Functional Symmetry Observation Scale, Version 2: Development and Content Validation Using a Modified Delphi Method.

PURPOSE: To describe the development of the Functional Symmetry Observation Scale (FSOS) Version 2 and its content validation. METHODS: The FSOS Version 2 is an observational assessment that quantifies symmetry in spontaneous movement and posture in infants with congenital muscular torticollis, age birth to 18 months. Twenty expert pediatric physical therapists were identified through purposive sampling and invited to participate in a modified Delphi study. Survey data were collected on Qualtrics. Consensus was evaluated using median ratings and percent agreement on Likert Scale items. Thematic analysis was performed for open-ended question responses. RESULTS: Thirteen experts completed Round 1 and 2 surveys. In Round 1, consensus was achieved on all but 1 item. The scale was modified based on received feedback. In Round 2, consensus was achieved on all items (median rating of 4, agreement at 85%-100%). CONCLUSIONS: This study established the content validity of the FSOS Version 2.

Perception-Action Approach Versus Standard Care for Infants With Congenital Muscular Torticollis: A Pilot Single-Blind Randomized Controlled Trial.

OBJECTIVE: The purposes of this pilot study were to compare short-term outcomes of the Perception-Action Approach (P-AA) and standard care based on 5 components of first-choice interventions listed in the congenital muscular torticollis (CMT) clinical practice guideline. Changes in postural alignment, symmetrical use of both sides of the body during movement and play, gross motor development, and behavior observed during therapy were considered. METHODS: Thirty-two participants were enrolled in a 2-group (P-AA and standard care) randomized, single-blind trial with pre-posttest measures. Participants were infants with CMT, age range 5 to 35 weeks at enrollment. Outcome measures administered at initial and final evaluations included still photography, arthrodial goniometry, Muscle Function Scale, Alberta Infant Motor Scale, and Functional Symmetry Observation Scale. Participants in both groups attended 3 intervention sessions. Their behavior exhibited during therapy was compared using the Therapy Behavior Scale Version 2.2. RESULTS: Data collection was interrupted by the COVID-19 pandemic lockdown. Twenty-four infants completed the study (10 in P-AA and 14 in the standard care group). There were no significant differences between the groups in performance at initial and final evaluations. Both groups improved on most outcome measures. The P-AA group made greater gains on the Functional Symmetry Observation Scale, and the Therapy Behavior Scale Version 2.2 scores were higher in the P-AA group; however, these results did not reach significance. CONCLUSION: Results suggest that similar short-term outcomes may be obtained in infants with CMT undergoing P-AA and standard care interventions. Definitive conclusions regarding the efficacy of the P-AA in infants with CMT cannot be made at this time. Nevertheless, the pilot findings provide valuable preliminary data for a future efficacy trial, which will require funding. IMPACT: This was the first randomized controlled trial to provide evidence for use of P-AA intervention in infants with CMT. LAY SUMMARY: Compared to standard treatment, the Perception-Action Approach (P-AA) provided similar short-term benefits to infants with congenital muscular torticollis. The P-AA group participants demonstrated higher symmetry and behavior scores, which needs to be confirmed in a larger future study.

Reliability of the Therapy Behavior Scale version 2.2 in infants with congenital muscular torticollis: A pilot study.

