Three-Dimensional Instrumented Gait Analysis for Children With Cerebral Palsy: An Evidence-Based Clinical Practice Guideline.

BACKGROUND: Children with cerebral palsy (CP) who walk have complex gait patterns and deviations often requiring physical therapy (PT)/medical/surgical interventions. Walking in children with CP can be assessed with 3-dimensional instrumented gait analysis (3D-IGA) providing kinematics (joint angles), kinetics (joint moments/powers), and muscle activity. PURPOSE: This clinical practice guideline provides PTs, physicians, and associated clinicians involved in the care of children with CP, with 7 action statements on when and how 3D-IGA can inform clinical assessments and potential interventions. It links the action statement grades with specific levels of evidence based on a critical appraisal of the literature. CONCLUSIONS: This clinical practice guideline addresses 3D-IGA's utility to inform surgical and non-surgical interventions, to identify gait deviations among segments/joints and planes and to evaluate the effectiveness of interventions. Best practice statements provide guidance for clinicians about the preferred characteristics of 3D-IGA laboratories including instrumentation, staffing, and reporting practices.Video Abstract: Supplemental digital content available at http://links.lww.com/PPT/A524.

Bridging Motor Learning Principles with Physiotherapy Specific Scoliosis Exercises: a Perspective Article.

AIM: This perspective paper illustrates the usefulness of explicitly integrating motor learning terminology with evolving therapeutic approaches. Physiotherapy specific scoliosis exercises (PSSEs) include a growing number of approaches to scoliosis management and serve as an example of this integration. METHODS: Three quintessential patient cases (a young hypermobile adolescent, a post-pubescent teen, and an adult with childhood diagnosis of scoliosis) serve to contrast the clinical decision-making process for a PSSE plan of care when organized within a motor learning framework. CONCLUSIONS AND IMPLICATIONS: As intervention approaches evolve, aligning the unique terminologies from different schools of thought with motor learning constructs would provide a common language for clinicians, academics and researchers to facilitate comparison of approaches and organize intervention care plans. Linking a motor learning framework and terminology to PSSE may facilitate comparison of PSSE treatment approaches by clinicians, academics, and researchers, as well as advance the global quality of care for patients with scoliosis.

Associations Between Congenital Muscular Torticollis Severity and Physical Therapy Episode.

PURPOSE: To determine how physical therapy utilization varies with Congenital Muscular Torticollis (CMT) Severity Grading Scale, considering episode of care and clinical practice guidelines. METHODS: A 3-year retrospective medical record review was conducted. Data were collected for 81 infants receiving physical therapy for CMT. Sample and service characteristics are described; 46 complete records (infants 6 months or younger) were analyzed to determine how physical therapy utilization varied across severity grades. RESULTS AND CONCLUSIONS: Of the 46 infants with complete care episodes, half had fully resolved all asymmetries. Units billed, episode duration, and total visits each increased across CMT severity grades 1 to 3. Cervical rotation restrictions correlated with total units billed, indicating a positive relationship between CMT severity and service utilization. WHAT THIS ADDS TO THE EVIDENCE: This study supports that as CMT severity increases, physical therapy utilization increases for grades 1 to 3 of the 2018 CMT Severity Grading Scale.

Physical Therapy Management of Children With Developmental Coordination Disorder: An Evidence-Based Clinical Practice Guideline From the Academy of Pediatric Physical Therapy of the American Physical Therapy Association.

BACKGROUND: Developmental coordination disorder (DCD), classified as a neurodevelopmental disorder in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), affects approximately 5% to 6% of school-aged children. Characteristics of DCD include poor motor coordination and delayed development of motor skills, not explained by other conditions. Motor deficits negatively affect school productivity, performance in activities of daily living, and recreation participation. Children with coordination problems, at risk for or diagnosed with DCD, should be evaluated by a team of professionals, including a physical therapist (PT). PURPOSE: This clinical practice guideline (CPG) provides management strategies for PTs and informs clinicians and families about DCD. It links 13 action statements with specific levels of evidence through critical appraisal of the literature and provides recommendations for implementation. RESULTS/CONCLUSIONS: The DCD CPG addresses examination, referral, first choice and supplemental interventions, discharge, compliance audits, implementation, and research recommendations. Supplemental tools are provided to support PT management.

Experiences of Parents of Infants Diagnosed With Mild or Severe Grades of Congenital Muscular Torticollis.

