Randomised clinical trial of group-based physiotherapy in extremely low birthweight children with minimal/mild motor impairment: A preliminary study.

AIM: Extremely low birthweight infants often present with mild neurodevelopmental impairments in gross motor function and postural stability in early childhood. The aim of the study was to undertake a randomised controlled trial to determine the short- and longer-term effects of group-based physiotherapy compared to standard care on performance in extremely low birthweight children with minimal/mild impairment. METHODS: Fifty children aged 4 years, born <28 weeks gestation and/or birthweight <1000 g with minimal/mild motor impairment were enrolled in a randomised controlled trial and randomly allocated to 6 weeks of group-based intervention (n = 24) or standard care (n = 26). The intervention consisted of a combination of traditional physiotherapy and task-oriented approaches of approximately 1 h in duration and varied according to each child's strengths and weaknesses. Baseline, post intervention and 1 year post baseline assessments included Movement Assessment Battery for Children-2 (MABC-2), single leg stance, lateral reach and long jump. RESULTS: Forty-eight (96%) children completed the study, which demonstrated no significant differences between the intervention and standard care groups on any of the assessments. Both groups improved initially from baseline to initial reassessment on the MABC-2 (P < 0.001). For both groups, however, MABC-2 manual dexterity, aiming/catching and total score declined from baseline to 1 year follow-up. However, for both groups, single leg stance and limb strength were significantly improved from baseline to 1 year follow-up. CONCLUSIONS: There were no differences in outcomes between groups. Both approaches may contribute to improved short-term performance and longer-term improvements on functional skills in extremely preterm children.

Are behaviour problems in extremely low-birthweight children related to their motor ability?

AIM: To investigate whether behaviour problems are independently related to mild motor impairment in 11-13-year-old children born preterm with extremely low birthweight (ELBW). METHODS: The cross-sectional study included 48 (27 males) non-disabled, otherwise healthy ELBW children (<1000 g) and 55 (28 males) term-born peers. Parents reported behaviour using the Child Behaviour Checklist (CBCL). Children completed the Movement Assessment Battery for Children (Movement ABC). RESULTS: Extremely low birthweight children had poorer behaviour scores (CBCL Total Problem T score: mean difference = 5.89, 95% confidence interval = 10.29, 1.49, p = 0.009) and Movement ABC Total Motor Impairment Scores (ELBW group median = 17.5, IQR = 12.3; term-born group median = 7.5, IQR = 9, p < 0.01) than term-born peers. Behaviour was related to motor score (regression coefficient 2.16; 95% confidence interval 0.34, 3.97, p = 0.02) independent of gender, socio-economic factors or birthweight. Motor score had the strongest association with attention (ρ = 0.51; p < 0.01) and social behaviours (ρ = 0.50; p < 0.01). CONCLUSION: Behaviour problems of otherwise healthy 11- to 13-year-old ELBW children are not related to prematurity independent of their motor difficulties. Supporting improved motor competence in ELBW preteen children may support improved behaviour, particularly attention and social behaviours.

Goal Attainment Scaling to Evaluate Intervention on Individual Gains for Children Born Extremely Preterm.

PURPOSE: To investigate the effect of group-based physical therapy on individual gains among preterm and/or extremely low-birth-weight children with minimal or mild impairment at 4 years using Goal Attainment Scaling (GAS). To explore the relationship between GAS with motor and postural outcomes and effect of gender on GAS scores. METHODS: Twenty-four 4-year-old children (born <28 weeks' gestation and/or birth weight <1000 g) with minimal or mild motor impairment completed 6 group-based weekly intervention sessions and a goal-based home program. Assessments included GAS, Movement Assessment Battery for Children-Second Edition (MABC-2), postural stability, and limb strength after intervention. RESULTS: GAS group T score improved, exceeding expected goal of "0" score after intervention (mean = 58.2, standard deviation = 0.82). GAS mean T-score and MABC-2 percentile were moderately correlated (r = 0.42, P = .04). Females improved more than males (P = .05). CONCLUSIONS: Goals were achieved above expected level after intervention and were related to motor coordination. Male gender is a risk factor for less favorable outcomes.