BACKGROUND: The Therapy Behavior Scale (TBS) is a standardized instrument that is used to evaluate behavior of infants and toddlers during physical, occupational, and developmental therapy sessions. The TBS can be applied in intervention comparison research to assess therapy-related behaviors exhibited by study participants. PURPOSE: The purpose of this pilot study was to establish the reliability of the TBS Version 2.2 prior to its use in a randomized clinical trial comparing two physical therapy (PT) interventions in infants with congenital muscular torticollis (CMT). METHODS: Three infants with right and 7 with left CMT, severity grades 1-3, 3 girls and 7 boys, age range 3-6 months, participated in this research. Examiners were 2 experienced pediatric physical therapists. To obtain the intrarater reliability estimates, each examiner conducted 2 PT sessions with 5 infants and scored their behavior "live," and then scored the video recordings of these 10 sessions at least 1 month later. To obtain the interrater reliability estimates, both examiners scored a total of 20 video recordings. RESULTS: Results indicated good intrarater reliability, with ICC (3,1) of 0.92, 95% CI = 0.81-0.99, and 0.95, 95% CI = 73-0.98, and moderate to good interrater reliability, with ICC (2,1) of 0.84, 95% CI = 0.48-0.96, and 0.91, 95% CI = 0.67-0.98. CONCLUSION: This study established the reliability of the TBS Version 2.2 for 2 examiners who subsequently used it in a RCT of 2 PT interventions. Further research is necessary to demonstrate the reliability of this instrument in a larger population of infants with CMT, and in infants and toddlers with other conditions.

Reliability of still photography measuring habitual head deviation from midline in infants with congenital muscular torticollis.

PURPOSE: To establish intrarater and interrater reliability of still photography for measuring habitual head deviation from midline in infants with congenital muscular torticollis (CMT). METHODS: Two investigators took still photographs of 30 infants with CMT in a supine position and measured head deviation angles with a protractor. Data analysis included paired t tests, Pearson r, and intraclass correlation coefficients (ICC) with 95% confidence intervals. RESULTS: Pearson r varied from 0.80 to 0.85 for the same rater and from 0.72 to 0.99 for 2 different raters. The ICC (3,1) varied from 0.79 to 0.84, and ICC (2,1) varied from 0.72 to 0.99. Participants with smaller head-tilt angles showed greater variability in head position. CONCLUSIONS: Still photography is a reliable method for measuring habitual head deviation from midline in infants with CMT. Several modifications to the measurement procedure have been suggested.

How does the intensity of physical therapy affect the Gross Motor Function Measure (GMFM-66) total score in children with cerebral palsy? A systematic review protocol.

INTRODUCTION: Intensive physical therapy (PT) interventions administered to children with cerebral palsy (CP) have received a significant amount of attention in published literature. However, there is considerable variability in therapy intensity among studies and notable lack of information on optimal intervention dosing. This makes it difficult for clinicians to use evidence to inform practice. Many studies use the Gross Motor Function Measure (GMFM-66) to assess functional progress in children with CP. The purpose of this systematic review will be to identify the GMFM-66 change score reported in published studies, with outcomes based on intervention intensity. Whether the type of PT intervention, child's age, and Gross Motor Function Classification System level influence the GMFM-66 scores will be also assessed. METHODS AND ANALYSIS: This systematic review protocol was developed based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols (PRISMA-P) 2015 checklist. In March 2018, nine databases (PubMed, Ovid MEDLINE, Cochrane Library, Embase, Scopus, Web of Science, CINAHL, ClinicalTrials.gov, and REHABDATA) were searched for controlled clinical trials and single-subject design studies of PT interventions of any kind and intensity that used the GMFM-66 as an outcome measure for children with CP, age up to 18 years. Two authors independently reviewed the titles and abstracts and arrived at consensus on paper selection for a full-text review. The same process was used for a full-text article screening based on further detailed inclusion criteria, with a final selection made for those suitable for data extraction. Prior to commencement of data extraction, all searches will be updated, and new results re-screened. ETHICS AND DISSEMINATION: This study will involve a systematic review of published articles and no primary data collection. Therefore, no ethical approval will be necessary. Results will be disseminated in a peer-reviewed publication and presented at scientific conferences. PROSPERO REGISTRATION NUMBER: CRD42020147669.

Feasibility of an intensive outpatient Perception-Action Approach intervention for children with cerebral palsy: a pilot study.

