Mary E. Gannotti

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.

The Second Physical Therapy Summit on Global Health: developing an action plan to promote health in daily practice and reduce the burden of non-communicable diseases

Abstract Based on indicators that emerged from The First Physical Therapy Summit on Global Health (2007), the Second Summit (2011) identified themes to inform a global physical therapy action plan to integrate health promotion into practice across the World Confederation for Physical Therapy (WCPT) regions. Working questions were: (1) how well is health promotion implemented within physical therapy practice; and (2) how might this be improved across five target audiences (i.e. physical therapist practitioners, educators, researchers, professional body representatives, and government liaisons/consultants). In structured facilitated sessions, Summit representatives (n = 32) discussed: (1) within WCPT regions, what is working and the challenges; and (2) across WCPT regions, what are potential directions using World CaféTM methodology. Commonalities outweighed differences with respect to strategies to advance health-focused physical therapy as a clinical competency across regions and within target audiences. Participants agreed that health-focused practice is a professional priority, and a strategic action plan was needed to develop it as a clinical competency. The action plan and recommendations largely paralleled the principles and objectives of the World Health Organization’s non-communicable diseases action plan. A third Summit planned for 2015 will provide a mechanism for follow-up to evaluate progress in integrating health-focused physical therapy within the profession.

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 …

Postoperative gait velocity and mean knee flexion in stance of ambulatory children with spastic diplegia four years or more after multilevel surgery.

Factors associated with longer-term outcomes of multilevel orthopaedic surgery in ambulatory children with cerebral palsy using a multivariate approach were evaluated using a retrospective pretest-posttest design. The population included 20 ambulatory children with spastic diplegia who had undergone multilevel orthopaedic surgery with a minimum of 4-year interval between a preoperative and a postoperative gait assessment. Multiple regression analysis was used to identify factors associated with postoperative velocity and mean knee flexion in stance. Independent variables included in the regression models were velocity, mean knee flexion in stance, age at preoperative evaluation, Gross Motor Function Classification System level, use of ankle-foot orthoses, leg length, age-adjusted body mass index, number of surgical procedures, and range of motion of hip and knee. Children who demonstrated faster postoperative gait velocity 4 years or more after surgery were younger at the time of initial evaluation, had undergone fewer surgical procedures, had faster preoperative gait velocity, used ankle-foot orthoses postoperatively, and had increased hip extension range of motion postoperatively (R2 = 0.55). Children who demonstrated greater knee flexion in stance 4 years or more after surgery had undergone more surgical procedures, greater postoperative popliteal angle, and less knee extension range of motion (R2 = 0.73). This study demonstrates the usefulness of a multivariate approach toward understanding and predicting outcomes. The results of this study will provide clinicians and researchers more information about those factors associated with maintained improvements in the longer term and may be useful for treatment planning.

Can exercise influence low bone mineral density in children with juvenile rheumatoid arthritis

Purpose: Low bone mineral density (BMD) is a common secondary condition associated with juvenile idiopathic arthritis (JIA). The purpose of this review was evaluate the literature pertinent to designing an effective, safe weight-bearing exercise program to reduce the risk of low BMD in children with JIA. Summary of key points: Thirty-seven articles on the risk of low BMD and children with JIA, weight-bearing interventions to improve BMD in healthy children, or safety and efficacy of exercise interventions with children with JIA were critiqued on the basis of their design. Three highly rated studies confirmed the multifactorial nature of low BMD in children with JIA, two highly rated studies support the efficacy of weight-bearing interventions for increasing BMD in children who are healthy, and one moderately rated study demonstrated the safety of low impact exercise by children with JIA. Statement of conclusions and recommendations for clinical practice: Weight-bearing activities should be included in exercise programs for individuals with JIA, although more research is needed to determine the amount, duration, and frequency of weight-bearing activity needed to reduce the risk for low BMD.

Weight Status and Gross Motor Skill in Kindergarten Children

Purpose: Childhood obesity rates are increasing globally. Physical activity is one behavioral variable that influences weight status. Participation in physical activity requires basic gross motor proficiency in early childhood. The purpose of this study was to examine the relationship between gross motor skill level and weight status in a large national representative sample of kindergarten-aged children. Methods: Body mass index percentile ranking was calculated for 4650 children from the Early Childhood Longitudinal Study-Birth Cohort. Children were classified into underweight, healthy, overweight, or obese categories according to the Centers for Disease Control and Prevention criteria. The Early Screening Inventory Revised was used to evaluate gross motor skill level. Results: Children with obesity displayed lower gross motor skill levels compared with peers of healthy weight. Largest differences were seen in locomotor and balance skills. Conclusions: Clinicians should consider adjusting gross motor expectations for locomotor or stability tasks in young children with obesity.