PURPOSE: The primary purpose of this study was to describe the experiences of parents of infants diagnosed with congenital muscular torticollis (CMT). A secondary purpose was to compare the experiences of parents of infants with mild grades versus severe grades of involvement based on the CMT severity classification system. METHODS: Through semistructured interviews, a qualitative phenomenological approach of inquiry was used to investigate the lived experiences of 12 parents. RESULTS: Eight themes common to both groups of parents were identified. Findings indicated having an infant with CMT has a significant effect on the parents and other caregivers. Two themes were unique to parents of the infants with severe CMT. CONCLUSIONS: Parents are faced with a diagnosis that requires regular therapy visits and a challenging home program. A multimodal approach by clinicians for teaching and supporting parents during the episode of care may best address their unique challenges and stresses.

Frequency-Specific Microcurrent for Treatment of Longstanding Congenital Muscular Torticollis.

PURPOSE: This case describes the first episode of care, using conservative treatment, massage, and frequency-specific microcurrent (FSM), for a 19-month-old boy with grade 8 left congenital muscular torticollis with fibrotic nodules. METHODS: Ten weeks of physical therapy provided stretching, strengthening, massage, and parent education, adding FSM in weeks 3 to 10 for this patient. RESULTS: Full passive cervical rotation and lateral flexion, 4/5 lateral cervical flexion strength, improved head tilt, and inability to palpate fibrotic nodules were achieved by week 8, with partial home program adherence. CONCLUSIONS AND RECOMMENDATIONS FOR PRACTICE: Excellent outcomes were achieved with conservative care in a patient with poor prognosis and likelihood of surgical referral. Combining stretching, strengthening, massage, postural reeducation, and FSM resulted in full range and good strength in an exceptionally short time. The combination of massage and FSM, not previously reported, are tools that may be effective in congenital muscular torticollis treatment.

Pediatric Physical Therapists' Use of the Congenital Muscular Torticollis Clinical Practice Guidelines: A Qualitative Implementation Study.

PURPOSE: This study is a follow-up to the quantitative survey to examine the perceptions of pediatric physical therapists (PTs) on the application of the 2013 Congenital Muscular Torticollis Clinical Practice Guideline (CMT CPG). METHOD: Qualitative semi-structured telephone interviews were completed. Interview questions focused on how the guidelines influenced practice, facilitators and barriers to implementation, and knowledge translation activities. RESULTS: Thirteen pediatric PTs from a variety of practice settings participated. Positive perceptions about the CMT CPG included the use of flow charts, synthesized literature in one place, and validation of examination and intervention approaches. Negative perceptions included its length and that approaches without published evidence were not addressed. Three major themes were identified: knowledge and evidence for practice, education of clinicians, and the CPG structure and components that influenced practice. CONCLUSIONS: The CMT CPG provided a number of benefits. Recommendations for future enhancement and development are provided.

A Core Set of Outcome Measures for Adults With Neurologic Conditions Undergoing Rehabilitation: A CLINICAL PRACTICE GUIDELINE.

BACKGROUND: Use of outcome measures (OMs) in adult neurologic physical therapy is essential for monitoring changes in a patient's status over time, quantifying observations and patient-reported function, enhancing communication, and increasing the efficiency of patient care. OMs also provide a mechanism to compare patient and organizational outcomes, examine intervention effectiveness, and generate new knowledge. This clinical practice guideline (CPG) examined the literature related to OMs of balance, gait, transfers, and patient-stated goals to identify a core set of OMs for use across adults with neurologic conditions and practice settings. METHODS: To determine the scope of this CPG, surveys were conducted to assess the needs and priorities of consumers and physical therapists. OMs were identified through recommendations of the Academy of Neurologic Physical Therapy's Evidence Database to Guide Effectiveness task forces. A systematic review of the literature on the OMs was conducted and additional OMs were identified; the literature search was repeated on these measures. Articles meeting the inclusion criteria were critically appraised by 2 reviewers using a modified version of the COnsensus-based Standards for the selection of health Measurement INstruments. (COSMIN) checklist. Methodological quality and the strength of statistical results were determined. To be recommended for the core set, the OMs needed to demonstrate excellent psychometric properties in high-quality studies across neurologic conditions. RESULTS/DISCUSSION: Based on survey results, the CPG focuses on OMs that have acceptable clinical utility and can be used to assess change over time in a patient's balance, gait, transfers, and patient-stated goals. Strong, level I evidence supports the use of the Berg Balance Scale to assess changes in static and dynamic sitting and standing balance and the Activities-specific Balance Confidence Scale to assess changes in balance confidence. Strong to moderate evidence supports the use of the Functional Gait Assessment to assess changes in dynamic balance while walking, the 10 meter Walk Test to assess changes in gait speed, and the 6-Minute Walk Test to assess changes in walking distance. Best practice evidence supports the use of the 5 Times Sit-to-Stand to assess sit to standing transfers. Evidence was insufficient to support use of a specific OM to assess patient-stated goals across adult neurologic conditions. Physical therapists should discuss the OM results with patients and collaboratively decide how the results should inform the plan of care. DISCLAIMER: The recommendations included in this CPG are intended as a guide for clinicians, patients, educators, and researchers to improve rehabilitation care and its impact on adults with neurologic conditions. The contents of this CPG were developed with support from the APTA and the Academy of Neurologic Physical Therapy (ANPT). The Guideline Development Group (GDG) used a rigorous review process and was able to freely express its findings and recommendations without influence from the APTA or the ANPT. The authors declare no competing interest.Video Abstract available for more insights from the authors (see Video, Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A214.

