The effect of constraint-induced movement therapy for children with hemiplegic cerebral palsy in Vietnam.

PURPOSE: Pediatric constraint-induced movement therapy (CIMT) is an evidence-based treatment that has a long history of demonstrating efficacy for children with hemiparesis. The purpose of this study is to determine the effectiveness of a culturally responsive CIMT program for children with hemiplegic cerebral palsy (CP) developed for the Vietnam healthcare system. METHODS: Thirty children with hemiplegic CP (mean age = 2.88 years, age range: 1 to 8 yrs, 60% male) were recruited to a CIMT program (7.5 h/week, 4 weeks) developed for the cultural context of Vietnam. Motor abilities of the affected arm and participation in daily activities were evaluated at 3 time points (one-week prior to CIMT (baseline), one-week before (pre) and after (post) CIMT) using the Quality of Upper Extremity Skill Test (QUEST) and Pediatric Motor Activity Log-Revised (PMAL-R). Individual goals were measured using the Goal Attainment Scale (GAS). RESULTS: There were significant increases in the "How often scale" and "How Well" scales of the PMAL-R (0.75 and 0.75, p < 0.00)). Score of Grasp and Dissociated Movement items on the QUEST increased significantly (6.47 and 7.63, p < 0.001). Group GAS T-Scores were 52.19 indicating that children met individual goals. CONCLUSIONS: A model of CIMT was successfully developed and delivered within the Vietnamese healthcare system. Future studies should explore the optimal model for CIMT in various regions of world where the delivery of rehabilitation services may vary.

This is the first study to investigate the effectiveness of a pediatric constraint-induced movement therapy (PCIMT), which was specially designed to be contextually and culturally relevant for Vietnam.The program was delivered by trained therapists and parents educated about the essential elements of PCIMT.The results provide important guidance on how to adapt current evidence-based components of PCIMT models to meet the needs of children globally in settings where culture, values, and models of healthcare may differ.Future global studies on PCIMT should continue to explore the optimal implementation model for CIMT to support all children with unilateral motor weakness in various regions of the world where the delivery of rehabilitation services may vary.

Neuromotor Rehabilitation Interventions After Pediatric Stroke: A Focused Review.

Pediatric stroke is a condition that often results in life-long motor, cognitive, or sensory deficits for children. The purpose of this focused review is to compile the most recent literature on pediatric stroke neuromotor interventions and summarize evidence for use by rehabilitation providers and researchers. Terms including stroke, pediatric, and neuromotor were searched with appropriate MeSH terms. Information was collected regarding interventions conducted and outcome measures used for each article. Interventions and outcome measures were organized based on ICF components (Body Structure and Function, Activity, Participation, and Environmental Factors). 16 articles were included after full-text screens. From these 16 articles, a large majority of them included some form of neuromodulation as a part of intervention. Results identified a potentially problematic gap between domains addressed by interventions and measured by outcomes, with a need to include more expansive outcome measures in research studies. There are several areas of potential growth in pediatric stroke literature. Research studies should be precise when describing included samples. As interventions for pediatric stroke shift toward neuromodulation and other neurologic treatments, there is a need for well-defined populations, both clinically in the community as well as in research studies. There is also a need for US guidelines for rehabilitation after pediatric stroke. Overall, the trend in the literature seems to suggest that combining some form of neuromodulatory technique with existing recommended rehabilitation technique (ex: CIMT) may promote overall recovery for children after stroke, though further research is needed.

Pediatric unilateral spatial neglect: A systematic review.

PURPOSE: Unilateral spatial neglect (USN), an inability to attend to one side of space or one's body, is commonly reported in adult stroke survivors and is associated with poor outcomes. USN has been reported in pediatric survivors of stroke, but its impact is unclear. The purpose of this systematic review was to summarize and evaluate the literature regarding USN in pediatric stroke survivors. METHODS: PRISMA guidelines, Scopus, CINAHL, PubMed, and other relevant databases were searched with terms including "children", "stroke", and "unilateral neglect", with the ages of participants limited from to birth to 18 years. Data were extracted from studies on the clinical presentation of pediatric USN, the assessment of this condition, treatment options, or USN recovery. RESULTS: A total of 18 articles met inclusion criteria. There were no current prevalence data available. USN presents similarly in children compared to adults. Several different USN assessments were used, however, there were little data regarding treatment options. Furthermore, the data suggest that not all children fully recover. CONCLUSION: This systematic review reveals a lack of quality research to inform the assessment and treatment of children with USN. Although the literature spans decades, there remain no guidelines for standardized assessment or treatment. Similar to adults, paper-and-pencil testing may be less able to identify USN than functional assessments. It is likely that there are children who struggle with undetected USN-related deficits years after their injuries. With a rise of pediatric stroke survivors, there is a pressing need for clinicians to be educated about USN in children, clinical presentations, assessments, and treatments.

