Folate and vitamin B-12 are important for nervous system functioning at all ages, with important ... more Folate and vitamin B-12 are important for nervous system functioning at all ages, with important roles in functions such as neurotransmitter synthesis. Although studies suggest a relation between folate and vitamin B-12 and cognitive function in the elderly population, there is relatively less evidence regarding these vitamins and childrenÕs cognitive function. The purpose of the study was to examine the associations of serum folate and vitamin B-12 with cognitive performance in children 6-16 y old in the NHANES III, conducted from 1988 to 1994, prior to the implementation of folic acid fortification. A cross-sectional analysis was conducted using data on 5365 children 6-16 y old from NHANES III. Serum folate and vitamin B-12 concentrations were measured, along with performance, on the Wide Range Achievement Test-Revised and the Wechsler Intelligence Scale for Children-Revised. Associations of B vitamins with cognitive performance were assessed using linear regression models adjusted for various covariates. Higher serum concentrations of folate were associated with higher reading and block design scores after adjusting for various covariates. For example, compared with the lowest quartile of folate, children in the highest quartile scored 3.28 points or 0.19 SD units higher on the reading test (P < 0.05). Vitamin B-12 was not associated with any of the test scores. In the largest study to date, higher folate concentrations were associated with better reading and block design scores. These associations appear to be biologically plausible and merit further study.
Numerous studies have reported that Vpr alters NF-κB signaling in various cell types, however, th... more Numerous studies have reported that Vpr alters NF-κB signaling in various cell types, however, the findings have been largely conflicting with reports of both stimulatory and inhibitory effects of Vpr. Our aim was to investigate the role of Vpr signaling in myeloid cells using an adenovirus based expression and indicator system. Our results show that Vpr is inhibitory to NF-κB, however, this effect is dependant on the particular manner of NF-κB stimulation. Consistent with this notion, we report that Vpr has inhibitory effects that are specific to the TNF-α pathway, but not affecting the LPS pathway, suggesting that differential targets of Vpr may exist for NF-κB regulation. Further, we identify VprBP as one possible cellular component of Vpr's regulation of IκBα in response to TNF-α stimulation. We did not identify such a role for HSP27, which instead seems to inhibit Vpr functions. Chronically HIV-1 infected U1 cells with knockdown constructs for Vpr were unexpectedly less responsive to TNF-α mediated viral replication, perhaps suggesting that other HIV-1 components may antagonize these anti-NF-κB effects in infected cells. We hypothesize that Vpr may serve an important role in the context of viral infection and immune function in vivo, through its selective inhibition of NF-κB pathways.
Resistance to Human Immunodeficiency Virus cohort of HIV-1-seropositive non-progressors (NP). Aft... more Resistance to Human Immunodeficiency Virus cohort of HIV-1-seropositive non-progressors (NP). After a short follow-up, NP were sub-grouped as stable (NP-S), or with signs of disease progression (NP-P). Initial TREC were higher in NP-S compared to NP-P ( P = 0.002), even after adjusting for CD4 and CD8 T-cell counts and viral load ( P = 0.048), but not p24 antigenemia ( P = 0.076). Higher initial TREC were 100% predictive of the maintenance of non-progression status during follow-up.
Objective. A comprehensive protocol is presented to identify muscular causes of regional pain syn... more Objective. A comprehensive protocol is presented to identify muscular causes of regional pain syndromes utilizing an electrical stimulus in lieu of palpation, and combining elements of Prolotherapy with trigger point injections. . One hundred seventy-six consecutive patients were evaluated for the presence of muscle pain by utilizing an electrical stimulus produced by the Muscle Pain Detection Device. The diagnosis of "Muscle Pain Amenable to Injection" (MPAI), rather than trigger points, was made if pain was produced for the duration of the stimulation. If MPAI was found, muscle tendon injections (MTI) were offered to patients along with post-MTI physical therapy, providing neuromuscular electrical stimulation followed by a validated exercise program [1]. A control group, evaluated 1 month prior to their actual consultation/evaluation when muscle pain was identified but not yet treated, was used for comparison. Results. Forty-five patients who met criteria completed treatment. Patients' scores on the Brief Pain Inventory decreased an average of 62%; median 70% (P < 0.001) for pain severity and 68%; median 85% (P < 0.001) for pain interference one month following treatment. These changes were significantly greater (P < 0.001) than those observed in the untreated controls. reproducible electrical stimulus to diagnose a muscle causing pain in a region of the body followed by an injection technique that involves the entirety of the muscle, and post injection restoration of muscle function, can successfully eliminate or significantly reduce regional pain present for years.
Part of the Neurology Commons This Article is brought to you for free and open access by the Jeff... more Part of the Neurology Commons This Article is brought to you for free and open access by the Jefferson Digital Commons. The Jefferson Digital Commons is a service of Thomas Jefferson University's Center for Teaching and Learning (CTL). The Commons is a showcase for Jefferson books and journals, peer-reviewed scholarly publications, unique historical collections from the University archives, and teaching tools. The Jefferson Digital Commons allows researchers and interested readers anywhere in the world to learn about and keep up to date with Jefferson scholarship. This article has been accepted for inclusion in Department of Neurology Faculty Papers by an authorized administrator of the Jefferson Digital Commons.
