Goal-directed therapeutic exercise for paediatric posterior fossa brain tumour survivors: a qualitative analysis of experiences.

PURPOSE: To explore child and parent experiences of a 12-week goal-directed therapeutic exercise intervention in paediatric posterior fossa brain tumours survivors and to identify features of the program that influenced program adherence and acceptability. METHODS: Eleven interviews were conducted; five parent-child dyads (mothers = 83%) and one parent only (mean child age = 10.6 ± 3.0 years; 83% male). Posterior fossa brain tumour survivors, who participated in a weekly goal-directed exercise program for 12 weeks, completed semi-structured interviews to discuss their experience of the program. An inductive content analysis was undertaken. Interviews were transcribed, imported into NVivo and independently coded by two reviewers. Code and content categories were iteratively discussed and refined. RESULTS: Five content categories were generated: (1) perceived improvements, (2) program logistics, (3) activity selection, (4) connection with the therapist and (5) options for technology. All participants valued the tailored exercise program and described improvements in movement competence. Children and their parents discussed preferring home- and community-based locations and favoured face-to-face delivery. Occasionally, parents reported difficulty completing the home program due to low child motivation or family time restrictions. Multiple families suggested an interactive digital application would be an effective delivery channel for the supplemental home-based program. CONCLUSION: A goal-directed exercise program delivered at home and in community-based locations was considered valuable and helpful for improving movement competence in paediatric survivors of posterior fossa brain tumour. TRIAL REGISTRATION: ACTRN12619000841178 June 12, 2019.

Diagnostic accuracy of the Hammersmith Neonatal Neurological Examination in predicting motor outcome at 12 months for infants born very preterm.

AIM: To evaluate the predictive validity of the Hammersmith Neonatal Neurological Examination (HNNE) performed early (at 32 weeks postmenstrual age) and at term-equivalent age (TEA) for 12-month motor outcomes in infants born very preterm. METHOD: This was a diagnostic study using data from a prospective birth cohort. A total of 104 infants born preterm at less than 31 weeks gestational age (males n = 61; mean = 28 weeks 1 day [SD 1 week 6 days], range 23 weeks 1 day-30 weeks 6 days) underwent HNNE early and at TEA, which were scored by comparison with term data. Motor outcomes at 12 months corrected age were determined using the Bayley Scales of Infant and Toddler Development, Third Edition (scores ≤85). Cut-off points were determined using receiver operating characteristic curves. RESULTS: Sixteen (15%) infants born preterm had motor impairment at 12 months corrected age. The HNNE total score cut-off points with the best combination of sensitivity and specificity at early and TEA assessments were 15.2 or lower (sensitivity 77%, 95% confidence interval [CI] = 46%-95%; specificity 74%, 95% CI = 63%-83%) and 23.5 or lower (sensitivity 67%, 95% CI = 38%-88%; specificity 66%, 95% CI = 54%-76%) respectively. The most predictive subscale at the early assessment was reflexes (sensitivity 86%, 95% CI = 57%-98%; specificity 62%, 95% CI = 51%-72%; cut-off point ≤3); at TEA, it was spontaneous movements (sensitivity 73%, 95% CI = 45%-92%; specificity 60%, 95% CI = 48%-70%; cut-off point ≤2). INTERPRETATION: The HNNE provides moderate predictive accuracy for motor outcome at 12 months corrected age in infants born very preterm. Although modest at both time points, early assessment had stronger predictive ability for motor outcomes than TEA when scored using term data, highlighting the value of performing the HNNE earlier in the neonatal period. Performing HNNE earlier may assist risk stratification when planning follow-up services.

Neurological examination at 32-weeks postmenstrual age predicts 12-month cognitive outcomes in very preterm-born infants.

