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Background. The attainment of walking is a focus of physical therapy intervention in children with cerebral palsy (CP) and may affect their independence in mobility and participation in daily activities. However, knowledge of determinants of independent walking to guide physical therapists' decision making is lacking. Objective. The aim of this study was to identify child factors (postural control, reciprocal lower limb movement, functional strength, and motivation) and family factors (family support to child and support to family) that predict independent walking 1 year later in young children with CP at Gross Motor Function Classification System (GMFCS) levels II and III. Design. A secondary data analysis of an observational cohort study was performed. Methods. Participants were 80 children with CP, 2 through 6 years of age. Child factors were measured 1 year prior to the walking outcome. Parent-reported items representing family factors were collected 7 months after study onset. The predictive model was analyzed using backward stepwise logistic regression. Results. A measure of functional strength and dynamic postural control in a sit-to-stand activity was the only significant predictor of taking ≥ 3 steps independently. The positive likelihood ratio for predicting a 'walker' was 3.26, and the negative likelihood ratio was 0.74. The model correctly identified a walker or 'nonwalker' 75% of the time. Limitations. Prediction of walking ability was limited by the lack of specificity of child and family characteristics not prospectively selected and measurement of postural control, reciprocal lower limb movement, and functional strength 1 year prior to the walking outcome. Conclusions. The ability to transfer from sitting to standing and from standing to sitting predicted independent walking in young children with CP. Prospective longitudinal studies are recommended to determine indicators of readiness for independent walking., The attainment of walking is an important goal for families of young children with cerebral palsy (CP) and is a focus of early physical therapy intervention. Cerebral palsy is a [...]

Background. Social participation provides youths with opportunities to develop their self-concept, friendships, and meaning in life. Youths with cerebral palsy (CP) have been reported to participate more in home-based leisure activities and to have fewer social experiences with friends and others than youths without disabilities. Objective. The objective of this study was to identify youth, family, and service determinants of the participation of youths with CP in leisure activities with friends and others who are not family members. Design. The study design was a cross-sectional analysis. Methods. The participants were 209 youths who were 13 to 21 years old (52% male), had CP, and were classified in Gross Motor Function Classification System (GMFCS) levels I to V as well as their parents. The participants were recruited from 7 children's hospitals in 6 different states. Youths completed the Children's Assessment of Participation and Enjoyment in structured interviews. Parents completed the Coping Inventory, Pediatric Outcomes Data Collection Instrument, Family Environment Scale, Measure of Processes of Care, and demographic and service questionnaires. Researchers determined GMFCS levels. A sequential multiple regression analysis was used to determine the youth, family, and service variables that predicted participation with friends and with others who were not family members. Results. Sports and physical function, communication or speech problems, educational program, and the extent to which the desired community recreational activities were obtained explained 45.8% of the variance in the number of activities engaged in with friends. A higher level of parental education explained 6.3% of the variance in the number of activities engaged in with others who were not family members. Limitations. The youths' activity preferences and intensity of participation were not examined. Conclusions. Youth and service characteristics were determinants of participation with friends but not others who were not family members. The findings have implications for the role of physical therapists in promoting sports and physical and communication abilities and enhancing community opportunities to optimize the social participation of youths with CP., Participation creates avenues to form friendships, develop a self-concept, and determine a sense of meaning in life. (1,2) Participation is defined as involvement in life situations and represents an interaction [...]

This perspective article provides an example of a study planned using guidelines for comprehensive rehabilitation outcomes research, an approach that is believed to give service providers meaningful evidence to support practice. This line of investigation has been guided by the World Health Organization's International Classification of Functioning, Disability and Health. The short title of a study under way is Move & PLAY (Movement and Participation in Life Activities of Young Children). The article briefly describes the conceptual model, provides guidelines on how indicators and measures are selected, alludes to the details of selected measures, and describes processes of preparing for data collection, including obtaining ethics approval, preparing data collection booklets, training assessors and interviewers, and sampling. The aim of this investigation is to gain a better understanding of the multiple child, family, and service factors associated with changes in mobility, serf-care, and play of preschool children with cerebral palsy as a result of using this research method. Comprehensive rehabilitation outcomes research holds promise in providing evidence that supports the complexities of planning rehabilitation services with clients with chronic conditions, such as children with cerebral palsy., Rehabilitation service providers work with clients with a range of conditions whose outcomes are associated with many factors, including, but not limited to, the services they receive. Traditionally, outcomes of [...]

