To analyze the clinimetric properties of maximal aerobic and anaerobic fitness measurement protoc... more To analyze the clinimetric properties of maximal aerobic and anaerobic fitness measurement protocols in adults with cerebral palsy (CP). A systematic search through March 2015 of databases PubMed, Embase, SPORTDiscus and PsycINFO was performed with medical subject heading terms for 'cerebral palsy' combined with search terms adults or adolescents and multiple text words for fitness and exercise tests that yielded 864 articles. Abstracts were screened by two reviewers to identify use of maximal fitness measurements in adolescents (14-18yrs) or adults (>18yrs) with CP of all abilities. Ninety-four articles were reviewed. No studies of adolescent (14-18yrs) qualified. Eight articles reported clinimetric properties for adults with CP who walk or propel a wheelchair independently. Five articles reported on aerobic capacity, one reported on anaerobic capacity and two reported on both. Methodological quality of the studies was rated using portions of the COSMIN (COnsensus-based Standards for the selection of health status Measurement INstruments) checklist. Quality of the measurement protocols was evaluated based on statistical strength of the clinimetrics. Synthesis of the overall evidence was based on the Cochrane review group guidelines which combine methodological quality and statistical strength. Eight articles reported on 4 aerobic and 1 anaerobic protocols. Overall synthesis revealed that for ambulatory adults with CP there is (i) moderate evidence for good reliability and good construct validity of maximal aerobic and anaerobic cycle tests, (ii) moderate evidence for good criterion validity of sub-maximal aerobic cycle tests, and (iii) strong evidence for poor criterion validity of the six-minute walk test as a maximal aerobic test. And for adults who propel a wheelchair there is limited evidence of good reliability for maximal aerobic wheelchair ergometer tests. Limited quality research exists on the clinimetric properties of aerobic and anaerobic capacity measures for adults with CP who have independent mobility. Quality aerobic and anaerobic measures for adults with more severe mobility impairments are absent.
Purpose: Cerebral palsy (CP) is the most prevalent childhood physical disability. Youth with CP o... more Purpose: Cerebral palsy (CP) is the most prevalent childhood physical disability. Youth with CP often have increased energy expenditure and decreased physical activity (PA) compared to peers without disabilities. Valid PA measures are important in the design and evaluation of health promotion programs. This study examined accelerometers to measure PA in youth with CP during daily activities. Methods: Fifty youth with CP aged 6-18 years (mean=11.98, SD= 3.35) participated in a 2.5 hour session consisting of 8 activities representing sedentary to vigorous PA. The majority of participants were female (54%), diagnosed with spastic hemiplegia (50%) and mild CP (GMFCS Level I; 46%). Participants wore accelerometers on arms, hips and ankles and a portable indirect calorimeter to measure PA levels and intensity during activities. Intra-class coefficient correlations (ICCs) were generated to evaluate inter-instrument reliability. Spearman correlations were used to evaluate validity between a...
Physical therapy (PT) for youth with cerebral palsy (CP) who are ambulatory includes intervention... more Physical therapy (PT) for youth with cerebral palsy (CP) who are ambulatory includes interventions to increase functional mobility and participation in physical activity (PA). Reliable and valid measures are thus needed to document PA in youth with CP. To evaluate inter-instrument reliability and concurrent validity of three accelerometer-based motion sensors with indirect calorimetry as the criterion for measuring PA intensity in youth with CP. Fifty-seven youth with CP (mean age = 12.5 ± 3.3 years; 51% girls; 49.1% spastic hemiplegia) participated. Inclusion criteria were: youth aged 6-20 years; ambulatory; GMFCS levels I - III; able to follow directions; and able to complete the full PA protocol. Protocol activities included standardized activity trials with increasing PA intensity (resting, writing, household chores, active video games, and walking at three self-selected speeds) as measured by weight-relative oxygen uptake (VO2 in ml/kg/min). During each trial participants wore ...
Although preliminary studies have established a good psychometric foundation for the Pediatric Ev... more Although preliminary studies have established a good psychometric foundation for the Pediatric Evaluation of Disability Inventory Computer Adaptive Test (PEDI-CAT) for a broad population of youth with disabilities, additional validation is warranted for young children. The study objective was to (1) examine concurrent validity, (2) evaluate the ability to identify motor delay, and (3) assess responsiveness of the PEDI-CAT Mobility domain and the Alberta Infant Motor Scale (AIMS). Fifty-three infants and young children (<18 months of age) admitted to a pediatric postacute care hospital and referred for a physical therapist examination were included. The PEDI-CAT Mobility domain and the AIMS were completed during the initial physical therapist examination, at 3-month intervals, and at discharge. A Spearman rank correlation coefficient was used to examine concurrent validity. A chi-square analysis of age percentile scores was used to examine the identification of motor delay. Mean s...
