Advancing the Evidence Base of Pediatric Physical Therapy: "Sincerely, From the Heart".

PURPOSE: To share reflections on themes that have become important to me as a developing pediatric physical therapy researcher contributing to knowledge generation in our field. KEY POINTS: The themes are: select strong mentors, assemble a research team with diverse perspectives and strengths, be family-centered, be rigorous in approaches to study design to match the research question, mentor the next generation, and engage in knowledge translation and exchange. CONCLUSIONS: I encourage everyone to reflect on who has been or could be your mentors or mentees, and on how you can be a part of an effective, family-centered research team, by encouraging a breadth of research designs to answer the many research questions that remain and by assisting in the implementation of knowledge to practice. CLINICAL RELEVANCE: Outcomes for children and families receiving pediatric physical therapy services are enhanced through the use of evidence-based knowledge.

Longitudinal trajectories and reference centiles for the impact of health conditions on daily activities of children with cerebral palsy.

AIM: First, to describe the impact of health conditions on daily activities over time in children with cerebral palsy (CP) and to create age-specific reference centiles. Second, to determine the amount of change typical over a 1-year period, across Gross Motor Function Classification System (GMFCS) levels. METHOD: A prospective, cohort design, with five assessments over 2 years, involved 708 children with a confirmed diagnosis of CP participating in the On Track Study (396 males, 312 females; mean age 6y [SD 2y 7mo]; range 18mo-12y at first assessment; 32.1% in GMFCS level I, 22.7% in GMFCS level II, 11.2% in GMFCS level III, 18.2% in GMFCS level IV, 15.7% in GMFCS level V). The impact of health conditions on daily activities was assessed using the Child Health Conditions Questionnaire. Data were analyzed using mixed-effects models and quantile regression. RESULTS: Linear longitudinal trajectories describe the relatively stable impact of health conditions over time for each functional level for children aged 2 years to 12 years, with the lowest scores (least impact) in GMFCS level I and the highest scores (highest impact) in GMFCS level V. Centiles were created for children in each GMFCS level. A system to interpret the magnitude of change over time in centiles was developed. INTERPRETATION: Longitudinal trajectories of co-occurring health conditions assist with understanding children's prognoses. Centiles assist in understanding a child's experience relative to children in similar GMFCS levels. Guidelines are provided to determine if children are progressing 'as expected', 'better than expected' or 'more poorly than expected' in regard to the impact of health conditions on daily activities. WHAT THIS PAPER ADDS: For children with cerebral palsy, the mean impact of health conditions on daily activities is relatively stable. Significant intraindividual and interindividual variability for the impact of health conditions exists, which complicates prognosis. Centiles enable interpretation of the impact of health conditions relative to Gross Motor Function Classification System level.

TRAYECTORIAS LONGITUDINALES Y CENTILES DE REFERENCIA PARA EL IMPACTO DE LAS CONDICIONES DE SALUD EN LAS ACTIVIDADES DIARIAS DE LOS NIÑOS CON PARÁLISIS CEREBRAL: OBJETIVO: Primero, describir el impacto de las condiciones de salud en las actividades diarias a lo largo del tiempo en niños con parálisis cerebral (PC) y crear centiles de referencia específicos de la edad. Segundo, para determinar la cantidad de cambio típica en un período de 1 año, a través de los niveles del Sistema de Clasificación de la Función Motora Bruta (GMFCS). MÉTODO: Un diseño de cohorte prospectivo, con cinco evaluaciones durante 2 años, involucró a 708 niños con un diagnóstico confirmado de PC que participó en el estudio On Track (396 varones, 312 mujeres; edad media 6 años de edad [SD 2 años 7 meses]; rango 18 meses-12 años a primera evaluación: 32,1% en GMFCS nivel I, 22,7% en GMFCS nivel II, 11,2% en GMFCS nivel III, 18,2% en GMFCS nivel IV, 15,7% en GMFCS nivel V). El impacto de las condiciones de salud en las actividades diarias se evaluó utilizando el Cuestionario de Condiciones de Salud Infantil. Los datos se analizaron utilizando modelos de efectos mixtos y regresión por cuantiles. RESULTADOS: Las trayectorias longitudinales lineales describen el impacto relativamente estable de las condiciones de salud a lo largo del tiempo para cada nivel funcional para niños de 2 años a 12 años, con las puntuaciones más bajas (menor impacto) en el nivel I de GMFCS y las puntuaciones más altas (mayor impacto) en el nivel de GMFCS V. Centiles fueron creados para los niños en cada nivel de GMFCS. Se desarrolló un sistema para interpretar la magnitud del cambio en el tiempo en centiles. INTERPRETACIÓN: Las trayectorias longitudinales de las condiciones de salud concurrentes ayudan a comprender los pronósticos de los niños. Los centiles ayudan a comprender la experiencia de un niño en relación con los niños en niveles similares de GMFCS. Se proporcionan pautas para determinar si los niños progresan "como se espera", "mejor de lo esperado" o "peor de lo esperado" en relación con el impacto de las condiciones de salud en las actividades diarias.