BACKGROUND: To determine the diagnostic accuracy of Hammersmith Neonatal Neurological Examination (HNNE) at 30-32 weeks postmenstrual age (PMA, 'Early') and term equivalent age (TEA) in infants born <31 weeks PMA to predict cognitive outcomes at 12 months corrected age (CA). METHODS: Prospective cohort study of 119 infants (73 males; median 28.4 weeks gestational age at birth) who underwent Early and TEA HNNE. At 12 months CA, 104 participants completed Bayley Scales of Infant and Toddler Development, 3rd Edition, (Bayley-III). Optimum cut-off points for each HNNE subscale were determined to establish diagnostic accuracy for predicting adverse cognitive outcomes on the Bayley-III Cognitive Composite Scale (≤85). RESULTS: The best diagnostic accuracy for HNNE total score at 30-32 weeks PMA predicting cognitive impairment occurred at cut-off ≤16.7 (sensitivity (Se) = 71%, specificity (Sp) = 51%). The Abnormal Signs subscale demonstrated the best balance of sensitivity/specificity combination (Se = 71%, Sp = 71%; cut-off ≤1.5). For HNNE at TEA, the total score at cut-off ≤24.5 had Se = 71% and Sp = 47% for predicting cognitive impairment. The Tone Patterns subscale demonstrated the strongest diagnostic accuracy at TEA (Se = 71%, Sp = 63%; cut-off ≤3). CONCLUSIONS: Early and TEA HNNE demonstrated moderate diagnostic accuracy for cognitive outcomes at 12-months CA in infants born <31 weeks gestational age. CLINICAL TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry; Trial Registration Number: ACTRN12613000280707; web address of trial: http://www.ANZCTR.org.au/ACTRN12613000280707.aspx . IMPACT: Early Hammersmith Neonatal Neurological Examination (HNNE) assessment at 30-32 weeks postmenstrual age has moderate diagnostic accuracy for cognitive outcomes at 12 months corrected age in infants born <31 weeks gestation. Early HNNE at 30-32 weeks has stronger predictive validity than HNNE at term equivalent age. Early HNNE may provide an early marker for risk-stratification to optimise the planning of post-discharge support and follow-up services for infants born preterm.

Therapeutic exercise interventions in pediatric survivors of brain cancer and other solid tumors: A scoping review.

Background: Improved survival rates for children with solid tumors presents an ongoing challenge of how to maximize quality of survivorship and effectively manage the short- and long-term complications of disease and treatment. To gain an understanding of the extent and nature of research pertaining to therapeutic exercise interventions and identify knowledge gaps, we conducted a scoping review of exercise training studies conducted in pediatric survivors of brain cancer and other solid tumors. Method: A systematic literature search was performed across four electronic databases. Papers were selected for full-text review if they included participants treated for brain cancer or other solid tumors, with at least 50% of participants aged ≤ 21 years, evaluated an exercise intervention ≥2-weeks in duration, and were published in an English, peer-reviewed journal. We included the following quantitative study designs; randomized controlled trials, non-randomized trials, and single-arm pre-test-post-test. Results: Of the 7,482 citations identified, 17 papers met the inclusion criteria (presenting findings from eleven studies). Two studies were randomized controlled trials, five studies were non-randomized controlled trials, and four studies were a single-arm pre-test post-test design. Average age of participants ranged from 7.3-15.5 years, and time since diagnosis ranged from 3 to 70 months. Five studies included participants with brain tumors exclusively, three studies included other solid tumors, and three studies included a mixed sample (brain and other solid tumors). A wide range of exercise modalities were employed, including cycle ergometry, resistance training, sport, yoga, and active gaming. The length of the exercise program ranged from 3-40 weeks and frequency from 3-11 sessions per week. Exercise session duration ranged from 15-180 min, with most studies reporting 30-90-min sessions. Adherence ranged from 77 to 100%, with none of the studies reporting adverse events. Studies reported improvements in cardiorespiratory fitness, functional strength, physical activity, and quality of life. Conclusions: A small number of mostly low methodological quality studies have examined the effects of therapeutic exercise in pediatric survivors of solid tumors. Although limited, the extant literature supports the feasibility and safety of therapeutic exercise interventions for pediatric survivors of brain cancer and other solid tumors.

Barriers and facilitators of physical activity in children with bronchiectasis: Perspectives from children and parents.

