Lynne Romeiser Logan

Single-subject research design: recommendations for levels of evidence and quality rating.

The aim of this article is to present a set of evidence levels, accompanied by 14 quality or rigor questions, to foster a critical review of published single‐subject research articles. In developing these guidelines, we reviewed levels of evidence and quality/rigor criteria that are in wide use for group research designs, e.g. randomized controlled trials, such as those developed by the Treatment Outcomes Committee of the American Academy for Cerebral Palsy and Developmental Medicine. We also reviewed methodological articles on how to conduct and critically evaluate single‐subject research designs (SSRDs). We then subjected the quality questions to interrater agreement testing and refined them until acceptable agreement was reached. We recommend that these guidelines be implemented by clinical researchers who plan to conduct single‐subject research or who incorporate SSRD studies into systematic reviews, and by clinicians who aim to practise evidence‐based medicine and who wish to critically review pediatric single‐subject research.

Rehabilitation Techniques to Maximize Spasticity Management

Abstract Improvement in functional skills is typically a goal of spasticity management. Spasticity management alone will improve the positive signs of the upper motor neuron syndrome without functional change. In this review, we demonstrate that a variety of therapy modalities are required to facilitate these improvements and impact the negative signs of the upper motor neuron syndrome. The evidence for neuromuscular electrical stimulation, surface electromyography training, serial casting, body weight–supported treadmill training, constraint-induced movement therapy, strengthening, and endurance training is reviewed as it relates to spasticity management.

Interrater reliability and convergent validity of the American Academy for Cerebral Palsy and Developmental Medicine methodology for conducting systematic reviews

Aim  The aim of this study was to evaluate the interrater reliability and convergent validity of the American Academy for Cerebral Palsy and Developmental Medicine’s (AACPDM) methodology for conducting systematic reviews (group design studies).

Children with cerebral palsy are just like everyone else: what you train is what you get

Children with cerebral palsy (CP) are weaker and have smaller muscles than children without CP. Early research in this area showed that children with CP can gain strength with resistance training without increasing spasticity (a long-held myth). We know that their muscles gain volume with strength training. Children with CP appear to benefit from the same exercise training principles as children or adults without CP, such as specificity of training, adaptation, overload, progression, and individualized training programs. Researchers in the subject area have been divided in recent years as to the benefits of strength training for children with CP. Some previous studies have found improvements in gait as a by-product of strength training. These studies included children with hemiplegia as well as diplegia and, mostly, children who were classified at Gross Motor Function Classification System (GMFCS) levels I or II. As our methods of measurement and research design have become more sophisticated, we are increasingly able to measure improvements in strength and function in a variety of ways. Important questions at this time are (1) Is strength a critical component for improved or maintained functional walking in children with cerebral palsy? (2) If so, how is strength for walking best trained and maintained in this population? (3) What are the important training strategies for functional walking at different ages? Speed? Endurance? Variability? What happens if we train these but not strength? The paper by Taylor et al. is interesting and at the same time disappointing. It is well designed with blinded assessors, intent-to-treat analysis, and had only one dropout in each group. The power analysis indicated that 31 participants would be required in each group but only 23 and 24 completed the study. The groups were fairly equivalent and included children with diplegia at GMFCS levels II and III. The children trained in local gyms using standard protocols for progressive resistance training. Children who trained for strength twice weekly for 12 weeks got significantly stronger in the specifically trained muscles but not in opposing muscles (leg press – trained vs reverse leg press-not trained). Mobility testing in the 6-minute walk test, stairs timed test, gait kinematics, and GMFM dimensions D (standing) and E (walking, running, and jumping) did not change. Taylor et al. have demonstrated that resistance training improves strength, as have many other authors. This study adds to the literature with a good design and quality indicators; however, it is limited because it does not inform us on how to improve or maintain functional gait or understand how strength is or is not related to gait. Because gait was not trained, at this point in the state of the literature (considering basic exercise science principles), it seems disingenuous to expect that it would change in spite of earlier articles to the contrary. The authors offer hypotheses for the divergence of results. Therapists who look to evidence in the literature to design their interventions will not find this article useful. The use of fundamental principles of exercise training and testing should be paramount in establishing the basic question of any research project.

