A research report submitted to the Faculty of Humanities, University of the Witwatersrand, Johannesburg, in partial fulfilment of the requirements for the degree of Master of Arts (Speech Pathology), 2017 / Background: The relevance and effectiveness of speech therapy interventions for children with Cerebral Palsy (CP) has come under scrutiny within the CP community. There is a need for evidence based research to be conducted within the CP population. Specifically with regard to the current speech therapy interventions that are being used for this population. There is a dearth of literature in favour of the efficacy of speech therapy interventions for the CP population. Furthermore, research within the South African context is required so as to identify the culturally specific needs of the population. In addition, South Africa faces challenges in providing culturally specific, cost effective and evidence based intervention for this population. This can be attributable to barriers such as the lack of human and financial resources. Purpose: The main aim of the study was to measure change in the use of communicative functions of nine children with cerebral palsy following a five week parent training program. The main aim was achieved with the following sub-aims; 1) To assess the participant’s baseline performance in the use of communicative functions before the commencement of the parent training, 2) To assess the participant’s performance in the use of communicative functions after the 5 week parent training had taken place, 3) To assess the participant’s performance in the use of communicative functions 3 months after the post intervention assessment and 4) To describe the effectiveness of a parent training program in improving a child with CP’s ability to make use of communicative functions. Method: The parents of nine children underwent a parent training program namely the Malamulel Onward Carer-2-Carer Training Program. The nine children were assessed before, immediately after and 3 months after the intervention. The scales, namely the Preschool Language Scale-5 and the Communication Matrix were used in the baseline assessment and reassessment phases of the study and yielded numerical data that described the children’s communication abilities. Results: All the children (n=9) demonstrated a positive increase in communication from test 1 through to test 3 on the Communication Matrix. The p-value for test 1 to test 2 was p=0.0078, test 2 to test 3 were p=0.0313 and test 1 to test 2 were p=0.0313 indicating significant change. The performance on the PLS-5 for majority (n=8) of the sample was unexpected. The majority of participants (n=7) displayed an increase in the PLS-5 score from test 1 to test 2; with one participant displaying a positive change across all three testing occasions on the PLS-5. However, a decrease in the PLS-5 score was seen in majority (n=5) of the participants from test 2 to test 3. Conclusion: Based on the findings of this research, the use of parent training appears to be a viable form of intervention to improve the use of communicative functions in children with CP. However, further steps need to be taken to incorporate an individual follow up component after the parent training to ensure carry over and maintenance of skills covered in the workshops. In addition, due to questions around the efficacy of the PLS-5 with individuals who have CP, assessments need to comprise of a standardized tool in addition to an observational tool so as to acquire a more holistic view of a child with CP’s communication skills. / XL2018

Postural control is essential for maintaining an upright sitting position. However, children with Cerebral Palsy (CP) Gross Motor Function Classification System (GMFCS) IV-V present with impaired postural control, often limiting their daily function and environmental interaction. Most interventions targeting postural dysfunction in CP consider the trunk as a single biomechanical segment and are challenging to use in the GMFCS IV-V population. The aim of this study was to develop the Segmental Intensive Trunk Training (SITT), which uses the segmental model of trunk control. The motor learning framework was chosen for structuring SITT to be an intensive approach, with a dosage of 2hrs/day, 3days/week for 4 weeks (24 hours). The development process included the test of feasibility and the initial evidence of effects, using a single subject research design (SSRD). An A-B-A design was used, where the first phase A included 4 baseline assessments, and phase B included the 4 weeks of SITT intervention. The second phase A was the withdrawal period including an immediate posttest, post 1 week test and a 3 month follow up evaluation. Postural control and reaching behavior were assessed during all 3 phases, using the Segmental Assessment of Trunk Control (SATCO) and Seated Postural and Reaching Control Test (SP&R-co). Hand dexterity and function was measured using the Box and Block test, and ABILHAND-kids questionnaire. Gross motor function was measured using the Gross Motor Function Measure Item Set (GMFM-IS). Performance on functional goals was assessed using the Canadian Occupational Performance Measure (COPM). Data analysis was descriptive, including visual analysis and the two standard deviation band method. One participant (11 years, GMFCS V) participated in the study with a 100% completion rate and 88% participation rate. SITT was a feasible approach for training segmental postural control and reaching behavior in children with CP GMFCS V. The improvements in postural control were associated with an improvement in manual dexterity, gross motor function, functional goal performance, and performance-related satisfaction. The gains in static control and COPM performance and satisfaction were retained at 3 months. These improvements were seen in the areas of body structure and function, and activity domains. Progress in motor performance in response to SITT was established at an individual level; however, more evidence is needed to establish the external validity of the approach.