Perinatal factors in non-disabled ELBW school children and later performance.

AIM: To determine the association between perinatal events and subsequent motor performance, cardiorespiratory endurance and respiratory function in non-disabled extremely low birthweight (ELBW) school children at 12 years of age. METHODS: Forty-eight ELBW infants were included in this study. The Movement Assessment Battery for Children (MABC), VO(2) max score as a measure of cardiorespiratory endurance and respiratory function testing were performed and perinatal variables were extracted from the children's hospital files. Children with MABC score ≤ 15th centile were described as having suspect motor performance. Children were classified as being unfit with a VO(2) max > 1 standard deviation below the mean according to gender and age. Perinatal risk factors were explored as risk factors for motor outcome, cardiorespiratory endurance and respiratory function. RESULTS: MABC category was significantly related with gender (P = 0.005) and chronic neonatal lung disease (P = 0.013). Multiple regression analysis showed motor outcome at 12 years to be independently related to male gender (P = 0.03) and chronic neonatal lung disease (P = 0.045). Sixty-five percent of all the children were identified as unfit. Chronic neonatal lung disease was significantly related to cardiorespiratory endurance (P = 0.03) and predicted VO(2) max at 12 years (P = 0.05). No perinatal factors were significantly related to respiratory function variables. CONCLUSION: Male gender and chronic neonatal lung disease were associated with later motor outcome of ELBW school children. It is suggested that objective and consistent follow-up from childhood through preadolescence are important to address motor and fitness issues especially for male children born with ELBW.

Fitness limitations in non-disabled extremely low birthweight adolescents.

AIM: This study aims to compare non-disabled otherwise healthy extremely low birthweight (ELBW) (<1000 g) children and term-born peers in an investigation of relationship between cardiorespiratory endurance and parent report of competence. METHODS: Forty-eight of 105 eligible ELBW 11- to 13-year-old children (27 male) and 55 term-born school peers (28 male) completed a 20-m shuttle run, anthropometric measures, respiratory function tests and the Motor Assessment Battery for Children. Parents completed the Child Behavior Checklist (CBCL). RESULTS: The ELBW group had poorer cardiorespiratory endurance (P = 0.002), growth (P = 0.002), respiratory function (P = 0.003) and motor ability (P < 0.001) than term-born peers. Parents reported the ELBW children to be less competent than term-born peers: CBCL total T score mean difference -9, 95% confidence interval -14, -5 (P < 0.001). Cardiorespiratory endurance predicted competence (regression coefficient 0.865; 95% confidence interval 0.352, 1.378; P = 0.001) independent of prematurity, growth, respiratory function, motor score, gender and socio-economic status. Cardiorespiratory endurance had association with social competence for all participating children, but was related to CBCL Activities Competence only for the ELBW children who were the significantly less fit group. CONCLUSIONS: The poor cardiorespiratory endurance prevalent in non-disabled otherwise healthy ELBW children is associated with general competence independent of prematurity and of the impact of other mild physical deficits, gender or socio-economic status. The relationship demonstrated between cardiorespiratory endurance and competence to engage in general activities of daily living, seen only in the less fit ELBW children, identifies the fitness levels in non-disabled ELBW children as a barrier to participation.

Perinatal events and motor performance of children born with ELBW and nondisabled.

PURPOSE: To explore the relationship between perinatal variables and motor performance in children who were born with extremely low birth weight (ELBW) and were nondisabled at 1 and 4 years. METHODS: Children without neurological or cognitive impairment (n = 48) born weighing less than 1000 g between 1992 and 1994 were assessed at 1 and 4 years corrected age using the Neurosensory Motor Developmental Assessment (NSMDA). Scores were used to categorize motor performance as normal or abnormal. RESULTS: Chronic lung disease (CLD) of prematurity, necrotizing enterocolitis (NEC), and patent ductus arteriosus were associated with NSMDA category at 1 year. Chronic lung disease, male gender, and NEC were associated with NSMDA category at 4 years. Multiple regression analyses revealed that CLD and NEC were independently associated with abnormal motor outcomes at 1 year. CONCLUSIONS: Early assessment and motor therapy is recommended for infants with CLD, because of its effect on motor performance in this otherwise healthy group of children born with ELBW.

