Optimal Management for People with Severe Spasticity

Spasticity is characterized by velocity-dependent increase in tonic stretch reflexes and tendon jerks. Many people affected by spasticity receive late treatment, or no treatment, which greatly reduces the potential to regain full motor control and restore function. There is much to consider before determining treatment for people with spasticity. Treatment of pediatric patients increases the complexity, because of the substantial difference between adult and pediatric spasticity. Proper patient evaluation, utilization of scales and measures, and obtaining patient and caregiver history is vital in determining optimal spasticity treatment. Further, taking into consideration the limitations and desires of individuals serve as a guide to best management. We have grouped contributing factors into the IDAHO Criteria to elucidate a multidisciplinary approach, which considers a person’s complete field of experience. This model is applied to goal setting, and recognizes the importance of a spasticity management team, comprising the treatment subject, his/her family, the environment, and a supportive, well-informed medical staff. The criteria take into account the complexity associated with diagnosing and treating spasticity, with the ultimate goal of improved function

Examining the Nature of Literacy Activity in Public Montessori Classrooms.

This study offers empirical analysis of how literacy practices in a contemporary enactment of the Montessori approach reflect and deviate from Maria Montessori’s original stance on literacy learning and teaching. Because few studies have systematically examined organized literacy practice in Montessori classrooms, it is not known how contemporary enactments of this approach reflect Montessori’s stance. Given this lack of research combined with the popularity of the Montessori approach, it is prudent to engage in rigorous study of the approach. This study contributes to a limited number of empirical studies that have examined this approach. Moreover, it examines an area, literacy instruction in early childhood settings, which is a focus of the broader educational community. Indeed, bodies of contemporary research reflect Montessori’s emphasis on promoting preschool- and kindergarten-aged children’s literacy acquisition as well as her efforts to individualize instruction to complement individuals’ unique learning profiles. The following question frames this study: How do teachers’ enactments of one contemporary version of Montessori literacy education reflect and differ from Maria Montessori’s views of learning—literacy learning, in particular—and teaching? Qualitative and quantitative data were collected in 11 public Montessori classrooms, serving preschoolers and kindergartners. Taken collectively, findings reveal that teachers implemented practices that generally reflected Montessori’s views. Although not all practices squared perfectly with her stance, deviations did not represent complete departures from it. Instead, deviations reflected teachers grappling with seemingly competing principles of her approach and teachers contending with outside pressures to assure that children acquired key literacy skills. This dissertation concludes with a discussion of findings in relation to Montessori’s views and to contemporary research. Some documented practices bode well when considered in relation to contemporary research, such as how teachers tailored instruction to individuals’ skill levels and socio-emotional characteristics. Other documented practices raise questions for Montessori educators when considered in relation to contemporary research, such as the nature of teacher participation during open-ended writing and book-reading activities. Implications are presented regarding how Montessori teachers participated in meaning-making activities as well as regarding other patterns of practice.Ph.D.EducationUniversity of Michigan, Horace H. Rackham School of Graduate Studieshttp://deepblue.lib.umich.edu/bitstream/2027.42/64667/1/dshilt_3.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/64667/2/dshilt_2.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/64667/3/dshilt_1.pd

Assessment of foot alignment and function for ambulatory children with cerebral palsy: Results of a modified Delphi technique consensus study

PURPOSE The purpose of this study was to establish consensus for the assessment of foot alignment and function in ambulatory children with cerebral palsy, using expert surgeon's opinion through a modified Delphi technique. METHODS The panel used a five-level Likert-type scale to record agreement or disagreement with 33 statements regarding the assessment of foot alignment and function. Consensus was defined as at least 80% of responses being in the highest or lowest of two of the five Likert-type ratings. General agreement was defined as 60%-79% falling into the highest or lowest two ratings. There was no agreement if neither threshold was reached. RESULTS Consensus was achieved for 25 (76%) statements, general agreement for 4 (12%) statements, and lack of consensus for 4 (12%) of the statements. There was consensus that the functional anatomy of the foot is best understood by dividing the foot into three segments and two columns. Consensus was achieved concerning descriptors of foot segmental alignment for both static and dynamic assessment. There was consensus that radiographs of the foot should be weight-bearing. There was general agreement that foot deformity in children with cerebral palsy can be classified into three levels based on soft tissue imbalance and skeletal malalignment. CONCLUSION The practices identified in this study can be used to establish best care guidelines, and the format used will be a template for future Delphi technique studies on clinical decision-making for the management of specific foot segmental malalignment patterns commonly seen in children with cerebral palsy. LEVEL OF EVIDENCE V

