Measuring Upper Extremity Activity of Children With Unilateral Cerebral Palsy Using Wrist-Worn Accelerometers: A Pilot Study.

IMPORTANCE: Children with unilateral cerebral palsy (UCP) have poor strength and movement control on one side of their body, leading to impaired bimanual coordination skills. OBJECTIVE: To compare duration and intensity of all-day habitual movement of the dominant and nondominant upper extremities (UEs) in typically developing (TD) children and children with UCP. DESIGN: Two-group observational study. SETTING: Children's naturalistic settings. PARTICIPANTS: Convenience sample of 9 TD children and 9 children with UCP. INTERVENTION: Children wore accelerometers on both wrists all day and night for 1 wk. OUTCOMES AND MEASURES: We compared the extent of asymmetry in bilateral arm use (intensity and duration) between the 2 groups. RESULTS: Compared with TD children who use both UEs equally, children with UCP were more likely to use their dominant or unaffected UE than their nondominant or affected UE during daily activities. There were no differences between groups in dominant UE activity. However, children with UCP engaged in lower levels of moderate to vigorous activity and greater levels of light activity with their nondominant or affected UE than their TD peers. CONCLUSIONS AND RELEVANCE: Wrist-worn accelerometry can provide objective information on real-world habitual activity with both arms in children. Accelerometers are nonintrusive, easy to use, and well tolerated by children, and they allow prolonged monitoring of UE activity outside therapeutic contexts. Occupational therapists can use wrist-worn accelerometers as sensitive tools to assess asymmetries in UE use at baseline and as an outcome measure to assess the efficacy of behavioral interventions and carryover into real-world settings among children with UCP. Plain-Language Summary: This pilot study provides promising evidence that supports the use of wrist-worn accelerometry as an accurate, easy-to-use, and objective assessment tool for children with unilateral cerebral palsy (UCP) to detect asymmetries in bilateral real-world arm activity at baseline and after intensive occupational therapy interventions to improve arm function. The authors used wrist-worn accelerometry for one week with 9 typically developing (TD) children and 9 children with UCP to compare dominant or unaffected versus nondominant or affected upper extremity (UE) use for intensity and duration of activity. Compared with TD children, children with UCP had lower relative intensity of activity in the nondominant UE than the dominant UE. Wrist-worn accelerometers seem to be a sensitive measure to detect asymmetries in bilateral all-day UE use in children with UCP. The findings have implications for the use of wrist-worn accelerometers as an outcome measure to assess the efficacy of intensive therapies to improve real-world affected UE activity and bimanual function among children with UCP.

Outcomes Associated with a Single Joystick-Operated Ride-on-Toy Navigation Training Incorporated into a Constraint-Induced Movement Therapy Program: A Pilot Feasibility Study.

Our research aims to evaluate the utility of joystick-operated ride-on-toys (ROTs) as therapeutic adjuncts to improve upper extremity (UE) function in children with hemiplegic cerebral palsy (HCP). This study assessed changes in affected UE use and function following a three-week ROT navigation training incorporated into an existing constraint-induced movement therapy (CIMT) camp in 11 children (3-14 years old) with HCP. We report changes in scores on the standardized Shriners Hospital Upper Extremity Evaluation (SHUEE) from pretest-to-posttest and changes from early-to-late sessions in percent time spent by the affected arm in: (a) "moderate-to-vigorous activity", "light activity" and "no activity" bouts based on accelerometer data and (b) "independent", "assisted", and "no activity" bouts based on video data. We also explored relationships between standardized measures and training-specific measures of affected UE activity. We found small-to-medium improvements in the SHUEE scores. Between 90 and 100% of children also showed medium-to-large improvements in affected UE activity from early-to-late sessions using accelerometers and small improvements via video-based assessments. Exploratory analyses suggested trends for relationships between pretest-posttest and training-specific objective and subjective measures of arm use and function. Our pilot data suggest that single joystick-operated ROTs may serve as motivating, child-friendly tools that can augment conventional therapies such as CIMT to boost treatment dosing, promote affected UE movement practice during real-world navigation tasks, and ultimately improve functional outcomes in children with HCP.

Feasibility of Using Joystick-Operated Ride-on-Toys to Promote Upper Extremity Function in Children With Cerebral Palsy: A Pilot Study.

