Journal of Pediatric Rehabilitation Medicine - Volume 13, issue 2
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The Journal of Pediatric Rehabilitation Medicine (JPRM): An Interdisciplinary Approach Throughout the Lifespan is designed to parallel the multidisciplinary teams caring for children, adolescents and adults with childhood-onset physical disabilities and complex care needs worldwide. Published quarterly, topics include, and are not limited to, cerebral palsy, traumatic brain injury, spinal cord injury, spina bifida, limb deficiency, muscular dystrophy, stroke, cancer, developmental delays, and rare disorders. Furthermore, the journal welcomes papers dedicated to pediatric rehabilitation from a global health perspective.
The aim of JPRM is to engage a diverse group of international experts with the goal of providing readers with comprehensive information regarding children and adolescents requiring rehabilitation. JPRM brings together specialists from medicine, nursing, psychology, social work, nutrition, child life, family centered care, and occupational, physical, and speech therapy. For manuscript submissions, authorship involving at least two different specialties is encouraged, although not required, to facilitate a transdisciplinary and collaborative approach. Manuscripts are blinded and peer reviewed including biostatistical analysis. Authors are invited to submit original research, systematic and scoping reviews, guidelines, protocols, care pathways, case reports, book reviews, commentaries, editorials, and dates for future conferences.
Abstract: Cerebral palsy (CP) is associated with complex health care needs and, although improved, a continued shortened life expectancy. In order to quantify and understand advances in the diagnosis and management of CP, systematic literature searches of key word groupings in the PubMed database were completed and revealed a recent increased incidence of publications focusing on quality of life, physical activity, exercise, and treatment options. Our bibliometric exploration revealed growing emphasis on function, performance, aging, and health compared to earlier studies when diagnostic features and brain pathology dominated research. Our findings highlight the transition from diagnosis and identification to management of…specific conditions and providing guidance for the continuum of needs our patients experience over the course of a lifetime. The field must be prepared to advance our understanding of best practices and implement evidence-based interventions and management options.
Keywords: Cerebral palsy, publications, research, bibliometrics, trends, rehabilitation, physical medicine
Abstract: OBJECTIVES: To study the effect of induced fatigue of the unaffected limb on the sensory components of standing balance; proprioception and vestibular symptoms in children with hemiplegic cerebral palsy. METHODS: Setting: Outpatient Clinic of Faculty of Physical Therapy, Cairo University. Patients: Twenty-nine children with hemiplegic cerebral palsy [(ages 8.9 ± 2.3 years), motor ability I/II according to the GMFCS and spasticity of I/I+ according to the Modified Ashworth Scale]. Outcome Measures: Before and after the induced fatigue of the unaffected limb, the following measures were recorded: postural balance, using the…Biodex Balance System and the Timed Up and Go test; vestibular sense, using the Paediatric Vestibular Symptom Questionnaire; and proprioception measures of both knees, using the Biodex isokinetic dynamometer. RESULTS: There was a significant increase in the post-fatigue values for the overall stability index (p < 0.05), the Timed Up and Go test (p < 0.05), reposition errors of proprioception of the unaffected limb (p < 0.05) and the vestibular questionnaire (p < 0.05); there was a non-significant decrease in the post-fatigue values for reposition errors of proprioception of the affected limb (p = 0.859). CONCLUSION: Fatigue of the unaffected limb negatively affects postural balance and related sensory systems (proprioception of the fatigued limb and vestibular function) but does not have an impact on proprioception of the unfatigued limb.
Abstract: PURPOSE: To investigate the effects of robot-assisted gait training (RAGT) alongside conventional therapy on the standing and walking abilities of children with cerebral palsy (CP). METHODS: The study sample consisted of children (aged 4–18 years) with CP whose gross motor function classification system (GMFCS) was at levels I–V. In total, 75 children with CP were evaluated and 38 patients completed the study. Patients were divided into two groups as GMFCS levels I–III (Group 1) and levels IV–V (Group 2). RAGT (30 min/session) and conventional physiotherapy (30 min/session) were applied together in the treatment. The treatment duration…was 60 min per session, 3 or 4 sessions per week, for a total of 30 sessions over 8–10 weeks. 10-meter walk test (10MWT), 6-min walk test (6MinWT), gross motor functional measurement 66 (GMFM66) -D, and -E tests were performed. RESULTS: We showed that in both groups of CP patients (mild-moderate and severe), meaningful improvements were seen in the standing (D) and walking (E) sections of GMFM-66 after treatment. When we compared the post-treatment changes in 10-m walk test, 6-min walk test, GMFM66-D, and -E between Groups 1 and 2, we noted that the improvements were statistically significant in favor of Group 1 (p < 0.01). CONCLUSION: RAGT in combination with a conventional treatment program was significantly associated with improvements in the standing and walking abilities of children with mild to moderate CP (GMFCS levels I–III).
