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1
Evidence For Clinical and Research Walking
Activity Measurement in Cerebral Palsy with
the StepWatch (SW)
Kristie F. Bjornson, PT, PhD, MSAssociate Professor Pediatrics
Seattle Children’s Research Institute
University of Washington
Kristie.bjornson@seattlechildrens.org
AACPDM 2018
FINANCIAL DISCLOSURE
AACPDM 72nd Annual Meeting
October 9-13, 2018
Speaker Name: Kristie Bjornson, PT, PhD, MS
1. Disclosure of Relevant Financial Relationships
Grant/Research support from:
F31NS48740-NINDS
SCH Dept of Orthopedic Surgery
SCRI Academic Enrichment Fund
K23HD060764 - NICHD
R21 HD077186- NICHD/NCMRR
2. Disclosure of Off-Label and/or investigative uses:
I will not discuss off label use and/or investigational use in my presentation.
Objectives:
� Understand validity & accuracy of the SW strides taken in typically developing children/youth (TDCY) & with CP.
� Understand the walking activity levels and intensity of TDCY & with CP.
� Examine evidence for SW monitoring duration by Gross Motor Function Level (GMFCS) in children/youth with CP.
� Exemplars- clinical & research SW application in children with CP.
2
Physical
Activity
Walking Activity
When we are not looking3
how and how much are they walking?
Terminology:
� Walking Activity (WA) – step or stride taken for mobility, depending on device may be “step” or stride
� Step - counts both left and right steps
� Stride – step of one leg/side-3DG lab
3
ICF model: WHO 2001
Health Condition
Body Functions & Structures
Activities Participation
Environmental Factors Personal Factors
International Classification of Functioning, Disability & Health. 2001; WHO
Walking Activity Measurement
“Level of Ability” versus “Level of Activity”
Capacity Performance
Relationship of Stride Activity to Mobility-
based Life Habits in Children with Cerebral
Palsy (Bjornson, 2013)
� Average total strides/day was positively associated with the Personal Care, Housing, Mobility, and Recreation Life-H categories.
� Moderate/High walking stride rates (Ave > 30 stride/min/day) was associated with all categories
� Walking activity performance is significantly associated with levels of participation in mobility-based life habits for ambulatory children with CP.
4
Why the StepWatch?
Left hip
Right hip
ActiGraph: child with Spastic Diplegia
Stott, MacKey, 2011
5
Pediatric StepWatch Accuracy/Precision
& comparison to Pedometers:
� Mitre et al (2009)-treadmill trial� Lean and obese children
� Omron and Digiwalker pedometers undercounting compared to manual counts (worse at slower speeds)
� StepWatch had negligible error to manual counts of steps taken
StepWatch Accuracy to Observed
Strides: TDY
� 20 normally developing children
� Age groups
� 5-7 years & 9-11 years
� 3- Two week intervals: 2 months apart
� Comparison manual counts
� Walking 96-97%
� Running 99%
Song K. J Peds Ortho, 26: 245-249;2006
6
StepWatch� Two dimensional accelerometer
� Detects foot leaving the surface
� Completely sealed
� Worn with strap or ankle cuff
� Continuously records steps/time interval
� Up to two months duration
� AKA “SAM”, “StepWatch3” and “GAM”
� www.modushealth.com
NEW UPDATE 2018
StepWatch 4 (SW4)-Activity Monitor� $400 ea with iPad app
� App $1300 1x
� Additional $ monthly cloud-based
� rechargeable
� SW4 available 2018
support@modushealth.com
Seattle Clinical/Research
SW Monitoring Guidelines
� Individually Set:
� Sensitivity
� Cadence
� Pre/Post intervention
� Wearing 7 to 14 days
� Analyze 5 to 14 days
� Depends on clinical question
7
StepWatch: How many days
monitored
� TDY (n= 428, ages 2- 13 yrs) (Kang 2014)
� Need to monitor ave 4.14 days
� (range 3 to 6 by days 2 year age bands)
� Children with CP: (n=209) (Ishikawa, 2013)
� GMFCS:
� Level I 6 days
� Level II 5 days
� Level III 4 days
Kang et al Phys Meas. 2014
Ishikawa et al APRM. 2013
What do we know about walking
with SW in TDY?
