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Rosenberger – Mobility and Children with Cerebral Palsy1

Jordan Rosenberger

DPT 598 – Special Topics in Physical Therapy

Annotated Bibliography: Mobility and Children with Cerebral Palsy

Rosenberger – Mobility and CP2

Table of Contents – Page # Title

3 Opening Statement

4-51. Campbell, SK, Vander Linden DW, Palisano RJ. Cerebral Palsy In: Physical Therapy for Children (4th edition). Philadelphia: W.B. Saunders Co: 2012: 577-627.

62. de Campos A, Costa C, Rocha N. Measuring changes in functional mobility in children with mild cerebral palsy. Developmental Neurorehabilitation [serial online]. 2011;14(3):140-144. Available from: CINAHL Plus with Full Text, Ipswich, MA. Accessed May 21, 2015.

7

3. Geytenbeek J, Vermeulen R, Becher J, Oostrom K. Comprehension of spoken language in non-speaking children with severe cerebral palsy: An explorative study on associations with motor type and disabilities. Developmental Medicine & Child Neurology [serial online]. 2015;57(3):294-300. Available from: CINAHL Plus with Full Text, Ipswich, MA. Accessed May 20, 2015.

8 4. Hadders-Algra M. Variability in infant motor behavior: A hallmark of the healthy nervous system. Infant Behavior & Development [serial online]. October 2002;25(4):433-451. Available from: Academic Search Complete, Ipswich, MA. Accessed July 31, 2015.

9 5. Herskind A, Greisen G, Nielsen J. Early identification and intervention in cerebral palsy. Developmental Medicine & Child Neurology [serial online]. 2015;57(1):29-36. Available from: CINAHL Plus with Full Text, Ipswich, MA. Accessed July 27, 2015.

106. Kenyon L, Blackinton M. Applying motor-control theory to physical therapy practice: A case report. Physiotherapy Canada [serial online]. J2011;63(3):345-354. Available from: CINAHL Plus with Full Text, Ipswich, MA. Accessed May 21, 2015.

11

7. Majnemer A, Shevell M, Law M, Poulin C, Rosenbaum P. Level of motivation in mastering challenging tasks in children with cerebral palsy. Developmental Medicine & Child Neurology [serial online]. 2010;52(12):1120-1126. Available from: CINAHL Plus with Full Text, Ipswich, MA. Accessed May 20, 2015.

12-13

8. Ragonesi C, Chen X, Agrawal S, Galloway J. Power mobility and socialization in preschool: a case study of a child with cerebral palsy. Pediatric Physical Therapy [serial online]. 2010;22(3):322-329. Available from: CINAHL Plus with Full Text, Ipswich, MA. Accessed June 26, 2015.

13-149. Ragonesi C, Galloway J. Short-term, early intensive power mobility training: Case report of an infant at risk for cerebral palsy. Pediatric Physical Therapy [serial online]. 2012;24(2):141-148. Available from: CINAHL Plus with Full Text, Ipswich, MA. Accessed June 26, 2015.

16-17 10. Salem Y, Godwin E. Effects of task-oriented training on mobility function in children with cerebral palsy. Neurorehabilitation [serial online]. 2009;24(4):307-313. Available from: CINAHL Plus with Full Text, Ipswich, MA. Accessed May 20, 2015.


Appendices18 Appendix A – Gross Motor Functional Classification System – Children 6-1219 Appendix B – Gross Motor Functional Classification System – Children 12-1820 Appendix C – Gentile’s Taxonomy 21 Appendix D – Gross Motor Function Measure22 Appendix E – Timed Up and Go (TUG) Test 23 Appendix F – Timed Up and Down (TUD) Test24 Closing Statement 25 Complete reference list

Opening Statement

My topic for this annotated bibliography was originally Mobility. After performing an initial search, I found many of the articles about mobility and children focused on children with cerebral palsy. After considering this, I realized I needed to learn more about the diagnosis of cerebral palsy. To accomplish this I have included an annotation from the Campbell book. While this annotation does not support or refute further research, it did help me come up with a research question. Campbell makes the point “the bigger the motor impairment, the bigger disturbances are found on other systems.”2 This statement lead me to question how motor impairment was measured, how improvement in functions were measured and what other variables have an impact on the intervention.


1. Campbell, SK, Vander Linden DW, Palisano RJ. Cerebral Palsy In: Physical Therapy for Children (4th edition). Philadelphia: W.B. Saunders Co: 2012: 577-627.

