Episode 256 (Assistant Professor Kari Kretch)
Early mobility and crawling: beliefs and practices of Pediatric Physical Therapists in the United States.
Abstract
Purpose: To characterize beliefs of pediatric physical therapists (PTs) in the United States regarding the role of crawling in infant development and clinical practice.
Methods: Pediatric PTs reported their beliefs about early mobility and crawling, clinical approaches related to early mobility and crawling, and agreement with the removal of crawling from the Centers for Disease Control and Prevention (CDC)'s updated developmental milestone checklists in an online survey. Analyses examined associations between information sources and beliefs, between beliefs and clinical approaches, and between beliefs and CDC update opinions.
Results: Most participants believed that crawling was important (92%) and linked to a variety of positive developmental outcomes (71%-99%) and disagreed with its removal from the CDC checklists (79%). Beliefs were linked with clinical approaches focused on promoting crawling and discouraging other forms of mobility.
Conclusions: Further research is needed to determine whether pediatric PTs' beliefs and clinical practices are supported by evidence.
Episode 255 (Professor Noelle Moreau)
Effects of Power Training combined with interval treadmill training on walking capacity versus performance in real world settings in youth with cerebral palsy.
AACPDM 2025 sneak peak!
Dr. Noelle G. Moreau, is the Associate Dean of Research and Professor of Physical Therapy at Louisiana State University Health Sciences Center in New Orleans. Dr Moreau is best known for her work regarding the neuromuscular mechanisms underlying movement impairments in children with neurological conditions like cerebral palsy with her research focusing on innovative interventions to enhance gait and function, including power training for ambulatory youth.
Marissa and I loved this conversation - so many great take homes and opportunities for implementation right now. This work shines a light on the importance of task specificity not just for motor learning but also walking capacity training. The selection of training protocols based on assessment outcomes is fantastic - Noelle describes this beautifully.
Once again, this work is yet to be published but was not just presented as a contender for the Gayle G Arnold Award at the AACPDM New Orleans Conference in 2025 - but as we have recently learnt - won the award! Congratulations to Dr Noelle Moreau and her team for receiving this very prestigious award from the Academy.
Background and Objective(s)
Children with cerebral palsy (CP) primarily ambulate at low intensity levels and fail to achieve moderate and high stride rates as observed in typically developing children in natural environments. We hypothesize that impaired power generation may be the key limiting factor affecting the ability to ramp up to higher strides rates during walking. The purpose of this study was to determine the effect of lower extremity Power Training combined with high intensity interval-based Treadmill Training (PT^3) on functional walking capacity (lab) vs. performance in real world settings in youth with CP.
Study Participants & Setting
Thirty-seven individuals with bilateral spastic CP (mean age 13.5 SD 2.4 years; range 10-17 years; 20 male; GMFCS level I=10, II=24, III=4) were enrolled at two sites (academic medical center and children’s hospital). Participants were recruited from the community and regional tertiary pediatric care centers using purposive sampling.
Materials/Methods
In this single-blinded randomized controlled trial, participants were randomized using covariate-adaptive randomization to receive either power training combined with interval treadmill training (PT^3) or traditional strength training combined with steady-state treadmill training (STT). All participants received 24 sessions delivered over 8-10 weeks. Outcomes were assessed at baseline (V1), immediately post-intervention (V2), 2mo post (V3) and 6mo post-intervention (V4). Participants wore a StepWatch accelerometer for 7 days at each assessment timepoint. Outcomes included normalized self-selected and fast gait speed, StepWatch average strides per day, and percent stride rate intensity (Low: < 30 strides strides/min.; Mod/High: >30 strides/min) as a percentage of all strides/day. Change scores (Δ) were analyzed using mixed effects linear regression.
Results
Significant increases in fast gait speed were observed for PT^3 at V2 (Δ=0.02; p=0.01), V3 (Δ=0.05; p< 0.001), and V4 (Δ=0.04; p=0.01). There were no differences in the average number of steps/day in either group. There were significant between group differences at V2 in stride rate intensity with an increase in the percentage of low intensity stride rates after STT and an increase in mod/high stride rates after PT^3 (p=0.04).
Conclusions/Significance
Increases in fast gait speed observed immediately post-PT^3 were accompanied by changes in community walking performance that involved a greater percentage of strides/day at mod/high stride rates. Percent strides in mod/high intensity has been associated with increased mobility-based participation in daily life. In conclusion, specificity of training effects from power training combined with high-intensity interval based treadmill training translated to changes in walking activity at both the capacity level (faster gait speeds) and the performance level (increased mod/high stride rates in everyday life). These results suggest that a combined impairment and task-specific training approach is necessary to drive changes in both walking capacity and performance.
