what are they really doing?? - physical activity measurement in cerebral … · what are they...

What Are They Really Doing?? - Physical Activity Measurement in

Cerebral Palsy© Kristie Bjornson, PhD, PT

March 28th, 2008

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O U T R E A C H E D U C A T I O N

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Kristie Bjornson, PhD, PT29th Annual Duncan Seminar

March, 28th 2008

What are they really doing??-Physical Activity Measurement in

Cerebral Palsy

Kristie F. Bjornson, PhD, PT, PCS

Assistant Research ProfessorBiobehavorial Nursing & Health Systems

School of NursingUniversity of Washington

Seattle, WA [email protected]


March, 28th 2008

When we are not looking…what are they really doing?”

Kristie Bjornson, PhD, PT29th Annual Duncan Seminar March, 28th 2008

Objectives:Understand measurement of physical activityin context of ICF frameworkExplore measures of physical activity in youth with CPCurrent documentation of physical activity via activity monitors in CPQuestions/implications for:

Constraint Induced Movement Therapy (CIMT)Body Weight-Supported Treadmill Training (BWSTT)Orthotics (DAFO)


ICF model, WHO 2001

Health Condition

Body Functions & Structures

Activities Participation

Environmental Factors Personal Factors

International Classification of Functioning, Disability & Health. 2001; WHO


ICF Model

*Social participation is valued differently by different individuals depending on his or her social and cultural context

Participating in a walking club

Participation = ‘involvement in a life situation’ *

Routine walking as part of every-day life

Activity =‘execution of a task’


Physical Activity - Ambulation

Versus

Level of Capability” vs. “Level of Performance”

2


ICF model, WHO 2001

Health Condition

Impairments of Body Functions & Structures

•Assessment of tone•Range of motion •Strength (MRC muscle grades)

•Muscle activity (EMG)•Joint angles (3-D kinematics)•Forces (3-D kinetics)•Oxygen consumption•Stride length / cadence•Gait patterns [OGS; PRS]

Limitation of Activities

CAPACITY:•GMFM•weeFIM•PEDI•Walking speed or distance•ASKc

PERFORMANCE:•ASKp•Physical activity monitors


Ambulatory Ability In CP:Capacity measures

Capacity = what individual can do in optimal or standardised environment [capability]

3-DGA kinematics and kineticsOxygen costGait patternsWalking speed from 3-D GATimed walking speed One minute walk test Six minute walk testGMFM [Gross Motor FunctionMeasure]weeFIM


Performance-based Measures of Physical and Walking Activity

Performance = what an individual actually does

GMFCSFunctional Mobility ScaleASKp vs ASKcLAQ-CP questionnairesOther questionnairesActivity Monitors


(ii) Functional Mobility Scale

Rates child’s usual walking ability (1-6) for different distances

5 / 50 / 500 metres

ICF categories assessedWalking – short & long distances; Different locations;Equipment

Graham et al (2004) JPO 24(5):514


Other Questionnaires

Morris C et al Dev Med Child Neurol. 2006 Dec;48(12):954-61.Kristie Bjornson, PhD, PT

29th Annual Duncan Seminar March, 28th 2008

(iii) Activity (and Participation) Questionnaires

Traditionally, variable responseDepends on who is reporting – child or parent (proxy) or doctor Can reflect subjective opinions, often proxy reports do not match self-report

No one measure assesses all aspects of activity and participation

Two recent excellent reviewsMorris et al (2005): Child: Care, Health and Development 31: 397-407Sakzewski et al (2007): DMCN 49: 232-240

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(iii) Activity (and Participation) QuestionnairesMorris et al (2005): Child: Care, Health and Development 31: 397-407

Identified 2 questionnaires with good psychometric properties that provided broadest description of how frequently children with CP perform a range of activities

ASK – 5-15 years, generic questionnaire addressing physical functioning

LAQ-CP – 3-10 years, condition specific questionnaire, addresses mobility, physical independence, schooling, social integration, clinical and economic burden


Activities Scale for Kids - ASK

Self-report measure for children aged 5-15 years with physical disability

30 items (9 domains)

ASKcapabilitymeasures what the child thinks he or she could do “last week, I think I could have…..”

ASKperformanceTakes into account the environment in which the child functions“last week, I did …….”


Young NL, et al. J Clin Epidemiol. 2000 Feb;53(2):125-37.


ASK questionnaire

Examples of questions relating to mobility

Walked without any supportGot around inside my houseWalked (or rolled) in crowded areasGot around inside without helpWalked up and down a flight of stairs


ASK scores by global rating of disability

Young NL, et al. J Clin Epidemiol. 2000 Feb;53(2):125-37. Kristie Bjornson, PhD, PT


Unpublished data. Miller, Bjornson 2007

TDYGMFCS level IGMFCS level IIGMFCS level III

Activity categories

100.00

80.00

60.00

40.00

20.00

Ask-P

38 Su

mmary

Score

s

4


Lifestyle Assessment Questionnaire for CP- LAQ - CP

46 items (37 questions), parent completed questionnaire covering following domains

Physical independenceMobility limitationEducational exclusionRestriction of social interaction Economic burdenClinical burden

Designed to assess impact of functional limitation

Initially validated for children aged 4 – 6 years, extended to 5 –16 years

Expressed as total life-style assessment score out of 100

Higher scores reflect higher impact on child and family’s life Score 50 suggests assistance in ADL needed, requires educationalsupport and limitation of family economic statusScore 70 suggests special education setting, child’s disability severely impacts on child and the family

Mackie et al 1998 Child: Care, Health & Development 24(6):473)Kerr et al 2006 Child: Care, Health & Development 33(22)


Summary

Clinic-based and lab-based measures tend to correlate well with each other.