Campbell defines cerebral palsy as a permanent disorder of development of movement and posture that leads to activity limitations that are attributed to non-progressive disturbances that occur in the developing fetal, or infant brain. The impairments are caused by a static brain lesion, but leads to dynamic, progressive musculoskeletal disturbances. The book also details different types of classifications of the condition such as:

o Topographical

Diplegia (lower limbs > upper limbs) Now referred to as Bilateral

Hemiplegia (upper and lower limbs, ipsilateral) Now referred to as Unilateral

Quadriplegia (all limbs, head and trunk involved)

o Movement Differences

Spastic

Pathophysiology/Anatomic Areas Effected: involvement of motor cortex or white matter projects to and from cortical sensorimotor areas of the brain

Clinical Presentation/Movement Characteristics: Abnormal posture and movement because of spasticity and exaggerated reflexes

Dyskinetic

Pathophysiology/Anatomic Areas Effected: involvement of the basal ganglia Clinical Presentations/Movement Characteristics: Atypical patterns of

posture and involuntary, uncontrolled, recurring and stereotyped movements of affected body parts

o Subtypes: Dystonia – dominated by involuntary sustained or intermittent muscle contraction with repetitive movements and abnormal postures

o Subtypes: Athetosis – slow, continuous writhing movements that prevent maintenance of stable posture

Ataxic

Pathophysiology/Anatomic Areas Effected: caused by a cerebellar lesion

Clinical Presentations/Movement Characteristics:

o Cerebellar lesions lead to a lack of coordination

o Hypotonic (decreased tone)


o Lack of tone leads to inability to generate normal or to follow expected voluntary movements patterns because of extreme weakness

o Results in instability, abnormal patterns of posture and lack of orderly, coordinated, rhythmic and accurate movements

Mixed

Clinical Presentations/Movement Characteristics:

o Symptoms of spasticity and dyskinesia may be present

o Elaboration of the component motor disorders

The rate of occurrence of each type of cerebral palsy has varied depending on the time frame in which the research study was conducted. This can be contributed to technological medical advances.

The motor impairments are coupled with disturbances in other various domains including: Cognition (operationally defined as an IQ less than 70 in 23-44 percent of children

diagnosed) Communication in 42-81 percent of children as well as sensation and perception deficiencies

It has been shown that the bigger the motor impairment, but bigger disturbances are typically found in other functions. Campbell breaks down a common classification system known as the Gross Motor Functional Classification System or GMFCS that will be referenced throughout many articles. This Scale can be found in Appendix A and B.

Having a background on cerebral palsy is integral in reading and understanding research articles. While there are no reliability statistics in the chapter, there are many references to other sources throughout – making the source reliable. The source is very objective in that it provides facts throughout and supplementary data as much as possible. The goal of the source is to educate readers about the diagnosis of cerebral palsy, how the condition is classified and how cerebral palsy occurs.

This source fit into my research because I now have a better understanding of the pathology itself as well as a commonly used classification system with cerebral palsy in the GMFCS (Appendices A and B). While this chapter may not help prove how beneficial movement and motor output is for children with cerebral palsy, it helped raise my research question, and purpose for completing the annotated bibliography, as explained in the opening statement.


2. de Campos A, Costa C, Rocha N. Measuring changes in functional mobility in children with mild cerebral palsy. Developmental Neurorehabilitation [serial online]. 2011; 14(3): 140-144. Available from: CINAHL Plus with Full Text, Ipswich, MA. Accessed May 21, 2015.

The main goal of this article was to determine if the Timed Up and Go Test (TUG) and the Timed Up and Down Stairs Test (TUDS) are able to detect changes in functional mobility in children with cerebral palsy (See Appendix E). This study emphasizes that the ability of a child to socialize and engage with age-matched, typically developing peers is impacted by limitations in participation (using the ICF model). Even if a child is classified as Level I or II on the GMFCS, their movement may not be as coordinated and smooth as an age matched child that is developing typically. The article highlights that participation of the child should be the main goal of their therapeutic intervention program (especially in school based physical therapy), but there needs to be objective, reliable and sensitive tools to measure this progress.

The Wilcoxon statistic was used to compare GMFM, TUG and TUDS scores pre-test and after 8 weeks of physical therapy intervention. Unfortunately, methods utilized during this 8 week intervention were not noted, and is a limitation of this study. Children in this study demonstrated functional improvements through lower times when completing the TUG test from the pre to post test (z=-2.023, p=0.043). There was similar improvement and significance seen in the TUDS test (z=-2.201, p=0.028). Additionally, after the 8 weeks of various interventions, the GMFM scores increased significantly in Dimension D (standing) (z=-2.041, p=0.04) and Dimension E (walking, running and jumping) (z=-2.060, p=0.039). While significant levels of improvement were noted in various dimensions of the GMFM, there was not a change in the overall GMFCS classification level for any of the participants.

This article is significant within the topic of this annotated bibliography because it shows that there are 3 objective measures (GMFM, TUG, TUD – see Appendices D, E and F respectively) that can detect small changes in a child’s performance. This can be useful to show parents to help keep their morale and compliance up throughout the therapeutic intervention. Instead of continually telling these parents that their child is “stuck” on a level of the GMFCS, we can show the parents that their TUG and TUDS tests are improving, therefore having an impact on the GMFM score. The article also addresses motivation in a social/participation context, and how important these interactions can be on an intervention program for children with cerebral palsy.



