Emmah Baque

Mitii™ ABI: Study protocol of a randomised controlled trial of a web-based multi-modal training program for children and adolescents with an Acquired Brain Injury (ABI)

BackgroundAcquired brain injury (ABI) refers to multiple disabilities arising from damage to the brain acquired after birth. Children with an ABI may experience physical, cognitive, social and emotional-behavioural impairments which can impact their ability to participate in activities of daily living (ADL). Recent developments in technology have led to the emergence of internet-delivered therapy programs. “Move it to improve it” (Mitii™) is a web-based multi-modal therapy that comprises upper limb (UL) and cognitive training within the context of meaningful physical activity. The proposed study aims to compare the efficacy of Mitii™ to usual care to improve ADL motor and processing skills, gross motor capacity, UL and executive functioning in a randomised waitlist controlled trial.Methods/DesignSixty independently ambulant children (30 in each group) at least 12 months post ABI will be recruited to participate in this trial. Children will be matched in pairs at baseline and randomly allocated to receive either 20 weeks of Mitii™ training (30 min per day, six days a week, with a potential total dose of 60 h) immediately, or be waitlisted for 20 weeks. Outcomes will be assessed at baseline, immediately post-intervention and at 20 weeks post-intervention. The primary outcomes will be the Assessment of Motor and Process Skills and 30 s repetition maximum of functional strength exercises (sit-to-stand, step-ups and half kneel to stand). Measures of body structure and functions, activity, participation and quality of life will assess the efficacy of Mitii™ across all domains of the International Classification of Functioning, Disability and Health framework. A subset of children will undertake three tesla (3T) magnetic resonance imaging scans to evaluate functional neurovascular changes, structural imaging, diffusion imaging and resting state functional connectivity before and after intervention.DiscussionMitii™ provides an alternative approach to deliver intensive therapy for children with an ABI in the convenience of the home environment. If Mitii™ is found to be effective, it may offer an accessible and inexpensive intervention option to increase therapy dose.Trial RegistrationANZCTR12613000403730

Randomized controlled trial of web-based multimodal therapy for children with acquired brain injury to improve gross motor capacity and performance

Objective: To compare efficacy of a web-based multimodal training programme, ‘Move it to improve it’ (MitiiTM), to usual care on gross motor capacity and performance for children with an acquired brain injury. Design: Randomized waitlist controlled trial. Setting: Home environment. Participants: A total of 60 independently ambulant children (30 in each group), minimum 12 months post-acquired brain injury were recruited and randomly allocated to receive either 20 weeks of MitiiTM training (30 minutes/day, six days/week, total 60 hours) immediately, or waitlisted (usual care control group) for 20 weeks. A total of 58 children completed baseline assessments (32 males; age 11 years 11 months ± 2 years 6 months; Gross Motor Function Classification System equivalent I = 29, II = 29). Intervention: The MitiiTM program comprised of gross motor, upper limb and visual perception/cognitive activities. Main measures: The primary outcome was 30-second, repetition maximum functional strength tests for the lower limb (sit-to-stand, step-ups, half-kneel to stand). Secondary outcomes were the 6-minute walk test, High-level Mobility Assessment Tool, Timed Up and Go Test and habitual physical activity as captured by four-day accelerometry. Results: Groups were equivalent at baseline on demographic and clinical measures. The MitiiTM group demonstrated significantly greater improvements on combined score of functional strength tests (mean difference 10.19 repetitions; 95% confidence interval, 3.26–17.11; p = 0.006) compared with the control group. There were no other between-group differences on secondary outcomes. Conclusion: Although the MitiiTM programme demonstrated statistically significant improvements in the functional strength tests of the lower limb, results did not exceed the minimum detectable change and cannot be considered clinically relevant for children with an acquired brain injury. Clinical Trial Registration: Australian New Zealand Clinical Trials Registration Number, ANZCTR12613000403730.