Background. Understanding family priorities for children and youth with cerebral palsy is essential for family-centered service. Objective. The purposes of this study were: (1) to identify family priorities for activity and participation in children and youth with cerebral palsy and (2) to determine differences based on age and Gross Motor Functional Classification System (GMFCS) level. Design. Five hundred eighty-five children and youth with cerebral palsy and their caregivers participated at regional children's hospitals. The children and youth were 2 to 21 years of age; 56% were male, and 44% were female. Their caregivers, predominantly mothers (80%), had a mean age of 40.3 years (SD=9.3). The Canadian Occupational Performance Measure was administered to caregivers to identify their priorities for their children. The priorities were coded into 3 categories (daily activities, productivity, and leisure) and 13 subcategories. The GMFCS levels were determined by assessors who met the criterion for reliability. Friedman and Kruskal-Wallis one-way analyses of variance were used to examine differences in priorities. Results. Parents of children in all age groups and GMFCS levels II to V identified more priorities for daily activities. Parents of school-aged children and youth had more priorities for productivity than parents of younger children. For parents of children in all age groups and motor function levels, self-care was the most frequent priority subcategory. Sixty-one percent of parents identified at least one priority related to mobility. Limitations. The study did not include qualitative analysis of priorities of parents. Conclusions. Parents' priorities for their children and youth with cerebral palsy differed depending on age and gross motor function level; however, the most frequent priority for all age groups was daily activities. Interviews with families are recommended for identifying outcomes for activity and participation and developing an intervention plan., Understanding the priorities and needs of children and youth with cerebral palsy and their families is essential for family-centered service. A family-centered approach embodies the belief that processes and outcomes [...]

Background. Through social and community participation, children and youth with cerebral palsy (CP) form friendships, gain knowledge, learn skills, express creativity, and determine meaning and purpose in life. Objective. The purposes of this study were: (1) to determine whether social and community participation of children and youth with CP differ based on age, sex, and gross motor function, and (2) to identify the types of activities in which social and community participation are highest. Design and Methods. A prospective cross-sectional analytic design was used. The participants were a sample of convenience of 291 children (6-12 years of age) and 209 youth (13-21 years of age) with CP (55.4% males, 44.6% females) receiving services from 7 children's hospitals. Participants completed the Children's Assessment of Participation and Enjoyment (CAPE) by structured interview. Gross Motor Function Classification System (GMFCS) level was determined by the researchers. Results. Youth did a higher percentage of activities with friends and others and outside the home than children. Children and youth in level I did a higher percentage of activities with friends and others compared with children and youth in levels II and III and in levels IV and V. Children and youth in level I and in levels IV and V did a higher percentage of activities outside the home than children and youth in levels II and III. Differences were not found between females and males. The percentage of activities done with friends and others and outside the home was highest for physical and skill-based activities. Limitations. Findings cannot be attributed only to GMFCS level. Conclusions. The ability to walk without restrictions is desirable for social and community participation. For children and youth with CP who have limitations in mobility, physical therapists have roles as consultants for accessibility, activity accommodations, and assistive technology and as advocates for inclusive environments., Cerebral palsy (CP) describes a group of disorders of posture and movement that occur as a result of a nonprogressive disturbance in the developing fetal or infant brain. (1) United [...]

Background and Purpose. Differences in the gastrocnemius-soleus muscle and tendon have been documented shortly after birth in infants born preterm compared with infants born at term. Knowledge of muscle tendon unit lengths at term age to 12 weeks of age in infants born preterm may be useful in understanding motor development. Participants and Method. Gastrocnemius-soleus muscle tendon unit lengths were compared at term age, at 6 weeks of age, and at 12 weeks of age (preterm adjusted age) in 20 infants born full term and 22 infants born preterm. Results. Significant differences were found between the 2 groups on taut tendon, relaxed muscle length ([A.sub.O]); taut tendon, stretched muscle length ([A.sub.Max]); and muscle stretch ([A.sub.O] to A.sub.Max). Infants born preterm demonstrated measures of [A.sub.O] and [A.sub.Max] in positions of greater plantar flexion compared with infants born full term. Significant differences in measurements of [A.sub.O] were found between term age and 12 weeks of age, indicating that the tendon lengthens during this period for both groups. Discussion and Conclusion. These results provide knowledge of musculoskeletal development of the gastrocnemius-soleus muscle and tendon. Differences in musculoskeletal measurements are consistent with uterine confinement in the last weeks of full-term gestation. These findings have implications when examining the musculoskeletal system in infants born preterm who are demonstrating functional changes., Motor development in infants traditionally has focused on maturation of the central nervous system, and less focus has been placed on posture of the infant and examination of the musculoskeletal [...]