Measurement of Walking Activity throughout Childhood: Influence of Leg Length
Bjornson et al, Ped Ex Sci 2010
8
Sample:
� 428 TDY children
� ages 2 to 15 years
� 30 boys / 30 girls per age group
� 7 groups of 2 year increments
� Calibration Accuracy: ave 100%
� (range 90-112, sd 4.0)
Age Group
(yrs) Gender (n)
Average
Stride/Day
60-min
peak 20-min peak 1-min peak
2-3 Boys (30) 8,159 (2,677) 28 (8) 40 (8) 70 (7)
Girls (30) 7,837 (1,771) 28 (5) 39 (7) 73 (10)
Total (60) 7,998 (2,257) 28 (7) 39 (8) 72 (7)
4-5 Boys (31) 9,411 (3,214) 30 (8) 44 (10) 71 (6)
Girls (31) 8,726 (1,992) 29 (6) 41 (8) 71 (7)
Total (62) 9,069 (2,674) 29 (7) 42 (9) 71 (7)
6-7 Boys (32) 9,880 (3,067) 31 (7) 43 (7) 68 (7)
Girls (30) 9,083 (2,492) 29 (5) 42 (6) 70 (6)
Total (62) 9,794 (2,810) 30 (6) 43 (6) 69 (7)
14-15 yr12-13 yr10-11 yr8-9 yr6-7 yr4-5 yr2-3 yr
Age
20000
15000
10000
5000
Avera
ge s
trid
e/d
ay
384
391
270
287
222
150
151
73
109
129
9
14-15 yr12-13 yr10-11 yr8-9 yr6-7 yr4-5 yr2-3 yr
Age group
20000
15000
10000
5000
Ad
juste
d f
or
leg
len
gth
avera
ge s
trid
e/d
ay
384
277
270222
151
73
82
129
150
Basis for Pediatric Walking Intensity
Cut-points for StepWatch (SW)� Intense walking adult US population documented peak
step/min rate of 101 (Tudor-Locke, 2012)
� Intense walking bursts for children (< 18 years of age) are
documented at 108 to 146 peak steps/min rates (10-12).(Barreira, 2012, Bjornson 2010, Tudorlocke, 2002)
� moderate to vigorous physical activity (MVPA) = 120 step/min -10 to 14 y/o boys and girls with another pedometer (Graser, 2011)
� “High” intensity walking for StepWatch > 60 stride/min- as it counts only one leg.
14-15 yr12-13 yr10-11 yr8-9 yr6-7 yr4-5 yr2-3 yr
Age group
100
80
60
40
20
Maxim
al 1 m
inu
te s
trid
es
371
410
353
275
272
209
213
178
7
268
130
10
Walking activity with StepWatch
in children with CP?
Neuromuscular TDY
Scoliosis (VEPTR)
11
Ambulatory Physical Activity Performance in Youth
with Cerebral Palsy & Youth Developing Typically Bjornson Physical Therapy 87(3), 2007
CP (n=81)
TDY (n=30) p
Average step/day
4,222 6,739 .000
% All Time Active
40.2 49.6 .000
Ratio Medium to low Activity
.33 .47 .000
% Time High Activity
5.6 9.7 .000
TDYGMFCS level IGMFCS level IIGMFCS level III
Activity Capacity Functional Categories
12000
10000
8000
6000
4000
2000
0
Av
era
ge
Da
ily
To
tal S
tep
co
un
t/s
tep
Wa
tch
42
TDY to levels I, II & III p <.001, TDY to level I p=.o4,Level I to II p=.09,Level I to III p<.001, level III to II p <.001.
