Jennifer Braswell Christy

A Path Model for Evaluating Dosing Parameters for Children With Cerebral Palsy

Dosing of pediatric rehabilitation services for children with cerebral palsy (CP) has been identified as a national priority. Establishing dosing parameters for pediatric physical therapy interventions is critical for informing clinical decision making, health policy, and guidelines for reimbursement. The purpose of this perspective article is to describe a path model for evaluating dosing parameters of interventions for children with CP. The model is intended for dose-related and effectiveness studies of pediatric physical therapy interventions. The premise of the model is: Intervention type (focus on body structures, activity, or the environment) acts on a child first through the family, then through the dose (frequency, intensity, time), to yield structural and behavioral changes. As a result, these changes are linked to improvements in functional independence. Community factors affect dose as well as functional independence (performance and capacity), influencing the relationships between type of intervention and intervention responses. The constructs of family characteristics; child characteristics (eg, age, level of severity, comorbidities, readiness to change, preferences); plastic changes in bone, muscle, and brain; motor skill acquisition; and community access warrant consideration from researchers who are designing intervention studies. Multiple knowledge gaps are identified, and a framework is provided for conceptualizing dosing parameters for children with CP.

Research Summit III Proceedings on Dosing in Children With an Injured Brain or Cerebral Palsy: Executive Summary

Children with brain injuries or cerebral palsy (CP) comprise a large percentage of pediatric clients served by physical therapists. There is no consensus on what the basic parameters should be for different treatment protocols. A very important parameter of intervention that is pivotal for treatment efficacy is dosing. Dosing decisions are complex. To date, the minimum doses for changing structure and function, activity, and participation in children with various disabilities are unknown. This article describes the process and outcomes of a research summit with the goals of: (1) fostering a critical debate that would result in recommendations for the development of large-scale, second-generation research proposals to address thresholds for effective dosing of interventions for children with brain injuries or CP and (2) enhancing the research capacity of pediatric physical therapists through collaborative research networks. The summit brought together an interdisciplinary cadre of researchers (physical therapists, basic and clinical scientists), representatives from funding agencies, and consumers to an intensive 2.5-day think tank. The summit targeted questions of treatment dosage related to 3 areas: practice and neuroplasticity, structure-behavior connections, and clinical trial design. The consensus was that the intervention must demonstrate some evidence of effectiveness before optimal dosing can be investigated. Constraint-induced movement therapy (CIMT) is used as an example of an intervention that has demonstrated effectiveness and that requires dosing-related research. Summit results, including factors that merit special consideration and recommendations for future dose-related studies, are highlighted. Physical therapy is an important service for children with physical disabilities, particularly those with an injured brain resulting in neuromotor impairments and functional limitations.1 These children typically have multiple health complications that often result in complex functional limitations and require extensive health care, education, and vocational training. The costs of interventions result in substantial financial and social challenges for families and society.2 …

Reliability and diagnostic accuracy of clinical tests of vestibular function for children.

Purpose: To determine reliability, diagnostic values, and minimal detectable change scores, 90% confidence (MDC90) of pediatric clinical tests of vestibular function. Methods: Twenty children with severe to profound bilateral sensorineural hearing loss and 23 children with typical development, aged 6 to 12 years, participated. The Head Thrust Test, Emory Clinical Vestibular Chair Test, Bucket Test, Dynamic Visual Acuity, Modified Clinical Test of Sensory Interaction on Balance, and Sensory Organization Test were completed twice for reliability. Reference standard diagnostic tests were rotary chair and vestibular evoked myogenic potential. Reliability, sensitivity, specificity, predictive values, likelihood ratios, and MDC90 scores were calculated. Results: Reliability ranged from an intraclass correlation coefficient of 0.73 to 0.95. Sensitivity, specificity, and predictive values, using cutoff scores for each test representing the largest area under the curve, ranged from 63% to 100%. The MDC90 for Dynamic Visual Acuity and Modified Clinical Test of Sensory Interaction on Balance were 8 optotypes and 16.75 seconds, respectively. Conclusions: Clinical tests can be used accurately to identify children with vestibular hypofunction.

