Pediatric physical therapy: the official publication of the Section on Pediatrics of the American Physical Therapy Association

Published by Lippincott, Williams & Wilkins
Print ISSN: 0898-5669
To discuss the developmental presentation, complicating factors, and delivery of physical therapy services through the Birth to Three System, for 1 child with 16p11.2 deletion syndrome. History, presenting problems, medical complexities, developmental and behavioral characteristics, interventions, and implications for service delivery are reviewed. The child experienced many difficulties reported in the literature related to the wide phenotype of 16p11.2 deletion syndrome. Focus on caregiver instruction and education to accomplish family-driven, functional outcomes increased carryover and allowed the greatest potential for success. Genetic disorders such as 16p11.2 deletion syndrome are increasingly being recognized as etiologic factors in neurodevelopmental conditions. It is critical for physical therapists to be aware of the varied manifestations and effects of this genetic disorder. Advanced problem solving and decision-making, ongoing assessment, and collaboration are required to comprehensively support the family in meeting the child's medical, behavioral, and developmental needs.
Mean and standard deviation values of TIMP z scores attained by infants with typical development (TD), full line; and infants with Down syndrome (DS), dotted line, at 2, 3, and 4 months of age. *Significant differences were found. 
Longitudinal gross motor scores in participants with typical development (TD) and Down syndrome (DS) assessed at 4 months of age using the TIMP and at 26 months of age using the Bayley-III gross motor scale. 
To compare gross motor performance of children with Down syndrome (DS) and typical development (TD) at 2 to 4 months (Phase I) and at 2 years of age (Phase II) and to investigate the relation between early motor performance and later outcome. Seventeen infants (10 with TD and 7 with DS) were assessed in Phase I using the Test of Infant Motor Performance (TIMP); 25 children were assessed in Phase II using the gross motor scale of the Bayley Scales of Infant and Toddler Development (Bayley-III); 10 participants were enrolled in both phases. TIMP and Bayley-III scores were lower in the DS group. In both groups, TIMP z scores were predictive of Bayley-III scores. Children with DS show difficulties in early postural control and activities requiring speed, postural control, and balance. The finding that early performance relates to later outcome reinforces the relevance of early and task-specific intervention.
: To study the effect of 1 year of daily, straddled weight-bearing on hip migration percentage (MP) and muscle length in children with cerebral palsy who were nonambulatory. : Participants stood upright in maximum tolerated hip abduction and hip and knee extension ½ to 1½ hours per day for 1 year. Controls, matched for age, motor ability, and surgery, were derived from a national cerebral palsy follow-up program. : Participants using straddled weight-bearing after surgery had the largest decrease in MP (n = 3, 20 controls; P = .026). Children using straddled weight-bearing at least 1 hour per day for prevention also improved (n = 8, 63 controls; P = .029). Hip and knee contractures were found only in controls. : Straddled weight-bearing, 1 hour per day, may reduce the MP after adductor-iliopsoas-tenotomies or prevent an MP increase and preserve muscle length in children with cerebral palsy who did not need surgery. Larger studies are needed to confirm the results.
The purposes of this study were to 1) determine test-retest reliability of hand-held dynamometer measurements of right hip abductor and knee extensor muscle strength in children with Down syndrome (DS), 2) identify differences in isometric muscle strength between children with DS and peers who are developing typically, and 3) determine the relationship between various anthropometric and demographic variables and isometric muscle strength. Seventeen children with DS between the ages of seven and 15 years and a comparison group of 17 age- and gender-matched peers who were developing typically participated in the study. A hand-held dynamometer was used to measure peak force during maximal isometric right hip abduction and knee extension at two test sessions approximately one week apart. Peak torque values were calculated by multiplying peak force measurements by the appropriate segment lengths. Anthropometric measurements were obtained, and a questionnaire was used to measure habitual physical activity levels. Test-retest reliability was high, with intraclass correlation coefficients ranging from 0.89 to 0.95. Children with DS had significantly lower mean peak torque values for hip abduction and knee extension than children in the comparison group. Regression analyses indicated that weight, body mass index, height, activity level, and gender were significant predictors of peak torque production for the sample as a whole. Hand-held dynamometry can be used to obtain reliable measurements of isometric muscle strength in children with DS. Anthropometric characteristics and activity levels may play a role in peak torque production in children with and without DS.
