP. It also discusses what is known about sedentary behavior of children and adolescents with CP and what research directions are needed to build foundational knowledge in this area with this population.

Sedentary behavior: implications for children with cerebral palsy.

PURPOSE: To review the research associated with sedentary behavior with adults and children in the general population and to discuss the application of this research for children with cerebral palsy. SUMMARY OF KEY POINTS: Increased sedentary behavior and decreased physical activity are independent constructs with different definitions, physiological mechanisms, and health outcomes. The parameters of sedentary behavior developed for children with typical motor abilities may not be valid for children with cerebral palsy. STATEMENT OF CONCLUSIONS: Research to identify measurement tools, health associations, and potential interventions for children with cerebral palsy is needed. RECOMMENDATIONS FOR CLINICAL PRACTICE: Interventions to decrease sedentary behavior differ from current interventions to increase physical activity with children with cerebral palsy. Before designing interventions to decrease sedentary behavior, research is needed to determine valid definitions and measurement approaches for children with cerebral palsy, as those derived for children with typical motor development may have limited application.

Infant rolling abilities--the same or different 20 years after the back to sleep campaign?

AIM: To compare the order and age of emergence of rolling prone to supine and supine to prone before the introduction of back to sleep guidelines and 20 years after their introduction. METHODS: The original normative data for the Alberta Infant Motor Scale (AIMS) were collected just prior to the introduction of back to sleep guidelines in 1992. Currently these norms are being re-evaluated. Data of rolling patterns of infants 36 weeks of age or younger from the original sample (n=1114) and the contemporary sample (n=351) were evaluated to compare the sequence of appearance of prone to supine and supine to prone rolls (proportion of infants passing each roll) and the ages of emergence (estimated age when 50% of infants passed each roll). RESULTS: The sequence of emergence and estimated age of appearance of both rolling directions were similar between the two time periods. CONCLUSION: The introduction of the supine sleep position to reduce the prevalence of Sudden Infant Death Syndrome (SIDS) has not altered the timing or sequence of infant rolling abilities. This information is valuable to health care providers involved in the surveillance of infants' development. Original normative age estimates for these two motor abilities are still appropriate.

A structured process to develop scenarios for use in evaluation of an evidence-based approach in clinical decision making.

BACKGROUND AND PURPOSE: Scenarios are used as the basis from which to evaluate the use of the components of evidence-based practice in decision making, yet there are few examples of a standardized process of scenario writing. The aim of this paper is to describe a step-by-step scenario writing method used in the context of the authors' curriculum research study. METHODS: Scenario writing teams included one physical therapy clinician and one academic staff member. There were four steps in the scenario development process: (1) identify prevalent condition and brainstorm interventions; (2) literature search; (3) develop scenario framework; and (4) write scenario. RESULTS: Scenarios focused only on interventions, not diagnostic or prognostic problems. The process led to two types of scenarios - ones that provided an intervention with strong research evidence and others where the intervention had weak evidence to support its use. The end product of the process was a scenario that incorporates aspects of evidence-based decision making and can be used as the basis for evaluation. CONCLUSION: The use of scenarios has been very helpful to capture therapists' reasoning processes. The scenario development process was applied in an education context as part of a final evaluation of graduating clinical physical therapy students.

Context therapy: a new intervention approach for children with cerebral palsy.

AIM: To describe the development of context therapy, a new intervention approach designed for a randomized controlled trial. METHOD: Therapists were trained to change task and environmental factors to achieve parent-identified functional goals for children with cerebral palsy. Therapists did not provide any remediation strategies to change the abilities of the child. Theoretical constructs were developed using dynamic systems theory and the principles of family-centered care. A primary therapist model was used. A three-step intervention strategy was developed. RESULTS: Therapists adhered to the treatment protocol. Parents participated in the development of both functional goals and intervention strategies. INTERPRETATION: A therapy approach focusing on changing the task and the environment rather than children's impairments can be a viable treatment strategy and merits further investigation. The detailed description of the context therapy approach allows replication by both researchers and clinicians. Such intervention descriptions are an important methodological consideration in rehabilitation research.