Background: Plantar pressure measures can be a useful way to clinically track dynamic foot functi... more Background: Plantar pressure measures can be a useful way to clinically track dynamic foot function in children. Different protocols to collect plantar pressures exist--mainly, a midgait method that measures plantar pressures in the midst of a longer walk and a two-step method for which plantar pressures are obtained on the second step. These two methods have been compared in adults with and without disabilities but not in children. We investigated the concurrent validity and reliability of the midgait and two-step methods. Methods: Plantar pressure data variables of contact area, contact time, peak pressure, and pressure-time integral were compared between these two methods in children of typical development (ages 5 to 14.5 years) in the heel, midfoot, and forefoot. Paired t tests were used to evaluate the validity of the two-step method. Paired sample correlations and Bland-Altman plots were also used to compare both methods. Intraclass correlation coefficients were calculated to determine reliability. Results: Both methods were reliable and differed only in contact time across all foot regions, with the midgait method having shorter contact times than the two-step method. Conclusion: Plantar pressure data collected with the two-step method are comparable to those collected with the midgait method and may be preferred for children because of ease and speed of data collection. Further investigation is necessary to have a more complete understanding of how these findings may apply to children with disabilities.
The purpose of this study was to identify determinants of self-determined behaviors of young chil... more The purpose of this study was to identify determinants of self-determined behaviors of young children with cerebral palsy. The participants were 429 children (56% boys, 18-60 months) and their parents. Structural equation modeling was used to test two models of self-determined behaviors, one for children with walking mobility (Gross Motor Function Classification System, GMFCS levels I-II) and the other for children with limited selfmobility (GMFCS levels III-V). Cognitive-behavioral problems and the extent family supports their child's self-determined behaviors explained 60% of the variance in selfdetermined behaviors of children with walking mobility. Cognitive-behavioral problems, playfulness, and the extent family supports their child's self-determined behaviors explained 68% of the variance in self-determined behaviors of children with limited selfmobility. The less the child's cognitive-behavioral problems affect daily activities (p < .05) and the more the extent family supports their child's self-determined behaviors (p < .05), the more effective the child's self-determined behaviors. Playfulness only had an effect on self-determined behaviors of children with limited self-mobility (p < .05). Service providers are encouraged to assess and support children's daily functioning in cognition, communication, and emotional/behavioral regulation, playfulness, and family strategies in providing opportunity for children to practice self-determined behaviors.
Background and Purpose. Mobility of children with cerebral palsy (CP) has generally been examined... more Background and Purpose. Mobility of children with cerebral palsy (CP) has generally been examined in terms of capability (what a child can do) in a controlled environment, rather than performance (what a child does do) in everyday settings. The purpose of this study was to compare gross motor capability and performance across environmental settings in children with CP. Subjects. The subjects were 307 children with CP, aged 6 to 12 years, who were randomly selected across Ontario, Canada. Methods. Children were grouped by capability (the highest of 3 items achieved on the Gross Motor Function Measure). Performance was measured via a parent-completed questionnaire on usual mobility methods in the home, at school, and in the outdoors or community. Results. There were statistically significant differences in performance across settings for children in all capability groups. Children who were capable of crawling performed crawling more at home than at school or in the outdoors or community. Children who were capable of walking with support performed walking with support more at school than in the outdoors or community. Children who were capable of walking alone performed walking alone more at home than at school or in the outdoors or community, and more at school than in the outdoors or community. Discussion and Conclusion. The results provide evidence that children with CP with similar capability demonstrate differences in performance across settings. The results suggest that physical therapists should examine performance in the settings that are important to the child's daily life. [Tieman BL, Palisano RJ, Gracely EJ, Rosenbaum PL. Gross motor capability and performance of mobility in children with cerebral palsy: a comparison across home, school, and outdoors/community settings.
Purpose: Development of individualized student goals is integral to special education. Although U... more Purpose: Development of individualized student goals is integral to special education. Although United States federal legislation and state, local, and professional guidelines outline preferred goal development processes, actual practice does not always reflect ideal practice. The purposes of this research were to understand how physical therapists develop student goals and to identify facilitators and barriers to development of participation-based goals. Methods: Twenty school-based physical therapists participated in one of five semi-structured focus groups. Two researchers conducted thematic analysis of transcriptions of audio recordings to identify qualitative themes; a third researcher reviewed the analysis. Results: Five themes emerged related to therapists' recommendations for goal development: (1) Understand the student: The foundation for individualized goal development, (2) Teaming: The critical component to integrate varied perceptions and establish a common vision, (3) Relevant focus of goal: Addressing what is meaningful for a student's day, (4) Best practices: Embracing professional advances, and (5) Develop and write the goal: The art and science of writing goals. The first four themes also reflected facilitators and barriers to development of participation-based goals. Conclusions: Therapists' comments reflected striving to follow ideal practice recommendations despite identified challenges. This research helps educational teams understand and reflect on goal development processes. ä IMPLICATIONS FOR REHABILITATION Although writing goals is a foundational task in school-based practice, meaningful goal development is a complex process. School-based physical therapists recommend working closely with students, parents, teachers, and other members of the educational team to establish good communication, trust, and a shared philosophy of collaboration and responsibility for student goals A thorough understanding of the student serves as the foundation for developing individualized student goals. Educational teams are encouraged to understand professional, federal, state, and local guidelines and embrace professional advances in goal development practices.
Physical & Occupational Therapy in Pediatrics, Feb 1, 2021
Abstract Aims: Legislation, perspectives, and guidelines support the use of goals that address st... more Abstract Aims: Legislation, perspectives, and guidelines support the use of goals that address student participation in school. The purpose of this study was to determine if students with participation-based goals receive school-based physical therapy services differently and demonstrate better outcomes than students with non-participation-based goals. Methods: Secondary data analysis. School-based physical therapists (n = 109) provided services to students (n = 294) over 20 weeks. The physical therapists determined a primary goal for each student and classified this goal based on if it was (n = 181) or was not (n = 113) performed and measured within a school activity or routine (participation-based versus non-participation-based). The physical therapists documented the proportion of services provided within a school activity, on behalf of the student, and consisting of activity-focused functional activities. They also measured goal attainment and assessed participation via the School Function Assessment at the beginning and end of the study. Results: Students with participation-based goals received a significantly greater proportion of services within a school activity than those with non-participation-based goals (p < 0.001). There was no significant difference for the remaining service variables, nor for the outcome variables. Conclusions: Use of participation-based goals may promote school-based physical therapy service delivery within a school activity, thus supporting best practice.