Episode 254 (Paleg et al)
Where’s the Evidence? Challenging Therapists to Stop Legitimizing Dynamic Movement Intervention and Cuevas Medek Exercises
A seminal paper with a stellar line-up of academic and clinical heavyweights:
Dr Ginny Paleg, Dr Dayna Pool, Associate Professor Álvaro Hidalgo-Robles, Clinical Assistant Professor Roslyn Livingstone, Dr David Frumberg MD and Professor Diane Damiano .
Dynamic Movement Intervention (DMI) and Cuevas Medek Exercises (CME) are promoted as innovative neurorehabilitation methods for children with neurological disabilities, yet both rely on outdated reflex-hierarchical models rather than contemporary motor learning principles.
A review of the literature reveals that CME, despite 5 decades of use, is supported only by a few case reports and 2 small, biased comparative studies. DMI, introduced in 2021, has no published empirical evidence beyond a single conference abstract. Thus, both interventions remain at Sackett Level 5—no evidence.
The ethical implications are substantial. Families often pay thousands for intensive, noncovered therapies that may displace meaningful participation in education and social life. Therapists have a professional responsibility to avoid legitimizing unproven practices and to prioritize interventions supported by robust evidence. Pediatric rehabilitation should shift toward child-led, functional, and task-specific approaches grounded in modern motor learning science, with professional bodies and insurers withholding endorsement of nonevidence-based methods.
Read the paper for FREE!
Episode 253 (Dr Karina Zapata)
Six-minute walk test reference values in ambulatory children with myelomeningocele
Karina A Zapata, Rosa H Cooksey, Daralyn K Fulton, Hayley B Shelton, Chan-Hee Jo, Richard C Adams PMID: 40556501 DOI: 10.1111/dmcn.16397
Abstract Aim: To determine the baseline pediatric reference values of the 6-minute walk test (6MWT) distance (6MWD) across spina bifida functional lesion levels, the associations between the 6MWD and the distances of the 1-minute and 2-minute walk tests, and assess the impact of social determinants on the 6MWD. Method: This prospective cohort study collected the 6MWD of 145 ambulatory children (72 male, 73 female; mean age = 11 years 2 months [range: 6 years 0 months-17 years 11 months]) with mid-lumbar-level (n = 59), low-lumbar-level (n = 28), and sacral-level (n = 58) myelomeningocele at a pediatric hospital. Proxies of social determinants included insurance type and Area Deprivation Index (ADI). Pairwise comparisons evaluated the 6MWD according to lesion level and myelomeningocele functional classification (MMFC) group.
Results: The mean 6MWD was shorter for myelomeningocele at the mid-lumbar versus low-lumbar versus sacral lesion levels (p less than 0.001), and MMFC2 versus MMFC3 versus MMFC4 (p less than 0.001). The mean 1-minute and 2-minute walking distances were strongly associated with the 6MWD. Children with public insurance and a high ADI walked significantly fewer meters than children with private insurance (p = 0.023) and a low ADI (p = 0.048). Interpretation: Children with higher anatomical functional lesion levels walked shorter distances than those with lower levels and according to MMFC group. The 1-minute and 2-minute walk tests are adequate substitutes for the 6MWT. Lower socioeconomic status affecting decreased walking capacity merits interventions to maximize opportunities for activity. https://pubmed.ncbi.nlm.nih.gov/40556501/
Episode 252 (Dr Colleen Peyton)
Trajectories of Fidgety Movements in Infants with and without medical complexity
AACPDM 2025 sneak peak!
Dr Colleen Peyton, is an Associate Professor in the Departments of Physical Therapy & Human Movement Sciences and Pediatrics at Northwestern University's Feinberg School of Medicine in Chicago. With over 15 years of clinical experience as a pediatric physical therapist specializing in high-risk infants, she earned her Doctorate from the MGH Institute of Health Professions.
A pioneer in early neurodevelopmental detection, Dr. Peyton became the first licensed tutor of the Prechtl General Movement Trust in North America, training clinicians worldwide in the General Movement Assessment to identify cerebral palsy as early as infancy. Her research integrates motor behavior analysis with advanced brain imaging to track developmental trajectories, driving better outcomes for vulnerable newborns.
It was wonderful to talk about this work - a piece of work that represents an international collaboration. This article is yet to be published but has been peer reviewed and like with our previous episodes, was a contender for the Gayle G Arnold award at the AACPDM New Orleans 2025 conference - a marker of scientific excellence.
Whilst you wait for the article - this conversation and abstract below can help to inform you about the latest in General Movement Assessments.
