Understanding Acceptability, Barriers, and Facilitators to Clinical Implementation of the on Track Developmental Monitoring System for Children with Cerebral Palsy: A Qualitative Study.

AIMS: On Track Developmental Monitoring System (DMS) is a novel series of tools to assist in shared-decision making, guide rehabilitation intervention based on functional ability levels, and promote episodic care service models. Further understanding of the acceptability, feasibility, and appropriateness of On Track DMS in clinical settings is critical. The purpose of this study was to understand clinician perspectives of the acceptability of On Track DMS and to identify potential implementation barriers and facilitators within pediatric physical therapist practice. METHODS: Three, day-long training workshops were conducted with 32 pediatric physical therapists across the US. Focus groups with 21 workshop participants were conducted following training. Results were audio recorded, transcribed verbatim, and coded into themes. RESULTS: Three themes emerged from the data: (1) Valuing the On Track Approach to Intervention; (2) Setting-Specific Needs and Challenges to Implementation; and (3) Training Material/Tool Strengths and Limitations. CONCLUSIONS: On Track DMS appears to have initial value and acceptability for pediatric physical therapists across practice settings. Perceived benefits include facilitation of data-driven practice and therapist/family collaboration to improve health outcomes for children with CP. Using this data to understand and assess barriers and facilitators to knowledge use are first steps in successfully implementing On Track DMS.

Measuring Early Problem-Solving in Young Children with Motor Delays: A Validation Study.

AIM: There is a lack of evidence-based tools for measuring problem-solving in young children with motor delays. The purpose of this study was to evaluate the construct validity and responsiveness of the Assessment of Problem-Solving in Play. METHODS: 125 young children (10.72, SD 2.62 months) with mild, moderate, and severe motor delays were assessed with the Bayley Scales of Infant and Toddler Development, Third Edition Cognitive Scale and the Assessment of Problem-Solving in Play up to 4 times over 12 months. The baseline and change over time assessment scores were compared. RESULTS: The Assessment of Problem-Solving in Play was strongly, positively correlated with the Bayley Scales of Infant and Toddler Development, Third Edition Cognitive Scale raw scores at baseline (r=.83, p<.001) and for changes in scores across time (r=.64, p<.001). On average, participants demonstrated positive change in problem-solving scores across time. Participants with severe motor delay scored lower at baseline and changed less as compared to other participants. CONCLUSIONS: Results provide evidence for the construct validity and responsiveness of the Assessment of Problem-Solving in Play scores in quantifying problem-solving in young children with motor delays 7-27 months of age.

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

AIM: To explore the relationship between rehabilitation therapies and development in children with cerebral palsy (CP). METHOD: We conducted a prospective, longitudinal study involving 656 children with CP (mean age [SD] 6y [2y 8mo] at study entry; 1y 6mo-11y 11mo; 287 females, 369 males), and their parents. Children were assessed two to five times over 2 years by therapists using standardized measures of balance and walking endurance. Parents completed questionnaires on demographics, rehabilitation therapies, and their children's performance in self-care and participation in recreation. Therapists and parents collaboratively classified children's Gross Motor Function Classification System (GMFCS) levels. We created longitudinal graphs for each GMFCS level, depicting change across time using centiles. Using multinomial models, we analyzed the relationship between therapies (amount, focus, family-centeredness, and the extent therapies met children's needs) and whether change in balance, walking endurance, and participation was 'more than' and 'less than' the reference of 'as expected'. RESULTS: Children were more likely to progress 'more than expected' when participating in recreation when therapies were family-centered, met children's needs, and focused on structured play/recreation. A focus on health and well-being was positively associated with participation and self-care. The amount of therapy did not predict outcomes. INTERPRETATION: Therapy services that are family-centered, consider the needs of the child, and focus on structured play/recreational activities and health/well-being may enhance the development of children with CP. WHAT THIS PAPER ADDS: Family-centered rehabilitation therapies were positively associated with greater participation in family/recreation activities and walking endurance. Parental perception that rehabilitation therapies met children's needs was associated with greater participation in family/recreation activities. Structured play, recreational activities, and health/well-being are important for self-care and participation when planning rehabilitation therapy. The amount of rehabilitation therapy was not related to developmental outcomes.