Background. The attainment of walking is a focus of physical therapy intervention in children wit... more Background. The attainment of walking is a focus of physical therapy intervention in children with cerebral palsy (CP) and may affect their independence in mobility and participation in daily activities. However, knowledge of determinants of independent walking to guide physical therapists' decision making is lacking. Objective. The aim of this study was to identify child factors (postural control, reciprocal lower limb movement, functional strength, and motivation) and family factors (family support to child and support to family) that predict independent walking 1 year later in young children with CP at Gross Motor Function Classification System (GMFCS) levels II and III. Design. A secondary data analysis of an observational cohort study was performed. Methods. Participants were 80 children with CP, 2 through 6 years of age. Child factors were measured 1 year prior to the walking outcome. Parent-reported items representing family factors were collected 7 months after study onset. The predictive model was analyzed using backward stepwise logistic regression. Results. A measure of functional strength and dynamic postural control in a sit-to-stand activity was the only significant predictor of taking Ն3 steps independently. The positive likelihood ratio for predicting a "walker" was 3.26, and the negative likelihood ratio was 0.74. The model correctly identified a walker or "nonwalker" 75% of the time. Limitations. Prediction of walking ability was limited by the lack of specificity of child and family characteristics not prospectively selected and measurement of postural control, reciprocal lower limb movement, and functional strength 1 year prior to the walking outcome. Conclusions. The ability to transfer from sitting to standing and from standing to sitting predicted independent walking in young children with CP. Prospective longitudinal studies are recommended to determine indicators of readiness for independent walking.
Background: The ability of medical students to recognize heart murmurs is poor (20%), and does no... more Background: The ability of medical students to recognize heart murmurs is poor (20%), and does not improve with subsequent years of training. A teaching method to improve this skill would be useful. Study objectives: To determine whether intensive repetition of four basic cardiac murmurs improves auscultatory proficiency in medical students. Design: Controlled intervention study. Subjects: Fifty-one second-year medical students in an east coast medical school. Interventions: Subjects were classified into three groups: (1) a monitored group, who listened to 500 repetitions of each murmur in a monitored setting, (2) an unmonitored group, who listened to 500 repetitions of each murmur in an unmonitored setting, and (3) a control group. All three groups were tested using a pretest and posttest methodology. Measurements and results: The 20 subjects in the monitored group improved from 13.5 ؎ 9.8 to 85 ؎ 17.6% following the intervention (mean ؎ SD). Similarly, 21 students in the unmonitored group improved from 20.9 ؎ 10.9 to 86.1 ؎ 15.6%. Ten control students showed no significant improvement (24 ؎ 21.7 to 32 ؎ 22.5%). The differences between the two intervention groups and the control subjects was significant at p < 0.001 by analysis of variance. Conclusion: Five hundred repetitions of four basic cardiac murmurs significantly improved auscultatory proficiency in recognizing basic cardiac murmurs by medical students. These results suggest that cardiac auscultation is, in part, a technical skill. (CHEST 2004; 126:470-475)
Background: More than 50% of multiple sclerosis patients experience chronic pain syndrome. We set... more Background: More than 50% of multiple sclerosis patients experience chronic pain syndrome. We set out to determine the specific type of chronic pain that was seen in our multiple sclerosis patients. Methods: Patients with multiple sclerosis were catalogued between January 2002 and April 2006 and identified by a search of the database. Only MS patients that met the 2005 revised McDonald criteria were included. Results: We determined the prevalence rate of complex regional pain syndrome in a cohort of multiple sclerosis patients. In our sample of 205 multiple sclerosis patients, the prevalence of complex regional pain syndrome was 4 cases per 205 compared to an expected age and sex-adjusted total prevalence of 0.078 cases per 205 (p < 0.0001). Conclusion: This study suggests that multiple sclerosis patients are at a higher risk of developing complex regional pain syndrome than the general population. Key words: Multiple sclerosis, complex regional pain syndrome, prevalence
Study design Cohort study. Objectives Shoulder pain prevalence is high in those with spinal cord ... more Study design Cohort study. Objectives Shoulder pain prevalence is high in those with spinal cord injury (SCI) and is associated with decreased function, participation restrictions and decreased quality of life. Limited evidence exists regarding physical impairments of newly acquired SCI. The current study compared musculoskeletal factors at rehabilitation initiation in individuals with newly acquired SCI to uninjured individuals. We hypothesized no impairment differences of shoulder pain, strength, mobility, muscle extensibility, or rotator cuff integrity would exist between groups. Setting Multi-site laboratory setting. Methods Thirty-five individuals with newly acquired SCI and age and gender-matched controls without SCI (n = 34) participated. Musculoskeletal Pain Survey, shoulder range of motion (ROM), strength, pectoralis minor muscle extensibility (PM) and tissue integrity [Ultrasound Pathology Rating Scale (USPRS)] were obtained. Results Higher pain was reported by individuals experiencing new SCI along with lower strength across all bilateral measures, reduced elevation, external rotation, and horizontal adduction ROM, with large effect sizes. PM bilateral extensibility was reduced compared to controls, with moderate between group effect size; however, no USPRS score difference existed. Conclusions This study provided the first comprehensive clinical description for individuals with newly acquired SCI. In comparison to matched uninjured controls, participants with new SCI reported greater shoulder pain with impairments in mobility, strength, and extensibility. The identified early clinical impairments aligned with progressive impairment including further pain development and persistence. Awareness and modification of these early clinical impairments may lead to improved long-term outcomes, improving the overall health and well-being of individuals with newly acquired SCI.
