Can We Enhance Shared Decision-making for Periacetabular Osteotomy Surgery? A Qualitative Study of Patient Experiences.

BACKGROUND: Periacetabular osteotomy (PAO) surgery presents an opportunity for shared decision-making (SDM) and may be facilitated by decision-making tools. Currently, no diagnosis or treatment-specific decision-making tools exist for this patient population. Understanding patient PAO surgery decision-making experiences and processes would enable development of a treatment-specific decision-making tool and would help hip preservation surgeons with SDM practices. QUESTIONS/PURPOSES: Qualitative methodology was used to address the following questions: (1) What were the information support needs of adult patients with hip dysplasia who decided to have PAO? (2) What was important to adult patients with hip dysplasia who decided to have PAO? (3) How did adult patients with hip dysplasia who have undergone PAO experience the surgical decision-making process? (4) What elements of SDM did adult patients with hip dysplasia experience with their surgeons when deciding to have PAO? METHODS: Fifteen volunteer, English-speaking patients in the United States who had been diagnosed with hip dysplasia and who had undergone PAO surgery 6 to 12 months prior to the study were recruited through five PAO surgery Facebook support groups. Individuals were excluded if they had an underlying neuromuscular condition or other diagnosis related to nondevelopmental dysplasia of the hip or if they had a previous PAO surgery > 12 months before data collection. We used purposive sampling strategies to promote sample heterogeneity based on age and preoperative activity level, as these are characteristics that may impact decision-making. Participants were categorized into three age groups: 20 to 29 years, 30 to 39 years, and ≥ 40 years. Participants were also categorized as having "low activity," "moderate activity," or "high activity" preoperatively based on self-reported University of California Los Angeles (UCLA) Activity Scale scores. Participants were enrolled consecutively if they met the inclusion criteria and fulfilled one of our sampling categories; we had plans to enroll more participants if thematic saturation was not achieved through the first 15 interviews. Participants included 14 women and one man ranging in age from 23 to 48 years, and all had undergone PAO surgery for hip dysplasia 6 to 12 months prior to the interview. One-on-one semistructured interviews were conducted with each participant by a single interviewer through Zoom video conferencing using video and audio recording. Participants answered semistructured interview questions and provided verbal responses to survey questions so researchers could gain demographic information and details about their symptoms, diagnosis, and PAO surgery between June 2021 and August 2021. Quantitative survey data were analyzed using descriptive statistics. Qualitative data were analyzed by three researchers using principles of reflexive thematic analysis. Candidate themes were iteratively defined and redefined until central themes were developed that were distinctly different, yet centrally relevant, and answered the research questions. All codes that informed category and theme development were generated within the first six transcripts that were analyzed. The team felt that thematic saturation was established with the 15 interviews. RESULTS: The main information needs for adult patients with hip dysplasia included diagnosis and treatment-related information, as well as logistics related to surgery and recovery. Many patients described that their information needs were only partially met by their surgeon; most engaged in additional information-seeking from scientific research and online resources and relied on patient peers to meet information needs about the lived experience and logistics related to surgery and recovery. It was important to patients that PAO surgery could preserve their native hip or delay THA and that PAO surgery was likely to reduce their pain and improve function; decision-making was facilitated when patients were able to identify how the indications and goals of PAO surgery aligned with their own situation and goals for surgery. Patients' experiences with decision-making were more positive when information needs were met, when indications and goals for PAO surgery aligned with their personal values and goals, and when their preferred and actual decision-making roles aligned. Adult patients with hip dysplasia described high variability in the extent to which patients were invited to share personal preferences, values, and goals around PAO surgery and the extent to which preferred patient decision-making roles were assessed. CONCLUSION: We found that elements of SDM are not consistently integrated into hip preservation practice. The knowledge gained through this work about patient PAO surgery information needs, what matters to patients when deciding to have surgery, and their experiences with PAO surgery decision-making can inform future PAO surgery decision-making tool development. Future studies are needed to validate the findings of this study and to determine whether they are generalizable to adult patients with hip dysplasia with different demographic characteristics or to patients who do not participate in social media support groups. CLINICAL RELEVANCE: Surgeons should recognize that patients are likely to leave their office without their information needs being met. SDM strategies can promote more effective information exchanges in the clinic so surgeons can help patients identify their information needs, provide education and direction to accurate and reputable resources to meet those needs, and help patients appraise information they gather and apply it to their personal situation. Hip preservation surgeons can use the sample SDM script and checklist offered here to support adult patients with hip dysplasia who are making PAO surgery decisions until a future diagnosis and treatment-specific decision-making tool is available.