The Impact of Early Neuroimaging and Developmental Assessment in a Preterm Infant Diagnosed with Cerebral Palsy.

Premature infants are at risk for cerebral palsy (CP) that is typically diagnosed between 18-24 months. We present a case study of an infant who was discharged from the neonatal intensive care unit (NICU) without obvious neurological deficits but was later diagnosed with hemiplegic CP. The infant was enrolled in an infant motor study, which included neuroimaging and developmental motor assessments. At term, anatomical MRI showed bilateral periventricular leukomalacia, abnormal brain metabolites in frontal white matter via MR spectroscopy (MRS), and low fractional anisotropy (FA) values obtained from diffusional kurtosis imaging (DKI) in several cortical white matter tracts compared to a group of typically developing infants without neuroimaging abnormalities. In addition, the infant scored below average on a developmental assessment administered at term and three months as well as on the standard Bayley III assessment at 12 months. Abnormal neuroimaging and low scores on the early developmental assessment prompted referral for intervention services at two months. With intensive therapy, by 45 months, the infant was average in self-care, mobility, and communication skills, although below average in visual motor and gross motor coordination. This case highlights the clinical impact of early detection and referral using combined neuroimaging and developmental testing.

Early developmental assessment with a short screening test, the STEP, predicts one-year outcomes.

OBJECTIVE: To evaluate the Specific Test of Early Infant Motor Performance (STEP), a rapid screening test of preterm infants at risk for developmental delay. STUDY DESIGN: We prospectively studied 23 preterm infants' performance on the STEP and the Test of Infant Motor Performance (TIMP) at term and 3 months, and on the Bayley-III at 12 months. We investigated the psychometric qualities of the STEP and determined STEP cutoff scores for low and high-performing infants. RESULTS: STEP scores at term and 3 months strongly correlate with 12-month Bayley-III gross motor and cognitive scaled scores, while TIMP scores did not. The STEP showed excellent reliability and required 6-10 min to administer. CONCLUSION: STEP is a short, easy to administer, early developmental assessment with unique scoring that emphasizes qualitative and quantitative aspects of muscle tone in movements and predicts 12-month Bayley gross motor and cognitive scaled scores.

How Accurately Do Both Parents and Health Professionals Assess Overweight in Children?

BACKGROUND: An accurate perception of weight status is important to prevent childhood obesity. OBJECTIVE: We investigated whether parents and health professionals accurately identify children's weight status. METHODS: On the 2012 National Health and Nutrition Examination Survey: National Youth Fitness Survey, parents and health professionals rated the same child's weight status as overweight or healthy. The sensitivity and specificity of their answers were computed by comparing parents' and health professionals' ratings to the age growth chart from the US Centers for Disease Control and Prevention. RESULTS: Participants were 1571 children. Parents' sensitivity and specificity were 0.386 and 0.992, respectively. Health professionals' sensitivity and specificity were 0.343 and 0.981, respectively. CONCLUSIONS: Parents and health professionals demonstrate low sensitivity in identifying children's weight status. Health professionals should use the Centers for Disease Control and Prevention categories to more accurately identify children who are overweight.

Exploring the feasibility and use of accelerometers before, during, and after a camp-based CIMT program for children with cerebral palsy.