This study that demonstrates the importance of differentiating expressive language (such as speech and gestures) and receptive language (comprehension) in classifying children with cerebral palsy in regards to their overall functional capacity. This article adds another integral variable (language comprehension) in the classification process of motor output. It has been previously proven that the severity of motor impairments associated with the diagnosis of cerebral palsy has a direct effect on communication patterns in the children with the diagnosis.1 Children with cerebral palsy are typically assessed using the GMFCS (see Appendices A and B), which does not take into account any receptive language capacity. This study utilizes the Computer-based instrument for low motor language testing or C-BiLLT, which is a test that requires minimal to no motor movement but is able to asses if a child has developed language comprehension skills. Knowing more about a child’s language comprehension can have a direct impact on both their physical therapy interventions as well as interventions in other domains such as occupational therapy and speech and language.

The researchers took a fair sample size of 87 non-speaking children with spastic or dyskinetic cerebral palsy at levels IV or V on the GMFCS (see Appendices A and B) and administered a C-BiLLT to compare their GMFCS (see Appendices A and B), C-BiLLT and chronological age to determine if there are significant relationships between the variables. To determine the relationships, Pearson’s r, t-tests and analysis of variance were used and scrutinized. It was found that children with spastic cerebral palsy had significantly lower age-equivalent scores that children with dyskinetic cerebral palsy (p<0.001). The study also found a significant different in C-BiLLT raw scores between children with dyskinetic and spastic cerebral palsy (t=-3.092, CI -26.14 to -5.68, p=0.003).

This study concluded that children with dyskinetic cerebral palsy, with motor and communication disorders matched to a similar level (on the GMFCS and C-BiLLT) were able to be more successful with spoken language comprehension. The authors alluded to the idea that the assessment of comprehensive language skills should be extended so a better determination can be made on the child’s overall level of impairment, instead of only relying on the GMFCS. This study suggests that children could be provided and instructed in the use of an augmentative communication device to utilize the stronger skill set of language comprehension. Interventions could be created for children that works the spoken language comprehension and cognition specifically in the future. Additionally, the study showed that the more motor output a child had, the more language comprehension and cognitive function the child had as well. This could propel future research studies incorporating mobility (with a harness system or in cars) to encourage movement, and also effecting the child’s communication patterns.


4. Hadders-Algra M. Variability in infant motor behavior: A hallmark of the healthy nervous system. Infant Behavior & Development [serial online]. October 2002;25(4):433-451. Available from: Academic Search Complete, Ipswich, MA. Accessed July 31, 2015.

This article explains the newest theory on motor development – Neuronal Group Selection Theory (NGST). Previous theories include the Neural-Maturationist and Dynamic Systems. Neural-Maturationist consider the internal-driven maturational state of the nervous system as the biggest constraint for developmental progress, whereas the Dynamic Systems theory that believe the make-up of the neural substrate plays only a subordinate role on developmental constraints. The NGST attempts to combine bridge the ideas in the previously mentioned theories. NGST states that development starts with primary repertories on the basis of afferent information gained from behavior and experience. A secondary repertoire is developed as behavior and experience continues and synaptic connections are strengthened. The driving component of the NGST is the amount of variability present. Originally, genetic information plays a big role in the initial determinations of brain development. After this initial development, variability is a key component to how the brain will develop. Primary variability can be seen by looking at General Movements. General movements are the most frequently used movement patterns of the newborn. Normal is considered to be highly variable in the amount, amplitude, velocity and number muscles contributing to the movement. Primary variability does not include environmental factors. Secondary variability takes into account environmental factors, which is where specific function and demands affects motor development.

This article is relevant to the annotated bibliography because it thoroughly discusses previous motor control theories as well as explaining the NGST in terms of both typically and atypically developing brains. The article concludes that motor development is dependent on two forms of variability (primary and secondary). Primary variability is when development starts and motor behavior is not geared to external conditions. Secondary variability starts at function-specific ages (meaning that it develops as a need for a specific task develops). In secondary variability, motor development adapts to the needs of the specific situation. Children with cerebral palsy, or other brain deficits have a limited amount of primary variability (because of the lesion) which leads to problems in selecting the most efficient neuronal activity when presented with the need to adapt to specific situations with secondary variability. The decrease in variability leads to problems with postural control as well as fine tuning of motor behavior – both of which can be addressed through physical therapy intervention techniques. While these strategies may be delayed in children with cerebral palsy because of the brain lesion, the children can still learn how to engage in postural control if intervention strategies such as practice, repetition of self-generated sensory input and augmentation of movement are incorporated into the interventions.


5. Herskind A, Greisen G, Nielsen J. Early identification and intervention in cerebral palsy. Developmental Medicine & Child Neurology [serial online]. 2015;57(1):29-36. Available from: CINAHL Plus with Full Text, Ipswich, MA. Accessed July 27, 2015.

This article was a systematic review that looked to define an operational definition for early intervention, as well as determining what early intervention strategies worked best in children with cerebral palsy. Other articles in this annotated bibliography have shown success in very short early intervention techniques, yet the article did not discuss reasons why early intervention strategies are utilized. This article helps a clinician to know what red flags there may be when working with children, as well as giving supported ideas for the types of intervention to develop when working with children with cerebral palsy.

