Patricia A. Burtner

Muscle activation characteristics of stance balance control in children with spastic cerebral palsy.

Two studies were conducted to investigate muscle recruitment of children with spastic cerebral palsy in response to unexpected perturbation of balance in stance. The aim of the studies was to investigate neural and non-neural mechanical contributions to muscle responses differences these children display when maintaining balance. In the first study, muscle responses of children with spastic diplegia were compared to typically developing children with similar levels of walking experience. Each child stood on a moveable platform that was displaced backward. Electromyographic recordings of posterior agonist and anterior antagonist muscles of the legs and trunk were analyzed and compared to those of normal children who had obtained a similar developmental levels of mobility. Children with spastic cerebral palsy were found to have an increase in antagonist recruitment and decreased trunk activation when compared to typically developing children at the same level of walking experience. Developmental trends were noted to be similar in all children with or without pathology. As children gained independent walking skills, they demonstrated shorter onset latencies in leg and thigh muscles. In the second study, older children with no pathology were perturbed in crouch stance, simulating the posture of their matched children with cerebral palsy. Changes in their muscle responses were observed to more clearly approximate the muscle onset latency organization of children with spastic diplegia. Results of these studies suggest that muscle recruitment differences for balance control in children with spasticity are due to CNS deficits as well as mechanical changes in posture. Copyright 1998 Elsevier Science B.V.

Endurance and gait in children with cerebral palsy after intensive body weight-supported treadmill training.

Purpose: This study was designed to investigate changes in endurance, functional gait, and balance after intensive body weight-supported treadmill training in children with CP who were ambulatory. Methods: Six school-aged children with CP (four boys, two girls; age range: six to 14 years) participated in an intensive program of body weight-supported treadmill training 30 minutes twice daily for two weeks. Results: Statistically significant improvement in walking velocity and energy expenditure were observed. Variability of individual outcomes was observed with some children showing positive changes, and others no change or a decline in performance. Four children showed minimal detectable changes in a positive direction on both an endurance measure and a functional gait measure. Each endurance and functional gait measure included at least one child with a positive minimal detectable change. Conclusion: Intensive body weight-supported treadmill training may be an effective intervention for some children with CP who are ambulatory.

Motor Learning in Children: Feedback Effects on Skill Acquisition

Background and Purpose: Reduced feedback during motor skill practice benefits motor learning. However, it is unknown whether these findings can be applied to motor learning in children, given that children have different information-processing capabilities than adults. The purpose of this study was to determine the effect of different relative frequencies of feedback on skill acquisition in children compared with young adults. Subjects: The participants were 20 young adults and 20 children. Methods: All participants practiced 200 trials of a discrete arm movement with specific spatiotemporal parameters. Participants from each group (adults and children) were randomly assigned to either a 100% feedback group or a reduced (62% faded) feedback group. Learning was inferred from the performance on the delayed (24-hour) retention and reacquisition tests. Results: All participants improved accuracy and consistency across practice trials. During practice, the adults performed with significantly less error than the children. Adults who practiced with reduced feedback performed with increased consistency during the retention test compared with those who practiced with 100% feedback. In contrast, children who received reduced feedback during practice performed with less accuracy and consistency during the retention test than those who received 100% feedback. However, when feedback was reintroduced during the reacquisition test, the children in the reduced feedback group were able to improve their performance comparable to those in the 100% feedback group. Discussion and Conclusions: During motor learning, children use feedback in a manner different from that of adults. To optimize motor learning, children may require longer periods of practice, with feedback reduced more gradually, compared with young adults.

Stance balance control with orthoses in a group of children with spastic cerebral palsy

Although ankle‐foot orthoses (AFOs) are frequently prescribed to correct skeletal malalignment in children with spastic diplegia, their effect on standing balance abilities has not been documented. This study investigated balance differences related to the presence of pathology and orthotic conditions during conditions of unexpected stance perturbation by comparing four children aged between 3 and 15 years with spastic cerebral palsy and four control children matched for years of independent walking experience. Electromyographic and kinematic data were collected and compared between groups and in three orthotic conditions (no AFOs, solid AFOs, dynamic AFOs). Results revealed that balance responses of children with spasticity were characterized by: increased coactivation of muscles as opposed to distal to proximal recruitment, decreased presence of upright posture in stance, increased use of‘on‐toes’strategies, and different sway characteristics compared with the typically developing children. In both groups of children, the use of solid AFOs during perturbed stance resulted in: decreased activation of gastrocnemius muscles, disorganized muscle‐response patterns, decreased use of ankle strategies, and increased joint angular velocities at the knee compared with conditions without AFOs or with dynamic AFOs. These preliminary results support the use of dynamic AFOs to correct skeletal malalignment in children with spastic diplegia.

Postural Control in Children: Implications for Pediatric Practice

SUMMARY Based on a systems theory of motor control, reactive postural control (RPA) and anticipatory postural control (APA) in children are reviewed from several perspectives in order to develop an evidence-based intervention strategy for improving postural control in children with limitations in motor function. Research on development of postural control, postural control in children with specific motor disabilities, and interventions to improve postural control is analyzed. A strategy for intervention to improve postural control systems at the impairment and functional activity levels based on a systems theoretical perspective is presented. Suggestions for research to improve evidence for best practice are provided.