Background: Current bronchiectasis management guidelines recommend regular physical activity but a large proportion of children with bronchiectasis do not meet public health recommendations which call for 60 min or more of moderate-to-vigorous intensity physical activity daily. Knowing the factors that influence physical activity in children with bronchiectasis is necessary for the development of effective interventions to increase physical activity in this patient group. The objective of this study was to identify facilitators and barriers to physical activity in children with bronchiectasis unrelated to cystic fibrosis (CF) from the perspectives of children and their parents. Materials and methods: This was a qualitative study informed by the theoretical domains framework (TDF). Children aged 7-15 years (8.8 years, 8.4-11.0) (median, interquartile range) and parents (45.8 years, 39.7-48.3) completed separate, semi-structured interviews (n = 21). Recordings were transcribed verbatim, and barriers and facilitators related to each TDF domain deductively coded. Emergent themes were inductively derived via consensus moderation. Results: From the perspectives of children, fun with friends, organized sport and activities, and family co-participation in physical activity emerged as facilitators. Inability to keep up with their peers and time on technology emerged as barriers. From the perspectives of parents, instrumental and logistic support for physical activity and supportive social and physical activity environments emerged as facilitators, while management of symptoms associated with bronchiectasis emerged as a barrier. Conclusion: Programs to increase physical activity in children with bronchiectasis should be fun, accessible, provide opportunities for social interaction and address barriers related to exercise tolerance, perceived competence, and presence of respiratory symptoms.

International Delphi Recommendations for Pediatric Lower Limb Neurological Test Protocols for Muscle Strength, Reflexes, and Tactile Sensitivity.

PURPOSE: To gain consensus from physical therapists on pediatric lower limb neurological tests of muscle strength, tactile sensitivity, and reflexes. METHODS: A Delphi technique was used for 2 sequential questionnaire rounds to gain consensus from a panel of pediatric physical therapists (n = 28). Physical therapists rated their agreement to items from statements on pediatric lower limb neurological tests, their protocols, and interpretation using a 6-point Likert scale. RESULTS: Ninety percent of items gained consensus: 80% on pediatric lower limb neurological tests, 88% on test protocols, and 92% on test interpretation. Fifty-one percent of items had high agreement and high importance. CONCLUSION: There is variability in pediatric neurological tests used, their protocols, and interpretation. Identification of items with high agreement and importance is the first step to develop a standardized lower limb neurological assessment for pediatric clients of varying ages and diagnoses.

Thinking beyond impairment: Recommendations from contemporary models of care for working with children and disability.

BACKGROUND: The National Disability Insurance Scheme emphasises the use of models that move beyond an impairment focus to a holistic and individualised approach to disability. Application of specific biopsychosocial models supports general practitioners (GPs) to advance best practice in disability care within these schemes by meeting the complex care needs of their clients. OBJECTIVE: The aims of this article are to: 1) review current biopsychosocial models that underpin the health and functioning of children living with a disability in order to identify common elements of relevance to the paediatric sector, and 2) provide considerations for applying a biopsychosocial approach to paediatric care in practice. DISCUSSION: A succinct summary of common concepts within biopsychosocial models used in the paediatric setting, and recommendations for how these models can be best applied in practice, are presented in this article. The GP plays a crucial part in initiating and supporting children and adolescents who have complex care needs. Understanding these key concepts is fundamental to this process.

Bronchiectasis - Exercise as Therapy (BREATH): rationale and study protocol for a multi-center randomized controlled trial.

