Gevorg Chilingaryan

Participation and Enjoyment of Leisure Activities in School-Aged Children with Cerebral Palsy.

The objective of this study was to characterize participation in leisure activities in children with cerebral palsy (CP) and identify determinants of greater involvement. Ninety‐five children of school age (9y 7mo [SD 2y 1mo]) with CP were recruited, and participation was evaluated with the Children’s Assessment of Participation and Enjoyment in a subset (67/95; 42 males, 25 females) who could actively participate in completion of the assessment. Most had mild motor dysfunction (Gross Motor Function Classification System: 59% level I, 23% level II, 18% levels III–V) and had a spastic subtype of CP (23 hemiplegia, 17 diplegia, 16 quadriplegia, 11 other). Biomedical, child, family and environmental predictor variables were considered in the analysis. Results demonstrated that these children were actively involved in a wide range of leisure activities and experienced a high level of enjoyment. However, involvement was lower in skill‐based and active physical activities as well as community‐based activities. Mastery motivation and involvement in rehabilitation services enhanced involvement (intensity and diversity) in particular leisure activities, whereas cognitive and behavioral difficulties, activity limitations, and parental stress were obstacles to participation.

Validity of Movement Pattern Kinematics as Measures of Arm Motor Impairment Poststroke

Background and Purpose— Upper limb motor impairment poststroke is commonly evaluated using clinical outcome measures such as the Fugl-Meyer Assessment. However, most clinical measures provide little information about motor patterns and compensations (eg, trunk displacement) used for task performance. Such information is obtained using movement quality kinematic variables (joint ranges, trunk displacement). Evaluation of movement quality may also help distinguish between levels of motor impairment severity in individuals poststroke. Our objective was to estimate concurrent and discriminant validity of movement quality kinematic variables for pointing and reach-to-grasp tasks. Methods— A retrospective study of kinematic data (sagittal trunk displacement, shoulder flexion, shoulder horizontal adduction, elbow extension) and Fugl-Meyer Assessment scores from 86 subjects (subacute to chronic stroke) performing pointing and reaching tasks was done. Multiple and logistic regression analyses were used to estimate concurrent and discriminant validity respectively. Cutoff points for distinguishing between levels of upper limb motor impairment severity (mild, moderate to severe) were estimated using sensitivity/specificity decision plots. The criterion measure used was the Fugl-Meyer Assessment (upper limb section). Results— The majority of variance in Fugl-Meyer Assessment scores was explained by a combination of trunk displacement and shoulder flexion (51%) for the pointing task and by trunk displacement alone (52%) for the reach-to-grasp task. Trunk displacement was the only variable that distinguished between levels of motor impairment severity. Cutoff points were 4.8 cm for pointing and 10.2 cm for reach-to-grasp movements. Conclusion— Movement quality kinematic variables are valid measures of arm motor impairment levels poststroke. Their use in regular clinical practice and research is justified.

Injury to the Premature Cerebellum: Outcome is Related to Remote Cortical Development

Cerebellar injury is an important complication of preterm birth with far-reaching neuropsychiatric sequelae. We have previously shown a significant association between isolated injury to the premature cerebellum and subsequent impairment of regional volumetric growth in the contralateral cerebrum. In the current study, we examine the relationship between these remote regional impairments of cerebral volumetric growth and domain-specific functional deficits in these children. In 40 ex-preterm infants with isolated cerebellar injury, we performed neurodevelopmental evaluations and quantitative magnetic resonance imaging (MRI) studies at a mean age of 34 months. We measured cortical gray matter volumes in 8 parcellated regions of each cerebral hemisphere, as well as right and left cerebellar volumes. We show highly significant associations between early signs of autism and dorsolateral prefrontal cortex volume (P < 0.001); gross motor scores and sensorimotor cortical volumes (P < 0.001); and cognitive and expressive language scores and premotor and mid-temporal cortical volumes (P < 0.001). By multivariate analyses, each unit increase in the corresponding regional cerebral volume was associated with lower odds of abnormal outcome score, adjusted for age at MRI and contralateral cerebellar volume. This is the first report linking secondary impairment of remote cerebral cortical growth and functional disabilities in survivors of prematurity-related cerebellar brain injury.