The purpose of this report is to discuss the scope of pediatric physical therapy practice in heal... more The purpose of this report is to discuss the scope of pediatric physical therapy practice in health promotion and fitness for youth with disabilities. Evidence is provided that supports integration of health promotion and fitness strategies in physical therapy clinical management. Physical therapists&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; roles in community-based adapted sports and fitness interventions and reimbursement considerations are discussed. Physical therapists are in a unique position to provide expertise in the design and implementation of health promotion and fitness programs for youth with disabilities. These programs are important to promote active, healthy lifestyles and reduce comorbidities associated with sedentary behaviors and unhealthy weight, which are often seen in youth with disabilities. Pediatric physical therapists should incorporate health promotion and fitness strategies into practice.
Journal of pediatric rehabilitation medicine, 2012
To examine the discriminant validity and scoring patterns of the PEDI-CAT Mobility item bank for ... more To examine the discriminant validity and scoring patterns of the PEDI-CAT Mobility item bank for children who use a walking aid or wheelchair. Parents whose children use a walking aid (n=35) or a wheelchair (n=31) completed the full PEDI-CAT Mobility item bank (105 items including 13 walking aid and 14 wheelchair items) on-line. An independent sample t-test was used to examine mean scores between the groups. Point spread and placement of the scores along the overall 20-80 test scale and response patterns for the 27 mobility device items were analyzed descriptively. Mean scaled scores were significantly different (p < 0.001) for the two groups. Mean score for the Wheelchair Group (38.37, SD=7.09) was lower than the Walking Aid Group (46.97, SD=5.10). The Walking Aid Group started and ended higher on the 20 to 80 scale metric than the Wheelchair Group. No floor or ceiling effects were seen for the scoring of the 27 items specifying use of a mobility device. The %scores of the PEDI-...
Journal of pediatric rehabilitation medicine, 2014
The purposes of this study were to: 1) establish inter-instrument reliability between left and ri... more The purposes of this study were to: 1) establish inter-instrument reliability between left and right hip accelerometer placement; 2) examine procedural reliability of a walking protocol used to measure physical activity (PA); and 3) confirm concurrent validity of accelerometers in measuring PA intensity as compared to the gold standard of oxygen consumption measured by indirect calorimetry. Eight children (mean age: 11.9; SD: 3.2, 75% male) with CP (GMFCS levels I-III) wore ActiGraph GT3X accelerometers on each hip and the Cosmed K4b<formula>^{2}</formula> portable indirect calorimeter during two measurement sessions in which they performed the six minute walk test (6MWT) at three self-selected speeds (comfortable/slow, brisk, fast). Oxygen consumption (VO2) and accelerometer step and activity count data were recorded. Inter-instrument reliability of ActiGraph GT3X accelerometers placed on left and right hips was excellent (ICC=0.96-0.99, CI<formula>_{95}</formu...
To examine concurrent validity, item-specific reliability, and score distributions of the new Ped... more To examine concurrent validity, item-specific reliability, and score distributions of the new Pediatric Evaluation of Disability Inventory-Computer Adaptive Test (PEDI-CAT) Mobility domain with the original PEDI Functional Skills (FS) Mobility Scale. Thirty-five parents of children with neurodevelopmental disabilities completed the PEDI-CAT on a computer and the paper PEDI FS via interview. Strength of association between the PEDI-CAT Mobility domain and PEDI FS Mobility Scale scores was good to excellent (r = 0.82; P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; .001). Intraclass correlation coefficients ranged from .3390 to 1.000, and agreement ranged from 60% to 100% for 8 specific items. No child had the minimum score on either test, whereas 9 children (26%) had a maximum score on the PEDI FS Mobility Scale. This study provides evidence for potential users that the concurrent validity, reliability, and score distribution for the PEDI-CAT Mobility domain are adequate for use with children with varied diagnoses and throughout the pediatric age span.