Background and Objective(s)
The General Movement Assessment (GMA) is highly predictive of cerebral palsy (CP) in 3-month-old infants, with the absence of fidgety movements (FM), between 10 and 16 weeks corrected age (CA), being a sensitive indicator. However, the typical time window for detection of FM may vary in infants with medical complexity (MC) who are commonly seen in follow-up clinics. Our goal was to examine FM trajectories from 10-20 weeks CA in infants with and without MC to identify infant groups that may have altered time course of FM.
Study Participants & Setting
484 infants with and without MC were recruited prior to 10 weeks CA across 4 international sites in Australia, Italy and the United States. Infants born full-term (FT) with no known MC (n=239) were recruited from the community and infants with MC (n=245) were recruited from tertiary NICU centers.
Materials/Methods
Families/carers filmed their infants every two weeks from 10 and 20 weeks CA, using a smartphone app, following standard GMA procedure. Blinded raters scored GMA and scores classified as FM presence yes/no at each timepoint. We determined trajectories of FM over time using discrete mixture models and used Bayesian information criterion (BIC) to determine the optimal number of trajectory classes. Fisher’s exact test or Kruskal-Wallis rank sum test identified differences in characteristics between trajectory groups.
Results
399 subjects returned ≥3 videos for analysis (2,010 total videos). We identified 4 FM trajectory groups (Fig 1):
Conclusions/Significance
Most infants in our sample had FM between 10-16 weeks CA, but those with MC (e.g. BPD, IVH, PVL) were more likely to delayed or altered FM trajectories. GMA testing in children with these conditions may need to be conducted later and more frequently to improve CP prediction accuracy. Long-term follow-up is warranted.
Episode 251 (Dr Christopher Modlesky)
Effect of high-frequency, low magnitude vibration on physical activity and physical function in children with cerebral palsy: a randomised controlled trial .
AACPDM 2025 sneak peak!
Dr. Christopher Modlesky is the Athletic Association Professor of Kinesiology at the University of Georgia. He earned his PhD in Exercise Science from UGA in 2002. Leading the Neuromusculoskeletal Health Laboratory, his research focuses on bone and muscle health in children with movement disorders, such as cerebral palsy, utilising MRI and vibration therapy to investigate physical activity interventions and mitigate long-term musculoskeletal deficits.
Another great conversation about an intervention that seems to have become more prominent again. What is the role of vibration therapy in children with cerebral palsy? This article is yet to be published but once again, was presented as a contender for the Gayle G Arnold Award at the AACPDM New Orleans Conference in 2025. This means that this paper has been peer reviewed and was put forward as a contender for the best scientific paper - a very prestigious award of the Academy.
Whilst you await this publication (as well as the other outcomes that will be analysed as part of the larger study), please refer to the abstract below!
Background and Objective(s)
Children with cerebral palsy (CP) have low levels of physical activity. It has been suggested that vibration may have a positive effect on their physical function; however, whether it also leads to an increase in their physical activity is unknown. The aim of the study was to determine if brief daily bouts of standing on a platform that vibrates at a high-frequency and low-magnitude leads to increases in physical activity in ambulatory children with CP, and if these increases are accompanied by improvements in physical function.
Study Participants & Setting
Ambulatory children with spastic CP (n = 44; Gross Motor Function Classification I and II) and between 5-11 y were recruited from children’s hospitals, non-profits, and schools and enrolled in a double-blind randomized controlled trial.
Materials/Methods
Children were randomly assigned to stand on a platform (1000R; Juvent) that vibrates (32-37 Hz, ~0.3 g) or makes a sound similar to vibration (i.e., placebo), 10 min/d for 6 months (n = 22/group). Compliance was determined using a monitoring device within the platforms. Physical activity was assessed using accelerometry (Actigraph GT9X) worn on the more affected hip and ankle (n = 2 monitors/site) and for 4 days/time point. Total physical activity counts were determined at the hip and ankle. Sedentary, light, moderate, vigorous, and moderate-to-vigorous physical activity were determined at the hip. Physical function was assessed using 6-minute walk and progressive lateral step-up tests. Analysis of covariance and an intention-to-treat analysis were used to determine the effect of the intervention.
Results
There were no group differences in the age, sex, or race (p > 0.05). 91 % of the children who were assigned to the vibration group (n = 20 of 22) and 86 % of the children assigned to the placebo group (n = 19 of 22) completed the 6-month intervention. Of those who completed the intervention, there was no group difference in the compliance (vibration = 83 ± 17 %; placebo = 77 ± 24 %). There was no group difference in any measure of physical activity or any measure of physical function at baseline (p > 0.05). There was a decrease in total (p = 0.040), moderate (p = 0.007), and moderate-to-vigorous (p = 0.016) physical activity assessed at the hip, and an increase in sedentary physical activity (p = 0.034) in the vibration group relative to the placebo group. There was no significant change in the 6-minute walk distance or performance on the lateral step-up test in the vibration group compared to the placebo group (both p > 0.50).
