Evidence-informed clinical perspectives on postural management for hip health in children and adults with non-ambulant cerebral palsy

Exploring experiences of parents of young children with cerebral palsy with a standing frame program promoting hip development

PURPOSE

Children with Cerebral Palsy (CP) are at risk for hip problems, and early monitoring and intervention are recommended. This study explores the experiences of parents of young children with CP with a standing frame program (SFP) promoting hip development and identifies factors promoting or hindering the program's feasibility.

METHODS

Qualitative data were collected through 11 interviews, which were transcribed, and analyzed thematically. Quantitative data were collected through ratings of the level of agreement with statements related to the SFP.

RESULTS

For parents, balancing between their roles as parent and co-therapist, implementing the SFP involved physical and mental load. Involving the social environment, sharing care responsibilities, and integrating the SFP in different settings facilitated implementation of the program. Parents were motivated by potential benefits for their child and the opportunity for quality time.

CONCLUSIONS

Implementing the SFP is challenging for parents. For better integration of the SFP program into daily life, it is important to consider parents' needs and to collaborate with all caregivers. Future research should strengthen evidence on the SFP's impact on hip development and parental burden. Additionally, it is essential to ensure that the perspectives of burdened parents are incorporated in the program's development and evaluation.

The goal-oriented collaborative approach with postural management strategies intervention via telehealth for children with non-ambulant cerebral palsy: Feasibility randomized clinical trial protocol

INTRODUCTION

Children with non-ambulant Cerebral Palsy (CP), have limitations in terms of self-mobility and require the use of assistive technology with extensive adaptations. However, purchasing assistive technology equipment is expensive and difficult to access in low- and middle-income countries, like Brazil. Guidelines recommend a postural management program to children with CP and emphasize the need for high doses of practice to achieve functional goals. Furthermore, collaborative practices are recommended, with active parental participation in the intervention.

AIMS

This study describes a protocol for assessing the feasibility of a future randomized clinical trial using a goal-oriented collaborative approach with postural management strategies via telehealth for non-ambulant children with CP.

METHODS

Eighteen children (1-5 years) with CP and their families will be randomized into two groups for 12 weeks: (A) goal-oriented collaborative approach with postural management strategies intervention via telehealth associated with conventional physical therapy or (B) conventional physical therapy. Feasibility measures will be verified, and outcomes will include parents' perceptions of performance and satisfaction, gross motor function, postural control, goal achievement and participation at home, preschool, and community.

IMPLICATIONS

The findings will inform the planning and preparation of a future randomized clinical trial of interventions for non-ambulant CP children via telehealth.

Effects of exercise intervention on balance function in children with cerebral palsy: a systematic review and meta-analysis of randomized controlled trials

OBJECTIVE

To determine the effectiveness of exercise intervention on postural balance, gait parameters, and muscle strength in children with cerebral palsy by quantifying the information from randomized controlled trials (RCTs).

METHODS

We conducted a systematical search for RCTs from the databases, including PubMed, ISI Web of Science, and Scopus using a between-group design involving children with cerebral palsy and assessing the effect of exercise intervention on postural balance, gait parameters, and muscle strength. The specified inclusion criteria were determined by the PICOS tool. The outcomes of included studies were evaluated by meta-analysis, and subgroup and sensitivity analyses were conducted to analyze the observed heterogeneities using Review Manager 5.4 and Stata version 18.0. The revised Cochrane risk of bias tool for randomized trials (RoB 2) was used to evaluate the risk of bias and quality of the included studies.

RESULTS

Twenty-four studies were included in this meta-analysis, with 579 children with cerebral palsy. Exercise intervention showed a statistically significant favorable effect on gross motor function (SMD = 0.32; 95%CI [0.03 to 0.61]; I2 = 16%), anteroposterior stability index (SMD = -0.93; 95%CI [-1.69 to -0.18]; I2 = 80%), and mediolateral stability index (SMD = -0.60; 95%CI [-1.16 to -0.03]; I2 = 73%) compared to control group among children with cerebral palsy. None of the above meta-analyses exhibited publication bias, as indicated by Egger's test with p-values greater than 0.05 for all.

CONCLUSIONS

Exercise is effective in improving gross motor function and balance in children with cerebral palsy. Due to the lack of studies examining the efficacy of each exercise type, we are unable to provide definitive training recommendations.