Facts and myths about therapeutic interventions in cerebral palsy: integrated goal development.

This article explores a variety of myths and facts about therapy for children who have cerebral palsy. Current evidence is used to refute popular myths and debunk harmful ones. A way of integrating interventions is suggested and a planning process for timing interventions is proposed.

Poster 315: Cervical Spine Stenosis in Adults With Bilateral Spastic Dystonic Cerebral Palsy: A Case Series

ment by the time of transfer to an acute inpatient rehabilitation hospital. Repeated MRI showed enhancing lesions more consistent with MS but the patient was clinically much improved. She progressed well but 6 weeks after her initial onset, she developed altered mental status and worsening weakness. Repeated MRI showed new lesions involving the cerebellar peduncles and splenium of the corpus callosum. Interferon beta-1b, IVIG, methylprednisolone were thus started for MS. The patient had significant improvement after treatment. Setting: Pediatric rehabilitation unit. Results: Interferon beta-1b, IVIG, and intravenous steroids demonstrated clinical improvement in muscle strength, mobility, cognition and ADLs. Discussion: In a patient with suspected ADEM with reoccurring or worsening symptoms, it is important to reconsider the differential diagnosis of multiple sclerosis. Although typically more gradual in course, MS can have a more dramatic presentation. Proper diagnosis and implementation of Interferon beta-1b, IVIG, and intravenous steroids can greatly improve functional outcome and prognosis in such patients. Conclusions: An atypical presentation for multiple sclerosis may mimic ADEM in the acute setting, and significant clinical improvement may be expected with appropriate change in management

Poster 334: The Use of a Shoe Lift for the Treatment of Pain and Apparent Leg Length Discrepancy in Pediatric Hemiparesis: A Case Report

Results: By using this program, the patient progressed from tall kneeling to minimal assisted standing in 8 weeks. Vectorial analysis, amplitude and frequency analysis of the SEMG signal as the child progressed will be discussed as well as how this kind of approach can assist in successful treatment of a very young, multiply impaired child. Discussion: This is the first reported case, to our knowledge, of using SEMG in this manner in the treatment of the motor deficits associated with Lowe syndrome. Conclusions: In this case report, SEMG was able to help the patient achieve additional physical therapy goals. Further study is needed as to the motor planning mechanisms by which this progress is achieved.

Poster 82: A preliminary study of dual-energy X-ray absorptiometry positioning protocols for women and girls with mobility disabilities1

Abstract Objective: To establish a protocol compensating for contractures in dual-energy x-ray absorptiometry (DXA) hip scans in people with mobility impairments using the DPX-IQ Lunar Pencil Beam Scanner. Design: 3 sets of proximal femur scans taken at 0°, 20°, and 30° of hip flexion, with repositioning between. The bone mineral density (BMD) in hip subregions and the precision of BMD with repeated scans at each angle were determined. Repeated DXA scans of the ipsilateral distal femur in lateral view were made for comparison with hip data as a potential surrogate site to substitute for direct hip data. Setting: This study was conducted as part of a research program examining BMD in premenopausal women and girls with mobility impairments, in whom standard hip positioning required by the typical DXA protocol may not be achievable. Participants: Female volunteers without mobility impairments (N=14), ages 22 to 44 years. Interventions: Not applicable. Main Outcome Measures: Total and subregion BMD at 0°, 20°, and 30° of hip flexion; and BMD in 4 subregions in the distal femur using a generic lumbar spine scan protocol (g/cm 2 ). Results: Data analysis examined both the average standard deviation among repeats and the differences between 20° and 30° compared with the 0° positions. Statistical comparisons using paired t tests for the cohort indicated little change in hip BMD readings up to 20° of flexion. At 30° of hip flexion, BMD appeared to increase in the shaft region and global reading by 9% and 7%, respectively ( P r =.55) and neck BMD ( r =0.5). Conclusions: Hip flexion angles of >20° can give false-positive or negative DXA readings. Distal femur readings correlated modestly with shaft and neck data, a possible surrogate site when typical extension is affected by contractures.