An Early Mobilization Protocol Successfully Delivers More and Earlier Therapy to Acute Stroke Patients: Further Results From Phase II of AVERT.

Background: The optimal physical therapy dose in acute stroke care is unknown. The authors hypothesized that physical therapy would be significantly different between treatment arms in a trial of very early and frequent mobilization (VEM) and that immobility-related adverse events would be associated with therapy dose. Methods: This study was a single-blind, multicenter, randomized control trial. Patients admitted to a stroke unit <24 hours of stroke randomized to standard care (SC) or intervention, SC plus additional early out-of-bed therapy (VEM). Timing, amount, and type of therapy recorded throughout the trial. Adverse events were recorded to 3 months. Results: A total of 71 patients (SC n = 33, VEM n = 38) received 788 therapy sessions in the first 2 weeks of stroke. Schedule (hours to first mobilization, dose per day, frequency and session duration) and nature (percentage out-of-bed activity) of therapy differed significantly between groups (P ≤ .001 for all components). Mobilization was earlier, happened on average 3 times per day in those receiving VEM, with the proportion of out-of-bed activity double in VEM session (median SC 42.5%, VEM 85.5%). SC consisted of 17 minutes of occupational and physiotherapy per day and was the same between groups. Number of immobility-related adverse events 3 months poststroke was not associated with therapy dose or frequency. Conclusions: The authors detailed usual care and intervention therapy provided to patients from admission to 14 days after stroke. The therapy schedule was markedly different in the intervention arm, but whether this schedule reduces complications or improves outcome is unknown

Response to Pediatric Physical Therapy in Infants With Positional Preference and Skull Deformation

Background Pediatric physical therapy (PPT) seems to reduce skull deformation in infants with positional preference. However, not all infants show improvement. \ud \ud Objective The purpose of this study was to determine which infant and parent characteristics were related to response to PPT in 2-4 month-old infants with positional preference and/or skull deformation. \ud \ud Design A prospective cohort study. \ud \ud Methods Infants 2–4 months old with positional preference and/or skull deformation were recruited by pediatric physical therapists at the start of PPT. Primary outcome was good or poor response (moderate/severe skull deformation) at 4.5 to 6.5 months of age. Potential predictors for response to PPT were assessed at baseline using questionnaires, plagiocephalometry, and the Alberta Infant Motor Scale. Univariate and multiple logistic regression analyses using a stepwise backward elimination method were performed. \ud \ud Results 657 infants participated in the study. At follow-up 364 infants (55.4%) showed poor response and 293 infants (44.6%) good response to therapy. Multiple logistic regression analysis resulted in the identification of four significant predictors at baseline for poor response to PPT: starting therapy after 3 months of age (adjusted odds ratio [aOR]: 1.50, 95% CI 1.04 to 2.17), skull deformation (plagiocephaly (aOR: 2.64, 1.67 to 4.17), brachycephaly (aOR: 3.07, 2.09 to 4.52)) and a low parental satisfaction score (aOR: 2.64, 1.67 to 4.17). \ud \ud Limitations Information about PPT was collected retrospectively and concerned general therapy characteristics. Subsequently no adjustment for therapy for the individual participants could be made. \ud \ud Conclusions Four predictors for response to PPT in infants of 2-4 months of age with positional preference and/or skull deformation were identified. Health professionals can use these predictors in daily practice to provide infants with more individualized therapy, resulting in better chances of a good outcom

Helmet therapy in infants with positional skull deformation: randomised controlled trial

Objective To determine the effectiveness of helmet therapy for positional skull deformation compared with the natural course of the condition in infants aged 5-6 months. Design Pragmatic, single blinded, randomised controlled trial (HEADS, HElmet therapy Assessment in Deformed Skulls) nested in a prospective cohort study. Setting 29 paediatric physiotherapy practices; helmet therapy was administered at four specialised centres. Participants 84 infants aged 5 to 6 months with moderate to severe skull deformation, who were born after 36 weeks of gestation and had no muscular torticollis, craniosynostosis, or dysmorphic features. Participants were randomly assigned to helmet therapy (n=42) or to natural course of the condition (n=42) according to a randomisation plan with blocks of eight. Interventions Six months of helmet therapy compared with the natural course of skull deformation. In both trial arms parents were asked to avoid any (additional) treatment for the skull deformation. Main outcome measures The primary outcome was change in skull shape from baseline to 24 months of age assessed using plagiocephalometry (anthropometric measurement instrument). Change scores for plagiocephaly (oblique diameter difference index) and brachycephaly (cranioproportional index) were each included in an analysis of covariance, using baseline values as the covariate. Secondary outcomes were ear deviation, facial asymmetry, occipital lift, and motor development in the infant, quality of life (infant and parent measures), and parental satisfaction and anxiety. Baseline measurements were performed in infants aged between 5 and 6 months, with follow-up measurements at 8, 12, and 24 months. Primary outcome assessment at 24 months was blinded. Results The change score for both plagiocephaly and brachycephaly was equal between the helmet therapy and natural course groups, with a mean difference of −0.2 (95% confidence interval −1.6 to 1.2, P=0.80) and 0.2 (−1.7 to 2.2, P=0.81), respectively. Full recovery was achieved in 10 of 39 (26%) participants in the helmet therapy group and 9 of 40 (23%) participants in the natural course group (odds ratio 1.2, 95% confidence interval 0.4 to 3.3, P=0.74). All parents reported one or more side effects. Conclusions Based on the equal effectiveness of helmet therapy and skull deformation following its natural course, high prevalence of side effects, and high costs associated with helmet therapy, we discourage the use of a helmet as a standard treatment for healthy infants with moderate to severe skull deformatio