Studies included in this systematic review included studies that initiated early intervention before the child was 6 months old as well as studies in which the infant showed active exploratory motor behaviors that could be facilitated through intervention. Research found that in children born before 28-30 weeks underwent neuroimaging (ultrasonography and MRI) to identify cerebral palsy. Infants born after 28-30 weeks are not always examined with the ultrasonography or MRI because the relative sensitivity decreases (66-79% in the ultrasonography and 71-88% in the MRI) and because of the financial resources required to conduct the MRI Another tool shown to be predictive of cerebral palsy was the General Movement Assessment or GMA. The GMA includes movements that are present during neonatal period, and disappear at about 5 months old. From 8-9 weeks, a pattern of “fidgety movement” is normally present absence of this pattern is associated with high risk of later cerebral palsy. Included in the article was a study that found that GMA combined with MRI have 100% specificity and sensitivity with children at 30 months corrected age with cerebral palsy – but it is not likely that this will become a standard practice.

This article is important because the earlier screening can be done to determine if a child has or is at risk for having cerebral palsy the earlier intervention can be started to decrease secondary effects of the condition. The article discusses studies on older children and adults with cerebral palsy showing that activities requiring active play and participation have been the most promising. Again showing that mastery pleasure and task oriented interventions show to be the most successful.


6. Kenyon L, Blackinton M. Applying motor-control theory to physical therapy practice: A case report. Physiotherapy Canada [serial online]. 2011;63(3):345-354. Available from: CINAHL Plus with Full Text, Ipswich, MA. Accessed May 21, 2015.

This article is a case study that considers the motor control theories (specifically ecological, dynamic systems theory and systems theory to create an intervention to teach a 5 year old child with spastic, left unilateral cerebral palsy. After movement patterns were observed and considered, the 5 year old child was classified at Level 1 on the GMFCS (See Appendix A). This child also scored at least average in all 5 domains of the GMFM-88 (See Appendix D). The study was developed because the child’s mother was worried about the boy starting kindergarten and being able to safely play on the ladder and slides with other kids during recess. As part of this study, there were many analyses completed including task analysis, environmental analysis and individual factors and constraints.

The intervention included 19, 60 minute sessions of purposeful intervention (using Gentile’s Taxonomy to increase or decrease the difficulty as necessary-see Appendix C). It was found that the child was able to safely and successful ascend the ladder to the slide as long as there were few environmental distractions and there were only a few other children on the playground. Unfortunately, during recess time when the playground was very busy the child’s attention to form and movement decreased and his safety was compromised ascending the slides. The biggest variable between the child’s successes and failures were the amount of kids on the playground during his attempts – alluding to the ecological model.

This article fits into the topic of this annotated bibliography because it demonstrates that the use of a specific intervention plan can positively affect movement patterns and more importantly a child’s ability to safely interact with peers at recess time. Similar to Majnemer et al, both internal and external motivation is referenced as a key component to the success and compliance of the child.1 The study found that internal motivation comes from successfully completing a task – so when the task is new and challenging, break it down using Gentile’s Taxonomy (see Appendix C) to a level a child can complete and use as stepping stone to completing the new task. External motivation in this study comes from making the physical therapy interventions “games” and “play.” As shown in other studies, mastery pleasure and persistence in social interactions are the biggest motivators for children with cerebral palsy.1 Both of these contributed to the 5 year old in this case study – as mastery pleasure was being able to climb the ladder to go down the slide and persistence in social interactions was being able to interact with peers at recess time. From his successes in a controlled environment, I believe this article correlates to what was found regarding motivation.

References

1. Majnemer A, Shevell M, Law M, Poulin C, Rosenbaum P. Level of motivation in mastering challenging tasks in children with cerebral palsy. Developmental Medicine & Child Neurology [serial online]. 2010;52(12):1120-1126. Available from: CINAHL Plus with Full Text, Ipswich, MA. Accessed M


7. Majnemer A, Shevell M, Law M, Poulin C, Rosenbaum P. Level of motivation in mastering challenging tasks in children with cerebral palsy. Developmental Medicine & Child Neurology [serial online]. 2010;52(12):1120-1126. Available from: CINAHL Plus with Full Text, Ipswich, MA. Accessed M

Motivation is a key component to foster any child’s engagement in a physical therapy setting. Extrinsic factor that inspires and encourages a child may lead to increased compliance, as well as bigger gains during their intervention time. Motivation can be broken down into two components, instrumental and expressive. The instrumental is regarding how much a person will continually try to problem solve a skill that requires either physical or psychological effort. The expressive component is about affective feelings associated with the attempt to complete the task. This article hoped to find what factors motivated a child that had cerebral palsy. For this study, the researchers took the Dimensions of Mastery Questionnaire (DMQ) and compared the results to many variables such as age, sex, development and functional scores and gross motor functioning.

The DMQ is a 45 item, parent answered, questionnaire that takes 10-15 minutes to complete. The scale involves ranking items on a 5-point scale (from not typical to very typical). There is a subscale embedded in the questionnaire that splits the instrumental and expressive motivation categories. This scale has a reliability of 0.68-0.89 and reports discriminant and concurrent validity. Researchers found that the highest motivation subscale scores were for mastery pleasure and persistence in social interactions while the lowest was with gross motor task persistence and persistence with object-oriented goals and tasks.