TRAJETÓRIAS LONGITUDINAIS E CENTIS DE REFERÊNCIA PARA O IMPACTO DAS CONDIÇÕES DE SAÚDE NAS ATIVIDADES DIÁRIAS DE CRIANÇAS COM PARALISIA CEREBRAL: OBJETIVO: Primeiro, descrever o impacto das condições de saúde nas atividades diárias ao longo do tempo em crianças com paralisia cerebral (PC) e criar centis de referência idade-específicos. Segundo, determinar a quantidade de mudança típica em um ano, nos diversos níveis do Sistema de Classificação da Função Motora Grossa (GMFCS). MÉTODO: Um desenho prospectivo de coorte, com cinco avaliações em 2 anos, envolveu 708 crianças com diagnóstico confirmado de PC que participavam do Estudo On Track (396 do sexo masculino, 312 do sexo feminino; méida de idade 6a [DP 2a 7m]; variação 18m-12a na primeira avaliação; 32,1% no nível GMFCS I, 22,7% no nível GMFCS II, 11,2% no nível GMFCS III, 18,2% no nível GMFCS IV, 15,7% no nível GMFCS V). O impacto das condições de saúde nas atividades diárias foi avaliado usando o Questionário das condições de saúde da criança. Os dados foram analisados usando modelos de efeitos mistos e regressão quantil. RESULTADOS: Trajetórias lineares longitudinais descrevem o impacto relativamente estável das condições de saúde ao longo do tempo para cada nível funcional para crianças com idades de 2 a 12 anos, com os menores escores (menor impacto) no nível GMFCS I e maiores escores (maior impacto) no nível GMFCS V. Centis foram criados para crianças em cada nível GMFCS. Um sistema para interpretar a magnitude da mudança ao longo do tempo em centis foi criado. INTERPRETAÇÃO: Trajetórias longitudinais de condições de saúde co-ocorrentes ajudam a entender o prognóstico da criança. Os centis ajudam a compreender a experiência da criança com relação a crianças em níveis GMFCS similares. Diretrizes são oferecidas para determinar se crianças estão progredindo "como esperado", "melhor do que o esperado"ou "pior do que o esperado" com relação ao impacto das condições de saúde nas atividades diárias.

Parents' Experiences and Perceptions when Classifying their Children with Cerebral Palsy: Recommendations for Service Providers.

