Margaret E. O'Neil

Changes in Mobility of Children with Cerebral Palsy Over Time and Across Environmental Settings

SUMMARY This study examined changes in mobility methods of children with cerebral palsy (CP) over time and across environmental settings. Sixty-two children with CP, ages 6-14 years and classified as levels II-IV on the Gross Motor Function Classification System, were randomly selected from a larger data base and followed for three to four years. On each of several assessments, parents completed a questionnaire on their childs usual mobility methods in the home, school, and outdoors/community settings. During the first assessment interval, mobility methods increased to methods requiring more gross motor control. During the second assessment interval, mobility methods were unchanged or decreased to methods requiring less gross motor control. Changes within the child and within the environment are hypothesized to occur and to impact changes in mobility methods. Screening at regular intervals is recommended to monitor changes in mobility. Interventions to enhance mobility may be indicated during periods of change in the child or exposure to new environments.

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 …

Systematic review of the clinimetric properties of laboratory- and field-based aerobic and anaerobic fitness measures in children with cerebral palsy

OBJECTIVE To systematically evaluate the level of evidence of the clinimetric properties of measures of aerobic and anaerobic capacity used for children with cerebral palsy (CP). DATA SOURCES A systematic search of databases PubMed, Embase, SPORTDiscus, and PsycINFO through April 2011 was performed. STUDY SELECTION Two independent raters identified and examined studies that reported laboratory- or field-based measures of maximal aerobic or anaerobic capacity in children with CP aged 5 to 14 years. DATA EXTRACTION The COnsensus-based Standards for the selection of health status Measurement INstruments (COSMIN) checklist was used by 2 independent raters to evaluate the methodologic quality of the included clinimetric studies and to identify measures used in these studies. DATA SYNTHESIS Twenty-four studies that used a maximal aerobic or anaerobic capacity measure were identified. Five studies reported clinimetric properties for 5 measures (2 aerobic and 3 anaerobic measures). Methodologic quality was excellent in 3 studies, showing good validity and reliability of field-based aerobic (Shuttle Run Test) and anaerobic (Muscle Power Sprint Test) measures. The studies on laboratory-based measures were rated fair, mainly because of inadequate statistics. The level of evidence was strong for good validity and reliability of the field-based tests. The level of evidence was unknown for validity and low to moderate for good reliability of laboratory-based tests. CONCLUSIONS There is a paucity of research on the clinimetric properties of measurement instruments to assess aerobic and anaerobic capacity for children with CP. Further clinimetric studies of laboratory-based measures in children with CP at all Gross Motor Function Classification System (GMFCS) levels, and clinimetric studies of field-based measures in children who are classified as GMFCS levels III to V are required.

Physical therapy clinical management recommendations for children with cerebral palsy - spastic diplegia: achieving functional mobility outcomes.

The purpose of this special report is to present recommendations for the clinical management of children with cerebral palsy, spastic diplegia when increased functional mobility is the identified outcome. These recommendations provide a framework that allows physical therapists to increase their accountability and promote effective interventions for improved patient outcomes. The key components of this special report on clinical management are: a) the Major Recommendations that provide the background and evidence for clinical management; b) a flow chart to assist in clinical decision-making; and c) a Table of Tests and Measures for information on useful tools in the management of children with spastic diplegia. These recommendations are suggestions for clinical management, not an all-inclusive document on physical therapy for children with cerebral palsy. These recommendations may help therapists develop systematic approaches to service delivery and documentation.

Profiles of family needs of children and youth with cerebral palsy

BACKGROUND To identify profiles of family needs of families of children and youth with cerebral palsy (CP), and determine whether profile membership is related to child, family and service characteristics. METHODS Participants were mostly mothers (80%) of 579 children and youth with CP. A family member completed modified version of the Family Needs Survey and questionnaires about their child, family and services. Research assistants determined the Gross Motor Function Classification System levels. K-means cluster analysis identified profiles of needs. Cluster membership was analysed to examine differences in clusters based on selected characteristics. RESULTS Four profiles of needs were identified: Low needs, Needs related to community and financial resources, Needs related to child health condition and High needs. Profile membership was differentiated based on child/youth gross motor function, adaptive behaviour, family relationships, family income, access and effort to co-ordinate services. CONCLUSION Despite heterogeneity among individuals with CP and their families, four profiles of family needs were identified. In total, 51% of families had low needs suggesting that they are effectively managing their childrens health conditions while 11% of families had high needs that may require high levels of services and supports. Service providers are encouraged to partner with families, provide anticipatory guidance and co-ordinate services.

Summative evaluation of a pilot aquatic exercise program for children with disabilities.