Behavioral genetics of temperament and frontal asymmetry in early childhood

Temperament has been suggested to be influenced by genetic and environmental factors. The current study examined genetic shared environmental and unique environmental factors accounting for variation in Fear, Effortful Control (EC), and Frontal Asymmetry (FA) in 4- to 6-year-old children using bivariate behavioral genetic modeling. We included a total of 214 same-sex twin pairs: 127 monozygotic (MZ) and 87 dizygotic (DZ) pairs. FA was measured during a rest electroencephalogram (EEG) recording, and Fear and EC were measured using parent report. Results show that differences between twins were best explained by genetic factors (about a quarter of the variance) and unique environmental factors (about three quarters of the variance). However, the cross-trait, within-twin correlations were not significant, implying no overlapping genetic or environmental factors on Fear and EC or on Fear and FA. Future research should try to elucidate the large role of unique environmental factors in explaining variance in these temperament-related traits

Positional skull deformation in infants: heading towards evidence-based practice

The shape of a young infant’s skull can deform as a result of prolonged external forces. The prevalence of positional skull deformation increased dramatically during the last decades. \ud The primary aim of this dissertation was to provide a stronger evidence base for the treatment of skull deformation. A second aim was a better understanding of the decision for treatment by parents and preferences for treatment of professionals. Both aims were met in the HEADS (HElmet therapy Assessment in Deformed Skulls) study. The HEADS study started as a cohort study for infants aged two to four months with positional preference and/ or skull deformation who started pediatric physical therapy. After follow-up at the age of five months, the study continued as an RCT into the effects and costs of helmet therapy. In parallel with the RCT, a non-randomized controlled trial (nRCT) was carried out. \ud Firstly, the dissertation described that infants presenting with skull deformation at baseline and infants who start therapy at an older age (>3 months) were more likely to respond poorly to pediatric physical therapy. Next, based on the equal effectiveness of helmet therapy compared with the natural course, the high prevalence of side effects and the high costs of treatment, the use of helmet therapy is being discouraged as a standard treatment for healthy infants with moderate or severe skull deformation.\ud Secondly, it was found that the parents’ decision to start helmet therapy for their five month-old with skull deformation was mostly influenced by the expected additional value of helmet therapy compared to the natural course of skull deformation and their (dis)satisfaction with their infant’s appearance. In a study into different prescription rates of helmet therapy in the Netherlands and New Zealand, differences in beliefs and attitudes with regard to consequences of helmet therapy and the natural course of skull deformation were found between healthcare professionals in both countries. \ud Outcomes presented in this dissertation should lead to evidence-based decision-making by parents and professionals regarding treatment for infants with skull deformation, more efficient health care, less infants with persistent skull deformation and less concerned parents

A comparison of two validated tests for upper limb function after stroke: The Wolf Motor Function Test and the Action Research Arm Test \ud

Objective: To investigate the concurrent validity between the Action Research Arm Test (ARAT) and the Wolf Motor Function Test (WMFT) and to compare their reproducibi­lity, internal consistency and floor and ceiling effects in the same sample of stroke patients.\ud Methods: Forty patients participated in this study. Concurrent validity was determined with Spearman’s rank correlation coefficients. Reproducibility was assessed with intraclass correlation coefficients (ICCs) and Bland-Altman plots, internal consistency by means of Cronbach’s alphas, and floor and ceiling effects were considered to be present if more than 20% of patients fell outside a preliminary set lower and upper boundary.\ud Results: Spearman’s rank correlation coefficients ranged from 0.70 to 0.86. ICCs for inter-rater and intra-rater reliability ranged from 0.92 to 0.97. Bland-Altman plots showed a less stable way of scoring for the WMFT, compared with the ARAT. Cronbach’s alpha was > 0.98 for both scales. No floor and ceiling effects were found. \ud Conclusion: The present study showed good clinimetric properties for both assessments. The high concurrent validity suggests that ARAT and WMFT have significant overlap with regard to the underlying construct that is being \ud measured.\ud \ud \u