Relationship of School-Based Physical Therapy Services to Student Goal Achievement.

PURPOSE: To explore the relationships of school-based physical therapy services to student goal achievement. METHODS: One hundred nine physical therapists and 296 students participated in a practice-based study. Therapists formatted goals using goal attainment scaling and evaluated goal achievement. Using the School-Physical Therapy Interventions for Pediatrics system, therapists documented services weekly for 20 weeks. Group comparisons and logistic regressions were conducted. RESULTS: For primary goals, no documented physical therapy services were associated with exceeding goal expectation. For posture/mobility goals, more minutes in self-care activities and services on behalf of the students were associated with exceeding goal expectation; use of cognitive and behavioral training interventions was associated with not exceeding goal expectation (P < .05). For recreation/fitness goals, greater use of functional strength and mobility for playground access and cognitive/behavioral interventions were associated with exceeding goal expectation (P < .05). CONCLUSION: A limited number of physical therapy services was associated with exceeding goal expectation.

"Look, Your Muscles Are Firing!": A Qualitative Study of Clinician Perspectives on the Use of Surface Electromyography in Neurorehabilitation.

OBJECTIVE: To examine the perceived value, benefits, drawbacks, and ideas for technology development and implementation of surface electromyography recordings in neurologic rehabilitation practice from clinical stakeholder perspectives. DESIGN: A qualitative, phenomenological study was conducted. In-depth, semistructured interviews and focus groups were completed. Sessions included questions about clinician perspectives and demonstrations of surface electromyography systems to garner perceptions of specific system features. SETTING: The study was conducted at hospital systems in a large metropolitan area. PARTICIPANTS: Adult and pediatric physical therapists, occupational therapists, and physiatrists from inpatient, outpatient, and research settings (N=22) took part in the study. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Interviews and focus groups were audio-recorded, transcribed verbatim, then coded for analysis into themes. RESULTS: Four major themes emerged: (1) low-tech clinical practice and future directions for rehabilitation; (2) barriers to surface electromyography uptake and potential solutions; (3) benefits of surface electromyography for targeted populations; and (4) essential features of surface electromyography systems. CONCLUSIONS: Surface electromyography systems were not routinely utilized for assessment or intervention following neurologic injury. Despite recognition of potential clinical benefits of surface electromyography use, clinicians identified limited time and resources as key barriers to implementation. Perspectives on design and surface electromyography system features indicated the need for streamlined, intuitive, and clinically effective applications. Further research is needed to determine feasibility and clinical relevance of surface electromyography in rehabilitation intervention.

Stability of the Gross Motor Function Classification System, Manual Ability Classification System, and Communication Function Classification System.

AIM: To determine the stability of the Gross Motor Function Classification System (GMFCS), Manual Ability Classification System (MACS), and Communication Function Classification System (CFCS) over 1-year and 2-year intervals using a process for consensus classification between parents and therapists. METHOD: Participants were 664 children with cerebral palsy (CP), 18 months to 12 years of age, one of their parents, and 90 therapists. Consensus between parents and therapists on level of function was ≥92% for the GMFCS, MACS, and CFCS. A linearly weighted kappa coefficient of ≥0.75 was the criterion for stability. RESULTS: Kappa coefficients varied from 0.76 to 0.88 for the GMFCS, 0.59 to 0.73 for the MACS, and 0.57 to 0.77 for the CFCS. For children younger than 4 years of age, level of function did not change for 58.2% on the GMFCS, 30.3% on the MACS, and 39.3% on the CFCS. For children 4 years of age or older, level of function did not change for 72.3% on the GMFCS, 49.1% on the MACS, and 55% on the CFCS. INTERPRETATION: The findings support repeated classification of children over time. The kappa coefficients for the GMFCS are attributed to descriptions of levels for each age band. Consensus classification facilitates discussion between parents and professionals that has implications for shared decision-making. WHAT THIS PAPER ADDS: The findings support repeated classification of children over time. Stability was higher for the Gross Motor Function Classification System than the Manual Ability Classification System and Communication Function Classification System. The function of younger children was more likely to be reclassified. Percentage agreement between parents and therapists using consensus classification varied from 92% to 97%. The intraclass correlation coefficient overestimated stability compared with the weighted kappa coefficient.