Cross-cultural adaptation of the Arabic version of Self-Care Domain of Child Engagement in Daily Life and Ease of Caregiving for Children measures.

PURPOSE: To cross-culturally adapt the Self-Care Domain of Child Engagement in Daily Life and the Ease of Caregiving for Children to Arabic language and Saudi culture and to examine the reliability of the Arabic version of both measures. METHODS: A modified cross-cultural adaptation procedure was employed. A total 36 children with cerebral palsy (aged 1.5-11 years) and their parents participated in the pilot and final testing steps. A committee of 7 stakeholders evaluated cross-cultural equivalence of both measures. Cronbach's alpha, intra-class correlation coefficient, and minimal detectable change were used to establish internal consistency, test-retest reliability, and distribution-based index, respectively. RESULTS: Minor linguistic, not cultural, adaptations were made in the Arabic version of both measures. Conceptual, item, semantic, and operational types of equivalences were supported. The Arabic version of Self-Care Domain of Child Engagement in Daily Life and Ease of Caregiving for Children demonstrated high internal consistency (0.97 and 0.91, respectively), excellent test-retest reliability (0.99 and 0.96, respectively), and appropriate minimal detectable change values (0.29, 0.43, respectively). CONCLUSIONS: The Arabic version of Self-Care Domain of Child Engagement in Daily Life and Ease of Caregiving for Children are reliable and culturally appropriate for use with parents of children with cerebral palsy in Saudi Arabia.

Longitudinal Changes in Physical Caregiving for Parents of Children with Cerebral Palsy.

Aims: To determine changes in physical caregiving for parents of children with cerebral palsy (CP) over a two-year period based on children's gross motor function level and age.Methods: 153 parents of children with CP rated their physical caregiving using the Ease of Caregiving for Children three times over two years. Parents and assessors classified children's gross motor function using the Gross Motor Function Classification System (GMFCS). Physical caregiving was compared at three test times among parents of children grouped by GMFCS level (I, II-III, and IV-V) and age (1.7-5.9 and 6-11 years) using a three-way mixed ANOVA.Results: Among all analyses, a two-way interaction was found between children's GMFCS level and test time on ease of caregiving, p < 0.01. Change over two-year period was found for parents of children in level I and II-III, p < 0.01, but not parents of children in levels IV-V. At each test time, parents of children in level I reported the greatest ease of caregiving followed by parents of children in levels II-III, and levels IV-V, who reported the lowest ease of caregiving, p < 0.001.Conclusions: Findings support evaluation and monitoring of physical caregiving for parents of children with CP over time.

Leisure participation-preference congruence of children with cerebral palsy: a Children's Assessment of Participation and Enjoyment International Network descriptive study.

AIM: To examine participation-preference congruence, regional differences in participation-preference congruence, and predictors of whether children with cerebral palsy participate in preferred activities. METHOD: The sample (n=236) included 148 males and 88 females aged 10 to 13 years, living in Victoria, Australia (n=110), Ontario (n=80), or Quebec (n=46), Canada. Ninety-nine (41.9%) were classed at Gross Motor Function Classification System (GMFCS) level I; 89 (37.7%) at GMFCS level II/III; and 48 (20.3%) at GMFCS level IV/V. Participants completed the Children's Assessment of Participation and Enjoyment and Preferences for Activity of Children questionnaires. Regional comparisons were performed using one-way analyses of variance and factors influencing participation-preference congruence were explored using multiple linear regression. RESULTS: The proportion of children doing non-preferred activities in each activity type was generally low (2-17%), with only one regional difference. Higher proportions were not doing preferred active physical (range 23.2-29.1% across regions), skill-based (range 21.7-27.9% across regions), and social activities (range 12.8-14.5% across regions). GMFCS level was the most important predictor associated with not doing preferred activities. INTERPRETATION: Children with cerebral palsy did not always participate in preferred active physical and skill-based activities. Understanding discrepancies between preferences and actual involvement may allow families and rehabilitation professionals to address participation barriers.

