Optimization of fMRI methods to determine laterality of cortical activation during ankle movements of children with unilateral cerebral palsy.

Measurement of laterality of motor cortical activations may provide valuable information about lower limb control in children with unilateral cerebral palsy (UCP). Evidence from upper limb research suggests that increased contralateral activity may accompany functional gains. However, lower limb areas of activation and associated changes have been underexplored due to challenges with imaging motor cortical leg representations. In this study, methods for a task-based functional magnetic resonance imaging (fMRI) ankle dorsiflexion paradigm were refined with three pilot groups of participants: (i) adults (n = 5); (ii) typically developing (TD) children (n = 5) and; (iii) children with UCP (n = 4). Parameters of experimental design, task resistance, reproducibility, and pre-scan procedures were tested/refined using a staged development approach with additions or changes introduced if image quality did not meet pre-defined standards. When image quality was acceptable for two consecutive participants, the next participant group was recruited to test/refine the next parameter. The final paradigm involved an event-related design of a single dorsiflexion movement against individualized resistance, with two runs per leg. It included a pre-scan session to increase child comfort and determine task resistance. This paradigm produced valid data for laterality index (LI) calculations to determine the ratio of activity in each hemisphere. Ventricle and lesion masks were used in non-linear image registration, and individual thresholds were used for extent-based LI calculations. LI of dominant ankle movements were contralateral (LI ≥ +0.2) for TD children (mean LI = +0.89, std = 0.27) and children with UCP (mean LI = +0.86, std = 0.26). For the affected ankle of children with UCP, LI values indicated ipsilateral and/or contralateral activation (mean LI = +0.02, std = 0.71, range -0.92 to +1.00). This fMRI paradigm will support investigations of cortical activation and mechanisms of skill improvement following lower limb interventions.

Reliability and validity of the acquired brain injury challenge assessment (ABI-CA) in children.

PRIMARY OBJECTIVE: The Acquired Brain Injury Challenge Assessment (ABI-CA) was created to fill a measurement gap and evaluate deficits in advanced motor skills in children with acquired brain injury (ABI). Study objectives were to refine ABI-CA response options and evaluate (i) inter-/intra-rater reliability, (ii) concurrent validity and difficulty level in relation to the Community Balance & Mobility Scale (CB&M) and (iii) administration efficiency of the refined ABI-CA. RESEARCH DESIGN: Measurement study. METHODS: Phase I involved ABI-CA revisions. Phase 2 consisted of live-/video-scoring of the ABI-CA with 15 typically-developing (TD) children and 15 with ABI (7-17 years) to assess reliability/validity. RESULTS: The revised 20-item ABI-CA displayed excellent reliability for the entire sample (ICCs > 0.90; 95% CI = 0.92-1.00; SEM ≤ 3.60) and within ABI and TD sub-groups. The ABI-CA and CB&M correlated strongly (r = 0.75, p < 0.0001). The ABI-CA mean score (/100) was 11.3 points lower (p < 0.0001) than the CB&M's mean score (/100). CONCLUSION: The ABI-CA demonstrated excellent reliability and initial evidence of validity. ABI-CA scores were lower overall than the CB&M, indicating the ABI-CA may have greater capacity to evaluate improvements in advanced motor skills in children with ABI. Multi-centre research is needed to confirm the ABI-CA's test-retest reliability and, assuming acceptability, assess responsiveness to change.

Community mobility assessment for adolescents with an acquired brain injury: preliminary inter-rater reliability study.

BACKGROUND: The Community Mobility Assessment (CMA) is an observational assessment that evaluates safety of an adolescent with an acquired brain injury (ABI) during a community outing. It consists of a 3-point level of accomplishment scale for 40 functional items, divided into two components (physical and cognitive). The CMA identifies areas of strength and weakness and facilitates development of compensating strategies. This study was undertaken to determine how reliably therapists rate a client's performance using the CMA on a community outing. PARTICIPANTS: Eight adolescents between the ages of 12 and 18 participated. All had an ABI and were involved in rehabilitation either as a day-patient or inpatient. METHODS: Each teen was independently evaluated by one expert rater and one of two student raters (A or B), using the CMA during a standard 2-h community outing. ANALYSIS: Descriptive statistics were computed for physical and cognitive component summary scores. Inter-rater reliability analyses used weighted Kappa statistics. A minimum Kappa score >0.70 was hypothesized a priori to indicate good reliability. RESULTS: The mean score for the physical component = 92% (min = 82%, max = 100%), and for the cognitive component = 77% (min = 58%, max = 97%). Minimum weighted Kappa scores for the two rater pairings were 0.80 for the physical component and 0.70 for the cognitive component. CONCLUSIONS: An acceptable Kappa score was reached for both components, indicating that with appropriate rater training, the CMA has good inter-rater reliability. Construct validity and responsiveness to change over a clinically meaningful follow-up period should now be evaluated.

