Reliability of the motor learning strategy rating instrument for children and youth with acquired brain injury

PURPOSE

To evaluate reliability and feasibility of the Motor Learning Strategy Rating Instrument (MLSRI) in children with acquired brain injury (ABI). The MLSRI quantifies the extent to which motor learning strategies (MLS) are used within physiotherapy (PT) interventions.

METHODS

PT sessions conducted by ABI team physiotherapists with a convenience sample of children with ABI (4-18 years) were videotaped and independently scored later by two raters trained in MLSRI use. Intraclass correlation coefficients (ICCs) and 95% confidence intervals (CIs) estimated intra- and inter-rater reliability.

RESULTS

Eighteen PT sessions were evaluated. Intra- and inter-rater reliability ICCs for total score were 0.86 (95% CI: 0.66-0.94) and 0.50 (95% CI: 0.08-0.78), respectively. MLSRI category ICCs were 0.56-0.86 (intra-rater) and 0.16-0.84 (inter-rater).

CONCLUSIONS

Intra-rater reliability of MSLRI total score was excellent. Moderate inter-rater reliability may partially be due to inconsistent item interpretation between raters. Revisions and further reliability testing are required before recommending the MLSRI for clinical and research use.

A Comparison of Solo and Multiplayer Active Videogame Play in Children with Unilateral Cerebral Palsy

OBJECTIVE

Active videogames (AVGs) have potential in terms of physical activity and therapy for children with cerebral palsy. However, the effect of social interaction on AVG play has not yet been assessed. The objective of this study is to determine if multiplayer AVG versus solo affects levels of energy expenditure and movement patterns.

SUBJECTS AND METHODS

Fifteen children (9.77 [standard deviation (SD) 1.78] years old) with hemiplegic cerebral palsy (Gross Motor Function Classification System Level I) participated in solo and multiplayer Nintendo(®) "Wii™ Boxing" (Nintendo, Inc., Redmond, WA) AVG play while energy expenditure and punching frequency were monitored.

RESULTS

Moderate levels of physical activity were achieved with no significant differences in energy measures during multiplayer and solo play. Dominant arm punching frequency increased during the multiplayer session from 95.75 (SD 37.93) punches/minute to 107.77 (SD 36.99) punches/minute. Conversely, hemiplegic arm punching frequency decreased from 39.05 (SD 29.57) punches/minutes to 30.73 (SD 24.74) punches/minutes during multiplayer game play. Children enjoyed multiplayer more than solo play.

CONCLUSIONS

Opportunities to play AVGs with friends and family may translate to more frequent participation in this moderate physical activity. Conversely, increased hemiplegic limb use during solo play may have therapeutic advantages. As such, new strategies are recommended to promote use of the hemiplegic hand during multiplayer AVG play and to optimize commercial AVG systems for applications in virtual reality therapy.

Children's and parents' beliefs regarding the value of walking: rehabilitation implications for children with cerebral palsy

BACKGROUND

Walking for children with cerebral palsy (CP) has physiological and functional benefits, but also holds symbolic significance that largely remains unexplored. The aims of this pilot study were to describe beliefs about the value of walking held by children with CP and their parents, and to examine how these beliefs inform rehabilitation choices and perceptions of 'success'.

METHODS

A critical qualitative design was employed. Six parents and six children with CP (Gross Motor Function Classification System III or IV, aged 9 to 18 years) each participated in a private interview. Analyses examined the relationship between dominant social beliefs regarding walking and participants' accounts.

RESULTS

Parents' accounts revealed that all adopted a stance of doing something/trying anything as part of being a 'good parent' and maintaining hope. Tapering of walking interventions contributed to feelings of guilt and doubt. Children primarily viewed walking as exercise rather than functional. Their accounts also demonstrated how they internalized negative attitudes towards disability and judged themselves accordingly.

CONCLUSIONS

The results of this pilot study provide provisional evidence regarding how dominant social values regarding walking and disability are taken up by parents and children. They suggest that rehabilitation programmes need to consider how they may unintentionally reinforce potentially harmful choices, and how best to engage families in discussions of their evolving values and treatment priorities. Further research is needed with a larger sample.

Identification of a core set of exercise tests for children and adolescents with cerebral palsy: a Delphi survey of researchers and clinicians

AIM

Evidence-based recommendations regarding which exercise tests to use in children and adolescents with cerebral palsy (CP) are lacking. This makes it very difficult for therapists and researchers to choose the appropriate exercise-related outcome measures for this group. This study aimed to identify a core set of exercise tests for children and adolescents with CP.

