Targeted Physical Therapy Combined with Spasticity Management Changes Motor Development Trajectory for a 2-Year-Old with Cerebral Palsy.

Therapies for children with cerebral palsy (CP) often fail to address essential components of early rehabilitation: intensity, child initiation, and an embodied approach. Sitting Together And Reaching To Play (START-Play) addresses these issues while incorporating intensive family involvement to maximize therapeutic dosage. While START-Play was developed and tested on children aged 7-16 months with motor delays, the theoretical construct can be applied to intervention in children of broader ages and skills levels. This study quantifies the impact of a broader START-Play intervention combined with Botulinum toxin-A (BoNT-A) and phenol on the developmental trajectory of a 24 month-old child with bilateral spastic CP. In this AB +1 study, A consisted of multiple baseline assessments with the Gross Motor Function Measure-66 and the Assessment of Problem Solving in Play. The research participant demonstrated a stable baseline during A and changes in response to the combination of BoNT-A/phenol and 12 START-Play sessions during B, surpassing the minimal clinically important difference on the Gross Motor Function Measure-66. The follow-up data point (+1) was completed after a second round of BoNT-A/phenol injections. While the findings suggest the participant improved his gross motor skills with BoNT-A/phenol and START-Play, further research is needed to generalize these findings.

Global prevalence of traumatic non-fatal limb amputation.

BACKGROUND: Reliable information on both global need for prosthetic services and the current prosthetist workforce is limited. Global burden of disease estimates can provide valuable insight into amputation prevalence due to traumatic causes and global prosthetists needed to treat traumatic amputations. OBJECTIVES: This study was conducted to quantify and interpret patterns in global distribution and prevalence of traumatic limb amputation by cause, region, and age within the context of prosthetic rehabilitation, prosthetist need, and prosthetist education. STUDY DESIGN: A secondary database descriptive study. METHODS: Amputation prevalence and prevalence rate per 100,000 due to trauma were estimated using the 2017 global burden of disease results. Global burden of disease estimation utilizes a Bayesian metaregression and best available data to estimate the prevalence of diseases and injuries, such as amputation. RESULTS: In 2017, 57.7 million people were living with limb amputation due to traumatic causes worldwide. Leading traumatic causes of limb amputation were falls (36.2%), road injuries (15.7%), other transportation injuries (11.2%), and mechanical forces (10.4%). The highest number of prevalent traumatic amputations was in East Asia and South Asia followed by Western Europe, North Africa, and the Middle East, high-income North America and Eastern Europe. Based on these prevalence estimates, approximately 75,850 prosthetists are needed globally to treat people with traumatic amputations. CONCLUSION: Amputation prevalence estimates and patterns can inform prosthetic service provision, education and planning.

A Novel Means-End Problem-Solving Assessment Tool for Early Intervention: Evaluation of Validity, Reliability, and Sensitivity.

PURPOSE: To evaluate validity, reliability, and sensitivity of the novel Means-End Problem-Solving Assessment Tool (MEPSAT). METHODS: Children with typical development and those with motor delay were assessed throughout the first 2 years of life using the MEPSAT. MEPSAT scores were validated against the cognitive and motor subscales of the Bayley Scales of Development. Intra- and interrater reliability, developmental trends, and differences among groups were evaluated. RESULTS: Changes in MEPSAT scores positively related to changes in Bayley scores across time for both groups of children. Strong intra- and interrater reliability was observed for MEPSAT scoring across all children. The MEPSAT was sensitive to identify change across time and differences in problem-solving among children with varying levels of motor delay. CONCLUSIONS: The MEPSAT is supported by validity and reliability evidence and is a simple tool for screening early problem-solving delays and evaluating change across time in children with a range of developmental abilities. What this adds to the evidence: The novel MEPSAT is supported by validity and reliability evidence. It is sensitive to detect problem-solving differences among young children with varying motor ability and to capture changes in problem-solving across time. It requires minimal equipment and time to administer and score and, thus, is a promising tool for clinicians to screen for early problem-solving delays or to track intervention progress in young children with or at risk for problem-solving delays.

Longitudinal Change in Common Impairments in Children With Cerebral Palsy From Age 1.5 to 11 Years.