Parent and therapist perceptions of an intense model of physical therapy.

Purpose: The purpose of this study was to determine parent and therapist perceptions regarding the effect of an intense model of physical therapy for children with cerebral palsy. Methods: Informants included 5 parents, 5 therapists, and 5 children with cerebral palsy who previously participated in an intense program (ie, strengthening and functional activities 4 hours/day, 5 days/week for 3 weeks). Parents and therapists were interviewed, and children were observed. Data were collected and analyzed using qualitative methodology. Results: Five common themes emerged, based on perceptions: (1) improvement in motor function, (2) improvement in confidence and independence, (3) stress during the program but a time of no therapy between sessions, (4) increased participation in the community, and (5) fatigue during the program but perceived rapid attainment of goals. Conclusions: The constructs identified should be considered by clinicians in program development and by researchers for further study.

Falling and Mobility Experiences of Stroke Survivors and Spousal Caregivers

ABSTRACT More than 50% of survivors of stroke (SSs) fall after discharge from the hospital, some of whom sustain significant injury. The purpose of this study was to explore SSs’ and spousal caregivers’ (CGs’) lived experiences about falling and general mobility. Qualitative methods were used to perform a secondary analysis of interviews obtained from a larger study of 133 couples. Time, loss, and life changes emerged as themes in the qualitative analysis of expressers with “keep stepping no matter what,” as the overarching theme. Number of SSs were examined for reports of falls and fall-related events. Of the 133 couples, 65 were in the original studys intervention group. Sixty-six percent of the intervention group reported at least one fall, and 12% of the intervention group and total study population sustained fall-related adverse events. Health care providers can learn from the experiences of SSs and CGs related to falling and mobility for enhanced discharge planning and fall prevention. Falling can cause injury in the SS or fear of falling of the SS, CG, or both.

The effect of intense physical therapy for children with cerebral palsy

PURPOSE To determine the effect of an intense physical therapy intervention on gross motor function, community walking and participation in children with cerebral palsy (CP). METHODS A single group design was used with two pre-test and two post-test measures. Subjects were 17 ambulatory children with CP who participated in an intense intervention (i.e., four hours per day, five days per week, three weeks), a modified version of the TheraSuit protocol. Gross motor function measure (GMFM-66), Step watch activity monitor (SAM), Canadian occupational performance measure (COPM) and pediatric outcomes data collection instrument (PODCI) were tested twice at baseline, immediately following the intervention, and three months later. RESULTS Immediately following the intervention, GMFM-66, COPM and PODCI scores improved significantly (p < 0.001). At three months, improvements remained for GMFM-66 and COPM (p < 0.01). Walking amount or intensity (SAM) did not improve. CONCLUSIONS Participants improved gross motor skills and participation but not community ambulation following this intense physical therapy intervention.

Academic Difficulty and Vision Symptoms in Children with Concussion.

PURPOSE Academic difficulty is reported in children with prolonged post-concussive symptoms. Despite growing evidence that vestibular-ocular and vision-specific dysfunction are common in children after concussion, vision is rarely mentioned in return-to-learn protocols. The purpose of this project was to evaluate a cohort of children with prolonged post-concussive symptoms to determine if vision symptoms are associated with those reporting academic difficulty. METHODS Data were obtained from the Childrens of Alabama Concussion Clinic REDCap dataset from the period January 2007 to October 2013. From this dataset of 1033 concussion events, a cohort of 276 children aged 5 to 18 years with three or more concussion-related symptoms present for 10 days or more was identified. A cross-sectional cohort study was undertaken to evaluate the association of concussion symptoms, SCAT2 scores, and demographic and concussion severity markers to reported educational difficulty among children with prolonged post-concussive symptoms. Univariate and multivariate logistic regression techniques were used to model the association of reported educational difficulty to self-reported vision abnormalities. RESULTS Mean age was 13.8 years. Median time since the concussive event was 21 days, with 33% (95/276) reporting their concussion more than 30 days before data collection. Academic difficulty was reported by 29% (79/270) and vision abnormalities in 46% (128/274). After model reduction, vision symptoms (OR 2.17, 95% CI 1.02, 4.62), hearing disturbance (OR 2.39, 95% CI 1.06, 5.36), and concentration difficulty (OR 21.62, 95% CI 9.50, 44.47) remained associated with academic difficulty. For those with symptoms 30 days or more after concussion, only vision (OR 3.15, 95% CI 1.06, 9.38) and concentration difficulty (OR 15.33, 95% CI 4.99, 47.05) remained statistically significant. CONCLUSIONS Vision problems were commonly reported in children with concussions and were independently associated with those reporting academic difficulty. Comprehensive vision assessment should be considered in children reporting academic difficulty and in the development of return-to-learn protocols.