Physical Therapy Management of Congenital Muscular Torticollis: A 2018 Evidence-Based Clinical Practice Guideline From the APTA Academy of Pediatric Physical Therapy.

BACKGROUND: Congenital muscular torticollis (CMT) is a postural deformity evident shortly after birth, typically characterized by lateral flexion/side bending of the head to one side and cervical rotation/head turning to the opposite side due to unilateral shortening of the sternocleidomastoid muscle; it may be accompanied by other neurological or musculoskeletal conditions. Infants with CMT should be referred to physical therapists to treat these postural asymmetries as soon as they are identified. PURPOSE: This update of the 2013 CMT clinical practice guideline (CPG) informs clinicians and families as to whom to monitor, treat, and/or refer and when and what to treat. It links 17 action statements with explicit levels of critically appraised evidence and expert opinion with recommendations on implementation of the CMT CPG into practice. RESULTS/CONCLUSIONS: The CPG addresses the following: education for prevention; referral; screening; examination and evaluation; prognosis; first-choice and supplemental interventions; consultation; discontinuation from direct intervention; reassessment and discharge; implementation and compliance audits; and research recommendations. Flow sheets for referral paths and classification of CMT severity have been updated.

Thirty-Second Walk Test: Expansion of Normative Data.

PURPOSE: To collect 30-second walk test (30sWT) normative data on a large, diverse sample of school children developing typically, ages 5 to 13 years, and describe the influences of gender, body mass index, and path shape on distance walked. METHODS: Five physical therapists administered the 30sWT on 1223 children developing typically (boys = 517, girls = 706) from 20 urban schools. RESULTS: Average distances (standard deviation) ranged from 139.1 (20.3) to 163.0 (18.6) ft; children aged 10 years walked the farthest and those aged 5 years the shortest. Distance steadily increased from ages 5 to 10 years, steadily decreased from ages 11 to 13 years; children aged 8, 9, and 10 years had statistical but not functionally meaningful gender differences. Body mass index and path shape had no meaningful effects. Distance and velocities are similar to prior studies. CONCLUSION: This study updated 30sWT normative values with a large, ethnically diverse, urban sample developing typically. Norms may be useful as part of a comprehensive examination.

Interrater and Intrarater Reliability of the Congenital Muscular Torticollis Severity Classification System.

PURPOSE: To establish inter- and intrarater reliability for determining severity grades of the congenital muscular torticollis severity classification system (CMT-SCS). METHODS: A prospective reliability study with 145 physical therapists recorded severity ratings on 24 randomly-ordered patient cases including age of infant, cervical range of motion, and presence or absence of sternocleidomastoid mass. To compute intrarater reliability, cases were randomly reordered and graded by 82 of the original raters. RESULTS: For the CMT-SCS, overall reliability was good with an interrater reliability intraclass correlation coefficient (ICC) (2,1) of 0.83 (95% confidence interval [CI], 0.74-0.91) and an intrarater reliability ICC (3,1) of 0.81 (95% CI, 0.66-0.91). CONCLUSIONS: The CMT-SCS has good reliability for infants up to 12 months of age. Physical therapists can use the scale for initial assessment of infants suspected to have CMT. The CMT-SCS should be standard documentation for infants with CMT.

Uptake of the Congenital Muscular Torticollis Clinical Practice Guideline Into Pediatric Practice.