Conclusions/Significance
The results of this tightly controlled double-blind, randomized controlled trial suggest that standing on a mildly vibrating platform 10 minutes/d does not have an effect on lower body physical function and may lead to a reduction in physical activity in ambulatory children with CP. The reason for a negative effect on physical activity is unclear.
Episode 250 (Arianna Trionfo MD)
The effect of immediate weightbearing after planovalgus foot reconstruction in ambulatory children with cerebral palsy
AACPDM 2025 sneak peak!
Dr. Arianna Trionfo, is a paediatric orthopaedic surgeon at Nemours Children’s Health in Delaware. She graduated Magna Combe Loud from Loyola College with dual degrees in biology and psychology, earned her MD from Rutgers, and trained in orthopaedic surgery at Temple University before completing her paediatric orthopaedic fellowship at the Children’s Hospital of Philadelphia.
Dr. Trionfo has led multidisciplinary clinics for neuromuscular and hip conditions, and her clinical focus includes cerebral palsy, hip dysplasia, and orthopaedic trauma. She is a published researcher, mentor to future women in medicine, and an active member of POSNA, AACPDM, AAOS, and the Ruth Jackson Orthopaedic Society. Her work reflects a deep commitment to advancing pediatric mobility and inclusive care.
This was a wonderful conversation that many clinicians will be interested in. This paper is yet to be published but was presented as a contender for the Gayle G Arnold Award at the AACPDM New Orleans Conference in 2025. This means that this paper has been peer reviewed and was put forward as a contender for the best scientific paper - a very prestigious award of the Academy.
Whilst you await this publication (along with many of the related upcoming papers as mentioned in our conversation), please refer to the abstract below!
Background and Objective(s)
Planovalgus (PV) is a common foot deformity in children with cerebral palsy (CP). Orthopedic surgery is widely established as an effective treatment for deformity correction though there is clinical variation in post-op therapy protocols. Immediate weightbearing (WB) after PV foot correction could accelerate recovery but concern for post-op complications causes reluctance. The aim of this study was to determine the prevalence of complications after PV foot surgery in children with early WB vs. non-WB (NWB).
Study Participants & Setting
135 ambulatory children with CP (GMFCS I (12%), II (58%), III (30%)) met inclusion criteria and were included from a children’s hospital setting and assessed in the gait laboratory.
Materials/Methods
This IRB-approved retrospective cohort study included ambulatory children (GMFCS I-III) with CP and PV foot deformity who underwent reconstructive surgery and pre (within 18 months) and post-op (1-3 years) gait analyses. Complications were defined in three timeframes: (1) short-term, within 6 months of surgery, by radiograph review for nonunion, hardware failure, or infection requiring return to surgery, (2) mid-term, at 1-3 years, by pedobarographic assessment, and (3) long-term, > 3 years, by recurrence requiring surgical revision. Fisher exact tests compared the prevalence of complications between immediate WB and NWB groups. Regression analysis evaluated the relationship between complications and child, surgical, and post-operative factors.
Results
140 surgical events were completed on 224 feet at age 12.7 ± 2.8 years. Following surgery, 84% of children followed an immediate WB protocol, and 16% were NWB for the first six weeks. The prevalence of short-term complications between the WB and NWB groups was no different (nonunion/hardware failure/infection, WB 3%/1%/0%; NWB, 0%/3%/0%; p>0.9). There were no between group differences in mid-term correction status (under- corrected/corrected/over-corrected, WB 31%/45%/24%; NWB, 32%/54%/14%; p>0.9). The prevalence of long-term recurrence necessitating surgery was not significantly different (WB/NWB, 3%/11%; 8.5±2.8 years post-op; p>0.9). Regression analysis demonstrated WB status was not a significant predictor of correction status or long-term recurrence requiring revision (p>0.05).
Conclusions/Significance
Complication rates were very low after planovalgus foot correction surgery in ambulatory children with CP. There were no significant differences in complications, clinical outcomes, or need for surgical revision between groups who followed immediate WB vs. NWB post-op protocols. Immediate WB after PV foot correction surgery presented no increased risks compared to NWB and should be encouraged in children with CP. Early WB, standing, and walking may prevent disuse muscle weakness and promote faster recovery of gross motor mobility, enhancing patient care. Future studies should examine the impact of early WB on recovery time and long-term functional outcomes.
Are there too many barriers to access and inclusion?
We catch up with Professor Andrew Whitehouse!
We discuss the review in Australia that asks: Does our law support every child to access and thrive in school — or are there too many barriers to access and inclusion for students with disability?