School-based physical therapy services and student functional performance at school.

AIM: We explored relationships of school-based physical therapy to standardized outcomes of students receiving physical therapy. METHOD: Using a practice-based evidence research design, School Function Assessment (SFA) outcomes of 296 students with disabilities (mean age 7y 4mo [standard deviation 2y]; 166 males, 130 females), served by 109 physical therapists, were explored. After training, therapists completed 10 SFA scales on students at the beginning and end of the school year. Therapists collected detailed weekly data on services (activities, interventions, types, student participation) using the School-Physical Therapy Interventions for Pediatrics (S-PTIP) system. Stepwise linear regressions were used to investigate S-PTIP predictors of SFA outcomes. RESULTS: Predictors of SFA section outcomes varied in strength, with the coefficient of determination (R2 ) for each outcome ranging from 0.107 to 0.326. Services that correlated positively with the SFA outcomes included mobility, sensory, motor learning, aerobic/conditioning, functional strengthening, playground access interventions, and higher student participation during therapy (standardized ß=0.11-0.26). Services that correlated negatively with the SFA outcomes included providing services within student groups, within school activity, with students not in special education, during recreation activities, and with positioning, hands-on facilitation, sensory integration, orthoses, and equipment interventions (standardized ß=-0.14 to -0.22). INTERPRETATION: Consideration of outcomes is prudent to focus services. Overall results suggest we should emphasize active mobility practice by using motor learning interventions and engaging students within therapy sessions. WHAT THIS PAPER ADDS: No specific interventions predicted positively on all School Function Assessment (SFA) outcomes. Active movement practice seems related to overall better SFA outcomes. Active mobility practice improved SFA participation, mobility, recreation, and activities of daily living. Engaging students in therapy activities and interventions improved outcomes.

Motor Planning and Gait Coordination Assessments for Children with Developmental Coordination Disorder.

AIMS: The purposes were to examine construct validity of the Motor Planning Maze Assessment (Maze) and three items from the Functional Gait Assessment (FGA) that were modified for children (pediatric modified FGA, pmFGA), by comparing performance of children with DCD and age matched peers with typical development (TD); the construct validity of total scores of the Dynamic Gait Index (DGI) and the FGA. METHODS: Twenty pairs of children with DCD and TD, age from 5 to 12 years, participated in this study. Children in both groups were tested on the Maze, pmFGA, DGI, and FGA. Paired t-tests and agreement tables were used to compare the motor performances between two groups. RESULTS: The DCD group showed higher summary scores in the Maze (p < 0.001) and demonstrated significantly fewer steps (p ≤ 0.001) while doing the pmFGA items than the TD group. However, the FGA quality scores demonstrated minimal differences between the two groups on all three items. Children with DCD showed significantly lower DGI and FGA total scores (p < 0.001) than the TD group. CONCLUSION: The Maze, DGI, and FGA tests are easily applied in clinical settings and can differentiate motor planning and gait coordination between children with DCD and with TD.

Interventions to improve gross motor performance in children with neurodevelopmental disorders: a meta-analysis.

BACKGROUND: Gross motor skills are fundamental to childhood development. The effectiveness of current physical therapy options for children with mild to moderate gross motor disorders is unknown. The aim of this study was to systematically review the literature to investigate the effectiveness of conservative interventions to improve gross motor performance in children with a range of neurodevelopmental disorders. METHODS: A systematic review with meta-analysis was conducted. MEDLINE, EMBASE, AMED, CINAHL, PsycINFO, PEDro, Cochrane Collaboration, Google Scholar databases and clinical trial registries were searched. Published randomised controlled trials including children 3 to ≤18 years with (i) Developmental Coordination Disorder (DCD) or Cerebral Palsy (CP) (Gross Motor Function Classification System Level 1) or Developmental Delay or Minimal Acquired Brain Injury or Prematurity (<30 weeks gestational age) or Fetal Alcohol Spectrum Disorders; and (ii) receiving non-pharmacological or non-surgical interventions from a health professional and (iii) gross motor outcomes obtained using a standardised assessment tool. Meta-analysis was performed to determine the pooled effect of intervention on gross motor function. Methodological quality and strength of meta-analysis recommendations were evaluated using PEDro and the GRADE approach respectively. RESULTS: Of 2513 papers, 9 met inclusion criteria including children with CP (n = 2) or DCD (n = 7) receiving 11 different interventions. Only two of 9 trials showed an effect for treatment. Using the least conservative trial outcomes a large beneficial effect of intervention was shown (SMD:-0.8; 95% CI:-1.1 to -0.5) with "very low quality" GRADE ratings. Using the most conservative trial outcomes there is no treatment effect (SMD:-0.1; 95% CI:-0.3 to 0.2) with "low quality" GRADE ratings. Study limitations included the small number and poor quality of the available trials. CONCLUSION: Although we found that some interventions with a task-orientated framework can improve gross motor outcomes in children with DCD or CP, these findings are limited by the very low quality of the available evidence. High quality intervention trials are urgently needed.