Background and Purpose Mobility and self-care are important considerations for successful transition of adolescents with cerebral palsy to adulthood. The purpose of this study was to characterize performance of physical activities from the perspective of adolescents themselves. Subjects The subjects were 156 adolescents with cerebral palsy, 11.6 to 17.7 years of age. Methods A therapist completed the Gross Motor Function Classification System (GMFCS). Adolescents completed the Activities Scale for Kids-Performance Version (ASKp) twice over a 1-year period. Results A repeated-measures analysis of variance indicated a main effect for GMFCS level. The main effect for time and the GMFCS level X time interaction were not significant. Post hoc comparisons indicated that ASKp scores differed among all GMFCS levels. Discussion and Conclusion Performance of physical activities by adolescents with cerebral palsy differed based on GMFCS level and did not change over 1 year. The ASKp scores of adolescents in levels II through V suggest the need for physical assistance at times throughout the day. The results have implications for the role of the physical therapist in transition planning., Adolescence is a period of development that involves reparation for social roles associated with young adulthood, including postsecondary education, employment, and independent living. The transition to adulthood is thought to [...]

Models of physical therapist service delivery provide a framework for integration of knowledge, research, and assumptions in a clinically relevant context that facilitates evidence-based decision making. In this perspective, a collaborative model of service delivery for children with movement disorders is presented. The focus is on services that address child and family priorities and preferences in settings where children live, learn, and play. The International Classification of Functioning, Disability and Health (ICF) is applied to identify relationships among the components of functioning, environmental, and personal factors that are important for the plan of care and achievement of outcomes. An assumption of the model is that physical therapists use multiple types of evidence to guide decision making. Application of the model and how child and family priorities change over time are illustrated through a longitudinal case report of a child with cerebral palsy Key Words: Children, Cerebral palsy, Clinical decision making, Evidence-based practice, International Classification of Functioning, Disability and Health, Movement disorders., On a daily basis, pediatric physical therapists interact with children, their families, educators, physicians and other health care professionals, and third-party payers to make decisions about patient or client management. [...]

Background and Purpose. Mobility of children with cerebral palsy (CP) has generally been examined in terms of capability (what a child can do) in a controlled environment, rather than performance (what a child does do) in everyday settings. The purpose of this study was to compare gross motor capability and performance across environmental settings in children with CP. Subjects. The subjects were 307 children with CP, aged 6 to 12 years, who were randomly selected across Ontario, Canada. Methods. Children were grouped by capability (the highest of 3 items achieved on the Gross Motor Function Measure). Performance was measured via a parent-completed questionnaire on usual mobility methods in the home, at school, and in the outdoors or community. Results. There were statistically significant differences in performance across settings for children in all capability groups. Children who were capable of crawling performed crawling more at home than at school or in the outdoors or community. Children who were capable of walking with support performed walking with support more at school than in the outdoors or community. Children who were capable of walking alone performed walking alone more at home than at school or in the outdoors or community, and more at school than in the outdoors or community. Discussion and Conclusion. The results provide evidence that children with CP with similar capability demonstrate differences in performance across settings. The results suggest that physical therapists should examine performance in the settings that are important to the child's daily life. [Tieman BL, Palisano RJ, Gracely EJ, Rosenbaum PL. Gross motor capability and performance of mobility in children with cerebral palsy: a comparison across home, school, and outdoors/community settings.] Key Words: Capability, Cerebral palsy, Environment, Locomotion, Mobility, Pediatrics, Performance., Cerebral palsy (CP), the most common physical in children, (1) represents the most frequent diagnosis of children who receive physical therapy. (2) The severity of limitations in gross motor function [...]

Background and Purpose. Evidence supporting factors predicting motor change for children with cerebral palsy is minimal. A consensus exercise using focus groups and survey methods was conducted to identify factors perceived to affect the acquisition of basic motor abilities among children with cerebral palsy from the time of diagnosis to 7 years of age. Subjects. Fifty-seven physical therapists participated in one of 12 focus groups, and 60 physical therapists participated in a follow-up questionnaire survey via mail. Methods. The nominal group technique was used to conduct the focus groups. Results. Participants reached consensus about 12 factors in 4 constructs, which we called: (1) primary impairments (muscle tone/movement patterns, distribution of involvement, balance, and sensory impairment), (2) secondary impairments (range of motion/joint alignment, force production, health, and endurance), (3) personality characteristics (motivation), and (4) family factors (support to child, family expectations, and support to family). Discussion and Conclusion. The recognition of potential determinants of motor change could assist in the clinical reasoning that physical therapists use when planning interventions for children with cerebral palsy. Participants identified a set of variables, some of which are found in the literature, that can provide foundation knowledge for decision making and research on factors that bring about change in motor ability among children with cerebral palsy. [Bartlett DJ, Palisano RJ. Physical therapists' perceptions of factors influencing the acquisition of motor abilities of children with cerebral palsy: implications for clinical reasoning. Phys Ther. 2002;82:237-248.] Key Words: Cerebral palsy, Clinical reasoning, Consensus, Motor outcomes, Prognosis., Cerebral palsy is the sensory and neuromuscular deficit caused by a nonprogressive brain defect or lesion occurring during the prenatal, intrapartum, perinatal, or early postnatal periods. (1) At the time [...]

