Journal of Pediatric Rehabilitation Medicine - Volume 12, issue 2
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Journal of Pediatric Rehabilitation Medicine: An Interdisciplinary Approach is an international journal designed to parallel the multi-disciplinary team approach of caring for a child with an acute or chronic disease. The issues will primarily be themed and broad in scope including, but not be limited to cerebral palsy, traumatic brain injury, spinal cord injury, spina-bifida, amputation, muscular dystrophies of all types, stroke, cancer, mental retardation, developmental delays, and others.
The aim is to include a wide range of experts who care for children with the above diagnosis. Authorship by two different disciplines is requested though not required to encourage an interdisciplinary and collaborative approach. The goal is for the reader to obtain not just the medical perspective, but also nursing, occupational, physical and speech therapy, psychology, home care, etc., in providing the most comprehensive care for children. Manuscripts will be blinded and peer reviewed with appropriate feedback. Statistical analysis will be reviewed by the biostatistician. Readers are encouraged to submit and or suggest case reviews, commentaries, editorials, original research, conference schedules, or reviews.
Abstract: AIM: This study evaluated the inter-observer reliability and stability over time of the Eating and Drinking Ability Classification System (EDACS) for children and young people with cerebral palsy (CP). METHOD: Case records for 97 children with CP were examined to collect retrospective data about eating and drinking abilities at four time-points with a minimum of 2 years between each time-point. Sex, Gross Motor Function Classification System (GMFCS) level, presence of feeding tube and orthopaedic issues were recorded from case records. One speech and language therapist (SaLT1) classified eating and drinking ability using EDACS for all cases at…all time-points; SaLT2 assigned EDACS levels for 50 cases at time-point 1; SaLT3 assigned EDACS levels for 24 cases at all time-points. Inter-observer reliability and stability over time were assessed using the Intraclass Correlation Coefficient (ICC). Associations between EDACS levels and functioning recorded with other Functional Classification Systems (FCSs) were calculated using Kendall’s tau (τ ). RESULTS: Out of 97 children, 48 were male, 48 had feeding tubes, and 83 had orthopaedic issues. ICC for EDACS levels recorded by SaLT1 across all time-points was 0.97 (95% CI 0.96–0.98); changes in EDACS levels occurred infrequently and never by more than one level. ICC between SaLT1 and SaLT2 at time-point 1 was 0.8 (95% CI 0.67–0.89); ICC between SaLT1 and SaLT3 across all time-points was 0.95 (95% CI 0.92–0.98). Association between GMFCS and EDACS was moderate (τ = 0.58). INTERPRETATION: Retrospective use of EDACS to classify children’s eating and drinking abilities appears reliable; EDACS appeared stable over 6 or more years in 86% of the cases.
Abstract: There is a considerable risk of malnutrition for children with Cerebral Palsy (CP) due to insufficient nutritional intake. The most important causes of insufficient intake are feeding problems which are highly prevalent in children with CP (depending on definition, age and heterogeneity of the researched population). Considering these facts, nutritional status should have the full attention of healthcare professionals but this is not yet the case. Evidence from research in clinical practice suggests that: 1) there is no consensus regarding who should perform the measurement and how often, 2) no standardised nutritional assessment is implemented, and 3) there is suboptimal…communication and management about feeding and nutritional status in most healthcare networks. To overcome these problems, validated and practical tools for the screening and assessment of nutritional status should be a topic of research and subsequently made available and implemented in clinical practice. Because body composition is an objective indicator of available energy stores, research should focus on optimising measurement methods to determine body composition using anthropometric measures or bioelectrical impedance analysis (BIA). Furthermore, there is a definite need among health care providers for explicit and clear agreements on organisation and communication about nutritional care for children with CP.