Motor coordination difficulties and physical fitness of extremely-low-birthweight children.

Motor coordination difficulties and poor fitness exist in the extremely low birthweight (ELBW) population. This study investigated the relative impact of motor coordination on the fitness of ELBW children aged 11 to 13 years. One hundred and nine children were recruited to the study: 54 ELBW participants (mean age at assessment 12y 6mo; 31 male, 23 female; mean birthweight 769g, SD 148g; mean gestational age 26.6 weeks, SD 2.1 weeks) and 55 comparison children (mean age at assessment 12y 5mo; 28 males, 27 females; at least 37 weeks' gestation). All children completed the Movement Assessment Battery for Children (MABC), functional tests of postural stability and strength, growth measures, and tests of respiratory function. Maximal oxygen uptake (VO(2)max) was calculated from a 20m shuttle run test as a measure of fitness. The ELBW group had greater problems with postural stability (p=0.001) and motor coordination (p=0.001), with 70% rated as having a definite motor problem on the MABC brackets (those who scored less than the 5(th) centile on the MABC). The ELBW was also less fit than the comparison group (p=0.001), with 45% below the 10th centile for VO(2)max. There were differences between the groups for growth, strength, and particularly respiratory function. However, respiratory function did not significantly correlate with VO(2)max in the ELBW group. Motor coordination was the most powerful predictor of VO(2)max in both the ELBW (p=0.001) and the comparison groups (p=0.001).

The association between early minor motor difficulties in extreme low birth weight infants and school age attentional difficulties.

INTRODUCTION: Extremely premature infants of normal intellectual ability have an increased prevalence of motor and attentional difficulties. Knowledge of the relationship between early motor difficulties and measures of attention at school age would enhance understanding of these developmental pathways, their interrelationship and opportunities for intervention. OBJECTIVE: This study examines whether an association exists between early findings of minor motor difficulties and school age clinical and psychometric measures of attention. METHODOLOGY: 45/60 eligible ELBW(1000 g) or preterm (< 27/40 gestation) infants born at the Mater Mother's Hospital were assessed at 12 and 24 months for minor motor deficits (using NSMDA) and at 7-9 years for attention, using clinical (Conners and Du Paul Rating Scales) and psychometric (assessing attention span, selective and divided attention) measures. RESULTS: NSMDA at 12 months was only associated with the psychometric measures of verbal attention span. It was not associated with later clinical measures of attention. NSMDA at 24 months was strongly associated with specific clinical measures of attention at school age, independent of biological and social factors. It was not associated with psychometric measures of attention. CONCLUSION: The major finding of this study is that motor difficulties in ELBW infants at 2 years are associated with later clinical measures of attention. Possible mechanisms underlying this relationship are considered.

Motor performance, postural stability and behaviour of non-disabled extremely preterm or extremely low birth weight children at four to five years of age.

BACKGROUND: Extremely preterm or extremely low birth weight (ELBW) children who are non-disabled and otherwise healthy are at risk of neurodevelopmental impairments. Further understanding of these impairments is needed before commencement of formal education to optimise participation levels at a critical time point for these children. AIMS: To explore motor co-ordination, postural stability, limb strength and behaviour of non-disabled four to five year old children with a history of extreme prematurity or ELBW. STUDY DESIGN: Prospective-descriptive-cohort-study. SUBJECTS: 50 children born at less than 28 weeks gestation or who had a birth weight less than 1000g with minimal/mild motor impairments and no significant neurological/cognitive impairments. OUTCOME MEASURES: Movement Assessment Battery for Children second-edition (MABC-2), single leg stance test (SLS), lateral reach test, standing long jump test and Child Behaviour Checklist for preschool children (CBCL). RESULTS: The mean percentile rank of the extremely preterm or ELBW sample on MABC-2 was 31% (SD 23%). SLS right (mean ± SD; 4.6 ± 2.5s) and lateral reach to the right (10.0 ± 3.9 cm) were slightly stronger than SLS left (4.4 ± 3.3s) and lateral reach left (9.9 ± 3.5 cm). The average for standing long jump was 71.6 cm (SD 21.0 cm). All participants were classified as 'normal' on CBCL syndrome scale scores, internalizing and externalizing syndrome T scores and total problem T score. CONCLUSIONS: This sample of non-disabled extremely preterm or ELBW children performed in the lower range of normal. These children continue to be at risk of impairments, therefore, ongoing monitoring and tailored intervention may optimise development.