Exploring the comparative responsiveness of a core set of outcome measures in a school-based conductive education programme.

BACKGROUND: Conductive education (CE) is a holistic educational system that uses an active cognitive approach to teach individuals with motor disorders to become more functional participants in daily activities. While CE's popularity continues to grow in North America and Europe, its effectiveness has not been established. The lack of definition of responsive outcome measures for evaluation of CE programmes has limited the interpretability of conclusions from earlier studies evaluating effectiveness. OBJECTIVE: To determine which measures from a core set were most responsive to physical, functional and psychosocial changes associated with a school-based CE programme. METHODS: This was a one-group before and after data collection design using an 8-month follow-up period. We enrolled a referral sample of nine children with cerebral palsy in Kindergarten or Grade 1 (Gross Motor Function Classification System levels 3, 4 or 5). The study took place within a school-based CE programme at a Canadian children's rehabilitation centre. Children participated in a CE full-day class for an entire school year. Physical, functional, psychosocial and participation measures included: Gross Motor Function Measure (GMFM), Quality of Upper Extremity Skills Test (QUEST), Peabody Developmental Motor Scales, Paediatric Evaluation of Disability Inventory (PEDI), Pictorial Scale of Perceived Competence and Social Acceptance for Young Children, Individualized Educational Plan, and Goal Attainment Scaling (GAS). Four children from the study's second year were also evaluated on the Impact on Family Scale (IFS), GAS and School Function Assessment. RESULTS: The Gross Motor Function Measure, QUEST, PEDI (Caregiver Assistance) and IFS were most responsive to change. GAS was useful in documenting and quantifying goals. Problems were encountered in evaluating self-esteem and school participation. CONCLUSIONS: Several strong measures of outcome were identified. Further work is needed to find valid and sensitive psychosocial and school participation measures for these young children.

The Prosthetic Upper Extremity Functional Index: development and reliability testing of a new functional status questionnaire for children who use upper extremity prostheses.

The Prosthetic Upper Extremity Functional Index (PUFI) was developed by the authors' clinical research group to evaluate the extent to which a child actually uses a prosthetic limb for daily activities, the comparative ease of task performance with and without the prosthesis, and its perceived usefulness. The PUFI's test-retest and interrater reliability were evaluated with 24 children. Intraclass coefficients (ICCs) were calculated for each of four subscales of the PUFI--specifically, method of performance, ease of prosthetic use, usefulness of the prosthesis, and ease of performance without the prosthesis. The ICCs were greater than 0.65, indicating good test-retest reliability for the older-child respondents (n = 10) and fair to good reliability (ICCs, 0.40 to 0.84) for the parent respondents overall (n= 21). Interrater (child-parent) reliability was lower, with ICCs from 0.30 to 0.77. This finding was not unexpected, since a child and parent may rate in the context of different functional environments. The prosthesis was used 53% of the time by older children and more than 75% of the time by younger children. The results provide evidence that the PUFI has good test-retest reliability overall as a measure of a child's ability to perform upper extremity activities with a prosthesis.

Evaluation of selective dorsal rhizotomy for the reduction of spasticity in cerebral palsy: a randomized controlled tria.

Selective dorsal rhizotomy (SDR) is widely used to treat spasticity in children with diplegic cerebral palsy (CP) but has never been shown conclusively to improve functional outcome. The study was designed to measure changes in gross motor function in children 1 year following rhizotomy compared with a control group receiving equivalent physiotherapy (PT) and occupational therapy (OT) with the exception that the rhizotomy group initially underwent a 6-week postoperative in-patient therapy program. Twenty-four children (mean age 58 months) with mild to moderate CP with spastic diplegia were randomly assigned to a therapy-only control group (CG) (N=12) or rhizotomy and therapy group (RG) (N=12). The Gross Motor Function Measure (GMFM) was administered at the baseline, 6-, and 12-month assessments. Extremity tone, range of motion (ROM), biomechanics of the ankle-stretch reflex, isometric contraction, and temporal gait components were also evaluated. GMFM scores in the RG improved by 12.1 percentage points versus 4.4 percentage points in the CG (P<0.02). RG knee and ankle tone was significantly reduced (P<0.005), associated with increased passive ankle ROM (P<0.001), and decreased soleus EMG reflex activity on forced dorsiflexion (P<0.008). Foot-floor contact pattern improved in the RG compared with the CG (P<0.05). In conclusion, SDR combined with PT and OT leads to significantly greater functional motor improvement at 1 year following surgery compared with PT and OT alone. This was achieved in part through reduced knee and ankle tone, increased ankle dorsiflexion ROM, and more normal foot-floor contact during walking.

The Juvenile Arthritis Functional Status Index (JASI): a validation study.