Arm Motor Recovery Using a Virtual Reality Intervention in Chronic Stroke Randomized Control Trial

Introduction. Despite interest in virtual environments (VEs) for poststroke arm motor rehabilitation, advantages over physical environment (PE) training have not been established. Objective. The authors compared kinematic and clinical outcomes of dose-matched upper-limb training between a 3D VE and a PE in chronic stroke. Methods: Participants (n = 32) were randomized to a 3D VE or PE for training. They pointed to 6 workspace targets (72 trials, 12 trials/target, randomized) for 12 sessions over 4 weeks with similar feedback on precision, movement speed, and trunk displacement. Primary (kinematics, clinical arm motor impairment) and secondary (activity level, arm use) outcomes were compared by time (PRE, POST, and follow-up, RET), training environment, and impairment severity (mild, moderate-to-severe) using mixed-model analyses of variance (ANOVAs). Results. Endpoint speed, overall performance on a reach-to-grasp task, and activity levels increased in both groups. Only participants in the VE group improved shoulder horizontal adduction at POST (9.5°) and flexion at both POST (6.3°) and RET (13°). Impairment level affected outcomes. After VE training, the mild group increased elbow extension (RET, 25.5°). The moderate-to-severe group in VE increased arm use at POST (0.5 points) and reaching ability at RET (2.2 points). The moderate-to-severe group training in PE increased reaching ability earlier (POST, 1.7 points) and both elbow extension (10.7°) and arm use (0.4 points) at RET, but these changes were accompanied by increased compensatory trunk displacement (RET, 30.2 mm). Conclusion. VE training led to more changes in the mild group and a motor recovery pattern in the moderate-to-severe group indicative of less compensation, possibly because of a better use of feedback.

Cerebellar Injury in the Premature Infant Is Associated With Impaired Growth of Specific Cerebral Regions

We have shown that cerebellar injury in the premature infant is followed by significant growth impairment of the contralateral cerebral hemisphere evident as early as term adjusted age. In this study, we hypothesize that this remote growth restriction is region specific in the cerebrum. In a prospectively enrolled cohort of 38 expreterm infants with isolated cerebellar injury by neonatal MRI, we performed follow-up volumetric MRI studies at a mean postnatal age of 35.5 ± 13.8 mo. We measured volumes of cortical and subcortical gray matter, and cerebral white matter within eight parcellated regions for each cerebral hemisphere. Unilateral cerebellar injury (n = 24) was associated with significantly smaller volumes of cortical gray and cerebral white matter in the following regions of the contralateral (versus ipsilateral) cerebral hemisphere: dorsolateral prefrontal, premotor (PM), sensorimotor, and midtemporal regions (p < 0.001 for all except midtemporal cortical gray, p = 0.01), as well as subcortical gray matter in the PM region (p < 0.001). Conversely, in cases of bilateral cerebellar injury (n = 14), there was no significant interhemispheric difference in tissue volumes for any of the cerebral regions studied. These findings suggest that regional cerebral growth impairment results from interruption of cerebellocerebral connectivity and loss of neuronal activation critical for development.

Leisure Activity Preferences for 6- To 12-Year-Old Children with Cerebral Palsy.

Aim  The objective was to describe leisure activity preferences of children with cerebral palsy (CP) and their relationship to participation. Factors associated with greater interest in leisure activities were identified.

Clinical evaluation of dynamic visual acuity in subjects with unilateral vestibular hypofunction.

Objectives: The objectives of this study are threefold: 1) to examine the effect of frequency of head motion on the clinical dynamic visual acuity (DVA) score in subjects with unilateral vestibular hypofunction (UVH); 2) to compare DVA scores between subjects with UVH and subjects with a complete unilateral vestibular deficit; and 3) to establish whether a relationship exists between the extent of the vestibular deficit and the DVA score. Design: Experimental study. Setting: Vestibular outpatient rehabilitation program. Methods: A convenience sample of 10 subjects with UVH. Main Outcome Measures: Dynamic visual acuity scores were recorded using 2 standard acuity charts: Snellen and E-chart. The DVA scores were obtained at slow (0.5 Hz), moderate (1 and 1.5 Hz), and fast (2.0 Hz) frequencies of head motion in the horizontal and the vertical planes. Percentage of caloric weakness was compared with DVA scores in each subject to test whether a relationship exists between the two. Results: As the frequency of head motion increased, the number of UVH subjects with an abnormal DVA score increased. Subjects with an abnormal DVA score at 1 Hz had the same or higher score as the frequency of the head motion was increased. Spearman correlation analyses revealed low-correlation coefficients between percentage of vestibular paresis at the caloric test and DVA scores (horizontal direction: r = 0.31, p = 0.38 for Snellen chart and r = −0.33, p = 0.35 for the E-chart; vertical: r = 0.05, p = 0.91 for the Snellen chart and r = −0.28, p = 0.50 for the E-chart). Conclusion: Subjects with UVH manifest impaired DVA. The frequency of head motion has an impact on clinical DVA scores in UVH subjects.

