Motor training for young children with cerebral palsy: A single-blind randomized controlled trial.

AIM: To compare the effect of iMOVE (Intensive Mobility training with Variability and Error) therapy with dose-matched conventional therapy on gross motor development and secondary outcomes in young children with cerebral palsy. METHOD: This single-blind, randomized controlled trial included repeated assessments of gross motor function (using the Gross Motor Function Measure) and secondary outcomes during a 12- to 24-week intervention phase and at three follow-up points after treatment. Treatment was delivered three times per week in both groups. Forty-two children aged 12 to 36 months were stratified by age and motor function to ensure equivalence between groups at baseline. RESULTS: Thirty-six children completed treatment and follow-up phases. Treatment fidelity was high and adherence was equivalent between groups (77.3% conventional therapy, 76.2% iMOVE). There were no group differences on the primary (gross motor function after 12 weeks p = 0.18; after 24 weeks p = 0.94) or any secondary (postural control p = 0.88, caregiver satisfaction p = 0.52, child engagement p = 0.98) measure after treatment or at the follow-up points. However, one-third of total participants exceeded predicted change after 12 weeks and 77% exceeded predicted change after 24 weeks of treatment. INTERPRETATION: Our observations indicate a potential dose-response effect of rehabilitation therapy. We further demonstrated that individual therapeutic ingredients can be manipulated. When delivered consistently, both iMOVE and conventional therapy interventions might both be more effective than standard care. WHAT THIS PAPER ADDS: Those receiving iMOVE therapy demonstrated more independent practice time, error, and child-initiation than those receiving the dose-matched control. iMOVE therapy was not superior to the control (conventional physical) therapy. Most participants exceeded predicted change after 24 weeks of treatment.

Agreement Between the Gross Motor Ability Estimator-2 and the Gross Motor Ability Estimator-3 in Young Children With Cerebral Palsy.

PURPOSE: The purpose of this study was to determine the agreement between Gross Motor Ability Estimator-2 (GMAE-2) and Gross Motor Ability Estimator-3 (GMAE-3) calculations of Gross Motor Function Measure-66 (GMFM-66) scores in infants and young children with cerebral palsy. METHODS: Data from 53 children 5 to 53 months of age were analyzed. Agreement between GMFM-66 scores using the GMAE-2 and the GMAE-3 was calculated using Bland-Altman plots and interclass correlation coefficients (ICCs). Eleven participants who had at least 1 GMFM-66 score of less than 25 using either method were identified for further analysis. RESULTS: The average difference between GMFM-66 scores was 0.27 for all participants and 0.63 for the subset of lower-scoring participants. Good agreement was found for GMFM-66 scores for all participants (ICC = 0.998) and for subset of lower-scoring participants (ICC = 0.879). CONCLUSIONS: High levels of agreement exist between the GMAE-2 and the GMAE-3, which suggests that scores are comparable using either algorithm.

The relationship between family empowerment and fine motor, gross motor and cognitive skills in young children with cerebral palsy.

BACKGROUND: Family empowerment in families of young children with cerebral palsy (CP) is an important consideration because the first few years of life can be overwhelming for parents. The purpose of this research was to investigate the relationship between family empowerment, fine motor (FM), gross motor (GM) and cognitive development in children with CP who were under 3 years of age. METHODS: Forty-one children with a mean age of 23.8 months participated in this study. The Family Empowerment Scale (FES) was completed by the participants' parents, whereas the FM, GM and cognitive subscales of the Bayley Scales of Infant and Toddler Development Third edition (B-III) were administered by physical therapists. RESULTS: Statistically significant positive correlations were found between the FES total and B-III raw scores for FM, GM and cognitive subscales with coefficients ranging from 0.35 to 0.41. Significant relationships were also found between the FES Community subscale and the B-III FM, GM and cognitive subscales. CONCLUSIONS: This study provides evidence of a relationship between family empowerment and FM, GM and cognitive abilities in young children with CP, with a greater severity of impairments related to lower levels of caregiver empowerment.

The relationship between the Family Empowerment Scale and Gross Motor Function Measure-66 in Young Children with cerebral palsy.