To determine the effects of a home exercise program of combined aerobic and strength training on ... more To determine the effects of a home exercise program of combined aerobic and strength training on fitness with a 10.5-year-old girl with Down syndrome (DS). Measurements included cardiovascular variables, strength, body composition, flexibility, and skill. The subject participated in a home exercise program: 30 to 60 minutes of moderate- to high-intensity exercise five to six days per week for six weeks. The cardiovascular variables monitored were heart rate, respiration rate, and oxygen consumption during a submaximal treadmill stress test. Other measures included 10-repetition maximal strength of selected muscle groups, body mass index, flexibility, Gross Motor Scales of the Bruininks-Oseretsky Test of Motor Proficiency, and anaerobic muscle power. Improvements in submaximal heart and respiration rates, aerobic performance, muscle strength and endurance, gross motor skills, and anaerobic power were observed for this subject. Body weight and flexibility were unchanged. For this subject, a combined aerobic and strength-training program resulted in improved cardiopulmonary functions not observed in previous studies of subjects with DS.
The purpose of this study was to evaluate the effects of an aquatic aerobic exercise program for ... more The purpose of this study was to evaluate the effects of an aquatic aerobic exercise program for a child with cerebral palsy. A 5-year-old girl with spastic diplegia classified at level III on the Gross Motor Function Classification System participated in this single-subject A-B-A design study. The aquatic aerobic exercise intervention was carried out 3 times per week for 12 weeks at an intensity of 50% to 80% of heart rate reserve. The Canadian Occupational Performance Measure, Gross Motor Function Measure, and 6-minute walk test were used as outcomes. Statistically significant improvements were found in the participation, activity, and body function components of the International Classification of Functioning, Disability, and Health model. Improvements in functional abilities and walking endurance and speed were recorded. These findings suggest that an aquatic aerobic exercise program was effective for this child with cerebral palsy and support the need for additional research in this area.
The purpose of this special report is to present recommendations for the clinical management of c... more The purpose of this special report is to present recommendations for the clinical management of children with cerebral palsy, spastic diplegia when increased functional mobility is the identified outcome. These recommendations provide a framework that allows physical therapists to increase their accountability and promote effective interventions for improved patient outcomes. The key components of this special report on clinical management are: a) the Major Recommendations that provide the background and evidence for clinical management; b) a flow chart to assist in clinical decision-making; and c) a Table of Tests and Measures for information on useful tools in the management of children with spastic diplegia. These recommendations are suggestions for clinical management, not an all-inclusive document on physical therapy for children with cerebral palsy. These recommendations may help therapists develop systematic approaches to service delivery and documentation.
To analyze the clinimetric properties of maximal aerobic and anaerobic fitness measurement protoc... more To analyze the clinimetric properties of maximal aerobic and anaerobic fitness measurement protocols in adults with cerebral palsy (CP). A systematic search through March 2015 of databases PubMed, Embase, SPORTDiscus and PsycINFO was performed with medical subject heading terms for &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;cerebral palsy&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; combined with search terms adults or adolescents and multiple text words for fitness and exercise tests that yielded 864 articles. Abstracts were screened by two reviewers to identify use of maximal fitness measurements in adolescents (14-18yrs) or adults (&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt;18yrs) with CP of all abilities. Ninety-four articles were reviewed. No studies of adolescent (14-18yrs) qualified. Eight articles reported clinimetric properties for adults with CP who walk or propel a wheelchair independently. Five articles reported on aerobic capacity, one reported on anaerobic capacity and two reported on both. Methodological quality of the studies was rated using portions of the COSMIN (COnsensus-based Standards for the selection of health status Measurement INstruments) checklist. Quality of the measurement protocols was evaluated based on statistical strength of the clinimetrics. Synthesis of the overall evidence was based on the Cochrane review group guidelines which combine methodological quality and statistical strength. Eight articles reported on 4 aerobic and 1 anaerobic protocols. Overall synthesis revealed that for ambulatory adults with CP there is (i) moderate evidence for good reliability and good construct validity of maximal aerobic and anaerobic cycle tests, (ii) moderate evidence for good criterion validity of sub-maximal aerobic cycle tests, and (iii) strong evidence for poor criterion validity of the six-minute walk test as a maximal aerobic test. And for adults who propel a wheelchair there is limited evidence of good reliability for maximal aerobic wheelchair ergometer tests. Limited quality research exists on the clinimetric properties of aerobic and anaerobic capacity measures for adults with CP who have independent mobility. Quality aerobic and anaerobic measures for adults with more severe mobility impairments are absent.