Visual vertigo analogue scale: An assessment questionnaire for visual vertigo

A common symptom for people with vestibulopathy is dizziness induced by dynamic visual input, known as visual vertigo (VV). The goal of this study is to present a novel method to assess VV, using a nine-item analog scale. The subjects rated the intensity of their dizziness on each item of the Visual Vertigo Analogue Scale (VVAS), which represented a daily situation typically inducing VV. The questionnaire was completed by participants with vestibulopathy (n=102) and by subjects receiving out-patient orthopaedic physiotherapy (n=102). The dizziness handicap inventory (DHI) was also completed by the vestibulopathic group. The Cronbachs Alpha index indicated the VVAS is internally consistent and reliable (Cronbachs Alpha=0.94). The study also found that the VVAS severity scores from vestibular and a non-vestibular population were significantly different (Wilcoxon-Mann Whitney test p < 0.0001). Spearman correlation analysis conducted between DHI and VVAS scores for the clients with vestibulopathy showed positive moderate correlations between the VVAS score and the total DHI score (r=0.67, p< 0.0001). This study showed that the VVAS scale may be useful in providing a quantitative evaluation scale of visual vertigo.

Clinical Management of Musculoskeletal Injuries in Active Children and Youth

Objective: To describe how different health care specialists manage musculoskeletal injury in children and examine factors influencing return to play decisions. Design: National survey. Setting: Secure Web site hosting online questionnaire. Participants: Medical doctors, physical therapists, and athletic therapists who were members of their respective sport medicine specialty organizations. Independent Variables: Professional affiliation and the effect of the following factors were examined: pushy parent, cautious parent, protective equipment, previous injury, musculoskeletal maturity, game importance, position played, team versus individual sport, and time since injury. Main Outcome Measures: Recommendation of return to activity after common injuries seen in children and adolescents as described in 5 vignettes; consistency of responses across vignettes. Results: The survey was completed by 464 respondents (34%). There were several differences between the professional groups in their recommendations to return to activity. Most factors studied did not tend to influence the decision to return to activity, although protective equipment often increased the response to return sooner. The number of participants who would return a child to activity sooner or later for each factor varied greatly across the 5 vignettes, except for pushy parent or cautious parent. Conclusions: Management practices of sport medicine clinicians vary according to profession, child, clinical factors, and sport-related factors. Decisions regarding return to play vary according to 5 specific characteristics of each clinical case. These findings help establish areas of consensus and disagreement in the management of children with injuries and safe return to physical activity.

Participation in Leisure Activities among Canadian Children with Arthritis: Results from a National Representative Sample

Objective. To describe the level of participation in leisure activities among children and youth with arthritis, as well as to identify the sociodemographic (age, sex, family income), disease-related (functional limitations, disease duration, pain, medication use, child’s need for assistance), and contextual factors (use of rehabilitation services, proximity of local recreation facilities, cost of activities) that may be associated. Methods. Data from the Participation and Activity Limitation Survey (PALS) 2006, a Canadian postcensus survey, was analyzed. Bivariate and multivariable linear regression analyses were applied to examine the associations between the sample’s level of participation in leisure activities, and sociodemographic, disease-related, and contextual characteristics. Results. In Canada in 2006, an estimated 4350 children ranging in age from 5 to 14 years were living with arthritis. Fifty-six percent of parents reported that arthritis restricted their child’s participation in leisure activities. Bivariate analysis showed that the availability of local recreational facilities, the affordability of activities, and the child not requiring any assistance were all associated (modified Bonferroni correction α < 0.005) with greater participation in various types of leisure activities. Multiple linear regressions showed that higher family income (β 0.47, 95% CI 0.09, 0.85) and greater perceived pain (β 0.59, 95% CI 0.07, 1.10) were positively associated with involvement in informal leisure. Conclusion. Our findings underline the importance of considering contextual factors in developing treatment plans aimed at improving participation in leisure activities among children with arthritis. Future longitudinal studies targeting children living with arthritis could provide pertinent information on participation over fluctuations in disease status.