For children with cerebral palsy, the long term outcomes are closely related/predicted by the age that motor output is produced.1 If a study can prove that there is a specific method or object that motivates a child, therapists and parents can engage to get the early movement patterns initiated.1 Other studies have shown that the more movement (motor output) the more speech and language comprehension the child has.2 This shows that if common motivational factor is found to enhance movement, there could also be improvements in other dimensions. There is also evidence showing that a group therapy approach can foster motivation, so if there are other children in the home, allow them to engage in play as much as possible.

References

1. Campbell, SK, Vander Linden DW, Palisano RJ. Cerebral Palsy In: Physical Therapy for Children (4th edition). Philadelphia: W.B. Saunders Co: 2012: 577-627.



8. Ragonesi C, Chen X, Agrawal S, Galloway J. Power mobility and socialization in preschool: A case study of a child with cerebral palsy. Pediatric Physical Therapy [serial online]. 2010; 22(3): 322-329. Available from: CINAHL Plus with Full Text, Ipswich, MA. Accessed June 26, 2015.

This case study focused on the use of a power mobility device (UD2) in a pre-school classroom with the goal of increasing participation and socialization with both the teacher as well as age matched peers that were typically developing. The participant was a 3 year old boy, Will who had been diagnosed with spastic quadriplegic cerebral palsy, and was classified at GMFCS Level III. (See Appendix A). To be able to compare with peers, two children in the classroom were included and analyzed during the study. They were classified throughout as “Peer 1” and “Peer 2.” In order to measure the time spent interacting, the researchers broke the study into two phase – Phase 1: Baseline phase, consisting of 10 days without the use of UD2 and Phase 2: Mobility phase, consisting of 13 days with the UD2. During these phases, a two hour time frame (8:30 am – 10:30 am) was recorded including all 3 children, and the “most active” minutes were coded according to the following six dimensions:

1. All minutes when the child was moving in space (walking/driving), and physically or verbally interacting with peers

2. All remaining minutes that the child was moving in space, but not interacting3. Minutes of interacting while stationary, but with body movement4. Minutes interacting while stationary with no body movements5. Minutes of body movement while stationary and not interacting6. Minutes stationary with no body movement and no interactions

After the recordings were coded, by an unbiased individual, the outcomes of Will’s mobility were as follows:

-80-100% of most active time was spent sitting in the UD2

-5-10% of the time (1-2 minutes) of most active time spent driving

-Increased range of time interacting

-Decreased the day-today range of time not interacting with others

-Majority of active time spent in non-interactive activities

-Less time in interactive activities compared to Peer 1 and Peer 2

This research shows that a mobility device can be placed and utilized in a pre-school classroom for a child to use effectively. The use of the UD2 did lead to an increase in time spent interacting with peers and teachers when compared with the time interacting when not in the UD2 device, even though it was less time than the peers spent on the same activities.

A key conclusion draw from this article that can be applied to other children with similar diagnoses is how Will’s socialization with peers increased even though he was not highly mobile in the UD2. In the Baseline Phase, Will started the time sitting at a table, which he could not move from independently. During this period, the majority of his interactions occurred when other children happened to pass by the table. The UD2 device was taller than the table top, so during the Mobility phase Will was put in


various places throughout the classroom, away from the table. During the course of the time being coded, Will would drive in the classroom, towards areas of “high traffic” and more children. In essence, Will placed himself in the middle of the action. Being in these busier areas meant more kids passed by him and interacted with him – opposed to interactions happening by chance when he was stationary at the table top.


9. Ragonesi C, Galloway J. Short-term, early intensive power mobility training: Case report of an infant at risk for cerebral palsy. Pediatric Physical Therapy [serial online]. 2012;24(2):141-148. Available from: CINAHL Plus with Full Text, Ipswich, MA. Accessed June 26, 2015.

This article was a case study with the purpose of seeing the effects of power mobility as part of an early intervention physical therapy plan. The subject was an 11 month old child, suspected of developing cerebral palsy. The goal of early introduction of power mobility was to decrease the impairments associated with cognition, language and socialization by decreasing the amount of early immobilization the child faced. Early intervention is typically not utilized until a child is 3 years old, so before this case study there was not much information on this topic. The study took place over 14 consecutive weekday sessions in which both training and testing occurred. In this study, a tennis ball was placed over the standard pediatric power chair’s joystick for the dual purpose of easier grasping for the child as well as drawing the child’s attention to the joystick. Each intervention consisted of Open Exploration in which the infant could move however she wanted with the power mobility device and Prompted Mobility in which the child was encouraged to move in the power chair towards a caregiver.