Keywords: Nutrition, cerebral palsy, body composition, malnutrition, nutritional management
Abstract: PURPOSE: To evaluate postural symmetry in sitting and standing for children with hemiplegic cerebral palsy (hCP) following the Combined Approach to Treatment for Children with Hemiplegia (CATCH) protocol, an intervention combining Constraint Induced Movement Therapy, Bimanual Intensive Therapy and Neuro-Developmental Treatment. METHODS: The study included 10 children with a diagnosis of hCP and 10 typically developing age-matched peers. Subjects participated in a CATCH camp for six hours daily for eight consecutive days. Postural symmetry measurements in quiet sitting and standing were obtained using a Boditrak pressure-mapping system at four time points: prior to start of camp…(T1), first day of camp (T2), last day of camp (T3), and one month post-camp (T4). RESULTS: Significant differences (p < 0.05) were found in quiet sitting when comparing postural symmetry pre-intervention and one-month post camp. In quiet standing, significant differences (p < 0.05) were found when pre-intervention was compared to one-month post-intervention. One month post-intervention, the intervention group showed no significant difference from the comparison group. CONCLUSIONS: Children with hCP demonstrate improvement in postural symmetry in sitting and standing following participation in a CATCH camp. Following the intervention, children with hCP continued to improve postural symmetry and approach age-matched peers.
Keywords: Hemiplegic CP, CIMT, BIT, NDT, postural control
Abstract: PURPOSE: To investigate how the onset of independent walking in children with Cerebral Palsy (CP) influences the Passive Range of Motion (PROM) of lower limb joints. METHOD: Sixteen children with CP, GMFCS levels I and II, and 16 Typical Development (TD) children who had just begun independent walking participated in the study. The PROM of the hip abduction and external rotation, knee extension, popliteal angle, and ankle dorsiflexion was recorded with a goniometer at the onset of independent walking and 8 months later. A repeated-measures two-way ANOVA was conducted to compare the main effects of “walking experience”…and “group of children” and the interaction effect between them on PROM of lower extremities’ joints. RESULTS: The effect of “group of children” in the PROM was significant; differences were observed between children with CP and TD children for all joints (p < 0.05). The effect of “walking experience” did not have a significant impact on PROM changes and the interaction effect of “group of children” and “walking experience” was also not significant for all the variables. CONCLUSIONS: The alternative gait pattern spontaneously adopted by children with CP does not significantly impact their PROM during the initial stages of walking development. The lower PROM in highly functional children with CP compared to TD children cannot be attributed to gait initiation with an “atypical” pattern, but possibly to other factors such as reduced voluntary movement and age.
Keywords: Passive range of motion, cerebral palsy, gait, goniometry, spasticity
Abstract: OBJECTIVE: To investigate outcomes after 8 weeks of a structured home-based exercise program (SHEP) for improving walking ability in ambulant children with cerebral palsy (CP). METHOD: Eleven children participated in this study (7 males and 4 females, mean age 10 years 3 months, standard deviation (SD) 3y) with Gross Motor Function Classification System (GMFCS) I–III. This study used a prospective multiple assessment baseline design to assess the effect of SHEP upon multiple outcomes obtained in three different phases. Exercise intensity was quantified by OMNI-RPE assessed by caregivers and children. Outcome assessments of walking speed, GMFM-66 and physiological cost index (PCI) were…measured four times at pre-intervention (Phase 1) and at 3-weekly intervals over eight weeks during intervention (Phase 2). Follow-up assessments were performed at one month and three months after intervention (Phase 3). Statistical analyses were repeated measures ANOVA and Wilcoxon signed-rank test. RESULTS: SHEP improved walking ability in children with CP, particularly for their walking speed (p = 0.01, Cohen’s d = 1.9). The improvement of GMFM-66 scores during Phase 2 and Phase 3 had a large effect size, with Cohen’s d of 1.039 and 1.054, respectively, compared with that during Phase 1 (p < 0.017). No significant change of PCI was observed (Cohen’s d = 0.39). CONCLUSION: SHEP can be a useful intervention tool, given as a written, structured, and practical exercise program undertaken at home to achieve short term goals for improving walking ability when added to standard care.