However, very little work done on defining the level of walking ability required to be a ‘community ambulator”

Little work done on how clinic and lab-based measures correlate with level of activity in the community


What do we know about ambulatory activity in children with CP out in the community ?

Until recently, not very much!


Activity Monitoring

Self report diary

Heart rate monitoring

Energy Expenditure

Pedometers

Accelerometers

Global Positioning System


Uptimer (Pirpiris et al, 04)

Attached to lateral thigh (various attachment sites) – contains

three mercury tilt switches that are responsive to limb position

relative to gravity

Records time spent upright (not intensity)

Advantages

Easy to use

Potential disadvantages

Doesn’t record what the child is doing

when upright ?standing or walking

or running

Pirpiris et al (2004): JPO 24(5): 521 Kristie Bjornson, PhD, PT29th Annual Duncan Seminar March, 28th 2008

Up Time – Typically Developing Children

Uptimerworn for 24 hrs

Median “up-time”5.5 hrs (range 1.5 -10.3 hrs)

Eldridge et al (2003): Dev Med Child Neurol 45(3): 189 - 193

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Up Time – Children with Cerebral Palsy

n=300 with CP, wore

device 4x 24hr periods

Children with hemiplegia

have similar up–time

compared to typically

developing peers

Reduced up-time in children

with bilateral spasticity

compared to typically

developing peers Pirpiris and Graham (2004): JPO 24(5): 521 Kristie Bjornson, PhD, PT


IDEEA® (Minisun.com)

Intelligent Device for Energy Expenditure & Physical Activity

5 Triaxial accelerometers

Gait parameters / 56 activities


IDEEA®IDEEA data box clips to waist band

5 sensors with wires: Front thigh (R & L)SternumUnder surface of foot (R & L)

Calibration in sitting


WalkStand

Activity type

From MiniSun ActView software

R. Initial Contact

R. Toe Off


IDEEA® Trial

Participants:Age 8 -25 years30 control subjects (mean 14.5 yrs)25 subjects with CP (mean 14.1 yrs)

16 subjects GMFCS Level I/II9 subjects GMFCS Level III

Simultaneous collection of 3-DGA & IDEEAAccuracy of IDEEA in detecting functional activitiesTrialled IDEEA for day in community

Stott, MacKey, AACPDM 2007


Summary: IDEEA® gait parameters

IDEEA® overestimated step / stride length & underestimated cadence (both groups)

Velocity underestimated for controlsVelocity overestimated in children with CP

Greater errors in step and stride length estimation were found in children with CP

GMFCS level was not significant influence

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Summary: IDEEA® activity detection

High accuracy for static activities

Increased error in dynamic tasks for subjects with cerebral palsy

Delay in detecting activities noted


IDEEA® - Practical Issues

Difficulty with wires Uncomfortable with splintsSensors come off Going to toilet Seen by other people

Not recommend for 1+ day use in paediatric population


StepWatchTM

Two dimensional accelerometer Detects foot leaving the surfaceCompletely sealedWorn with strap or ankle cuffContinuously records steps/time interval Up to two months duration


StepWatch TM Activity MonitorMac/PCPager sizeDock

(www.orthocareinnovations.com)


StepWatch TM

SensitivityCadenceRecording TimeExcel


24 hour: Data Capture

Continuous Data CollectionTime Interval Adjustable

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March, 28th 2008

Ambulatory Physical Activity Performance in Youth with Cerebral Palsy & Youth Developing Typically

Bjornson, Belza, Kartin, Logsdon, & McLaughlin, Physical Therapy 87(3), 2007


Outcomes

Functional levelTDY/GMFCS levels for CP

Activity PerformanceStepWatch Activity Monitor

Accuracy to manual counts-99.7%Song et al (2006) 96-97% walk-run

Activity Scale for Kids (ASKp38)

Control Variable- Current Day Outlook


Participants:

Youth with CP (n=81)Mean age 11.8 yrsGMFCS

Level I -31Level II- 30Level III- 20

TDY (n=30)Mean age 11.8 yrsNo difference age, race, gender, SES, parental education


Ambulatory Physical Activity Performance in Youth with Cerebral Palsy & Youth Developing Typically

Bjornson Physical Therapy 87(3), 2007

.0009.75.6% Time High Activity

.000.47.33Ratio Medium to low Activity

.00049.640.2% All Time Active

.0006,7394,222Average step/day

pTDY (n=30)CP (n=81)



Activity Capacity Functional Categories

12000

10000

8000

6000

4000

2000

0

Ave

rage

Dai

ly T

otal

Ste

p co

unt/s

tepw

atch

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.