The intervention sessions were recorded, and data was taken in various categories including:

-Independent Joystick Contacts: # of physical interactions with the joystick

-Visual Attention to Joystick: # of times the child looked at the joystick

-Independent Mobility Time: # of minutes of independent mobility per session

-Assisted Mobility Time: # of minutes infant moved after caregiver placed her hand on the joystick

-Caregiver Mobility Time: # of minutes caregiver moved by pushing infants hand on the joystick

-Success in Prompted mobility: # of times out of 5 trials that the infant independently moved the power chair in response to verbal prompting by caregiver per session.

All of the counted data in the above categories were divided by the total number of minutes in the session except for success in prompted mobility. Additionally, from the first half to the second half of the intervention, the infant looked at the joystick more, had increased independent interaction with the joystick and increased independent movement of the power chair. From the first half to the second half, the infant looked at the joystick more, had increased independent interaction with the joystick and increased independent movement of the power chair.

Results Comparison: First Half to Second HalfCategory First Half of Study Second Half of Study

Time spent in Assisted Mobility 6% 4%Time spent in Independent Mobility 3% 12%Prompted mobility trials (% successful)

20% 60%

Time spent in Caregiver Mobility Did not changeJoystick contacts not associated with looking

50% 20%


This data shows that there are positive short term effects for a young infant at risk for cerebral palsy. The family was engaged throughout the intervention process, which will lead to compliance and continuation of the intervention process – especially because of the level of success the infant exhibited. This article most closely relates other articles discussed in the annotated bibliography about power mobility and socialization – in which it was found the child had more mobility and interaction in the device, but not a significant difference. The researchers believe if these devices were introduced earlier in infancy that the socialization of the child would be enhanced, but future studies would need to be done to support this idea.


10. Salem Y, Godwin E. Effects of task-oriented training on mobility function in children with cerebral palsy. Neurorehabilitation [serial online]. 2009; 24(4): 307-313. Available from: CINAHL Plus with Full Text, Ipswich, MA. Accessed May 20, 2015.

This study looked to prove that functional task training is a more effective therapeutic intervention then conventional physical therapy methods in children with cerebral palsy. Participants included 10 children aged 4-12 years old diagnosed with cerebral palsy. Inclusion criteria included ability to walk with or without aids or orthotics and the ability to follow directions. Pretesting was completed to develop baseline scores in the Gross Motor Function Measure (GMFM) (see Appendix D) and the Timed-Up and Go (see Appendix E), or TUG test (see Appendix F). Dimension D (standing) and E (walking, running and jumping) were the dimensions of interest in this study (see Appendix D).

After pre-test scores were taken, participants were randomly assigned into 1 of 2 groups. While interventions were initiated in both groups for a duration of 5 weeks, the type of intervention varied. The first group (control) received conventional physical therapy focused on improving walking and balance through facilitation and normalization of movement patterns. The second group (experimental) received task-oriented training to focus on strengthening the lower extremities and practicing functional tests. The intervention protocol for the control group was not detailed. The experimental intervention consisted of:

1. Walking activities including walking forward, backward, sideways and walking through an obstacle course

2. Walking up and down ramps and stairs3. Stepping forward, backward and sideways from floor onto blocks of various heights4. Standing balance activities such as reaching in different directions5. Standing up from a chair6. Performing single leg stance7. Kicking a ballThese exercises were progressed by increasing the number of repetitions performed, or increasing the difficulty of the task.

To begin the statistical analysis, it is important to report that there were no significant differences between groups found in the demographics or pre-test baseline measures of the GMFM or the TUG tests. After comparing the post-tests in the control and experimental group with independent-t tests, there were significant changes seen in the GMFM

Standing category (p=0.009) GMFM Walking category (p=0.009) TUG score (p=0.017).

These statistics show that the more functional, task-oriented training yielded more benefits over a 5 week span in children with cerebral palsy. While this study is limited in that it has a sample size of only 10 children, these findings could have an impact on future research studies and intervention protocol to increase mobility in children with the cerebral palsy diagnosis.

This study contributed to answering what various factors can contribute to increased movement/mobility in children with cerebral palsy. The researchers found that a task-oriented


intervention routine produced increased movement and functional abilities within this population. Motivation is also noted in this study, and the study found that task-oriented activities were associated with activities the children used in everyday tasks and play leading to more practice and compliance with the intervention plans.


Appendix A:Gross Motor Functional Classification System – Children 6-12

Taken From: Campbell, SK, Vander Linden DW, Palisano RJ. Physical Therapy for Children (4th edition). Chapter 18, Cerebral Palsy Pages 577-582. Philadelphia: W.B. Saunders Co., 2012.