BACKGROUND: Cerebral palsy (CP) is the most common cause of motor disability in children. A concept to consider in order to meet the needs of children with CP and their families is family empowerment. Family empowerment can be defined as the process by which families acquire the skills, knowledge and resources to allow them to gain control and improve the quality of their lives. The relationship between gross motor function and family empowerment may be important because children with CP vary so widely in their ability to perform motor skills, which may affect their family's levels of empowerment. The purpose of this research was to investigate the relationship between the Family Empowerment Scale (FES) and Gross Motor Function Measure-66 (GMFM-66) in children with CP who were under 3 years of age. METHODS: Forty-one children with a mean age of 23.8 months participated in this study. The FES was completed by the participants' parents or regular caregivers and includes a total score and subscales of empowerment in the family, in service situations and in community/political environments. The GMFM-66 was administered by a physical therapist and consists of a total score of gross motor function (GMFM-66) and subscores for Dimension B (sitting), Dimension C (crawling and kneeling), Dimension D (standing) and Dimension E (walking, running and jumping). RESULTS: Statistically significant positive correlations were found between the FES total and GMFM (total score and Dimensions B-E) with coefficients varying from 0.43-0.62. Significant relationships were also found between most subscales of the FES and the GMFM-66. CONCLUSIONS: This study provides evidence of a relationship between family empowerment and gross motor function in young children with CP and suggests that caregivers of children with higher gross motor function report higher levels of self-efficacy.

The Use of Dynamic Weight Support with Principles of Infant Learning in a Child with Cerebral Palsy: A Case Report.

AIMS: Typical infant movement is characterized by a high degree of motor exploration, error, and variability. However, children with cerebral palsy (CP) often cannot create these experiences due to their neuromotor impairments. The purpose of this case study is to describe a 6-month course of physical therapy (PT) incorporating principles of infant motor learning using dynamic weight support (DWS) in a child with CP. METHODS: The child was a 27-month-old girl with diplegic CP who functioned at Gross Motor Function Classification System Level IV. The child received 68 PT sessions over a six-month period. DWS was used during therapy to encourage motor practice. The therapy area was arranged to encourage active exploration, motor variability, and error experience. Gross motor function, postural control, parent perception of performance, and parent satisfaction were measured before, during, and after the course of therapy. RESULTS: Gross motor function increased during the treatment beyond the level predicted from natural progression. Postural control fluctuated and demonstrated no appreciable improvement. Parent-perceived performance and satisfaction improved on three of four goals. CONCLUSIONS: Using DWS to incorporate principles of infant learning may have facilitated the development of gross motor skills in a child with diplegic CP.

Linear and Nonlinear Measures of Postural Control in a Toddler With Cerebral Palsy: Brief Report.

PURPOSE: The purpose of this study was to describe changes in linear and nonlinear measures of postural control along with motor outcomes in a young child with cerebral palsy. SUMMARY OF KEY POINTS: Posturography in sitting and standing, the Gross Motor Function Measure-66 (GMFM-66), and the Early Clinical Assessment of Balance (ECAB) were performed prior to, during, and after physical therapy. The child demonstrated independent sitting throughout the study and developed independent standing during the study. He made improvements in the GMFM-66 and ECAB throughout the study. Higher average values were found in all linear and nonlinear measures in standing when compared to sitting, which may indicate less predictable movement due to less experience with standing. RECOMMENDATIONS FOR CLINICAL PRACTICE: Greater variability and lower predictability in postural control likely reflect early stages of skill acquisition. Research is needed to understand the optimal levels of movement variability and predictability.

Locomotor learning in infants at high risk for cerebral palsy: A study protocol.