METHOD

Fifteen experts (10 physical therapists/researchers and five exercise physiologists; three from the Netherlands, two from the USA, one from the UK, five from Canada, and four from Australia) participated in a Delphi survey which took four stages to achieve a consensus. Based on the information that was collected during the survey, a core set of measures was identified for levels I to IV of the Gross Motor Function Classification System (GMFCS).

RESULTS

For children with CP classified at GMFCS levels I and II, tests were identified for two motor skills (walking and cycling). For the subgroup of children with CP classified at GMFCS level III, the tests that were identified related to walking, cycling, and arm cranking. For children with CP classified at GMFCS level IV, the tests included in the core set were related to cycling and arm cranking.

INTERPRETATION

The core set will help physical therapists, exercise physiologists, and other health professionals who work with children and adolescents with CP to decide which test(s) to use in clinical practice or research. This will facilitate comparability of results across studies and clinical programmes.

Applying the ICF framework to study changes in quality-of-life for youth with chronic conditions

OBJECTIVE

The objective of this paper is to describe how the ICF framework was applied as the foundation for a longitudinal study of changes in quality-of-life (QoL) for youth with chronic conditions.

METHOD

This article will describe the study's aims, methods, measures and data analysis techniques. It will point out how the ICF framework was used--and expanded upon--to provide a model for studying the impact of factors on changes in QoL for youth with chronic conditions. Further, it will describe the instruments that were chosen to measure the components of the ICF framework and the data analysis techniques that will be used to examine the impact of factors on changes in youths' QoL.

CONCLUSIONS

Qualitative and longitudinal designs for studying QoL based on the ICF framework can be useful for unraveling the complex ongoing inter-relationships among functioning, contextual factors and individuals' perceptions of their QoL.

Multiple protein extract microarray for profiling human food-specific immunoglobulins A, M, G and E

Existing food immunoglobulin (Ig) tests require large volumes of serum, are limited to one immunoglobulin class, are not amenable to high throughput analysis and only give a limited picture of the immunological response to food antigens. Conversely a new generation of Component Resolved Diagnostic systems using pure proteins is highly specific and totally dependent on the availability of the protein in its recombinant or natural origin form. Here we demonstrate a proof-of-concept of a microarray test based on protein extracts of food components. Our approach relies on innovations on three different fronts: the novelty of using arrayed food samples sequentially extracted with detergent and chaotropic agents, the ability to measure four different Ig classes simultaneously and the ability to analyse the generated data via a suitable bioinformatics/statistical analysis interface. This approach combines high numerical power of microarrays with automation, high throughput analysis and enables detailed investigation of the Ig profiles to food antigens. The prototype shown contains extracts of approximately 350 food ingredients that cover most of the food products found in the UK. Here we showed that the use of a sequential extraction technique to solubilise and then denature food samples has its benefits in the assessment of variations in antigenicity when tested with human sera. A patient dependent degree of class specificity was observed with human sera (IgG specificity correlates well with IgA>IgM>>>>>IgE). Besides generating a simultaneous profile for IgA, IgM, IgG and IgE the array system has shown good discrimination between challenge responders in atopic and non-atopic individuals. Poly- and mono-specific IgE responders were easily identified. The mathematical modelling of specific IgE content showed good correlations when compared with established IgE antibody testing assay (UniCAP). Although in its proof-of-principle stages, the immune profiling technique described here has the potential to provide unique insights into exposure/sensitization and establish relationships between specific immunoglobulin classes and subclasses against food protein antigens. In further developments, the immune profiling technique could also be extended to other related areas such as parasite and bacterial gut infection. Full analyses of large longitudinal and retrospective clinical trials are on going to determine the positive and negative predictive values of the technique.

The ICF model of functioning and disability: incorporating quality of life and human development

OBJECTIVE

Since its 2001 publication, a number of issues have been raised about the ICF. The World Health Organization anticipated the ICF would undergo a continuous process of revision. This paper adds to this process.

METHOD

This article describes how the ICF framework shares a number of tenets with a systems perspective. An argument is built for why the ICF model of functioning and disability should be expanded to include the concepts of quality of life and human development. A modified model is presented that depicts a person's life quality and his/her potential for development as the outcomes and processes that arise from the interconnected, ever-changing influences of health, functioning and contextual factors.

CONCLUSIONS

A modified ICF model based on a systems perspective depicts a holistic view that acknowledges health, functioning, life quality and development are intertwined and are essential concepts to consider in the lives of all people.