PURPOSE: The aim of this pilot study was to determine the feasibility and use accelerometers before, during, and after a camp-based constraint-induced movement therapy (CIMT) program for children with hemiplegic cerebral palsy. METHODS: A pre-test post-test design was used for 12 children with CP (mean = 4.9 yrs) who completed a 30-hour camp-based CIMT program. The accelerometer data were collected using ActiGraph GT9X Link. Children wore accelerometers on both wrists one day before and after the camp and on the affected limb during each camp day. Three developmental assessments were administered pre-post CIMT program. RESULTS: Accelerometers were successfully worn before, during, and directly after the CIMT program to collect upper limb data. Affected upper limb accelerometer activity significantly increased during the CIMT camp compared to baseline (p< 0.05). Significant improvements were seen in all twelve children on all assessments of affected upper limb function (p< 0.05) measuring capacity and quality of affected upper limb functioning. CONCLUSION: Accelerometers can be worn during high intensity pediatric CIMT programs to collect data about affected upper limb function. Further study is required to determine the relationship between accelerometer data, measure of motor capacity, and real-world performance post-CIMT.

Correlating early motor skills to white matter abnormalities in preterm infants using diffusion tensor imaging.

PURPOSE: Diffusion tensor imaging (DTI) can detect injury to specific white matter (WM) tracts involved with sensorimotor processing and may provide sensitive measures for latent or nascent motor skills. We hypothesized that DTI measures of WM fractional anisotropy (FA) could predict early motor scores on a standardized assessment in a cohort of preterm infants at risk for WM injury. METHODS: In this prospective study, preterm infants (n= 26, 11 female, 15 male, mean gestational age 29.1 ± 2.5) underwent the Test of Infant Motor Performance (TIMP) at term and at 12 weeks corrected age (CA) and underwent an non-sedated magnetic resonance imaging (MRI) with DTI at a mean of 42 ± 1.5 weeks CA. Fractional anisotropy (FA) was measured by Voxelwise statistical analysis using Tract-Based Spatial Statistics (TBSS) in the specific regions of interest. RESULTS: Significant differences were found between infants with poor versus average performance on motor assessments at 12-weeks and FA values in several left hemispheric WM tracts (p< 0.05). High FA of the left anterior limb of the internal capsule (ALIC) predicted mean increase in TIMP scores on specific items for head lift in prone and head lift turn to sound (p= 0.045 and p= 0.002). CONCLUSION: Subtle WM injury, as indicated by low FA in left WM tracts, can predict outcomes of early motor skills performance testing at 3 months. Early DTI may identify infants with silent WM injury who need early intervention. Further studies may establish if individual tract FA improve after targeted treatment.

Predicting motor outcomes with 3 month prone hip angles in premature infants.

PURPOSE: This study used kinematic analysis to identify a reliable and rapid assessment method for abnormal patterns of motor development in preterm infants. METHODS: In a retrospective analysis, we examined video of n= 35 preterm infants at 3mo corrected age (CA) who had concurrent Test of Infant Motor Performance (TIMP) scores. Hyperflexion at the hip produces common gait anomalies seen in children with CP, therefore we analyzed hip angle in the prone head lift position at 3 months CA. Magnetic Resonance Spectroscopy (MRS) was performed at term equivalent (n= 23) and Bayley-III neurodevelopmental tests were performed at 1 year (n= 28). We correlated hip angles with TIMP and Bayley-III scores, and MRS neuronal metabolites. RESULTS: Hip angle positively correlated with TIMP at 3 months (r= 0.642, p≤ 0.001), but not with Bayley-III at 1 year (r= 0.122, p= 0.529). Hip angle correlated negatively with myo-inositol (mI) ratios in frontal white matter tracts (mI/Cr r= -0.520, p= 0.011). CONCLUSIONS: These results suggest prone hip angle may be a quantitative proxy for the 42-item TIMP at 3 months, and that hypertonicity in the hip flexor musculature is a manifestation of white matter metabolic abnormalities (elevated mI ratios) that may indicate occult white matter injury.

Relationship Between Physical Activity and Overweight and Obesity in Children: Findings From the 2012 National Health and Nutrition Examination Survey National Youth Fitness Survey.