This study was designed to evaluate the use of the Berg Balance Scale (BBS) to assess the balance abilities of children with cerebral palsy. Thirty-six ambulatory children with cerebral palsy and 14 children with no motor impairment (ages eight to 12 years) were assessed on the BBS and the Gross Motor Function Measure (GMFM). Participants with cerebral palsy comprised three groups based on diagnosis (spastic hemiplegia, spastic diplegia who ambulated without aids, and spastic diplegia who ambulated with aids). A fourth group consisted of control subjects with no motor impairment. It was hypothesized that these four groups demonstrated a hierarchy of balance abilities. A one-way ANOVA was used to detect significant differences in test scores among the four groups. The analysis was repeated categorizing children on the Gross Motor Function Classification System (GMFCS) instead of diagnosis. The ability to use scores on the GMFM was slightly better than using BBS scores to distinguish among the groups when children were classified using diagnosis. Significant pair-wise differences among the groups were present on both the BBS and the GMFM when the children were grouped on the GMFCS. The results suggest that the BBS can be considered as a clinical measure of balance for children with cerebral palsy, and a functional classification system can be used to group children more homogeneously than traditional classification by diagnosis.
To determine whether participation in aerobic exercise before classroom activities improves academic engagement and reduces stereotypic behaviors in young children with autism spectrum disorder. This study employed a within-subjects crossover design, using a treatment condition (aerobic exercise) and a control condition, across 4 classrooms. The treatment condition included 15 minutes of running/jogging followed by a classroom task. The control condition included a classroom task not preceded by exercise. The number of stereotypic behaviors, percentage of on-task behavior, and correct/incorrect responses were measured. The Wilcoxon signed rank test was used to compare differences between conditions. Statistically significant improvements were found in correct responding following exercise (P < .05). No significant differences were found for on-task behavior or stereotypic behaviors. Consistent with findings in older children, these results indicate that aerobic exercise prior to classroom activities may improve academic responding in young children with autism spectrum disorder.
To examine whether parenting behaviors and childrearing practices in the first 3 years of life among Mexican American (MA) families predict children's academic performance at school age. Thirty-six children were assessed using the Parent Behavior Checklist, Nursing Child Assessment Teaching Scale, Home Observation for Measurement of the Environment Inventory, and Bayley Scales of Infant Development II. Academic performance was measured with the Illinois Standards Achievement Test during third grade. Correlation between parents' developmental expectations, nurturing behaviors, discipline, and academic performance were statistically significant (P < .05). Developmental expectations and discipline strategies predicted 30% of the variance in the Illinois Standards Achievement Test of reading. The results of this study suggest that early developmental expectations that MA parents have for their children, and the nurturing and discipline behaviors they engage in, are related to how well the children perform on academic tests at school age.
: To determine factors associated with mothers' concern about infant development and intent to access therapy services following neonatal intensive care unit (NICU) discharge. : Infant medical factors, magnetic resonance imaging results, neurobehavior at term, maternal factors, and maternal perceptions about developmental concern and intent to access therapy at NICU discharge were prospectively collected in 84 infants born premature (<30 weeks gestation). Regression was used to determine factors associated with developmental concern and intent to access therapy at NICU discharge. : Decreased developmental concern was reported by mothers with more children (P = .007). Infant stress signs (P = .038), higher maternal education (P = .047), reading books (P = .030), and maternal depression (P = .018) were associated with increased developmental concern. More maternal education was associated with more intent to access services (P = .040). Conclusion: Maternal factors, rather than infant factors, had important associations with caregiver concern. In contrast, abnormal term neurobehavior and/or the presence of cerebral injury were not associated with caregiver concern about development.
This study examined parents' (caregivers') perspectives on problems related to access to therapy services for their children with special healthcare needs (CSHCN) as predicted by child, family, and health insurance characteristics. Secondary data analysis was conducted using the Family Partners Project database. A subsample of 1027 parents of CSHCN who received rehabilitation services in the year before the study were the participants. Child, family, and insurance characteristics explained 19.1% of problems related to access to rehabilitation services with family characteristics being the strongest predictor (10.8%). Odds ratios are reported for these characteristics. Family financial hardship, the child's age, and managed care practices in health insurance plans may be the primary factors contributing to problems related to access to therapy services for CSHCN. Therapists may need a better understanding of family challenges with access to services to be more effective advocates.