PURPOSE: This project aimed to determine whether change occurs over time for impairments of balance, range of motion, endurance, and strength of children with cerebral palsy, by Gross Motor Function Classification System (GMFCS) levels. METHODS: Measurements were completed in 77 children at 2 sessions (T1, T2) on average 5.8 years apart. Mean ages were 2.9 years (SD = 0.9) and 8.7 years (SD = 1.1) at T1 and T2, respectively. RESULTS: There were significant differences from T1 to T2 for some children (GMFCS levels I, II, and III/IV: balance increased; GMFCS levels I and II: strength increased; and GMFCS levels III/IV and V: range of motion decreased). Endurance scores were not different and did not change. CONCLUSIONS: Longitudinal changes in most impairments occurred in children with cerebral palsy. Monitoring and targeted interventions should support each child's development.

Sitting skill and the emergence of arms-free sitting affects the frequency of object looking and exploration.

The development of sitting changes how much infants are able to explore objects. Infants who can sit with their arms free are likely to explore their environment more effectively than prop sitters, as their hands are free to explore. We sought to quantify how prop sitters differed in the amount of visual and manual exploration of objects from arms-free sitters. Infants younger than 7 months (n = 31) were recruited at sitting emergence, either prop or arms-free sitting without the ability to change positions. Infants were grouped into sitting stages at baseline: prop (n = 17) or wobbly/arms-free (n = 14). Across three visits (baseline, 3 weeks later, 6-8 weeks later), researchers assessed the infants' total gross motor skill, sitting skill, and object looking and active exploration. Infants' gross motor and sitting skill was assessed using the Gross Motor Function Measure (GMFM)-66 total scores and GMFM-88 sitting dimension scores. While researchers supported infants in sitting, object looking and exploration were assessed using a series of three object exploration tasks and scoring modified slightly from the Early Problem Solving Indicator at each visit. Differences between trajectories of prop and wobbly/arms-free sitters for the frequencies of two behaviors, looks and explores, were analyzed using longitudinal multilevel modeling. Prop sitters initially explored toys less frequently, but increased their exploration more quickly, than wobbly/arms-free sitters. Sitting skill predicted minor changes in the development of looking; both stage and skill predicted changes uniquely in the development of exploration. These findings suggest that independent, arms-free sitting changes how capable infants are of exploring objects visually and manually.

Validity of the Early Activity Scale for Endurance and the 6-Minute Walk Test for Children With Cerebral Palsy.

PURPOSE: This study aimed to describe Early Activity Scale for Endurance (EASE) scores and 6-minute walk test (6MWT) distances of children with cerebral palsy (CP) by functional ability level, sex, and age and to examine the convergent validity of the 2 tests. METHODS: A total of 708 participants with CP, Gross Motor Function Classification System (GMFCS) levels I to V, completed the EASE, and 376 of the study participants (3-12years), GMFCS levels I to III, completed the 6MWT. RESULTS: Children with CP vary in EASE scores and 6MWT distances based on GMFCS level and, to a lesser extent, age. The EASE and the 6MWT demonstrate a statistically significant but low, positive correlation. CONCLUSIONS: Understanding the relationship between these outcomes and GMFCS levels and age assists clinicians in establishing plans of care targeted at improving endurance for activity and functional walking capacity for children with CP.

Developmental Trajectories and Reference Percentiles for Range of Motion, Endurance, and Muscle Strength of Children With Cerebral Palsy.

BACKGROUND: Children with cerebral palsy (CP) frequently present with secondary impairments in spinal alignment and extremity range of motion, endurance for activity, and muscle strength. Creation of developmental trajectories for these impairments will help guide clinical decision-making. OBJECTIVE: For children in each level of the Gross Motor Function Classification System (GMFCS) this study aimed to: (1) create longitudinal developmental trajectories for range of motion (Spinal Alignment and Range of Motion Measures [SAROMM]), endurance (Early Activity Scale for Endurance [EASE]), and functional strength (Functional Strength Assessment [FSA]); and (2) develop age-specific reference percentiles and amount of change typical over 1 year for these outcomes. DESIGN: This study used a longitudinal cohort design. METHODS: Participants comprised 708 children with CP across GMFCS levels, aged 18 months up to the 12th birthday, and their families. In 2 to 5 assessments every 6 months over 2 years, trained therapists performed the SAROMM and FSA, and parents completed the EASE questionnaire. For children in each GMFCS level, longitudinal trajectories using linear and nonlinear mixed-effects models from all visits, and reference percentiles using quantile regression from the first, 12-month, and 24-month visits were created for each measure. RESULTS: Longitudinal trajectories and percentile graphs for SAROMM, FSA, and EASE were primarily linear, with different performance scores among GMFCS levels. There was much variability in both longitudinal trajectories and percentiles within GMFCS levels. LIMITATIONS: Limitations included a convenience sample and varying numbers of participants assessed at each visit. CONCLUSIONS: The longitudinal trajectories and percentile graphs have application for monitoring how children with CP are performing and changing over time compared with other children with CP. The resources presented allow therapists and families to collaboratively make decisions about intervention activities targeted to children's unique needs.