Predictors of Independent Walking in Young Children With Cerebral Palsy.

BACKGROUND: The attainment of walking is a focus of physical therapy intervention in children with cerebral palsy (CP) and may affect their independence in mobility and participation in daily activities. However, knowledge of determinants of independent walking to guide physical therapists' decision making is lacking. OBJECTIVE: The aim of this study was to identify child factors (postural control, reciprocal lower limb movement, functional strength, and motivation) and family factors (family support to child and support to family) that predict independent walking 1 year later in young children with CP at Gross Motor Function Classification System (GMFCS) levels II and III. DESIGN: A secondary data analysis of an observational cohort study was performed. METHODS: Participants were 80 children with CP, 2 through 6 years of age. Child factors were measured 1 year prior to the walking outcome. Parent-reported items representing family factors were collected 7 months after study onset. The predictive model was analyzed using backward stepwise logistic regression. RESULTS: A measure of functional strength and dynamic postural control in a sit-to-stand activity was the only significant predictor of taking ≥3 steps independently. The positive likelihood ratio for predicting a "walker" was 3.26, and the negative likelihood ratio was 0.74. The model correctly identified a walker or "nonwalker" 75% of the time. LIMITATIONS: Prediction of walking ability was limited by the lack of specificity of child and family characteristics not prospectively selected and measurement of postural control, reciprocal lower limb movement, and functional strength 1 year prior to the walking outcome. CONCLUSIONS: The ability to transfer from sitting to standing and from standing to sitting predicted independent walking in young children with CP. Prospective longitudinal studies are recommended to determine indicators of readiness for independent walking.

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

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

The determinants of self-determined behaviors of young children with cerebral palsy.

The purpose of this study was to identify determinants of self-determined behaviors of young children with cerebral palsy. The participants were 429 children (56% boys, 18-60 months) and their parents. Structural equation modeling was used to test two models of self-determined behaviors, one for children with walking mobility (Gross Motor Function Classification System, GMFCS levels I-II) and the other for children with limited self-mobility (GMFCS levels III-V). Cognitive-behavioral problems and the extent family supports their child's self-determined behaviors explained 60% of the variance in self-determined behaviors of children with walking mobility. Cognitive-behavioral problems, playfulness, and the extent family supports their child's self-determined behaviors explained 68% of the variance in self-determined behaviors of children with limited self-mobility. The less the child's cognitive-behavioral problems affect daily activities (p<.05) and the more the extent family supports their child's self-determined behaviors (p<.05), the more effective the child's self-determined behaviors. Playfulness only had an effect on self-determined behaviors of children with limited self-mobility (p<.05). Service providers are encouraged to assess and support children's daily functioning in cognition, communication, and emotional/behavioral regulation, playfulness, and family strategies in providing opportunity for children to practice self-determined behaviors.

Geographical patterns in the recreation and leisure participation of children and youth with cerebral palsy: a CAPE international collaborative network study.

PURPOSE: To examine geographical variation in the leisure participation of children/youth with cerebral palsy (CP), using Children's Assessment of Participation and Enjoyment (CAPE) data from Australia, Canada (Ontario and Quebec) and the U.S. METHOD: Data from 1076 children/youth ages 6-20 years with CP were included. Analyses examined CAPE diversity scores in activity types as a function of region, age group and Gross Motor Function Classification System (GMFCS) group, controlling for family income, education and child gender. RESULTS: There were only two substantial geographical differences: children/youth from the U.S. took part in the fewest active physical activities; those from Ontario took part in the most self-improvement activities. The youngest age group took part in the most recreational activities, and those in GMFCS level IV/V had the lowest levels of participation in recreational, active physical and self-improvement activities, confirming previous findings. CONCLUSIONS: There were more similarities than differences in participation patterns for the three countries.

Determinants of intensity of participation in leisure and recreational activities by youth with cerebral palsy.