OBJECTIVE: This study examined the relationship between childhood obesity and overweight and functional activity and its enjoyment. METHOD: A cross-sectional design was used to analyze data from the 2012 National Health and Nutrition Examination Survey National Youth Fitness Survey. Multivariate logistic regression models were used. RESULTS: Data for 1,640 children ages 3-15 yr were retrieved. Physical activity was negatively associated with risk of obesity (odds ratio [OR] = 0.93; 95% confidence interval [CI] [0.87, 0.98]). Although children who were obese and overweight were more likely to have functional limitations (ORs = 1.58-1.61), their enjoyment of physical activity participation was not significantly different from that of the healthy-weight group. CONCLUSION: Physical activity lowered the risk of obesity. Children who were obese had functional limitations compared with healthy-weight children, but both groups enjoyed physical activity equally. Future studies are needed to determine barriers to participation among these children in recreation and sporting activities.

Training Paediatric Therapists to Deliver Constraint-Induced Movement Therapy (CIMT) in Sub-Saharan Africa.

Hospitals and therapists in developing countries often seek to learn how to deliver new forms of evidenced-based practice (EBP), including paediatric constraint-induced movement therapy (CIMT). This study examines a partnership implemented in Ethiopia, which trained therapists in CIMT and proposes a framework for sustainable EBP training. The aim of this study is to apply a translational and implementation framework to build capacity for CIMT in Addis Ababa, Ethiopia, that included intensive in-country training and hands-on delivery with patients, followed by clinical implementation and feedback. A goal was to develop a locally feasible, culturally relevant form of CIMT. We framed our partnership model in terms of an implementation science model for therapists from multiple hospitals in Addis Ababa. Measures included workshop attendance, delivery of the curriculum and assessment of therapist's knowledge, skills and feedback postworkshop. We established a successful partnership with a lead hospital and completed training for 12 therapists from five hospitals who demonstrated increases in knowledge and skills following training. We developed a new, practically useful, culturally appropriate form of CIMT for later implementation. This partnership was limited to training of paediatric therapists in sub-Saharan Africa. Future studies will report on therapists' ability to integrate this EBP training into clinical practice as well as future training.

Kinematic measurement of 12-week head control correlates with 12-month neurodevelopment in preterm infants.

BACKGROUND: Although new interventions treating neonatal brain injury show great promise, our current ability to predict clinical functional outcomes is poor. Quantitative biomarkers of long-term neurodevelopmental outcome are critically needed to gauge treatment efficacy. Kinematic measures derived from commonly used developmental tasks may serve as early objective markers of future motor outcomes. AIM: To develop reliable kinematic markers of head control at 12week corrected gestational age (CGA) from two motor tasks: head lifting in prone and pull-to-sit. STUDY DESIGN AND SUBJECTS: Prospective observational study of 22 preterm infants born between 24 and 34weeks of gestation. OUTCOME MEASURES: Bayley Scales of Infant Development III (Bayley) motor scores. RESULTS: Intrarater and interrater reliability of prone head lift angles and pull-to-sit head angles were excellent. Prone head lift angles at 12week CGA correlated with white matter NAA/Cho, concurrent Test of Infant Motor Performance (TIMP) scores, and 12-month Bayley motor scores. Head angles during pull-to-sit at 12-week CGA correlated with TIMP scores. CONCLUSIONS: Poor ability to lift the head in prone and an inability to align the head with the trunk during the pull-to-sit task were associated with poorer future motor outcome scores. Kinematic measurements of head control in early infancy may serve as reliable objective quantitative markers of future motor impairment and neurodevelopmental outcome.

Use of simulated patients and reflective video analysis to assess occupational therapy students' preparedness for fieldwork.

Educators must determine whether occupational therapy students are adequately prepared for Level II fieldwork once they have successfully completed the didactic portion of their coursework. Although studies have shown that students regard the use of video cameras and simulated patient encounters as useful tools for assessing professional and clinical behaviors, little has been published in the occupational therapy literature regarding the practical application of simulated patients or reflective video analysis. We describe a model for a final Comprehensive Practical Exam that uses both simulated patients and reflective video analysis to assess student preparedness for Level II fieldwork, and we report on student perceptions of these instructional modalities. We provide recommendations for designing, implementing, and evaluating simulated patient experiences in light of existing educational theory.

Identifying premature infants at high and low risk for motor delays using motor performance testing and MRS.