Movement and motor development in ELBW infants at 1 year is related to cognitive and motor abilities at 4 years.

A relationship between motor ability and cognitive performance has been previously reported. This study aimed to investigate the association between movement and cognitive performance at 1 and 4 years corrected age of children born less than 1000 g, and whether developmental testing of movement at 1 year is predictive of cognitive performance at 4 years. Motor development was assessed at both ages using the neurosensory motor developmental assessment (NSMDA) and motor development was classified as normal, or minimal, mild, moderate-severe dysfunction. Cognitive performance was assessed on the Griffith Mental Developmental Scale at 1 year and McCarthy Scales of Children's Abilities at 4 years. Subjects included 198 children of birthweight less than 1000 g. Of these 132 children returned for follow-up at the corrected ages of both 1 and 4 years. The 66 children not included had a slight increase in gestational age, while the mothers were younger and had a lower level of education. A significant association was found between NSMDA group classification at 1 year and cognitive performance at both 1 and 4 years (p<0.001; p<0.0001) and between the subscales of each test (1 year, p<0.0001; 4 years, p<0.001). Group classification of motor development at 1 year was predictive of cognitive performance at 4 years (p<0.0001) and this was independent of biological and social factors and presence of cerebral palsy (CP). The findings support a close link between motor and cognitive development in children born <1000 g and emphasise the advantage of detailed assessment of movement at 1 year.

Differences in postural control and movement performance during goal directed reaching in children with developmental coordination disorder.

Poor upper-limb coordination is a common difficulty for children with developmental coordination disorder (DCD). One hypothesis is that deviant muscle timing in proximal muscle groups results in poor postural and movement control. The relationship between muscle timing, arm motion and children's upper-limb coordination deficits has not previously been studied. The aim of this study was to investigate the relationship between functional difficulties with upper-limb motor skills and neuromuscular components of postural stability and coordination. Sixty-four children aged 8-10 years, 32 with DCD and 32 without DCD, participated in the study. The study investigated timing of muscle activity and resultant arm movement during a rapid, voluntary, goal-directed arm movement. Results showed that compared to children without DCD, children with DCD took significantly longer to respond to visual signals and longer to complete the goal-directed movement. Children with DCD also demonstrated altered activity in postural muscles. In particular, shoulder muscles, except for serratus anterior, and posterior trunk muscles demonstrated early activation. Further, anterior trunk muscles demonstrated delayed activation. In children with DCD, anticipatory function was not present in three of the four anterior trunk muscles. These differences support the hypothesis that in children with DCD, altered postural muscle activity may contribute to poor proximal stability and consequently poor arm movement control when performing goal-directed movement. These results have educational and functional implications for children at school and during activities of daily living and leisure activities and for clinicians assessing and treating children with DCD.

Hand positioning sense in children with spina bifida myelomeningocele.

This study was undertaken to establish whether children with myelomeningocele have abnormal kinaesthesia of the hands. Twenty-one children with myelomeningocele and 21 control children aged between six and 12 years were involved in the study. The level of kinaesthetic awareness in the hands was measured by examining the child's ability to copy hand positions, using visual cueing and kinaesthetic cueing. Both accuracy and speed of copying hand gestures were assessed. Children with spina bifida were significantly less accurate in achieving hand positions than the control group (chi square(1) = 22.60, p < 0.001), with 73% of the children with spina bifida achieving accurate replications compared with 87% in the control group. Furthermore, children with myelomeningocele were shown to be slower than the controls (F(1,280) = 15.49, p < 0.001). The impaired kinaesthetic awareness found in this study is considered to be one of the factors behind the poor hand function observed in children with myelomeningocele.