Focus on function: a cluster, randomized controlled trial comparing child- versus context-focused intervention for young children with cerebral palsy.

AIM: This study evaluated the efficacy of a child-focused versus context-focused intervention in improving performance of functional tasks and mobility in young children with cerebral palsy. METHOD: A randomized controlled trial cluster research design enrolled 128 children (49 females, 79 males; age range 12 mo to 5 y 11 mo; mean age 3 y 6 mo, SD -1 y 5 mo) who were diagnosed with cerebral palsy. Children across levels I to V on the Gross Motor Classification System (GMFCS) were included in the study. Children were excluded if there were planned surgical or medication changes during the intervention period. Therapists from 19 children's rehabilitation centers were block randomized (by occupational therapist or physical therapist) to a treatment arm. Children from consenting families followed their therapists into their assigned group. Children received child-focused (n=71) or context-focused intervention (n=57) over 6 months, returning to their regular therapy schedule and approach between 6 and 9 months. The primary outcome measure was the Pediatric Evaluation of Disability Inventory (PEDI). Secondary outcome measures included the Gross Motor Function Measure (GMFM-66), range of motion of hip abduction, popliteal angle and ankle dorsiflexion, the Assessment of Preschool Children's Participation (APCP), and the Family Empowerment Scale (FES). Outcome evaluators were masked to group assignment and completed assessments at baseline, 6 months, and 9 months. RESULTS: Ten children did not complete the full intervention, six in the child group and four in context group. GMFCS levels for children in the study were level I (n=37), level II (n=23), level III (n=21), level IV (n=21), and level V (n=26). There were no significant differences at baseline between the treatment groups for GMFCS level, parental education, or parental income. For the PEDI, there was no significant difference between the treatment groups, except for a small effect (p<0.03) on the Caregiver Assistance Mobility subscale between baseline and 9 months. The mean scores of both groups changed significantly on the Functional Skills Scales (p<0.001) and Caregiver Assistance Scales (p<0.02) of the PEDI after the 6-month intervention. There was no additional statistically significant change on the PEDI during the follow-up period from 6 to 9 months. A subgroup effect was found for age (p<0.001), with children younger than 3 years changing significantly more than older children. GMFCS level at baseline did not influence the amount of change on the PEDI scales. There were no significant differences between the treatment groups on the GMFM, range of motion measures, APCP or FES assessments. For the GMFM, there was a significant change over time from baseline to 6 months (p<0.001) and no significant change between 6 and 9 months. There was no adverse side effect as range of motion did not decrease in either group. Hip abduction increased significantly (p<0.01) at the 9-month assessment for both groups. For the APCP, significant changes for both treatment groups were found between baseline and 6 months for play intensity (p<0.04), physical activity intensity and diversity (p<0.001), and total score intensity (p<0.01). INTERPRETATION: This study shows that child- or context-focused therapy approaches are equally effective and that frequency of intervention may be a critical component of successful intervention. Further evaluation is required to identify the various 'dose-response' relations of amount of treatment and changes in functional abilities.

Adults with a diagnosis of cerebral palsy: a mapping review of long-term outcomes.

AIM: Cerebral palsy (CP) is recognized as a lifespan condition. This mapping review identifies outcomes that have been measured in adults with CP between 1970 and 2010 to determine if either the outcomes evaluated or the research methodologies have changed substantially. METHOD: We performed a literature review. For studies to be included, participants had to be 16 years or older and 80% of the sample had to have a diagnosis of CP. Articles were grouped by decade, and outcomes were categorized using the International Classification of Functioning, Disability and Health (ICF) framework and terminology. RESULTS: Fifty-eight articles were included in the mapping review. Both the number of studies and the types of outcomes investigated increased from 1970 to 2010. Outcomes representing the ICF component of Body Function and Structure were present across the period reviewed, whereas interest in contextual (personal or environmental) factors has primarily emerged since 2000. INTERPRETATION: Gaps were identified by the mapping review. Large age ranges and heterogeneity of sample populations made it difficult to determine if the outcomes reported were due to ageing or the long-term consequences of CP. In addition, most reviewed articles described outcomes categorically, with few papers providing explanations or solutions to reported outcomes.