This case report describes the history of a 26-year-old man with Duchenne muscular dystrophy. The report includes descriptions of the natural progression of his physical disability and the adaptive equipment and home modifications that were used to maintain independence. The transition from childhood to adulthood for individuals with Duchenne muscular dystrophy requires a physical therapy care plan that focuses on the use of assistive technology to maintain independence in mobility and to minimize or to facilitate caregiver assistance. Disability in Duchenne muscular dystrophy can be minimized by the use of properly fitting and functioning equipment. Assisting the family with available equipment options, documentation of medical necessity, and coordination of services are all important tasks for the physical therapist in carrying out a comprehensive plan of care.
This study assessed the validity and usefulness of the Bayley Scales of Infant and Toddler Development, Third Edition (Bayley-III) Low Motor/Vision accommodated version. Accommodations are adaptations to minimize impairment bias, without altering what the test measures. Of the items, 66% have Low Motor accommodations like enlarged materials; 62% have Low Vision accommodations. Using a within-subject design, we tested 19 children with the accommodated and standard Bayley-III, in a randomly counterbalanced order. The children had motor and/or visual impairment and a chronological age between 22 and 90 months. The test administrators completed an evaluation form. A subgroup of children benefited from the accommodations; 2 children obtained a large raw score difference. Test administrators considered the accommodations as practical, and advantageous for most children. The Low Motor/Vision accommodated version seems to validly assess the development of this population. Future, larger-scale research should study whether the accommodations improve the construct validity of the Bayley-III.
To determine reliability, diagnostic values, and minimal detectable change scores, 90% confidence (MDC90) of pediatric clinical tests of vestibular function. Twenty children with severe to profound bilateral sensorineural hearing loss and 23 children with typical development, aged 6 to 12 years, participated. The Head Thrust Test, Emory Clinical Vestibular Chair Test, Bucket Test, Dynamic Visual Acuity, Modified Clinical Test of Sensory Interaction on Balance, and Sensory Organization Test were completed twice for reliability. Reference standard diagnostic tests were rotary chair and vestibular evoked myogenic potential. Reliability, sensitivity, specificity, predictive values, likelihood ratios, and MDC90 scores were calculated. Reliability ranged from an intraclass correlation coefficient of 0.73 to 0.95. Sensitivity, specificity, and predictive values, using cutoff scores for each test representing the largest area under the curve, ranged from 63% to 100%. The MDC90 for Dynamic Visual Acuity and Modified Clinical Test of Sensory Interaction on Balance were 8 optotypes and 16.75 seconds, respectively. Clinical tests can be used accurately to identify children with vestibular hypofunction.
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.
The purpose of this study was to examine changes in item-specific functional activities and caregiver support in children and youths with acquired brain injury (ABI) in an inpatient setting using the Pediatric Evaluation of Disability Inventory (PEDI). The PEDI was administered by therapy staff at admission and discharge to a consecutive sample of 94 children and youths with brain injury (62 males and 32 females; age range = one to 19 years of age) admitted to the inpatient service at Franciscan Children's Hospital and Rehabilitation Center during a two-year, 10-month period. Individual PEDI item scores were abstracted from the medical records. Using the Wilcoxon matched-pairs signed rank test (two-tailed), significant differences between admission and discharge scores were found for most mobility, self-care, and social activity item groups and for all domains of caregiver support. Patterns of activity-specific improvements were contrasted between children with traumatic ABI and those with nontraumatic ABI. Recovery in children with ABI can be detected during inpatient rehabilitation across many areas of functioning as represented by item content of the PEDI. Changes at the item level may serve as a guide for defining specific physical therapy goals for inpatient episodes. Item groups in which changes are not detected provide information about sections of the PEDI that are less relevant for hospital-based recovery of children with ABI.
To develop a performance-based challenge assessment to evaluate gross motor abilities of high-functioning youth with an acquired brain injury (ABI). 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. 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). 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.
This study investigated whether positioning infants in the prone position while awake affected the quality and achievement of developmental motor milestones. One hundred four-month-old infants were administered the Alberta Infant Motor Scale to assess motor development. A Parent Questionnaire was used to gather information on time spent in various positions throughout a typical 24-hour day. Significant differences (p < 0.001) in the achievement of seven prone, three supine, and three sitting milestones were evidenced in infants who spent time awake in the prone position compared to those whose time in the prone position was limited. Prone positioning while awake appears to be associated with certain motor milestones achieved by four-month old infants.