Reproducibility in measuring physical activity in children and adolescents with an acquired brain injury

Abstract Aim: To examine the reproducibility in measurement of physical activity performance using the ActiGraph® GT3X+ accelerometer in children aged 8–16 years with Acquired Brain Injury (ABI). Methods: Reproducibility of standardized tasks: Thirty-two children with ABI (12 years 1 month, SD = 2 years 4 months; 20 males; Gross Motor Function Classification System I = 17, II = 15) performed the following activities on 2 consecutive days while wearing an accelerometer and a heart rate monitor: quiet sitting, slow walking (SW), moderate walking (MW), fast walking (FW) and rapid stepping on/off a block (STEP). Intra-class correlation coefficients (ICC) were calculated. Performance variability: Fifty-one participants (12 years 1 month, SD = 2 years 5 months; 27 males; GMFCS I = 26, II = 25) wore an accelerometer for 4 days in the community and reliability coefficients were calculated using standardized 12-hour time spent in moderate-to-vigorous physical activity (MVPA). Results: Test–re-test reproducibility was excellent for all activities (SW, ICC = 0.90; MW, ICC = 0.83; FW, ICC = 0.91; STEP, ICC = 0.89). Three days of monitoring produced excellent variability estimates of MVPA (R = 0.78). Conclusion: Therapists can confidently use accelerometry as a reproducible measure of physical activity under standardized walking and stepping conditions, as well as in the community for children with ABI.

Test-re-test reproducibility of activity capacity measures for children with an acquired brain injury.

Abstract Objective: To determine test–re-test reproducibility of the Timed Up & Go (TUG) test, 30-second repetition maximum (repmax) of functional exercises, 6-Minute Walk Test (6MWT) and High-level Mobility Assessment Tool (HiMAT) in children with Acquired Brain Injury (ABI). Secondarily, to assess the accuracy between hand-timed and video-timed scores for the TUG test and HiMAT. Methods: Thirty children at least 1 year post-ABI (mean age at assessment = 11 years 11 months, SD = 2 years 4 months; 14 males; Gross Motor Function Classification Scale I = 17, II = 13) were assessed twice. Intra-class correlation coefficients (ICC), standard error of measurement and minimum detectable change (MDC) were determined. The Bland-Altman method and 95% limits of agreement (LOA) were used to assess the agreement between hand and video-timed TUG test and HiMAT scores. Results: Test–re-test reproducibility was acceptable for the TUG test (ICC = 0.92; MDC = 1.2s); repmax of functional exercises (ICC = 0.84–0.98; MDC = 4–8 reps); 6MWT (ICC = 0.90; MDC = 69.38 m) and HiMAT (ICC = 0.98; MDC = 6). Comparison of hand and video scores for the TUG test and HiMAT demonstrated a mean difference of 0.23 (LOA = –0.3–0.7) and –0.07 (LOA = –1.99–1.85), respectively. Conclusions Test–re-test reproducibility of lower limb activity capacity measures in children with ABI are acceptable. The MDC scores provide a useful reference to interpret treatment effectiveness. Video timing was more accurate than hand-timing for the TUG test.

Characteristics associated with physical activity capacity and performance in children and adolescents with an acquired brain injury

ABSTRACT Aim: To examine characteristics associated with physical activity capacity and performance in children with acquired brain injury (ABI). Methods: 58 children (32 men; age 11 years 11 months ± 2 years 6 months; Gross motor function classification system [GMFCS] equivalent I = 29, II = 29) >12 months post ABI were recruited. Physical activity capacity measures included: (i) combined score of three 30-second repetition maximum functional strength exercises; (ii) timed up and go; (iii) 6-minute walk test and (iv) high-level mobility assessment tool (HiMAT). Physical activity performance determined time spent in sedentary, light and moderate to vigorous physical activity (MVPA). Full scale intelligence quotient (FSIQ) was assessed using the Wechsler intelligence scale for Children-IV. Regression models were constructed with functional strength score (n = 56), activity counts/minutes and time spent in MVPA and sedentary (n = 37). Results: The HiMAT and FSIQ explained 69% of the variance in functional strength. Age explained 12% of the variance in counts/min and 14% of the variance in time spent sedentary. GMFCS explained 10% of the variance in time spent in MVPA. Conclusions: The ability to perform functional strength exercises is associated with mobility beyond independence and adequate intellectual ability for children with ABI. Age was the most significant factor associated with physical activity performance, and interventions should target adolescents with ABI.

Randomised controlled trial of a web-based multi-modal training program on gross motor capacity and performance for children with an acquired brain injury

centage frequency of attendance of 85.1 8.7%. Conclusions/Significance: VR intervention encouraged attendance and was an effective intervention to improve clinically meaningful gross motor function in children with GMFCS level I/II. We believe that interaction between the biomechanical demands and multisensory feedbacks provided by the performance of the games allows an increase in the levels of motivation of the children during therapy and determines improvements in complex motor action.