GMFCS (Children 6-12)

GMFCS Level I Children walk at home, school, outdoors and in the community. They can climb stairs w/o use of a railing. Perform gross motor skills like running, and jumping but with limited speed, balance and coordination

GMFCS Level II Walking utilized in most settings and climb stairs holding onto a rail. May experience difficulty walking long distances and balancing on uneven terrain, inclines, in crowded areas or confined spaces. Children may walk with physical assistance, a hand-held mobility device or use wheeled mobility over long distances. Children have only minimal ability to perform gross motor skills like running and jumping

GMFCS Level III Walk using hand-held mobility device in most indoor settings. May climb stairs holding onto railing with supervision or assistance. Children use wheeled mobility when traveling long distances and may self-propel for shorter distances

GMFCS Level IV Children use methods of mobility that require physical assistance or powered mobility in most settings. They may walk for short distances at home with physical assistance or use powered mobility or a body support walker when positioned. At school, outdoors and in community children are transported in a manual wheelchair or use powered mobility

GMFCS Level V Children are transported in a manual wheelchair in all settings. Children are limited in their ability to maintain antigravity head and trunk postures and control leg and arm movements


Appendix B: Gross Motor Functional Classification System – Children 12-18


GMFCS (Children 12-18)GMFCS Level I Youth walk at home, school, outdoors and in the community. Able

to climb curbs and stairs w/o physical assistance or a railing. Can running/jump but have limited speed, balance and coordination

GMFCS Level II Walk in most settings but environmental factors and personal choice influence mobility choices. At school or work they may require a hand-held mobility device for safety and climb stairs holding onto a railing. Outdoors and in the community youth may use wheeled mobility when traveling long distances.

GMFCS Level III Capable of walking using a hand-held mobility device. May climb stairs holding a rail with supervision/assistance. At school, may self-propel a manual wheelchair or use powered mobility. Outdoors and in the community youth are transported in a wheelchair or use a powered mobility.

GMFCS Level IV Youth use wheeled mobility in most settings. Physical assistance of 1-2 people is required for transfers. Indoors, youth may walk short distances with physical assistance, use wheeled mobility or a body support walker when positioned. May operate a powered chair, otherwise are transported in a manual wheelchair.

GMFCS Level V Transported in a manual wheelchair in all settings. Limited in their ability to maintain antigravity head and trunk postures and control leg and arm movements. Self-mobility is severely limited, even with the use of assistive devices.


Appendix C:Gentile’s Taxonomy

Taken from: Reinthal A. Motor Learning. Presented at Cleveland State University, Cleveland Ohio. Revised February 2013. Presented April 15, 2015.


Appendix D:Gross Motor Function Measurement (GMFM)


a. Key Concepts: Test specifically designed and validated for measuring change over time in gross motor function in children with CP (also has been validated with children with Downs Syndrome)

b. Purpose/Measures: To determine a child’s degree of achievement of a motor behavior (regardless of quality) when instructed to perform or when placed in a particular position. Spontaneous movements are not assessed.

c. 5 Dimensions of the test:

A. Lying and rolling

B. Sitting

C. Crawling and Kneeling

D. Standing

E. Walking, Running, Jumping

d. Validated for sensitivity to change over 6 months period

Change correlated with GMFM were 0.82

e. Reliability1

Intrarater – ICC = 0.99 Interrater – ICC = 0.99

Reference

1. Salem Y, Godwin E. Effects of task-oriented training on mobility function in children with cerebral palsy. Neurorehabilitation [serial online]. 2009;24(4):307-313. Available from: CINAHL Plus with Full Text, Ipswich, MA. Accessed May 20, 2015.


Appendix E:Timed Up and Go (TUG) Test

Taken From: Posiadlo D, Richardson S., The timed “Up & Go”: a test of basic functional mobility for frail elderly persons, Journal of the American Geriatric Society. 1991;39:142-148.

a. Description : Measure of function which correlates to balance and fall risk

b. Equipment : Stopwatch, Standard Chair, Measured distance of 3 meters (10 feet)

c. Patient Instructions : “My commands for this test are going to be “ready, set, go.” When I say go, I want you to stand up from the chair. You may use the arms of the chair to stand up or sit down. Once you are up, you may take any path you like, but I want you to move as quickly as you feel safe and comfortable until you pass this piece of tape (or end of marked course) with both feet. Turn around and walk back to the chair. I will stop the clock when your back touches the back of the chair.”

d. Therapist Instructions : Start timing on the word “go” and stop timing when the subject is seated again correctly in the chair with their back resting on the back of the chair. The subject wears their regular footwear, may use any gait aid that they normally use during ambulation, but may not be assisted by another person. There is no time limit. They may stop and rest (but not sit down) if they need to.

e. Reliability 1 A. Intrarater – ICC = 0.99B. Interrater – ICC = 0.99

Reference

1. Salem Y, Godwin E. Effects of task-oriented training on mobility function in children with cerebral palsy. Neurorehabilitation [serial online]. 2009;24(4):307-313. Available from: CINAHL Plus with Full Text, Ipswich, MA. Accessed May 20, 2015.