OBJECTIVE: To test a model of determinants of intensity of participation in leisure and recreational activities by youth with cerebral palsy (CP). DESIGN: Prospective cohort study. SETTING: Children's hospitals (N=7). PARTICIPANTS: Youth with CP (N=205; age, 13-21y) and their parents. The sample included 107 (57.2%) males and 26 (12.7%) to 57 (27.8%) youth in each of the 5 levels of the Gross Motor Function Classification System (GMFCS). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Youth completed the Children's Assessment of Participation and Enjoyment by means of an interview. Parents completed the Pediatric Outcomes Data Collection Instrument, Family Environment Scale, Coping Inventory, Measure of Processes of Care, a demographic questionnaire, and a services questionnaire. RESULTS: Structural equation modeling was used to test the model. Fit statistics indicate good model fit. The model explains 35% of the variance in intensity of participation. Path coefficients (P ≤ .05) indicate that higher physical ability, higher enjoyment, younger age, female sex, and higher family activity orientation are associated with higher intensity of participation. GMFCS level and caregiver education have indirect effects on intensity of participation. The path between services and intensity of participation was not significant. CONCLUSIONS: Participation by youth with CP is influenced by multiple factors. The influence of physical activity supports the importance of activity accommodations and assistive technology for youth who are not capable of improving physical ability. Knowledge of family activity orientation is important for identifying opportunities for participation. The unexplained variance suggests that the model should include other determinants, such as physical accessibility and availability of transportation and community leisure and recreational activities.

Comparing the priorities of parents and young people with cerebral palsy.

PURPOSE: Adolescence is a period of change and transition that may pose unique challenges for young people with cerebral palsy (CP). We compared statements of priorities, i.e. what adolescents (13-17) and youth (18-21) and their parents would like to be able to do to enable greater activity and participation. METHODS: Participants were 198 parents and 135 young people with CP (45% males) from seven Children's Hospitals in the United States. The interviews were structured using The Canadian Occupational Performance Measure. Priority statements were categorised as Adult Tasks, Biology, Self-Identity or Physical Activity. RESULTS: All parents identified more priorities for Biology and Adult Tasks (p  <  0.001). Adolescents identified the fewest priorities for Self-Identity (p  <  0.01). Youth identified, in descending order of frequency, priorities in Adult Tasks, Biology, Self-Identity and Physical Activity (p  <  0.05). In the parent-young people dyads when disagreements occurred, Self-Identity issues were identified more often by parents (p  <  0.05) and priorities for Physical Activity were identified more often by young people (p  <  0.01). CONCLUSIONS: The shared and differing priorities of parents and young people with CP may reflect different roles, perceptions and experiences. The findings have implications for healthcare professionals, providing a framework to compare and contrast the priorities of young people and their parents.

Determinants of intensity of participation in leisure and recreational activities by children with cerebral palsy.

AIM: To test a model of child, family, and service determinants of intensity of participation in leisure and recreational activities by children with cerebral palsy (CP). METHOD: Participants were 288 children with CP, age range 6 to 12 years (mean 9y 8mo, SD 2y), and their parents from seven children's hospitals. The sample comprised 166 (57.6%) males and 122 (42.4%) females, and between 40 (13.9%) and 74 (25.7%) children in each of the five levels of the Gross Motor Function Classification System. Children completed the Children's Assessment of Participation and Enjoyment by interview. Parents completed the Pediatric Outcomes Data Collection Instrument, Family Environment Scale, Coping Inventory, Measure of Processes of Care, and two questionnaires. Structural equation modeling was used to test the model. RESULTS: Fit statistics indicated a good model fit. The model explains 32% of the variance in intensity of participation. Path coefficients (p ≤ 0.05) indicate that higher gross motor function, higher enjoyment, more effective adaptive behavior, younger age, and higher family activity orientation are associated with higher intensity of participation. The path between services and participation was not significant. INTERPRETATION: Intensity of participation of children with CP is influenced by multiple child and family determinants. Children's gross motor function and behavior in life situations are important for participation; knowledge of activities the child and family enjoy has implications for opportunities for participation. Professionals are encouraged to address priorities for leisure and recreation identified by children with CP and their families.

Determinants of social participation--with friends and others who are not family members--for youths with cerebral palsy.