Developmental Trajectories and Reference Percentiles for the 6-Minute Walk Test for Children With Cerebral Palsy.

PURPOSE: The purposes of this study were to document longitudinal developmental trajectories in 6-minute walk test (6MWT) distances and to develop age-specific reference percentiles for children across different Gross Motor Function Classification System (GMFCS) levels. METHODS: A TOTAL OF: 456 children with cerebral palsy ages 3 to 12 years of, GMFCS levels I to III participated. Children's motor function was classified on the GMFCS, and children completed the 6MWT 2 to 5 times in 2 years. RESULTS: Longitudinal developmental trajectories support that 6MWT distances increase with age followed by a tapering, as children approach their functional limit relative to their GMFCS level. Reference percentile graphs were created to monitor change over time. CONCLUSIONS: The 6MWT longitudinal developmental trajectories, reference percentiles, and interpretation of percentile change should assist collaborative and proactive intervention planning relative to functional walking capacity for children with cerebral palsy.

Sitting Together And Reaching To Play (START-Play): Protocol for a Multisite Randomized Controlled Efficacy Trial on Intervention for Infants With Neuromotor Disorders.

Background: There is limited research examining the efficacy of early physical therapy on infants with neuromotor dysfunction. In addition, most early motor interventions have not been directly linked to learning, despite the clear association between motor activity and cognition during infancy. Objective: The aim of this project is to evaluate the efficacy of Sitting Together And Reaching To Play (START-Play), an intervention designed to target sitting, reaching, and motor-based problem solving to advance global development in infants with motor delays or neuromotor dysfunction. Design: This study is a longitudinal multisite randomized controlled trial. Infants in the START-Play group are compared to infants receiving usual care in early intervention (EI). Setting: The research takes place in homes in Pennsylvania, Delaware, Washington, and Virginia. Participants: There will be 140 infants with neuromotor dysfunction participating, beginning between 7 to 16 months of age. Infants will have motor delays and emerging sitting skill. Intervention: START-Play provides individualized twice-weekly home intervention for 12 weeks with families to enhance cognition through sitting, reaching, and problem-solving activities for infants. Ten interventionists provide the intervention, with each child assigned 1 therapist. Measurements: The primary outcome measure is the Bayley III Scales of Infant Development. Secondary measures include change in the Early Problem Solving Indicator, change in the Gross Motor Function Measure, and change in the type and duration of toy contacts during reaching. Additional measures include sitting posture control and parent-child interaction. Limitations: Limitations include variability in usual EI care and the lack of blinding for interventionists and families. Conclusions: This study describes usual care in EI across 4 US regions and compares outcomes of the START-Play intervention to usual care.

Muscle recruitment and coordination during upper-extremity functional tests.

Performance-based tests, such as the Jebsen Taylor Hand Function Test or Chedoke Arm and Hand Activity Inventory, are commonly used to assess functional performance after neurologic injury. However, the muscle activity required to execute these tasks is not well understood, even for unimpaired individuals. The purpose of this study was to evaluate unimpaired muscle recruitment and coordination of the dominant and non-dominant limbs during common clinical tests. Electromyography (EMG) recordings from eight arm muscles were monitored bilaterally for twenty unimpaired participants while completing these tests. Average signal magnitudes, activation times, and cocontraction levels were calculated from the filtered EMG data, normalized by maximum voluntary isometric contractions (MVICs). Overall, performance of these functional tests required low levels of muscle activity, with average EMG magnitudes less than 6.5% MVIC for all tests and muscles, except the extensor digitorum, which had higher activations across all tasks (11.7 ±â€¯2.7% MVIC, dominant arm). When averaged across participants, cocontraction was between 25 and 62% for all tests and muscle pairs. Tasks evaluated by speed of completion, rather than functional quality of movement demonstrated higher levels of muscle recruitment. These results provide baseline measurements that can be used to evaluate muscle-specific deficits after neurologic injury and track recovery using common clinical tests.

Virtual Reality and Serious Games in Neurorehabilitation of Children and Adults: Prevention, Plasticity, and Participation.