The validity of button fastening as a test of hand disability in myotonic dystrophy.

This study evaluated the validity of testing button fastening ability as a measurement of hand disability in patients with myotonic dystrophy. Forty subjects with myotonic dystrophy were tested on their ability to fasten four shirt buttons. The association between button fastening ability, strength of selected proximal upper limb muscles and lateral pinch grip was determined. A significant association (F(4,35) = 7.55, p < 0.01) was demonstrated between proximal upper limb strength and button fastening ability, but there was no relationship with lateral pinch grip strength. Myotonia was not a factor affecting button fastening performance. Comparison of these results with those of a group of 13 subjects with other neuromuscular diseases showed button fastening disability in myotonic dystrophy could not be attributed solely to proximal upper limb weakness but is a valid measure of hand disability. A standard for normal button fastening performance was also determined.

Bronchopulmonary dysplasia: a comparative study of motor development to two years of age.

This study investigated the influence of bronchopulmonary dysplasia (BPD) on the motor development of children in the first two years of life. Sixty-four children with BPD and 53 control infants were assessed at eight months and two years corrected for prematurity using the neuro-sensory and motor development assessment (NSMDA). Results indicated a significant delay in gross motor performance of the study children at eight months. By two years, considerable catch-up had occurred, but a significant difference in postural control and balance between the study and control groups was identified. When corrected for periventricular haemorrhage and ventricular dilatation, although substantial, the difference was not statistically significant. When growth <10th centile was considered in the study infants, postural control, overall motor performance and neurological status were significantly less than in those whose growth was within normal limits.

Neuromotor behavioural assessment of preterm infants at risk for impaired development.

This study was undertaken to evaluate the effectiveness of a new neuromotor behavioural assessment in identifying preterm infants whose development was potentially at risk as a result of their early birth and immediate postnatal experiences. All infants born at less than 30 weeks gestation or who weighed less than 1000g at birth and cared for in the Mater Hospital's Neonatal Intensive Care Unit in Brisbane over a two year period were included in the study. Infants were assessed in their third week of life and again at 36 weeks gestational equivalent age, or prior to discharge, whichever occurred sooner. Results indicate that the assessment is effective in differentiating those infants who suffered from adverse neonatal events from those who did not, when assessed between 30 and 36 weeks gestational equivalent age. The assessment did not prove useful for infants of less than 30 or greater than 36 weeks gestational equivalent age.

The effect of task uncertainty on muscle activation patterns in 8-10-year-old children.

BACKGROUND AND PURPOSE: Postural muscle activity accompanying voluntary arm movements has been researched extensively in adults; however, few studies of this kind have been conducted with children. It is not clear whether children respond like adults to internal perturbations, and if so, whether this response is similar across a variety of task conditions. The aims of the present study were to determine the postural muscle activity demonstrated by 8-10-year-old children when performing a rapid shoulder flexion movement and to compare the pattern produced under simple reaction-time versus complex reaction-time conditions. METHOD: Fifteen children with typical motor development participated in this comparative design study. The activity of anterior deltoid and contralateral rectus abdominis, internal oblique, erector spinae, rectus femoris, biceps femoris, tibialis anterior and gastrocnemius muscles was recorded via surface electromyography (EMG). Two tasks were performed: a simple task involving a right shoulder flexion movement; and a complex task involving a right or left shoulder flexion movement. Reaction time (RT) and movement time (MT) of the arm action were also recorded. RESULTS: Muscle latencies in the complex task were longer than those for the simple task, although only the gastrocnemius muscle showed a significant difference (p = 0.013). Reaction time was also significantly later in the complex task (p = 0.003). Movement time was not significantly different between conditions. CONCLUSIONS: A decrease in task certainty delayed postural muscle activation and reaction time in children aged 8-10 years. The study also demonstrated that children in this age group utilized a mixed postural strategy rather than a proximal-to-distal or distal-to-proximal pattern, reported in adult studies. Movement time remained unchanged.

Goal-directed upper limb movements by children with and without DCD: a window into perceptuo-motor dysfunction?