AIMS: This study investigated the experiences and perceptions of parents of children with cerebral palsy (CP) when classifying their children using the Gross Motor Function Classification System (GMFCS), the Manual Ability Classification System (MACS), and the Communication Function Classification System (CFCS). The second aim was to collate parents' recommendations for service providers on how to interact and communicate with families. METHODS: A purposive sample of seven parents participating in the On Track study was recruited. Semi-structured interviews were conducted orally and were audiotaped, transcribed, and coded openly. A descriptive interpretive approach within a pragmatic perspective was used during analysis. RESULTS: Seven themes encompassing parents' experiences and perspectives reflect a process of increased understanding when classifying their children, with perceptions of utility evident throughout this process. Six recommendations for service providers emerged, including making the child a priority and being a dependable resource. CONCLUSIONS: Knowledge of parents' experiences when using the GMFCS, MACS, and CFCS can provide useful insight for service providers collaborating with parents to classify function in children with CP. Using the recommendations from these parents can facilitate family-provider collaboration for goal setting and intervention planning.

Description of Primary and Secondary Impairments in Young Children With Cerebral Palsy.

PURPOSE: We describe primary and secondary impairments in young children with cerebral palsy (CP); report differences in impairments on the basis of Gross Motor Function Classification System (GMFCS), age, and sex; and examine the extent that individual impairments account for the construct of primary and secondary impairments. METHODS: Participants included 429 children with CP (242 [56%] male; 1½ to 5 years) representing all GMFCS levels. Reliable assessors collected primary and secondary impairment data using clinical measures. Analyses included descriptive statistics, comparisons among GMFCS, age, and sex, and factor analysis. RESULTS: Young children with CP present with primary and secondary impairments. Significant differences in impairments occur among some GMFCS levels and age groups but not sex groups. Postural stability contributed most to primary impairments and strength to secondary impairments. CONCLUSION: Young children with CP across GMFCS levels may have already developed secondary impairments that should be addressed within therapy services.

Determinants of gross motor function of young children with cerebral palsy: a prospective cohort study.

AIM: The aim of this study was to test a model of determinants of gross motor function of young children with cerebral palsy (CP). METHOD: Four hundred and twenty-nine children with CP (242 males, 187 females; mean age 3 y 2 mo, SD 11 mo) representing all levels of the Gross Motor Function Classification System (GMFCS) participated. Children in levels I to II and III to V were classified as Groups 1 and 2 respectively. Distribution of CP was quadriplegia, 44%; hemiplegia, 24%; diplegia, 23%; triplegia, 6%; and monoplegia, 2% (data not available for 1%). Impairment and motor function data were collected by reliable assessors; parents completed questionnaires on health conditions and adaptive behavior. Seven months later, parents were interviewed about family life and services received. One year after the study onset, motor function was re-evaluated. Analysis involved structural equation modeling. RESULTS: The well-fitting model explained 58% and 75% of the variance in motor function at study completion for Groups 1 and 2 respectively. Primary impairments (spasticity, quality of movement, postural stability, and distribution of involvement; ß=0.52-0.68) and secondary impairments (strength, range of motion limitations, and reduced endurance; ß=0.25-0.26) explained the most variance. Adaptive behavior was a significant determinant only for Group 2 (ß=0.21) and participation in community programs was significant only in Group 1 (ß=0.13). INTERPRETATION: Motor function is supported by optimizing body structures and function for all children and enhancing adaptive behavior for children with greater motor challenges.

Measuring postural stability in young children with cerebral palsy: a comparison of 2 instruments.

PURPOSE: To compare construct validity, interrater and test-retest reliabilities of the Pediatric Reach Test and the Early Clinical Assessment of Balance (ECAB), and their relationships with the Gross Motor Function Measure, 66-item version, Basal and Ceiling approach (GMFM-66-B&C) to appraise clinical utility of postural stability measures for children with cerebral palsy (CP). METHODS: A total of 28 children with CP, 2 to 7 years old, across all functional ability levels participated in 2 assessments over 2 weeks. Two assessors scored the measures during the first assessment. RESULTS: Both measures demonstrated construct validity, rs of 0.88 (P < .001). Both measures correlated with GMFM-66-B&C, rs > 0.95. Interrater and test-retest reliabilities were stronger for the ECAB than for the Pediatric Reach Test (intraclass correlation coefficients > 0.98 vs 0.87-0.94). The ECAB demonstrated lower measurement error and proportionately smaller minimal detectable change values. CONCLUSION: The ECAB is considered the better measure of postural stability among children with CP.