Development of a challenge assessment tool for high-functioning children with an acquired brain injury

PURPOSE

To develop a performance-based challenge assessment to evaluate gross motor abilities of high-functioning youth with an acquired brain injury (ABI).

METHODS

Potential items were identified from the literature. A panel of 4 expert physical therapists selected items on the basis of 3 criteria: safety to test, feasibility to administer, and importance to perform. Item reduction was completed using ratings from a physical therapist web survey. The Acquired Brain Injury-Challenge Assessment (ABI-CA) was created and pilot tested with youth with an ABI.

RESULTS

Seventy-eight items were identified and reduced to 47 items following expert panel discussion. Web-survey item reduction by 75 pediatric physical therapists yielded a 24-item ABI-CA that was administered to 6 youth with an ABI, aged 8 to 17 years. The ABI-CA mean score was 50.7/81.0 (SD = 17.4).

CONCLUSION

The ABI-CA was feasible to administer and demonstrated gross motor activity challenges beyond the Gross Motor Function Measure. Response option refinement and measure validation are required prior to clinical/research use.

Individualized Outcome Measures for Evaluating Life Skill Groups for Children with Disabilities

Background. The challenge of evaluating life skill groups is the need to assess skills reflecting the priorities and abilities of the individuals as well as the program focus.Purpose. This study describes the feasibility and utility of goal menus and individualized outcome measures in two life skill groups for children with disabilities.Methods. Eleven children were evaluated at baseline and 5 weeks post-program using a modified Canadian Occupational Performance Measure (COPM) and modified Goal Attainment Scaling (mod-GAS).Findings. COPM satisfaction median scores across all goals increased post-program by 3.0 points (P=0.001) and performance scores by 1.0 point (P=0.002). Mod-GAS scores for all participants were at least −1 (partial achievement), and 55% of participants achieved their functional goal (Mod-GAS = 0) with carryover into their community environments.Implications. This study supports the positive contribution of individualized measures to evaluate outcomes within life skill programs for children with disabilities.

Feasibility and effectiveness of an aerobic exercise program in children with fibromyalgia: results of a randomized controlled pilot trial

OBJECTIVE

To determine the feasibility of conducting a randomized controlled trial of a 12-week exercise intervention in children with fibromyalgia (FM) and to explore the effectiveness of aerobic exercise on physical fitness, function, pain, FM symptoms, and quality of life (QOL).

METHODS

FM patients ages 8-18 years were randomized to a 12-week exercise intervention of either aerobics or qigong. Both groups participated in 3 weekly training sessions. Program adherence and safety were monitored at each session. Data were collected at 3 testing sessions, 2 prior to and 1 after the intervention, and included FM symptoms, function, pain, QOL, and fitness measures.

RESULTS

Thirty patients participated in the trial. Twenty-four patients completed the program; 4 patients dropped out prior to training and 2 dropped out of the aerobics program. Better adherence was reported in the aerobics group than in the qigong group (67% versus 61%). Significant improvements in physical function, functional capacity, QOL, and fatigue were observed in the aerobics group. Anaerobic function, tender point count, pain, and symptom severity improved similarly in both groups.

CONCLUSION

It is feasible to conduct an exercise intervention trial in children with FM. Children with FM tolerate moderate-intensity exercise without exacerbation of their disease. Significant improvements in physical function, FM symptoms, QOL, and pain were demonstrated in both exercise groups; the aerobics group performed better in several measures compared with the qigong group. Future studies may need larger sample sizes to confirm clinical improvement and to detect differences in fitness in childhood FM.

Single-session reliability of discrete gait parameters in ambulatory children with cerebral palsy based on GMFCS level

The single-session reliability of 28 discrete spatiotemporal and kinematic variables was evaluated from computerized gait analysis (CGA) in 33 ambulatory children with cerebral palsy (CP), subcategorized according to Gross Motor Function Classification System (GMFCS) Levels I (n=11), II (n=12) and III (n=10). Nineteen boys and 14 girls participated, mean age=8 years 1 month (S.D.=3 years 0 month). Intraclass correlation coefficients (ICCs) estimated reliability, and the number of strides required to obtain an ICC of at least 0.90 was determined. The reliability of discrete gait parameters was dependent upon GMFCS level, with children in GMFCS Level I exhibiting the highest reliability (ICC range=0.70-0.96). GMFCS Levels II and III had lower levels of reliability with ICC values varying from 0.54 to 0.95 and 0.45 to 0.98, respectively. With the exclusion of pelvis range of motion (ROM), an average of four strides provided a reliability estimate of at least 0.90 for GMFCS Level I, while six strides were needed for children in Levels II and III. On the basis of the intrasession reliability results from the present study, further work is recommended to examine the test-retest reliability of these gait parameters in children with CP.

