Linda Fetters

Quantitative assessment of infant reaching movements.

We have identified a fundamental property of human motor behavior as a tight coupling of the curvature-speed relationship in the reaching movements of 5- to 9-month-old infants. This relationship termed a movement unit, occurs regardless of the distance of duration of the reach and in spite of the developmental change that occurs in grasping during this period. Movement unit durations are tightly clustered around 200 ms regardless of overall duration or distance or the position of the unit in the reach. The curvature-speed coupling has been identified by others in adult reaching and handwriting. Models of biological motor control must account for this invariant relationship.

Bound for Success: A Systematic Review of Constraint-Induced Movement Therapy in Children With Cerebral Palsy Supports Improved Arm and Hand Use

Background Constraint-induced movement therapy (CIMT) is a potentially effective intervention for children with hemiplegic cerebral palsy (CP). Purpose The objectives of this systematic review are: (1) to investigate whether CIMT is supported with valid research of its effectiveness and (2) to identify key characteristics of the child and intervention protocol associated with the effects of CIMT. Data Sources and Study Selection A search of MEDLINE (1966 through March 2009), Entrez PubMed (1966 through March 2009), EMBASE (1980 through March 2009), CINAHL (1982 through March 2009), PsychINFO (1887 through March 2009), and Web of Science (1900 through March 2009) produced 23 relevant studies. Data Extraction and Synthesis The 2 objectives of the review were addressed by: (1) scoring the validity and level of evidence for each study and calculating evidence-based statistics, if possible, and (2) recording and summarizing the inclusion and exclusion criteria, type and duration of constraint, intervention and study durations, and outcomes based on the International Classification of Functioning, Disability and Health (ICF). Limitations Only studies published in journals and in English were included in the systematic review. Conclusions Studies varied widely in type and rigor of design; subject, constraint, and intervention characteristics; and ICF level for outcome measures. One outcome measure at the body functions and structure level and 4 outcome measures at the activity level had large and significant treatment effects (d≥.80), and these findings were from the most rigorous studies. Evidence from more-rigorous studies demonstrated an increased frequency of use of the upper extremity following CIMT for children with hemiplegic CP. The critical threshold for intensity that constitutes an adequate dose cannot be determined from the available research. Further research should include a priori power calculations, more-rigorous designs and comparisons of different components of CIMT in relation to specific children, and measures of potential impacts on the developing brain.

Making the mobile move: Constraining task and environment

We examined the effects of mobile reinforcement on intralimb coordination of kicking of 4-month-olds with and without ankle weight. Subjects in each of two experiments were 10 healthy, 4-month full-term infants. The experimental protocol was 2-min of baseline (spontaneous kicking), 8-min of acquisition (mobile reinforcement without weight (Experiment I) and with weight (Experiment II)), 4-min of extinction (spontaneous kicking). Kicks were differentiated based on foot contact/no contact with a touch pad that triggered the mobile. Intralimb kicking patterns were defined from in-phase (flexing or extending) to out-of-phase (flexing and extending). Infants in both experiments successfully learned to contact the panel during acquisition. Contact kicks were less in-phase than no-contact kicks. In Experiment I, mobile reinforcement elicited more in-phase patterns than in the baseline and extinction conditions. In Experiment II, mobile reinforcement elicited more in-phase patterns only in no-contact kicks but there was no significant mobile effect in contact kicks. Mobile reinforcement and weight provided constraints that affect the frequency and pattern of kicking of 4-month-old infants.

Self-Optimization of Walking in Nondisabled Children and Children With Spastic Hemiplegic Cerebral Palsy

Children voluntarily adopt a frequency and movement pattern for walking. The force-driven harmonic oscillator (FDHO) model was used in this study for accurate prediction of the preferred walking frequency of nondisabled children and children with spastic hemiplegic cerebral palsy. Four potential optimality criteria with which the preferred walking pattern was forced to comply were examined: minimization of physiological costs, maximization of mechanical energy conservation, minimization of asymmetry in lower limb movements and minimization of variability of interlimb and intralimb coordination. Age and gender-matched nondisabled children (n = 6) and children with spastic hemiplegic cerebral palsy (n = 6) were tested under six frequency conditions of walking at a constant speed on a treadmill. For the nondisabled children, the results indicated that their preferred walking frequency could be accurately predicted by the FDHO model. They freely adopted a walking pattern that minimized physiological costs, asymmetry, and variability of inter- and intralimb coordination. For the children with spastic hemiplegic cerebral palsy, the prediction of preferred overground walking frequency required that the FDHO model be modified to account for muscle mass and leg length discrepancies between limbs and increased stiffness. Most of the children achieved the same optimality goals as the nondisabled when walking at the preferred frequency. However, the children were found to use different mechanisms to attain these goals: for example, a steeper increase observed in physiological cost at higher frequencies; a lowered center of gravity of the body, which allowed for angular symmetry; and greater variability of between-joint coordination in the nonaffected limb and less variability in the affected limb.

Efficacy of ankle-foot orthoses on gait of children with cerebral palsy: systematic review of literature.

Purpose: To perform a literature review evaluating the quality of current research on the influence of ankle-foot orthoses (AFOs) on gait in children with cerebral palsy (CP). Methods: A qualitative systematic review of intervention studies including the following words/phrases in the title/abstract: children with CP, AFO, gait and inferential statistical analysis, and outcomes related to gait. Databases searched included PubMed, Cochrane Library, PEDro, OTSeeker, Lilacs, and Scielo. Level of evidence was graded using the PEDro Scale. Results: Two between-group and 18 within-group studies met the inclusion criteria indicating a low level of evidence. Between-group studies each scored 4 on the PEDro Scale, and 17 within-group studies scored 3 and 1 scored 2, indicating low quality. Standard terminology for AFOs was not used and only 6 studies described functional status using appropriate instruments. Conclusions: Studies using high quality methods are still needed to support evidence-based decisions regarding the use of AFOs for this population.