PURPOSE: To evaluate the feasibility of implementation, acceptance, and perceived efficacy of a joystick-operated ride-on-toy intervention to promote upper extremity (UE) function in 3- to 14-year-old children with hemiplegic cerebral palsy. METHODS: Exit questionnaires were collected from children, caregivers, and clinicians/camp staff following a 3-week ride-on-toy training program incorporated within a summer camp for children with hemiplegic cerebral palsy. Training encouraged children to use their affected UE to maneuver the ride-on-toy. Questionnaires included Likert scale and open-ended questions to assess enjoyment, acceptance, feasibility, and perceived efficacy of the training. RESULTS: All stakeholder groups indicated that the training was enjoyable. Clinicians/staff and caregivers indicated that the training increased children's motivation to use their affected UE and reported perceived improvements in UE movement control and function following training. CONCLUSIONS: Our promising preliminary findings call for future research to systematically assess the efficacy of ride-on-toys to promote UE control and function in children with hemiplegic cerebral palsy.Supplemental Digital Content 1 video abstract, available at: http://links.lww.com/PPT/A404.

Balance and Functional Outcomes for Older Community-Dwelling Adults Who Practice Tai Chi and Those Who Do Not: A Comparative Study.

BACKGROUND AND PURPOSE: A growing body of literature substantiates that Tai Chi is a form of exercise that may help older adults increase strength, improve balance, lower fall rates, and experience less fear of falling. Few studies, however, offer controlled experimental design and simultaneously investigate multiple factors known to contribute to fall risk. The purpose of this study was to compare performance on measures relating to fall risk (strength, balance, functional mobility, and fear of falling) in older community-dwelling adults who participated in a community-based Tai Chi program with a control group of their peers who had no Tai Chi training over the same time period. METHODS: A quasi-experimental comparative pre- and posttest design was used to compare an experimental group of 16 community-dwelling older adults, mean (SD) age = 80.4 (6.8) years, participating in a 16-week Tai Chi training program with a group of 13 adults, mean (SD) age = 71.2 (6.1) years, who had no Tai Chi experience in the areas of knee extension strength (measured by handheld dynamometry), functional strength (by five-time sit to stand), mobility (by Timed Up and Go [TUG] test and Fifty-Foot Walk Test), balance (by Functional Reach and Berg Balance Scale), and fear of falling (by Activity-specific Balance Confidence scale). Within-group and between-groups comparisons were made using 2×2 mixed analysis of variance. RESULTS: Tai Chi participants improved in nearly all measures, whereas controls did not. Tai Chi participants experienced significant improvement in the TUG test during the training period (P = .003), with significant difference when compared with controls (P = .049) and moderate effect size and observed power (ηp = 0.165; observed power = 0.512). Significant knee extension strength improvement occurred (P = .042) with moderate effect size and observed power (ηp = 0.183; observed power = 0.543). While the total balance confidence scale score did not change significantly, responses on many individual items did reach a level of significant change for persons participating in the Tai Chi training. CONCLUSION: Older adults' participation in a community-based Tai Chi program may lead to improvement in strength, mobility, and confidence in performing functional tasks. Incorporation of elements of Tai Chi into therapy programs for older adults at risk for fall and referral to community-based Tai Chi programs may be viable options in the continuum of health-related care for older adults.

Normative Two-Minute Walk Test Distances for Boys and Girls 3 to 17 Years of Age.

AIMS: To provide normative reference values for the 2-minute walk test (2MWT) for children and adolescents. METHODS: A population-based sample of 2,631 boys and girls (3-17 years) contributed data to this 2011 study which was part of the NIH Toolbox for the Assessment of Neurological and Behavioral Function Norming Project. The 2MWT was performed over a 50 foot (15.2 meter) out-and-back course. RESULTS: Overall, the mean (standard deviation) distance walked by the participants was 186.2 (33.9) meters. As a general linear model demonstrated that gender (F = 11.0, p =.001) and age (F = 127.6, p <.001) affected 2MWT distance, separate norms are provided for each gender and age stratum (e.g., 3-year-old boys,16-year-old girls). Based on these findings and correlational and regression analysis, separate explanatory equations for 2MWT distance for boys and girls are provided. The separate equations for boys and girls include age, age squared, height, and body mass as variables that explain around 40% of the variance in 2MWT distance. CONCLUSIONS: The study presents norms for the 2MWT performed by American boys and girls. The norms can be used to determine the presence of limitations in walking endurance in this population.