Objectives: There is limited data describing the role of health disparity factors and socioeconom... more Objectives: There is limited data describing the role of health disparity factors and socioeconomic status (SES) on emergent versus nonemergent gastrointestinal (GI) procedures within pediatrics. We aimed to characterize risk factors and determine the role of SES on emergent versus nonemergent GI care. We hypothesized that patients with lower SES incur higher risk of having emergent procedures performed. Methods: Retrospective chart review was performed between 2012 and 2016, with 2556 patient records reviewed. Demographic data and SES categories were determined. The majority of emergent procedures were performed on an inpatient basis. Health disparity factors analyzed included age, gender, insurance type, race, language, and SES using census tracts. Logistic regression analyses and paired t-tests were utilized. Results: Two hundred eighty-six (11.2%) patients had emergent GI procedures performed. Logistic regression (odds ratio [OR], confidence interval (95% CI)] showed patients from 6-11 to 12-17 years of age were less likely to seek emergent care than the youngest group [0.47, 0.33-0.66 and 0.61, 0.45-0.84]. Patients with Medicaid insurance [1.68, 1.27-2.26], African American or ''other'' race [2.07, 1.48-2.90 and 2.43, 1.77-3.36, respectively], as well as ''other'' language [2.1, 1.14-3.99] more often sought emergent care. Using geocoded data, we found that as SES increases by 1, emergent risk for procedures decreased by 2.9% (OR 0.97, p = 0.045). Conclusions: Children with lower SES, at extremes of age (< 5, > 18 years), non-English or Spanish speaking and with Medicaid insurance are at higher risk of undergoing emergent GI procedures. This study gives us an opportunity to plan targeted interventions to improve access and quality of care.
Peer Review History: PLOS recognizes the benefits of transparency in the peer review process; the... more Peer Review History: PLOS recognizes the benefits of transparency in the peer review process; therefore, we enable the publication of all of the content of peer review and author responses alongside final, published articles. The editorial history of this article is available here:
Background and Objectives: Hospice and palliative medicine (HPM) is one of three Accreditation Co... more Background and Objectives: Hospice and palliative medicine (HPM) is one of three Accreditation Council for Graduate Medical Education accredited clinical subspecialties available to family medicine graduates for fellowship training. Despite this, training is not currently a curriculum requirement. We have pioneered a required 4-week palliative medicine rotation into the curriculum. Methods: Twenty-eight residents who completed the palliative medicine rotation across four classes were surveyed to assess how the rotation improved their level of comfort with providing end-of-life (EOL) care and to demonstrate the need of formal palliative medicine training. Wilcoxon signed ranks test was used to detect statistical differences between the mean level of comfort of residents pre- and postrotation with providing the basic skills needed to practice HPM. Results: The HPM rotation significantly improved the residents’ level of comfort in all areas of measured EOL care (P<0.001). All reside...
Objective. To determine whether there is a significant difference in initial successful contact w... more Objective. To determine whether there is a significant difference in initial successful contact when attempting follow-up of patients discharged from a pediatric emergency department (ED) using either pagers or the telephone. In addition, to evaluate whether the combination of both pager and telephone follow-up is more successful than telephone follow-up alone when confined to a 2-hour period. Design and Setting. A prospective comparison of intervention and control groups taken from convenience samples of patients seen in an ED of an urban, tertiary care children’s hospital. Participants. One hundred eighty-five patients whose families had access to both a pager and a telephone (intervention group) and 112 patients whose families had access to only a telephone (control group) were enrolled. Intervention. Before discharging the patient from the ED, the investigators verified a pager number and/or a best contact telephone number for a follow-up telephone call. Participants were divide...
Although research supports family-professional collaboration, challenges to implementation have b... more Although research supports family-professional collaboration, challenges to implementation have been reported. The case reports describe the implementation of a 4-step practice model that incorporates specific strategies to facilitate family-professional collaboration. The participants were two mothers of children with physical disabilities and two physical therapists. Therapists received instruction in the strategies for collaboration including client-centred interview, visualising a preferred future, scaling questions, and family routine and activity matrix. The intervention was implemented during 6-weekly sessions. The 2nd and 5th sessions were videotaped to analyse the interactions between the parent and therapist using Response Class Matrix. Telephone interviews were conducted to explore participants' experiences. Therapists were able to implement all strategies following 6 h of instruction. Analysis of the videotapes indicated that mother-therapist interactions were charac...
Journal of the American Podiatric Medical Association
Plantar pressure measures can be a useful way to clinically track dynamic foot function in childr... more Plantar pressure measures can be a useful way to clinically track dynamic foot function in children. Different protocols to collect plantar pressures exist--mainly, a midgait method that measures plantar pressures in the midst of a longer walk and a two-step method for which plantar pressures are obtained on the second step. These two methods have been compared in adults with and without disabilities but not in children. We investigated the concurrent validity and reliability of the midgait and two-step methods. Plantar pressure data variables of contact area, contact time, peak pressure, and pressure-time integral were compared between these two methods in children of typical development (ages 5 to 14.5 years) in the heel, midfoot, and forefoot. Paired t tests were used to evaluate the validity of the two-step method. Paired sample correlations and Bland-Altman plots were also used to compare both methods. Intraclass correlation coefficients were calculated to determine reliability...