Physical therapy management of congenital muscular torticollis: an evidence-based clinical practice guideline: from the Section on Pediatrics of the American Physical Therapy Association.

BACKGROUND Congenital muscular torticollis (CMT) is an idiopathic postural deformity evident shortly after birth, typically characterized by lateral flexion of the head to one side and cervical rotation to the opposite side due to unilateral shortening of the sternocleidomastoid muscle. CMT may be accompanied by other neurological or musculoskeletal conditions. KEY POINTS Infants with CMT are frequently referred to physical therapists (PTs) to treat their asymmetries. This evidence-based clinical practice guideline (CPG) provides guidance on which infants should be monitored, treated, and/or referred, and when and what PTs should treat. Based upon critical appraisal of literature and expert opinion, 16 action statements for screening, examination, intervention, and follow-up are linked with explicit levels of evidence. The CPG addresses referral, screening, examination and evaluation, prognosis, first-choice and supplemental interventions, consultation, discharge, follow-up, suggestions for implementation and compliance audits, flow sheets for referral paths and classification of CMT severity, and research recommendations.

Early, Accurate Diagnosis and Early Intervention in Cerebral Palsy: Advances in Diagnosis and Treatment

Importance Cerebral palsy describes the most common physical disability in childhood and occurs in 1 in 500 live births. Historically, the diagnosis has been made between age 12 and 24 months but now can be made before 6 months’ corrected age. Objectives To systematically review best available evidence for early, accurate diagnosis of cerebral palsy and to summarize best available evidence about cerebral palsy–specific early intervention that should follow early diagnosis to optimize neuroplasticity and function. Evidence Review This study systematically searched the literature about early diagnosis of cerebral palsy in MEDLINE (1956-2016), EMBASE (1980-2016), CINAHL (1983-2016), and the Cochrane Library (1988-2016) and by hand searching. Search terms included cerebral palsy, diagnosis, detection, prediction, identification, predictive validity, accuracy, sensitivity, and specificity. The study included systematic reviews with or without meta-analyses, criteria of diagnostic accuracy, and evidence-based clinical guidelines. Findings are reported according to the PRISMA statement, and recommendations are reported according to the Appraisal of Guidelines, Research and Evaluation (AGREE) II instrument. Findings Six systematic reviews and 2 evidence-based clinical guidelines met inclusion criteria. All included articles had high methodological Quality Assessment of Diagnostic Accuracy Studies (QUADAS) ratings. In infants, clinical signs and symptoms of cerebral palsy emerge and evolve before age 2 years; therefore, a combination of standardized tools should be used to predict risk in conjunction with clinical history. Before 5 months’ corrected age, the most predictive tools for detecting risk are term-age magnetic resonance imaging (86%-89% sensitivity), the Prechtl Qualitative Assessment of General Movements (98% sensitivity), and the Hammersmith Infant Neurological Examination (90% sensitivity). After 5 months’ corrected age, the most predictive tools for detecting risk are magnetic resonance imaging (86%-89% sensitivity) (where safe and feasible), the Hammersmith Infant Neurological Examination (90% sensitivity), and the Developmental Assessment of Young Children (83% C index). Topography and severity of cerebral palsy are more difficult to ascertain in infancy, and magnetic resonance imaging and the Hammersmith Infant Neurological Examination may be helpful in assisting clinical decisions. In high-income countries, 2 in 3 individuals with cerebral palsy will walk, 3 in 4 will talk, and 1 in 2 will have normal intelligence. Conclusions and Relevance Early diagnosis begins with a medical history and involves using neuroimaging, standardized neurological, and standardized motor assessments that indicate congruent abnormal findings indicative of cerebral palsy. Clinicians should understand the importance of prompt referral to diagnostic-specific early intervention to optimize infant motor and cognitive plasticity, prevent secondary complications, and enhance caregiver well-being.

Effectiveness of motor interventions in infants with cerebral palsy: a systematic review

To systematically review the evidence on the effectiveness of motor interventions for infants from birth to 2 years with a diagnosis of cerebral palsy or at high risk of it.

Perspective on Variability in the Development of Human Action

Humans are designed not only with variability but for variability. This article explores the important contribution of variability to successful human action. Human systems for action have abundant variability of tissues and processes. This plasticity provides for the necessary flexibility when humans encounter the metric and dynamic changes of growth, development, and adaptation of action across the life span. However, variability must have definable limits. The reduction of possible solutions to probable solutions and the reduction of variability appear to be common assumptions of most theories of human action. The lack of variability of action is a hindrance to the development of skilled, functional action, and excessive variability interferes with the production of automatic, dependable, and typical functional action. The lack of variability and excessive variability are hallmarks of the movement patterns produced by people across the life span following neurological insult. Active problem solving as therapy, with its inherent error as a part of the therapeutic process, is critical to the successful learning of functional actions. The role of the physical therapist is to create movement environments and provide personal and environmental constraints that elicit and support self-produced functional actions.

Critically Appraised Topics

This article describes the critically appraised topic (CAT) as a means to disseminate evidence from research literature to rehabilitation professionals. A CAT is a standardized, one-page summary of research evidence organized around a clinical question. A CAT includes a clinical bottom line that reflects synthesis of a research article and clinical application of the results. The synthesis includes a critique of the internal, external, and statistical validity of the research. The process of writing CATs has been used in the preparation of evidence-based practitioners. Commonly used websites for preparation and posting of CATs are included as well as an example of a CAT on the topic of cerebral palsy.