Abstract: PURPOSE: This study aims to evaluate the effectiveness of a prefabricated carbon-composite ankle foot orthoses (c-AFOs) on gait parameters in children with unilateral spastic cerebral palsy (USCP) exhibiting a drop foot pattern. METHODS: Sixteen ambulatory children with USCP and a drop foot pattern were included (mean age: 9 years; gross motor function classification system: I = 14, II = 2) and three-dimensional gait analysis was applied under randomly assigned conditions (barefoot; shoe; c-AFO). Kinematics, kinetics, time-distance parameters and gait indices were investigated. RESULTS: Effects on the drop…foot pattern were investigated while the children walked in shoes only. The shoes already increased the maximum ankle dorsiflexion in swing (p = 0.004) and initiated more knee flexion during single support (p ⩽ 0.013). Compared to shoe walking, the c-AFO led to additional benefits regarding further ankle dorsiflexion during swing (p ⩽ 0.001) and initial contact (p < 0.001), ankle movement during loading response (p = 0.002), improved the sole angle during initial contact (p < 0.001) and during mid stance (p = 0.015). Plantarflexion and ankle power generation during push-off decreased when wearing the c-AFO (p ⩽ 0.008). CONCLUSION: Investigated c-AFOs are beneficial for improving drop foot patterns in children with USCP. Significant effects on pathological barefoot pattern were already achieved with the child’s regular shoes. This could be considered in clinical decision processes. In comparison to shoe walking, c-AFO additionally improved foot clearance and normalized initial heel contact. The third rocker deteriorates with the c-AFO. Since kinematics improved with the orthoses during swing and early stance phase, c-AFOs might reduce tripping and falling caused by a drop foot during long distance walking.
Abstract: PURPOSE: To understand the relationship of walking speed to self-reported pain, fatigue, and physical function in adults with CP. METHODS: Design : Cross-sectional study. Setting : Accredited clinical motion analysis laboratory in a regional children’s hospital. Participants : 72 ambulatory patients ⩾ 18 years of age, diagnosed with CP, who previously had ⩾ 1 prior instrumented gait analysis at our facility. Main Outcome Measures : PROMIS-57 pain interference/intensity, physical function, and fatigue measures and walking speed. RESULTS: Physical function was significantly lower than able-bodied normal values…by 1–2 standard deviations (40.3 ± 8.5). Pain interference (51.4 ± 9.0) and fatigue (50.2 ± 9.2) were not significantly different when compared to able-bodied normal values. Only physical function was statistically correlated with walking speed (p < 0.001), while pain interference (p = 0.39), pain intensity (p = 0.36), and fatigue (p = 0.75) were not. Pain interference, pain intensity, and fatigue were not statistically significant factors in the multiple regression of walking speed. Fatigue could significantly predict physical function, pain interference, and pain scores (p = 0.032, p < 0.001, p < 0.01, respectively), however, fatigue did not directly predict walking speed (p = 0.747). CONCLUSIONS: Self-reported physical function correlates with objectively measured walking speed in young adults with CP while patient-reported pain and fatigue did not, contrary to what would be predicted by the literature.
Abstract: OBJECTIVE: To evaluate the safety of combining salivary gland onabotulinumtoxinA (BTX-A) injections for sialorrhea with intramuscular BTX-A injections for spasticity in the same procedure. DESIGN: A retrospective cohort study in a tertiary hospital center. Patients selected were younger than 20 years, diagnosed with cerebral palsy, and received their first salivary gland BTX-A injection between March 2011 and July 2015. Chart review and telephone interviews were performed. The primary outcome measure was the rate of adverse events after combined BTX-A injections into salivary glands and muscles. The secondary outcome measure was the efficacy of injections, as reported by…patients. RESULTS: Twenty-five of the 52 selected patients received salivary gland BTX-A injections only, and 27 received concurrent salivary gland and multi-level intramuscular chemodenervation with BTX-A with or without alcohol. The rate of adverse events was < 10% in both groups; 4% in “Salivary Only Group” and 7% in the “Salivary + Multilevel Intramuscular Chemodenervation with BTX-A group (with or without alcohol)”. Both approaches were equally effective in meeting their goals of salivary injections (> 50% improvement for at least two months). In the “salivary only” and in the “salivary + multi-level intramuscular” group, 76 and 85% of the patients reached their goals respectively. CONCLUSIONS: Combining BTX-A injections for sialorrhea with multilevel intramuscular BTX-A injections (with or without alcohol) appears to be safe and effective and allows treatment of patients for both conditions simultaneously.