Luba Zuk

Developmental coordination disorder in children with attention‐deficit–hyperactivity disorder and physical therapy intervention

Although physical therapy (PT) is effective in improving motor function in children with developmental coordination disorder (DCD), insufficient data are available on the impact of this intervention in children with combined attention‐deficit–hyperactivity disorder (ADHD) and DCD. This prospective study aimed to establish the prevalence of DCD among a cohort of patients with ADHD, characterize the motor impairment, identify additional comorbidities, and determine the role of PT intervention on these patients. DCD was detected in 55.2% of 96 consecutive children with ADHD (81 males, 15 females), mostly among patients with the inattentive type (64.3% compared with 11% of those with the hyperactive/impulsive type, p<0.05). Mean age was 8 years 4 months (SD 2y). Individuals with both ADHD and DCD more often had specific learning disabilities (p=0.05) and expressive language deficits (p=0.03) than children with ADHD only. Twenty‐eight patients with ADHD and DCD randomly received either intensive group PT (group A, mean age 9y 3mo, SD 2y 3mo) or no intervention (group B, mean age 9y 3mo, SD 2y 2mo). PT significantly improved motor performance (assessed by the Movement Assessment Battery for Children; p=0.001). In conclusion, DCD is common in children with ADHD, particularly of the inattentive type. Patients with both ADHD and DCD are more likely to exhibit specific learning disabilities and phonological (pronunciation) deficits. Intensive PT intervention has a marked impact on the motor performance of these children.

Neonatal general movements: an early predictor for neurodevelopmental outcome in infants with intrauterine growth retardation.

Intrauterine growth retardation plays a significant role in neurodevelopmental outcome. The assessment of general movements during the first 20 weeks is a new method for early detection of brain dysfunction. General movements in 31 infants with asymmetric intrauterine growth retardation and their appropriate for gestational age—matched controls were examined. General movements were scored as normal or abnormal by sequential videotape recordings in the writhing (term to 2 weeks), early fidgety (9—11 weeks), and late fidgety (14—16 weeks) periods. Scores were compared between the groups and correlated with neurodevelopmental outcome at 2 years. The incidence of normal general movements was lower in the intrauterine growth retarded infants than in the controls (P < .001). Significant correlations were found between general movement quality and neurodevelopmental scores in the intrauterine growth retarded group. The fidgety movements were the most sensitive and specific for prediction of neurologic outcome. The general movement assessment can, therefore, serve as an additional tool for examining the neurologic status of the preterm and term intrauterine growth retarded infant. (J Child Neurol 2004;19:14—18).

Contribution of stepping while standing to function and secondary conditions among children with cerebral palsy.

Purpose: To explore the feasibility and efficacy of stepping while standing and its effect on function and prevalence of secondary conditions among children with severe cerebral palsy. Methods: Of 22 children with severe cerebral palsy, 11 underwent treatment using a Hart Walker (HW) device, and the other 11 underwent a passive standing program. Constipation prevalence and adverse events were recorded. Bone quantitative ultrasound was performed for the tibia. The Pediatric Evaluation of Disability Inventory was used to assess activities of daily life. Results: Children exposed to the HW improved bowel function, but no added quantitative benefit to bone was observed when compared with passive standing. Children using the HW were able to take steps independently in the device, but did not reach a functional walking level. Conclusions: Providing a child who is nonambulatory the opportunity to walk may be important both for participation in activities of daily living and social roles and for preventing secondary conditions.

The effect of maternal sleep-disordered breathing on the infant's neurodevelopment

OBJECTIVE We sought to examine the effect of maternal sleep-disordered breathing (SDB) on infant general movements (GMs) and neurodevelopment. STUDY DESIGN Pregnant women with uncomplicated full-term pregnancies and their offspring were prospectively recruited from a community and hospital low-risk obstetric surveillance. All participants completed a sleep questionnaire on second trimester and underwent ambulatory sleep evaluation (WatchPAT; Itamar Medical, Caesarea, Israel). They were categorized as SDB (apnea hypopnea index>5) and controls. Infant GMs were assessed in the first 48 hours and at 8-11 and 14-16 weeks of age. At 12 months of age the Infant Developmental Inventory and the Brief Infant Sleep Questionnaire were administered. RESULTS In all, 74 women and their full-term infants were studied. Eighteen (24%) women had SDB. Mean birthweight was 3347.1±423.9 g. Median Apgar score at 5 minutes was 10 (range, 8-10). In adjusted comparisons, no differences were found between infants born to mothers with SDB and controls in GM scores in all 3 evaluations. Low social developmental score was detected at 12 months in 64% of infants born to SDB mothers compared to 25% of infants born to controls (adjusted P=.036; odds ratio, 16.7). Infant snoring was reported by 41.7% of mothers with SDB compared to 7.5% of controls (P=.004). CONCLUSION Our preliminary results suggest that maternal SDB during pregnancy has no adverse effect on neonatal and infant neuromotor development but may affect social development at 1 year.