Folate and vitamin B-12 are important for nervous system functioning at all ages, with important ... more Folate and vitamin B-12 are important for nervous system functioning at all ages, with important roles in functions such as neurotransmitter synthesis. Although studies suggest a relation between folate and vitamin B-12 and cognitive function in the elderly population, there is relatively less evidence regarding these vitamins and childrenÕs cognitive function. The purpose of the study was to examine the associations of serum folate and vitamin B-12 with cognitive performance in children 6-16 y old in the NHANES III, conducted from 1988 to 1994, prior to the implementation of folic acid fortification. A cross-sectional analysis was conducted using data on 5365 children 6-16 y old from NHANES III. Serum folate and vitamin B-12 concentrations were measured, along with performance, on the Wide Range Achievement Test-Revised and the Wechsler Intelligence Scale for Children-Revised. Associations of B vitamins with cognitive performance were assessed using linear regression models adjusted for various covariates. Higher serum concentrations of folate were associated with higher reading and block design scores after adjusting for various covariates. For example, compared with the lowest quartile of folate, children in the highest quartile scored 3.28 points or 0.19 SD units higher on the reading test (P < 0.05). Vitamin B-12 was not associated with any of the test scores. In the largest study to date, higher folate concentrations were associated with better reading and block design scores. These associations appear to be biologically plausible and merit further study.
Numerous studies have reported that Vpr alters NF-κB signaling in various cell types, however, th... more Numerous studies have reported that Vpr alters NF-κB signaling in various cell types, however, the findings have been largely conflicting with reports of both stimulatory and inhibitory effects of Vpr. Our aim was to investigate the role of Vpr signaling in myeloid cells using an adenovirus based expression and indicator system. Our results show that Vpr is inhibitory to NF-κB, however, this effect is dependant on the particular manner of NF-κB stimulation. Consistent with this notion, we report that Vpr has inhibitory effects that are specific to the TNF-α pathway, but not affecting the LPS pathway, suggesting that differential targets of Vpr may exist for NF-κB regulation. Further, we identify VprBP as one possible cellular component of Vpr's regulation of IκBα in response to TNF-α stimulation. We did not identify such a role for HSP27, which instead seems to inhibit Vpr functions. Chronically HIV-1 infected U1 cells with knockdown constructs for Vpr were unexpectedly less responsive to TNF-α mediated viral replication, perhaps suggesting that other HIV-1 components may antagonize these anti-NF-κB effects in infected cells. We hypothesize that Vpr may serve an important role in the context of viral infection and immune function in vivo, through its selective inhibition of NF-κB pathways.
Resistance to Human Immunodeficiency Virus cohort of HIV-1-seropositive non-progressors (NP). Aft... more Resistance to Human Immunodeficiency Virus cohort of HIV-1-seropositive non-progressors (NP). After a short follow-up, NP were sub-grouped as stable (NP-S), or with signs of disease progression (NP-P). Initial TREC were higher in NP-S compared to NP-P ( P = 0.002), even after adjusting for CD4 and CD8 T-cell counts and viral load ( P = 0.048), but not p24 antigenemia ( P = 0.076). Higher initial TREC were 100% predictive of the maintenance of non-progression status during follow-up.
Objective. A comprehensive protocol is presented to identify muscular causes of regional pain syn... more Objective. A comprehensive protocol is presented to identify muscular causes of regional pain syndromes utilizing an electrical stimulus in lieu of palpation, and combining elements of Prolotherapy with trigger point injections. . One hundred seventy-six consecutive patients were evaluated for the presence of muscle pain by utilizing an electrical stimulus produced by the Muscle Pain Detection Device. The diagnosis of "Muscle Pain Amenable to Injection" (MPAI), rather than trigger points, was made if pain was produced for the duration of the stimulation. If MPAI was found, muscle tendon injections (MTI) were offered to patients along with post-MTI physical therapy, providing neuromuscular electrical stimulation followed by a validated exercise program [1]. A control group, evaluated 1 month prior to their actual consultation/evaluation when muscle pain was identified but not yet treated, was used for comparison. Results. Forty-five patients who met criteria completed treatment. Patients' scores on the Brief Pain Inventory decreased an average of 62%; median 70% (P < 0.001) for pain severity and 68%; median 85% (P < 0.001) for pain interference one month following treatment. These changes were significantly greater (P < 0.001) than those observed in the untreated controls. reproducible electrical stimulus to diagnose a muscle causing pain in a region of the body followed by an injection technique that involves the entirety of the muscle, and post injection restoration of muscle function, can successfully eliminate or significantly reduce regional pain present for years.
Part of the Neurology Commons This Article is brought to you for free and open access by the Jeff... more Part of the Neurology Commons This Article is brought to you for free and open access by the Jefferson Digital Commons. The Jefferson Digital Commons is a service of Thomas Jefferson University's Center for Teaching and Learning (CTL). The Commons is a showcase for Jefferson books and journals, peer-reviewed scholarly publications, unique historical collections from the University archives, and teaching tools. The Jefferson Digital Commons allows researchers and interested readers anywhere in the world to learn about and keep up to date with Jefferson scholarship. This article has been accepted for inclusion in Department of Neurology Faculty Papers by an authorized administrator of the Jefferson Digital Commons.