Paediatric Application of Individualised Client-Centred Outcome Measures: A Literature Review

A literature review was conducted to identify and compare the clinical utility of client-centred, individualised outcome measures for paediatric rehabilitation. Five measures were identified: the Canadian Occupational Performance Measure (COPM) (28 studies); Goal Attainment Scaling (GAS) (34 studies); Perceived Efficacy and Goal Setting System (PEGS) (2 studies); Target Complaints (TC) (1 study); and the Paediatric Activity Card Sort (PACS) (instruction manual only). The COPM and GAS have been used with children across a wide age range and variety of clinical settings. The PEGS and PACS provided young children direct involvement in the goal-setting process. Little evidence supports the use of TC in paediatrics.

Clinicians need to use individualised measures in a way that facilitates the maximal participation of children and families in goal setting and outcome evaluation. Clinicians should document their own role in goal setting. The use of individualised and client-centred measures can motivate children and families and focus their attention on therapy goals.

Focus on Function - a randomized controlled trial comparing two rehabilitation interventions for young children with cerebral palsy

BACKGROUND

Children with cerebral palsy receive a variety of long-term physical and occupational therapy interventions to facilitate development and to enhance functional independence in movement, self-care, play, school activities and leisure. Considerable human and financial resources are directed at the "intervention" of the problems of cerebral palsy, although the available evidence supporting current interventions is inconclusive. A considerable degree of uncertainty remains about the appropriate therapeutic approaches to manage the habilitation of children with cerebral palsy. The primary objective of this project is to conduct a multi-site randomized clinical trial to evaluate the efficacy of a task/context-focused approach compared to a child-focused remediation approach in improving performance of functional tasks and mobility, increasing participation in everyday activities, and improving quality of life in children 12 months to 5 years of age who have cerebral palsy.

METHOD/DESIGN

A multi-centred randomized controlled trial research design will be used. Children will be recruited from a representative sample of children attending publicly-funded regional children's rehabilitation centers serving children with disabilities in Ontario and Alberta in Canada. Target sample size is 220 children with cerebral palsy aged 12 months to 5 years at recruitment date. Therapists are randomly assigned to deliver either a context-focused approach or a child-focused approach. Children follow their therapist into their treatment arm. Outcomes will be evaluated at baseline, after 6 months of treatment and at a 3-month follow-up period. Outcomes represent the components of the International Classification of Functioning, Disability and Health, including body function and structure (range of motion), activities (performance of functional tasks, motor function), participation (involvement in formal and informal activities), and environment (parent perceptions of care, parental empowerment).

DISCUSSION

This paper presents the background information, design and protocol for a randomized controlled trial comparing a task/context-focused approach to a child-focused remediation approach in improving functional outcomes for young children with cerebral palsy.

TRIAL REGISTRATION

[clinical trial registration #: NCT00469872].

The effects of vigorous exercise training on physical function in children with arthritis: A randomized, controlled, SINGLE-BLINDED trial

OBJECTIVE

To examine the effectiveness of high-intensity aerobic training compared with low-intensity training in terms of energy cost of locomotion, peak oxygen uptake, peak power, and self-reported physical function in children with juvenile idiopathic arthritis (JIA).

METHODS

Eighty children with JIA, ages 8-16 years, were enrolled in a randomized, single-blind controlled trial. Both groups participated in a 12-week, 3-times-weekly training program consisting of high-intensity aerobics in the experimental group and qigong in the control group. Subjects underwent exercise testing measuring submaximal oxygen uptake at 3 km/hour (VO(2submax)) as the primary outcome, maximal oxygen uptake, and peak power at the beginning and end of the program. Physical function was measured using the Child Health Assessment Questionnaire (C-HAQ).

RESULTS

The exercise program was well tolerated in both groups. There was no difference in VO(2submax) or any other exercise testing measures between the groups through the study period and no indication of improvement. Both groups showed significant improvements in C-HAQ with no difference between the groups. Adherence was higher in the control group than the experimental group.

CONCLUSION

Our findings suggest that activity programs with or without an aerobic training component are safe and may result in an important improvement in physical function. The intensity of aerobic training did not seem to provide any additional benefits, but higher adherence in the qigong program may suggest that less intensive regimens are easier for children with JIA to comply with, and provide a degree of benefit equivalent to more intensive programs.