Fetal and infant spontaneous general movements as predictors of developmental disabilities.

The challenge of identifying infants who are at risk for developmental delay and possible adverse neurodevelopmental outcome demands methods of evaluation that will lead to early intervention to minimize developmental disability and to maximize the infants potential. A qualitative assessment of spontaneous general movements (GMs) in the preterm, term, and young infant at risk is a valid and reliable tool for evaluation (Prechtl [1990] Early Hum. Dev. 23:151-158). The aim of this review is to describe the theoretical and clinical bases for the assessment of GMs and its relationship to developmental delay and brain dysfunction. Thirty-seven studies related to the predictive validity of GMs were included in this review. Results suggested that consistent cramped synchronized GMs are highly predictive of later development of cerebral palsy. The fidgety movement quality that appears at the age of 2 to 3 months was found to be a most sensitive predictor of neurodevelopmental outcome in different populations of infants.

Does Physical Therapy Improve Outcome in Infants with Joint Hypermobility and Benign Hypotonia

This study examined the effect of the frequency of physical therapy on the outcome of infants referred for delayed motor development due to joint hypermobility and benign hypotonia. The study groups comprised 29 infants (8-12 months) who were randomly placed into a monthly and weekly treatment groups. No difference was found between the 2 study group scores on the different tests at all assessment points. However, assessment of walking at the age of 15 months revealed a clear advantage of the infants who were treated weekly. Our study demonstrated a minor benefit of weekly treatment protocol only in the achievement of independent walking in children with joint hypermobility and benign hypotonia. It did not prove an advantage of weekly physical therapy. It seems that monthly physical therapy combined with a home treatment protocol implemented by the primary caregivers is sufficient to achieve motor catch-up.

Long-term neurodevelopmental follow-up of children with congenital muscular torticollis

Congenital muscular torticollis is a common condition, but long-term neurodevelopmental follow-up is lacking. This study reports on neurodevelopmental outcome of 68 children, aged 7 to 9 years, with a history of congenital muscular torticollis, excluding children with torticollis due to other conditions. Thirty-eight children were examined for presence of neurodevelopmental disorders. Telephone interview data were available for an additional 30 children. Of those examined, 22/38 (57.9%) had or were at risk for a developmental disorder (attention-deficit hyperactivity disorder (ADHD), developmental coordination disorder, language impairment, autistic spectrum disorder) on at least 1 of the assessments administered, 23/38 (60.5%) had received developmental treatment during childhood. One child, based on a telephone interview, had a history of developmental treatment. Therefore, 30/68 (44.1%) children of the total sample demonstrated a developmental delay/disorder, currently (22/68) or previously (8/68). Our findings suggest congenital muscular torticollis to be a significant risk factor for later neurodevelopmental conditions with disorders presenting at different stages of development.

Upper limb movements and outcome in intrauterine-growth-retarded infants at 2 years

This study aims to examine the usefulness of spontaneous upper limb movements (ULM) as an early marker for predicting neurodevelopmental outcome in infants with intrauterine-growth retardation (IUGR). The assessment of general movements (GMs) during the first 20 weeks is an accepted method for early detection of brain dysfunction. During this period, spontaneous upper limb movements were examined in 32 infants with IUGR and 32 appropriate-for-gestational-age-matched controls. ULM (arms, forearms and hands) were scored as optimal or suboptimal by sequential videotape recordings in the writhing (term-2 weeks: score 0-5); early fidgety (9-11 weeks: score 0-6); and late fidgety (14-16 weeks: score 0-6) periods, and correlated with neurodevelopmental score at 2 years of age. The mean ULM score was lower in the IUGR infants than the controls (p<0.05) and in the IUGR group was lower in the infants with abnormal outcome (p<0.05). Significant correlations were found between ULM and 2-year neurodevelopmental scores in the IUGR group. The ULM during late-fidgety period was most predictive for 2-year neurodevelopmental score. No difference was found in the mean ULM score between the pre-term and term IUGR infants. We conclude that ULM score can serve as an early predictor for neurodevelopmental outcome at 2 years of age in infants with IUGR.