8


TDYGMFCS level IGMFCS level IIGMFCS level IIl

Activity Capacity Functional Levels

0.700

0.600

0.500

0.400

0.300

0.200

0.100

Perc

enta

ge o

f All

time

Activ

e

TDY to III p<.001, TDY to level II p=.10, TDY to level I p=.39, Level I to III P<.001,Level III to II p=.88, Level II to III <.001


TDYGMFCS level IGMFCS level IIGMFCS Level III


0.800

0.600

0.400

0.200

0.000

Ratio

of %

Med

ium

to L

ow a

ctiv

ity L

evel

s

TDY to level I p= .31, TDY to level II & III p<.002, Level I to II p=.18,Level I to III p<.001, Level II to III p<.001.




0.250

0.200

0.150

0.100

0.050

0.000Perc

ent A

ctiv

e T

ime

at H

igh

Act

ivity

Lev

el

TDY to Level I p=.08, TDY to levels II & III p<.001, Level I to II p=.33, Level I to IIIp<.001, Level II to III P<.001.


.55.50ASKp-38 Transfers

.43.44ASKp-38 Standing

.54.55ASKp-38 Locomotion

.52.52ASKp-38 Dressing

.35.38ASKp-38 Personal Care

.55.57ASKp-38 summary score

% All Time Active

Average Steps/dayActivity Scale for Kids (ASKp-38)

Correlation of StepWatch to ASKp

P= <.01


Case Study:

Spastic DiplegiaGMFCS Level II, 8 yr/oTwin gestation, 32 wk premieCognition- WNLGMFM Scores:

Lying/rolling 90%Sitting- 86%Standing-66%Walk/run/Jump 45%


Case: Spastic Diplegia

Self reported goals:Play short stop on little league baseball teamNot look ‘funny’ getting on and off school busContinue walking

recently experienced decrease in walking distance out in community (i.e. mall/school)

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0

1000

2000

3000

4000

5000

6000

7000

Nov-99 Btx 3/00 Bac Btxstreng8/00

3/01WithoutAFO's

Pre Sx8/01

post sx4/02

F/U10/04

Average steps/day: CP-GMFCS II


0102030405060708090

100

Baselin

e 11/9

9

Botox 3

/00

BAC BTX Streng 8

/00

With

out A

FO's 3/01

Pre ca

rdiac

/ortho S

x

Postsx

4/02

F/U 10

/04

LowMedHigh

Walking intensity: CP-GMFCS II


Implications & ?’sActivity Measurement for:

Constraint Induced Movement Therapy (“forced use”)Treadmill (partial weight-bearing) trainingOrthotic (DAFO) functional


Constraint Induced Movement Therapy

Based on behavioral research on primates post rhizotomy(Taub, 1980)Fundamental Principles

Constrain non-involved limb (casting, binding, sling/removable splint)Mass practice activity with involved limb


Constrain-induced movement therapy in the treatment of the upper limb in children with hemiplegic cerebral palsy (Review) Hoare et al 2007 Cochrane Review

Found significant treatment effect in a single non-randomized trialPositive trend favoring CIMT/forced useLevel of evidence for effectiveness/efficacy inconclusiveFuture Research Focus:

Uniform outcome measuresAdequately powered?? Upper extremity activity in daily life?


Body Weight-Supported Treadmill Training (BWSTT)

Increased walking velocity & EE (Provost et al 2007)Improve stride length, decrease double limb support (Cherng et al, 200, Begnoche 2007)Improve standing, walk/run/jump skills –GMFM (Cherng2007, Begnoche 2007 )Intensive PT+BWSTT (Begnoche 2007)Increased cortical activation during ankle dorsiflexion (Phillips, 2007)Clinical matched pairs trial-improved walking speed (Dodd, 2007)What about impact on daily walking activity and participation?

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March, 28th 2008

Effect of Dynamic Ankle Foot Orthoses (DAFOs) on Function in Children with Cerebral PalsyBjornson KF, Schmale G, Adamczyk-Foster A, McLaughlin, JF. JPO 28(6), 773-776, 2006


Methods/Sample:Cross-over designDAFO- Cascade Orthotics (www. DAFO.com)

N = 23 children Average age of 4.3 years (1.9-7.3), 52% male, primarily Caucasian (70%), GMFCS

I = 6, II = 3 III =14

OUTCOME- GMFM scores


0102030405060708090

100

Crawl/kneel

Standing

Walk/run/ju

mp

GMFM Total

GMAE Total

GM

FM DAFO ONDAFO OFF


Conclusions:Positive short term effect in young ambulatory youth with CPIndependent walkers appear to benefit more

StandingWalk/run/jump

Average leg length was positive association Total GMFMDoes NOT confirm long term influence on motor skill acquisitionEffect of DAFO on physical activity in daily life?


March, 28th 2008

Physical Activity:

“Some is better than none …… and more is better than some”

USDDHS, 1996Pate et al, 1995


In order to know if…chidlren/youth are doing ‘some or more’??

-Will need direct measures of physical activity within the context of their daily lives

Welk, 2002

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