Description of Primary and Secondary Impairments in Young Children With Cerebral Palsy.

PURPOSE: We describe primary and secondary impairments in young children with cerebral palsy (CP); report differences in impairments on the basis of Gross Motor Function Classification System (GMFCS), age, and sex; and examine the extent that individual impairments account for the construct of primary and secondary impairments. METHODS: Participants included 429 children with CP (242 [56%] male; 1½ to 5 years) representing all GMFCS levels. Reliable assessors collected primary and secondary impairment data using clinical measures. Analyses included descriptive statistics, comparisons among GMFCS, age, and sex, and factor analysis. RESULTS: Young children with CP present with primary and secondary impairments. Significant differences in impairments occur among some GMFCS levels and age groups but not sex groups. Postural stability contributed most to primary impairments and strength to secondary impairments. CONCLUSION: Young children with CP across GMFCS levels may have already developed secondary impairments that should be addressed within therapy services.

Student Outcomes of School-Based Physical Therapy as Measured by Goal Attainment Scaling.

PURPOSE: The main purposes were to describe individualized outcomes of students receiving school-based physical therapy and determine if goal attainment differed by gross motor ability and age. METHODS: One hundred nine physical therapists and 296 students participated. At the beginning of the school year, therapists translated students' Individualized Education Program goals into subgoals using Goal Attainment Scaling and determined students' Gross Motor Functional Classification System level. Researchers categorized goals (posture/mobility, recreation/fitness, self-care, or academics), and therapists identified students' primary goal. At the end of the school year, therapists scored the goals. Descriptive statistics and 2-way analyses of variance were conducted. RESULTS: Students exceeded their expected goal level for primary goals and goals categorized as posture/mobility, recreation/fitness, and self-care and made progress on academic goals. No differences were found by gross motor ability. Younger students had higher goal attainment for primary and recreation goals. CONCLUSION: Students achieve individualized outcomes addressed by school-based physical therapy.

Outcomes for Students Receiving School-Based Physical Therapy as Measured by the School Function Assessment.

PURPOSE: To describe School Function Assessment (SFA) outcomes after 6 months of school-based physical therapy and the effects of age and gross motor function on outcomes. METHODS: Within 28 states, 109 physical therapists and 296 of their students with disabilities, ages 5 to 12 years, participated. After training, therapists completed 10 SFA scales on students near the beginning and end of the school year. RESULTS: Criterion scores for many students remained stable (46%-59%) or improved (37%-51%) with the most students improving in Participation and Maintaining/Changing Positions. Students aged 5 to 7 years showed greater change than 8- to 12-year-olds on 5 scales. Students with higher gross motor function (Gross Motor Function Classification System levels I vs IV/V and II/III vs IV/V) showed greater change on 9 scales. CONCLUSIONS: Positive SFA change was recorded in students receiving school-based physical therapy; however, the SFA is less sensitive for older students and those with lower functional movement.

Physical Therapy-Related Child Outcomes in School: An Example of Practice-Based Evidence Methodology.