PURPOSE: To determine specific motor skills in premature infants, match those that correlate with standards tests of motor performance, and MRS measures of abnormal brain biochemistry. METHODS: Prospective cohort study of preterm infants (n=22). Infant motor assessments were completed at term and 12 weeks corrected gestational age (CGA) using the Test of Infant Motor Performance (TIMP) and Bayley Scales of Infant and Toddler Development-III at 12 months CGA. Infants (n=12) received MRS scans at term CGA. Rasch analysis and MRS findings investigated TIMP items well targeted to high and low risk infants. RESULTS: A 10 item subset of motor skill items correlated strongly with full 42-item TIMP at term and 12 week testing (r> 0.90, p< 0.001 for both), and with Bayley gross motor scores. MRS metabolites in basal ganglia correlated significantly with both TIMP and 10 item motor tests at term, while frontal white matter metabolites correlated with TIMP and 10 item tests at 12 weeks and Bayley motor scores. CONCLUSION: A short motor skill assessment may be representative of a longer standardized test and relate to brain metabolic function in key areas for motor movement and development. Validation of a shortened assessment may improve early identification of high-risk preterm infants.

The development of clinical reasoning and interprofessional behaviors: service-learning at a student-run free clinic.

This article examines the benefits of a student run free clinic (SRFC) as a service learning experience for students in medicine, pharmacy, occupational therapy, physical therapy and physician assistant programs. We hypothesized that students who participate in an interprofessional service learning course and volunteer at a SRFC would demonstrate significant increases in perceptions and attitudes for working in interprofessional health care teams and clinical reasoning skills compared to students who did not participate. Three assessments were administered to an experimental and control group of pre-clinical students from medical, occupational therapy, physical therapy, pharmacy and physician assistant programs before and after participation in an interprofessional service-learning course and volunteering at the SRFC. The tools were the Interdisciplinary Education Perception Scale (IEPS), Readiness for Interprofessional Learning Scale (RIPLS) and the Self-Assessment of Clinical Reflection and Reasoning (SACRR). Students who completed the course had improvements in interprofessional perceptions and attitudes (p = 0.03) and perceptions of clinical reasoning skills when compared to the control group (p = 0.002). This study is novel as it examined students' perceptions of interprofessional attitudes and clinical reasoning following participation in an interprofessional service-learning course and participation in a SRFC.

The effects of oral motor stimulation on feeding behaviors of infants born with univentricle anatomy.

The purpose of this pilot study was to determine the effects of oral motor stimulation on infants born with complex univentricle anatomy who required surgery shortly after birth. A quasi-experimental group design was used to compare 18 infants receiving an oral motor stimulation program with 10 infants who did not receive any oral motor intervention. Infants in the treatment group received the oral motor treatment prior to cardiac surgery and immediately following surgery, one time a day, 6 days a week. Outcomes data were collected for length of time to reach full bottle-feeds and length of hospital stay. A statistically significant difference was seen in the overall length of hospital stay between the two groups (p = .04). Infants in the experimental group were hospitalized for a mean of 28.6 days and infants in the comparison group for a mean of 35.3 days. Infants in the treatment group achieved full bottle-feeds 2 days earlier than infants in the comparison group, although this was not statistically significant. There is positive support for the use of oral motor stimulation for infants born with univentricle anatomy, but further study is needed to determine the long-lasting effects of this intervention.

The Caring Professionals Program: educational approaches that integrate caring attitudes and empathic behaviors into health professions education.

Caring attitudes and empathic behaviors are considered by most Americans to be an essential and intrinsic element of appropriate health care, yet little attention is given to this in the curricula of most healthcare professional training programs. This paper describes an ongoing educational intervention to develop healthcare professionals with caring attitudes and empathic behaviors that will be sustained in their professional practice environments. The Caring Professionals Program was designed to enhance and redesign existing learning experiences in four academic programs: physical therapy, occupational therapy, physician assistant, and nurse practitioner. Students entering in the summer of 2009 were engaged in the initial program and study. Six educational elements were employed in the Caring Professionals Program: experience, reflection, problem-solving, didactic, active participation, and role modeling. Educational interventions were designed to be appropriate to the students' temporal progress through their programs, specifically the early, middle or late stages. The Caring Professionals Program may serve as a model for other allied health schools and also contribute to a college culture that supports caring and humanism.