Keywords: Cerebral palsy, gait, rehabilitation, robot, training, therapyImplications for rehabilitation:•Robot-assisted gait training (RAGT) in addition to conventional treatment might contribute significantly to improvements in the standing and walking abilities of children with cerebral palsy (CP).•Children with mild to moderate CP had more significant improvements in standing and walking ability than did those who were severely affected after RAGT with conventional therapy.
Abstract: PURPOSE: To investigate the effectiveness of outpatient robot-assisted gait training (RAGT) in ambulatory children with spastic cerebral palsy. METHODS: Children were randomized to two different intervention sequences within a pragmatic crossover design. They performed five weeks of RAGT (3 sessions per week) and five weeks of usual care (UC). Dimension E of the Gross Motor Function Measure-88 (GMFM E) as the primary outcome as well as Dimension D (GMFM D), and timed walking tests were assessed before and after each treatment sequence and after a 5-week follow-up. RESULTS: The trial was stopped early…because of recruitment problems. We included 16 children with a mean age of 11.3 years (6.0–15.3 years). GMFM E median (IQR) change scores were - 0.7 (- 2.8 to 3.5) after RAGT and 0 (- 2.4 to 2.4) after UC. Neither GMFM E nor any secondary outcome measure changed significantly after RAGT or UC, nor were any period, follow-up, or carry-over effects observable. CONCLUSIONS: RAGT as a single intervention was not effective in improving walking abilities in the included children. It should be embedded in a holistic treatment approach, as it cannot cover all aspects relevant to gait. Furthermore, children’s personalized rehabilitation goals should be carefully monitored with individualized measurement instruments.
Abstract: PURPOSE: To examine the results of repeated episodes of 21-day pediatric constraint induced movement therapy (PCIMT) paired with gross motor training (GMT). METHODS: Nineteen children, age 14 months – 6 years with unilateral upper extremity impairment enrolled in this cohort study to receive repeated episodes of 21 day PCIMT-GMT. Outcome measures included the Peabody Developmental Motor Scales-2 (PDMS-2), the Assisting Hand Assessment (AHA) and the Canadian Occupational Performance Measure (COPM). RESULTS: All children demonstrated improvement in raw scores following each episode of PCIMT-GMT with a statistically significant change in the least squares estimated…mean for all measures except the PDMS-2 total motor raw score and gross motor quotient for the preferred hand in the fourth episode (p < 0.05). Gains were noted on the Scaled Score for the AHA for 39/39 episodes, all greater than the smallest detectable difference. COPM Performance and Satisfaction scores for 17/17 episodes were above the clinically meaningful threshold. Additional improvements in scores were noted in all children with each repeated episode. CONCLUSION: Children with unilateral upper extremity impairment demonstrate improvements in fine motor, gross motor, and bimanual skills, along with functional changes in participation in daily life, following PCIMT-GMT. Participation in repeated episodes can lead to further improvements.
Keywords: Pediatric, cerebral palsy, paresis, constraint induced movement therapy, hand function, intensive training
Abstract: PURPOSE: Youth with disabilities face challenges regarding achieving autonomy. The ‘Skills for Growing Up’ tool was adapted for use in Dutch pediatric rehabilitation (SGU-D) to support development of autonomy. This study presents the experiences with the SGU-D tool. METHODS: The SGU-D was implemented in 18 settings, of which 4 participated in the evaluation. Rehabilitation professionals were trained in the use of the SGU-D. In a qualitative study, participants were interviewed for their opinions regarding the tool. RESULTS: Experience with the SGU-D was evaluated in 11 youth with disabilities, 11 parents and 8 rehabilitation…professionals. They perceived the SGU-D as a helpful tool: i) to support development of autonomy, ii) to focus on future perspectives, and iii) to facilitate communication with family and rehabilitation professionals. Additional support from rehabilitation professionals on using the SGU-D was appreciated. CONCLUSION: Youth with disabilities, their parents and rehabilitation professionals value the SGU-D as a practical tool for working on autonomy, and to identify important areas of development.