PURPOSE: To describe the use of practice-based evidence research methodology in a prospective, multisite observational study to investigate changes in students' participation in school activity, self-care, posture/mobility, recreation/fitness, and academic outcomes, and the relationships of these changes to characteristics of school-based physical therapy. METHODS: One hundred nine physical therapists completed the training and data collection and 296 students, 5 to 12 years of age (mean age = 7.3 years) had 6 months of complete data. Therapists completed individualized (Goal Attainment Scaling) and standardized (School Function Assessment) outcome measures for students at the beginning and end of the school year and during the year collected weekly data on services to and on behalf of the students. SUMMARY: This research design enabled the investigation of complex research questions related to school-based practice. The findings of this study, to be reported later, should influence school-based therapy by providing guidance related to what activities, interventions, and services influence student outcomes.

Statistical analysis of clinical prediction rules for rehabilitation interventions: current state of the literature.

Deriving clinical prediction rules (CPRs) to identify specific characteristics of patients who would likely respond to certain interventions has become a research priority in physical rehabilitation. Understanding the appropriate statistical principles and methods of analyses underlying the derivation of CPRs is important for future rehabilitation research and clinical applications. In this article, we aimed to provide an overview of statistical techniques used for the derivation of CPRs to predict success following physical therapy interventions and to generate recommendations for improvements in CPR derivation research and statistical analysis in rehabilitation. We have summarized the current state of CPR intervention-related research by reviewing 26 studies. A common technique was found in most studies and included univariate association of factors with treatment success, stepwise logistic regression to determine the most parsimonious set of predictors for success, and calculation of accuracy statistics (focusing on positive likelihood ratios). We identified several shortcomings related to inadequate ratio of events by number of predictors, lack of standardization regarding acceptable interobserver reliability of predictors, questionable handling of predictors including reliance on univariate analysis and early categorization, and not accounting for dependence and collinearity of predictors in multivariable model construction. Interpretation of the derived CPRs was found to be difficult due to lack of precision of estimates and paradoxical findings when a subset of the predictors yielded a larger positive likelihood ratio than did the full set of predictors. Finally, we make recommendations regarding how to strengthen the use of statistical principles and methods to create consistency across rehabilitation research for CPR derivations.

Preliminary investigation of an electromyography-controlled video game as a home program for persons in the chronic phase of stroke recovery.

OBJECTIVE: To investigate the preliminary effectiveness of surface electromyography (sEMG) biofeedback delivered via interaction with a commercial computer game to improve motor control in chronic stroke survivors. DESIGN: Single-blinded, 1-group, repeated-measures design: A1, A2, B, A3 (A, assessment; B, intervention). SETTING: Laboratory and participants' homes. PARTICIPANTS: A convenience sample of persons (N=9) between 40 and 75 years of age with moderate to severe upper extremity motor impairment and at least 6 months poststroke completed the study. INTERVENTION: The electromyography-controlled video game system targeted the wrist muscle activation with the goal of increasing selective muscle activation. Participants received several laboratory training sessions with the system and then were instructed to use the system at home for 45 minutes, 5 times per week for the following 4 weeks. MAIN OUTCOME MEASURES: Primary outcome measures included duration of system use, sEMG during home play, and pre/post sEMG measures during active wrist motion. Secondary outcomes included kinematic analysis of movement and functional outcomes, including the Wolf Motor Function Test and the Chedoke Arm and Hand Activity Inventory-9. RESULTS: One third of participants completed or exceeded the recommended amount of system use. Statistically significant changes were observed on both game play and pre/post sEMG outcomes. Limited carryover, however, was observed on kinematic or functional outcomes. CONCLUSIONS: This preliminary investigation indicates that use of the electromyography-controlled video game impacts muscle activation. Limited changes in kinematic and activity level outcomes, however, suggest that the intervention may benefit from the inclusion of a functional activity component.

Use of the Child Engagement in Daily Life and Ease of Caregiving for Children to Evaluate Change in Young Children with Cerebral Palsy.

ABSTRACT Aims: Participation in family and recreational activities, self-care, and parent ease of caregiving are important outcomes for young children with cerebral palsy (CP). The aim of this study was to examine use of the Child Engagement in Daily Life and the Ease of Caregiving for Children to measure change over time. Methods: A convenience sample of 387 parents of young children with CP (18 months to 5 years of age) completed the measures twice, a mean of 12.7 months apart. Results: For the Child Engagement in Daily Life, parents of children in Gross Motor Function Classification System level I and levels II-III reported more change for the Self-care domain (medium effect) than the Family and Recreational Activities domain (small effect) and the Ease of Caregiving for Children (small effect). The change reported by parents of children in levels IV-V on all three measures was less than the criterion for a small effect. Minimal detectable change for each measure varied from 12.1 to 14.1, out of a total possible score of 100. Conclusion: Further research is recommended to determine responsiveness to change following intervention.

