CHOP Rehabilitation Experts Present Research, Including “Top Abstract,” at National Conference

For children with motor impairments, physical therapy is an important intervention that can help improve function and independence. At the Academy of Pediatric Physical Therapy Annual Conference (APPTAC) this year, rehabilitation researchers from Children Hospital of Philadelphia (CHOP) presented six abstracts on measuring key “ingredients” for successful pediatric physical therapy, including one abstract that won the APPTAC “Top Abstract” award.

The research focused on six components of pediatric physical therapy:

• Initiation: Laura Prosser, PT, PhD, an Investigator in the Division of Rehabilitation Medicine, presented the APPTAC “Top Abstract” on self-initiated movement in young children with cerebral palsy (CP). Typically developing infants initiate movement on their own the vast majority of the time, which opens the door for learning opportunities. However, prior research has not quantified how often children with CP self-initiate movement (versus how much is initiated by caregivers or therapists). To better understand this, Dr. Prosser and her colleagues divided 37 toddlers with CP into two groups: one receiving conventional physical therapy and one receiving physical therapy that specifically encouraged child-directed movement by using dynamic body weight support. Using video coding techniques, the researchers found that while children with CP self-initiated movement only 68% of the time during conventional therapy, the test group self-initiated movement 80% of the time, indicating that physical therapy can significantly increase the amount of child-initiated movement in children with CP.
• Motor Activities: Dr. Prosser also presented work analyzing the type, amount, and timing of gross motor activities during physical therapy sessions in young children with CP. In typical development, new walking toddlers move 32% of the time during free play, accumulated from very short bouts that are usually less than 6 seconds at a time. In 37 toddlers with CP, the researchers found that the children spent only 18% of physical therapy sessions in motion – only half as much as their typically developing peers, despite have much longer active bouts, most of which lasted longer than 6 seconds at a time.  The children with CP spent more than half of their therapy time in fairly static sitting (23.7%) and standing (31.5%) positions.
• Independent practice: Athylia Paremski, BA, CCRC, a clinical research coordinator with Dr. Prosser’s team, presented work on measuring the amount of independent motor practice in physical therapy compared to practice time that is assisted by the therapist. Typically developing toddlers spend most of their motor practice moving independently, but it is unknown the level to which children with CP have independent practice experience. In children with CP, physical therapists need to balance encouraging independent movement with offering hands-on assistance. The researchers compared children with CP who received conventional physical therapy to those who received physical therapy that encouraged more independent practice time by using a dynamic body weight support. They found that children in the test group were much more likely to practice motor skills independently as compared to the conventional therapy group (73.6% vs. 26.7%). Therapists only assisted 26.4% of the time in the test therapy group, compared to 73.3% in the conventional therapy group. Greater independent practice was related to higher gross motor function in both groups, suggesting that future research should look at balancing the tradeoffs between independent practice and assisted movement.
• Difficulty: Morgan Alcott, PT, DPT, PCS, a physical therapist in the Center for Rehabilitation, presented work on measuring the extent to which children with CP independently practice challenging skills and whether this can be manipulated during a physical therapy. The researchers compared toddlers with CP who received conventional physical therapy to a group who received physical therapy using a dynamic weight support harness to facilitate the practice of harder motor skills. The researchers found that both groups practiced more difficult skills in physical therapy than their current level of function, but that the relative difficulty of the test group’s practice was three times greater than that of the conventional therapy group. The researchers concluded that the dynamic weight support harness encouraged the practice of harder motor skills; their work demonstrates that innovative rehabilitation technology may be useful in facilitating more challenging motor practice during physical therapy in young children with CP.
• Error: Julie Skorup, PT, DPT, PCS, a physical therapist with the Center for Rehabilitation and Cerebral Palsy Clinic, presented work measuring movement error – that is, how often children lost their balance during physical therapy sessions. Other research has shown that typically developing toddlers fall about 17 times per hour while learning to walk. In this case, falling is useful – it shows a child is attempting new and challenging movements and gives the child feedback to refine their postural control and balance. The researchers suspected toddlers with CP might fall less often because they have more impaired movement ability, which might limit their opportunities for learning and for the refinement of their balance and postural coordination. The researchers compared children with CP who received conventional physical therapy, which often prevents falls, to children with CP who received physical therapy designed to encourage postural error and falling. The therapists did not prevent falls and focused the therapy on upright activities that would challenge the child’s balance. Losses of balance were lower in both groups compared to peers’ typical development but were significantly greater in the test group (7.6 falls compared to 1.6 falls per hour). This provides key evidence that despite significant motor impairment, the degree of error experience can be increased in children with CP by physical therapy, which may be an important factor in the acquisition of motor skills.

• Motivation to Move: Skorup also presented an abstract measuring the motivation to move in young children with CP and the relationship between this motivation and the child’s motor ability. Studying 37 toddlers with CP who were 1-3 years of age, the researchers found that on average, the children with CP demonstrated motivation to move on par with that of 7-month-old infants with typical development and lower than reported in 12-month-old children with typical development. As expected, they found that toddlers with higher motor function were more motivated to move.

Ultimately, the researchers hope to understand which components of motor practice – and how much of each – are related to better outcomes, so that in the future, physical therapists can maximize the benefit of therapy sessions for children with movement disorders.