To examine whether participation in sensorimotor groups and individual intervention resulted in greater improvements in motor skill acquisition than solely individual intervention for young children with Down syndrome. Ten children with Down syndrome, 13 to 29 months of age, participated. Children in both groups received individual intervention, and children in the intervention group participated in 10 weekly sensorimotor groups. All children were assessed at 3 points using the Gross Motor Function Measure and Goal Attainment Scaling. Children in the intervention group demonstrated significant improvement compared with children in the control group at the p < 0.10 level in lying and rolling, crawling and kneeling, and total score domains of the Gross Motor Function Measure and in Goal Attainment Scaling. Participation in sensorimotor groups and individual intervention resulted in greater improvement in motor skill acquisition than solely individual intervention for young children with Down syndrome. Additional research to support these exploratory findings is needed.
The purposes of this study were to describe (1) the types of exercise participation of adolescents with cerebral palsy; (2) the weekly duration of stretching, strengthening, and cardiovascular exercise; (3) how the level of activity compares with national health guidelines; and (4) the change in participation over 4 years. Participants included 126 males and 104 females (mean age = 14.7 years, SD = 1.7 years) who reported physical activities in the previous week. Analyses included frequency counts and proportions, stacked bar graphs, and 2-way analyses of variance of exercise participation by Gross Motor Function Classification System (GMFCS) and sex. A significant main effect of GMFCS level was detected for light and moderate exercise. A significant interaction of GMFCS level and sex was found for stretching; females stretched more. An average of 9.4% and 11.4% of our sample participated in weekly levels of moderate and vigorous exercise, respectively. Pediatric physical therapists should promote increased exercise participation rates among youths with cerebral palsy.
Purpose: To characterize how infants with myelomeningocele (MMC) activate lower limb muscles over the first year of life, without practice, while stepping on a motorized treadmill. Methods: Twelve infants with MMC were tested longitudinally at 1, 6, and 12 months. Electromyography was used to collect data from the tibialis anterior, lateral gastrocnemius, rectus femoris, biceps femoris. Results: Across the first year, infants showed no electromyographic activity for approximately 50% of the stride cycle with poor rhythmicity and timing of muscles, when activated. Single muscle activation predominated; agonist-antagonist coactivation was low. Probability of individual muscle activity across the stride decreased with age. Conclusions: Infants with MMC show high variability in timing and duration of muscle activity, few complex combinations, and very little change over time.
Characteristics of the DCD and TDC children 
(1) To explore participation in leisure time physical activities (LTPAs) in children with developmental coordination disorder (DCD) compared with children developing typically. (2) To examine the association between participation in LTPA and aerobic fitness. Thirty-eight children with DCD (aged 7-12 years) were age and gender matched with 38 children developing typically. Participation in LTPA was self-administered by using an activity questionnaire, and aerobic fitness was estimated using a Shuttle Run Test. Children with DCD spent significantly less time in overall, nonorganized, and vigorous LTPA compared with children developing typically. Aerobic fitness was significantly lower for children with DCD. The best model, including age, group, and overall LTPA, explained 46.2% of the variance in aerobic fitness. Suitable physical activities should be fostered in children with DCD, who have a low participation rate and aerobic fitness level.
Equine-Assisted Activities and Therapies Experiences by Quote Frequency
To identify the physical and psychosocial effects of equine-assisted activities and therapies (EAATs) on children with spinal muscular atrophy (SMA) from the perspective of the children and their parents. The families of all eligible children with SMA, who reported participation in EAAT, from a Western metropolitan academic center were contacted and invited to participate. This study implemented qualitative, semistructured interviews of children with SMA and their parents. Three themes emerged from the qualitative content analysis: physical/psychosocial benefits; relationship development with the horses, instructors, and children; and barriers to continued EAAT engagement. The data suggest that the overall EAAT experience was a source of enjoyment, self-confidence, and normalcy for the children with SMA. The results of this study provide preliminary support for the use of EAAT among children with SMA.
This study documented ankle dorsiflexion range of motion (DF-ROM) in children during treatment for leukemia and studied the effects of preventative education and individualized intervention as a standard of care. Active and passive DF-ROM were measured throughout a two-year treatment period and one year after treatment in 40 subjects. Children without health problems and historical controls who had not received therapeutic input were used for comparison. Active DF-ROM showed an average tendency to decline significantly during treatment, whereas passive DF-ROM did not. Both increased significantly following the end of treatment. There were substantial individual differences around these patterns of average change. Gender (female) was a predictor of negative change in DF-ROM during treatment. Average DF-ROM one year after treatment was significantly greater than for the historical controls and not significantly different from the healthy controls. None of the children required surgical intervention, in contrast to the historical controls. Education and intervention appears to have improved DF-ROM outcome in children treated for leukemia.