Background: Physical disability in individuals with cerebral palsy (CP) creates lifelong mobility challenges and healthcare costs. Despite this, very little is known about how infants at high risk for CP learn to move and acquire early locomotor skills, which set the foundation for lifelong mobility. The objective of this project is to characterize the evolution of locomotor learning over the first 18 months of life in infants at high risk for CP. To characterize how locomotor skill is learned, we will use robotic and sensor technology to provide intervention and longitudinally study infant movement across three stages of the development of human motor control: early spontaneous movement, prone locomotion (crawling), and upright locomotion (walking). Study design: This longitudinal observational/intervention cohort study (ClinicalTrials.gov Identifier: NCT04561232) will enroll sixty participants who are at risk for CP due to a brain injury by one month post-term age. Study participation will be completed by 18 months of age. Early spontaneous leg movements will be measured monthly from 1 to 4 months of age using inertial sensors worn on the ankles for two full days each month. Infants who remain at high risk for CP at 4 months of age, as determined from clinical assessments of motor function and movement quality, will continue through two locomotor training phases. Prone locomotor training will be delivered from 5 to 9 months of age using a robotic crawl training device that responds to infant behavior in real-time. Upright locomotor training will be delivered from 9 to 18 months of age using a dynamic weight support system to allow participants to practice skills beyond their current level of function. Repeated assessments of locomotor skill, training characteristics (such as movement error, variability, movement time and postural control), and variables that may mediate locomotor learning will be collected every two months during prone training and every three months during upright training. Discussion: This study will develop predictive models of locomotor skill acquisition over time. We hypothesize that experiencing and correcting movement errors is critical to skill acquisition in infants at risk for CP and that locomotor learning is mediated by neurobehavioral factors outside of training.Project Number 1R01HD098364-01A1.ClinicalTrials.gov Identifier: NCT04561232.

Construct Validity of the Early Clinical Assessment of Balance in Toddlers with Cerebral Palsy: Brief Report.

Purpose: The purpose of this research was to investigate differences in Early Clinical Assessment of Balance (ECAB) scores within children with cerebral palsy (CP) with different Gross Motor Function Classification System (GMFCS) levels and between children with CP and typical development (TD) who are under three years of age.Methods: The ECAB was administered to fifty children (13 with TD, 16 with GMFCS level II, 11 with GMFCS level III, 10 with GMFCS level III).Results: The group of children of TD had significantly higher scores than all groups of children with CP. There were significant differences in ECAB within the groups of children with CP with different GMFCS levels.Conclusion: The results of this study support the construct validity of the ECAB as a measure of postural control in children under three years of age with CP.

The responsiveness and validity of the Early Clinical Assessment of Balance in toddlers with cerebral palsy: Brief report.

Purpose: The Early Clinical Assessment of Balance (ECAB) is a measure of postural stability for children with cerebral palsy (CP). The purpose of this research was to investigate the relationship between the ECAB and Gross Motor Function Measure-66 (GMFM-66) and to determine the responsiveness of the ECAB in children with CP under three years of age. Methods: Twenty seven children (mean age of 25 months) participated. Data were collected before and after 3 and 6 months of physical therapy. Responsiveness was calculated using standardized response means (SRM). Results: Significant relationships were observed between the ECAB, GMFM-66 score (r = 0.87), and GMFM subscales (r = 0.63-0.86). A moderate effect size (SRM = 0.62) and a large effect size (SRM = 0.92) for the ECAB were found over the 3- and 6-month intervention periods, respectively. Conclusion: These results support the validity and responsiveness of the ECAB in young children with CP.

Physical activity in non-ambulatory toddlers with cerebral palsy.

BACKGROUND: Children with cerebral palsy are less likely to be physically active than their peers, however there is limited evidence regarding self-initiated physical activity in toddlers who are not able, or who may never be able, to walk. AIMS: The aim of this study was to measure self-initiated physical activity and its relationship to gross motor function and participation in non-ambulatory toddlers with cerebral palsy. METHODS AND PROCEDURES: Participants were between the ages of 1-3 years. Physical activity during independent floor-play at home was recorded using a wearable tri-axial accelerometer worn on the child's thigh. The Gross Motor Function Measure-66 and the Child Engagement in Daily Life, a parent-reported questionnaire of participation, were administered. OUTCOMES AND RESULTS: Data were analyzed from the twenty participants who recorded at least 90 min of floor-play (mean: 229 min), resulting in 4598 total floor-play minutes. The relationship between physical activity and gross motor function was not statistically significant (r = 0.20; p = 0.39), nor were the relationships between physical activity and participation (r = 0.05-0.09; p = 0.71-0.84). CONCLUSIONS AND IMPLICATIONS: The results suggest physical activity during floor-play is not related to gross motor function or participation in non-ambulatory toddlers with cerebral palsy. Clinicians and researchers should independently measure physical activity, gross motor function, and participation.