BACKGROUND: Globally, bronchiectasis (BE) unrelated to cystic fibrosis (CF) is recognized as a major cause of respiratory morbidity, mortality, and healthcare utilization. Children with BE regularly experience exacerbations of their condition resulting in frequent hospitalizations and decreased health-related quality of life (HR-QoL). Guidelines for the treatment and management of BE call for regular exercise as a means of improving aerobic fitness and HR-QoL. Moreover, research in adults with BE has shown that exercise can reduce the frequency of exacerbations, a potent predictor of future lung function decline and respiratory morbidity. Yet, to date, the health benefits resulting from therapeutic exercise have not been investigated in children with BE. The BREATH, Bronchiectasis - Exercise as Therapy, trial will test the efficacy of a novel 8-week, play-based therapeutic exercise program to reduce the frequency of acute exacerbations over 12 months in children with BE (aged ≥ 4 and < 13 years). Secondary aims are to determine the cost-effectiveness of the intervention and assess the program's impact on aerobic fitness, fundamental movement skill (FMS) proficiency, habitual physical activity, HR-QoL, and lung function. METHODS: This multi-center, observer-blinded, parallel-group (1:1 allocation), randomized controlled trial (RCT) will be conducted at three sites. One hundred and seventy-four children ≥ 4 and < 13 years of age with BE will be randomized to a developmentally appropriate, play-based therapeutic exercise program (eight, 60-min weekly sessions, supplemented by a home-based program) or usual care. After completing the baseline assessments, the number of exacerbations and secondary outcomes will be assessed immediately post-intervention, after 6 months of follow-up, and after 12 months of follow-up. Monthly, parental contact and medical review will document acute respiratory exacerbations and parameters for cost-effectiveness outcomes. DISCUSSION: The BREATH trial is the first fully powered RCT to test the effects of a therapeutic exercise on exacerbation frequency, fitness, movement competence, and HR-QoL in children with bronchiectasis. By implementing a developmentally appropriate, play-based exercise program tailored to the individual needs of children with bronchiectasis, the results have the potential for a major paradigm shift in the way in which therapeutic exercise is prescribed and implemented in children with chronic respiratory conditions. The exercise program can be readily translated. It does not require expensive equipment and can be delivered in a variety of settings, including the participant's home. The program has strong potential for translation to other pediatric patient groups with similar needs for exercise therapy, including those with obesity, childhood cancers, and neurological conditions such as cerebral palsy. TRIAL REGISTRATION: Australian and New Zealand Clinical Trials Register (ANZCTR) ACTRN12619001008112.

Physical ACTivity in Survivorship (PACTS): study protocol for a randomized controlled trial evaluating a goal-directed therapeutic exercise program in pediatric posterior fossa brain tumor survivors.

BACKGROUND: Posterior fossa brain tumors (PFBT) are the most common solid tumor in children. Recent increases in survival rates are encouraging; however, survivors may experience a plethora of disease- and treatment-related complications that can persist into adulthood. Therapeutic exercise interventions have been shown to improve quality of survivorship in other pediatric cancer diagnoses. There is also evidence that goal-directed interventions are effective at improving motor activities, function, and self-care in children with complex health conditions. Yet, there is currently no evidence on the efficacy of goal-directed therapeutic exercise in pediatric PFBT survivors. The Physical ACTivity in Survivorship (PACTS) study aims to investigate the effects of a novel goal-directed therapeutic exercise program on cardiorespiratory fitness and physical activity-related goal attainment in pediatric survivors of PFBT. METHOD: PFBT survivors, aged five to 17 years, who underwent surgery at least 12 months earlier and completed radiation therapy and/or chemotherapy at least 6 months prior will be recruited from the Queensland Children's Hospital (Brisbane, Australia) (target n = 48). Following baseline assessment, participants are randomized into either the intervention or usual care group. The intervention group will receive weekly individualized, goal-directed exercise therapy delivered face-to-face for 12 weeks, along with an accompanying home-based program (three sessions per week). Outcomes will be assessed at baseline, immediately post-intervention, and at 6- and 12-months post-intervention. The primary outcomes are cardiorespiratory fitness (Peak VO2) and physical activity-related goal attainment. Secondary outcomes are cardiorespiratory endurance, high-level mobility skills, functional muscle strength, habitual physical activity, gait, balance, quality of life, fatigue, participation, perceived movement skill competence and parameters of body composition. DISCUSSION: PACTS is the first study to investigate the efficacy of goal-directed therapeutic exercise in children with PFBT and provide evidence needed to inform clinical practice recommendations for managing quality of survivorship in PFBT survivors. TRIAL REGISTRATION: ACTRN12619000841178 .

Perceived Barriers, Enablers, and Modifications to Tests Assessing Pediatric Lower Limb Neurological Impairment: An International Delphi Survey.