Finding consensus for hamstring surgery in ambulatory children with cerebral palsy using the Delphi method

PURPOSE There is marked variation in indications and techniques for hamstring surgery in children with cerebral palsy. There is particular uncertainty regarding the indications for hamstring transfer compared to traditional hamstring lengthening. The purpose of this study was for an international panel of experts to use the Delphi method to establish consensus indications for hamstring surgery in ambulatory children with cerebral palsy. METHODS The panel used a five-level Likert-type scale to record agreement or disagreement with statements regarding hamstring surgery, including surgical indications and techniques, post-operative care, and outcome measures. Consensus was defined as at least 80% of responses being in the highest or lowest two of the five Likert-type ratings. General agreement was defined as 60%-79% falling into the highest or lowest two ratings. There was no agreement if neither of these thresholds was reached. RESULTS The panel reached consensus or general agreement for 38 (84%) of 45 statements regarding hamstring surgery. The panel noted the importance of assessing pelvic tilt during gait when considering hamstring surgery, and also that lateral hamstring lengthening is rarely needed, particularly at the index surgery. They noted that repeat hamstring lengthening often has poor outcomes. The panel was divided regarding hamstring transfer surgery, with only half performing such surgery. CONCLUSION The results of this study can help pediatric orthopedic surgeons optimize decision-making in their choice and practice of hamstring surgery for ambulatory children with cerebral palsy. This has the potential to reduce practice variation and significantly improve outcomes for ambulatory children with cerebral palsy. LEVEL OF EVIDENCE level V

Distal femoral extension osteotomy and patellar tendon advancement or shortening in ambulatory children with cerebral palsy: A modified Delphi consensus study and literature review

PURPOSE In children with cerebral palsy, flexion deformities of the knee can be treated with a distal femoral extension osteotomy combined with either patellar tendon advancement or patellar tendon shortening. The purpose of this study was to establish a consensus through expert orthopedic opinion, using a modified Delphi process to describe the surgical indications for distal femoral extension osteotomy and patellar tendon advancement/patellar tendon shortening. A literature review was also conducted to summarize the recent literature on distal femoral extension osteotomy and patellar tendon shortening/patellar tendon advancement. METHOD A group of 16 pediatric orthopedic surgeons, with more than 10 years of experience in the surgical management of children with cerebral palsy, was established. The group used a 5-level Likert-type scale to record agreement or disagreement with statements regarding distal femoral extension osteotomy and patellar tendon advancement/patellar tendon shortening. Consensus for the surgical indications for distal femoral extension osteotomy and patellar tendon advancement/patellar tendon shortening was achieved through a modified Delphi process. The literature review, summarized studies of clinical outcomes of distal femoral extension osteotomy/patellar tendon shortening/patellar tendon advancement, published between 2008 and 2022. RESULTS There was a high level of agreement with consensus for 31 out of 44 (70%) statements on distal femoral extension osteotomy. Agreement was lower for patellar tendon advancement/patellar tendon shortening with consensus reached for 8 of 21 (38%) of statements. The literature review included 25 studies which revealed variation in operative technique for distal femoral extension osteotomy, patellar tendon advancement, and patellar tendon shortening. Distal femoral extension osteotomy and patellar tendon advancement/patellar tendon shortening were generally effective in correcting knee flexion deformities and extensor lag, but there was marked variation in outcomes and complication rates. CONCLUSION The results from this study will provide guidelines for surgeons who care for children with cerebral palsy and point to unresolved questions for further research. LEVEL OF EVIDENCE level V

Anterior distal femoral hemiepiphysiodesis in children with cerebral palsy: Establishing surgical indications and techniques using the modified Delphi method and literature review