Handgrip Strength: A Population-Based Study of Norms and Age Trajectories for 3- to 17-Year-Olds.

PURPOSE: To provide normative values and equations for grip strength obtained from a population-based sample of individuals 3 to 17 years of age. METHODS: This cross-sectional study used grip strength data from 2706 participants (49.2% males, 91% right-hand dominant) in the normative phase of the National Institutes of Health Toolbox project. RESULTS: Analyses showed greater strength in the dominant hand in boys and with each yearly increase in age. Normative data are presented separately for each side, sex, and age. Separate regression equations using age and weight as explanatory variables of grip strength are provided for each side by sex. CONCLUSIONS: The normative data can serve as a guide for interpreting grip strength measurements. The trajectories can be used to investigate the effect of various pathologies and conditions on grip strength during physical maturation.

Six-Minute Walk Test Vs. Three-Minute Step Test for Measuring Functional Endurance.

The purpose of this study was to compare 2 practical measures of functional endurance. Specifically, the six-minute walk test (SMWT) and three-minute step test (TMST) were compared to determine their appropriateness for use as field tests and inclusion in the NIH Toolbox for the assessment of neurological and behavioral function. Individuals between 14 and 85 years performed both the SMWT and TMST in random order. We documented completion rates, criterion performance, heart rate responses, and subjective exertion associated with the 2 tests. All 189 participants completed the SMWT, but only 73.0% completed the TMST. Those completing the TMST were more likely to be male, report better health, and have a younger age and lower body mass index. The SMWT distance was greater for those who did vs. those who did not complete the TMST. For those completing both tests, the average distance walked in 6 minutes was 595.9 m; the average cumulative heart beats during the minute after the TMST was 107.4. Distance walked and cumulative heart beats correlated weakly. Average heart rate and perceived exertion were significantly higher after the TMST than the SMWT. Posttest heart rate and perceived exertion for the 2 tests correlated significantly but not strongly. We conclude that the SMWT is more likely to be completed and is usually less stressful physiologically than the TMST and therefore may be a better option for field testing functional endurance and inclusion in the NIH Toolbox.

Comparison of walking performance over the first 2 minutes and the full 6 minutes of the Six-Minute Walk Test.

BACKGROUND: Although the Six-Minute Walk Test (6MWT), as recommended by the American Thoracic Society, is widely used as a measure of functional endurance, it may not be applicable in some settings and populations. We sought to examine, therefore, performance over the first 2 minutes and the full 6 minutes of the 6MWT. Specifically, we investigated completion rates, distances walked, test-retest reliability, and the relationship between distances walked over the first 2 and the full 6 minutes of the 6MWT. METHODS: Community-dwelling children and adults age 3-85 years (n = 337) were asked to walk back and forth on a 15.24 meter (50 ft) course as far as possible without running over a 6 minute period. Test completion and the distance covered by the participants at 2 and 6 minutes were documented. The reliability of distances covered at 2 and 6 minutes was determined by retesting a subsample of 54 participants 6 to 10 days later. The relationship between distances covered at 2 and 6 minutes was determined for the 330 participants completing the 6MWT. RESULTS: All 337 participants completed at least 2 minutes of walking, but 7 children less than 5 years of age ceased walking before 6 minutes had elapsed. For the remaining 330 participants the mean distance walked was 186 meters at 2 minutes and 543 meters at 6 minutes. The distances covered at 2 and 6 minutes were reliable between sessions (intraclass correlation coefficients = 0.888 and 0.917, respectively). The distances covered over 2 and 6 minutes were highly correlated (r = 0.968). CONCLUSIONS: The completion rate, values obtained, test-retest reliability, and relationship of the distances walked in 2 and 6 minutes support documentation of 2 minute distance during the 6MWT. The findings also provide support for use of a Two-Minute Walk Test as the endurance component in the Motor Battery of the NIH Toolbox.

Effect of interactions between a child and a robot on the imitation and praxis performance of typically devloping children and a child with autism: a preliminary study.

Interactions between a robot and a child (robot-child interactions) provide a unique context to engage children in whole body movements through a reciprocal imitation game. The effects of a novel, 8-session, robot-child interaction protocol on the imitation and praxis skills of 15 typically developing children and one child with autism between 4 and 7 years of age were examined. A quasi-experimental observational comparison of pretest and posttest performance was conducted. A task-specific robot imitation test and a standardized praxis measure were coded for changes in imitation and praxis errors at pretest and posttest. All children showed improvements in task-specific imitation and generalized praxis. Interpretation is limited by the lack of a control group. These findings serve as a foundation for further investigation of robot-child interactions as a potential training tool for children with dyspraxia.