Appendix F:Timed Up and Down Stairs (TUD) Test

Taken From: de Campos A, Costa C, Rocha N. Measuring changes in functional mobility in children with mild cerebral palsy. Developmental Neurorehabilitation [serial online]. June 2011;14(3):140-144. Available from: CINAHL Plus with Full Text, Ipswich, MA. Accessed May 21, 2015.

a. Description : Measure of function which shows efficiency and safety with ascending and descending stairs

b. Equipment : Stopwatch, Tapemeasure, 14-step flight of stairs

c. Patient Instructions : “Quickly, but safely go up the stairs, turn around on the top step and come all the way down until both feet land on the bottom step.”

d. Therapist Instructions : Start timing on the word “go” and stop timing when the subject has the second foot landed on the bottom step. The subject wears their regular footwear, may use any gait aid that they normally use during ambulation, but may not be assisted by another person. There is no time limit. They may stop and rest if they need to.

e. Statistics: a. Sensitive to verify functional changes resulting from motor development in typical

children, and can discriminate children with disorders of functional mobility and balance

b. Proven to have adequate reliability and validity in children with and without cerebral palsy and complements clinical measures of functional mobility and balance.1

Reference

1. Zaino C, Marchese V, Westcott S. Timed up and down stairs test: preliminary reliability and validity of a new measure of functional mobility. Pediatric Physical Therapy. [serial online]. 2004;16(2):90-98. Accessed July 23, 2015.


Closing Statement

After reading and scrutinizing 8 articles it is clear that motivation is a key factor in motor output and mobility/movement in children who have been diagnosed with cerebral palsy. There are classification systems that classify the level of motor impairment a child has (GMFCS). Three tests have proven to be reliable, valid and sensitive in determining motor function changes over time in this population. These tests are the GMFM, the TUG test and the TUD test. For a physical therapist working with a child with cerebral palsy classified as Level I or II on the GMFCS, these would be 3 very good objective measures to track the child’s progress.

Motivation in this population seems to come from social participation and an interest in the stimulus. Task-oriented interventions have proven to be the best way to engage the child and keep the child practicing. Another method of integrating mobility in children with a bigger motor impairment is the use of mobility devices. While the mobility devices did not significantly or permanently change the child’s behaviors, there were positive benefits from the interventions, encouraging future studies to incorporate mobility devices. This research focused almost exclusively on variables that effected motor performance. To continue the research, articles correlating the effect of motor impairment and improvement with cognition and sensory variables could be done.


References1. Campbell, SK, Vander Linden DW, Palisano RJ. Physical Therapy for Children (4th edition).

Chapter 18, Cerebral Palsy Pages 577-582. Philadelphia: W.B. Saunders Co., 2012. 2. de Campos A, Costa C, Rocha N. Measuring changes in functional mobility in children with mild

cerebral palsy. Developmental Neurorehabilitation [serial online]. 2011;14(3):140-144. Available from: CINAHL Plus with Full Text, Ipswich, MA. Accessed May 21, 2015.

3. Geytenbeek J, Vermeulen R, Becher J, Oostrom K. Comprehension of spoken language in non-speaking children with severe cerebral palsy: an explorative study on associations with motor type and disabilities. Developmental Medicine & Child Neurology [serial online]. 2015;57(3):294-300. Available from: CINAHL Plus with Full Text, Ipswich, MA. Accessed May 20, 2015.

4. Hadders-Algra M. Variability in infant motor behavior: A hallmark of the healthy nervous system. Infant Behavior & Development [serial online]. October 2002;25(4):433-451. Available from: Academic Search Complete, Ipswich, MA. Accessed July 31, 2015.

5. Herskind A, Greisen G, Nielsen J. Early identification and intervention in cerebral palsy. Developmental Medicine & Child Neurology [serial online]. 2015;57(1):29-36. Available from: CINAHL Plus with Full Text, Ipswich, MA. Accessed July 27, 2015.

6. Kenyon L, Blackinton M. Applying motor-control theory to physical therapy practice: a case report. Physiotherapy Canada [serial online]. 2011;63(3):345-354. Available from: CINAHL Plus with Full Text, Ipswich, MA. Accessed May 21, 2015.

7. Majnemer A, Shevell M, Law M, Poulin C, Rosenbaum P. Level of motivation in mastering challenging tasks in children with cerebral palsy. Developmental Medicine & Child Neurology [serial online]. 2010;52(12):1120-1126. Available from: CINAHL Plus with Full Text, Ipswich, MA. Accessed May 20, 2015.

8. Ragonesi C, Chen X, Agrawal S, Galloway J. Power mobility and socialization in preschool: a case study of a child with cerebral palsy. Pediatric Physical Therapy [serial online]. September 2010;22(3):322-329. Available from: CINAHL Plus with Full Text, Ipswich, MA. Accessed June 26, 2015.

9. Ragonesi C, Galloway J. Short-term, early intensive power mobility training: Case report of an infant at risk for cerebral palsy. Pediatric Physical Therapy [serial online]. 2012; 24(2): page numbers? . Available from: CINAHL Plus with Full Text, Ipswich, MA. Accessed June 26, 2015.

10. Salem Y, Godwin E. Effects of task-oriented training on mobility function in children with cerebral palsy. Neurorehabilitation [serial online]. 2009; 24(4):307-313. Available from: CINAHL Plus with Full Text, Ipswich, MA. Accessed May 20, 2015.

11. Zaino C, Marchese V, Westcott S. Timed up and down stairs test: preliminary reliability and validity of a new measure of functional mobility. Pediatric Physical Therapy. [serial online]. 2004; 16(2):90-98. Accessed July 23, 2015.

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