BACKGROUND: Social participation provides youths with opportunities to develop their self-concept, friendships, and meaning in life. Youths with cerebral palsy (CP) have been reported to participate more in home-based leisure activities and to have fewer social experiences with friends and others than youths without disabilities. OBJECTIVE: The objective of this study was to identify youth, family, and service determinants of the participation of youths with CP in leisure activities with friends and others who are not family members. DESIGN: The study design was a cross-sectional analysis. METHODS: The participants were 209 youths who were 13 to 21 years old (52% male), had CP, and were classified in Gross Motor Function Classification System (GMFCS) levels I to V as well as their parents. The participants were recruited from 7 children's hospitals in 6 different states. Youths completed the Children's Assessment of Participation and Enjoyment in structured interviews. Parents completed the Coping Inventory, Pediatric Outcomes Data Collection Instrument, Family Environment Scale, Measure of Processes of Care, and demographic and service questionnaires. Researchers determined GMFCS levels. A sequential multiple regression analysis was used to determine the youth, family, and service variables that predicted participation with friends and with others who were not family members. RESULTS: Sports and physical function, communication or speech problems, educational program, and the extent to which the desired community recreational activities were obtained explained 45.8% of the variance in the number of activities engaged in with friends. A higher level of parental education explained 6.3% of the variance in the number of activities engaged in with others who were not family members. Limitations The youths' activity preferences and intensity of participation were not examined. CONCLUSIONS: /b> Youth and service characteristics were determinants of participation with friends but not others who were not family members. The findings have implications for the role of physical therapists in promoting sports and physical and communication abilities and enhancing community opportunities to optimize the social participation of youths with CP.

Family priorities for activity and participation of children and youth with cerebral palsy.

BACKGROUND: Understanding family priorities for children and youth with cerebral palsy is essential for family-centered service. OBJECTIVE: The purposes of this study were: (1) to identify family priorities for activity and participation in children and youth with cerebral palsy and (2) to determine differences based on age and Gross Motor Functional Classification System (GMFCS) level. DESIGN: Five hundred eighty-five children and youth with cerebral palsy and their caregivers participated at regional children's hospitals. The children and youth were 2 to 21 years of age; 56% were male, and 44% were female. Their caregivers, predominantly mothers (80%), had a mean age of 40.3 years (SD=9.3). The Canadian Occupational Performance Measure was administered to caregivers to identify their priorities for their children. The priorities were coded into 3 categories (daily activities, productivity, and leisure) and 13 subcategories. The GMFCS levels were determined by assessors who met the criterion for reliability. Friedman and Kruskal-Wallis one-way analyses of variance were used to examine differences in priorities. RESULTS: Parents of children in all age groups and GMFCS levels II to V identified more priorities for daily activities. Parents of school-aged children and youth had more priorities for productivity than parents of younger children. For parents of children in all age groups and motor function levels, self-care was the most frequent priority subcategory. Sixty-one percent of parents identified at least one priority related to mobility. LIMITATIONS: The study did not include qualitative analysis of priorities of parents. CONCLUSIONS: Parents' priorities for their children and youth with cerebral palsy differed depending on age and gross motor function level; however, the most frequent priority for all age groups was daily activities. Interviews with families are recommended for identifying outcomes for activity and participation and developing an intervention plan.

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

AIM: Participation in home, extracurricular, and community activities is a desired outcome of rehabilitation services for children and young people with cerebral palsy (CP). The purpose of this study was to investigate the effect of age and gross motor function on participation among children and young people with CP. METHOD: Five hundred participants (277 males, 223 females) were grouped by age and Gross Motor Function Classification System (GMFCS) level. There were 291 children aged 6 to 12 years and 209 young people aged 13 to 21 years. There were 128 participants in GMFCS level I, 220 in levels II/III, and 152 in levels IV/V. Participants completed the Children's Assessment of Participation and Enjoyment to measure number of activities (diversity) and how often they were performed (intensity) in the past 4 months. RESULTS: Children had higher overall participation diversity and intensity than young people (p<0.001). Children and young people in GMFCS level I had the highest overall participation, followed by children and young people in levels II/III and IV/V. Children had higher participation in recreational (p<0.001) but not formal (such as team sports or clubs) or physical activities. Children (p<0.01) and young people (p<0.001) in level I had the highest participation in physical activities; diversity and intensity were generally low. INTERPRETATION: The findings provide evidence of the effect of age and gross motor function on participation of children and young people with CP. Low participation in physical activities may have implications for fitness and health, especially for children and young people in GMFCS levels IV and V.