PURPOSE: This study describes survey responses about implementation of the congenital muscular torticollis clinical practice guideline (CMT-CPG) by pediatric physical therapists (PT) and successes and challenges with knowledge-brokering activities. METHODS: An online survey was distributed to pediatric PTs who self-identified with practice experience with congenital muscular torticollis. Data were analyzed for implementation frequency of guideline recommendations and differences pre and postpublication of the CMT-CPG. RESULTS: After publication, guideline recommendation implementation improved such that no recommendation was being implemented by less than 50% of respondents, and most were implemented by greater than 90%. The majority of respondents participated in knowledge brokering; however, many indicated minimal effectiveness of those activities. CONCLUSIONS: The CMT-CPG has successfully aided in changing practice. Participants identified areas of challenge and success in translating recommendations into practice and in knowledge brokering that may be helpful for the development of future CPGs.

Timed Floor to Stand-Natural: Reference Data for School Age Children.

PURPOSE: To collect reference data for the Timed Floor to Stand-Natural (TFTS-N) on a large, diverse sample of school children who are typically developing, taking into account age, sex, and body mass index (BMI). METHODS: Five physical therapists administered the TFTS-N on a sample of convenience of 1476 school children who were typically developing, aged 5 to 14 years (male = 637, female = 839), using previously tested, standardized reliable procedures. RESULTS: The average time ranged from 7.91 ± 1.65 seconds to 8.98 ± 1.62 seconds; 8 year-old students were the quickest and the 13-year-old students were the slowest. The mean difference between males and females was clinically negligible at 0.38 seconds. Post hoc analyses revealed no significant differences among BMI categories. CONCLUSIONS: Reference data for the TFTS-N test are now available. Neither sex nor BMI affects the timing of the task in this age range.

Timed Up and Go: Reference Data for Children Who Are School Age.

PURPOSE: To collect normative data for the Timed Up and Go (TUG) on a large, diverse sample of urban school children who are typically developing, accounting for age, sex, and body mass index. METHODS: Physical therapists administered the TUG with natural walking speeds on 1481 children (M = 635, F = 846), ages 5 to 13 years representing 29.60% whites, 24.2% Asian/Pacific Islanders, 19.7% Latino/Hispanics, 16.3% African Americans, 1.40% Native American/Alaskans, and 8.80% other. RESULTS: Average TUG speeds ranged from 6.20 to 7.12 seconds across all ages, with speeds decreasing from 5 to 9 years and increasing from 9 to 13 years. Differences between 8-, 9-, and 11-year-old males and females and across age groups did not exceed a clinically important threshold. Body mass index was not consistently correlated with TUG speed. CONCLUSION: This study provides reference data on the TUG. These data should complement clinical observations and additional tests and measures to determine whether a student is functioning slower than age-matched peers.

Reliability and validity of the Timed Floor To Stand Test-Natural in school-aged children.

PURPOSE: To establish reliability for the Timed Floor to Stand-Natural (TFTS-N) test as a stand-alone measure for schoolchildren with typical development (TD) in preparation for normative data collection. METHODS: Five physical therapists working in schools standardized testing procedures for a "natural" pace version of the TFTS. Time data were collected using a repeated-measures design. RESULTS: Twenty-two students with TD (8 years 7 months to 12 years 7 months; (Equation is included in full-text article.)= 10 years, SD = 1.13) completed the TFTS-N in 6.27 (SD = 0.30) to 8.45 (SD = 0.68) seconds. Intraclass correlation coefficients (ICCs) (3,1) ranged from 0.713 to 0.800 for intrarater reliability and was 0.988 for interrater reliability. The ICC (3,3) was 0.871 for test-retest reliability. CONCLUSION: The TFTS-N has high intra-, inter-, and test-retest reliability. TFTS-N has face validity as the task frequently occurs in school settings. The test procedures are reliable for trained physical therapists to establish individual baseline measures of schoolchildren with TD.

Two Seating Systems' Effects on an Adolescent With Cerebral Palsy and Severe Scoliosis.

BACKGROUND AND PURPOSE: To compare physiological functioning, communication switch activation, and response accuracy in a 19-year-old young man with quadriplegic cerebral palsy and neurological scoliosis using 2 seating systems within the school setting. METHODS: Prospective single-subject alternating treatment design with 2 conditions: baseline phase with standard planar inserts (A1), custom-molded back with original seat (B), and return to baseline (A2). Measures included oxygen saturation (SaO2), heart rate (HR), respiration rate (RR), body temperature (BT), processing time to activate switches, and response accuracy. RESULTS: SaO2 levels increased from "distressed" to "normal"; variability decreased. HR, RR, and BT fluctuations decreased with the custom-molded back. Processing time decreased with increased variability, affected by subject's motivation; accuracy improved slightly. Reported social approachability and student-initiated communication increased. CONCLUSIONS: SaO2 increased and HR, RR, and BT fluctuations decreased with a custom-molded back. Graphing data may help determine seating effect with complex clients.