OBJECTIVE: To evaluate aspects of reliability and validity of the Juvenile Arthritis Functional Status Index (JASI). We developed this questionnaire to assess a variety of daily living and functional mobility tasks in children with juvenile rheumatoid arthritis (JRA). JASI part I consists of 100 functional items divided into 5 activity categories (self-care, domestic, mobility, school, extracurricular). A 7 point degree of difficulty rating scale is used for responses. JASI Part II is a priority function section within which the child identifies and scores important activities for improvement. METHODS: The JASI was administered to 30 children with JRA 8 to 19 years of age at baseline, 3 weeks, and 3 months to determine test-retest reliability. Various rheumatology measures were used to evaluate the JASI construct validity. RESULTS: Reliability of JASI Part I was excellent (intraclass correlation coefficients > or = 0.95) for both retest intervals. Reliability was lower for respondents with mild disease than those with polyarticular disease. JASI Part I scores correlated strongly with rheumatology measures including joint count, grip strength, hip synovitis, timed walk and run. ACR functional class, and range of motion (r > 0.50), indicating construct validity. There was fair to good agreement between scores from the child's self-report and those from therapist observation of the child's abilities on the same activities. This provides evidence that children as young as 8 years of age can realistically report on function on their own. In JASI Part II, respondents identified a mean of 5.9 functional items in the baseline priority activity list. Test-retest reliability for JASI Part II was fair (kappa = 0.57). Further work is needed to determine the most reliable and sensitive response sequence for evaluating change in priority functions with JASI Part II. CONCLUSION: JASI Part I is a reliable and valid functional measure for school age children and adolescents with JRA. Research is under way to evaluate responsiveness to change. Comparisons will be made with shorter JRA functional measures to determine differences in sensitivity.

Development of a self-report functional status index for juvenile rheumatoid arthritis.

OBJECTIVE: There are few functional indices available for juvenile rheumatoid arthritis (JRA). Our goal was to develop a reliable, valid and responsive self-report physical functional status index for individuals with JRA, ages 8-18 years. METHODS: Activity (item) generation by interview of children, parents, teachers, clinicians yielded 280 items. Categories of self-care, domestic, mobility, school, and extracurricular were chosen by clinicians. Twelve clinicians sorted the items into categories. Item reduction was by these clinicians who rated items for common problems in JRA, importance of performance, and potential for change. RESULTS: Ninety-nine items were retained. A separate section was designed for respondents to identify their priority activities. Content validity of the questionnaire, the Juvenile Arthritis Self-Report Index (JASI), was evaluated by 17 different clinicians. One item was added and none eliminated; all rated the index as a credible functional measure for JRA. CONCLUSION: The JASI has been rigorously developed, and has demonstrated content validity. Index validation is being completed.

Feedback of triceps surae EMG in gait of children with cerebral palsy: a controlled study.

Children with spastic hemiplegia secondary to cerebral palsy show disrupted patterns of work and power in gait. A computer-assisted feedback system was used to deliver EMG feedback from the triceps surae muscle group to walking subjects in conjunction with amplitude and timing targets for muscle relaxation and activation. Biofeedback of triceps surae muscle activity during gait was compared with physical therapy (PT) in a two-period crossover design, with intervening biomechanical gait analyses to assess the effects of each type of treatment. Kinematic and kinetic gait variables were affected differently by each type of treatment. Stride length and velocity were positively affected by the biofeedback protocol. Positive work done by the affected ankle increased through PT, but gait symmetry was negatively affected, such that the stance phase was prolonged, and peak ankle power at push-off was not improved. In contrast, the biofeedback treatment improved gait symmetry, and was associated with greater ankle power for push-off, as well as increases in total positive work at the hip and ankle. It is concluded that the feedback protocol might be an effective adjunct to physical therapy in hemiplegic children.

Observer variation in an audit of charts of patients with rheumatoid arthritis.

Arthritis Society physiotherapists (PTs) in Ontario adopted Problem Oriented Records (POR) to monitor patient care; goals were to encourage patient specific treatment plans and standardized records. After nine months in practice, the POR system was evaluated by an audit on charts of patients with Rheumatoid Arthritis. Audit teams of two PTs were created within each of five geographic areas. Auditors attended an audit instruction workshop. Two charts, selected randomly from the discharged patients of each of 38 therapists, were independently scored on 56 items by an audit team. The extent of agreement within the auditor team (observer variation) was measured, and adequacy scores computed for each chart. Adequate reliability of the audit instrument was established before examination of adequacy scores and making inferences about quality of care. The auditor agreement measures (kappa) varied from 0.13 to 0.97, mean = 0.74 and SD = 0.16; these estimates were indicative of adequate reliability of the audit form, although agreement scores were different amongst the five areas (P2 less than .01). POR adequacy scores varied from 10.0 to 93.1, mean = 64.5 and SD = 16.9. There were no differences in adequacy scores amongst the five areas (P2 = .61). To reduce observer variation, increased pre-audit emphasis is needed on auditor guidelines and training for items relating to assessment findings, problem identification, and treatment planning.