Measuring postural stability in young children with cerebral palsy: a comparison of 2 instruments.

PURPOSE: To compare construct validity, interrater and test-retest reliabilities of the Pediatric Reach Test and the Early Clinical Assessment of Balance (ECAB), and their relationships with the Gross Motor Function Measure, 66-item version, Basal and Ceiling approach (GMFM-66-B&C) to appraise clinical utility of postural stability measures for children with cerebral palsy (CP). METHODS: A total of 28 children with CP, 2 to 7 years old, across all functional ability levels participated in 2 assessments over 2 weeks. Two assessors scored the measures during the first assessment. RESULTS: Both measures demonstrated construct validity, rs of 0.88 (P < .001). Both measures correlated with GMFM-66-B&C, rs > 0.95. Interrater and test-retest reliabilities were stronger for the ECAB than for the Pediatric Reach Test (intraclass correlation coefficients > 0.98 vs 0.87-0.94). The ECAB demonstrated lower measurement error and proportionately smaller minimal detectable change values. CONCLUSION: The ECAB is considered the better measure of postural stability among children with CP.

Adaptive behavior and mastery motivation in children with physical disabilities.

BACKGROUND: Adaptive behavior consists of conceptual, social, and practical skills and describes the ability of individuals to manage environmental demands, interact with others, and engage in activities to meet ones needs. Mastery motivation is an intrinsic characteristic that enables persistence when attempting to master a skill. Children with physical disabilities often demonstrate less effective adaptive behaviors and lower mastery motivation than their peers without disabilities, which may subsequently impact development and participation in daily activities. Therefore, it may be beneficial for pediatric rehabilitation practitioners to focus intentionally on facilitating effective adaptive behaviors in children with physical disabilities as they aim to support child development and function. OBJECTIVE: This perspective paper highlights the importance of adaptive behavior for children with physical disabilities, discusses methods of assessment, and illustrates intervention principles and strategies to support the development of appropriate adaptive behaviors across childhood. Key intervention principles include: 1) engage children and address motivation; 2) collaborate with others; 3) support real-life meaningful experiences; 4) scaffold the just-right challenge; and 5) guide children in discovering solutions.

Child engagement in daily life measure V2: validation of psychometric properties for children with cerebral palsy.

PURPOSE: Measurement development is a reiterative process requiring refinements and revalidation. The purpose of this study was to examine structural validity and reliability of the Child Engagement in Daily Life Measure (Version 2) for parents of children with cerebral palsy (CP) across a broader age span. METHODS: Participants were 1054 parents of children with CP 1.5-11 years of age. Parents completed the Child Engagement in Daily Life measure that consists of the Participation in Family and Recreational Activities domain (11 items) and the Performance of Self-care Activities domain (18 items) as part of two longitudinal studies related to outcomes for children with CP. RESULTS: Rasch analysis indicated acceptable fit of items, stable item calibration, and logical ordering of items by difficulty for both frequency of participation in family and recreational activities and performance of self-care activities. Test-retest reliability was good to excellent: ICC = 0.78 for frequency of participation, ICC = 0.68 for enjoyment of participation, and ICC = 0.97 for self-care. CONCLUSIONS: Evidence supports reliability and validity of the Child Engagement in Daily Life Measure (Version 2) for parent-report of their children's participation in family and recreational activities and performance of self-care activities for children with CP 1.5-12 years of age.IMPLICATIONS FOR REHABILITATIONParticipation in family and recreational activities and performance of self-care activities of children with cerebral palsy can be assessed using the concise parent-report Child Engagement in Daily Life Measure V2.Knowledge of the continuum of difficulty of the frequency of participation in family and recreational activities and performance of self-care activities can assist practitioners in progressing service plans.Practitioners are encouraged to use the measure to guide discussions with parents and children on areas to focus services to support participation in family and recreational activities and performance of self-care activities.