• Compared walking with StepWatch• 5 days of monitoring• 209 youth with CP• 368 TDY• Ages 2-13 years
• Intensity:• Low 1- 30 stride/min• Moderate 31-60 stride/min• High > 60 stride/min
12
39923856
533
0
500
1000
1500
2000
2500
3000
3500
4000
4500
Low (1-30) Mod (31-60) High > 60
TDY
GMFCS level I
GMFCS level II
GMFCS III
39923856
533
3436
2599
262
0
500
1000
1500
2000
2500
3000
3500
4000
4500
Low (1-30) Mod (31-60) High > 60
TDY
GMFCS level I
GMFCS level II
GMFCS III
39923856
533
3436
2599
262
2977
2004
213
0
500
1000
1500
2000
2500
3000
3500
4000
4500
Low (1-30) Mod (31-60) High > 60
TDY
GMFCS level I
GMFCS level II
GMFCS III
13
39923856
533
3436
2599
262
2977
2004
213
1347
433
360
500
1000
1500
2000
2500
3000
3500
4000
4500
Low (1-30) Mod (31-60) High > 60
TDY
GMFCS level I
GMFCS level II
GMFCS III
Clinical/Research Exemplars:
StepWatch Measurement:
� Longitudinal monitoring-
� Scoliosis
� Diplegia (multiple interventions)
� Treadmill training
� Orthotics
� SW combined with GPS-
community mobility
Neuromuscular Scoliosis (VEPTR):
Average Steps/Day
0
1000
2000
3000
4000
5000
6000
Pre A
PR 03
Post D
ec 03
Post A
pr 05
Post F
eb 07
14
0
1000
2000
3000
4000
5000
6000
7000
Nov-99 Btx 3/00 Bac Btx
streng
8/00
3/01
Without
AFO's
Pre Sx
8/01
post sx
4/02
F/U
10/04
Average steps/day: CP Spastic diplegia 8 y/o -GMFCS II
0102030405060708090
100
Base
line 11/
99
Bot
ox 3/0
0
BA
C B
TX
Str
eng
8/00
Withou
t AFO
's 3
/01
Pre
card
iac/
orth
o Sx
Pos
tsx 4
/02
F/U
10/0
4
Low
Med
High
Walking intensity: CP-GMFCS II
Short-burst interval treadmill training walking capacity &performance in cerebral palsy: a pilot study
Bjornson, et al Dev Neurorehab 2018Funding:
R21 HD077186- NICHD/NCMRR
15
Average Strides/day at baseline, post
SBLTT and 6 weeks post SBLTT (n=12).
Walking
Performance
(n= 12, PRE/POST SBLTT)
BL Mean
(SD)
Post 1
Mean
chang
e
p
value
Post 2
Mean
Chang
e
p
value
Average Total
Steps/day
2677
(1060)
+1712 <.001 +948 <.00
1
Percent Time
walking
37.1 (9.5) +7.68 .006 +4.89 .55
Percent Time > 30
steps/min(Mod/Hig
h)
8.37 (4.0) +4.4 .04 +3.8 .04
# Step >30
steps/min
8245 (442) +991 <.001 +627 <.00
1
Peak Activity Index
(ave top 30 one
min)
33.9 (5.4) +9.4 <.001 +6.1 <.00
1
Max # steps 60
mins
13.2 (4.2) +5.8 .006 +4.2 <.00
1
Max # steps 20 22.9 (4.3) +7.3 <.001 +7.1 <.00
Percent of total strides/day in low,
moderate& high stride rates: 368 TDY, 209
youth with CP ,12 youth with CP, Pre/ Post
short-burst LTT.