Statement of the Problem Children with bilateral cerebral palsy (BCP) oftentimes have difficulty coordinating their hands to perform bimanual tasks. However, the characteristics of bimanual coordination in children with BCP have not yet been explored. Furthermore, although intensive motor learning-based interventions such as Hand-Arm Bimanual Intensive Training Including the Lower Extremities, (HABIT-ILE) are aimed at improving bimanual function in children with BCP, there is no evidence, to date, that bimanual coordination improves in these children following interventions such as HABIT-ILE. Since the Both Hands Assessment (BoHA) is the only validated measure of bimanual performance in children with BCP, this study also sought to determine whether the kinematic measure of bimanual coordination used in this study as well as the BoHA are both responsive to change following HABIT-ILE. Methods Vicon motion capture was used to collect 3-D kinematic data during a drawer-opening task to compare bimanual coordination in 14 children with BCP with that of 14 typically developing children (TDC) using speed and hand constraints. Children with BCP classified at Manual Ability Classification System (MACS) levels I to III were also evaluated on the Box and Blocks Test (BBT), a test of unimanual dexterity, and the BoHA. The BoHA uses video analysis to evaluate spontaneous use of both hands during a board game. Correlations between temporal measures of bimanual coordination and these clinical measures of hand function and asymmetry were also examined. A subset of 6 children with BCP were evaluated on the drawer-opening task and the BoHA pre- and post-HABIT-ILE to determine the effect of HABIT-ILE on both bimanual coordination and performance and to compare the responsiveness to change between these two measures. Results Compared to TDC, children with BCP performed the bimanual task more slowly (p < 0.001) and sequentially, as evidenced by greater time differences between the two hands completing the two components of the task (p < 0.05). Performing the task at a faster speed facilitated bimanual coordination, particularly in children with BCP (p < 0.05). The use of the less affected hand to initiate the more complex component of the task under speeded conditions also had a greater facilitatory effect on bimanual coordination in children with BCP (p = 0.02). Bimanual coordination measures correlated significantly with clinical measures of hand function and asymmetry. For instance, faster task completion times correlated with higher BBT scores (Spearman’s rho ranged from r = -0.74 to r = -0.82). Following HABIT-ILE, children with BCP improved on several temporal measures of bimanual coordination (r = -0.64; p = 0.03) and the BoHA (r = -0.61; p = 0.03). Conclusion This study found significant differences in bimanual coordination between children with BCP and TDC. It also highlighted the facilitatory effect of faster speeds and hand role on bimanual coordination. Correlations between temporal measures of bimanual coordination and clinical measures of hand function suggest that children with BCP with lesser impairment of both hands are better able to coordinate their hands to perform bimanual tasks. Following HABIT-ILE, children with BCP improved significantly on several temporal measures of bimanual coordination as well as the BoHA. Thus, this study demonstrated that both a kinematic measure of bimanual coordination as well as a measure that relies on video analysis of bimanual performance were both responsive to change following HABIT-ILE.