Considerations for Testing and Treating Children with Central Vestibular Impairments

This perspective explores common pediatric diagnoses that could present with central vestibular pathway dysfunction, leading to delays in motor development and postural control, and gaze instability. Specifically, the following diagnoses are considered: cerebral palsy, myelomeningocele, vestibular migraine, attention-deficit hyperactivity disorder, developmental coordination disorder, concussion, childhood cancer, congenital muscular torticollis, adolescent idiopathic scoliosis, and autism. Suggestions for clinical screening, vestibular function testing, and vestibular rehabilitation for children with these diagnoses are based on evidence for the efficacy of testing and interventions for children with peripheral vestibular hypofunction. More research is needed to explore peripheral and central vestibular function in children with these diagnoses. Testing and intervention methods may need to be modified to accommodate for the specific behavior and motor challenges that some children might present. Researchers should develop technology so that gaze stabilization exercises can be delivered in a fun, functional, and effective way.

Creative Dance Practice Improves Postural Control in a Child With Cerebral Palsy

PURPOSE To investigate the effect of creative dance instruction on postural control and balance in an 11-year-old with spastic triplegic cerebral palsy, Gross Motor Function Classification Scale level II. DESCRIPTIONS We conducted 1-hour dance interventions twice weekly for 8 weeks, with a focus on somatosensory awareness and movement in all planes of motion. Computerized dynamic posturography using the SMART Balance Master/EquiTest (NeuroCom) was used to assess postural control and balance reactions before the first class and following the final class. OUTCOMES Gains in standing stability, balance recovery, directional control, and endpoint excursion of movement were found. Participation in creative dance lessons appears to improve somatosensory effectiveness and postural control in a child with cerebral palsy. WHAT THIS CASE ADDS Dance is a fun way to improve balance and coordination. These interventions could be easily implemented into programs for children with cerebral palsy.

Development of a challenge assessment tool for high-functioning children with an acquired brain injury.

“How could I apply this information?” Consider the following: An 8-year-old boy sustained acquired brain injury (ABI) 1 year ago and presented for physical therapy evaluation. The child obtained a perfect score on the Gross Motor Function Measure and was almost age-appropriate on the Bruininks-Oseretsky Test for Motor Proficiency, Second Edition. However, he wants to return to playing soccer and riding his bicycle and is currently unable to do these activities. It is for this type of case that the Challenge Assessment (CA) was developed. The CA is an outcome tool to assess advanced gross motor skills in school-aged youth with ABI. This article describes the content validity stage of pilot testing the items on 6 children with ABI. The authors justify the need for a new tool that is sensitive to progress and ability to return to sports in higher-functioning children with ABI. The rationale is that existing outcome tools lack real-life activities, do not include tasks performed in sports, lack multidimensional dynamic tasks, or have a ceiling effect in high-functioning children with ABI and functional limitations. The CA was developed in the following stages: On the basis of review of the literature and existing outcome tools, an expert panel (n = 4) chose items (n = 78) to each represent a gross motor category. Items were judged by experts (n = 75) who scored each item on safety, feasibility, and importance. Items that met a priori criteria (n = 28 items) were chosen for pilot testing on 6 children with ABI. Table 2 provides the participants’ scores for each item. Instructions and scoring for each item were adjusted on the basis of observations and feedback from subjects in the pilot study. The test took 1 hour to complete, children were not fatigued, and there did not appear to be a ceiling or floor effect.