Abstract: PURPOSE: For children with cerebral palsy (CP) and equinus, the conventional practice of setting the ankle angle in an ankle-foot orthosis (AA-AFO) at 90 ∘ may not adequately accommodate gastrocnemius length/stiffness. Therefore, this study compared the effects of statically-optimized solid AFOs with individualized AA-AFOs (iAA-AFOs) and conventionally-prescribed AFOs on gait for children with CP and equinus. METHODS: Ten children with CP and equinus (15 limbs with AFOs), and 15 typically-developing (TD) children participated. For the children with CP, solid AFOs with iAA-AFOs (range = 5 ∘…–25 ∘ plantarflexion) were compared with their usual AFOs using three-dimensional gait analysis. TD children walked in shoes only. Peak values and Gait Variable Scores (GVS) for joint and segment variables were calculated for stance phase. Responses were categorized using 90% confidence intervals relative to TD data, for each affected leg. RESULTS: Net responses to iAA-AFOs were positive for 60% of limbs and negative for 40%. Knee variables (GVS and peak extension, flexion, and midstance moment) were most positively affected, and foot-floor angle and vertical ground reaction force were most negatively impacted. CONCLUSION: Individualized AFO prescription and iAA-AFOs can impact gait biomechanics for some children with equinus, compared to conventionally-prescribed AFOs. Optimizing dynamic alignment for walking may further improve outcomes.
Keywords: Cerebral palsy, individualized ankle-foot orthosis prescription, AFO ankle angle, equinus, AFO tuning, gait
Abstract: PURPOSE: Hepatoblastoma is the most common primary liver tumor in children and has a greater incidence in children with a history of prematurity and very low birth weight. To increase awareness of the association between prematurity and hepatoblastoma for health care providers who treat children with Cerebral Palsy (CP), we present two case reports. METHODS: Two case reports of premature, very low birth weight infants with hepatoblastoma are described and a literature review of hepatoblastoma in the setting of prematurity and cerebral palsy is performed. RESULTS: Each patient had a history of 26–28…week prematurity, very low birth weight, and CP. Both presented with worsening constipation and abdominal distension that did not respond to oral medications. Appropriate referrals to the ER were made which lead to a diagnosis of hepatoblastoma. Pediatric rehabilitation was a source of referral for diagnosis in one patient and aided in the rehabilitation course following treatment for both patients. CONCLUSIONS: Hepatoblastoma is the most common primary liver tumor in children and has an increased incidence in children with a history of prematurity and very low birth weight. Providers who frequently care for the very low birth weight and premature children with CP should be aware of this correlation and include hepatoblastoma in the differential when managing patients with suddenly worsening constipation or abdominal distension. Pediatric physiatrists and other providers for these patients could be a source of referrals and diagnosis leading to timely treatment.
Abstract: Recent studies have generally shown favorable outcomes for the use of botulinum toxin (BoNT) injections for the treatment of lower extremity spasticity in children with cerebral palsy. The randomized controlled trials and placebo trials are well described although even those and other studies show high variability in methodology for use of BoNT. This raises questions about which strategies are the most effective. In order to hone the technique, the aim of this review is to discuss these specific parameters: toxin type, dosing, series of injections, localization method, age, number of muscles, and troubleshooting poor outcomes.
Abstract: Botulinum Toxin (BoNT) is widely used to treat hypertonia in pediatric patients. Although serious adverse events (AEs) occur infrequently, they can lead to significant patient morbidity and mortality. This paper will discuss potential safety risks that may affect outcomes, medical comorbidities, medication dosing, targeting techniques, and muscle morphology. It is the responsibility of the physician to discuss risks and benefits regarding the use of BoNT and mitigate risks of AEs while maximizing the effectiveness of the medication.
Abstract: Botulinum toxins (BoNT) are a standard of care for spasticity management of children with a variety of neuromuscular (NM) conditions. BoNT relaxes skeletal muscles by inhibiting the release of acetylcholine from the neuromuscular junction (NMJ). As part of their training physiatrist become proficient in the targeted injections of BoNT into affected skeletal musculature. While the pharmacology and pharmacokinetics of BoNT are well characterized, there is limited literature on the clinical impact that varying the volume of diluent that a toxin is reconstituted within. In theory, injection of a larger volume of dilute BoNT would allow for a larger spread affect…reaching more distant NMJs; the reverse is also be true. Dilution volume of BoNT injections in children produces some unique situations due to their low weight, smaller muscle bulk, an increased relative risk of spread to surrounding structures, and novel differences in concentration of NMJ in immature muscle. Some of these factors may act as guiding principles that providers can use when adjusting from their standard BoNT dilutional practices. Although, there are recommended dosing strategies available each child’s spasticity pattern represents a unique situation and providers must be allowed flexibility to think creatively about dilution strategies for BoNT injections.
Abstract: Botulinum toxin is frequently used as a therapeutic for a variety of non-FDA approved indications in children. This narrative literature review explores three off-label uses of botulinum toxin in pediatric conditions including congenital muscular torticollis, spastic trismus, and neonatal brachial plexus palsy. While more research is needed to establish treatment, dosing and localization guidelines for the use of botulinum toxin in these commonly treated conditions, available evidence is discussed.