PURPOSE The purpose of this study was to develop consensus for the surgical indications of anterior distal femur hemiepiphysiodesis in children with cerebral palsy using expert surgeon opinion through a modified Delphi technique. METHODS The panel used a 5-level Likert-type scale to record agreement or disagreement with 27 statements regarding anterior distal femur hemiepiphysiodesis. Consensus was defined as at least 80% of responses being in the highest or lowest 2 of the Likert-type ratings. General agreement was defined as 60%-79% falling into the highest or lowest 2 ratings. RESULTS For anterior distal femur hemiepiphysiodesis, 27 statements were surveyed: consensus or general agreement among the panelists was achieved for 22 of 27 statements (22/27, 82%) and 5 statements had no agreement (5/27, 18%). There was general consensus that anterior distal femur hemiepiphysiodesis is indicated for ambulatory children with cerebral palsy, with at least 2 years growth remaining, and smaller (<30 degrees) knee flexion contractures and for minimally ambulatory children to aid in standing/transfers. Consensus was achieved regarding the importance of close radiographic follow-up after screw insertion to identify or prevent secondary deformity. There was general agreement that percutaneous screws are preferred over anterior plates due to the pain and irritation associated with plates. Finally, it was agreed that anterior distal femur hemiepiphysiodesis was not indicated in the absence of a knee flexion contracture. CONCLUSION Anterior distal femur hemiepiphysiodesis can be used to treat fixed knee flexion contractures in the setting of crouch gait, but other associated lever arm dysfunctions must be addressed by single-event multilevel surgery. LEVEL OF EVIDENCE V

Experience with an online prospective database on adolescent idiopathic scoliosis: development and implementation

Considerable variability exists in the surgical treatment and outcomes of adolescent idiopathic scoliosis (AIS). This is due to the lack of evidence-based treatment guidelines and outcome measures. Although clinical trials have been extolled as the highest form of evidence for evaluating treatment efficacy, the disadvantage of cost, time, lack of feasibility, and ethical considerations indicate a need for a new paradigm for evidence based research in this spinal deformity. High quality clinical databases offer an alternative approach for evidence-based research in medicine. So, we developed and established Scolisoft, an international, multidimensional and relational database designed to be a repository of surgical cases for AIS, and an active vehicle for standardized surgical information in a format that would permit qualitative and quantitative research and analysis. Here, we describe and discuss the utility of Scolisoft as a new paradigm for evidence-based research on AIS. Scolisoft was developed using dot.net platform and SQL server from Microsoft. All data is deidentified to protect patient privacy. Scolisoft can be accessed at www.scolisoft.org. Collection of high quality data on surgical cases of AIS is a priority and processes continue to improve the database quality. The database currently has 67 registered users from 21 countries. To date, Scolisoft has 200 detailed surgical cases with pre, post, and follow up data. Scolisoft provides a structured process and practical information for surgeons to benchmark their treatment methods against other like treatments. Scolisoft is multifaceted and its use extends to education of health care providers in training, patients, ability to mine important data to stimulate research and quality improvement initiatives of healthcare organizations

Photoacoustic Techniques for Trace Gas Sensing Based on Semiconductor Laser Sources

The paper provides an overview on the use of photoacoustic sensors based on semiconductor laser sources for the detection of trace gases. We review the results obtained using standard, differential and quartz enhanced photoacoustic techniques

EVALUATION OF THE SAFETY RISKS IN DEVELOPING AND IMPLEMENTING AUTOMATED BATTLE MANAGEMENT AIDS FOR AIR AND MISSILE DEFENSE

The modern battlefield is more complex than ever, and the technological advancement of weapons is accelerating. In order to win the next fight, faster response time to an adversary's actions is critical. Artificial intelligence (AI) has the potential to enable warfighters to outpace enemy decision cycles and reduce information overload, thus overcoming the "fog of war." When developing combat systems, reliability could be the difference between life and death. Therefore, it is of utmost importance that these weapon systems (especially novel systems such as AI) are developed with the highest standards of reliability and safety, long before they are introduced to the battlespace and entrusted to protect our nation's warfighters. This project utilizes a Systems Engineering approach to identify potential hazards and risks associated with AI and its role in the battlespace. Using an established Risk Management Framework (RMF), the team provides some mitigation strategies that developers must consider as they foster this technology for future use in U.S. weapon systems and processes.Civilian, Office of the Secretary of DefenseCivilian, NAVSEA NH-03Civilian, Department of the ArmyCivilian, Department of the ArmyMajor, United States Marine CorpsApproved for public release. Distribution is unlimited