Background: Plantar pressure measures can be a useful way to clinically track dynamic foot functi... more Background: Plantar pressure measures can be a useful way to clinically track dynamic foot function in children. Different protocols to collect plantar pressures exist--mainly, a midgait method that measures plantar pressures in the midst of a longer walk and a two-step method for which plantar pressures are obtained on the second step. These two methods have been compared in adults with and without disabilities but not in children. We investigated the concurrent validity and reliability of the midgait and two-step methods. Methods: Plantar pressure data variables of contact area, contact time, peak pressure, and pressure-time integral were compared between these two methods in children of typical development (ages 5 to 14.5 years) in the heel, midfoot, and forefoot. Paired t tests were used to evaluate the validity of the two-step method. Paired sample correlations and Bland-Altman plots were also used to compare both methods. Intraclass correlation coefficients were calculated to determine reliability. Results: Both methods were reliable and differed only in contact time across all foot regions, with the midgait method having shorter contact times than the two-step method. Conclusion: Plantar pressure data collected with the two-step method are comparable to those collected with the midgait method and may be preferred for children because of ease and speed of data collection. Further investigation is necessary to have a more complete understanding of how these findings may apply to children with disabilities.
The purpose of this study was to identify determinants of self-determined behaviors of young chil... more The purpose of this study was to identify determinants of self-determined behaviors of young children with cerebral palsy. The participants were 429 children (56% boys, 18-60 months) and their parents. Structural equation modeling was used to test two models of self-determined behaviors, one for children with walking mobility (Gross Motor Function Classification System, GMFCS levels I-II) and the other for children with limited selfmobility (GMFCS levels III-V). Cognitive-behavioral problems and the extent family supports their child's self-determined behaviors explained 60% of the variance in selfdetermined behaviors of children with walking mobility. Cognitive-behavioral problems, playfulness, and the extent family supports their child's self-determined behaviors explained 68% of the variance in self-determined behaviors of children with limited selfmobility. The less the child's cognitive-behavioral problems affect daily activities (p < .05) and the more the extent family supports their child's self-determined behaviors (p < .05), the more effective the child's self-determined behaviors. Playfulness only had an effect on self-determined behaviors of children with limited self-mobility (p < .05). Service providers are encouraged to assess and support children's daily functioning in cognition, communication, and emotional/behavioral regulation, playfulness, and family strategies in providing opportunity for children to practice self-determined behaviors.
Background and Purpose. Mobility of children with cerebral palsy (CP) has generally been examined... more Background and Purpose. Mobility of children with cerebral palsy (CP) has generally been examined in terms of capability (what a child can do) in a controlled environment, rather than performance (what a child does do) in everyday settings. The purpose of this study was to compare gross motor capability and performance across environmental settings in children with CP. Subjects. The subjects were 307 children with CP, aged 6 to 12 years, who were randomly selected across Ontario, Canada. Methods. Children were grouped by capability (the highest of 3 items achieved on the Gross Motor Function Measure). Performance was measured via a parent-completed questionnaire on usual mobility methods in the home, at school, and in the outdoors or community. Results. There were statistically significant differences in performance across settings for children in all capability groups. Children who were capable of crawling performed crawling more at home than at school or in the outdoors or community. Children who were capable of walking with support performed walking with support more at school than in the outdoors or community. Children who were capable of walking alone performed walking alone more at home than at school or in the outdoors or community, and more at school than in the outdoors or community. Discussion and Conclusion. The results provide evidence that children with CP with similar capability demonstrate differences in performance across settings. The results suggest that physical therapists should examine performance in the settings that are important to the child's daily life. [Tieman BL, Palisano RJ, Gracely EJ, Rosenbaum PL. Gross motor capability and performance of mobility in children with cerebral palsy: a comparison across home, school, and outdoors/community settings.
Purpose: Development of individualized student goals is integral to special education. Although U... more Purpose: Development of individualized student goals is integral to special education. Although United States federal legislation and state, local, and professional guidelines outline preferred goal development processes, actual practice does not always reflect ideal practice. The purposes of this research were to understand how physical therapists develop student goals and to identify facilitators and barriers to development of participation-based goals. Methods: Twenty school-based physical therapists participated in one of five semi-structured focus groups. Two researchers conducted thematic analysis of transcriptions of audio recordings to identify qualitative themes; a third researcher reviewed the analysis. Results: Five themes emerged related to therapists' recommendations for goal development: (1) Understand the student: The foundation for individualized goal development, (2) Teaming: The critical component to integrate varied perceptions and establish a common vision, (3) Relevant focus of goal: Addressing what is meaningful for a student's day, (4) Best practices: Embracing professional advances, and (5) Develop and write the goal: The art and science of writing goals. The first four themes also reflected facilitators and barriers to development of participation-based goals. Conclusions: Therapists' comments reflected striving to follow ideal practice recommendations despite identified challenges. This research helps educational teams understand and reflect on goal development processes. ä IMPLICATIONS FOR REHABILITATION Although writing goals is a foundational task in school-based practice, meaningful goal development is a complex process. School-based physical therapists recommend working closely with students, parents, teachers, and other members of the educational team to establish good communication, trust, and a shared philosophy of collaboration and responsibility for student goals A thorough understanding of the student serves as the foundation for developing individualized student goals. Educational teams are encouraged to understand professional, federal, state, and local guidelines and embrace professional advances in goal development practices.
Physical & Occupational Therapy in Pediatrics, Feb 1, 2021
Abstract Aims: Legislation, perspectives, and guidelines support the use of goals that address st... more Abstract Aims: Legislation, perspectives, and guidelines support the use of goals that address student participation in school. The purpose of this study was to determine if students with participation-based goals receive school-based physical therapy services differently and demonstrate better outcomes than students with non-participation-based goals. Methods: Secondary data analysis. School-based physical therapists (n = 109) provided services to students (n = 294) over 20 weeks. The physical therapists determined a primary goal for each student and classified this goal based on if it was (n = 181) or was not (n = 113) performed and measured within a school activity or routine (participation-based versus non-participation-based). The physical therapists documented the proportion of services provided within a school activity, on behalf of the student, and consisting of activity-focused functional activities. They also measured goal attainment and assessed participation via the School Function Assessment at the beginning and end of the study. Results: Students with participation-based goals received a significantly greater proportion of services within a school activity than those with non-participation-based goals (p < 0.001). There was no significant difference for the remaining service variables, nor for the outcome variables. Conclusions: Use of participation-based goals may promote school-based physical therapy service delivery within a school activity, thus supporting best practice.