Knowledge brokering in children's rehabilitation organizations: perspectives from administrators.

INTRODUCTION: Administrators must balance the demands of delivering therapy services with the need to provide staff with educational opportunities promoting evidence-based practice. Increasingly, the use of multifaceted, interactive knowledge translation strategies, such as knowledge brokering, is suggested as an effective way to encourage clinician behavior changes and implement new knowledge. The purpose of this qualitative study is to describe administrators' perceptions of the successes and challenges in using a knowledge broker (KB) to promote the use of evidence-based measures of motor function for children with cerebral palsy. METHODS: Administrators from 27 pediatric facilities completed a semi-structured telephone interview following 6 months of knowledge brokering within their organizations. Using thematic analysis, interview transcripts were reviewed to identify common themes. RESULTS: Six interview themes were identified: "Efficient and Effective," "Stimulating Peer-to-Peer Learning Environment," "Committed and Respected Knowledge Brokers," "Sharing Beyond," "Organizational Beliefs and Values," and "The Dilemma of Moving Forward". Administrators were positive about the KB experience, acknowledging its efficiency and effectiveness. They commented on the stimulating peer-to-peer and interdisciplinary learning environment that the KB process encouraged. Administrators referred to their organizational beliefs and values when discussing their need to make priorities for limited resources, which influenced their decisions about whether to continue with a KB after the study was completed. DISCUSSION: Although administrators were philosophically supportive of knowledge brokering, they identified funding and resource constraints and the absence of evidence of the effectiveness of knowledge brokering as major barriers to the continuation of a KB role in their facility.

Using knowledge brokers to facilitate the uptake of pediatric measurement tools into clinical practice: a before-after intervention study.

BACKGROUND: The use of measurement tools is an essential part of good evidence-based practice; however, physiotherapists (PTs) are not always confident when selecting, administering, and interpreting these tools. The purpose of this study was to evaluate the impact of a multifaceted knowledge translation intervention, using PTs as knowledge brokers (KBs) to facilitate the use in clinical practice of four evidence-based measurement tools designed to evaluate and understand motor function in children with cerebral palsy (CP). The KB model evaluated in this study was designed to overcome many of the barriers to research transfer identified in the literature. METHODS: A mixed methods before-after study design was used to evaluate the impact of a six-month KB intervention by 25 KBs on 122 practicing PTs' self-reported knowledge and use of the measurement tools in 28 children's rehabilitation organizations in two regions of Canada. The model was that of PT KBs situated in clinical sites supported by a network of KBs and the research team through a broker to the KBs. Modest financial remuneration to the organizations for the KB time (two hours/week for six months), ongoing resource materials, and personal and intranet support was provided to the KBs. Survey data were collected by questionnaire prior to, immediately following the intervention (six months), and at 12 and 18 months. A mixed effects multinomial logistic regression was used to examine the impact of the intervention over time and by region. The impact of organizational factors was also explored. RESULTS: PTs' self-reported knowledge of all four measurement tools increased significantly over the six-month intervention, and reported use of three of the four measurement tools also increased. Changes were sustained 12 months later. Organizational culture for research and supervisor expectations were significantly associated with uptake of only one of the four measurement tools. CONCLUSIONS: KBs positively influenced PTs' self-reported knowledge and self-reported use of the targeted measurement tools. Further research is warranted to investigate whether this is a feasible, cost-effective model that could be used more broadly in a rehabilitation setting to facilitate the uptake of other measurement tools or evidence-based intervention approaches.