Background and Purpose. The purpose of this study was to compare the Gross Motor Function Measure (GMFM) and the Peabody Developmental Gross Motor Scale (PDMS-GM) as measures of change in infants with cerebral palsy (CP) and infants with motor delays. We hypothesized that mean change scores would be greater for the GMFM than for the PDMS-GM. Subjects and Methods. Subjects were 42 infants with a mean adjusted age of 13.9 months (SD=6.1, range=4.2-24.2). Twenty-four infants had CP, and 18 infants had motor delays. The GMFM and the PDMS-GM were administered to the infants 3 times over a 6-month period. Raw scores were standardized for data analysis. Data were analyzed using a g-factor repeated-measures analysis of variance. Results. For the 6-month period, mean PDMS-GM age-equivalent scores increased 3.8 months and mean scaled scores increased 35 points for infants with motor delays compared with increased scores of 1.8 months and 13 points for infants with CP. Mean GMFM scores increased by 12.2% for infants with motor delays and by 4.2% for infants with CP. The diagnosis X time interaction was significant. Infants with motor delays had a greater change in motor development compared with the infants with CP. The hypothesis that the GMFM is more responsive to change than the PDMS-GM was not supported. Conclusion and Discussion. The findings suggest that the GMFM and the PDMS-GM are comparable in measuring change in infants with CP or motor delays. Implications for selection and use of either measure are discussed. [Kolobe THA, Palisano RJ, Stratford PW. Comparison of two outcome measures for infants with cerebral palsy and infants with motor delays. Phys Ther. 1998;78:1062-1072.], Key Words: Cerebral palsy, Developmental tests, Gross motor development, Measurement, Responsiveness. Children with cerebral palsy (CP) and infants who are at risk for gross motor developmental disabilities are among the [...]

Background and Purpose. Do individuals with severely limited physical and cognitive abilities improve their gross motor abilities when given physical therapy intervention, and does improvement transfer to nontreatment settings? Subjects. The subjects were 24 individuals (10 female, 14 male), aged 3 to 30 years ([bar] X=20.1, SD=8.1), who were nonambulatory and had limited adaptive behavior. Methods. Change in gross motor ability, during 18 weeks of twice-weekly therapy was measured using goal attainment scaling (GAS). Three gross motor goals were developed for each subject based on individual or caregiver needs, with one goal randomly selected as a control. Physical impairments were treated, and behavioral management principles, low-level communication approaches, high-repetition practice of goals, and a progressive reduction of both physical assistance and multisensory cues were used. An independent rater scored goal level from randomly ordered videotapes recorded during therapy and in recess and home settings. Results. Mean GAS T scores were higher for treatment goals ([bar] X=45.6, SD=10.5) compared with control goals ([bar] X=34.6, SD=11.8). When the expected goal level (50) was met during therapy, mean GAS T scores in recess settings ([bar] X=35.9, SD=11.5) and home settings ([bar] X=42.2, SD=12.2) were lower. At the conclusion of therapy, there were no differences in goal levels between treatment and control goals in both the recess and home settings. Conclusion and Discussion. The subjects demonstrated improvement of gross motor abilities practiced during therapy. Level of ability during therapy, however, did not consistently transfer to the recess and home settings. [Brown DA, Effgen SK, Palisano RJ. Performance following ability-focused physical therapy intervention in individuals with severely limited physical and cognitive abilities. Phys Ther. 1998;78:934-950.], Key Words: Ability-focused physical therapy, Generalization, Goal attainment scaling, Motor learning, Severe physical and cognitive disability, Transfer. Gross motor abilities that allow individuals to interact with people and their environment [...]

