Carolyn B. Heriza

Single-subject research design: recommendations for levels of evidence and quality rating.

The aim of this article is to present a set of evidence levels, accompanied by 14 quality or rigor questions, to foster a critical review of published single‐subject research articles. In developing these guidelines, we reviewed levels of evidence and quality/rigor criteria that are in wide use for group research designs, e.g. randomized controlled trials, such as those developed by the Treatment Outcomes Committee of the American Academy for Cerebral Palsy and Developmental Medicine. We also reviewed methodological articles on how to conduct and critically evaluate single‐subject research designs (SSRDs). We then subjected the quality questions to interrater agreement testing and refined them until acceptable agreement was reached. We recommend that these guidelines be implemented by clinical researchers who plan to conduct single‐subject research or who incorporate SSRD studies into systematic reviews, and by clinicians who aim to practise evidence‐based medicine and who wish to critically review pediatric single‐subject research.

Neonatal Physical Therapy. Part II: Practice Frameworks and Evidence-Based Practice Guidelines

Purpose: (1) To outline frameworks for neonatal physical therapy based on 3 theoretical models, (2) to describe emerging literature supporting neonatal physical therapy practice, and (3) to identify evidence-based practice recommendations. Key Points: Three models are presented as a framework for neonatal practice: (1) dynamic systems theory including synactive theory and the theory of neuronal group selection, (2) the International Classification of Functioning, Disability and Health, and (3) family-centered care. Literature is summarized to support neonatal physical therapists in the areas of examination, developmental care, intervention, and parent education. Practice recommendations are offered with levels of evidence identified. Conclusions: Neonatal physical therapy practice has a theoretical and evidence-based structure, and evidence is emerging for selected clinical procedures. Continued research to expand the science of neonatal physical therapy is critical to elevate the evidence and support practice recommendations.

Neonatal physical therapy. Part I: clinical competencies and neonatal intensive care unit clinical training models.

Purpose: To describe clinical training models, delineate clinical competencies, and outline a clinical decision-making algorithm for neonatal physical therapy. Key Points: In these updated practice guidelines, advanced clinical training models, including precepted practicum and residency or fellowship training, are presented to guide practitioners in organizing mentored, competency-based preparation for neonatal care. Clinical competencies in neonatal physical therapy are outlined with advanced clinical proficiencies and knowledge areas specific to each role. An algorithm for decision making on examination, evaluation, intervention, and re-examination processes provides a framework for clinical reasoning. Because of advanced-level competency requirements and the continuous examination, evaluation, and modification of procedures during each patient contact, the intensive care unit is a restricted practice area for physical therapist assistants, physical therapist generalists, and physical therapy students. Conclusions/Practice Implications: Accountable, ethical physical therapy for neonates requires advanced, competency-based training with a preceptor in the pediatric subspecialty of neonatology.

Pediatric Physical Therapy: Part I. Practice Scope, Scientific Basis, and Theoretical Foundation.

Widespread change has occurred in pediatric physical therapy and in the scientific and theoretical foundations of the specialty since the poliomyelitis epidemics in the 1890s. The focus in this first article of a two-part series is on the scope of clinical practice, scientific basis, and theoretical foundation of pediatric physical therapy. In the second article, methods of assessing and treating movement dysfunction and physical disability will be addressed, as well as analyses of efficacy studies.

Clinimetric properties of the alberta infant motor scale in infants born preterm.

Purpose: The Alberta Infant Motor Scale (AIMS) is a standardized motor assessment for young infants. This study aimed to examine the reliability of the AIMS in a group of infants born at or before 29 weeks of gestation. Methods: Fifty-nine infants born preterm were recruited. Two experienced pediatric physical therapists participated in this reliability study. Infants were assessed at 4, 8, 12, and 18 months corrected age (CA). Results: Intrarater reliability was high (intraclass correlation coefficient [ICC] ≥0.99). The ICC for interrater reliability varied from 0.85 to 0.97. The ICC was low at 4 and 18 months CA. Conclusions: The AIMS is reliable in evaluating motor development in infants born preterm. Clinicians should be cautious about using the AIMS in infants at very young ages and those approaching independent ambulation. Accurate placement of the window on a movement repertoire is crucial. Attention is required when using the AIMS in infants developing atypically.