Purpose: Cerebral palsy (CP) is the most prevalent childhood physical disability. Youth with CP o... more Purpose: Cerebral palsy (CP) is the most prevalent childhood physical disability. Youth with CP often have increased energy expenditure and decreased physical activity (PA) compared to peers without disabilities. Valid PA measures are important in the design and evaluation of health promotion programs. This study examined accelerometers to measure PA in youth with CP during daily activities. Methods: Fifty youth with CP aged 6-18 years (mean=11.98, SD= 3.35) participated in a 2.5 hour session consisting of 8 activities representing sedentary to vigorous PA. The majority of participants were female (54%), diagnosed with spastic hemiplegia (50%) and mild CP (GMFCS Level I; 46%). Participants wore accelerometers on arms, hips and ankles and a portable indirect calorimeter to measure PA levels and intensity during activities. Intra-class coefficient correlations (ICCs) were generated to evaluate inter-instrument reliability. Spearman correlations were used to evaluate validity between a...
Physical therapy (PT) for youth with cerebral palsy (CP) who are ambulatory includes intervention... more Physical therapy (PT) for youth with cerebral palsy (CP) who are ambulatory includes interventions to increase functional mobility and participation in physical activity (PA). Reliable and valid measures are thus needed to document PA in youth with CP. To evaluate inter-instrument reliability and concurrent validity of three accelerometer-based motion sensors with indirect calorimetry as the criterion for measuring PA intensity in youth with CP. Fifty-seven youth with CP (mean age = 12.5 ± 3.3 years; 51% girls; 49.1% spastic hemiplegia) participated. Inclusion criteria were: youth aged 6-20 years; ambulatory; GMFCS levels I - III; able to follow directions; and able to complete the full PA protocol. Protocol activities included standardized activity trials with increasing PA intensity (resting, writing, household chores, active video games, and walking at three self-selected speeds) as measured by weight-relative oxygen uptake (VO2 in ml/kg/min). During each trial participants wore ...
Although preliminary studies have established a good psychometric foundation for the Pediatric Ev... more Although preliminary studies have established a good psychometric foundation for the Pediatric Evaluation of Disability Inventory Computer Adaptive Test (PEDI-CAT) for a broad population of youth with disabilities, additional validation is warranted for young children. The study objective was to (1) examine concurrent validity, (2) evaluate the ability to identify motor delay, and (3) assess responsiveness of the PEDI-CAT Mobility domain and the Alberta Infant Motor Scale (AIMS). Fifty-three infants and young children (<18 months of age) admitted to a pediatric postacute care hospital and referred for a physical therapist examination were included. The PEDI-CAT Mobility domain and the AIMS were completed during the initial physical therapist examination, at 3-month intervals, and at discharge. A Spearman rank correlation coefficient was used to examine concurrent validity. A chi-square analysis of age percentile scores was used to examine the identification of motor delay. Mean s...
The purpose of this report is to discuss the scope of pediatric physical therapy practice in heal... more The purpose of this report is to discuss the scope of pediatric physical therapy practice in health promotion and fitness for youth with disabilities. Evidence is provided that supports integration of health promotion and fitness strategies in physical therapy clinical management. Physical therapists&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; roles in community-based adapted sports and fitness interventions and reimbursement considerations are discussed. Physical therapists are in a unique position to provide expertise in the design and implementation of health promotion and fitness programs for youth with disabilities. These programs are important to promote active, healthy lifestyles and reduce comorbidities associated with sedentary behaviors and unhealthy weight, which are often seen in youth with disabilities. Pediatric physical therapists should incorporate health promotion and fitness strategies into practice.
Journal of pediatric rehabilitation medicine, 2012
To examine the discriminant validity and scoring patterns of the PEDI-CAT Mobility item bank for ... more To examine the discriminant validity and scoring patterns of the PEDI-CAT Mobility item bank for children who use a walking aid or wheelchair. Parents whose children use a walking aid (n=35) or a wheelchair (n=31) completed the full PEDI-CAT Mobility item bank (105 items including 13 walking aid and 14 wheelchair items) on-line. An independent sample t-test was used to examine mean scores between the groups. Point spread and placement of the scores along the overall 20-80 test scale and response patterns for the 27 mobility device items were analyzed descriptively. Mean scaled scores were significantly different (p < 0.001) for the two groups. Mean score for the Wheelchair Group (38.37, SD=7.09) was lower than the Walking Aid Group (46.97, SD=5.10). The Walking Aid Group started and ended higher on the 20 to 80 scale metric than the Wheelchair Group. No floor or ceiling effects were seen for the scoring of the 27 items specifying use of a mobility device. The %scores of the PEDI-...