OBJECTIVES: Accurate, clinically meaningful outcome measures that are responsive to change are essential for selecting interventions and assessing their effects. Little guidance exists on the selection and administration of neurological impairment tests in children with a neurological condition. Clinicians therefore frequently modify adult assessments for use in children, yet the literature is inconsistent. This study aims to establish consensus on neurological conditions most likely to require neurological impairment test in pediatrics and the barriers, enablers, and modifications perceived to enhance test reliability. METHODS: Over a 2-round modified Delphi study, a panel of experts (n = 24) identified neurological conditions perceived to typically require pediatric neurological testing and the modifications to address barriers/enablers to testing. Experts comprised physical therapists with evidence of advanced training or research in pediatrics. Using a 6-point Likert scale (6 = strongly agree, 5 = agree, 4 = somewhat agree, 3 = somewhat disagree, 2 = disagree, 1 = strongly disagree), experts rated statements from existing literature. Thematic analyses were conducted on responses to open-ended questions. A priori consensus was pre-set at 65% agreement/disagreement. Median, mode, and interquartile ranges estimated perceived importance. Cessation was pre-determined by non-consensus items <10% and panel fatigue. RESULTS: Experts reached consensus on 107/112 (96%) items, including identifying 25/26 (96%) neurological conditions they perceived to require routine neurological testing. Experts strongly agreed with high importance that appropriately trained, experienced therapists are less variable when testing children. Communication modifications were perceived as most important. CONCLUSION: High levels of consensus support the use of lower limb neurological testing in a range of pediatric neurological conditions. Trained clinicians should document modifications such as visual aid use. Using recommended modifications could encourage consistency among clinicians. IMPACT: This is the first study to our knowledge to identify the barriers and enablers to pediatric neurological testing. Barriers and enablers were partially addressed through suggested modifications. Further rigorous examination of these modifications is required to support their use. LAY SUMMARY: This study supports that clinicians should adapt their communication for children and young people with neurological problems to include visual aids and equipment demonstration.

A Survey of Pediatric Competencies in Entry-Level Physical Therapy Programs in Australia.

PURPOSE: To describe perspectives of pediatric physical therapy clinical facilitators on contemporary curricula for Australian entry-level physical therapy programs. METHODS: Physical therapy clinical facilitators completed an online survey based on the Academy of Pediatric Physical Therapy of the APTA essential competencies. RESULTS: Conditions including cerebral palsy, cystic fibrosis, and prematurity were highly rated by most participants to include in an entry-level program. Exercise prescription, goal-directed training, and group-based physical therapy were the highest rated interventions. Outcome measures considered important to include were the Alberta Infant Motor Scale and Goal Attainment Scale. Students should demonstrate knowledge and skills using relevant frameworks and have practical opportunities to interact with children. CONCLUSION: Pediatric clinical facilitators perceived that theoretical knowledge on frameworks, human development, movement skills, pediatric conditions, exercise prescription, and outcome measurement as well as face-to-face experiences with children are important to include in Australian entry-level physical therapy programs.

Machine Learning to Quantify Physical Activity in Children with Cerebral Palsy: Comparison of Group, Group-Personalized, and Fully-Personalized Activity Classification Models.

Pattern recognition methodologies, such as those utilizing machine learning (ML) approaches, have the potential to improve the accuracy and versatility of accelerometer-based assessments of physical activity (PA). Children with cerebral palsy (CP) exhibit significant heterogeneity in relation to impairment and activity limitations; however, studies conducted to date have implemented "one-size fits all" group (G) models. Group-personalized (GP) models specific to the Gross Motor Function Classification (GMFCS) level and fully-personalized (FP) models trained on individual data may provide more accurate assessments of PA; however, these approaches have not been investigated in children with CP. In this study, 38 children classified at GMFCS I to III completed laboratory trials and a simulated free-living protocol while wearing an ActiGraph GT3X+ on the wrist, hip, and ankle. Activities were classified as sedentary, standing utilitarian movements, or walking. In the cross-validation, FP random forest classifiers (99.0-99.3%) exhibited a significantly higher accuracy than G (80.9-94.7%) and GP classifiers (78.7-94.1%), with the largest differential observed in children at GMFCS III. When evaluated under free-living conditions, all model types exhibited significant declines in accuracy, with FP models outperforming G and GP models in GMFCS levels I and II, but not III. Future studies should evaluate the comparative accuracy of personalized models trained on free-living accelerometer data.