Telerehabilitation in Physical Therapist Practice: A Clinical Practice Guideline From the American Physical Therapy Association.

A clinical practice guideline on telerehabilitation was developed by an American Physical Therapy Association volunteer guideline development group consisting of international physical therapists and physiotherapists, a physician, and a consumer. The guideline was based on systematic reviews of current scientific literature, clinical information, and accepted approaches to telerehabilitation in physical therapist practice. Seven recommendations address the impact of, preparation for, and implementation of telerehabilitation in physical therapist practice. Research recommendations identify current gaps in knowledge. Overall, with shared decision-making between clinicians and patients to inform patients of service delivery options, direct and indirect costs, barriers, and facilitators of telerehabilitation, the evidence supports the use of telerehabilitation by physical therapists for both examination and intervention. The Spanish and Chinese versions of this clinical practice guideline, as well as the French version of the recommendations, are available as supplementary material (Suppl. Materials).

Physical therapy management of congenital muscular torticollis: an evidence-based clinical practice guideline: from the Section on Pediatrics of the American Physical Therapy Association.

BACKGROUND: Congenital muscular torticollis (CMT) is an idiopathic postural deformity evident shortly after birth, typically characterized by lateral flexion of the head to one side and cervical rotation to the opposite side due to unilateral shortening of the sternocleidomastoid muscle. CMT may be accompanied by other neurological or musculoskeletal conditions. KEY POINTS: Infants with CMT are frequently referred to physical therapists (PTs) to treat their asymmetries. This evidence-based clinical practice guideline (CPG) provides guidance on which infants should be monitored, treated, and/or referred, and when and what PTs should treat. Based upon critical appraisal of literature and expert opinion, 16 action statements for screening, examination, intervention, and follow-up are linked with explicit levels of evidence. The CPG addresses referral, screening, examination and evaluation, prognosis, first-choice and supplemental interventions, consultation, discharge, follow-up, suggestions for implementation and compliance audits, flow sheets for referral paths and classification of CMT severity, and research recommendations.

Developing evidence-based physical therapy clinical practice guidelines.

PURPOSE: Recommended strategies for developing evidence-based clinical practice guidelines (CPGs) are provided. KEY POINTS: The intent is that future CPGs developed with the support of the Section on Pediatrics of the American Physical Therapy Association would consistently follow similar developmental processes to yield consistent quality and presentation. Steps in the process of developing CPGs are outlined and resources are provided to assist CPG developers in carrying out their task. These recommended processes may also be useful to CPG developers representing organizations with similar structures, objectives, and resources.

Evidence-Based Practice Doctor of Physical Therapy Curricular Guideline Utilization: A Convergent Parallel Mixed Methods Study.

INTRODUCTION: In 2014, an expert panel from the American Physical Therapy Association Academy of Research Evidence-Based Practice (EBP) special interest group created the Doctor of Physical Therapy (DPT) EBP Curricular Guideline (EBP-CG). This study describes faculty awareness of the EBP-CG, DPT curricular alignment with its terminal objectives, EBP-CG uses, and challenges addressing the objectives. REVIEW OF LITERATURE: DPT educators frequently use core curriculum guidelines (CGs) that articulate entry-level knowledge and skills to determine competencies. No such guidelines existed for EBP in 2012 leading to the EBP-CG development to assist educators. Few CGs have been studied for their impact on content standardization. A mixed methods design was chosen to more completely describe this CG's impact. SUBJECTS: Faculty teaching EBP in US accredited DPT programs. METHODS: A mixed-methods design explored what EBP-CG objectives are addressed, to what expected mastery levels, and how faculty use the document. RESULTS: Eighty-three of 252 accredited programs completed the survey; 14 respondents were interviewed. The EBP-CG was valued and viewed as reflecting curricular content. Its 33 objectives were taught by most respondents at knowledge and practice levels with independent mastery expected for 7. Interviewees described EBP as commonly practiced through group over individual projects. More EBP curriculum credits predicted more objectives taught (R = .29, R2 = .09, P = .03) and expected for mastery (R = .28, R2 = .08, P = .04). No interviewees shared the EBP-CG with clinical partners or Directors of Clinical Education; EBP carryover from classroom to practice is unknown. DISCUSSION AND CONCLUSION: Respondents confirmed that the EBP-CG objectives were useful and consistent with curricular content. Four EBP preparation gaps were identified: 1) limited EBP-CG awareness by faculty who teach EBP, 2) use of group over independent projects to practice EBP, 3) communication gaps between academic and clinical education settings about the EBP-CG, and 4) no consensus on minimum EBP competencies.