16
Orthotic Intervention: Walking
Activity with StepWatch
�
SW Orthotics: n= 8 diplegia
4 y/o, spastic diplegia CP:
Average # of Strides/day- low, mod & high
4029 3862
742
0
500
1000
1500
2000
2500
3000
3500
4000
4500
Low (1-30) Mod (31-60) High > 60
TDY (n=62, 4-5y/o)
Avera
ge S
trides/
day
17
4 y/o, spastic diplegia CP:
Average # of Strides/day- low, mod & high
40293862
742
2807
2175
114
0
500
1000
1500
2000
2500
3000
3500
4000
4500
Low (1-30) Mod (31-60) High > 60
TDY (n=62, 4-5y/o)
4 y/o, AFO- OFF
Avera
ge S
trides/
day
4 y/o, spastic diplegia CP:
Average # of Strides/day- low, mod & high
40293862
742
2807
2175
114
3755
3359
492
0
500
1000
1500
2000
2500
3000
3500
4000
4500
Low (1-30) Mod (31-60) High > 60
TDY (n=62, 4-5y/o)4 y/o, AFO- OFF
4 y/o, AFO- ON
Avera
ge S
trides/
day
What are they really doing?Community Walking Activity in Cerebral Palsy: StepWatch &
Global Positioning System (GPS)
Bjornson KF, Hurvitz P, Kerfeld C. (2015) Funding:
SCRI CHBD Stimulus Fund 2013NIH R21 HD077186
18
Stride count intensity home/community
(low, med, high), pre/post Interval
Treadmill training (n=1)
Percent walking time-home/community,
pre/post Interval Treadmill Training (n=12).
19
StepWatch -Take Home
� Highest accuracy to strides taken
of current devices
� Published normative data for TDCY
� Emerging data for children with CP
� Evidence- Monitoring duration
� GMFCS level
I = 6 days; II = 5 days; III = 4 days
� Pediatric cut points for intensity analysis
Potential SW Clinical/Research
Applications
� PRE/POST
� New assistive device/orthotics
� Botox L/E/serial casting
� Ortho surgery- SEML and Spinal
� SDR
� Oral medication movement disorders
� Dose change of ITB pump
� Burst of therapy (OT/PT)
QUESTIONS ?
20
References: Bjornson KF, Zhou C, Stevenson RD, Christakis D. Relation of stride activity and participation in
mobility-based life habits among children with cerebral palsy. Arch Phys Med Rehabil. 2014 Feb;95(2):360-8.
Bjornson KF, Zhou C, Stevenson R, Christakis D, Song K. Walking activity patterns in youth with
cerebral palsy and youth developing typically. Disabil Rehabil. 2014;36(15):1279-84.
Bjornson KF, Belza B, Kartin D, Logsdon R, McLaughlin J, Thompson EA. The relationship of
physical activity to health status and quality of life in cerebral palsy. Pediatr Phys Ther. 2008 Fall;20(3):247-53
Bjornson K, Song K, Lisle J, Robinson S, Killien E, Barrett T, et al. Measurement of walking activity throughout childhood: influence of leg length. Pediatric exercise science. 2010;22(4):581-95.
Bjornson, Lennon Walking and Physical Activity Monitoring in Children with Cerebral Palsy;
Springer International Publishing AG 2017B. Müller, S.I. Wolf (eds.), Handbook of Human Motion,
Bjornson KF, Moreau N, Bodkin A. (2018) Short-burst interval treadmill training walking capacity
and performance in cerebral palsy: a pilot study. Dev Neurorehabil. 2018 Apr 16:1-8
Ishikawa S, Kang M, Bjornson KF, Song K. Reliably Measuring Ambulatory Activity Levels of Children and Adolescents With Cerebral Palsy. Archives of Physical Medicine and Rehabilitation.
2013;94(1):132-7.
Kang M. Bjornson KF BT, Ragan BG, Song K. The minimum number of days required to establish
reliable physical activity estimates in children aged 2–15 years. Physiological Measurement. 2014;35(11):2229
Treacy D. et al. Validity of Different Activity Monitors to Count Steps in an Inpatient Rehabilitation
Setting Phys Ther. 2017 May 1;97(5):581-588.
Toth, LP et al.. Med Sci Sports Exerc 2018StepWatch was the Most Accurate in Real World
Walking
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