Motor assessment using the NIH Toolbox.

Motor function involves complex physiologic processes and requires the integration of multiple systems, including neuromuscular, musculoskeletal, and cardiopulmonary, and neural motor and sensory-perceptual systems. Motor-functional status is indicative of current physical health status, burden of disease, and long-term health outcomes, and is integrally related to daily functioning and quality of life. Given its importance to overall neurologic health and function, motor function was identified as a key domain for inclusion in the NIH Toolbox for Assessment of Neurological and Behavioral Function (NIH Toolbox). We engaged in a 3-stage developmental process to: 1) identify key subdomains and candidate measures for inclusion in the NIH Toolbox, 2) pretest candidate measures for feasibility across the age span of people aged 3 to 85 years, and 3) validate candidate measures against criterion measures in a sample of healthy individuals aged 3 to 85 years (n = 340). Based on extensive literature review and input from content experts, the 5 subdomains of dexterity, strength, balance, locomotion, and endurance were recommended for inclusion in the NIH Toolbox motor battery. Based on our validation testing, valid and reliable measures that are simultaneously low-cost and portable have been recommended to assess each subdomain, including the 9-hole peg board for dexterity, grip dynamometry for upper-extremity strength, standing balance test, 4-m walk test for gait speed, and a 2-minute walk test for endurance.

Grip and knee extension muscle strength reflect a common construct among adults.

INTRODUCTION: Both grip and knee extension strength are often used to characterize overall limb muscle strength. We sought to determine if the measures actually reflect a common construct. METHODS: The isometric grip and knee extension strength of 164 healthy men and women (range, 18-85 years) were measured bilaterally using standard procedures. Pearson correlations (r), Cronbach alpha, principal components analysis, and multiple regression/correlation were used to investigate the dimensionality of the measures. RESULTS: Left and right grip forces and knee extension torques were highly correlated, internally consistent, and loaded on a single component. Gender and age explained the variance in both measures, but height added to the explanation of grip strength, whereas weight added to the explanation of knee extension strength. CONCLUSIONS: Among healthy adults, grip and knee extension strength reflect a common underlying construct. The measures, however, are affected differently by height and weight.

Assessing dexterity function: a comparison of two alternatives for the NIH Toolbox.

STUDY DESIGN: Clinical measurement. INTRODUCTION: Manual dexterity is an important aspect of motor function across the age span. PURPOSE OF THE STUDY: To identify a single measure of manual dexterity for inclusion in the National Institutes of Health (NIH) Toolbox Assessment of Neurological and Behavioral Function. METHODS: A total of 340 subjects participated in our study. Two alternatives, Rolyan® 9-Hole Peg Test (9-HPT) and Grooved Pegboard test, were compared by assessing their score range across age groups (3-85 yr) and their test-retest reliability, concurrent, and known groups validity. RESULTS: The 9-HPT was a simple, efficient, and low-cost measure of manual dexterity appropriate for administration across the age range. Test-retest reliability coefficients were 0.95 and 0.92 for right and left hands, respectively. The 9-HPT correlated with Bruininks-Oseretsky Test (BOT) of Motor Proficiency, dexterity subscale, at -0.87 to -0.89 and with Purdue Pegboard at -0.74 to -0.75. The Grooved Pegboard had good test-retest reliability (0.91 and 0.85 for right and left hands, respectively). The Grooved Pegboard correlated with BOT at -0.50 to -0.63 and with Purdue Pegboard at -0.73 to -0.78. However, the Grooved Pegboard required longer administration time and was challenging for the youngest children and oldest adults. CONCLUSIONS: Based on its feasibility and measurement properties, the 9-HPT was recommended for inclusion in the motor battery of the NIH Toolbox. LEVEL OF EVIDENCE: NA.

Adequacy of belt-stabilized testing of knee extension strength.