Machine learning to quantify habitual physical activity in children with cerebral palsy.

AIM: To investigate whether activity-monitors and machine learning models could provide accurate information about physical activity performed by children and adolescents with cerebral palsy (CP) who use mobility aids for ambulation. METHOD: Eleven participants (mean age 11y [SD 3y]; six females, five males) classified in Gross Motor Function Classification System (GMFCS) levels III and IV, completed six physical activity trials wearing a tri-axial accelerometer on the wrist, hip, and thigh. Trials included supine rest, upper-limb task, walking, wheelchair propulsion, and cycling. Three supervised learning algorithms (decision tree, support vector machine [SVM], random forest) were trained on features in the raw-acceleration signal. Model-performance was evaluated using leave-one-subject-out cross-validation accuracy. RESULTS: Cross-validation accuracy for the single-placement models ranged from 59% to 79%, with the best performance achieved by the random forest wrist model (79%). Combining features from two or more accelerometer placements significantly improved classification accuracy. The random forest wrist and hip model achieved an overall accuracy of 92%, while the SVM wrist, hip, and thigh model achieved an overall accuracy of 90%. INTERPRETATION: Models trained on features in the raw-acceleration signal may provide accurate recognition of clinically relevant physical activity behaviours in children and adolescents with CP who use mobility aids for ambulation in a controlled setting. WHAT THIS PAPER ADDS: Machine learning may assist clinicians in evaluating the efficacy of surgical and therapy-based interventions. Machine learning may help researchers better understand the short- and long-term benefits of physical activity for children with more severe motor impairments.

Validity of Accelerometry to Measure Physical Activity Intensity in Children With an Acquired Brain Injury.

PURPOSE: To evaluate the validity of the ActiGraph accelerometer (AG) to differentiate between standardized, physical activity tasks using oxygen consumption ((Equation is included in full-text article.)O2) as the criterion measure in children and adolescents with an acquired brain injury; to determine vector magnitude activity intensity cut-points; to compare performance of cut-points to previously published cut-points. METHODS: Twenty-seven children performed standardized walking and stepping activities wearing a portable indirect calorimeter, AG, and heart rate monitor. Differences in (Equation is included in full-text article.)O2 and AG vector magnitude activity counts were measured during activities. Receiver operating characteristic curves were determined for intensity cut-points. RESULTS: (Equation is included in full-text article.)O2 and AG activity counts significantly increased as walking speed increased. Discrimination of the newly derived cut-points was excellent and demonstrated greater agreement compared with the previously published cut-points. CONCLUSION: Output from accelerometers can differentiate physical activity intensity in children with an acquired brain injury. Future studies can apply these cut-points to evaluate physical activity performance.

Characteristics associated with physical activity capacity and performance in children and adolescents with an acquired brain injury.

AIM: To examine characteristics associated with physical activity capacity and performance in children with acquired brain injury (ABI). METHODS: 58 children (32 men; age 11 years 11 months ± 2 years 6 months; Gross motor function classification system [GMFCS] equivalent I = 29, II = 29) >12 months post ABI were recruited. Physical activity capacity measures included: (i) combined score of three 30-second repetition maximum functional strength exercises; (ii) timed up and go; (iii) 6-minute walk test and (iv) high-level mobility assessment tool (HiMAT). Physical activity performance determined time spent in sedentary, light and moderate to vigorous physical activity (MVPA). Full scale intelligence quotient (FSIQ) was assessed using the Wechsler intelligence scale for Children-IV. Regression models were constructed with functional strength score (n = 56), activity counts/minutes and time spent in MVPA and sedentary (n = 37). RESULTS: The HiMAT and FSIQ explained 69% of the variance in functional strength. Age explained 12% of the variance in counts/min and 14% of the variance in time spent sedentary. GMFCS explained 10% of the variance in time spent in MVPA. CONCLUSIONS: The ability to perform functional strength exercises is associated with mobility beyond independence and adequate intellectual ability for children with ABI. Age was the most significant factor associated with physical activity performance, and interventions should target adolescents with ABI.

Randomized controlled trial of web-based multimodal therapy for children with acquired brain injury to improve gross motor capacity and performance.