Background and Purpose. Physical therapists strive to promote children's motor function and the parents' abilities to interact with their children, thus aiming to positively influence the parent-child relationship. This study examined a model for provision of home-based physical therapy within the context of motor play on mother-child interactions and motor behaviors of children. Subjects. The subjects were 38 mothers and their children with motor delay, aged 6 to 34 months (X = 18.8, SD = 7.2), who were receiving center-based early intervention. Method. Children were ranked by motor development, using the Bayley Motor Scale, and assigned to either an experimental or control group. The experimental group received five home-based sessions of physical therapy. Conventional physical therapy strategies were incorporated into interactive play activities between mothers and their children. Both groups continued to receive their centered-based services. Mother-child interactions were videotaped before and after intervention and were analyzed using a modification of the response-class matrix. Results. The mothers in the experimental group demonstrated an increase in appropriate holding of their children, whereas mothers in the control group demonstrated a decrease. The mothers in the experimental group became more directive, thus controlling their children's behavior, but they were not less positive or more negative when interacting with their children. Conclusion and Discussion. The integration of conventional physical therapy within the context of interactive play was well received and may promote generalization of motor skills during play without interfering with positive mother-child interactions. [Chiarello LA, Palisano RJ. Investigation of the effects of a model of physical therapy on mother-child interactions and the motor behaviors of children with motor delay. Phys Ther. 1998;78:180-194], Parent-child interaction is an important component of a family-focused approach to early intervention.[1,2] The parent-child relationship contributes to the child's development.[3-9] In addition, parents and practitioners reported enhancement of parent-child [...]

Background and purpose. The purpose of this study was to examine the validity of the Peabody Developmental Gross Motor Scale (PDMS-GM) as an evaluative measure of infants receiving physical therapy. Subjects and Methods. Infants who attended an early intervention program (N=124) were grouped by diagnosis.- cerebral palsy, Down syndrome, hydrocephalus, preterm with developmental delay, full term with developmental delay, and other. The PDMS-GM was administered to each infant three times over a 6-month period by a therapist who did not provide treatment. Results. Mean scaled scores and age-equivalent scores increased for each group. Individual change was examined using the reliable change index. The results indicated that the change in total raw score for 62% of the infants was greater than what could be attributed to measurement error. When minimal clinically important change was defined as 10 scaled score points, the index of responsiveness was equal to 0.5. This finding indicates that a sample size of 68 subjects per group would be needed when the PDMS-GM is used as an outcome measure in research. Conclusion and Discussion. The mean change scores for each group support the use of the PDMS-GM as an evaluative measure. For many infants, particularly infants with cerebral palsy, the PDMS-GM was not responsive to change over a 6-month period. The index of responsiveness suggests that the PDMS-GM should be used only as an outcome measure in large clinical trials. The PDMS-GM is not recommended for evaluating the direct effects of physical therapy but is recommended for providing a global measure of change in motor development as part of a multidimensional assessment. [Palisano RJ, Kolobe TH, Haley SM, et al. Validity of the Peabody Developmental Gross Motor Scale as an evaluative measure of infants receiving physical therapy. Phys Ther. 1995;75:939-951.], Selection of a developmental assessment should be dependent on the ability of the physical therapist to identify the purpose of assessment and to critically review published information for evidence of [...]

Background and Purpose. The purpose of this study was to examine (1) content validity of goal attainment scaling (GAS), (2) the responsiveness of GAS compared with a behavioral objective, and (3) concurrent validity of GAS and the Peabody Developmental Gross Motor Scale Subjects and Methods. Two motor goals were developed for two consecutive 3-month periods for 21 infants with motor delays. The goals were put into behavioral objective and Gas formats and scored by independent examiners Content validity was examined by having 10 physical therapists rate 10 randomly selected GAS-formatted goals on three dimensions (1) the importance of the goal for motor development and function, (2) whether the expected progress was achievable, and (3) whether each of the four levels of change was clinically important. Results. Between 77% and 88% of the therapists' ratings for each dimension met the criterion for content validity. The ratings did not differ significantly among the therapists for any of the three dimensions. Change that could not be measured with the behavioral objective format was measured with the Gas format for 61% of the goals, including 73% of the goals in which the behavioral objective was achieved Correlations between GAS T-scores and Peabody gross motor age-equivalent change scores were not significant. Conclusion and Discussion. The results support content validity and the responsiveness of GAS, and provide evidence that GAS and the Peabody Scale measure different aspects of motor development. Goal attainment scaling is recommended for use in clinical practice and in treatment outcomes research. [Palisano RJ. Validity of goal attainment scaling in infants with motor delays Phys Ther. 1993;73:651-660.], Key Words: Early intervention, Goal attainment scaling, Measurement, Physical theraphy, Validity. Validity of Goal Attainment Scaling in Infants With Motor Delays Goal attainment scaling (GAS)[1] is an individualized criterion-referenced measure [...]