Statement of the Problem: Understanding physical activity (PA) behaviors in children with cerebral palsy (CP) who are non-ambulatory is important to design optimal fitness interventions that reduce sedentary behaviors and promote health. There is a growing body of evidence for children with CP who are ambulatory that indicates they have decreased PA as compared to neurotypical peers. These children are at risk for poor health status and in need of adapted strategies to promote activity and reduce sedentary behaviors. However, information on PA behaviors is limited for children with CP who are non-ambulatory. Evaluating the amount and intensity of PA in children with CP who are non-ambulatory is challenging because of the heterogeneous nature of the disease and the limited repertoire of movements available to these children. Developing assessments that accurately describe PA in this population is essential to understand the nature of these limitations and to develop targeted interventions. Materials & Methods: In Study 1, PA amount and intensity in children with CP who were non-ambulatory were examined using PA (accelerometers) and HR monitors along with video observation and parent journaling over 7 days. Children were observed during a range of daily tasks to provide a detailed observation in their home and school. Parents were asked to rate their opinion of their child’s level of PA intensity during these tasks (easy, medium or hard), and these ratings were compared to the PA intensity derived from the PA and HR monitors. Levels of agreement were reported between parent report and HR and PA monitors during video recording. In Study 2, Interviews with parents of children with CP who were non-ambulatory and physical therapists (PTs) working with this population were conducted to understand how they operationalized PA and to evaluate the face validity of the Patient Reported Outcome Measurement Information System (PROMIS) ® PA parent proxy short form 8a survey as a measure of PA in this population. Each child was classified by Gross Motor Functional Classification Scale (GMFCS), the eating, drinking, classification scale (EDACS), the communication and feeding classification scale (CFCS), and the manual abilities classification scale (MACS).Results: For Study 1, 10 children and families participated in the exploratory observation with a video recording of PA in the home. A minimum of 4 consecutive days of monitor wear data was obtained for 7 of the 10 children; 3 children experienced equipment or use malfunction. There was a positive correlation between the parent level of PA intensity and intensity measured by the HR monitors, but no correlation with the PA monitors. The level of agreement of parent-reported PA intensity and HR monitors were correlated with PediCAT daily activity and mobility scores and the EDACS, CFCS, and MACS, There was no correlation between the parent responses and PA monitor-derived PA intensity levels with any functional measure. The PA monitor-derived level of intensity was correlated with the parent-reported PROMIS T-scores. No correlation was seen with the HR monitors. For Study 2, 22 PTs and 15 parents of children with CP who were non-ambulatory participated in the interviews. The PT’s and parents’ interview responses generated shared opinions about PA and how it should be operationally defined in this population. Four major themes emerged: a) PA is defined by functional activities and active movement; b) PA is challenging to measure objectively in this population; c) the environment plays a crucial role in supporting PA; and d) personal factors influence PA uptake. Both parents and PTs believed PA in this population should be increased to improve health related benefits. PA definition focused on active mobility and independent motor control by PTs, whereas the parent's definition of PA highlighted the functional and mobility achievements of their children with examples of communication and use of assistive technology and adaptive equipment. Level of assistance was used by both PTs and parents to indicate PA measurement. Parents and PTs agreed on the appropriateness of various questions on PROMIS scale, with the most appropriate questions being those that inquired about PA frequency during the week (Questions 6 and 7) Conclusions: Accelerometers, HR monitoring, and video monitoring can provide insight into daily PA in children with CP who are non-ambulatory. PA derived from HR monitors was correlated with parent-reported PA intensity during specific daily tasks, suggesting that HR monitors may better reflect PA intensity than accelerometry-based monitors in this population. In capturing PA over a longer period (e.g., 1 week), the PROMIS parent-proxy measure correlated with PA monitor-derived levels of intensity. PA monitors may best reflect general activity levels throughout the week rather than specific intensity levels during daily activities. Defining PA in children with CP who are non-ambulatory is challenging, however, parents and PTs provided insights into methods that can be used to conceptualize this challenging construct. The PROMIS short form 8a PA had some qualities that were deemed appropriate by PTs and parents alike with a preference for specific questions (Questions 6 and 7) for children with CP who are non-ambulatory. Methods to address the implementation of cardiovascular and fitness goals in this population need to be further explored.