OBJECTIVE: To compare efficacy of a web-based multimodal training programme, 'Move it to improve it' (MitiiTM), to usual care on gross motor capacity and performance for children with an acquired brain injury. DESIGN: Randomized waitlist controlled trial. SETTING: Home environment. PARTICIPANTS: A total of 60 independently ambulant children (30 in each group), minimum 12 months post-acquired brain injury were recruited and randomly allocated to receive either 20 weeks of MitiiTM training (30 minutes/day, six days/week, total 60 hours) immediately, or waitlisted (usual care control group) for 20 weeks. A total of 58 children completed baseline assessments (32 males; age 11 years 11 months ± 2 years 6 months; Gross Motor Function Classification System equivalent I = 29, II = 29). INTERVENTION: The MitiiTM program comprised of gross motor, upper limb and visual perception/cognitive activities. MAIN MEASURES: The primary outcome was 30-second, repetition maximum functional strength tests for the lower limb (sit-to-stand, step-ups, half-kneel to stand). Secondary outcomes were the 6-minute walk test, High-level Mobility Assessment Tool, Timed Up and Go Test and habitual physical activity as captured by four-day accelerometry. RESULTS: Groups were equivalent at baseline on demographic and clinical measures. The MitiiTM group demonstrated significantly greater improvements on combined score of functional strength tests (mean difference 10.19 repetitions; 95% confidence interval, 3.26-17.11; p = 0.006) compared with the control group. There were no other between-group differences on secondary outcomes. CONCLUSION: Although the MitiiTM programme demonstrated statistically significant improvements in the functional strength tests of the lower limb, results did not exceed the minimum detectable change and cannot be considered clinically relevant for children with an acquired brain injury. CLINICAL TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registration Number, ANZCTR12613000403730.

Reproducibility in measuring physical activity in children and adolescents with an acquired brain injury.

AIM: To examine the reproducibility in measurement of physical activity performance using the ActiGraph® GT3X+ accelerometer in children aged 8-16 years with Acquired Brain Injury (ABI). METHODS: Reproducibility of standardized tasks: Thirty-two children with ABI (12 years 1 month, SD = 2 years 4 months; 20 males; Gross Motor Function Classification System I = 17, II = 15) performed the following activities on 2 consecutive days while wearing an accelerometer and a heart rate monitor: quiet sitting, slow walking (SW), moderate walking (MW), fast walking (FW) and rapid stepping on/off a block (STEP). Intra-class correlation coefficients (ICC) were calculated. Performance variability: Fifty-one participants (12 years 1 month, SD = 2 years 5 months; 27 males; GMFCS I = 26, II = 25) wore an accelerometer for 4 days in the community and reliability coefficients were calculated using standardized 12-hour time spent in moderate-to-vigorous physical activity (MVPA). RESULTS: Test-re-test reproducibility was excellent for all activities (SW, ICC = 0.90; MW, ICC = 0.83; FW, ICC = 0.91; STEP, ICC = 0.89). Three days of monitoring produced excellent variability estimates of MVPA (R = 0.78). CONCLUSION: Therapists can confidently use accelerometry as a reproducible measure of physical activity under standardized walking and stepping conditions, as well as in the community for children with ABI.

Test-re-test reproducibility of activity capacity measures for children with an acquired brain injury.

OBJECTIVE: To determine test-re-test reproducibility of the Timed Up & Go (TUG) test, 30-second repetition maximum (repmax) of functional exercises, 6-Minute Walk Test (6MWT) and High-level Mobility Assessment Tool (HiMAT) in children with Acquired Brain Injury (ABI). Secondarily, to assess the accuracy between hand-timed and video-timed scores for the TUG test and HiMAT. METHODS: Thirty children at least 1 year post-ABI (mean age at assessment = 11 years 11 months, SD = 2 years 4 months; 14 males; Gross Motor Function Classification Scale I = 17, II = 13) were assessed twice. Intra-class correlation coefficients (ICC), standard error of measurement and minimum detectable change (MDC) were determined. The Bland-Altman method and 95% limits of agreement (LOA) were used to assess the agreement between hand and video-timed TUG test and HiMAT scores. RESULTS: Test-re-test reproducibility was acceptable for the TUG test (ICC = 0.92; MDC = 1.2s); repmax of functional exercises (ICC = 0.84-0.98; MDC = 4-8 reps); 6MWT (ICC = 0.90; MDC = 69.38 m) and HiMAT (ICC = 0.98; MDC = 6). Comparison of hand and video scores for the TUG test and HiMAT demonstrated a mean difference of 0.23 (LOA = -0.3-0.7) and -0.07 (LOA = -1.99-1.85), respectively. Conclusions Test-re-test reproducibility of lower limb activity capacity measures in children with ABI are acceptable. The MDC scores provide a useful reference to interpret treatment effectiveness. Video timing was more accurate than hand-timing for the TUG test.