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

BACKGROUND: Through social and community participation, children and youth with cerebral palsy (CP) form friendships, gain knowledge, learn skills, express creativity, and determine meaning and purpose in life. OBJECTIVE: The purposes of this study were: (1) to determine whether social and community participation of children and youth with CP differ based on age, sex, and gross motor function, and (2) to identify the types of activities in which social and community participation are highest. DESIGN AND METHODS: A prospective cross-sectional analytic design was used. The participants were a sample of convenience of 291 children (6-12 years of age) and 209 youth (13-21 years of age) with CP (55.4% males, 44.6% females) receiving services from 7 children's hospitals. Participants completed the Children's Assessment of Participation and Enjoyment (CAPE) by structured interview. Gross Motor Function Classification System (GMFCS) level was determined by the researchers. RESULTS: Youth did a higher percentage of activities with friends and others and outside the home than children. Children and youth in level I did a higher percentage of activities with friends and others compared with children and youth in levels II and III and in levels IV and V. Children and youth in level I and in levels IV and V did a higher percentage of activities outside the home than children and youth in levels II and III. Differences were not found between females and males. The percentage of activities done with friends and others and outside the home was highest for physical and skill-based activities. LIMITATIONS: Findings cannot be attributed only to GMFCS level. CONCLUSIONS: The ability to walk without restrictions is desirable for social and community participation. For children and youth with CP who have limitations in mobility, physical therapists have roles as consultants for accessibility, activity accommodations, and assistive technology and as advocates for inclusive environments.

Comparison of the two-step and midgait methods of plantar pressure measurement in children.

BACKGROUND: Plantar pressure measures can be a useful way to clinically track dynamic foot function in children. Different protocols to collect plantar pressures exist--mainly, a midgait method that measures plantar pressures in the midst of a longer walk and a two-step method for which plantar pressures are obtained on the second step. These two methods have been compared in adults with and without disabilities but not in children. We investigated the concurrent validity and reliability of the midgait and two-step methods. METHODS: Plantar pressure data variables of contact area, contact time, peak pressure, and pressure-time integral were compared between these two methods in children of typical development (ages 5 to 14.5 years) in the heel, midfoot, and forefoot. Paired t tests were used to evaluate the validity of the two-step method. Paired sample correlations and Bland-Altman plots were also used to compare both methods. Intraclass correlation coefficients were calculated to determine reliability. RESULTS: Both methods were reliable and differed only in contact time across all foot regions, with the midgait method having shorter contact times than the two-step method. CONCLUSION: Plantar pressure data collected with the two-step method are comparable to those collected with the midgait method and may be preferred for children because of ease and speed of data collection. Further investigation is necessary to have a more complete understanding of how these findings may apply to children with disabilities.

Test-retest reliability of isokinetic dynamometry for the assessment of spasticity of the knee flexors and knee extensors in children with cerebral palsy.

OBJECTIVE: To assess test-retest reliability of the peak resistance torque and slope of work methods of spasticity measurement of the knee flexors and extensors in children with cerebral palsy (CP). DESIGN: Test-retest reliability study. SETTING: Pediatric orthopedic hospital. PARTICIPANTS: Fifteen children with CP. INTERVENTION: Knee extensor and flexor spasticity was assessed with an isokinetic dynamometer using passive movements at 15 degrees, 90 degrees, and 180 degrees/s taken 1 hour apart. MAIN OUTCOME MEASURES: Peak resistive torque and work were calculated. The relative and absolute test-retest reliability was calculated by using intraclass correlation coefficients (ICCs) and Bland-Altman plots, respectively. RESULTS: Relative reliability was good (ICC>.75) for slope-of-work and peak resistance torque measurements at a velocity of 180 degrees/s, whereas reliability of peak torque measurements was decreased (ICC<.51) at slower velocities for both muscle groups. The 95% limits of agreement of Bland-Altman plots contained most data points for both methods, but the width of the limits of agreement were wide. CONCLUSIONS: The measurement of spasticity of the knee extensors and flexors in children with CP using peak-resistance torque at 180 degrees/s and the slope of work method has acceptable relative test-retest reliability. However, the absolute reliability of spasticity data should be considered cautiously.