Children with unilateral spastic cerebral palsy (USCP) have impairments affecting upper limb function, particularly in grasping abilities. Specifically, children with USCP may display precision grip impairments, which can lead to activity limitations. The interplay between feedforward and feedback control is essential for successful grasping, requiring somatosensory information to be integrated with the motor output. This integration occurs through the transmission of somatosensory information through the dorsal column medial lemniscus (DCML) pathway, while independent finger movement to grasp an object is controlled by the motor cortex via the corticospinal tract (CST). While previous studies demonstrated the CST relates to anticipatory control of grasping, this may not explain all the variance of grasp impairments in children with USCP. Although studies have highlighted the importance of sensory information in grasping in typically developing (TD) adults, there are no studies examining the relationship between brain structure and function in terms of precision grip impairments in children with USCP. Additionally, sensorimotor integration plays an important role in precision grip. In some children with USCP, the lesion that occurs in the brain can cause the CST to reorganize to the contralesional hemisphere. This results in the sensory and motor tracts in different hemispheres, impacting motor impairments. When this sensory-motor dissociation occurs or when there are successive lifts of an object with each hand, it is thought that the information is transferred through the corpus callosum (CC). However, damage to the CC can restrict somatosensory processing, which can further impair grasping abilities. Previous studies have only looked at precision grip impairments in relation to the CST. Therefore, an integrative approach is necessary to fully understand the mechanisms of precision grip impairments in children with USCP. In this study our aim was to examine the neural basis of precision grip in children with USCP. Twenty-seven children participated in an MRI assessment. This included the acquisition of structural and diffusion-weighted images (DWI) to extract diffusion metrics of the CST, DCML pathway, and CC. Children also participated in clinical sensory measures, including the stereognosis test, grating orientation task, and the two-point discrimination task. Additionally, children performed precision grip lifts using a custom-made object. All children were asked to grasp an object with interchangeable surfaces (i.e., sandpaper and rayon) to measure adaptation of grip force (GF) to object texture. They were also asked to grasp the same object, hold it in the air and slowly release their grip so that the object gradually slips from their fingertips. Twenty-seven children performed these tasks with their less affected hand, and 16 with their more affected hand. Additionally, 17 participants grasped an object with various weights with each lifting sequence consisting of lifting an object in succession with the same hand and then one lift with the contralateral hand. The results demonstrate the greater reduction of integrity (more damage) of the DCML pathway, the poorer the grasp task performance, as indicated through the safety margin (the difference between the minimum amount of force needed to prevent slipping and the applied grip force). Regression analyses and cluster analyses display that CST integrity and organization may also contribute to safety margin. This suggests that diffusion metrics of multiple pathways and CST organization when considered together contribute to grasping impairments in children with USCP. To assess this further, we examined the relative difference in the peak rate of force between objects with various weights during successive lifts with each hand. Children with USCP did demonstrate anticipatory control within hands and a generalization of anticipatory control between hands. However, a loss of the transfer information was shown when first grasping the object with their less affected hand and then their more affected hand, in children with an absent contralateral CST. Therefore, the results suggest precision grip impairments may not exclusively be due to sensory impairments, but instead how the sensory information is integrated with the motor output of the same hand.

published_or_final_version / Social Work / Master / Master of Social Work

The aim of this study was to investigate factors that influence the burden of caregiving on the caregivers of children with cerebral palsy (CP) in Windhoek, Namibia. Ethical approval was obtained from researcher’s university and Namibia Ministry of Health and Social Services ethics committee. A quantitative, non-experimental, descriptive and cross-sectional design in the form of a survey was used. Total population sampling technique was used to draw 91 respondents drawn from the patient register at the two public hospitals in Windhoek. A questionnaire adapted from the Zarit Burden Interview (ZBI) was used to collect data. Data which was obtained was complete and the researcher paid consistent attention to the data collection process. The results showed the following characteristics to be significantly related to increased burden among caregivers; living in the same household as a child with cerebral palsy, marital status, knowledge and understanding of cerebral palsy, ethnic group and caregiver having previously been treated for a physical ailment. It was recommended that the social grant and housing policies be reviewed, and support groups for caregivers and community awareness on cerebral palsy be introduced. / Health Studies / M. P. H. (Public Health)

This investigation aimed to objectively measure physiological deficiencies across the continuum of airway protection and clinical feeding and swallowing severity in children with spastic cerebral palsy (SCP), and to make comparisons with a healthy control group. Eleven children with SCP (GMFCS I-V) and 10 controls (mean age: 7+ 2 years) were tested. Results revealed significantly impaired oropharyngeal function and greater clinical feeding and swallowing severity for children with SCP. These children also demonstrated impaired respiratory-swallow coordination evidenced by frequent post-swallow inhalation across all bolus types. Reduced cough volume acceleration was also observed in children with SCP compared to controls. In the SCP group, significant correlations with clinical feeding and swallowing severity were observed with oral praxis and post-swallow inhalation. Additionally, clinical feeding and swallowing severity and peak expiratory flow rate were significantly correlated with gross motor function. This is the first study to objectively identify the co-occurrence of dysphagia and dystussia in children with SCP, and to quantify factors underlying these deficits. Future research should address functional deficits along the continuum of airway protection in both assessment and treatment paradigms in order to maximize the quality of life for this population.