Practice Guidelines for the Physical Therapist in the Neonatal Intensive Care Unit (NICU)

Neonatal physical therapy is an advanced practice, subspecialty area within pediatric physical therapy. Because of the structural, physiological, and behavioral vulnerabilities of neonates, pediatric physical therapists need postprofessional precepted training and experience before providing neonata

Gastrocnemius-Soleus Muscle Tendon Unit Changes Over the First 12 Weeks of Adjusted Age in Infants Born Preterm

Background and Purpose: Differences in the gastrocnemius-soleus muscle and tendon have been documented shortly after birth in infants born preterm compared with infants born at term. Knowledge of muscle tendon unit lengths at term age to 12 weeks of age in infants born preterm may be useful in understanding motor development. Participants and Method: Gastrocnemius-soleus muscle tendon unit lengths were compared at term age, at 6 weeks of age, and at 12 weeks of age (preterm adjusted age) in 20 infants born full term and 22 infants born preterm. Results: Significant differences were found between the 2 groups on taut tendon, relaxed muscle length (AO); taut tendon, stretched muscle length (AMax); and muscle stretch (AO to AMax). Infants born preterm demonstrated measures of AO and AMax in positions of greater plantar flexion compared with infants born full term. Significant differences in measurements of AO were found between term age and 12 weeks of age, indicating that the tendon lengthens during this period for both groups. Discussion and Conclusion: These results provide knowledge of musculoskeletal development of the gastrocnemius-soleus muscle and tendon. Differences in musculoskeletal measurements are consistent with uterine confinement in the last weeks of full-term gestation. These findings have implications when examining the musculoskeletal system in infants born preterm who are demonstrating functional changes.

Considerations for single-subject research designs.

The lead article in this issue by Johnson and colleagues uses a single-subject design (SSD). Like all research designs, SSDs have strengths and limitations1 in comparison to randomized controlled trials that are typically considered the “reference standard” design for intervention research.2 One advantage is applicability in the clinic. A single-subject participant may have characteristics that more closely match a specific patient and the intervention and results may then directly inform clinical practice. Randomized controlled trials have samples that may not fit as well to a specific patient’s characteristics, thus making the applicability more challenging. Of course, this strength is also the weakness in terms of applicability, as results from an SSD are more challenging to apply to patients with a wider range in the characteristics of interest. Designs are chosen to answer specific questions and to address certain constraints of implementation. This makes SSDs a reasonable alternative for implementation in a clinical setting and by clinician/researcher teams. Johnson and colleagues assembled such a team and implemented a variation of SSDs: a multiple baseline multiple probe design.3 In this design, durations of baselines, the number of data points in baselines, and the number of measurement points during intervention all varied by subject and the specific task. While this presents challenges for interpretation, it also provides detailed information regarding specific points when specific patients may benefit from an intervention. This design is used typically for interventions with tasks that have multiple components

Student experiences in the neonatal intensive care unit: addendum to neonatal physical therapy competencies and clinical training models.

PURPOSE To describe the appropriate experience for entry-level physical therapist students in the neonatal intensive care unit (NICU). KEY POINTS Care for infants in the NICU represents a subspecialty within pediatric physical therapy delivered in a very complex environment. Recommendations for designing student educational experiences related to the NICU are provided. CONCLUSIONS/PRACTICE IMPLICATIONS Supervised observation is the appropriate level of NICU experience for physical therapy students. Observation in the NICU cannot be used to demonstrate entry-level clinical competency defined as managing 100% patient caseload in the setting. Additional closely supervised experiences with older, less fragile infants and children in neonatal follow-up clinics and pediatric wards can provide opportunities for entry-level physical therapist students interested in pediatrics to participate in examination and intervention with young children.

Effects of NICU intervention on preterm infants: Part 1—Implications for neonatal practice

Dynamic models of development in infants are described within the context of the neonatal intensive care unit (NICU) environment. Clinical studies of the effects of NICU developmental intervention, which relate to movement parameters and behavioral state, are analyzed. Implications of the reviewed studies for neonatal developmental treatment planning and NICU intervention are discussed. Recommendations for research designs and instrumentation for future studies of infant movement will be offered in Part II appearing in the next issue.