: To evaluate longitudinal applicability of the Gross Motor Function Measure (GMFM) in infants younger than 2 years. : Twelve infants at very high risk for cerebral palsy were enrolled between 1 and 9 months corrected age. The children were assessed 4 times during 1 year with the GMFM-66, GMFM-88, and other neuromotor tests. : Longitudinal use of the GMFM in infancy was hampered by age and function-specific limitations. The GMFM-66 differentiated less at lower-ability levels than at higher-ability levels. The GMFM-88 demonstrated flattening of the developmental curve when infants had developed more motor abilities. We formulated adaptations for the longitudinal use of GMFM in infancy. : To facilitate use of the GMFM in infancy, an adapted version may be an option. Further research is required to assess reliability and validity, and in particular, the sensitivity to change of the suggested adaptations.
We reviewed research on the effect of adaptive seating on sitting posture/postural control in children with cerebral palsy. Second, we examined whether changes in postural control related to changes in other aspects of functioning. Electronic database/hand searches were undertaken to locate studies published in English. Reviewers screened studies for inclusion criteria, extracted data, indexed outcomes to the International Classification of Functioning, Disability and Health, assigned levels of evidence, and assessed study quality. Thirteen of 14 articles used group designs and the other a single-subject design. Conflicting findings were reported for saddle seats and optimal seat/back angle for improving sitting posture/postural control. Significant improvements were reported with seat inserts, external supports, and modular seating systems. Evidence supporting effects of postural control on functional abilities was limited. Future studies on the effects of adaptive seating should describe participants with standardized classification systems and employ stronger research designs.
To examine concurrent validity, item-specific reliability, and score distributions of the new Pediatric Evaluation of Disability Inventory-Computer Adaptive Test (PEDI-CAT) Mobility domain with the original PEDI Functional Skills (FS) Mobility Scale. Thirty-five parents of children with neurodevelopmental disabilities completed the PEDI-CAT on a computer and the paper PEDI FS via interview. Strength of association between the PEDI-CAT Mobility domain and PEDI FS Mobility Scale scores was good to excellent (r = 0.82; P < .001). Intraclass correlation coefficients ranged from .3390 to 1.000, and agreement ranged from 60% to 100% for 8 specific items. No child had the minimum score on either test, whereas 9 children (26%) had a maximum score on the PEDI FS Mobility Scale. This study provides evidence for potential users that the concurrent validity, reliability, and score distribution for the PEDI-CAT Mobility domain are adequate for use with children with varied diagnoses and throughout the pediatric age span.
The study was designed to examine the effect of adaptive downhill skiing (ADS) on gross motor function in children with spastic cerebral palsy. One girl and four boys participated (mean age = eight years, five months). All were ambulatory. Participants' Gross Motor Function Measure (GMFM) classifications were: Level I (n = 2); Level II (n = 2); Level III (n = 1). ADS was conducted for a 10-week period at one ski resort. Each participant had the same ski instructor. GMFM was obtained every five weeks: beginning five weeks before ADS instruction and continuing to 10 weeks after ADS instruction. After 10 weeks of ADS GMFM-D, and GMFM-Total Score increased 5.4% (p = 0.022) and 3.2% (p = 0.035), respectively, and remained increased 10 weeks after ADS. ADS could be recommended by clinicians as a recreational activity for the gross motor rehabilitation of ambulatory children with spastic cerebral palsy.
PURPOSE: To describe the appropriate experience for entry-level physical therapist students in the neonatal intensive care unit (NICU). KEY POINTS: Care for infants in the NICU represents a subspecialty within pediatric physical therapy delivered in a very complex environment. Recommendations for designing student educational experiences related to the NICU are provided. CONCLUSIONS/PRACTICE IMPLICATIONS: Supervised observation is the appropriate level of NICU experience for physical therapy students. Observation in the NICU cannot be used to demonstrate entry-level clinical competency defined as managing 100% patient caseload in the setting. Additional closely supervised experiences with older, less fragile infants and children in neonatal follow-up clinics and pediatric wards can provide opportunities for entry-level physical therapist students interested in pediatrics to participate in examination and intervention with young children.
Top-cited authors
Wendy Coster
  • Boston University
Larry Ludlow
  • Boston College
Jane Haltiwanger
  • MA Department of Elementary and Secondary Education
Suzann Campbell
  • University of Illinois at Chicago
Mary Coleman
  • Foundation for Autism Research Inc.