Exploring the utility of measures of critical thinking dispositions and professional behavior development in an audiology education program.

BACKGROUND: Discussions about professional behaviors are growing increasingly prevalent across health professions, especially as a central component to education programs. A strong critical thinking disposition, paired with critical consciousness, may provide future health professionals with a foundation for solving challenging practice problems through the application of sound technical skill and scientific knowledge without sacrificing sensitive, empathic, client-centered practice. In this article, we describe an approach to monitoring student development of critical thinking dispositions and key professional behaviors as a way to inform faculty members' and clinical supervisors' support of students and ongoing curriculum development. PURPOSE: We designed this exploratory study to describe the trajectory of change for a cohort of audiology students' critical thinking dispositions (measured by the California Critical Thinking Disposition Inventory: [CCTDI]) and professional behaviors (using the Comprehensive Professional Behaviors Development Log-Audiology [CPBDL-A]) in an audiology program. Implications for the CCTDI and CPBDL-A in audiology entry-to-practice curricula and professional development will be discussed. RESEARCH DESIGN: This exploratory study involved a cohort of audiology students, studied over a two-year period, using a one-group repeated measures design. STUDY SAMPLE: Eighteen audiology students (two male and 16 female), began the study. At the third and final data collection point, 15 students completed the CCTDI, and nine students completed the CPBDL-A. DATA COLLECTION AND ANALYSIS: The CCTDI and CPBDL-A were each completed at three time points: at the beginning, at the middle, and near the end of the audiology education program. Data are presented descriptively in box plots to examine the trends of development for each critical thinking disposition dimension and each key professional behavior as well as for an overall critical thinking disposition score. RESULTS: For the CCTDI, there was a general downward trend from time point 1 to time point 2 and a general upward trend from time point 2 to time point 3. Students demonstrated upward trends from the initial to final time point for their self-assessed development of professional behaviors as indicated on the CPBDL-A. CONCLUSIONS: The CCTDI and CPBDL-A can be used by audiology education programs as mechanisms for inspiring, fostering, and monitoring the development of critical thinking dispositions and key professional behaviors in students. Feedback and mentoring about dispositions and behaviors in conjunction with completion of these measures is recommended for inspiring and fostering these key professional attributes.

Amount and focus of physical therapy and occupational therapy for young children with cerebral palsy.

The aims of this study were to describe physical therapy (PT) and occupational therapy (OT) services for a cohort of 399 children with cerebral palsy (CP), 2-6 years old, residing in the United States and Canada. Parents completed a services questionnaire by telephone interview. Therapists classified children's Gross Motor Function Classification System (GMFCS) level. Mean minutes per month of PT and OT were greater for children receiving services in both an educational and clinic setting. Mean minutes per month of PT and OT were greater for children in levels IV-V than children in level I and greater for children in the United States than children in Canada. Parents reported that interventions focused a moderate to great extent on primary impairments, secondary impairments, activity, and structured play activities, a moderate extent on environmental modifications and equipment; and a moderate to small extent on self-care routines. The results support the importance of coordination of PT and OT services.

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.

Effectiveness of Tai Chi for Health Promotion of Older Adults: A Scoping Review of Meta-Analyses.

Background. Tai Chi is a form of exercise that is accessible to people from different socioeconomic backgrounds, making it a potentially valuable activity for health promotion of older adults. Purpose. The objective of this scoping review was to summarize the current knowledge about the effectiveness of Tai Chi for older adults across a range of general health outcomes from published, peer reviewed, unique meta-analyses. Methods. Meta-analyses were retrieved from Medline, Embase, AMED, CINAHL, SPORTDiscus, PsychINFO, Web of Science, PubMed Health, and the Cochrane Library from database inception to late August 2019. Multistage deduplication and screening processes identified eligible full-length meta-analyses. Two people independently appraised 27 meta-analyses based on the GRADE system and organized results into 3 appendices subsequently collated into heterogeneous, statistically significant, and statistically insignificant tables. Results. "High" and "moderate" quality evidence extracted from these meta-analyses demonstrated that practicing Tai Chi can significantly improve balance, cardiorespiratory fitness, cognition, mobility, proprioception, sleep, and strength; reduce the incidence of falls and nonfatal stroke; and decrease stroke risk factors. Conclusions. Health care providers can now recommend Tai Chi with high level of certainty for health promotion of older adults across a range of general health outcomes for improvement of overall well-being.

