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.

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.

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.

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.