Validity of accelerometry to measure physical activity in children with acquired brain injury

Background/Objectives: Pediatric intrathecal baclofen pump infection rates of 4% to 21% have been reported in the literature. A majority of pump infections have been shown to be surgically acquired. It is necessary to refill baclofen pumps on a scheduled basis which is an invasive procedure performed with aseptic technique. Evidence for infection related to baclofen pump refills is underreported in the literature. Study Design: A retrospective chart review of all patients undergoing placement of intrathecal baclofen pump at Cook Children’s Medical Center as a quality improvement initiative. Study Participants and Setting: The study period spans 16 years from program inception in 1998 through December 2014 and includes all patients undergoing placement or replacement of intrathecal pumps. Materials/Methods: Patients with pump infections were identified, and sorted with regard to timing and etiology of infection. Three experienced pediatric neurosurgeons are responsible for all pump surgeries. The institutional practice is to train and keep a small, dedicated number of personnel including physicians, a clinical nurse specialist, and nurse practitioners prepared to refill the pumps following aseptic precautions either in a clinic or inpatient setting. Training for refills is provided from a single individual initially with ongoing monitoring of trainees performing refill procedures for several months. Two people are usually present during the refill. Results: Two hundred seventy-five pumps have been placed during the 16 year study period (mean 10.6 per year). There were 195 initial placements and 80 pump replacements. Mean age at implant was 10 years. Cerebral palsy was the most common indication for implant (n=135; 69%). A total of 14 pump infections in 13 patients occurred during this period, an overall infection rate of 5%. One patient with chronic cellulitis had 2 separate explants for infection at days 15 and 57 post pump placements. Seven patients with cerebral palsy developed an infection (5.2%) and did not differ from the entire cohort. Mean age of all patients with infection is 10.1 years. Excluding two late infections (122 and 964 days from implant) that occurred in the context of chronic cellulitis, mean duration from implant to identification of infection is 20 days Six pumps were re-implanted after infection was treated with a mean interval of 238 days. Seven families opted not to have pump re-implanted. One patient with an acquired post-infectious dystonia had resolution of symptoms and ITB was no longer deemed appropriate. Conclusions/Significance: Most (71%) ITB pump infections occured within 36 days of implantation and could be attributed to surgical infection. Late infections (n=3) were noted in only 1% of patients, and were all attributable to external factors. No infections could be related to refill procedure. ITB pump management done by a dedicated group under controlled circumstances can be done safely in the pediatric population with a minimal risk of infection. SP5 Validity of accelerometry to measure physical activity in children and adolescents with an acquired brain injury E BAQUE, L BARBER, L SAKZEWSKI, R BOYD The University of Queensland, Brisbane, Qld, Australia; Queensland Cerebral Palsy and Rehabilitation Research Centre, The University of Queensland, Brisbane, Qld, Australia

Validity of Accelerometry to Measure Physical Activity Intensity in Children With an Acquired Brain Injury

Purpose: To evaluate the validity of the ActiGraph accelerometer (AG) to differentiate between standardized, physical activity tasks using oxygen consumption ( O2) as the criterion measure in children and adolescents with an acquired brain injury; to determine vector magnitude activity intensity cut-points; to compare performance of cut-points to previously published cut-points. Methods: Twenty-seven children performed standardized walking and stepping activities wearing a portable indirect calorimeter, AG, and heart rate monitor. Differences in O2 and AG vector magnitude activity counts were measured during activities. Receiver operating characteristic curves were determined for intensity cut-points. Results: O2 and AG activity counts significantly increased as walking speed increased. Discrimination of the newly derived cut-points was excellent and demonstrated greater agreement compared with the previously published cut-points. Conclusion: Output from accelerometers can differentiate physical activity intensity in children with an acquired brain injury. Future studies can apply these cut-points to evaluate physical activity performance.

Randomised controlled trial of web-based multimodal therapy for children with acquired brain injury to improve gross motor capacity and performance

1Brain Resource Company, Sydney, Australia; 2Brain Dynamics Centre, Westmead Millenium Institute and University of Sydney, Sydney, Australia; 3Neuroscience Institute of Schizophrenia and Allied Disorders, Sydney, Australia; 4Early Psychosis Intervention Program, Liverpool Hospital, NSW, Australia; 5Department of Psychiatry, University of Adelaide, SA, Australia; and 6The University of Sydney, Sydney, Australia