Background. The attainment of walking is a focus of physical therapy intervention in children wit... more Background. The attainment of walking is a focus of physical therapy intervention in children with cerebral palsy (CP) and may affect their independence in mobility and participation in daily activities. However, knowledge of determinants of independent walking to guide physical therapists' decision making is lacking. Objective. The aim of this study was to identify child factors (postural control, reciprocal lower limb movement, functional strength, and motivation) and family factors (family support to child and support to family) that predict independent walking 1 year later in young children with CP at Gross Motor Function Classification System (GMFCS) levels II and III. Design. A secondary data analysis of an observational cohort study was performed. Methods. Participants were 80 children with CP, 2 through 6 years of age. Child factors were measured 1 year prior to the walking outcome. Parent-reported items representing family factors were collected 7 months after study onset. The predictive model was analyzed using backward stepwise logistic regression. Results. A measure of functional strength and dynamic postural control in a sit-to-stand activity was the only significant predictor of taking Ն3 steps independently. The positive likelihood ratio for predicting a "walker" was 3.26, and the negative likelihood ratio was 0.74. The model correctly identified a walker or "nonwalker" 75% of the time. Limitations. Prediction of walking ability was limited by the lack of specificity of child and family characteristics not prospectively selected and measurement of postural control, reciprocal lower limb movement, and functional strength 1 year prior to the walking outcome. Conclusions. The ability to transfer from sitting to standing and from standing to sitting predicted independent walking in young children with CP. Prospective longitudinal studies are recommended to determine indicators of readiness for independent walking.
Background: The ability of medical students to recognize heart murmurs is poor (20%), and does no... more Background: The ability of medical students to recognize heart murmurs is poor (20%), and does not improve with subsequent years of training. A teaching method to improve this skill would be useful. Study objectives: To determine whether intensive repetition of four basic cardiac murmurs improves auscultatory proficiency in medical students. Design: Controlled intervention study. Subjects: Fifty-one second-year medical students in an east coast medical school. Interventions: Subjects were classified into three groups: (1) a monitored group, who listened to 500 repetitions of each murmur in a monitored setting, (2) an unmonitored group, who listened to 500 repetitions of each murmur in an unmonitored setting, and (3) a control group. All three groups were tested using a pretest and posttest methodology. Measurements and results: The 20 subjects in the monitored group improved from 13.5 ؎ 9.8 to 85 ؎ 17.6% following the intervention (mean ؎ SD). Similarly, 21 students in the unmonitored group improved from 20.9 ؎ 10.9 to 86.1 ؎ 15.6%. Ten control students showed no significant improvement (24 ؎ 21.7 to 32 ؎ 22.5%). The differences between the two intervention groups and the control subjects was significant at p < 0.001 by analysis of variance. Conclusion: Five hundred repetitions of four basic cardiac murmurs significantly improved auscultatory proficiency in recognizing basic cardiac murmurs by medical students. These results suggest that cardiac auscultation is, in part, a technical skill. (CHEST 2004; 126:470-475)
Background: More than 50% of multiple sclerosis patients experience chronic pain syndrome. We set... more Background: More than 50% of multiple sclerosis patients experience chronic pain syndrome. We set out to determine the specific type of chronic pain that was seen in our multiple sclerosis patients. Methods: Patients with multiple sclerosis were catalogued between January 2002 and April 2006 and identified by a search of the database. Only MS patients that met the 2005 revised McDonald criteria were included. Results: We determined the prevalence rate of complex regional pain syndrome in a cohort of multiple sclerosis patients. In our sample of 205 multiple sclerosis patients, the prevalence of complex regional pain syndrome was 4 cases per 205 compared to an expected age and sex-adjusted total prevalence of 0.078 cases per 205 (p < 0.0001). Conclusion: This study suggests that multiple sclerosis patients are at a higher risk of developing complex regional pain syndrome than the general population. Key words: Multiple sclerosis, complex regional pain syndrome, prevalence
Study design Cohort study. Objectives Shoulder pain prevalence is high in those with spinal cord ... more Study design Cohort study. Objectives Shoulder pain prevalence is high in those with spinal cord injury (SCI) and is associated with decreased function, participation restrictions and decreased quality of life. Limited evidence exists regarding physical impairments of newly acquired SCI. The current study compared musculoskeletal factors at rehabilitation initiation in individuals with newly acquired SCI to uninjured individuals. We hypothesized no impairment differences of shoulder pain, strength, mobility, muscle extensibility, or rotator cuff integrity would exist between groups. Setting Multi-site laboratory setting. Methods Thirty-five individuals with newly acquired SCI and age and gender-matched controls without SCI (n = 34) participated. Musculoskeletal Pain Survey, shoulder range of motion (ROM), strength, pectoralis minor muscle extensibility (PM) and tissue integrity [Ultrasound Pathology Rating Scale (USPRS)] were obtained. Results Higher pain was reported by individuals experiencing new SCI along with lower strength across all bilateral measures, reduced elevation, external rotation, and horizontal adduction ROM, with large effect sizes. PM bilateral extensibility was reduced compared to controls, with moderate between group effect size; however, no USPRS score difference existed. Conclusions This study provided the first comprehensive clinical description for individuals with newly acquired SCI. In comparison to matched uninjured controls, participants with new SCI reported greater shoulder pain with impairments in mobility, strength, and extensibility. The identified early clinical impairments aligned with progressive impairment including further pain development and persistence. Awareness and modification of these early clinical impairments may lead to improved long-term outcomes, improving the overall health and well-being of individuals with newly acquired SCI.