A new tool for identifying children with motor problems: reliability and validity study.

This study examined reliability and validity of the Zuk Assessment for diagnosis of motor problems and determined standardized scores in an Israeli population aged 5 to 6 years. For standardization, 156 children recruited from 13 Kindergartens of typically developing children were evaluated with the Zuk Assessment. Intrarater and interrater reliability were examined on 2 samples of 15 and 13 children, respectively. A total of 151 children referred for motor problems were examined with the Zuk and Movement Assessment Battery for Children assessment tools for validation of the Zuk Assessment. Findings showed that the Zuk total score had a normal distribution similar to that found in the literature identifying 5.1% (–2 standard deviations) and 12% (between –1 and –2 standard deviations) of children with motor-related problems. Reliability was indicated by high intraclass correlation scores both in intrarater (intraclass correlation = .89) and interrater (intraclass correlation = .95) paradigms. The Zuk assessment identified differences in subgroups, namely, typical, suspicious, and impaired, as found in the Movement Assessment Battery for Children, confirming the Zuk validity.

Fidgety movements, cerebral palsy, and cognitive ability

Infants born before 30 weeks are a high-risk population for brain injury (cerebral palsy [CP]) and neurodevelopmental impairment (cognitive dysfunction). Most lesions occur between 24 weeks post-menstrual age and term age, a period during which developmental activity in the brain is at its peak. Early detection and prediction for optimal motor and cognitive outcome, both at home and in the community, warrants the use of a reliable assessment tool. Prechtl’s qualitative assessment of general movements, standardized and utilized for 25 years, evaluates an infant’s spontaneous movements and can be used from birth until 20 weeks post-term. The quality of the general movements reflects the integrity of the infant’s brain. Validity was established and interrater reliability of general movement assessment has been demonstrated repeatedly. From 3 months to 5 months post-term, small-amplitude movements of variable acceleration are observed in the neck, trunk and limbs (i.e. fidgety movements). They may present as normal, abnormal, or absent. Normal general movements have a high correlation with normal outcome, while abnormal general movements, in particular absent fidgety movements, are highly predictive of CP (sensitivity up to 98%, specificity 91%). Prediction of CP in early infancy is best when based on a series of assessments (including brain imaging) along a developmental trajectory. However, when a single assessment is used, the optimal time is the fidgety movements period. In a routine clinical setting where background distractors may influence findings, it is important to maintain the reliability of general movement assessment. Two multicenter clinical studies examined infants born very preterm and infants born at term with the general movement assessment for motor outcome (especially CP) at 2 years. To optimize reliability, both studies involved only three general movement raters. They confirmed that absent fidgety movements predict CP with high sensitivity and specificity. Subsequently, Datta et al. replicate this important finding by involving a large number of raters with different professional backgrounds in a multicenter study. More refined results, however, would likely require more limited numbers of experienced raters (e.g. in assessing the predictive value of abnormal or sporadic fidgety movements for milder outcomes). Another area of high relevance in infants born preterm is prognostication of cognitive skills. A systematic review suggested that the lack of normalization of ‘poor repertoire’ general movements by 8 weeks indicates a risk for cognitive dysfunction. All reviewed studies but one showed that fidgety movements alone did not correlate with cognition. However, concurrent movements and postures assessed as part of the Assessment of Motor Repertoire (a video-based assessment of infants between 3 and 5 months post-term, which includes evaluation of fidgety movements) showed a correlation with cognitive functioning. In conclusion, abnormal fidgety movements, particularly absent fidgety movements, can be regarded as highly predictive of CP. Fidgety movements abnormalities can indicate mild motor dysfunction, but not cognitive problems. In addition, the role of the Assessment of Motor Repertoire in early prediction of future cognitive problems deserves further study.