Correspondence of classifications between parents of children with cerebral palsy aged 2 to 6 years and therapists using the Gross Motor Function Classification System.

AIM: The aim of this study was to determine the agreement and reliability of parent report using a lay version of the Gross Motor Function Classification System (GMFCS) among children with cerebral palsy in the two youngest age bands. METHOD: Data were obtained from the Canadian section of the Movement and Participation in Life Activities of Young Children study database. One hundred and thirty-two parents of two groups of children participated: children aged 2 to 4 years (35 males, 26 females; mean age 3y 2mo; SD 5mo) and children aged 4 to 6 years (39 males, 32 females; mean age 4y 11mo; SD 6mo) at the final data collection point. Therapists classified motor function using the GMFCS and parents used the GMFCS Family Report Questionnaire, with parents and therapists being masked to the others' responses. Agreement between respondents was determined using precise agreement and Cohen's unweighted kappa statistic. Reliability between respondents was determined using the intraclass correlation coefficient (ICC). RESULTS: Overall, precise agreement was 77%, chance-corrected agreement was κ = 0.70 (95% confidence interval [CI] 0.61-0.79), and reliability was ICC = 0.95 (95% CI 0.93-0.96). INTERPRETATION: These values indicate substantial agreement and reliability between parents of children aged 2 to 6 years and therapists. Some parents had a tendency to rate their children as more functionally limited than did therapists, leading us to question whose the true criterion standard' rating should be.

A multivariate model of determinants of change in gross-motor abilities and engagement in self-care and play of young children with cerebral palsy.

A multivariate model of determinants of change in gross-motor ability and engagement in self-care and play provides physical and occupational therapists a framework for decisions on interventions and supports for young children with cerebral palsy and their families. Aspects of the child, family ecology, and rehabilitation and community services may influence children's activity and participation. Aspects of the child include primary and secondary impairments, associated and comorbid health conditions, and adaptive behaviors. Literature support for the model is reviewed. A clinical scenario illustrates the use of the model as a framework for practice. The model encourages therapists to broaden the focus of rehabilitation services for young children with CP to include not only development of motor abilities but also comprehensive interventions and supports to enhance participation in daily activities and routines. Therapists are encouraged to consider how child, family, and service factors interact when planning interventions and evaluating outcomes.

Perceptions of vulnerability and variations in childrearing practices of parents of infants born preterm.

INTRODUCTION AND PURPOSE: To determine differences in Canadian, Norwegian, and Dutch parents' perceptions of vulnerability of their infants born preterm and their childrearing practices. METHODS: This observational study included 62 infants born preterm (46% boys) and their parents. Parents completed the Beliefs About My Baby Scale and the Daily Activities of Infants Scale when infants were between 4 and 11 months corrected age. One-way analyses of variance were conducted. RESULTS: Parents in the Netherlands perceived their infants as being more vulnerable than parents in the other countries (P < .001). The total Daily Activities of Infants Scale scores did not differ across countries. Parents who received therapy services had greater perceptions of their infants' vulnerability than parents not receiving services (P = .01). CONCLUSIONS: Prematurity stereotyping is not limited to North America. Service providers need to consider therapy for infants born preterm from a strength-based rather than disability perspective.

Effectiveness of Tai Chi for health promotion for adults with health conditions: a scoping review of Meta-analyses.