Changes in Gait Velocity, Mean Knee Flexion in Stance, Body Mass Index, and Popliteal Angle With Age in Ambulatory Children With Cerebral Palsy

Background The purpose of this study was to explore changes in body mass index (BMI), gait velocity, mean knee flexion in stance, and popliteal angle with age in ambulatory children with cerebral palsy. Methods A cross-sectional sample of 188 ambulatory children with cerebral palsy Gross Motor Function Classification System II or III who had a motion analysis evaluation. Subjects had no previous surgical interventions and were between the ages of 4 and 21. Velocity was normalized to limb length, and BMI was converted to age-adjusted percentile scores (BMI-a). Results For GMFCS level II children, age and normalized velocity demonstrated a moderate and significant relationship (r = −0.4; P = 0.000). Age explained 20% of the variance in normalized velocity (P = 0.000). Weak but significant relationships were found between mean knee flexion in stance and normalized velocity (r = −0.3; P = 0.000) and popliteal angle and age (r = 0.3; P < 0.002). For GMFCS level III children, the following variables demonstrated a weak but significant association: normalized velocity and BMI-a (r = 0.3; P < 0.006), popliteal angle, and mean knee flexion in stance (r = 0.3; P < 0.022). Age was not associated with velocity, mean knee flexion in stance, BMI-a, or popliteal angle. Conclusions For GMFCS level II children, as age increases, there is a slight decrease in normalized velocity, and with decreasing normalized velocity, there is slightly increased mean knee flexion in stance. For GMFCS level III children, age was not associated with slower velocities, increased mean knee flexion in stance, or increased popliteal angle. Increased BMI-a was not associated with slower gait velocities or increased mean knee flexion in stance. Increasing BMI-a was not associated with increasing age. Level of Evidence Prognostic study, level IV (case series [no or historical control group]).

Self-concept of adults with cerebral palsy

Purpose. To describe the self-concept of adults with cerebral palsy (CP). Method. Cross-sectional design included the Tennessee Self-Concept Scale, version 2 (TSCS:2), Functional Independence Measure (FIM™), Beck Depression Index II (BDI®-II), Craig Hospital Inventory of Environmental Factors (CHIEF), Dieners Satisfaction with Life Scale (SWLS), Gross Motor Functional Classification System (GMFCS) levels and demographic questions. Results. One hundred and two people with CP (52 females, mean age = 26) participated. Thirty-eight participants had unreliable answers as indicated by validity scales and were excluded from the analysis. Ten participants had high self-concept; 41 had average self-concept and 13 had low total self-concept. Self-concept had a fair and inverse association with the BDI-II (Pearsons r = −0.3, p < 0.01) and a moderate and direct association with the SWLS (Pearsons r = 0.4, p < 0.001). Self-concept was not associated with GMFCS level or FIM score. Family and Personal sub-domain scores were lowest sub-domain scores for people with low self-concept (p < 0.01). Conclusion. The majority of the participants in this sample had a healthy self-concept; and self-concept was not associated with severity of CP, but with lack of depression and life satisfaction. Results suggest the need for family centred care into adulthood.

Which Children Are Not Getting Their Needs for Therapy or Mobility Aids Met? Data From the 2009–2010 National Survey of Children With Special Health Care Needs

Background Pediatric rehabilitation therapy services and mobility aids have an important role in the health of children with special health care needs, and the Affordable Care Act (ACA) may increase coverage for these needs. Identifying the prevalence of and factors associated with therapy and mobility aid needs and unmet needs prior to the full implementation of the ACA will be useful for future evaluation of its impact. Objective The purpose of this study was to identify the prevalence of and factors associated with caregiver perceived needs and unmet needs for therapy or mobility aids among children with special health care needs living in the United States. Design A cross-sectional, descriptive, multivariate analysis was conducted. Methods The 2009–2010 National Survey of Children With Special Health Care Needs was used to identify a nationally representative sample of children with special health care needs with needs for therapy (weighted n=2,603,605) or mobility aids (weighted n=437,971). Odds of having unmet needs associated with child and family characteristics were estimated. Results Nearly 1 in 5 children with therapy needs had unmet needs, and nearly 1 in 10 children with mobility aid needs had unmet needs. Unmet needs were most strongly associated with how frequently the condition affected function and being uninsured in the previous year. Limitations Data were caregiver reported and not verified by clinical assessment. Survey data grouped physical therapy, occupational therapy, and speech therapy; analysis was not discipline specific. Conclusions This evidence serves as a baseline about the future impact of the ACA. Pediatric rehabilitation professionals should be aware that children with special health care needs whose condition more frequently affects function and who have insurance discontinuity may need more support to meet therapy or mobility aid needs.

Addressing muscle performance impairments in cerebral palsy: Implications for upper extremity resistance training

STUDY DESIGN Case study and literature review. INTRODUCTION Muscle performance consists of not only strength but also muscle power, rate of force development, and endurance. Therefore, resistance training programs should address not only the force-generating capacity of the muscle but also the ability to produce force quickly. PURPOSE To discuss the National Strength and Conditioning Associations resistance training guidelines for youth as specifically related to optimal dosing for muscle strength versus muscle power. Dosing parameters of frequency, volume, intensity, duration, and velocity are discussed independently for strength and power. METHODS We describe how resistance training principles can be applied to the upper extremity in CP through a case study. The case describes an individual with spastic CP, who has a severe motor disability and is non-ambulatory, but has been able to perform resistance training focused on speed, power, and strength. DISCUSSION Recommendations to optimize the dosing of this individuals resistance training program are made.