Journal of pediatric rehabilitation medicine, 2014
The purposes of this study were to: 1) establish inter-instrument reliability between left and ri... more The purposes of this study were to: 1) establish inter-instrument reliability between left and right hip accelerometer placement; 2) examine procedural reliability of a walking protocol used to measure physical activity (PA); and 3) confirm concurrent validity of accelerometers in measuring PA intensity as compared to the gold standard of oxygen consumption measured by indirect calorimetry. Eight children (mean age: 11.9; SD: 3.2, 75% male) with CP (GMFCS levels I-III) wore ActiGraph GT3X accelerometers on each hip and the Cosmed K4b<formula>^{2}</formula> portable indirect calorimeter during two measurement sessions in which they performed the six minute walk test (6MWT) at three self-selected speeds (comfortable/slow, brisk, fast). Oxygen consumption (VO2) and accelerometer step and activity count data were recorded. Inter-instrument reliability of ActiGraph GT3X accelerometers placed on left and right hips was excellent (ICC=0.96-0.99, CI<formula>_{95}</formu...
To examine concurrent validity, item-specific reliability, and score distributions of the new Ped... more To examine concurrent validity, item-specific reliability, and score distributions of the new Pediatric Evaluation of Disability Inventory-Computer Adaptive Test (PEDI-CAT) Mobility domain with the original PEDI Functional Skills (FS) Mobility Scale. Thirty-five parents of children with neurodevelopmental disabilities completed the PEDI-CAT on a computer and the paper PEDI FS via interview. Strength of association between the PEDI-CAT Mobility domain and PEDI FS Mobility Scale scores was good to excellent (r = 0.82; P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; .001). Intraclass correlation coefficients ranged from .3390 to 1.000, and agreement ranged from 60% to 100% for 8 specific items. No child had the minimum score on either test, whereas 9 children (26%) had a maximum score on the PEDI FS Mobility Scale. This study provides evidence for potential users that the concurrent validity, reliability, and score distribution for the PEDI-CAT Mobility domain are adequate for use with children with varied diagnoses and throughout the pediatric age span.
To determine the effects of a home exercise program of combined aerobic and strength training on ... more To determine the effects of a home exercise program of combined aerobic and strength training on fitness with a 10.5-year-old girl with Down syndrome (DS). Measurements included cardiovascular variables, strength, body composition, flexibility, and skill. The subject participated in a home exercise program: 30 to 60 minutes of moderate- to high-intensity exercise five to six days per week for six weeks. The cardiovascular variables monitored were heart rate, respiration rate, and oxygen consumption during a submaximal treadmill stress test. Other measures included 10-repetition maximal strength of selected muscle groups, body mass index, flexibility, Gross Motor Scales of the Bruininks-Oseretsky Test of Motor Proficiency, and anaerobic muscle power. Improvements in submaximal heart and respiration rates, aerobic performance, muscle strength and endurance, gross motor skills, and anaerobic power were observed for this subject. Body weight and flexibility were unchanged. For this subject, a combined aerobic and strength-training program resulted in improved cardiopulmonary functions not observed in previous studies of subjects with DS.
The purpose of this study was to evaluate the effects of an aquatic aerobic exercise program for ... more The purpose of this study was to evaluate the effects of an aquatic aerobic exercise program for a child with cerebral palsy. A 5-year-old girl with spastic diplegia classified at level III on the Gross Motor Function Classification System participated in this single-subject A-B-A design study. The aquatic aerobic exercise intervention was carried out 3 times per week for 12 weeks at an intensity of 50% to 80% of heart rate reserve. The Canadian Occupational Performance Measure, Gross Motor Function Measure, and 6-minute walk test were used as outcomes. Statistically significant improvements were found in the participation, activity, and body function components of the International Classification of Functioning, Disability, and Health model. Improvements in functional abilities and walking endurance and speed were recorded. These findings suggest that an aquatic aerobic exercise program was effective for this child with cerebral palsy and support the need for additional research in this area.
The purpose of this special report is to present recommendations for the clinical management of c... more The purpose of this special report is to present recommendations for the clinical management of children with cerebral palsy, spastic diplegia when increased functional mobility is the identified outcome. These recommendations provide a framework that allows physical therapists to increase their accountability and promote effective interventions for improved patient outcomes. The key components of this special report on clinical management are: a) the Major Recommendations that provide the background and evidence for clinical management; b) a flow chart to assist in clinical decision-making; and c) a Table of Tests and Measures for information on useful tools in the management of children with spastic diplegia. These recommendations are suggestions for clinical management, not an all-inclusive document on physical therapy for children with cerebral palsy. These recommendations may help therapists develop systematic approaches to service delivery and documentation.
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Papers by Maria Fragala-pinkham