PURPOSE: The purpose of this pilot study was (1) to evaluate feasibility of attendance and parent satisfaction with an intensive outpatient physical and occupational therapy program for young children with spastic cerebral palsy (CP) and (2) to examine changes in motor function. Methods: Sixteen children with CP, age range 18-36 months (mean 24.3 ± 6.3 months), received physical and occupational therapy sessions (30 minutes each) 5 days per week for 12 weeks. Attendance rates and parent satisfaction were assessed. Change in motor function using a one-group pre-post design was evaluated using the Gross Motor Function Measure-66 (GMFM-66), Quality of Upper Extremity Skills Test, and Pediatric Evaluation of Disability Inventory. GMFM-66 outcomes were also compared with expected outcomes using previously published normative developmental trajectories of children receiving standard therapies. Results: An average of 82% of scheduled outpatient physical and occupational therapies for 16 children were completed and the 11 parents who completed the Hills and Kitchen's Physiotherapy Outpatient Satisfaction Questionnaire were satisfied with the therapies and with their child's progress. Participants showed notable, statistically significant improvement across all activity-related measures. Conclusion: An intensive protocol of outpatient therapies utilizing Perception-Action Approach was feasible for most families of young children with spastic CP to attend at the outpatient clinic location. As this was not an experimental study, no reliable conclusions related to efficacy can be made, but the promising results suggest that further research into the effectiveness of intensive protocols is worthwhile.

Effects of music on crying behavior of infants and toddlers during physical therapy intervention.

PURPOSE: This study was designed to investigate the effects of music on the amount of time that infants and toddlers cried during physical therapy sessions. METHODS: An A-B-A withdrawal multiple single-subject design was used with 9 infants and toddlers with or at risk for developmental disabilities. Music was played during therapy in the intervention period but not in the baseline periods. The number of minutes that the participants cried was documented in a Crying Log. Results were analyzed using a celeration line approach and descriptive statistics. RESULTS: Responses to music varied among the participants, with 6 of 9 children crying less when music was used during therapy. CONCLUSIONS: Infants and toddlers with or at risk for developmental disabilities may benefit from the use of music during physical therapy to reduce crying. Effects of music on other aspects of infant and toddler behavior need to be studied.

Development Through the Lens of a Perception-Action-Cognition Connection: Recognizing the Need for a Paradigm Shift in Clinical Reasoning.

Clinical assessment of movement and posture guides the decision-making process in designing interventions for infants and children with movement disorders. Clinical reasoning is influenced by the therapist's understanding of developmental processes. The views of development grounded in perception-action, dynamic systems, and neuronal group selection theories are well recognized in current literature and supported by a large body of research. Based on the available evidence, intervention must be task-specific, repetitive, and highly salient to the child. Furthermore, it must honor spontaneous exploration and active problem-solving, enhance the child's ability to perceive environmental affordances, and target optimal variability and adaptability of movement and posture. However, a neuromaturational approach to developmental assessment and intervention that relies on "teaching" motor milestones and emphasizes the importance of correcting movement patterns in infants and children developing atypically is still prevalent in the clinic. This perspective paper will: (1) examine evidence in support of a paradigm shift from neuromaturational views toward bringing the concepts of grounded cognition, variability, complexity, and adaptability to the forefront of clinical reasoning; and (2) introduce the Perception-Action Approach as a method of assessment and intervention that may serve as an agent of such a shift by augmenting knowledge translation for the clinician.

Use of music during physical therapy intervention for an infant with Erb's palsy: a single-subject design.

Evidence supporting the use of music during pediatric physical therapy intervention is limited. The purpose of this single-subject design was to evaluate the effects of music on patient progress, the amount of crying during therapy, and parent satisfaction with physical therapy services. The subject was an infant girl with Erb's palsy who participated in this study from age 8 months to age 20 months. An A-B-A withdrawal single-subject design was used. The patient's progress was assessed by using the T.I.M.E. The amount of crying was documented in the Crying Log. A parent satisfaction questionnaire was administered three times over the course of the study. The subject's progress in the music intervention period increased on three of five primary subtests of the T.I.M.E. The amount of crying decreased and parent satisfaction increased when music was played during therapy. Music may be used by pediatric physical therapists to decrease the patient's crying, increase parent satisfaction, and possibly to increase the child's rate of progress. Further research conducted with a group of infants and toddlers may help generalize these findings to a wider patient population.