Systematic review of physiotherapy interventions to improve gross motor capacity and performance in children and adolescents with an acquired brain injury.

AIM: To systematically review the efficacy of physiotherapy interventions to improve gross motor capacity, performance and societal participation in children aged 5-17 years with an acquired brain injury (ABI). METHODS: Randomized and non-randomized controlled trials, cohort, case series, case-control and case studies were included and classified according to grades of evidence. Methodological quality of studies was assessed using the Downs and Black (D&B) scale and quantitative data was analysed using effect sizes. RESULTS: Two home-based studies investigated functional strength training (one randomized controlled trial, n = 20, level 2b, D&B = 16/32 and one non-randomized self-control study, n = 19, level 4, D&B = 15/32). Four studies evaluated virtual reality including: one pilot study, n = 50, level 4, D&B = 22/32; one single-subject, non-concurrent, randomized multiple baseline study, n = 3, level 4, D&B = 15/32; one case series study, n = 2, level 4, D&B = 15/32; one case study, n = 1, level 4, D&B = 15/32. Effect sizes for the randomized controlled trial ranged between 0.30-1.29 for the Functional Reach and Timed Up and Go outcome measures. CONCLUSION: There is preliminary evidence to support the efficacy of physiotherapy interventions to improve gross motor outcomes in children with an ABI. Both functional strength training and virtual-reality based therapy are potential treatment options for clinicians to prescribe in either home or clinical settings.

Mitii™ ABI: study protocol of a randomised controlled trial of a web-based multi-modal training program for children and adolescents with an Acquired Brain Injury (ABI).

BACKGROUND: Acquired brain injury (ABI) refers to multiple disabilities arising from damage to the brain acquired after birth. Children with an ABI may experience physical, cognitive, social and emotional-behavioural impairments which can impact their ability to participate in activities of daily living (ADL). Recent developments in technology have led to the emergence of internet-delivered therapy programs. "Move it to improve it" (Mitii™) is a web-based multi-modal therapy that comprises upper limb (UL) and cognitive training within the context of meaningful physical activity. The proposed study aims to compare the efficacy of Mitii™ to usual care to improve ADL motor and processing skills, gross motor capacity, UL and executive functioning in a randomised waitlist controlled trial. METHODS/DESIGN: Sixty independently ambulant children (30 in each group) at least 12 months post ABI will be recruited to participate in this trial. Children will be matched in pairs at baseline and randomly allocated to receive either 20 weeks of Mitii™ training (30 min per day, six days a week, with a potential total dose of 60 h) immediately, or be waitlisted for 20 weeks. Outcomes will be assessed at baseline, immediately post-intervention and at 20 weeks post-intervention. The primary outcomes will be the Assessment of Motor and Process Skills and 30 s repetition maximum of functional strength exercises (sit-to-stand, step-ups and half kneel to stand). Measures of body structure and functions, activity, participation and quality of life will assess the efficacy of Mitii™ across all domains of the International Classification of Functioning, Disability and Health framework. A subset of children will undertake three tesla (3T) magnetic resonance imaging scans to evaluate functional neurovascular changes, structural imaging, diffusion imaging and resting state functional connectivity before and after intervention. DISCUSSION: Mitii™ provides an alternative approach to deliver intensive therapy for children with an ABI in the convenience of the home environment. If Mitii™ is found to be effective, it may offer an accessible and inexpensive intervention option to increase therapy dose. TRIAL REGISTRATION: ANZCTR12613000403730.