The Montana Postural Care Project: A pilot study implementing posture care management in a rural, low-resource region

Background

Mobility impairment limits control of posture and body alignment. This leads to altered body shapes, co-occurring problems with pain and sleep, cardiopulmonary concerns, digestive health issues, and emergent health outcomes, which further complicate functions of daily living. 24-hour posture care management was developed to remedy these challenges by restoring body symmetry.

Objective

To determine the feasibility of introducing posture care management to a rural-based, medically complex patient population, evaluate response of body symmetry, and examine its impact on pain and sleep quality.

Methods

This pilot study employed a longitudinal, quasi-experimental study design from March 2016 to September 2018. The posture care management intervention introduced positioning support for use when lying down, a personalized training workshop for caregiver teams, and in-home initial and follow-up assessments to provide materials and collaboratively develop a personalized care plan. Participants were followed pre-post for 6-9 months.

Results

A total of 73 participants enrolled in the study; 55 (75 %) completed. The majority were male (55 %) with a median age of 11. Most caregivers were immediate family members, and most participants had 1+ diagnosis characterized as a neurodevelopmental disorder. A majority of participants improved body symmetry (56-76 %), and 53 % with comparable information saw improvement in body symmetry with no worsening of pain or sleep quality.

Conclusion

This study established the feasibility of administering posture care management in North America. These findings provide preliminary evidence of improvements in body symmetry and address concerns that posture care management can interfere with pain and sleep. Future research should consider levels of caregiver engagement and explore remote-monitored options of a posture care management intervention.

Reliability and Construct Validity of the Japanese Version of the Posture and Postural Ability Scale in Individuals with Cerebral Palsy

OBJECTIVE

This study aimed to develop the Japanese version of the Posture and Postural Ability Scale (PPAS) and verify its inter- and intra-rater reliability, construct validity, and internal consistency in individuals with cerebral palsy (CP) in Japan.

METHODS

This cross-sectional study recruited 73 children and adults with CP at all Gross Motor Function Classification System (GMFCS) levels. The translation procedure was performed by three Japanese physiotherapists and the developer of the original version. Intra- and inter-rater reliability were evaluated using the weighted kappa coefficients, and construct validity was based on the correlation coefficients between PPAS and GMFCS. Cronbach's alpha coefficients were calculated to assess internal consistency.

RESULTS

Weighted kappa coefficients for intra- and inter-rater reliability exceeded 0.81 for all items. The correlation coefficients between the PPAS and GMFCS were negative and showed "moderate" to "very strong" in almost all items (ρ = -0.66 to -0.91), except for one item (ρ = -0.37). Cronbach's alpha coefficients exceeded 0.80 in all four positions.

CONCLUSION

This study supports the Japanese version of the PPAS with excellent intra- and inter-rater reliability, good construct validity, and internal consistency in the Japanese CP population.

Supported Standing and Supported Stepping Devices for Children with Non-Ambulant Cerebral Palsy: An Interdependence and F-Words Focus

Children functioning at Gross Motor Function Classification System (GMFCS) levels IV-V cannot maintain an aligned standing position or take steps without support. Upright positioning and mobility devices have psycho-social significance for these children and their families, enhancing use of vision, communication, functioning and emotional well-being. Standers and supported stepping devices facilitate opportunities for biomechanical loading, potentially helping to build and maintain muscle and bone integrity, and they promote physical development. However, families are often required to choose between these two devices for their young child. This study aims to synthesize evidence for use and benefits of both supported standing and stepping devices through the lens of two contemporary theoretical frameworks to support clinical reasoning and implementation. The F-words for childhood development (functioning, family, fitness, fun, friends, future) and the interdependence-Human Activity Assistive Technology (iHAAT) models were combined to illustrate the complex interactions between the child, family, caregivers, peers and contextual factors when implementing standing and stepping devices with children at GMFCS levels IV and V. Supported standing and stepping devices provide complementary benefits, and both may be necessary starting at 9-15 months. We propose they both be included ON-Time, along with other age-appropriate positioning and mobility devices, to promote more equitable developmental opportunities for children with non-ambulant cerebral palsy.