BACKGROUND Children with disabilities have lower physical activity levels and participate less in community-based sport and exercise programs than do children without disabilities. This in part is due to environmental barriers and lack of appropriate resources in these programs. Adaptive programs encouraging increased physical activity for children with disabilities are needed, and as these programs are developed, they should be critically evaluated. PURPOSE The purposes of this article are to describe a pilot aquatic exercise program for children with disabilities, to evaluate the program, and to determine areas of strength and areas needing modifications. METHODS A summative program evaluation design was used to assess this twice per week aquatic exercise program lasting 14 weeks. Sixteen children, ages 6-12 years, with developmental disabilities participated in the program. Children swam laps, participated in relay races and water basketball games, and performed arm and leg strengthening exercises using aquatic noodles, foam barbells, and water for resistance. Swimming skills, program evaluation questionnaires, physical activity questionnaires, and interviews of pool site directors were used to determine program outcomes. RESULTS Findings suggest that children made improvements in their swimming skills, parents were satisfied with the program, and children increased their physical activity levels during the program and maintained the increased physical activity levels six months after the program ended. The program continued in some form after the 14-week intervention ended. CONCLUSIONS The program was successful in achieving its objectives and recommendations for application of this program are provided.

Expert consensus on physical therapist intervention after botulinum toxin a injection for children with cerebral palsy.

Purpose: The purpose of this study was to gather expert consensus on physical therapist (PT) intervention after lower extremity botulinum toxin A (BtA) injection(s) for children with cerebral palsy (CP) and lower extremity spasticity. This study also examined differences in expert opinion on intervention for two groups of children with CP and differing levels of functional ability. Methods: The Guide to Physical Therapist Practice was used to develop a questionnaire. Sixty‐two therapists identified as experts in the field of pediatric physical therapy rated the importance of the three PT intervention components and the seven types of direct intervention from Neuromuscular Pattern 5A for both groups. The Wilcoxon signed rank test was used to identify differences in expert responses between the groups. Experts also ranked the importance of specific intervention strategies. Consensus criteria were used to determine the importance of interventions. Results: All three intervention components and four direct interventions (Therapeutic Exercise; Functional Training‐Self‐Care; Functional Training‐Community and Work; and Prescription of Devices/Equipment) met consensus criteria for both groups. Significant differences between groups were found for Patient/Client‐Related Instruction and Direct Interventions and for Therapeutic Exercise, Functional Training in Self‐Care, Functional Training‐Community and Work, and Electrotherapeutic Modalities, suggesting that these items were more important for children with greater functional abilities. Twenty (35%) specific intervention strategies met consensus criteria for one or both groups. Discussion and Conclusions: All three intervention components and four direct interventions in Neuromuscular Pattern 5A are important in the PT plan of care after botulinum toxin A injection for children with CP and lower extremity spasticity. Functional ability influences therapists’ intervention choices.

impairment, Disability, and Satisfaction Outcomes After Lower-extremity Botulinum Toxin A Injections for Children with Cerebral Palsy

Purpose: The purpose of this study was to document impairment, disability, and parent satisfaction outcomes for children with cerebral palsy who received botulinum toxin A (BtA) injections. Methods: Seven children, three to 11 years old, participated in this multiple single‐subject AB design study. Impairment, disability, and satisfaction outcomes were documented using passive range of motion measurements, Modified Ashworth Scale scores, and the Canadian Occupational Performance Measure. These outcomes were measured every two weeks during the two‐month baseline phase and the four‐month intervention phase. Outcomes for each child were graphed and visually analyzed for changes in level, trend, and slope. Results: After BtA injections, all children demonstrated an increase in passive range of motion and a decrease in spasticity in at least some of the injected muscles. Six of the seven children demonstrated improvements in disability and parent satisfaction outcomes. Conclusions: Improvement in a variety of outcomes may be observed after BtA injections in children with cerebral palsy and lower‐extremity spasticity who are ambulatory. (Pediatr Phys Ther 2002;14:132‐144)

Clinical Findings and Resource Use of Infants and Toddlers Dependent on Oxygen and Ventilators

Medical records were reviewed to describe characteristics, report clinical and resource measures, and determine if differences exist between the diagnostic groups of prematurity and multiple congenital anomalies/neurologic conditions for initial admissions of 37 infants and toddlers to an inpatient pulmonary rehabilitation program. More than 75% of the children had a tracheostomy at admission and discharge. Forty-six percent of the sample was admitted requiring only oxygen, whereas 51% were discharged requiring only oxygen and not mechanical ventilation. Thirty percent of the children weaned to a less invasive mode of ventilation while just under half of the children were discharged home. Between-group comparisons indicated statistically significant differences for nutritional support at discharge (p < = 0.05) and discharge disposition (P = 0.04). Complete weaning of oxygen or ventilator support during an initial inpatient pulmonary rehabilitation admission occurred less frequently than weaning to a less invasive mode of ventilation. This is an important consideration for referring children to rehabilitation programs, for clinical program improvement activities, and for setting realistic expectations for referral sources, patients and families, clinical staff, and payers. Further study is recommended using clinical data in program planning, in program improvements, and for setting outcome expectations for infants and toddlers dependent on pulmonary technology.

Determinants of Needs of Families of Children and Youth With Cerebral Palsy

Several models of determinants of needs of families of children and youth with cerebral palsy were tested using structural equation modeling. Five hundred seventy-nine parents completed the Family Needs Survey and measures of child, family, and service characteristics. The models explained 32% of variance in needs related to child condition, 43% of variance in needs related to community and financial resources, and 33% of variance in needs related to family functioning. Access to services, service coordination, processes of care, and family relationships were common determinants of family needs; whereas child adaptive behavior, communication problems, gross motor function, and family income were unique determinants of specific types of needs. The implications for family-centered services that address family needs are discussed.