No description available.

Orientador: Gimol Benzaquen Perosa / Banca: Letícia Claudia de Oliveira Antunes / Banca: Eucia beatriz Petean / Resumo: Paralisia Cerebral (PC) é uma das principais causas de incapacidade crônica na infância tendo como sequela desordens motoras que vêm acompanhadas de distúrbios de sensibilidade, percepção, cognição comunicação e comportamento, e secundariamente por desordens musculoesqueléticas. O presente estudo transversal teve como objetivo avaliar a qualidade de vida (QV) das crianças portadoras de Paralisia Cerebral (PC) e sua relação com o nível funcional (Gross Motor Function Classification System GMFCS), características sociodemográficas e frequência a fisioterapia além de sua idade de início. A amostra foi constituída de 71 cuidadores primários e 45 crianças. Para avaliação da qualidade de vida foram utilizados os instrumentos Child Health Questionnaire - Parent Form 50 (CHQ PF50) e Autoquestionaire Qualité de Vie Efant Imagé (AUQEI) Nível funcional, dados sociodemográficos e relacionados a reabilitação (frequência e idade de início na fisioterapia) foram utilizados com o objetivo de verificar o quanto eles interferem na qualidade de vida do indivíduo portador de paralisia cerebral. Crianças e cuidadores primários foram avaliados na Unidade de Apoio de Reabilitação do Hospital Estadual de Bauru (HEB). Foi realizada análise descritiva dos dados sociodemográficos, tais como idade, escolaridade, renda familiar entre outros. Para as variáveis categóricas foi aplicado o Teste de Tukey quando houve significância. A correlação de Pearson foi utilizada para correlacionar dados sociodemográficos com os escores obtidos pela avaliação da qualidade de vida. A média de idade das crianças foi de 9,83 (DP 1,5) e a maioria das crianças era do sexo masculino (54,9%). Como resultado o escore físico foi o mais prejudicado principalmente na forma mais grave de PC quando comparado aos outros níveis. Sob o ponto de vista das crianças não houve diferença significativa entre os níveis. Em relação à fisioterapia foi ... / Abstract: Cerebral Palsy (CP) is a major cause of chronic disability in childhood as having sequel motor disorders that are accompanied by disturbances of sensation, perception, cognition, communication and behavior, and secondarily by musculoskeletal disorders. This cross-sectional study aimed to evaluate the quality of life (QOL) of children with Cerebral Palsy (CP) and its relation to the functional level (Gross Motor Function Classification System GMFCS), sociodemographic characteristics and frequency physiotherapy beyond his years start. The sample consisted of 71 primary caregivers and 45 children. To assess quality of life instruments Child Health Questionnaire were used - Parent Form 50 (CHQ PF50) and Autoquestionaire Qualité de Vie Efant image (AUQEI) functional level, demographic data and related rehabilitation (frequency and age of onset in physiotherapy) were used in order to check how much they affect the quality of life of the individual with cerebral palsy. Children and primary caregivers were assessed at Rehabilitation Support Unit Hospital Estadual de Bauru (HEB). Descriptive analysis of demographic data such as age, education, household income and other was performed. For categorical variables we used the Tukey test when significance was found. The Pearson correlation was used to correlate demographic data with the scores obtained by assessing the quality of life. The mean age of children was 9.83 (SD 1.5) and the majority of children were male (54.9%). As a result the physical score was the most affected mainly the most severe form of PC when compared to other levels. From the point of view of the children there was no significant difference between the levels. Regarding physical therapy was observed that the higher the frequency in physiotherapy, better quality of life indices. Conclusion: in the present study it was concluded that the quality of life evaluated from the point of view ... / Mestre