Identifying and Evaluating Young Children with Developmental Central Hypotonia: An Overview of Systematic Reviews and Tools

Children with developmental central hypotonia have reduced muscle tone secondary to non-progressive damage to the brain or brainstem. Children may have transient delays, mild or global functional impairments, and the lack of a clear understanding of this diagnosis makes evaluating appropriate interventions challenging. This overview aimed to systematically describe the best available evidence for tools to identify and evaluate children with developmental central hypotonia aged 2 months to 6 years. A systematic review of systematic reviews or syntheses was conducted with electronic searches in PubMed, Medline, CINAHL, Scopus, Cochrane Database of Systematic Reviews, Google Scholar, and PEDro and supplemented with hand-searching. Methodological quality and risk-of-bias were evaluated, and included reviews and tools were compared and contrasted. Three systematic reviews, an evidence-based clinical assessment algorithm, three measurement protocols, and two additional measurement tools were identified. For children aged 2 months to 2 years, the Hammersmith Infant Neurological Examination has the strongest measurement properties and contains a subset of items that may be useful for quantifying the severity of hypotonia. For children aged 2-6 years, a clinical algorithm and individual tools provide guidance. Further research is required to develop and validate all evaluative tools for children with developmental central hypotonia.

Rehabilitation Practices Delivered by Physical and Occupational Therapists to Brazilian Children With Congenital Zika Syndrome: A Cross-Sectional Study

INTRODUCTION

Congenital Zika syndrome (CZS) is a health condition that has affected the development of thousands of children in Brazil. Because it is a new condition, its understanding is an ongoing process. Therefore, it is important to know the rehabilitation interventions being delivered to improve the functioning of these children. We aimed to describe the practices of physical therapists (PTs) and occupational therapists (OTs) who provide follow-up care for children with CZS in Brazil.

METHODS

This cross-sectional study included PTs and OTs who assist children with CZS in Brazil. An online questionnaire was used to verify the participants' personal characteristics and professional work environment, as well as the rehabilitation programs they implemented in Brazil for children with CZS. Data were analyzed using descriptive statistics.

RESULTS

A total of 116 professionals (79 PT and 37 OT) who work mainly in public health services (81.9%) participated in the study. Of these, 24.1% plan interventions based on reading scientific articles, 66.4% did not report using the biopsychosocial model, 52.6% do not perform any assessments before starting an intervention, 31.9% use neurodevelopmental treatment, and 22.4% use sensorimotor stimulation interventions. The majority of the interventions are delivered 1 to 2 times a week, lasting up to 1 hour.

CONCLUSIONS

Professional training and knowledge translation strategies are needed to implement evidence-based practices and improve the quality of rehabilitation programs for Brazilian children with CZS.

"It is something that gives us hope": Lived experience among parents to children with cerebral palsy who are non-ambulant of the phenomenon physical activity, with or without the use of a novel dynamic standing device

Introduction

Regular physical activity confers health benefits for all. Parents commonly want their children to be physically active, and want to be physically active themselves, but children with cerebral palsy (CP) who are non-ambulant face challenges, and they need support to be physically active. Dynamic standing in the novel motorized assistive device Innowalk has positive effects in children who are non-ambulant-it gives them a chance to be physically active. The aim of this study was to explore the lived experience of physical activity of parents themselves and for their children with cerebral palsy who are non-ambulant.

Methods

A descriptive inductive design with a hermeneutic phenomenological approach was used for the analysis of interviews with 11 parents of children with CP who are non-ambulant who participated in a study of exercise effects of dynamic standing.

Results

The parents experienced physical activity for their children as being important but difficult, especially for their child, as described in Theme 1: "Being aware of health benefits while struggling with family time." The children were perceived as being dependent on other people, the environment, and equipment for participating in physical activity, referring to Theme 2: "Being dependent." The opportunity for their children to become physically active on a regular basis through an assistive device gave the parents hope for a better life, which formed Theme 3: "Getting hope in a challenging life situation."

Conclusion

Physical activity for children with CP who are non-ambulant is possible through an elaborate network of social relations and environmental conditions. Limiting the degree of dependence and containing the negative consequences of high a degree of dependence are vital in the support of physical activity. Relations, support, and assistive devices that strengthen empowerment and autonomy should be prioritized, and if this works, the experience of physical activity can be positive, giving families hope.