PURPOSE: To complete a scoping review of meta-analyses summarizing evidence of the effectiveness of Tai Chi for adults with health conditions. MATERIALS AND METHODS: Meta-analyses were retrieved from Medline, Embase, AMED, CINAHL, SPORTDiscus, PsychINFO, Web of Science, PubMed Health and the Cochrane Library from database inception to early September 2018. Multistage deduplication and screening processes identified full-length, unique, peer-reviewed meta-analyses. Two people independently appraised 42 meta-analyses based on the GRADE system and organized results into 3 appendices subsequently collated into heterogeneous, statistically significant, and statistically insignificant tables. RESULTS: "High" and "moderate" quality evidence indicates that Tai Chi can significantly benefit adults with health conditions including cancers, chronic obstructive pulmonary disease, coronary heart disease, depression, heart failure, hypertension, low back pain, osteoarthritis, osteoporosis, Parkinson's Disease and stroke. Outcomes included significant improvements in activities of daily living, balance, exercise capacity, gait, mastery, mental health, mobility, motor function, participation in daily life, physical function, quality of life, range of motion, and strength; with reductions in blood pressure, body mass index, depression, disability, dyspnea, falls, fatigue, pain, stiffness, and waist circumference. CONCLUSIONS: Healthcare providers now have information to advise clients with health conditions on the effectiveness of Tai Chi for overall health promotion. IMPLICATIONS FOR REHABILITATIONTai Chi is a form of safe, enjoyable, light-to-moderate aerobic physical activity for adults that is inexpensive to implement in diverse community settings.Adults with health conditions require physical activity for prevention of secondary impairments and over-all health promotion.This scoping review of meta-analyses elucidates "high" and "moderate" quality evidence of the effectiveness of Tai Chi in improving important outcomes for people with numerous health conditions.This information can be useful for healthcare providers who wish to recommend effective community-based physical activity to clients they are serving.

Correlates of decline in gross motor capacity in adolescents with cerebral palsy in Gross Motor Function Classification System levels III to V: an exploratory study.

AIM: To explore associations between clinical variables and decline in motor capacity in adolescents with cerebral palsy (CP). METHOD: Participants included 76 males and 59 females, whose mean age at the beginning of the study was 14 years 6 months (SD 2.4, range 11.6-17.9); 51 at Gross Motor Function Classification System (GMFCS) level III, 47 at level IV, and 37 at level V. Ninety-six participants had tetraplegia, 32 had diplegia, and one had hemiplegia. Types of motor disorder were spastic n=98; mixed, n=11; dystonic, n=9; hypotonic, n=7; and ataxic n=3 (seven participants were not classified). Reliable raters collected data annually for 4 years on anthropometric characteristics, the Spinal Alignment and Range of Motion Measure, as well as the Gross Motor Function Measure, 66 items (GMFM-66); participants or their parents reported on health status (using the Health Utilities Questionnaire), pain, and exercise participation (using measures developed for this study). The predicted drop in GMFM-66 scores after childhood was calculated using data on the same children from an earlier study. Correlations were calculated between the drop in GMFM-66 scores and the average and change scores of the clinical variables (the alpha level for statistical significance of this exploratory study was 0.10). RESULTS: The drop in GMFM-66 score was significantly correlated with limitations in range of motion (r=0.42) and spinal alignment (r=0.28), and pain (r=0.16). Increases in triceps skinfold (r=-0.19), mid-arm circumference (r=-0.23), and the ratio of mid-arm circumference to knee height (r=-0.23) were associated with less decline. INTERPRETATION: Preventing range-of-motion limitations and pain experiences and optimizing nutrition might contribute to less decline in the gross motor capacity of adolescents with CP. Further investigation is required to clarify the role other factors that contribute to maintained function over time.

Development and validation of item sets to improve efficiency of administration of the 66-item Gross Motor Function Measure in children with cerebral palsy.