Objectives: There is limited data describing the role of health disparity factors and socioeconom... more Objectives: There is limited data describing the role of health disparity factors and socioeconomic status (SES) on emergent versus nonemergent gastrointestinal (GI) procedures within pediatrics. We aimed to characterize risk factors and determine the role of SES on emergent versus nonemergent GI care. We hypothesized that patients with lower SES incur higher risk of having emergent procedures performed. Methods: Retrospective chart review was performed between 2012 and 2016, with 2556 patient records reviewed. Demographic data and SES categories were determined. The majority of emergent procedures were performed on an inpatient basis. Health disparity factors analyzed included age, gender, insurance type, race, language, and SES using census tracts. Logistic regression analyses and paired t-tests were utilized. Results: Two hundred eighty-six (11.2%) patients had emergent GI procedures performed. Logistic regression (odds ratio [OR], confidence interval (95% CI)] showed patients from 6-11 to 12-17 years of age were less likely to seek emergent care than the youngest group [0.47, 0.33-0.66 and 0.61, 0.45-0.84]. Patients with Medicaid insurance [1.68, 1.27-2.26], African American or ''other'' race [2.07, 1.48-2.90 and 2.43, 1.77-3.36, respectively], as well as ''other'' language [2.1, 1.14-3.99] more often sought emergent care. Using geocoded data, we found that as SES increases by 1, emergent risk for procedures decreased by 2.9% (OR 0.97, p = 0.045). Conclusions: Children with lower SES, at extremes of age (< 5, > 18 years), non-English or Spanish speaking and with Medicaid insurance are at higher risk of undergoing emergent GI procedures. This study gives us an opportunity to plan targeted interventions to improve access and quality of care.
Peer Review History: PLOS recognizes the benefits of transparency in the peer review process; the... more Peer Review History: PLOS recognizes the benefits of transparency in the peer review process; therefore, we enable the publication of all of the content of peer review and author responses alongside final, published articles. The editorial history of this article is available here:
Background and Objectives: Hospice and palliative medicine (HPM) is one of three Accreditation Co... more Background and Objectives: Hospice and palliative medicine (HPM) is one of three Accreditation Council for Graduate Medical Education accredited clinical subspecialties available to family medicine graduates for fellowship training. Despite this, training is not currently a curriculum requirement. We have pioneered a required 4-week palliative medicine rotation into the curriculum. Methods: Twenty-eight residents who completed the palliative medicine rotation across four classes were surveyed to assess how the rotation improved their level of comfort with providing end-of-life (EOL) care and to demonstrate the need of formal palliative medicine training. Wilcoxon signed ranks test was used to detect statistical differences between the mean level of comfort of residents pre- and postrotation with providing the basic skills needed to practice HPM. Results: The HPM rotation significantly improved the residents’ level of comfort in all areas of measured EOL care (P<0.001). All reside...
Objective. To determine whether there is a significant difference in initial successful contact w... more Objective. To determine whether there is a significant difference in initial successful contact when attempting follow-up of patients discharged from a pediatric emergency department (ED) using either pagers or the telephone. In addition, to evaluate whether the combination of both pager and telephone follow-up is more successful than telephone follow-up alone when confined to a 2-hour period. Design and Setting. A prospective comparison of intervention and control groups taken from convenience samples of patients seen in an ED of an urban, tertiary care children’s hospital. Participants. One hundred eighty-five patients whose families had access to both a pager and a telephone (intervention group) and 112 patients whose families had access to only a telephone (control group) were enrolled. Intervention. Before discharging the patient from the ED, the investigators verified a pager number and/or a best contact telephone number for a follow-up telephone call. Participants were divide...
Although research supports family-professional collaboration, challenges to implementation have b... more Although research supports family-professional collaboration, challenges to implementation have been reported. The case reports describe the implementation of a 4-step practice model that incorporates specific strategies to facilitate family-professional collaboration. The participants were two mothers of children with physical disabilities and two physical therapists. Therapists received instruction in the strategies for collaboration including client-centred interview, visualising a preferred future, scaling questions, and family routine and activity matrix. The intervention was implemented during 6-weekly sessions. The 2nd and 5th sessions were videotaped to analyse the interactions between the parent and therapist using Response Class Matrix. Telephone interviews were conducted to explore participants' experiences. Therapists were able to implement all strategies following 6 h of instruction. Analysis of the videotapes indicated that mother-therapist interactions were charac...
Journal of the American Podiatric Medical Association
Plantar pressure measures can be a useful way to clinically track dynamic foot function in childr... more Plantar pressure measures can be a useful way to clinically track dynamic foot function in children. Different protocols to collect plantar pressures exist--mainly, a midgait method that measures plantar pressures in the midst of a longer walk and a two-step method for which plantar pressures are obtained on the second step. These two methods have been compared in adults with and without disabilities but not in children. We investigated the concurrent validity and reliability of the midgait and two-step methods. Plantar pressure data variables of contact area, contact time, peak pressure, and pressure-time integral were compared between these two methods in children of typical development (ages 5 to 14.5 years) in the heel, midfoot, and forefoot. Paired t tests were used to evaluate the validity of the two-step method. Paired sample correlations and Bland-Altman plots were also used to compare both methods. Intraclass correlation coefficients were calculated to determine reliability...
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Papers by Edward Gracely