Ankle dorsiflexion fMRI in children with cerebral palsy undergoing intensive body‐weight‐supported treadmill training: a pilot study

This pilot study investigated the feasibility of using functional magnetic resonance imaging (fMRI) as a physiological marker of brain plasticity before and after an intensive body‐weight‐supported treadmill training (BWSTT) program in children with cerebral palsy (CP). Six ambulatory children (four males, two females; mean age 10y 6mo, age range 6–14y) with spastic CP (four hemiplegia, two asymmetric diplegia, all Gross Motor Function Classification System Level I) received BWSTT twice daily for 2 weeks. All children tolerated therapy; only one therapy session was aborted due to fatigue. With training, over ground mean walking speed increased from 1.47 to 1.66m/s (p=0.035). There was no change in distance walked for 6 minutes (pre‐: 451m; post‐: 458m;p 0.851). In three children, reliable fMRIs were taken of cortical activation pre‐ and post‐intervention. Post‐intervention increases in cortical activation during ankle dorsiflexion were observed in all three children. This study demonstrates that children with CP between 6 and 14 years of age can tolerate intensive locomotor training and, with appropriate modifications, can complete an fMRI series. This study supports further studies designed to investigate training‐dependent plasticity in children with CP.

Survey of occupational therapy practitioners in southwestern schools: assessments used and preparation of students for school-based practice.

Purpose: The purpose of this study was to identify current practice in assessment useof school-based occupational therapy practitioners and to identify their expectations of student performance in assessment upon completion of the pediatric Fieldwork II experience. A survey of school-based occupational therapists in the southwestern states was conducted to answer three research questions: (1) what standardized assessments are currently used frequently and occasionally by occupational therapy practitioners in the school setting, (2) what level of competency in assessment administration by Fieldwork II students is expected by supervising occupational therapists, and (3) what educational preparation did the practitioners receive prior to their employment in schools and what professional support is currently available to them? Method: A five page questionnaire was mailed to 406 practicing thera-pists in four southwestern states with a response rate of 74.1 percent using Dillmans Total Design Method. Results: Respondents reported use of motor and visual perception tests most frequently in their practice. When trends of this survey were compared to previous surveys, practitioners reported similar use of motor and visual perception tests, a decreased use of sensory integration measures, and an increasein the use of function-based assessments.

The Evolving Practice of Developmental Care in the Neonatal Unit: A Systematic Review

ABSTRACT Many neonatal intensive care units (NICUs) are experiencing changes in their approaches to preterm infant care as they consider and incorporate the philosophy of individualized developmental care. The aim of this systematic review is to research current literature documenting the short-term effects of developmental care and the Newborn Individualized Developmental Care and Assessment Program (NIDCAP). The following databases were reviewed: PubMED, CINAHL, and PsychINFO by using the keywords developmental care, individualized care, preterm infant, early intervention, and NIDCAP. Fifty-four articles were found with a total of 15 matching the selection criteria. All 15 articles were assessed using a research design developed by the American Academy for Cerebral Palsy and Developmental Medicine (AACPDM). Twelve of the 15 articles contained strong Levels of Evidence (I or II). Our findings suggest evidence supporting developmental care and NIDCAP, however, further research documenting outcomes for preterm infants receiving developmental care and/or NIDCAP is needed.

Effects of constraint-induced movement therapy on hand skills and muscle recruitment of children with spastic hemiplegic cerebral palsy.

BACKGROUND Constraint-Induced Movement Therapy (CIMT) is a therapeutic intervention using constraint of the less-affected limb and intensive use of the hemiplegic extremity in individuals with hemiplegia. The purpose of this study was to determine whether children with cerebral palsy (CP) who have undergone a 2-week function-based CIMT show improved hand function and underlying muscle activation changes associated with functional gains. METHODS Six children with hemiplegic CP participated in the study, receiving 4 hours of therapy 5 days a week coupled with bi-valve casts worn 8-12 hours for 14 days. Outcome measures of grip strength, pinch strength, dexterity tests and electromyography (EMG) were compared before, immediately post- and 3 months post-intervention. RESULTS Repeated measures ANOVA and post hoc paired t-tests showed significant group improvements in all strength and dexterity measures (p < 0.05). EMG analysis showed significant increases in muscle activation on pinch measures (p = 0.05). Visual inspection of the EMG data suggested increased muscle activation during grip and a decrease in the muscle activation required during dexterity tasks. CONCLUSIONS Our preliminary results support CIMT for improving strength and dexterity in children with hemiplegic CP. Further studies with greater sample sizes and longer study periods are recommended to determine muscle activation changes post CIMT.

A comparison of static and dynamic wrist splints using electromyography in individuals with rheumatoid arthritis

This study compared strength, dexterity, and the muscle activation of individuals with rheumatoid arthritis (RA) when different splints were worn. Five persons with RA were observed in four splint conditions (none, static, hinged, spiral) during grip, pinch, and dexterity tests by recording muscle activity of eight muscles in the upper extremity using electromyography (EMG). Statistically significant differences were found in clinical tests when hinged (p<0.001) and spiral splints (p=0.02) were worn. Grip strength decreased when hinged splints were worn, whereas two-point pinch increased and dexterity improved on the Nine-Hole Peg Test with the spiral splint. Although no significant EMG differences were found during different splint conditions, wrist muscles were recruited more for grip, and shoulder muscles were used most during pinch and dexterity tests. Individuals with RA who wore splints had decreased grip when wearing hinged splints, but improved pinch and dexterity were found when the spiral splint was worn. Increased use of proximal shoulder muscles was observed during pinch and dexterity tests with and without splints.