BACKGROUND AND PURPOSE: Developmental co-ordination disorder (DCD) occurs in at least 6% of school-aged children. Researchers agree that motor co-ordination problems evident in DCD are, in part, the result of perceptual and cognitive processes, but the limited research available remains inconclusive. The present study investigated perceptual-motor abilities, with regard to vision, kinaesthesia and cross-modal judgement, in children with and without DCD. METHOD: A cross-sectional study design was used. Nine children, aged six years (+/- six months) with DCD, and nine children without DCD, matched for age and gender, participated in the study. The children were required to point with the preferred hand to a target in three different positions under four sensory conditions, either with or without vision. Three-dimensional motion analysis was used to investigate trajectory lengths, endpoint error and movement time. The results were analysed using a generalized linear mixed model to examine the systematic effects of group, target position and task. RESULTS: Compared with children without DCD, the children with DCD produced larger endpoint errors, greater movement times and longer trajectories. Children in both groups produced larger endpoint errors, greater movement times and longer trajectories in non-visually guided aiming versus visually guided aiming tasks. CONCLUSIONS: Children with DCD moved more slowly, with longer movement trajectories and were less accurate than children without DCD when aiming to all target positions under all sensory conditions. The greatest error and trajectory length occurred for both groups when aiming movements were performed in the absence of vision. As children in the DCD group had difficulties with movement executed under kinaesthetic or visual control, the results indicate that the normal advantage of vision displayed by children without DCD is not apparent, and visual and kinaesthetic problems may be present in children with DCD.

The long-term predictive validity of early motor development in "apparently normal" ELBW survivors.

BACKGROUND: Within the able majority of ELBW survivors, there is a lack of identified predictors of which children will require extra support despite having escaped significant disability. AIMS: Investigate the predictive validity of early motor scores, compared to that of perinatal descriptors or early growth, on long-term motor impairment in non-disabled ELBW (<1000g) children. STUDY DESIGN: Prospective longitudinal study. OUTCOME MEASURES: 48 non-disabled ELBW children (27 male) completed the Neurosensory Motor Developmental Assessment (NSMDA) at 8 months, 2 years and 4 years post term and The Motor Assessment Battery for Children (MABC) at 11-13 years of age. Other possible predictors of long-term outcomes (gestational age, birthweight, multiple birth, head circumference measures and gender) were retrieved from the records. RESULTS: Early motor assessment (NSMDA score) independently predicted the MABC total score at 11-13 years of age with a positive predictive value of 87% by 4 years post term. There was increased risk of long-term motor impairment associated with male gender but the degree of prematurity, multiple birth status or early growth measures did not predict motor outcome. Postural control and sensory motor scores at 4 years post term, rather than neurological score, were associated with long-term motor outcomes for the ELBW children at 11-13 years of age. CONCLUSIONS: Early motor scores are valid markers of long-term motor outcomes for "apparently normal" ELBW children. Early postural competence and sensory motor function are discriminating in regards to long-term motor function in neurologically normal ELBW children.

The influence of preparedness on rapid stepping in young and older adults.

OBJECTIVE: To investigate the influence of age and preparation level on postural muscle activation and step completion time during a rapid step task. DESIGN: Postural muscle onset times (EMG) and ground reaction forces were recorded from healthy young (n = 20, age 21 +/- 3 years) and older (n = 25, age 71 +/- 5 years) female adults during a choice reaction-time stepping paradigm. MAIN OUTCOME MEASURES: Onset times of six trunk and hip muscles, reaction time and components of the step (weight shift time, step time and task time) were recorded. RESULTS: Muscle activation was delayed and movement time was lengthened in both young and older adults when poorly prepared for a stepping task. While reduced preparation did not influence older adults to a greater extent than young adults, the slowest step response and completion time was evident in older adults when poorly prepared to move. CONCLUSIONS: A late postural response when poorly prepared to move may be a contributing factor to an increased risk of overbalancing in older adults. Future assessment of and intervention to improve postural stability in older adults should be expanded to incorporate tasks performed at various levels of preparation.