Development and content validity of the Therapy Behavior Scale.

The purpose of this study was to develop an assessment instrument that would allow clinicians to (1) evaluate behaviors of infants and toddlers during therapeutic intervention based on their own observations; (2) be applicable in a home-based or an outpatient therapeutic setting; and (3) be appropriate for use with infants and toddlers from birth to three years of age regardless of their developmental level or level of disability. Six pediatric therapists participated in the development and content evaluation of the instrument, Therapy Behavior Scale (TBS) with its subsequent revision into the TBS Version 1.0. Three raters pilot tested the scale with seven infants and toddlers. The results supported the content validity of the TBS Version 1.0 and led to the development of the TBS Version 1.1. Further research is needed to validate the newest version of the scale and to establish its intra-rater and interrater reliability.

An individualized intermittent intensive physical therapy schedule for a child with spastic quadriparesis.

Current research literature supports the use of intensive physical therapy (PT) for children with cerebral palsy (CP) but lacks consensus on the selection of a specific therapy schedule. The purpose of this case report was to describe the use of an individualized intermittent intensive PT schedule for a child with CP who was otherwise seen following a traditional, two times per week, schedule. The patient was a 4.5-year-old girl with spastic quadriparesis, GMFCS level III. The new schedule was tried over a 3-month period. Each of the 3 months included a 2-week, five times per week intensive therapy phase, followed by a 2-week resting phase. Outcomes were assessed by using the GMFM-66 and by documenting the attainment of functional gross motor skills related to the patient's PT goals. Intervention included TAMO therapy and family instruction. The patient demonstrated a gradual increase in GMFM-66 scores throughout the 9-month period covered by this case report, with the greatest mean change score obtained when the intermittent intensive therapy schedule was used. Acquired skills were retained and even improved during the resting phases. The child's parents expressed their interest in using the new PT schedule in the future.

TAMO therapy as a major component of physical therapy intervention for an infant with congenital muscular torticollis: a case report.

PURPOSE: Tscharnuter Akademie for Motor Organization (TAMO) therapy is a therapeutic approach based on dynamic theories of motor control. Research evidence supporting this approach is limited. The purpose of this case report is to describe the use of TAMO therapy in the physical therapy intervention for an infant with congenital muscular torticollis (CMT). The patient was a 4.5-month-old baby boy (corrected age) with left CMT. METHODS: Intervention included TAMO therapy, active range of motion exercise, soft tissue mobilization, and parent instruction. Changes in the amount of lateral head tilt were documented using still photography RESULTS: The infant assumed a midline head position in the supine position by the second weekly visit and maintained a midline head alignment during all functional activities by the eighth visit. CONCLUSION: This case report is the first attempt to describe a successful application of TAMO therapy as a major component of physical therapy intervention for an infant with CMT.

Evaluation of the primary subtests of toddler and infant motor evaluation: implications for clinical practice in pediatric physical therapy.

PURPOSE: The Toddler and Infant Motor Evaluation (T.I.M.E., The Psychological Corporation, San Antonio, Tex) is a norm-referenced, comprehensive qualitative assessment of the motor abilities of children between the ages of four months and 3.5 years. The purpose of this article is to describe the strengths and the limitations of the primary subtests of the T.I.M.E. on the basis of the previously published reviews, the authors' clinical experience, and two A-B-A single-subject studies. SUMMARY OF KEY POINTS: Five primary subtests of the T.I.M.E. and their possible modifications for the future use by pediatric clinicians are discussed. CONCLUSIONS: The T.I.M.E. is a family-friendly assessment tool that can be used by pediatric clinicians who work with infants and toddlers. Although it has high test-retest and interrater reliability, our use of the instrument in two case studies has revealed several structural and scoring problems. Physical therapists using the T.I.M.E. for research and in clinical practice should be aware of its strengths and limitations.