Exploring physical therapy clinical decision making for children with spastic diplegia: survey of pediatric practice.

PURPOSE: The purpose of this special interest report is to describe the outcomes of a research round table discussion regarding the physical therapy management of mobility for children with spastic diplegia. DESCRIPTION: Sixty-two pediatric physical therapists and physical therapists assistants participated in focus groups during the Research Round Table at the American Physical Therapy Association (APTA) 1999 Combined Sections Meeting. A case description of a child with spastic diplegia and guiding questions were used to facilitate discussion. SUMMARY OF EXPERIENCE: Common practices in patient management across the child's life-span emerged from the discussion. Practices in examination, evaluation and prognosis, and intervention differed depending on the age and function of the child and the family's needs. In general, therapists reported that younger children receive examinations that include standardized tests of development and ongoing intervention with a frequency of one to five times per week. In contrast, older children receive therapy services on an episodic basis that address their specific needs. The elements of patient management served as a useful framework for exploring decision making. IMPORTANCE TO PEDIATRIC PHYSICAL THERAPY: The information compiled from this project needs to be validated through systematic inquiry. Therapists may, however, use the practices reported here to reflect on their clinical decision making and to identify questions for further exploration. This descriptive document is the first step in the development of a guideline for evidence-based practice. The development of such a clinical guideline could serve as an education tool for novice therapists, a program evaluation tool to ensure quality care, and a foundation for future research to promote evidence-based practice.

Immediate effect of percutaneous intramuscular stimulation during gait in children with cerebral palsy: a feasibility study.

The feasibility of percutaneous intramuscular functional electrical stimulation (P-FES) in children with cerebral palsy (CP) for immediate improvement of ankle kinematics during gait has not previously been reported. Eight children with CP (six with diplegia, two with hemiplegia; mean age 9 years 1 month [SD 1 y 4 mo; range 7 y 11 mo to 11 y 10 mo]) had percutaneous intramuscular electrodes implanted into the gastrocnemius (GA) and tibialis anterior (TA) muscles of their involved limbs. Stimulation was provided during appropriate phases of the gait cycle in three conditions (GA only, TA only, and GA/TA). immediately after a week of practice for each stimulation condition, a gait analysis was performed with and without stimulation. A significant improvement in peak dorsiflexion in swing for the more affected extremity and dorsiflexion at initial contact for the less affected extremity were found in the GA/TA condition. Clinically meaningful trends were evident for improvements in dorsiflexion kinematics for the more and less affected extremities in the TA only and GA/TA conditions. The results suggest that P-FES might immediately improve ankle kinematics in children with CP.

Scapular kinematics during humeral elevation in adults and children.

BACKGROUND: Appropriate motion of the scapula is important for dynamic positioning of the glenoid during humeral elevation. A number of studies have described the typical scapular kinematics during humeral elevation in adults. However, children and adults may have differences in scapulothoracic musculature and scapular osteology. To our knowledge, no study has been performed examining scapular kinematics in children with either typical or atypical development. Consequently in children the influence of age and development on scapular motion is currently unknown. The aim of this study was to describe and compare the kinematic patterns of the scapula during humeral elevation in children with typical development and healthy adults. METHODS: Fifteen adults, 7 females, 25-37 years of age, and 14 children, 8 females, 4-9 years of age, participated in this study. Kinematic data were collected using a magnetic tracking device. Subjects were asked to elevate their arm in the scapular plane (40 degrees anterior to the frontal plane) in a sequence of three trials. FINDINGS: Significant differences were seen between the two age groups in the dependent variables. During scapular plane rotation from 25 degrees to 125 degrees , children showed greater upward rotation (43.9 degrees SD 6.39 degrees ) than adults (29.1 degrees SD 10.1 degrees ). The mean glenohumeral to scapulothoracic ratio in the scapular plane was 2.4:1 for adults, 1.3:1 for children. INTERPRETATION: This study demonstrates that there are significant differences in scapular kinematic patterns between children and adults. Children have a greater contribution from the scapulothoracic joint, specifically upward rotation toward humeral elevation. From a clinical perspective, these results can be used to help determine the incorporation of stabilization and mobilization of the scapulothoracic joint during exercises for a child with impairment at the shoulder for improving shoulder function.