Use of virtual reality (VR) and serious games (SGs) interventions within rehabilitation as motivating tools for task specific training for individuals with neurological conditions are fast-developing. Within this perspective paper we use the framework of the IV STEP conference to summarize the literature on VR and SG for children and adults by three topics: Prevention; Outcomes: Body-Function-Structure, Activity and Participation; and Plasticity. Overall the literature in this area offers support for use of VR and SGs to improve body functions and to some extent activity domain outcomes. Critical analysis of clients' goals and selective evaluation of VR and SGs are necessary to appropriately take advantage of these tools within intervention. Further research on prevention, participation, and plasticity is warranted. We offer suggestions for bridging the gap between research and practice integrating VR and SGs into physical therapist education and practice.

Virtual Sensorimotor Training for Balance: Pilot Study Results for Children With Fetal Alcohol Spectrum Disorders.

PURPOSE: To examine the effects of Sensorimotor Training to Affect Balance, Engagement, and Learning (STABEL), a virtual reality system to train sensory adaptation for balance control, for children with fetal alcohol spectrum disorders (FASDs). METHODS: Twenty-three children with FASDs received STABEL training in a university laboratory, or home, or were controls. The Movement Assessment Battery for Children-2nd edition (MABC-2) and Pediatric Clinical Test of Sensory Interaction for Balance-2 (P-CTSIB-2) were analyzed by group (lab, home, and control), session (pre-STABEL, 1 week post-STABEL, and 1 month post-STABEL), and group-by-session interaction. RESULTS: Significant effects were group and session for MABC-2 Balance and interaction for MABC-2 Total Motor and P-CTSIB-2. CONCLUSION: Preliminary results support improved sensory adaptation, balance, and motor performance post-STABEL, which warrant further study with a larger, randomized sample.

Development of the Early Activity Scale for Endurance for children with cerebral palsy.

PURPOSE: The Early Activity Scale for Endurance (EASE) was developed as a clinically feasible measure of endurance for physical activity in young children with cerebral palsy (CP). Validity and reliability were evaluated. METHODS: Participants included 414 children with CP and 106 without CP. Parents completed the EASE, an 11-item self-report measure. For construct validity, EASE scores were compared by Gross Motor Function Classification System levels (0 assigned for children without CP), age, and gender. In subgroups, convergent validity with the 6-minute walk test and test-retest reliability with a second EASE were evaluated. RESULTS: EASE scores differed significantly by Gross Motor Function Classification System, but not by age or gender. The EASE correlated moderately (rs = 0.57) with the 6-minute walk test. Test-retest reliability was high, intraclass correlation (2,1) = 0.95. CONCLUSION: The EASE has acceptable psychometrics for use in practice and research to estimate endurance for physical activity in young children with CP.

Harris Infant Neuromotor Test: comparison of US and Canadian normative data and examination of concurrent validity with the Ages and Stages Questionnaire.

BACKGROUND: The Harris Infant Neuromotor Test (HINT) was developed as a screening tool for potential motor and cognitive developmental disorders in infants. Scoring on the HINT has been shown to be reliable, and several studies have supported the validity of the HINT. Normative values for the tool have been developed using Canadian infants. OBJECTIVE: The aims of this study were (1) to further evaluate the validity of the HINT by comparing data obtained on US infants who were developing typically with data previously acquired on Canadian infants and (2) to determine the concurrent validity of the HINT with the Ages and Stages Questionnaire (ASQ). Secondary analyses of HINT scores for US white and nonwhite infants and for US infants who had parents with lower levels of education and US infants who had parents with higher levels of education (as a proxy for socioeconomic status [SES]) were conducted. DESIGN: Cross-sectional exploratory and quasi-experimental comparative research designs were used to evaluate the validity of the HINT. METHODS: Sixty-seven infants from the United States who were developing typically and who were aged 2.5 to 12.5 months were recruited via convenience sampling. Sixty-four of these infants were compared with Canadian infants matched for age, sex, ethnicity or race, and parental education. The HINT was administered by raters who had been trained to attain acceptable levels of interrater reliability, and parents completed the ASQ. The HINT scores for US white versus nonwhite infants (n=46) and infants who had parents with lower SES versus a higher SES (n=52) were compared. RESULTS: There were no significant differences between HINT total scores for US and Canadian infants or for US racial or ethnic groups and SES groups. There were high correlations (r=-.82 to -.84) between HINT and ASQ scores. LIMITATIONS: The study used a small US sample with limited geographical diversity. Small sample numbers also did not allow for comparisons of specific racial or ethnic groups. The SES groups were created primarily using parental education as a proxy for SES. CONCLUSIONS: The results suggest that HINT screening in the United States is supported on the basis of Canadian norms and the validity of the HINT in screening for motor and cognitive delays. Although there is preliminary support for the HINT as an appropriate screening tool for US infants who are nonwhite or who have parents with a lower SES, more research is warranted.