AIM: To develop an algorithmic approach to identify item sets of the 66-item version of the Gross Motor Function Measure (GMFM-66) to be administered to individual children, and to examine the validity of the algorithm for obtaining a GMFM-66 score. METHOD: An algorithmic approach was used to identify item sets of the GMFM-66 (GMFM-66-IS) using data from 95 males and 79 females with cerebral palsy (CP; mean age 14y 7mo, SD 1y 8mo, range 12y 7mo to 17y 8mo). The GMFM-66-IS scores were then validated using combined data from three Dutch studies involving 134 males and 92 females with CP (mean age 7y, SD 4y 6mo, range 1y 4mo to 13y 8mo), representing all levels of the Gross Motor Function Classification System. RESULTS: The final algorithm contains three decision items from the GMFM-66 that determine which one of four item sets to administer. The GMFM-66-IS has excellent agreement with the full GMFM-66 both at a single assessment (intraclass correlation coefficient [ICC]=0.994, 95% confidence intervals [CI] 0.993-0.996) and across repeat assessments (ICC=0.92, 95% CI 0.89-0.95). INTERPRETATION: The GMFM-66-IS is a promising alternative to the full GMFM-66. Users should be consistent in their choice of measure (GMFM-66 or GMFM-66-IS) on repeat testing and clearly identify which method was used.

The prevalence, distribution, and effect of pain among adolescents with cerebral palsy.

PURPOSE: : To describe the prevalence, distribution, and intensity of pain and determine the relationship between pain intensity and effect on daily activities in adolescents with cerebral palsy. METHODS: : A sample of 104 girls and 126 boys, mean ages 14.7 (SD = 1.7) and 14.8 (SD = 1.7) years, were asked "Have you experienced physical pain in the past month?" RESULTS: : Sixty-four percent of girls and 50% of boys reported pain. Pain was most frequent in the feet and ankles, knees, and lower back of girls and boys at Gross Motor Function Classification System levels I to IV. Foot and ankle and knee pain were also frequent at level V. The Spearman rho value between intensity and effect on daily activities was 0.75 (p < 0.01) and 0.82 (p < 0.01) for girls and boys. CONCLUSIONS: : The high prevalence of pain and its effect on daily activities suggests a need for greater focus on health promotion.

Description of exercise participation of adolescents with cerebral palsy across a 4-year period.

PURPOSE: The purposes of this study were to describe (1) the types of exercise participation of adolescents with cerebral palsy; (2) the weekly duration of stretching, strengthening, and cardiovascular exercise; (3) how the level of activity compares with national health guidelines; and (4) the change in participation over 4 years. METHODS: Participants included 126 males and 104 females (mean age = 14.7 years, SD = 1.7 years) who reported physical activities in the previous week. Analyses included frequency counts and proportions, stacked bar graphs, and 2-way analyses of variance of exercise participation by Gross Motor Function Classification System (GMFCS) and sex. RESULTS: A significant main effect of GMFCS level was detected for light and moderate exercise. A significant interaction of GMFCS level and sex was found for stretching; females stretched more. An average of 9.4% and 11.4% of our sample participated in weekly levels of moderate and vigorous exercise, respectively. CONCLUSIONS: Pediatric physical therapists should promote increased exercise participation rates among youths with cerebral palsy.

Sharing of lessons learned from multisite research.

PURPOSE: To highlight key considerations for planning and implementing multisite research based on experiences and reflections in conducting a large, international, multisite study. DESCRIPTION: Successes and challenges encountered throughout a multisite study process, and collective recommendations for future researchers are presented. Considerations addressed include creation of the research team and a "community of practice," study preparation and management time, approval by institutional review boards, training of future researchers, recruitment and retention of participants, and dissemination and translation of study materials to consumers. IMPORTANCE TO MEMBERS: Multisite research has the potential to create knowledge for pediatric physical therapy through collaboration among knowledgeable researchers and expert practitioners and by increasing the potential for generalization of findings. Effective planning, including anticipation of challenges, is critical to a successful study. Our collective experiences may assist practitioners and researchers in planning, implementing, and completing future multisite studies.