Tester strength can limit the forces that can be measured using a hand-held dynamometer (HHD). A solution is to use belt stabilization in conjunction with an HHD. The purposes of this study were to determine if a portable belt-stabilized HHD (BSHHD) setup was capable of measuring a broad range of isometric knee extension torques and whether isometric knee extension torques measured using a portable BSHHD system were comparable to those obtained using a Biodex isokinetic dynamometer. Participants in the study were 113 women and 71 men (14-85 years of age) community-dwelling enrollees in the National Institutes of Health Toolbox for the Assessment of Neurological and Behavioral Function. Knee extension torques measured using a BSHHD ranged from 35.0-416.0 N·m. Torques measured with the BSHHD were significantly lower (p < 0.001) than those measured using the isokinetic dynamometer (mean difference: 35.6 N·m left, 33.7 N·m right). However, the measures were highly correlated (r > 0.86, p < 0.001). Torques obtained with a BSHHD may not equal the maximum that individuals can generate, but they reflect such torques. We conclude, therefore, that a portable BSHHD setup is a viable option for measuring a wide spectrum of knee extension torques in diverse settings.

Relative reliability of three objective tests of limb muscle strength.

If measures of muscle strength are to be broadly applied, they should be objective, portable, quick, and reliable. Through this component of the NIH Toolbox study we sought to compare the test-retest reliability of 3 tests of muscle strength that are objective, portable, and quick: the five-repetition sit-to-stand test (FRSTST), hand-grip dynamometry (HGD), and belt-stabilized hand-held dynamometry (BSHHD) of knee extension. Three sets of each test were performed- 1 warm-up and 2 maximal. Measures from the maximal tests obtained 4 to 10 days apart were compared. Reliability was described using descriptive statistics, intraclass correlation coefficients (ICCs) and 4 measures of response stability: standard error of measurement (SEM), method error (ME), coefficient of variation of SEM (SEM CV ), and coefficient of variation of variation of ME (ME CV ). The ICCs of all tests were good (≥ 0.853). Measures of response stability showed less variability between test and retest for FRSTST and HGD than for BSHHD. In conclusions all 3 tests demonstrated good test-retest reliability. However, greater differences would need to be observed between tests sessions to conclude that a real change had occurred in measures obtained by BSHHD.

Deterministic and stochastic postural processes: effects of task, environment, and age.

Upright standing is always environmentally embedded and typically co-occurs with another (suprapostural) activity. In the present study, the authors investigate how these facts affect postural dynamics in an experiment in which younger (M age = 20.23 years, SD = 2.02 years) and older (M age = 75.26 years, SD = 4.87 years) participants performed a task of detecting letters in text or maintaining gaze within a target while standing upright in a structured or nonstructured stationary environment. They extracted the coefficients of drift (indexing attractor strength) and diffusion (indexing noise strength) from the center of pressure (COP) time series in anteroposterior (AP) and mediolateral (ML) axes. COP standard deviation decreased with drift and increased with diffusion. The authors found that structure reduced AP diffusion for both groups and that letter detection reduced younger SDAP (primarily by diffusion decrease) and increased older SDML (primarily by drift decrease). For older and younger participants, ML drift was lower during letter detection. Further, in older letter detection, larger visual contrast sensitivity was associated with larger ML drift and smaller SDML, raising the hypotheses that ML sway helps information detection and reflects neurophysiological age.

Sit-to-stand test: Performance and determinants across the age-span.

Although the validity of the sit-to-stand (STS) test as a measure of lower limb strength has been questioned, it is widely used as such among older adults. The purposes of this study were: 1) to describe five-repetition STS test (FRSTST) performance (time) by adolescents and adults and 2) to determine the relationship of isometric knee extension strength (force and torque), age, gender, weight, and stature with that performance. Participants were 111 female and 70 male (14-85 years) community-dwelling enrollees in the NIH Toolbox Assessment of Neurological and Behavioral Function. The FRSTST was conducted using a standard armless chair. Knee extension force was measured using a belt-stabilized hand-held dynamometer; knee extension torque was measured using a Biodex dynamometer. The mean times for the FRSTST ranged from 6.0 sec (20-29 years) to 10.8 sec (80-85 years). For both the entire sample and a sub-sample of participants 50-85 years, knee extension strength (r = -0.388 to -0.634), age (r = 0.561 and 0.466), and gender (r = 0.182 and 0.276) were correlated significantly with FRSTST times. In all multiple regression models, knee extension strength provided the best explanation of FRSTST performance, but age contributed as well. Bodyweight and stature were less consistent in explaining FRSTST performance. Gender did not add to the explanation of FRSTST performance. Our findings suggest, therefore, that FRSTST time reflects lower limb strength, but that performance should be interpreted in light of age and other factors.